The Influence of Renal Cancer on the Urinary Microbiome: A Pilot Study
R Bhatt, A Brevik, KL Morgan, S Ali, A Peta, L Xie, R Karani, P Jiang, RM Patel, J Landman
University of California
Introduction & Objective: The urogenital tract has only recently been found to harbor its own microbiome. Data regarding which bacterial flora are favorable and which may be detrimental remain sparse. The purpose of this study was to examine the differences in the urinary microbiome between patients with simple or low‐risk renal cyst(s) and individuals with newly diagnosed, clear cell renal cell carcinoma (ccRCC).
Methods: Twenty patients with renal masses suspicious for renal cancer and 20 patients with a simple or very low‐risk cyst(s) provided urine samples at two office visits. Patients with presumed renal cell carcinoma provided samples at their pre‐operative visit and post‐operative visit. Patients with renal cysts provided urine samples at two separate office visits. All urine samples were analyzed using 16S rRNA sequencing. Bacterial diversity, as determined by the number of observed species (alpha diversity) and dissimilarity (beta diversity) between samples, was compared between the groups using PERMANOVA analysis.
Results: Seventeen patients with renal cysts and 18 patients with confirmed ccRCC provided 53 total urine samples, including one sample at the time of initial clinic presentation and a second sample at a median of 159 days (range 84‐595) later for renal cyst patients and 102 days postoperatively (range 44‐401) for ccRCC patients. Urine samples underwent 16S rRNA sequencing. Those with renal cysts were older and more often female when compared to those with clear cell carcinoma (65.4 years vs. 52.6 years, p < 0.01 and 58% female vs. 7% female, p < 0.01, respectively). The mean number of amplicon sequence variants was found to be significantly decreased in the ccRCC group when compared to those with renal cysts (22.6 vs. 33.5, p < 0.01) with no noted difference in bacterial evenness, as determined by the Pielou evenness and Shannon diversity indices. Gardnerella and Enterococcus were both found to have a relative abundance >2% in the ccRCC group.
Conclusions: Urine samples from pathologically confirmed ccRCC patients revealed a younger and predominantly male population with decreased microbial diversity when compared to patients with renal cysts. Among bacterial species identified, Gardnerella and Enterococcus had a relative abundance >2% in the ccRCC group.
24‐hour Urine Parameters in Kidney Stone Patients with Obesity
M Chen, AA Nourian, C Nourian, J Ghoulian, E Ghiraldi, J Friedlander
Einstein Healthcare Network
Introduction & Objective: Patients with obesity are known to be at higher risk for kidney stone disease, however it is unknown whether this risk is independent of metabolic syndrome. The purpose of the current study was to investigate abnormalities on 24‐hour urine collections in patients with obesity.
Methods: 24‐hour urine collections from a single tertiary care center were retrospectively reviewed from May 2014 to May 2021. Univariate analysis was performed using Chi‐square test and unpaired T‐test for categorical and continuous variables, respectively. A multivariable logistic regression was performed controlling for age, race, gender, and diabetes. Obese patients were characterized as those with body mass index (BMI) ≥30.
Results: 404 patients met inclusion criteria, of which 194 (48%) were not obese and 210 (52%) were obese (BMI ≥30). There were no differences in baseline characteristics between groups including age, race, and gender. On univariate analysis, patients who were obese had lower urinary pH (5.94 vs 6.10, p = 0.025), increased urinary calcium (207 vs 180, p = 0.031) and sodium (185 vs 151, p < 0.001) relative to patients who were not obese. When controlling for age, gender, race, and diabetes mellitus (DM), patients with obesity had persistently elevated urinary sodium (p = 0.001) relative to those without DM.
Conclusions: After adjusting for confounding factors, obese patients without DM were found to have elevated urinary sodium compared to non‐obese patients. When counseling obese patients on stone prevention strategies, education on reducing dietary sodium may help reduce future risk of stone formation.
Risk Factors for Nephrolithiasis in 24‐hour Urine Studies of Patients with Nonalcoholic Fatty Liver Disease (NAFLD)
M Chen, AA Nourian, C Nourian, J Ghoulian, E Ghiraldi, J Friedlander
Einstein Healthcare Network
Introduction & Objective: Nonalcoholic fatty liver disease (NAFLD) has been suggested to be an independent risk factor for renal stone disease by several studies. We aimed to identify abnormalities on 24‐hour urine collections in this patient population.
Methods: 24‐hour urine collections from a single tertiary care center were retrospectively reviewed from May 2014 to May 2021. Univariate analysis was performed using Chi‐square test and unpaired T‐test for categorical and continuous variables, respectively. A multivariable logistic regression was performed controlling for age, body mass index (BMI), diabetes mellitus (DM).
Results: 98 (24%) of 406 patients who met inclusion criteria were identified to have radiographic hepatic steatosis. There were no differences in baseline characteristics between groups including age, race, and gender. On univariate analysis, patients with NAFLD had decreased urinary pH (5.88 vs 6.06, p = 0.02), elevated urinary oxalate (40 vs 36, p = 0.04), calcium (219 vs 186, p = 0.02) and sodium (185 vs 163, p = 0.02) relative to those who did not have fatty infiltration of the liver on imaging. After controlling for DM and obesity as defined as BMI ≥30, no 24‐hour urine abnormalities were identified.
Conclusions: After adjusting for confounding factors, patients with hepatic steatosis did not have identifiable abnormalities in their 24‐hour urine studies. Increased risk of nephrolithiasis in patients with NAFLD is likely related to contributors of metabolic syndrome such as diabetes and obesity.
The Effect of Laser Scanning Speed and Moses 2.0 Extended Frequency Range in a Dusting Model of the Moses Pulse 120H 2.0 Laser System
P Whelan, C Tabib, C Kim, J Chen, ZR Dionise, F Soto‐Palou, P Zhong, GM Preminger, M Lipkin
Division of Urology, Duke University Medical Center
Introduction & Objective: Moses 2.0 Extended Frequency Range (EFR) technology allows high frequency laser lithotripsy with a unique EFR pulse type over 80Hz compared to first‐generation Moses technology (i.e. Moses Distance (MD)) at less than 80Hz. It is also accepted that dusting efficiency increases with faster scanning of the laser fiber tip across stone surface. Our aim was to compare stone dusting efficiency by varying scanning speeds across stone surface to isolate the dusting efficiency of the Moses 2.0 EFR and first‐generation MD pulse shapes.
Methods: All tests were conducted using the Moses 2.0 laser system on hard and soft Begostone phantoms. Using a 3D laser positioning system, the laser was fired across a Begostone surface (hard and soft), creating ablated areas or trough segments. Treatment efficiency was compared between MD at 80Hz and Moses 2.0 EFR at 100 and 120Hz with energy settings of 0.2 and 0.3J. Scanning speeds were determined by laser pulses per mm (10, 25, 50, 75, 100 pulses/mm) at a standoff distance of 0mm. Ablation volumes (mm3) of 1 mm trough segments were quantified with optical commuted tomography and volumetric treatment rate was calculated (mm3/s). By evaluating 1mm trough segments and varying scanning speed by pulses/mm, damage from EFR and MD pulses (which are inherently available at different frequencies) could be directly compared.
Results: Volumetric stone treatment rate increased with increasing scanning speed (p < 0.0005). At the fastest scanning speed (10 pulses/mm), both EFR frequencies had significantly higher volumetric stone treatment rates compared with MD (80Hz). There was no difference in ablation volume rates between EFR frequencies of 100 and 120Hz at this speed. At slower speeds (50‐100 pulses/mm), there was no difference in ablation volume for any of the laser settings.
Conclusions: The novel Moses 2.0 EFR pulse type provided more stone damage than MD, suggesting potentially gains at high frequency for stone dusting. Additionally, increased laser fiber scanning speed resulted in increased stone damage with both MD and EFR pulse types. However, gains in dusting efficiency with increasing scanning speed must be balanced with safety of faster scanning speeds.
Benchtop Evaluation of Miniature Percutaneous Nephrolithotomy Lithotrites
C Tabib, P Whelan, C Kim, RS Terry, F Soto‐Palou, GM Preminger, M Lipkin
Division of Urology, Duke University Medical Center
Introduction & Objective: Percutaneous nephrolithotomy (PCNL) is the preferred surgical treatment for kidney stones >2cm. While PCNL has traditionally been performed using access sheaths from 24‐30Fr in size, there is presently a trend toward using increasingly smaller sheaths (< 20Fr) and scopes to perform what has been termed “mini‐PCNL.” Smaller mechanical lithotripsy instruments have therefore been developed for this purpose, but are limited in comparative effectiveness. We performed benchtop assessment of multiple mini‐PCNL lithotrites.
Methods: One 1cm3, hard (5:1), Begostone phantom was placed in a cylinder with four 5.5mm cylindrical openings to simulate size of a 16.5Fr mini‐PCNL sheath to drain via Venturi effect. Lithotripsy was then performed with either the 1.9mm Trilogy (EMS), 1.83mm ShockPulse (SP, Olympus) and 200mm Holmium:YAG laser. Suction was used for the mechanical lithotrites. The Trilogy probes were used at 50% impact, 6Hz, 80% ultrasound and 10% suction. The ShockPulse was used at high‐power setting. The 1.9mm probe was used with a 15Fr mini nephroscope (Olympus). The ShockPulse, 1.5mm Trilogy and laser fiber were used with a 12Fr mini nephroscope (Karl‐Storz). The laser was set at 0.5J/70Hz Moses‐Distance (MD) (Lumenis). 10 independent runs were performed with each probe. Time to complete stone clearance was recorded and mass stone clearance rates were calculated.
Results: The Trilogy 1.9mm probe showed superior stone clearance rate (11.69 ± 3.68 mg/s) vs the SP 1.83mm probe (6.29 ± 1.37 mg/s, p = 0.003) and the laser fiber (4.73 ± 0.61 mg/s, p < 0.0005), respectively (Figure 1). The SP was also superior to the laser (p = 0.016). This translates to 4.6 and 7.9 minutes less treatment time vs the SP and laser, respectively, for a spherical 1.5cm diameter calcium oxalate monohydrate stone.
Conclusions: Among these three commonly used mini‐PCNL probes, the Trilogy 1.9 demonstrated clearly superior stone clearance rates in this benchtop model. This could be due to improved lithotrite properties and use of suction evacuation, especially compared to the laser. Future clinical testing is warranted to evaluate optimal lithotrite for miniPCNL.
Calcium Oxalate Stimulated Renal Tubular Epithelial Cells Promote the Expression of S100A8 and S100A9 in M1 Macrophages via Secreting IL6
Q Wang, G Zeng, F Sun
Department of Urology, Guizhou Provincial People's Hospital, Guiyang, Guizhou, 550000, China.
Introduction & Objective: S100A8 and S100A9 were the most common proteins in kidney stone matrix and were increased in the renal interstitium and urinary exosomes of patients with nephrolithiasis. The potential role of S100A8 and S100A9 in stone formation required further exploration. In the current study, we aimed to demonstrate the origination and primary regulators of S100A8 and S100A9 in kidney stone disease.
Methods: Single Cell Type Atlas database was searched to explore the renal origination of S100A8 and S100A9. Human myeloid leukemia mononuclear cells were differentiated into different types of macrophages. Calcium oxalate monohydrate (COM) stimulated human renal tubular epithelial cells (HK‐2) were co‐cultured with M1 macrophages. Western blotting, qPCR, immunofluorescence, and Elisa were conducted to detect the expression of S100A8, S100A9 and IL6.
Results: Single‐cell sequencing map revealed that renal S100A8 and S100A9 mainly originated from macrophages. Among different types of macrophages, M1 macrophages showed the most abundant expression of S100A8 and S100A9. Directly cultured with COM didn't influence the expression of S100A8 and S100A9 in M1 macrophages, while co‐cultured with COM stimulated HK‐2 cells did. IL6 was up‐regulated in COM stimulated HK‐2 cells and it could promote M1 macrophages to express S100A8 and S100A9. IL6 inhibitor SC144 could significantly inhibit COM stimulated HK‐2 cells promoting M1 macrophages to express S100A8 and S100A9.
Conclusions: Renal S100A8 and S100A9 in calcium oxalate patients mainly originate from M1 macrophages. Calcium oxalate can stimulate renal tubular epithelial cells to secret IL6, which then promotes the expression of S100A8 and S100A9 in M1 macrophages.
The Role of CXCL14 Secretion by PMN‐MDSCs in the Bone Marrow Tumor Microenvironment to Induce the Dissemination of Prostate Cancer Cells from the Bone Marrow
Z Chen, D Gu, T Deng, G Zeng
Department of Urology and Guangdong Key Laboratory of Urology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, 510230, China.
Introduction & Objective: Both clinical and basic studies have shown the bone tumor microenvironment (TME) can promote the visceral dissemination of prostate cancer from bone, to lead the high mortality. However, the molecular mechanism is still unclear. This study aimed to evaluate, in the bone marrow TME, the roles of PMN‐MDSCs and the its secretion chemokine CXCL14 in the visceral dissemination process of prostate cancer cells from bone marrow.
Methods: Primary tumor tissues samples were obtained from Bone metastatic PCa (BoM PCa), Lung metastatic PCa (LuM PCa) patients (15 cases versus 10 cases, respectively) and MyC‐CaP mice models (8 cases versus 7 cases, respectively). The multiplex immunofluorescence staining, with CD11b, CD33, CD15 antibodies for human samples and Ly‐6G, CD11b antibodies for mice samples, were performed to identify the PMN‐MDSCs infiltration in the TME. PMN‐MDSCs were obtained from bone marrow of PCa mice model, and isolated using flow cytometry sorting for in vitro and in vivo assays. In function study, Matrigel migration, invasion were performed to analyze effects of PMN‐MDSCs and CXCL14 on prostate cancer cells metastasis. Western blot and qPCR were carried out to measure the expression of EMT markers (Vimentin, Slug, β‐catenin, ZEB1) in cancer cells.
Results: Our results showed that, PMN‐MDSCs and CXCL14 in the BoM PCa were significantly increased than in the LuM PCa in both of patients and mice tissues. It was verified that infiltrating PMN‐MDSCs in bone tissues of BoM PCa expressed high level of chemokine CXCL14 than in the bone and lung tissues of LuM PCa. Moreover, in vitro, PMN‐MDSCs from bone marrow of BoM PCa could effectively enhance migration and invasion and increase the expression of mesenchymal protein and genes in PC3 and MyC‐CaP cells. Furthermore, the effect of PMN‐MDSCs and CXCL14 could be reversed by knockdown of CCRL2 in the prostate cancer cells.
Conclusions: Our data suggestion that, in the TME of bone marrow, PMN‐MDSCs may induce the visceral dissemination of prostate cancer cells by secretion of chemokine CXCL14. Mechanistically, CXCL14 increased the expression of EMT protein and genes by upregulation of CCRL2. This research is the first to demonstrate that PMN‐MDSCs and CXCL14 play the key roles in the visceral dissemination of bone marrow tumor cells and is a potential target for pharmacological treatment.
Determining the Threshold of Acute Renal Parenchymal Damage for Intrarenal Pressure During Flexible Ureteroscopy Using an in Vivo Pig Model
MS Lee, B Connors, DK Agarwal, MA Assmus, J Williams, T Large, AE Krambeck
Ohio State University
Introduction & Objective: Ureteroscopy (URS) is the most commonly performed surgery for kidney stones. Multiple studies have defined the range of intrarenal pressures (IRPs) occuring during URS. However, no one has attempted to identify a threshold for IRP, that if exceeded, will result in renal parenchymal damage. Herein, we attempted to identify this IRP safety threshold by subjecting in vivo porcine kidneys to various levels of pressurized irrigation.
Methods: Ten female pigs (60‐80 kg) were intubated and sedated. The abdomen was opened, the ureters were isolated and incised. A LithoVueÔ (Boston Scientific) ureteroscope was inserted and advanced up to the kidney. An 0‐silk tie was then used to tie the ureter around the scope to create a closed system (to achieve a maximum level of pressure). Realtime IRPs were measured using the CometÔ Pressure guidewire (Boston Scientific). Kidneys were subjected to various levels of pressure (0, 50, 100, and 150 mmHg) for 36 minutes (based on published mean URS times). The control arm had 3 kidneys and each pressure group had 5 kidneys. Kidneys were fixed with an intravascular perfusate and harvested. Two expert histologists independently analyzed kidney slides to identify areas of renal damage.
Results: The differences in mean IRPs between the groups was significant (p < 0.0001). Two kidneys were exposed to IRPs >185 mmHg as we initially planned to have a 300 mHg group. We identified that IRPs greater than 185 mmHg routinely resulted in forniceal rupture and large areas of hematoma. The other IRP groups had no differences in renal parenchymal damage.
Conclusions: No differences in renal parenchymal damage were identified between pressure groups of 50, 100, or 150 mmHg. However, IRPs >185 mmHg did result in forniceal rupture.
Renal Microbiome Dysbiosis Promotes a Lithogenic Environment
J Agudelo, X Chen, S Mukherjee, A Miller
Cleveland Clinic
Introduction & Objective: The objectives of the study were to 1) Characterize the microbiome of the upper and lower urinary tracts in mice; 2) Determine the impact of antibiotics on the renal microbiome; and 3) Determine the role of uroprotective and uropathogenic bacteria in promoting a lithogenic environment.
Methods: One‐hundred twenty Swiss‐Webster mice, housed in metabolic cages, were fed with a 1.5% oxalate diet. The animals were assigned to cefazolin groups or control arms for 8 or 19 days, with or without 14‐day recovery, for a total of 8 different treatments. Urine was asceptically collected at three‐day intervals for molecular microbial quantification. At the end of the experimental period, animals were necropsied. Kidneys were collected for either metagenomic bacterial quantification or direct bacteria counting in bisected kidneys with fluorescence in situ hybridization (FISH) using one of three probes that selected for all bacteria, Lactobacilli or Enterobacteriaceae. An in vitro study was subsequently run in a bioreactor with artificial urine, inoculated with either E. coli or L. crispatus, as pro‐lithogenic and antilithogenic strains respectively, or as a coculture. The media from this study was analyzed with qPCR for bacterial growth and live/dead bacteria assay. Sampling coupons were also analyzed for crystal characterization with scanning electron microscopy.
Results: The upper and lower urinary tracts were significantly different as assessed through species richness (p < 0.05) and microbiome composition (p < 0.05) metrics. Long‐term, but not short‐term, use of cefazolin impacted the lower urinary tract microbiome, with some recovery. Long‐term antibiotic use also had a significant impact in renal bacterial numbers. However, in both the upper and lower urinary tracts, the Enterobacteriaceae were resistant to the effect of antibiotics. In the media analysis of the in vitro experiment, we observed that E. coli outgrows L. crispatus in a competitive fashion with a higher rate of live cells. E coli was also associated with larger octahedral crystals compared with the L crispatus experiment (Fig. 1).
Conclusions: The present study provides evidence that the renal microbiome has implications for the formation of kidney stones, as we observed that antibiotic resistance E coli was associated with an increase in crystallization metrics, and L. crispatus was linked to an anti lithogenic environment.
Immunogenic and Tumoricidal Effects of Sterile Water and Glycine on Urothelial Cancer Cells – an in vitro and Clinical Comparison
H Herzberg, R Babaoff, R Marom, Y Veredgoren, S Dekalo, S Amir, S Bercovich, S Neufeld, R Lasmanovitz, D Kedar, A Beri, J Baniel, O Yossepowitch, D Margel, M Sofer, R Mano
Department of Urology, Tel Aviv Sourasky Medical Center
Introduction & Objective: A growing body of evidence highlights the key role of immune regulation in bladder cancer. Previous in‐vitro studies demonstrate a tumoricidal effect of sterile water on urothelial cancer cells. Studies evaluating the immunogenic response induced by different irrigation fluids and their clinical effect are lacking.
We aimed to evaluate the tumoricidal and immunologic effect of sterile water and glycine on urothelial cancer cells. Clinical data were analyzed to evaluate oncologic outcomes of patients with non‐muscle invasive bladder cancer (NMIBC) who underwent sterile water and glycine irrigation during TURBT.
Methods: Bladder cancer cell lines (RT4, T24 and 5637) were treated with glycine and sterile water. Cell viability was evaluated with the XTT assay. Cell membrane calreticulin levels were evaluated with flow cytometry and extracellular high mobility group box 1 (HMGB1) and heat shock 70 (HSP70) protein levels were evaluated using western blot.
After obtaining institutional review board approval, clinical data was retrospectively collected from 537 consecutive patients who underwent TURBT for an initial presentation of NMIBC. Patients were treated at two tertiary referral centers, each of which routinely use different irrigation fluids for TURBT. Propensity score matching was performed, and recurrence and progression rates were evaluated.
Results: In‐vitro studies showed that sterile water treatment resulted in the lowest number of viable cells; however, early and late immunogenic cell death markers, as evident by elevated membrane calreticulin levels and the release of HMGB1 and HSP70, respectively, were markedly elevated in cells treated with glycine (Figure 1).
After propensity score matching each study arm included 201 patients. Median follow‐up for patients was 13.6 months (IQR 6.2, 24.5). Two‐year recurrence free survivals were 57.5% and 68.9% (p = 0.004) for sterile water and glycine irrigation, respectively. Two‐years progression free survivals were 88.2% and 92% (p = 0.37), respective
Conclusions: We demonstrate a substantial increase in immune response inducers when exposing urothelial cancer cells to glycine despite the greater tumoricidal effect of sterile water.
Clinically, glycine irrigation during TURBT was associated with lower recurrence rates consistent with our in vitro findings.
Validating the Kidney Injury Test (KIT) as a Point of Care Diagnostic for Urinary Stone Recurrence
XC Cortez, S Ghosh, R Sarwal, N Titzler, W Yazar, M Stoller, M Sarwal, T Chi
UCSF
Introduction & Objective: The gold standard to monitor for stone recurrence is imaging, which is inconvenient and costly for patients. This contributes to poor follow‐up care for nephrolithiasis patients. A point of care, non‐imaging test to monitor for stone growth and recurrence would thus be impactful for patients. The KIT assay measures 4 biomarkers in a spot urine sample. Our lab previously demonstrated that KIT score, a composite of the measured values, accurately demonstrated the presence of calcium‐based stones in patients with imaging‐proven stones compared to patients without stones. The primary objective of this study was to validate KIT as a method for monitoring stone recurrence and growth by comparing KIT scores over time in a longitudinal cohort of patients.
Methods: Spot urine samples were prospectively collected from stone patients during clinical encounters including routine follow‐ups and surgical cases since 2018. A retrospective cohort of patients who provided at least two samples was identified from the Registry for Stones of the Kidneys and Ureter (ReSKU). Samples were found to have corresponding imaging studies within 2 months of each sample collection date to confirm stone presence, absence, or recurrence. Cystinuric patients were excluded. Urine supernatant was assayed for all patients using the KIT assay and KIT scores were calculated.
Results: A cohort of 36 patients with 89 samples was analyzed using the KIT assay. 76 samples were collected during stone events. 13 samples were collected during non‐stone events. Mean KIT score in patients with active stone events was 69.37 ± 17.04 compared to 51.60 ± 19.07 for non‐stone events (p = .0023). The Spearman correlation coefficient between stone size and KIT score was 0.440 (p < .01) [Figure 1]. Nine patients provided at least 1 sample during both a stone and non‐stone event for 18 total samples. In a sub analysis of this group, mean KIT score during active stone events was 65.05 ± 18.05 compared to 49.96 ± 17.85 for non‐stone events (p = 0.094).
Conclusions: KIT score can differentiate between stone and non‐stone events in nephrolithiasis patients, demonstrating its utility in identifying patients for recurrence in lieu of imaging.
Inner Surface Modification of Polyurethane Ureteral Stent by the Plasma‐enhanced Chemical Vapor Deposition for Resistance to Encrustation and Biofilm Formation
J Chung, Y Boo, J Kim, D Jung, D Han
Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
Introduction & Objective: Encrustation and biofilm formation in ureteral stents are major causes of obstruction and reduce the lifetime of a ureteral stent. Many studies have been conducted to extend the lifespan of the ureteral stent. However, only few studies have been conducted on the inner surface modification of stents. Inner surface modification of stents has a technical difficulty to forming thin, uniform coatings in such a narrow area. In this study, to develop the inner plasma surface modified ureteral stent to improve resistance to both encrustation and biofilm development.
Methods: The inner surfaces of polyurethane tubes (inner and outer diameters of 1.2 and 2.0 mm, respectively) were reformed with Ar, O2, and C2H2 gases using specialized plasma‐enhanced chemical vapor deposition techniques (Figure 1). Then, the modified PU tubes were immersed in urine for 15 days, and the characteristics of the inner surfaces were analyzed.
Results: Depending on the modification procedure, the corresponding inner surface exhibited different chemical properties and different rates of encrustation and biofilm formation. For a hydrophilic surface treated with Ar and O2, encrustation and biofilm formation increased, while for the C2H2 coating, the development of encrustation and biofilm reduced by more than five times compared with the untreated bare PU tube (Figure 2, 3).
Conclusions: This study demonstrated that inner plasma surface modification of ureteral stents greatly enhances resistance to encrustation and biofilm formation. Therefore, the lifetime of ureteral stents can be increased, thereby enabling patients to avoid the immense pain associated with surgical treatment.
Renal Tolerance to Prolonged Warm Ischemia Time During Partial Nephrectomy in a Solitary Kidney Canine Model: A Biochemical and Morphological Evaluation
A Samy, A Elkashef, N Barakat, S Khater, S Hamed, M Gomaa, M Abdel‐Maboud, Y Osman
Department of Urology, Urology and Nephrology Center, Mansoura University, Egypt
Introduction & Objective: Renal ischemia is an essential step during partial nephrectomy. The safe maximum duration of renal warm ischemia that the kidney can tolerate during partial nephrectomy remains controversial. Therefore, we studied the effect of different renal warm ischemia times on the kidney function and morphology during partial nephrectomy in a canine model of solitary kidney.
Methods: Thirty dogs underwent open right nephrectomy to create a solitary kidney model. The animals were allocated into 3 groups (10 dogs each) at which they were exposed to warm ischemia by open occlusion of the left renal artery during partial nephrectomy for 30, 60 and 90 minutes, respectively. One month later, the kidney function was evaluated using serum creatinine (SCr) and renographic glomerular filtration rate (GFR). Dogs were then sacrificed and their kidneys were harvested for histopathological examination and immunohistochemistry by CD95 and proliferating cell nuclear antigen (PCNA).
Results: There was no statistically significant variation in the renal function among the three groups after one month of partial nephrectomy. Histopathological examination showed comparable results regarding inflammation, interstitial fibrosis and regeneration. There was also no significant difference in immunostaining of CD95 and PCNA (Figure 1).
Conclusions: The solitary kidney can tolerate prolonged renal warm ischemia time up to 90 minutes during partial nephrectomy without further deterioration in the renal function and morphology.
Assessment of the Cytotoxicity of a Mitomycin Drug‐Eluting Ureteral Stent in a T24 Urothelial Carcinoma Cell Line
F Soria, S Aznar‐Cervantes, L Martinez‐Pla, J Aranda, J de la Cruz, J Galan, A Budia, F Cabrera, F Sánchez‐Margallo
Jesus Uson Minimally Invasive Surgery Centre
Introduction & Objective: The use of upper tract chemotherapy intracavitary instillation for adjuvant treatment of low‐grade upper tract urothelial carcinoma is scarce due to current limitations in suitable instillation. Reducing the prophylactic use of this technique, which could lead to a higher recurrence rate in this type of patient.
Assessing Renal Damage Caused by New High Power Lasers During Ureteroscopic Laser Lithotripsy: A Randomized Trial
AJ Yaghoubian, R Shimonov, B Gallante, D Lundon, J Khusid, M Patel, K Nie, H Xie, J Qi, N Zaki, S Kim Schulze, WM Atallah, N Kyprianou, M Gupta
Mount Sinai
Introduction & Objective: The high power Holmium (Ho:YAG) and thulium fibre lasers (TFL) generate enough heat in surrounding fluid to cause renal cellular damage, yet the degree to which this occurs has yet to be quantified. We aim to establish a relative safety profile of the TFL and Ho:YAG by quantifying the degree of renal damage during ureteroscopic laser lithotripsy (URSLL).
Methods: This is an ongoing randomized controlled trial of patients undergoing URSLL with unilateral non‐obstructing renal stones. Patients are randomized to undergo URSLL with either the TFL or Ho:YAG laser. Each patient's urine is collected immediately pre‐op (V1), 1 hour post‐op (V2), and 10 days post‐op (POD#10, V3). Samples are analyzed by enzyme‐linked immunosorbent assay (ELISA) for the following biomarkers: Kidney injury molecule‐1 (KIM‐1), Neutrophil gelatinase‐associated lipocalin (NGAL), and β2‐microglobulin (β2M), then normalized to urine creatinine. Primary outcome is degree of renal injury based on urinary biomarker changes.
Results: To date 26 patients (16 TFL, 10 Ho:YAG) have been included. Baseline patient and stone characteristics were similar. Relative to controls, both lasers caused pronounced rises in biomarkers in the immediate postoperative period with a trend back towards baseline by postoperative day 10 (Fig. 1). However, the Ho:YAG laser caused a persistent rise in NGAL at 10 days. In terms of percent change from baseline, there were no significant differences between cohorts for any of the biomarkers (Fig. 2).
Conclusions: Our pilot analysis suggests that there is notable laser‐induced renal parenchymal damage for both TFL and Ho:YAG. The renal damage safety profile appears similar for both lasers.
Assessment of the Bladder Microbiome in Patients with Non‐muscle Invasive Urothelial Cell Carcinoma by Gene Sequencing of Tissue Specimens
JT Emerson, CL Coogan, S Green, P Engen, A Naqib, A Keshavarzian
University of California, Irvine
Introduction & Objective: There has been minimal investigation of the bladder microbiome by means of interrogation of ribonucleic acid (RNA) or deoxyribonucleic acid (DNA) extracted from bladder tissue. We used targeted gene sequencing to analyze the microbiota of transurethral bladder resection of tumor (TURBT) specimens in patients with urothelial cell carcinoma (UCC).
Methods: Formalin‐fixed paraffin‐embedded (FFPE) TURBT specimens from 20 patients with negative standard urine culture and non‐muscle invasive UCC were identified. Microbial 16S ribosome (RNA‐based) amplicon sequencing was performed. Differential abundance analyses were performed using DESeq2 software to compare high versus low grade and disease stage.
Results: 75% (15/20) of specimens were high grade. 75% (15/20) were stage Ta and the remaining were stage T1. Microbial communities were dominated by the genera Streptococcus, Rothia, Staphylococcus, and Corynebacterium. Both grade and stage differential abundance analysis yielded significant (p < 0.05) differences in 8 genera (Figure 1). Phylogenic analysis identified increased acidobacteriota in high grade disease.
Conclusions: RNA based amplicon sequencing of TURBT specimen is a feasible means of assessing bladder microbiome. Many gut microbial features were detected, as well as Fusobacterium, oral bacteria that have been associated with colon cancer. These pilot data indicate that RNA extraction of FFPE can be performed to further inform our understanding of the bladder microbiome in UCC patients.
WITHDRAWN
Renal Warm Ischemia During Simulated Laparoscopic Partial Nephrectomy Results in Circulatory Toll‐like Receptor 4 (TLR4) Overexpression, Which Correlates with Kidney/BASI Function in a Solitary‐kidney Porcine Model
RL Steinberg, BA Johnson, I Sorokin, A Garbens, Z Zhang, B Haimovich, J Cadeddu, EO Olweny
University of Iowa Healthcare
Introduction & Objective: To determine whether TLR4, a mediator of organ ischemia‐reperfusion injury (IRI), is overexpressed during warm ischemia in a porcine solitary kidney model, and whether its expression correlates with kidney function.
Methods: Eight adult Yorkshire pigs underwent initial laparoscopic nephrectomy, and 1 week subsequently, were randomized into 2 groups: group 1 underwent laparoscopic renal hilar dissection, cross‐clamping, and kidney reperfusion (ischemia group); group 2 underwent laparoscopic renal hilar dissection alone (sham group). Animals were survived to day 7 post‐randomization. Peripheral blood was sampled at the following time points or corresponding intervals: baseline, pre‐clamp, after 90 minutes of ischemia, after 30 minutes of reperfusion and at sacrifice. Serum creatinine (sCr) and relative TLR4 expression were assayed. Relative TLR4 expression was compared for the ischemia vs. sham groups using Mann‐Whitney's test, while correlation between sCr and relative TLR4 expression level was analyzed using Spearman's test.
Results: Seven animals successfully completed the experiment (4 ischemia, 3 sham). Relative TLR4 expression level was significantly higher for the ischemia group during the ischemia phase (p = 0.034), while sCr was significantly higher for the ischemia group during the reperfusion phase (p = 0.048). Relative TLR4 expression level significantly correlated with sCr in the overall cohort (Spearman's rho = 0.69), and in the ischemia group (Spearman's rho = 0.82), (p < 0.0001 for each).
Conclusions: Warm ischemia in a porcine solitary kidney induces acute overexpression of TLR4 in peripheral blood leukocytes which is detectable prior to an observable change in sCr. Relative TLR4 expression level strongly correlated with sCr. Pending further investigation, TLR4 overexpression during renal ischemia may represent a sensitive, quantitative marker of unilateral renal injury sustained during nephron‐sparing surgery.
In vitro Intrarenal Pressure Comparison of Ureteroscopy Irrigation Systems
C Cerrato, J Berger, J Gerrity, M Monga
Università degli studi di Verona, Urology Department UC San Diego Health
Introduction & Objective: To examine relative pressures generated by ureteroscope irrigation systems.
Methods: A ureteroscope (Lithovue, Boston Scientific, Marlborough, MA, USA) was placed into a ureteral model (14F silicone tube) and a silicone renal model (12/14 F x28 cm ureteral sheath). 3 irrigation devices were tested: pressure bag inflated to 280 mmHg; URAMIX Easy‐Jet Irrigator (UEJI, Lansdowne, PA, USA); Single Action Pumping (SAP, Boston Scientific, Marlborough, MA, USA). Pressures within the models were recorded via an arterial line transducer connected to a retrograde 5F catheter. In the renal model, max pressures achieved via 3 irrigation devices were recorded with an empty working channel, with a 1.9F basket, and with a 2.2F basket. The SAP was tested in both a “pulsed” manner and a “max plunge” manner. In the ureteral model, simulated blood (Food Coloring Whole Foods Market, diluted 1:21.3) was dripped at a rate of 6 mL/min near an artificial stone and the pressure was noted once the stone was visualized. Grip strength was measured after 10 min of active pumping of the SAP. Data was analyzed with T‐test or ANOVA.
Results: The UEJI had the lowest comparative intrarenal pressures with an empty working channel of 2.2 mmHg (PB p = < 0.001, SAP p = 0.007, SAP max plunge p < 0.001) within the renal model. The SAP at max plunge generated the highest pressures of 12.5 mmHg (PB, UEJI, SAP pulsed p = 0.007). See table 1. Clearance of “blood” for visualization in the ureteral model when a basket was present was only achieved with the SAP. After 10 min of SAP use to maintain visualization of stone in ureteral model, operator grip strength was significantly decreased from 37.6 to 33.5 kg (p = 0.005).
Conclusions: The UEJI maintained the lowest intrarenal pressures but failed to provide adequate visualization through simulated blood. SAP is associated with relatively higher pressures but allowed for visualization—though decreased grip strength occurred after 10 minutes of use. Balancing safety and efficacy remains a priority with irrigation systems; with the use of a ureteral access sheath intrarenal pressures remained below 20mmHg even with maximal irrigation.
Outcomes of Concurrent Bladder Botox Administration at the Time of HoLEP: A Feasibility Evaluation
MA Assmus, MS Lee, J Helon, AE Krambeck
University of Calgary
Introduction & Objective: Select patients with significant preoperative urgency and/or urge urinary incontinence along with lower urinary tract symptoms due to benign prostatic hyperplasia may require post‐HoLEP anticholinergic, B3 agonist or intravesical botox administration. Consideration of concurrent urinary bladder botox at the time of HoLEP may help reduce postop urgency, urge urinary incontinence, and need for incontinence products or medications. Our primary objectives were to assess whether concurrent bladder botox during HoLEP was safe while improving urgency and urge urinary incontinence.
Methods: We prospectively examined 10 consecutive patients enrolled within our IRB approved clinical registry that underwent HoLEP and urinary bladder botox (200 Units) at our center from July – October, 2021. Patient demographics and perioperative course was examined in the context of urgency, urinary incontinence, incontinence products and complications. Continuous variables were expressed as median (IQR) and mean (range) with heteroscedastic two‐tailed T‐Test and Fishers Exact with significance set at p < 0.05.
Results: We examined 10 patients with median age 72 years (IQR 68‐75), BMI 30 (28‐38), preop PSA 2.3 (1.4‐5.3), prostate volume 102mL (60‐125mL) (4 CT, 4 MRI, 3 DRE), AUASS 24 (23‐27), MISI severity 13 (12‐26) and MISI bother 4 (2‐6). All patients had preop urgency and urinary incontinence with mean number of daily incontinence products 3.1 (range 0‐11) and 5/10 having history of anticholinergic +/‐ B3agonist medication use. Only 2/10 patients had prior BPH surgery (1 TURP, 1 TURP & PVP). There were 7/10 patients discharge on the same day as surgery with 7/7 passing a same day trial of void. The 3 admitted patients all passed first trial of void on postop day 1. Nine patients completed a 1‐week postop phone follow up with 4/9 (44%) continent. 1‐week postop mean incontinence product use improved (3.1 vs 0.75, p = 0.03). Within 3 month follow up only 1/9 patients had ongoing urinary incontinence (1 pending follow up) with improved MISI bother (4 vs. 1, p = 0.002). There was one 90‐day Clavien‐Dindo ≥IIIa: UTI with hematuria and clot retention >1month postop requiring catheter, irrigation, and antibiotic course prior to successful foley removal(IIIa). No patients had urinary retention within 30days of surgery.
Conclusions: In this single center feasibility study, concurrent urinary bladder botox at the time of HoLEP was safe in select patients and improved urgency, UUI and incontinence product usage.
Thermal Injury and Laser Efficiency with Ho:YAG and TFL. An in vitro Study
A Sierra, M Corrales, M Kolvatzis, F Panthier, O Traxer
Hôpital Tenon
Introduction & Objective: To evaluate using an inanimate model the thermal injury and laser efficiency on high frequency, high energy and its combination in hands of junior and experienced urologists during holmium YAG (Ho:YAG) and Thulium fiber laser (TFL) lithotripsy.
Methods: A Cyber: Ho 150 WTM and Fiber Dust TFL (Quanta System) with 200μm core‐diameter laser fibers (LF) were used in a saline in vitro ureteral model. Each participant (5 junior ‐5 experienced urologist) performed 32 sessions of 5 minutes lasering (125 mm3 phantom BegoStonesTM), comparing four modes (3J/5Hz (1.5W), 0.3J/20Hz (6W), 1.2 J/5Hz (6W), and 1.2J/20Hz (24W)). Transparent tip and cleaved LF, and digital and fiberoptic ureteroscopes were also compared. Ureteral damage was classified in a scale (0‐5) according to the burns and holes seen in the ureteral model's surface.
Results: High‐power setting (24W) was associated with higher delivered energy and higher ablation rates in both lasers (p < 0.001). For the same power setting (6W), there were no differences in delivered energy nor stone ablation rates. Regardless the settings, higher ablation rate was observed with TFL than with Ho:YAG ((0.5Δmg/s ± 0.33 vs 0.39 Δmg/s ± 0.31, p:0.002) laser. Higher mean ablation rate was found with cleaved tip vs transparent tip (p:0.03) in TFL. For both lasers, higher ureteral damage was observed in the 24W group (p: 0.006) and in the junior urologists (p: 0.03). Between 6W groups, different type of lesions were found and junior urologist have more lesions when high frequency was used, for both Ho:YAG (p = 0.05) and TFL (p = 0.04).
Conclusions: High‐power settings can have more stone ablation rate and may reduce the operative time; however, more ureteral thermic‐related damage is produced. When comparing the same power, higher energy or frequency does not modify the ablation rate. Nonetheless, more ureteral thermic‐related thermal damage is observed in high frequency settings in unexperienced hands.
Thulium Fiber Laser's Dust for Stone Composition Analysis: Is It Enough?
A Sierra, M Corrales, M Kolvatzis, M Daudon, O Traxer
Hôpital Tenon
Introduction & Objective: We aimed to evaluate if the biochemical composition of urinary stones can be determined by analyzing the stone dust only, and whether a photo taken during the surgery could be useful for completing the morpho‐constitutional analysis.
Methods: 20 patients went through a retrograde intrarenal surgery (RIRS) for renal stone treatment with TFL (Fiber Dust, Quanta, 2020) using 150 μm silica core laser fibers. After laser lithotripsy, residual fragments (RF) were removed with a basket (ZeroTip, Boston Scientific) and spontaneously floating stones particles were considered stone dust and were aspirated through the working channel. Pairs of RF and stone dust were labelled and sent to analysis by scanning electron microscopy and Fourier transform infrared spectroscopy (FTIR). Photos of the stone (surface and section) were taken from videos recorded during the surgery.
Results: A total of 20 patients were included in the study. Mean age was 49,8 years old with metabolic and genetic disorders. Mean stone volume was 750 mm3 for ureteral stones and 2334 mm3 for renal stones. Mean stone density was 1187 HU. Positive urine culture was found in 25% patients. In 2/20 (10%) the biochemistry differed only in the relative proportions of each constituent, whilst 5/20 (25%) only one component was missing. Laser crystalline conversion was found in 3/20 (15%). Whewellite and weddellite layers were found in photos thus adding missing information from dust stone analysis.
Conclusions: Analyzing aspirated dust through the ureteroscope's working channel by physical techniques, we can understand the lithogenic process of the urinary stone, without needing to analyze the stone fragment. Morphological analysis, given by a proper stone picture, adds missing information in specific cases.
The Heat Is On: Moses 2.0 Popcorning in a Novel Benchtop 3D Kidney Model Reaches Thermal Damage Thresholds Rapidly
ZR Dionise, C Tabib, S Tran, F Soto‐Palou, P Zhong, GM Preminger, M Lipkin
Division of Urology, Duke University Medical Center
Introduction & Objective: Heat generation during laser lithotripsy increases with increasing power. With improved Ho:YAG laser technology, surgeons routinely operate with higher frequency, energy, and therefore power, increasing the potential for thermal injury. Though colleagues have examined temperatures during laser lithotripsy, most have used non‐anatomic in vitro models and few have evaluated the extended frequency range of MosesTM 2.0. Our aim was to test, high‐power popcorn laser settings in an anatomically accurate 3D kidney model to determine the time to thermal damage and cool down, as well as the effects irrigation flow rate has on dampening thermal dose.
Methods: A 3D‐printed, anatomically accurate kidney model derived from CT images was submerged in room temperature water. Thermocouples were placed flush with the tip of a single‐use ureteroscope and at the tissue‐fluid interface of the model upper pole calyx 5mm from laser tip. Hard Begostone stone phantom fragments, similar physical properties of calcium oxalate monohydrate stones, were placed within the calyx to represent a popcorning scenario. The laser was fired for 30 seconds at increasing rates of room temperature irrigation (Figure) followed by a maximal flow (200mm Hg) ‘cool down’ period. If temperature increased to 60°C, lasering was terminated and ‘cool down’ initiated. Laser settings included: 0.4J/100Hz, 0.4J/110Hz, 0.5J/90Hz, 0.5 and 0.6J/80Hz using Short Pulse (SP) and Moses Distance (MD). Testing was performed in triplicate. Settings were compared by time to reach threshold thermal dose of tissues injury (t43 70 and 120 min), as well as cooldown to less than 43C, using two‐sample t and ANOVA tests.
Results: Laser settings with higher power reached threshold thermal dose more quickly (Figure; p < 0.01). Increasing flow rate slowed accumulation of tissue thermal dose substantially (p < 0.01). With 0mm and 50mmHg irrigation, threshold thermal dose for tissue injury was achieved rapidly, while at higher rates it was never approached (Figure).
Conclusions: High‐powered lasers reach thermal injury thresholds rapidly on popcorn settings (< 3 seconds), exacerbated with no irrigation. However, even minimal irrigation significantly decreases time to reach these thresholds, which may allow increased laser versus ‘cool down’ time during treatment.
Biodegradable Metals for Ureteral Stents: Understanding the Degradation Profile Under Simulated Urinary Tract Environment
M Pacheco, I Aroso, S Lamaka, M Zheludkevich, J Bohlen, M Nienaber, D Letzig, C Hassila, C Persson, E Lima, A Barros, RL Reis
I3Bs Research Group on Biomaterials, Biodegradables and Biomimetics
Introduction & Objective: A biodegradable metallic ureteral stent (BMUS) is expected to have unique properties, such as a slower degradation rate and improved radial strength (compared to polymeric counterparts), ideal characteristics for prolonged treatments and/or cases of high external compressions. Therefore, a BMUS will be a ground‐breaking step in ureteral stent development1. The aim of this work was to assess the corrosion profile of different biodegradable metals in simulated urinary conditions in detail.
Methods: AZ31, Mg‐1Zn, Mg‐1Y, Mg‐4Ag and pure Mg wires were produced by direct extrusion with 1 mm diameter at 350 ⁰C with 0.2 mm/s speed. WE43 powder was used for additive manufacturing (AM) assays. Through AM, wires of 1 mm diameter were produced using a hatch distance of 0.05 and 0.06 mm (WE43‐0.05_W and WE43‐0.06_W, respectively) as well as tubes with an external diameter of 2.34 mm, an internal diameter of 1.56 mm using hatch distances of 0.04, 0.05 and 0.06 mm (WE43‐0.04_T, WE43‐0.05_T and WE43‐0.06_T, respectively). The produced samples were studied under in vitro dynamic conditions with artificial urine (AU) – ASTM F 1828 – 97 (2006), mimicking the ureteral stent's physiological environment. SEM‐EDS, ICP‐OES, XPS, XRD analysis, and weight loss were performed.
Results: A corrosion layer was formed in all the samples. In Mg4Ag, the corrosion layer was characterized by the presence of various spots of agglomeration of encrustation. AZ31 and Mg1Zn presented a similar pattern but with a lower amount of encrustation, while pure Mg and Mg1Y presented a more homogeneous corrosion layer. The chemical analysis indicated that the elements, P, O, C and Mg were the most abundant, and struvite was detected as well, as indicated by XRD. Mg1Y was the alloy with the most promising results in terms of adequate degradation for a possible biodegradable metal material's candidate as it presented homogeneous corrosion. On the other hand, the other alloys were prone to heavy localized corrosion, leading to an inhomogeneous corrosion profile. The samples produced by AM have also developed a corrosion layer and further analysis and characterization are currently being performed (Fig. 1).
Conclusions: The extruded wires of Mg1Y showed homogeneous corrosion, which is crucial for a biodegradable ureteral stent2. The samples produced by AM require further studies to reach precise conclusions, but this seems to be a promising technique for the development of ureteral stents with innovative designing features. Overall, this study revealed important preliminary results on the performance of biodegradable metals in urinary environment, acting as a key starting point for the development of a BMUS.
MPBS2: Basic Science: Stones II
First 3D Vascular Map of a Rabbit Urethra Visualized by a Photoacoustic Catheter Probe
T Kim, Y Ha, J Yang, T Kim
Donga University
Introduction & Objective: Peripheral vascular networks play an important role of an organ's function, and their vascularity and vascular pattern are known to be very closely related to its aging and pathophysiology. However, current clinical methods for a urinary system examination mostly rely on the visual inspection assisted by cystoscope or the tomographic images provided by ultrasound when advanced by one step further – none of which however provides a micron level vascular map.
Methods: In this study, we acquired the first 3D vascular map of a rabbit urethra by using a recently developed 2.6 mm outer diameter flexible photoacoustic catheter probe, through which a co‐registered 3D ultrasound image also can be acquired.
Results: Although the presented result is from one case, it is our working hypothesis that there could be accompanied micro‐vascular changes in the walls of bladder or urethral sphincter in the presence of aging or degenerative diseases, especially related to aging bladder or urinary incontinence.
Conclusions: As the developed photoacoustic catheter probe can provide an unprecedented high‐resolution vascular map as detailed as 20um. We expect that this imaging new tool could be utilized for the diagnosis of those urological diseases.
Energy Drinks and Their Risk Factors for Nephrolithiasis
AA Nourian, C Nourian, A Higgins, G Gorman, E Ghiraldi, J Friedlander
Einstein Healthcare Network
Introduction & Objective: Energy drinks, which are rich in caffeine, have exploded in popularity in the United States and are being marketed to and consumed by younger age groups. Although the caffeine in these drinks may play a protective role with respect to lithogenesis, energy drinks are composed of chemicals and artificial products which may contain metabolites that affect lithogenesis. The purpose of this study is to analyze the content of energy drinks to assess potential impact on lithogenesis.
Methods: We selected eight of the most common energy drinks (Bang, Celsius, Monster, Rockstar, Red Bull, NOS, Reign, ZOA) using an internet search in February 2022. Sodium, calcium, potassium and caffeine were extracted from the nutrition label. A pH meter was used to determine the pH values. High‐performance liquid chromatography was utilized to determine concentrations of oxalate, uric acid, and citric acid.
Results: The eight analyzed energy drinks had minimal amounts of sodium, calcium, and potassium. The caffeine content per serving ranged from 75.4‐300 mg. Energy drinks were quite acidic, with pH ranging from 2.73‐3.48. Uric acid was minimally existent in energy drinks. Monster and Red Bull contained the highest concentrations of citric acid, 9532 and 9519 ug/mL, levels comparable to orange juice. Many beverages had high oxalate content, with NOS the greatest at 205 ug/mL.
Conclusions: While energy drinks are known to have high concentrations of caffeine, our analysis demonstrates they are acidic, with some having considerable amounts of citric acid and oxalate. The true impact on lithogenesis requires additional studies, however these beverages may play a role in the ever increasing prevalence of nephrolithiasis.
Effect of Oxalate on Primary Human Glomerular Mesangial Cells
S Mukherjee, A Miller
The Cleveland Clinic Foundation
Introduction & Objective: Hyperoxaluria is the excessive urinary excretion of oxalate and is associated with calcium oxalate stone formation, which comprises 80% of all cases of urinary stone disease (USD). The canonical hypothesis for calcium oxalate stone formation is that oxalate causes oxidative stress on tubular epithelial cells, which transforms them into osteoblast‐like cells, leading to Randall's plaque. However, the impact of oxalate on glomerular mesangial cells which plays an important role in glomerular filtration is not known. The objective of the current study was to determine the effect of oxalate on primary human glomerular mesangial cells.
Methods: We used commercially available, well characterized primary human glomerular mesangial cells for studies. These cells were exposed to sodium oxalate diluted in growth media at concentrations ranging from 100uM to 1000uM for 24 hours. Cell viability and size was measured using trypan blue staining using cell countess instrument and reactive Oxygen species (ROS) assay was performed using a commercially available kit.
Results: Our data broadly indicate that oxalate induces oxidative stress by ROS generation on the mesangial cells, decreases cell viability and reduces cell size of both live and dead cells. These changes occurred in a dose dependent manner with increasing oxalate concentration being the most detrimental. Figure1 depicts image of the cells pre and post 24‐hour oxalate, ROS assay and cell viability assay results (* p < 0.05, ** p < 0.01, *** p < 0.001).
Conclusions: Results suggest that the canonical hypothesis in which oxalate‐induced oxidative stress on tubular epithelial cells cause a transition to osteoblast like cells, by itself, is insufficient to explain the initial stages of lithogenesis. Additional studies are required to further triangulate the precise mechanisms of initial lithogenic stages.
Cooperative Oxalate and Formate Metabolism in the Gut Mitigates the Impact of Oxalate Exposure on Epithelial Barrier Function and Reduces Hyperoxaluria
A Miller, S Mukherjee, J Agudelo, A Adler
Cleveland Clinic
Introduction & Objective: Hyperoxaluria is one of the primary risk factors for the development calcium oxalate kidney stones. The canonical hypothesis states that Oxalobacter formigenes, which requires oxalate for growth, is solely responsible for the breakdown of oxalate in the gut and can reduce the risk of stone formation. However, recent clinical and animal studies have challenged this hypothesis in favor of a microbial community‐based hypothesis. The objective of the current study was to determine which bacteria and metabolic functions are minimally required to persistently reduce hyperoxaluria and renal calcium oxalate deposition.
Methods: Using oxalate‐consuming wild rodents, we took a metagenomic approach to determine which bacteria and metabolic functions are altered by oxalate consumption, then quantified what proportion of the microbiota engage in those metabolic functions. To validate that the identified bacteria persistently reduce urinary oxalate and renal calcium oxalate function, bacteria either directly isolated from the wild rodent or commercially available strains matching the taxonomy and metabolism of target bacteria were obtained. Target bacteria were transplanted into a naïve mouse model on a high oxalate diet in different combinations and the impact on oxalate metabolism and renal calcium oxalate deposition was quantified in a longitudinal study.
Results: Comparative metagenomics revealed that in wild rodents, 60% and 41% of bacteria contain at least one gene for oxalate or formate metabolism, respectively. In microbial transplant animal studies, hyperoxaluria and renal calcium oxalate deposition was lowest when oxalate and formate metabolizing bacteria were combined, particularly when additional bacteria were added capable of using the by‐products of formate metabolism (Fig. 1). Comparison of fecal and urinary oxalate suggest that the combined microbial community reduced urinary oxalate by both lowering oxalate levels in the gut while simultaneously improving intestinal epithelial barrier function.
Conclusions: Data show that oxalate and formate metabolism are highly redundant in the gut and are required in tandem to persistently reduce hyperoxaluria and calcium oxalate deposition.
Lithogenic Activities of Key Metabolites on Calcium Oxalate Stone Formation
J Agudelo, R Ramos‐Carpinteyro, S De, A Miller
Cleveland Clinic
Introduction & Objective: Clinical studies have revealed that the urinary metabolome of active stone formers differs significantly from that of healthy individuals. Furthermore, recent research has shown that metabolites highly abundant in the matrix of calcium‐based stones are also significantly enriched in the urine of patients with recurrent USD. In this study, we aimed to investigate the influence of stone‐associated metabolites on calcium oxalate lithogenesis in an in vitro model.
Methods: To determine the influence of urinary metabolites on lithogenesis, metabolites that were both highly prevalent in kidney stones and in the urine of recurrent stone formers were given putative identification based on curated databases. Lab grade chemicals were purchased for the in vitro assays that targeted crystallization, crystal growth, and crystal aggregation. For crystallization and crystal growth assays, calcium and oxalate ions were added to a basic buffer solution and incubated. Metabolites were either added at the beginning of the reaction to assess their influence on crystallization, or 1‐hour later as a second hour step to assess crystal growth. Aggregation was assessed with the use of previously harvested crystals added to the basic buffer, as a 1‐hour reaction in a plate shaker at low speed. Samples were imaged in an inverted microscope and compared to a negative control. Results were quantified and compared with two‐way Anova and post hoc t‐tests.
Results: Analysis of the lithogenic and anti‐lithogenic effects of metabolites are shown in figure 1. We observed a broad relationship between the presence of the metabolites. Results indicate that several of the candidate biomolecules promoted both the precipitation and growth of calcium oxalate crystals. Aggregation metrics were enhanced in potentially pro‐lithogenic metabolites like butanal.
Conclusions: Our findings provide in vitro evidence of the effects of metabolites and underlying mechanism of stone‐associated metabolites derived from clinical studies. Our results support the hypothesis that lithogenic metabolites in the urine promote the formation of calcium‐based stones through increased precipitation, growth and aggregation of crystals. Future studies will determine if metabolites also impact lithogenesis through indirect interactions with host cells.
Nobody Likes Burnt Popcorn: The Most Efficient Popcorning Settings in a Novel 3d‐kidney Model That Limits Thermal Injury
ZR Dionise, C Tabib, S Tran, F Soto‐Palou, P Zhong, GM Preminger, M Lipkin
Division of Urology, Duke University Medical Center
Introduction & Objective: When stone popcorning, the use of higher energy with little to no irrigation is preferred. However, this combination of high power with low flow can lead to increased risk of thermal damage with longer laser firing times. Using predetermined lasering and irrigation ‘cool down’ durations within a novel, anatomically accurate 3D kidney model, our aim was to identify the laser settings that produce the most efficient popcorning without reaching thermal dose (t43) that causes tissue damage.
Methods: Hard Begostone phantoms, mimicking calcium oxalate monohydrate stones, were crushed and sieved to 2‐4mm fragments. Fragments were then separated by size measuring 2‐2.8mm, 2.8‐3.35mm, and 3.35‐4mm and mixed by mass at a ratio of 2:2:1, respectively. Approximately 0.5g of fragments were placed in the upper pole of our anatomical 3D‐printed kidney model. Each triplicate trial consisted of iterative laser/irrigation cooling cycles for two minutes using a MosesTM 120H 2.0 laser (Table). Laser firing and cooling times were determined by measuring t43 with each laser setting, allowing for maximal laser to cooling ratio that would not exceed tissue injury threshold (t43 70 min). After treatment, stones were dried and sieved into <1mm, 1‐2mm, 2‐2.8mm, 2.8‐3.35, and 3.35‐4mm fragments, which were then weighed. Ablation efficiency was calculated as post‐treatment mass <1mm with comparisons by ANOVA and Tukey post‐hoc tests.
Results: Overall, the most efficient setting was 0.5J/90Hz with no irrigation; while the most efficient setting using low irrigation were 0.4J/110Hz and 0.5/J/80Hz SP (Figure). Even with shorter laser times, popcorning was more efficient with no irrigation, especially at high powers (all p < 0.05).
Conclusions: When accounting for thermal dose, 0.5J/90Hz without irrigation provides the most efficient popcorning, despite shorter laser times. When thermal injury is of special concern and the surgeon prefers low flow, 0.4J/110Hz appears most efficient. Last, if extended frequency is unavailable, 0.6J/80Hz without irrigation should be used.
MOSES 2.0 or MasterPULSE? An in Vitro Comparison of Two Novel Laser Systems for Dusting and Fragmenting in a Benchtop Model
H Brar, G Werneburg, J Gutierrez‐Aceves, S Sivalingam
Cleveland Clinic
Introduction & Objective: We sought to compare stone disintegration using two holmium laser systems: Lumenis Pulse 120H “MOSES 2.0” versus the Quanta MasterPULSE 100H.
Methods: Two in‐vitro experimental models were designed to investigate dusting and ablation of Bego
TM stones. Stone dusting was tested in the calyceal model using settings: MOSES 2.0 contact (CM) and distance modes (DM) at 0.3J/70 Hz, 0.5J/50Hz and 0.3J/120 Hz, and MasterPULSE Virtual Basket (VB) and standard modes (SM) at 0.3J/70 Hz and 0.5J/50Hz. The ureteral model assessed fragmentation using MOSES 2.0 CM and DM at 0.8J/8 Hz and 1.2J/10Hz and MasterPULSE VB and Vapor tunnel (VT) at 0.8J/8 Hz and 1.0J/12Hz. Primary outcomes were time to complete dusting and time for retropulsion of stones to 60cm; secondary outcomes were total energy used and residual fragment weight after 4 minutes of fragmentation
Results: No significant difference was noted in dusting across all groups at 0.3J/70Hz. Moses 2.0 at CM and DM dusted the stone quicker at 0.5J/50Hz and 0.3J/120Hz compared to VB and SM. However, there was no difference between the Moses 2.0 at these settings. Moses CM and DM at 0.5J/50Hz expended the least amount of energy dusting the stones. Retropulsion was only noted to be more rapid in DM with compared to VT at 0.8J/8Hz.
Conclusions: In this initial benchtop model we tested two novel variants of holmium laser technology. Both systems were comparable in dusting time, stone retropulsion, and fragmentation at 4 minutes. MOSES 2.0 CM and DM performed best at dusting at 0.5J and 50Hz. Quanta VT demonstrated the least amount of retropulsion at 0.8J and 8Hz. Further clinical studies will help validate these findings.
Relationship Between Renal Pelvis Pressure and Post‐ureteroscopy Infection in a Live Swine Model
DE Hinojosa‐Gonzalez, C Kottooran, J Saunders, M Franco, B Eisner
Introduction & Objective: Urosepsis is reported to occur after 5% of ureteroscopic stone procedures; rates of pyelonephritis are higher. While it is hypothesized that these infections are the result of retrograde flow of infected urine into the kidney and bloodstream during ureteroscopy, the relationship between infection and renal pelvis pressure is poorly understood. In this study, a live swine model was used to evaluate these relationships.
Methods: In anesthetized pigs (n = 13; female; ∼60 kg each), ureteroscopy was performed as follows: cystoscopy was performed to position a 0.014” pressure sensor guidewire (Comet™, Boston Scientific, Marlborough, MA) and standard guidewire. A flexible ureteroscope was then introduced into the renal pelvis and the position of the ureteroscope and the pressure sensor wire were confirmed. Infusion of saline irrigation fluid alone (placebo) or with a standardized concentration of uropathogenic e. coli strain CFT073 (1.5 x 107 CFU/ml) at target renal pelvic pressures (37 mm Hg and 75 mm Hg) was maintained for 60 minutes using a pressure bag and instantaneous feedback from the pressure‐sensing guidewire. Venous blood sampling was performed during the procedure as well as at 1, 3,6, 12, and 24 hours after surgery. Vital signs were monitored, inflammatory biomarkers were assayed, and renal tissue and blood cultures were obtained.
Results: Thirteen (13) pig kidneys were used during the study and study groups were as follows: 37 mm Hg with saline irrigation (n = 3), 75 mm Hg with saline irrigation (n = 3), 37 mm Hg with saline irrigation with 1.5 x 107 CFU/ml e. coli added (n = 3), and 75 mm Hg with saline irrigation with 1.5 x 107 CFU/ml e. coli added (n = 4). Table 1 shows the results of the study: changes in inflammatory biomarkers were most pronounced in the 75 mm Hg saline irrigation + e. coli. All kidneys in both groups treated with saline + e. coli irrigation cultured positive for bacteria but interestingly, bacteremia was seen in 0/4 animals treated at 37 mm Hg with saline + e. coli irrigation and 4/4 animals treated at 75 mm Hg with saline + e. coli irrigation.
Conclusions: In this study of a swine model of ureteroscopy, irrigation with saline + e. coli produced an inflammatory response as well as positive kidney cultures (i.e. pyelonephritis). However, bacteremia was only seen in animals treated at 75 mmHg. These data suggest that there may be a renal pelvis pressure threshold above which it is more likely that animals with infected urine may develop post‐ureteroscopy bacteremia.
Comparison of Ureteral Stent Biomaterial Encrustation Profile in Lithogenic Artificial Urine Models
R Bhatt, Y Wu, KL Morgan, E Choi, A Vu, P Jiang, S Ali, RM Patel, J Landman, RV Clayman
Department of Urology, University of California, Irvine
Introduction & Objective: Encrustation complicates and limits ureteral stent indwell time. To date, no material has shown complete encrustation resistance over long‐term urine exposure. Recently, 2‐hydroxyethyl methacrylate (HEMA)‐coated Pellethane showed promise as a possible encrustation‐resistant biomaterial when studied in a nonlithogenic artificial urine environment (AUE). Accordingly, we evaluated the degree and composition of encrustation on this material in comparison to other stent brands using two lithogenic AUEs; (1) calcium oxalate (CaOx) and (2) struvite (NH4MgPO4) and calcium phosphate (Ca10(PO4)6 ⋅ 2 H2O).
Methods: Five 8 mm pieces of HEMA‐coated Pellethane, Boston Scientific Tria, Bard InLay Optima, Cook Universa Hydrogel, and Cook Black Silicone were suspended in each AUE batch flow model at 37°C. Every 24 hours, 50% of the AUE was replaced using a programmed peristaltic pump system. Stent pieces were removed, air‐dried, and subjected to scanning electron microscopy (SEM) to assess the degree of encrustation at the 2 and 4 week intervals. At the termination of the study (11 weeks), harvested stent pieces were weighed and analyzed to quantify the composition of stent encrustation (i.e., calcium, magnesium, and phosphorus) using inductively coupled plasma mass spectrometry.
Results: In the struvite‐forming AUE, SEM revealed complete encrustation of both the HEMA‐coated Pellethane and Cook Hydrogel after 2 weeks, with partial encrustation of all other stents. All stents were fully encrusted at 4 weeks. In the CaOx‐forming AUE, HEMA‐coated Pellethane and Cook Hydrogel stents were fully encrusted at 2 weeks with partial encrustation of the Boston Scientific and Bard stents; however, the latter two were fully encrusted by 4 weeks. Cook Silicone remained relatively resistant to encrustation, even after 4 weeks. After the 11 week trial, HEMA‐coated Pellethane had the most average mass gain (189.8% CaOx AUE and 66.9% struvite AUE), and Cook Silicone had the least average mass gain (17.2% CaOx AUE and ‐5.3% struvite AUE) (Table 1).
Conclusions: In this study, HEMA‐coated Pellethane was found to be a poor material for ureteral stent construction. Among the various commercial stent materials tested, silicone performed the best.
External Validation of a Nomogram for Outcome Prediction in Management of Medium‐sized (1‐2 Cm) Kidney Stones
M Sighinolfi, T Calcagnile, S Puliatti, S Kaleci, M Ticonosco, M Benedetti, S Assumma, S Di Bari, A Ragusa, A Piro, S Ciarlariello, B Rocco, S Micali
University of Modena and Reggio Emilia, Department of Urology, Modena, Italy
Introduction & Objective: To externally validate a previously developed stone nomogram, able to predict treatment failure of SWL, RIRS and PNL in management of 1‐2 cm single renal stones. The model was developed on 2,605 patients and showed a high predictive accuracy, with an area under ROC curve of 0.793. The purpose of the present study was to assess whether it displayed a satisfactory predictive performance if applied to different populations.
Methods: External validation was performed using data shared by 26 centers about 3,025 surgical procedures performed from December 2010 to June 2021. Collected variables included: age, gender, previous renal surgery, presence of preoperative positive urine culture and hydronephrosis, stone side, stone site, density, skin‐to‐stone distance. The outcome was defined as treatment failure (residual fragments >4 mm at 3 months CT‐scan). To assess the adjusted relation between the variables, a propensity score matching was performed.
Results: Model discrimination in the external validation datasets was good, showing an area under ROC curve was 0.66. Sensitivity was 95% and specificity was 13%. As expected, the prediction model, when tested in new individuals, displayed a poorer performance than the one found in the development study, reflecting the presence of geographical, temporal and domain biases.
Conclusions: Stone nomogram to predict treatment failure after SWL, RIRS and PNL performed well in temporal and external validation. From the present external validation study, the nomogram provides an acceptable discrimination to predict the outcomes of different stone treatments. Further prospective studies are required to corroborate the preliminary findings and to assess the clinical utility of the nomogram.
Urinary Markers of Renal Injury During Narrow Focus versus Wide Focus Shock Wave Lithotripsy in Management of 1‐2cm Renal Calculi Using Tri‐focal Lithotripsy Machine: First Double‐blind Randomized Trial
YA Noureldin, W Abdel Halim, E Elnahif, A Abdelbaky, S El Hamshary
Faculty of Medicine, Benha University, Egypt and King Abdulaziz Medical City, Riyadh, Saudi Arabia
Introduction & Objective: Piezo Lith3000 plus (Richard Wolf, Germany) was recently introduced with unique characteristics that offer tri‐focal lithotripsy. The objectives of this study were to compare the changes in two markers of renal injury, and the outcomes following shock wave lithotripsy (SWL) using a narrow focus of 2mm (F1) versus a wide focus of 8 mm (F3) for renal stones 1‐2cm using Piezo Lith3000 plus (Richard Wolf, Germany) tri‐focal SWL machine.
Methods: This double‐blind randomized study recruited adult patients with solitary radio‐opaque renal pelvic stone 1‐2 cm. Patients were randomized into two groups; F1‐group received narrow focus (2 mm) SWL while F3‐group received wide focus (8mm) SWL. Baseline patient's and stone characteristics were collected. Two urinary renal injury markers; [neutrophil gelatinase‐associated lipocalin (NGAL) and Kidney Injury Molecule‐1 (KIM‐1) were measured with ELISA before, 2‐hours and 72‐ hour after the 1st SWL session. Renal arterial Resistive Index (RI) was measured before and 3‐month after the last SWL. Other outcome parameters such as stone free status (SFS) (%) (< 4mm) and complications were recorded. The primary outcome was the change in NGAL and KIM‐1. Secondary outcomes included overall SFS (%) calculated one month following the 3rd session of SWL and occurrence of complications.
Results: A total of 135 patients were recruited for this study; 67 patients in F1‐group and 68 patients in F3‐group. Preoperative parameters were comparable in terms of age, female gender, BMI, stone size, and HU (p‐values >0.05). Pre‐operative NGAL (101.7 ± 32.5 vs. 104 ± 38 ng/dL; p = 0.7), KIM‐1 (4.3 ± 0.9 vs. 4.5 ± 1.1 ng/dL; p = 0.17), and RI (0.63 ± 0.05 vs. 0.61 ± 0.05; p = 0.08). Following the first SWL session, the rise in 2‐h NGAL was comparable between both groups (109 ± 32 vs. 112 ± 40; p = 0.62). However, the rise in the 2‐hr KIM‐1 was significantly higher in F1‐group (4.9 ± 1 vs. 4.4 ± 1; p = 0.02). Nevertheless, 3‐day markers were significantly improved (56.7 ± 14 vs. 59.7 ± 16; p = 0.263) and (2.1 ± 0.5 vs. 2.1 ± 0.6; p = 0.963), respectively. The 3‐month RI was significantly higher in the F1‐group (0.61 ± 0.1 vs. 0.59 ± 0.1; p = 0.002) but it was still within the normal values (0.5‐0.7). The overall SFS was comparable between the two groups (92.5% vs. 91.2%; p = 0.77). Nevertheless, hematuria (95.5% vs. 83.8%; p = 0.02) and pain (65.7% vs. 19.1%; p < 0.001) were significantly higher in F1‐ compared with F3‐group, respectively.
Conclusions: Both F1 and F3 SWL of Piezo Lith3000 plus were potentially safe in terms of the renal injury and were associated with comparable lithotripsy outcomes. However, F1 was associated with significantly higher morbidity in terms of pain and hematuria
Comparative Proteomic Profiling of Uric Acid, Ammonium Acid Urate, and Calcium‐Based Kidney Stones
B Wallace, J Bjazevic, J Burton, J Chmiel, K Al, H Goldberg, H Razvi
Western University
Introduction & Objective: The pathogenesis of infectious kidney stones is poorly understood. Urinary modulators in calcium oxalate stone disease cannot be considered to have equivalent effect with infectious stones because of the significant differences in urinary environment. The role of bacteria has been associated with urease production, however there is mounting evidence indicating the relationship is more complex than previously suspected. The aim of our study was to characterize suspected biotic and abiotic extrinsic factors which may explain the formation or reduction of infectious stones.
Methods: A high‐throughput experimental model using Griffith's artificial urine was used to test a wide variety of urinary modulators and bacterial strains commonly associated with struvite and calcium phosphate stones to evaluate their potential roles in influencing crystal formation. Crystal formation was evaluated with spectrophotometry and growth curve analysis. Light microscopy, scanning electron microscopy (SEM), and X‐ray diffraction (EDX) were used for crystal structure identification and composition.
Results: Acidic urinary modulators prevented crystal formation. Osteopontin appears to have a strong inhibitory effect. The remaining modulators had a neutral, mixed, or positive effect. P. mirabilis has high urease productivity and produced calcium phosphate and struvite crystals. K. pneumoniae and K. oxytoca had low urease production and produced crystals including calcium phosphate and calcium oxalate, respectively. P. aeruginosa had no urease production and produced calcium phosphate crystals.
Conclusions: Urinary modulators can have a wide variety of effects on infectious stone formation. The role of pH is important but does not guarantee robust crystal formation. The presence of urease may not directly lead to calcium phosphate and struvite stones in all cases. Bacteria may promote the formation of calcium phosphate stones in the absence of urease.
Various urinary modulators appear to influence the process and are worthy of further evaluation as a potential therapeutic strategy to prevent infection‐related urinary stone formation. Stones formed from UTIs may be a result of multiple metabolic pathways and discovering these would truly improve our understanding of the stone‐bacterial relationship.
Randall's Plaques at the Single Cell Resolution
H Yang, H Song, T Chi, M Stoller, F Huang, S Ho
Introduction & Objective: Idiopathic calcium stone disease is strongly associated with the presence of Randall's plaques in the kidney. There are no effective therapies to reduce the formation of Randall's plaques, and the biological mechanisms are poorly understood. The objective of this study was to characterize gene expression within Randall's plaque tissue at the single cell resolution in order to identify the cell types responsible for Randall's plaque formation.
Methods: Randall's plaque and renal papillary tissues were collected from 20 adult patients (12 stone formers, 8 non‐stone formers). Randall's plaques were obtained from endoscopic biopsies while whole renal papilla samples were obtained from fresh nephrectomy specimens. Single nuclear RNA sequencing was performed on each sample using the 10X Genomics platform and Illumina NovaSeq S4. Additional tissue was saved for immunohistologic stains. Analysis was conducted using R Studio and Seurat software. Gene interactions were predicted using CellphoneDB software.
Results: After quality control, 51,204 cells were obtained for analysis. Unsupervised clustering revealed 14 distinct cell types with a high concordance with previous kidney single‐cell data sets. Randall's plaque tissue was found to have a distinct macrophage cluster defined by differential expression of Osteopontin and a distinct vascular endothelial cell cluster defined by differential expression of E‐Selectin. There was a 10‐fold increase in the number of intercellular gene interactions between vascular endothelial cells and macrophages in Randall's plaque tissue compared with non‐Randall's plaque tissue. Immunohistologic staining confirmed the presence of abnormal macrophage clusters associated with Randall's plaques.
Conclusions: Region‐specific single cell analysis illustrates that cell types involved in Randall's plaque formation include macrophages and vascular endothelial cells. Understanding these interactions will bring us one step closer to treating idiopathic calcium stone disease.
Gut Microbiota Derived Uremic Toxins Enhance Calcium Oxalate Stone Formation in Vitro and in Vivo
GA Stuivenberg, J Chmiel, PP Akouris, K Al, J Bjazevic, J Burton
University of Western Ontario
Introduction & Objective: Approximately 1 in 10 people will develop a kidney stone in their lifetime with most stones containing either calcium oxalate (CaOx, ∼80%) or calcium phosphate (∼20%) as the primary constituent. While significant advances to mitigate and treat stones have been made in the clinical setting, the inadequacies in our understanding of the disease etiology are reflected by the increasing prevalence of renal calculi. The mechanisms behind vascular and renal calcification are highly similar; and interestingly, the gut microbiota of stone formers is primed with bacterial species that produce uremic toxins associated with chronic kidney disease and atherosclerosis. The microbiota‐derived uremic toxins indoxyl sulfate, p‐cresyl sulfate, and their precursors enhance the production of reactive oxygen species (ROS) in the kidneys and can lead to increased calcium concentrations in the blood of humans. Thus, we believe that by increasing amounts of circulating calcium and oxidative stress, renal cells damaged by these uremic toxins act as crystal nucleation sites for kidney stone production. We therefore sought to determine if uremic toxins and their precursors enhance CaOx stone formation in both in vitro and in vivo models.
Methods: The direct effect of uremic toxins on CaOx crystallization was assessed using a standard high‐throughput gel‐based assay and artificial urine. Next, a Drosophila melanogaster model of nephrolithiasis was used to determine if the uremic toxins promote CaOx crystallization and renal ROS in vivo. To enhance translatability of these findings, uremic toxin exposure was investigated for the ability to induce oxidative stress and the adherence of CaOx crystals to mammalian kidney cells.
Results: Indoxyl sulfate, p‐cresyl sulfate, and their precursors directly promoted CaOx crystal production in vitro. D. melanogaster exposed to uremic toxins demonstrated a drastically increased stone burden within Malpighian tubules (i.e., fly kidneys). Increased stone burden was associated with greater ROS production in the Malpighian tubules of exposed flies. Our results also indicate uremic toxins alter crystallization in cell culture, but further investigation is required.
Conclusions: This is the first study to investigate the role of uremic toxins in kidney stone disease and it demonstrated that microbiota‐derived uremic toxins directly promote CaOx crystallization. By promoting ROS, uremic toxins may bolster the production of stones even further. Given that chronic kidney disease is a common comorbidity in stone formers, this work will be of interest to clinicians for the development of novel therapeutic and preventative measures against stone disease.
Vitamin C Therapy in Cancer Patients: Identifying Predictors of Stone Formation
M Roshandel, CW Liaw, M Alom, MT Keddis, JC Lieske, K Koo, A Potretzke
Mayo Clinic
Introduction & Objective: Ascorbic acid has been proposed as a therapeutic and complementary therapy in cancer patients. However, vitamin C is a known metabolic precursor of oxalate, potentially increasing the risk of kidney stone disease. We aimed to assess the use of vitamin C in patients with cancer and investigate the possible relationship with lithogenesis.
Methods: Patients with cancer who were taking vitamin C ≥ 200 mg for ≥3 months were retrospectively identified via the electronic medical record. The daily and cumulative dose and duration of therapy were recorded. Patients with stones for the first time, or patients with residual small stones (≤3mm) who were stable for at least one year prior to vitamin C supplementation were considered post‐supplementation stone formers. New kidney stone formation and changes in the previous condition were characterized based on imaging studies before and after initiation of vitamin C therapy. Descriptive statistics were used to analyze stone formation risk, and potential predictors were investigated using simple logistic regression.
Results: A total of 81 patients with a malignancy diagnosis and receiving vitamin C therapy were included in the analysis. Patient demographics and vitamin C therapy details are summarized in Table 1. Median age for total cohort was 64. 42 patients had solid cancers including urologic and non‐urology patients and 29 had hematologic malignancies. Median dose and duration of supplementation were 500 milligrams and 6 years, respectively, with a cumulative dose of 1.4 kilograms. The total duration of vitamin C (regardless of changes in dosage) and cumulative dose were associated with new stone development. Age, gender, and average daily use were not associated with stone development.
Conclusions: In a cohort of cancer patients receiving vitamin C therapy, cumulative dose and duration of therapy were associated with increased new stone formation. The findings suggest that vitamin C supplementation may confer lithogenic risk even at doses lower than previously suggested, and especially at higher doses used for complementary therapy. Patients starting vitamin C therapy should be informed that dose titration and careful stone surveillance may be required.
Reliable Kidney Stone Volumes: Segmentation Protocol Validation
KL Morgan, R Bhatt, A McCormac, C Chantaduly, S Hosseini Sharifi, J Shi, P Jiang, S Ali, P Chang, RM Patel, J Landman, RV Clayman
Department of Urology, University of California, Irvine
Introduction & Objective: Computed tomography (CT) based volumes more accurately describe the 3D nature of kidney stones compared to traditional linear measurements. However, human error in the manual segmentation process may limit their reliability. We evaluated kidney stone volumes of segmentations from individuals with varying levels of training and expertise to evaluate a segmentation protocol aimed towards rapid, consistent, and reproducible kidney stone volume data.
Methods: A radiologist, an endourologist, a research fellow, and two fourth‐year medical students each segmented the same set of intra‐renal stones from CT scans of 98 kidneys using a web‐based software with a paintbrush fixed to a specific Hounsfield Unit (HU) range (120‐10,000 HU). Segmentations were then converted into 3D virtual objects and total stone volume was calculated for each kidney. Agreement between the group's volumes was assessed with an intra‐class correlation coefficient (ICC). Averaging volumes between the attending radiologist and endourologist as the standard, the fellow and medical students were evaluated using Bland‐Altman plots to visualize volume agreement (Figure 1). Dice score, a measure of virtual object 3D overlap, was used to compare segmentations for possible pairing of individuals (Table 1).
Results: The ICC for volumes from all five participants was 0.994. Average Dice scores for every possible pairing of individuals were greater than or equal to 0.89 (Table 1). Bland‐Altman plots comparing the fellow and medical students to the averages from the radiologist and endourologist showed strong consistency and agreeance (Figure 1).
Conclusions: Segmentations and kidney stone volumes for all five participants showed strong agreeance (ICC = 0.998 and mean Dice scores > 0.89). The use of web‐based software with fixed segmentation parameters yielded low variability between individuals and can be reliably used by multiple individuals of varying training levels for kidney stone volume calculation.
Relative Medullary Thickness and Urine Osmolality in Kidney Stone Formers
J Rose, M Iorga, S Wiener
SUNY Upstate Medical University
Introduction & Objective: Prevalence of kidney stones has increased from 3.2% in 1980 to 10.1% in 2016 with up to 50% of individuals experiencing a recurrent stone if left untreated. Urine osmolality is one risk factor that has previously been correlated with stone development. Maximum concentrating ability of an individual is dictated primarily by the renal medulla. The metric of relative medullary thickness has previously been correlated with urine concentration across hundreds of mammalian species. The objective of this study is to review the relationship between relative medullary thickness and urine osmolality in a population of stone formers.
Methods: Retrospective cohort study of kidney stone formers who underwent metabolic analysis of 24‐hour urine collection at SUNY Upstate Medical University between 2013‐2020. Relative medullary thickness was calculated as: RMT = 10 x medullary thickness ÷ ∛(renal length x breadth x width). 24‐hour urine osmolality was calculated as: Uosm = (2 x sodium (mmol) + potassium (mmol) +35.7 x urea nitrogen (g)) / urine volume (L). Ultrasounds within 1 year of 24‐hour urine collection were assessed.
Results: Across ninety‐three stone formers, mean relative medullary thickness was 1.38 (SD = 0.29) and mean urine osmolality was 591.2mOsm/kg (SD = 175.8). Relative medullary thickness had a weak, negative correlation with 24‐hour urine osmolality (r = ‐0.316, p = 0.002), urine sodium (r = ‐0.264, p = 0.011), urine chloride (r = ‐0.272, p = 0.008), and urine urea nitrogen (r = ‐0.221, p = 0.034).
Conclusions: Results of this study demonstrate a larger relative medullary thickness of the kidney is associated with decreased urine osmolality and increased retention of sodium, chloride, and urea nitrogen. The negative correlation found here between relative medullary thickness and urine osmolality is in contrast to the positive correlation seen previously across hundreds of mammalian species. Therefore, increased solute retention coupled with reduced urine concentration in this population of stone formers may be a function of renal papillae in poor health.
Raise Your Glass! American Chestnut Leaves Can Reduce Tea Oxalate Content
W Donelan, B Lemack, T Quesada, D Mathews, S Khan, V Bird, W Powell, BK Canales, P Dominguez‐Gutierrez
University of Florida
Introduction & Objective: Throughout the 19th century, American chestnut tree (ACT) leaf teas were commercially available and widely used to treat coughs and colds. However, in the early 20th century, the ACT became functionally extinct due to a fungus called “chestnut blight.” As part of the initiative to restore ACT in the US, a blight‐tolerant ACT was developed with enhanced production of oxalate oxidase (OxOx), an enzyme capable of degrading soluble oxalate. Since many stone formers avoid tea due to its high oxalate content and potential to raise stone risk, we investigated the addition of enhanced ACT leaves to commercially available teas to reduce oxalate content.
Methods: A total of 3 teas were brewed per manufacturer's recommendations using calcium/magnesium free phosphate buffered saline (PBS). To assess oxalate reduction, 250mg of tea with 250mg of ACT leaves were steeped in 25ml of boiling PBS for 5 min. As a reference, total oxalate was determined from 0.5g of each tea using the acid extraction method. Oxalate was measured using the Trinity Biotech Oxalate Assay.
Results: The tea contained 3.3 to 6.3 mg of soluble oxalate per serving (Table 1). When ACT leaves were steeped with the tea, soluble oxalate was reduced by 65% to 84%.
Conclusions: Our results indicate that OxOx enhanced ACT dried leaves have the potential to reduce oxalate content found in several commercially available tea products. American Chestnut leaves alone, or in combination with other tea leaves, may be an alternative tea‐product for stone formers who wish to enjoy the health benefits of tea without the potential kidney stone side effects.
The Rich History of the American Chestnut: From the Brink of Extinction to a Novel Kidney Stone Therapy
P Dominguez‐Gutierrez, T Quesada, B Lemack, D Mathews, S Khan, V Bird, BK Canales, W Powell, W Donelan
University of Florida
Introduction & Objective: The American chestnut tree (ACT) was once considered one of the most important forest trees throughout its range in North America. The tea from its leaves was even used as a popular home remedy and was commercially available in the 1800s. Unfortunately, nearly 100 years ago, a fungal disease, chestnut blight, decimated the ACT to the point of near‐extinction. The fungus, Cryphonectria parasitica, secretes oxalate to kill and accelerate tissue decay in its host. Interestingly, most kidney stones are composed of calcium oxalate; the same byproduct that the fungus uses to kill ACT tissue. As the initiative to restore ACT unfolds through the deployment of blight‐tolerant trees with enhanced oxalate oxidase (OxOx) production, there are important ramifications for stone disease. OxOx is the same enzyme that is currently used for FDA approved clinical assays to measure urinary oxalate to assess kidney stone risk.
Methods: ACT leaves, from Dr. Powell's laboratory, were processed with a masticating juicer to extract OxOx. The OxOx was ammonium sulfate precipitated followed by dialysis. OxOx enzymatic kinetics were tested using our laboratory developed oxalate oxidase assay. Oxalate degradation assays were performed at 37°C with Trinity Biotech OxOx and PBS used as positive and negative controls, respectively.
Results: We demonstrate that the OxOx enzyme from ACT leaves has a specific activity of 10U/100g tissue, which is ten times the amount found in germinating barley roots‐ the industry standard. ACT extract degraded 20% of oxalate in spinach within 30 min at 37°C, pH4 which is similar to that found in human stomach conditions.
Conclusions: Our results indicate that OxOx extracted from the ACT has the potential of reducing oxalate burden and may be beneficial to stone formers. As an abundant source of OxOx on a per tissue‐mass basis, the potential of ACT OxOx to lower healthcare costs by reducing the cost of manufacturing diagnostics and therapeutics should also be explored.
The Role of Urinary Modulators in the Development of Infectious Kidney Stones
J Khusid, A Vasquez, AS Sadiq, J Stockert, B Gallante, AJ Yaghoubian, R Shimonov, A Stock, WM Atallah, N Kyprianou, W Yang, M Gupta
Introduction & Objective: Kidney stone matrix proteins may help explain cellular mechanisms of stone genesis. However, most existing proteomic studies have focused on calcium oxalate stones. Here, we present a comparative proteomic analysis of different kidney stone types.
Methods: Proteins were extracted from the stones of patients undergoing percutaneous nephrolithotomy (PCNL). Approximately 20 μg of protein was digested into tryptic peptides using filter aided sample preparation, followed by liquid chromatography tandem‐mass‐spectrometry. A standard false discovery rate cutoff of 1% was used for protein identification. Stone analysis was used to organize stone samples into groups. We selected the top 5% of proteins based on total ion intensities and used DAVID and Ingenuity Pathway Analysis to identify and compare significantly enriched gene ontologies and pathways between groups.
Results: Six specimens were included and organized into the following groups: mixed uric acid (UA) and calcium, pure UA, pure ammonium acid urate (AAU), and pure calcium. We identified 2,426 unique proteins (1,310‐1,699 per sample) (Table 1). Between 11‐16 significantly enriched KEGG pathways per group were identified (Table 2) and compared via heatmap (Figure 1). Based on number of unique proteins identified, this is the deepest proteomic study of kidney stones to date and the first such study of an AAU stone.
Conclusions: The results indicate that mixed UA and calcium‐based kidney stones are more similar to pure UA stones than pure calcium‐based stones. AAU stones appear more similar to pure calcium‐based stones than UA containing stones and may be related to parasitic infections. Further research with larger cohorts and histopathologic correlation is warranted.
Arbutin: A Novel Preventative Agent for Oxalate‐based Kidney Stone Disease
T Dayarathna, A Roma, M Tcheng, N Ahmed, P Spagnuolo, L Nott, J Bjazevic, H Razvi
Western University, London, Ontario, Canada
Introduction & Objective: Currently available pharmacological interventions for calcium oxalate (CaOx) stone prevention produce mixed health outcomes in patients. Novel agents with anti‐lithogenic potential are required to improve outcomes for more than 30 million Americans suffering from kidney stones.
Methods: Arbutin, (4‐hydroxyphenyl‐β‐D‐glucopyranoside), a glycosylated phenol has previously been shown to inhibit CaOx nephrolithiasis in in vitro models. In this study, the safety and efficacy of arbutin in a rat model of CaOx kidney stone disease as well the safety of a specially formulated arbutin‐containing product (called: Kidnease) in a Phase I human study was tested.
Results: Kidney stones were induced in Wistar rats by addition of Hydroxy‐L‐proline (HLP; 5% (wt/wt)) to rat diets which resulted in quantifiable CaOx stones after 2 weeks of feeding. A treatment group (arbutin given 6 weeks after HLP exposure; n = 16), a prevention group (arbutin given concurrent to HLP diet exposure; n = 16), and a positive control group (no arbutin given while on HLP diet) were compared to a control group (n = 16, rats not given arbutin and maintained on a normal diet). In all models, experiments were terminated at 14 weeks.
Oral supplementation of arbutin at doses up to 125 mg/kg body weight three times per week did not change gross morphological (body, kidney or liver weights) or serological markers of safety and was well‐tolerated in rats. In both treatment and prevention group rats, arbutin decreased both the size and overall volume of stones (as quantified via micro‐CT scans of kidneys collected at endpoint), and reduced renal tissue damage (as measured by microscopy, immunohistochemistry and urine markers) at endpoint (stone volume arbutin vs. positive control: Treatment model: Male rats: p < 0.0001; Female rats: p < 0.05; Prevention: Male rats: p < 0.0001; Female rats: p < 0.001). A Phase I human clinical trial was then conducted comparing Kidnease to placebo. There were no significant treatment‐related side effects observed.
Conclusions: Arbutin is a novel therapeutic that demonstrates CaOx crystal inhibition in vitro, and has be shown to be safe in humans. Further human efficacy trials are warranted.
Public Interest in Vitamin C Therapy and Associated Risk of Nephrolithiasis During the COVID‐19 Pandemic
CW Liaw, J Alamiri, G Ungerer, A Potretzke, K Koo
Hartford HealthCare, Hartford, CT
Introduction & Objective: High‐dose vitamin C therapy is commonly believed to treat or protect against viral illnesses, such as seasonal influenza. However, not only is there a lack of supporting evidence for this practice, but high‐dose vitamin C can also carry clinical risks. This includes its metabolic conversion to oxalate and resultant hyperoxaluria, which increases the risk of oxalate‐based kidney stones. During the COVID‐19 pandemic, there has been new interest in vitamin C therapy. This study aims to characterize public interest in vitamin C therapy and its association with nephrolithiasis.
Methods: The Google Trends platform was queried to assess worldwide searches for vitamin C, influenza, and COVID‐19 using multiple related keywords. We analyzed search traffic from 2011 to 2021 for influenza and from 12/2019 to 9/2021 for COVID‐19. To assess sources and accuracy of information about vitamin C therapy, we performed Google searches of “vitamin C COVID” and analyzed top results by support for the therapy and discussion of potential risks.
Results: Online searches for vitamin C and influenza show a yearly chronicity with seasonal fluctuations (Fig. 1A). Online search traffic for vitamin C therapy paralleled interest in COVID (Fig. 1B). Subsequent peaks in COVID searches during the summer 2020, winter 2021, and summer 2021 surges were all associated with increased interest in vitamin C therapy. Among the top results for COVID‐related vitamin C queries, most (90%) were medical websites or scientific publications. About a third of results stated without support that vitamin C may have potential benefit in treating COVID. No sources discussed the increased risk of kidney stones due to vitamin C therapy; only 1 source noted “potential adverse effects” but did not specify risks. Consistent with the lack of public information about stone risk, there were no apparent associations in search patterns between vitamin C or COVID and kidney stones (Fig. 1C).
Conclusions: Online interest in vitamin C therapy reflects surges in COVID‐19 incidence. Despite the known association between high‐dose vitamin C and oxalate stones, no online sources discussing this therapy for COVID cited this risk. Continued public interest in COVID therapies may have unexpected epidemiological consequences including increased risk of kidney stones.
Local Decrease in Fatty Acid Binding Protein 4 in the Kidney Is Responsible for Urolithiasis
R Unno, K Taguchi, H Yang, G Hosier, F Hamouche, D Bayne, M Stoller, T Chi
University of California, San Francisco, Department of Urology
Introduction & Objective: We previously reported that fatty acid binding protein (FABP) 4, a regulator of lipid metabolism, was associated with Randall's plaques formation in the kidney using a transcriptomics approach in patients with urolithiasis. FABP4 is expressed most abundantly in adipocytes but has also been detected in macrophages and a subset of endothelial cells. Improved understanding of FABP4 expression could help identify a novel treatment target and biomarker for urolithiasis. The aim of this study was to characterize the protein expression of FABP4 in the kidney, adipose, serum, and macrophages of patients with and without urolithiasis.
Methods: Under IRB approval, we collected samples of kidney papilla, perinephric and subcutaneous fat, and blood (serum and peripheral blood mononuclear cells (PBMCs)) from stone formers undergoing PCNL or nephrectomy (n = 5), and non‐stone formers undergoing nephrectomy due to nonfunctional kidney from urinary stricture (n = 5). We extracted proteins from each specimen and performed ELISA then compared the levels of FABP4 in each specimen.
Results: In both groups, there were no significant differences in FABP4 expression for adipose, serum, and PBMCs tissue samples. FABP4 expression in the kidney was significant lower in the stone former group (Figure 1).
Conclusions: Consistent with our previous findings, the FABP4 expression in the kidney from stone formers was decreased compared to non‐stone former. This was a tissue‐specific phenomenon and FABP expression in other tissue types did not differ, suggesting that localized and not systemic changes in Fatty acid binding protein 4 in the kidney is associated with urolithiasis formation. These data support the argument that FABP4 may represent both a novel biomarker and potential therapeutic target for urinary stone management.
Temporal Relationship Between Dietary Oxalate Load and Fluid Intake on Spot Urine Oxalate Testing: Missing the Trees for the Forest?
W Donelan, J Joseph, B Lemack, P Dominguez‐Gutierrez, V Bird, RS Terry, BK Canales
University of Florida
Introduction & Objective: 24‐hour urinary oxalate testing is a key component of comprehensive metabolic evaluation, yet it cannot measure transient spikes in oxalate concentration such as following an oxalate‐rich meal. These spikes may confer an increased risk of stone formation and represent targets for lifestyle modification to offset this risk. To further characterize the presence of oxalate spikes, we sought to assess the (1) temporal pattern of spot urine oxalate excretion following dietary oxalate load, and (2) impact of increasing fluid intake on spot urine oxalate concentrations after high‐oxalate load (HOL).
Methods: With IRB approval, healthy non‐stone formers (6 M, 1 F) were prospectively enrolled to maintain a low oxalate diet and collect voids over a 48 hr period. At noon on both days, subjects were asked to consume a HOL (10 oz spinach, 820 mg oxalate) and to collect voids every 2 hr for the 8 hr post‐HOL interval. On Day 2, subjects increased water intake (12 oz/2 hr) for the 8 hr post‐HOL interval. Oxalate levels were evaluated using the Trinity Biotech Assay. Hyperoxaluric voids (HOVs) were those with estimated excretion rate >1.67 mg/hr ( > 40 mg/day).
Results: Mean urinary oxalate concentrations for Day 1 and Day 2 were 0.19 ± 0.11 mM and 0.15 ± 0.06 mM respectively, within normal physiologic range. Following HOL on Day 1, mean peak oxalate excretion rate was 3.10 ± 2.43 mg/hr with significant temporal variability noted between subjects (Fig. 1). The 8 hr post‐HOL interval on Day 1 accounted for 46.7% of the respective 24 hr oxalate excretion. On Day 1, 71.4% (n = 5) had ≥1 HOV following HOL, among whom 80% of HOVs were within the 8 hr post‐HOL interval. With increased post‐HOL water consumption on Day 2, there was a trend towards attenuation of change in oxalate concentration post‐HOL with respect to pre‐HOL baseline (Fig. 2).
Conclusions: Significant spikes in urinary oxalate excretion occur following HOL, which may be attenuated by increasing water intake. These findings suggest a role for temporally‐sensitive monitoring of urinary oxalate levels.
Moderated Poster Session
MP1: Education and Simulation
Evaluation of Augmented Reality Technology in Global Urologic Surgery
G Dominique, K Kunitsky, G Natchagande, KA McCammon, G Watson, KB Scotland
Charles R. Drew University/David Geffen School of Medicine at UCLA
Introduction & Objective: Surgical missions are still largely on pause due to COVID‐19, leading to missed opportunities for skill sharing between high‐income and middle to low‐income countries. New commercially available augmented reality (AR) technology facilitates surgical training, allowing mentors in one country to virtually train and skill‐share with a mentee in another country during surgical cases in real‐time. We hypothesize that AR technology is an effective live surgical training and mentorship modality.
Methods: To evaluate perceived effectiveness of AR technology in global urologic surgery training, surgeon mentors in the USA and UK worked with mentees in Benin performing surgical cases using the Proximie AR system. Proximie includes audiovisual capabilities allowing a mentor in any location to provide a mentee with real‐time guidance during the procedure. Following each case, mentor and mentee individually completed a questionnaire assessing the technology.
Results: Trainers reported AR technology as easy to set‐up and use in 73.3% of cases while the trainee reported easy set‐up and use in 100% of cases. The visual quality was acceptable to trainers in 60% of cases and “looks like I'm there” in 40%. Visual input/ability to draw on screen had high impact in 80% of cases, with trainers rating the ability to provide anatomical guidance as invaluable or significant in 93.4% of cases. Audio and anatomical guidance had a significant impact for the trainee in 100% of cases. The quality of virtual training v. in‐person training was equivalent in 100% of cases for the trainee while trainers found virtual training inferior in 66.7% of cases and equivalent in only 6.7% of cases. Difficulty connecting occurred often in only 1% of cases for trainers but in 12.5% of cases for the trainee. Trainers reported delay or time lag while using the technology in 40% of cases, with lag being problematic in 12.5% of cases. In contrast, the trainee reported rarely experiencing delay or time lag while using the technology in 100% of cases.
Conclusions: AR technology is useful in facilitating real‐time surgical mentorship during the COVID‐19 pandemic. The Proximie technology provides visualization that is acceptable and audiovisual capabilities that have significant positive impact on successful case completion. Though AR technology presents its own set of challenges such as difficulty in connecting virtually between trainer and trainee as well as delay or time lag during surgical cases, AR technology may prove a welcome alternative when in‐person training is unavailable or limited.
Design and Validation of a Non‐biological 3D Printed Pelvocalyceal System (RIRS Box) for Simulation‐Based Training of Flexible Ureteroscopy
RH Kalbit, ES Lorenzo, EL Reyes
Jose R. Reyes Memorial Medical Center
Introduction & Objective: Training models were incorporated into simulation‐based training to allow novice trainees to gain comfort and overcome the steep learning curve associated with the procedure without potentially compromising patient outcomes and minimizing complications.
We design a low‐cost non‐biological model for flexible ureteroscopy training to help improve residents in their surgical performance and may help ease the learning curve of novice endoscopists. Our study aims to evaluate the face and content validity of our RIRS box for simulation based training for flexible ureterorensocopy.
Methods: RIRS box is composed of four anatomically correct (4) different siliconized pelvocalyceal system. The pelvocalyceal system model was made using a three dimensional (3D) printer based on computed tomography (CT) urogram reconstructions of actual patients. CT images were imported and opened in a PACS‐DICOM viewer (Figure 1A). The files were exported and opened in 3D slicer (http://www.slicer.org) and exported as Standard Triangulation Language (STL) files (Figure 1B). STL files were exported and printed using a 3D printer (Anycubic Mega) using Poly Lactic Acid (PLA) filament. A variety of collecting systems was obtained from CT urograms (Figure 1C).
Urology consultants and residents performed flexible ureteroscopy on the 3D printed model using AnQing EU‐Scope (Shanghai AnQing Medical Instrument Co. Ltd) for three to five minutes. (Figure 2A, 2B) Each participant performed a diagnostic flexible ureteroscopy (fURS) with systematic intrarenal inspection of a calyceal system on the model. (Figure 2C) After completion, participants were invited to a structured questionnaire, with demographic information as well as participant experience of the realism, acceptability, and feasibility of the model. We measured face and content validities to assess the model's utility for fURS training.
Results: We surveyed a total of 32 urologists, with 12 (37.5%) consultants and 20 (62.5%) residents. (Table 1) They were predominantly male (84.38%), and right‐handed (93.75%). Majority of those surveyed (53.13%) has limited exposure and training in Endourology. Large number of the participants, > 40% of them, had seen the innovation to be promising in terms of availability for training, interest in utilizing it for bench stimulator, and it potential to improve the endoscopist's technique in performing the RIRS after training sessions using this simulator tool. (Table 2 and 3)
Conclusions: The RIRS Box showed a satisfactory face and content validity. Further study about construct, concurrent, predictive validity and its usefulness in a simulation‐based curriculum is highly suggested.
A Prospective, Randomized, Multi‐centre Trial on the Efficiency and Effectiveness of Proficiency Based Progression Robotic Surgical Skills Training
M Amato, S Puliatti, A Paludo, G rosiello, R DeGroote, A Mari, L Langhendries, R Farinha, l Bianchi, P Piazza, E Mazzone, F Migliorini, S Forte, B Rocco, S Micali, B Van Cleynenbreugel, P Kiely, A Mottrie, A Gallagher, M Lassel
Introduction & Objective: We report the use of full Proficiency Based Progression (PBP) methodology to train robotic surgical skills in comparison to other conventional training approaches. We evaluated:1) if all trainees reached the proficiency benchmark, 2) the number of training trials and time required.
Methods: 47 participants randomized to 4 different groups i) Full PBP group that received eLearning on the ORSI chicken anastomosis with the requirement to reach the proficiency benchmark before starting practical training. ii) eLearning group, received the exact same information as Full PBP group, but they were not required to reach the eLearning benchmark. iii) Traditional group received the same content in face‐to‐face lectures, before the practical module. iv) The Apprenticeship group received conventional preparation (Figure 1). The task evaluated was the Robotic suturing and knot tying anastomosis in a chicken model.
Results: All of the participants, except five in group 4, demonstrated the proficiency benchmark (Figure 2A‐C). Group 1 took ∼6 trials or ? 3 hours; Group 2 required 14% longer, Group 3, 103% (p < 0.01) and Group 4, 162% (p < 0.01) longer to reach proficiency (Figure 3A‐C).
Conclusions: The efficiency and effectiveness observed with a full application of a PBP approach to skills training could have profound implications for how training is conducted in the future.
Radical Cystectomy Video Consensus: A Simple and Effective Way to Improve Awareness of Patients Undergoing Radical Cystectomy
F Esperto, F Prata, A Civitella, P Tuzzolo, V Crimi, F Tedesco, A Ragusa, A Minore, L Cacciatore, A Testa, N Deanesi, R Scarpa, R Papalia
Department of Urology, Campus Bio‐Medico University of Rome
Introduction & Objective: In the age of information technology, new platforms are consulted by patients (pts) to acquire their own consciousness about medical treatments. The European Association of Urology Patient Information (EAU PI) delivers, with the support of EAU guidelines, high quality video‐content about surgical procedures with a language easy to understand for patients. The aim of this study was to assess the level of understanding and feasibility of video consensus administration in pts scheduled for radical cystectomy (RC) comparing it with standard written informed consensus.
Methods: The EAU PI video content about RC was translated in Italian and implemented with possible complication explanation at the end of it. After Ethical Committee approval, from January 2021 to September 2021 all pts who underwent RC for bladder cancer (BC) at our institution were prospectively included in this study. A print‐based traditional consensus was administered to all pts and, after that, a video information about RC showing potential complications. After paper‐based consensus and video consensus, pts received a preformed Likert 10 scale questionnaire to evaluate: 1)comprehension; 2)contents; 3)satisfaction; 4)simplicity; 5)details; with a score from 1 to 10.
Results: 30 pts were included in our study and 50 questionnaires were evaluated. 17% (5) of pts were female and 83% (25) were male, 66.6 % (20) were aged 50–70 years, 33.4 % (10) over 70 years. Mean score ± standard deviation (SD) for different domains analysed was the following: mean comprehension score ± (SD) was 6.5 ± (0.58) in standard consensus group versus 8.2 ± (0.725) in the video consensus group, p* = 0.0001. Mean contents score ± (SD) was 6.4 ± (0.4) in standard consensus group versus 8.4 ± (0.82) in the video consensus group, p* = 0.0001. Mean satisfaction score ± (SD) was 6.4 ± (0.65) in standard consensus group versus 8.5 ± (0.8) in the video consensus group, p* = 0.0001. Mean simplicity score ± (SD) was 6.1 ± (0.45) in standard consensus group versus 8.4 ± (0.65) in the video consensus group, p* = 0.0001. Mean details score ± (SD) was 6.25 ± (0.3) in standard consensus group versus 8.8 ± (0.9) in the video consensus group, p* = 0.0001
*U Mann‐Whitney test for independent samples
Conclusions: All the domains analysed showed a higher statistically significant appreciation for video consent compared to traditional informed consent. Overall satisfaction, with a mean score of 8.4 out of 10, showed to our advice the way to chase for the future. Video consent represents a simple and comprehensive tool for pts and can improve their awareness and satisfaction.
Endourology Fellowship: More Than a Stone's Throw Away for Women
M Srinath, L Beland, T Aro
The Smith Institute for Urology, Northwell Health, 450 Lakeville Rd New Hyde Park, New York.
Introduction & Objective: To trend and compare advancement in female representation in the endourology fellowship and urology residency match cycles over the last six years.
Methods: Available de‐identified match data from 2017 to 2022 was obtained from American Urological Association (AUA) and Endourology Society annual census. We evaluated gender‐specific participation in the urology residency and endourology fellowship match and compared differences in the trends over the last 6 years.
Results: Between the years 2017 to 2021 there was a total of 313 applicants for a fellowship in endourology, of those only 8.6% were women. In that same time period, a significantly larger number of women (27.1%) participated in the urology residency match (p = 0.0002). When specifically examining the endourology applicant trend, there is no significant increase in participation (R = 0.7, p = 0.35) between 2017 and 2021, as compared to the significant increase in total number of applicants (R = 7.1, p = 0.04). However, in the urology match, there has been a constant and significant increase in both female (R = 13.7, p = 0.03) and total applicants (R = 27, p = 0.04) between 2017 and 2022.
Conclusions: While there has been an overall increase in the number of applicants to urology, the number of women in endourology fellowship has not increased at a commensurate rate. In light of these findings, it is the responsibility of the endourology community to identify social and systemic barriers for women in this field and advocate for change.
Biases in Residency Match Interviews: 3‐year Comparison and How Urology Stacks Up
S Mohaghegh P, K Puttmann, H Mohammed, E Garza, N Payne, S Goldenthal, V Wong, K Kopechek, A Khuhro, F Begun, T Posid
The Ohio State University
Introduction & Objective: Despite the development of the National Resident Matching Program code of conduct, “illegal or coercive” interview questions were still being asked of applicants in recent years. This study sought to examine the prevalence of those topics comparatively in the last three interview cycles, particularly given the switch to a virtual platform during COVID‐19 social distancing restrictions, and whether this impacted applicants' ranking of that program or how that program would rank them.
Methods: Residency applicants were contacted at the completion of the last three interview seasons (prior to receiving their Match results) to complete a survey. Respondents (2019‐2020: N = 136, n = 79 Urology; 2020‐2021: N = 92, n = 55 Urology; 2021‐2022: N = 117, n = 79 Urology) were asked about demographics, applications, and about the prevalence of inappropriate topics they either volunteered themselves or were asked by interviewers directly.
Results: Applicants reported that sensitive topics were discussed in their interviews >50% of the time. Although fewer questions were explicitly asked from 2019‐2020 (44.4%) to 2020‐2021 (38.4%) to 2021‐2022 (31.0%), Urology applicants received significantly more ‘illegal’ questions compared to non‐Urology applicants across all three cycles (p < 0.01). Even when not asked explicit ‘illegal’ questions, many applicants volunteered that information themselves, although this remained steady and slightly above 50% across all three cycles. Applicants were typically asked about race/background and marital status/children, with women more likely to be asked than men (p < 0.01). This did not impact how applicants rated the program but felt that this would impact how programs ranked them (p = 0.002). Illegal questions were overwhelmingly asked by Senior Faculty (p < 0.001).
Conclusions: “Illegal and coercive” questions were still asked of applicants in the last three interview cycles and these questions impacted how applicants felt the program would rank them. Work is still needed to promote equity and diversity, as well as applicant comfort, during the Match process.
Use of Porcine Animal Labs Promotes Comfort and Confidence with Advanced Procedures in Urologic Training: 3 Year Review
C Kleinguetl, T Posid, D Szabo, A Khuro, J Sciuva, G Box
Ohio State University Wexner Medical Center
Introduction & Objective: Use of animal models can help teach and hone critical surgical skills in a controlled environment outside of the operating room. In this three‐year review of a robotic surgical skills curriculum, we evaluated the effectiveness of a porcine model as an adjunct‐learning tool to improve surgical skills, knowledge and confidence in select urologic procedures.
Methods: Across three timepoints (2019, 2021, 2022), 34 residents (Junior, PGY1‐3: n = 19, Senior, PGY4‐5: n = 15) participated in a single porcine lab. Procedures included left partial nephrectomy, right sided nephrectomy and pyeloplasty, vesicourethral anastomosis, and emergent conversion from laparoscopic to open procedures. Participants filled out a post‐curriculum evaluation survey measuring improvements in perceived procedural skills and knowledge, plus effectiveness of the curriculum.
Results: Across all timepoints, residents reported significant increases in skill and knowledge (Figure 1; 24% average gains for Junior residents and 20% average gains for Senior residents; ps <0.001). Procedural improvements were similar for junior and senior residents for partial nephrectomy and vesicourethral anastomosis (p > 0.05), although Senior residents began the curriculum with higher rates of knowledge and skill. Residents reported that the curriculum improved their robotic surgery skills, was beneficial to their education, that they would recommend it to a peer, that it better prepared them to be in the operating room, that it better prepared them for upcoming national exam/s, that it was beneficial to their ability to work with a team, was intellectually challenging, that it improved their leadership skills, and that it improved their problem‐solving skills (ps <0.001).
Conclusions: Use of porcine animal models to teach urologic procedures may improve surgical skills and confidence in the operating room across resident levels for more advanced procedures and for emergency conversion to open surgery.
Assessing Wellness and Wellness Initiatives Across Medical Schools and Residency Programs: A Pre‐ vs. Post‐Pandemic Comparison
C Kleinguetl, D Diab, A Scimeca, A Khuro, A Bsatee, A Ndumele, M McCormick, O Alshami, T Posid
Ohio State University Wexner Medical Center
Introduction & Objective: Burnout continues to increase in the healthcare field, particularly amongst our trainees, yet there is no ‘gold standard’ for preventing burnout or promoting wellness. Given reports on the impact of the COVID‐19 pandemic on mental health combined with increased calls by institutional leadership to prevent burnout amongst healthcare workers, our objective was to assess wellness initiatives and burnout levels amongst trainees at the start and two years into the pandemic.
Methods: This was a prospective survey distributed to medical students and residents at two timepoints: (1) Peak onset of the COVID‐10 pandemic (April‐May 2020, N = 121) and two years later following vaccine availability and reductions in social distancing precautions (March 2022, N = 77). Trainees provided demographic information and described wellness or burnout prevention initiatives currently available to them. They also took two standardized assessments (Maslach Burnout Inventory, Perceived Stress Scale).
Results: Satisfaction with burnout mitigation education appears in Figure 1. Trainees were only slightly satisfied with their current ability to reduce wellness and mitigate burnout, as well as with the education or training currently provided to them (ps <0.05). Over the two‐year pandemic, trainees reported that the amount of wellness education provided by their program formally had increased (p < 0.01) but remained very low (p < 0.001). Trainees also reported less ability to fulfil work requirements without compromising their own health and wellness (p < 0.001). Although levels of burnout (MBI) and stress (PSS) did not differ across training level (p > 0.1), scores on the MBI were significantly related to perceived need for additional wellness education and training (ps <0.05).
Conclusions: Even following calls from leadership to increase burnout mitigation for healthcare workers, trainees are still not satisfied with the amount of education and training related to burnout mitigation and think more is needed to succeed in their current and post‐graduation careers, with those experiencing higher burnout reporting this more strongly. These results suggest the need for formalized wellness and burnout mitigation education.
Is Twitter an Effective Platform for the Promotion of Endourology Academic Manuscripts?
A Chen, JM Torres, K Adler, J Aronov, D Schulsinger
Introduction & Objective: Twitter is a social media platform that can be used to disseminate academic information in the form of "tweets." It is estimated that Twitter utilization is 34.1% amongst Urologists. The adoption of Twitter appears widespread, but it is still unclear how viable this platform is in promoting new academic ideas. Our objective was to investigate the correlation between social media attention on Twitter and the academic impact of all manuscripts published in the Journal of Endourology in the year 2019.
Methods: All manuscripts in the 2019 Journal of Endourology were included. Editorials and video abstracts were excluded. The Altmetric social media analysis software was utilized to index all social media activity on Twitter and all papers which have utilized the manuscript as a reference. Variables of interest include gender and institution of the first author, and number of tweets garnered by the manuscript. The outcome measure was the number of citations utilizing the manuscript in question. Continuous variables were correlated with linear regression and ANOVA where appropriate and categorical variables with Chi‐Square statistics.
Results: 237 total manuscripts, with 107 first authors from an international institution, were obtained. 195 authors were male and 4 were of an unknown gender. The average number of tweets per manuscript was 1.9, average number of users tweeting per manuscript was 1.7, and average number of manuscript citations was 8.7.
For every 10 tweets, the author can expect to garner 2.8 citations (F(1,235) = 116,R2 = 0.33; #Citations = 0.28(#Tweets)‐0.48,p <0.001). Papers that were tweeted have almost 3 times higher likelihood of being cited compared to papers that were not (OR = 2.9 95%CI[1.6,5.5],p <0.001).
Promotion on alternate websites, such as Physician's Weekly, increased the likelihood of being cited by 12.9 times (95%CI[1.7,97.4],p = 0.002). Male and female authors were just as likely to have their articles tweeted (OR = 1.0 95%CI[0.50,2.14],p = 0.938). International articles were less likely to be tweeted when compared to domestic articles (OR = 0.44 95%CI[0.26,0.76],p = 0.003).
Conclusions: Twitter appears to be an effective tool for the promotion of academic manuscripts. Future studies should be dedicated towards identifying the most productive way to utilize this platform for the dissemination of new ideas.
A Quality Assessment of Information Available on Renal Cancer on YouTube
J Saad, R Shanmugasundaram, D Ashrafi, D Gilbourd
Canberra Hospital
Introduction & Objective: Many people are turning to alternative means outside of the conventional doctor‐patient relationship such as web‐based search engines and video forums for their healthcare information. We undertook this study to investigate the quality of videos and information on renal cancer available on the streaming platform YouTube.
Methods: We completed a search of YouTube (www.youtube.com) in September, 2021 with the term “kidney cancer”. The first 120 videos found which met the inclusion criteria were selected. We recorded information including length of video, number of views, likes, dislikes, comments, publisher and author. The modified DISCERN tool and Global Quality Score (GQS) questionnaire provide a reliable method to assess the quality of the included videos. The amount of misinformation was assessed with a Likert 5‐point scale. Descriptive statistics were used to analyse the collected data. A 2 sample t‐test was used to further analyse the quality assessment tool results pre and post 2016.
Results: Most of the videos were published after 2016 (63.3%), they were predominantly created in North America (77.5%) and presented by healthcare professionals (60%). The median length of the videos was 4.23 (1.01 – 65.55) minutes and had 3087 views (514 ‐ 228,152). The median number of likes and dislikes was 24 and 5, respectively. The median modified DISCERN score was 3, the median GQS score was 3 and the grading for overall level of misinformation was moderate.
Conclusions: The quality of information accessed from YouTube on kidney cancer is of a low to moderate overall standard. The information available has been greatly influenced by the commercial impact on the videos being produced.
Tools for Teaching Intimate Examinations to Medical Students: A Systematic Review
A Vijayanathan, J Traboulssi, D Bruce, C Yiu, A Aydin, J Makanjuola, A Sahai
King's College London
Introduction & Objective: Genital and rectal examinations are challenging intimate examinations for medical students to learn. This is often related to a lack of content in the curriculum, poor training or difficulty in gaining access to practice these skills in a comfortable environment for both student and patient. The aim of this study is to identify studies that utilised different educational tools for teaching intimate examinations and assess their efficacy in terms of student competence and confidence.
Methods: PubMed, Embase and Cochrane Library were searched for English language published articles which evaluated teaching tools for rectal, gynaecological and testicular examinations to medical students. Risk of bias was assessed according to Cochrane Risk of Bias Tool and ROBINS‐I. The GRADE tool was used to determine a level of effectiveness for each teaching modality.
Results: In total, 5619 articles were screened and 26 were ultimately eligible for inclusion in the study, enrolling 2456 students. All (n = 21) of the studies looking at the use of teaching associates saw an increase in student competence and 93% (n = 14) saw an increase in student confidence. One study assessed the effect of real patients on student competence and one study on confidence. There was an increase in student competence and confidence respectively. When comparisons were made between teaching associates and models, 80% (n = 4) showed a significant superiority in favour of teaching associates regarding student competence and 100% (n = 3) regarding student confidence. Two studies (67%) comparing teaching associates with real patients saw a significant increase in student competence. One study (33%) comparing teaching associates with real patients saw a significant increase in student confidence; the remaining studies showed no significant difference. One study (50%) comparing models with lectures saw a significant increase in student competence. The other showed the reverse; a significant increase in student competence in favour of lecture‐based teaching. With regards to student competence when comparing model and lecture‐based teaching, 100% (n = 1) saw no significant difference.
Conclusions: Intimate genital examination education should be adopted into the medical school curriculum. Several educational tools have been developed. Whilst in the studies eligible for inclusion, it appears that the use of teaching associates is the most effective teaching method for genital examinations, further trials directly comparing teaching methods need to be conducted.
Training and Implementation of Handheld Ultrasound Technology at Georgetown Public Hospital Corporation: A Low‐cost Intervention to Improve Diagnostic Evaluation in a Resource‐limited Urology Clinic
M Bui, A Fernandez, B Ramsukh, O Noel, C Prashad, D Bayne
Introduction & Objective: Lack of diagnostic imaging availability constitutes a major barrier to providing quality care in low and middle‐income countries. Georgetown Public Hospital Corporation (GPHC) in Guyana is a prime example, where urinary retention is assessed with catheterization rather than point‐of‐care ultrasound (POCUS). The objectives of our study were to start and sustain a virtual POCUS training program at GPHC and study its efficacy and quality.
Methods: This was a prospective cohort study enrolling 20 medical students in a POCUS training program at GPHC, taught by providers from the hospital and from the University of California, San Francisco (UCSF). In the training phase, students learned ultrasound basics through provided educational materials, attended a Zoom interactive lecture, and practiced using the Butterfly iQ ultrasound system in structured sessions with peers. They were evaluated using a written exam and OSCE and gave feedback on the program via a satisfaction survey. In the clinical phase, they practiced using the Butterfly iQ on GPHC patients, received feedback from UCSF urologists, and completed a follow up written exam. In the end, 14 students completed this initial training phase, from didactics to patient imaging.
Results: The written exam average in the training phase was 2.95/5 compared to 3.5/5 in the clinical phase. Students performed better on knowing when to use bladder POCUS volume measurement vs catheterization (25% pre‐test vs 53% post‐test), identifying the correct probe for transabdominal scans (90% vs 100%), and recognizing grades of hydronephrosis (40% vs 93%). They performed worse on differentiating tissues on POCUS (95% vs 60%) and similarly on differentiating peritoneal fluid and urine (45%). All students earned 100% on the OSCE, which tested their ability to set up for a scan, identify pelvic anatomy, and explain findings. The satisfaction survey average was 3.9/5 on a Likert scale (1 = not satisfied at all, 5 = very satisfied), with suggestions for more emphasis on renal pathologies and opportunities for practice. In the clinical phase, 32 POCUS studies were conducted by the students in aggregate.
Conclusions: Preliminary results suggest that our virtual POCUS training program was effective in teaching clinical skills and satisfactory to participants. Overall, this pilot study demonstrates the potential of virtual, longitudinal global health teaching programs in POCUS.
Understandability, Actionability, and Readability of Online Information for Patients with Kidney Stone Disease
A Sudhakar, R Hsi
Maine Medical Center Urology
Introduction & Objective: Patients often seek online resources to learn about and make informed decisions regarding kidney stone disease. We examined the top websites from the Google search engine using terms related to kidney stone symptoms, surgery, and prevention to assess their understandability, actionability, and readability.
Methods: From a Google search of terms relating to kidney stones ‐ “kidney stones”, “kidney stone prevention”, “kidney stone surgery”, and “kidney stone symptoms”, we extracted the first 25 websites for each term and excluded duplicates, those with non‐English language, and academic publications. Websites were categorized as provider‐based if linked to institutions or providers that could offer kidney stone care, whereas all other websites were considered non‐provider based. We evaluated understandability and actionability of each site using the Patient Education Materials Assessment Tool (PEMAT). We assessed readability using the Flesch Reading Ease (FRE), Flesch‐Kincaid Grade (FKG), and Dale‐Chall Readability (DCR) formulas. Comparisons between the two groups were made with the T‐test with p < 0.05 considered significant.
Results: Of 87 websites meeting criteria, there were 52 websites (60%) that were provider‐based and 35 (40%) that were non‐provider based (see Table 1). Information from providers had a higher mean understandability score than non‐providers (80.6 vs. 68.1; p < 0.001), while there were no significant differences between the groups in measures of actionability. Provider‐based websites required a higher reading level than non‐providers according to FRE (53.9 vs. 61.9, p = 0.004), FKG (10.5 vs. 8.9, p = 0.006), and DCR (8.4 vs. 7.8, p = 0.01) estimates. Provider‐based websites were less likely to cite references (16% vs 57%, p = 0.02) and be updated within the last 2 years (14% vs 71%, p = 0.01).
Conclusions: Provider‐based websites for kidney stone disease have greater understandability than non‐provider‐based websites, but they require higher literacy levels. Ensuring online information is assessable to patients may better inform decision‐making and improve adherence to preventive care.
Development of an Automated Composite Ureteroscopic Efficiency Score Through Simulated Ureteroscopic Skills Assessment
DA Wollin, M Valovska, N Chen, J Yang, D Yu
Brigham and Women's Hospital
Introduction & Objective: Flexible ureteroscopy (fURS) is the most common surgical procedure for treatment of urolithiasis. We previously utilized kinematic evaluations of simulated fURS to determine that certain body movements are associated with efficient ureteroscopic manipulation for complex tasks. Herein, we incorporated computer vision techniques to create an efficiency score which accounts for ureteroscope tip travel distance (DIST), task time (TIME), spectral arc length (SPARC, a measure of path smoothness), and percentage of purposeful or efficient wall collisions (COLL). The goal is a simulation‐based system that, using artificial intelligence, can abstract automated performance metrics (APMs) to reliably differentiate between novice and expert ureteroscopic handling.
Methods: A ureteroscopic simulation box was used to perform ureteroscopic tasks. Body kinematics, task time, and ureteroscopic movements were analyzed using a motion capture system and video camera. Optical flow computer vision was used to track the ureteroscope tip. Data were processed and variables ‐ including DIST, TIME, and SPARC ‐ were automatically calculated. Wall collisions were automatically captured and independently judged by two authors (MTV, DAW) as beneficial or not; an algorithm was then developed to utilize computer vision to automatically categorize these collisions and determine the COLL variable. A mixed effects model was then used to aggregate the above variables and distinguish between surgeons' first and final attempts at each task. The normalized values of these metrics were added to create a Composite Ureteroscopy Efficiency Score (CUES).
Results: 12 urologists completed the simulated ureteroscopic tasks. Using average values, TIME, DIST, SPARC, and COLL were all correlated, with the TIME:DIST correlation strongest (r = 0.84, p < 0.05). Each metric improved on average from the initial tasks to their final repetitions, suggesting an increase in efficiency. The algorithm for COLL assessment was able to determine beneficial wall collisions with an accuracy of 76.6%. Furthermore, the CUES was also able to differentiate between first and final repetitions with AUC of 0.80.
Conclusions: Our research suggests that APMs, including task time, scope movement distance, movement smoothness, and use of wall collisions (and passive deflection) can be abstracted using computer vision and artificial intelligence; preliminary results suggest that a composite efficiency. score (CUES) based on these APMs may be useful for evaluation of ureteroscopic efficiency.
A Flipped Classroom Model to Enhance Simulation Education for Percutaneous Renal Surgery
K Koo, CW Liaw, E Bearrick, B Findlay, G Ungerer, C Granberg, B Viers, A Potretzke
Mayo Clinic
Introduction & Objective: The pedagogical limitations of didactic lectures are magnified when teaching technical skills. A “flipped classroom” (FC) model allows learners to review prerecorded material at their own pace and replaces in‐person lectures with active teacher‐learner engagement. FC has been shown to improve knowledge retention, but its impact on skill acquisition is unknown. This pilot study assesses the feasibility and learner perception of a FC model for surgical simulation.
Methods: Residents participated in a percutaneous nephrolithotomy (PCNL) simulation curriculum. Prior to the sim lab, residents reviewed a video lecture and articles detailing technical aspects of perc access. During the in‐person lab, lecture time was instead devoted to answering questions and problem‐solving, followed by four sim activities for perc access. Pre/post‐lab surveys were collected regarding prior PCNL experience, confidence in PCNL skills (rating scale from 1, unable to perform, to 5, can perform independently), and scores on a validated Flipped Classroom Perception Instrument (agreement scale 1–5). Repeated measures analysis was performed.
Results: Residents (N = 13) ranged from PGY‐1 to PGY‐5 and had completed 0–4 months of PCNL rotations. Mean resident‐reported confidence in ability to perform perc access significantly increased across all measures (all p < 0.01): performing new access overall, new access with fluoroscopy or ultrasound, and using existing access (Figure). There was no significant difference in the magnitude of the positive effect on confidence ratings based on prior PCNL experience, suggesting that FC benefits both novice and advanced residents. FC was highly rated by learners before and after the lab without significant change; mean scores on the perception instrument ranged 4.0–4.5 before and 4.2–4.7 after. Finally, each lab component was rated as highly effective based on mean scores (overall, 4.7; pre‐lab materials, 4.3; in‐person discussion, 4.4; sim activities, 4.8). There was no difference in effectiveness based on prior PCNL experience.
Conclusions: A flipped classroom model for surgical simulation of PCNL was feasible and rated as highly effective for teaching technical skills. The model significantly improved residents' skill confidence regardless of prior surgical experience.
Trans‐urethral Resection of the Bladder Video Consensus: A Simple and Effective Way to Improve Awareness of Patients
F Esperto, F Tedesco, F Prata, A Civitella, P Tuzzolo, V Crimi, A Ragusa, L Cacciatore, A Testa, A Minore, N Deanesi, R Scarpa, R Papalia
Introduction & Objective: In the age of information technology, new platforms are consulted by patients (pts) to acquire their own consciousness about medical treatments. The European Association of Urology Patient Information (EAU PI) delivers, with the support of EAU guidelines, high quality video‐content about surgical procedures with a language easy to understand for patients. The aim of this study was to assess the level of understanding and feasibility of video consensus administration in pts scheduled for trans‐urethral resection of the bladder (TURB) comparing it with standard written informed consensus.
Methods: The EAU PI video content about TURB was translated in Italian and implemented with possible complication explanation at the end of it. After Ethical Committee approval, from January 2021 to September 2021 all pts who underwent TURB for bladder cancer (BC) at our institution were prospectively included in this study. A print‐based traditional consensus was administered to all pts and, after that, a video information about TURB showing potential complications. After paper‐based consensus and video consensus, pts received a preformed Likert 10 scale questionnaire to evaluate: 1)comprehension; 2)contents; 3)satisfaction; 4)simplicity; 5)details; with a score from 1 to 10.
Results: 90 pts were included in our study and 90 questionnaires were evaluated. 30% (27) of pts were female and 70% (63) were male, 45% (40) were aged 50–69 years, 55% (50) 70–80 years. Mean score ± standard deviation (SD) for different domains analysed was the following: mean comprehension score ± (SD) was 6.5 ± (0.8) in standard consensus group versus 8.6 ± (0.77) in the video consensus group, p* = 0.0001. Mean contents score ± (SD) was 6.4 ± (0.6) in standard consensus group versus 8.4 ± (0.69) in the video consensus group, p* = 0.0001. Mean satisfaction score ± (SD) was 6.38 ± (0.49) in standard consensus group versus 9 ± (0.7) in the video consensus group, p* = 0.0001. Mean simplicity score ± (SD) was 6.3 ± (0.4) in standard consensus group versus 8.4 ± (0.75) in the video consensus group, p* = 0.0001. Mean details score ± (SD) was 6.15 ± (0.55) in standard consensus group versus 8.8 ± (0.65) in the video consensus group, p* = 0.0001
*U Mann‐Whitney test for independent samples
Conclusions: All the domains analysed showed a higher statistically significant appreciation for video consent compared to traditional informed consent. Overall satisfaction, with a mean score of 9 out of 10, showed to our advice the way to chase for the future. Video consent represents a simple and comprehensive tool for pts and can improve their awareness and satisfaction.
Comparison of the Learning Curve for Percutaneous Renal Access Between Supine and Prone Position in a Cadaveric Training Model
BO Manzo, J Robles, L Garcia, J Zapata, J Lozano, A montelongo, E Elizondo, S Guzman, A Quiroga, A Gutierrez
Hospital Regional de Alta Especialidad del Bajío
Introduction & Objective: Training models reduce the learning curve assessed by operation time, fluoroscopy time, puncture attempts, and complications. However, animal and non‐biological models have the drawback of presenting significant anatomical differences compared to the human body. Furthermore, no studies have evaluated the learning curve comparing supine and prone positions. Therefore, this study compares the learning curve for percutaneous renal access in supine versus prone positions in cadaveric training models.
Methods: Seven embalmed cadavers were used. Ureteral open‐end catheters were placed, and retrograde pyelography was performed to confirm the image of the collecting system by fluoroscopy. Two residents performed the percutaneous punctures using a bi‐planar technique guided by fluoroscopy. The return of fluid confirmed access through the needle and the placement of a hydrophilic guidewire into the collecting system. Residents were taught to puncture in both positions. Punctures were randomly assigned in supine and prone positions. The primary outcomes were the number of punctures attempts and fluoroscopy screening until renal access was achieved. Punctures were grouped in 1st‐5th, 6th‐10th, and ≥11th punctures to analyze the learning curve. A secondary analysis was performed comparing residents vs. experts.
Results: Eleven kidneys were punctured, with 12.5 ± 7.6 punctures per kidney and 6.27 ± 4.44 per calyx. The mean puncture attempts per renal access were 1.6 ± 0.77 in prone vs. 2.57 ± 1.12 in supine (p < 0.001). The mean fluoroscopy time was 48.6 ± 29.4s vs. 80.31 ± 37.9s (p < 0.001), respectively. A significant decrease in puncture attempts and fluoroscopy time was observed in the prone position after the 6th‐10th punctures (p < 0.001). A significant decrease in puncture attempts and fluoroscopy time was achieved in the supine position after ≥11th. Compared with the expert, similar outcomes were achieved after 6th‐10th punctures in the prone position (p = 0.355 for puncture attempts and p = 0.08 for fluoroscopy time). In the supine position, significant differences in puncture attempts (p = 0.03) and fluoroscopy time (p = 0.001) were still observed after ≥11th punctures compared with the expert.
Conclusions: The cadaveric training model is another option for renal access in percutaneous surgery. However, the learning curve for percutaneous renal access in the prone position might be shorter than in the supine position. Therefore, additional studies would show if this improvement in a cadaveric model will represent a difference with an actual patient.
Development of a Novel High‐Fidelity Laparoscopic Simulation Platform
A Rabley, J Speich, D Traina, D Burke, D Hananel, RM Sweet
University of Washington
Introduction & Objective: Current hands‐on laparoscopic simulation platforms are limited in their ability to replicate pneumoperitoneum. Given this, we sought to develop a high‐fidelity laparoscopic simulation platform that could replicate pneumoperitoneum within a cavity and serve as a trainer for various laparoscopic skills including access with a Veress needle and trocar placement.
Methods: A cognitive task analysis was completed to determine the design requirements. Next a three‐dimensional (3D) computer drawing of the model was created from a male anatomy dataset. The solid components of the trainer were then 3D printed via fused deposition modeling. Molds for the soft components, including a textured organ slab and a multi‐layered abdominal wall, were printed and cast with silicone. All parts were then assembled (Image 1) and proof‐of‐concept testing was then completed.
Results: On Veress needle puncture and insufflation, the model was successful in creating and maintaining pneumoperitoneum within a cavity. A saline drop test was successful. The opening pressure was low at 6mmHg. The cavity was filled to a maximum pressure of 12mmHg and 6.3L of CO2 insufflation. Graph 1 displays the insufflation pressure‐volume curve for the initial trial. These findings are consistent with human abdominal cavity insufflation parameters at the studied pressures. Fail states were accurately represented by the simulator. The abdominal wall recreated the two pops classically heard with Veress needle use. Trocars were able to be placed through the abdominal wall and into the cavity while maintaining pneumoperitoneum. No leaks were identified on initial testing.
Conclusions: The preliminary data suggests that this novel laparoscopic simulation platform holds pneumoperitoneum and shows similar pressure characteristics to those seen in the human abdominal cavity during insufflation. The trainer shows potential to simulate multiple laparoscopic skills. Further testing is needed to determine the fidelity of the trainer and its educational benefit to clinicians.
Advances in Artificial Intelligence Can Expand the Pool of Renal Donors by Facilitating Laparoscopic or Robotic Donor Nephrectomy Through the Creation of Virtual 3D Anatomical Kidney Models in Patients with Complex Renal Anatomy
J Kuo, R Munver, E Tong, M Degen, R Munver
Hackensack University Medical Center
Introduction & Objective: Potential kidney donors with complex renal anatomy may not be considered suitable candidates for donor nephrectomy due to surgical complexity for donor and recipient surgeons. A novel artificial intelligence (AI) software can create virtual segmented three‐dimensional (3D) anatomical kidney models for preoperative planning and intraoperative navigation to facilitate laparoscopic or robotic donor nephrectomy in this setting. This technology delivers a virtual 3D model of kidney anatomy that is created from CT scan imaging with thin (≤ 3 mm) slice width. Images are delivered to an iOS device and can also be displayed from the iOS device to the robotic surgical console via a hardwire connection.
Methods: Since June 2020, a total of 73 potential living renal donors underwent preoperative computed tomography angiography (CTA) as part of the routine evaluation. In addition, segmented 3D modeling was performed for all patients based on the CTA images, highlighting the renal anatomy, arterial and venous vasculature, collecting system, and ureteral course. The CTA and 3D models were reviewed by the living donor and recipient teams for those patients with complex renal anatomy to further assess the candidacy of the renal donors.
Results: Six of the 73 patients (8.2%) were not considered to be suitable candidates for renal donation based on CTA or magnetic resonance imaging findings of renal abnormalities, including 3 renal arteries bilaterally (n = 1), 3 right renal arteries and 2 left renal arteries with a circumaortic left renal vein (n = 1), right renal artery/vein anatomy (n = 3), and a right 3 cm perirenal mass of unclear origin in the area of the renal hilum (n = 1). Following review of the 3D anatomical reconstructed images, all patients were cleared to undergo donor nephrectomy based on the additional information that was provided from these images. In the patient with the perihilar mass, the 3D imaging delineated the mass as arising from the renal parenchyma. This patient underwent robotic donor nephrectomy with ex‐vivo excision of the mass (pathology: lipid‐poor renal angiomyolipoma), with successful subsequent renal transplantation. The other 5 patients underwent uneventful left laparoscopic donor nephrectomy without complications in the renal donors or recipients.
Conclusions: AI virtual 3D anatomical modeling offers preoperative interpretation of renal anatomy, provides confidence in the setting of complex vasculature, and facilitates planned procedural completion. This technology allows surgeons to perform donor nephrectomy in patients that may otherwise be excluded from renal donation, thus expanding the pool of potential renal donors.
Could Finger Assignment at the Robotic Console Hands Control Play a Role in Surgical Accuracy or Any Possible Adverse Outcomes? A Prospective Blinded Simulation Pilot Study
Z Connelly, M Moss, E Tong, KN Morgan, N Khater
LSU Health Shreveport
Introduction & Objective: Robotic surgery has become a standard approach in urology. Greater range of motion and efficiency may be attributed to the EndoWrist instruments that provide 7 degrees of freedom and an angle up to 90 degrees. This allows surgeons to gain precision and have fewer surgical complications. To our knowledge, no prior studies support one way to handle the controls at the surgical console. In our experience, volunteers report discomfort during wrist manipulation while using the thumb and middle finger (1&3). We hypothesize that using the thumb and index finger (1&2) will allow superior surgical proficiency via the da Vinci Skills Simulator.
Methods: After IRB approval, we recruited 42 medical students across all 4 years in one university‐based medical center. Each volunteer was given a standardized orientation. Students were then randomly assigned to start with their thumb and index finger (1&2) or (1&3). Two standardized modules were used with metrics calculated upon completion. These include: score, total time, economy of motion, efficiency score, collisions, inaccurate puncture, wound approximation, out of view, and penalty subtotal. Statistical analysis of the metrics was calculated using SPSS.
Results: Three were found to have statistically significant differences between the finger placement of 1&3 compared to 1&2 (Figure 1). The number of collisions, wound approximation, and penalty score were all significant where 1&3 had a lower score in each. The number of collisions was 5.6 less in the 1&3 finger placement (p = 0.017). The wound approximation was 0.2 points smaller when using the 1&3 placement (p = 0.001). Lastly, the penalty assigned was 6.42 points lower when using 1&3 (p = 0.023). The overall score (p = 0.615), total time (p = 0.385), out of view (p = 0.462), and economy of motion (p = 0.184) were not significant from one another.
Conclusions: Although finger placement did not affect the overall score of the completed simulation, instrument collisions and unnecessary wound
complications may lead to adverse outcomes. This may be due to decreased comfort in hand position resulting in a more cautious surgical approach. Better understanding of how finger placement can lead to decreased ergonomics and increased complications may shape robotic training.
Kidney Cancer in Social Media: A Natural Language Processing Analysis of the Online Perspective
C Dominy, K Okhawere, K Badani, I Saini
Icahn School of Medicine at Mount Sinai
Introduction & Objective: Social media has grown into a powerful driver of social interaction, network building, and information sharing, but it is not a monolith. Different platforms can be utilized for different reasons. The purpose of this study is not only to assess how kidney cancer is portrayed on social media, but also to analyze how it is represented differently on varying platforms using natural language processing (NLP).
Methods: Public Twitter and Instagram data were collected using Application Programming Interface (API) packages and the search hashtag #KidneyCancer from 2020 to 2021. A random subset of 500 Tweets and 500 Instagram posts were selected from those that satisfied inclusion criteria. These posts underwent analysis by a natural language processing algorithm.
Results: 2069 Tweets and 2508 Instagram posts in total were collected. 500 of each underwent natural language processing analysis. In terms of content, natural language processing word and phrase frequency analysis revealed that the most tweeted about content revolved around kidney cancer treatments (17.2%), new research articles (19.8%), and support for and within the kidney cancer community (10%). 22.2% of posts were about specific physicians involved in kidney cancer care, treatment, or research. In terms of tone, 42.0% of Tweets analyzed using NLP were positive in tone, 9.2% were negative, and 48.8% were neutral. Instagram content centered around kidney cancer education and awareness (60.0%), community (28.2%), and transplantation and organ donation (36.0%). In terms of tone, 40.0% of Instagram posts were positive, 16.6% were negative, and 43.4% were neutral.
Conclusions: Our study revealed differences in how kidney cancer is portrayed across platforms. On Twitter, sharing research appeared to be a major use of the platform. Organizations, physicians, and hospitals seem to use Twitter to share progress and updates about the newest research in kidney cancer. Other popular content on Twitter included kidney cancer treatment and the patient experience, which could indicate a potential outlet for physicians to more directly connect with their patients outside of the clinic. As opposed to Twitter, Instagram posts were more centered around education and awareness and kidney donation. This shows two major uses of Instagram for this topic: spreading educational content about kidney cancer and people posting personal stories related to theirs or a loved one's kidney donation. Thus, Instagram should be noted as a potential space for kidney cancer awareness campaigns.
Development and Application of a Novel Skills Assessment Tool to Evaluate Resident Competency During Ureteroscopy
C Kleinguetl, S Mohaghem Poor, S Ray, MW Sourial, BE Knudsen, A Khuhro, T Posid
Ohio State University Wexner Medical Center
Introduction & Objective: There has been a continuing push towards competency‐based training during residency that has led to development of various tools for skills assessment, particularly for robotic surgery. There is a still a need for standardized and time‐efficient methods for more accurate evaluation of non‐robotic procedures, particularly in endourology. We evaluate the use of a mobile phone application to provide real‐time assessment of resident surgical skill and progression during ureteroscopy.
Methods: A procedure‐based application was created to evaluate critical steps during ureteroscopy. Cases were subdivided by distal/semi‐rigid and proximal/flexible ureteroscopy and we present pilot data from X residents for proximal/flexible ureteroscopy cases. Residents were evaluated across 15 steps (Figure 1) via Yes/No completion score or via Likert‐scale (1–novice to 5–expert). Case complexity was also rated on a scale of 1‐3 (simple to complex).
Results: Two residents (“A:” PGY2, “B:” PGY4) performed 15 cases for this pilot use of the evaluation tool. Figure 1 compares their average proficiency across steps of this procedures. The PGY4 resident demonstrated higher competency than the PGY2 resident, with both demonstrating greater proficiency at earlier/simpler steps of the procedure. This tool can also be used to compare (a) a single resident to their cohort (e.g. Resident A to all PGY2s), (b) competence across case complexity (Figure 2), (c) or (c) progression of competency over time (Figure 3). Average duration to enter feedback was 130.9 seconds (just over 2 minutes).
Conclusions: The Qualtrics‐based mobile phone application is an easily created and accessible tool that allows for reliable evaluation and progression tracking of real‐time resident performance during ureteroscopy both prospectively and longitudinally.
Robotic Console Position Effects Surgeon Muscle Activation
HD Kominsky, JC Dai, R Gillum, BA Johnson, J Gahan
UT Southwestern Medical Center
Introduction & Objective: The musculoskeletal strain from surgery is a major risk to surgeon health. Robotic surgery proposes to improve surgical ergonomics, however console mispositioning can lead to surgeon fatigue and muscle strain. Robotic console ergonomic adjustment is often overlooked, especially with trainees. To that end, objective evaluation of musculoskeletal strain during robotic urologic surgery has not previously been described. We seek to design a quantitative assessment of muscle activation and strain in different muscle groups as a function of robotic console positioning.
Methods: Three right‐handed surgeons (1 resident, 2 fellows) each performed a ring‐walk activity on the Da Vinci robotic simulator. The activity was performed with the console ergonomics adjusted to operator comfort and again with the console adjusted to maximum height on the arm bar. Muscle contraction data for trapezius, flexor digitorum and extensor digitorum muscle groups were collected using electromyogram sensors. The raw data was processed by calculating the Root Mean Square (RMS) of EMG voltage over 100ms rolling windows. The threshold for contraction detection was set at the first quartile of maximal contraction voltage. Percentage time of exercise above the contraction threshold is reported. Median RMS voltage of total time contracted is report as a percentage of maximal contraction. Figure demonstrates a 10 second clip of Fellow 2 with arms at optimal height. This illustrates the raw EMG data (black), calculated RMS voltage (blue), and contraction threshold (red).
Results: Results summarized in table 1. For all three participants, the trapezius muscle was contracted more often and at greater levels. The forearm extensors and flexors had variable contraction duration, but trended to needing greater contraction with the arms out of position. As a comparison, trapezius, extensor and flexor muscle contraction while sitting and typing at a computer for two minutes was 6%, 51%, and 31% above the exercise contraction threshold, respectively. The RMS voltage as percentage of maximal contraction for this exercise for trapezius, ED and FD was 8% of max, 16% of max, and 13% of max, respectively.
Conclusions: Quantitative measurement of muscle activation during robotic surgery is feasible. Proper ergonomic adjustment of the surgeon console during a robotic procedure can change the amount of time and intensity of muscle contraction. The trapezius muscle is sensitive to proper arm placement. Utilizing this workflow, further testing is required for additional muscle groups and ergonomic adjustments as well as different robotic surgery tasks.
Development and Application of a Novel Skills Assessment Tool to Evaluate Resident Competency During Percutaneous Nephrolithotomy
C Kleinguetl, T Posid, S Mohaghem Poor, S Ray, BE Knudsen, A Khuhro, MW Sourial
Ohio State University Wexner Medical Center
Introduction & Objective: With the continuing push towards competency‐based training during residency, there have been tools developed for skills assessment. There is currently a lack of a standardized assessment for non‐robotic procedures, as well as those in endourology, such as percutaneous nephrolithotomy (PCNL). We aim to evaluate the implementation of a mobile phone‐based application to provide real‐time assessment of resident surgical skill competence and progression during PCNL.
Methods: A procedure‐based assessment was created to evaluate critical steps during PCNL. To date, 11 residents in our program performing PCNL were immediately evaluated by the faculty involved in the case. Residents were evaluated across 20 steps (see Figure 1), with critical steps of the case being assessed with use of either a Yes/No completion score or via Likert‐scale (1–novice to 5–expert). Case complexity was also rated on a scale of 1‐3 (simple to complex).
Results: As an example, data from a single Resident (“X”, n = 3 cases to date) was compared across their cohort (PGY2) and program (all residents). Across cohorts, this resident exhibited similar competency to their cohort and program, with higher competency for Steps 8 and 9 (Figure 1). Similar metrics can be tracked based on Junior vs Senior designation (Figure 2) or by Case Complexity (Figure 3). Lower competence both as an average and over time (tracked case‐by‐case) would indicate areas of operative practice where resident/s can improve their skills or where faculty can provide additional feedback or education. Average duration to enter feedback was 154 seconds (3.5 minutes).
Conclusions: Given the need and push for real‐time feedback in the operating room to assess learner autonomy, this mobile phone‐based application is easily created and accessed and allows for prospective and longitudinal tracking of operative skill and progress during PCNL.
Improving OR Communication During Robotic‐Assisted Laparoscopic Urologic Surgery
H Brown, A Rai
Introduction & Objective: Operating theaters wherein robotic cases occur can often present the challenge of significant noise which can complicate communication between bedside assistant and the operating surgeon at the console. Our aim was to determine if the utilization of Air Pods over a private audio server reduced noise in the OR and improved communication between bedside assistant and operating surgeon. We sought to compare measured sound pressure levels during robotic‐assisted surgery via the da Vinci robotic speaker system to Air Pods.
Methods: A series of 12 robotic‐assisted prostatectomies were evaluated including 6 with the built in da Vinci robotic speaker and 6 with Air Pods. The surgeon and the bedside assistant wore Air Pods and had their cellphones connected via a private audio server. The sound pressure measurements in decibels (dB) were recorded in two locations in the operating room, at the console and at the robot boom where the bedside assistant is stationed. Subjective communication outcomes including clarity and effectiveness were obtained from participating surgeons and bedside assistants using a Likert scale.
Results: Overall, the wireless, hands‐free earbud system had lower peak and lower average sound pressure than the da Vinci robotic speaker system. The peak sound pressures at the robot boom and console were 6 and 4.5 dB lower with Air Pods than with the traditional speaker system. The mean peak pressure at the console with Air Pods was 89 dB (SD 8.8) versus 94.8 dB (SD 9.3) without. The average sound pressure at the robotic console with the standard speaker was 75.5 dB (SD 10.7) compared to 63 dB (SD 5.2) with Air Pods. The average sound pressures at the robot boom and console were 8.6 and 12 dB lower with Air Pods than with the Di Vinci speaker. Subjectively Air Pods improved clarity of communication for both the surgeons and the bedside assistants. All surveyed participants reported clarity improvement with Air Pods over the standard speaker system.
Conclusions: Communication in robotic operating theaters can be impaired by significant noise created by the built‐in audio system. The da Vinci robotic sound systems have higher peak and average sound pressures. The use of a secure audio servers and Air Pods decreased sound in the operating theater and improved communication. This approach limits noise and improves communication thereby may minimize surgical errors and improve patient safety, while also potentially serve as a future means for real‐time communication during tele‐surgery.
The Effect of Simulation‐based Ureteroscopy Training: A Randomised Controlled Clinical and Educational Trial (SIMULATE)
A Aydin, K Ahmed, T Abe, N Raison, M Van Hemelrijck, H Ahmed, W Zhu, G Zeng, J Sfakianos, A Tewari, A Gozen, J Rassweiler, A Skolarikos, T Kunit, T Knoll, F Moltzahn, A Lantz Powers, BH Chew, S Khan, P Dasgupta
Introduction & Objective: With increasing challenges in surgical training, simulation has been hypothesised to enhance progression along the initial phase of the surgical learning curve. SIMULATE aims to assess whether supplementary simulation training is superior to the current standard of exclusive OR‐based learning in helping residents reach a level of proficiency sooner through the example of ureteroscopy as an index urological procedure.
Methods: This international, multicentre randomised controlled superiority trial recruited residents (n = 94) who had performed ≤10 ureterorenoscopy (URS) cases, as a selected index procedure, with no prior simulation experience. Recruits were randomised to simulation‐based training (SBT) or non‐simulation‐based training (NSBT) groups, the latter of which is the current standard of training. Training sessions were conducted for the SBT arm, utilising an expert‐developed multi‐modality training curriculum. The primary outcome was the number of procedures required to achieve proficiency, defined as achieving a score of ≥28 on an Objective Structured Assessment of Technical Skill (OSATS) assessment scale, on 3 consecutive operations, without complications. Secondary outcomes included number of surgical complications and stone‐free status in each arm. All participants were followed up for 25 procedures or over 18 months.
Results: A total of 1140 cases were performed by 65 participants who continued with follow‐up (69%) from the simulation (n = 32) and conventional (n = 33) training arms. Proficiency was achieved in 66% of simulation (n = 21/32) and 55% of conventional (n = 18/33) groups (OR 1.59 [95% CI 0.59‐4.33]) over a mean of 9.6 and 10.9 sessions (HR: 1.41 [95% CI 0.72‐2.75]). Simulation participants (OR 3.33 [95% CI 1.09‐10.24]) required fewer number of procedures to reach proficiency (HR 0.89 [95% CI 0.39‐2.02]) in flexible ureterorenoscopy, the more complex form of the index procedure. Significant differences were observed in overall comparison of OSATS scores between groups (27.3 vs 25.9; p < 0.0001). Fewer complications (2.5% vs 6.8%) and non‐stone‐free patients (6.6% vs. 8.6%) were reported in favour of simulation.
Conclusions: Residents undergoing supplementary simulation‐based training achieved higher overall proficiency scores than those conventionally trained. They required fewer procedures to reach proficiency in flexible URS, and demonstrated less number of overall and serious complications.
Roboticsurgery101: A Novel Online Learning Management System for Implementing a Robotic‐assisted Surgery Training Curriculum
JY Lee, S Czajkowski
Division of Urology, Department of Surgery, University of Toronto & University Health Network
Introduction & Objective: Over the last decade, the prevalence of robotic‐assisted surgery (RAS) has increased globally. Given this growth, there is a need for structured as well as validated training and evaluation of RAS skills. To address this need, we have developed RoboticSurgery101 (RS101), an online learning management system (LMS) with an embedded RAS training curriculum. Our LMS allows for educators to easily monitor, track, assess, and provide feedback to trainees as they progress through the curriculum.
Methods: Our novel LMS was developed in collaboration with a team of web‐designers. The RAS training curriculum includes pre‐clinical (i.e. orientation videos, hands‐on workshops, virtual reality training modules) and clinical components (i.e. bedside assistant, console surgeon, procedure‐specific assessments). The curriculum is structured, evidence‐based, and comprehensive; it is standardized yet amenable to customization in order to suit the specific requirements of different residency and fellowship programs. Moreover, while the current curriculum is designed for training on the da Vinci Surgical System, it can easily be modified for any future robot. All assessment criteria are modeled on two previously validated tools for surgical skills assessment: the Global Evaluative Assessment of Robotic Skills and the Objective Structured Assessment of Technical Skills.
Results: Approved RAS trainees are assigned a user account on the LMS (www.RoboticSurgery101.com) where educators upload assignments and learning materials (e.g. lectures, surgical videos). Trainees can request performance assessments and track their progress using the dashboard. Educators can verify and track trainee progress, provide performance assessments, and modify the curriculum based on the needs and demonstrated competencies of individual learners.
Conclusions: RS101 is a novel LMS and RAS training curriculum that enables structured as well as validated tracking and evaluation of progress in RAS skills training. While several RAS basic skills curricula have previously been proposed, there has never been a published or industry‐offered LMS solution to manage RAS trainees. RS101 offers educators an easy‐to‐use platform for RAS training that can be modified to suit other curricula and future RAS systems.
MP2: Urothelial Cancer and Miscellaneous Oncology
WITHDRAWN
Changes in Renal Function After Nephroureterectomy for Upper Urinary Tract Carcinoma: Analysis of a Large Multicenter Cohort (Radical Nephroureterectomy Outcomes (RaNeO) Research Consortium)
A Tafuri, M Marchioni, C Cerrato, F Porpiglia, C Terrone, M Ferro, A Minervini, P Gontero, S Shariat, A Antonelli
Introduction & Objective: To investigate the prevalence and predictors of renal function variation in a large multicenter cohort of patients who underwent radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC).
Methods: Patients who underwent RNU at 17 tertiary centers were included. Renal function variation was evaluated at post‐operative day (POD)‐1, 6 and 12 months; timepoints differences were evaluated as follows: Δ1: POD‐1 eGFR‐baseline eGFR; Δ2:6‐months eGFR‐POD‐1 eGFR; Δ3:12‐months eGFR – 6‐monthseGFR. We defined POD‐1 acute kidney injury (AKI) as an increase in serum creatinine by ≥0.3 mg/dl or a 1.5‐1.9‐fold from baseline. A cutoff of 60mL/min in eGFR was considered to define renal decline at 6‐ and 12‐months. Linear mixed models were used to evaluate the effect of clinical factors on eGFR decline and variation and their interaction with follow‐up.
Results: 576 patients were included. Median age was 72years, 239(41.5%) patients developed POD‐1 AKI. eGFR at 6 and 12 months were 49.8(IQR 37.8‐62.2) and 48.8(IQR 37.8‐64.3) mL/min. 409 (71.0%) and 403 (70.0%) patients had an eGFR <60 ml/min at 6‐and 12‐months.
In multivariable analysis age(OR:1.05, p < 0.001), gender (male,OR:0.44,p = 0.003), AKI (OR:2.88, p < 0.001) and pre‐operative eGFR <60ml/min(OR:7.58,p <0.001) were predictors of 6‐months eGFR <60ml/min. Age (OR:1.06, p < 0.001), CAD(OR:2.68,p = 0.007), AKI(OR:1.83,p = 0.02), and pre‐operative eGFR <60 ml/min (OR:7.80,p <0.001) were predictors of eGFR <60ml/min at 12‐months (Table 1). AKI has a detrimental effect on eGFR <60 ml/min at 6 months; this effect was more pronounced at 12months (Figure1). Age (p = 0.019), hydronephrosis (p < 0.001), AKI (p < 0.001), pT‐stage (p = 0.001) influenced renal function (ß:9.2 ± 0.7, p < 0.001) during follow‐up. Among AKI patients hydronephrosis (b: 2.6 ± 1.3, p = 0.045) and ASA >2(b: 6.7 ± 3.3, p = 0.045) were associated with a lower renal function reduction during time.
Conclusions: Age, pre‐operative eGFR and POD‐1 AKI are independent predictors of 6‐ and 12 months renal function decline after RNU for UTUC.
Antegrade Administration of Reverse Thermal Mitomycin Gel for Primary Chemoablation of Upper Tract Urothelial Carcinoma via Percutaneous Nephrostomy Tube: A Multi‐institutional Real‐world Experience
JP Campagna, KM Rose, G Narang, G Rosen, C Labatte, A Yu, B Manley, P Speiss, R Li, M Adibi, KS Murray, WJ Sexton, MR Humphreys
Mayo Clinic Arizona
Introduction & Objective: Reverse thermal mitomycin gel (MG) is approved for treatment of low grade upper tract urothelial carcinoma (UTUC). The initial trial which led to approval of this agent required repeated retrograde instrumentation of the upper tract under general anesthesia. This increased the cost and morbidity associated with therapy and may have contributed to the 44% incidence of ureteral stenosis. Given these findings, we sought to assess the safety profile and efficacy of antegrade (MG) instillation through a percutaneous nephrostomy tube.
Methods: After institutional review board approval, patients who underwent (MG) therapy for (UTUC) via a percutaneous nephrostomy tube at several institutions were pooled and analyzed. We compared patient demographics, side effect profile, response to therapy, and recurrence patterns. Patients underwent induction therapy which included six installations of once‐weekly (MG). Post‐induction ureteroscopy was used to assess treatment response. The primary outcome was safety profile following antegrade administration of (MG). The secondary outcome was complete response (CR) rate.
Results: Thirty two patients received at least one dose of (MG) via percutaneous nephrostomy tube, of whom twenty nine completed induction therapy and underwent post‐induction ureteroscopy. Ten (34%) patients went on to receive at least one dose of maintenance therapy. Ureteral stenosis occurred in three (9%) patients. Other adverse events included fatigue (22%), flank pain (19%), UTI (9%), sepsis (6%), and hematuria (3%). No patients had impaired renal function during follow up and no deaths occurred. Seventeen patients (59%) exhibited a (CR) at post‐induction ureteroscopy, while eleven (38%) had a partial response. At a median follow up of seven months (IQR 3‐9) post‐induction, no patients who experienced a (CR) recurred.
Conclusions: Antegrade administration of (MG) via a percutaneous nephrostomy tube offers similar efficacy with a lower rate of ureteral stenosis compared to a retrograde approach. This technique also allows for chemoablation without the use of general anesthesia. Antegrade administration of (MG) via a percutaneous nephrostomy tube is safe, efficacious and should be considered in the armamentarium of urologists for the treatment of low grade upper tract urothelial carcinoma.
WITHDRAWN
Survival Outcomes Comparing Radical Nephroureterectomy versus Endoscopic Treatment in Solitary Kidney Patients Diagnosed with High‐grade Upper Tract Urothelial Carcinoma
R Alam, J Cheaib, M Biles, J Winoker, N Singla, T Bivalacqua, P Pierorazio, M Kates, S Patel
Johns Hopkins University School of Medicine
Introduction & Objective: Solitary kidney patients who develop high‐grade upper tract urothelial carcinoma (HG‐UTUC) present a significant management challenge. Radical nephroureterectomy (RNU) renders these patients anephric with a need for dialysis, which is associated with lower life expectancy and decreased quality of life. However, organ‐sparing endoscopic treatment may result in undertreatment of the cancer process. We sought to compare survival outcomes between RNU and endoscopy in solitary kidney patients diagnosed with clinically localized HG‐UTUC.
Methods: The Surveillance, Epidemiology, and End Results database was linked to Medicare records to identify patients diagnosed with UTUC through 2017. This data was then linked to the Medicare Provider Analysis and Review and National Claims History databases to identify patients with a solitary kidney. Only patients with an established diagnosis of solitary kidney prior to developing clinically node‐negative and non‐metastatic (cN0M0) HG‐UTUC were included. Notably, data on patient comorbidities and tumor size is not available due to the nature of the dataset. Patients were stratified by treatment with RNU versus endoscopy. The Kaplan‐Meier method and Fine and Gray competing risks regression were performed to compare survival between the two groups.
Results: We identified 1531 solitary kidney patients with cN0M0 HG‐UTUC, of whom 1344 underwent RNU and 195 underwent endoscopy. The median age at diagnosis was 75.9 years (IQR 69.9‐81.4) and the median follow‐up time was 2.6 years (IQR 1.6‐4.2). There were 762 deaths (49.8%). There was no difference in overall survival between the RNU and endoscopy groups (P = 0.10) [Figure 1]. Upon competing risks regression, there was no difference in cancer‐specific mortality (P = 0.08) [Figure 2].
Conclusions: Solitary kidney patients diagnosed with clinically localized HG‐UTUC demonstrate no difference in survival outcomes when comparing RNU to endoscopic treatment. While selection bias is a major concern of this analysis, it reiterates the importance of weighing the benefits of oncologic control against the risks of becoming anephric.
Robot‐assisted Radical Cystectomy with Totally Intracorporeal Ileal Neobladder for Females
M Kobayashi, K Numakura, S Kashima, R Yamamoto, A Koizumi, T Nara, M Saito, S Narita, T Habuchi
Akita university graduate school of medicine
Introduction & Objective: Robot‐assisted radical cystectomy (RARC) with intracorporeal neobladder construction is now one of the standard treatments for muscle‐invasive bladder cancer. However, little is known about perioperative and long‐term outcomes of the neobladder for female patients. The objective of this study was to verify our surgical technique and clinical outcome of RARC with totally intracorporeal neobladder construction in females with bladder cancer.
Methods: From May 2020 to November 2021, four women underwent RARC with a totally intracorporeal neobladder. We preserve the anatomical structure of the vagina to facilitate postoperative urinary function, unlike the traditional en bloc resection of gynecological organs with the anterior vaginal wall. The procedure of neobladder construction is performed under a 10° Trendelenburg position. A total of 43 cm of a segment is divided from the terminal ileum. The distal 30 cm segment is detubularized along its anti‐mesenteric border for a reservoir, residual proximal 13 cm for an afferent limb. After making the dorsal ileum plate by running sutures with barbed strings, the plate is anastomosed to the urethral stump. The neobladder pouch is constructed according to the South California University Method. The left ureter is pass‐through behind the sigmoid mesentery to the right side. After confirmation of enough blood supply to ureters by FireFly®□, ureters are spatulated at least 2.5 cm in length. Single‐J ureteric stents are pushed up into the renal pelvis, and ureters are anastomosed to the proximal end of the afferent limb by the Wallace method.
Results: The median age was 64 (63‐69) years old, median operative and urinary diversion times were 730 (700‐810) and 347 (287‐543) minutes, respectively. Median blood loss was 1257 (880‐2355) mL, while no blood transfusion was required. The median hospital stay was 42 (27‐66) days. The recurrence was diagnosed in one patient. Clavien‐Dindo grade Ⅲ or more complications were observed in two patients within 90 days after surgery. Urinary continence was achieved in one patient, and the last patient is still under observation.
Conclusions: In our institute, RARC was successfully performed for women without any perioperative complications. After improving the surgical procedure, patients achieved balanced urinary continence. Further study must be needed to verify the outcome of our surgery.
Perioperative Characteristics and Outcomes for Minimally Invasive vs Open Retroperitoneal Lymph Node Dissection for the Treatment of Testicular Cancer
M Wynne, A Sparks, M Whalen
The George Washington University School of Medicine and Health Sciences
Introduction & Objective: Primary retroperitoneal lymph node dissection (RPLND) is an established post‐orchiectomy treatment option for men with clinical stage I and IIA/B non‐seminomatous germ cell tumors. While the open approach remains the gold standard for RPLND, a minimally invasive surgical (MIS) approach may afford patients similar oncologic outcomes with decreased morbidity. The present study queries the National Surgical Quality Improvement Program (NSQIP) database to assess 30‐day perioperative outcomes and characteristics for MIS vs open RPLND along with trends over time.
Methods: The NSQIP database (2005‐2018) was queried for patients with non‐disseminated testicular cancer ± retroperitoneal lymph node involvement. Patients with distant metastasis, history of chemotherapy, or history of radiation therapy were excluded. Chi‐square, Fisher's exact test, independent samples t‐test, and Mann‐Whitney U test were used to identify unadjusted associations and potential confounding covariates. Multivariable logistic regression and multivariable generalized linear models were used to analyze independent associations between treatment approach and perioperative outcomes. Trends over time were analyzed by way of Spearman's rank correlation coefficient analysis.
Results: 646 patients were identified. 337 (52.2%) underwent MIS treatment and 309 (47.8%) underwent open treatment. Compared to open, MIS RPLND was significantly associated with older age, non‐White race, diabetes, hypertension, weight loss >10% 6 months prior to surgery, and lymph node involvement (all respective p < 0.05). There was a trend level association between MIS RPLND and a higher proportion of chronic steroid use, pre‐operative transfusion, and higher ASA (all respective p < 0.1). Multivariable analysis detected no significant difference in rates of superficial surgical site infection, 30‐day mortality, unplanned return to OR, acute care stay >30 days, reoperation, readmission, or C. Difficile complications. MIS RPLND was significantly associated with 35 ± 9 minute shorter adjusted operative time and 51% ± 7% shorter adjusted hospital stay (respective p < 0.05). RPLND was more often performed via open approach in recent years (ρ = ‐0.101; p = 0.013).
Conclusions: MIS RPLND demonstrated comparable perioperative outcomes to open RPLND with decreased length of hospital stay, despite higher burden of comorbidities. Although lymph node yield could not be assessed within the limitations of NSQIP, the shorter operative time of MIS reinforces the importance of thorough dissection and adherence to template‐based or full bilateral dissection as indicated, regardless of the surgical modality.
A Matched‐paired, Index‐control Cohort Long‐term Trial Comparatively Assessing the Narrow Band Imaging – En Bloc Bipolar Plasma Resection Hybrid Approach versus the Standard Management Protocol – the 4 Years' Oncologic Outcome
B Geavlete, C Moldoveanu, C Ene, C Bulai, A Ene, P Geavlete
“Saint John” Emergency Clinical Hospital, Department of Urology, Bucharest, Romania
Introduction & Objective: A combined diagnostic (white light cystoscopy‐WLC and narrow band imaging‐NBI) and treatment (en bloc bipolar plasma resection) approach was compared to the standard protocol (WLC and monopolar transurethral resection of bladder tumors‐TURBT) in medium size papillary non‐muscle invasive bladder tumors (NMIBT).
Methods: A matched‐paired, index‐control, cohort study included 240 patients with at least 1 bladder tumor 1‐3 cm in diameter diagnosed by abdominal ultrasound, contrast CT and flexible cystoscopy. Index patients were prospectively enrolled and underwent standard and NBI cystoscopy, followed by bipolar plasma en bloc resection. In the retrospectively selected control cases, WLC and TURBT were solely applied. The matched pairs were determined based on the similar recurrence and progression risk categories according to the EORTC risk classification. The follow‐up protocol included WL and NBI cystoscopy, performed every 3 months for 2 years and every 6 months for another 2 years.
Results: Significantly reduced rate of obturator nerve reflex causing bladder wall perforation (5.8% versus 13.3%) was described in the en bloc study arm. Significantly decreased mean operation time (13.4 versus 21.6 minutes), hemoglobin level drop (0.32 versus 0.85 g/dL), catheterization period (1.8 versus 2.9 days) and hospital stay (2.1 versus 3.2 days) were emphasized in the en bloc group. NBI cystoscopy was characterized by significantly improved tumors' detection rates (CIS‐95.4% versus 68.7%; pTa‐93.5% versus 81.7%; overall NMIBT‐94.6% versus 84.2%). Significantly lower cumulated recurrence rates (17.1% versus 25%) were found in the en bloc group at 1 (13.6% versus 22.3%), 2 (18.7% versus 29.5%), 3 (22.1% versus 34.6%) and 4 (25.4% versus 38.9%) years due to the substantially fewer other site recurrent lesions (10.8% versus 18.4%, 14.9% versus 26.7%, 17.3% versus 29.1% and 19.2% versus 32.0%, respectively).
Conclusions: En bloc plasma resection provided the advantages of superior surgical safety, decreased perioperative morbidity (bleeding risks in particular) as well as faster postoperative recovery. NBI cystoscopy significantly improved the NMIBT lesions‐based diagnostic accuracy. The hybrid approach was characterized by improved oncologic outcome based on the significantly reduced other site NMIBT recurrences during the 4 years' follow‐up.
Predictors of Mental Wellbeing Outcomes in Prostate Cancer: Interim Results from the Multi‐institutional MIND‐P Cohort Study
O Brunckhorst, J Liszka, C James, J Fanshawe, M Hammadeh, R Thomas, S Khan, M Sheriff, H Ahmed, M Van Hemelrijck, G Muir, R Stewart, P Dasgupta, K Ahmed
MRC Centre for Transplantation, Guy's Hospital Campus, King's College London, King's Health Partners, London, United Kingdom
Introduction & Objective: Increasingly, the quality of life implications of prostate cancer are being recognised. While physical consequences are often the focus of research and clinicians, the impact on the mental wellbeing of patients is becoming more apparent. However, less is understood about associative patient, treatment, and oncological factors that predict poorer wellbeing outcomes which we aim to evaluate in this study.
Methods: The Mental wellbeIng aND quality of life in Prostate cancer (MIND‐P) cohort study is an ongoing prospective study across 8 sites in the United Kingdom (NCT04647474). Newly diagnosed patients are followed for 1 year post diagnosis through 3‐monthly questionnaires evaluating mental, physical, and social wellbeing. We calculated the incidence of developing significant mental wellbeing symptoms with univariate logistic and cox regression models utilised to evaluate patient, oncological and treatment factors against a composite mental outcome of developing any significant mental wellbeing issue (depressive or anxiety symptoms, fear of cancer recurrence, body image or masculine self‐esteem). These selected outcomes were based on multiple extensive reviews of the literature and qualitative patient interviews.
Results: Of 270 participants recruited, 196 have undergone at least 3 months follow up and were included in the interim analysis. 12.8% and 9.7% of individuals demonstrated symptoms of probable depression or anxiety respectively. Overall, 36.2% have developed at least one significant mental wellbeing issue. While undergoing hormone monotherapy was associated with higher risk of developing mental wellbeing issues (HR 2.05, p = 0.045), little difference was seen between those undergoing surveillance, prostatectomy, or radiotherapy. Younger age (OR 1.04, p = 0.049), black ethnicity (OR 3.33, p = 0.027) and a previous psychiatric history (OR 2.97, p = 0.024) were all demonstrated patient associative features for poorer mental wellbeing. Additionally, baseline wellbeing scores were highly associative with poorer outcomes across all domains measured. However, oncological features such as stage or grade did not appear to be associated with poorer outcomes.
Conclusions: Mental wellbeing issues are common in the initial prostate cancer phase and must therefore be evaluated for during routine follow up. Furthermore, predictive patient factors and baseline mental wellbeing status should be considered during screening, to ensure early detection and referral for treatment to improve quality of life.
Retrograde En Bloc Resection for Non‐muscle Invasive Bladder Tumor Can Reduce the Risk of Seeding Cancer Cells into the Peripheral Circulation
H Huang, J Xing
The First Affiliated Hospital of Xiamen University
Introduction & Objective: To ascertain whether en bloc resection could reduce the risk of seeding cancer cells into the circulation during the resection of non‐muscle invasive bladder cancer (NMIBC).
Methods: Patients with primary NMIBC were enrolled in this prospective study from October 2017 to May 2018. Patients were allocated to receive conventional transurethral resection of the bladder (TURB) or retrograde en bloc resection technique of the bladder tumor (RERBT). The process of the RERBT technique was introduced briefly as follows. Blood vessels entering the tumor were blocked before resection by electro‐coagulating the macroscopic normal mucosa approximately 0.5 to 1.0 cm away from the tumor base to reduce intraoperative hemorrhaging. During the resection, bleeding vessels were coagulated simultaneously, providing a better visualization. Therefore, the time and degree of vascular opening was reduced and the opportunity for tumor cells to enter the bloodstream was kept to a minimum. Most importantly, the tumors were removed en bloc resection in RERBT rather than a piece‐by‐piece resection as in TURB; there was no tumor chip floating in the bladder during the resection. We employed a new device, a size‐dictated immunocapture chip (SDI‐Chip), to measure the CTC counts(Fig 1). Blood samples (1 ml) for circulating tumor cell (CTC) enumeration were drawn from the peripheral vein prior to resection (PV1), immediately after resection of the tumor base (PV2) and at 12 hours after resection (PV3). Intra‐group comparisons of the changes in the number of CTCs identified among the PV1, PV2 and PV3 blood samples were performed in each group.
Results: A total of 21 patients (12 in the RERBT group and 9 in the TURB group) were recruited. There were no statistically significant differences in terms of demographics, smoking history, operation duration, postoperative tumor grade or stage (Table 1). For patients receiving TURB, the level of CTCs identified in PV3 was significantly higher than that in PV1 (p = 0.047). However, there was no significant difference in CTC counts before and after resection in the RERBT group.
Conclusions: RERBT did not increase the number of tumor cells in the bloodstream.
Radical Prostatectomy 15‐year Overall and Prostate Cancer Specific Mortality: A Novel Analysis of Radiation Therapy and Androgen Deprivation
E Huang, L Huynh, H Su, J Tran, T Ahlering
University of Nebraska Medical Center
Introduction & Objective: Salvage radiation therapy (sRT) reduces PSA and biochemical recurrence (BCR) after radical prostatectomy (RP). However, no studies directly comparing patients receiving concurrent sRT and androgen deprivation therapy (sRT+ADT) and ADT monotherapy has been published. This study compares 15‐year prostate cancer‐specific survival (PCSS) and overall survival (OS) between sRT+ADT and ADT monotherapy.
Methods: A retrospective cohort study of prospective data was conducted for 407 BCR's (adjuvant therapy of PSA >0.2 ng/dl, x2). Patients were managed with concurrent sRT+ADT (n = 91), ADT alone (n = 156) or active observation only (AO, n = 136). Primary outcome was PCSS and secondary outcome was OS, measured via Kaplan‐Meier and Cox regression. Ad hoc analysis combining AO (candidates for sRT) with sRT+ADT group was conducted to simulate published trials.
Results: Follow‐up was 7.6 (IQR 3.3‐11.9) years. In Kaplan‐Meier analysis, PCSS was 73.7% vs 72.5% (p = 0.39) and OS was 61.2% vs 51.6% (p = 0.082) between sRT+ADT and ADT at 15 years respectively. In Cox regression, PCSS and OS were not significantly different after adjusting for age, Gleason grade, stage, and preoperative PSA.
136 (33.4%) BCR patients managed with only AO and no treatment were added to the sRT+ADT group in ad hoc analysis, simulating patients who would have been treated in trials. AO patients had 100% PCSS and 92% OS. In ad hoc analysis, PCSS/OS improved significantly compared to ADT monotherapy in Kaplan‐Meier analysis (p < 0.005).
Conclusions: This suggests that addition of sRT to ADT did not improve PCSS/OS compared to ADT monotherapy at 15 years. The lack of PCSM in AO patients, all candidates for sRT, suggest the reason previous benefits of sRT were seen in trials. The ad hoc addition of the AO group statistically significantly lowered PCSM in the RT/ADT group.
A Comparative Study on Postoperative Complications After Open vs Robotic‐assisted Radical Cystectomy with Intracorporeal Urinary Diversion
MR Peradejordi Font, R Martos Calvo, M Musquera Felip, A Tello Delsors, C Mercader Barrull, A Sierra del Rio, A Vilaseca Cabo, L Izquierdo Reyes, M Ribal Caparros, A Alcaraz Asensio
Hospital Clínic de Barcelona
Introduction & Objective: Radical cystectomy is the standard treatment for muscle‐invasive or high‐risk non‐muscle‐invasive bladder cancer. Robotic‐assisted surgery seems to reduce postoperative complications.
The objective of our study is to analyze and compare postoperative morbidity of open radical cystectomy (ORC) vs robotic‐assisted radical cystectomy (RARC) with intracorporeal urinary diversion (IUD) after three years of experience with robotic surgery.
Methods: Retrospective analysis of the ORC and RARC with IUD performed in our center between January 2016 and May 2021. Comparison of the morbidity and postoperative complications.
Results: During the mentioned period, 93 ORC and 193 RARC with IUD were performed in our center. There were no statistically significance differences in between groups regarding age, sex, BMI and Charlson Comorbidity Index. The ORC group had a higher number of patients ASA IV. There were no differences on urinary diversion performed between groups. Surgical time was significantly longer for RARC (p = 0.029). Transfusion rates, ICU requirement, hospital stay and postoperative complications were significantly lower in the RARC group (Table 1).
Conclusions: Patients after RARC with IUD in our center had better postoperative results in terms of complication rates.
Comparative Analysis of Oncological Results After Open, Laparoscopic and Robotic‐assisted Radical Cystectomy
MR Peradejordi Font, R Martos Calvo, M Musquera Felip, A Tello Delsors, C Mercader Barrull, A Sierra del Rio, A Vilaseca Cabo, L Izquierdo Reyes, M Ribal Caparros, A Alcaraz Asensio
Hospital Clínic de Barcelona
Introduction & Objective: The development of minimally invasive techniques such as laparoscopy and robot‐assisted surgery have been introduced in the treatment of bladder cancer in order to reduce postoperative morbidity after a radical cystectomy. The aim of our study is to analyze and compare the oncological outcomes after open (ORC), laparoscopic (LRC) and robotic‐assisted radical cystectomy (RARC).
Methods: Retrospective analysis of the radical cystectomies performed as treatment for bladder cancer in our center from January 2016 to May 2021 and comparison of oncological outcomes after ORC, LRC or RARC.
Results: During the mentioned period 269 radical cystectomies for bladder cancer were performed in our center. Oncological features of the patients are shown in Table 1.
Mean follow‐up times were 32 (± 32.5), 35 (±17.1) and 19 (± 12.3) months after ORC, LRC and RARC respectively. Overall survival and progression‐free survival were significantly superior for patients after RARC compared to ORC (p = 0.004 and p = 0.034 respectively) (Figures 1 and 2). LRC didn't show any statistical differences in terms of overall survival and progression‐free survival compared to RARC or ORC (Figure 1 and 2).
Conclusions: In our series, overall survival and progression‐free survival were superior for patients after RARC compared to ORC.
Diet and Exercise Delays Time to Systemic Secondary Intervention Post Robotic Assisted Radical Prostatectomy
MM Epino, K Liang, E Huang, L Huynh, R Derderian, A Jaime, J Tran, T Ahlering
Introduction & Objective: Approximately 20‐30% of prostate cancer (PC) patients experience a biochemical recurrence (BCR), requiring systemic secondary interventions (SI). In an effort to delay time to SI, the present study seeks to evaluate the impact of intent to treat with a heart‐healthy diet and exercise (DE) on time to SI for patients with BCR.
Methods: 32 DE patients with BCR (PSA >0.2 ng/mL), doubling times (DTs) >12 months were included in the study. 24 Matched Historic BCR Controls (MHC) who predated DE were selected based on age, oncologic factors, DTs, and BMI. The DE group was stratified into DE success (DES, n = 18) with increasing DT or DE fail (DEF, n = 14) based on rapidly decreasing DTs and need for SI. PSA, PSAdt increasing/decreasing pattern, and time to SI were evaluated.
Results: At entry, DE and MHC groups were the same in particular time to BCR (p = 0.318) and PSAdt (p = 0.542, Table 1). Intervention occurred in all MHC patients, with adverse DT kinetics (decreasing DT, DT <12 mos) versus 44% (14/32) of DE patients at median 3.7 years versus 8.9 years, respectively (p < 0.001). At the end of study, DT was significantly longer in the DE (22.2 ± 12.5 mo) versus the MHC (9.4 ± 4.7 mo, p < 0.001).
Furthermore, end of study comparisons between DES versus DEF, and DEF versus MHC confirmed benefits of intent to treat with DE. DT was significantly longer in the DES (26.7 ± 11.7 mo) versus DEF group (17.3 ± 13.7 mo) groups (p = 0.045). When DEF was compared to MHC, DT patterns (p = 0.001), DT (p = 0.008), and time to SI (p < 0.001) differed significantly from the MHC group.
Conclusions: In DE patients, 56% have avoided SI through 8 years. Further, DE failures had significantly delayed time to SI by 3.8 years and increased DT (17.3 mos) compared to MHC (10.0 mos). We hypothesize that this benefit is due to improved metabolic syndrome.
Effect of Intravesical Neoadjuvant Therapy on Surgical Outcomes in Patients Undergoing Robot‐Assisted Radical Cystectomy
T Iarajuli, T Corse, K Kim, R Sanchez De La Rosa, N Bou Diab, C Stanislaus, S Das, M Stifelman, M Billah, M Ahmed
Hackensack University Medical Center
Introduction & Objective: We aim to evaluate the effect of intravesical neoadjuvant therapy on surgical outcomes in patients undergoing robot‐assisted radical cystectomy for bladder cancer.
Methods: This is an IRB approved prospective cohort study of 81 patients who underwent radical cystectomy between 2019 and 2021. Continuous data was analyzed using the Wilcoxon Rank Sum test. Categorical data was analyzed using Chi‐Squared and Fisher's Exact Tests where appropriate. Major complications were defined as a Clavien‐Dindo Classification Grade >2.
Results: 31 (38.3%) patients received intravesical neoadjuvant therapy prior to radical cystectomy. Patients most commonly received Bacillus Calmette‐Guerin (BCG, 14.8%) and Gemcitabine‐Cisplatin (11.1%) regimens with an average of four induction cycles. Patients who received intravesical neoadjuvant therapy had significantly higher rates of prior tobacco use (74.2% vs 56.0%, p = 0.26). There was no significant difference in age, body mass index, or comorbidities including hypertension and diabetes between patients who received and did not receive neoadjuvant therapy.
Intraoperatively, there was no significant difference in operating time (235.4 vs 237.1 min, p = 0.87), estimated blood loss (137.3 vs 150.3 mL, p = 0.73) between the two groups. Postoperatively, there was no significant difference in rate of major complications (10.7% vs 20.0%, p = 0.99), intravenous opioid requirements (2.0 vs 1.3 days, p = 0.35), length of stay (6.8 vs 6.3 days, p = 0.14), or rates of 30 day readmission (19.2% vs 15.6%, p = 0.75) between the two groups.
Conclusions: We did not find intravesical neoadjuvant therapy to have any significant association with intraoperative and postoperative outcomes in patients who underwent radical cystectomy for bladder cancer. Larger scale studies are needed to confirm these findings.
Association Between Postoperative Opioid Administration and Surgical Outcomes in Patients Undergoing Radical Cystectomy
T Iarajuli, J Zaifman, T Corse, R Sanchez De La Rosa, K Kim, C Stanislaus, S Das, M Stifelman, M Billah, M Ahmed
Hackensack University Medical Center
Introduction & Objective: Patients undergoing radical cystectomy are frequently prescribed prolonged courses of opioids for management of pain and have high rates of readmission postoperatively. We aim to determine the association between opioid use and postoperative outcomes.
Methods: 185 total patients who underwent radical cystectomy between 2016 and 2021 were identified in IRB‐approved retrospective and prospective databases, respectively. Continuous data was analyzed using the Wilcoxon‐Rank‐Sums test. Categorical data was analyzed using Chi Squared and Fisher's Exact Tests where appropriate. Multivariate logistic regressions were performed to analyze independent factors associated with postoperative outcomes. Major postoperative complications were defined as greater than Grade 2 according to the Clavien‐Dindo classification system.
Results: Of the 185 patients included in our analysis (Table 1), 40 patients (21.62%) were readmitted within 90 days of surgery. There was no statistically significant difference found in age, body mass index, prior tobacco use, incidence of comorbidities between patients who did and did not require readmission (p > .05). Patients who were readmitted were significantly more likely to have received a longer course (4 vs 3 days, p = .0040) of opiates than those who did not undergo readmission. When adjusting for independent demographic variables, multivariate regression analysis demonstrated that each individual day of postoperative opioid use was associated with an increase in the odds of postoperative complication by 26.84% (OR 1.2684, p = 0.0025) and an increase in the odds of readmission by 22.23% (OR 1.2223, p = .0244).
Conclusions: Opioid use represents a possible risk factor for postoperative complications and readmission following radical cystectomy. Further studies are needed to demonstrate if certain classifications of complications are avoidable with conservative administration of opiates in the postoperative period.
Impact of Lymph Node Density on Outcomes Following Radical Cystectomy: A Single Center Analysis
J Zaifman, K Kim, T Iarajuli, T Corse, R Sanchez De La Rosa, C Stanislaus, S Das, N Bou Diab, S Sorin, M Stifelman, M Billah, M Ahmed
Hackensack University Medical Center
Introduction & Objective: The association between the presence of lymph node metastasis and oncological outcomes in patients undergoing radical cystectomy for bladder cancer has been previously identified. We aim to determine if there is an association between the extent of lymph node positivity and surgical outcomes in this patient population.
Methods: This is an IRB approved prospective and retrospective cohort study of 167 patients who underwent radical cystectomy between 2019 and 2021. Continuous data was analyzed using the Wilcoxon Rank Sum test. Categorical data was analyzed using Chi‐Squared and Fisher's Exact Tests where appropriate. A cutoff value for lymph node density (LND) was determined according to a receiver operating characteristic (ROC) curve.
Results: Using the ROC curve (Figure 1), we found that the recommended cutoff value for lymph node density was 3.64% (sensitivity, 50.0; specificity, 83.2; AUC, 0.68). Using this value, we divided all patients into ≤3.64% (n = 128) and >3.64% (n = 39) lymph node density to compare oncologic outcomes (Table 1). There was no significant difference in age, body mass index, smoking status, comorbidities, number of prior abdominal surgeries, or having received neoadjuvant chemotherapy between the two groups.
There was no significant difference between the median number of nodes examined (21 vs 21, p = 0.631), but the higher LND group had significantly higher node involvement (2 vs 0 nodes, p < 0.0001) and median percent positivity (12.5% vs 0%, p < 0.0001). The higher LND group had a significantly increased rate of readmission within 90 days (28.21% vs 12.5%, p = 0.028) and mortality (43.6% vs 14.8%, p = 0.0001).
Conclusions: Our analysis showed that a threshold of >3.64% lymph node density may serve as a prognostic indicator for patients with bladder cancer following radical cystectomy.
Renal Failure Worsens Radiation Cystitis in Robot‐Assisted Laparoscopic Prostatectomy Patients Treated with XRT
S Song, RR Chen, D Jhang, C Ritchie, AS Amasyali, CE Baas, A Assidon, J Belle, DD Baldwin
Introduction & Objective: Chronic kidney disease (CKD) is associated with high morbidity and mortality. In CKD patients, some centers require prostate cancer treatment prior to life‐saving renal transplantation. We hypothesize that XRT following robot‐assisted laparoscopic prostatectomy (RALP) may increase bladder radiation dose in ESRD patients due to decreased bladder volume and a new anatomic location. This could theoretically increase the risk and severity of radiation cystitis. The purpose of this study is to explore the relationship between renal function and severity of hemorrhagic cystitis in patients who underwent XRT following RALP.
Methods: A retrospective review was conducted including patients who underwent adjuvant XRT after RALP at a single academic institution between December 2006 and July 2020. Severity of radiation cystitis was compared between patients in three groups: CKD 0‐2, CKD 3‐4, and CKD 5. Primary outcomes included occurrence of gross hematuria, need for indwelling urethral catheter, continuous bladder irrigation, blood transfusion, hyperbaric oxygen therapy (HBOT), or surgical intervention in the form of clot evacuation and bladder fulguration. Statistical analysis was performed using ANOVA and chi‐square testing, with significance defined as p < 0.05.
Results: Of 110 patients included in this study, 101 had CKD 0‐2, 7 had CKD 3‐4 and 2 had CKD‐5. There was no significant difference between groups in age (p = 0.32), BMI (p = 0.07), pre‐treatment PSA (p = 0.36), post‐radiation PSA (p = 0.94), type of radiation (p = 0.57), total dose of radiation received (p = 0.88), cancer stage (p = 0.17), and length of follow‐up (p = 0.89). When comparing CKD 0‐2, CKD 3‐4 and CKD‐5, incidence of gross hematuria was 15.7%, 14.3%, and 100% (p = 0.008); indwelling catheterization was 1.1%, 14.3%, and 100% (p < 0.001); continuous bladder irrigation was 1.1%, 14.3% and 100% (p < 0.001), blood transfusion was 0%, 14.3%, and 100% (p < 0.001), HBOT was 0%, 14.3%, and 100% (p < 0.001), and operative clot evacuation with fulguration was 1.1%, 14.3%, and 50% (p < 0.001), respectively.
Conclusions: Renal dysfunction is strongly correlated with risk and severity of radiation cystitis in RALP patients following XRT. Our findings suggest that strategies should be developed to reduce the complications of radiation cystitis in patients with compromised renal function, such as bladder distention prior to irradiation. In addition, ESRD patients should be carefully counseled prior to undergoing XRT following RALP.
Genetic Analysis of Focal Barbotages– a Complementary Diagnostic Tool in Upper Tract Urothelial Carcinoma
T Axelsson, F Sydén, J Eisfeldt, Y Eriksson, G Lundberg, A Grahn, E Tham, M Brehmer
Karolinska Institutet and South General Hospital, Stockholm, Sweden
Introduction & Objective: Improving diagnostics in UTUC is important to identify patients that risk disease progression despite full treatment. At diagnosis, tumour stage and grade are evaluated through cytological samples, biopsies and radiology. Genetic analysis of tumour tissue from nephroureterectomy (NU) and tumour biopsies may improve risk assessment of UTUC. Biopsies can be hard to obtain, hence genetic analysis of focal barbotages can be a more feasible alternative. The aim of this study was to investigate if gene analysis of focal barbotages obtained at ureterorenoscopy (URS) is possible.
Methods: This prospective study included 40 patients with UTUC confirmed at URS from 2018 to 2021. Patients were followed until March 2022. At URS, barbotage specimens from the ureter and renal pelvis were collected and sent for cytology analysis and for gene sequencing. If possible, tumour biopsies were taken. Final tumour grades (WHO‐classifications 1999 and 2004) were determined from cytology and/or biopsy, or from radical NU samples when available. A total of 40 barbotage samples were sent for genetic analysis. For 3 patients, 2 samples from different operative episodes were analysed. Next generation sequencing using a 388‐gene panel was performed. Manual filtering of the sequencing data from each sample was performed to identify possible pathogenic mutations.
Results: 40 patients, 25 men and 15 women were included. Mean age at inclusion was 75 years. In 14 patients the tumour was low grade (8 G1, 5 G2 and one unclear) and in 26 patients the tumour was high grade (14 G2 and 12 G3). During the follow‐up period, 4 patients died from UTUC and 5 patients had tumour progression. Out of 40 focal barbotages analysed we identified known and suspected pathogenic mutations in 38. Known pathogenic mutations in the fibroblast growth receptor 3 (FGFR3) gene was common in grade 1 and 2 tumours but not present in any G3 tumour. No patients with an FGFR3 mutation died during follow‐up. Six patients had a pathogenic mutation in tumour protein 53 (TP53), 5 of these had high grade tumours and 2 of which died from UTUC during follow‐up. One patient with a TP53 mutation had a low grade, G1‐tumor, that progressed with metastasis.
Conclusions: Gene mutations can be identified in focal barbotage samples obtained at URS and may be complementary to cytologic analysis to determine tumour aggressiveness and to identify patients who are at risk of disease progression.
Is Preoperative Thrombocytosis a Good Predictor for Urothelial Carcinoma from Renal Calyx to Distal Ureter, as Has Been Observed for Bladder Cancer?
P Song, K Oh, J Choi, Y Ko, K Moon, H Jung
Department of Urology, Yeungnam University College of Medicine, Daegu, Korea
Introduction & Objective: In urothelial carcinoma (UC) of the bladder, preoperative thrombocytosis (PTC) has been identified as a predictor for oncologic outcome and survival after radical cystectomy. The aim of this study was to investigate the influence of an elevated platelet count in patients undergoing radical nephroureterectomy with bladder cuff excision (NUx) for UC from renal calyx to distal ureter on the oncological prognosis. Furthermore, the correlations of PTC with pathological parameters and perioperative blood transfusion (PBT) rates were analyzed.
Methods: A retrospective analysis of 111 patients undergoing NUx for UC between 2005 and 2021 was performed. For the cohort PTC was defined as a platelet count >450 G/. Chi‐square test was used to analyze the association of PTC with categorical variables including tumor stage, grade and PBT parameters. Cox regression analyses were used to investigate the association of PTC with outcome.
Results: The median age of patients at the moment of each operation was 69 years, 20.8% were female and 73.2% were male. The median PPC in the cohort was 272 G/l. PTC was detected in 29.67% of the patients. The median follow‐up was 49 months. The cancer specific survival adapted to PTC (thrombocytes: <450 G/l vs. >450 G/l) was 98.4% vs. 92.5% after 1 years and 92.1% vs. 12.2% after 5 years, respectively. PTC was significantly associated with muscle invasion, periureteral fat invasion and lymphovascular invasion (p < 0.001). PTC was also significantly associated with a higher rate of PBT (62.94% vs. 58.83%; p < 0.001). In the multivariate analysis PTC was significantly related to poor oncological survival (Hazard Ratio = 6.052; p = 0.008).
Conclusions: In this study, PTC was significantly associated with impaired oncological outcomes of patients undergoing NUx for UC. It represents an independent prognostic factor in oncological outcomes after NUx. PTC is also significantly correlated to an increased rate of PBT, which can be explained through tumor associated alterations of hemostasis.
Large State‐Level Variation in Intravesical Treatment for Non‐Muscle Invasive Bladder Cancer During the BCG Drug Shortage
B Chun, M He, C Jones, R Vasan, B Jacobs, I Hernandez, B Davies
UPMC
Introduction & Objective: Bacillus Calmette‐Guerin (BCG) is the gold standard for treatment of non‐muscle invasive bladder cancer. In the last two decades, the two major manufacturers of BCG have suffered production failures or have left the market completely due to economic infeasibility. This has resulted in a worldwide shortage of this important biologic drug. We used a nationally representative dataset to describe the effect of this shortage on intravesical treatment patterns for non‐muscle invasive bladder cancer.
Methods: Using claims data from a 5% random sample of Medicare beneficiaries, we identified patients ≥66 years of age who received intravesical therapy within 1 year of bladder cancer diagnosis from 2010‐2017. The BCG shortage period was defined from 2013 to the study end point. We estimated changes in the proportion of patients treated with BCG, mitomycin C, gemcitabine, or other intravesical agents before and during the shortage. We also evaluated state‐level changes in BCG induction rates before and during the shortage period.
Results: 8,122 patients were included in our study. The proportion of eligible patients receiving BCG induction therapy decreased 12.6% during the shortage period (37.9% in 2010‐2012 to 33.1% in 2013‐2017, p < 0.001). Over the same period, mitomycin C use increased 9.8% (26.7% to 29.3%, p = 0.01). The use of gemcitabine (p = 0.27) and other intravesical agents (p = 0.16) remained stable. Among 23 states reporting data on ≥50 patients, 15 (65.2%) had a decrease in BCG initiation rate during the shortage period, ranging from 4.9% (Ohio) to 36.8% (Washington). There was no regional pattern among states with decreased BCG use.
Conclusions: During the BCG drug shortage, BCG use for non‐muscle invasive bladder cancer decreased with a compensatory rise in mitomycin C. A large variation in state‐level BCG utilization may reflect differences in regional practice patterns or BCG availability.
Effect of Body Mass Index on Oncological Outcomes for Those Who Have Undergone Radical Nephroureterectomy for Upper Tract Urothelial Carcinoma: Analysis of the ROBUUST Registry
SR Dhanji, K Hakimi, C Cerrato, H Djaladat, DD Eun, V Margulis, R Uzzo, C Sundaram, A Minervini, M Ferro, K Rha, G Simone, I Derweesh, R Autorino, R Mehrazin, M Gonzalgo, J Porter, F Abdollah, A Mottrie, Z Wu
University of California San Diego
Introduction & Objective: We sought to analyze the impact of Body Mass Index (BMI) on upper tract urothelial carcinoma (UTUC) outcomes in a contemporary cohort of patients who underwent minimally invasive Radical Nephroureterectomy (RNU).
Methods: We performed a multi‐center retrospective analysis of patients who underwent RNU for UTUC utilizing the ROBUUST (ROBotic surgery for Upper tract Urothelial cancer STudy) database. Primary outcome was all‐cause mortality (ACM); secondary outcomes included cancer‐specific mortality (CSM) and recurrence. The cohort was divided into groups based on BMI (BMI ≤25 kg/m2, BMI 25‐30 Kg/m2, and BMI >30 Kg/m2) for descriptive and survival analyses. Multivariable cox regression analyses were conducted to elucidate predictors for outcomes, and Kaplan‐Meier analyses (KMA), were performed to analyze for overall survival (OS), cancer‐specific survival (CSS) and recurrence‐free survival (RFS) stratified by BMI group.
Results: A total of 845 patients (BMI ≤25 n = 297, BMI 25‐30 n = 352, and BMI >30 n = 197; mean follow up 13.8 months) were included in our analysis. Comparing BMI ≤25, BMI 25‐30, and BMI >30 groups, there were no significant differences with respect to tumor size (3.9, 3.7, and 3.9 cm, p = 0.743) and proportion of high‐grade tumors (76.8%, 75.9%, and 72.1%, p = 0.710). On MVA, BMI group was not associated with ACM (p = 0.136‐0.861), CSM (; p = 0.127‐0.429) or recurrence (p = 0.627‐0.808). Increasing age (HR 1.04, p = 0.003), high‐grade disease (HR 3.8, p = 0.027), metastasis (HR 4.0, p < 0.001) lymphovascular invasion (LVI) (HR 2.2, p = 0.001), and post‐operative complications (HR 2.1, p < 0.001) were significant risk factors for ACM. With regards to CSM, increasing age (HR, 1.04, p = 0.032), metastasis (HR 6.1, p < 0.001) and LVI (HR 2.0, p = 0.001) were significant risk factors. Comparing BMI ≤25, BMI 25‐30, and BMI >30 groups, KMA found no significant differences between for 3 year OS (86.9%, 86.1% and 88.8%, p = 0.90)., 3 year CSS (93.60%, 90.34% , and 93.91%, p = 0.22), and 3 year RFS (69.02%, 72.16%, and 72.08%, p = 0.87).
Conclusions: BMI was not associated with survival outcomes in UTUC patients treated with RNU.
Is Radical Cystectomy Safe in Octogenarians with Localized MIBC?
F Esperto, F Tedesco, P Tuzzolo, F Prata, V Crimi, A Ragusa, A Testa, L Cacciatore, N Deanesi, A Minore, A Civitella, R Scarpa, R Papalia
Introduction & Objective: Bladder cancer (BC) is actually the tenth most commonly diagnosed cancer worldwide and the fourth leading type of cancer death in the United States in men aged ≥80 years. Approximately 25% of patients (pts) have a muscle‐invasive (MI) cancer at diagnosis and most of them will underwent radical cystectomy (RC). The octogenarians' population is expected to double by 2050 and with that the subgroup affected by MIBC, becoming a though challenge to face for Urologists all over the world. Aim of this study is to investigate the survival rate in octogenarians' pts who underwent open RC at a single oncological center.
Methods: From January 2018 to December 2019, we selected and retrospectively evaluated all patients ≥80 years who underwent open RC for localized MIBC at our center. Pts were excluded if <80 years, underwent RC for non BC reasons (actinic cystitis) or data were not available. BMI, American Society of Anesthesiologists (ASA) score, urinary diversion, operative time (OT), estimated blood loss (EBL), post‐operative complications according to Clavien‐Dindo classification, length of hospitalization, survival and cause of death were collected.
Statistical analysis was performed with SPSS v 27
Results: Table 1 Shows the descriptive analysis of our cohort with variance analysis. Cause of death were due to metastasis (20%), comorbidity (80%). Overall survival (OS) at 12 months was of 27.5 %.
Fig 1 estimates OS using the Kaplan‐Meier method.
Conclusions: This study showed how open RC in pts ≥80 years has a low rate of major post‐operative complications, however the OS of these pts at 1 year of FU was low.
This study shows how RC should be proposed with extreme attention to pts over 80 because of the impact it can have on OS.
Comparison of Perioperative Outcomes and Complication of Laparoscopic and Robotic Nephroureterectomy Approaches in Patients with Upper‐Tract Urothelial Carcinoma
L Peng
Second Clinical Medical College of Lanzhou University, China
Introduction & Objective: Compare the efficacy and safety of robot‐assisted radical nephroureterectomy (RANU) and laparoscopic radical nephroureterectomy (LNU) in the treatment of upper tract urothelial carcinoma (UTUC).
Methods: Through a systematical search of multiple scientific databases in May 2022, we performed a systematic review and cumulative meta‐analysis of the primary outcomes of interest according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta‐Analyses) and AMSTAR (Assessing the methodological quality of systematic reviews) Guidelines, whose protocol was registered with PROSPERO(CRD42021264046).
Results: A total of 9 studies were included in this meta‐analysis, and the 9 included studies were all high‐quality studies. We conducted a meta‐analysis of the operation time, estimated blood loss, hospital stay, positive surgical margins, complication. We found that there was no statistically significant difference between the RANU group and LNU group in OT [WMD = 29.41, 95%CI (‐1.10, 59.92), P = 0.22], EBL [WMD = ‐55.30, 95%CI (‐171.14, 60.54), P = 0.13], LOS [WMD = ‐0.39, 95%CI (‐1.03, 0.25), P = 0.12], PSM [OR = 0.91, 95%CI (0.72, 1.15), P = 0.12], and complications [OR = 0.91, 95%CI (0.49, 1.69), P = 0.13].
Conclusions: In summary, this meta‐analysis shows that the perioperative indicators and safety indicators of RANU and LNU in the treatment of UTUC are similar, and both RANU and LNU are effective and safe treatments for UTUC. However, there are some uncertainties in the implementation and selection of LND.
The Prognostic Significance of Controlling Nutritional Status (CONUT) Score for Surgically Treated Renal Cell Cancer and Upper Urinary Tract Urothelial Cancer: A Systematic Review and Meta‐analysis
L Peng
Second Clinical Medical College of Lanzhou University, China
Introduction & Objective: In order to evaluate the predictive effect of the controlled nutritional status (CONUT) score on the prognosis of patients with renal cell carcinoma (RCC) and upper urinary tract urothelial carcinoma (UTUC), a meta‐analysis was performed.
Methods: This systematic review has been registered on PROSPERO, the registration ID is CRD42021251879. A systematic search of the published literature using PubMed, Web of Science, Cochrane Library, EMBASE, and MEDLINE was performed. The fields of "renal cell cancer", "upper tract urothelial cancer", and "controlling nutritional status" and other fields were used as search terms. STATA 16 software was used to carry out data merging and statistical analysis of binary variables, Q test and chi‐square tests were used to verify the heterogeneity between the included works of studies. Subgroup analysis and sensitivity analysis are used to explain the sources of heterogeneity between studies. The Begg's test is used to assess publication bias between studies.
Results: From the first 542 studies retrieved, through strict inclusion and exclusion criteria, 7 studies finally met the requirements and were included in the meta‐analysis. Pooled results indicated that high CONUT indicates worse over survival (OS) [HR = 1.70, 95%CI (1.43‐2.03), P = 0.02], cancer‐specific survival (CSS) [HR = 1.84, 95%CI (1.52‐2.23), P = 0.01], recurrence‐free survival (RFS) [HR = 1.60, 95%CI (1.26‐2.03), P = 0.116] and disease‐free survival (DFS) [HR = 1.47, 95%CI (1.20, 1.81), P = 0.03]. Based on cancer type, cut‐off value, region and sample size, a subgroup analysis was performed. The results showed that OS and CSS were not affected by the above factors, and the high CONUT score before surgery predicted worse OS and CSS.
Conclusions: In conclusion, this meta‐analysis revealed that the preoperative CONUT score is a potential independent predictor of the postoperative prognosis of RCC/UTUC patients. A high CONUT predicts worse OS/CSS/DFS and RFS in patients.
Primary Localized Bladder Amyloidosis ‐ Long Term Experience from an Apex Tertiary Health Care Centre
P Singh, S Jain, S Panaiyadian, S Kumar, A Seth, A Sachan, N Aggarwal, S Kumar
All India Institute of Medical Sciences, New Delhi, India
Introduction & Objective: Primary localized bladder amyloidosis (PLBA) is a rare pathological variant of genitourinary amyloidosis with limited understanding of its etiopathogenesis. Its overlapping clinical presentation with several chronic bladder pathologies including carcinoma bladder makes it a unique differential diagnosis. Practising urologists need to understand the clinical spectrum and management strategies to tailor treatment in such patients. PLBA needs to be differentiated from secondary genitourinary amyloidosis. Transurethral resection and histological examination is essential to exclude malignancy and to establish the benign nature of amyloidosis. Regular follow‐up is required as recurrence is common.
Methods: We retrospectively reviewed our medical records for patients with PLBA between April 2013 and December 2020. PLBA was confirmed by the presence of subepithelial amyloid deposits and ruling out secondary amyloidosis with serum and urine electrophoresis; rectal biopsy, and abdominal fat aspiration for amyloid protein. Patient, imaging and cystoscopic characteristics, and clinical outcomes were evaluated.
Results: We identified 11 patients with PLBA during the study period with a median age of 52 years. Hematuria (72.7%) was the most common symptom followed by irritative lower urinary tract symptoms (LUTS) (45.5%). Of note, 3/11(27.3%) had irritative LUTS alone. The bladder lesions were focal, multiple and diffuse in 3(27.3%), 7(63.6%) and 1(9.1%) patients, respectively (Figure 1). All patients had transurethral resection of the bladder tumor, except for three patients with exclusive irritative LUTS who had cold cup biopsy. At a mean follow‐up of 56.1 months, 2 patients (18.2%) developed recurrence, one at 18 months and another at 24 months post TURBT. Both were managed endoscopically by re‐resection and none of the patients required radical surgery.
Conclusions: PLBA is a rare entity with varied clinical presentations. Although histologically benign, recurrences are common and require long‐term cystoscopic surveillance. With overlapping presentation it remains an important differential of carcinoma bladder.
MP3: Pediatrics, ESWL, Socioeconomics and Health Policy I
Timing of Lithotripsy Does Not Effect Outcomes of Acute Ureteric Stones
R Menzies‐Wilson, M Spencer, B Turney
Introduction & Objective: It is generally accepted that performing ESWL early for acute ureteric stones improves stone clearance rates. Consequently many guidelines advocate early use of ESWL. However, the quality of evidence supporting this is poor. Kumar et al's (2010; n = 160) comparison of early (< 48 hours) vs delayed (48 hours ‐ 1 week) ESWL for proximal ureteric stones found no statistical difference in stone free rate, but did find an increased use of auxiliary procedures and ESWL sessions in the delayed group. Uguz et al (2015; n = 62) found improved clearance rates from early ESWL in proximal ureteric stones but did not find any difference in distal ureteric stones.
This study's objectives were: 1) to assess the effect that early (< 48 hours) vs. delayed ( >48 hours) ESWL has on stone clearance of all ureteric stones; 2) to assess the effect that early vs. delayed ESWL has on stone clearance of distal ureteric stones.
Methods: This study retrospectively analysed data from all ESWL treatments for acute ureteric stones performed from 1st January 2019 ‐ 18th October 2021 in a single tertiary‐level hospital. Patients who underwent at least one session of ESWL for an acute radio‐opaque ureteric stone >5mm which had not passed conservatively were included in the study. Our exclusion criteria were pregnancy, bleeding diathesis, sepsis, acute kidney failure. All ESWL treatments were delivered by a specialist trained radiographer with standard settings of 2000 shocks at 1.0Hz with an extended focus.
The data was analysed to assess clearance rates and number of ESWL treatments for those undergoing treatment at three separate time periods: <48 hours vs. 48 hours – 7 days vs >7 days
Results: 234 patients met our inclusion criteria. There was no statistical difference in clearance rates, or number of ESWL treatments, between the three groups (Table 1). Subgroup analysis of distal ureteric stones showed a similar outcome (Table 2).
Conclusions: Our data does not support the widely held perception that early ESWL leads to improved stone clearance rates.
Clinical Patterns and Implications of Prescription Opioid Use in a Pediatric Population for the Management of Acute Renal Colic
R Alam, R Becker, A Alam, J Winoker, C Wu, H Di Carlo, J Gearhart, E Katz, B Matlaga
Johns Hopkins University School of Medicine
Introduction & Objective: The pediatric population is particularly vulnerable to the effects of opioid use, but these drugs remain a viable second‐line option, after non‐opioid analgesics, for those suffering from acute renal colic. We sought to examine the practice patterns of pain management in the emergency room (ER) for acute renal colic and the impact of opioid prescriptions on return visits and persistent opioid use in a contemporary pediatric population.
Methods: TriNetX is a collaborative research enterprise which collects real‐time data from over 87 million patients located in 58 healthcare organizations nationwide. We queried the research network for pediatric patients (< 18 years) who visited the ER between 2010 and 2021 for urolithiasis, stratified by the receipt of oral opioid prescriptions (opioid vs non‐opioid). We compared clinicodemographic characteristics between the two groups and calculated the risk ratio (RR) of patients returning to the ER within 14 days and persistent opioid use ≥6 months from the initial visit. Propensity score matching was performed to control for confounders.
Results: We identified 2,536 pediatric patients who visited the ER for urolithiasis, of whom 390 (15.4%) were prescribed oral opioids. Patients receiving opioid prescriptions were more likely to be older (11.5 years vs 9.6 years, P < 0.001) and female (56.4% vs 43.6%, P = 0.03). Black patients were less likely than all other races to receive opioid prescriptions (P < 0.001). Patients receiving opioids were more likely to have a prior history of urolithiasis (31.3% vs 18.8%, P < 0.001), anxiety (15.9% vs 8.9%, P < 0.001), and opioid use (42.8% vs. 22.9%, P < 0.001). On unmatched analysis, the opioid group demonstrated an increased risk of return ER visits (RR 1.82, P < 0.001) and persistent opioid use (RR 7.28, P < 0.001) than the non‐opioid group. Propensity score matching yielded 377 patients in each group. On matched analysis, patients who were prescribed opioids remained at increased risk of a return ER visit (RR 1.69, P = 0.02) and persistent opioid use (RR 7.55, P < 0.001) compared to patients who were not prescribed opioids, demonstrating the robustness of these findings even after controlling for confounders.
Conclusions: Administration of opioids for acute renal colic in a pediatric population is associated with an increased risk of return ER visits as well as long‐term opioid use, even after matching for potential confounders.
Development of a Surgical Decision Aid for Patients with Nephrolithiasis: Shockwave Lithotripsy versus Ureteroscopy
J DiBianco, R Becker, S Daignault‐Newton, B Conrado, S Hawley, G Lane, K Ghani, C Dauw, f Surgery Improvement Collaborative
The University of Florida
Introduction & Objective: Treatment decision satisfaction for patients with symptomatic nephrolithiasis remains low for many patients. Shared decision making is recommended to help deciding between ureteroscopy (URS) or shockwave lithotripsy (SWL) in this population. We aimed to develop a surgical decision aid (SDA) to facilitate decision making for nephrolithiasis.
Methods: The scope of the SDA was identified through formal and informal discussions with patients, patient advocates and urologists in the Michigan Urological Surgery Improvement Collaborative (MUSIC). A steering committee consisted of patient advocates, the MUSIC coordinating center, decision making content experts, biostatisticians and MUSIC urologists. Content domains were assessed through best available evidence and content experts. For content validation we conducted anonymous survey of 35 MUSIC urologists. Content Validity Ratios (CVR), numeric value indicating degree of expert validity, were calculated. Face validation interviews were conducted with patient advocates.
Results: A prototype using descriptive plain language and pictorial information was designed for nephrolithiasis patients who are candidates for SWL or URS. Page 1 addressed patient education and page 2 informed urologists of patient treatment goals. Six content domains were chosen: anesthesia type, effectiveness, number of procedures, risk, pain and recovery. 91.4% and 85.7% of urologists indicated that Page 1 and Page 2 accomplished their goals, respectively (Table 1). Anesthesia type was the only domain to receive a lower than acceptable CVR. Patient advocates reported high levels of face validation (Table 2).
Conclusions: We developed a SWL vs URS treatment choice SDA to aid with promising content and face validity. Agreement and contradiction between content and face validation regarding relevance of anesthesia type and recovery time indicate further work is required to determine clinical utility and understand its potential ability to improve patient understanding and treatment satisfaction.
IS “ROUTINE” VOIDING CYSTOURETHROGRAM (VCUG) NECESSARY AFTER ROBOTIC URETERAL REIMPLANTATION FOR PRIMARY VESICOURETERAL REFLUX IN PEDIATRIC AGE GROUP?
AA Elbakry, K Aldabek, T Trump, O Al‐Omar
West Virginia University Hospital
Introduction & Objective: American Urological Association guidelines recommend follow‐up VCUG after endoscopic management, however it is listed as an “Option” after open reimplantation giving high resolution rate after open surgery 98.1% (95% CI: 95.1‐99.1). There was no recommendation regarding robotic reimplantation. We are aiming to shed the light on this topic in our study.
Methods: We retrospectively reviewed all pediatric patients who underwent robotic reimplantation. We identified 29 patients between July 2018 and December 2021. We excluded 5 patients who did not have follow‐up VCUG. The remaining 24 patients were included in this study. Patients' demographics, perioperative data, and outcomes were collected and reviewed.
Results: 24 patient (25 ureters) had postoperative VCUG (83%). Patients' mean age is 6 (SD 2.1) years. Most patients (52%) had grade 3 reflux. One patient underwent bilateral reimplantation. Mean operative time was 157 min (SD 29.3). The tunnel length was 3.4 (SD 0.5) cm. No reported intraoperative complications. Hospital stay was less than 24 hours in 23 (95.8%) patients. Urinary extravasation that required stent placement was reported in a bilateral reimplantation. Subsequent evaluation showed complete healing with no long‐term consequences. Postoperative VCUG showed complete resolution of reflux in all ureters except one patient (96%), who showed improvement from grade 4 down to 1. Also, 4 patients (16.6%) developed de novo contralateral grade 1 reflux.
Conclusions: Giving similar success rate of robotic ureteral reimplantation to those in open approach, we suggest that VCUG should not be “routinely” done after robotic ureteral reimplantation once the surgeon complete the learning curve.
Outcomes of Extravesical Robotic Assisted Laparoscopic Ureteral Reimplantation (ERALUR) in Pediatric Patients with Vesico‐Ureteral Reflux and Bladder and Bowel Dysfunction Syndrome
AA Elbakry, K Aldabek, T Trump, O Al‐Omar
Introduction & Objective: Bladder and bowel dysfunction syndrome (BBD) is reported to have no impact on success rate after open ureteral reimplantation (OUR). However, Bladder dysfunction (BD) and urinary retention is reported to be one of the complications after OUR, especially when it is done bilaterally. The aim of this study is to report the outcomes of ERALUR in this group.
Methods: We retrospectively reviewed all pediatric patients who underwent ERALUR. We identified 29 patients between July 2018 and December 2021. We excluded 3 patients who did not have at least 3 months follow. Out of the remaining 26 cases, a total of 23 patients/24 ureters were found to have preoperative BBD. All patients received an average of 6 weeks of preoperative standard Urotherapy.
Results: Patients' mean age is 6.1 years (SD 2). Most patients (50%) had grade 3 reflux. Only one patient underwent bilateral reimplantation. Mean operative time is 155 min (SD 27). Blood loss was minimum. The average tunnel length was 3.2 cm (SD 0.4). No reported intraoperative complications. Hospital stay was less than 24 hours in 22 (95.7%) patients and one patient was discharged after 48 hours. One postoperative complication was reported in a bilateral reimplantation, as patient had urinary extravasation that required stent placement. Subsequent evaluation showed complete healing with no long‐term consequences. Postoperative ultrasound was normal in all patients except one who showed improvement of the preexisting hydronephrosis but not complete resolution. Postoperative VCUG was done in 21 patients (22 ureters) and showed resolution of reflux 20 patients/21 ureters (95%) and one patient showed improvement from grade 4 down to 1. Also, 3 patients (14.3%) developed de novo contralateral grade 1 reflux. All patients showed stable or improved BBD without any case of urinary retention.
Conclusions: Our preliminary data suggests that robotic approach is a safe option for ureteral reimplantation in BBD patients, with high success rate, like those reported in open series.
Malfunctions and Corresponding Injuries Associated with Lithotripsy Devices. A Review of the FDA MAUDE Database
M Levy, C Chin, KA Moody, KT Ravivarapu, D Qian, E Garden, M Palese
Icahn School of Medicine at Mount Sinai
Introduction & Objective: Lithotripsy is a common minimally invasive nephrolithiasis treatment with a low complication rate. We analyzed the Food and Drug Administration's Manufacturer and User Facility Device Experience (MAUDE) database to identify injuries caused by perioperative lithotripsy device malfunctions.
Methods: The MAUDE database was queried for Ultrasonic and Electro‐Hydraulic Lithotripters (UEHL), Shock Wave Lithotripters (SWL), and Lithotripsy Transducers and Footswitches (LTF) between January 1, 2017 – January 1, 2022. Duplicate reports, summaries of published literature, known procedural complications, and reports related to biliary lithotripsy were excluded. Malfunctions were categorized as having no related injuries, patient injury, or employee injury. Causes of malfunctions, injuries, and aborted cases were recorded.
Results: 592 reports were identified, of which 343 met inclusion criteria (UEHL: 80, SWL: 60, LSA: 203). For UEHL, the most common malfunction was probes breaking during the procedure. This led to injury 54% of the time due to probes breaking inside the patient, of which 17% were not fully removed. Other injuries included tissue perforations, patient burn, physician burn, and physician injury from a damaged device. The most common malfunction for SWL was a non‐functional device which led to case abortion in 57% of reports. All SWL injuries were clinical complications (67% post‐operative; 33% intra‐operative) that may or may not be associated with a device malfunction, though there was one report of a physician injury from a damaged device. There were similar numbers of reported malfunctions between UEHL (n = 80) and SWL (n = 60). UEHL had a significantly greater rate of either patient or physician injury compared to SWL (43.8% vs 16.7%, p < 0.001), however SWL had a significantly greater rate of case abortions (48.3% vs 3.8%, p < 0.001). Though there were roughly 3x more LTF malfunctions reported compared to UEHL and SWL, they caused no injuries and lead to abortion in 5.4% of cases [Table 1].
Conclusions: Few studies have emphasized the effect of perioperative lithotripsy device malfunctions on patient and procedure outcomes. Though rare, minor device malfunctions may lead to procedure delays, case abortions, and injuries. Physicians should be aware of common device malfunctions and troubleshooting options to reduce these risks.
Predictors of Potentially Avoidable Emergency Department Presentations for Renal Colic and Their Associated Costs
SJ Chadwick, O Dave, J Frisbie, C Scales, DF Friedlander
University of North Carolina, Chapel Hill School of Medicine
Introduction & Objective: Renal colic represents a leading cause of emergency department (ED) presentation nationally, yet most patients require neither hospital admission nor surgical intervention. Patient and facility factors associated with potentially avoidable ED visits and their economic burden on the health care system were investigated.
Methods: Patients presenting to the ED for index renal colic events were selected using Florida and New York all‐payer data from the 2016 Healthcare Cost and Utilization Project (HCUP) State Databases. Avoidable visits were defined as those that did not result in intervention, admission, or referral to an acute care facility. Utilizing multivariable logistic and linear regression, researchers discerned patient and facility factors predictive of avoidable ED presentations, as well as associated costs.
Results: Of the 167,102 ED encounters for renal colic, 68.2% met pre‐determined criteria as potentially avoidable visits, with cumulative costs totaling $229,269,273.77 over one year. Factors associated with avoidable visits included Hispanic ethnicity (Hispanic vs. White: OR 1.12, 95%CI 1.02‐1.24: p = 0.02), higher education levels (≥13% less than high school level education vs. <9.7%: OR 0.73, 95%CI 0.63‐0.86: p < 0.001), and rural care settings (rural vs. large metropolitan OR, 1.41 95%CI 1.26‐1.59: p = 0.001). Conversely, increased comorbidities (Elixhauser score ≥3 vs. 0: OR 0.02, 95%CI 0.02‐0.02: p < 0.001), female gender (female vs. male: OR 0.76, 95%CI 0.73‐0.79: p < 0.001), and Medicare/Medicaid beneficiary status (Medicare vs. private: OR 0.64, 95%CI 0.60‐0.67: p < 0.001)/(Medicaid vs. private: OR 0.70, 95%CI 0.66‐0.75: p < 0.001) were protective against avoidable visits. Experiencing an avoidable visit was associated with a greater number of renal‐colic related ED visits (OR 4.01, 95%CI 3.69‐4.36; p < 0.001).
Conclusions: Several non‐clinical factors are associated with potentially avoidable ED visits for renal colic. Given the high incidence of emergency department visits that we posit may have been safely managed in outpatient or urgent care settings, our findings support investment into outpatient diagnostic and procedural alternatives to inpatient care to divert these patients to lower acuity care settings. If appropriately targeted, standardization of care may represent an opportunity to reduce healthcare spending without compromising the quality of care delivery.
An Analysis of Regionally Based Public Demand for Urologists in the United States
M Wynne, H Pakhchanian, R Raiker, M Whalen
The George Washington University School of Medicine and Health Sciences
Introduction & Objective: An expanding, aging population in the United States (US) poses a substantial challenge to the urology workforce. Adults age 65 and older account for one of the most rapidly growing segments of the population and utilize urologic services at a higher rate than the general population. Exacerbating the increasing need for urologic services is an aging urology workforce and shortage of urologists. Quantifying and tracking patient demand on a geographic basis will help urologists determine how to best meet healthcare needs across the nation as we face this unprecedented challenge. With Americans increasingly seeking health information online, analysis of internet search engine data affords a novel methodology by which we can assess demand for urologic care. The objective of this study is to quantify patient demand for urologists on a state‐by‐state basis through analysis of Google Trends data.
Methods: Google Trends data was analyzed from 2004–2019 to determine the average relative search volume (RSV) for the term “urologist” in each state. The 2019 American Urological Association Census was used to determine the number of practicing urologists per state. A per capita concentration of urologists was calculated by dividing the number of providers by the estimated population in each state as reported by the 2019 Census Bureau. RSV values were then divided by the concentration of urologists to estimate a physician demand index (PDI) for each state scaled 0‐100.
Results: The PDI was highest in Mississippi (100), Nevada (89), New Mexico (87), Texas (82), and Oklahoma (78). The concentration of urologists per 10,000 people was greatest in New Hampshire (0.537), New York (0.529), and Massachusetts (0.514), and lowest in Utah (0.268), New Mexico (0.248) and Nevada (0.234). RSV was highest in New Jersey (100.00), Louisiana (91.67), and Alabama (87.67), and lowest in Wisconsin (31.17), Oregon (29.17), and North Dakota (28.50).
Conclusions: The findings of this study suggest that demand for urologists is greatest in the Southern and Intermountain regions of the United States. Amidst a shortage in the urology workforce, this data may aid physicians and policymakers in focusing interventions. These findings may further aid in future job allocation and practice distribution.
Preliminary Validation of the 6‐item Short Form of the Wisconsin Stone Quality of Life Questionnaire (WISQOL)
MA Knoedler, S Li, C Haas, S Nakada, KL Penniston
University of Wisconsin, Department of Urology
Introduction & Objective: The 28‐item Wisconsin Stone Quality of Life questionnaire (WISQOL) is used to assess patients' health‐related quality of life (HRQOL) related to kidney stones. We developed a 6‐item short‐form version (WISQOL‐SF) to meet providers' needs for fast and reliable outcomes and reduce patients' burden in reporting their HRQOL. Our aims were to (1) pilot the WISQOL‐SF in a clinical population of stone formers and (2) assess its congruent validity.
Methods: Patients are invited to complete the WISQOL at each appointment in our urology clinic. Patients (n = 844) who completed the WISQOL between 6/2017‐8/2021 were randomly split into two groups (422 patients each). Scores for the WISQOL were calculated for one group while those for the WISQOL‐SF were calculated for the other. Two‐way ANOVA was used to compare standardized scores for each group. The impact of age, gender, symptoms and current stone status at the time of WISQOL completion were examined using multivariate ordinal logistic regression by creating quantiles of the standardized scores (20, 40, 60, and 80).
Results: Nearly half had self‐reported current stones (49% vs 50%, p = 0.917) and those experiencing stone‐related symptoms were similar (30% vs 34%, p = 0.406). The internal consistency of the WISQOL‐SF (Cronbach's alpha = 0.944) was similar to the original (Cronbach's alpha = 0.973). No significant differences for HRQOL were found (Table 1). Interestingly, while both instruments revealed significantly lower HRQOL among patients with symptoms at the time of the survey, only the WISQOL‐SF demonstrated differences between patients with and without current stones (p = 0.042; Table 2).
Conclusions: The 6‐item WISQOL‐SF version demonstrates similar findings to the 28‐item WISQOL version. If further validity testing in a broader, multi‐center, prospective settings confirms these findings, the WISQOL‐SF will be a valuable addition to current clinical and research tools for assessing patients' HRQOL related to kidney stones.
Trends in the Surgical Management of Adult Urolithiasis in Ontario, Canada: A Population‐Based Retrospective Cohort Study
D Golomb, S Dave, FC Gabrigna Berto, A McClure, B Welk, P Wang, J Bjazevic, H Razvi
Assuta Ashdod Hospital
Introduction & Objective: The incidence of urinary stone disease is increasing. The aim of this review was to document the trends and incidence of surgical intervention for adults with upper urinary tract stones in Ontario, Canada.
Methods: We carried out a retrospective, population‐based cohort study utilizing administrative databases held at the Institute of Clinical Evaluative Sciences to identify all adults ( >18 years) who underwent their first surgical treatment for urolithiasis as recorded in the Canadian Institute for Health Information, Discharge Abstract Database or via physician billing information using the Ontario Health Insurance Plan database from 2002‐2018. During this period, we assessed the incidence of surgically treated urolithiasis, age and gender distribution and modality of surgical treatment. Descriptive statistics were used to summarize patient demographics and surgical trends were analyzed using the Cochrane‐Armitage test for trend.
Results: Between 2002‐2018, 140,263 patients were treated surgically for urolithiasis. During this time period, the total number of surgically treated stone disease increased by 80.5%. By type of procedure, percutaneous nephrolithotomy (PCNL) increased by 187%, ureteroscopy (URS) increased by 158%, while the number of shock wave lithotripsy (SWL) declined by 31.4%. The adult population in Ontario in the years evaluated grew by 24.4%. The number of surgical procedures per 100,000 people over this time grew by 45.3%. For every 1% increase in the population, there was a 2.6% rise in stone related surgical procedures.
Conclusions: The number of stone related surgical procedures performed rose significantly and cannot be accounted for by population growth alone. This rise was proportionally larger in the female population, further supporting a narrowing of the gender gap in urinary stone disease. The reasons for the increase are likely multifactorial and may imply an increasing incidence of surgically treated stone disease. The rise in the number of URS as well as the decrease in SWL demonstrate a continued shift in surgical preference. The increase in PCNL volumes may also suggest a greater complexity of cases. These findings may have future resource planning implications and require further study.
A Social Needs Screening Tool Facilitates Reduced Length of Stay and Total Encounter Cost for Surgical Patients
XC Cortez, E Finlayson, S Smith, C Lau, R Gonzales, T Chi, H Jolly
UCSF
Introduction & Objective: Prolonged length of stay (LOS) after surgery has been shown to worsen patient recovery and utilize health system resources unnecessarily. Logistical and social support barriers to optimizing surgical care have been under‐examined. The primary objective of this study was to implement a social needs screening tool amongst patients undergoing urologic surgical care and measure its impact on length of stay and total direct cost.
Methods: This was a single institution prospective cohort study where a social needs screening tool was applied to patients undergoing elective surgery in seven surgical departments (Urology, Ophthalmology, OHNS, Vascular, Neurosurgery, Orthopedics, and Plastics) from July 1, 2020 to June 30, 2021. Social needs screening was conducted by a staff member via phone or electronic messaging after surgery was scheduled. Patient ability to obtain mandatory COVID testing, transportation to and from the hospital for surgery, availability of a post‐operative caregiver, and current mood were queried during screening. Referral to Social Work Services was conducted if the patient reported a resource deficiency. LOS and total direct cost were collected for each encounter and compared to a historical control cohort of patients from the same departments from January 1, 2019 to February 28, 2020 that did not undergo social needs screening.
Results: 3284 patients were screen‐eligible during the study period and were compared to 3360 control encounters. Of the screened patients, 190 screened positive and required social work support. There were no significant differences in age, gender, and race between the screened and control cohorts. Screen‐positive patients were more likely to reside in a county outside of the greater San Francisco Bay Area and more likely to have government insurance as their primary payor (p < 0.05). Median and average LOS was lower in the intervention (1, 2.67 days) compared to the control cohort (2, 3.58 days). Median and average direct cost was lower in the intervention ($11,661; $20,406) compared to the control ($18,193; $30,084) cohort.
Conclusions: The implementation of a social needs screening tool to proactively address logistical barriers to care reduces LOS and total direct cost for surgical patients, optimizing comprehensive healthcare delivery.
Pediatric Urolithiasis in Ontario, Canada: A Retrospective Review of Surgical Trends and Management
FC Gabrigna Berto, A McClure, P Wang, J Bjazevic, D Golomb, G Filler, B Welk, H Razvi, S Dave
Western University
Introduction & Objective: Pediatric urolithiasis (PUL) is a chronic recurrent condition with a growing incidence worldwide that results in significant patient morbidity and health care expenditures. This study evaluates surgical trends and management of PUL in the province of Ontario, Canada from 2002‐2018.
Methods: This retrospective cohort identified all children (< 18 years) who underwent their first surgical treatment for PUL using the Canadian Institute for Health Information ‐ Discharge Abstract Database or a physician billing in the Ontario Health Insurance Plan administrative databases held at the Institute of Clinical Evaluative Sciences (ICES). Patient demographics and surgical trends were analyzed with descriptive statistics, and logistic regression was used to identify independent risk factors for repeat surgical intervention.
Results: This retrospective cohort identified all children (< 18 years) who underwent their first surgical treatment for PUL using the Canadian Institute for Health Information ‐ Discharge Abstract Database or a physician billing in the Ontario Health Insurance Plan administrative databases held at the Institute of Clinical Evaluative Sciences (ICES). Patient demographics and surgical trends were analyzed with descriptive statistics, and logistic regression was used to identify independent risk factors for repeat surgical intervention.
Conclusions: This retrospective cohort identified all children (< 18 years) who underwent their first surgical treatment for PUL using the Canadian Institute for Health Information ‐ Discharge Abstract Database or a physician billing in the Ontario Health Insurance Plan administrative databases held at the Institute of Clinical Evaluative Sciences (ICES). Patient demographics and surgical trends were analyzed with descriptive statistics, and logistic regression was used to identify independent risk factors for repeat surgical intervention.
Trends of Practice and Intervention in Paediatric Endourology: A European Survey via EAU Sections
A Pietropaolo, Z Hameed, F Esperto, E Keller, A Bujons, S Griffin, C Seitz, BK Somani
Introduction & Objective: A survey was distributed to Urologists with particular interest in endourology to understand the current standard of treatment of paediatric patients with urolithiasis. Within the urological community, only some treat paediatric urolithiasis. With this survey we wanted to collect the trends and standard of treatment within Europe.
Methods: The survey was distributed through the European association of urologists (EAU) section of Urolithiasis (EULIS) and Young academic urologists (YAU), endourology and urolithiasis working party.
Results: 54 Urologists answered the survey of which two‐third actively managed paediatric stones. Of those who responded, 28 were adult urologists, 20 were paediatric urologists and 6 did not respond to their speciality. 57% of adult urologists and all paediatric urologists were involved in paediatric stone management. A nephrologist was also present in 15% of these clinics. The surgical procedure was performed as a joint adult‐paediatric twin surgeon model by 21 (39%). There was a wide variation in treatment modality used for renal and ureteric stone. While percutaneous nephrolithotomy (PCNL), shockwave lithotripsy (SWL) and ureteroscopy (URS) were offered by all clinicians, for renal stones there was higher uptake for SWL and URS. Overall, while URS was more favoured for renal stones, it was significantly more common as a choice for ureteric stone (Table). While an access sheath was not used at all by a third of clinicians, two‐thirds of them used it for half of their renal stone URS procedures. Of all the PCNL procedures, mini‐PCNL was performed in 50‐75% of cases. Overall, endoscopic combined intrarenal surgery (ECIRS) was performed by almost half of the respondents and no difference was noted in positioning in those performing prone versus supine PCNL.
Conclusions: Treatment of paediatric stones is variable with all modalities offered by clinicians. It seems that ureteroscopy is gaining more popularity for both renal and ureteric stones. There is also an uptake of modern advances such as ureteric access sheath, mini‐PCNL, supine position and ECIRS. A shared decision making in a multi‐disciplinary fashion involving paediatric, adult urology, radiology and nephrology teams needs to have wider adoption in future.
Transitioning Urological Inpatient Procedures as Same‐Day Procedures During the COVID Pandemic– A Retrospective Feasibility Study
N Siron, A Assad, J Lattouf, KC Zorn, M Meskawi, N Bhojani
University of Montreal
Introduction & Objective: In line with Canadian provincial directives and due to the COVID pandemic, certain urological procedures that are normally performed as inpatient procedures were performed as same‐day procedures to reduce the usage of healthcare resources. At our centre, during the pandemic, we began performing laser enucleation of the prostate (LEP), robotic assisted radical prostatectomy (RARP) and percutaneous nephrolithotomy (PCNL) as outpatient surgeries. Recent literature has suggested that these procedures are safe and feasible as same day surgeries. Our goal was to determine if there was a difference in patient outcomes in LEP, RARP, and PCNL patients operated as same day surgery vs inpatient.
Methods: Patients operated for LEP, RARP or PCNL were studied between May 2020 to March 2022. Amongst LEP patients, 104 were identified as planned same‐day (PSD‐LEP) surgeries and 65 were planned inpatient surgeries (PIP‐LEP). Amongst RARP patients, 46 were identified as planned same‐day (PSD‐RARP) procedures and 148 were planned inpatient (PIP‐RARP) procedures. Amongst PCNL patients, 36 were identified as planned same‐day (PSD‐PCNL) and 12 were planned inpatient (PIP‐PCNL). PSD procedures were compared to PIP procedures with primary outcomes being SDD failure, 30‐day complications, and readmission rates.
Results: General patient characteristics such as age, ASA, and Revised Cardiac Risk Index (RCRI) were similar between PSDD and PIP in all 3 surgical populations (table 1). Of the PSDD‐LEP patients, 77.9% were successfully discharged the day of the surgery. The overall post‐operative complication, 30‐day ED visits and readmission rates were 8.7%, 3.8%, and 1.0% in PSDD‐LEP patients versus 23% (p = 0.017), 9.2% (p = 0.27), 4.6% (p = 0.32) for PIP‐LEP, respectively (table 2). Of the PSDD‐RARP patients, 73.9% were successfully discharged the day of the surgery. The overall post‐operative complication, 30‐day ED visits and readmission rates were 15.2%, 17.4%, and 4.3% in PSDD‐RARP patients versus 6.1% (p = 0.097), 4.1% (p < 0.05), 1.4% (p = 0.51) for PIP‐RARP, respectively. Of the PSDD‐PCNL patients, 69.4% were successfully discharged the day of the surgery. The overall post‐operative complication, 30‐day ED visits and readmission rates were 22.2%, 8.3%, and 2.8% in PSDD‐PCNL patients versus 16.7% (p = 1.0), 8.3% (p = 1.0), 8.3% (p = 1.0) for PIP‐PCNL, respectively.
Conclusions: Same‐day discharge for LEP, RARP, and PCNL is safe and feasible in select patients with an acceptable and comparable complication rate.
Efficacy of Narrow Focus versus Wide Focus Shock Wave Lithotripsy in Management of 1‐2cm Renal Calculi Using Tri‐focal Lithotripsy Machine: First Double‐Blind Randomized Trial
YA Noureldin, W Abdel Halim, E Elnahif, A Abdelbaky, S El Hamshary
Faculty fo Medicine, Benha University, Egypt and King Abdulaziz Medical City, Riyadh, Saudi Arabia
Introduction & Objective: Piezo Lith3000 plus (Richard Wolf, Germany) was recently introduced with unique characteristics that offer tri‐focal lithotripsy. The objectives of this study were to compare the stone free status (SFS) and complications following shock wave lithotripsy (SWL) using a narrow focus of 2mm (F1) versus a wide focus of 8 mm (F3) for renal stones 1‐2cm
Methods: After obtaining ethics approval and informed consents,this double‐blind randomized study recruited adult patients with solitary radio‐opaque renal pelvic stone 1‐2 cm. Patients were electronically randomized into two groups; F1 group received narrow focus (2 mm) SWL while F3 group received wide focus (8mm) SWL. Baseline patient's and stone characteristics were collected. The SFS (%) and complications sorted by Clavien‐Dindo classification system were identified. Primary outcome was overall SFS (%) calculated one month following the last SWL session, with a maximum of 3 sessions. Secondary outcomes included presence of complications such as hematuria, fever, pain, and peri‐renal hematoma. Both SFS and complications were compared between the two groups.
Results: A total of 135 patients were recruited for this study; 67 patients in F1 group and 68 patients in F3 group. Preoperative parameters were comparable in terms of age (p = 0.16), female gender (p = 0.52), BMI (p = 0.71), stone size (1.19 ± 0.3 vs. 1.12 ± 0.3mm; p = 0.18), and HU (858 ± 246 vs. 844 ± 192; 0.70). The overall SFS was comparable between both groups (92.5% vs. 91.2%; p = 0.77). Similarly, the need for auxiliary intervention was comparable between both groups (23.4% vs. 23.2%; p = 0.23), respectively. In terms of complications, perinephric hematoma (Clavien 1) and fever (Clavien 1) were comparable between both groups (0% vs. 1.5%; p = 0.32) and (3% vs. 2.9%; p = 0.99). Nevertheless, patients in F1 group had significantly higher experience of hematuria (Clavien 1) (95.5% vs. 83.8%; p = 0.02), and pain (Clavien 1) (65.7% vs. 19.1%; p < 0.001). However, the overall satisfaction was comparable between the two groups (77.6% vs. 77.9%; p = 0.96).
Conclusions: Narrow‐focus and wide‐focus SWL were associated with comparable outcomes and re‐treatment rates. However, narrow‐focus lithotripsy was associated with significantly higher morbidity in terms of pain and hematuria
Comparison of External Stents and DJ Stents Techniques for Pediatric Pyeloplasty: A systematic Review and Meta‐Analysis
C Meng
Department of Urology, The affiliated Nanchong Central Hospital of North Sichuan Medical College (University)
Introduction & Objective: To evaluate and compare the efficacy and safety between an external stent and a double J stent in young children with pyeloplasty.
Methods: Through a systematical search of multiple scientific databases in Aug 2021, we performed a systematic review and meta‐analysis of the primary outcomes of interest according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta‐Analyses), whose protocol was registered with PROSPERO(CRD42021274087).
Results: Ten studies involving 1108 patients were included. No significant differences were observed in operative time (MD: ‐0.11; 95% CI ‐15.15 to 14.93; P = 0.989), operative success rate (OR:1.10; 95% CI 0.57 to 2.10; P = 0.780), length of hospital stay (MD: 0.65; 95% CI ‐0.04 to 1.34; P = 0.063), or complications (OR:0.77; 95%CI 0.41 to 1.43; P = 0.407) between external stents and double J stents in pediatric pyeloplasty. According to the subgroup analysis, we found the external stent group had a shorter operative time than the double J stent group in terms of robot‐assisted laparoscopic pyeloplasty (MD: ‐17.13; 95% CI ‐32.8 to ‐1.45; P = 0.032).
Conclusions: There were no significant differences in operative time, operative success rate, length of hospital stay, or complications between external stents and double J stents in pediatric pyeloplasty. The external stented procedure seemed to have less operative time when using robot‐assisted laparoscopic pyeloplasty. However, due to the limitations of our analysis, more studies are still required to support our conclusion.
P Lotan, H Hendel, R Babaoff, R Tor, D Ben‐Meir, R Morag, D Lifshitz
Introduction & Objective: Previous studies suggested possible associations between the relative proportions of calcium oxalate dihydrate (COD) and calcium oxalate monohydrate (COM) and age, gender, and ethnicity in pediatric stone formers. Therefore, we investigated these associations, the metabolic parameters, and the stone composition distribution in children.
Methods: We retrospectively reviewed, using infrared analysis, the primary stone components of first‐time pediatric stone formers divided into three age groups: 1‐5, 6‐12, and 13‐18 years between 2014 and 2019. Clinical and metabolic correlates were analyzed.
Results: A total of 220 first‐time pediatric stone formers were identified. Table 1 describes their clinical characteristics. COD and COM distribution were age‐dependent. They were the predominant stone subtypes in the youngest and oldest age groups, respectively (OR 0.39, 95% CI:0.18‐0.86, p = 0.036) (figure 1). For the intermediate age group of 6‐12 years, COM was more prevalent in Arab boys, while COD was the predominant component in girls of all ethnicities. COD was associated with hypercalciuria and COM with hyperoxaluria (Table 2). Hypercalciuria and hypocitraturia were the most prevalent abnormalities at ages 1‐5 and 13‐18 years, respectively.
Conclusions: Calcium oxalate subtype analysis and metabolic correlates have significant clinical relevance, specifically in children. COD and hypercalciuria are more common in younger children, while COM and hypocitraturia in adolescents. These findings suggest unique, complex interactions driving stone composition formations in children that may guide metabolic evaluations, age‐related treatment modalities, and preventive measures.
Long‐term Psychosexual and Urinary Continence Outcomes of Male Patients Who Underwent Repair of Bladder Exstrophy‐Epispadias Complex During Their Childhood: Does Magnetic Resonance Imaging Have a Role?
A Elkashef, A Abdelhalim, M Dawaba
Department of Urology, Urology and Nephrology Center, Mansoura University, Egypt
Introduction & Objective: Bladder exstrophy–epispadias complex (BEEC) refers to a rare spectrum of genitourinary malformations, for which the patients undergo a series of operations for repair during childhood, starting in infancy. The primary goals of these surgeries are urinary continence as well as cosmetically and functionally acceptable genitalia. Therefore, we aimed to evaluate the long‐term psychosexual and urinary continence outcomes of BEEC repair in male patients.
Methods: In a retrospective study, we reviewed the database of the post pubertal male patients who underwent repair of BEEC at our tertiary center from 1990 till 2006. Patients were evaluated for their sexual functions and urinary continence. They were considered to be continent if they were dry for more than 3 hours. History of normal voiding or clean intermittent catherization (CIC) was taken. Patients were evaluated by International Prostate Symptom Score (IPSS), International Index of Erectile Function (IIEF) questionnaire and Ejaculatory Domaine of Men Sexual Health Questionnaire (MSHQ). All patients were subjected to pad test. Pelvic magnetic resonance imaging (MRI) was also performed to assess penile length and vascularity of the corporeal bodies.
Results: A total of 21 male patients with mean ages 21.7 ± 5.2 years old, were included. Complete primary repair was done in 18 cases and the remaining 3 cases were managed by modified staged repair. Seven patients underwent repair as a primary procedure, while 14 patients had redo procedures. Augmentation ileocystoplasty and continent cutaneous outlet were performed in 17 patients, modified rectal bladder was done in 3 patients and 1 patient had no urinary diversion. Bladder neck closure was carried out in 10 patients, while bladder neck reconstruction was reported in 11 patients for which secondary interventions were offered, such as sling procedure (3 patients) and silicon injection (2 patients). Complete penile disassembly was done in 18 patients, whereas modified penile disassembly was carried out in 3 patients. 80.9% of patients were voiding via CIC, 4.8% were voiding per urethra and 14.3% were urinary diverted. Median IPSS score was 6 (0‐30), median IIEF score was 15 (4‐25) and median ejaculatory domain of MSHQ score was 6 (0‐34). Pad test results were negative in 19 patients. Pelvic MRI showed mean penile length 5.5 ± 1.96 cm and the vascularity of corporeal bodies was preserved in 20 patients.
Conclusions: Male adolescents and adults might have good long‐term sexual and urinary outcomes post BEEC repair, but this may require multiple surgeries. Pelvic MRI may play an important role in follow up of BEEC patients.
Predictors of Resolution of Hydronephrosis After Pyeloplasty in Children: Will It Go Away?
M Soltan, A Elkashef, M Edwan, A Atwa, A Abdelhalim, T Helmy, M Abol‐Ghar, A Hafez, M Dawaba, A Shokeir
Department of Urology, Urology and Nephrology Center, Mansoura University, Egypt
Introduction & Objective: Pyeloplasty is the gold standard surgical intervention for ureteropelvic junction obstruction which entails removal of this obstruction. However, hydronephrosis (HN) may persist despite adequate surgical techniques, such as patent, water‐tight and tension‐free anastomosis. Resolution of HN is still not well understood and time to HN resolution varies greatly among individuals. Therefore, we aimed to identify predictors of resolution of HN after pyeloplasty.
Methods: In a retrospective study, data of children who are younger than 15 years and underwent pyeloplasty at a tertiary center between January 2015 and October 2019 were reviewed. Patients who underwent redo pyeloplasty and those with missing data were excluded from the study. Resolution of HN was defined as decrease of the antero‐posterior diameter (APD) to less than 10 mm or >50% reduction of the APD. Analysis of survival using Kaplan Meier's curve was performed with adjustment to perioperative and clinical data.
Results: A total of 256 children were included in the study. Resolution of HN rate was 74.6%, 87.3%, 93.7% and 97% at 1, 2, 3 and 4 years of follow‐up, respectively (Figure 1). Univariate analysis showed no difference in resolution neither between patients with preoperative APD <2, 2‐4 and >4 cm (p = 0.15) nor between different HN grades (p = 0.38). No difference was found among patient age groups <1, 1‐5, 5‐10 and >10 years old (Log rank 0.21). Bilateral cases and those with poorly functioning kidneys (< 20% split renal function) did not show any difference in resolution of HN (Log rank 0.2 and 0.7 respectively). However, patients with solitary kidneys had less resolution rates (Log rank 0.03). On the other hand, cases with percent of improvement of APD (PIAPD) more than 10% within the initial visit showed significantly better resolution rates (Log rank 0.0001) (Figure 2). Both were significant in cox regression analysis.
Conclusions: HN tends to resolve within 3 years after pyeloplasty in more than 90% of cases. Patients with decrease in APD more than 10% from the preoperative value have higher rates of resolution of HN, however, patients with solitary kidneys have lower rates of resolution of HN.
Impact of Delay in Surgical Intervention on Functional Outcomes in Children with Unilateral Ureteropelvic Junction Obstruction
M Soltan, A Elkashef, M Edwan, A Atwa, A Abdelhalim, T Helmy, M Abol‐Ghar, A Hafez, M Dawaba, A Shokeir
Department of Urology, Urology and Nephrology Center, Mansoura University, Egypt
Introduction & Objective: Uretero‐pelvic junction obstruction (UPJO) is the most common cause of obstructive uropathy in children. However, the timing of surgical intervention is debatable and the effect of delayed surgical intervention is also not well‐understood. For example, COVID‐19 pandemic has led to institutional delays and surgical shutdowns in all medical fields worldwide. Therefore, we aimed to identify the effect of delay in surgical intervention on renal function in cases of of unilateral UPJO and factors that may affect it.
Methods: In a retrospective study, database of children who underwent pyeloplasty for unilateral UPJO in a tertiary center from January 2016 to October 2020 was reviewed. Patients who had a delay in pyeloplasty for more than 3 months from the time of diagnosis were identified. Patients for whom 3 renograms were performed at the time of surgical decision, immediately before surgery and within one year postoperatively were included in the study. Deterioration was defined as 5% or more decline in the split renal function (SRF) between 2 consecutive renograms. Patients were then categorized into 2 groups; group of preserved renal function (group 1) and group of deteriorated renal function (group 2) based on the difference in preoperative renograms. Both groups were compared regarding the preoperative and postoperative Antero‐posterior diameter (APD), grading of hydronephrosis (HN), percent of change of HN, change in SRF and duration of delay in months.
Results: A total of 46 children were included in the study; 30 patients had preserved renal function (group 1), while 16 patients had significant deterioration of SRF (group 2). Group 2 showed higher percent increase of APD and more delay in the surgical intervention on univariate analysis, p value = 0.016 and 0.001, respectively (Table 1). On multivariate analysis these factors showed significant difference between both groups. However, other factors did not show any significant difference between the two groups. None of the patients who had surgery within 6 months showed functional deterioration.
Conclusions: Delaying of surgical intervention for less than 6 months may not lead to functional deterioration. Moreover, worsening of HN might precede functional deterioration.
Trends in Urologic Cancer Surgical Volume and Post‐Operative Length of Stay During the COVID‐19 Pandemic
B Chun, H Ramian, C Jones, R Vasan, B Davies, L Sabik, B Jacobs
UPMC
Introduction & Objective: At the peak of the COVID‐19 pandemic, a significant number of cancer surgeries were postponed or cancelled due to lockdown measures and redistribution of hospital assets to address emerging outbreaks. Additionally, hospitals and surgeons triaged which surgeries to schedule and prioritized reducing post‐operative length of stay in order to minimize nosocomial COVID‐19 infection and maximize bed availabilities. We sought to describe patterns in surgical volume and post‐operative length of stay among patients receiving urologic cancer surgery during the COVID‐19 pandemic.
Methods: Using the Pennsylvania Health Care Cost Containment Council database, we identified 24,768 cancer patients ≥18 years of age who received a prostatectomy, radical or partial nephrectomy, or radical cystectomy using ICD‐9 and ICD‐10 codes between Q1 2016 and Q2 2021. We compared rates of surgery and post‐operative length of stay before and during the COVID‐19 pandemic, adjusting for surgical approach (open vs minimally invasive) and patient factors (age, sex, race/ethnicity, Elixhauser comorbidity index, insurance status, and urban/rural status).
Results: Compared to pre‐COVID‐19 surgical volumes, prostatectomy and partial nephrectomy rates decreased by as much as 30.2% in Q4 2020 (p < 0.001) and 20.1% in Q2 2020 (p < 0.01), respectively. The rates of radical cystectomy (p = 0.22) and radical nephrectomy (p = 0.07) did not significantly change. In our adjusted analysis, median post‐operative length of stay after partial nephrectomy was 0.7 days shorter during COVID‐19 (p < 0.01). Open surgery, age, comorbidity index, Medicaid insurance, and Black race were associated with longer length of stay.
Conclusions: The rates of high priority urologic cancer surgery (radical cystectomy and radical nephrectomy) in Pennsylvania did not change during the COVID‐19 pandemic, whereas lower priority surgeries (prostatectomy and partial nephrectomy) decreased in the first and second COVID‐19 waves. Post‐operative management patterns were affected by COVID‐19, as length of stay following partial nephrectomy was shorter.
Combating Physician Burnout: Protecting the Physical Health and Mental Wellbeing of Surgeons Through Preoperative COVID Testing in Patients Undergoing Minimally Invasive Surgery
S Munver, E Tong, J Kuo, R Munver
Hackensack University Medical Center
Introduction & Objective: The impact of COVID‐19 in the United States has adversely impacted physicians. Fears of contracting SARS‐CoV‐2 has led to institutions requiring preoperative COVID screening in patients undergoing surgery. We present the results at a single institution with regard to the effectiveness of a screening program in patients scheduled for minimally invasive surgery.
Methods: Since April 2020, all patients that were scheduled for elective minimally invasive surgery by a single surgeon underwent COVID testing between 48 and 72 hours prior to surgery. Patients were advised to self‐quarantine between the testing date and surgery date. In patients that tested positive for SARS‐CoV‐2, the surgery was postponed. The surgeon also underwent routine COVID testing between 1‐4 times per month during this time period.
Results: A total of 631 surgeries were scheduled between April 2020 and February 2022. Of these, 221 were performed in 2020, 352 in 2021, and 58 in 2022 YTD. Nine asymptomatic patients (1.4%) tested positive for SARS‐CoV‐2 and had surgery postponed for a minimum of 2 weeks. Eight patients rescheduled surgery after a repeat negative test result. The surgeon tested negative for SARS‐CoV‐2 based on rapid and PCR testing.
Conclusions: At a time when the physician burnout rate is high, the added stress of the COVID‐19 pandemic has had a deleterious effect on the quality of life of physicians. The institution of mandatory COVID screening in patients prior to surgery is not only effective in protecting the physical health of surgeons, but it can also have a positive impact on mental wellbeing.
Healthcare Utilization & Costs of Ureteroscopy Patients Among a Us‐Based Commercial Population
J Khusid, R Paranjpe, B Cutone, M Gupta
Introduction & Objective: Ureteroscopy (URS), is a minimally invasive and common procedure for the treatment of patients with kidney stones. The objective of the current study was to evaluate the healthcare utilization and costs of patients undergoing a URS procedure.
Methods: A retrospective claims data analysis was conducted using the IBM MarketScan commercial database. Patients ≥18 years were included if they had an index URS procedure between January 2015 and June 2019. Healthcare utilization including Emergency Department (ED) visits, inpatient visits, Intensive Care Unit (ICU) visits, and imaging (CT, ultrasound, x‐ray), were measured 6‐months prior till 1‐year post URS procedure. Retreatment including a primary diagnosis of URS/percutaneous nephrolithotomy /shock wave lithotripsy/stent placement was measured 1‐month post URS procedure till 1‐year post URS procedure. Readmissions were measured 3‐days post till 30‐days post URS procedure. Two descriptive analyses measuring healthcare utilization associated with a primary diagnosis of stone/ infectious complications as well as all‐cause were conducted. Further, to estimate incremental all‐cause medical costs a general cohort excluding patients with a URS procedure was created and compared with the URS cohort. Patients in both cohorts were propensity score matched on clinical and demographic characteristics. Lastly, descriptive analyses were conducted to compare all‐cause medical costs, adjusted to 2021 USD.
Results: Propensity score matching generated 68,421 patients in the general cohort and URS cohort. The average 18‐months all‐cause medical cost was $14,399 (95% CI: 14,102‐14,696) in the general cohort and $42,124 (95% CI: 41,718‐42,530) in the URS cohort (p < 0.0001). For healthcare utilization, the URS cohort comprised of 70,942 patients. Results of healthcare utilization associated with a primary diagnosis of stone/infectious complications revealed that 25.68% required an inpatient visit, 58.44% required an ED visit, 3.13% required an ICU visit, and 2.16% had a readmission. Further 91.4% required imaging, and 1.50% underwent retreatment. Results of all‐cause healthcare utilization revealed that 33.23% required an inpatient visit, 69.46% required an ED visit, 6.23% required an ICU visit, 97.61% required imaging and 3.09% had a readmission.
Conclusions: Ureteroscopy is a commonly performed procedure in the United States for the management of kidney stone disease, but urologists and economic stakeholders should be aware that it's also a significant economic event with substantial associated healthcare utilization.
Healthcare Utilization & Costs of Percutaneous Nephrolithotomy Patients Among a US‐Based Commercial Population
J Khusid, R Paranjpe, B Cutone, M Gupta
Introduction & Objective: Percutaneous Nephrolithotomy (PCNL), remains the standard of care for most large kidney stones. The current study aims to evaluate the healthcare utilization and costs of patients undergoing a PCNL procedure.
Methods: A retrospective claims data analysis was conducted using the IBM MarketScan commercial database. Patients ≥18 years were included if they had an index PCNL procedure between January 2015 and June 2019. Healthcare utilization including Emergency Department (ED) visits, inpatient stay, Intensive Care Unit (ICU) stay, and imaging (CT, ultrasound, x‐ray), were measured 6‐months prior till 1‐year post PCNL procedure. Retreatment including a primary diagnosis of ureteroscopy/PCNL/shock wave lithotripsy/stent placement was measured 1‐month post PCNL surgery till 1‐year post PCNL surgery. Readmissions were measured 3‐days post till 30‐days post PCNL surgery. Two descriptive analyses measuring healthcare utilization associated with a primary diagnosis of stone/ infectious complications as well as all‐cause were conducted. Further, to measure all‐cause medical costs a general cohort excluding patients with a PCNL procedure was created and compared with the PCNL cohort. Patients in both cohorts were propensity score matched on clinical and demographic characteristics. Lastly, descriptive analyses were conducted to compare all‐cause medical costs, adjusted to 2021 USD.
Results: Propensity score matching generated 4,814 patients in the general cohort and PCNL cohort. The average 18‐months all‐cause medical cost was $21,257 (95% CI: 19,703‐22,811) in the general cohort and $87,378 (95% CI: 84,629‐90,126) in the PCNL cohort (p < 0.0001). For healthcare utilization, the PCNL cohort comprised of 4,972 patients. Results of healthcare utilization associated with a primary diagnosis of stone or infectious complications revealed that 58.41% required an inpatient visit, 33.91% required an ED visit, 10.86% required an ICU visit, and 5.73% required readmission. Further, 85.72% required imaging, and 5.95% underwent retreatment. Results of all‐cause healthcare utilization revealed that 64.80% required an inpatient visit, 54% required an ED visit, 18.02% required an ICU visit, 97.81% required imaging, and 8.27% required readmissions.
Conclusions: To our knowledge this is the first analysis to investigate the all‐cause healthcare utilization and costs associated with PCNL over an 18‐month time horizon. Although PCNL is an efficacious surgical method for the management of kidney stones, urologists, patients, and economic stakeholders should be aware that PCNL is also a significant economic event with meaningful healthcare utilization.
WITHDRAWN
Trends in Urologic Cancer Surgical Volume and Post‐Operative Length of Stay During the COVID‐19 Pandemic
O Elgebaly, W Sameh, A Fahmy
Alexandria University Faculty of Medicine, Egypt
Introduction & Objective: Single step dilation technique has been reported to be safe and effective. In contrast, other reports have shown that single step dilation may cause more trauma to the renal parenchyma than sequential dilation. Data on the use of this technique during pediatric PCNL in the literature are sparse. In this study, we aimed to compare the safety, efficacy and perioperative complications of single step versus serial tract dilation, using Alken metal telescopic dilators during pediatric PCNL.
Methods: Between April 2017 and May 2020, all children who were candidates for PCNL were enrolled in this prospective randomized study. Patients were randomized between the two treatment groups according to the dilation technique used. In group A. Alken telescopic metal dilation was employed, and in group B, single step dilation technique was performed.
The primary outcomes were access time and dilation fluoroscopy time. The secondary outcomes were tract dilation time, operative time, stone free rate, complications rate, postoperative hospital stay, haemoglobin deficit, and need for blood transfusion.
Results: There were no differences in demographic characteristics, operative duration, total fluoroscopy time and postoperative hospital stay between the two groups.
Access was successfully obtained in all procedures. We did not encounter any difficulties in tract dilation in either technique. All of the procedures were performed through a single tract. Access time and dilation fluoroscopy time was statistically significantly shorter in group B compared to group A (p = 0.034 and 0.042, respectively).
The overall complication rate was 21.4% in all patients (25.7% in group A and 17.1% in group B). There were no major complications (modified Clavien IV or higher) in the study population.
The mean haemoglobin deficit before and after surgery was not significantly different between the two groups (p = 0.517). There overall stone‐free rates at one month was similar for the two groups (33/35, 94.3%).
Conclusions: Compared with serial metal track dilation, single step dilation technique showed comparable safety and efficacy during pediatric PCNL, with significantly reduced access time and dilation fluoroscopy time.
MP4: Imaging and Thermal Ablation: Kidney
Preliminary Renal Cell Carcinoma Embolization Before Laparoscopic Partial Nephrectomy. Outcomes on Surgical Procedure
D Perri, M Maltagliati, L Berti, U Besana, C Buizza, A Gozen, M Sighinolfi, B Rocco, S Micali, G Bozzini
Sant'Anna Hospital Como
Introduction & Objective: The aim of the study was to evaluate preliminary lesion embolization before partial nephrectomy for renal malignancy.
Methods: From August 2020 to October 2021, 40 patients, underwent laparoscopic partial nephrectomy with (group A) and without (group B) superselective embolization. The of tumor size ranged from 0.9 to 4.2 cm (mean 2.6 cm). All patients underwent standard preoperative evaluation including multislice computed tomography (MSCT) with contrast enhancement, renal scintigraphy and separate assessment of each kidney function. The complexity of the planned partial nephrectomy was evaluated using a R.E.N.A.L. nephrometry scoring system based on MSCT data. The mean score averaged 6.2 points.
Results: In group A the mean blood loss was 72.8 ml while in group B was 214.2 ml. The duration of the procedure was reduced from a mean of 121.8 minutes in group B to a 86.5 minutes in group A. No complication were observed with no difference in postoperative outcomes according to hospitalization, need for ancillary procedure and blood transfusion. Selective embolization provided completely dry resection margins for full control. Renal ultrasound on the 3rd day postoperatively showed no pathological formations in the perirenal space and no changes in the pelvicalyceal system and kidney size.
Conclusions: The proposed method of preliminary renal embolization of the lesion to be enucleated by laparoscopic partial nephrectomy reduced the time procedure and the intraoperative blood loss. Longer follow‐up is needed is this procedure can affect renal function
Nationwide Ultrasound and Computed Tomography Utilization Rates for Urinary Stone Disease in the Emergency Department
C Ganesan, R Goyal, MR Stedman, S Liu, S Conti, G Chertow, J Leppert, A Pao
Stanford University
Introduction & Objective: There is growing evidence in support of ultrasound use as an initial imaging modality to evaluate suspected urinary stone disease in the emergency department; however, it remains unclear if imaging practices have changed. This study aims to characterize imaging practice in the evaluation of suspected urinary stone disease and identify factors associated with ultrasound use.
Methods: We conducted an observational study in patients presenting to the emergency department with suspected urinary stone disease using the Nationwide Emergency Department Sample (NEDS). We identified if computed tomography, ultrasound or both were performed during a visit and analyzed imaging trends. We used multivariable logistic regression to identify patient‐ and hospital‐ level factors associated with ultrasound use.
Results: We identified between 821,406 and 1,214,724 annual emergency department visits for suspected urinary stone disease from 2012 to 2018. The proportion of visits that included a computed tomography scan increased from 44.2% in 2012 to 57.3% in 2018. The proportion of visits that included an ultrasound remained below 5%. Women had a higher likelihood of receiving an ultrasound (OR 1.65, CI 1.50‐1.83 in 2012; OR 1.26, CI 1.17‐1.35 in 2018). Patients covered by Medicare also had higher likelihood of receiving an ultrasound in 2012, 2014, and 2016. Emergency departments located in the Northeast had a higher likelihood of ordering an ultrasound for suspected urinary stone disease.
Conclusions: Computed tomography remains the primary imaging modality performed in the emergency department for the evaluation for suspected urinary stone disease despite increasing evidence supporting the use of ultrasound. Moreover, rates of computed tomography use in the emergency department are rising. Greater awareness regarding the relative benefits of ultrasonography in lieu of CT scanning for the evaluation of suspected urinary stone disease is needed.
Oncologic Outcomes of Percutaneous Ablation for Localized Renal Masses: First Large Multicenter‐Experience
U Carbonara, S Pandolfo, A Beksac, A Celia, R Schiavina, C Cerrato, MF Meagher, L Hampton, U Capitanio, J Kaouk, I Derweesh, R Autorino
VCU commonwealth
Introduction & Objective: Percutaneous thermal ablation (PTA) is a valid alternative to partial nephrectomy in patients with small renal mass, especially in those unfit for surgery. In this study, we assessed and compared the outcomes of percutaneous cryoablation (PCA), radio frequencIes (PRF), and microwave (PMW) in the largest contemporary multicenter series.
Methods: Overall, we identified 691 patients with localized (N0M0), cT1 solid renal mass who underwent PTA from a multi‐institutional US and European database. The cohort was divided according to percutaneous techniques. Baseline characteristics, treatment, and post‐treatment data were collected and analyzed. Kaplan‐Meier method was used to analyze survival outcomes after PTA, and the log‐rank test was applied to assess statistical significance.
Results: Overall, 691 cases of PTA were included. Of these, 492 (71.2%) 151 (21.8%), and 48 (7.0%) underwent PCA, PRF, and PMW approach, respectively. PCA cases presented a statistically significant higher female rate (p = 0.001), and lower preoperative eGFR (p = 0.03) compared to PRF and PMW ones. The techniques had no differences in terms of ASA score, BMI, clinical tumor size, and cT stage. A higher rate of clear cell carcinoma was observed in the PCA group (34.4%) as compared to the PMW (23.2%) and PMW (2.1%) groups (p < 0.0001). Overall, 137 patients did not perform the preoperative biopsy. No differences were observed among groups in overall and major (Clavien‐Dindo ≥ III) complications. Also, there was no difference in the 30‐days re‐admission rate among PCA, PRF, and PMW (0.6 vs 0.6 vs 2%, p = 0.5). Median follow‐up was statistically different between groups, with a median of 43, 37, and 14 mt for PCA, PRF, and PMW, respectively. The number of recurrences was 69 (14%) for PCA, 27 (17.9%) for PRF, and 1 (2.1%) for MWA, with a statistical difference between groups (p = 0.02). No metastasis occurred in PMW group, instead 17 (3.5%) and 7 (4.6%) cases of metastasis were presented in PCA and PRF (p = 0.3). Overall and cancer‐related death were different among the percutaneous techniques. Kaplan‐Meier analysis did not show any difference in terms of recurrence free‐survival (p = 0.186), metastasis‐free survival (p = 0.554), and overall survival (p = 0.754) with a f/up of 5‐years.
Conclusions: Our series confirm that PTA is a safe and effective treatment option in patients with small renal mass. Despite some differences in terms of baseline characteristics, no differences were reported when comparing the oncological outcomes at 5 years of follow‐up. However, the PMW approach presented a significant lower follow‐up compared to the other two approaches.
Contrast‐Enhanced Computed Tomography Prior to Angiogram Does Not Reduce Procedural Radiation Exposure for Post Renal Surgery Bleeding
T Stout, J Campbell, B Sherwood, M Amarneh, C Tracy, RL Steinberg
University of Iowa
Introduction & Objective: Angiography has tradiationally been used to evaluate post‐renal surgery bleeding for possible pseudoaneurysm but has recently been supplanted by contrast‐enhanced computed tomography (ceCT) as initial imaging. Debate continues over ceCT diagnostic sensitivity and potential double contrast load. Proposed benefits of ceCT include reduced procedural radiation exposure and time. We sought to assess whether ceCT reduces radiation exposure, contrast use and procedural time during traditional angiography.
Methods: A single‐institution retrospective study was performed. All patients who underwent partial nephrectomy or percutaneous nephrostolithotomy with subsequent traditional renal angiogram for the purposes of post‐operative bleeding from 1/2000‐11/2021 were identified. Patients were stratified by having undergone pre‐angiography ceCT or not. ceCT was defined as CT abdomen with intravenous contrast or CT abdomen angiography. Demographic, procedural, radiographic and serologic data were collected. Statistical analysis was performed using the Chi squared and Mann Whitney U tests (p < 0.05).
Results: 36 patients were identified, of which 28 met study critera; 7 were excluded given non‐contrast imaging. No differences in patient demographics were noted. ceCT included 4 with CT Angiogram and 6 with CT with IV contrast. Nine of 10 patients with ceCT had undergone partial nephrectomy as compared to 6 of 11 without CT (p = 0.174). Median day of angiography after surgery was 11 (6‐26) for ceCT and 2 (0‐13) without ceCT. There was no difference in angiography radiation dose, contrast volume, or angiography procedure time between groups (Table 1). Median creatinine and GFR between groups were different both before and after angiography but no/minimal change occurred within each group.
Conclusions: Contast‐enhanced CT does not appear to reduce radiation exposure, contrast volume, or procedural time of traditional angiography for bleeding after urologic renal surgery. Double contrast exposure does not appear to lead to worsening renal function. Multi‐institutional evaluation is underway.
Validation of Mayo Adhesive Probability Score and Preoperative Factors to Predict Adherent Perinephric Fat in Robotic Assisted Partial Nephrectomy
NJ Pathak, R Prajapati, A Singh, A Ganpule, R Sabnis, M Desai
Muljibhai Patel Urological Hospital, Nadiad
Introduction & Objective: Mayo Adhesive Probability (MAP) score is based on posterior perinephric fat thickness and perinephric fat stranding and ranges from 0 to 5. We intend to validate the score and identify preoperative factors predictive of Adherent Perinphric Fat(APF) encountered in robotic assisted partial nephrectomy.
Methods: The retrospective and prospective observational study was done at a single tertiary care hospital after appropriate ethical clearance. 62 patients with clinical stage cT1 renal mass planned for robotic assisted partial nephrectomy were selected over a study period of 3 years after obtaining informed consent. Demographic details, and preoperative investigations and preoperative CT renal angiography was done in all patients. Intraoperative and postoperative data was collected. Associations of patient and tumor characteristics with the presence of APF during RAPN were evaluated by multivariable logistic regression models and using Chi‐square test to calculate p value.
Results: Out of total 62 patients included, 24 patients(38.7%) had intraoperative Adhesive Perinephric Fat(APF). 3 patients were converted to open surgery and 3 patients underwent radical nephrectomy. 35 patients were males. Mean age was 51.27(20‐77) years. We noted an increased likelihood of APF with an increase in age (p = 0.003), higher preoperative creatinine(p = 0.003), greater posterior perinephric fat thickness (p = 0.002), and perirenal fat stranding ( p < 0.001). From these 4 variable, posterior perinephric fat thickness and fat stranding were the most predictive. The combined score given to these 2 highly predictive factors for APF and the calculated score, termed Mayo Adhesive Probability (MAP) score ranges from 0 to 5. APF was seen in 10.7% of patients with a MAP score of 0, 25% with a score of 1, 50% with a score of 2, 44.4% with a score of 3, 88.8% with a score of 4, and 100% of patients with a score of 5 was found. Our study validates the MAP score given by Andrew J. Davidiuket. Smoking, high BMI, Sex of patient, tumor size, lateral perinephric fat thickness do not significantly predict APF in our study.
Conclusions: MAP score can be easily calculated from a CT scan. We validate the MAP score in RAPN. Higher MAP score has higher APF which would be useful to all urologists doing RAPN.
The Technique Employed for Needle Introduction During PCNL Access Influences Both Surgeon and Patient Radiation Dose
E Joo, CE Baas, RR Chen, JC Hartman, AS Amasyali, J Belle, C Ritchie, E Baldwin, DD Baldwin
Loma Linda University Medical Center
Introduction & Objective: Radiation exposure from fluoroscopy during percutaneous nephrostolithotomy (PCNL) may result in deleterious outcomes for both patients and surgeons. Patients receive primarily direct radiation exposure, while surgeons may receive both scatter and direct radiation exposure when the hand is placed directly in the fluoroscopy beam. To reduce this exposure, some surgeons either wear lead gloves, or use specialized needle holders. The purpose of this study is to compare radiation dose to the surgeon and patient under 3 different scenarios: 1‐ Surgeon's hand directly holding the needle, 2‐ wearing a lead glove, or 3‐ using a specialized needle holder.
Methods: A PCNL procedure was simulated using a cadaver patient and a separate cadaver arm to mimic the surgeon's hand. Three different techniques for holding the needle were compared: wearing a conventional surgical glove, wearing a lead glove, and using a specialized needle holder. Radiation exposure was directly measured using thermoluminescent dosimeters (TLDs), attached to the cadaver hand (thumb, middle finger, hypothenar eminence, and wrist), and the dorsal skin overlying the kidney of the cadaver patient. Five trials were performed for each treatment arm in which five minutes of fluoroscopy were delivered using automatic exposure control. Radiation doses were compared using ANOVA with p < 0.05 considered significant.
Results: The average current deployed by the fluoroscopy machine was 3.22 mA with use of lead gloves, compared to 3.16 mA with conventional gloves and 3.04 mA with the specialized needle holder.
Use of a lead glove reduced radiation exposure to the surgeon's hand compared to a conventional glove (mean dose 248.4 vs. 391.9 mRad; p < 0.001). However, the greatest radiation reduction to the surgeon's hand was seen when using a specialized needle holder (137.3 mRad, p < 0.001). Of note, use of a lead glove on the surgeon's hand significantly increased the patient's exposure (842.90 mRad, p = 0.024) compared to use of a conventional glove (816.65 mRad) and the specialized needle holder (703 mRad).
Conclusions: Wearing a lead glove reduced radiation exposure to the surgeon's hand (37%), but increased the patient dose (3%). In contrast, using a specialized needle holder reduced radiation exposure to both the surgeon (65%) and patient (14%).
WITHDRAWN
Cognitive‐Fusion vs Software‐Based Fusion Transperineal Prostate Biopsy: The Canberra Experience
J Saad, D Ashrafi, H Haxhimolla
Canberra Hospital
Introduction & Objective: The optimal approach to histopathological confirmation of prostate cancer is a continued area of debate amongst Urologists. Pre‐biopsy multiparametric MRI are now the standard of care and recent literature comparing cognitive‐fusion transrectal biopsies with software‐based fusion transrectal biopsies have shown improved detection rate of clinically significant disease with software‐based fusion. In this project, we aim to compare cancer detection rates between cognitive‐fusion transperineal biopsies to software‐based fusion transperineal biopsies.
Methods: We completed a retrospective cohort study of consecutive patients who underwent both cognitive‐ fusion and software‐fusion MRI biopsies by a single, experienced urological surgeon. Data was collected on all cases from January 2016 to December 2017. We compared the proportion of biopsies which returned results positive for prostate cancer between the two groups. Continuous variables were analysed using the two tailed student and categorical variables were analysed using the Chi‐squared test.
Results: In our population group we found 46 total lesions which underwent both Cognitive‐fusion and software‐fusion biopsies. Patient demographics were reviewed including average age (68), pre op PSA (6.9), prostate density (0.13) and prostate volume (46.9cc). Of the 46 lesions, 19 were PIRADs 3, 14 were PIRADS 4 and 13 were PIRADS 5 lesions. We found that cognitive‐fusion biopsy detected 54.3% of prostate cancers. While the software fusion detected 52.2% patients with prostate cancer. One patient did not return a positive cancer for both groups was an ISUP 1 cancer (2/40 cores) found only on the cognitive fusion biopsy.
Conclusions: This is the first study to compare the two forms of prostate biopsy within the same patient. We found no statistically significant difference when comparing cognitive fusion MRI biopsy to software fusion MRI biopsies in cancer detection rates.
Renal Location Within the Retroperitoneum in Various Body Positions Using Magnetic Resonance Imaging: Implications for Percutaneous Nephrostolithotomy
AC Smith, C Metz, M Rajput, C Tracy, RL Steinberg
University of Iowa Hospitals and Clinics
Introduction & Objective: The majority of cross‐sectional imaging used in pre‐operative planning prior to percutaneous nephrostolitotomy (PCNL) is performed in the supine position; yet historically, PCNL has been performed in the prone position. Knowledge of the kidney position is imperative to minimize the risk of complications, particulary with supracostal access. We sought to assess the difference in renal position in both the supine and prone position, as well as the effect of arm position on renal location.
Methods: In a prospective IRB approved trial, 10 subjects underwent magnetic resonance imaging in the supine and prone positions with arms at the side and prone position with arms up using vertically placed towel bolsters. Distances between the kidney and other fixed anatomical landmarks, including the diaphragm (KDD), top of the L1 vertebra (KVD) and lower edge of the 12th rib (KRD), were recorded. Additionally, nephrostomy tract length (NTL) and measures for visceral injury (maximum access angle (MAA) and anterior‐posterior (AP) colon position were assessed. Wilcoxon signed rank test was used for analysis (p < 0.05).
Results: Ten subjects (5 male, 5 female) with median age of 29 years and BMI of 24 kg/m2 were imaged. Right KDD was not significantly different between positions but KRD and KVD noted significant cephalad movement in both prone positions as compared to supine (Table 1). Left KDD notably increased with prone positioning (caudal movement) as compared to supine with no difference in KRD or KVD. Arm position did not affect any measurements when in the prone position. Right lower pole NTL was shorter relative to supine in both prone positions (p = 0.03 & p = 0.04) but not on the left. There was no difference in visceral injury measures in any position.
Conclusions: In subjects with BMI <30, prone positioning leads to significant cephalad movement of the right kidney, but not the left kidney. Arm position has no effect on anticipated renal position. These results suggest pre‐op supine CT reliably predicts left kidney location.
Efficacy and Safety Comparison Between Robotic‐Assisted Fluoroscopic‐Guided with Ultrasound‐Guided PCNL: A Randomized, Single‐Center, Clinical Trial
K Taguchi, S Hamamoto, T Sugino, T Kato, R Ando, A Okada, T Yasui
Nagoya City University Graduate School of Medical Sciences
Introduction & Objective: Renal access during percutaneous nephrolithotomy (PCNL) is crucial step to achieve favorable surgical outcome. While fluoroscopy and ultrasound (US) guidance require a certain learning‐curves, robotic technology with artificial intelligence will provide an alternative solution for shortening the learning‐curves with, hopefully, better results. We have previously reported the efficacy of the robotic‐assisted fluoroscopic (RAF)‐guided renal access for PCNL using automated needle target with X‐ray (ANT‐X) by a benchtop study and a case series. In this study, we conducted a randomized, single‐center, clinical trial comparing surgical outcomes between RAF‐ and US‐guided renal access in mini‐PCNL.
Methods: We recruited the patients who underwent mini‐PCNL with ureteroscopic assistance for large renal stones between January 2020 and May 2021. Randomization was performed by adjusting for age, sex, laterality, stone burden, and hydronephrosis grade. ANT‐X® was used for fluoroscopic‐guided renal access in the RAF group whereas ARIETTA® was used for US‐guided access. PCNLs were mainly performed by residents using pneumatic lithotripsy system with 16.5/17.5Fr tracts. The primary outcome was single puncture success, and the secondary outcomes were the stone‐free rate, complication rate, parameters measured during renal access, and fluoroscopy time.
Results: In total, 71 patients (US group = 35, RAF group = 36) were enrolled. No difference was seen in the single puncture success rate between the US and RAF groups (34.3% and 50.0%, p = 0.2). In 14.3% cases in the US group whereas no case in the RAF group, the resident was unable to obtain access due to difficult targeting (p = 0.025). The mean number of needle punctures was significantly fewer and the median duration of needle puncture was shorter in the RAF group (1.83 vs. 2.51 times, p = 0.025; 5.5 vs. 8.0 minutes, p = 0.049, respectively). The stone‐free rate at 3 months after surgery was 83.3% and 70.6% in the RAF and US groups, respectively (p = 0.26) (Table 1). Multivariate analysis revealed that RAF guidance reduced the mean number of needle punctures by 0.73 times (p = 0.021).
Conclusions: Robotic‐assisted fluoroscopic‐guided renal access in mini‐PCNL may have further potential applications in this field, especially for trainees to achieve safe tract creation with short learning‐curve.
Tumour Growth Rate, Changes in Renal Function and Outcomes of Patients with Oncocytomas Managed by Surveillance
FE Rodger, J Thompson, JL Hendry, GM Oades
Introduction & Objective: Oncocytomas present a challenge to the clinician and histopathologist. The aim of this study document the natural history of renal oncocytomas and address indications for intervention by determining how growth is associated with renal function over time, the reasons for active treatment, and disease‐specific survival.
Methods: A retrospective cohort of patients diagnosed with oncocytomas on renal mass biopsy and enrolled in an active surveillance programme was identified from 3 UK hospitals. Clinicopathological and follow‐up details were reviewed for each case. In particular: tumour growth, Changes in eGFR and definitive intervention and reason for intervention. Where possible, correlation was made between the final surgical and the initial biopsy specimen. Comparison between groups was performed using Mann–Whitney U‐testing (SPSS v 26).
Results: Retrospective data from 93 patients with 100 tumours was analysed. 74% were male and the average age was 71 years. Median follow up was 33 months. Most lesions were small renal masses although 21% measured over 4cm. The average growth rate was 3.3mm/yr. No association was observed between tumour size and change in eGFR over time (p = 0.74). 14 lesions (14%) were subsequently treated. Growth rate was given for change in management strategy in 93% of cases. These tumours grew at a rate of 7.5mm/year. In no case was symptomatic progression recorded as a reason to abandon a surveillance strategy. Where definitive pathology was available following surgical treatment, there was 100% concordance with the initial core biopsy. 4 deaths were reported but no morbidity or mortality was related to the diagnosis of oncocytoma or development of renal cancer.
Conclusions: Our data suggests that renal function is not negatively impacted by growing oncocytomas and confirms clinical outcomes are excellent after a median follow‐up of nearly 3 years of active surveillance. Active surveillance should be considered the 'gold standard' management of renal oncocytomas in the medium term.
Does Obstruction According to Diuretic Renal Scintigraphy During Acute Stone Event Mandates Ureteral Drainage, Prospective Single Blinded Study
Y Yacobi, G Verhovsky, I Sabler, A Zisman
Shamir medical center
Introduction & Objective: Diuretic renal Scintigraphy (DRS), used sometimes as a decision‐making tool in the setting of acute ureteral stone event (ASE). We evaluated its probable importance in clinical outcomes and decision making of completely obstructed renal unit.
Methods: Consecutive patients with ASE were evaluated by routine NCCT and Diuretic Renal Scintigraphy, technetium‐99m mercaptoacetyltriglycine (MAG3), (DRS). Symptomatic patients with a single small ureteral stone were included, cases with absolute indications for upper tract drainage were excluded. The clinicians, managing the patients, were blinded to Diuretic Renal Scintigraphy results and decision making was based upon clinical, laboratory and non‐contrast CT findings only. All the patients were followed for 24 months regarding serum creatinine levels and ultrasound (3 weeks, 6 month and yearly then after), those who were drained during ASE passed elective ureteroscopy/RIRS few weeks later. Blinded DRS data was opened in 24 months period. Obstructed patients according to DRS were chosen as a study cohort and divided to those who had ureteral drainage (group 1) and those who were treated conservatively (group 2). Original tables will be included to the presentation.
Results: Nineteen patients composed the study cohort, group 1(31%). The median (IQR) stone size and location in proximal ureter (according to study groups 1 and 2) were 5.4 (3.6‐8.2) mm, 4.8 (4.2‐7.3) mm, (p = 0.17) and 32%, 25% (p = 0.36), respectively. Hydronephrosis (Grade 2 and higher) and stranding were identified in 25% and 36%, respectively. Pick serum median (IQR) creatinine levels 1.55 (0.9‐2.1) mg/dL and 1.63 (0.96‐1.8) mg/dL (p = 0.3), respectively. Stone passage was documented during first follow‐up visit in 36% group 2 and median time to surgery was 26(18‐26) and 21(16‐29) days, respectively, p = 0.22. 24 months follow‐up serum creatinine levels were normal in all patients. There wasn't a significant difference between Emergency Room visits, fever or the need for the analgesics between the groups.
Conclusions: Diuretic Renal scintigraphy provides a brief physiologic status of ureteral obstruction. Our findings did not support an obstruction according to DRS having a significant influence on clinical course of ASE in patients with single small ureteral stone, and thus our data does not support its use as decision making tool. Further studies should be conducted to understand the nature of ureteral obstruction impact during ASE.
Evaluating 99m Tc‐sestamibi Single Photon Emission Computed Tomography/Computed Tomography Concordance with Surgical Pathology for Renal Masses
SP Argade, C Ronstrom, J Vetter, BG Patel, MG Biebel, J Mhlanga, S Figenshau
Barnes Jewish Hospital/Washington University School of Medicine
Introduction & Objective: Benign renal masses are challenging to differentiate from malignant renal masses using noninvasive techniques. 99m Tc‐sestamibi scan single photon emission computed tomography/computed tomography (sestamibi scan) has emerged as a potential diagnostic tool. Already widely utilized in the diagnosis of hyperparathyroidism, sestamibi scans differentiate renal masses on the basis of differences in mitochondrial content between malignant renal masses and oncocytomas. This study sets out to evaluate the concordance between renal mass sestamibi scan interpretation and surgical pathology.
Methods: We retrospectively identified patients undergoing sestamibi scan and renal mass biopsy or excision between September 2016 and May 2021 at our institution. The sestamibi scan final diagnostic report and surgical pathology results were compared. Sensitivity, specificity, positive predictive value, and negative predictive value were calculated.
Results: We identified 26 patients with 31 tumors. The average age of patients was 65.7 years. Sestamibi scan identified 7 oncocytomas, 20 renal cell carcinomas, and 4 mixed tumors with average size 4.8 cm, 3.2 cm, and 4.9 cm, respectively. Surgical pathology from 12 renal mass biopsies and 19 renal mass excisions showed 8 oncocytomas, 22 renal cell carcinomas, and 1 angiomyolipoma. Sestamibi scan overall accuracy was 61.3% with sensitivity 70.8%, specificity 28.6%, positive predictive value 77.3%, and negative predictive value 22.2% (Table 1).
Conclusions: Previous studies have shown that as many as 20‐30% of excised renal masses are benign, calling attention to the need for improved diagnostic techniques. While the overall accuracy of sestamibi scans was moderate, positive predictive value was the highest at 77.3%. This study demonstrates that sestamibi scans can be a useful noninvasive adjunct to differentiate between benign and malignant renal masses.
Introduction & Objective: Fluoroscopy is essential in percutaneous nephrolithotomy (PCNL) but exposes patients and operating room staff to radiation. We investigated whether a “low‐dose” (LD) protocol could reduce radiation exposure during fluoroscopy‐guided access without compromising clinical outcomes.
Methods: Patients undergoing PCNL with fluoroscopy‐guided access at a tertiary care stone center between January 2019 to July 2021 were identified. Prior to September 3, 2020, the Philips Veradius C‐arm's default settings were used: standard “per‐frame” dose, 15 pulses per second (PPS) frame rate. After this date, a “low‐dose” protocol was used: reduced “per‐frame” dose, reduced frame rate of 8 PPS for needle puncture and 4 PPS for all other steps. Clinical and radiographical data were retrospectively collected. The primary outcome was cumulative radiation dose. Secondary outcomes were stone‐free status (SFS; defined as no fragments ≥2mm) and complications. Multivariate regression analysis was performed.
Results: 100 patients were identified; 31 were in the LD group. The LD cohort was exposed to a significantly lower mean cumulative radiation dose of 11.68 mGy compared to 48.88 mGy (p < 0.0001). There were no differences in operative time, fluoroscopy time, stone burden, SFS or complications. In a multivariable regression model adjusting for several variables, LD protocol was associated with lower radiation dose while skin‐to‐calyx‐distance (STCD) was positively associated with cumulative radiation dose. Higher preoperative stone burden was associated with longer operative time (p = 0.0001) and lower odds of postoperative SFS (odds ratio = 0.959, p = 0.0007).
Conclusions: “Low‐dose” fluoroscopy and decreased frame rate during PCNL decreased radiation exposure four‐fold without affecting SFS or complication rates.
Comparative Radiation Exposure for Patients Who Required Intervention for Suspected Acute Renal Colic During Pregnancy
ME Lyon, A Sun, AB Shah, NC Llarena, C Bennett, S Sivalingam, JC Calle. MD. FASN., AM Zampini, S De
Cleveland Clinic Foundation
Introduction & Objective: The incidence of nephrolithiasis in pregnancy is low; however, the repercussions for both mother and fetus can be significant. Pregnancies with stones have an increased risk of adverse birth outcomes and are associated with significant morbidity. In cases of obstructing nephrolithiasis, intervention may include double‐J stent (DJS), percutaneous nephrostomy tube (PCN), or ureteroscopy (URS) with the potential for subsequent procedures such as frequent DJS or PCN exchanges. These interventions often utilize intra‐procedural fluoroscopy, which could result in harmful levels of radiation to the fetus. In the present study, we sought to identify the differences in radiation dose per stone episode between initial intervention with PCN, DJS and URS.
Methods: After IRB approval, pregnant patients undergoing a procedure for urolithiasis were retrospectively reviewed at a large multi‐center hospital system. Patients who presented during an active pregnancy with acute renal colic and imaging suggestive of obstructing calculi, and who subsequently required an intervention (DJS, PCN, or URS) were included in the analysis. The primary outcome was total fluoroscopy dose per stone episode. Secondary outcomes included fluoroscopic exposure per procedure and average number of procedures required per stone episode. Kruskal‐Wallis Rank‐Sum Tests were used to assess statistical significance. If significant with a 2‐sided p‐value of 0.05, post‐hoc pairwise testing was performed with a Wilcoxon Rank‐Sum test.
Results: 85 patients met inclusion criteria, of whom 40 (55.6%) were managed with DJS, 22 (30.6%) PCN, and 10 (13.9%) primary URS. 13 patients were excluded due to incomplete radiation data. Median total number of procedures was significantly higher in those who underwent initial PCN placement (4.5) compared to primary URS (1) or stent (2) (p < 0.001). Those that underwent PCN were more likely to undergo procedures that required radiation (p < 0.001), with a mean radiation per procedure of 61.5 mGy, compared to 0.1 mGy for stent and URS. Total radiation exposure per stone episode was significantly higher in patients that underwent PCN placement (mean 250.8 mGy for PCN, 2.0 mGY for DJS, and 2.2 mGy for URS, p < 0.001).
Conclusions: In pregnant patients with suspected acute renal colic requiring intervention, initial PCN placement was associated with a significantly higher number of procedures, higher radiation dose per procedure, and higher total radiation exposure per stone episode compared to DJS and URS.
Scrub Team‐Led Theatre Fluoroscopy Radiation: As Low as Reasonably Achievable?
F Tse
Introduction & Objective: Fluoroscopy is a commonly utilised tool in endourology, especially in management of urinary tract stones. It is important to be aware of ionising radiation exposure during such procedures, and adhere to ALARA principles, and keep radiation exposure “as low as reasonably achievable”. The recent FLASH study has attempted to define a national reference level for intraoperative radiation for the most common endourology procedures. Our department is additionally unique in using a scrub team‐led theatre fluoroscopy service for most endourology procedures requiring screening.
We aimed to compare our department's endourology fluoroscopy usage against the national reference levels as set by the FLASH study, and to compare usage between lead surgeon grades and between C‐arm operators.
Methods: Retrospective analysis of all ureteroscopy (URS) and stent cases over a 12‐month period. 333 URS and 108 stent procedures included. Radiation exposure was defined using total fluoroscopy time (FT) in seconds and dose area product (DAP) in Gy⋅cm2.
Results: Our median FT was lower than the national reference level identified in the 2019 FLASH multicentre study for both URS [17 vs 57 seconds] and stent [21 vs 49 seconds] procedures. Similarly, our median DAP levels were lower for URS [0.86 vs 2.8 Gy⋅cm2] and stent [0.73 vs 2.0 Gy⋅cm2] procedures. There was no significant difference between lead surgeon grade or C‐arm operator.
Conclusions: Our scrub team‐led fluoroscopy service offers reduced radiation doses for endourology procedures. Other benefits of this in‐house service include constant availability, reduced delays in waiting for external radiographers, and less variability with staff members. We would recommend monitoring and audit of fluoroscopy usage in all departments and consider implementation of a scrub team‐led fluoroscopy service to improve services and minimise patient harm.
Estimated Doses of Radiation Received by the Eye Lens During Endourological Procedures: Are We Being Careful Enough? ESUT‐YAU Endourology Group Collaboration
E Emiliani, A Bravo‐Balado, S Fontanet, A Skolarikos, A Gozen, BK Somani, O Traxer, M Talso, L Villa, A Papatsoris, A Pietropaolo, S Tonyali, E Keller, TO Tailly, P Kallidonis, E Sener, U Nagele, A Ruiz Martínez
Fundacion Puigvert, Autonomous University of Barcelona
Introduction & Objective: The protection of the lens during interventional radiology procedures has become an aspect of special concern since the appearance of cataracts at relatively low doses (below 0.1 Gy). Current knowledge about radiosensitivity of the eye lens has led the European Atomic Energy Community (EURATOM) to reduce the annual limit of equivalent dose for the eye lens from 150 mSv/year to 20 mSv/year. Our objective is to estimate the radiation doses received by the lens during endourological procedures to determine if endourologists comply with current recommendations.
Methods: A multicenter study was conducted recollecting the prospective data of annual dosimeters between 2017 and 2020. Four endourologists used an eye dosimeter to estimate radiation doses received by the lens in all endourological procedures, including ureteroscopy (URS), retrograde intrarenal surgery (RIRS) and percutaneous nephrolithotomy (PCNL). Two of them wore leaded protection glasses while two of them did not; in addition, one of the surgeons used a fluoroless protocol. Statistical analysis was performed using SPSS 22.0.
Results: Surgeons 1, 2, 3 and 4 performed a median of 158.5, 585.5, 102.0 and 129.0 endourological procedures, respectively, for a total of 641, 2,340, 413 and 350 between 2017 and 2020. The mean annual dose of lens radiation exposure for Surgeon 1, 2, 3 and 4 was 0.16, 1.18, 3.79 and 1.41 mSv per year, which corresponds to 0.001, 0.002, 0.032 and 0.014 mSv per procedure. The two surgeons who used leaded glasses registered a lower radiation dose per procedure (0.001 vs. 0.027). Similarly, the urologist who used a fluoroless protocol registered a lower lens radiation dose compared to the three surgeons who did not use it (0.001 vs. 0.023).
Conclusions: According to our study, endourologists successfully comply with current recommendations on radiation exposure to the eye lens. Leaded glasses as well as a fluoroless protocol may further reduce radiation doses. Eye protection glasses may be recommended for radiation protection as well as for exposure to fluids.
Comparing Radiation Dose and Image Quality in Three Different Flat‐Panel Detector C‐arms During Simulated PCNL
DR Peverini, AS Amasyali, S Jensen, RR Chen, JC Hartman, A Assidon, E Joo, CE Baas, C Ritchie, J Belle, E Baldwin, DD Baldwin
Loma Linda Academy
Introduction & Objective: Flat‐Panel Detector C‐arms (FPDs) are reported to reduce radiation exposure and improve image quality compared to conventional image intensifier C‐arms. Because FPDs employ proprietary designs, radiation doses and image quality may differ between manufacturers. The purpose of this study was to compare radiation exposure and image quality between three FPD manufacturers.
Methods: A male cadaver (BMI = 33.4) was placed prone on an operating table to simulate percutaneous nephrolithotomy (PCNL). Three optically stimulated luminescence dosimeters (OSLDs) were placed on the cadaver skin: one ventrally overlying the renal pelvis and two dorsally overlying the upper and lower kidney poles. FPDs from three manufacturers (GE, Philips, and Ziehm) were positioned to maintain 35.5 cm between the source and the bottom of the operating table. For each FPD, five trials were conducted under three different conditions: automatic exposure control (AEC), AEC with low‐dose (LD), and low‐dose with lowest pulse rate (LDLP). Each trial applied 300 seconds of radiation. Radiation doses were measured using a Landauer microStar OSLD reader. 10 blinded urologists (5 attendings and 5 residents) completed a survey of image quality. Results were analyzed using ANOVA and Tukey's B post‐hoc analysis.
Results: At the AEC setting, the Philips C‐arm produced significantly less exposure to the ventral OSLD than both GE and Ziehm (42,446 vs. 51,076 vs. 83,178 mrad, p < 0.001, respectively). Similarly, at the LD setting, the Philips C‐arm produced significantly less exposure to the ventral OSLD than both Ziehm and GE (25,926 vs. 30,956 vs. 38,209 mrad, p < 0.001, respectively). At the LDLP setting, the Ziehm C‐arm produced significantly less exposure to the ventral OSLD than both GE and Philips (4,019 vs. 7,418 vs. 8,229 mrad, p < 0.001, respectively). Under all three conditions, dorsal OSLD exposures paralleled ventral exposures. Image quality was rated adequate for clinical procedures at AEC and LD settings in all three manufacturers. At LDLP, the Ziehm C‐arm was rated inadequate in 8% of images, compared to 0% of GE and 0% of Philips (p = 0.016).
Conclusions: Radiation produced by flat‐panel C‐arms varies dramatically between manufacturers. Improved picture quality may come at the cost of increased radiation dose at the LDLP setting. Surgeons must use care to select the device and settings to minimize radiation exposure while maintaining adequate image quality.
Percutaneous Ablation versus Robot‐assisted Partial Nephrectomy for Completely Endophytic Renal Masses: A Multicenter Trifecta Analysis with a Minimum 3‐year Follow‐up
S Pandolfo, A Beksac, A Celia, R Schiavina, l Bianchi, G Costa, U Carbonara, D Loizzo, G Lucarelli, C Cerrato, C Imbimbo, V Mirone, G Basile, L Hampton, F Kim, U Capitanio, J Kaouk, I Derweesh, MF Meagher, R Autorino
VCU commonwealth
Introduction & Objective: This study aimed to compare outcomes of robotic‐assisted partial nephrectomy (RAPN) and percutaneous tumor ablation (PTA) for completely endophytic renal masses.
Methods: Data of patients who underwent RAPN or PTA for treatment of masses ranked with 3 points for the “E” domain of the R.E.N.A.L. score were collected from seven high‐volume US and European centers. PTA included cryoablation, radiofrequency, or microwave ablation. Baseline characteristics, clinical, surgical, and postoperative outcomes were compared. Recurrence‐free survival (RFS) was calculated with Kaplan‐Maier analysis. Trifecta was used as arbitrary combined outcome parameter as proxy for treatment “quality”. A multivariable logistic regression model assessed predictors of trifecta failure.
Results: 152 patients (RAPN, n = 60; PTA, n = 92) met inclusion criteria. Patients undergoing RAPN were younger (p < .001), had a lower ASA score (p = 0.002) and higher pre‐operative renal function in terms of Creatinine (p < .001), eGFR (p < .001), and CKD > III stage (p < .001). No difference in clinical tumor size, clinical T stage, and tumor complexity scores. PTA had a significantly lower rate of overall (p < 0.001) and minor (p < 0.001) complications. ΔeGFR at 1‐yr was statistically higher for RAPN (‐15.5 vs ‐3.1 ml/min; p = 0.005), but no difference in ΔeGFR at last follow‐up (p = 0.22) was observed. No difference in recurrences rate (RAPN, n = 2; PTA, n = 6) and RFS was found (p = 0.154). Trifecta achievement was higher for the RAPN but not statistically different (65.3% vs 58.8%; p = 0.477). RENAL score resulted predictive of trifecta failure (OR 1.47; CI 1.13‐1.90; p = 0.004).
Conclusions: PTA confirms to be an effective treatment for completely endophytic renal masses, offering low complication rates, good mid‐term functional and oncological outcomes. These outcomes compare favorably to those of RAPN, which remains the preferred NSS option for younger and less comorbid patients.
Robot‐Assisted Partial Nephrectomy Versus Percutaneous Thermal Ablation for Renal Mass in Solitary Kidney
S Pandolfo, D Loizzo, A Beksac, A Celia, L Bianchi, J Elbich, U Carbonara, G Lucarelli, C Cerrato, L Hampton, G Basile, U Capitanio, F Kim, R Schiavina, J Kaouk, V Mirone, C Imbimbo, MF Meagher, I Derweesh, R Autorino
VCU commonwealth
Introduction & Objective: Renal cell carcinoma (RCC) in solitary kidney (SK) is a concerning issue. The aim is to present outcomes after Robot‐assisted partial nephrectomy (RAPN) versus percutaneous thermal ablation (PTA) of RCC in patients with SK.
Methods: Between July 2008 and December 2019, data of 198 SK patients who underwent RAPN (n = 77) or PTA (n = 121) in seven Center across U.S. and Europe were collected. PTA included cryoablation (CA) or radio‐frequency ablation (RFA). We collected baseline characteristics, clinical, intraoperative, pathological, and post‐operative data. RFS analysis was performed using the Kaplan‐Meier method. Univariable and multivariable regression analysis were performed to determine independent predictors of “Trifecta” failure
Results: We included 198 SK patients treated with RAPN (n = 77) or PTA (n = 121). The PTA cohort had higher BMI (p = 0.02), a significantly higher proportion of ASA score ≥2 (p = 0.005), a significantly lower mean value of preoperative eGFR (p = 0.05), and a higher proportion of CKD ≥ stage III patients (p = 0.04). Mean clinical tumor size was significantly different between the two groups (RAPN = 3.5 cm; PTA 2.5 cm; [SD 2.2 – 1.1 respectively]; p = 0.001), with R.E.N.A.L. and P.A.D.U.A. scores of RAPN higher than PTA (p = 0.001). No significant differences in the frequency of intraprocedural complications and major post‐procedural complications (Clavien‐Dindo ≥ III) was found (p = 0.624). Pathology showed a malignant histology in 74% of cases and 66.9% for RAPN and PTA respectively (p = 0.003). Latest eGFR was significantly lower in PTA cohort, which was affected by a higher prevalence of CKD ≥ stage III at latest follow‐up (eGFR RAPN vs eGFR PTA: 51.2 vs 43.7, p = 0.018; CKD ≥ stage III 62.4% vs 81.1% p = 0.001). Recurrence rate was higher rate in PTA group (3.9 % vs 13.2%, p < 0.001). No significant difference in metastasis was found (p = 0.07). RFS was 96.1% in RAPN and 86.8% in PTA cohort (log‐rank p = 0.003) while no difference in progression‐free survival (PFS) was detected (p = 0.1). Trifecta was achieved in 72.5% of RAPN vs 75.2% of PTA (p = 0.778). Multivariable logistic regression analysis revealed that BMI was the only predictor for Trifecta failure (OR 1.07, p = 0.032).
Conclusions: PTA offers good outcomes in the management of SK patients with RCC. Compared with RAPN, it might carry a higher risk of recurrence. On the other hand, re‐treatment is possible. Overall, PTA can be safely offered to treat SK patients presenting with a renal mass.
Microwave versus Cryo‐ And Radiofrequency Ablation for Renal Mass: Comparative Outcomes
S Pandolfo, A Beksac, A Celia, l Bianchi, J Elbich, U Carbonara, G Lucarelli, C Cerrato, L Hampton, G Basile, F Kim, R Schiavina, U Capitanio, J Kaouk, V Mirone, N Longo, MF Meagher, D Loizzo, I Derweesh, R Autorino
VCU commonwealth
Introduction & Objective: Cryoablation (CRYO) and radiofrequency ablation (RFA) are the two guidelines‐recommended ablative techniques for the treatment of renal masses. Microwave ablation (MWA) is a newer technology, and it is supported by more limited evidence. Aim of this study was to compare outcomes of MWA to those of CRYO and RFA in a contemporary multicenter patient cohort.
Methods: Data of patients who underwent Cryo/RFA or MWA for the treatment of T1a‐T1b renal mass between 2010 and 2020 was collected in a dataset from seven high‐volume US and European centers. Baseline characteristics, clinical, surgical, and postoperative outcomes were compared between the two groups (Cryo/RFA vs MWA). Trifecta was used as an arbitrary combined outcome parameter as surrogate measure of treatment “quality”. A multivariable logistic regression model was used to find independent predictor of post‐procedural complications.
Results: We extracted 789 cases (Cryo/RFA = 739; MWA = 50). No statistical differences were found between groups in terms of age (p = 0.057), BMI (p = 0.215), ASA score (p = 0.196) and preoperative eGFR mean (p = 0.333). CKD >III was significantly lower for CRYO/FRA group (19.9% vs 46%, p = 0.006). No difference in clinical tumor size (p = 0.734), cT stage (p = 0.309), and RENAL nephrometry score (p = 597) was detected. Occurrence of intra and post‐procedural complications (p = 0.180, p = 0.126) did not differ. Significant higher rate of technical failure for CRYO/RFA group was seen (2.7% vs 0%, p = 0.048). eGFR at 1 year and at latest follow up was higher for the CRYO/RFA group but without statistical difference (70.8 vs 61.5, ml/min; p = 0.182 and 74.9 vs 67.5, ml/min; p = 0.070, respectively). Disease recurrence was observed in 10.8% vs 2% of cases in the CRYO/FRA and MWA groups, respectively (p = 0.048). No significance in metastases (p = 0.203) and death (p = 0.265) rate was observed. No significant difference in terms of trifecta achievement was recorded between the CRYO/RFA group (73%) and the MWA (69.6%) (p = 0.719). At multivariable analysis, no parameter was found to be an independent predictor of post‐procedural complications.
Conclusions: MWA offers comparable functional outcome and a favorable safety profile compared to CRYO and RFA for the treatment of renal masses.
Accuracy of Radiology Reports of Ureteral Stone Size in the Emergency Department
C Staniorski, D Pelzman, C Staniorski, M Semins
University of Pittsburgh Medical Center
Introduction & Objective: Radiology reports of computed tomography (CT) scans are used to guide medical and surgical management of nephrolithiasis, especially in patients presenting to the emergency department (ED). However, many reports only provide one‐ or two‐dimensional stone sizes, which may incompletely describe stone size. We aimed to evaluate the number of dimensions described in the radiology CT report and evaluate measurement discrepancies when considering additional CT dimensions.
Methods: We conducted a single‐center retrospective study of patients who presented to the ED with unilateral, solitary, obstructing stones between March 2018 through 2021. Stone size as reported by the radiologist and number of reported dimensions were obtained. Each stone was then measured by a urologist who calculated stone size in three dimensions. Our primary outcome was whether the maximal stone dimension was included in the radiology report
Results: In total, 129 patients were included for analysis. 83.7% of reports described the stone in 1‐dimension, 15.5% in 2‐dimensions, and 0.8% in 3‐dimensions. There was a significant difference in overall mean maximal stone size between radiologist and urologist measurement (5.5 vs 6.5 mm, p < 0.01). If the anteroposterior (AP) dimension was the largest dimension, the mean size was 4.1mm per radiology compared to 4.5mm per our read (p = 0.01). Seventy‐four of 129 patients (57%) had stones with craniocaudal (CC) diameter as the longest, but of these, only 26 (35%) had CC diameter in the report. In this subpopulation, stone size was significantly underreported in the radiology report (6.2 vs 7.8 mm, p < 0.01).
Conclusions: We show that in a cohort of patients presenting to the ED for obstructing ureterolithiasis, stone size is frequently measured in only 1 or 2 dimensions. This is most likely underestimating the true stone size. In many cases, this is associated with an absence of a reported craniocaudal measurement. Inadequate characterization of stone size may affect acute management decisions and patient counseling on rates of passage.
Radiologic Interventional Urethral Realignment May Be Complementary Compared to Primary Endoscopic Urethral Realignment of Treatment in Patients After Traumatic Urethral Injury
S Kim, K Park, J Huh, S Park, M Park, D Sohn
Department of Urology, College of Medicine, Jeju National University
Introduction & Objective: Recently, it has been known effectively to perform primary endoscopic urethral realignment for traumatic urethral injury as early as possible. However, there are limitations of failure of endoscopic operation due to poor visual field if severe bleeding is present or patients of general condition who can't perform surgery. We evaluated the outcomes of primary endoscopic urethral realignment(PEUR) vs radiologic interventional urethral realignment(RIUR) in these patients as alternative treatment.
Methods: This retrospective study included 35 patients with traumatic urethral injuries between 2011 and 2021. These patients were divided two groups(PEUR group vs RIUR group) according to treatment. The primary outcome was the success rate of primary realignment, procedure time, length of hospital day, duration of urethral catheterization. Secondary outcomes were the incidence and time to develop symptomatic urethral stricture.
Results: Procedure of PEUR and RIUR were technically successful in 15 of 20 patients(75.0%), 11 of 15 patients(73.3%) respectively. The rest of the patients (9/35,25.7%) underwent suprapubic cystostomy. There was no statistically significant difference between two groups. Mean procedure time of PEUR group was significantly longer than that of RIUR group(35 ± 10.5 vs 22 ± 18.8 min, p < 0.001). And the former required general or spinal anesthesia, but the latter was only sufficient for local anesthesia. While there were no significant differences in the period of hospital day, duration of urethral catheterization between both groups, respectively(7.6 ± 1.4 vs 6.4 ± 2.2 days, p > 0.05), (15.5 ± 3.8 vs 13..4 ± 4.9 days, p > 0.05) although terms of the former were slightly longer than these of the latter. There were no immediately important complications related to both procedure, although the 7 patients (7/15, 46.7%) treated with PEUR and 6(6/11, 54.5%) with RIUR developed symptomatic urethral stricture after procedure. Mean time to develop symptomatic urethral stricture after procedure was 3.3 ± 1.8, 2.4 ± 1.2 months in each group. There were slightly higher incidence and shorter time to develop urethral stricture in the RIUR group, but they was not statistically significant difference(p > 0.05, respectively).
Conclusions: RIUR is excellent short‐term outcomes such as simplicity of anesthesia and short procedure time, while PEUR has a merit that the incidence of urethral stricture, which is a complication, is low and takes longer time.
Accuracy in Stone Volumes: An In‐Vitro Comparison of CT‐Based 3D Software and the Ellipsoid Formula
R Bhatt, KL Morgan, Y Wu, A Rojhani, S Lavasani, S Ali, P Jiang, RM Patel, J Landman, RV Clayman
UC Irvine Urology
Introduction & Objective: Kidney stone measurements are essential in nephrolithiasis treatment and follow up. Currently, 3‐dimensional (3D) stone volume determinations are recommended to be calculated using the European Association of Urology's (EAU) ellipsoid formula using the largest length, width, and depth of the stone. As many stones are irregularly shaped (i.e., staghorn calculi), the EAU formula is a suboptimal method for stone volume and burden. Accordingly, we compared the accuracy of computed tomography (CT)‐based 3D volumes (CTv) and ellipsoid formula volumes (EFv) to gas pycnometer measured volumes (GPv).
Methods: Twenty‐five human, lab‐characterized calcium oxalate stones were air‐dried and weighed. The AccuPyc II gas pycnometer was used to calculate stone volume and density. All measurements were obtained using a 1 cm3 nonporous steel chamber and performed in replicates of five. Stones were then scanned with a CT and 3D stone volumes were calculated using a CT‐based 3D rendering software. Stone volumes were also calculated using the EAU ellipsoid formula. Correlation concordance coefficients were calculated to determine precision and accuracy of CTv and EFv to GPv. Bland‐Altman plots were generated to depict the concordance of stone volumes estimated by CTv and EFv to GPv.
Results: Mean GPv, CTv, and EFv were 0.0556 cm3 (range 0.0141‐0.1185 cm3), 0.0645 cm3 (range 0.0173‐0.1323 cm3), and 0.1488 cm3 (range 0.0265‐0.2758 cm3), respectively. The correlation concordance coefficient for GPv vs. CTv was 0.953 (95% confidence interval (CI) 0.917‐0.973), demonstrating strong agreeance despite CTv overestimating stone volumes by 16%. The correlation concordance coefficient for GPv to EFv was 0.265 (95% CI 0.143‐0.380), indicating poor agreeance with EFv overestimating stone volumes two‐fold (168%).
Conclusions: CT‐based 3D volumes accurately represent the volume obtained via a precise analytical equipment. In contrast, the ellipsoid formula greatly overestimated the true stone volume.
Intermittent Flash Fluoroscopy During Supine Mini Percutaneous Nephrolithotomy: A Single Centre Review on Radiation Exposure and Safety
R McLennan, FE Rodger, S Nalagatla
Introduction & Objective: Of the urological procedures involving fluoroscopy, Percutaneous Nephrolithotomy (PCNL) exposes patients to some of the higher rates of radiation. A multicentre retrospective study from 2019 published PCNL reference levels for Fluoroscopy time at 431 seconds and Dose Area Product (DAP) at 24.1 Gy.cm2. As Urologists we should adopt the ALARA principle, “As Low as Reasonably Achievable”, when exposing a patient to radiation. There is great variation in PCNL radiation exposure rates across the UK. What is not clear is what methods are being utilised in those centres with higher or lower radiation exposure rates. This single centre study looks at the radiation exposure and safety of using an Intermittent Flash Fluoroscopy method for PCNL.
Methods: Data on Dose area product (DAP) and screening time (SC) was collected retrospectively from patient files on Carestream Vue's PACS imaging system. 39 PCNL cases were included from an 18month period. The PCNL access technique primarily used Intermittent Flash Fluoroscopy (IFF). The combined radiation exposure was recorded in the case of Endoscopic combined intrarenal surgery or concurrent stent or nephrostomy.
Results: 100% of punctures successfully gained access to the collecting system. There were zero complications relating to access. The average radiation DAP was 8.81 Gy.cm2 (mean) and 7.72 Gy.cm2 (median), with a range of 3.29‐27.00 Gy.cm2. The average screening time was 97.58s (mean) and 81s (median), with a range of 46‐190s.
Conclusions: This study suggests that using Intermittent Flash Fluoroscopy is a safe method for gaining access in PCNL. Furthermore, Intermittent Flash Fluoroscopy resulted in patient radiation exposure far below previously reported reference levels. Continued publication on access technique with corresponding radiation doses would be beneficial to those looking to align their practice with the ALARA principle.
CO2 Pyelography: Indications and Experience in Standard and Hybrid Operating Rooms
AJ Hannemann, E Ballon‐Landa, M Sawyer
University of Colorado School of Medicine
Introduction & Objective: Air pyelography is a common technique for obtaining percutaneous renal access with fluoroscopy. However, cases of air embolism resulting in serious or even life‐threatening morbidity have been attributed to this technique. While there were reports of injection of carbon dioxide (CO2) as a contrast medium for percutaneous stone procedures in the 1980s, it has not subsequently been reported, except by our group. However, vascular surgeons commonly use CO2 as an iodinated contrast medium (ICM) alternative.
With an IRB‐approved, prospective QI study, our facility standard is now to use a hybrid room with a robotic multiplanar fluoroscopy system RMPFS (Artis Zeego, Siemens) for treatment of large stones. CO2 pyelography may be relevant for these procedures.
Methods: We have performed CO2 pyelography in five total endoscopic procedures (four patients). CO2 gas is injected via dual lumen catheter, ureteral access sheath, or ureteroscope (Fig. 1a). Cases have been performed in a hybrid room (n = 3) or standard OR (n = 2). Digital subtraction techniques (CO2‐DSP) can be performed in either location. Using an RMPFS CO2‐DSP protocol, image stacking can be performed to generate contoured imaging.
Results: CO2 pyelography has facilitated five endoscopic kidney stone cases, including a patient with severe iodine allergy. Procedures were well tolerated without postoperative complications. Excellent imaging can be obtained with or without concomitant ICM. However, bowel gas can be a limitation when used alone.
CO2 contrast dissipated rapidly in cases in which CT was performed (n = 2), even when administered only minutes before. By comparison, in one case, residual dilute ICM was seen on the 3D imaging of one kidney, despite administration occurring before treating the contralateral side. (Fig. 1b) This artefact raised concern for remaining stone, prompting additional endoscopic evaluation.
Conclusions: Air embolism is a rare but potentially fatal risk of endourology. CO2 is more soluble than nitrogen or oxygen making it safer than room air. CO2 pyelography offers a safer alternative to room air pyelography. In our treatment paradigm with primarily ultrasound guided percutaneous access, avoidance of ICM artefact with intraoperative CT may be the most relevant application for CO2 contrast.
MP5: Clinical Stones: Equipment & Medical Management I
Medical Expulsive Therapy for Distal Ureteral Stones <10mm: A Bayesian Network Meta‐Analysis and Meta‐Regression
DE Hinojosa‐Gonzalez, B Eisner
Massachusetts General Hospital
Introduction & Objective: Medical Expulsive Therapy(MET) is recommended for distal urethral stones <10mm by both American and European Urological Associations. Alpha‐blockers and/or calcium channel blockers(CCB) are commonly used for MET, however controversy exists over the actual effectiveness of these interventions, as some large trials have not been shown benefits.
This study aims to compare the effectiveness of various MET drugs at increasing expulsion rate.
Methods: In December 2021, randomized controlled clinical trials(RCTs) on medical expulsive therapy for distal stones <10mm. These were used to build a Bayesian network which modelled 200000 Markov Chain Monte Carlo Iterations for sampling. Results are reported as Risk Ratio(RR). Studies were assessed for reported median or mean stone size and dichotomized into <5mm or >5mm. A meta‐regression was performed to adjust for differences in stone‐size. Treatments were ranked using Surface Under the Cumulative Ranking Curve(SUCRA)
Results: Sixty‐nine RCTs were included for analysi, providing data for the comparison of over 10 drugs. Combined Silodosin and Tadalafil regimens had the highest rates of stone expulsion RR vs Placebo 13[4.5,36])and had the highest SUCRA rank at 0.921. Among monotherapies, Silodosin had the highest expulsion rate; RR vs Placebo 7.4[5.3,11] and a SUCRA rank of 0.791. Sixty‐four had mean/median >5mm stones while only 5 had <5mm mean/median stones. Meta regression revealed a non‐significant β of 0.324[‐0.26,0.92].
Conclusions: While various effective treatments exist, combined therapy with Silodosin and Sildenafil or monotherapy with Silodosin appear to be the most effective interventions at increasing expulsion rates. Urologists should tailor MET to patient needs and tolerance. More real world studies are needed to confirm these findings.
Effect of Age on Outcome of Renal Colic
D Golomb, A Shemesh, H Goldberg, B Shalom, E Hen, F Atmana, E Barkai, H Abu Nijmeh, A Cooper, O Raz
Assuta Ashdod Hospital
Introduction & Objective: There is a paucity of data on age‐related differences in the presentation, management, and outcome of patients with ureteral stones presenting to the ED. Our objective was to examine these differences in patients admitted to the ED in a large single medical center in a country with known warm weather.
Methods: A retrospective analysis of all patients who visited the ED at a single institution that were found to have a ureteral stone on CT. Clinical, laboratory, and imaging parameters were collected, including outcomes. Patients were subdivided into age groups: 18‐30, 31‐50, 51‐70 and >70 years.
Results: Between January 2018 and December 2020, 778 patients were admitted to the ED with a ureteral stone. 78% (609) were males and 22% (169) were females. The mean ages were 49.4 (SD 14.4) and 51.6 (SD 15.7) in males and females, respectively (p = 0.08). Patients in the 36‐50 age group, had significantly higher visual analogue scale (VAS) scores (p < 0.0001). Patients older than 70 years old presented with significantly higher serum creatinine levels (p < 0.0001), C‐ reactive protein (CRP) (p < 0.001) and leukocyte levels (p = 0.002). These patients were also found to have significantly larger stones [mean size of 6.2 mm (SD 4.8) (p < 0.0001)] and underwent percutaneous nephrolithotripsy (PCNL) in significantly higher numbers [56.3% vs. 43.8%, (p < 0.0001)]. Less than half of the patients older than 50 years were given medical expulsive therapy (MET) with alpha‐blockers, compared to more than 50% in the other age groups (p = 0.002). Spontaneous stone expulsion was noted in 70.2% of the 18–35‐year group, 62.4% of the 36–50‐year‐old group, 51.8% of the 51–70‐year‐old group and 37% of the >70‐year‐old group (p < 0.0001). The ED re‐admission rates at 7 and 30 days were not significantly different among all age groups.
Conclusions: Our data suggests that older patients presented with larger stones, elevated inflammatory markers and creatinine and were more likely to require surgical intervention. The Spontaneous stone expulsion rate was inversely associated with age.
Effect of Gender on Presentation and Outcome of Renal Colic
D Golomb, A Shemesh, H Goldberg, E Hen, F Atmana, E Barkai, B Shalom, A Cooper, O Raz
Assuta Ashdod Hospital
Introduction & Objective: There is a paucity of data on gender‐related differences in the presentation, management, and outcome of patients with ureteral stones admitted to the ED. Our objective was to examine these differences in patients that were found to have ureteral stones on CT.
Methods: Retrospective analysis of all patients admitted to the ED at our institution, found to have a ureteral stone on CT. Clinical, laboratory, imaging parameters and outcomes were collected.
Results: 778 patients were admitted to the ED with ureteral stones between January 2018 and December 2020. 78% (609) were males and 22% (169) were females. The mean ages were 49.4 (SD 14.4) and 51.6 (SD 15.7) in males and females, respectively (p = 0.08). Female patients presented with a higher body temperature (p = 0.01), pulse rate (p < 0.0001), nausea and vomiting (p < 0.0001), elevated serum C reactive protein (CRP) (p = 0.002) and a had an increased incidence of positive urine cultures (p < 0.0001) compared to males. The prevalence of elevated serum creatinine was higher in males (p < 0.0001). The indications for admission to hospital were pain (45.2% vs. 54.8%), elevated creatinine (32% vs. 15.4%) and fever (5.4% vs. 11.5%) in males and females respectively (p = 0.006). Alpha‐blockers were recommended on discharge in 54.8% (334) of males, compared to only 29.6% (50) of females (p < 0.0001). ED readmission rates within 7 and 30 days were similar in both genders (p = 0.3 and p = 0.4, respectively). Spontaneous stone expulsion was significantly higher in males compared to females [59.5% (323) vs 48.7% (75), (p = 0.01)].
Conclusions: Our results demonstrate that females admitted to the ED with ureteral stones presented with elevated infectious parameters, nausea, vomiting and a higher incidence of positive urine cultures. Males admitted to the ED were found to have elevated serum creatinine. Medical expulsive therapy (MET) with alpha‐blockers was prescribed significantly less in female patients, which may have resulted in a lower spontaneous stone expulsion rate.
Improved Quality of Life in Patients with Obstructing Ureteral Stone on Alpha‐Blocker Medical Expulsive Therapy
BG Patel, T Phillips, J Palka, A Chow, A Desai, K Sands, R Venkatesh
Washington University in Saint Louis
Introduction & Objective: Though controversial, alpha blockers are used widely for ureteral stone passage. However, its effects on the patient reported Quality of life (QOL) is unknown. We compared the QoL of patients on alpha‐blocker medical expulsive therapy (MET) to patients not on MET (noMET) utilizing a validated Wisconsin Stone Quality of Life (WISQOL).
Methods: We performed an IRB‐approved prospective study including patients on either MET or noMET after presenting to a tertiary‐care ED with symptomatic, obstructing ureteral stones. Medical treatment type was decided at the point of care by the initial treating physician including medications for analgesia and nausea. Additionally, tamsulosin (0.4mg orally, daily) was prescribed for the MET group. The WISQOL survey was administered at baseline, 7‐, 14‐, 21‐ and 28‐days following discharge from the ED or until stone expulsion.
Results: 197 patients were enrolled, of which 116 (59.2%) completed questionnaires for analysis, 91 in the MET group and 25 in noMET. Average ureteral stone size was 4.7 (STD 1.8) mm and 3.1 (STD 1.0) mm for MET and noMET, respectively. Of completed surveys, 105 (90%) were completed at day 7, 67 (57.6%) at day 14, 53 (45.7%) at day 21, and 40 (34.5%) at day 28. Spontaneous stone passage occurred in 38 (41.8%) while on MET compared to the 7 (28.0%) in noMET (p = 0.21). In total, 8 (6.8%) patients returned to the ED for intractable pain and 11 (9.5%) required surgical intervention. MET was associated with an improved QoL scores across all WISQOL domains compared to noMET (Fig.1). Stone size, age, race, sex, comorbidity score and a prior stone history were not associated with risk of negative effect on QoL (Table 1).
Conclusions: Use of alpha‐blocker MET was associated with improved QOL on all WISQOL metrics compared to noMET patients. Alpha‐blocker treatment may be an indication to improve stone QOL in patients with ureteral stone colic.
Opioid Prescriptions for Urolithiasis in the Emergency Setting: Impact on Return Visits and Long‐Term Opioid Dependence
R Alam, R Becker, A Alam, B Matlaga, E Katz
Johns Hopkins University School of Medicine
Introduction & Objective: Although opioid analgesics are not recommended as first‐line therapy for acute renal colic, they continue to be commonly used in this setting, particularly in the emergency room (ER). We sought to examine the practice patterns of pain management in the ER for acute renal colic and the impact of opioid prescription on return ER visits and persistent opioid use.
Methods: TriNetX is a collaborative research enterprise which collects real‐time data from 92 healthcare organizations (HCOs) representing 212 million patients. We queried the TriNetX Research Network, which is a subset comprising 87 million patients in 58 HCOs, for adults who visited the ER between 2010 and 2020 for urolithiasis. Patients were stratified by receipt of oral opioid prescriptions to calculate the risk ratio (RR) of patients returning to the ER within 14 days and persistent opioid use ≥6 months from the initial visit. Propensity score matching was performed to control for confounders. The analysis was repeated in the full TriNetX database to test the generalizability of our model.
Results: We identified 269,929 patients in the research network who visited the ER for urolithiasis, of whom 87,135 (32.3%) were prescribed oral opioids. Patients receiving opioid prescriptions were more likely to be younger (47.0 years vs 48.3 years, P < 0.001), have a previous history of urolithiasis (31.3% vs 21.2%, P < 0.001), have a history of anxiety (21.4% vs 14.5%, P < 0.001), or have a history of opioid use (56.8% vs 39.7%, P < 0.001). Black patients were less likely to receive opioid prescriptions than other races (P < 0.001). After propensity score matching, patients who received opioids were at increased risk of a return ER visit (RR 1.26, P < 0.001) and persistent opioid use (RR 3.86, P < 0.001) compared to patients who did not receive opioids. The validation cohort included 2,112,324 patients presenting to the ER for urolithiasis, of whom 396,373 (18.8%) were prescribed oral opioids. The baseline differences in age, medical history, and race were still present in this cohort (all P < 0.001). After propensity score matching, the risk of a return ER visit and persistent opioid use were 28% (RR 1.28, P < 0.001) and 44% (RR 1.44, P < 0.001) higher, respectively, in the opioid group.
Conclusions: Reassuringly, the majority of patients presenting to the ER for urolithiasis are not prescribed oral opioids. However, there remains a significant proportion who do receive opioid prescriptions, and this carries a markedly increased risk of return ER visits and long‐term opioid use.
Initial Clinical Experience with the Thulium Fiber Laser from Quanta System: First 50 Reported Cases
A sierra, M Corrales, M Kolvatzis, O Traxer
Hôpital Tenon
Introduction & Objective: To evaluate the efficiency, safety, and laser settings of the Fiber DustTM, the new Thulium fiber laser (TFL) from Quanta System, in laser lithotripsy during retrograde intrarenal surgery (RIRS) for ureteral and renal stones.
Methods: We prospectively analyzed the first 50 patients in our center (10 ureteral and 40 renal stones) who underwent RIRS using the new TFL, Fiber Dust, Quanta System, Italy. 200 μm and 150 μm laser fibers were used. Stone size, stone density, laser‐on time (LOT) and laser settings were recorded. We also assessed the ablation speed (mm3/s), Joules/mm3 and laser power (W) values for each endocorporeal laser lithotripsy (ELL).
Results: A total of 50 patients were included in the study with a median (IQR) age of 54.5 (43‐65) years old. Median (IQR) stone volume was 347 (147‐1800) mm3 and 1125 (294‐4000) mm3 for ureteral and renal stones, respectively. Median (IQR) stone density was 900 (400‐1500) HU for ureteral stones and 950 (725 – 1125) HU for renal stones. All ELL used short pulse. Median (IQR) pulse energy was 0.6 (0.5‐1) J and 0.6 (0.5‐0.9) J for ureteral and renal stones, respectively. Median (IQR) frequency for ureteral stones was 10 (10‐20) Hz; and for renal stones, 15 (10‐20) Hz. There were no statistically significant differences in pulse energy, frequency, laser power or LOT in both groups. The median (IQR) J/mm3 was 8.7 (4.8‐65.2) for ureteral stones vs 14.3 (7.8‐24.7) for renal stones. The median (IQR) ablation rate was 0.3 (0.2 – 1.3) mm3/s for ureteral stones vs 0.7 (0.4‐1.2) mm3/s for renal stones. Neither of those results reached the threshold of significance. Overall complication rates were low in both groups, and none were related to TFL.
Conclusions: TFL laser is safe and effective for renal and ureteral stones lithotripsy, using different settings according to stone type and localization without complication rates.
One Step Further in Flexible Ureterorrenoscopy's Security: Continuous Monitoring of Intrapelvic Pressure
A sierra, M Corrales, M Kolvatzis, S Doizi, O Traxer
Hôpital Tenon
Introduction & Objective: During last decades, technological advances in flexible ureteroscopy (f‐URS) led to expand its indications. To achieve a good visibility during those procedures, a good irrigation flow is required. The intrapelvic pressure (IPP) reached during f‐URS is the result of the irrigation inflow and the outflow. The aim of this study was to evaluate the feasibility of measuring the intrapelvic pressure (IPP) during f‐URS with a pressure sensor wire and to optimize safety by assessing IPP profiles during surgery.
Methods: Patients undergoing f‐URS for different treatments were recruited. A wire with a pressure sensor was placed into the renal cavities to measure IPP. For these cases, either no ureteral access sheath (UAS) or 10/12 or 12/14 were used according to surgeon choice. Irrigation was ensured by a combination of a gravity irrigation at 40 cmH2O above the patient and a hand‐assisted irrigation system providing on‐demand forced irrigation to provide proper visibility. Pressures were monitored in real time and recorded for analysis.
Results: 20 patients undergoing f‐URS for lithotripsy, ureteral stenosis and urothelial tumor diagnosis and treatment were included. IPP monitoring was successful in all patients. Mean baseline IPP was 11 mmHg. After the placement of the UAS, the mean IPP was 12,5 mmHg. During f‐URS with the endoscope in the renal cavities and irrigation pressure set at 40 cmH2O without any forced irrigation, the mean IPP was 31 mmHg. Mean IPP during laser lithotripsy or tumour treatment with the use of on‐demand forced irrigation was 61 mmHg. The maximum pressure peaks recorded during therapeutic periods using forced irrigation ranged from 40 to 175 mmHg.
Conclusions: High IPP levels may be achieved during f‐URS with on‐demand irrigation systems. Continuous pressure monitoring let us to avoid high IPP. The impact of these high pressures on the risk of complications and long‐term consequences still needs to be evaluated adequately. But, in this descriptive study, IPP was reliably and conveniently monitored and recorded using a wire with a digital pressure sensor.
Ureteroscopy with Laser Lithotripsy Using Moses Holmium Laser Mode May Not Yield Improved Efficiency to Offset Increased Cost of Use Compared to Standard Mode
J Zipkin, C Li, J Walia, M White
Albany Medical Center
Introduction & Objective: The holmium:yttrium‐aluminum‐garnet (Ho:YAG) laser is one of the most frequently used devices for ureteroscopy (URS) with laser lithotripsy (LL). The recently developed “Moses Technology” has been shown to improve stone ablation efficiency and cause less retropulsion than standard mode, leading to decreased procedure times. We examine the cost effectiveness of URS with Moses and standard mode Ho:YAG LL based on its proposed improvements in efficiency.
Methods: We conducted a retrospective chart review of patients that underwent URS with Ho:YAG LL by a single surgeon at our institution from 2019 to 2021. We collected data on patient demographics, laser mode utilized, and specific efficiency and cost parameters to conduct statistical analyses comparing two groups: (1) patients with the procedure in Moses mode, and (2) patients with the procedure in standard mode. Categorical and continuous variables were analyzed using Chi‐square and Mann‐Whitney U tests, respectively.
Results: 192 patients met inclusion criteria (57, standard mode; 135, Moses mode). Patient demographics were similar between cohorts. Mann‐Whitney U tests indicated that total equipment cost and total lasing energy were statistically significantly greater for patients in the Moses cohort (Mdn = $1,042 and 3.83 kJ, respectively) than for patients in the standard cohort (Mdn = $868 and 1.36 kJ, respectively), U = 2677.5 and 2972.5, respectively, p < .001 and = .013, respectively (Table 1). There was no statistically significant difference in operating room time, procedure time, total cost of stay, operating room cost, or anesthesia cost between cohorts.
Conclusions: URS with Ho:YAG LL in Moses mode did not impact the efficiency of the procedure compared to standard mode. In addition, patients undergoing URS with LL in Moses mode incurred higher costs than patients undergoing the procedure in standard mode. Thus, the increased costs that may be associated with conducting URS with Ho:YAG LL in Moses mode are not offset by improvements in efficiency when compared to standard mode. The disproportion in total lasing energy could represent a confounding variable. As such, we plan to assess the potential impact of stone burden, composition, and location in the future.
Ureteroscopy with Laser Lithotripsy Using Moses Holmium Laser Mode May Not Yield Improved Efficiency to Offset Increased Cost of Use Compared to Standard Mode: A Multi‐surgeon Patient Cohort
J Zipkin, C Li, J Walia, L Alshara, M White
Albany Medical College
Introduction & Objective: The holmium:yttrium‐aluminum‐garnet (Ho:YAG) laser is one of the most frequently used devices for ureteroscopy (URS) with laser lithotripsy (LL). The recently developed “Moses Technology” has been shown to improve stone ablation efficiency and cause less retropulsion than standard mode, leading to decreased procedure times. We examine the cost effectiveness of URS with Moses and standard mode Ho:YAG LL based on its proposed improvements in efficiency.
Methods: We conducted a retrospective chart review of patients that underwent URS with Ho:YAG LL by multiple surgeons at our institution from 2019 to 2021. We collected data on patient demographics, laser mode utilized, and specific efficiency and cost parameters to conduct statistical analyses comparing two groups: (1) patients with the procedure in Moses mode, and (2) patients with the procedure in standard mode. Categorical and continuous variables were analyzed using Chi‐square and Mann‐Whitney U tests, respectively.
Results: 307 patients met inclusion criteria (69, standard setting; 238, Moses setting). Patient demographics were similar between cohorts. Mann‐Whitney U tests indicated that total cost of stay, anesthesia cost, and total equipment cost were statistically significantly greater for patients in the Moses setting cohort (Mdn = $6,025, $417, and $1,043, respectively) than for patients in the standard setting cohort (Mdn = $5,520, $367, and $789, respectively), U = 6600, 6608, and 5323, respectively, p = .013, .012, and < .001, respectively (Table 1). There was no statistically significant difference in operating room time, procedure time, operating room cost, or total lasing energy between cohorts.
Conclusions: URS with Ho:YAG LL in Moses mode did not impact the efficiency of the procedure compared to standard mode. In addition, patients undergoing URS with LL in Moses mode incurred higher costs than patients undergoing the procedure in standard mode. Thus, the increased costs that may be associated with conducting URS with Ho:YAG LL in Moses mode are not offset by improvements in efficiency when compared to standard mode. We plan to assess the impact of stone burden, composition, and location in the future.
Evaluation of Renal Function Outcomes and Stent Durability in Patients Who Have Undergone Resonance Stent Placement for Benign Ureteral Obstruction
R Bhatt, K Vo, A Shin, KL Morgan, S Ali, A Peta, A Brevik, C Kosmala, P Jiang, RM Patel, RV Clayman, J Landman
Department of Urology, University of California, Irvine
Introduction & Objective: The metallic Resonance stent (RS) is most commonly placed in patients with short life expectancy due to malignancy; however, these stents are also deployed in patients with an inoperable benign obstruction. Ideally, according to the manufacturer's specifications, RS can be maintained for a year with subsequent annual replacement. The long‐term utility of the RS among patients with a benign ureteral obstruction has yet to be explored.
Methods: We reviewed our database for patients with benign disease undergoing RS placement between 2010 and 2020. The impact of chronic RS placement on renal function was evaluated by preplacement and long‐term postplacement serum creatinine based, estimated glomerular filtration rates (eGFR), Lasix renal scans, and CT‐based renal parenchymal volume measurements (3D Slicer). The number of RS stent exchanges during the follow‐up period, incidence of encrustation, and the average indwell time were recorded.
Results: Among 43 RS patients with benign ureteral obstruction, the mean age was 63 years (range 31‐88) and the median Charlson comorbidity index was 4 (range 0‐12). At a mean follow up of 26 months (range 3‐134), there was no change in eGFR (p = 0.99), parenchymal volume (p = 0.44), or split renal function (Right p = 0.18, Left p = 0.34). Patients on average underwent a replacement 1.1 times. The mean stent indwell time was 9.7 months (range 3‐33). Eleven patients (26%) underwent stent replacement or removal prematurely (i.e., within 6 months of placement), of which 4 had their stents removed before an exchange due to various causes (i.e., obstruction, stent colic, definitive surgery). Nine patient's (32%) stents were encrusted at time of replacement or removal, of which 4 (44%) required laser lithotripsy. The mean indwell time for encrusted stents was 12.5 months (range 5‐23). Overall, 12 patients (28%) had an average stent indwell time of >12 months.
Conclusions: Resonance stent deployment in the setting of benign ureteral obstruction results in successful preservation of renal function and parenchymal volume during follow‐up at < 6 years; however, only 28% of patients fulfilled the one‐year criterion for stent duration.
Asymptomatic Bacteriuria in Candidates for Active Treatment of Renal Stones: Results from an International Multicentric Study on More Than 2600 Patients
T Calcagnile, M Sighinolfi, B Rocco, R Galli, P Curti, L Schips, P Ditonno, L Villa, S Ferretti, F Bergamaschi, G Bozzini, A Zoeir, A El Sherbiny, A Frattini, P Fedelini, Z Okhunov, A Tubaro, J Landman, S Puliatti, S Micali
University of Modena and Reggio Emilia, Department of Urology, Modena, Italy
Introduction & Objective: The occurrence of asymptomatic bacteriuria concomitant to urolithiasis is still an issue for patients undergoing renal stone treatment. Disposing of a preoperative urine culture is essential to reduce the risk of septic events. The primary endpoint of the study is to report which characteristics of candidates for active renal stone treatment are more frequently associated with positive urine culture.
Methods: 2,605 patients were retrospectively enrolled from 14 national and international centers; inclusion criteria were age >18 and presence of a single renal stone 1‐2 cm in size. The variables collected included age, gender, previous renal surgery, body mass index, stone size, location, density, presence of hydronephrosis, renal comorbidities (chronic kidney disease (CKD), renal congenital anomalies, medical illness affecting renal function), presence of preoperative urine culture. After a descriptive analysis, the association between continuous and categorical variables and the presence of bacteriuria was assessed using a logistic regression model.
Results: The sample was composed by 1,555 male and 1,049 female patients. Mean age was 54 years (SD 14). Mean stone size was 14 mm (SD 3.7); mean density was 848 H.U. (300‐1718, SD 293).
Overall, 240/2,605 patients (9%) had a preoperative bacteriuria. Positive urine culture was more frequent in females (58% vs 42% M, p = 0.00); in patients with previous renal interventions (18% vs 6%, p = 0.00); in patients with CDK (34%), congenital anomalies (20%), kidney‐related medical illness (17%), in comparison to those without comorbidities (7.4%, p = 0.00). Patients with bacteriuria had larger stones (p = 0.00) and increased density (p = 0.02).
Multivariate analysis demonstrated that previous renal interventions (OR 2.6; 95%CI 1.9‐3.4; p = 0.00), renal‐related comorbidities (OR 1.31; 95%CI 1.19‐1.4; p = 0.00), higher stone size (OR 1.06; 95%CI 1.02‐1.1; p = 0.01) and density (OR 1.00; 95%CI 1.0‐1.00; p = 0.02) were significantly related to bacteriuria. On the other hand, male gender (p = 0.00) and lower caliceal location (p = 0.02) were inversely related to it.
Conclusions: Beyond expected risk factors, such as female gender, other parameters (e.g. concomitant CDK or medical illnesses) are seemingly favoring the presence of positive urine culture. The awareness of variables associated with bacteriuria in patients with concomitant renal stones is of paramount importance. In particular during pandemic time, when renal stone treatment is often deferred or improvised, assessing which patients are at increased risk of presenting bacteriuria could reduce the rate of septic complications.
A 'Never Event' in Urology: Cost of Smart Irrigation Systems in Routine Ureteral Stent Cases
ZR Dionise, C Tabib, F Soto‐Palou, GM Preminger, M Lipkin
Division of Urology, Duke University Medical Center
Introduction & Objective: Cystoscopic placement of the ureteral stent is one of the most common and straightforward urologic procedures, requiring only limited supplies. However, in large hospital settings, surgical supplies have increased risk of inappropriate use. Use of smart irrigation systems and tubing (i.e. Thermedx®) is useful for procedures like ureteroscopy, but is also expensive and unnecessary for simple stent insertion. Our objective was to retrospectively evaluate the prevalence and cost of inappropriate irrigation system use in stent cases, and then implement an intervention to decrease its use.
Methods: We retrospectively identified stent placement/exchanges (CPT 52332) at our institution from January 1, 2021 through July 31, 2021, excluding cases with other concurrent procedures. Operative supply costs were calculated using our institution's internal cost data, which for proprietary reasons may only be reported as a percentage of total case cost. Case information including ‘leveling’ (acuity) and time of surgery were recorded. Costs were compared using Student's t‐test and proportions compared using two‐proportion Z‐test. Our intervention was threefold: 1) A dedicated case card for ‘leveled’ stent cases prohibiting smart irrigation, 2) verbal instruction by the surgeon to operative staff to avoid smart irrigation prior to each case, and 3) standardized language in case posting sheets to avoid smart irrigation.
Results: A total of 128 stent placement/exchanges were identified. Smart tubing was used in 18 cases (14.1%). Cases that used smart tubing cost, on average, 24.5% more than those that used standard Y‐tubing (p < 0.01). Smart tubing comprised 25.2% of total case cost when used, compared to standard Y‐tubing, which comprised only 2.2% of total cost. Cases that used smart tubing were significantly more likely to occur at night (p < 0.05) and have emergency Level 1 or 2 designation (p < 0.05). Since intervention implementation, no cases have inappropriately used smart irrigation tubing (0/11; p < 0.10).
Conclusions: Use of smart irrigation systems for simple stent cases results in substantially increased cost compared to standard tubing. Improved pre‐operative communication with standardized case cards decreases inappropriate irrigation system use, with the potential for substantial cost savings over time.
Dusting Efficiency of the Moses Pulse 120H 2.0 Laser System: An In Vitro Assessment Using a 3D Laser Positioning System
P Whelan, C Tabib, C Kim, ZR Dionise, F Soto‐Palou, J Chen, P Zhong, GM Preminger, M Lipkin
Division of Urology, Duke University Medical Center
Introduction & Objective: Moses laser technology utilizes pulse modulation to enhance energy delivery, minimize retropulsion, and improve stone dusting compared with the standard short pulse. The Moses 2.0 laser system provides Extended Frequency Range (EFR) technology allowing for higher frequency pulse settings up to 120Hz. Our aim is to compare the dusting efficiency of Moses EFR technology and non‐EFR using Moses Distance (MD) pulse mode in an automated in vitro model.
Methods: All tests were conducted using a Moses 2.0 laser system on hard and soft Begostone phantoms. The settings for MD and EFR were compared amongst groups using similar power (MD: 0.3J/80Hz vs EFR: 0.2J/120Hz; MD: 0.4J/80Hz vs EFR: 0.3J/120Hz). The laser fiber was scanned in a spiral to deliver 1kJ of energy over a 1 cm2 area using an automated 3D positioning system across a submerged Begostone surface at standoff distances (SD) of 0 and 1mm. Stone ablation volume was measured. The laser was then scanned across a Begostone surface without contacting the same location twice, creating a trough. Equivalent energies were used for MD and EFR (0.2, 0.3, and 0.4J). Using the frequency setting, the laser was scanned at a rate equivalent to allow for 50 pulses fired per mm. Ablation volumes of 1 mm trough segments were quantified.
Results: In spiral testing (Figure 1), EFR showed equivalent mass loss to MD and was significantly superior when comparing MD: 0.3J/80Hz vs EFR: 0.2J/120Hz at SD 0 mm (p < 0.05). EFR had superior trough ablation volume to MD across all pulse energies at SD 0mm (p < 0.05). These differences increased when using lower energy settings. Ablation volume increased with higher energy for both MD and EFR. At SD 1mm, MD was only significantly better using 0.2J on hard stones. However, 0.4J was needed to show ablation using either MD or EFR at 1mm (Figure 2).
Conclusions: The EFR provided by Moses 2.0 technology offers superior trough ablation volumes when using similar energy settings. However, spiral scan testing only showed improved efficiency at 0mm. It is likely that in order to improve stone ablation and dusting, the laser should be scanned across the stone surface at a faster rate when using EFR settings.
Transiting Ureteric Stent Change Under General Anaesthesia in Major Operation Theatre to a Procedure Under Local Anaesthesia in Ambulatory Endoscopy Suite
J Kwok, R Salada, S Yeo, W Chong
Tan Tock Seng Hospital, Singapore
Introduction & Objective: Patients with long term ureteric stents for urinary diversion need regular changes, done at intervals appropriate for their condition, type of stent and adjusted to stent encrustation risks. This is usually done under General Anaesthesia in the operating room. We present our series of patients on ureteric stents with change of stents done under local anaesthesia in the endoscopy suite as an outpatient day procedure.
Methods: Since July 2021, we started a stent change service for our patients on long term ureteric stents done solely by Urologists in the outpatient day procedure setting under Local anaesthesia. This is done in the outpatient endoscopy suite away from the operating theatre, with flexible cystoscopy aided by fluoroscopy. We review our series of ureteric stent changes including indications and technical success rate of stent change.
Results: 56 patients underwent stent change under local anaesthetic from 7th July 2021 to 16th Feb 2022, with mean age of 75 years old (range 55 to 97). 24(42%) were male and 32(57%) female. 9 patients had bilateral stents changed (16%), with the rest unilateral. Etiology wise, 34 (61%) had strictures, 13 (23%) had stones, and 9 (16%) had extraluminal compression. Mean duration from the last stent change was 4.6 months (SD = 1.38) based on clinical condition and stent type. 54 (96%) of patients had successful stent changes. The two patients with unsuccessful stent changes had failed retrograde wire access, one with tight extraluminal compression and the other with severe stent encrustation.
Advantages of the new service for the patients include avoiding risks of sedation or general anaesthesia, and procedure performed as day surgery with decreased duration of hospital stay, particularly in this time of COVID‐19 pandemic. From a resource point of view, this has freed up operating theatre space and anaesthetist manpower to focus on Urological procedures needing general anaesthesia, decreasing waiting time for higher acuity cases.
Conclusions: Moving flexible cystoscopy guided ureteric stent change from major operation theatre under general anaesthesia to an ambulatory endoscopy center setting under local anaesthesia is a feasible and safe option for patients with long‐term ureteric stents. It avoids risk of general anaesthesia, is potentially cost saving and conserves hospital resources.
Ureteral Stent Biomaterial Encrustation After Ureteroscopic Lithotropisy: A Prospective, Randomized Study
S Hamamoto, K Taguchi, T Sugino, A Okada, T Yasui
Nagoya City University Graduate School of Medical Sciences
Introduction & Objective: Ureteral stents are commonly used in endoscopic surgery for urinary calculi but are frequently associated with stent encrustation and stent‐related infections. New biomaterials and coatings have been designed to overcome these disadvantages. However, there are no real‐world reports comparing biomaterial encrustation of different stents. In this study, we prospectively evaluated the adherence of bacteria, Ca, and Mg to three different ureteral stents after endoscopic surgery for urinary calculi.
Methods: A total of 61 patients requiring insertion of ureteral stents after the treatment of urinary calculi were randomly placed into 3 groups [PercuflexⓇwith a coating composition of Hydroplus, Group 1 (n = 21); Tria, with a coating composition of PercushiedⓇ, Group 2 (n = 22); InLay OptimaⓇ, which had a proprietary pHreeCoat coating, Group 3 (n = 18)]. All stents were removed one month after treatment and evaluated. A stent was immersed in a solution of saline and hydrochloric acid at pH 2 and subsequently vortexed for one hour. Ca and Mg contents were measured using atomic absorption spectrometry. Bacteria were measured using flow cytometry.
Results: There were no significant differences about patients and stone characteristics. The incidence of stone encrustation was significantly higher in Group 1 than in Groups 2 and 3 (33.3%, 11.7%, and 7.7%, respectively; p = 0.02). The median amount (IQR) of Ca adhered to the stents in Group 1 was significantly higher than that in Groups 2 and 3 (5.51 (2.28‐6.18), 1,91 (0.53‐4.48), 2.30 (0.76‐3.03) mg/dL respectively, p = 0.024). The median amount (IQR) of Mg in Group 1 was significantly higher than that in Groups 2 and 3 (0.20 (0.15‐0.23), 0.06 (0.04‐0.20), 0.03 (0.03‐0.13) mg/dL respectively, p = 0.005). The median number (IQR) of bacteria was also highest in Group 1 (33.76 (23.13‐109.43), 13.80 (6.23‐56.25), 8.33 (6.80‐21.20), respectively, p = 0.056); however, there were no significant differences in bacterial adhesion.
Conclusions: This randomized study showed that stents with Percusheild coating and pHreeCoat coating decreased the adherence of Ca, Mg after endoscopic treatment. These stents could reduce stent encrustation and stent‐related infections.
Impact of Antidiabetic Medications on Nephrolithiasis
K Zhao, B Shkolnik, JY Lu, JD Miller, D Schulsinger
Stony Brook University
Introduction & Objective: Type 2 diabetes mellitus (T2DM) is associated with increased risk of calcium oxalate (CaOx) and uric acid (UA) stones. Metformin, a first line agent in the management of T2DM, has been shown to increase urinary oxalate, increase urinary calcium and decrease urine pH, further increasing this risk. Despite more recent development and greater use of other antidiabetic agents (i.e. SGLT‐2 inhibitors, GLP1 agonists, DDP‐4 inhibitors), their effects on stone formation have not been studied. This assesses the effects of various diabetes medications on 24‐hour urine studies in stone‐formers with T2DM.
Methods: A retrospective review was conducted for all patients with a history of nephrolithiasis and a 24‐hour urine study seen in 2019 for an outpatient visit. Stone analysis, 24‐hour urine study, history of T2DM, medication use and laboratory results were obtained. Two‐tailed t‐tests were used for mean comparison and chi square tests for stone rate comparison.
Results: Among the 369 patients (174 males, 195 females, mean age of 55.4 years) with history of nephrolithiasis, 63 patients had a diagnosis of T2DM (34 males, 19 females, mean age 64.5 years). Stone formers with diabetes had significantly lower urine pH and higher rates of UA stones compared to those without diabetes (5.61 vs 6.11, p < 0.001; 33.3% vs 12%, p < 0.001, respectively). Among the antidiabetic agents (metformin, sulfonylureas, GLP‐1 agonists, DPP‐4 inhibitors, SGLT‐2 inhibitors, insulin), only GLP‐1 agonists demonstrated a significant improvement in urine study parameters. GLP‐1 agonist users had a greater urine citrate compared to the remainder of the diabetes cohort (1028.73 vs 544.43, p = 0.003) as well as those without diabetes (1028.73 vs 572.28, p < 0.0001). Though subjects with diabetes on other agents had higher rates of UA stones, individuals on GLP‐1 agonists did not have a higher rate of UA stones compared to those without diabetes (22.2% vs 12%, p = 0.363). However, GLP‐1 agonist users maintained lower urine pH compared to those without diabetes (5.74 vs 6.11, p = 0.027); there was no difference in CaOx stone formation rate between cohorts (p = 0.43).
Conclusions: T2DM is a known risk factor for nephrolithiasis and metformin further exacerbates this risk. This study highlights that GLP‐1 agonists may by litho‐protective, with significant increase in urine citrate and reduction in UA stone formation. In addition to the impact of this therapy on obesity, glycemia and cardiovascular risk reduction, GLP‐1 therapy should be considered in patients with diabetes and nephrolithiasis to minimize lithogenic risk factors.
Patients' Awareness of Facts and Myths Associated with Dietary Intake and Nephrolithiasis, and Their Efforts to Make Dietary Changes
M Levy, C Chin, E Garden, KT Ravivarapu, O Al‐Alao, J Sewell‐Araya, C Dinlenc, M Palese
Icahn School of Medicine at Mount Sinai
Introduction & Objective: Evidence‐based medicine has demonstrated associations between dietary intake and nephrolithiasis. However, myths can spread and misinform patient populations. We identified factors influencing patients' awareness of such facts or myths and their efforts to alter their diet accordingly.
Methods: Patients at a multi‐provider urology clinic in New York City were administered surveys which collected age, gender, education, prior stone history, awareness of five facts and four myths about diet and nephrolithiasis, and efforts to alter one's diet accordingly. Facts were concealed until after survey completion. Multivariable and Chi Square tests compared awareness and dietary alterations in patients based on history of prior stones, and sub‐analysis compared those with one and recurrent stone episodes.
Results: 202 surveys were analyzed. Those with a history of stones were significantly more aware than those with no history of stones for 4/5 facts and 1/4 myths. No differences were found between those with one or recurrent stones. This was consistent with multivariate analysis controlling for demographic variables, with awareness ranging from 1.7x – 3.9x greater in stone formers [Figure 1]. 43% of stone formers reported speaking to a urologist about their diet. Stone formers who had spoken to urologists about their diet were significantly more likely to alter at least one of their dietary customs accordingly compared to those that had never spoken to a urologist about diet (87% vs 65% p = 0.018). Single stone formers were more likely to alter their diet after speaking to a urologist (91.7% vs. 60.6% p = 0.047), but there was no significant difference in diet alterations in recurrent stone formers after speaking to a urologist (84.6% vs. 66.7% p = 0.162).
Conclusions: Any history of stones influences one's awareness of facts as well as myths related to diet and nephrolithiasis, however, recurring stone episodes does not necessarily correlate to additional awareness. Conversations with urologists about diet leads to significant action taken by patients, especially for first‐time stone formers. Therefore, physicians should be encouraged to educate all patients about evidence based dietary interventions and to debunk myths to reduce the spread of misinformation and to promote nephrolithiasis prevention.
Pre‐Operative Stents and Previous Cystoscopy Associated with Decreased Emergency Department Visits for Stent Colic
A Huang, C Weinstein, S Pak, J Bamberger, JM Gaines, B Desroches
Stony Brook University
Introduction & Objective: Ureteral stents are commonly used in the management of renal and ureteral calculi. Stent‐related colic (SRC), a frequent complication of stent placement, can greatly decrease a patient's quality of life. Many studies have investigated ideal stent properties and medical prophylaxes, however there are no clear guidelines for the prevention of stent‐related complications. The objective of this study is to expand on predictors of stent colic, focusing on patient‐specific characteristics that predispose a patient with SRC to present to the emergency department (ED).
Methods: We reviewed the records of all patients who underwent cystoscopy for stent placement or exchange at a single institution from December 17, 2019 to January 20, 2021. Patients were classified into two groups: (1) those who visited the ED within 90 days postoperatively for SRC and (2) those who did not visit the ED at all or visited the ED within 90 days postoperatively for issues not related to stent colic (NSRC). Patient demographics and relevant clinical data were also collected from the electronic medical record.
Results: One hundred thirty nine patients were included in this study. Forty five patients visited the ED at least once within the 90‐day postoperative period, and 21 patients met criteria to be defined as SRC. No demographic differences were found between the SRC and NSRC groups. Significantly more patients in the NSRC group had a history of cystoscopic/endoscopic procedures compared to the SRC group (57.6% vs 28.6%, p = 0.020). Additionally, a higher proportion of patients in the NSRC group had preoperative stents compared to the SRC group (42.4% vs 9.5%, p = 0.004). No other preoperative medical differences were found (Table 1).
Conclusions: Stent‐naïve patients and those without a history of cystoscopic procedures were significantly more likely to present to the ED post‐operatively with complaints of SRC, suggesting a need for greater counseling and close postoperative monitoring among this group of patients. These findings are the first to explore patient characteristics in relation to SRC and should be studied further.
Association Between On‐Treatment Follow‐Up Testing and Medication Adherence Among Patients Prescribed Preventive Pharmacologic Therapy for Urinary Stone Disease
JJ Crivelli, P Yan, R Hsi, V Shahinian, B Denton, J Hollingsworth
University of Alabama at Birmingham Heersink School of Medicine
Introduction & Objective: Guidelines on medical management for urinary stone disease (USD) recommend that clinicians obtain a 24‐hour urine specimen within six months of initiating preventive pharmacological therapy (PPT) to assess therapeutic response. We examined whether there are beneficial spillover effects associated with this testing, specifically increased PPT adherence.
Methods: Using claims data from working‐age, commercially insured adults with USD (2008 to 2019), we identified those who were prescribed PPT (i.e., a thiazide diuretic, alkali citrate therapy, or allopurinol). Next, we sorted patients into three groups: 1) those who did not complete any 24‐hour urine testing, 2) those who completed only a baseline 24‐hour urine collection prior to initiating PPT, and 3) those who completed both baseline testing and on‐treatment follow‐up testing within six months of initiating PPT. We defined PPT adherence based on percentage days covered using pharmacy claims and assessed this over 0 to 180 days and 180 to 360 days following the initial prescription fill. Finally, we fit multivariable logistic regression models to evaluate the association between on‐treatment follow‐up testing and PPT adherence.
Results: Among a cohort of 5,072 patients receiving PPT for USD, 3,517 (69.3%) did not complete 24‐hour urine testing, 1,214 (23.9%) completed a baseline collection only, and 341 (6.7%) completed both baseline and on‐treatment follow‐up testing. Adjusted adherence rates based on results from multivariable logistic regression are shown in the Figure. There were no significant differences in adherence rates between patients without any 24‐hour urine testing and those who performed a baseline urine collection only; however, compared to patients without any 24‐hour urine testing, rates of PPT adherence were significantly higher for those who completed both baseline and on‐treatment follow‐up testing (45.9% vs. 24.7% at 0 to 180 days [P < 0.01] and 29.5% vs. 15.7% at 180 to 360 days [P < 0.01]).
Conclusions: On‐treatment follow‐up testing for patients with USD managed with PPT was associated with higher rates of medication adherence. Further research is needed to understand how the timing of on‐treatment follow‐up testing can be optimized to maximize PPT adherence.
Primary Contributors to Dietary Acid Load in Patients with Urolithiasis
MV Betz, KL Penniston
University of Wisconsin School of Medicine and Public Health
Introduction & Objective: In susceptible individuals, high dietary acid load contributes to the formation of certain types of kidney stones by lowering urine citrate and pH and altering calcium metabolism. We assessed food sources of dietary acid load in patients with a history of urolithiasis.
Methods: Patients with a history of calcium urolithiasis were invited to complete 4‐day food records at a kidney stone prevention clinic. Instructions for accurate weighing and reporting of foods consumed were provided. Data were entered into the Nutrient Data System for Research nutrient analysis software. Output for a wide range of macro‐ and micronutrients for each patient were reviewed. Patients' 4‐day averages for intake of foods and food groups of interest were calculated. Potential Renal Acid Load (PRAL) and estimated Net Endogenous Acid Production (NEAPest) were calculated. Descriptive and correlation statistics were assessed.
Results: Patients (n = 83) were majority male (66%), white (94%), and 57 ± 12 years of age. Most (76%) were recurrent stone formers. Patients consumed 9,612 food items (including spices and condiments) and averaged 29 items/d. PRAL, NEAPest, and other specific values are shown (TABLE). PRAL correlated directly with protein from animal sources (r = 0.555, p < 0.001), total protein (r = 0.463, p < 0.001), fat (r = 0.399, p < 0.001), sodium (r = 0.385, p < 0.001), and phosphorus (r = 0.345, p < 0.001). PRAL was moderately inversely correlated with fiber (r = 0.246, p = 0.03). NEAPest correlated directly with protein from animal sources (r = 0.377, p < 0.001) but only moderately with total protein (r = 0.269, p = 0.01) and sodium (r = 0.250, p = 0.02). NEAPest was inversely correlated with fiber (r = 0.399, p < 0.001) and potassium (r = 0.360, p < 0.001) and moderately inversely correlated with magnesium (r = 0.233, p = 0.03). Meats, grains, cheeses, and combination foods contributed most to both PRAL and NEAPest. When assessed for PRAL, 47% of patients consumed >10 mEq acid/d and only 28% consumed a net alkaline load (PRAL <0). For NEAPest, 96% of patients exceeded 30 mEq acid/d.
Conclusions: Dietary patterns with a high dietary acid load increase stone recurrence risk in susceptible patients. Consumption of excess meats and grains, especially when unopposed by adequate intake of vegetables and fruits, resulted in a high dietary acid load for nearly all patients.
Positive Beliefs in the Effectiveness of Prescriptive Urinary Alkali But Not Thiazide Diuretics are Associated With Patients' Stone‐Specific Quality of Life
KL Penniston, S Li, R Jhagroo, S Nakada
University of Wisconsin School of Medicine and Public Health
Introduction & Objective: Effectiveness of medical therapy for stone prevention is compromised with suboptimal adherence. Adherence is influenced by patients' beliefs about their medications. If adherence to therapy is lower, relapse risk is higher, potentially affecting patients' health‐related quality of life (HRQOL). Little is known about patients' beliefs in stone‐prevention medications.
Methods: Patients from our stone prevention clinic who were taking thiazide diuretics (TD) and/or prescriptive urinary alkali (PUA) completed the validated 10‐item Brief Medication Questionnaire (BMQ). Patients' responses about beliefs and adherence were calculated. HRQOL was assessed with the 6‐item Wisconsin Stone Quality of Life short‐form (WISQOL‐SF). We compared responses by medication and by various clinical parameters. Associations between beliefs and HRQOL were assessed.
Results: Response rate was 45% (of 244 questionnaires mailed). Patients were 55% male, 66 ± 9.4 years, had a median of 3 lifetime stone events (min‐max, 1 to >100), and had stone disease for median 12 years (min‐max, <1 to 52). At questionnaire completion, 34% reported currently having stones (14% were symptomatic); 26% were unsure (3.6% were symptomatic). While there was no difference in reported bother from the medications, overall beliefs in PUA were more positive than TD (P = 0.002). While only 33% of patients taking PUA scored below the mean for beliefs, 52% taking TD did so. While adherence to the PUA regimen was lower than for TD (P = 0.013 for difference in adherence), responses to the item, "How well does this drug work for you" differed (P < 0.001), with patients reporting a nearly 3‐fold more favorable opinion about PUA than for TD. As shown in the figure, correlation with HRQOL was moderately strong for PUA (R = 0.54) but weak for TD (R = 0.34). No differences in beliefs by sex, lifetime stone events, duration of stones, or other factors were observed.0.001).
Conclusions: While patients reported no difference in bother between PUA and TD, reported adherence to PUA was lower than for TD. Nonetheless, beliefs about the effectiveness of PUA were stronger and correlated directly with HRQOL was higher. Correlation with other stone parameters is underway.
Efficacy and Safety of Ureteral Double J Stent Insertion in the Outpatient Clinical Setting: A Pilot Study
A Stolzle, R Vanlangendonck, W Price, Z Connelly, N Khater
LSU Health Shreveport
Introduction & Objective: Ureteral stent insertion is a common urological procedure. It is performed almost exclusively in the operating room within the hospital. Very few medical centers offer stent insertion in the clinic. To our knowledge, we present a unique study conducted at an academic medical center where ureteral stents insertion is performed in the clinical outpatient setting without the need for nitrous oxide.
Methods: At LSU Health Shreveport, double J stent insertion in the clinic has become a common procedure. We retrospectively analyzed 57 patients who underwent ureteral stent placement with successful removal at a later date. Patient demographics, comorbidities, stent insertion, and complications until stent removal were all analyzed in SPSS statistical software.
Results: Fifty‐seven patients were divided into two groups based on procedural location. 47 patients had their stents inserted in the operating room, and 10 patients had their stents placed in clinic without the use of Nitrous Oxide. T‐test analysis revealed no difference in patients' age, weight, or height. Within the clinical setting, 8 out of 10 patients were noted to be female, in comparison to 26 out of 47 female patients who underwent stent insertion in the operating room. However, this difference was not significant (p = 0.149). There was a significant difference in indwelling stent duration, 18 days when procedure was performed in the operating room vs 51 days when done in the clinic (p < 0.01). Chi‐squared analysis of comorbidities in patients revealed no differences in diabetes mellitus or heart disease. There was no reported injury of kidney, ureter, bladder, or urethra in neither of the two groups, upon stent insertion. Among the 10 patients who underwent stent insertion in the clinic, none of them had any new urolithiasis during the study period. While 1 patient among the 47 patients who underwent stent insertion in the hospital had a new episode of urolithiasis. Following stent placement, 5 patients had urinary tract infections when the procedure was performed in the operating room, while only 2 patients had infections when it was performed in the clinic (p = 0.413).
Conclusions: We conclude that ureteral stent insertion in the clinic without the use of Nitrous Oxide is feasible, safe and effective. In our pilot study, we observed no increased risk of infection or urolithiasis with stent insertion in the clinic, while decreasing all the risks associated with procedures performed in the operating room. It remains a pilot study, with a small sample size. With upcoming future studies, we may be able to validate that ureteral stent insertion in the clinical setting could be the next adopted approach in the near future.
The Impact of Urolithiasis History on Spontaneous Stone Expulsion
D Golomb, A Shemesh, H Goldberg, E Hen, F Atmana, E Barkai, H Abu Nijmeh, B Shalom, A Cooper, O Raz
Assuta Ashdod Hospital
Introduction & Objective: Proper selection of patients most likely to benefit from conservative management of stones, in contrast to those at risk for significant morbidity is vital. With the increase in prevalence of urolithiasis, better predictors of patients at risk for complications is imperative. In the present retrospective study, we aimed to investigate possible predictors for spontaneous stone expulsion.
Methods: A retrospective analysis of all patients who visited the ED at a single institution that were found to have a ureteral stone on CT. Clinical, laboratory, and imaging parameters were collected, including outcomes. Patients were stratified based on history of previous urolithiasis.
Results: 778 patients were admitted to the ED with ureteral stones between January 2018 and December 2020. 78% (609) were males and 22% (169) were females. The mean ages were 49.4 (SD 14.4) and 51.6 (SD 15.7) in males and females, respectively (p = 0.08). Patients in group 1 (no history of urolithiasis) presented with a higher mean serum creatinine [1.2 (SD 0.5) vs. 1.15 (SD 0.4), p = 0.02], a larger mean stone size [5.5 mm (SD 3.5) vs. 4.2 mm (SD 2.5), p < 0.0001] and a higher proportion of proximal ureteral stones [40.8% (131) vs. 24.1 (110), p < 0.0001] than patients in group 2 (with prior history of urolithiasis). The 30‐day re‐admission rate was significantly higher in group 1 [36.3% (57) vs. 26.9% (85), p = 0.02]. Spontaneous stone expulsion was higher in group 2 [65.9% (261) vs. 45.5 (137), p < 0.0001], whereas the need for endourological procedures was higher in group 1 [53.3% (160) vs. 33.1% (130), p < 0.0001]. On logistic multivariable analysis, the following were associated with a lower spontaneous stone expulsion rate: serum creatinine (OR 0.264, 95% CI 0.091‐0.769, p = 0.01), and stone size (OR 0.623, 95% CI 0.503‐0.771, p < 0.0001). In contrast, a history of prior endourological procedures (OR 0.225, OR 0.066‐0.765, p = 0.01) was associated with a higher spontaneous stone expulsion rate.
Conclusions: Our data suggests that patients who are first time stone formers present with larger and more proximal ureteral stones, with a lower likelihood of spontaneous stone expulsion and a subsequent need for surgical intervention. Previous stone surgery and not previous stone expulsion was found to be a predictor for spontaneous stone passage.
Percutaneous Nephrostomy versus Retrograde Ureteral Stent for Acute Obstructive Urolithiasis: Predictors of Stone Passage
A Halawani, M Hasan
The Unoversity of British Columbia
Introduction & Objective: Acute obstruction of the urinary system caused by urolithiasis is a common urological emergency that necessitate an immediate action. Retrograde ureteral stent (RUS) or percutaneous nephrostomy tube (PCN) are considered the standard methods of urinary drainage. The effect of ureteral stents on ureteric peristalsis has been experimentally studied on some models and have shown that the ureteric stent associated with ureteric dilatation, diminished ureteric peristalsis and impairment of stone passage. However, there is currently no evidence supporting the superiority of none of them. The aim of the study is to compare the probability of spontaneous stone passage and its predictors after drainage by RUS and PCN.
Methods: A total of 298 patients with obstructive urolithiasis were identified retrospectively from two tertiary centers from May 2018 to April 2019. The patients were divided into three groups, RUS group (104 patients), PCN group (93 patients), and spontaneous stone passage (SSP) (101 patients). The patients were followed up with a non‐contrast CT until the stone is passed or a surgical intervention was planned. Following characteristics were assessed: age, gender, BMI, side of the stones, location, size (total stone surface area), stone density, duration of follow up , and rate of stone passage at final time of follow up.
Results: The age was highest in the PCN group (61 years) with significant difference between the groups (P = 0.003), while BMI and gender distribution were similar amongst groups. Stone size was largest in the PCN group than the other two groups (p = 0.0001) (Table 1). The stones were located mainly in the distal ureter in the SSP group, while in PCN and RUS groups, the stones were significantly located in the proximal ureter (table1). The stones' width, length, surface area, and density were highest in the PCN group, then the RUS group, and lastly in the SSP group, with significant differences between groups (P < 0.0001). Stone passage rate was significantly higher in the PCN group (39.8%) than the RUS group (36.5%) (P < 0.0001). Length of follow‐up was longer in double J stent group, then nephrostomy tube group, and lastly spontaneous stone passage with significant difference between groups (P < 0.0001).
Conclusions: In our study, the PCN group was associated with a high stone passage rate after the SSP group, despite the larger stone size in the PCN group. In our experience, PCN can be a more appropriate way of drainage, especially in frail patients at a higher risk of surgical intervention, as it showed a high spontaneous stone passage rate and a shorter follow‐up period. Further clinical studies are warranted.
Robotic‐Assisted Electromagnetic Guidance Minimizes Radiation Exposure in Gaining Percutaneous Access for Nephrolithotomy: A Cadaveric Study with Novices
MR Humphreys, KM Wymer, BH Chew, J Zhen, F Elkhoury, S Sivalingam, M Dunn, M Borofsky
Mayo Clinic Arizona
Introduction & Objective: Fluoroscopy plays a big role in endourologic stone procedures and intra‐operative radiation exposure poses risks to the patient, surgeon, and staff. Fluoroscopic guidance is the most utilized imaging modality for obtaining access for percutaneous nephrolithotomy (PCNL). Radiation usage may also be higher by urologists who are less experienced. In this study, radiation utilization is considered while gaining percutaneous access in a cadaveric model, using either fluoroscopy or a novel robotic‐assisted electromagnetic (EM) method in a cohort of novice urologist.
Methods: Seven novices (individuals who use IR for access, or gain percutaneous access <24 times/year, or have gained access <30 times after training) used robotic‐assisted EM‐guidance provided by the Monarch® Platform, Urology (Auris Health, Inc., Redwood City, CA) to obtain upper pole, mid kidney, and lower pole access in a modified supine position vs. the same tasks in a prone position using fluoroscopy in a human cadaver. Total radiation time and dosage, defined as from pyelogram to wire insertion, and access radiation time and dosage, defined as from needle insertion to wire insertion, were measured. Statistical comparisons were made using paired t‐tests.
Results: Robot‐assisted EM‐guidance decreased total radiation time (0.11 ± 0.01 min vs. 1.30 ± 0.33 min, mean ± SEM, p < 0.05) and total radiation dosage (1.00 ± 0.15 mGy vs. 5.43 ± 0.88 mGy, p < 0.01), compared to fluoroscopy‐guided navigation (Figure 1). Additionally, robotic‐assisted EM‐guidance reduced access radiation time (0.08 ± 0.05 min vs. 1.08 ± 0.24 min, p < 0.01) and access radiation dosage (0.25 ± 0.11 mGy vs. 4.25 ± 0.86 mGy, p < 0.01) compared to fluoroscopic‐guidance.
Conclusions: Robotic‐assisted EM‐guidance provided by the Monarch® Platform robotic system decreased radiation exposure when compared to fluoroscopic‐guidance during percutaneous access in novice urologists with limited access experience. Keeping in mind the principals of ALARA, these limited data suggest that this novel technology could have significant benefits for patients and providers alike.
Optimizing Stone Retrieval in Miniature Percutaneous Nephrolithotomy – An Examination of Access Angle, Technology, and the Role They Play in Operative Efficiency
KE Schmanke, WE Ito, BB Whiles, M Sardiu, D Prokop, B Kannady, W Molina
University of Kansas School of Medicine
Introduction & Objective: Stone retrieval can be a laborious aspect of percutaneous nephrolithotomy (PCNL). A unique phenomenon of miniaturized PCNL (mPCNL) is the vacuum cleaner effect (VCE), a hydrodynamic form of stone retrieval that does not require additional tools. Additionally, a new tool for stone retrieval, the vacuum‐assisted sheath (VAS) was recently developed. We investigated the impact of renal access angle (as a surrogate for patient positioning) on stone retrieval efficiency. We also compared efficiency of the VCE, VAS and stone retrieval basket.
Methods: A rubber kidney model was filled with standardized 3 mm artificial stones. Access to the mid‐calyx was obtained using a 15/16 Fr access sheath. Stones were retrieved over three‐minutes at sheath angles of 0° (horizontal), 25° (upwards) and 75° (steep upwards) with the VCE, VAS and basket. A manometer standardized pressure at <25 cm H20. The stones were dried and weighed for comparison with measures of stones/retraction and stones/minute. The trials were repeated three times at each angle.
Results: Renal access angle of 0° was associated with increased stone retrieval with both the VCE and VAS (p < 0.05). The VCE was the most effective method with respect to stones retrieved per individual retraction at an angle of 0° (p < 0.005), though when analyzed as stones retrieved per minute, the VCE and VAS were no longer statistically different (p = 0.08). At the 75° angle, none of the methods were significantly different with regard to either stones retrieved per retraction or per minute (p = 0.2‐0.4).
Conclusions: Kidney access angle of 0° (surrogate for supine positioning) is more efficient for stone retrieval and a steep upward angle (surrogate for prone positioning) is less favorable. There is no difference between stone retrieval efficiency between the VCE and VAS methods, though both are superior to the basket at lower sheath angles.
MP6: BPH I
Improving Patient Understanding of Post‐HoLEP Recovery Expectations: A Quality Improvement Initiative
MA Assmus, MS Lee, J Helon, AE Krambeck
University of Calgary
Introduction & Objective: Although an effective BPH surgery; it is important that patients fully understand the recovery process of Holmium Laser Enucleation of the Prostate (HoLEP). A notable finding from a quality assessment performed at our center revealed 10.9% of patients were not aware that ejaculate volume may change postoperatively with >25% recommending a patient handout to improve communication. Therefore, a multidisciplinary team created a HoLEP expectations communication handout to improve surgeon‐patient communication.
Methods: Patients presenting for preoperative consultation prior to HoLEP were assessed with post procedure PRO questionnaires before (N = 50) and after (N = 50) the implementation of a surgeon‐patient HoLEP expectations handout. Patient demographics and perioperative course was examined in the context of their responses. Comparisons were made with a Chi‐squared test (p < 0.05). Our primary objective was to improve patient understanding of postoperative retrograde ejaculation and HoLEP recovery expectations.
Results: We observed a response rate of 96% (46/50 baseline, 50/50 post‐handout). Overall, 89/96 (93%) patients felt they had a reasonable understanding of HoLEP expectations with no significant difference between cohorts (45/46 vs 48/50, p = 0.71). There was no difference in proportion of respondents reporting an understanding of post‐HoLEP dysuria (p = 0.59), hematuria (p = 0.12) or urinary incontinence (UI) (p = 0.99). The implementation of the communication handout improved patient understanding of retrograde ejaculation (41/46 baseline vs. 50/50 post‐handout, p = 0.022). When seeing hematuria post‐HoLEP, 84% of patients reported, “I'm not worried,” with only 1 patient in the baseline cohort reporting, “something went wrong,” in their surgery. 55 patients experienced any dysuria postop with 85% reporting less than or equal to what they expected. Close to 30% (28/94) of respondents offering ways to improve communication suggested a HoLEP website for more information.
Conclusions: The implementation of a summative surgeon‐patient communication handout during preoperative HoLEP consultation improved the understanding of postoperative retrograde ejaculation at our center. We identified additional areas for future technology‐aided improvements in post‐HoLEP communication.
Predictors of Failed Same‐Day Catheter Removal after Holmium Laser Enucleation of the Prostate
MA Assmus, l Cooley, M Ganesh, MS Lee, J Helon, AE Krambeck
University of Calgary
Introduction & Objective: HoLEP is increasingly utilized for patients with benign prostatic hyperplasia (BPH). Advancements in technology have improved operative efficiency and hemostasis making same‐day, catheter‐free discharge possible. Our objective was to determine factors associated with failure of same‐day trial of void (SDTOV) following holmium laser enucleation of the prostate (HoLEP).
Methods: A retrospective review was conducted on 190 patients who underwent HoLEP from July, 2021 to January, 2022 by a single center. We assessed pre‐ and intra‐operative variables associated with our primary outcome: failure of same‐day catheter removal. Post‐operative complications and outcomes at a ≤7 days and 3‐month follow up were examined. Continuous and categorical variables were analyzed using unpaired t‐tests (Mann Whitney) and chi‐square, respectively. Univariate and multivariable logistic regression models were fitted to examine the associations of failed SDTOV.
Results: Of 190 candidates for a SDTOV, 90% (171/190) were successful. We found no difference between SDTOV success and failures with regards to age, comorbidities, presence of pre‐operative urinary retention, anesthesia factors, operative time, volume resected, enucleation time, and morcellation time (all p > 0.05). Pre‐operatively, 32.6% (50/190) were on antiplatelet and 6.2% (12/190) were on anticoagulation. While pre‐operative antiplatelet therapy was not associated with SDTOV failure (p = 0.78), pre‐operative anticoagulation use was (4.7% vs. 21.1%, p = 0.021). Patients who continued anticoagulation through surgery had the highest rate of SDTOV failure (5.7% (3/171) vs. 33.3% (3/19), p = 0.035). For those with successful SDTOV, 4.1% (7/171) required catheterization following discharge. At 3 months, no patient required catheterization.
Conclusions: On the day of surgery, patients eligible for SDTOV successfully voided 90% of the time. History of preop anticoagulation, whether continued or held, increased SDTOV failure.
En‐Bloc Holmium Laser Enucleation of Prostate in Octo and Nonagenarians: Clinical Characteristics and Outcomes
Z Savin, N Alsaraia, H Herzberg, O Yossepowitch, M Sofer
Department of Urology, Tel Aviv Sourasky Medical center
Introduction & Objective: The increase in longevity results in expanding burden of elderly patients with lower urinary tract symptoms (LUTS) related to benign prostatic hyperplasia (BPH) needing effective surgical solutions. We assessed clinical characteristics and outcome of BPH octo/nonagenarians patients treated by en‐bloc holmium laser enucleation of prostate (HoLEP).
Methods: All 225 HoLEP patients treated in the period January 2020 ‐ April 2022 were divided in 2 comparison groups by age: <80 years (N = 175) and ≥80 years (N = 50). Statistical analyses were conducted in terms of demographics, presentation, indication and outcome.
Results: Octogenarians/nonagenarians had higher rates of indwelling catheter (p = 0.00001), chronic retention (p = 0.0008), larger prostates (p = 0.04), American Anesthesiology Association (ASA) score (p = 0.000001) and antiplatelets medications (p = 0.0003) at presentation. This group was characterized by longer operations (median 120 vs 90 minutes, p = 0.07E‐9), hospital stay (median 2 vs 1 days, p = 0.01E‐9), higher complication rate (24% vs 10%, p = 0.012) and higher transitory urinary incontinence (TUI) rate (54% vs 13%, p = 0.00001). TUI was more prevalent in the older group with indwelling catheter (20% vs 67%, p = 0.0004). The functional outcome was similar in both comparison groups and all patients voided spontaneously after the procedure. After a median follow‐up of 10 months (IQR 4‐16) no other adverse events occurred.
Conclusions: En‐bloc HoLEP provides good functional results in patients ≥80 years despite more challenging presentation than in the younger population. Institutions providing this treatment should be aware that HoLEP in the aging men carries a longer operating time, hospital stay and higher rate of complications, however its effectiveness results in significant improvement in urologic quality of life indifferent of age group.
The Impact of the Number of Injections on Rezum Outcomes: Is Less Really More?
M Babar, U Azhar, J Loloi, K Tang, S Singh, M Ines, N Iqbal, M Ciatto
Albert Einstein College of Medicine
Introduction & Objective: Traditional treatment approach for Rezum employs injections based on prostate volume. However, there is little literature on the ideal number of injections needed to achieve symptom improvement with minimal adverse events (AEs). Thus, we assessed the efficacy and safety of Rezum outcomes in relationship to the number of injections employed during treatment.
Methods: A single office, retrospective study was conducted on men with moderate to severe lower urinary tract symptoms (LUTS) who were treated with Rezum. Men were stratified into four cohorts based on the number of injections received per lateral prostatic lobe: 1, 2, 3, or 4 injections. International Prostate Symptom Score (IPSS), quality of life (QoL), maximum urinary flow rate (Qmax), postvoid residual (PVR), and AEs were collected at baseline, 1‐, 3‐, 6‐, and/or 12‐months postoperatively. The impact of the number of injections on urinary outcomes and AEs were assessed using multiple linear regression and multiple logistic regression models, respectively, after adjusting for confounders at baseline.
Results: A total of 179 men were included: 58, 91, 22, and 8 men in the 1, 2, 3, and 4 injections cohorts, respectively. Baseline demographics that were significantly different across cohorts were age, history of urinary retention, prostate‐specific antigen, prostate volume, prostatic urethral length, and presence of median lobe (p < 0.05). At 3‐months, all cohorts saw significant mean changes in IPSS (‐9.7 ± 7.9) and QoL (‐1.9 ± 1.9), and improvements remained durable to 12‐months (p < 0.05). The 2 injections cohort saw a significantly greater mean change in Qmax at 6‐months (10.2 ± 10.1 ml/s) when compared to the 1 injection cohort (0.6 ± 4.6 ml/s, p = 0.02). There were no significant differences in mean changes in IPSS, QoL, and PVR between the cohorts at any follow‐up (p > 0.05). The most common AE was gross hematuria (69.8%), followed by penile burning (65.8%). Gross hematuria rate was significantly lower in the 1 injection cohort (53.2%) when compared to the 2 (74.7%), 3 (90.0%), and 4 (71.4%) injections cohorts (p = 0.01). Multiple linear regression showed that the number of injections did not significantly predict changes in IPSS, QoL, and PVR at any follow‐up (p > 0.05) but significantly predicted change in Qmax at 6‐months (β = 5.7, p = 0.02). Multiple logistic regression showed that for each additional injection, the odds of gross hematuria, penile burning, penile pain, and dysuria increased by 3.8 (95% CI 1.7, 9.1), 2.6 (95% CI 1.2, 5.9), 2.2 (95% CI 1.1, 4.9), and 3.0 (95% CI 1.3, 7.5), respectively.
Conclusions: Utilizing less injections is safer than utilizing more injections while still achieving durable relief in LUTS.
HoLEP Outcomes after Water Vapor Thermal Therapy, Prostatic Urethral Lift, Robotic Waterjet Treatment or Prostatic Artery Embolization
MA Assmus, MS Lee, J Helon, AE Krambeck
University of Calgary
Introduction & Objective: The 2021 American Urologic Association benign prostate hyperplasia (BPH) guideline recommends several alternative minimally invasive surgical techniques. We look to describe outcomes of individuals undergoing holmium laser enucleation of the prostate (HoLEP) after failing an alternative minimally invasive BPH surgery, specifically water vapor thermal therapy (WVTT), prostatic urethral lift (PUL), robotic waterjet treatment (RWT) or prostatic artery embolization (PAE).
Methods: We retrospectively examined patients within our IRB approved clinical database that underwent HoLEP over a 6‐month period (March 2021 ‐ September 2021) with a prior history of WVTT, PUL, RWT or PAE. Patient demographics and perioperative course was examined. Continuous variables were expressed as mean (range) with heteroscedastic two‐tailed T‐Test and Fishers‐exact test (p < 0.05).
Results: We identified 17 patients that underwent PUL (n = 8), PAE (n = 4), WVTT (n = 3) and RWT (n = 2) an average 28.5 months prior to HoLEP (range 10‐83 months). Average age was 71 (60‐81) years, with preop prostate size 95.3mL (range 31‐191mL) (MRI‐8, CT‐7, TRUS‐1, DRE‐1), intraoperative specimen weight 59.7g (15‐125g) and BMI 28 (21‐35). Pre‐HoLEP urinary incontinence (UI) was present in 8/17 (47%) with patients using alpha blockers (n = 14), 5ARi (n = 6), anticholinergics (n = 3) & beta‐3 agonists (n = 1) following their alternative BPH surgery. Post‐HoLEP only 2 patients requiring anticholinergic medications at 3months (0‐alpha blockers, 0‐5ARi, 0‐beta‐3 agonists). IPSS scores improved post‐HoLEP (20.0 (6‐30) vs. 8.9 (2‐21), p = 0.0043). Michigan incontinence symptom index bother scores improved post‐HoLEP (5.5 vs. 1.2, p = 0.028). No patients required indwelling catheters at 3 months post‐HoLEP.
Conclusions: In patients that have undergone alternative minimally invasive BPH surgeries (PUL, WVTT, RWT, PAE) with persistent lower urinary tract symptoms, UI or need for medical management; our single center 6‐month series shows IPSS and UI bother score improvements post‐HoLEP. All patients were able to discontinue alpha blockers, 5ARIs and beta‐3 agonists at 3month follow up.
Improving Prostatic Volume Estimation and Preoperative Planning before Laser Enucleation
Z Savin, S Dekalo, O Yossepowitch, M Sofer
Sourasky Medical Center, Tel Aviv, Israel
Introduction & Objective: A novel formula adjusting age and AUS volume improved the preoperative prostatic adenoma volume prediction before open prostatectomy. The aim of our study was to validate the accuracy of this formula to predict volume before laser enucleation, which is a size‐independent procedure, and investigate its yield for preoperative time planning.
Methods: We conducted a retrospective analysis of patients who underwent laser enucleations of the prostate between 2019‐2020. Each patient had an abdominal US (AUS) volume estimation and an adjusted volume estimation according to the formula: 1.082*Age +0.523*AUS −53.845. We assessed the accuracy of the formula compared to the enucleated tissue weight using intraclass correlation coefficient test (ICC). Ratios of enucleated tissue weight to volume estimation were used to compare between estimation methods.
Results: The cohort consisted of 178 patients and the median age, AUS prostatic volume, adjusted volume and enucleated tissue weight were 72 years, 80 ml, 67 ml and 56 grams, respectively. The median length of the laser enucleation procedure was 100 minutes (IQR 80‐130). The ICC between adjusted volumes and enucleated tissue weights was 0.86 (p < 0.001). Adjusted volume predicted more accurately the adenoma weight than AUS (Ratio of 0.82 compared to 0.67, p < 0.001) and was more precise for prostates >80 grams. Using the adjusted volume estimation, preoperative time planning could have been shorter by a median of 25 minutes than using the AUS estimation.
Conclusions: The adjustment formula predicts accurately the prostate volume before laser enucleations and may improve the preoperative time planning by 25%.
Single‐Port Tranvesical Robotic Simple Prostatectomy vs Prostatic Artery Embolization: A Comparison to the Literature
M Abou Zeinab, E Ferguson, A Kaviani, A Beksac, J Li, J Ulchaker, J Kaouk
Cleveland Clinic
Introduction & Objective: In the last decade, different minimally invasive procedures were developed to treat symptomatic benign prostatic hyperplasia. Single‐port transvesical robotic simple prostatectomy (TVSP) using the purpose‐built single‐port (SP) robot has achieved promising outcomes and patients' satisfaction. Recently, several new minimally invasive procedures were developed such as prostatic artery embolization (PAE). We sought to compare the perioperative and functional outcomes of our initial SP TVSP series to PAE data outcomes presented in the literature.
Methods: From an IRB‐approved protocol, data of 42 patients who underwent SP TVSP in a single institution from February 2020 to October 2021were prospectively collected. Mean values of Perioperative and functional outcomes from a recent systematic review on PAE (1) were used as a comparison too to the SP TVSP group. One sample t‐test was used for the comparison of continuous variables.
Results: The mean age at surgery was 70 years for both groups. SP TVSP cohort had a higher preoperative PSA value (11.8 vs 5.1 ng/ml, p < 0.001), higher mean preoperative post‐void residue (PVR) (284 vs 114 cc, p < 0.001), and a bigger prostate size (183 vs 88 cc, p < 0.001). There was no significant difference between the mean preoperative International Prostate Symptom Score (IPSS = 22), quality of life score (QOL = 4), or maximum flow rate before surgery (6 and 7 ml/sec). Within one year after surgery, patients in the SP TVSP group had a mean IPSS and QOL decrease of 26.5 and 3.8 points from baseline compared to a mean decrease of 12.3 and 2.2 points in the PAE group (p < 0.001). Similarly, postoperative PVR was lower in the SP TVSP group (16 vs 56 cc, p < 0.001). The Maximum flow rate improved by 28 ml/sec compared to 7 ml/sec for ST TVSP and PAE, respectively, however, it did not reach statistical significance due to the low sample size. There was no difference in Sexual Health Inventory for Men (SHIM) score between the two groups (p = 0.1)
Conclusions: Our results favor robotic transvesical simple prostatectomy compared to prostatic artery embolization in terms of early functional outcomes, such as low post‐operative PVR, improved urinary symptoms without affecting the sexual function, in addition to no radiation exposure. Prostatic artery embolization might be the treatment of choice for non‐surgical candidates
Holmium Laser vs. Bipolar Enucleation of Prostate Larger than 80 Grams with Bladder Outlet Obstruction; Dual‐Center Study
M Elsaqa, O Elgebaly, M Sakr, T Abou Youssif, H Rashad, MM El Tayeb
Baylor Scott and White Health Medical Center, Temple, Texas ; Alexandria University Faculty of Medicine, Egypt
Introduction & Objective: Transurethral enucleation and morcellation of prostate has been used as an effective minimally invasive technique for management of enlarged prostates. We aimed to compare Holmium laser enucleation (HoLEP) and Bipolar transurethral enucleation (B‐TUEP) of large volume prostates regarding efficacy, perioperative and early postoperative outcomes.
Methods: A prospectively maintained database in 2 separate centers was retrospectively reviewed for patients with HoLEP (G1) and B‐TUEP (G2) for voluminous prostate larger than 80 gm. We compared operative data, perioperative complications, and early postoperative outcomes.
Results: Out of 1200 patients, 201 patients were included in the study, 170 and 31 patients had HoLEP and B‐TUEP, respectively. The baseline characteristics are shown in Table 1.
Operative enucleation rate (weight of adenoma/ minute) was higher in G1 compared to G2 (p < 0.0001). Pathological weight gained in correlation to preoperative volume, operative complication rate, hemoglobin‐drop, and re‐admission rate were comparable in both groups (p = 0.13, 0.35, 0.29, 0.59 respectively), Table 2. All patients in both cohorts voided after surgery with satisfactory residual.
Three‐months follow up data showed lower international prostate symptom score (IPSS) and lower prostate specific antigen (PSA) level in G1 (p = 0.034, 0.0072 respectively). Overall incontinence and stress incontinence rates were comparable in both groups (p = 0.3831, 1 respectively) as shown in Table 3.
Conclusions: In voluminous prostate, HoLEP is associated with shorter enucleation time, better symptom score, and lower postoperative PSA compared B‐TUEP. Otherwise, both techniques were comparable regarding operative and early postoperative outcomes.
Surgical Outcomes of Transurethral Enucleation with Bipolar for Benign Prostatic Hyperplasia: Single Surgeon's Initial Experience
H Kim, W Bang, J Park, S Jeong
Department of Urology, Hallym University Sacred Heart Hospital, Anyang, Korea
Introduction & Objective: We investigated the outcomes of the transurethral enucleation with bipolar (TUEB) performed by a single surgeon.
Methods: From 04/2016 to 06/2021, 387 patients underwent TUEB by a single surgeon. TUEB was performed using the transurethral resection in saline system with spatula loop (spatula attached to the standard tungsten wire loop). One‐lobe enucleation technique with 26‐Fr continuous‐flow resectoscope was implemented. Patients were stratified by surgery period (early vs late period) and evaluated 1, 3, 6, and 12 months after surgery, and then annually.
Results: Baseline Qmax was 9.5 mL/sec and postvoid urine measured 106.6cc. Total prostate and transitional volumes were 73.1cc and 42.1cc, respectively. Total operation time (116.0 vs 116.8min, p = 0.863), detailed procedure time (enucleation time: 49.2 vs 46.1min, p = 0.099; morcellation time: 26.5 vs 23.6min, p = 0.162), and enucleated tissue weight (26.1g vs 27.9g, p = 0.350) did not differ significantly between groups. There were significant differences in enucleated tissue weight per time unit (g/min) (0.52 vs 0.58, p = 0.037), and rates of reoperation due to bleeding (9.8% vs 2.5%, p = 0.002), and conversion to transurethral prostatectomy (TURP) (19.2% vs 1.5%, p < 0.001). With median follow‐up of 11.0 months, there were insignificant differences at postoperative 6 months in rate of de novo stress incontinence (p = 0.188), urethral stricture (p = 0.158) or bladder neck contracture (p = 0.477).
Conclusions: From a single surgeon's initial experience, TUEB is a safe and effective technique for BPH treatment with substantial improvement in subjective and objective symptoms. As the surgical experience increased, the rates of bleeding‐related complications and TURP conversion decreased significantly.
Single‐Port Transvesical vs Multiport Robotic Simple Prostatectomy: A Multi‐Institutional Comparison
M Abou Zeinab, T Corse, K Okhawere, L Morgantini, A Beksac, A Kaviani, E Ferguson, R Harrison, S Talamini, S Crivellaro, M Stifelman, M Ahmed, K Badani, J Kaouk
Cleveland Clinic
Introduction & Objective: We sought to compare the perioperative outcomes between Single port transvesical (SP) and multiport robotic‐assisted simple prostatectomy (MP) in a multi‐institutional setting
Methods: Prospective data collection of 91 SP patients from February 2020 to October 2021 were collected from three different SP Institutions. Data of 201 patients who underwent MP from January 2017 to October 2021 were retrospectively collected from two separate institutions. All procedures were performed by surgeons with extensive robotic experience. A 1:1 matched‐pair analysis for the preoperative prostate volume was performed. Baseline characteristics and perioperative data were analyzed. Mean follow‐up was 8 and 5 months for MP and SP, respectively
Results: After matching, the median preoperative prostate volume was 161 cc for both groups (p = .235). Baseline characteristics were comparable between the two groups. Total operative time was shorter in the SP group (172 vs 162 minutes for MP and SP, respectively, p = .005). Patients in the SP group had less estimated perioperative blood loss, less pelvic drainage, and less continuous bladder irrigation (CBI) (p < .001), however CBI practice varied between centers. There was no difference in the median specimen weight between the two groups (p = .336). Postoperatively, SP patients were more likely to be discharged the same day after the surgery (0 vs 24%, P < .001), with a less median pain score (3 vs 1, P = .010). Both groups had comparable rates of intraoperative or postoperative complications (p = .155 and .204, respectively), however, 8.8% in the MP group got readmitted after surgery compared to 0% in the other group (p = .016). Postoperatively, the MP group had a slightly higher median post‐void residue on bladder scans (20 vs 0 cc, p = .003)
Conclusions: In experienced hands, SP RASP is a good alternative to MP RASP prostatectomy. It allows for shorter hospital stay, less pain on discharge, and a potential shorter Foley catheter stay, with no perioperative or functional compromise
Role of Holmium Laser Enucleation of the Prostate (HoLEP) in Patients with Pre‐Existing Prostate Cancer
M Elsaqa, S Jhavar, S Virani, K Wagner, MM El Tayeb
Baylor Scott and White Health Medical Center, Temple, Texas ; Alexandria University Faculty of Medicine, Egypt
Introduction & Objective: Holmium laser enucleation of the prostate (HoLEP) has been used as an effective minimally invasive technique for management of enlarged prostates. In this study, we aim to study the role of HoLEP in prostate cancer patients either on active surveillance with bothersome lower urinary tract symptoms (LUTS) or for prostate debulking before radiation therapy and the effect of PSA drop post‐HoLEP on further prostate cancer management plans.
Methods: A prospectively maintained database was reviewed for patients with localized prostate cancer managed by HoLEP with at least a follow‐up of 1‐year post HoLEP. We assessed the PSA trend, effect on international prostate symptom score (IPSS), the impact of HoLEP on further management of prostate cancer, and any associated complications.
Results: Out of 1060 patients, 43 patients with pre‐existing prostate cancer had HoLEP between April 2016 and August 2020. Table 1 shows patients' baseline data. Table 2 shows the effect on PSA and IPSS.
Thirty‐two (74%) patients continued active surveillance, while 10 (23%) patients had radiotherapy for PSA relapse or persistently high PSA after HoLEP. Only 1 (2.3%) patient had High‐intensity Focused Ultrasound (HIFU).
Specific analysis of the 13 intermediate‐risk patients showed that their mean (SD) preoperative PSA was 11.6 (7.2) while three months and one year mean (SD) PSA was 2.3(2.5) and 1.3(0.8), respectively. Eight (61.5%) patients continued active surveillance, while 5 (38.4%) patients had radiotherapy.
Stress incontinence rate was 18.5% and 0 % at three months and one year follow up. Only one (2.3%) patient developed bulbar urethral stricture.
Conclusions: HoLEP is very beneficial in debulking large prostate in prostate cancer patients with bothersome LUTS on active surveillance or prior to radiotherapy. Moreover, HoLEP reduces the contribution of large volume adenoma to PSA level in prostate cancer patients, thus giving a better reflection of PSA level and reducing overtreatment, especially in intermediate‐risk category patients.
Re‐Treatment for Lower Urinary Tract Symptoms (LUTS) After Water Vapor Thermal Therapy
C Cerrato, MV Nguyen, S Bechis
Università degli studi di Verona, Urology Department UC San Diego Health
Introduction & Objective: Water vapor thermal therapy (Rezum, Boston Scientific, Marlborough, MA, USA) has become increasingly used as a minimally invasive surgical treatment for LUTS due to benign prostatic hyperplasia (BPH) with a low retreatment rate. We sought to identify predictors of retreatment or symptom recurrence.
Methods: We retrospectively reviewed patients treated with water vapor thermal therapy at a single institution from August 2017 to February 2022. Patient demographics, pre‐ and peri‐operative data, and international prostate symptom scores (IPSS) were evaluated. Patients who underwent a second BPH procedure (“re‐treatment”) for persistent or recurrent LUTS within 2 years of original treatment were compared to the remainder of the cohort who did not undergo re‐treatment. Multivariate analysis (MVA) was used to assess for predictors of retreatment.
Results: Data from 192 consecutive patients undergoing water vapor thermal therapy were collected and analyzed. 10 (5%) patients were retreated (1 with Rezum, 4 with transurethral resection, 4 with laser vaporization, 1 with robot‐assisted simple prostatectomy at an average of 58 months). Men in the re‐treatment cohort had smaller prostate volumes (48.5 vs 50.4, p = 0.003) and received a greater number of water vapor injections (5 vs 4, p < 0.001). Baseline IPSS score or median lobe treatment was not associated with re‐treatment (Table 1a). At 6‐month follow‐up, total IPSS (10.13 vs 18.5, p = 0.044) and IPSS voiding sub‐scores (4.59 vs 9.5, p = 0.006) were significantly worse in the re‐treated group (Table 1b). On MVA, ≥3 treatments during an initial Rezum procedure were independently associated with increased risk of retreatment (HR 8.51, p = 0.039). Increasing prostate volume, catheter duration, and treatment of the median lobe were not significantly associated with an increased risk of retreatment in these patients (Table 1c).
Conclusions: We found that water vapor thermal therapy has a good performance with a low retreatment rate, consistent with larger published studies. Men who did require retreatment of their LUTS from BPH tended to receive more vapor injections and showed significant worsening of voiding symptom scores around 6 months post‐operatively. Decreasing the number of vapor injections when possible may help further reduce treatment failure rates.
En‐Bloc Holmium Laser Enucleation for Benign Prostatic Hypertrophy with Urinary Retention: Clinical Characteristics and Outcomes
H Herzberg, Y Veredgoren, Z Savin, K Lifshitz, N Alsaraia, O Yossepowitch, M Sofer
Department of Urology, Tel Aviv Sourasky Medical center
Introduction & Objective: Benign prostatic hyperplasia (BPH) with chronic or recurrent acute urinary retention (CUR and AUR, respectively) is an absolute indication for surgical intervention. We aimed to determine patients' clinical characteristics and outcomes after holmium laser enucleation of prostate (HoLEP) performed in these situations.
Methods: The study comprises 231 consecutive patients treated by HoLEP between January 2020 and March 2022. Comparison groups were created by indication for surgery: Group A ‐ lower urinary tract symptoms (LUTS) (n = 132); group B ‐ CUR (n = 65); and group C ‐ AUR (n = 34). No preoperative urodynamic evaluation was done. Preoperative and operative characteristics, and postoperative outcomes were compared between groups.
Results: The results are presented in the Table 1. Groups B and C were significantly older and had longer hospital stay than group A. In addition, CUR was characterized by significantly larger prostates, higher American Association of Anesthesiology (ASA) score, higher BPH enucleated weight, higher rates of beach balls, longer operations, and longer hospital stay. There was no difference between comparison groups in improvements in International Prostate Symptoms Score (IPSS) and quality of life question (QoL), as well as postoperative complications. All patients were free of catheter after the operation. The median follow‐up was 10 months (IQR 4‐16).
Conclusions: Men with urinary retention secondary to BPH are more challenging for surgical treatment, being older, with more co‐morbidities and having larger prostates. However, HoLEP provides an effective solution in these cases. It appears that no preoperative urodynamic evaluation is needed since all patients were postoperatively free of catheter. The findings of longer operation and hospital stays associated with preoperative urinary retention may contribute to a better logistic preparation and use of medical system resources.
Preoperative Imaging Is Equally Accurate in Trilobar and Bilobar Prostates Undergoing BPH Treatment
CM Forbes, C Peterson, NL Miller
Vanderbilt University Medical Center
Introduction & Objective: Benign prostate hyperplasia (BPH) treatment options differ by prostate volume. Some procedures are recommended only for certain volumes. The presence of a median lobe affects imaging size estimates in prostate cancer surgery. However, this impact in BPH patients, who have a markedly different prostate zone configuration, is not well established. We assessed the accuracy of preoperative imaging for bilobar vs trilobar prostates undergoing enucleation.
Methods: Patient records at a quaternary academic center were retrospectively reviewed with Internal Review Board approval. Patients undergoing BPH enucleation who had preoperative cystoscopy assessing prostate configuration and preoperative imaging were included. Difference between preoperative imaging and pathology weight was compared between groups with trilobar and bilobar prostate configuration. One imaging modality per patient was used in order of MRI; CT; US. Differences between means were calculated using unpaired, two‐way Student's t‐tests.
Results: 120 patients had preoperative prostate configuration recorded on cystoscopy undergoing BPH treatment with enucleation from Jan – Oct 2020, of whom 94 met inclusion criteria with preoperative imaging studies. Preoperative imaging studies were greater than enucleation volume by 47 cc in the bilobar group, versus 60 cc in the trilobar group. This difference was not statistically significant (p = 0.09) (Table 1).
Conclusions: In this study, preoperative prostate size estimates for BPH enucleation differed from pathology weight in all prostates on average, likely due to inclusion of intentionally untreated peripheral zone on imaging. The differences between pathology volume and preoperative imaging volume were not statistically significant for bilobar versus trilobar prostates. The trend toward greater difference in trilobar prostates may be due to limitations of the prolate ellipsoid formula used for size estimation for this prostate shape.
Comparison of the Efficacy and Safety of Minimally Invasive Simple Prostatectomy and Endoscopic Enucleation of Prostate for Large Benign Prostatic Hyperplasia: A Systematic Review and Meta‐Analysis
J Li, Q Wei, D cao
West China Hospital, Sichuan University
Introduction & Objective: Minimally invasive simple prostatectomy (MISP) and endoscopic enucleation of the prostate (EEP) are the two most commonly used methods for large benign prostatic hyperplasia (BPH), but it remains unclear which of the two is superior. This study aims to perform a meta‐analysis to compare efficacy and safety profiles between MISP and EEP.
Methods: This present study was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta‐Analysis) statement and was registered on PROSPERO: CRD42021239950. We conducted a comprehensive search of PubMed, Embase, Web of Science, and ClinicalTrials.gov databases to identify eligible studies comparing MISP with EEP for the treatment of large prostates and published in English from database establishment through October 2021. Parameters including efficacy and safety outcomes were compared using Stata 14.0 version.
Results: Eight comparative trials with 1504 patients were included. Compared to MISP, EEP demonstrated shorter operative time (mean difference [MD] 46.37, 95% confidence interval [CI] 19.92‐72.82, p = 0.0006), lesser hemoglobin decrease (standardized MD [SMD] 0.59, 95% CI 0.23‐0.95, p = 0.001), lower catheterization time (SMD 4.13, 95% CI 2.16‐6.10, p < 0.001), and shorter length of stay (SMD 2.38, 95% CI 1.40‐3.36, p < 0.001). However, overall complications and blood transfusions did not differ between the two groups. Moreover, EEP had better postvoid residual volume (PVR) at 6‐month (MD 14.39, 95% CI ‐9.73‐7.30, p = 0.78) and comparable 3‐ and 6‐month International Prostate Symptom Score, 3‐ and 6‐month maximum flow rate, 3‐month PVR, and 3‐month quality of life compared with MISP.
Conclusions: Both MISP and EEP are effective and safe surgical procedures for the treatment of large BPH. EEP appears to have a superior perioperative profile compared to MISP. This should be interpreted with caution due to the significant heterogeneity between studies. Hence, treatment selection should be based on the surgeon's experience and availability.
The Incidence of Urethral Strictures and Bladder Neck Contractures with Transurethral Resection (TURP) versus Holmium Laser Enucleation of Prostates (HoLEP); A Matched Dual‐center Study
M Elsaqa, M Serag, M Elsawy, N Leelani, MM El Tayeb
Baylor Scott and White Health Medical Center, Temple, Texas; Alexandria University Faculty of Medicine, Egypt
Introduction & Objective: Urethral strictures (US) and bladder neck contracture (BNC) are common long‐term complications of transurethral prostate surgery. We aimed to compare TURP, either monopolar or Bipolar and HoLEP, regarding the incidence of US and BNC and identifying the risk factors for these complications.
Methods: Retrospective charts review of patients who underwent TURP and HoLEP with follow‐up data of at least one year in 2 separate institutions was performed. The incidence of postoperative US or BNC in both groups was compared. Multivariate analysis for risk factors was performed.
Results: Out of 1130 patients, 208 patients were included in the study; 101 and 107 patients in the TURP and HoLEP arm, respectively. The two groups were matched for age and prostate size. Baseline characteristics of both groups are shown in Table 1. Eight (7.92%) and five (4.72%) patients in the TURP and HoLEP arm respectively developed US (p = 0.3423) while 2 (1.87%) patients in the HoLEP arm had BNC (p = 0.2634). Table 2 Of the 8 patients with the US in the TURP arm, 6 (9.8%) patients had Bi‐polar TURP, while 2 (5%) patients had monopolar TURP. Multivariate analysis of the risk factors in patients with the US have found no statistically significant difference regarding their age, prostate volume, history of previous catheterization, operative time, catheterization time, or history of DM as shown in Table 3.
Conclusions: There is no significant difference between TURP and HoLEP regarding the incidence of US or BNC, although there is a tendency towards a higher rate of US associated with Bi‐polar TURP.
Evaluation of the Learning Curve for Thulium Laser Enucleation of the Prostate Using Multiple Outcome Measures
D Perri, L Berti, M Maltagliati, U Besana, C Buizza, J Roche, B Rocco, S Micali, M Sighinolfi, A Pacchetti, G Bozzini
Sant'Anna Hospital Como
Introduction & Objective: To assess and quantify the surgical learning curve of Thulium laser enucleation of the prostate (ThuLEP) of a single surgeon.
Methods: A prospective analysis of 543 consecutive cases performed by the same surgeon from 2017 to 2019 was conducted. Primary outcomes included enucleation ratio and morcellation efficiencies and complication rates. Three‐month postoperative prostate‐specific antigen values were used as secondary measures. Cases were divided into cohorts of 20 cases to assess changes in means analyzed through Analysis of Variance (ANOVA) tests. Scatter plots of cases with a best‐fit line were drawn to analyze the learning curve.
Results: The mean age of patients across the cases was 73.13 years with an average transrectal ultrasound prostate volume of 89.77 ml. Enucleation ratio efficiency was significantly different between cohorts (P = .03) plateau after 50‐60 cases conducted. Similarly, a significant difference is shown for morcellation efficiency (P = .01) with stabilization in performance after 60 cases. Complication rates decreased through the caseload but did not show a statistical difference (P = .47) or plateauing on the graph. Finally, no difference between 3‐month postoperative prostate‐specific antigen values was seen (P = .075); however, a learning curve of 50 cases was observed graphically.
Conclusions: Within our single‐surgeon cohort, we experienced a learning curve of 40‐60 cases for the ThuLEP procedure. Large variability in performance late into the caseload demonstrates the technical difficulty of ThuLEP. Owing to this, adjuncts to training such as simulation‐based training may be of use for the new surgeon to shorten the initial phase of learning.
Pulsed vs Continuous TFLEP: A Multi‐Institution Trial to Compare Intra and Early Postoperative Outcomes
D Perri, L Berti, U Besana, C Buizza, M Maltagliati, S Micali, B Rocco, M Sighinolfi, A Pacchetti, J Roche, G Bozzini
Sant'Anna Hospital Como
Introduction & Objective: To compare clinical intra and early postoperative outcomes between pulsed and continuous Thulium Fiber laser enucleation of the prostate (pTFLEP vs cTFLEP) for the treatment of benign prostatic hyperplasia (BPH).
Methods: 238 patients suffering from lower urinary tract symptoms due to BPH were consecutively enrolled and randomized to either pTFLEP (123 patients) or cTFLEP (115 patients). Patients urinary function was assessed preoperatively using the International Prostate Symptom Score (IPSS), Quality of Life score (QoL), maximum flow rate (Qmax), and postvoid residual urine volume (PVR). Preoperative prostate volume, PSA and haemoglobin were recorded. All the patients were evaluated postoperatively with regards to blood loss, catheterization time, irrigation volume, hospital stay and operative time. 3 months after surgery micturition improvement was evaluated using the IPSS, Qmax and PVR.
Results: The patients in each study arm each showed no significant differences in preoperative parameters. Compared with pTFLEP, cTFLEP determined shorter operative time (61.52 ± 33.74 vs 67.49 ± 36.12 minutes, p = 0.041). Haemoglobin decrease (0.38 vs 0.39 g/dL, p = 0.53), catheterization time (2.2 vs 2.1 days, p = 0.29), irrigation volume (32.9 vs 32.8 l, p = 0.71), and hospital stay (2.8 vs 2.6 days, p = 0.29) were comparable between pTFLEP and cTFLEP. During the 3‐month follow‐up, the procedures did not demonstrate any significant difference in Qmax, IPSS, PVR, and QoL.
Conclusions: pTFLEP and cTFLEP both relieve lower urinary tract symptoms equally, with high efficacy and safety. cTFLEP was significantly shorter to perform compared to pTFLEP. Whereas, catheterization time, irrigation volume, hospital stay and operative time showed no differences.
Holmium Laser Enucleation of the Prostate (HoLEP) vs Prostate Artery Embolization (PAE) in the Treatment of Lower Urinary Tract Symptoms (NCT04236687): Initial Results of a Randomized Controlled Trial (RCT)
R Bultó Gonzalvo, J Sampere, G Tovar, D Salvador, M Bernardello, J Areal, F Agreda
Introduction & Objective: PAE is a minimally invasive technique used in the treatment of LUTS produced by prostatic bladder outlet obstruction (BOO). Some studies have proved PAE reduces IPSS (International Prostate Symptom Score), improves urinary flow and is safe. No prospective controlled trial vs HoLEP has been done. Our RCT (still recruiting) (ID NCT04236687) pretends to include 50 patients in each arm and follow them for 1 year after intervention, and we aim to compare changes in IPSS score, International index of Erectile function (IIEF5), complications and urodynamics. Here, we present results of 39 patients with 6 months of follow‐up.
Methods: We analyzed and compared with Student's T test the first 39 subjects recruited in the trial; 19 underwent HoLEP and 20 PAE.
Results: In the preoperative evaluation we found no differences regarding age, prostate volume, PSA, IPSS score, QoL score, IIEF5 and urodynamics. PAE subjects showed significant reduction of void IPSS (‐7,87 points, 95%CI ‐4,19 to ‐10,91), storage IPSS (‐4,54points, 95%CI ‐1,83 to ‐6,49), QoL score (‐2,86 points, 95%CI ‐1,79 to ‐3,78), post‐void volume (PVV) (‐54,93mL, 95%CI ‐7,24 to ‐102,62) and PSA (‐2,62, 95CI ‐0,29 to ‐5,44) at 6 months. No significant differences were observed in IIEF5 score, maximum urinary flow (MUF) and prostate volume. HoLEP subjects showed significant reduction of void IPSS (‐10,5 points, 95%CI ‐7,67 to ‐13,62), storage IPSS (‐6,5 points, 95%CI ‐2,98 to ‐9,17), QoL score (‐3,91 points, 95%CI ‐3,08 to ‐4,75), PVV (‐139,37mL, 95%CI ‐32,15 to ‐312,89), PSA (‐3,75ng/dL, 95%CI ‐1,47 to ‐3,95) and improvement in MUF (9,07mL/s, 95%CI 1,9 to 16) at 6 months. No significant differences were observed in IIEF5 score. When compared inbetween at 6 months, no significant differences were observed in change of void IPSS, storage IPSS, IIEF5, QoL, and PSA. HoLEP was superior improving MUF and reducing PVV (p < 0,05). No major complications were registered. Eleven (55%) PAE patients had post‐embolization syndrome.
Conclusions: HoLEP and PAE proved to reduce IPSS score, not affect IIEF5 score and be safe interventions. HoLEP showed better urodynamics results than PAE.
Characteristics and Clinical Outcomes of Patients Undergoing Concurrent Bladder Neck Incision During Holmium Laser Enucleation of the Prostate
MS Lee, M Ganesh, MA Assmus, J Han, J Helon, AE Krambeck
Ohio State University
Introduction & Objective: Prior work has identified that small prostate size is a risk factor for bladder neck contracture (BNC) after Holmium laser enucleation of the prostate (HoLEP). Thus, surgeons will often perform bladder neck incision (BNI) concurrently in smaller prostates. However, the effect of concurrent BNI on postoperative outcomes is unknown. Herein, we sought to define clinical characteristics and postoperative outcomes of patients undergoing concurrent BNI during HoLEP.
Methods: A retrospective review of all patients who underwent HoLEP by a single expert surgeon was performed from Jan – Oct 2021. We compared patients who received concurrent BNI to those who did not. Variables were abstracted from the electronic medical record. Statistical analysis was performed using SAS Studio (SAS institute, 2021). Student t‐tests and chi‐square tests were performed for continuous and categorical variables, respectively. Paired t‐tests were used to compare the same variables over time. Variables with a p‐value of <0.05 were deemed statistically significant.
Results: 324 patients underwent HoLEP. BNI was performed in 47 patients. BNI patients were younger 66.36 (8.77) vs. 71.65 (7.99) (p < 0.001). Preoperative prostate measurements were smaller in the BNI group 60.94 (26.88) vs. 134.8 (63.68) (p < 0.0001). Procedure, enucleation, and morcellation time were shorter in the BNI group. There was no difference in the ability to achieve same‐day discharge between the two groups (91.30% vs 85.47%). There were no statistically significant difference in ED visits or readmissions between the two groups. At 3 month follow up, no bladder neck contractures have developed in the entire cohort.
Conclusions: BNI is performed in patients who are younger and with smaller prostates. Concurrent BNI has not resulted in an increased rate of ED visits, readmissions or decreased ability to achieve same‐day discharge. At 3 month follow up there were no BNCs in either cohort. Further follow up is required to see concurrent BNI can reduce the risk of BNC.
Positive Pre‐Operative Urine Culture Is Associated with Culture‐discordant Post‐operative Urinary Tract Infection in Patients Undergoing Holmium Laser Enucleation of the Prostate
T Campbell, K Doersch, H LaMascus, S Quarrier, R Jain
Introduction & Objective: Holmium Laser Enucleation of the Prostate (HoLEP) is a preferred surgical treatment for medication‐refractory benign prostatic hyperplasia. The purpose of this study was to evaluate risk factors for urinary tract infections (UTIs) following HoLEP.
Methods: Individuals undergoing HoLEP at a tertiary referral center between 11/2020 and 12/2021 were identified retrospectively. Pre‐op positive cultures were treated with appropriate antibiotics, all subjects received perioperative antibiotics per guidelines. Post‐op UTI was defined as over 100,000 colony‐forming units of bacteria on a urine culture requiring antibiotics or hospitalization for UTI within 60 days of HoLEP. Logistic regression and ANOVA were performed in R (version 4.2.0 2022) to evaluate the impact of age, prostate size, Charlson Comorbidity Score, post‐op urinary retention, and positive pre‐op urine culture on post‐op UTI risk.
Results: Seventy‐five subjects were identified with a median follow‐up of 9.3 months. Sixteen (21%) post‐operative UTIs were detected at a median of 22.5 days post‐op. One patient was treated empirically, one had unavailable culture data, and the other 14 had positive urine cultures. Multivariable analysis demonstrated an association between positive pre‐op urine culture and post‐op UTI (p = 0.02) (Table 1). Subjects with a positive pre‐op urine culture were 4.38 times more likely to have a post‐op UTI on multivariable analysis. Of the 14 positive post‐op urine culture results, 11 were associated with discordant pre‐op urine culture results including negative culture or a positive culture with different speciation or antibiotic resistance pattern.
Conclusions: Pre‐operative positive urine culture is associated with post‐operative UTI even when cultures are appropriately treated pre‐operatively. Post‐operative urine culture species in patients with UTI who underwent recent HoLEP are frequently discordant with pre‐operative urine species.
MP7: Clinical Stones: Outcomes & PCNL I
Determining the Safety and Effectiveness of Percutaneous Nephrolithotomy and Retrograde Intrarenal Surgery in Treating Nephrolithiasis in Patients with Solitary Kidneys
L Peng
Second Clinical Medical College of Lanzhou University, China
Introduction & Objective: We performed a meta‐analysis to compare the safety and effectiveness of percutaneous nephrolithotomy (PCNL) and retrograde intrarenal surgery (RIRS) in treating nephrolithiasis in patients with solitary kidneys.
Methods: This systematic review was registered on PROSPERO (registration ID: CRD42021270519). The search time was set from the establishment of the databases until April 30, 2021. A systematic search was performed in the PubMed, MEDLINE, Web of Science, Scopus, China National Knowledge Infrastructure (CNKI), Cochrane Library, and Embase databases. Stata 16 was used to perform the statistical analysis of the extracted data.
Results: After screening using strict inclusion and exclusion criteria, five studies with a total of 474 patients were included in the final meta‐analysis. According to the literature quality assessment scale statistics, the five studies included were of high quality. The results of the meta‐analysis showed that RIRS had lesser hemoglobin loss (HL), shorter length of hospital stay (LOS), lower initial (OR = 3.39, 95% CI [1.97, 5.83], P = 0.02) and final stone‐free rates (OR = 2.24, 95% CI [1.24, 4.06], P = 0.03), but a higher incidence of grade III‐IV complications (OR = 0.29, 95% CI [0.08, 0.97], P = 0.04) than PCNL. The difference between the two surgical methods was not statistically significant in terms of operation time (OT), grade I–II complication rate, and total complication rate.
Conclusions: For nephrolithiasis ≥2 cm in patients with solitary kidneys, RIRS has less HL and shorter LOS, preserving kidney function to the greatest extent. RIRS may be an effective alternative to PCNL in the treatment of nephrolithiasis in patients with solitary kidneys. However, it should be noted that RIRS may cause higher‐level complications.
Ureteral Stent Discomfort: What Do the Data Reveal about the Best Approaches for Symptom Mitigation?
S Brockman, Z Leopold, EO Olweny
Introduction & Objective: Severity of ureteral stent discomfort is modifiable by biomaterial alteration and/or addition of pharmacologic therapy. However, the optimal biomaterial / drug combination for mitigation of stent discomfort has not been reported to date.
Methods: Randomized controlled trials (RCTs) comparing symptom scores in stented patients (derived from the ureteral stent symptom questionnaire (USSQ)), published between Jan 2005 and Oct 2020, were systematically reviewed. For each study arm of eligible studies, stent biomaterial, pharmacologic agent (if any) utilized and demographic data were recorded. Each study arm represented a unique biomaterial +/‐ drug stenting strategy; USSQ scores in 3 domains (urine index, pain index, general health index) were compared across the strategies using frequentist network meta‐analysis. Strategies were ranked from best to worst using the surface under the cumulative ranking curve (SUCRA) method.
Results: 18 stenting strategies were identified across 13 RCTs enrolling 1,606 patients. The most common strategy, Percuflex®+ control (i.e. placebo or no drug) was designated the referent. Relative to this, USSQ urine and pain index scores for silicone + tamsulosin and Percuflex® + solifenacin + pregabalin were significantly lowest (i.e. better HRQoL), and these were the top 2 ranked strategies by SUCRA across all 3 USSQ domains.
Conclusions: In patients requiring ureteral stents, use of Percuflex® stents along with solifenacin + pregabalin, or silicone stents along with tamsulosin, may best mitigate stent‐associated discomfort.
Outcomes of Prone versus Supine Percutaneous Nephrolithotomy: A Systematic Review and Meta‐Analysis
K Wang, J Leow, J Foo, Y Yeow, Y Lee
National University Hospital
Introduction & Objective: Contemporary practice guidelines recommend the prone and supine positions for percutaneous nephrolithotomy (PCNL). Despite numerous studies comparing the two, no clear consensus has been reached regarding the best position for optimal outcomes. This meta‐analysis was thus conducted to assess the efficacy and safety of PCNL in the supine position compared to the prone position, when performed on patients with renal or upper ureteric stones.
Methods: In March 2021, a systematic review was conducted on the digital databases PubMed, EMBASE and the Cochrane Central Register of Controlled Trials according to the Preferred Reporting Items for Systematic Review and Meta‐analysis statement. The Cochrane Collaboration Risk of Bias 2 tool was used to assess randomised controlled trials, and the Newcastle‐Ottawa Scale was used for non‐randomised prospective and retrospective cohort studies.
Results: Thirty‐five publications, consisting of 10,230 patients, were selected for inclusion in this analysis. Notably, there were no significant differences in stone‐free rate (p = 0.80) and duration of hospitalisation (p = 0.13) between supine and prone PCNL. However, supine PCNL had a shorter operating time (WMD ‐12.0 min, 95% CI ‐18.4 to ‐5.5, p = 0.001), lower total complication rate (RR 0.83, 95% CI 0.75 to 0.91, p < 0.001), fewer blood transfusions (RR 0.77, 95% CI 0.64 to 0.93, p = 0.007) and lower post‐operative fever rates (RR 0.74, 95% CI 0.62 to 0.88, p = 0.001) than the prone group.
Conclusions: Evidence suggests supine PCNL was as effective as, and safer, than prone PCNL. Supine PCNL also presents other advantages, including anaesthesia considerations, surgeon safety and ergonomics. In view of this, we propose that PCNL in the supine position should be considered for patients with renal or upper ureteric stones larger than 2cm.
Abdominal Taping and Impact on Supine Percutaneous Nephrolithotomy Access
Y Yeow, Y Lee, J Kwok
Tan Tock Seng Hospital, Singapore
Introduction & Objective: Supine percutaneous nephrolithotomy (PCNL) is gaining traction worldwide, however in the supine position skin to stone distance is usually longer. Patients with thick abdominal subcutaneous fat have an increased skin to kidney distance, making it more difficult for percutaneous access, particularly in supine PCNL. By abdominal taping, this brings away the subcutaneous folds of the skin from the flank. Abdominal taping to bring away subcutaneous fat has been described widely in literature and is common standard practice in our institution in patients with higher Body Mass Index (BMI). We wanted to evaluate abdominal taping's exact impact on decreasing skin to stone distance.
Methods: All patients listed from 29th June 2021 to 8th Mar 2022 for supine PCNL were approached to participate in our study with written consent prospectively. We carried out taping of the abdomen in the Modified Galdakao‐Valdivia‐Giusti position for all patients recruited, with the skin to stone distance measured with ultrasound pre and post taping at the intended access site by the same physician, ensuring the same coronal ultrasound cut of the kidney and same part of the stone was maintained.
Results: 27 patients were recruited with a mean age of 59 years old. The mean BMI was 26 (range 19 to 36, SD = 4.78) and mean weight 68.4kg (range 48.7 to 93.9, SD = 13). Laterality wise, 13 (48%) were left sided and 14 (52%) were right sided PCNLs. There was a significant change in mean skin to stone distance pre and post abdominal taping (5.88cm pre vs 6.15cm post, p = 0.03). 8 patients had a shorter skin to stone distance post abdominal taping, with a surprising finding of 19 patients having a longer skin to stone distance post taping (range of change ‐0.91cm to +1.81cm).
Regression analysis showed a statistically significant negative association of skin to stone distance with average decrease ‐0.02cm for every unit increase of weight in kilograms (p = 0.03). There was a negative association of skin to stone distance with average decrease ‐0.03cm for every unit increase in BMI, but this was not significant (p = 0.30).
Conclusions: Our results suggest that abdominal taping does significantly affect skin to stone distance, decreasing skin to stone distance in heavier patients, but may paradoxically increase skin to stone distance in lighter patients. Therefore, abdominal taping should be considered mainly in heavier patients planned for supine PCNL.
Routine Blood Tests Day 1 after 14Fr Super‐Mini Percutaneous Nephrolithotomy: Are They Clinically Indicated?
TR Fonseka, N De Luyk, K Byrnes, V Arumuham, N Ramachandran, C Allen, S Choong
Institute of Urology at University College London Hospitals, London, UK
Introduction & Objective: Routine blood tests are often performed after percutaneous nephrolithotomy. We aimed to identify if day 1 post‐operative routine blood tests are clinically indicated following 14Fr Super‐mini percutaneous nephrolithotomy (14Fr‐SMP) and whether they affected patient outcomes.
Methods: Patients undergoing 14Fr‐SMP were identified over a 4‐year period. Pre‐ and post‐operative day 1 blood analyses were recorded. The number of blood transfusions and cases of acute kidney injury (AKI) were also identified.
Results: Total number of patients was 75. Patient demographics, stone characteristics and surgical outcomes are summarised in Table 1. Fifty patients (66.7%) were discharged on day 1. Stone‐free rate was 89% and 64% of patients were completely tubeless (no stent or nephrostomy tube).
Mean Haemoglobin (Hb) drop was 10.7g/L (SD = 10.6g/L). Twelve patients (16%) had a significant drop in Hb level (20g/L‐30g/L) and 4 patients (5.3%) had a Hb drop ≥30g/L. All of these patients had evidence of haemodilution and 75% were ASA grade ≥2. No patient required a blood transfusion.
Two patients (2.67%) developed AKI stage 1, which resolved with fluids. Both patients were ASA grade 2. Mean percentage rise in serum Creatinine was 3.33% (SD = 18.0%).
Conclusions: Routine blood analyses after 14Fr‐SMP did not alter patient management. Foregoing these routine blood tests could have several benefits including cost‐saving, better time‐management and increased resource utility without adversely affecting patient outcomes.
Defining the Non‐Contrast Computerized Window Setting for Optimal Colon Identification Prior to Percutaneous Nephrolithotomy
Z Savin, S Dekalo, H Herzberg, O Yossepowitch, M Sofer
Sourasky Medical Center, Tel Aviv, Israel
Introduction & Objective: Colonic injury during percutaneous nephrolithotomy (PCNL) is a rare, however, disastrous complication. Therefore, preoperative accurate identification of colon on cross sectional imaging, usually non‐contrast computed tomography (NCCT), is essential in planning the access and reducing the risk of its occurrence. The lack of contrast material, collapsed bowel segments and previous intraabdominal operations may limit proper colonic recognition on NCCT. We aimed this study to assess which NCCT window setting provides the optimal colonic identification for PCNL preoperative planning
Methods: Twenty‐two axial NCCT images of 11 consecutive patients scheduled for PCNL were reviewed by a senior endourologist who chose the most representative ones for planning the PCNL puncture. Eight urologic surgeons (2 specialists, 6 residents) reviewed these images in a randomized blinded order using 2 window settings (abdomen and lung). They were asked to mark the colonic area in each image (Figure 1) using a dedicated commercially available area calculator software (Bluebeam, Pasadena, USA). Statistical assessment was conducted.
Results: Overall, the mean marked colonic area was greater in the lung window in comparison to abdomen window: 8.82 cm2 vs 7.4 cm2 , respectively, p < 0.001). Changing the CT‐window from abdomen to lung resulted in increased identified colonic area in 44 images (50%), similar area in 30 images (34%) and decreased area in 14 images (16%). Intraclass correlation showed good agreement between the senior readers and among all readers (0.92 and 0.87 respectively). Senior urologists had consistent area measurements (no difference in area measurements between abdomen and lung windows) in 13/22 cases, while residents had no difference in area measurements in only 17/66 cases (p = 0.008).
Conclusions: Lung window solely or in combination with abdomen window appear to provide the most accurate colonic demarcation for pre‐operative planning of PCNL access. This pattern is more evident among young urologists and may reduce the risk of colonic injury.
Are Intra‐Operative Stone Cultures Worthwhile in the Management of Post‐Operative Sepsis Following Mini‐PCNL?
FE Rodger, R McLennan, J Tan, S Nalagatla
Introduction & Objective: The aim of this study was to assess the clinical utility of intra‐operative stone culture sent at the time of mini percutaneous nephrolithotomy (mPCNL) for the management of post‐operative sepsis.
Methods: A retrospective case note review was carried out for consecutive mPCNL cases performed by a single surgeon between May 2020 and May 2021
Results: 38 patients under went mPCNL, 13 females and 15 males. 13 patients had a positive pre‐op culture (5 mixed organisms, 4 E coli and 1 klebsiella). Intra‐operative antibiotics were given in all cases (27 single agent gentamicin, 6 gentamicin with amoxicillin, 2 gentamicin and co‐amoxiclav, 1 gentamicin with meropenem, 1 single agent vancomycin and 1 vancomycin with meropenem. Intra‐op stone cultures were sent in 31 cases. 1 grew mixed anaerobes, 3 staph aureus and 27 showed no growth. The post‐op sepsis rate was 14% however a causative organism was only identified in 1 case. Of the 5 patients with post‐op sepsis 4 had an intra‐operative stone culture sent all of which showed no growth. Of the positive intra‐operative stone cultures none of these organisms correlated with the pre‐op urine culture results.
Conclusions: In our study intra‐operative stone cultures did not correlate with the pre‐op urine culture results. Intra‐operative stone cultures were predominantly sterile and did not correlate with post‐operative sepsis rate or the sepsis causing organism. Intra‐op stone cultures could therefore not be used to guide antibiotic choice in any case in this study. Our study suggests that intra‐operative stone culture does not show clinical utility in the prediction and management of sepsis following PCNL.
A Preliminary Study on the Role of Preoperative Procalcitonin in Predicting Post‐Operative Sepsis among Culture Negative Patients Undergoing Percutaneous Nephrolithotomy: A Prospective Single Surgeon Study
D Rubio, AP Castro
National Kidney and Transplant Institute, Philippines
Introduction & Objective: Percutaneous nephrolithotomy (PCNL) is the standard treatment for kidney stones ( >2cms). Post‐operative infection is its most common complication. Procalcitonin (PCT) is a biomarker used for early diagnosis of sepsis, however, its diagnostic value for patients with urosepsis following PCNL has not been previously reported.
Methods: All patients underwent PCNL , with a preoperative negative urine culture, and a baseline procalcitonin. PCNL was done by a single surgeon and was blinded with the procalcitonin levels. Patients' demographics, stone characteristics, location of puncture site,,number of tracts,,operative time, estimated blood loss (EBL), stone‐free rates and complications based on the Clavien‐Dindo (CD) were analyzed. A repeat urine culture was done in patients who showed signs and symptoms of sepsis post operatively.
Results: A total of 40 patients were studied with a mean age of 48, 22 were male and 18 were female. Majority (n = 21) had a GSS IV, while 16 and 3 had a GSS of III and II, respectively. The mean stone diameter was 4.1 cm. In terms of laterality, 22 were right sided and 18 were left sided. Majority (n = 34,) were treated with a single tract access and 6 with multitract access. Thirty seven utilized the upper pole access, 6 via inferior pole and 3 via the middle pole access. The average OR time was 125.3 minutes and EBL was 287.5 mL. The stone free rate was 98%. Post‐operatively, 11 had complications, 9 (22.5%) had fever (CD I) and 2 (5%) required blood transfusion (CD II) with no mortalities recorded. A total of 7 patients showed signs and symptoms of sepsis and had a positive urine culture. Considering >0.07 ng/mL as elevated procalcitonin, there was sufficient evidence that showed association between elevated preoperative procalcitonin and occurrence of sepsis in patients who underwent PCNL with a preoperative negative urine culture.
Conclusions: Procalcitonin is a useful biomarker in predicting sepsis in post PCNL patients with preoperative negative urine culture.
An Assessment of Quality of Life after 14Fr Super‐Mini Percutaneous Nephrolithotomy
TR Fonseka, N De Luyk, K Byrnes, V Arumuham, N Ramachandran, C Allen, S Choong
Institute of Urology at University College London Hospitals, London, UK
Introduction & Objective: Mini percutaneous nephrolithotomy has received widespread interest and uptake as a novel technique in the treatment of renal stones. However, there is limited research on patient quality of life (QOL) after 14Fr Super‐mini percutaneous nephrolithotomy (14Fr‐SMP). The objective of this study was to assess quality of life before and after 14Fr‐SMP.
Methods: Data was prospectively collected on 55 cases of 14Fr‐SMP at a tertiary referral center. The EQ‐5D‐5L survey, developed by the EuroQol group, was conducted at three time points in the patient journey; 1 day pre‐, 1 day post‐ and 6 weeks post‐operatively. The survey was used to assess five dimensions of health including ‘mobility’, ‘self‐care’, ‘daily activities’, ‘pain/discomfort’ and ‘anxiety/depression’. Each dimension of health was assessed on a 5‐point scale, giving a score out of 5. Scores from these five dimensions were used to calculate an index value specific to the UK population. A visual analogue scale (VAS) score assessing overall health was also included. Index values and VAS scores were compared between the three different time intervals using paired T‐tests. Statistical significance was granted for p value ≤0.05.
Results: In total, 55 patients were included in the study. Mean stone size was 15.1mm (SD = 8.15mm) and complete stone clearance was achieved in 47 patients, giving a stone‐free rate of 85.5%. Overall QOL, as derived from the EQ‐5D‐5L Index value, significantly improved from 1 day before surgery compared to 6 weeks after surgery (p = 0.003). QOL also improved from post‐operative day 1 compared to post‐operative week 6 (p = < 0.001). QOL decreased from the day before surgery to post‐operative day 1, however, this was not statistically significant (p = 0.412). The only individual dimension of health in which there was significant improvement post‐surgery was in ‘anxiety/depression’ (p = 0.02). There was no significant difference between VAS scores before and after surgery.
Conclusions: This study demonstrates that 14Fr‐SMP significantly improves overall quality of life. Interestingly, the greatest improvement was seen in ‘anxiety/depression’, rather than traditionally assessed categories such as pain and activities of daily life. This has important implications for counselling patients pre‐operatively and managing patient expectations. Further research is needed into which specific aspects of overall health 14Fr‐SMP has potential to improve as well as the mental health implications of nephrolithiasis.
Post‐Operative Events in Patients with Post‐Operative Day One Stent Removal after Percutaneous Nephrolithotomy
JP Mershon, T Goodstein, A Khuhro, M Charleton, A Ndumele, T Posid, C Arnold, C Kleinguetl, BE Knudsen, MW Sourial
Introduction & Objective: Percutaneous nephrolithotomy (PCNL) is the gold standard for treating large or complex renal stones. Renal drainage after the procedure is most commonly via nephrostomy tube or indwelling ureteral stent. The optimal duration of ureteral stents after PCNL is unknown. This study describes the post‐operative events occurring with early stent removal on post‐operative day one (POD1) in patients undergoing uncomplicated PCNL.
Methods: We identified 336 patients from a single institution that underwent PCNL between 1/1/2020 and 6/1/2021. Of these, 106 patients with uncomplicated procedures that met inclusion criteria for early stent removal on POD1 were included. Retrospective chart review was performed to collect demographic information, operative data, and to identify adverse outcomes including additional procedures, patient phone calls for symptoms, complications and emergency department visits.
Results: Mean (SD) patient age was 54 (15.1) years and 56% of patients were morbidly obese (BMI >30). Overall post‐operative complication rate was low (18.8%) and limited primarily to Clavien I/II complications with only two Clavien III (1.9%) complications. Telephone calls or electronic messages were received from 37.7% of patients, with 16% requiring a visit to the emergency department (ED) or clinic. The most common reason for an ED visit was flank pain (11.1%).
Conclusions: Early stent removal on POD1 may lead to pain‐related telephone calls but appears to be a generally safe and effective management option in patients undergoing uncomplicated PCNL.
The Road to X‐Ray Free Surgery ‐ Percutaneous Nephrolithotomy (PCNL)
B Neeman, B Chertin, S Qadan, I Kafka
Shaare Zedek Medical Center
Introduction & Objective: Since its introduction in 1976 by Fernstrom and Johansson, PCNL has remained the gold standard for the treatment of large and/or complex renal stones. Generally performed under fluoroscopy guidance, it usually exposes both patient and medical staff to ionizing radiation.
The Objective of the study was to evaluate our learning curve in the adoption of US guided PCNL and to show it can be performed safely with equivalent results to standard fluoroscopy‐guided PCNL.
Methods: We prospectively evaluated our experience with 69 patients who underwent US guided PCNL at our hospital from 2019 to 2020 by a single surgeon. In all patients the kidney access attempt was commenced with US in supine position. Perioperative and operative data was included and analyzed. A repeat non‐contrast CT scan of the abdomen is requested for follow up usually 1 to 3 months after discharge.
Results: Mean procedure duration was 69.5 ± 27.8 minutes. In 59.3% of surgeries, fluoroscopy was used with a mean dose of 276.68 ± 560.71 (cGycm3) and mean fluoroscopy time 40.25 ± 77.69 (seconds). There was a steady decrease over time in the use of fluoroscopy intraoperatively down to only a quarter of cases in the last six months (figure 1). 76.5% of the patients were stone free (fragments ≤5 mm) during follow‐up imaging. Complication rate was 9.7% (5 cases Clavien Dindo I, 1 case Clavien Dindo III).
Conclusions: X‐ray free PCNL is a safe, feasible and reproducible procedure. The stone free rate is comparable to standard fluoroscopy guided PCNL. US guided PCNL has a learning and improvement curve demonstrates in the reduced use of fluoroscopy during surgery over the learning curve.
Analysis of Morbidity and Mortality after Percutaneous Nephrolithotomy in Patients with Renal Calculi: Evaluation of 16,201 Patients from a Nationwide German Database
B Becker, C Schulz, T Herrmann, C Rosenbaum, AJ Gross, H König, C Netsch
Department of Urology, Asklepios Hospital Barmbek, Hamburg, Germany
Introduction & Objective: The aim of this study was to evaluate the percutaneous nephrolithotomy (PCNL) in patients with renal calculi. All complications, re‐intervention and re‐hospitalization rates within 30 days after surgery based on data of a german health insurance (AOK) were analyzed.
Methods: All AOK policyholders who were treated with a PCNL between 2008‐2016 were analyzed. All coded complications, re‐intervention and re‐hospitalization rates within the first 30 days after surgery were assessed.
Results: 16,201 patients treated with PCNL were included. Median age was 55.3 years and 56.1% of policyholders were male. Arterial hypertension (39.6%), diabetes mellitus (19.1%) and obesity (10.7%) were the most common comorbidities. Re‐intervention rates were 18.9% and the most common treatment was the insertion and replacement of a double‐J stent in 1,951 (12.%) and 551 (3.40%) patients. For the analysis of the patients who received a second stone treatment within the same hospital stay, 15,842 policyholders were evaluated. Out of this group, 1,450 (9.15%) patients were re‐treated with a second PCNL, 543 (3.43%) with ureteroscopy (URS) and 430 (2.71%) with shockwave lithotripsy (SWL). The total re‐hospitalization rate was 14.1% within the first month after surgery.
Conclusions: There are only few studies with large PCNL series in which the complications and re‐intervention rates after PCNL have been investigated. By analyzing the data of the AOK database, a deeper insight into big data of endoscopic stone treatment can be assessed. It was shown that the PCNL is associated with higher re‐intervention and re‐hospitalization rates than previously stated in the literature.
Amplatz versus Balloon for Tract Dilation in Percutaneous Nephrolithotomy: A Safety, Efficacy and Cost Effectiveness Study
O Singh, N Arvind, Q Ali
Shrimann Superspeciality Hospital, Jalandhar, India
Introduction & Objective: To compare Amplatz dilation (AD) and balloon dilation (BD) for tract dilatation in PCNL in terms of safety, efficacy and cost effectiveness.
Methods: We performed retrospective review of data of 780 patients who underwent PCNL by three different urologists over a period of 14 years. AD was performed in 508 and BD in 272 patients. Preoperative, intraoperative and postoperative data were collected. Access time, fluoroscopy exposure time, hemoglobin drop, transfusion rate, complication rates based on Clavien classification, stone‐free rate and cost were analyzed and compared.
Results: Baseline preoperative characteristics were comparable in both groups. There was no significant difference between the in terms of access time, hemoglobin drop, transfusion rate, stone‐free rate, total operation time, complication rates, and postoperative hospital stay. Time taken for successful tract dilatation (access time) was significantly more in AD (18.7 +/‐ 6.2 vs 11.3 +/‐ 4.2 minutes; P 0.02), which also lead to significantly more fluoroscopy exposure time until the successful tract dilatation in AD group. This was possibly because of higher rate of short dilation in AD group (48%) compared with BD group (39%) (P = 0.18). BD was the more expensive than AD.
Conclusions: Both AD and BD are equally safe and effective. Although, BD provides faster successful access and is associated with lesser fluoroscopy exposure time to successful dilation, AD is much cheaper method. AD may be preferred dilation method in the developing countries.
Postoperative Events and Complications of Next Day Stent Removal Following Uncomplicated PCNL Compared to Longer Stenting: A Retrospective Review
T Goodstein, JP Mershon, A Khuhro, M Charleton, A Ndumele, C Arnold, T Posid, C Kleinguetl, BE Knudsen, MW Sourial
Ohio State University
Introduction & Objective: At our institution, following uncomplicated PCNL with no plans for second‐look procedure, ureteral stent on a tether may be removed in tandem with the foley catheter on post‐operative day one (POD1) prior to patient discharge. This study compares the number of post‐operative complications and patient issues between POD1 stent removal patients and their longer‐stented counterparts.
Methods: Retrospective chart review was performed on all patients who underwent PCNL at our institution from January 1, 2020 to June 31, 2021. Demographics, stone, and operative data was collected. Patients with concomitant contralateral procedures, neurogenic patients, patients with reconstructed urinary tracts, and patients with a planned second look procedure were excluded. Post‐operative issues were recorded, including patient phone calls, Emergency Department (ED) visits, additional clinic visits, and complications. Analysis was performed to determine differences in these outcomes between patients whose stent was removed POD1 vs. patients with longer indwelling stent times.
Results: We analyzed 245 patients; 45% had their stent removed on POD1. Baseline demographics were similar between groups, except black patients were less likely to have stent removed on POD1 (p = 0.03). There were significant operative differences between groups; this was largely secondary to surgeon differences, and when logistic regression was applied, these differences did not remain significant. Number of phone calls (p = 0.17), post‐operative complications (p = 0.9), and ED/clinic visits (p = 0.26) did not differ between patients whose stent was removed POD1 vs. their longer stented counterparts (Figure 1).
Conclusions: Removing stent POD1 and sending patients home “totally tubeless” after uncomplicated PCNL is a reasonable practice and does not lead to increase in post‐operative phone calls, complications or ED/clinic visits.
Percutaneous Nephrolithotomy Access: A Meta‐Analysis Comparing Renal Access by Urologist versus Radiologist
J Ghoulian, AA Nourian, Z Dalimov, E Ghiraldi, J Friedlander
Loma Linda University Health
Introduction & Objective: Percutaneous nephrolithotomy is a minimally invasive procedure indicated for the management of staghorn calculi or renal calculi larger than 2.0 cm. Percutaneous renal access is a critical step in this procedure and can be performed by either urologists or interventional radiologists. The purpose of this study is to perform a meta‐analysis to compare outcomes between urologist and interventional radiologist mediated access.
Methods: An electronic literature search was conducted to identify studies comparing urologist and interventional radiologist acquired access. Studies must have included both urologist and intervention radiologist acquired access data, but were excluded if (1) not in English; (2) abstract without full text; (3) unable to determine who acquired access; (4) only included either urologist or interventional radiologist data. Meta‐analysis comparison was generated with the Review Manager 5.4 software.
Results: After screening the abstracts and title, 55 relevant studies were identified. Nine articles were utilized in the meta‐analysis. Urologist acquired access was associated with a greater stone free rate (RR = 1.10; 95% CI, 1.01, 1.20), a reduction in major complications (RR = 0.69, 95% CI, 0.53, 0.92), and a shorter hospital stay (mean difference ‐0.40, 95% CI, ‐0.64, ‐0.16) in comparison to radiologist acquired access. Urologist acquired access was associated with greater mean difference blood loss (RR = 0.46; 95% CI, 0.32, 0.60) when compared to interventional radiology acquired access. No significant differences were found with regards to unusable access, multiple tracts, supracostal access, ancillary procedure requirement, operative time, minor complications, and transfusions.
Conclusions: Urologist acquired access may be associated with a higher stone free rate and a reduction in major complications, whereas interventional radiologist mediated access may be associated with a reduction in blood loss, despite similar transfusion rates.
Machine Learning Model to Predict Likelihood of Spontaneous Ureteral Stone Passage
KM Fischer, J Logan, E Choi, A Xiang, D Hamden, I Nadeem, R Daniel, JB Ziemba, G Tasian
Children's Hospital of Philadelphia
Introduction & Objective: When patients present with a ureteral stone the two main treatment options are a trial of passage or surgical intervention. Prior studies have attempted to identify factors that predict the likelihood of spontaneous passage, such as stone size and location, but this remains difficult. Our objective was to create a machine learning model incorporating patient clinical and imaging characteristics to accurately predict the likelihood of ureteral stone passage.
Methods: Children and adults presenting with ureteral stones on CT scan were identified using institutional radiology and nephrolithiasis databases. Chart review was performed to determine occurrence and timing of either spontaneous stone passage or surgery. Patient and imaging characteristics and clinical presentation details were abstracted from the electronic health record and incorporated into two different machine learning models to predict stone passage: a random forest model for the binary prediction of spontaneous passage versus surgery and a random survival forest model which is a hazard analysis that predicts the likelihood and probability of spontaneous passage over time. Each model was cross validated using Stratified 5 K‐fold cross validation.
Results: 126 patients with confirmed ureteral stones were identified, 63 (50%) of whom were male. 75 patients passed their stones spontaneously and 51 required surgical intervention. Features included in the predictive models were BMI, recurrent UTIs, prior stone episodes, vomiting and fever at presentation, gender, location of the stone, ureteral dilation, history of spina bifida or spinal cord injury, and stone size measured in two dimensions. Factors associated with likelihood of passage on analysis included stone size, gender (females less likely to have spontaneous passage) and ureteral dilation (patients with ureteral dilation less likely to have spontaneous passage). The binary prediction model had 76% accuracy and random survival forest model had a C‐index of 65%.
Conclusions: We created a model that predicted ureteral stone passage based on clinical and imaging characteristics with moderate accuracy. Our long‐term aim is to create a deep learning model that incorporates these clinical characteristics and automated segmentation of CT imaging characteristics to accurately predict the likelihood of ureteral stone passage without the need for human abstraction and input.
Are Pre‐Operative Urine Cultures Adequate to Predict Culture Specific Antibiotic Treatment in Patients with Obstructing Infected Ureteral Stones?
M Alsyouf, J Belle, P Stokes, AS Amasyali, M Keheila, M Hajiha, J Groegler, C Ritchie, CE Baas, M Buell, DD Baldwin
Loma Linda University Department of Urology
Introduction & Objective: In patients with infected, obstructing stones, initial antibiotic coverage is empiric while awaiting preoperative urine cultures. Voided urine cultures may not always correlate with renal urine cultures obtained at the time of surgical decompression, or final blood cultures. Prompt administration of appropriate culture‐directed antibiotics may significantly improve patient outcomes. The purpose of this study is to correlate preoperative urine cultures (UCx), intraoperative renal urine cultures (RCx), and final blood cultures (BCx) with outcomes in patients with obstructing, infected ureteral stones.
Methods: A four‐year retrospective review of 100 consecutive patients presenting to a single academic institution with obstructing, infected ureteral stones was performed. All patients underwent retrograde ureteral stenting, and renal cultures were obtained with a ureteral catheter. Data regarding patient demographics, preoperative UCx, intraoperative RCx and final BCx were correlated with patient outcomes. The Mann‐Whitney U test and Spearman′s rank correlation coefficient were performed, with p < 0.05 considered significant.
Results: Forty seven out of 100 patients had UCx, RCx, and final BCx available. The mean patient age was 51.3 years (16‐88) and mean BMI was 30.6 (15.0‐65.6). RCx and BCx demonstrated the strongest correlation (76% of cases), while UCx correlated less frequently with RCx and BCx (69.2 and 63.6%, respectively). Patients had a significantly longer hospital stay when their preoperative UCx was discordant with RCx (7.3 vs. 4.6 days; p < 0.05) or BCx (9.3 vs 4.6 days; p < 0.05). Finally, patients with positive RCx had a significantly longer hospital stay than patients with negative RCx (6.6 vs 3.5 days; p < 0.05).
Conclusions: RCx differed from preoperative UCx in almost a third of patients. Patients fared significantly worse when their RCx or BCx differed from their initial UCx. Positive RCx correlated with BCx and predicted significantly longer hospital stays. This indicates that a positive intrarenal culture could be used as a prognostic tool, suggesting higher grade obstruction and poor antibiotic penetration. A high‐grade obstruction could also explain why the RCx and UCx's were different. This highlights the importance of obtaining intraoperative renal urine cultures in patients with obstructing, infected ureteral stones to potentially improve patient outcomes.
Assessment of Renal Stone Risk Related to Urinary Derivatives of Ascorbic Acid in Malignancies
M Roshandel, L Wen, CW Liaw, MT Keddis, JC Lieske, K Koo, A Potretzke
Mayo Clinic
Introduction & Objective: Vitamin C (ascorbic acid) has been proposed as a complementary therapy in cancer patients to improve survival and quality of life. The role of laboratory tests in evaluating patients taking high doses of vitamin C is not well‐established. We investigated the possibility of links between the results of tests for urinary vitamin C derivatives and stone formation in various malignancies.
Methods: All cases of malignancies with oxalate testing and available record of vitamin C were extracted from Mayo Clinic Health System records based on ICD‐10 and CPT codes. Patients were evaluated retrospectively for vitamin C dose, lab tests at the time of vitamin supplementation, and subsequent development of stones. Cancer patients with less than three months of supplementation and those with recurrent events of urolithiasis or stones ≤3 mm who were not stone‐free for at least one year before vitamin C initiation or had rapid growth in stone within six months of initiation of vitamin C were excluded. The resultant cohort was evaluated for associations between low‐dose (< 1g/day) or high‐dose (≥1 g/day) supplementation, abnormality of urinary oxalate, calcium oxalate supersaturation testing, and stone formation using the Fisher exact test.
Results: A total of 36 patients were included. The median age was 64 years. 15 and 21 cases were on low‐dose and high‐dose supplementation of vitamin C, respectively, for a median duration of 85 months. A significant association was found between calcium oxalate supersaturation and the risk of subsequent stone formation in patients taking vitamin C (RR = 2.54, 95% CI = 1.25‐6.26, P = 0.01), see Figure. However, patients with and without stones were not significantly different in urinary oxalate results (RR = 0.8, P = 0.66). Furthermore, vitamin C was not significantly associated with the results of urinary oxalate or supersaturation tests, which was in accordance with the results of subgroup analysis in the urolithiasis cohort.
Conclusions: Our study highlights the importance of supersaturation urinary testing in the medical management of oncological patients. However, our findings suggest that decreasing vitamin C doses or relying on normal urinary oxalate levels in this group of patients might not be sufficient to monitor and prevent urinary stone development.
Ureteral Stent Placement during Kidney Stone Surgery is Associated with Higher Post‐Operative Emergency Department Visits, Opioid Prescriptions, and Specialist Visits Within the PEDSnet Learning Health Network
G Tasian, M Maltenfort, K Rove, C Ching, A Bani‐Hani, N Fernandez, C Forrest, J Ellison, B DeFoor
The Children's Hospital of Philadelphia
Introduction & Objective: While ureteral stents are known to cause adverse symptoms and impair daily activities, there has been little investigation on how ureteral stents impact outcomes among children having urinary stone surgery. Using data from PEDSnet, we assessed the association of ureteral stent placement before or concurrent with ureteroscopy (URS) and shockwave lithotripsy (SWL) on subsequent emergency department (ED) visits at six large health systems in the United States.
Methods: We conducted a retrospective cohort study of individuals < 24 years of age who underwent URS or SWL for nephrolithiasis at six pediatric hospitals in PEDSnet from January 2009 to December 2019. PEDSnet is a multi‐instuitional clinical research network that has harmonized the diverse EHR systems of participating institutions to assemble a longitudinal database for >8 million children by transforming source institutional EHR data into the Observational Medical Outcomes Partnership common data model. The comparators were presence or absence of ureteral stent placement within 60 days before or concurrent with an index URS or SWL procedure. The outcomes were all‐cause ED visits, opioid prescriptions, and visits to urologists or nephrologists within 120 days of the index procedure. Poisson regression models were adjusted for surgery type, race, distance to hospital, non‐genitourinary chronic conditions defined by the pediatric medical complexity algorithm, and PEDSnet site.
Results: A total of 1,736 unique patients (58.8% female) of a median age of 15.1 years (IQR 10.8, 17.1) and a had 2,075 surgical episodes of which 1,683 had URS as an index surgery and 280 had SWL. An initial stent was used in 1,297 (77.1%) of URS episodes and 29 (10.4%) of SWL episodes. Placement of ureteral stents were associated with a 30% higher rate of ED visits (IRR 1.30; 95% CI 1.02 – 1.66), 24% higher rate of opioid prescriptions (IRR 1.24; 95% CI 1.05, 1.48), and 59% higher rate of urology and nephrology visits (IRR 1.59; 95% 1.44, 1.75).
Conclusions: Ureteral stent placement before or at the time of URS or SWL was associated with excess ED visits, opioid prescription, and post‐operative specialist visits across 6 pediatric health systems compared to URS and SWL without ureteral stenting. These results support elucidating the situations in which ureteral stents are not necessary in order to decrease unplanned medical care and morbidity for the growing population of youth with kidney stone disease.
Rate, Causes and Predictors of Perioperative Complications after Retrograde Intrarenal Surgery for Renal Stones; A Prospective Clinical Analysis
AA Elsawy, N El‐Tabey, M Zahran, A Shoma
Mansoura University
Introduction & Objective: Retrograde intrarenal surgery (RIRS) is an efficient, widely used tool for treatment of medium sized (Less than 2‐3 cm) renal stones. However, a variety of complications have been reported either intraoperative or post‐operatively. We evaluated prospectively, the rate, causes, grade and predictors of both intraoperative and post‐operative complications after RIRS for medium sized renal.
Methods: At our tertiary referral institute, a prospective study on adult patients who underwent RIRS for renal stones was carried out. Baseline patient's demographics and perioperative outcomes were recorded. Rate, causes and grade (using Dindo‐Clavian system) of both intraoperative and postoperative complications were identified. Predictors of both complications were evaluated accordingly using multivariate logistic regression analysis.
Results: Between January 2020 and July 2021, 340 RIRS procedures were performed. Stone free rate SFR, intraoperative and post‐complications were identified in 302 (88.8%), 23 (6.8%) and 67 (19.7%) patents, respectively. Intraoperative complications were attributed to wire/laser fiber mucosal injury and infections complications (16 and 5 patients, respectively). None of these complications interrupt the procedures continuity. For post‐operative complications, fever, hematuria and infectious complications were the predominant causes (47. 11 and 7 patients, respectively). The majority of post‐operative complications (62 patients) were low grade (Grade 1 or 2). On multivariate logistic regression analysis, prestenting (p = 0.04), emergent setting of prestenting (p = 0.04), chronic kidney disease (CKD) patients (p = 0.01), patient with solitary/solitary functioning kidney (p = 0.01) and positive preoperative urine culture (p = 0.04) were significantly associated with post‐operative complications.
Conclusions: RIRS is a safe and efficient tool for treating renal stones. Our study highlighted the rate and causes of intra/post‐operative complications. We demonstrated the impact of prestenting, kidney factors (solitary or CKD) and positive preoperative urine culture on post‐operative complications.
Urolithiasis in Patients with Kidney Transplantation: Multicenter KSER Research Series
K Shim, K Choi, W Kim, S Yang, D Kim, M Choo, D Chung, H Jung, S Paick, S Jeon, J Lee
Department of Urology, Ajou University School of Medicine, Suwon, Korea
Introduction & Objective: The incidence of urolithiasis in kidney transplantation (KT) patients is reported to be very low, from 0.4% to 1%, but it is a serious disease that can lead to fatal results from acute kidney injury in a transplanted kidney. We examined the main causes of urolithiasis in KT patients, the diagnostic process, and outcome of the multimodal management.
Methods: From January 1997 to December 2021, searching diagnostic codes, we collected datasets for KT patients with urolithiasis from KSER research committee database. Ppatients with stones in the native kidney before KT were excluded. Causes of occurrence, time of diagnosis and diagnostic tools, characteristics of the stone and their location, treatment method and their outcome were analyzed.
Results: Total 52 KT patients from 7 hospitals were analyzed. The mean age was 57.6 ± 11.4 years and 61.5% were male. The mean period from KT to diagnosis was 83.2 ± 193.2 days. The most common cause of stone detection was asymptomatic regular check‐up (51.9%). Hematuria and recurrent urinary tract infection (28.8%) were followed by pain (7.7%) and others (11.5%) (Table 1). A single stone was found in 30 patients and two or more stones were found in 22 patients. Of the 52 patients, 45 underwent stone treatment, including shock wave lithotripsy. In the ureter stone group, 97.1% of patients were treated for stones, which was relatively high compared to the renal stone group in which 66.7% of the patients were treated, which was statistically significant (P = 0.005). In success rates, there was no difference between renal (80%) and ureter stone (87.1%) groups (P = 0.581) (Table 2).
Conclusions: Most of urolithiasis in KT patients asymptomatic and usually detected through regular check‐up, but about half are serious diseases requiring emergency intervention. Endourological interventional treatment can be effective in KT patients with urolithiasis as comparing with non‐KT patients.
Management of Urolithiasis in Patients with Renal Anomaly: Multicenter KSER Research Series
W Kim, K Choi, K Shim, S Yang, D Kim, M Choo, D Chung, H Jung, S Paick, S Jeon, J Lee
Department of Urology, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea.
Introduction & Objective: Urolithiasis, which occurs in patients with urinary tract malformations, is a challenging area due to its abnormal anatomical structure. Depending on the type of anomaly and the location of the stone, it should be considered in the appropriate method for removing the stone. We investigated the characteristics and success rates of urolithiasis treatment in various renal anomalies through a multicenterdatabase.
Methods: From January 2015 to April 2021, we reviewed adult patients who underwent surgical intervention for urolithiasis in kidney anomalies from 10 hospitals in Korea. Renal anomalies included duplicated ureter, horseshoe and ectopic kidneys, and ureterocele. The location and characteristics of the stones, the type of procedure, and treatment outcomes were analyzed.
Results: Total 83 patients who underwent intervention for urolithiasis accompanying renal anomaly were included in the study. The types of kidney anomalies were duplicated ureter in 47 patients, 22 horseshoe and 8 ectopic kidneys, and ureterocele in 6 cases (Table 1). In treatment outcome, the success rate was 63.6% in horseshoe kidney, 62.5% in ectopic kidney, and 100% in ureterocele. For each procedure performed, success rates were relatively high at 81.3% for ureteroscopic surgeries and 75% for shock wave lithotripsy, whereas retrograde intrarenal surgeries and percutaneous nephrolithotomy were 53.8% and 66.7%, respectively. The mean stone density (MSL) in the failure group (1005.1 ± 298.1 HU) was significantly higher than the success group (749.8 ± 326.3 HU; P < 0.05), but there was no significant difference in stone burden between success (450.3 ± 592.5 mm3) and failure groups (598.7 ± 519.5 mm3; P = 0.458) (Table 2).
Conclusions: For stones arising from renal anomaly, various interventions were performed depending on the location and burden. When deciding the treatment option, MSL can be a significant factor for successful outcomes in patients with renal anomalies
Patient‐Reported Pain Outcomes and Opioid Use Patterns Following Percutaneous Stone Surgery
CW Liaw, J Winoker, A Potretzke, J Alamiri, G Ungerer, K Koo
Hartford HealthCare, Hartford, CT
Introduction & Objective: Percutaneous nephrolithotomy (PCNL) is guideline‐recommended for complex kidney stones. The AUA Position Statement on opioid use recommends prescribing the lowest possible dose to control postoperative pain. However, there is a lack of published evidence on opioid requirements after PCNL. This study aims to characterize post‐PCNL opioid use patterns to guide prescribing recommendations.
Methods: Adult patients who underwent uncomplicated standard PCNL during a 6‐month study period were included. We retrospectively analyzed patient demographics, intraoperative factors, medication use during postoperative admission, and discharge prescriptions including opioids per surgeon discretion. We conducted surveys regarding patient‐reported postoperative pain, post‐discharge medication use, and most bothersome symptoms during recovery.
Results: A total 26 patients were included. All patients underwent local anesthetic infiltration in the nephrostomy tract during surgery and were prescribed acetaminophen, tamsulosin, and anticholinergics during admission and at discharge unless contraindicated. Patients who were discharged with (N = 9) and without (N = 17) a prescription for opioids used a mean of 44 vs 8 morphine milligram equivalents during admission, respectively; there were no significant differences in age, BMI, operative time, or length of stay (Table). All patients who did not use opioids during admission were discharged without opioids, and none requested an opioid prescription after discharge. Among patients who were discharged without opioids, the majority (76%) reported postoperative pain was well‐controlled; the others reported their most bothersome symptom was stent colic or bladder spasms. Overall, 85% patients reported that postoperative symptoms were better than or similar to what they expected; for the others, bladder spasms were the most bothersome symptom.
Conclusions: Patients who do not require opioids during admission after PCNL may be safely discharged without opioids. The most common patient‐reported sources of post‐PCNL pain are least effectively treated with opioids, suggesting opioids are unlikely to accelerate recovery or improve patient experience. These findings may support further reductions in evidence‐based opioid prescribing after PCNL.
Machine Learning Prediction of Symptomatic Kidney Stone Recurrence Using 24‐hour Urine Data and Electronic Health Record Derived Features
PW Doyle, W Gong, R Hsi, N Kavoussi
Vanderbilt University School of Medicine
Introduction & Objective: While 24‐hour (24H) urine studies offer insight into the metabolic profile of recurrent stone formers, their use towards predicting stone recurrence events is limited. We sought to assess the prediction of symptomatic kidney stone recurrence episodes using machine learning models.
Methods: We trained three separate machine learning (ML) models (least absolute shrinkage and selection operator regression [LASSO], random forest [RF], and gradient boosted decision tree [XGBoost] to predict symptomatic kidney stone recurrences from electronic health‐record (EHR) derived features and 24H urine data. ML models were compared to logistic regression [LR]. We included all patients with an index stone surgery at our institution and a 24H urine test performed with at least 5 years of follow‐up (N = 1231). A manual, retrospective review was performed to evaluate for a symptomatic stone event, defined as pain, acute kidney injury or recurrent infections attributed to a kidney stone identified in the clinic or the emergency department, or for any stone requiring surgical treatment. We evaluated performance using area under the receiver operating curve (AUC‐ROC) and identified predictors for each model.
Results: The 2‐ and 5‐ year symptomatic stone recurrence rates were 25% and 31%, respectively. The LASSO model (Figure 1) performed best for symptomatic stone recurrence prediction (2‐yr AUC: 0.62, 5‐yr AUC: 0.63). The other models demonstrated modest overall performance at 2‐ and 5‐years: LR (0.585, 0.618), RF (0.570, 0.608), and XGBoost (0.580, 0.621). Top prioritized features among all models included age, diabetic status, stone composition and urine pH. Additionally, the LASSO model prioritized BMI and history of gout for prediction.
Conclusions: Throughout our cohorts, ML models demonstrated comparable results to that of LR, with the LASSO model outperforming all other models. Further model optimization should incorporate 24H urine testing and EHR‐derived features.
Pain Catastrophizing is Associated with Stent‐Related Pain after Ureteroscopic Laser Lithotripsy
AJ Yaghoubian, S Mozafarpour, R Shimonov, B Gallante, D Lundon, J Khusid, WM Atallah, M Gupta
Mount Sinai
Introduction & Objective: Ureteral stent‐related pain varies in intensity for different patients. While stent‐specific factors (e.g. stent position) may influence symptoms, patient‐specific factors remain elusive. The pain catastrophizing scale (PCS) is a validated questionnaire quantifying the degree to which an individual may catastrophize painful stimuli. We aim to determine whether PCS score is associated with stent symptoms after ureteroscopic laser lithotripsy (URSLL).
Methods: This is an ongoing prospective study of patients undergoing URSLL. All patients completed the PCS prior to undergoing URSLL with stent placement and were labeled as catastrophizers (top third), non‐catastrophizers (bottom third), or semi‐catastrophizers (middle third). The ureteral stent symptom questionnaire (USSQ) was completed at 2 time points: post‐op day (POD)#1 and POD#10. Prescriptions for phenazopyridine, ibuprofen, and oxybutynin were given. Outcomes included USSQ scores, total analgesic pills taken, pain‐related office phone calls, and need for narcotic prescriptions.
Results: In sum 41 patients have been enrolled. Median USSQ pain scores on POD#10 were significantly higher among catastrophizers as compared to non‐catastrophizers (24.5 vs. 14.0, p = 0.036). There were no differences between all 3 groups in other USSQ domains. Catastrophizers took more tablets of phenazopyridine (11.0 vs. 5.5, p = 0.027) and total prescribed tablets (26.5 vs. 15.5, p = 0.023) compared to non‐catastrophizers. Differences between number of pain‐related calls between catastrophizers and non‐catastrophizers approached significance (46.2% vs. 0%, p = 0.057). Semi‐catastrophizers had no significantly different outcomes from the other two groups.
Conclusions: Pain catastrophizers have higher post‐URSLL pain index scores, use more pain medications, and likely call the office more frequently. The PCS may ultimately become a practical tool to personalize patient care by identifying those at highest risk for severe stent pain.
Underinsurance and Multiple Surgical Treatments for Kidney Stones
CR Hicks, S Srirangapatanam, M Armas‐Phan, J maru, E Gennatas, D Bayne
UCSF
Introduction & Objective: To further elucidate the relationship between low socioeconomic status (SES) and larger, more complex stones requiring staged surgical interventions. Specifically, we aimed to determine if underinsurance (Medicaid and self‐pay insurance types) is associated with multiple surgeries within one year.
Methods: We performed a retrospective longitudinal analysis of prospectively collected data from the California statewide Department of Health Care Access and Information (HCAI) dataset. We included adult patients who had their first recorded kidney stone encounter between 2009‐2019 and underwent at least one urologic stone procedure. We followed these patients within the dataset for one year after their initial surgery to assess for factors predicting multiple surgical treatments for stones.
Results: A total of 168,197 adults were included in the study. Compared to private insurance, Medicaid (1.44 [1.39‐1.50] p < 0.001), Medicare (1.10 [1.06‐1.14] p < 0.001), and self‐pay/indigent insurance types were associated with significantly greater odds of multiple surgeries. Percutaneous nephrolithotomy (PCNL) at first procedure (1.12 [1.08‐1.17] p < 0.001), Black race (1.15 [1.08‐1.22] p < 0.001), and Charlson Comorbidity Index (1.05 [1.04‐1.06] p < 0.001) were similarly associated with higher odds of multiple surgeries.
Conclusions: In a statewide, California database from 2009‐2019, underinsured adults, individuals who received PCNL, Black adults and those with more comorbidities had higher odds of undergoing a second procedure for kidney stones within one year of initial surgical treatment. This study adds to the expanding body of literature linking suboptimal healthcare access and disparate outcomes for kidney stone patients.
MP8: Clinical Stones: PCNL II and Ureteroscopy I
Prospective Comparative Study of Thulium Fiber Laser vs Holmium Laser with Moses Technology for Kidney Stone in Percutaneous Nephrolithotomy: A Randomised Controlled Single‐Center Trial
A Singh, D Shah, A Patil, A Ganpule, R Sabnis, M Desai
Muljibhai Patel Urological Hospital Nadiad
Introduction & Objective: To present initial clinical comparison between high‐power Holmium with MOSES technology (HPH‐M) and Thulium Fiber laser(TFL) during mini‐PCNL for renal calculi with specific emphasis on fragmentation efficiency, fragment size distribution and stone‐free rates(SFR)
Methods:A prospective randomized control trail was performed using mini‐PCNL with suction for renal calculi <3cm using HPH‐M 120 w (Lumenis, Israel) or TFL 60 w (Urolase SP, IPG Photonics). In both laser dusting mode used . For <1200 HU stone TFL settings ranged between the energy of 0.1 to 0.15 J and frequency of 200 Hz. In the HFH‐M group, energy ranged from 0.4 to 0.5 J and frequency from 50 to 60 Hz. For >1200 HU stone TFL settings ranged between the energy of 0.15 to 0.2 J and frequency of 200 Hz. In the HFH‐M group, energy ranged from 0.5 to 0.6 J and frequency from 60 to 70 Hz by keeping power constant between 20 to 40 watts.
Data was collected prospectively in our institutional stone registry. Each arm had 45 patients each. Stone fragments were retrieved and segregated to assess proportion of dust(< 1mm), small(1‐3mm) and large( >3mm) fragments.
Results: Both groups were comparable in terms of stone size(p = 0.11), volume(p = 0.71) and density(p = 0.96). Lasing time(671v/s634 seconds;p = 0.73), stone fragmentation rate(4.8v/s5.1 mm3/s;p = 0.49) and total laser energy(25v/s20 KJ;p = 0.29) were comparable in both arms. Both groups produced similar dusting (49v/s46.4%;p = 0.62). On sub‐set analysis based on stone density, all outcome parameters were comparable except 1‐3 mm and >3 mm fragments were more in TFL(p < 0.001). Stone‐free rates at 1 month was 95.5% in HPH‐M group and 93.3 % in TFL group.
Conclusions: Within constraints of the laser fiber size and energy settings, both modalities were equivalent in terms of fragmentation efficiency, proportion of dusting and stone‐free rates across stone densities.
Clinical Evaluation of Miniature Flexible Scope for Diagnosis of Ureteroscope Working Channel Defects
MV Nguyen, TT Chen, C Cerrato, J Berger, J Gerrity, K Vartanian, S Bechis, RL Sur, M Monga
UC San Diego School of Medicine
Introduction & Objective: The durability and maintenance costs of ureteroscopes are important considerations in the management of nephrolithiasis. Due to narrow working channels and scope design, ureteroscopes are at inherent risk of damage. Our study aims to assess the feasibility of evaluating flexible ureteroscope working channels with a 1.06mm digital borescope (Clarus Medical, Minneapolis, MN, USA) and identify factors contributing to scope damage over time.
Methods: We performed a single‐institution prospective study of all patients undergoing stone surgery using a non‐disposable flexible ureteroscope. A 1.06mm borescope was used to evaluate scopes before and after surgery. Borescope videos were reviewed by two independent researchers (TC and MN) to quantify average pre‐ and post‐procedural damage.
Results: 25 procedures were performed with pre‐ and post‐procedural borescope assessment between 8/2021 and 02/2022. All patients received pre‐op CT imaging depicting a mean axial stone size of 14.1 + 8.4 mm and density of 923.4 + 458.1 HU. Mean operative time was 63.8 + 34.0 minutes. The average number of instrument passes through the working channel was 2.1 + 1.6. Laser was used in 11/25 cases with mean laser time of 18.8 + 19.7 minutes and mean total energy of 5.8 + 4.2 KJ. On pre‐op assessment, all ureteroscopes had some form of damage (24% shave, 32% pinhole, 96% dents and scratches, and 28% discolorations). During post‐op assessment, 23/25 (92%) scopes showed additional damage with an average of 14.2 + 8.8 imperfections found per scope. An average of 3.7 + 2.8 imperfections were acquired after one use. Significant differences were seen in acquired shavings (p = 0.028) and scratches or dents (p = 0.018). Of the 355 imperfections seen on post‐op evaluation, 0.4% were shave, 3% were pinhole, 85.8% were dents and scratches, and 10.8% were discolorations (Fig 1).
Conclusions: The Clarus borescope visualized new damages after the majority of flexible ureteroscopy procedures for nephrolithiasis. While such iterative disruptions may not immediately render scopes nonfunctional, they are more common than previously described and can increase maintenance costs. Further studies are needed to investigate the burden of unit damage per procedure to raise operator awareness and reduce preventable scope imperfections.
WITHDRAWN
Retrograde Nephrolithotripsy Retrograde Treatment of Large Kidney Stones, First Series Using LUMENIS® MOSES™ 120W Laser, Nomenclature Proposition and Comparison to Matched Mini‐PCNL
Y Yacobi, G Verhovsky, E Genessin, A Neheman, K Stav, I Gielchinsky, A Zisman, I Sabler
Shamir medical center
Introduction & Objective: The international (EAU and AUA) guidelines state that stones above 20 mm and complicated stones should be treated by PCNL. Modern technological advancements in endoscopes and lasers allow for efficient retrograde stone reaching and dusting. PCNL is a complex procedure with possible complications such as bleeding, longer operation time and known contraindications. This work presents our first case series of retrograde treatment of large and complex kidney stones.
Objective: Comparison between two treatment methods for large kidney stones: mini ‐ PCNL and RNL.
Methods: RNL is performed in the lithotomy position. We use a single‐use ureteroscope and an access sheath. Dusting is completed by high frequency and low energy laser parameters. Tandem ureteral stents are placed at the end of the procedure to maximize dust clearance. Mini‐PCNL cases used 14‐20F access sheath. RNL cases were chosen and compared to PCNL cases, matched by the size and complexity of the stones. The three dimensional stone size was measured by CT scans. Maximal length, surface area and volume were calculated accordingly and matched. Perioperative data: operation time, postoperative complications (by Clavien Dindo), ER visits, re‐hospitalizations, auxiliary procedures and stone free rates, were assigned.
Results: 50 procedures with the largest stone volume were chosen and matched, 26 RNL and 24 mini‐PCNL. The average stone volume size was (SD) 3601.8 mm3 (3849.2) and 3213.8 mm3 (5824.6) respectively, (p = 0.26). Average stone density was 898.1HU (474.2) and 956HU (304), respectively, (p = 0.819). Average operation time was 65.12 (29.8) and 128.5 (49.2) minutes respectively, (p < 0.0001). 17/26 RNL and 7/24 PCNL cases were stone free on follow up and did not require auxiliary procedure (p = 0.009). The mini‐PCNL group had more re‐hospitalizations compared with the RNL group 5/24 Vs 1/26, respectively, (p = 0.041). The median hospitalization days were 2 for RNL (between 1‐4 days) and 3 for mini‐PCNL (3‐5 days), (p = 0.008). There were no differences between the groups regarding acute kidney injury or fever events following the operation.
Conclusions: ‐ Retrograde Nephrolithotripsy (RNL) is a nomenclature proposition for treatment of large and complex renal stones.
‐ Using high power laser, RNL shows better results than mini‐PCNL with significantly shorter operation duration, less auxiliary procedures and fewer complications, closer to RIRS.
‐ Randomized prospective trials should be conducted, taking financial considerations into account.
‐ Indications for antegrade approach are narrowed due to technological advancements and represent the shifting of the paradigm.
Positive Upper Urinary Tract Cultures May Be More Accurate Predictors of Septic Shock than Lower Tract Cultures for Patients with Obstructing Ureteral Stones
DE Hinojosa‐Gonzalez, C Kottooran, J Lee, A Yaghoubian, N Uppaluri, K Hanson, M Borofsky, B Eisner
Massachusetts General Hospital
Introduction & Objective: Renal stones are one of the most common urological conditions. Ureteral obstruction with concomitant infection is considered a urologic emergency with a mortality of up to 19%. In patients with upper tract stone disease, stones may be colonized by different pathogens and prior studies have suggested bladder culture may not be representative of the offending organism.
This study aims to establish and compare urine and upper urinary tract culture discordance in acutely ill patients with stone obstruction and concomitant infection.
Methods: An IRB‐approved retrospective review of records of consecutive patients at 2 centers presenting between April 2016 and 2020 was performed. Patients with unilateral ureteral obstruction by a stone who underwent ureteral stent placement for suspicion of obstruction in the setting of urinary tract infection were identified. Bladder culture results as well as renal pelvis culture results were recorded and compared.
Results: A total of 145 patients were included of which 29(20%) developed septic shock. Of the 42 patients with negative lower urinary tract cultures, 13(33.3%) had positive upper urinary tract cultures. Conversely, of the 72 patients with negative upper urinary tract cultures, 44(61.1%) had positive lower urinary tract cultures.In patients with positive lower urinary tract cultures, 23(79.3%) developed septic shock and 80(69.0%) did not p = 0.362. Conversely, in patients with positive upper urinary tract cultures, 21(72.4%) developed septic shock compared to 52(44.8%) who did not, p = 0.012. In patients with positive lower urinary tract cultures, 23(79.3%) developed septic shock and 80(69.0%) did not p = 0.362. Conversely, in patients with positive upper urinary tract cultures, 21(72.4%) developed septic shock compared to 52(44.8%) who did not, p = 0.012
Conclusions: While culture positivity may be discordant between upper and lower urinary tracts, positive upper urinary tract cultures are better predictors of septic shock. Urologists should consider taking samples of the upper tract while placing stents during emergent decompression of stone obstruction with concerns for infection.
Outcomes of Urinary Tract Calculi Treatment with 2.0 Mode Dusting at 0.3J 120Hz
MA Assmus, MS Lee, J Helon, AE Krambeck
University of Calgary
Introduction & Objective: Novel laser technology has further increased the widespread utilization of laser lithotripsy to manage upper tract urinary calculi. Moses 2.0 Mode allows dusting settings that utilize 0.3J and 120Hz. There is little data examining real world clinical outcomes on stone treatment using these combined laser settings and technology. Our objective was to describe the use of this laser technology and specific settings during percutaneous nephrolithotomy (PCNL) and ureteroscopy (URS) management of upper tract calculi at a high‐volume academic center.
Methods: With IRB approval we queried our clinical registry to identify consecutive patients that underwent urinary tract calculi treatment using laser lithotripsy with 2.0 mode set to 0.3J and 120Hz between January 1, 2021 and September, 2021. Patient demographics and perioperative course was examined in the context of total cumulative stone burden. Our primary objectives were to assess efficiency of stone treatment by operative time, 90days stone free rate and complication rates.
Results: Overall, 44 eligible patients (24 Male, 20 Female) underwent 60 total urinary tract calculi procedures (16 bilateral cases) using Moses 2.0 dusting settings of 0.3J and 120Hz during our study period. There were 21 right URS, 26 left URS, 6 PCNL and 7 left PCNL – all of which utilized the Moses 2.0 laser as described above. Mean age was 60 years (range 23‐94) with BMI 26.7 (17.0‐36.0). There was 1 (2.3%) case that resulted in an unplanned admission with 68.2% discharged same day and 29.5% planned admission. Average OR duration was 1h21min (Minimum: 31min, Maximum: 2h43min) to treat a total cumulative average stone burden of 20.9mm (IQR: 11.3‐23.8mm) for total average operative efficiency of 0.26mm/min. Of patients with a postoperative CT scan within 6weeks of surgery, 31/35 (88.6%) were stone free. Of the 4 patients that did not achieve a stone free state, none had a stone fragment ≥4mm. A CT scan was not completed within 6weeks postop for 9/44 (20.4%) patients. At 90‐day follow up, only 1/44 patients had no reviewable postop imaging and 2/43 (4.7%) had residual stone. Overall, 90‐day complication rate was 20.5% (I‐2, II‐6, IIIa‐1, None ≥IIIb).
Conclusions: In our single center cohort of patients undergoing upper urinary tract procedures using holmium 2.0 Mode technology dusting settings (0.3J & 120Hz); we observed efficient and effective stone treatment of large stone burden with no Clavien‐dindo ≥3b complications.
Spectrum of Management of Renal Calculus Disease in Horseshoe Kidney: Experience from a Tertiary Centre
A Sachan, S Jain, R Goel, A Seth
All India Institute of Medical Sciences, New Delhi
Introduction & Objective: Horseshoe kidney is a rare congenital anomaly resulting in fusion of lower pole leading to medial and caudal deviation of kidneys. These anatomical variations pose challenges to successful stone clearance. We report our 7‐year experience with management of renal calculus in horseshoe kidneys.
Methods: We included 36 patients with renal stone disease in horseshoe kidney from August 2012
to June 2019. These included 28 males and 8 females with a median age of 38 years (11‐56). Mean calculus size was 39.27 mm (21‐70). 22 patients had left renal calculus disease , 10 had right and 2 patients had bilateral disease. 12 patients (33%) had previous intervention done for renal calculi. As per Guy stone score, 14 patients had Grade 4 calculus disease, 16 patients had Grade 3 and 6 patients had Grade 2 disease. Of these patients, 26 underwent Percutaneous nephrolithotomy, 6 had pyelolithotomy, 2 had Right renal moiety nephrectomy and 2 patient had shockwave lithotripsy (Size‐2 cm, GSS – Grade 2). Intra‐operative details were noted along with need for additional procedures and stone free rates at 2 weeks follow up.
Results: All six patients undergoing pyelolithotomy had complete clearance. One patient undergoing Shockwave lithotripsy had residual calculi and required flexible Ureterorenoscopy. All patients undergoing PCNL had infra‐costal puncture, 16 of them had superior calyceal access, 8 middle calyceal and 2 inferior calyceal. Complete clearance was seen in 12 cases with superior calyceal access ( 75 % stone free rates, SFR), 2 case with middle calyceal puncture (25% SFR) and 2 case with inferior calyceal puncture (100% SFR). Factors affecting stone clearance: Guy Stone score i.e. Grade <4 vs Grade 34 (71.4% vs 50% , P = 0.42), STONE index less than 12 vs 312 (83.3% vs 28.57%, P = 0.048). Stone size <4cms vs 34 (50 % vs 71.4 % , P = 0.42). Among patients with incomplete clearance, 4 patients required re‐look PCNL and 6 patients were managed with SWL.
Conclusions: Horseshoe kidney offer greater surgical challenge for stone clearance as evident from our study. As seen in our analysis stone clearance was independent of type of access, Guy stone or stone size. Although, STONE index was far better predictor of successful outcomes in PCNL. Other modalities like pyelolithotomy is a feasible option in selected cases.
Early UK Experience of Thulium Fibre Laser for Ureterorenoscopy: Case Series and Comparative Cost‐Analysis versus Holmium‐YAG
E Edison, N De Luyk, V Arumuham, S Choong, S Allen, D Smith
Introduction & Objective: Recent studies evaluating Thulium Fibre Laser (TFL) as an emerging energy source have called for comparative studies and cost analysis against HolmiumYAG (HoYAG) lithotripsy.
Methods: A retrospective analysis of ureterorenoscopies was performed, from May to December 2021. Stone volume was calculated as (4/3)*π*A*B*C. A “Large” stone burden was defined as >200mm3 total (eg 12x7x5mm stone).
The primary endpoint was difference in cost of theatre time and consumables used. Operating speed (mm3/min) was calculated as volume cleared, divided by total operative time. Secondary analysis of “small” stones was completed from July to December 2021.
Results: There were 355 operations during the study period; 168 were retrograde stone operations and 42 of these involved lasering of large stones (15 HoYAG, 27 TFL). TFL was faster than HoYAG overall, particularly for large stones (6.8mm3/min vs 13.4mm3/min, p < 0.05, Table 1). Baskets were used less frequently with TFL for large stones (55% vs 93%, p < 0.05, Table 1). Other consumables were utilised equally. A gross saving of £1283 per case was estimated when TFL was used instead of a 20 W HoYAG for large stones (Table 1).
Conclusions: TFL was faster than Ho overall, and nearly twice as fast for larger stones. Baskets were used nearly half as frequently with TFL in larger stones. This translates to a gross saving of £1283 per case.
Feasibility of Flexible Ureteroscopy for Urolithiasis Under Local Anesthesia
H Kim, M Shim, J Park, C Oh, J Cho, W Bang
Department of Urology, Hallym University Sacred Heart Hospital, Anyang, Korea
Introduction & Objective: Flexible ureterorenoscopy (f‐URS) is usually performed under general anesthesia. There could be plausible hesitance to conduct f‐URS under local anesthesia because of patients' pain, or fear of ureteral injury secondary to patient intolerance. We investigated our single‐center experience of f‐URS using only local anesthetic lubricant via urethra.
Methods: 65 patients were retrospectively analyzed from 01/2020 to 12/2021. Baseline characteristics were collected for all patients. Perioperative outcomes, including stone‐free rates, tolerability, and complications, were analyzed. Stone‐free state was defined as no evidence of residual stones intraoperatively and no stones on imaging at a postoperative 3‐month time point.
Results: The median age was 59 and 30.8% of all patients were men. Indications for f‐URS are mostly pain (76.9%) and azotemia (16.9%). Nearly 10% of patients had previous retrograde stenting due to sepsis. The median stone size was 7 mm. All patients were able to tolerate the procedure without an incompletion. The overall stone‐free rate was 89.2% after one procedure. The stone‐free rate for mid and distal ureteral stones was 95.1%. All patients were left with a ureteral stent after the procedure. The median length of stay was 1 day. There were no high‐grade complications (Clavien‐Dindo grade ≥3).
Conclusions: In carefully selected patients, f‐URS under local anesthesia is a feasible option with favorable outcomes. This could be a useful alternative for patients deemed unfit for general or spinal anesthesia.
Intraurethral Lidocaine Jelly Significantly Reduces Stent Related Pain in the Immediate Postoperative Period
V Sabharwal, A Murray, E Morales, D Andrews, K Simon, C Washington, A Baumann, K Braun
Advent Bolingbrook Hospital
Introduction & Objective: Managing stent related pain in the recovery room after stone surgery has been a dilemma for many Urologists. Often patients are given incremental doses of narcotics in the form of iv injection or suppositories to control the discomfort. This can often lead to constipation, nausea, vomiting and other side effects related to narcotic use. This sutdy was designed to determine if the localized instillation of lidocaine in the form of gel or solution after surgery had any impact on postoperative pain in the recovery room.
Methods: Sixty patients who underwent stone surgery by the same physician were included in the study. These patients were randomized to receive either 10cc of 2% intraurethral lidocaine jelly, vs 50cc of 1% intravesical lidocaine solution vs lidocaine jelly +lidocaine solution vs nothing. They were asked to fill a questionnaire before leaving the recovery room, asking them to grade their pain from 1‐10, and to compare the pain to any previous stent they may have had‐as equal, worse or better. Pain scores between 1‐3 were defined as mild, 4‐6 as moderate, and 7‐10 as severe pain. 7 of the patients were excluded from the study because they either did not complete the full questionnaire or were transferred to the intensive care unit for sepsis.
Results: Of the patients that received lidocaine 2% intraurethral jelly, 78% reported that they had no pain in the PACU. the remaining patients that did report pain defined it as mild. In contrast, only 30% of patients that received no form of lidocaine reported no pain. The remaining 70% that did report pain varied between mild to severe. The addition of lidocaine solution alone did not signficantly improve the pain scores. The addition of lidocaine solution with the lidocaine jelly did not improve pain scores beyond lidocaine jelly alone. Higher pain scores also equated with use of more narcotic analgesia. Furthermore, patients with prior stents reported less pain with intraurethral lidocaine jelly.
Conclusions: The results of this study suggest a strong correlation with the use of intraurethral lidocaine jelly at the conclusion of stone surgery with stent placement, and decreased pain in the recovery room. The addition of 50cc of 1% lidocaine solutioin intravesically did not appear to add a significant advantage to pain control. With less pain reported in the PACU, there was a lower demand for parenteral or oral narcotic analgesics. Not only did the intraurethral lidocaine jelly reduce the requirement for narcotic pain medications, but it was also a more cost effective alternative to using iv narcotics.
Superpulse Thulium Fiber Laser vs. Holmium Laser for “Dusting” of Renal Calculi in an In‐Vivo Porcine Model
P Jiang, AS Afyouni, R Bhatt, Z Okhunov, S Hosseini Sharifi, S Ali, A Brevik, M Ayad, K Larson, RM Patel, J Landman, RV Clayman
University of California, Irvine Department of Urology
Introduction & Objective: In this study, we sought to evaluate the effectiveness and efficiency of the superpulse thulium fiber laser (sTFL) and the holmium laser (Ho:YAG) at dusting renal stones during retrograde flexible ureteroscopy in an in‐vivo porcine model.
Methods: Twenty‐four kidneys from 12 juvenile female Yorkshire pigs were randomized to either Ho:YAG or sTFL treatment groups. Canine calcium oxalate stones were scanned with computed tomography to calculate stone volume (mm3) and stone density (Hounsfield unit). The stones were then randomized and implanted into each renal pelvis via a pyelotomy. Retrograde flexible ureteroscopy was performed with a dual lumen ureteroscope and a 14Fr, 35cm ureteral access sheath in all trials. Laser lithotripsy was performed using dusting settings with either a Ho:YAG 200μm laser fiber at 16W (0.4J, 40Hz) or a sTFL 200μm laser fiber at 16W (0.2J, 80Hz). Lithotripsy was continued until no fragments over 1 mm were observed by two surgeons (PJ and ZO). No stone basketing was performed. Intra‐renal temperatures were measured by two percutaneously placed K‐type thermocouples positioned in an upper pole calyx and renal pelvis. At the conclusion, the kidneys were bi‐valved and irrigated to capture all residual fragments, which were then dried, weighed, and measured with an optical laser particle sizer (Fritsch Milling and Sizing Inc., Idar‐Oberstein, Germany).
Results: At the initiation of the study, there were no differences in stone volume or stone density (Hounsfield units) between sTFL and Ho:YAG groups. Compared to Ho:YAG, stones treated with sTFL lithotripsy were ablated three times faster (9min vs. 27min, p < 0.001) with a three‐fold less energy expenditure (8kJ vs. 26kJ, p < 0.001), and a 1.6 times higher stone clearance rate (73% vs. 45%, p = 0.001). After sTFL lithotripsy, 77% of the remaining fragments were ≤1 mm versus only 17% of fragments ≤1 mm following Ho:YAG treatment (p < 0.001).
Conclusions: Superpulse thulium fiber laser lithotripsy resulted in shorter ablation times, higher stone clearance rates, and markedly smaller stone fragments than holmium laser lithotripsy in an in‐vivo porcine model with calcium oxalate stones.
Imaging after Ureteroscopy: Practice Patterns, Patient Adherence and Impact on Subsequent Management in an Urban Academic Hospital System
K Gupta, N Feiertag, J Gottlieb, D Zhu, BW Green, K Watts, AC Small
Introduction & Objective: Ureteroscopy with laser lithotripsy (URS) is the most common operation for kidney stones. There are no firm guidelines for imaging after URS. We evaluated practice patterns of post‐ureteroscopy (URS) imaging, to assess predictive factors of imaging order, type and completion, and to analyze whether these studies changed subsequent patient management.
Methods: We conducted a retrospective review of adult patients who underwent URS for kidney stones at a single institution with 12 urologists between May 2020 to May 2021. Demographic, clinical and operative characteristics were reviewed. Details of post‐URS imaging studies within 6 months post‐op were reviewed. Changes in subsequent patient management were defined as additional surveillance imaging tests ordered or subsequent unplanned surgery. Patient, provider and surgical variables were compared between those who had post‐URS imaging ordered and those who did not.
Results: 289 patients underwent URS for nephrolithiasis. 234 (81.0%) had post‐operative imaging ordered and 147 (62.8%) completed their imaging study within 6 months. There were similar baseline demographics, stone features and surgical characteristics among patients who had post‐operative imaging ordered and not ordered, as well as among patients who completed imaging and did not. Urologists less than 5 years in practice were significantly more likely to order post‐op imaging compared to those in practice for greater than 5 years (< 5: 90.6%, 5‐15: 74.4%, 15+: 53.7%; p < 0.001). Average time to imaging completion was 57 days ±36 days post‐op. Management significantly changed for 52/147 (35.4%) patients who completed imaging. Additional surveillance imaging was ordered for 38 patients (25.9%) and second, unplanned surgery was required for 14 (9.5%) who underwent post‐URS imaging.
Conclusions: Post‐URS imaging is important. The main predictive factor of ordering post‐URS imaging was surgeons' time in practice. Post‐op imaging changed management in patients 35.4% of the time. We recommend the development of evidence‐based guidelines that encourage and define routine imaging for patients following ureteroscopy.
The Efficacy of Preoperative Ureteral Stenting in Ureteral Calculi Coexisting with Ipsilateral Renal Calculi for Retrograde Intrarenal Surgery: Compared to Percutaneous Nephrostomy
K Oh, J Ha, R Lee, J Choi, Y Ko, P Song, K Moon, H Jung
Department of Urology, Yeungnam University College of Medicine, Daegu, Korea
Introduction & Objective: To evaluate the efficacy of preoperative ureteral stenting for ureteral calculi coexisting with ipsilateral renal calculi before retrograde intrarenal surgery (RIRS), compared with preoperative percutaneous nephrostomy (PCN).
Methods: From January 2019 to December 2020, a total of 487 patients who underwent RIRS for ureteral calculi with or without ipsilateral renal calculi were included in this study. We divided three groups: group 1; no PCN or stenting (n = 205), group 2; preoperative ureteral stenting (n = 148), group 3; preoperative PCN (n = 134). We compared the perioperative complications, such as infection and re‐admission, ureteral injury during operation, operation times, and stone‐free rate (SFR) among the groups.
Results: Of 487 patients, 266 patients had ureteral calculi with ipsilateral renal calculi. The mean stone size was 7.18 ± 3.14 mm in patients with only ureteral calculi and the mean number of stones in patients with ureteral calculi coexisting with renal calculi was 3.87 ± 2.11. The mean duration of preoperative ureteral stenting was 9.8 ± 4.1 days. In only ureteral calculi, there were no significant difference in all clinical variables between three groups (p > 0.05, Table 1) in only ureteral calculi. However, in patients with ureteral and renal calculi, operation time, the rate of intraoperative ureteral balloon dilatation, and indwelling duration of postoperative ureteral stent in group 2 were significantly lower than those in group 1 and 3 (p = 0.035, 0.042, and <0.001, respectively, Table 2).
Conclusions: Although there was no advantage for preoperative ureteral stenting before RIRS for only ureteral calculi, preoperative ureteral stenting in ureteral calculi coexisting with renal calculi is an effective procedure for reducing operation time and indwelling time of postoperative ureteral stent.
MiniPCNL vs RIRS in Large Burden Stones from 1.5cm to 3cm Using Thulium Fiber Laser: A Propensity Matched Analysis
RS Batra, D Patel, A Singh, A Ganpule, R Sabnis, M Desai
Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India
Introduction & Objective: To compare outcomes between miniPCNL and RIRS for renal stones between 1.5 to 3 cm size using Thulium Fiber Laser(TFL)
Methods: Data was retrospectively collected from patients undergoing miniPCNL and RIRS with stone size 1.5 to 3 cm operated between January 2020 to December 2021.TFL was used in both the procedures. Propensity score matching (1:1) was performed using stone size, stone volume and stone density which resulted in matched cohort of 44 patients in each group.16 fr sheath was used in miniPCNL.RIRS was done with 9.5 fr flexible ureteroscope.Primary end point was stone free rates(SFR) immediately and at 1 month using a CT scan/X Ray KUB.
Results: Both the groups were comparable for age, stone size, volume and density. SFR at first post operative day was 86.36% and 72.72% in miniPCNL and RIRS respectively while it was 93.18 % in miniPCNL and 86.36 % in RIRS at 1 month(p = 0.219).Lasing time(607.79 ± 407.01 vs1451.36 ± 485.88 seconds) (p < 0.001),total energy(18.82 ± 11.52 vs24.96 ± 14.03 watts(p = 0.027)),stone fragmentation rate (3.89 ± 3.52 vs 1.09 ± 1.09 mm3/s) (p < 0.001) and hospital stay(2.37 ± 1.22 vs 1.05 ± 0.96 days (p = 0.001)) were statistically significant in miniPCNL and RIRS respectively.However, complication rate according to Clavien‐Dindo classification was not statistically significant.
Conclusions: MiniPCNL and RIRS have comparable stone free rates for renal stones between 1.5 to 3 cm at 1 month. RIRS requires more lasing time, more operative time but lesser hospital stay and has lower fragmentation rate than miniPCNL.TFL is safe and effective energy source for larger stones in miniPCNL and RIRS.
Outcomes of Ambulatory Percutaneous Nephrolithotomy in Patients with Complex Renal Calculi: A Retrospective Study
S Pak, AJ Yaghoubian, B Gallante, J Khusid, R Shimonov, WM Atallah, M Gupta
Montefiore Medical Center
Introduction & Objective: In an effort to minimize hospital admissions in the COVID‐19 era, ambulatory percutaneous nephrolithotomy (PCNL) has gained popularity. The safety of this practice in patients with complex renal stones has not been studied. We evaluated the safety of ambulatory PCNL in patients with complex stones.
Methods: We retrospectively identified adult patients who underwent PCNL (24 Fr sheath) for complex stones from April 2019‐September 2021 at a single institution. Patients were considered to have complex stones with either a Guy's Stone Score ≥3 or S.T.O.N.E. nephrolithometry score ≥9. Mini, ultra‐mini, and synchronous bilateral PCNL's were excluded. Patients were divided into ambulatory (Cohort 0) and admitted (Cohort 1) groups. Primary outcome was hospital readmission or emergency department (ED) visit within 7 days postoperatively. Secondary outcomes included office phone calls (within 7 days), 30‐ and 90‐day readmission rates, and overall complication rate.
Results: Of 173 patients with complex stones, 47 (27.2%) patients underwent ambulatory PCNL and 126 (72.8%) patients were admitted. Baseline patient and stone characteristics are detailed in Table 1. There was a significantly higher rate of 7‐day readmission or ED visit in Group 1 compared to Group 2 (14.9% vs. 5.6%, p = 0.045). However, there were no differences seen in 30‐ or 90‐day readmission or ED visit rates, overall complication rates, or phone calls to the office (Table 2).
Conclusions: Patients with complex stones who underwent ambulatory PCNL had a higher rate of readmission or ED visit compared to those admitted, yet overall complications did not differ. This suggests a similar safety profile between ambulatory and inpatient PCNL. Furthermore, the additional ED visits/readmissions did not seem to be driven by surgical complications. Our findings suggest that patients who are discharged on the same day may benefit from additional counseling on postoperative expectations and recovery course.
Ultra‐Low Dose Intraoperative CT during Endoscopic Stone Surgery: A Prospective Quality Improvement Study
XG Glover, E Ballon‐Landa, M Sawyer
University of Colorado School of Medicine, Division of Urology
Introduction & Objective: Stone free rate (SFR) is an important quality metric, determined with imaging involving ionizing radiation. Intraoperative CT imaging during PCNL can improve SFR. Cumulative longitudinal radiation exposure for recurrent stone patients is an increasing concern. Initial results of a quality improvement (QI) study intended to improve retreatment rates and reduce radiation exposure are reported.
Methods: Patients with kidney stones appropriate for percutaneous treatment are scheduled into a hybrid operating room for endoscopic surgery (PCNL and/or ureteroscopy) by default. Intraoperative CT imaging collimated to the affected kidney(s) is performed with an Artis Zeego Care+Clear (Siemens) robotic‐armed multi‐planar fluoroscopy system (RMPFS). After the initial case, a reduced dose protocol was used.
Results: Intraoperative CT scans were performed in 13 patients during endoscopic stone procedures with effective radiation dose (ERD) of 1.43 mSv. This value is a 94% lower median radiation dose than reported in contemporary literature. Clinically significant residual stones (≥3 mm) were identified in four patients (30.8%) and further treated in three (final SFR = 92.3%). In 11/13 patients, ERD was less than one‐fifth that of the pre‐operative CT and 85% of patients had ERD <2.0 mSv. Combining reduced dose CT protocol and collimation in the operating room yields about one‐tenth the radiation dose of a standard protocol study.
Conclusions: Intraoperative ultra‐low dose (ULD) CT could change practice in treatment of large kidney stones to simultaneously improve SFR and reduce radiation. Our techniques are likely to benefit not only high‐risk surgical patients, but also children, women of child‐bearing age, and select pregnant patients. Additionally, ULD CT definitions should consider patient size to optimize radiation exposures.
The Safety and Efficacy of Endoscopic Combined Intrarenal Surgery (ECIRS) versus Percutaneous Nephrolithotomy (PCNL): A Systematic Review and Meta‐Analysis
VA Abdullatif, RL Sur, Z Abdullatif, S Szabo, J Abbott
Ascension Macomb‐Oakland Hospital
Introduction & Objective: Our aim is to evaluate the safety and efficacy of Endoscopic Combined Intrarenal Surgery compared to percutaneous nephrolithotomy to guide practitioners and inform guidelines. Materials and Methods. A detailed database search was performed in PubMed, OVID, Scopus, and Web of Science in October 2021 to identify articles pertaining to ECIRS published between 2001‐2021.
Methods: A detailed database search was performed in PubMed, OVID, Scopus, and Web of Science in October 2021 to identify articles pertaining to ECIRS published between 2001‐2021.
Results: Four non‐randomized comparative studies and one RCT were identified, yielding five studies with a total 546 patients (ECIRS/mini‐ECIRS, n = 277; PCNL/mini‐PCNL, n = 269). Subjects in these five studies met the predefined inclusion criteria established by two reviewers (J.E.A. and R.L.S.) and were therefore eligible for analysis. The results demonstrated that ECIRS was associated with a higher SFR (OR: 4.20; 95% CI: 2.79, 6.33; p < 0.00001), fewer complications (OR: 0.63; 95% CI: 0.41, 0.97; p = 0.04), and a shorter hospital stay (WMD: ‐1.27; 95% CI: ‐1.55, ‐0.98; p < 0.00001) when compared to PCNL. There were no statistically significant differences in blood transfusions (OR: 0.45; 95% CI: 0.12, 1.68; p = 0.24), operative time (SMD: ‐1.05; 95% CI: ‐2.42, 0.31; p = 0.13), or blood loss (SMD: ‐1.10; 95% CI: ‐2.46, 0.26; p = 0.11) between ECIRS and PCNL.
Conclusions: ECIRS may be a more suitable approach for the surgical management of large and complex kidney stones currently indicating PCNL due to its superior efficacy with comparable surgical time and complication rate, though it is thought that a lack of resources and properly trained personnel may preclude ECIRS from becoming the standard. It is our impression that ECIRS may become the preferred technique in the endourologic community corresponding to the evolutionary sequence of percutaneous stone surgery.
Removal of Small, Asymptomatic Kidney Stones and Relapse Rates
M Sorensen, J Harper, M Borofsky, T Hameed, K Smoot, B Burke, B Levchak, J Williams, M Bailey, Z Liu, J Lingeman
University of Washington
Introduction & Objective: The benefits of removing small (< ![if !msEquation] > < ![endif] >6 mm) asymptomatic kidney stones endoscopically is unknown. Guidelines presently leave such decisions to the urologist and the given patient. A prospective study with older non‐endoscopic technology and some retrospective studies favor observation. However, published data indicate that about half of small renal stones cause another symptomatic event within five years.
Methods: In a multi‐center, randomized, controlled trial during endoscopic removal of ureteral or contralateral kidney stones, 38 patients had remaining small asymptomatic stones removed, and 35 patients (control group) did not. The primary outcome was relapse as measured by future emergency department (ED) visits, surgeries, and stone growth.
Results: After a mean follow up duration of 4.2 years, the treatment group had longer time to relapse than controls (P < 0.0001, log rank test). The restricted mean time‐to‐relapse was 57% longer in the treatment group compared with controls (1631.6 days (standard error 72.8) vs. 934.2 (SE 121.8)). Relapse risk was 82% lower in the treatment group (hazard ratio 0.18, 95% confidence interval 0.07‐0.44) with 16% vs. 63% of participants relapsing. Treatment added a median of 25.6 (interquartile range 18.5‐35.2) minutes to surgery. ED visits within two weeks of surgery were five in the treatment group and four in the control group. Eight treatment and 10 control participants reported passing stones.
Conclusions: Removal of small, asymptomatic kidney stones during surgery for ureteral or contralateral kidney stones reduced relapse and did not increase surgery‐related ED visits.
Simultaneous Bilateral Endoscopic Surgery (SBES): Is It Ready for Prime Time?
S Proietti, MH Pupulin, M Triquell, S Di Pietro, F Gaboardi, G Giusti
Ospedale San Raffaele
Introduction & Objective: To date, some data available in literature on simultaneous bilateral endoscopic surgery (SBES) have shown good outcomes in terms of both effectiveness and safety.
The aim of this study was to report the outcomes pertaining to the effectiveness and safety of SBES performed in our series of patients with bilateral renal stones.
Methods: A prospective analysis of consecutive patients who underwent SBES for bilateral renal stones at our institution between June 2017 and September 2021 was performed. Routine preoperative and 1‐month postoperative work‐up included history, physical examination, urinalysis, urine culture, and blood tests, including the evaluation of estimated glomerular filtration rate (eGFR) using the Cockcroft‐Gault equation. An abdominal non‐contrast computerized tomography (NCCT) scan was performed in all cases preoperatively and 1‐month postoperatively. Peri/postoperative complications were reported according to the Clavien‐Dindo classification system. The primary endpoint of the study was stone‐free rate (SFR), and the secondary endpoints were Clavien‐Dindo complications grade 1 or higher.
Results: Altogether, 101 patients met the inclusion criteria and were enrolled in the study. SFR for all renal units was achieved in 82 patients (81.1%) at the 1‐month follow‐up. Twelve patients underwent additional flexible ureteroscopy for residual fragments, and seven asymptomatic patients with a single small residual fragment were observed.
Eighteen patients (17.8%) experienced Clavien‐Dindo Grade I‐II complications, whereas one patient (1%) experienced Clavien‐Dindo Grade IIIa complication (renal arteriovenous fistula embolization under local anesthesia).
Demographic and stone characteristics of patients and the outcomes are reported in Table 1 and 2, respectively
Conclusions: SBES is a safe and effective procedure for the treatment of bilateral renal stones.
Further randomized studies with larger populations are needed to confirm these favorable outcomes of SBES to establish it as an alternative to staged surgeries in patients with bilateral renal stones.
Factors Precluding Same Day Discharge from Hospital in Patients Undergoing Percutaneous Nephrolithotomy
M Drescher, DC Rosen, NL Arias Villela, J Abbott, M Dunne, J Davalos
University of Maryland Medical Center
Introduction & Objective: Despite the movement in recent years of percutaneous nephrolithotomy (PCNL) towards an outpatient procedure, many patients are still admitted to the hospital for observation. Identification of selection criteria for same day discharge may reduce unnecessary hospital admissions and allow for safe performance of PCNL on an outpatient basis.
Methods: We analyzed patients selected for treatment at the hospital from 2018‐2021, representing ∼20% of PCNL patients treated during this period, with the other 80% treated at an ambulatory surgery center. When considered safe and feasible, patients were discharged on the same day. We compared patients able to be discharged on the day of surgery to those requiring admission using Fischer's exact and two tailed t tests. Multivariate regression analysis was performed to identify factors associated with admission.
Results: 131 patients were available for analysis, with 52% of patients selected for treatment at the hospital able to be discharged on the day of surgery. Demographic and intraoperative characteristics of the patients are shown in Table 1. Patients requiring admission were older and sicker, and required more extensive surgeries with higher rates of staghorn calculi and multiple access sites. On multivariate analysis (Table 2) the strongest predictor of admission was the requirement for multiple access sites, while BMI was a negative predictor of admission. Stone burden was not a strong predictor of requirement for hospital admission.
Conclusions: Half of PCNL patients were able to be discharged on the same day. Notably, age, non‐staghorn stone burden, BMI, nor OR time was a predictor of requirement for admission. Concerns for sepsis – e.g. staghorn patients, positive cultures on initial preoperative culture ‐ as well as concerns for bleeding – e.g. intraoperative blood loss, anticoagulation status, number of access sites – were the primary drivers of hospital admission. Accordingly, patients should be triaged based on these factors as the criteria for treatment at a hospital vs. ASC and as an outpatient vs. inpatient basis is further refined.
Performance of Percutaneous Nephrolithotomy for Staghorn Calculi in an Ambulatory Surgery Center
DC Rosen, NL Arias Villela, M Drescher, J Abbott, M Dunne, J Davalos
University of Maryland/Chesapeake Urology
Introduction & Objective: Staghorn calculi present challenging cases for percutaneous nephrolithotomy (PCNL), often requiring multiple accesses. Nonetheless, in properly selected patients, their treatment can be accomplished in the outpatient setting. We aimed to identify the outcomes and selection criteria of patients treated with PCNL in a free‐standing ambulatory surgical center (ASC), compared to those performed at the hospital.
Methods: We analyzed patients with staghorn stones who underwent PCNL from 2015‐2021 at an ASC and 2019‐2021 at a hospital. Patients were selected for treatment at the hospital due to comorbidities, anticoagulation status, or concern for infection. Demographic, preoperative, and postoperative data was prospectively collected. Accesses were achieved by the treating urologist at time of surgery. Tract number was generally limited to two in the ambulatory setting, with a endoscopic combined intrarenal surgery (ECIRS) technique employed. Patients were left with an indwelling double J stent and nephrostomy tube tracts were plugged using thrombin and a gelatin sponge. Comparisons between the groups were done using Fischer's exact and two tailed t tests.
Results: 93 patients were available for analysis. Demographic and intraoperative characteristics of the patients are shown in Table 1. Patients selected for treatment at the hospital were sicker (ASA 2.94 vs. 2.33, p < .001) but had equivalent stone burdens (p = 0.25). Patients operated on at the ASC required a planned 2nd look procedure 7% of the time. 5 patients required transfer to the hospital, but the only unifying identifier between them was 4/5 having ASA 3.
Conclusions: Staghorn calculi treatment is feasible in an ambulatory center with a high stone free rate and an acceptable transfer rate. Patients who meet criteria for treatment in an ambulatory surgery may be selected, regardless of stone size.
Morbidly Obese Patients May Safely Undergo Percutaneous Nephrolithotomy at an Ambulatory Surgery Center
DC Rosen, M Drescher, NL Arias Villela, J Abbott, M Dunne, J Davalos
Introduction & Objective: Obesity can pose surgical challenges in patients undergoing percutaneous nephrolithotomy (PCNL). Obesity's association with other comorbidities as well as concern for body habitus leading to difficulties with intubation and ventilation often preclude patients above a certain Body Mass Index (BMI) from being treated in an ambulatory surgical center (ASC). We examined outcomes of morbidly obese patients treated at an ASC to see which outcomes may differ compared to non‐obese patients.
Methods: Patients with BMI 40‐50 underwent airway evaluation prior to clearance for ambulatory surgery. All patients underwent PCNL at a free‐standing ASC. We queried our prospectively maintained database for patients with BMI >40 and compared them to patients with BMI <30. Demographic and intraoperative characteristics between the cohorts were compared using Fisher's exact and two‐tailed t tests.
Results: 728 patients had complete data for analysis. Obese patients had higher ASA (2.7 vs. 2.2 p < 0.01) and required 9% longer OR time (100 vs 92 min, p < .01), fluoroscopy time (94.5 vs. 71.5 sec, p < .01), and renal access time (4.6 vs. 3.6 min, p < .01). Obese patients did not show any significant difference in stone treatment or intracorporeal time, stone burden or stone free rate, or rate of hospital transfer. There were no airway related complications.
Conclusions: Obese patients were younger and sicker than their non‐obese counterparts but required only minimal additional OR and procedure time in order to be safely treated at an ambulatory center. Patients with morbid obesity up to BMI 50, with proper screening and patient selection, can be safely treated with percutaneous nephrolithotomy at an ambulatory center.
Holmium vs. Trilogy in Kidney Stones GUY´s 1‐2 (TriHolmium) “Preliminary Results”
BO Manzo, E Lozada, H Sanchez, J Galvan, Y Gomez, P Alarcon, E Flores
Hospital Regional de Alta Especialidad del Bajío
Introduction & Objective: The desire to reduce complications related to percutaneous access and morbidity related to tract size has led researchers to evaluate PCNL using smaller‐caliber instruments. In this context, mini‐PCNL has emerged. Furthermore, its efficacy and safety have been demonstrated at the cost of a lower stone‐free rate.
Currently, mini‐PCNL has been performed with High power laser lithotripsy; therefore, it is convenient to make a comparison between the results of lithotripsy with Ho: YAG laser energy and the new LithoClast Trilogy EMS; and thereby determine which is the most effective method in the resolution of kidney stones through a miniaturized percutaneous tract.
Methods: A total of 116 patients will be subjected to simple randomization with a table of random numbers; 58 patients will undergo a mini‐PCNL with Trilogy EMS probe 1.5 mm (Group1), and the remaining will undergo mini‐PCNL with 100 W laser lithotripsy (group 2). Comparing both groups will be made by evaluating lithotripsy rate, stone‐free status, operation time, and complications.
Results: We present the preliminary results of 32 randomized patients (18 in group 1 and 14 in group 2). Demographic data were homogeneous between both groups, including age, the side affected, BMI, maximum stone diameter, and stone volume (p values: 0.362, 0.221, 0.441, 0.569, and 0.120, respectively). Total fluoroscopy screening time was 24.3 and 26.4 seconds for groups 1 and 2, respectively (p: 0.547). Endoscopic stone‐free status at the end of the surgical procedure was not statistically different in both groups (p: 0.394). Lithotripsy rate and operative time were not statistically different in both groups (p: 0.815 and p: 0.268, respectively). The overall mean stone‐free rate was 78.9 % (80.9% and 76.9%, respectively, with a p‐value: of 0.371). The complications rate was similar in both groups (5.6 vs. 7.1% for groups 1 and 2, respectively, with a p‐value: of 0.854).
Conclusions: Our preliminary data show that mini‐PCNL with Trilogy lithotripsy (1.5 mm probe) shows similar results and efficacy to the current energy to perform mini‐PCNL (high power holmium laser) by means of stone‐free rate, lithotripsy rate, operative time, and complications rate.
Planned Percutaneous Nephrolithotomy in Patients Who Initially Presented with Urosepsis: Analysis of Outcomes and Complications
O Elgebaly, W Sameh, A Fahmy
Alexandria University Faculty of Medicine, Egypt
Introduction & Objective: Renal decompression is almost always the first step in managing patients presenting with an obstructing stone and urosepsis followed by definitive treatment for the stone, once patient's general condition improved and sepsis controlled. The aim of this study was to compare the outcomes and complications of planned percutaneous nephrolithotomy (PCNL) in patients with a prior urosepsis with those without.
Methods: We recorded patients who presented initially with obstructive urosepsis, as identified by systemic inflammatory response syndrome and obstructing kidney stones. We compared the surgical outcomes and complications among those patients who had planned PCNL after control of prior urosepsis with urgent decompression and antibiotics (Group A) to a cohort group who presented for PCNL with no previous history of a septic presentations (Group B).
A 1:1 matched‐pair analysis was performed using four parameters (age, gender, MBI and ASA) to eliminate potential allocation bias. Primary outcomes included were stone‐free and complications rates. Secondary outcomes included length of operative time, estimated blood loss and duration of postoperative hospital stay.
Results: A total of 80 patients underwent PCNL (48 male and 32 females) divided equally between both treatment groups, mean age of 47 yr (range, 19–75 yr).
There were no differences in demographic data or stone characteristics between both groups. Both groups had comparable stone free rate (92.5% vs. 97.5 %, p = 0.212) and mean operative time ( 77 vs. 74 min, p = 0.728) with no statistically significant difference.
Patients in group A had significantly higher overall complications rate (35% vs. 10%, p = 0.03),
There were no postoperative mortalities in our study. Mean length of hospital stay was significantly longer in group A patients compared to group B (4.2 vs. 1.5 days, p = 0.042).
Conclusions: Planned PCNL after decompression for urolithiasis‐related sepsis has comparable operative time and stone free rate but higher complication rates and longer postoperative hospital stay. This is critical in counseling patients prior to definitive treatment of kidney stones after urgent decompression for urosepsis and adequate preoperative planning and preparation.
Is a Low Body Mass Index Associated with Higher Percutaneous Nephrolithotomy Complication Rates?
P Mota, D Ferreira, R Perrella, R Florêncio, D Cohen, C Batagello, C Murta, J Claro, F Vicentini
Division of Urology, HMASP, Sao Paulo, Brazil
Introduction & Objective: Due to a lower amount of fat tissue surrounding the kidney, there is a hypothesis that thin patients could have more complications after PCNL. No studies have looked into the effect of low BMI (< 20 kg/m2) on complications and perioperative parameters of patients undergoing PCNL. The purpose of the current study was to evaluate the impact of low BMI on the complications of PCNL in a single tertiary center. To the best of our knowledge, this is the first study on this topic.
Methods: A retrospective matched case‐control study was performed using our prospectively collected database of all patients who underwent PCNL. The patients were stratified into two groups according to their BMI at the time of surgery: <20 kg/m2 (group 1, low BMI / case group G < 20) and ≥20 kg/m2 (group 2, non low BMI / control group G ≥ 20). Patients were randomly matched based on Guy's Stone Score (GSS) as a surrogate of case complexity at a ratio of 3:1.
Results: Two hundred and four patients were enrolled in this study, 51 cases (group 1 / G < 20) and 153 controls (group 2 / G ≥ 20). The demographic characteristics are shown in Table 1. The median BMI was 24.94 kg/m2 (16‐47) and median age 49 years (15‐82). There were no statistically significant differences in age, gender and American Society of Anesthesiologists Classification between groups. Complex stones (GSS 3 or 4) were found in more than half of the cases in both groups. Complications were seen in 13.5% of the patients. Among the complications, 42.9% were Clavien ≥3. Evaluating postoperative complication rates, no significant difference was found between the groups, it was 17.6% in G < 20 and 14.9% in G > = 20 (p 0.347) (Table 2).
Conclusions: In this study, BMI <20 kg/m2 was not associated with higher complication rates in patients who undergo a PCNL compared to BMI ≥20 kg/m2. This technique can be used safely in this group (G < 20).
Thulium Laser Lithotripsy with a Novel Pulsed Thulium: YAG Laser: First Clinical Results during Mini‐PCNL
B Becker, J Bergmann, C Rosenbaum, AJ Gross, C Netsch
Department of Urology, Asklepios Hospital Barmbek, Hamburg, Germany
Introduction & Objective: Laser lithotripsy during Mini‐PCNL is of utmost importance in getting the patient stone‐free. In recent years, a new era in stone treatment has been initiated with the introduction of new pulsed thulium lasers. The aim of this study was to investigate the safety and efficacy of laser lithotripsy of a new pulsed thulium laser during mini‐PCNL.
Methods: All patients, regardless of stone size, who were treated with a Mini‐PCNL using the new pulsed thulium laser were prospectively enrolled. Operation times, stone size, laser time and laser settings were noted. The stone‐free rate was assessed postoperatively with sonography and either x‐ray or computed tomography as clinical standard. The complications were analyzed using the Clavien‐Dindo classification.
Results: A total of 50 patients with an average age of 52 years were included. 31 (62 %) patients were male. The average stone size was 242.3 (±233.1) mm2 with an average density of 833 (±325) Hounsfield units (HU). The mean operating time was 30.56 min (±28.65) and the laser on time was 07:07 (± 07:08) minutes. The most commonly used settings were 0.4 J and 115 Hz (46 W). The mean total energy for stone ablation was 14,166 (±17,131) kJ. The total stone‐free rate was 80 % with an overall complication rate of 32% according to Clavien‐Dindo (grade 1: n = 9, grade 2: n = 6, 3b: n = 1). In the group of patients with singular stones (n = 25) the stone‐free rate was 88%.
Conclusions: The new hybrid thulium laser showed a safe and effective lithotripsy during Mini‐PCNL. There were high stone‐free rates regardless of stone size with a comparable low rate of complications.
MP9: Endoscopy & New Technology I
A Novel Technique for the Distal Ureter and Bladder Cuff During Nephro‐Ureterectomy: Thulium Laser Resection
J Saad, H Soh, D Gilbourd, H Haxhimolla
Canberra Hospital
Introduction & Objective: Controversy remains regarding management of the distal ureter and bladder cuff during nephro‐ureterectomy for upper tract urothelial carcinoma. Herein we present a novel technique for management of the bladder cuff using Two‐micron Thulium laser.
Methods: We performed a retrospective single surgeon review of all patients who underwent nephroureterectomy at National Capital Private Hospital, Canberra from March 2010 until August 2019. All patients had their bladder cuff excised with Thulium laser and either underwent a laparoscopic or robotic nephroureterectomy. The demographics as well perioperative measures and oncological outcomes were assessed.
Results: A total of 24 patients underwent nephroureterectomy with bladder cuff excision utilising the Thulium laser. A total of nineteen (80%) laparoscopic and five (20%) robotic nephroureterectomies were performed. All cases had the distal ureter and bladder cuff managed by transurethral Thulium laser. Twenty‐one (88%) patients were aged over 65 years and 9 (38%) patients had a history of smoking or were current smokers. Fifteen patients were male, nine patients were female. Fifteen patients (63%) were either overweight or obese according to their body mass index. Eleven were left sided tumours and thirteen were right sided tumours. Regarding perioperative outcomes, the average blood loss for the laparoscopic approach was 229ml compared with 240ml for the robotic approach, both managed with Thulium laser for the bladder cuff. The average length of stay was 8 days for laparoscopic and 6 days for robotic approach. The average operative time was 183 minutes for laparoscopic and 262 minutes for robotic approach respectively. All patients had clear margins, fourteen patients (58%) had high‐grade tumours and twelve patients (50%) had T2 disease or above. Eighteen patients had renal pelvis, calyceal or upper ureteric involvement, three had mid ureteric tumours while two had distal tumours and one had multiple tumours. One patient had recurrence of their urothelial carcinoma within the bladder four months post nephro‐ureterectomy and evidence of metastatic disease ten months post‐operatively.
Conclusions: Thulium laser resection is a viable alternative to open and electrosurgical approaches of the distal ureter and bladder cuff for patients undergoing nephroureterectomy for upper tract urothelial carcinoma. Further studies are required to compare the technique with the commonly performed approaches, however our study demonstrates that it is safe, provides the surgeon with optimal vision, minimises blood loss and has sound oncological outcomes.
A Prospective, Cross‐Sectional Study on the Role of Cxbladder in Bladder Cancer Detection and Surveillance
J Saad, D Ashrafi, H Haxhimolla
Canberra Hospital
Introduction & Objective: Cxbladder is a simple, urinary genomic test which measures the amount of messenger RNA (mRNA) of certain biomarkers, with higher levels indicating a higher likelihood of bladder cancer. Though urine cytology, upper tract imaging and lower tract endoscopy are the mainstay of workup for bladder cancer. Cxbladder has been shown to have a high negative predictive value (99.4%) It has been used predominantly in patients undergoing surveillance and shown to reduce the amount of follow up cystoscopies required. The primary objective was to review the efficacy of Cxbladder urine test in the diagnosis and surveillance of bladder cancers. We propose that its use may reduce the number of investigations, particularly cystoscopy, that patients with suspected or confirmed bladder cancer require.
Methods: We conducted a prospective, cross‐sectional study at two institutions within the Australian Capital Territory. Patients who were undergoing initial investigation or surveillance for bladder urothelial carcinoma from May 2018 to August 2021 were recruited. The inclusion criteria was patients who underwent urine cytology x3 and subsequent cystoscopic examination. The exclusion criteria was patients under the age of 18, were pregnant or had a history of renal inflammatory disorders. Data analysis was completed using RevMan 5.
Results: One hundred and ninety‐two consecutive patients were enrolled. The mean age was 68.5 years old with a 3:1 preponderance towards male gender. 66% of the patients were for initial investigation and 34% for ongoing surveillance. The primary indication for investigation was macroscopic haematuria (59%). A total of 43% of the Cxbladder tests returned with negative results. Of those with negative Cxbladder tests, 100% had negative cystoscopy and histopathology results. All histologically proven urothelial carcinoma had positive Cxbladder tests. We found 13% of the Cxbladder tests returned with no results, with 48% of these due to high inflammatory markers in the urine. Others were due to either expired or incorrectly taken samples.
Conclusions: Cxbladder can be used to safety rule out the risk of urothelial carcinoma. Cxbladder could reduce the number of investigations (urine cytology and cystoscopy) a patient with potential bladder cancer requires.
Opioid Use and Associated Patient Satisfaction with Pain Control After Common Urologic Surgeries?
C An, ED Jones, P Callas, K Sternberg
University of Vermont Medical Center
Introduction & Objective: Non‐opioid postoperative pathways have been shown to be successful after various urologic surgeries. Success has been based on outcomes showing no increased utilization of healthcare resources when opioids are omitted in the postoperative setting. The patient perspective however has not been reported. Here we evaluate these important measures in patients undergoing endourologic procedures and robotic assisted radical prostatectomy (RARP).
Methods: A 2‐phased study performed which included a retrospective review of prescribing patterns after 13 surgeries followed by a prospective patient telephone questionnaire. We present a secondary analysis of the 2 most common urologic surgeries included and describe patient reported outcomes including degree of pain control, satisfaction with pain control, and actual pain compared to expected pain. Opioid prescription and opioid use were recorded. Bivariate analyses were used to compare patients who did and did not use opioids in the RARP cohort while overall trends were reported for the endourologic procedures.
Results: Of the 68 patients undergoing endoscopic intervention, 14 (21%) were prescribed an opioid and 6 (9%) reported any opioid use. 58 (85%) reported their pain was very well or well controlled while 9 reported their pain was poorly controlled. 59 (87%) were satisfied or very satisfied with their pain control. 14 patients had more pain than they expected, 22 as expected, and 30 less than expected.
Fifty‐three (93%) of the 57 patients undergoing RARP received an opioid prescription and only 23 reported any opioid use. All but one patient reported that their pain was well or very well controlled and almost all (54) of the patients were satisfied with their level of pain control. 36 (63%) reported their pain was less than expected while only 7 (12%) reported it was more than expected. Of the 23 patients requiring opioid use, 7 (30%) reported they were given more opioids than needed.
Conclusions: Most patients undergoing endourologic procedures do not use postoperative opioids and report favorable outcomes regarding their pain control. Similarly, after RARP, most patients do not use opioids even when they are prescribed, and are satisfied with their pain control. This challenge of identifying which patients require opioids after surgery requires additional future focus and remains a roadblock to a zero‐ opioid approach for all.
Clinical Results of Neoadjuvant Hormone Therapy Performed Before Endoscopic Intervention in Patients with Ureteral Stricture Due to Endometriosis
J Kim, Y Boo, C Lee, K Ko, J Chung, H Sung, M Baek, D Han
Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
Introduction & Objective: Ureteral endometriosis (UE) is a rare disease and can cause ureteral strictures and loss of renal function. Currently, laparoscopic or open surgery is recommended as a first‐line treatment for ureteral endometriosis. However, some patients can't be treated with open or laparoscopic surgery because of their comorbidity. We investigated whether endoscopic intervention (EI) including laser endoureterotomy and balloon dilatation with neoadjuvant hormone therapy (HT) can be a good choice of treatment instead of laparoscopic or open surgery in UE.
Methods: From 2004 to 2021, 12 patients with neoadjuvant HT and 6 patients without HT were reviewed for this single‐center, retrospective study. The inclusion criterion was the presence of ureteral stricture due to UE. Primary outcome was success rate of EI at three and six months after intervention. Success was defined as improvement of patients' symptoms and non‐obstructive pattern of MAG3 renal scan.
Results: Mean age of patients at surgery were 41 in hormone untreated group and 42.08 years‐old in hormone treated group. The success rate of EI was higher in patients with neoadjuvant HT than patients without HT at three months (76.9% vs. 0%, p = 0.003), and at six months (75% vs. 0%, p = 0.005). In addition, the success rates tended to be higher for hormone response group than non‐response group (100% vs. 57.1%, p = 0.122).
Conclusions: EI is effective for ureteral stricture caused by UE in selected patients. The success rate of EI with neoadjuvant HT showed higher success rate than patients without HT. In addition, for patients with good response to the neoadjuvant HT on CT or MRI, EI can be a better choice of treatment than open or laparoscopic surgery.
Study of Real Time Intra Renal Temperature Changes during Laser Lithotripsy with Thulium Fiber Laser during RIRS through an In‐Situ Percutaneous Nephrostomy Tube: An Experimental Study
RS Batra, A Singh, A Ganpule, R Sabnis, M Desai
Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India
Introduction & Objective: Thulium Fiber Laser (TFL) is a high‐powered laser. There are many concerns regarding the heat generated with the use of thulium Fiber lasers. The aim of the study was to measure real time intrarenal temperature changes with TFL at different energy levels in a patient undergoing RIRS with an already percutaneous nephrostomy in‐ situ.
Methods: Ethical committee approval and patient consent was taken prior to this study. Patient had a complete staghorn stone in the right side of horseshoe kidney. Patient was explained multistage PCNL and need for ECIRS if required. Patient underwent stage 1 PCNL with Olympus Shockpulse which cleared around 60% of stone bulk. After 2 days, patient underwent RIRS with Thulium fiber Laser (IPG Photonics) for the remaining stone bulk in inaccessible calyces. During this stage, the nephrostomy was in situ. We measured the intrarenal and irrigation fluid temperature with a thermometer with two K‐ type Thermocouples. The sterilized thermocouple was inserted through the nephrostomy tube inside the pelvicalyceal system. RIRS was done through LithoVueTM 9.5 fr (Boston Scientific, USA) flexible ureteroscope with TFL as energy source. Irrigation was kept at 100 ml/min for first 20 min and 130 ml/min thereafter using a pressure pump. The energy used for TFL varied from 0.1 J to 2 J at 200 Hz frequency (dusting mode) (20‐40 watts). Temperature was measured every 15 seconds.
Results: The baseline intrarenal temperature was 32° Celsius. The baseline irrigating fluid temperature was 24° Celsius. The maximum intra renal temperature reached was 37.3° Celsius. The mean temperature was 33.5° Celsius with range of 31° Celsius to 35° Celsius which is a safe range for the tissues. Mean irrigation rate was 120 ml/min. The temperature drastically increases when irrigation is discontinued. The graph also shows there is maximum temperatures are present at high power (40 watts). Whereas temperatures are lower when energy settings are 20 watts to 30 watts.
Conclusions: Average temperature remains the same in power settings between 20 watts to 40 watts. With an irrigation between 100 ml/min to 130 ml/min, the maximum temperature reached is 37.3° Celsius which is safe temperature for the tissues. Thus, TFL is safe with irrigation of 100 ml/min at power settings of 20‐40 watts with minimal concern of thermal damage to renal and pelvicalyceal tissues.
Clinical Utility of a Single‐Use Flexible Cystoscope Compared with a Standard Reusable Device: A Randomized Non‐Inferiority Study
A Holmes, A Wombwell, D O'kane, RJ Grills
Barwon Health, Geelong, Victoria
Introduction & Objective: A non‐inferiority assessment of single‐use digital flexible cystoscopy (FC) compared with standard reusable FC for bladder cancer surveillance, and investigation of lower urinary tract symptoms.
Methods: Patients requiring flexible cystoscopy who met inclusion criteria were randomly assigned to have their procedure performed using a single‐use cystoscope (Ambu® aScopeTM️ 4 Cysto System) or a standard reusable scope (Olympus CYF‐VH flexible video cystoscope). Primary outcomes were non‐inferiority of the single‐use scope, in terms of successful procedure completion rate, image quality, light quality, maneuverability. Secondary objectives compared safety, operative and perioperative time. The non‐inferiority margin was set at ‐10%.
Results: 101 patients completed the study (n = 50 trial, n = 51 control). All primary outcomes demonstrated non‐inferiority of the single‐use scope, compared to standard reusable FC. Successful completion rate, image quality, light quality, and maneuverability between single‐use and reusable scopes were 100% and 98% (CI: ‐0.059 to 0.019); 96% and 100% (CI: ‐0.014 to 0.092); 98% and 100% (CI: ‐0.018 to 0.058); 98% and 100% (CI: ‐0.018 to 0.058). There was no difference in operation time (p = 0.415) or total theatre use time (p = 0.441) between groups. Adverse event rates were 4.08% and 4.16% in the trial group and control groups, respectively.
Conclusions: The single‐use Ambu® flexible cystoscope is non‐inferior to standard FC in terms of procedure completion and light quality, image quality and maneuverability. Single‐use flexible cystoscopes are an effective and safe alternative to reusable flexible cystoscopes and may act as a suitable alternative or adjunct in the urologist's armamentarium.
Urine Sample Analysis with an Ultra‐Compact Spectrometer to Evaluate the Presence of Patterns Associated with Bladder Cancer
A Civitella, F Prata, F Esperto, P Tuzzolo, F Tedesco, A Ragusa, V Crimi, R Scarpa, R Papalia
Department of Urology, Campus Bio‐Medico University of Rome
Introduction & Objective: Urine cytology is characterized by a high percentage of false negative results: the sensitivity of cytology in high grade tumors is 78% and it takes between 5 and 10 days, depending on the laboratory, for the withdrawal of the report. The aim of this study is to evaluate the development of a fast, reliable and economical method for the research of neoplastic patterns in the urine.
Methods: From January 2021 to September 2021, 120 patients underwent transurethral resection of the bladder (TURB and Re‐TURB) were enrolled in our center, 77 with a positive histology report for bladder cancer and 43 patients with a negative histology report. A urine sample was collected before surgery from all patients enrolled in the study. The sample was subsequently analyzed through an ultra‐compact spectrometer with a measurement range between 340 and 850 nm, produced by our engineering department. The results were reprocessed in a data matrix containing the information relating to the voltage response, which were analyzed using multivariate unsupervised Principal Component Analysis (PCA) or supervised Partial Least Square Discriminant Analysis (PLS) techniques.
Results: The analysis of the urine sample with the ultra‐compact spectrometer compared to the histological examination showed an agreement of 78% (κ = 0.55) a sensitivity of 72% and a specificity of 81%, a positive predictive value of 67% and a negative predictive value 80%.
Conclusions: The analysis of the urine sample with the ultra‐compact spectrometer appears to have a fair agreement with the outcome of the histological examination in patients with bladder cancer. It also appears to be a fast, reproducible and inexpensive method.
Complications Associated with Flexible Cystoscopy: Review of a National Administrative Database
J Lee, E Kaplan‐Marans, A Schulman
Maimonides Medical Center
Introduction & Objective: To identify device‐related issues associated with flexible cystoscopes as described in the US Food and Drug Administration (FDA) Manufacturer and User Facility Device Experience (MAUDE) database.
Methods: We reviewed the MAUDE database to identify all reported adverse events between January 2015 to December 2020 related to the use of flexible cystoscopes. The MAUDE adverse event classification system was used to standardize complication severity.
Results: A total of 335 adverse events related to flexible cystoscopes were identified in the MAUDE database. The types of complications included infection, mechanical malfunction, and allergic reaction. There were 132 adverse events that resulted in patient harm, and most were related to infection (n = 123) (Table 1). There were at least six separate infectious outbreaks identified, where the isolated growth of the same organism was found in both the submitted device and the patient's samples (Table 2). Each outbreak was associated with the use of a single cystoscope.
Conclusions: The MAUDE database demonstrates an array of device‐related complications related to the use of flexible cystoscopes. Although flexible cystoscopy is a well‐tolerated outpatient procedure, our findings demonstrate that infections were the most commonly reported complication that resulted in patient harm. Understanding the clinical significance of device contamination may play a crucial role in improving the overall safety of cystoscopy. Urologists should be aware of potential complications and sources of contamination when performing these procedures.
Holmium: YAG vs Thulium Fiber Laser in Junior and Experienced Users: Which Parameters for Which Efficacy? An in vitro Comparative Study
M Corrales, A sierra, O Traxer
Introduction & Objective: A few years ago, the Thulium fiber laser (TFL) was introduced on the market for the treatment of urinary stones. In vitro and clinical studies have shown promising efficacy results over Holmium: YAG (Ho:YAG) for endocorporeal laser lithotripsy (ELL). We aim to compare the ablation percentage per time unit and the laser efficiency (J/mm3) of the TFL with the Ho: YAG laser with different settings in hands of junior and experienced urologists.
Methods: A Holmium:YAG laser and a Thulium fiber laser with 200μm core‐diameter laser fibers (LF) were used in a saline in vitro ureteral model through a single‐use ureteroscope. Five junior urologists and five senior urologists lasered Bego‐stones (125 mm3) for 3 minutes continuously. Both TFL and Ho: YAG tests were conducted with the following parameters, all of which were retained from the user interface pre‐settings of the Coloplast TFL Drive, for stone dusting: 0.5J/10 Hz, 0.5J/20 Hz, 0.7J/10 Hz, 0.7J/20 Hz, 1J/12 Hz and 1J/20 Hz.
Results: The overall ablation percentage was 27% greater with the TFL technology than with the Ho: YAG laser after 3 minutes of continuous lasering in each setting (P < 0.0001). The J/mm3, meaning the energy needed to ablate 1 mm3 of the stone, was 24% lower when using the TFL (P < 0.0001). While junior urologists performed less well than senior ones in all the tests, they benefited more from the TFL technology, with 36% more ablation and 36% fewer J/mm3 compared to the Ho: YAG laser.
Conclusions: When used under the pre‐set values of Coloplast TFL Drive, the TFL technology appears to be more efficient than the Ho: YAG laser, producing more stone ablation at any setting without augmentation of the J/mm3. Interestingly, this new technology seems also beneficial to junior urologists for managing ELL, reducing the gap against senior users.
Thulium Fiber Laser: Soltive vs Quanta ‐ Initial Clinical Experience
M Corrales, A sierra, O Traxer
Introduction & Objective: Thulium fiber laser (TFL) is the latest laser technology available in the market. Brand‐new thulium fiber laser machines are being developed by renowned medical device companies. We aim to compare our initial clinical experience with the SOLTIVE Premium (Olympus, Japan) and the Fiber Dust (Quanta System, Italy)
Methods: We performed a comparative analysis between the first 40 patients that underwent RIRS for renal stones with the Fiber Dust (Quanta System, Italy) with our first prospective series using TFL (SOLTIVE Premium, Olympus, Japan) published on January 2021, in witch 41 patients underwent RIRS for renal stones. 150 μm laser fibers were used in both cases. Stone size, stone density, laser‐on time (LOT) and laser settings were recorded. We also assessed the ablation speed (mm3/s), Joules/mm3 and laser power (W) values for each lithotripsy.
Results: A total of 81 patients were included in the study. There was statistically significance difference in terms of median (IQR) pulse energy, frequency and total power; the Quanta group used more energy (0.6 J vs 0.3 J) but much less frequency (15 Hz vs 100 Hz) and total power (10 W vs 24 W). Laser on time and median J/mm3 were similar in both groups. Ablation speed rate was slightly higher with the Soltive laser (p = 0.05). The overall complication rate was low in both groups.
Conclusions: From this initial evaluation we can conclude that both types of laser devices are safe and effective. More evaluations are needed to confirm and understand these differences found between them, in terms of laser settings and efficiency.
Assessing the Safety and Feasibility of Electromotive Drug Administration in the Ureter in an in‐Vivo Animal Model
S Hosseini Sharifi, S Ali, KL Morgan, R Bhatt, S Miri Lavasani, C Johnson, P Jiang, RM Patel, J Landman, RV Clayman
Department of Urology – University of California, Irvine
Introduction & Objective: Electromotive drug administration (EMDA) is a technique used to amplify drug delivery to targeted tissues. The application of a low‐power, local electrical current induces the movement of charged molecules into and through the surrounding tissues. We evaluated the safety and feasibility of using EMDA to drive a positively charged, small molecule into the tissue layers of the ureter.
Methods: Two male pigs were placed under general anesthesia. Cystoscopy was used to introduce a 0.035” stiff guidewire into each ureter. The cystoscope was removed and a modified 10 Fr ureteral catheter with equidistant fenestrations in its distal 20 cm was advanced over the guidewire. The guidewire was removed and a 22 gauge silver wire was passed into each ureteral catheter; the larger circumference of the conduction wire prevented fluid from exiting the catheter's tip. Methylene blue, a water‐soluble, traceable stain with a positive charge, was infused through each catheter at 5 ml/min. In the experimental ureter, a positive pulsed electrical current of 10mA was applied using an EMDA generator for 20 minutes. The pigs were then euthanized and both ureters were harvested and flash‐frozen for histopathological analysis.
Results: Macroscopically, the experimental ureter was stained densely (Fig 1A). Both ureters showed mild urothelial cell denudation that did not extend to the basal layer of the urothelium; the deeper tissues revealed no injury. (Fig.1B&C) In the experimental ureters, there was diffuse penetration of methylene blue into the urothelium, lamina propria, and muscularis propria (Fig 1D). In the control ureter, patchy methylene blue staining was seen in the urothelium without deeper penetration (arrow) (Fig. 1E).
Conclusions: In the porcine ureter, electromotive drug administration resulted in safe and successful penetration of a charged molecule into the full thickness of the ureteral wall without incurring any acute tissue injury.
MultiphzeTM Device: A Self‐Contained Bladder Irrigation System
S Soltanzadeh Zarandi, S Ali, KL Morgan, R Bhatt, P Jiang, RM Patel, J Landman, RV Clayman
Department of Urology – University of California, Irvine
Introduction & Objective: Current standard bladder irrigation methods for clot evacuation are cumbersome, inefficient, and hazardous due to the risk of blood and urine contamination. Herein, we present the latest iteration of the MultiphzeTM enclosed irrigation system (Multiphze LLC), a novel self‐contained system designed to eliminate spillage while improving the efficiency of clot evacuation (figure 1).
Methods: Two female, juvenile Yorkshire pigs were anesthetized, following which 100 ml of blood was drawn via a femoral vein and mixed with 44.4 ml of Glow‐Bright Concentrate. The bladders were drained with a 24 Fr 6 eye hematuria urinary catheter; 100 ml of blood and Glow‐Bright Concentrate mixture was instilled into the bladder using a Bard Irrigation Kit (BIK). After 5 minutes, 4 individuals (a urology intern, an endourology fellow, a senior faculty endourologist, and a foreign‐trained urologist‐researcher) with prior experience using a BIK performed bladder irrigation with 3L of sterile water utilizing both the BIK technique and the MultiphzeTM system in two separate trials. The time of each irrigation cycle and clarity of drainage fluid using a spectrophotometer were recorded after each liter of irrigation. Total areas of spillage on the procedural fields were identified with a Wood's lamp and quantified.
Results: The mean clarity measurements at the end of 2 liters of irrigant for the MultiphzeTM and BIK trials were similar to the clarity obtained after 3 liters; however, the mean time to achieve this level of clarity with the MultiphzeTM was 50% less than with the BIK (6.98 min. vs. 14.07 min.) (p < 0.001) (Table 1). Wood's lamp illumination revealed a 100% reduction of spillage with MultiphzeTM compared to BIK (208.95 cm2 vs. 0) (p = 0.036), as there was no spillage with MultiphzeTM.
Conclusions: In a porcine model, the MultiphzeTM irrigation system significantly halved the time to successfully clear a clot‐filled bladder and eliminated spillage and contamination.
Flow‐through Uroflow: The Design and Development of a Novel, Toilet‐Attached Uroflowmetry Device
A Koven, T Li, B Carrillo, M Farcas
Introduction & Objective: Uroflowmetry or uroflow is an important tool for the assessment and management of patients with lower urinary tract symptoms (LUTS). Traditionally, the system requires a patient to urinate into a weight‐sensing or gravimetric collection vessel and then outputs urine flowrate or volume over time. Although non‐invasive, this approach has major limitations. Patients undergo testing in uncomfortable and unrepresentative voiding environments that may compromise diagnostic accuracy. Furthermore, it requires manual cleaning and setup between each use, which leads to interruptions in clinic workflow and longer wait times. This study aims to design and implement a toilet‐attached uroflow device that performs the same standard of care measurements as gravimetric uroflow, but inside any standard toilet and without an external urine collection vessel.
Methods: The design leverages flow sensors housed in a unit that attaches via universal adapters to any standard toilet. Voided urine passes into the device to be measured, then empties into the toilet automatically. Standard uroflow metrics are output by custom software. Multiple flow states were simulated using saline irrigation bags and the device performance was tested for accuracy against a standard gravimetric uroflow device.
Results: The novel uroflow device enables uroflow measurements in any standard toilet and automatically empties after each use. The device is accurate to within +/‐ 5% for total volume and +/‐ 1cc/sec for maximum and average flowrates, consistent with International Continence Society equipment performance guidelines.
Conclusions: This novel uroflow device has the potential to reduce disruptions to clinician workflow, improve diagnostic accuracy through more representative voiding and enhance the patient experience through improved comfort, reduced test anxiety, and shorter wait times. A trial is being conducted to confirm results in an outpatient urology clinic.
Single‐Use Disposable Flexible Cystoscopes: Implementation in a Mobile Bedside Portable Cystoscopy Service
A Yeap, S Yeo, J Kwok
Tan Tock Seng Hospital, Singapore
Introduction & Objective: Single‐use disposable cystoscopes have recently been introduced, with portable smaller screens and good quality images. Within our institution, emergency cystoscopy was mainly done in the emergency operating theatre with reusable cystoscopes. We report our experience in developing a mobile bedside portable cystoscopy service with use of single‐use disposable cystoscopes.
Methods: With the increase in COVID‐19 admissions and unwell patients in isolation, to decrease patient transfers, exposure risks, reduce inpatient admissions and bed occupancy, we introduced the single use portable bedside cystoscopy service in our department. The Ambu® aScope™ 4 Cysto single‐use disposable flexible cystoscope paired with a small portable viewing screen was used. From 24th September 2021 to 22nd Feb 2022, we deployed 17 cystoscopes, with 16 in the emergency setting. With the scope, we had a portable accessory kit, with an inventory of adjunct equipment including guidewires and urethral dilators. We also developed a standardised workflow to activate the service. We retrospectively review our series.
Results: A total of 17 cystoscopes were deployed in this 5‐month period. Location wise, 7 (41%) were in the emergency department, 3 (18%) in COVID‐19 isolation ward and intensive care unit, 1 (6%) in high dependency, 5 (29%) in general ward, and 1 (6%) in the angiography suite. 6 patients (35%) had challenges for transfer out of the ward due to infectious isolation or clinical status. Indications included difficult urethral catheter insertion (n = 14, 82%), urethral evaluation in trauma (n = 1, 6%), urethral catheter malfunction (n = 1, 6%) and ureteric catheterisation before renal tumour ablation (n = 1, 6%).
Adjunctive procedures performed with cystoscopy included: indwelling urethral catheter insertion (n = 10, 59%), urethral dilatation with indwelling catheter insertion (n = 5, 29%), suprapubic catheter insertion (n = 1, 6%) and ureteric catheterisation (n = 1, 6%). No immediate complications were noted. 3 emergency department patients were discharged from the emergency department directly after cystoscopy, saving an inpatient bed and inpatient stay costs.
Conclusions: The advent of single‐use disposable flexible cystoscopes and its utilisation in a portable cystoscopy service has allowed us to bring cystoscopy in a compact mobile manner to the bedside of patients including those who emergently need cystoscopy, reducing need for patient transfer, inpatient stay, operating theatre usage and operating theatre nurse manpower, avoiding arrangements for emergency operating theatre.
Novel Guideline Based Clinical Decision Support Software ‐ Evaluation in Prostate Cancer Patient Treatment
C Wetterauer, M Henkel, T Horn, P Trotsenko, F Leboutte, B Stieltjes, P Cornford, A Stalder, H Seifert
Dept. of Urology, University Hospital Basel
Introduction & Objective: Prostate cancer is the most relevant cancer in urology. However, physicians spend more than half of their workday interacting with health information systems to care for their patients. Effective data management that provides physicians with comprehensive patient information from various information systems is required to ensure high quality clinical decision making.
We evaluated the impact of a novel, CE‐certified clinical decision support tool on data quality, physician's effectiveness and satisfaction in the clinical decision‐making process.
Methods: Using cases of newly diagnosed prostate cancer prior to primary treatment, we compared physician's expenditure of time, data quality, and user satisfaction in the decision‐making process comparing the current standard with the software. Ten urologists from our department conducted the diagnostic work‐up to the treatment decision for a total of 10 patients using both approaches.
Results: Overall, using the software resulted in a significant reduction in urologists expenditure of time for the decision making process by 41.5 % (p < 0.001) (Fig 1). Usage of the new software showed a high positive effect on representational data quality parameters like format (Cohen's d of 3.23) and understandability (Cohen's d of 1.41), as well as on contextual data quality parameters like completeness, relevance and timeliness (Cohen's d of 1.72, 1.56 and 2.53 respectively).
Furthermore, net benefits in terms of productivity as well as user satisfaction in the clinical decision‐making process wer significantly improved (Cohen's d of 5.75 and 4.41 respectively).
Conclusions: The software demonstrated that effective data management can improve physician's effectiveness and satisfaction in the clinical decision‐making process. Further development is needed to map more complex patient pathways, such as the follow‐up and treatment of metastatic prostate cancer.
Office‐Based Ureteral Stent Insertion Without Fluoroscopy Under Minimal Sedation is Safe and Effective
N Sharma, S Quarrier, R Jain
University of Rochester Medical Center
Introduction & Objective: Acute renal colic due to obstructing stones has been a challenge for urologists to manage during the COVID‐19 pandemic. Due to overwhelmed hospital resources, operating room (OR) time and staff became scarce, resulting in prolonged pain and suffering for patients. Early during the pandemic, we instituted an office‐based ureteral stent placement protocol to relieve immediate discomfort. Later with less constrained OR availability, we extended this protocol to patients undergoing chronic stent changes.
Methods: Patients who presented with severe renal colic due to obstructing stones were offered immediate office‐based ureteral stent placement under minimal sedation. Patients filled a prescription of diazepam 10mg and were brought to the procedure suite 2 hours later. Intramuscular ketorolac 15mg was given and 2% lidocaine lubricant jelly was inserted per urethra. Flexible cystoscopy was performed with a standard 16Fr scope, and the stent was placed through the cystoscope. For the first two cases, a 0.038” hybrid wire and 4.8fr stent were used while subsequently, a 0.035” stiff hydrophilic nitinol wire and 4.5fr stent were used. No intraoperative fluoroscopy was used. After stent placement, KUB X‐Ray was done to confirm stent placement.
Results: Seven patients (4 females, 3 males) with a mean age of 62.5 years and a mean BMI of 31.3 underwent an office‐based procedure. Five stent insertions were done for obstructing ureteral stone (unilateral = 4, Bilateral = 1) and 2 stent changes for ureteral stricture and ureteral obstruction due to fibroids. In most cases, it was clear when the wire had gone past the stone, as there was immediate efflux of urine into the bladder. The efficiency of the procedure was greatly increased by changing the wire and stent size. Stent placement failed in one case due to overfilling of the bladder causing acute angulation of the ureteral orifice. The stent was later inserted under general anesthesia.
Conclusions: Office‐based ureteral stent insertion and exchange are safe and effective even in the absence of fluoroscopy. Further studies are needed to
investigate predictors of success of office‐based stent insertion, along with cost analysis to expand its use routinely.
A Global Survey of Ergonomics Practice Patterns and Rates of Musculoskeletal Pain Among Urologists Performing Retrograde Intrarenal Surgery
AT Gabrielson, Y Tanidir, D Castellani, DR Ragoori, L Ee Jean, M Corrales, J Winoker, Z Schwen, B Matlaga, C Seitz, A Skolarikos, A Gozen, M Monga, BH Chew, J Teoh, O Traxer, BK Somani, V Gauhar
Brady Urological Institute, Johns Hopkins Medicine
Introduction & Objective: Retrograde intrarenal surgery (RIRS) requires awkward body posture for long durations. Few urologists receive ergonomics training despite the availability of ergonomics best practices utilized by other surgical specialties. We characterize ergonomics practice patterns and rates of musculoskeletal (MSK) pain among urologists performing RIRS.
Methods: A web‐based survey was distributed via the Endourological Society, the EAU, and social media. Surgeon anthropometrics and ergonomic factors were compared to ergonomics best practices. Pain was assessed with the Nordic Musculoskeletal Questionnaire (NMQ). Multivariate logistic regression analysis was performed to evaluate demographic and ergonomic factors associated with pain metrics collected on the NMQ.
Results: Overall, 519 of 526 participants completed the survey (99% completion rate). Ninety‐three percent of urologists consider ergonomic factors when performing RIRS to reduce fatigue (68%), increase performance (64%), improve efficiency (59%), and reduce pain (49%). Only 16% received ergonomics training. Residents/fellows had significantly lower confidence in ergonomic technique compared to attending surgeons of any career length. Adherence to proper ergonomic positioning for modifiable factors was highly variable (Figure 1). On NMQ, 12‐month rates of RIRS‐associated pain in ≥1 body part, pain limiting activities of daily living, and pain requiring medical evaluation were 81%, 51%, and 29%, respectively (Table 1). Annual case volume >150 cases (OR 0.55 [0.35‐0.87]) and higher adherence to proper ergonomic techniques (OR 0.67 [0.46‐0.97]) were independently associated with lower odds of pain. Limitations include a predominantly male cohort which hindered the ability to assess gender disparities in pain and ergonomic preferences.
Conclusions: Adherence to ergonomics best practices during RIRS is variable and may explain high rates of MSK pain among urologists. These results underscore the importance of utilizing proper ergonomic technique and may serve as a framework for establishing ergonomics guidelines for RIRS.
A Comparison Among Retrograde Intrarenal Surgery (RIRS) and Mini‐Percutaneous Nephrolithotomy (MiniPerc) for Renal Stones Between 1 and 2 cm Using Fiber Dust: A Randomized Controlled Trials
L Berti, M Maltagliati, D Perri, U Besana, C Buizza, A Pacchetti, S Micali, M Sighinolfi, B Rocco, G Bozzini
Sant'Anna Hospital Como
Introduction & Objective: We performed a prospective randomized comparison among Retrograde IntraRenal Surgery (RIRS) and MiniPerc (MP) for stones between 1 and 2 cm to evaluate outcomes with the same Laser device: Fiber Dust
Methods: Patients with a single renal stone with an evidence of a CT diameter between 1 and 2 cm were enrolled in this multicentric study. Exclusion criteria were the presence of coagulation impairments, age less than 18 or more then 75, presence of acute infection, presence of cardiovascular or pulmonary comorbidities. Patients were randomized into two groups: Group A: patients treated with RIRS; Group B: patients treated with MP. Both groups underwent the procedures performed with the Fiber Dust Laser Device. Patients were followed‐up with a CT scan after 3 months. A negative CT scan or asymptomatic patients with stone fragments smaller than 3 mm and a negative urinary culture were the criteria to assess the stone‐free status. A statistical analysis was carried out to assess preoperative patient data, success, complication and re‐treatment rates and need for auxiliary treatment
Results: Between January 2019 and January 2021, 186 consecutive patients were enrolled in this study. 90 pts in group A and 96 in group B. Mean stone size was 15.84 mm. in Group A and 14.99 mm. in Group B (p = 0.23). The overall stone free rate was 73.3% for group A and 84.4% for group B. The higher stone‐free rate was reached for upper calyceal stones in group A (19/21, 90.4%) while group B showed a better performance on lower calyceal stones (33/36, 91.6%). Retreatment rate was similar (p = 0.31). Auxiliary procedure rate was comparable between group A and B (p = 0.18). Complication rate was 5.5% and 5.2% for groups A and B, respectively
Conclusions: RIRS and MP are both effective to obtain a postoperative stone free rate with fiber dust. According to the stone position one treatment is superior to the other one
Interventional Radiologist vs Urologist Access and Radiation Exposure to Patient
E Ballon‐Landa, XG Glover, M Sawyer
University of Colorado School of Medicine, Division of Urology
Introduction & Objective: Percutaneous nephrolithotomy (PCNL) requires first obtaining percutaneous renal access. In preparation for stone surgery, interventional radiologists (IR) more frequently perform renal access procedures than urologists. Prior studies have demonstrated that even with percutaneous renal access training, few urologists perform this procedure in practice. We hypothesized that patients undergoing PCNL with prior IR access would experience decreased radiation exposure.
Methods: A consecutive case series was retrospectively reviewed in a single Veterans Affairs Medical Center for all first‐stage PCNL surgeries performed. Access specialty (urology, IR) and patient factors (BMI, total stone burden) were abstracted. Reported radiation dose was converted to effective radiation dose (ERD) in mSv for IR access procedure, if performed, as well as for PCNL. A negative binomial regression model was fit to adjust for anatomical and technical factors contributing to radiation exposure, and to account for the non‐normally distributed dependent variable. Predicted ERD by access specialty were calculated, controlling for BMI and stone size.
Results: 35 PCNL surgeries (excluding second stage PCNL) were performed between 2014‐2021. 14 received percutaneous renal access by IR pre‐operatively, and 21 access procedures were performed by the urologist at the time of PCNL. Median ERD of IR renal access was 6.16 mSv (IQR 2.63‐35.6). When combined with the percutaneous stone surgery, median ERD for IR‐access PCNL was 8.37 mSv (IQR 5.50‐36.7) vs. 2.58 mSv (IQR 1.38‐5.60) for urologist‐obtained PCNL and access (p = 0.0007). Stone burden (IRR 1.27, p = 0.009), BMI (IRR 1.12, p = 0.003), and percutaneous access by IR (IRR 5.78, p < 0.001) were significantly associated with increased radiation exposure by adjusted risk models.
Conclusions: Contrary to our hypothesis, pre‐operative renal access by IR was associated with significantly higher radiation exposure per stone episode, even when controlling for risk factors, in this veteran population. Urologists desiring to limit radiation exposure should consider which patients require IR collaboration for renal access. Further study is needed to assess whether these findings are generalizable to a broader group.
Intracavitary Instillation in Upper Tract Urothelial Carcinoma. Biodegradable Drug Eluting Ureteral Stent Assessment in Porcine Animal Model
F Soria, S Aznar‐Cervantes, J de la Cruz, J Aranda, A Serrano, E Arguelles, D Pérez‐Fentes, F Sánchez‐Margallo
Is There a Specific Duration of Indwelling Retained Ureteral Stents that Would Predict the Necessity of a Percutaneous Nephrolithotomy?
Z Connelly, A Azzawe, KN Morgan, N Khater
LSU Health Shreveport
Introduction & Objective: Retained ureteral stents may represent a complex situation. With prolonged indwelling time, there is an increased technical difficulty in retained stent removal, leading to potential morbidity and sometimes mortality. The purpose of this study is to evaluate our patients who had retained ureteral stents, to better analyze the indication of a multimodal endourological approach in an attempt to identify if there would be a certain duration after which a percutaneous nephrolithotomy becomes required.
Methods: After IRB approval, we retrospectively reviewed data of patients who underwent multimodal endourological procedures for the removal of their retained ureteral stents from January 2010 to June 2018. The primary outcomes analyzed were patients' characteristics, potential etiologies for stent encrustation, and outcomes of multimodal endourological approaches.
Results: We included 38 patients with 41 ureteral stents. Indications for stents included malignancy, urolithiasis, ureteropelvic junction obstruction and trauma. All patients had encrustation on fluoroscopy and failed stent removal. The median (IQR) age was 43.5 (19‐77) years; 60% were females. Patients traveled a median of 144 miles (12‐ 180) for care. Only 31% of patients had financial support for medical care. Stents were indwelling for a median of 10 months (2‐ 264). Encrustations were visible on the upper coils only (4), lower coils only (12), or both (22). Reasons for delayed stent removal included transportation (22); prolonged management (14); and pregnancy (2). Successful stent removal required shock wave lithotripsy (SWL) in 22 patients, combined SWL and cystolitholapaxy (CLL) in 16, CLL in 13, ureteroscopy (URS) in 5, percutaneous nephrolithotomy (PCNL) in 5, and robotic ureterolithotomy in one. Median operative time was 102.5 minutes. Among those, was a 22‐year‐old retained stent, one of the oldest reported in the literature. It was removed at our institution with a combination of SWL, CLL, URS and PCNL. No intraoperative complications were encountered. Postoperatively, one patient developed a myocardial infarction, another had a pleural effusion.
Conclusions: Ureteral stent encrustation should be avoided. Female patients may be at higher risk. Socioeconomic factors and transportation issues play a major role. A multimodality surgical approach including PCNL was often needed in our patients, when both coils were encrusted or when stents were bilateral or have been retained for more than at least 10 months.
Time Efficiency and Performance of Disposable versus Reusable Cystoscopes: A Prospective, Randomized Benchtop Comparison
CE Baas, RR Chen, DR Peverini, JC Hartman, A Assidon, AS Amasyali, J Belle, E Baldwin, DD Baldwin
Loma Linda University School of Medicine
Introduction & Objective: While reusable cystoscopes (RC) are commonly used for urologic procedures, bulky equipment and lengthy sterilization times can impact efficiency. Disposable cystoscopes (DC) may offer advantages including increased availability, greater portability, and faster setup times. The aim of this study is to compare procedure times, cystoscope specifications, and physician satisfaction between RC and DC.
Methods: Ten urologists performed simulated bedside cystoscopies with target identification using a prospective, randomized, crossover study design. Each subject used both a new disposable Ambu aScope 4 Cysto and a reusable Olympus CYF‐5 flexible cystoscope. Afterward, participants completed a satisfaction survey. Times required for supply‐gathering, setup, cystoscopy, and cleanup were compared. Image definition, field of view, deflection angle, force required for deflection, irrigation rate, weight, and working length were also compared.
Results: The DC required less time for supply‐gathering (187.5 s vs. 289.4 s, p < 0.05), setup (203.3 s vs. 327.5 s, p < 0.01), and cleanup (183.7 s vs. 356.2 s, p < 0.05) while cystoscopy times were similar (230.4 s vs. 274.1 s, p = 0.575). Optical testing showed higher image definition for the DC (6.30 vs. 2.00 line pairs/mm, p < 0.01), but a smaller field of view (67° vs. 108°, p < 0.01) and no adjustable optical settings. The DC had increased deflection (214° up/182° down vs. 198° up/109° down, p < 0.01) but required more force to deflect 180° up (6.86 N vs. 4.46 N, p < 0.01) and 90° down (4.66 N vs. 3.55 N, p < .01). The RC was heavier (325 g vs. 159 g, p < 0.01), had a shorter working length (37.5 cm vs. 39.0 cm, p < .001), and a faster irrigation rate at 200 cm H2O (494.1 mL/min vs. 387.4 mL/min, p < 0.01). Post‐testing, deflection was reduced for two DCs, but optical qualities remained unchanged. Survey results showed higher ratings in time‐efficiency (9.5/10 vs. 6.2/10, p = 0.00) and overall satisfaction (9.3/10 vs. 7.9/10, p = 0.00) for the DC. There was no difference in maneuverability or image quality.
Conclusions: While the DC had better image quality, greater deflection, and was faster to assemble and disassemble, the RC had greater durability, more optical settings, wider field of view, faster irrigation rates, and required less force for deflection. Knowledge of the strengths and weaknesses of each device could assist surgeons in optimizing cystoscope utilization in specific clinical scenarios.
In Vitro Assessment of Biodegradable Chemotherapy‐Eluting Ureteral Stent for Adjuvant Therapy in Upper Tract Urothelial Carcinoma
F Soria, S Aznar‐Cervantes, M Cepeda, L Resel, T Fernandez, M Pamplona, F Sánchez‐Margallo
Methods: Three groups are used that are different in the concentration of Mitomycin used for coating, as well as in the formulation of the polymeric matrix that delivers the MMC in a controlled manner. The stents are formulated for release within 6‐12 hours post‐stenting. Group I‐ 20mg MMC; Group II‐40 mg MMC; Group III‐70 mg MMC without excipients. Twenty‐nine 3 cm long fragments of the biodegradable BraidStent biodegradable ureteral stent coated with a polymeric matrix followed by a dip coating technique for coating with MMC are used. After coating stabilisation, all study samples are introduced into individual tubes containing 5 ml of artificial urine with orbital shaking at 36°C. The artificial urine is exchanged in the test tubes. The artificial urine is changed at follow‐up times: 6, 12, 24, 24, 48, 72, 96, 120 hours. Mitomycin C release kinetics is evaluated at each follow‐up by HPLC‐DAD.
Results: 203 samples were analysed by HPLC‐DAD. MMC is released in all groups between the first 6 and 12h of immersion in artificial urine. The mean MMC concentration detected in Groups I, II and III is 6.39, 10.64 and 52.22 mg/L respectively. No significant alterations in the urinary pH of the samples were detected during the study.
Conclusions: The present in vitro study confirms the adequate release of Mitomycin C in urine through a drug eluting stent, with better results with increasing concentration of MMC. The polymeric matrix used allows the delivery and release of Mitomycin after contact with artificial urine. However, the dose released is lower than that described for clinical application. Further experimental studies are needed to increase the dose and assess the effectiveness and safety of the released MMC.
How Many Cases Are Necessary to Overcome the Learning Curve for Retrograde Intra‐Renal Surgery
D Kim, J Lee, S Jeon, S Lee, J Park, S Lee
Kyung Hee University, School of Medicine, Deptartment of Urology
Introduction & Objective: Retrograde intra‐renal surgery (RIRS) has become one of the preferred treatment options for renal stones. Technique of RIRS may be challenging, which needs adequate training to achieve optimal results. However, the learning curve for RIRS has not been well established. The aim of this study is to estimate the minimum number of cases for a surgeon to perform RIRS consistently.
Methods: From January 2014 to May 2017, 279 patients received RIRS at Kyung Hee University Medical Center. All cases were performed by single surgeon. We retrospectively reviewed their medical records and included patients if the main stone had a maximal diameter between 10 and 30mm. All patients checked non‐enhanced CT at one month after surgery. According to the previous report, procedures were divided into 4 groups: first fifty procedures (Group 1), second fifty procedures (Group 2), third fifty procedures (Group 3), and fourth fifty procedures (Group 4). We excluded patients who did not follow our schedule or do not check postoperative CT yet. Success of treatment was defined as complete stone free or the presence of residual stone size less than 3mm.
Results: There was no difference in mean age, male to female ratio, and body mass index. Furthermore, mean stone sized showed no significant difference between the groups: 13.51 ± 5.43 vs. 14.11 ± 4.95 vs. 14.65 ± 7.05 vs. 14.81 ± 6.92 (p = 0.932, Group 1, 2, 3, and 4, respectively). However, as the case accumulates, mean operative time significantly decreased from 87.30 ± 41.66, 79.82 ± 44.61, 67.22 ± 36.67, and 56.43 ± 35.33 (p = 0.025). Success rate of Group 1 was only 62.2%. On the other hands, success rate of Group 2, 3 and 4 revealed 89.3%, 80.6%, and 90.5%, which was significantly higher than that of Group 1.
Conclusions: As the case accumulates, mean operative time decreases. And to achieve the stone free after RIRS, it seems that 50 cases is a reasonable estimative for experience needed.
Using Hounsfield Unit (HU) ‐ Volume Models of Kidney Stones to Predict Successful Stone Dusting During Retrograde Intra‐Renal Surgery (RIRS)
D Kim, J Lee, S Jeon, S Lee, J Park, S Lee
Kyung Hee University, School of Medicine, Deptartment of Urology
Introduction & Objective: Computer tomography (CT) of renal stones and measurement of their Hounsfield unit (HU) is commonly used for evaluation before the treatment of urolithiasis. We measured the volume of all HUs in a single stone and drew a model depicting the stone's HU distribution in order to predict success of dusting technique during retrograde intrarenal surgery (RIRS).
Methods: The medical records of 131 patients who underwent RIRS from January 2018 to January 2019 at Kyung Hee University Hospital were reviewed and 168 kidney stones were initially examined. Stones that were larger than 1cm were included and a total of 49 patients with 55 stones were evaluated. The stones were divided into two groups according to intra‐operative dusting success. Dusting was considered successful when stone disintegration was achieved with a laser setting of energy 0.2‐0.4 J and frequency 50 Hz. If higher laser energy settings (fragmentation) and extraction was needed, it was considered as dusting failure. 3‐dimensional models of the stones were reconstructed, and maximal HU, minimal HU, difference between max and minimal HU, HU standard deviation, stone volume, volume of peak HU was evaluated.
Results: Among the total 55 stones, 32 were successfully dusted and 23 were fragmented during surgery. Dusted stones showed a more heterogenous distribution of HU while fragmented stone HUs were more homogenous. “Success of dusting” group had higher mean difference in max and minimal HU (1102.94 ± 376.63 vs 794.91 ± 415.05, p = 0.0073), higher HU standard deviation (262.73 ± 112.61 vs 155.65 ± 95.69, p = 0.001)) and smaller volume of peak HU (4.52 ± 2.53 vs 13.28 ± 8.10, p < 0.0001). When we drew histograms of the HU, dusted stones were wide and rugged while fragmented stones were mostly narrow and peaked.
Conclusions: Stone reconstruction models and evaluation of HU volumes showed that stones with smaller peak HU volumes and higher differences in max and minimal HU could be considered more fragile and prone to successful dusting. Stones that show this type of HU distribution should be considered candidates for RIRS even if their size is larger than current recommendations.
Long Term Safety of Per Urethral Povidone Iodine Instillation in Patients Undergoing Office Cystoscopy: Follow‐up Results from a Clinical Trial
M Khattar, R Nayyar, R Dadhwal
Introduction & Objective: Post procedural urinary tract infections (UTI) cause significant morbidity and increase cost of care. Amidst rising antimicrobial resistance, indiscrimate use of antimicrobials is discouraged. Antimicrobial stewardship is the need of the hour. A previous randomized trial at our center studied the role of irrigating distal urethra with 2% povidone‐iodine solution prior to office cystoscopy as an adjunct to standard surgical parts preparation and showed strong efficacy (22 vs 7.2%, p < 0.007) in preventing UTI's. In this follow up study we present our long‐term safety results from the same trial.
Methods: We followed up the patients undergoing regular office cystoscopy enrolled in the previous randomized study, with or without povidone‐iodine instillation, for new onset LUTS, flow rate, and stricture development.
Results: Out of the 192 patients enrolled in the original study, follow up data was available for 149 patients; 78 patients in the povidone‐iodine irrigation group (Group A) and 71 in the non‐irrigation group (Group B). After a mean follow up period of 22 months, new LUTS and urethral stricture rates were found to be comparable between the two groups. Twenty‐two (28.2%) patients in group A and 21 (29.5%) patients in group B developed new LUTS (p = 0.85). Among these patients, 9 (11.5%) patients in group A and 7 (9.8%) patients in group B developed urethral stricture during follow up (p = 0.74). Five (6.4%) patients in group A as compared to 4 (5.6%) patients in group B required endodilation or optical internal urethrotomy (p = 1.00). Additional risk factors like number of previous cystoscopies and history of intravesical therapy were comparable between the two groups.
Conclusions: We conclude that povidone‐iodine irrigation of urethra is a safe and effective practice that can decrease risk of post‐procedural UTI's without increasing risk of development of new LUTS or urethral stricture.
Untethered Thermal‐actuated Microgrippers as a Novel Latching Device for Urothelial Tissue
R Alam, W Liu, K Lombardo, E Baraban, B Matlaga, A Matoso, D Gracias, J Winoker
Johns Hopkins University School of Medicine
Introduction & Objective: The upper urinary tract presents a challenge to surgeons due to the microscopic caliber of the ureter and its relative inaccessibility compared to the bladder. As a result, the development of instruments to biopsy tissue or deliver therapeutics in a reliable manner using natural orifices has proven difficult. Therefore, we propose the development of untethered submillimeter tools called microgrippers to obtain tissue samples from the upper urinary tract using an in vitro model of porcine urothelium.
Methods: Microgrippers are microsurgical tools measuring 1 mm in the open configuration (Figure 1A). These devices are fabricated using materials safe for use within the human body. A thermosensitive layer keeps the microgrippers in the open configuration at 4°C but softens at 37°C, allowing the microgrippers to close (Figure 1B). The closing motion allows the device to capture contents within its phalanges. Experiments were conducted by placing microgrippers on a sample of porcine urothelial tissue prior to placement in a warm air incubator. The microgrippers were retrieved using a magnet. Tissue samples were analyzed for the presence of cells using 4’,6‐diamidino‐2‐phenylindole (DAPI), which is a blue‐fluorescent dye that stains DNA.
Results: Urothelial tissue was successfully obtained when tested on porcine ureteral and renal pelvic tissue. DAPI staining confirmed the presence of DNA material within the closed microgrippers (Figure 2).
Conclusions: Untethered thermal‐actuated microgrippers demonstrate the ability to latch onto and sample urothelial tissue in vitro. Ongoing studies are focused on ex vivo and in vivo experimentation for biopsy and drug delivery mechanisms.
MP10: Socioeconomics and Health Policy II
Ongoing Improvement in Access and Quality Improvement to Kidney Stone Patients in an Underserved Community
M Stout, M Mcnamara, A Khuhro, M Murtha, M Yudovich, A Scimeca, D Diab, T Posid, G Shidham, E Weinandy, BE Knudsen, MW Sourial
The Ohio State University Wexner Medical Center Department of Urology
Introduction & Objective: Federal programs are implemented to improve Medicaid patient access to healthcare, enhance quality and outcomes of care, as well as reduce overall financial burden. We sought to build a comprehensive kidney stone program at our institution to address this specific population by helping patients navigate through the acute and preventative aspects of stone disease.
Methods: A collaborative, multi‐disciplinary program was established at our single institution consisting of urology, nephrology, and dietary specialists. Patients were evaluated for initial stone intervention by urology and then followed for outpatient follow‐up including specialty referrals to nephrology and dieticians when indicated for targeted preventative measures.
Results: One hundred and eighty‐three Medicaid‐designated stone patients were evaluated from 2018‐2021. Sixty‐eight percent of patients identified as white, 18% identified as black/African‐American, and 14% identified as “other”. Patients underwent specialty referrals to nephrology or a dietician in 20% and 13% of cases, respectively. Thirty‐six percent reported making suggested dietary changes while 14% utilized preventative medications or nutritional information at initial follow‐up. Since the program's implementation, no‐show rates for initial urology follow‐up decreased from 24.6% to 23.45% with reported compliance for all recommendations or referrals placed at 50%. Outpatient clinic appointment volume increased by 21% after the first year of program implementation.
Conclusions: There is continued supporting evidence of the importance of a comprehensive kidney stone program targeted towards patients of lower socioeconomic status with encouraging results of increasing access to intervention and multi‐disciplinary specialty referrals, with resultant promising improvement in follow‐up and compliance related to stone prevention strategies.
Effect of Complications on Urology Trainees: An Epidemiological Survey
W Du Comb, B Milliner, K Suson, J Palka
Detroit Medical Center
Introduction & Objective: Death, taxes and surgical complications are all guarantees for urologists. Trainees are taught to diagnose and operate; however, little formal education is provided on coping with surgical complications.
Methods: After obtaining IRB approval, an electronic survey was distributed to all ACGME accredited urology programs via email. The survey consisted of 15 questions regarding surgical complications.
Results: Overall, 106 residents and fellows responded. Average age of responders was 31 years old. Senior level residents (PGY4‐6) comprised the majority (58.5%) of responses. Junior residents (PGY2‐3) and interns (PGY1) represented 29.3% and 8.5% of respondents, respectively. Fellows accounted for 8.5% of responses.
Discussion of the case among peers was the main coping mechanism (98.1%), while 83% stated they discussed the case with faculty. Over a quarter (26.4%) of trainees used alcohol to cope with their complication, and 38.7% utilized exercise. Thirty percent of trainees were uncertain or denied existence of a mental health support system at their institution.
Surgical complications affected trainees by causing performance anxiety (70%), loss of confidence (70.7%), and excessive thoughts regarding the complication (70%). Trainees also expressed emotional damage including feelings of anxiety/fear (72%), sadness/grief/depression (68%), and feelings of being overwhelmed, helpless, or hopeless (51.5%). Just over half of responders lost sleep over their complications.
Thirty‐seven percent of trainees felt they were unsure or did not feel prepared to handle complications upon graduation.
Conclusions: Although complications are inevitable for urologists, residents may suffer psychologic consequences when they occur and often feel unsure/unprepared for managing them upon graduation. Further research into didactic complication preparation is warranted.
Patient‐Reported Financial Toxicity from Management of Nephrolithiasis
S Setia, D Gelikman, R Hsi
Vanderbilt University Medical Center
Introduction & Objective: The financial burden of nephrolithiasis care may impact treatment decisions taken by the patient and healthcare provider. We sought to characterize stone‐related financial burden among adults with history of nephrolithiasis through validated questionnaires for financial toxicity.
Methods: We performed a cross‐sectional survey of adults with history of nephrolithiasis through convenience sampling at an outpatient clinic. The survey contained an 11‐item measure of stone‐related financial toxicity (COST score), and assessed demographics, stone event history, and burden of overall, ancillary, preventative, and insurance costs related to nephrolithiasis. After grouping into high or low financial toxicity (COST score <21– high toxicity), univariate comparisons were performed to evaluate whether financial toxicity was associated with certain demographic variables, number of stone events/surgeries, and questions related to burden of nephrolithiasis care.
Results: Of 75 participants with complete surveys, the median COST score was 31 (IQR 22.5‐39), of which 15 patients (20%) were grouped as high financial toxicity versus 60 (80%) as low toxicity. Univariate analysis revealed insurance status, household income, stone surgeries during lifetime and within the last 3 years were each significantly associated with financial toxicity of nephrolithiasis care (p < 0.05). Additionally, all questions related to burden of nephrolithiasis care were significantly different between groups (p < 0.05, table 1). 68% of patients believed that providers should be at least some‐what mindful of the patients' financial situation when making recommendations for nephrolithiasis (fig 1).
Conclusions: In this cohort, 1 in 5 patients seeking care for nephrolithiasis meet criteria for high financial toxicity based on COST score. Financial toxicity was associated with certain demographics as well as number of lifetime stone events/surgeries. Most patients would want physicians to keep these factors in mind when making recommendations for nephrolithiasis.
Effect of Surgery‐Specific Financial Incentive on Opioid Prescribing Practices: Outcomes of a Statewide Surgical Collaborative
J DiBianco, S Daignault‐Newton, B Conrado, D Wenzler, H Pimentel, S Jafri, R Frontera, A Higgins, J Phelps, J Hollingsworth, K Ghani, C Dauw, f Surgery Improvement Collaborative
The University of Florida
Introduction & Objective: Reducing unnecessary opioid prescriptions after ureteroscopy (URS) has been advocated for. The Michigan Pain Optimization Pathway (MPOP) was a payor initiative begun in 7/2019 funded by Blue Cross Blue Shield of Michigan that provided a 35% increased reimbursement to urologists if no opioids were prescribed after URS. It is unknown how financial incentives effect opioid prescribing practices after ambulatory URS. We therefore aimed to understand the effect of this statewide financial incentive on opioid prescribing after URS as compared to shockwave lithotripsy (SWL) where no such incentive was in place.
Methods: Using the Michigan Urological Surgery Improvement Collaborative (MUSIC) registry we identified all SWL and URS cases from 2018‐2020. We separated cases by date with January 2018 ‐ June 2019 as pre‐MPOP and July 2019 ‐ December 2020 as post‐MPOP. We assessed surgeon rates of postoperative opioid prescription by treatment modality. Urologists (N = 80) who had performed at least 5 URS and SWL during the study period were included. We compared opioid prescription rates pre‐ and post‐MPOP by modality. Changes were classified as increase, small decrease and large decrease, defined as any rate increase, ≤20% and >20%, respectively. Change in pre‐ and post‐MPOP opioid rates between SWL and URS paired by surgeon were compared using the signed rank test.
Results: A total of 17,355 cases (5,027 SWL and 12,328 URS) were performed. Rates of opioid prescriptions pre‐ and post‐MPOP after SWL were 64.2% and 45.6% (p < 0.001) and URS were 54.4% and 24.4% (p < 0.001). For SWL, 31% of urologists demonstrated an increase, 39% demonstrated a small decrease, and 30% demonstrated a large decrease. For URS, 16% of urologists demonstrated an increase, 35% demonstrated a small decrease, and 49% demonstrated a large decrease (Figure). Both SWL and URS had a reduction in opioid prescriptions, with urologists reducing their prescribing more for URS than for SWL (p = 0.001).
Conclusions: Opioid prescriptions after ambulatory stone surgery decreased over the last 3 years in the state of Michigan. Urologists reduced opioid prescriptions significantly more for URS than SWL, suggesting the benefit of payor incentives to change practice to align with quality improvement.
Evaluating Perceptions and Usage of Natural Remedies, Herbal Medicine, and Dietary Supplements for Kidney Stones among a Diverse, International, Urban Patient Population
BW Green, N Feiertag, K Watts, AC Small
Albert Einstein College of Medicine
Introduction & Objective: To assess the use and perceptions of complementary and alternative medicine (CAM) for kidney stones among a diverse, urban population.
Methods: This was a cross‐sectional study of patients treated for kidney stones in the Bronx, NY. We assessed demographic information, personal history of kidney stones, as well as knowledge and use of CAM for kidney stones. Patient demographics and responses were analyzed using chi square and t‐tests.
Results: 113 patients were surveyed. 90% identified as non‐white, of whom 58% indicated Hispanic, 46% Latinx, and 23% Black. 56% of patients were born outside the United States. 56% of patients had heard of CAM for kidney stones and 44% had used CAM for kidney stones. The most common CAM were fruits (N = 42, 84%). Recurrent stone formers were more likely than first‐time stone formers to have heard of CAM (68% vs 44% p = 0.013) and to have used CAM (56% vs 30%, p = 0.008). Those identifying as Hispanic were more likely to have both heard of and tried CAM for kidney stones (p = 0.036 and 0.022, respectively) compared to non‐Hispanic patients.
Conclusions: CAM are commonly used among our diverse, urban patient population. While some remedies are high in citrate and alkali (i.e., lemon, cranberry), others are high in oxalate (i.e., beets) and could potentially contribute to stone formation. These findings underpin the importance that medical providers educate themselves on the CAM used in their specific patient populations and discussing usage with patients. Providers should aim to identify and reconcile therapeutics that oppose goals of treatment.
Financial Toxicity of Nephrolithiasis: The First Assessment of the Economic Stresses of Kidney Stone Treatment
BW Green, N Feiertag, K Gupta, J Donnelly, K Watts, AC Small
Albert Einstein College of Medicine
Introduction & Objective: “Financial toxicity” (FT) is the economic stress associated with the treatment of a condition. It includes direct/indirect costs and the cumulative effect on quality of life. FT is a patient‐centered, clinically relevant outcome that has yet to be assessed in kidney stone treatment.
Methods: We performed a cross‐sectional survey on the Reddit Online Support Group and adult kidney stone patients in the Bronx, NY using the COST tool (COmprehensive Score for financial Toxicity). The maximum score is 44 and lower scores indicate increased FT. Groups were defined as “moderate FT” for COST scores between 25‐14 points and “severe FT” for scores <14 points based on prior studies.
Results: 200 patients were surveyed. 52% were from the in‐person cohort and 48% were from the online cohort. The mean COST score for all patients was 22.4 ± 11.6. “Moderate FT” (score 25‐14) was found in 32% of participants and “severe FT” (score <14) was found in 26%. Compared to those with “low FT” (scores >25), “moderate to severe FT” cohorts were younger (CI 10.3 ‐ 1.1 years, p = .016) and missed more work (mean difference of 17 days, CI 7.8‐26, p < .001). English as first language, Medicare/Medicaid insurance, or higher level of education were all associated with lower FT (p < .05). Higher out‐of‐pocket expense was associated with increased FT (p < .05). The two groups were comparable in number of kidney stone episodes, number of kidney stone procedures, gender, and employment status.
Conclusions: Most participants reported moderate to severe FT. Prior studies show that patients with “moderate FT” employ cost‐coping strategies (i.e., medication rationing) and those with “severe FT” have worse health outcomes. Urologists should investigate the financial context of their patients and educate themselves on the cost of treatments. Understanding how treatment may affect financial well‐being will allow for better shared decision making between patients and urologists.
Vulnerability to Financial Toxicity Following Stone Surgery
KF Michel, B Schurhamer, G Lin, H Stambakio, JB Ziemba
University of Pennsylvania
Introduction & Objective: There is a growing recognition and dedication to studying the financial burdens that healthcare places on patients, which is termed financial toxicity. The mechanisms that lead to financial toxicity are multifactorial and include not only the direct and indirect costs of the procedure, but also the insurance coverage, socioeconomic status, medical comorbidity, and financial literacy of the patient before they incur the costs. There are no studies exploring the financial toxicity of nephrolithiasis. We therefore sought to describe the population of patients undergoing surgical stone management at our institution with the lens of assessing their vulnerability to experiencing financial toxicity following their procedure.
Methods: We administered a modified version of the Commonwealth Biennial Health Insurance questionnaire, which measures health insurance coverage, affordability, and financial impact of medical bills. All patients at our institution undergoing either ureteroscopy or percutaneous nephrolithotomy were eligible to participate. The questionnaire was completed electronically prior to surgery. Percentages, median, and interquartile range were used to describe the data.
Results: A total of 32 participants completed a questionnaire between 1/21/2022 ‐ 4/4/2022. The median age was 52 (IQR 44,58) with 67% male (22/32) and 75% white (24/32). The majority were employed (69%; 22/32). Median household income had a bi‐peaked distribution, with one peak in the $45,000‐$60,000 bracket (7/32) and the second in the $140,000+ bracket (10/32).
While all participants were insured, most privately (66%, 21/32), approximately a third (11/32) did not know their deductible amount. A total of 28% (9/32) participants were currently paying off other medical bills, 16% (5/32) had used up all their savings, and 16% (5/32) had been unable to pay for basic necessities like food, heat, or rent.
Conclusions: Although the population undergoing stone surgery is heterogeneous with respect to income, education, and employment, there is a subgroup who is at risk of experiencing financial toxicity from post‐operative medical costs. All participants in this study were insured, yet a high portion did not know their deductible amount, which suggests merely having insurance does not necessarily coincide with good financial literacy or the ability to anticipate and prepare for future medical costs. This is most pronounced for the portion already experiencing financial strain in the form of unpaid medical bills, lack of savings, and possibly even an inability to pay for basic costs of living.
Inpatient, ICU Admissions & Readmissions Associated with Sepsis Post Ureteroscopy among a US‐Based Commercial Population
BH Chew, B Eisner, N Bhojani, R Paranjpe, B Cutone, M Monga
University of Montreal
Introduction & Objective: It has been determined that sepsis post ureteroscopy (URS) occurs at a rate of about 5%. Associated post‐URS sepsis can lead to inpatient and ICU admissions/readmissions. The objective of the current study is to examine the rate of admissions (inpatient and ICU) and readmissions in patients undergoing URS.
Methods: Two retrospective claims analyses were conducted using IBM MarketScan commercial data. Patients were included if they were 18+ and had a URS procedure. A non‐severe sepsis and severe sepsis event was defined as an event within 30‐days post‐URS. In the first analysis, ICU admissions (all‐cause) were measured within 30‐days of the non‐severe septic/severe septic event and within 30‐days of URS in the non‐sepsis cohort. Inpatient mortality from all causes was recorded within 30‐days of the non‐severe septic/severe septic event and within 30‐days of URS in the non‐sepsis cohort. In the second analysis, inpatient and ICU admissions were measured on the index date only (date of URS in the non‐sepsis cohort and date of non‐severe sepsis/severe sepsis in the sepsis cohorts) while readmissions (all‐cause) were measured within 30‐days post inpatient discharge.
Results: The URS cohort consisted of 109,496 patients. Of these, 4.1% developed non‐severe sepsis while 1.5% developed severe sepsis. In the first analysis, ICU admissions within 30‐days among the severe sepsis, non‐severe sepsis and non‐sepsis cohort were 65.1%, 24.6%, and 2.1% respectively (p < 0.001) while the all‐cause inpatient mortality was 3.2%, 0.63%, and 0.56%, respectively (p < 0.001). The length of ICU stay in the severe sepsis cohort was significantly longer than the non‐severe sepsis and non‐sepsis cohort (4.1, 3.8, vs 3.0 days, respectively p < 0.001). In the second analysis, inpatient admissions on index date among the severe sepsis, non‐severe sepsis and non‐sepsis cohort were 76.9%, 74.9%, and 18.3% respectively (p < 0.001) while ICU admissions on index date were 52.4%, 19.8%, and 1.5% respectively (p < 0.001). Lastly, readmissions were highest among the severe sepsis cohort as compared to the non‐severe sepsis and non‐sepsis cohorts (15.9% vs 12.0% vs 7.1%; p < 0.001).
Conclusions: Both non‐severe sepsis and severe sepsis post‐URS leads to a significant increase in both inpatient and ICU admissions as well as readmissions. Severe sepsis was associated with the highest rate ICU admission or readmission.
Mortality Following Ureteroscopy in a Large US‐based Commercial Database
N Bhojani, B Eisner, M Monga, R Paranjpe, B Cutone, BH Chew
University of Montreal
Introduction & Objective: Real‐world outcomes including mortality post‐ureteroscopy (URS) with or without associated sepsis have not been previously reported. The objective of the current study was to evaluate 30‐day all‐cause inpatient mortality among patients who develop sepsis and severe sepsis post‐URS compared to a non‐sepsis cohort.
Methods: A retrospective claims analysis of the IBM MarketScan database was conducted identifying patients aged 18+ who had a URS. A sepsis or severe sepsis event was defined as the first sepsis or severe sepsis event within 30‐days post‐URS.
All‐cause inpatient mortality was measured within 30‐days of the septic/severe septic event and within 30‐days of URS in the non‐sepsis (control) cohort. Descriptive analyses were conducted in the sepsis (further subdivided into severe and non‐severe) and non‐sepsis cohorts comparing all‐cause inpatient mortality and time to all‐cause death in inpatients. Lastly, two multivariable cox regression models were conducted to evaluate the effect of sepsis and severe sepsis on all‐cause inpatient mortality.
Results: The URS cohort consisted of 109,496 patients. The 30‐day all‐cause mortality post URS was 0.07%. The overall incidence of developing sepsis was 5.6% which accounted for 63% of all deaths. Further sub‐analysis revealed that 4.1% developed non‐severe sepsis while 1.5% developed severe sepsis. Further, the all‐cause inpatient mortality among the severe sepsis, non‐severe sepsis and non‐sepsis cohort was 2.5%, 0.27%, and 0.03%, respectively (p < 0.001). The mean time to death in the severe sepsis cohort was significantly shorter than the non‐severe sepsis and non‐sepsis cohort (8.7 days vs 11.1 days vs 16.7 days, p < 0.001). Other than sepsis, other predictors of higher all‐cause inpatient mortality post URS included older age (55‐64; p = 0.024) and higher Elixhauser comorbidity index (p < 0.001). Lastly, patients who developed sepsis were associated with higher all‐cause inpatient mortality compared to patients who did not develop sepsis post‐URS (HR: 17.2; 95% CI: 10.5‐28.0; p < 0.001). Similarly, patients who developed severe sepsis were associated with significantly higher all‐cause inpatient mortality compared to patients who did not develop sepsis post‐URS (HR: 49.5; 95% CI: 28.9‐84.7; p < 0.001).
Conclusions: The all‐cause inpatient mortality post‐URS was low but not insignificant; sepsis accounted for 63% of these deaths and substantially increased the risk of 30‐day inpatient death.
Yearly Trends in Sepsis and Mortality After Ureteroscopy
N Bhojani, B Eisner, M Monga, R Paranjpe, B Cutone, BH Chew
University of Montreal
Introduction & Objective: Sepsis is a serious potential complication that may occur after ureteroscopy (URS). A recent metanalysis and retrospective US claims analysis demonstrated that the risk of sepsis post‐URS is approximately 5%. Sepsis has also been shown to increase the risk of mortality post URS. The objective of the current study is to examine the trends over time of sepsis and inpatient mortality post URS.
Methods: A retrospective claims analysis of the IBM MarketScan database was conducted identifying patients aged 18+ who had a URS procedure. A sepsis event was defined as the first sepsis event within 30‐days post‐URS. Inpatient mortality was measured within 30‐days of an inpatient septic event. Annual trends in sepsis events and inpatient mortality were conducted from 2015‐2019. Further, nationally weighted trends were calculated to reflect the national employer‐sponsored insurance patient population.
Results: According to the national estimates, the annual prevalence of sepsis post URS increased significantly from 4.7% in 2015 to 6.6% in 2019 (p < 0.001). Further, the national annual estimates of the 30‐day inpatient mortality among patients who developed sepsis post‐URS remained relatively stable from 0.7% in 2015 to 0.2% in 2019.
Conclusions: Sepsis post‐URS increased significantly and steadily over the 5‐year study period although inpatient mortality remained stable. Increasing trends in post‐URS sepsis may be the result of the proliferation of URS procedures and the treatment of more complex patients and disease. Potential reasons for the stability in the sepsis associated mortality could include better preoperative and postoperative care of patients at risk of sepsis post‐URS. Although URS is the gold standard surgical treatment for kidney stones, urologists should be aware of the increasing incidence of this serious and potentially deadly post‐operative complication.
Female Surgeon Involvement in Robotic/laparoscopic Surgery Across Specialties: How Does Urology Fare?
N Passarelli, F Munshi, R Ortiz, J Tanzer, E Hyams
Alpert Medical School of Brown University
Introduction & Objective: Over time, robotic and laparoscopic surgery have become core approaches to varied surgical problems. Simultaneously, women have had an increasing presence in surgical specialties, though they remain minority participants. It is not clear to what extent women are performing laparoscopic and/or robotic surgery compared to male peers, and how participation has changed over time. This is an important question to ensure there is parity in access and recruitment for women interested in minimally invasive surgery. In this study, we evaluated the involvement of female surgeons in robotic/laparoscopic surgery (RLS) across surgical fields, with the hypothesis that women in urology may have lower involvement than other specialties.
Methods: We obtained country‐wide data by provider from the Data.CMS.gov database for 2014‐2019 for the following CPT codes: 44204, 44205, 44207, 58548, 58571, 32663, 55866, 50545, and 50543. Data were sorted by gender and CPT code and the percentage of female providers performing each procedure as well as the number of procedures performed per provider were determined per year. Temporal trends were assessed, and estimation was performed by exponential regression comparing means and rates of change between departments and provider genders.
Results: Providers across disciplines and genders showed increases in robotic/laparoscopic surgery performance over time (p < 0.05; see Figure 1). There was a significant difference between male and female provider rates of change over time (p = 0.0057), as well as between specialties in terms of the average number of providers (p < 0.0001). Within all specialties, there were more male RLS providers than female (all disciplines, p < 0.0003), however only in urology was the rate of increase in male provider involvement significantly higher than that of female providers. (p = 0.0452).
Conclusions: Women in urology have had a slower rate of increase in their participation in RLS compared with men in the field. Also, urology had a lower rate of female involvement in RLS than thoracic surgery, despite having a slightly higher percentage of female physicians (9.5% vs. 8.5%). Further research is needed to explore potential barriers to female surgeons' involvement in RLS and how these barriers can be overcome.
The Unaccounted Morbidity of Covid 19 Pandemic: A Tertiary Level Center's Assessment of Impact of Pandemic on Urolithiasis Patients
S Jain, A Sachan, R Goel, N Aggarwal, G Shubhankar, P Singh
All India Institute of Medical Sciences, New Delhi
Introduction & Objective: Severe acute respiratory syndrome coronavirus 2 causes coronavirus disease 2019 (COVID‐19). Since March 2020, this pandemic has caused unprecedented human suffering. With limiting medical services available and prolonged neglect, patients with urolithiasis have seen significant increase in morbidity during this pandemic.
Methods: The study was conducted at a tertiary level apex medical centre of north India from November 2020 to July 2021. Patients who were diagnosed with urolithiasis before March 2020 but could not receive timely management due to pandemic situations were enrolled for study.
Results: The study included 91 patients(53 ‐male, 38 ‐female) with mean age of 40.3 ± 13.2 (18–65) years. Among these 83 patients had urolithiasis whereas 8 patients had encrusted DJS. Sixty four (70.3%) patients had primary stones whereas 21 (23.1%) had recurrent stones.
Proposed management at initial assessment of these patients pre‐pandemic was Medical (5), ESWL (38), URSL (17), RIRS (5), DJR (8) and PCNL (18). The mean (range) stone size (n = 83) pre pandemic was 13.8 ± 8.43 (5‐55) mm and at the time of final management due to pandemic delay was 19.1 ± 10.1 (6‐60) mm. This translates into a mean increase of stone size of 5.3 ± 5.7 (0‐35) mm. Mean (range) delay in management of these patients was found to be 11.2 ± 5.8 (9‐15) months. Thirty‐two patients required change in management due to delay as a result of Covid pandemic. Despite restrictions during the pandemic, a total of 19 patients had to visit emergency department out of which 7 patients required percutaneous nephrostomy (PCN) placement. Among seven patients undergoing PCN placement, 3 had accidental slippage of PCN which required additional emergency department visit for PCN re‐placement. Two patients who were planned for URSL at initial presentation with stone sizes of 8mm and 7mm in the lower ureter passed their stone spontaneously with self‐continued medical expulsive therapy
During the pandemic imposed restrictions, 8 patients presented with encrusted stents and underwent URSL in 5, CLT in 2 and URSL,CLT with PCNL in 1 patient for stent removal.
Conclusions: Effect of Covid 19 pandemic on urolithiasis has been immense. Urolithiasis patients need to be carefully evaluated and in presence of complications or loss of renal function early intervention should be offered. Role of non ot procedures like ESWL, DJ stenting, PCN insertion have to be given importance beyond traditional practices. Surgical interventions providing maximal clearance in least attempts should be chosen over miniaturization.
Associations of Food Access and Neighborhood Walkability with Urinary Risk Factors for Kidney Stone Disease
JJ Crivelli, D Redden, N Maalouf, K Wood, DG Assimos, G Oates
University of Alabama at Birmingham Heersink School of Medicine
Introduction & Objective: Differences in nutrition and lifestyle can explain some differences in 24‐hour urine measurements among kidney stone formers. Socioeconomic aspects of these factors underlying stone formation require further investigation. We evaluated associations of neighborhood indices of food access and walkability with 24‐hour urine measurements among patients with kidney stone disease (KSD).
Methods: We performed a retrospective analysis of adult patients with KSD evaluated with 24‐hour urine collection (2001‐2020). Based on the Food Access Research Atlas, low‐income neighborhoods >0.5 miles (urban areas) or >10 miles (rural areas) from a full‐service grocery store met the definition of low food access. Using the National Walkability Index (NWI), we identified neighborhoods with low walkability (NWI ≤5.75). We then assessed associations of these measures of food access and walkability with groupings of 24‐hour urine abnormalities (stone risk factors and dietary factors, as defined by a commercial vendor; see Table) through multivariable logistic regression, as well as individual 24‐hour urine measurements through analysis of covariance (ANCOVA) with adjustment for multiple testing.
Results: Among 1,119 patients with KSD and at least one adequate 24‐hour urine collection based on urinary creatinine, 173 (15.5%) were from neighborhoods with low food access and 516 (46.1%) were from neighborhoods with low walkability. Using multivariable logistic regression (Table), patients from neighborhoods with low food access had higher odds of multiple ( >1) stone risk factors (odds ratio: 1.78, 95% confidence interval: 1.03 to 3.09), but not multiple dietary factors. Patients from neighborhoods with low walkability did not have increased odds of multiple stone risk factors or dietary factors. Using ANCOVA, neighborhoods with low food access and or low walkability were not associated with significant differences in individual 24‐hour urine measurements.
Conclusions: Among patients with KSD, residence in a neighborhood with low food access was associated with multiple stone risk factors on 24‐hour urine testing, though there were no significant differences in individual urinary measurements. The contribution of other sociodemographic factors to 24‐hour urine abnormalities should be evaluated.
Sex Differences in 24‐hour Urine Studies
K Zhao, B Shkolnik, JY Lu, JD Miller, D Schulsinger
SUNY Stony Brook University Hospital
Introduction & Objective: Gender is a known risk factor for nephrolithiasis, with a male to female incidence ratio of 1.3. Differing BMI, diet, or fluid intake may be factors for stone disease between males and females; 24‐hour urine studies remain invaluable yet underused to elucidate factors contributing to gender predominance. This study aims to assess the sex differences in urine parameters to better determine factors underlying the increased incidence of stones in males and factors for stone predilection and stone formation.
Methods: Retrospective chart review was conducted for patients with recent diagnosis of nephrolithiasis and a 24‐hour urine study seen at a tertiary Urology clinic in 2019. Stone analysis, 24‐hour urine and blood test results were evaluated. Two‐tailed t‐tests and chi‐square tests for comparison of mean urine parameter and stone rate were conducted respectively.
Results: A total of 510 patients (228 males, 282 females) were included. No significant difference in ethnicity, BMI, HbA1c, baseline creatinine (Cr), LDL, and total cholesterol was noted between genders. Females were significantly younger (51.35 vs 56.40 years, p = 0.0006) and had higher HDL (57.27 vs 48.79, p = 0.008).
Females had lower rates of uric acid (UA) stone (10.6% vs 21.2%, p = 0.005) and higher rates of calcium phosphate (CaP) stones (24.6% vs 11.2%, p = 0.001); no significant difference for calcium oxalate (p = 0.098) or struvite stones (p = 0.69) was seen.
24‐hour urine parameters were significantly lower for volume, urine calcium (Ca), oxalate, citrate, magnesium (Mg), UA, Cr, and UA supersaturation (SS) in females and decreased urine pH and CaP SS in males (see table).
Conclusions: Males demonstrate greater rates of UA stone formation, with concurrent elevation in UA SS and excretion and lower pH seen in 24‐hour urine samples. Despite having higher urine citrate and Mg, the greater levels of urine Ca, oxalate, and UA likely outweigh the benefit of these inhibitory factors and may contribute to the greater rate of stone formation in men. However, it is imperative to continue tracking sex comparisons as the incidence ratio evolves and to explore the higher rates of CaP stones and younger age of stone formation in females.
Drivers of Operative Supply Cost in Ureteroscopy with Laser Lithotripsy
C Tabib, ZR Dionise, F Soto‐Palou, GM Preminger, M Lipkin
Division of Urology, Duke University Medical Center
Introduction & Objective: Americans spend more on health care than any other nation, with expenditures comprising 18% of annual GDP. Difference in surgical practice often leads to variability in operative supply costs, especially in endourology where surgeons choose from a myriad of equipment. Initiatives aimed at providing supply cost transparency can result in healthcare spending savings without compromising outcomes. Our goal was to retrospectively examine surgical supplies used during ureteroscopy with laser lithotripsy (URSLL) to provide surgeons with the price‐transparency to understand the drivers of their own operative costs.
Methods: We retrospectively identified URSLL cases (CPT 52356) performed by four surgeons at our institution from January 1, 2019 through September 31, 2019, excluding cases with other concurrent procedures. Operative supply costs were calculated using our institution's internal cost data, which for proprietary reasons may only be reported as percentages of total case cost. We also examined each surgeon's case preference card. Costs and supply use between surgeons were compared with two‐way ANOVA or Student's t and Wilcoxon‐Mann‐Whitney tests, respectively. To avoid confounding per‐use costs of re‐usable versus disposable ureteroscopes, all ureteroscope costs were excluded from surgeon‐to‐surgeon comparisons.
Results: A total of 158 URSLL cases were identified. Case preference card costs between the four surgeons were similar, varying only by wire preference (14% difference in wire cost). Per‐item, the most costly supplies were laser fibers, baskets, ureteral stents, and access sheaths representing 24.2%, 9.6%, 6.7%, and 5.8% of average case cost, respectively. Items were “wasted” in 14 (8.9%) cases, accounting for 3.2% of total cost for all cases. Interestingly, the Dakota™ basket cost 1.8‐fold more than the Zero‐Tip™ basket. Overall, variation in total cost between all surgeons was not significant (F 1.12, p = 0.35). However, cases for surgeon B (highest cost surgeon) cost, on average, 18.7% more than surgeon C (t 2.82, p < 0.01). Surgeon B was more likely to use an access sheath (Z 2.03, p < 0.04) and post‐operative stent (Z 2.39, p < 0.01).
Conclusions: Though case cards were relatively similar, we identified variation in cost related to access sheath and ureteral stent preferences. Also, basket cost variability was more substantial than surgeons realized. This provides important information to surgeons when self‐evaluating their operative costs.
Prognostic Factors for Mental Wellbeing Outcomes in Patients with Prostate Cancer: A Systematic Review
N Vyas, O Brunckhorst, R Stewart, P Dasgupta, K Ahmed
MRC Centre for Transplantation, Guy's Hospital Campus, King's College London, King's Health Partners, London, United Kingdom
Introduction & Objective: Improving prostate cancer survivorship has led to more appreciation of patient's mental wellbeing and quality of life. However, little is known about patient, oncological and treatment factors that are associated with developing mental wellbeing problems. This review aims to evaluate the current evidence of prognostic factors for developing mental wellbeing issues during prostate cancer care.
Methods: A systematic literature search was conducted in duplicate using MEDLINE, EMBASE and CINHAL databases to 03/12/21. Studies evaluating prognostic factors for mental wellbeing outcomes using validated methods were included. Patient, oncological and treatment factors and their association with wellbeing outcomes (depression, anxiety, masculinity, body image and fear of cancer recurrence) were extracted and evaluated. Risk of bias of the studies was evaluated using the Quality in Prognostic Studies (QUIPS) tool. Protocol was registered on the International Prospective Register of Systematic Reviews prior to starting review (PROSPERO, protocol number: CRD42021297396)
Results: Three thousand and forty studies were screened, with twenty studies meeting inclusion criteria. This consisted of a sample of 90,709 patients with a median age of 67.1 years old. Significant findings included increasing levels of education more consistently associated with a reduction in depression (OR 0.84‐1.56) and reduced fear of cancer recurrence (OR 0.65). A positive family history of prostate cancer led to increased risk of anxiety (OR 1.03) and increased fear of cancer recurrence (OR 2.24). Whilst numerous other prognostic factors were identified, the majority were evaluated by single studies or with contrasting results seen.
Conclusions: We highlight the existing evidence for prognostic factors in mental wellbeing outcomes in prostate cancer, allowing clinicians to target specific high‐risk groups of patients. This allows for early support and follow‐up to improve patient care and outcomes. However, further evidence is required exploring less conclusive factors, and more peripheral outcomes of mental wellbeing.
Implementation and Usability of an Electronic Medical Record‐Based Ureteral Stent Tracker
K Gupta, N Feiertag, D Jacobs, M Abramson, AC Small, K Watts, A Harris
Introduction & Objective: Ureteral stent trackers aim to reduce the complications associated with retained ureteral stents; however, while most stent trackers have focused on patient‐driven applications, none have evaluated usability. We developed a simple, electronic medical record‐based (EMR) ureteral stent tracker that mandates data entry from an operating room (OR) nurse when any ureteral stent is implanted and flags patients with overdue stents for follow‐up. We evaluated the impact of this EMR‐ based ureteral stent tracker on stent dwell time, outcomes, and complication rates, as well as its usability among OR nurses.
Methods: Patients with ureteral stents placed 12 months before and 6 months after implementation of the stent tracker were identified and compared. Patient demographics, stent characteristics (e.g., indication, string, dwell time) and clinical outcomes (e.g., positive urine cultures, complications) were reviewed and compared between pre‐ and post‐tracker cohorts. Those with stents‐on‐strings and intentionally chronic indwelling stents (greater than 90 days) were excluded from analysis. A 12‐question usability survey was also administered to OR nurses across 3 hospital sites to assess tracker usability.
Results: A total of 323 stents (173 stents pre‐ and 150 stents post‐tracker) were placed in 217 patients. The pre‐stent tracker cohort had a longer mean dwell time (pre: 40.9 ± 59.1 days vs. post: 28.8 ± 22.0 days, p = 0.02) and a higher rate of stents retained for longer than 90 days (pre: 8.1% (14/173) vs. post: 1.3% (2/150), p = 0.005). The two cohorts had no significant difference in rates of positive urine cultures, patient phone calls to providers, or stent‐related emergency department visits or hospitalizations. The usability survey showed that 86.4% of OR nurses found the tracker to be user‐friendly and 95.5% reported it added less than one minute of work per surgery.
Conclusions: Implementation of an EMR‐based ureteral stent tracker decreased average stent dwell time and frequency of retained stents. OR nurses reported the tracker to be user‐friendly and convenient. Our tracker serves as a model for timely post‐operative management of patients requiring removal of indwelling ureteral stents.
Surgical Waste Audit of 5 Representative Urologic Procedures at an Academic Center
D Stephens, D May, N Choi, M Banti, D Jensen, WE Ito, E Lee
University of Kansas Medical Center Department of Urology
Introduction & Objective: Operating rooms are material intensive environments with significant waste production that is often disproportionate compared to other departments within healthcare systems. We aim to quantify the recyclable and non‐recyclable waste generated by commonly performed urologic procedures at our institution in order to further determine the environmental burden created by modern surgical practice.
Methods: Between January and March 2022, 5 commonly performed urologic procedures including ureteral stent exchange, ureteroscopy and laser lithotripsy for stone removal (URS/LL), percutaneous nephrolithotomy (PCNL), robotic assisted radical prostatectomy (RALP), and radical cystectomy (RC) were audited for waste production. These audits were repeated with 3 separate cases for each procedure with various surgeons and weight was collected both prior to start of the case and at completion. Waste was categorized into 4 groups: non‐recyclable solid waste, recyclable plastic, recyclable paper, and biohazard. Anesthesia derived waste and reusable/reprocessed instruments were excluded. Departmental billing data from CPT coding was then utilized to extrapolate an estimated annual waste generation from each procedure at this institution.
Results: Three case audits were recorded from the 5 representative urologic procedures, with exception of only 2 radical cystectomy cases. Table 1 details the average total of non‐recyclable solid waste including biohazard material and the combined (paper and plastic) recyclable material generated by each procedure.
CPT coding from 2021‐2022 showed that 757 stent placements were performed for an average waste generation of 2324 kg, 417 URS/LL procedures were performed for an average waste generation of 1960 kg, 113 PCNL procedures were performed for an average waste generation of 920 kg, 246 RALPs were performed for an average waste generation of 3,510 kg, and 102 RCs were performed for an average waste generation of 1479 kg.
Conclusions: The results of this descriptive study highlight the burden of waste that is generated by urologic procedures as well as the not insignificant proportion of potentially recyclable material that often is included in the waste. Next steps include more investigation into the potential implementation of a recycling program at this institution.
Evaluation of Internet Trends and Public Interest in Natural Health Ingredients
S Thaker, K Thaker, K Tran, J Komberg, KL Penniston, KB Scotland
University of California, Los Angeles
Introduction & Objective: Public interest in herbal/alternative medicines has risen as the over‐the‐counter (OTC) supplement market grows in popularity. Online interest and content of such alternative supplements provides a potential source of concern particularly for endourologists, since the information patients are interacting with may be inaccurate and the supplements may be lithogenic. This study analyzes the ingredients of commonly bought general health supplements by evaluating the reliability of online information on these ingredients as well as the oxalate content of selected herbal ingredients.
Methods: Amazon Bestseller's Rank, review count, and consumer rating were utilized to gauge popularity and compile a list of the top ten most popular general health supplements on Amazon. We then analyzed consumer interest and engagement with the most common ingredients in these supplements by searching for them on the online analytics platforms Google Trends and BuzzSumo. The DISCERN questionnaire was then utilized to determine the reliability of the top ten most popular online articles on a 1‐5 scale. Popular ingredients' supplement formulations were analyzed to determine oxalate content.
Results: Black pepper, ginger, apple cider vinegar, and turmeric were the most commonly found ingredients based on the Amazon list of top ten supplements. Google Trends indicated that apple cider vinegar, ginger, and turmeric were high‐interest ingredients. Mean engagements (190820) and YouTube video views (1084096) for apple cider vinegar were the highest. Average DISCERN reliability scores for all ingredients were between 1.0‐3.0, indicating low to moderate reliability. Oxalate concentration analysis revealed the oxalate level per dose of aloe vera with cactus to be high.
Conclusions: The oxalate concentration of several health supplements may prove problematic for kidney stone formers. Additionally, this study highlights the importance of physicians remaining aware of the popularity and prevalence of OTC supplements and monitoring patient use of supplements for their health.
Predictors and Cost Comparison of Subsequent Urinary Stone Care at Index versus Non‐Index Hospitals
W French, DP Viprakasit, C Scales, RL Sur, DF Friedlander
University of North Carolina
Introduction & Objective: To examine the effects of care fragmentation, or the engagement of different health care systems along the continuum of care, on patients with urinary stone disease.
Methods: All‐payer data from the 2016 Healthcare Cost and Utilization Project (HCUP) State Databases from Florida (FL) and New York (NY) were used to identify a cohort of adult patients with an emergency department visit for a diagnosis of urolithiasis, who subsequently re‐presented to an index or non‐index hospital for renal colic and/or urological intervention. Patient demographics, regional data, and procedural information were collected and 30‐day episode‐based costs were calculated. Multivariable logistic and gamma generalized linear regression were utilized to identify predictors of receiving subsequent care at an index hospital and associated costs, respectively.
Results: Of the 33,863 patients who experienced a subsequent encounter related to nephrolithiasis, 9,593 (28.3%) received care at a non‐index hospital. Receiving subsequent care at the index hospital was associated with fewer acute care encounters prior to surgery (2.5 vs. 2.7; p < 0.001) and less days to surgery (29 vs. 42; p < 0.001). Total episode‐based costs were higher in the non‐index setting, with a mean difference of $783 (Non‐index: $13,672, 95% CI $13,292 ‐ $14,053; Index: $12,889, 95% CI $12,677 ‐ $13,102; p < 0.001).
Conclusions: Re‐presentation to a unique healthcare facility following an initial diagnosis of urolithiasis is associated with a greater number of episode‐related health encounters, longer time to definitive surgery, and increased costs.
Urologic Adverse Events of the COVID‐19 Vaccination
MJ Davis, J Cadwell, F Sheckley, M Ahmed, M Billah
Henry Ford Health System
Introduction & Objective: There have been anecdotal reports of adverse events associated with the COVID‐19 vaccine, especially within media coverage of the vaccine's initial rollout. We aim to quantify and analyze urologic adverse events and symptoms after COVID‐19 vaccination.
Methods: We queried the FDA Vaccine Adverse Event Reporting System (VAERS) for all reported symptoms following COVID‐19 vaccination, as well as following any vaccination, for the period of December 2020 through April 1st, 2022. We identified fifteen common adverse urologic events. Using proportional reporting ratio (PRR) and reporting odds ratio (ROR), we analyzed the reporting data in the VAERS database.
Results: A total of 6,027,972 vaccinations, including 3,666,529 COVID‐19 vaccinations were identified from the queried period with 1,560,835 and 803,169 adverse events reported, respectively. Out of all adverse event reports reported following COVID‐19 vaccination, the most common adverse event was urinary tract infections which only accounted for 2,263 adverse events. The median age of the patients reporting urologic symptoms was 50 years old (IQR 22 ‐ 64) and 66% of the patients were female.
Conclusions: Urologic symptoms reported after COVID‐19 vaccination continue to be extremely rare in total number but furthermore, none of the adverse urologic events had positive signals. Although there have been anecdotal reports of adverse events associated with the COVID‐19 vaccine, a review of the VAERS database did not find any positive signals. Our findings suggest these adverse events are not related to the COVID‐19 vaccine but further evaluation and analysis are ongoing.
Evaluation of Kidney Stone Patients' Reported Outcomes and Satisfaction with Urologic Telehealth Services
T Posid, M Guerrero, M Stout, A Khuhro, I Crescenze
Department of Urology, The Ohio State University Wexner Medical Center
Introduction & Objective: Infection control practices and public policy in response to the COVID‐19 pandemic shifted healthcare practices towards a telemedicine format. Even two years after peak onset of the pandemic, many clinics, including our own institution, maintain a working telehealth option for patient visits. Our objective was to evaluate patient satisfaction with a urologic telehealth program at our institution.
Methods: This was a prospective survey study sent to patients being seen by our institution's urology providers beginning in October 2021. All patients seen via any telemedicine platform were eligible to participate and were contacted via MyChart or email after their visit to complete this survey. We present a sub‐analysis comparing patients being seen for kidney stones or pain (n = 52, 17.6%) vs. patients being seen for other benign conditions (Benign‐Other: n = 107, 36.1%) or oncology diagnoses and care (Oncology: n = 137, 46.3%).
Results: Patients were 89.6% Caucasian, 88.9% non‐Hispanic, 70.7% male, with a mean Age of 59.7 years (SD = 15.1). 34.4% of patients used phone/audio, 45.0% used video by EPIC/MyChart, and the remaining used Doximity, UpDox, or Other. Kidney stone patients were most likely to use video by EPIC/MyChart (55.8%) compared to other method, and this was also higher compared to Benign‐Other and Oncology patients (p = 0.013). Patients were overall very satisfied (M = 6.3/7, p < 0.001 vs. ‘neutral’) with their telehealth appointment, with kidney stone patients marginally more satisfied p = 0.084). Patients, regardless of diagnosis, indicated they would like to continue using telehealth even after COVID‐19 restrictions and thought that their doctor managed their appointment and diagnosis appropriately via telemedicine. Finally, kidney stone patients reported higher satisfaction (p = 0.031) with troubleshooting prompts when an error occurred during their appointment.
Conclusions: Patients seen via telemedicine for kidney stones and pain at our institution highly satisfied with their telemedicine visits, even as in‐person visits could be scheduled, and this held across platform type. This suggest a usable program moving forward, even as social distancing requirements and patient safety concerns during the COVID‐19 pandemic are reduced.
The Endourology Society Inaugural Census: Initial Results
V Stowasser, A Ghazi, L Smith, HE Moreland, M Sighinolfi, M Bultitude, JB Ziemba, AE Krambeck, B Rocco, TD Averch
University of South Carolina School of Medicine‐ Columbia
Introduction & Objective: The Endourological Society, the premier urological society covering endourology, robotics, and focal surgery, is composed of a diverse group of over 1,300 urologists. However, limited information has been collected about society members. Recognizing this need, a survey was initiated to capture data regarding current members' practices, as well as help the society shape the future direction of the organization. Presented herein is the inaugural Endourological Society census report as the beginning of a continued effort for global improvement in the field of endourology.
Methods: Using a Redcap database, an email survey was circulated to the membership of the Endourology Society from May through June 2021. Twenty questions were asked, categorizing member data in terms of epidemiology/demographics, practice patterns, member opinions, and future educational preferences.
Results: Responses were received from 534 members, representing 40.3% of the membership, Data demonstrated that the average age, sex, race, and ethnicity of the typical endourological society member respondent is a 48‐year‐old Caucasian male working in the United States, with a mean of 25 years in practice. Retrograde endoscopy and percutaneous nephrolithotomy were identified as the most common practice skills, and fifty percent of members are involved in robotics. Importantly, the census confirmed that the World Congress of Endourology and Technology (WCET) remains popular with society members as a means of educational advancement.
Conclusions: To sustain and advance the Endourological Society, information is required to understand the career interests and future educational desires of society members. This inaugural census provides crucial data regarding its membership and how the society can achieve continued success and adjust its focus. Future census efforts will expand on the initial findings and stratify the data to elucidate changes in the needs of the Society as a whole. Circulating an annual census will allow for continued improvements in the field of endourology, and ultimately better care for urologic patients.
Patient and Regional Characteristics Affecting Surgical Treatment Delay in Nephrolithiasis
M Iorga, J Cai, A Kaae, W Parks, M Stoller, S Wiener
SUNY Upstate Medical University
Introduction & Objective: Given that only 10.4% of urologists practice outside of metropolitan areas, patient populations without resources to travel may experience differences in health outcomes. Stone size and treatment choice have been shown to be independently predicted by factors such as distance to urologic care and socioeconomic factors. We hypothesized that socioeconomic factors and geographic restriction from access to urologic care is associated with increased rates of delayed treatment of nephrolithiasis.
Methods: We reviewed insurance records of 48,650 patients diagnosed and treated for kidney and ureteral stones in California from October 2016 through January 2018. Patients were followed for 62 days after their diagnosis date. The county of diagnosis and county where surgical treatment occurred were linked to publicly available US Census and Department of Agriculture Economic Research Service data and assessed relative to the interval between diagnosis and treatment using Chi‐squared and Fisher's exact testing.
Results: Approximately 70% of patients did not receive surgical treatment before day 62 and county‐level treatment rates varied by a factor of >70 between counties (Figure 1A). There was a higher variance among small metropolitan counties with a trend towards less treatment in non‐metropolitan counties. Counties with above mean treatment rates had fewer males (p = 0.0003), higher percentage of private insurance coverage (0.0003), lower percentage of Medicare coverage (p = 0.026), and higher percentage of college education (p = 0.00009). White race, age ≥65, female head of household, and percentage below the poverty threshold did not differ significantly between high and low treatment counties.
Conclusions: Factors associated with high socioeconomic status and access to urologic care were associated with increased treatment for renal and ureteral calculi in California during the study period. These findings may assist in targeting bottlenecks to definitive stone treatment and the need for increased access to urological care or treatments for renal and ureteral calculi that can be administered broadly.
Stone Culture Practice Patterns Amongst Fellowship Trained Endourologists: A Multi‐institutional Survey
DT Tzou, B Duty, C Royal, Z Okeke, J Friedlander, D Leavitt, J Harper, T Chi, J Bell, JB Ziemba, S De, AM Zampini, N Patel, M Borofsky, S Bechis, N Canvasser, R Hsi, KL Stern, G Vedantam, W Lainhart
University of Arizona
Introduction & Objective: Kidney stone cultures can detect microorganisms not identified in bladder or upper tract urine at the time of stone surgery. While previous studies have suggested stone culture utility, microbiology lab protocols are not universal and not all institutions can perform such cultures. How frequently stone cultures are performed, for what clinical scenarios, and using which laboratory methods remain largely unknown. Such information is currently absent from American Urological Association / Endourological Society Guidelines. This study aimed to assess the contemporary state of practice for kidney stone cultures amongst fellowship trained endourologists.
Methods: A comprehensive REDCap electronic survey was created and completed by a multi‐institutional group of fellowship‐trained endourologists. Questions included which clinical scenarios prompt a stone culture order and how results influence clinical management regarding post‐operative antibiotics. Additionally, microbiology lab protocols from each institution were obtained with respect to processing and resulting stone cultures.
Results: Nineteen fellowship trained endourologists completed the survey, representing training from 12 different Endourological Society accredited fellowship programs. Figure 1 shows the frequency of stone cultures ordered per month. Only 6/19 (32%) reported that an actual ‘stone culture’ order exists at their institution, as the remainder order the test as a tissue (n = 6, 32%), urine (n = 6, 32%) or miscellaneous (n = 1, 5%) culture. Among those who order stone cultures routinely, 8/14 (57%) perform them for both percutaneous nephrolithotomy and retrograde intrarenal surgery. Table 1 lists the clinical scenarios prompting stone cultures and how these results influence endourologist antibiotic practice patterns.
Conclusions: For kidney stone cultures, practice patterns differ between fellowship‐trained endourologists and institutional protocols differ in how to process these specimens. Future studies would help identify best practices to improve patient outcomes and direct future guidelines.
MP11: BPH II
Identification of Germline Mutations in Early Onset Renal Cell Carcinoma: The Role of Gene Panel Testing to Assess Cancer Susceptible Genes
DF Roadman, WA Langbo, E Bond, L Usha, A Chow
Rush University Medical Center
Introduction & Objective: Renal cell carcinoma (RCC) represents a heterogeneous malignancy, of which, approximately 5% have a hereditary cause. Guidelines recommend genetic counseling for patients ≤46 years with renal malignancy, multifocal/bilateral masses, or strong family history. We aim to describe our experience with genetic markers for early‐onset RCC.
Methods: We identified patients with early‐onset RCC who underwent gene panel testing after certified genetic counselor evaluation at our institution (2015‐present). Based on risk factors, patients underwent specific panel testing ranging from 19‐84 genes. Tests included: RenalNext, CancerNext, CancerNext‐Expanded, Invitae Renal/Urinary Tract Cancers panel, and Multi‐Cancer. Positivity rate, treatment, recurrence, and genetic recommendations were evaluated.
Results: In total, 32 patients met inclusion criteria, 17 (53%) had positive gene variants (high/intermediate/low/variant of uncertain significance). Patients underwent partial nephrectomy (34%), radical nephrectomy (59%), or biopsy (6%). Of patients, 41% had non‐clear cell histology: Chromophobic (16%), Papillary (13%), and Unclassified (13%). Mean follow‐up was 5.1‐years, 3 patients (9%) had recurrence at a mean of 4.7‐years. All patients underwent counseling regardless of test results for further implication, surveillance, and family member recommendations.
Conclusions: Patients who underwent testing had high incidence of germline mutations that can increase the risk of not only renal, but other cancers for themselves and family members. Gene panel testing offers a means to save time and money by looking at multiple suspicious genes at one time rather than testing individually. With greater genetic understanding of inherited RCC, specifically within the variants of uncertain significance, genetic panels may help translate into novel therapeutic practices.
Preoperative Screening for Clinically Significant Prostate Cancer in HoLEP Patients
O Noel, A Hassan, N Shah, J Moore, N Canvasser
University of Texas, San Antonio
Introduction & Objective: Higher rates of incidental prostate cancer (iPCa) are expected after HOLEP compared to transurethral resection owing to larger volumes of tissue resected. While a significant portion of iPCa is expected to represent indolent disease, patients with undiagnosed clinically significant PCa can experience delays or unnecessary HOLEP prior to definitive cancer treatment. Our goal was to the determine the role of digital rectal exam (DRE), MRI, and PSA screening for clinically significant prostate cancer prior to HOLEP.
Methods: We conducted a retrospective review of patients undergoing HoLEP from February 2020 to November 2021 at a single institution. Patients with iPCa were compared to patents with benign disease. We further compared patients with clinically significant PCa, defined as grade group (GG) 2 or higher, to patients with benign or GG1 disease.
Results: All patients who underwent HOLEP (n = 193) had clinically negative DRE prior to surgery. Of note, only one patient seen in our clinic, not included in this database, had a significant positive DRE. He was diagnosed with metastatic prostate cancer and was not offered HOLEP. A total of 41 patients (21%) underwent MRI prior to HOLEP: 83% were negative, 7% (n = 3) showed PIRADS 3 lesions, and 10% (n = 4) showed PIRADS 4+ lesions. Only one patient with a PIRADS 4 lesion was found to have GG1 disease on biopsy.
After HOLEP, the rate of iPCa was 16% (n = 31). GG2 or higher disease was detected in 7% (n = 14); six patients underwent additional local and/or systemic treatment. A total of 40 patients did not have a PSA checked prior to HOLEP: 34 with benign disease, 4 with GG1 (10%), and 2 with GG2+ (5%) on final pathology. When comparing patients with benign pathology to patients with iPCa, there was no significant difference in mean (± SD) age (71 ± 7.4 vs 73 ± 8 years, p = 0.12), preoperative PSA (7 ± 8.7 vs 8 ± 9.5 ng/ml, p = 0.62), or PSA density (PSAD) (0.09 ± 0.07 vs 0.07 ± 0.07 ng/ml2, p = 0.24).
Comparing patients with <GG1 to GG2+ disease there was no significant difference in age (71 ± 9 vs 75 ± 8 years, p = 0.07), but significant differences in both preoperative PSA (6.8 ± 8.3 vs 12.6 ± 12.1 ng/ml, p = 0.03) and PSAD (0.05 ± 0.07 vs 0.19 ± 0.3 ng/ml2, p < 0.001).
Conclusions: Preoperative PSA and PSAD are still important screening tools for patients undergoing HoLEP even if they are beyond recommended screening age. In our series, DRE and MRI were low yield screening tools for GG2+ prostate cancer. A significant limitation is that patients with a clinically significant DRE or MRI might never be referred to our clinic.
WITHDRAWN
Prostate MRI Transitional Zone Volume Predicts BPH Enucleation Volume Better than Alternative Modalities
CM Forbes, C Peterson, NL Miller
Vanderbilt University Medical Center
Introduction & Objective: Guidelines for BPH treatment offer suggested thresholds for interventions based on volume. Accurate preoperative volume estimates help predict efficacy of a proposed intervention. The degree to which different imaging modalities correlate to treated transitional zone volume is not known for BPH. To address this unknown, the present study compares the accuracy of preoperative imaging modalities in BPH treatment.
Methods: With internal review board approval, records at a high‐volume, quaternary academic center were reviewed. Patients were included who underwent prostate enucleation for BPH and had preoperative TRUS, CT, and/or MRI. Baseline demographics were recorded. Total prostate volumes were measured for CT and MRI using the prolate ellipsoid formula; MRI transitional zone volume was also separately measured. TRUS volumes were recorded. The primary outcome was difference between enucleated pathology weight in grams and preoperative imaging volume. Prostate tissue has a specific gravity ∼1 making this conversion acceptable. Differences between means were calculated with one‐way analysis of variance (ANOVA), with Tukey's honest significance test to determine pairwise significance (RStudio V1.2).
Results: From Jan – Oct 2020, there were 115 preoperative imaging studies available for 95 patients. 34 (30%) of the studies were TRUS, 46 (40%) were CT, and 34 (30%) were MRI. Patient demographics including prostate sizes can be found in Table 1. Preoperative imaging was greater than enucleation volume by 48 cc for TRUS, 60 cc for CT, 61 cc for MRI, and 18 cc for MRI transitional zone. There was a significant difference between imaging modalities (F‐statistic <0.001). Pairwise significance was reached for MRI transitional zone over CT (p‐adj <0.001), MRI transitional zone over MRI (p‐adj <0.001) and MRI transitional zone over US (p‐adj = 0.03).
Conclusions: In this study, enucleation volume for BPH was most accurately predicted by transitional zone volume on MRI. This was statistically superior to total prostate volume on CT, TRUS and total MRI volume, likely due to inclusion of intentionally untreated peripheral zone in these estimates. MRI total volume was not superior to CT total volume. Focusing on MRI transitional zone volume rather than total prostate volume may more accurately stratify patients for BPH treatment.
Trends in the Surgical Management of BPH over the Past 5 Years
KM Wymer, G Narang, A Slade, V Sharma, V Thao, B Borah, G Vedantam, s Cheney, MR Humphreys
Mayo Clinic
Introduction & Objective: The number of surgical treatment options available for men with BPH have increased significantly over the past decade. Specifically, in addition to TURP and simple prostatectomy (SP), laser‐based procedures, enucleation techniques, and minimally invasive surgery (MIST) are all now within AUA guidelines. However, there is a paucity of data describing the relative prevalence of these modalities.
Methods: We conducted a retrospective cohort study using administrative claims data from the OptumLabs Data Warehouse, which includes data for commercially insured and Medicare Advantage enrollees. Our cohort consisted of patients with a BPH diagnosis who underwent simple prostatectomy (SP), TURP, HoLEP, PVP, UroLift, or Rezum from 2015‐2019. Our analysis was limited to patients continuously enrolled in their health plan for at least 1 year pre and post‐procedure, ages 30‐80. The distribution of BPH surgical modalities was recorded by year and comparisons were made using one‐way ANOVA.
Results: In total, 21,946 patients were included in the analysis. There were significant differences in the prevalence of each treatment type by year (Figure 1). Although TURP was the most common procedure across all years, this decreased from 49.4% of BPH procedures in 2015 to 41.1% in 2019 (p < .001). Similarly, PVP prevalence decreased from 29.7% to 19.2% (p < .001). These decreases corresponded to a significant increase in the use of MIST procedures with the relative prevalence of both UroLift and Rezum more than doubling over the 5 years (p < .001). HoLEP and SP were the least commonly used modalities (combined <5%) and remained relatively stable across time.
Conclusions: The landscape of BPH surgical management has significantly changed over the past 5 years with minimally invasive treatment options becoming increasingly common as transurethral and laser prostatectomy became less utilized. The reasons for this are likely multifactorial including clinical outcomes, ease of use, and reimbursement among others and further investigation is warranted.
Prostatic Urethral Lift (PUL) Outcomes are Consistent and Durable in Diverse Patient Cohorts
M Rochester, P Chin, N Barber, S Gange, G Eure
Norfolk & Norwich University Hospital
Introduction & Objective: Outcomes in real‐world, understudied populations may inform therapeutic decision‐making in diverse BPH patients. This analysis examines PUL outcomes in racial cohorts, and comorbidities including diabetes mellitus, prostate cancer, and Parkinson's disease.
Methods: The Real‐World Retrospective (RWR) study includes 3226 patients who underwent PUL after market clearance at 22 international sites. Patients were stratified into race cohorts (White (n = 1737), Hispanic or Latino (n = 107), Black (n = 80), and Asian (n = 24)), diabetes mellitus (DM; controlled (n = 362), uncontrolled (n = 33) and non‐diabetic (n = 1917)), prostate cancer (n = 134), treated prostate cancer (n = 90), prostate cancer treated with radiation (n = 73), and Parkinson's disease (PD; n = 16). Outcomes were evaluated through 36 months post‐PUL.
Results: Baseline IPSS, Qmax, and QoL were similar across respective cohorts; compared to controlled DM and non‐DM patients, uncontrolled DM were significantly younger with higher BMI. Uncontrolled diabetics, Black, and Asian patients were more likely to be treated in a hospital setting compared to respective subgroups, while more White and Hispanic patients were treated in an outpatient setting. Racial subgroups experienced similar improvements in IPSS, Qmax, and PVR through 3 months, as did DM vs. non‐DM, treated prostate cancer vs. no cancer through 24 months, and PD vs. non‐PD patients through 1 month; sample size limited improvement analysis in some cohorts. Total AEs were similar across racial subgroups and between PD and non‐PD groups; significantly higher rates of overall adverse events were seen in uncontrolled diabetics compared to controlled and non‐DM patients. Incontinence rates in the treated cancer group were significantly higher, resolving after an average of 64 days; rates of stricture, hematuria, and UTI were similar between treated cancer and non‐cancer patients. Post‐procedural catheter free rates were similar across all racial cohorts and treated cancer groups.
Conclusions: The real‐world study confirms PUL is a safe, durable treatment for BPH‐associated LUTS in diverse patient populations.
Poor Voiding Efficiency after Active Void Trial is Associated with Urinary Retention After Benign Prostate Surgery
T Gaither, PM Patel, C Del Rosario, Z Baxter, S Pannell, M Dunn
UCLA Urology
Introduction & Objective: No standardized protocols address the timing of urethral catheter removal after benign prostate surgery. While early de‐catheterization reduces patient discomfort and risk of catheter‐associated infections, patients may be at risk of post‐discharge urinary retention, which has been reported in up to 15% of such patients. We sought to assess the reliability of voiding efficiency (percent of bladder emptied) after active void trials as a predictive measure of urinary retention after discharge. This abstract builds upon our existing work on this concept but with statistically significant findings, which we were previously unable to achieve due to smaller sample size.
Methods: We performed a prospective observational cohort study of three surgeons' practices from December 2019 through August 2021. All men who were discharged without a catheter after undergoing transurethral resection of prostate (TURP) or holmium laser enucleation of prostate (HoLEP) were included. Active void trials were performed on post‐operative day one and voiding efficiency was calculated using voided volume and post‐void residual. Multivariable logistic regression was performed to determine predictors of developing acute urinary retention requiring catheterization.
Results: A total of 188 men were included, with a median age of 70 years (IQR 65‐75y) and median pre‐operative prostate size of 100g (IQR 61‐138g). Fifty‐nine percent of patients underwent HoLEP and 41% underwent TURP. Nineteen patients (10%) returned after discharge with acute urinary retention requiring catheterization. On multivariable analysis, patients with a voiding efficiency less than 50% were 3.8 times more likely (95% CI 1.1‐12.8) to present in retention compared to those with a voiding efficiency greater than 75%. Increasing preoperative prostate size was associated with lower risk of urinary retention after discharge (aOR 0.8, 95%CI 0.6‐0.9).
Conclusions: Voiding efficiency after an active void trial can help predict the risk of urinary retention in patients undergoing benign prostate surgery. High‐risk patients include those with voiding efficiencies less than 50% and smaller preoperative prostate sizes (< 80g).
Prostatic Urethral Lift (PUL) Outcomes are Independent of Prostate Size and Shape in Controlled Trial and Real‐World Settings
M Rochester, C Gratzke, N Barber, S Gange, T Mueller, G Eure
Norfolk & Norwich University Hospital
Introduction & Objective: Urologists may consider prostate gland size and shape when selecting a treatment modality for BPH‐associated LUTS. This analysis examines the effect of gland size and shape on PUL outcomes, comparing controlled trial results from BPH6 for small, medium and large prostates, and MedLift for obstructive median lobe patients to outcomes from the large, real‐world retrospective study.
Methods: The real‐world retrospective (RWR) study included 3226 patients with varying prostate morphologies and sizes who underwent PUL after market clearance at 22 international sites. PUL cases were reviewed retrospectively after stratification according to prostate size ((small (< 30 cc; n = 256)), medium (30‐< 80 cc; n = 923), and large (≥80 cc; n = 70)) and morphology (obstructive median lobes (OML, n = 244), and lateral lobe obstruction only (n = 1834)). Outcomes were evaluated through 24 months post‐PUL procedure; RWR small prostates were compared to the corresponding size group in the BPH6 trial, while RWR OML patients were compared to the controlled MedLift study.
Results: All volume groups demonstrated significant IPSS improvement at 24 months. IPSS improvements were similar in small prostates in RWR and BPH6 subjects and were equivalent to outcomes in medium and large prostates through 24 months post‐PUL; compared to the BPH6 study, RWR subjects experienced significantly lower AE and catheterization rates. AEs were significantly lower in small prostates compared to medium prostates; large prostates were not associated with an increased AE rate. IPSS, QoL and peak flow rate outcomes were significant and comparable between MedLift and RWR OML subjects. Post‐PUL non‐standard‐of‐care catheterization rates were similar between RWR OML and MedLift; overall AEs were significantly lower in the RWR OML group.
Conclusions: This comprehensive analysis of PUL outcomes in varying prostate volumes and morphologies confirms that UroLift is safe and effective in the treatment of BPH‐associated LUTS consistent with previous clinical trial outcomes for OML (MedLift) and small prostates (BPH6).
Analysis of US Healthcare Claims Demonstrates Lower Rates of Continued and De Novo BPH Medical Therapy Use after PUL Compared to TURP and PVP
C Roehrborn, D Rukstalis, S Kaplan
UT Southwestern
Introduction & Objective: To‐date, little is known regarding medical therapy usage prior to and after treatment with surgical and minimally invasive BPH therapies. This real‐world analysis of US healthcare claims presents rates of pre‐operative, post‐operative, and continued BPH pharmacological treatment after TURP, photo‐vaporization of the prostate (PVP), and Prostatic Urethral Lift (PUL).
Methods: 40,267 patients who underwent outpatient TURP, PVP, or PUL for BPH were identified within a representative sample of Medicare and commercial claims from 2015‐2020. Pharmaceutical claims were linked to outpatient surgical data; rate and duration of BPH medication usage (i.e. a‐blocker, 5‐ARI, combination, PDE5‐inhibitor, beta‐3‐agonist, anti‐cholinergic) was calculated for these patients. Odds ratios demonstrate likelihood of continued and de novo medication use after each surgical treatment relative to PUL.
Results: Of the surgery patients who had records of BPH medication usage prior to their index procedure, more patients stop taking medication after PUL (66%) vs TURP (60%) and PVP (58%). Fewer PUL patients (13%) begin taking medication de novo after their procedure vs TURP and PVP (19% and 20%, respectively). Alpha‐blockers were the most utilized medication prior to and continued after surgery. Odds ratios estimated 58% and 39% increased likelihood of continuing medication after PVP and TURP vs. PUL, and 65% and 51% increased likelihood of de novo medication usage after PVP and TURP vs. PUL.
Conclusions: Unavoidable data inaccuracies notwithstanding, these results suggest that following procedures with the greatest expectation for symptomatic improvement (TURP/PVP), more patients continue or start medications compared to PUL, a procedure associated with lesser expectations of improvement. Whether this is due to an underperformance of TURP and PVP or an overperformance against expectations for PUL requires more investigation.
Peri‐Operative Out‐comes of Robotic Millin's Prostatectomy in an Australian Patient Cohort
J Saad, A Okullo, D Ashrafi, N Bagheri, D Gilbourd, H Haxhimolla
Canberra Hospital
Introduction & Objective: To describe perioperative outcomes following Robotic Millin's Prostatectomy (RMP) in an Australian patient cohort
Methods: We retrospectively reviewed prospectively collected data for patients who underwent RMP from June 2019 to October 2021. Perioperative and outcomes data were used to assess the feasibility, safety, and efficacy of RMP in an Australian patient cohort
Results: 21 patients underwent RMP over the study period. Mean age: 68 years (55‐75), Body Mass Index (BMI): 28 (21‐40), American Society of Anaesthetists (ASA) score: 3(2‐3), Prostate volume: 156.4 cc (100‐275). Mean console time: 165 mins (122‐211), Blood loss 240mls (100‐600), Length of stay: 4 days (3‐8), indwelling catheter (IDC) dwell time: 7 days (4‐8).
The pre‐operative versus post‐operative mean; serum PSA was 10.2 Vs 1.3 mml/L, IPPS score was 17.8 Vs 2.1, Quality of life score (QOL) 3.4 Vs 0.4 , post‐void residual volume (PVR) of: 241.1 Vs 64.4 mls , Q‐max 8.5 Vs 29.4 mls/sec all statistically significant ( p < 0.001)
The mean weight of resected tissue was 75.4 grams (43‐206). 19 patients had benign histopathology. One patient had a small focus of Gleason 2 + 2 = 4 prostate cancer with the other having a focus of Gleason 3 + 4 = 7 prostate cancer
None of the patients in this cohort had a clinically significant anastomotic leak requiring an extended IDC dwell time neither did any patient require a return to theatre or a post‐operative blood transfusion
Conclusions: Data from our patient cohort demonstrates the feasibility, safety and efficacy of the Robotic Millin's procedure for BPH in an Australian patient cohort.
In addition to improved visualisation of the distal margin of resection allowing reliable preservation of continence, RMP resulted in significantly reduced blood loss compared to published data on open simple prostatectomy procedure.
Our perioperative outcomes compare favourably with published international studies on robotic simple prostatectomy.
Mentorship Model of Holmium Laser Enucleation of the Prostate (HoLEP) Utilizing MOSES 2.0 May Lead to Shorter Learning Curve
BB Whiles, A Makedon, F Kim, R Donalisio Da Silva, K Thurmon
Department of Urology, University of Florida, Gainesville, FL, USA
Introduction & Objective: Holmium Laser Enucleation of the Prostate (HoLEP) is a guideline recommended treatment for benign prostatic hyperplasia (BPH) with excellent outcomes; yet, it has been adopted by a small number of urologists nationwide. The learning curve has been identified as a limitation for high diffusion. Our objective was to present our institution's initial experience with HoLEP utilizing a mentorship model and Moses 2.0.
Methods: A prospective study was conducted on diffusion of HoLEP at Denver Health (DH) using the Lumenis Pulse 120H laser system with Moses 2.0. An experienced HoLEP surgeon began her practice and mentorship of a novice urologist at DH. A total of 23 patients underwent HoLEP from July – October 2021. Enucleation efficiency (gm/min) was used to generate a learning curve for our novice surgeon.
Results: Table 1 shows patient demographics. A total of 23 HoLEPs were successful without intraoperative complications. Our novice surgeon completed 10 cases; first 8 cases with expert surgeon assisting and final 2 cases independently with expert surgeon available for phone consultation. Table 2 demonstrates intraoperative parameters. Enucleation efficiency was used to calculate a learning curve for novice surgeon shown in Figure 1. Average length of stay was 0.7 days. Same day discharge occurred in 13/23 patients (56.5%). Two of those patients completed same day voiding trial and were discharged without catheter. No blood transfusions were required. There was 1 readmission for hematuria on POD #1 that resolved with CBI. There were no reoperations.
Conclusions: Utilizing a mentorship model and Moses 2.0, our institution began a prostate enucleation program and demonstrated successful training of novice surgeon in 10 cases.
Same Day Discharge after Transurethral Resection of the Prostate Is not Associated with Higher Odds of Unplanned Post‐Operative Return to Hospital
M Jentzsch, R Greenberg, F Kazal, RN Spence, SH Eaton
The Warren Alpert Medical School of Brown University
Introduction & Objective: Transurethral resection of the prostate (TURP), long considered the gold standard of surgery for benign prostatic hyperplasia (BPH) is now among a bevy of surgical management options. While the efficacy of this treatment is well‐demonstrated, the utilization and safety of same‐day discharge following this surgery has not been definitively established as a standard of care. Our objective was to assess the safety of this practice at our institution.
Methods: We retrospectively identified 459 patients who underwent TURP surgery at our institution between January 1, 2016 and June 23, 2021. We categorized the patients based on their length of stay and found that 179 patients were admitted to the hospital for 1 or more nights and 280 patients were discharged on the same day as their surgery. Logistic regression was utilized to compare the odds of post‐operative presentation to the emergency department (ED) and/or readmission to the hospital as a composite outcome between the two groups while controlling for patient‐related factors (age, hypertension, diabetes, ASA score) and surgery‐related factors (resected prostate weight).
Results: Patient demographics and surgical information are presented in Table 1. Comparison of the odds of hospital readmission or re‐presentation to the ED is presented in Table 2.
Conclusions: In this study, same‐day discharge of patients undergoing TURP was not associated with a higher odds of re‐presentation to the ED or readmission to the hospital compared to patients who were admitted post‐operatively. This suggests that in appropriately selected patients, same day discharge after TURP is safe and has the potential of improving patient experience and lowering health care costs.
Impact of Surgical Duration on Complications After Transurethral BPH Procedures: A National Analysis from 2015‐2019
KT Ravivarapu, E Garden, C Chin, M Levy, O Omidele, AC Small, J Sewell‐Araya, M Palese
Icahn School of Medicine at Mount Sinai
Introduction & Objective: Prior studies have assessed the impact of operative time on complications following TURP. We aimed to build upon this work by evaluating the impact of operative time for holmium laser enucleation (HoLEP) and photovaporization (PVP) in addition to TURP in a large national database.
Methods: We reviewed all cases of TURP, HoLEP, and PVP in the American College of Surgeons National Surgical Quality Improvement (NSQIP) database from 2015 to 2019. Emergency cases, preoperative sepsis, and concurrent procedures were exclusion criteria. Cases were sorted into operative time quartiles to ensure an equal number in each group: TURP (0‐31, 31‐47, 47‐69, 69+ mins), HoLEP (0‐60, 60‐90, 90‐126, 126+ mins), and PVP (0‐32, 32‐47, 47‐68, 68+ mins). Multivariate analysis controlling for age, race, BMI, ASA, CCI, anesthesia type, and year of operation was used to determine if operative time is an independent predictor of adverse outcomes for each procedure.
Results: 31431 TURP cases, 2873 HoLEP cases, and 12204 PVP cases were included. Mean operative times were 54 minutes (SD 35), 98 minutes (SD 53), and 54 minutes (SD 32) respectively. Longer operative time quartiles across all three procedures were associated with older age, Asian race, Black race, general anesthesia, and higher BMI (all p < 0.05). Multivariate regression showed that longer operative time quartiles were independently associated with adverse outcomes for each procedure (Table 1). Longer surgical duration quartile was correlated with significantly increased length of stay for all procedures (all p < 0.05). Multivariate regressions were also performed for specific complications. For TURP, operative >75th percentile was an independent predictor of postoperative sepsis (OR: 1.67, p = 0.008), UTI (OR: 1.38, p < 0.001), and transfusion (OR: 3.13, p < 0.001). For HoLEP, longer operative times were predictors of transfusion (50‐75th percentile OR: 9.17, p = 0.040; >75th percentile, OR: 17.45, p < 0.001). For PVP, longer operative times were predictors of UTI (50‐75th percentile OR: 1.28, p = 0.029) and transfusion (>75th percentile, OR: 5.04, p = 0.003).
Conclusions: Patients undergoing prolonged BPH surgery were at significantly increased risk for postoperative sepsis, transfusions, and UTI as well as increased hospital length of stay.
HoLEP Outcomes in Neurologic Disease States
MA Assmus, MS Lee, J Helon, AE Krambeck
University of Calgary
Introduction & Objective: Despite durable outcomes for patients undergoing holmium laser enucleation of the prostate (HoLEP) there remains a paucity of literature specifically examining lower urinary tract function and urinary tract infection (UTI) rates in patients with neurologic disease states undergoing HoLEP. We describe our experience with HoLEP in patients with neurologic diseases at a high‐volume center. Our primary objective was to determine if HoLEP affected UTI rates.
Methods: We prospectively enrolled 50 patients with neurologic diseases: (Parkinson's (PD), myasthenia gravis (MG), cerebrovascular accident (CVA), transient ischemic attack (TIA), traumatic brain injury (TBI), dementia (D), brain/spine tumors (BT), diabetes with neuropathy neurogenic bladder (DM) and other) undergoing HoLEP from March, 2021 to September, 2021 into our IRB approved clinical registry. Patient demographics and perioperative course was examined in the context of UTI rates and 90‐day complications. Continuous variables were expressed as mean (range) with heteroscedastic two‐tailed T‐Test and Chi‐squared (p < 0.05).
Results: Fifty patients with the following neurologic diseases were included: CVA‐13, DM‐11, D‐7, TIA‐5, PD‐4, MG‐3, BT‐3, TBI‐2, other‐2. Average preop prostate size was 128mL (range 23‐400mL), intraop specimen weight 77g (5‐206g) and BMI 27 (19‐40). Preop retention was present in 35/50 (70%) with average preop catheter duration of 83 days (range 7‐ 456). Within the 3 months preop, 28/50 (56%) had ≥1 UTI which decreased to 6/50 (12%) post‐HoLEP (p < 0.001). Average preop UTI rate was 0.86/3mon (0‐5) which was reduced to 0.12/3mon (0‐1) (p < 0.001). We discharged 67% same day with the remaining 17 admitted (12 planned, 5 unplanned). Same day catheter removal occurred in 30/50 (60%) patients with 4/30 (13%) failing. There were 12/50 (24%) postop emergency department visits with 7 admitted (5 non‐urologic etiology). Only 3/50 (6%) patients utilized indwelling catheters/ CIC at 3 months (p < 0.001). Urinary incontinence in any form remained in 17/50 (34%) patients at 3month follow up. Overall, 90‐day complication rate was 34% (I‐6, II‐6, IIIa‐3, IIIb‐1, IVa‐1, IVb‐0, V‐0).
Conclusions: In this complex heterogenous cohort with neurologic disease states; undergoing HoLEP reduced indwelling catheter and 3‐month UTI rates with only a 4% Clavien‐Dino ≥IIIb complication rate. However, urinary incontinence rates and inability to void at 3 months postop are higher than historically observed in patients without neurologic diseases. This information should be disclosed when considering HoLEP in these patients.
Single‐Port Transvesical Simple Prostatectomy vs Open Simple Prostatectomy: A Comparison Study
M Abou Zeinab, A Kaviani, E Ferguson, A Beksac, Z Schwen, B Gill, P Bajic, J Ulchaker, J Kaouk
Cleveland Clinic
Introduction & Objective: Open simple prostatectomy (OSP) is a frequently adopted approach to treat moderate to severe lower urinary tract symptoms in men with marked prostate enlargement. The introduction of the “purpose‐built” single‐port (SP) robot allows simple prostatectomy to be performed using a percutaneous transvesical approach. We sought to compare the perioperative outcomes between open and SP transvesical simple prostatectomy (SP‐TVSP).
Methods: Using IRB approved databases, we retrospectively collected data of 43 consecutive patients who underwent OSP at a single institution, from 2017 to 2021. Similarly, we prospectively collected data of 42 consecutive patients who underwent SP‐TVSP from 2018 to 2021. SP‐TVSP was performed using a 3 cm suprapubic midline incision using the da Vinci SP platform. OSP was performed through the standard open approach
Results: There was no significant difference in baseline demographic data except for higher preoperative post‐void residue (PVR) in the OSP (p = .004). The median preoperative prostatic volume was 140 vs 185cc for SP‐TVSP and OSP, respectively (p = .930). While the total operative time was shorter in OSP (p < .001), patients in the SP‐TVSP group had less estimated blood loss (150 vs 400 cc, p < .001) and no drain, suprapubic tube insertion or continuous bladder irrigation required at the end of the procedure (0% vs 100%, p < .001). Postoperatively, SP‐TVSP patients were discharged home the same day of the procedure compared to a median of 2 days in the OSP group (p < .001) and had less opioid analgesics use (19% vs 79%, p < .001). Median foley catheter duration was shorter (7 vs 10 days, p < .001) and patients had less postoperative complications (5% vs 19%, p = .015) in the SP‐TVSP group compared to the OSP group
Conclusions: Single‐port robotic simple prostatectomy through the transvesical approach is a surgical alternative to the conventional open approach. It allows for minimal blood loss, shorter hospital and Foley catheter duration, and has less postoperative complications
Impact of Untreated Pre‐Operative Asymptomatic Bacteriuria in Patients Undergoing Holmium Laser Enucleation of Prostate
D Bheenick
Mid and South Essex NHS Trust
Introduction & Objective: Treatment of pre‐operative asymptomatic bacteriuria (ASB) prior to endoscopic surgery is recommended by EAU guidelines. UK practice varies however, due to the historic nature of the evidence behind the guidelines, risk of increased anti‐microbial resistance, the paradoxical view that treatment of ASB leads to increased infection and inefficiencies in rescheduling.
We do not routinely treat ASB in our practice prior to Holmium enucleation of the prostate (HoLEP). We present our experience, focusing on the infective complications
Methods: Retrospective data collection was performed on consecutive patients undergoing HoLEP between 2015 and 2020. Indication, pre‐operative urine cultures, and infective complications were recorded. No patients were pre‐treated with oral antibiotics. All patients received intravenous antibiotics on induction and routine postoperative oral antibiotics at the surgeon's discretion.
Results: 443 patients were studied. No urosepsis occurred in the 125 patients with ASB compared to two of 318 patients (0.6%) with no growth on pre‐operative urine culture.
29 (7%) patients were treated with oral antibiotics for symptomatic post‐operative complications (UTI without fever, epididymitis and haematuria). ASB did not predict for infective complications (urosepsis OR: 0.50 p = 0.66; oral antibiotics OR: 0.97 p = 0.93).
Conclusions: Not treating ASB prior to a HoLEP procedure is safe. This supports the judicious use of anti‐microbials pre‐operatively. Other modalities of endoscopic surgery should be similarly assessed.
Post‐Operative Bladder Pressure Monitoring in Same Day Catheter Removal After HoLEP
G Narang, CA Pougnier, A Chavez, KM Wymer, MR Humphreys, S Cheney
University of North Carolina
Introduction & Objective: Early catheter removal represents an easy target for improving quality of life and limiting treatment burden for patients undergoing BPH procedures. Early catheter removal has proven feasible in patients undergoing HoLEP but only under strict criteria. Furthermore, the influence of patient factors, such as post‐operative bladder function, on catheter removal has not been studied. We sought to determine if same day catheter removal was feasible in a generalizable population of HoLEP patients and if bladder pressure monitoring assisted with successful catheter removal.
Methods: From February 2021 to August 2021, patients scheduled to undergo HoLEP without a history of atonic or hypocontractile bladder were enrolled for same day catheter removal. All patients were anesthetized with general anesthesia and paralyzed. Criteria for proceeding with same day catheter removal included: an uncomplicated procedure, continuous bladder irrigation weaned within 120 minutes of arrival to PACU, minimal hematuria rated with a standardized scale and a bladder pressure over 30 cmH20 as measured using the VP TestTM device (SRS Medical).
Results: Over a 6‐month period, 45 patients were enrolled in our study. The median age was 68 years old (IQR: 63.0‐72.0), BMI 27.5 kg (IQR: 24.2‐30.1) and prostate volume 79.1cc (IQR: 61.0‐103.5). Criteria for catheter removal was met by 35 patients; 9 patients were unable to meet bladder pressure cutoffs and 1 was excluded for hematuria. Of those that attempted a trial of void, 29/35 passed for an effective pass rate of 83%. For those that failed trial of void, 100% had uncomplicated catheter replacement in PACU with a median catheter duration of 2 days (IQR: 1‐3). Median measured detrusor pressure for those that passed and failed trail of void were 55.0 cmH20 (IQR: 43.0‐84.0) and 46.0 cmH20 (IQR: 35.0‐61.0), respectively.
Conclusions: In a population of patients who received general anesthesia and paralysis for HoLEP, same day catheter removal is feasible. There are differences in measured post‐operative bladder pressure between those that passed and failed trial of void. Bladder pressure measurements in the post‐operative setting may be a helpful adjunct for those considering same day catheter removal in HoLEP patients.
A Comparative Propensity Score‐Matched Analysis of Perioperative Outcomes of Laser Enucleation of the Prostate vs Simple Prostatectomy for BPH: Will Approach Affect Morbidity and Mortality Post Prostatectomy?
Z Dalimov, E Lutnick, A Houjaij, N Nader, O Darwish
Introduction & Objective: Open simple prostatectomy (SP) and laser enucleation of the prostate (LEP) remain recommended surgical treatment options for the large prostates with bothersome lower urinary tract symptoms. LEP offers endoscopic approach for simple prostatectomy. In this study, we aimed to assess perioperative outcomes of SP vs LEP.
Methods: ACS‐NSQIP data was queried for patients who underwent SP and LEP between January 2015 and December 2017. A total of 2321 patients were identified, of which 628 underwent SP and 1693 underwent LEP. After propensity score (1:1) matching for all confounding variables, LEP was compared to SP for operative time, perioperative complications, blood transfusions, risk of mortality and morbidity, and total length of stay. Chi‐square and t‐tests were used for statistical analysis for categorial and continuous variables respectively.
Results: LEP patients had fewer overall complications (4.1% vs 25.8%, p < 0.001). They experienced fewer respiratory complications (0.2% vs 1.5%, p = 0.021), pulmonary embolisms (0.3% vs 2%, p = 0.012), acute renal failures (0.2% vs 1.4%, p = 0.038), urinary tract infections (2.6% vs 4.9%, p = 0.045), and sepsis (2.7% vs 6.7%, p = 0.002). There was no significant difference in cardiac complications. LEP patients required less perioperative blood transfusions (0.7% vs 14.8%, p < 0.001) and had shorter hospital stay (1.2 days vs 4 days, p < 0.001). NSQIP estimated probability of mortality (0.2% vs 0.3%, p < 0.001) and morbidity (3% vs 9.2%, p < 0.001) were lower for LEP.
Conclusions: LEP is associated with fewer complications, shorter hospital stay, and lower risk of morbidity and mortality after surgical treatment of enlarged prostate with bothersome lower urinary tract symptoms.
Increased Bleeding Risk is Associated with 30‐day Mortality After TURP
Z Dalimov, E Lutnick, A Houjaij, N Nader, O Darwish
Introduction & Objective: Transurethral Resection of the Prostate (TURP) is the gold standard of treatment for bothersome lower urinary tract symptoms in men with benign prostatic hyperplasia (BPH). Anticoagulant medications are increasingly common in this patient population that carries the risk of bleeding and complications. In this study, we aimed to assess post‐operative outcomes after TURP in patient with increased bleeding risk.
Methods: ACS‐NSQIP data was queried for patients who underwent TURP between the January 2005 and December 2016. History of bleeding disorder, patients on chronic anticoagulation that was not stopped prior to the surgery, INR above 1.1, PTT above 35 seconds, and platelet counts below 70,000 were used to classify patients as increased bleeding risk. Patients with and without increased bleeding risk were compared in terms of complications, return to operating room, and 30‐day mortality. Multivariate logistic regression models were fit to evaluate variables associated with 30‐day mortality after TURP. We used chi‐square and t‐tests for statistical analysis of categorical and continuous variables respectively.
Results: Of the 28,486 patients that underwent TURP, 12.5% were with increased bleeding risk. Patients with increased bleeding risk were older, African American race, had more comorbidities, functionally dependent, required blood transfusion prior to surgery, and more likely to undergo TURP as an emergency case (Table 1). There were no differences in operative time but patients with increased bleeding risk had longer hospital stay (4.1 vs 1.7, p < 0.001). They had higher 30‐day mortality (2.1% vs 0.4%, p < 0.001), 30‐day complications (15.4% vs 7.8%, p < 0.001), and re‐interventions (3.9% vs 1.9%, p < 0.001) (Table 2). On multivariate analysis, disseminated cancer (OR 9.77, 95% 6.45‐ 14.81, p < 0.001), significant weight loss prior to surgery (OR 3.46, 95% CI 1.67‐7.15, p < 0.001), increased bleeding risk (OR 3.45, 95% CI 2.48‐4.80, p < 0.001), African American Race (OR 2.55, 95% CI 1.53‐4.23, p < 0.001), and severe COPD (OR 2.04, 95% CI 1.31‐ 3.19, p = 0.02) were associated with mortality within 30 days of TURP (Table 3).
Conclusions: Patients with increased bleeding risk who underwent TURP had more 30‐day mortality, complications, and reoperations. Increased bleeding risk was independent predictor of the 30‐day mortality.
Trends of Benign Prostatic Hyperplasia and Surgical Treatment Rates among Medicare Beneficiaries
G Narang, S Rojanasarot, B Cutone, MR Humphreys
University of North Carolina
Introduction & Objective: While it is well‐known benign prostatic hyperplasia (BPH) is common in older men, limited studies have explored the current rates of BPH among Medicare enrollees. This study estimated the 11‐year trend of BPH prevalence among a subset of Medicare beneficiaries.
Methods: A real‐world administrative claims data analysis was conducted using 5% Medicare Standard Analytic Files from 2009 to 2019. Annual BPH prevalence was determined by dividing the number of men with at least one BPH diagnosis in a given year by the total number of men enrolled in Medicare in that year. Patient characteristics and concomitant conditions from the Charlson Comorbidity list, identified using the International Classification of Diseases, ninth and tenth revisions, Clinical Modification (ICD‐9‐CM and ICD‐10‐CM) diagnosis codes, were examined to understand the profiles of men with BPH. Annual BPH treatment rates among men with a BPH diagnosis were assessed to explore treatments trends. Cochran‐Armitage trend tests were used to determine the underlying trends of BPH prevalence and surgical treatment access.
Results: The annual BPH prevalence increased from 22.6% in 2009 to 25.8% in 2019, reflecting a 14.2% increase (p < 0.0001; Figure). Mean age remained stable at 74 years old (SDs: 1.1‐1.9) during the study period. In 2019, the most common concomitant conditions among men with BPH were diabetes without complications (14.1%), renal disease (14.0%), and chronic pulmonary disease (11.8%). Between 2009 and 2019, the proportion of men with BPH undergoing surgery decreased from 3.4% to 2.7% (p < 0.0001), respectively. Among those who underwent a BPH surgery, the surgical treatment shifted towards less invasive surgical procedures (25.1% in 2009 vs. 32.7% in 2019; p < 0.0001).
Conclusions: Although BPH prevalence is on the rise among Medicare beneficiaries, surgical treatment rates are declining. The findings suggest that patients undergoing BPH treatment are choosing less invasive options. Increased disease prevalence and decreased treatment rates may be a lagging indicator of difficulties accessing urologic care. Alternatively, this may signal a change in the balance between medical and surgical management of BPH. Further studies will be needed to explore and monitor these trends.
Benign Prostatic Hyperplasia Knowledge Deficits Among American Men: A Preliminary Analysis
P Orji, WR Jevnikar, SA Ramanujan, D Corrigan, N Almassi, D Montague, P Bajic, S De
Introduction & Objective: Benign prostatic hyperplasia (BPH) with lower urinary tract symptoms (LUTS) is highly prevalent, however, there is little data regarding patient knowledge about this common condition. Our study assesses patients' knowledge of BPH, its symptoms, complications, and treatments. Secondarily, we investigated patients' health information‐seeking behaviors.
Methods: Male patients, new to our large tertiary care Urology department, were recruited and completed an IRB‐approved 26‐question survey prior to their appointment with the urologist. Responses are recorded as percentages of participants. Fisher's exact and chi‐squared tests were performed, as applicable.
Results: Respondents had a median age of 68 years [n = 69, IQR: 56‐71]. 86% identified as White and 65% possessed a college degree or higher. 52% of patients were referred by a primary care doctor or a urologist.
68% of patients correctly answered at least half of the questions measuring BPH familiarity (Fig 1). However, only 51% answered at least half of the questions about BPH complications correctly (Fig.1) and they were more likely to be graduate degree holders (76%, p = 0.019). There were no differences in knowledge between education levels or insurance statuses as it related to familiarity. 'Weak stream' was the most easily identified symptom (55%). 'Leakage' was the least recognized symptom. 69% of patients reported that BPH could be treated with medication or surgery but patients were more familiar with medical options than surgical options; tamsulosin was the most easily identified medication (52%). 35% of respondents were not familiar with any surgical therapy.
90% of patients preferred to receive health information from their doctor. While 80% of individuals had heard of BPH before, only 48% heard about it from their doctor.
Conclusions: Most men were fairly familiar with basic information about BPH. However, unless they possessed graduate‐level education, they were less likely to be knowledgeable potential outcomes of untreated BPH. Despite increased availability of online resources, patients continue to prefer their physician as their source of health information yet most patients did not learn about BPH from a provider. Our preliminary findings highlight opportunities for improved BPH‐related patient education at primary care and specialty levels of care.
The Untold “Disposable” Cost of Percutaneous Nephrolithotomy
JM Gaines, EJ Macdonald, M Ou, M Kuster, A Rai, J Winoker, C Hartman, D Hoenig, AD Smith, Z Okeke, T Aro
SUNY Downstate Health Sciences University, Brooklyn, New York.
Introduction & Objective: Advances in percutaneous nephrolithotomy (PCNL) have greatly improved management of large renal calculi over the past two decades. Concurrently, there has been an increased emphasis on procedure costs and financial optimization for hospitals and the healthcare system. The use of disposable equipment in PCNLs has become widespread. We aimed to investigate the financial burden of single‐use equipment during PCNLs.
Methods: In collaboration with the financial operations and category management team in the operating rooms, a retrospective data collection was performed for all PCNL cases (CPT codes 50080 and 50081) between January and June of 2021 in a high‐volume center for two fellowship‐trained endourologists with more than 30 years of experience. All disposable equipment used in those procedures was recorded and the average cost per procedure was subsequently calculated.
Results: A total of 146 PCNL cases in the six‐month period were performed. Usage of disposable equipment varied with certain items used only once, while other pieces were used more than 300 times. A total of 4,529 unique disposables were used in all cases, for an average of 30.8 disposable items per case. A total of $242,550 was spent only on disposable equipment, with an average of $1,650 per case.
Conclusions: Although often overlooked, the cost of disposable equipment in the operating room can accumulate rapidly, exceeding $1,500 per case. In an era of exorbitant costs for hospital systems and patients alike, reducing unnecessary spending while still providing quality care is vitally important. This requires further investigation to better characterize such expenditures and optimize performance, especially in high‐volume centers.
MP12: Clinical Stones: Medical Management II
Telemedicine for Adult Nephrolithiasis Postoperative Care: Sub‐Analysis of the Randomized Evaluation and Metrics Observing Telemedicine Efficacy (REMOTE) Trial
M Babar, D Zhu, J Loloi, M Laudano, EL Ohmann, N Abraham, AC Small, K Watts
Albert Einstein College of Medicine
Introduction & Objective: Evaluate patient satisfaction and outcomes of postoperative face‐to‐face (F2F) versus telemedicine (TM) visits for adult ambulatory nephrolithiasis (NL) surgery in an urban academic center.
Methods: This was a prospective, randomized controlled trial. Patients undergoing ambulatory urological surgery were randomized 1:1 to a postoperative F2F or TM visit between June 2021 and December 2021. Telephone surveys assessing satisfaction with postoperative care were administered. Patient demographics and 30‐day postoperative complications were collected. Primary outcome was patient satisfaction; secondary outcomes were time‐ and cost‐savings, and 30‐day safety outcomes. Patients who underwent operations for NL were selected for this analysis. Intention‐to‐treat sensitivity analysis was performed to investigate the impact of postoperative visit type.
Results: A total of 197 patients were approached and 165 (83%) enrolled for the study. Of these, 106 (64%) underwent surgery for NL. 94 (88.7%) consented and were randomized ‐ 50 (53.2%) to F2F and 44 (46.8%) to TM cohorts. 85 patients (90.4%) completed their assigned visit, and 83 (97.6%) completed the telephone survey. Surgical modalities included ureteroscopy (95.1%), percutaneous nephrolithotomy (3.7%), and extracorporeal shock wave lithotripsy (1.2%). There were no significant differences in demographics between the cohorts. Both cohorts were equally satisfied with their postoperative visits (F2F 100% vs. TM 97.4%, p = 0.29) and found their visits to be an acceptable form of healthcare (F2F 100% vs. TM 92.3%, p = 0.18). TM cohort saved a significant amount of time (TM 69.2% spent <15 minutes vs. F2F 48.8% spent 1‐2 hours, p < 0.0001) and money associated with travel (41.0% TM saved $5‐$25 vs. 14.0% F2F spent $5‐$25, p = 0.0002). TM cohort was more likely to choose their visit modality again (TM 92.3% vs. F2F 69.8%, p = 0.02). There were no significant differences in 30‐day safety outcomes between the cohorts. 14 patients (17%) changed visit modality after randomization (3 F2F and 11 TM). F2F patients changed their visit modality because of convenience with TM (3) while TM patients changed their visit modality because of preference of a F2F visit (8) or desired a physical examination due to flank pain (2) or suspected a UTI (1). Intention‐to‐treat analysis showed similar satisfaction, time savings, and safety outcomes as the as‐treated analysis.
Conclusions: TM for postoperative visits after NL surgery saves patients time and money without compromising satisfaction or safety. TM can be offered as an alternative to F2F for routine postoperative care following NL surgery.
WITHDRAWN
Feasibility of Risk Stratification Using the Recurrence of Kidney Stone (ROKS) Nomogram
N Kavoussi, C Floyd, A McCoy, T Koyama, R Hsi
Vanderbilt University Medical Center
Introduction & Objective: The Recurrence of Kidney Stones (ROKS) nomogram predicts subsequent symptomatic kidney stone recurrence. However, while external validation studies have shown fair predictive performance for predicting percentile risk, the predictive performance of ROKS to assign patients into categorical risk groups is unknown. Therefore, we sought to assess the performance of the ROKS nomogram for risk stratification in a retrospective study.
Methods: We performed a case‐control study of 200 patients (100 with and 100 without subsequent recurrence) who underwent kidney stone surgery between 2013‐2015, and had at least 5 years of follow‐up imaging and clinic visits for stone disease. We analyzed the performance of the 2018 ROKS nomogram via area under the receiver operating curve (ROC‐AUC) for predicting 2‐ and 5‐year symptomatic or radiographic recurrence. We evaluated the ability of the ROKS nomogram to stratify patients based on low or high risk of recurrence at two thresholds along the ROC at: a) an optimized cutoff point (i.e. optimized for both sensitivity and specificity), and b) a sensitive cutoff point (i.e. high sensitivity (0.80) and low specificity). Time‐to‐recurrence data were estimated using the Kaplan Meier method and compared by log rank testing.
Results: The ROKS nomogram demonstrated fair ability to predict recurrence at 2 and 5 years (ROC‐AUC of 0.67 and 0.63, respectively). At 2 years recurrence prediction, sensitivity and specificity were 0.60 and 0.68 at the optimized cutoff point, and 0.80 and 0.45 at the sensitive cutoff point, respectively. At 5 years recurrence risk prediction, sensitivity and specificity were 0.54 and 0.72 at the optimized cutoff point, and 0.80 and 0.26 at the sensitive cutoff point, respectively. At the optimized cutoff threshold, recurrence rates for the low and high risk groups were 20 % and 45% at two years, and 50% and 70% at five years, respectively. At the sensitive cutoff threshold, the corresponding recurrence rates for the low and high risk groups was of 16% and 38% at two years, and 42% and 66% at five years, respectively. Kaplan‐Meier analysis revealed a significant recurrence‐free advantage between the groups for both cutoff thresholds (p < 0.01, see figure).
Conclusions: The ROKS nomogram has potential to serve as a tool for recurrence risk stratification into lower and higher risk groups, which may facilitate adherence to risk‐based follow‐up protocols.
Pharmacologic Management of Ureteral Stent‐related Symptoms: A Drug‐class and Drug Specific Bayesian Network Meta‐Analysis
DE Hinojosa‐Gonzalez, B Eisner
Massachusetts General Hospital
Introduction & Objective: Ureteral stents (US) are commonly used for the treatment of ureteral obstruction. Their use may be associated with significant bothersome symptoms and discomfort. Prior studies have examined the effects of various medication regimens on ureteral stent symptoms. This study utilized Bayesian network meta‐analysis to analyze all available evidence on the pharmacological management of ureteral stent‐related symptoms(USRS).
Methods: In August 2021 a systematic review was conducted following PRISMA guidelines on randomized prospective studies on pharmacological management of USRS reporting outcomes using the USSQ score on urinary symptoms and pain. Data was analyzed in Review Manager 5.3 and R Studio where a Bayesian network meta‐analysis was performed. Treatments were ranked using surface under the cumulative ranking curve(SUCRA) and mean difference(MD) vs placebo with 95% Credible Intervals(CrI).
Results: 22 studies were analyzed. These were used to build networks which were modelled to run 100,000 Markov Chain Montecarlo simulations each. Drug‐class analysis revealed the most effective class for each domain: for urinary symptoms, sexual performance, general health and work performance ‐ combined Alpha‐Blocker & Anticholinergic & PDI; for pain ‐ combined Anticholinergic & Pregabalin. The following were the most effective drugs and dosages for specific symptoms: for urinary symptoms ‐ combined Silodosin 8mg + Solifenacin 10mg; for pain ‐ combined Silodosin 8mg + Solifenacin 10mg; for sexual performance ‐ Tadalafil 5mg. Combined Silodosin 8mg + Solifenacin 10mg + Tadalafil 5mg has the best general health scores while Solifenacin 10mg had the best work experience scores.
Conclusions: This network meta‐analysis demonstrated the most effective therapy is different for each symptom domain. It is important to consider patient chief complaints and domains in order to ascertain the optimal medication regimen for each patient.
Pregnancy & Stones: Neonatal Outcomes Are Dependent on Type of Intervention for Maternal Renal Colic
A Sun, C Bennett, AB Shah, ME Lyon, S Sivalingam, JC Calle. MD. FASN., AM Zampini, S De
Introduction & Objective: Nephrolithiasis during pregnancy is rare but has been linked to multiple obstetric complications including preterm labor, premature rupture of membranes, and loss of pregnancy. For pregnant women with renal colic who fail conservative management, the American Urological Association (AUA) recommends primary ureteroscopy (URS), double‐J stent (DJS), or a percutaneous nephrostomy tube (PCN). To our knowledge, this is the first study to compare neonatal outcomes following 3 different interventions in pregnant women presenting with an acute stone event.
Methods: Women undergoing a procedure for renal colic during pregnancy at a large multi‐center, high‐volume institution were retrospectively reviewed and categorized by initial intervention: DJS, PCN, and URS. Procedural and obstetric outcomes were recorded; neonatal outcomes were linked to maternal data. Intervention groups were compared by a Kruskal‐Wallis or Fisher's Exact Test, followed by pairwise post‐hoc testing with Wilcoxon rank‐sum test (α = 0.05) as appropriate.
Results: 99 patients met inclusion criteria, of which 36 were managed with PCN, 50 with DJS, and 13 with URS. Maternal age at presentation, BMI, and maternal comorbidities such as diabetes, hypertension, and chronic kidney disease were similar between groups. Rates of premature delivery did not significantly differ between groups, but gestational age at delivery was lower in the PCN group versus the DJS group (p = 0.001). Neonatal Intensive Care Unit (NICU) admission, respiratory distress syndrome (RDS), and neonatal abstinence syndrome (NAS) rates were higher in the PCN group versus DJS group (p = 0.005, p = 0.03, and p = 0.04, respectively). Rates of other neonatal complications like APGAR scores did not differ between groups.
Conclusions: The AUA guidelines currently list DJS and PCN as equally safe alternative interventions to URS for managing nephrolithiasis in pregnancy, but our study demonstrates higher rates of NAS, RDS, and NICU admissions for babies born to mothers managed with PCN compared to DJS. All cases of NAS observed in our study occurred in the PCN group, with narcotic use directly linked to management of pain due to PCN. Larger multi‐institutional studies are warranted to further explore these associations.
Effect of Cannabidiol Oil on Post‐Ureteroscopy Pain for Urinary Calculi: A Randomized Double‐Blind Controlled Trial
G Narang, KM Wymer, E Lim, O Adeleye, M jonathan, MR Humphreys, KL Stern
University of North Carolina
Introduction & Objective: Post‐ureteroscopy stent placement carries significant morbidity and pain which can interfere with daily life. This discomfort unfortunately leads many to opioid pain medications, which have a known risk of addiction. Cannabidiol (CBD) oil represents an alternative analgesic that has proven anti‐inflammatory and antinociceptive effects. We sought to evaluate the effect of an FDA‐approved CBD oil (Epidiolex) on pain control and opioid usage in the post‐ureteroscopy setting.
Methods: This was a prospective, placebo‐controlled, double‐blind, randomized controlled trial at a tertiary care center. 90 patients undergoing ureteroscopy with stent placement for urinary stone disease were randomized 1:1 to placebo or 20 milligrams of CBD oil daily for 3 days post‐operatively. Both groups were prescribed a rescue narcotic, tamsulosin, oxybutynin and phenazopyridine. Daily pain scores, medication usage and ureteral stent symptoms using the validated USSQ questionnaire were recorded for 3 days post‐operatively.
Results: Both the placebo and CBD group were similar in pre‐ and peri‐operative characteristics. We found no difference in average pain scores or opioid usage between groups post‐operatively. Both groups endorsed similar discomfort with ureteral stents that affected their physical activity, sleep, urination, and daily life. Lastly, the majority of patients would have either mixed feeling or would be unhappy if they had to have a stent placed in the future.
Conclusions: CBD oil showed no difference compared to placebo in minimizing post‐ureteroscopic stent discomfort or opioid usage. Despite the availability of numerous analgesic agents, patient experienced notable stent related symptoms and would be unhappy to have a stent placed in the future.
Risk Factors for Persistent Opioid Use Following Ureteroscopy and Percutaneous Nephrolithotomy
AA Nourian, E Ghiraldi, S Christianson, C Nourian, J Simhan, J Friedlander
Einstein Healthcare Network
Introduction & Objective: We examined opioid prescribing patterns following surgical management of nephrolithiasis. Our goal was to identify the rate of persistent opioid use as well as risk factors for long‐term opioid use following endoscopic stone surgery.
Methods: We performed a single‐center retrospective review of opioid naive patients undergoing ureteroscopy and percutaneous nephrolithotomy (PCNL) from 2014‐2019. Perioperative opioid prescribing trends were assessed with the Pennsylvania Prescription Drug Monitoring Program (PA‐PDMP). Persistent opioid use was defined as ongoing use of opioids 6 months after surgery.
Results: PA‐PDMP data was available for 169 patients who were opioid naive prior to ureteroscopy (N = 113) or PCNL (N = 56). The incidence of persistent opioid use was 8.0% (9/113) and 1.8% (1/56) for ureteroscopy and PCNL groups, respectively. The relative risk for persistent opioid use for ureteroscopy compared to PCNL was 4.5 (95% CI 0.58‐34.34, p = 0.1091). Patients who underwent ureteroscopy received higher average morphine milligram equivalents (MME) at discharge (157.6 vs 44.3, p < 0.001) and were more likely to receive an opioid refill within 3‐months after surgery (49.6% vs 8.3%, p < 0.001). When examining both groups, higher mean MME at discharge (251.7 vs 119.8, p = 0.0006), and 3 months (308.7 vs 106.6, p = 0.0007) were associated with persistent opioid use.
Conclusions: Patients undergoing ureteroscopy may have a higher risk of developing persistent opioid use compared to those following PCNL. Limiting MME and number of prescriptions between discharge and 6 months after endoscopic stone surgery can help reduce the risk of persistent opioid use.
Is the “COVID‐19 Diet” Non‐Lithogenic?
JY Lu, B Shkolnik, K Zhao, P Kothari, S Herfel, H Schulsinger, Y Sheynkin, D Schulsinger
Renaissance School of Medicine at Stony Brook University
Introduction & Objective: The COVID‐19 pandemic and subsequent world‐wide quarantine resulted in a major change in individual lifestyles. In New York State, March 16, 2020 marked the end of any in‐restaurant dining and the general population reported a shift to more cooking at home. Reducing dietary sodium intake, such as less dining out, is often considered first line dietary therapy for calcium stone formers due to known risk factors of hypernatriuria and hypercalciuria. We investigated the 24‐hour urine of our patients with known history of nephrolithiasis to see if these dietary changes during COVID‐19 pandemic may have also changed the risk of stone disease.
Methods: Retrospectively, patients with a history of nephrolithiasis seen for an outpatient visit from April 1, 2020‐December 31, 2020 were studied. All patients included had a 24‐hour urine study pre‐COVID, defined as before March 16, 2020 as well as a study during‐COVID, March 16, 2020‐December 31, 2020; a post‐COVID study including January 1, 2021‐December 31, 2021 was also included. Mean pre‐COVID, during‐COVID and post‐COVID values were compared using paired, 2‐tailed t‐tests.
Results: 94 patients (M = 54, F = 40) with a mean age of 60 years were evaluated. Stone analysis revealed calcium oxalate (61%), calcium phosphate (15%), uric acid (15%), other (9%). The 24‐hour urine revealed a significant reduction in urinary sodium (uNa) levels from pre‐COVID (165.64 ± 7.5 mEq/L) compared to during‐COVID (149.16 ± 7.6 mEq/L) (p = 0.018). There was also a significant reduction in urinary calcium (uCa) from pre‐COVID (214.18 ± 13.05mEq/L) compared to during‐COVID levels (191.48 ± 13.03 mEq/L) (p = 0.010). Post‐COVID 24‐hour urine (N = 59) levels for both post‐COVID uNa (137.43 ± 8.03mEq/L, p = 0.02) and post‐COVID uCa (193.07 ± 13.23, p = 0.035) remained significantly reduced compared to the pre‐COVID values, but with no difference compared to during‐COVID values. There were no significant differences in 24 hour urine total volume, magnesium, or citrate levels.
Conclusions: During the COVID‐19 lockdown, dietary choices limited to home cooked meals allowed patients to better identify their food choices. This study demonstrates that home cooked meals improved urinary parameters to minimize the lithogenic risk factors for stone formation including hypernatriuria and hypercalciuria. Persistently improved urinary factors during the post‐COVID period may be secondary to improved dietary practices combined with continued lockdown as a result of new virus variants.
Calcium Phosphate Stone Composition Varies Based on Whether Stone Analyses are Whole Stones versus Stone Fragments
MA Knoedler, S Li, S Nakada, S Best, SP Hedican, KL Penniston
University of Wisconsin, Department of Urology
Introduction & Objective: Stone analysis is a cornerstone of metabolic stone treatment. Our objective was to evaluate if the prevalence of calcium phosphate in stone composition varied based on whether the specimen was submitted as a whole stone or as fragments of a stone.
Methods: An IRB approved surgical database of patients at a single institution was evaluated for stone analyses between 1997 and 2021. All stone analyses were performed at one of two labs (Dianon Systems and Louis C. Herring Company). Stone analyses were assessed for presence and percent of any calcium phosphate species. Stones were considered primarily calcium phosphate stones if the composition was ≥60% calcium phosphate. We used univariate analysis with chi‐square and independent T test to compare percentage of stone specimens submitted as calcium phosphate as well as frequency of primarily calcium phosphate stones submitted as whole stones vs fragments.
Results: Of the 5069 stone specimens analyzed, 4350 specimens contained any amount of calcium phosphate and 572 were primarily calcium phosphate stones. When comparing all specimens containing calcium phosphate submitted as whole stones vs fragments of stones, there was a statistical difference between the percent of specimen that was calcium phosphate (17.7 ± 24.6% vs 26.0 ± 28.2%, p < 0.001). See table. For primarily calcium phosphate stones, the frequency of stones submitted as whole stones vs fragments also differed significantly. See table.
Conclusions: In our analysis, the frequency and percentage of calcium phosphate composition differed when samples were submitted as fragments vs whole stones. Specimens submitted as fragments had a higher frequency and percentage of calcium phosphate than specimens submitted as whole stones. Knowing the percentage of calcium phosphate in patients' stones is vital in correctly identifying the patient's stone phenotype and developing a preventive regimen. Other ongoing considerations include the value of repeated stone analysis in these patients.
A Geographic Analysis of the Endourologic Management of Stones Demonstrates a Variation between Northeastern States
AA Arcese, F Munshi, R Ortiz, J Tanzer, SH Eaton, E Hyams, G Pareek, DW Sobel
The Warren Alpert Medical School of Brown Univeristy
Introduction & Objective: Shockwave lithotripsy (SWL), ureteroscopy (URS), and percutaneous nephrolithotomy (PCNL) remain the mainstay of treatment options for urologists to manage nephrolithiasis. Of particular interest is whether practice patterns tend to vary among urologists based on geographic location or the volume of total stone procedures per provider. We evaluated practice patterns among urologists performing endourologic procedures in the Northeast for stone disease between 2016‐2019 to assess if utilization of certain stone procedures varies over time and by surgeon location.
Methods: Utilization of SWL, URS and PCNL from 2016 to 2019 was obtained from the Centers for Medicare & Medicaid Services medicare physician dataset via CPT code query. Relevant provider information, including location of practice, and number of procedures performed were analyzed. States included in the final analysis were MA, VT, RI, CT, NY, ME, NH, DE, PA, and NJ. Utilization rates in the two largest states in the region, MA and NY, were compared to smaller states. Generalized vector regression was used to compare procedure usage of urological procedures between years. Fixed effects modeled deterministic trends over time as a quadratic function and heterogeneous slopes by procedure (SWL or URS/PCNL) and proximity to New York and Massachusetts.
Results: Figure 1 plots changes over time by region and procedure, and Figure 2 plots the rates of change for SWL usage versus URS and PCNL usage over four years. The overall rate of change in SWL usage was not significant (β = 0.05, p = 0.5344). However, NY, MA, and bordering smaller states (i.e. CT and RI) tended toward steeper declines in usage as compared to smaller surrounding states (β = ‐0.13, p = 0.0239). Utilization of URS and PCNL procedures increased on average, regardless of region (β = 0.22, p = 0.0158).
Conclusions: The rate of utilization of URS and PCNL increased in New York and Massachusetts from 2016‐2019, while SWL declined at a significantly steeper rate in these regions for medicare patients. SWL use is therefore not decreasing as rapidly in the remaining Northeast states, such as DE or ME. Evaluation of national trends is ongoing. Future studies aimed at understanding the drivers favoring one procedure over another, as well as the provider makeup of these regions may aid in better understanding of these findings.
Machine Learning Models to Predict 24‐Hour Urinary Abnormalities for Kidney Stone Disease
N Kavoussi, C Floyd, A Abraham, R Hsi
Vanderbilt University Medical Center
Introduction & Objective: To help guide empiric therapy for kidney stone disease, we sought to demonstrate the feasibility of predicting 24‐hour urine abnormalities using machine learning methods.
Methods: We trained a machine learning model (XGBoost [XG]) to predict 24‐hour urine abnormalities from electronic health record‐derived demographic, clinical, laboratory and stone composition data (n = 1,314). The machine learning model was compared to a logistic regression model [LR]. Additionally, an ensemble (EN) model combining both XG and LR models was evaluated as well. Models predicted binary (normal vs high) 24‐hour urine values for sodium, oxalate, calcium, and uric acid; and (normal vs low) for citrate; as well as a multiclass prediction of pH (low, normal, high). We evaluated performance using area under the receiver operating curve (ROC‐AUC) and accuracy and identified predictors for each task.
Results: The XG model was able to discriminate 24‐hour urine abnormalities with fair performance, comparable to LR. The XG model most accurately predicted abnormalities of urine volume (accuracy = 98%, AUC‐ROC = 0.59), uric acid (69%, 0.73) and elevated urine sodium (71%, 0.79). The LR model outperformed the XG model alone in prediction of abnormalities of urinary pH (AUC‐ROC of 0.66 vs 0.57) and citrate (0.69 vs.0.64). The EN model most accurately predicted abnormalities of oxalate (accuracy = 65%, ROC‐AUC = 0.70) and citrate (65%, 0.69) with overall similar predictive performance to either XG or LR alone. Body mass index, age, and gender were the three most important features for training the models for all outcomes.
Conclusions: Urine chemistry prediction for kidney stone disease appears to be feasible with machine learning methods. Further optimization of the performance could facilitate dietary or pharmacologic prevention.
The Impact of Dietician Counselling in Reducing Sodium Consumption among Hypercalciuric Stone Formers
FC Gabrigna Berto, J Bjazevic, JS Kwong, A Alathel, L Nott, H Razvi
Western University
Introduction & Objective: Kidney stones are a common medical condition with a rising prevalence worldwide. Diet plays a significant role in the pathogenesis of urolithiasis and goal specific dietary advice based on metabolic assessment has been shown to be effective in modifying patients' risks of further stones. Excessive dietary sodium (Na) consumption is linked to a number of poor health outcomes including urinary stone disease. Elevated urinary Na due to excessive intake may induce hypercalciuria. Thiazide diuretics are often prescribed to manage persistent hypercalciuria but may not be required if dietary modifications can address the excess dietary Na intake. Our study aimed to assess the impact of targeted dietary counseling, and its effect on normalizing urinary Na and Calcium levels in previously identified hypercalciuric stone patients.
Methods: A retrospective analysis of a prospectively collected metabolic stone clinic database was performed from September 2001 to June 2019. Patients with hypercalciuria and elevated urine Na on 24‐hour urine collection (24‐HUC) were counselled by a registered dietician to limit their intake of dietary Na to <2g/day in addition to receiving general dietary advice. Repeat testing was performed at least 6 months after the dietary modifications were recommended. Logistic regression was used to determine correlations between elevated urinary Ca and urinary Na to other urinary abnormalities. The effect of normalizing urinary Na in patients with hypercalciuria on other urinary parameters was analyzed with a chi‐squared coefficient.
Results: 95 patients were identified with concomitant hypercalciuria and hypernatriuria, and 69.5% of these patients were male with a median BMI of 31.06 Kg/m2. Elevated urinary Na correlated with hyperuricosuria (p < 0.001) and hyperphosphaturia (p < 0.001). In the second 24‐HUC, 58.9% of the patients corrected their urinary Na, and 42.8% of those also had their urinary Ca corrected. Patients who corrected their urinary Na were more likely to have a normal urinary urate (p = 0.003), normal urinary oxalate (p = 0.002), and low urinary volumes (p = 0.011) than patients with persistent hypernatriuria.
Conclusions: Elevated urinary Na is a common finding in stone formers, is frequently seen in association with hypercalciuria and maybe a marker for other metabolic risk factors. Detailed, targeted dietary counseling regarding Na intake can be effective in normalizing both elevated urinary Na and Ca levels in patients with concomitant hypercalciuria and hypernatriuria and may obviate the need for pharmacotherapy for the treatment of hypercalciuria in some patients.
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Evaluation of a Smart Urinary pH Meter and Mobile Medical App in Kidney Stone Formers
JM Lopez, J Mainez, JA Mora Christian, J Peña
Clinic Hospital ‐ Barcelona University / Teknon Hospital ‐ Quiron Salud
Introduction & Objective: The prevalence of kidney stone disease is 12%, recurrent patients are associated with kidney disease. Control and modification of urinary pH can dissolve and prevent some types of kidney stones. The prevalence of uric acid stones is 10‐15%. This patients are at increased risk of kidney disease due to higher rate of recurrence and the association with metabolic syndrome and obesity. Main underlying pathophysiology is related to low urinary pH (< 5.5). An self monitoring with electronic pH meter can facilitates personalized treatment and increase adherence by empowering the patient. Lit‐Control® pH Meter with Bluetooth connectivity and myLit‐Control® App (android and iOS platforms) were tested. We evaluate adherence, compliance, usefulness, acceptability, and satisfaction with the device and the App.
Methods: Multicenter prospective study in 10 hospital in Spain in 2020. Inclusion criteria: adult, history of kidney stones and with smart phone, capable of reading, with no physical limitations to use the digital pH meter or a smart phone. All participants received oral and written information and signed the informed consent.. Participants were instructed to carry out a pH measurement three times per day for a two‐week period. Adherence, usefulness, acceptability, and satisfaction with the device and the App were evaluated. Satisfactory adherence definition: entered pH readings with a time interval ≤2 days. Usage compliance: number of readings divides by number of proposed readings (3/day for 14 days = 42). App usability evaluated with a modified CSUQ. User acceptance and satisfaction with the system evaluated with an ad hoc Patient Subjective Questionnaire of 13 points.
Results: The participants included 41 patients, four patient dropped out. Mean age of participants was 48.7 (SD = 10.4) years, ranging from 25 to 66. App usage metrics table I. Usability rate of the App 5.4 and above (on a 7‐point scale). Patients scored their probability to recommend the App to other patients with an average of 8.2 on a 0 to 10 scale.
Conclusions: Compliance rates for use of the Smart pH Meter and its application were high and satisfaction with the products was good. The smart device and app can improve the medical management of patients with urinary pH‐dependent diseases, such as uric acid kidney stones. Studies should be done to monitor adherence to treatment and better dosing of treatment potentially reducing side effects and costs.
Age of Urologist Predicts Treatment Preference for the Management of Stone Disease
AA Arcese, F Munshi, R Ortiz, A Homer, E Hyams, G Pareek, SH Eaton, DW Sobel
The Warren Alpert Medical School of Brown Univeristy
Introduction & Objective: Flexible ureteroscopy (URS) has become the most widely taught surgical modality for kidney stone treatment in residency training programs over the past two decades. While shockwave lithotripsy (SWL) has long been used as a minimally invasive treatment for kidney stones, it has been supplanted by URS as the most commonly taught procedure in US residency programs. Given this, many surgeons with expertise in SWL trained before the advent of flexible URS. This study examines practice patterns among urologists performing endourologic procedures in New England for stone disease, focusing on SWL, URS, and PCNL between years 2016‐2019 to assess how provider age may impact practice patterns.
Methods: Data were extracted using CPT codes from the Centers for Medicare & Medicaid Services data set that contained provider information, including location of practice, and number of PCNL, SWL, and URS procedures performed from 2016‐2019. Data from CT, ME, MA, RI, VT, and NH were included in the final analysis. Surgeon age records were matched by NPI number across the 4 years studied, and procedure counts for URS, PCNL, and SWL were aggregated using Python. SWL proportion was calculated as the number of SWL procedures performed by providers, divided by the total number of URS, PCNL, and SWL procedures performed by the same physician during the same period. Odds‐ratio of a provider performing SWL when compared to URS or PCNL was assessed using a logistic regression model, controlling for total volume of the three procedures.
Results: Mean provider age was 54.96 (ST DEV 11.12, IQR = 17). Mean SWL, URS, and PCNL volume were 5.67 (SD 9.81), 48.17 (SD 48.62), and 1.24 (SD 7.54), respectively. Mean SWL proportion was 0.18 (SD 0.33, IQR = 0.21). Minimum and maximum SWL proportion was 0 and 1, respectively. The logistic regression model revealed a positive 0.0661 (p = 0.022) log‐odds‐ratio association between provider age and SWL proportion. Thus, each one year increase in a provider's age was associated with 1.068 times likelihood of using SWL over URS or PCNL. Sum total SWL, URS, and PCNL was not associated with the proportion of SWL performed.
Conclusions: Our findings support the hypothesis that age correlates with procedure preference amongst urologists performing stone procedures from 2016‐2019. We found that an older urologist, whom we assume trained earlier, is more likely to perform SWL than other endourologic procedures. Younger urologists are more likely to prefer URS, a newer but more invasive procedure than SWL with potentially better stone‐free rates. Future studies will aim to understand if practice type and location as well as national trends in residency training influence these findings.
Impact of Medical Stone Management on Serum Potassium
KM Wymer, N Payne, G Narang, KL Stern
Introduction & Objective: Thiazide diuretics and potassium supplements represent two of the most commonly used pharmacologic therapies for the medical management of kidney stones. Although effective at reducing the risk of recurrent stones, these therapies are associated with adverse effects, commonly electrolyte abnormalities. However, the incidence and risk factors for these abnormalities among kidney stones patients has not been studied.
Methods: A retrospective chart review was performed for patients treated at our instituational stone clinic from 2014‐2020. All patients who were prescribed a thiazide diuretic, potassium supplement (potassium citrate or potassium chloride), or both were evaluated. Patients without serum electrolytes recorded from before and after initiation of medication management were excluded. Demographics and clinical characteristics were compared between patients based on medication group. Univariate and multivariable regression were performed to assess for predictors of follow up serum potassium.
Results: 100 patients were included in our analysis with a median age of 63 years. Potassium supplements, diuretics, and combination therapy were prescribed to 38, 6, and 56 patients, respectively. At follow up, hypo and hyperkalemia were found in 10 and 7 patients, respectively. On univariate analysis, medication group, GFR, age, and history of hypertension were all significantly associated with changes in serum potassium. On multivariable analysis, only medication group remained a significant predictor of follow up serum potassium. Specifically, the diuretics‐only group had a mean change of ‐0.52 (SD 0.23) mEq/L compared to ‐0.36 (SD 0.08) mEq/L for the diuretic + potassium group, and +0.11 (SD 0.09) mEq/L for the potassium‐only group (Figure 1).
Conclusions: Among patients with kidney stones, medical management with diuretics and/or potassium supplements are associated with relatively small changes in serum potassium. These changes are unlikely to be clinically significant for the majority of patients and support the overall safety of these medications as either standalone or combination therapy.
Do Sequential 24‐Hour Urine Collections in an Individual Patient Improve Urinary Parameters?
AS Amasyali, J Groegler, H Sung, D Jhang, M Buell, J Belle, M Keheila, DD Baldwin
Loma Linda University Department of Urology
Introduction & Objective: 24‐hour urine collections are commonly used to stratify risk for future urinary stone formation. However, little evidence demonstrates the effectiveness of repeated 24‐hour urine collections in altering urine composition. The purpose of this study was to determine whether sequential 24‐hour urine collections from the same patient result in improved stone risk parameters.
Methods: A retrospective review of a 24‐hour urinalysis database, including 1832 tests from 688 patients collected between January 2008 and June 2017 was conducted. Patients included in the analysis had a minimum 2‐year follow‐up and at least three 24‐hour urine collections (LithoLink™) from distinct time periods. Changes in risk parameters were evaluated over time with each patient acting as their own control. Statistical analysis was performed using repeated measures ANOVA with a Greenhouse‐Geisser correction and post‐hoc analysis with Bonferroni correction, with p < 0.05 set as significant.
Results: The mean age of the 225 patients with complete data sets was 56.6 years and mean BMI was 28.5. 117 patients (52%) were male. From the first to the second urinalysis, there were significant improvements in volume, supersaturation (SS) of CaOx, SS CaP, and SS UA (p < 0.05, Table 1). From the second to the third urine collection, the only parameter which significantly improved was SS CaP. Approximately half of patients continued to see improvement in stone risk parameters between the second and third urine collections.
Conclusions: Risk factors for stone formation such as low urine volume, SS CaOx, SS CaP, and SS UA were shown to improve between the first and second 24‐hour urine tests, while only SS CaP showed significant improvement on the third collection. Although it did not reach statistical significance in the overall group, approximately half of patients did continue to see improvement in the majority of stone risk parameters on the third 24‐hour urine collection. Future studies should be designed to help determine which patients benefit most from repeated 24‐hour urine collections.
Evaluating the AUA Dietary Recommendations for Kidney Stone Management Using the National Health and Nutritional Examination Survey (NHANES)
KF Labagnara, K Liu Kot, AC Small, BW Green, K Watts, E Macdonald
Albert Einstein College of Medicine
Introduction & Objective: To retrospectively investigate the impact of dietary recommendations cited by the AUA for kidney stone medical management.
Methods: Data were collected between years 2011‐2018 from the National Health and Nutritional Examination survey (NHANES), a publicly available database representative of the United States population. Individual dietary recommendations were evaluated using a weighted multivariate logistic regression, controlling for age, race, and gender.
Results: Our unweighted population consisted of 17,100 survey respondents. Kidney stones were present in 10.1% (95% CI: 89.2‐90.6) of our weighted population. On multivariate analysis we found significant associations between stone formation and low potassium intake (< 2000mg) (OR = 1.302, p = 0.003), low fiber (< 8g) (OR = 1.285, p = 0.037), low magnesium (< 200mg) (OR = 1.332, p = 0.001), and low vitamin K (150mcg) (OR = 1.231, p = 0.043). Of note high vitamin C ( >60mg) was associated with a decreased risk of stone formation (OR = 0.799, p = 0.012). Conversely, other dietary recommendations were not significantly associated such as low water intake (< 2500ml) (OR = 0.905, p = 0.495), high salt ( >2300mg) (OR = 0.972, p = 0.599), high caffeine ( >400ml) (OR = 1.182, p = 0.357), high protein ( >80g) (OR = 0.880, p = 0.145), and high total fat (67g) (OR = 0.612, p = 0.203). Additionally, as demonstrated in other analyses, older age (OR = 1.020, p = 0.001) and male gender (OR = 1.354, p = 0.004) were associated with increased likelihood of stone formation, while Non‐Hispanic Black (OR = 0.516, p = 0.001) and Mexican American race (OR = 0.695, p = 0.002) were associated with a decreased likelihood of stone formation compared to Non‐Hispanic White patients.
Conclusions: Our findings show that some widely supported dietary recommendations for kidney stone prevention lack retrospective validation. Further research is needed to analyze the effect of these recommendations on risk of kidney stone formation.
Factors Predicting for Change in Serial 24‐hour Urine Panel
DG Wong, A Ostergar, R Venkatesh, K Sands
Washington University in Saint Louis
Introduction & Objective: We sought to analyze how obesity or other factors may affect the changes in 24‐hour urine stone risk profile (24H‐UP) after standard dietary and medical recommendation for stone prevention.
Methods: We retrospectively investigated 24H‐UP data in 197 patients from June 2015 to January 2021 as provided by Litholink Labcorp. We included patients with baseline 24H‐UP and a follow up 24H‐UP between 4‐18 months after the initial test. We excluded patients with cysteine or struvite stones. A baseline 24H‐UP was compared to a follow up 24H‐UP. All patients received standard dietary recommendations. 24H‐UP assessed concentrations of calcium, oxalate, citrate, uric acid, sodium, pH, ssCaOx,ssCaP, and ssUA. Linear regression models were used to test baseline BMI, age, sex, and time to follow up as predictors for change in each urinary parameter.
Results: The median time to post‐intervention 24H‐UP was 8.0 months. There was no significant difference between baseline and follow up BMI. (Table 1) On multivariable linear regression analysis, increased BMI was correlated with increased SSCaOx (Regression coefficient = 0.06, p = 0.05) while citrate was inversely correlated with time to follow‐up (Regression coefficient = ‐15.21, p = 0.027) and male sex (Regression coefficient = ‐117.11, p = 0.009). Otherwise, impact of BMI, age, time to follow‐up, and sex did not have a significant impact on change in 24H‐UP. (Table 2)
Conclusions: Patients with higher BMI were more likely to have higher ssCaOx despite standard follow up and dietary recommendations. Male patients and those that wait longer between 24H‐UP were less likely to improve 24Cit levels.
Feasibility and Acceptability of Shared Medical Appointments Utilizing Telehealth Medicine for Kidney Stone Prevention
N Streeper, R Smith, M Beyer
Penn State Health
Introduction & Objective: Shared medical appointments (SMA), or group visits, provide an efficient way to improve patient care and education to patients with chronic diseases such as kidney stones. Metabolic evaluation for the prevention of kidney stones requires extensive patient education and a multidisciplinary approach is preferable to deliver both medical and dietary therapy. However, it can be time‐consuming to deliver quality care within the constraints of individual appointments. The purpose of this study was to determine the feasibility and acceptability of SMA utilizing telehealth medicine for kidney stone prevention.
Methods: Patients with a history of recurrent kidney stones who were agreeable to metabolic evaluation for kidney stone prevention as well as participating in a SMA telehealth visit were enrolled (November 2020‐ October 2021). Patients signed consent to participate in this setting. SMA telehealth visits were performed via Zoom platform led by both a dietician and urologist. Sessions included both group education as well as individualized discussion of results and treatment plans. After the visit, patients completed an electronic questionnaire assessing patient satisfaction, quality of education and acceptability of SMA telehealth visits (5‐point Likert scale).
Results: 28 patients with a history of recurrent kidney stones were seen in SMA telehealth visits for new metabolic stone evaluation and 14 patients responded to the electronic questionnaire (age = 47.4 ± 17.0 years; 79% female; 50% response rate). Sessions lasted approximately 1‐hour and typically included 3‐4 patients, which compared to 1.5 patients being seen during typical individual appointments during the same timeframe. The quality of education was rated highly by the majority of patients for both general education on kidney stones /dietary strategies and individualized education on risk factors/ diet recommendations (86% and 79% respectively). The overall patient satisfaction was positive for the majority of patients (86%) and the majority would recommend this type of visit to a family member or friend (79%). However, 21% of patients would have preferred an individual appointment.
Conclusions: We found that SMA utilizing telehealth medicine for education of kidney stone prevention and review of individual metabolic evaluations is both feasible and acceptable to patients. Overall patient satisfaction was positive for the majority of patients and patient education was highly rated. Furthermore, SMA telehealth visits provide clinicians with an efficient approach to provide improved patient education for kidney stone prevention.
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Voided Volume does not Impact Stone Outcomes: Retrospective Review of an Automated Nephrolithiasis Registry
W Sui, K Shee, H Yang, C Chan, F Hamouche, LD Charondo, S Ho, T Chi, M Stoller
Introduction & Objective: Urologic guidelines universally recommend increasing fluid intake for kidney stone prevention. Increased voided volume is thought to help reduce stone recurrence and severity, but supporting evidence is limited.
Methods: A retrospective review of data from the Registry for Stones of the Kidney and Ureter (ReSKU), an automated prospective nephrolithiasis registry, and 24‐hour urine samples was performed. Each patient had at least one prospectively collected 24‐hour urine test. Donor nephrectomy patients with no history of kidney stones and 24‐hour urine samples were obtained as controls. Outcomes include stone events, either an office visit where a patient reports symptomatic passage of stones or surgery for stone removal, and number of stones, either reported number of spontaneously passed stones or stones removed during surgery.
Results: We identified 450 stone patients with 24‐hour urine and kidney stone outcome data and 200 donor nephrectomy controls. After controlling for age, gender, BMI, 24‐hour sodium and creatinine per kilogram, no significant associations were found between voided volume and stone events or number of stones on multivariate logistic regression. There was a statistically significant negative correlation noted between voided volume and stone events in calcium oxalate dihydrate stone formers (Spearman R = ‐0.42, p = 0.04), but not others.
Conclusions: 24‐hour voided volume was not associated with stone events or number of stones in a large prospectively recruited cohort, and subset analysis reveals that some stone formers may benefit more from increased voided volume than others; identifying such patients represents a novel precision medicine opportunity.
Urinary Citrate and pH are not Correlated in Calcium Stone Formers, Only in Uric Acid Stone Formers
W Sui, K Shee, H Yang, C Chan, F Hamouche, S Ho, T Chi, M Stoller
Introduction & Objective: Prescribing citrate therapy to nephrolithiasis patients with low urinary pH in order to alkalinize the urine is common clinical practice. In this study, we sought to determine whether increased urinary citrate, a surrogate for citrate intake, is associated with increased urinary pH in all nephrolithiasis patients, or only in specific subsets of patients.
Methods: Prospective data from the Registry for Stones of the Kidney and Ureter (ReSKU) and a large database of 24‐hour urine samples collected from 1996 to 2020 were queried for overlap. 24‐hour urine samples from healthy donor nephrectomy patients served as controls. Demographic data and stone composition data were collected. 24‐hour urine data for 24‐hour urine citrate (Cit24) and pH were obtained. Correlation analyses were performed using nonparametric Spearman correlations. Statistical analysis and visualization was performed in Graphpad Prism.
Results: We identified 450 patients with 24‐hour urine data and kidney stone outcome data from the ReSKU and 24‐hour urine datasets, and 200 donor nephrectomy controls with 24‐hour urine data. There was a statistically significant positive correlation between Cit24 and pH in stone formers (p = 0.04), but not in donor nephrectomy controls (p = 0.61). When dividing patients according to stone composition, there was a statistically significant positive correlation between Cit24 and pH only in uric acid stone formers (p = 0.017), but not in calcium oxalate (p = 0.97), calcium phosphate (p = 0.5), or carbonate apatite stone formers (p = 0.43).
Conclusions: Cit24 and urinary pH are significantly correlated only in uric acid stone formers, but not others. These findings suggest that citrate therapy may only be effective at increasing urinary pH in uric acid stone formers, and that identifying strategies to raise urinary pH in other stone formers is warranted. Furthermore, the data suggests that prescribing citrate for stone disease caused by hypocitraturia may be safe to use in the setting of high urinary pH.
Food Insecurity is Associated with Increased Risk of Nephrolithiasis: An Analysis of the National Health and Nutrition Examination Survey
BW Green, N Feiertag, E Macdonald, KF Labagnara, M Zhu, K Gupta, CS Mohan, K Watts, A Rai, AC Small
Albert Einstein College of Medicine
Introduction & Objective: To investigate the relationship between self‐reported food security and kidney stone formation.
Methods: Data were collected from the National Health and Nutrition Examination Survey (NHANES), a database representative of the United States population. Kidney stone history was assessed using the kidney conditions module and food security status was assessed using the US Household Food Security Survey Module: Six‐Item Short Form. Multivariate logistic regression was performed using a multi‐model approach.
Results: We analyzed 6,800 NHANES survey respondents. Food insecurity was present in 61.2% of respondents, with 37.2% having “low food security” (scores 2‐4) and 24% having “verying low food security” (scores 5‐6). 8.4% of respondents had a history of kidney stones.We found that people with a history of kidney stones had a 38% increased likelihood of food insecurity compared to those without kidney stones, after controlling for race, age, and comorbidities (OR 1.38; 95% CI 1.02‐1.88). Between the food secure and insecure groups, no significant differences observed in age, race/ethnicity, body mass index, gout history, osteoporosis history, or coronary artery disease history. Conversely, in the food insecure group, history of diabetes was higher (p = 0.018); history of hypertension was higher (p = 0.03); history of hyperlipidemia was higher (p = 0.02); and low socioeconomic status was more prevalent (p = 0.001).
Conclusions: Our study provides evidence for a link between food access and the risk of kidney stone disease. Given these findings, food insecurity should be treated as a modifiable risk factor for the development of kidney stone disease.
MP13: CLINICAL STONES: PCNL III
Mini‐PCNL Outcomes in the Obese Population, a Retrospective Review
A Slade, T Large, E Sahm, G Vedantam
Indiana University
Introduction & Objective: Mini‐PCNL has gained popularity over the last decade due to its stone free rate comparable to traditional PCNL but with decreased risk of complications. Mini‐PCNL has also furthered the movement of PCNL into the ambulatory setting. While the data on mini‐PCNL has been favorable thus far, no study today has evaluated outcomes in obese patients.
Methods: All patients undergoing mini‐PCNL at our institution since we began its use in 2019 were included in this study. Mini‐PCNL was defined as access sheath ≤22 French in size. An obese group with BMI ≥30 was compared to a non‐obese group with BMI <30. A patient was considered stone free if there were no fragments >3 mm on follow‐up CT. Fisher exact test was used to compare dichotomous differences between variables, and T‐test to compare continuous variables.
Results: We identified 67 patients who underwent mini‐PCNL during the study period with 33 patients in the obese group. Median BMI in the obese group was 36.4 kg/m2 compared to 25.05 kg/m2 in non‐obese. There were no blood transfusions in either group during the study period. There was no statistical difference between the obese vs non‐obese group for age, access sheath size, change in hemoglobin, same day discharge, percent stone free, Emergency Department visit within 30 days, and median largest single stone diameter (see table 1). There was a significant difference in the sum of all treated stone diameter in the obese group (median 15mm) versus non‐obese (median 18mm, p = 0.02) (table 1). There were no significant differences in overall complications or complication type. The two grade III complications included a pleural effusion requiring IR drainage, and an obstructing stone fragment that required ureteral stent placement.
Conclusions: Mini‐PCNL appears to be equally safe and effective in obese and non‐obese patients alike. While there was a statistically significantly higher amount of overall stone burden in the non‐obese groups, the overall difference is not clinically significant. Further research is needed to validate our experience.
Liver Injury During Percutaneous Nephrolithotomy (PCNL): A Case Series Study
MV Nguyen, J Berger, A Flores, TT Chen, J Yared, V Pais, BH Chew, MR Humphreys, KL Stern, RL Sur
UC San Diego School of Medicine
Introduction & Objective: Although percutaneous nephrolithotomy (PCNL) remains the standard for treating large renal stones, it is not without risk. Hopper and Yakes (Am J Roentgenol 1990) noted a 14% risk of liver injury via prone intercostal access for PCNL. Despite known risk, there are few publications reporting liver injury during PCNL. We present the largest series of liver injury during PCNL, subsequent management, and review of pertinent literature.
Methods: Three liver injuries during PCNL were compiled by urologists across four academic medical centers—patient history/management is reported. Existing case reports are reviewed.
Results: Case 1: A 49‐year‐old female with 2.4 cm right renal pelvis stone underwent a PCNL. In the intermediate dorsal decubitus position, the right renal collecting system was accessed by fluoroscopic and ultrasound (US) guidance. At conclusion of PCNL, patient appeared free of stone and complications—a PCN was placed. Routine post‐operative (post‐op) imaging noted the PCN traversing the liver with a hematoma. The PCN was removed and the patient was observed through post‐op day (POD) two. Imaging six weeks later noted resolving liver hematoma.
Case 2: A 53‐year‐old female with bilateral nephrolithiasis (including 2.2cm right renal pelvis stone and scattered small stones) underwent right sided PCNL in prone position with subcostal renal access in two locations (after noted to have a partially duplicated collecting system). At conclusion of PCNL, the patient appeared free of stone and complications—a PCN was placed. Routine post‐op imaging noted the PCN traversing the liver. She was observed inpatient through POD5 (PCN was removed on POD4). Outpatient imaging demonstrated resolution of liver injury.
Case 3: A 68‐year‐old male with horseshoe kidney and 5.9 cm right moiety stone underwent a prone PCNL through an existing PCN (placed earlier by radiology via US guidance). At conclusion of PCNL, patient appeared free of stone and complications—a PCN was replaced. Routine post‐op imaging noted the PCN traversing the liver, small hematoma, and few residual stones. On POD5 patient underwent repeat PCNL and had PCN replaced. Two days later, imaging noted stable hematoma and no residual stone (the PCN was removed). Outpatient imaging noted resolution of hematoma.
A literature review noted three separate prior case reports of liver injury during PCNL—all managed non‐operatively (with exception of drain placement for bile leak in one case).
Conclusions: Risk factors for liver injury during PCNL may include distorted or complex renal anatomy. Liver injuries may often be treated without surgical intervention.
Comparison between Standard, Mini and Ultra‐Mini Percutaneous Nephrolithotomy for Single Renal Stones: A Prospective Study
C Adamou, K Pagonis, A Peteinaris, A Tsaturyan, P Kallidonis
University Hospital of Patra
Introduction & Objective: Based on the current trend of miniaturization of instruments used in percutaneous nephrolithotomy(PCNL), it is necessary to compare different PCNL modalities regarding their access sheath size used. Thus, the safety and efficacy among standard, mini and ultra‐mini PCNL (s‐PCNL, m‐PCNL, um‐PCNL) were compared.
Methods: We performed a prospective, non‐randomized trial between January 2018 and July 2020. Patients with stones classified as Guy's stone score grade I were included. The set‐up for s‐PCNL and m‐PCNL included a 30Fr and 22Fr percutaneous tract, respectively. In both set‐ups, an ultrasonic/ballistic lithotripter was utilized. In the case of um‐PCNL, a 12Fr percutaneous tract was established. A high‐power laser was used for lithotripsy. Hemoglobin drop, complication rate, hospitalization time, stone‐free rate(SFR) and operation time were evaluated.
Results: A total of 84 patients, 28 patients per method, were evaluated. Hemoglobin drop was higher in the s‐PCNL group when compared to m‐PCNL(p = 0.008) and um‐PCNL groups(p < 0.001), while um‐PCNL group had the slightest hemoglobin drop. Hospital stay was similar between s‐PCNL group and m‐PCNL group, but um‐PCNL group required shorter hospital stay than the other two modalities(p < 0.001). The complication and transfusion rates as well as SFR did not differ between groups. Operation time in the um‐PCNL set‐up was longer compared to s‐PCNL(p < 0.001) and m‐PCNL(p = 0.011), whereas s‐PCNL and m‐PCNL did not differ significantly.
Conclusions: m‐PCNL showed less hemoglobin drop, but similar operation time and SFR when compared to s‐PCNL. um‐PCNL showed even less hemoglobin drop, but the operation time was longer compared to the two other modalities.
Urologist Involvement in Preoperative Antegrade Access Improves Utility for Percutaneous Nephrolithotomy
C Staniorski, C Staniorski, M Semins
University of Pittsburgh Medical Center
Introduction & Objective: Gaining antegrade access for percutaneous nephrolithotomy (PCNL) can be challenging especially in patients with anatomic abnormalities with large stone burdens. Emergently placed nephrostomy tubes have previously been shown to require additional access at the time of PCNL in 21‐51% of patients. The purpose of this study is to determine the utility of preoperatively placed nephrostomy tubes when a Urologist was involved in planning of access with consideration of subsequent PCNL. The primary objective was to examine rates of new access at the time of PCNL in patients with and without a Urologist involved in planning of access.
Methods: We conducted a retrospective review of patients undergoing PCNL at a single hospital from 2011 to 2022. Adult patients undergoing PCNL with established pre‐operative access were included. Chart review evaluated demographics, comorbidities, complications, stone free rate, and operative variables.
Results: A total of 141 cases with pre‐operative access (119 patients) were included, with 111 cases planned with interventional radiology prior to antegrade access. There were high rates of anatomic abnormality (49.6%) and staghorn calculus (53%) that were similar among those with and without planning while patients with planned access had higher BMI. Both groups frequently used the pre‐operative access (97%). However, 6% required additional access to be obtained intraoperatively to complete the procedure with higher rates in those with unplanned access (3% vs 16%, p < 0.05). Stone free rates (90%) and total stages (2) were similar between planned and unplanned groups. Planned access however trended towards ureteroscopy as a second stage as opposed to PCNL. Complications were similar between groups.
Conclusions: In this retrospective review of complex patients with large stone burden presenting for PCNL with preoperative antegrade access, planned access with the urologist's involvement was associated with a low rate of requiring new intraoperative access. Pre‐operative access also appears to lead to higher rates of second stage ureteroscopy compared to second look percutaneous nephroscopy. Communication between urologists and interventional radiologists prior to nephrostomy tube placement may improve outcomes for those undergoing subsequent PCNL.
Rates and Prevention of Residual Ureteral Fragments after Percutaneous Nephrolithotomy
A Arora, S Monda, G Fananapazir, N Canvasser
UC Davis Urology
Introduction & Objective: Percutaneous nephrolithotomy (PCNL) represents the most efficacious procedure to treat large renal stones, although residual fragments post‐procedure are common. While residual renal fragments have been studied, there is less information regarding retained ureteral fragments. During PCNL, various techniques exist to prevent and identify ureteral fragments, including occlusion balloons, antegrade ureterography, and antegrade ureteroscopy. We determined the rate and predictors of ureteral fragments immediately after PCNL in a single‐institution series. We hypothesized that performing antegrade ureteroscopy eliminates the chance of significant ureteral fragments and could allow for utilization of a kidney only CT protocol to reduce the radiation dose in post‐operative patients.
Methods: We retrospectively reviewed all patients who underwent PCNL between August 2017 and July 2020, and had a CT scan of the abdomen and pelvis on postoperative day (POD) 1. Patient demographics, stone variables, and operative techniques were recorded. Each CT was re‐reviewed by an attending abdominal radiologist to identify all retained ureteral fragments.
Results: A total of 125 patients with 139 renal units were reviewed. Table 1 lists patient demographics and stone details. Of these, 30% had an occlusion balloon, 47% had antegrade ureterography, and 56% underwent antegrade ureteroscopy at the conclusion of the case. 15 patients with 16 renal units had a ureteral fragment on POD #1. Each unit only had 1 ureteral fragment with a median size of 2 mm. Of these, 14 fragments were felt to be clinically insignificant (≤ 2mm). In patients with an occlusion balloon, antegrade ureterogram, and antegrade ureteroscopy, rates of all ureteral fragments were 14%, 8%, and 10%, respectively. The significant fragments requiring second‐look ureteroscopy were 9 mm and 13 mm. One had an antegrade ureteogram, neither had an occlusion balloon or antegrade ureteroscopy at the conclusion of the case.
Conclusions: Rates of ureteral fragments after PCNL approximate 12%, despite utilizing prevention techniques. Antegrade ureteroscopy reduces this complication, demonstrating that it may be unnecessary to image the ureter after PCNL. Next steps involve examining a kidney only CT protocol in post‐operative patients.
Ambulatory Tubeless Supine Mini‐PCNL under Spinal Anaesthesia for Stones Size 1.5 ‐ 3 cm: A Novel Approach in the COVID‐19 Era for Minimising Risk of Contagion
JA Kalathia, K Patel, D Valiya, D Vala, D Khetarpal, D Aggarwal, D Joshi
Fortune Urology Clinic
Introduction & Objective: In the ongoing Covid‐19 era where physical distancing is utmost important, we assessed the feasibility of ambulatory tubeless supine mini‐PCNL under spinal anaesthesia for stone size between 1.5 – 3 cm to minimise hospitalisation.
Methods: Between June 2020 to August 2021, total 284 patients underwent PCNL out of which 122 underwent ambulatory tubeless mini‐PCNL. The inclusion criteria were those consented for study, size of the stone 1.5 – 3 cm, pre‐operative Covid‐19 negative test (CT‐chest and RT‐PCR). Those excluded were with solitary kidney, morbidly obese, active UTI, congenital abnormalities. Patient's demographics, peri‐operative parameters, stone free rate, blood loss, pleural complications and requirements of auxiliary procedures were prospectively evaluated
Results: All the patients underwent supine mini‐PCNL in FOSML (Flank‐Oblique Supine Modified Lithotomy) position through a single tract of size 14/16 Fr. In, 18 (15%) patients' additional tracts were made for inaccessible secondary stones. Holmium laser and pneumatic source of energy were used for fragmentation of stones. Supra 12th rib tracts were made in 23 (19%) patients while in remaining 99 (81%) had infra‐costal tracts. Complete SFR (stone‐free rate) was achieved in 112 (92%) under fluoroscopy and the remaining 10 (8%) needed auxiliary procedure to render stone free. Average total operative time was 44 ± 15 minutes and no nephrostomies were placed. All patients were discharged within 24 hours of operation with only 7 (6%) patients required readmission within 48 hours of discharge with hematuria and were managed conservatively. No other major complications occurred except for mild fever in few.
Conclusions: Ambulatory supine tubeless mini‐PCNL under spinal anaesthesia is safe and effective in this uncertain rapidly spreading COVID‐19 era to minimise hospitalisation. It should be recommended whenever feasible, and it is easy to adapt to this newer approach especially for urologist already performing supine PCNL.
Mini‐Percutaneous Nephrolithotomy and Ureteral Stent Drainage Facilitate Ambulatory Discharge Compared to Standard Percutaneous Nephrolithotomy
F Hamouche, K Chang, R Unno, G Hosier, H Yang, D Bayne, JS Ahn, M Stoller, T Chi
Introduction & Objective: Mini‐percutaneous nephrolithotomy (mPCNL) establishes a tract diameter less than the traditional 24‐30 French tract in hopes of reducing perioperative hemorrhage and postoperative complications. Little prospective data exists comparing clinical outcomes between these two approaches. This study was undertaken to compare the clinical characteristics and outcomes of mini compared to standard PCNL (sPCNL).
Methods: Prospectively collected data from the Registry for Stones of the Kidney and Ureter (ReSKU) was queried on all patients who underwent PCNL at a single center from 2015‐2021. Patients were divided in two cohorts based on tract dilation size, sPCNL ( >/ = 24 French) and mPCNL(< 24 French). Demographics, clinical characteristics, and outcomes of both cohorts were compared. Statistical analysis was performed using the student t‐test and chi‐square test for the univariate analysis as well as logistic regression for the multivariate analysis.
Results: 212 consecutive patients with complete operative and follow up data were included for analysis. This comprised 150 sPNL and 62 mPNL cases. Demographic data, comorbidities and ASA scores were comparable between both cohorts. The majority of patients had a stone burden larger than 2 cm in both groups (117 [78%] vs 39 [62.9%] p = 0.0673). Supine positioning and ureteral stent drainage were more common in the mPCNL cohort (85 % vs 45.3% p < 0.001 and 41.9% vs 6%, respectively). Percutaneous access was achieved with ultrasound guidance in the majority of patients and calyceal access location was similar between the groups. Complete visual clearance was comparable (119(79.3%) vs 48 77.4% p = 0.468). Same‐day discharge was higher in the mPCNL cohort (14(22.6%) vs 6(4.0 %) p < 0.001). There was no difference in postoperative complications or perioperative events. On multivariate analysis, post‐operative drainage by a ureteral stent was also associated with discharge within 1 day of surgery in both groups (OR 0.15 (0.03‐0.64) p = 0.01
Conclusions: Mini PCNL is comparable to standard PCNL in managing large kidney stones with comparable stone clearance and operative outcomes and a more favorable outpatient surgery profile. In both groups, postoperative drainage with a ureteral stent only seems to be a facilitator factor for a faster hospital discharge
WITHDRAWN
Staged Urinary Drainage and Percutaneous Approach Is the Preferred Management for Urolithiasis in Urinary Diversion Patients
K Maciolek, D Watson, N Schenkman, N Patel
University of Virginia
Introduction & Objective: Urinary diversion is associated with increased risk of urolithiasis due to chronic bacteriuria, metabolic abnormalities and urinary stasis or dilation. Surgical management in this setting presents a challenge for urologists. We report our experience with surgical management for symptomatic upper tract stone disease in patients with urinary diversion. We evaluated treatment modality, stone characteristics, and complications.
Methods: We retrospectively reviewed 658 patients from 2010 to 2021 who underwent both urinary diversion (malignant or benign indications) and extracorporeal shock wave lithotripsy (ESWL), ureteroscopy (URS) or percutaneous nephrolithotomy (PCNL) at our institution based upon CPT codes. Patient, stone, and procedural characteristics were collected. Data was analyzed with descriptive statistics.
Results: Between 2010 and 2021, 19 patients with urinary diversion (16 ileal conduit, 2 Indiana pouch, 1 neobladder) underwent the following procedures: 3 ESWL, 7 retrograde URS, 8 antegrade URS and 8 PCNL. The majority of patients were male (57%). Mean age at stone procedure was 56 years (interquartile range (IQR) 44.5‐66.5 years). Median interval between diversion and stone management was 3.4 years (IQR 1.5‐4.6 years). Most patients required pre‐procedure drainage tubes (60% PCN, 11% stent, 7% both, 21% none). More left ureteral stones (64%) were seen possibly due to stasis from ureteral tunnel beneath mesentery in ileal conduit diversions. Stone size was highly variable. Percutaneous procedures (antegrade URS or PCNL) were required even for smaller stone sizes, due to ureteral stones (Table 1).
Conclusions: Surgical management of urolithiasis after urinary diversion requires individualized consideration including diversion type, stone location, and stone burden. Patients often require staged drainage procedure followed by definitive therapy. Data are limited by small sample size, but complications, especially infectious complications, were higher than published literature.
Access Sheath Irrigation: A Safe and Effective Technique to Optimize Renal Pelvic Pressure and Visibility during Endoscopic Combined Intrarenal Surgery
C Ritchie, JC Hartman, AS Amasyali, J Jung, A Assidon, J Belle, DD Baldwin
Loma Linda University
Introduction & Objective: Endoscopic combined intrarenal surgery (ECIRS) utilizes both percutaneous renal access and retrograde ureteroscopy to optimize calyceal visualization and achieve high stone free rates. Irrigation through a 3Fr ureteroscopic working channel can be limited, resulting in build‐up of blood and debris, collapse of the collecting system, and compromised visibility. We have noted that visibility can be improved by plugging the percutaneous sheath with the irrigation stopcock and delivering antegrade flow. The purpose of this study was to compare renal pelvic pressure (RPP) and retrograde ureteroscopic visibility during ECIRS, both with and without access sheath irrigation (ASI), to determine the safety and efficacy of this novel technique.
Methods: RPP measurements from 15 patients undergoing ECIRS at a single academic institution were retrospectively reviewed. During retrograde ureteroscopy, a pressure monitor was connected to the working channel of a flexible ureteroscope. With the tip of the ureteroscope positioned in the renal pelvis, RPP measurements were performed with and without ASI, delivered from a constant height of 1.28m. Study endpoints were RPP and endoscopic visibility, the latter based on a blinded review of intraoperative photos by ten urologists using a 10‐point Likert scale. Statistical analysis was performed using a paired samples t‐test and Mann‐Whitney U test, with significance defined as p < 0.05.
Results: Antegrade ASI yielded significantly greater RPP (25.9 vs. 8.5 mmHg, p < 0.001) and subjective visibility (6.9 vs. 1.9, p < 0.001), when compared to ECIRS without antegrade irrigation. Using ASI, RPP did not exceed the threshold for pyelovenous backflow. On analysis of intra‐operative pictures, ASI effectively distends the renal collecting system, with higher clarity of instruments and less bleeding obscuring the field (Fig. 1).
Conclusions: Antegrade access sheath irrigation represents a novel strategy for optimizing renal pelvic pressure and endoscopic visibility during ECIRS. Delivering continuous antegrade irrigation is a safe and effective method to improve visibility, without exceeding the threshold for pyelovenous backflow.
Extreme Percutaneous Nephrolithotomy: A Case Series of Procedures Requiring Five or more Access Tracts
JH Altschuler, S Goel, AJ Yaghoubian, B Gallante, J Khusid, R Shimonov, WM Atallah, L Horodyski, M Mason, N prakash, R Marcovich, M Gupta
Mount Sinai Hospital
Introduction & Objective: While open, laparoscopic, and robotic approaches have high stone‐free rates for treating complete staghorn nephrolithiasis, they are associated with increased morbidity. For this reason, the percutaneous approach to staghorn stones has gained favor. In complex cases, multiple access tracts may be required. In this study, we describe a series of patients undergoing percutaneous nephrolithotomy (PCNL) with minimum 5 dilated access tracts.
Methods: We retrospectively analyzed the records of 10 patients with complete staghorn stones who underwent PCNL with a minimum of 5 tracts. Baseline patient and stone characteristics were recorded, as were postoperative complications and stone‐free rates. The primary endpoint of the study was any postoperative complication as denoted by Clavien grade. Secondary endpoints included stone‐free rate (absence of fragments >2mm), operative time, and length of hospital stay.
Results: Ten patients with complete staghorn stones from two institutions were included. Patient and stone characteristics as well as primary and secondary outcomes are described in Table 1. The number of access tracts used ranged from 5 to 11, and average stone volume was 246,643 mm3 (preoperative CT). Seven patients (70%) experienced postoperative complications, ranging in severity from Clavien II to IV. Three patients (37.5%) required blood transfusions, only one of whom was on anticoagulation preoperatively. The average duration of procedure was 301 minutes with range of 180 to 560 minutes. Only 3 patients (30%) were rendered stone‐free after the initial procedure, yet of those with residual fragments, only 3 required reoperation with ureteroscopy. The remainder were observed without need for further intervention after a mean follow up of 16 months. Average length of stay was 3.1 days, with a range of 1 to 6 days.
Conclusions: To our knowledge, this is the largest series of patients undergoing PCNL with 5 or more access tracts reported to date. Patients in our series experienced a significantly higher rate of postoperative complications than those undergoing PCNL with fewer access tracts as compared with previous studies. Our data suggest that PCNLs with 5 or more tracts in particular, warrant the utmost vigilance postoperatively.
Drivers of Operative Supply Cost in Percutaneous Nephrolithotomy
ZR Dionise, C Tabib, F Soto‐Palou, GM Preminger, M Lipkin
Division of Urology, Duke University Medical Center
Introduction & Objective: At $3.8 trillion annually, healthcare expenditure in the United States is the highest worldwide. As health systems attempt to reduce costs, the surgical suite has been an area of focus, since surgical costs can vary greatly by provider. Initiatives aimed at providing supply cost transparency have resulted in savings without compromising care. Our goal was to retrospectively examine surgical supplies used during percutaneous nephrolithotomy (PNL), a surgery with great variation in surgical preference, to provide surgeons with the price‐transparency to understand the drivers of their own operative costs.
Methods: We retrospectively identified PNL cases (CPT 50080, 50081) performed by two high volume endourologists at our institution from January 1, 2019 through December 31, 2019, excluding those cases with other concurrent procedures. Operative supply costs were calculated using our institution's internal cost data, which for proprietary reasons may only be reported as percentages of total case cost. We also examined each surgeon's case preference card. Costs were compared using Student's t‐test.
Results: A total of 105 PNLs were identified. Case preference card costs between the two surgeons were nearly identical, differing materially only in that Surgeon B had a percutaneous access needle open. On a per‐item basis, the most costly items were lithotripters, laser fibers, baskets, and balloon dilators, representing 24.7%, 16.0%, 6.3%, and 7.6% of average case cost, respectively. Items were “wasted” in 14 (13.3%) cases, accounting for 1.2% of total cost for all cases. On average, cases performed by surgeon A were 27.3% more costly than surgeon B (p < 0.01) and had twice the cost variance. Compared to surgeon B, surgeon A had greater costs associated with lithotripters (t 3.90, p < 0.01) and access sheaths (t 10.5, p < 0.01). There was no significant difference between the surgeons in stent, laser fiber, or “wasted” item costs.
Conclusions: The majority of supply costs in PNL were from one‐time use instruments. Variability in cost was primarily associated with need to use additional lithotripters during cases, as well as by technique using an access sheath to aid in percutaneous access under direct vision. Our study provides important information to surgeons, which will allow them to make the informed changes to their practice in the future.
Does Endourology Fellowship Training Affect Outcomes for Percutaneous Nephrolithotomy?
M Rudoff, P Domenig, J O'Connor, P Hurley, D Wenzler
Michigan State University College of Human Medicine
Introduction & Objective: t is naturally assumed that the more a surgeon or trainee does a procedure, the better they are at it. One procedure that is particularly difficult is percutaneous stone procedures. These have historically poor stone free rates. We sought to determine differences in percutaneous nephrolithotomy (PCNL) outcomes between a fellowship‐trained endourologist and two urologists who are not fellowship trained over a three year period.
Methods: After IRB approval, we performed a retrospective review of all PCNL procedures performed at our institution from September 2014 through August 2018. These were exclusively performed by one of three urologists; one of whom (Surgeon A) had completed endourology fellowship training and two (Surgeons B and C) who had not. We then examined the charts for operative time, abortion rate, length of stay, stone free rate, complication rate, and reoperation rate.
Results: Comparing intra and peri‐operative parameters between Surgeons A, B, C in cases without preoperative percutaneous access there are comparable outcomes in case abortion rate due to inability to gain access. When comparing cases with intraop access versus those with preoperative access the stone free rate was greater (45.3% vs 40.0%), reoperation rate lower 54.6% vs 60.0%) and rate of complication the same (16.0%). Surgeon A mean stone diameter (3.76cm) was the greatest compared to 2.93 cm and 2.94 cm respectively for Surgeon B and C. Operative times were significantly less compared to cases without preoperative access.
Surgeon A had the lowest 60 day reoperation rate (45.5%) and LOS (1.45 days) but longest mean operative time (152min) as well as more frequent Clavien III+ complications (27.3%). Stone free rate for Surgeon A, B, C was 42.9%, 33.3% and 36.4% respectively. Compared to Surgeon B and C combined, Surgeon A had an overall lower stone free rate (36.4%),
Conclusions: Although Surgeon A is fellowship trained and personally obtained percutaneous access in the majority of cases there was an increase in operative time and complication rate. This may be due to overall greater stone diameter and case complexity. There was an improvement in stone free and reoperation rates. When access is gained intra‐operatively there is improvement in stone free rate and reoperation rate without an increase in complications indicating it may be best for surgical outcomes to obtain access at the time of the procedure.
Predictors of Second Look Flexible Nephroscopy after Percutaneous Nephrolithotomy
JC Dai, HD Kominsky, V Kommidi, H Trivedi, BA Johnson, JA Antonelli, MS Pearle
Evergreen Health
Introduction & Objective: Second look flexible nephroscopy (SLFN) after percutaneous nephrolithotomy (PCNL) enhances stone free rates. We routinely perform SLFN in most patients with residual fragments (RF) >2 mm. We sought to identify characteristics associated with SLFN.
Methods: After obtaining institutional review board approval all PCNL patients at our institution from 1/2016‐5/2020 were reviewed retrospectively. Demographics, patient and stone characteristics and perioperative data were extracted from the electronic medical record. Patients with RF on post‐operative day #1 CT after PCNL who underwent SLFN were compared to those who did not. Chi‐square and Mann‐U Whitney tests were used for categorical and continuous variables, respectively. Multivariable logistic regression analysis (MVA) was performed to identify independent factors associated with SLFN
Results: 368 patients underwent PCNL during the study period, 247 (67%) of whom underwent SLFN. Among the those not undergoing SLFN (n = 121), 40 patients had RF (median 4 mm, IQR 2‐7) and 81 patients were stone‐free. The median size of the largest RF was larger in those who underwent SLFN (median 5 mm, IQR 3‐8) compared to those who did not (median 3 mm, IQR 2‐5, p < 0.001). There were no significant differences between those who did and did not undergo SLFN with regard to demographics (all p > 0.05), median BMI (p = 0.31) or ASA class (p = 0.51). Patients undergoing SLFN had a longer time interval from presentation to procedure (median 46 days vs 34 days, p = 0.003) and were more likely to have larger stones (median 41.4 mm vs 30 mm, p < 0.001), bilateral stones (p < 0.001), any staghorn configuration (p < 0.001), and predominantly non‐renal pelvis stone locations (p = 0.002). Additionally, SLFN patients had longer operative times (median 158 min vs 115 min; p < 0.001) and greater blood loss (median 200 vs 100 cc; p < 0.001) at initial PCNL. On MVA, bilateral stone burden, lower pole partial staghorn calculi, and greater intra‐operative blood loss were independent predictors of need for SLFN (Table 1).
Conclusions: Patients with larger and bilateral stones and those experiencing greater blood loss are more likely to undergo SLFN for RF. With operative time at a premium at most institutions, knowledge of these factors may streamline the scheduling of SLFNs.
Systemic vs In‐Irrigation Tranexamic Acid in Percutaneous Nephrolithotomy: A Bayesian Network Meta‐Analysis and Meta‐Regression
DE Hinojosa‐Gonzalez, BK Somani, D Olvera‐Posada, B Eisner
Massachusetts General Hospital
Introduction & Objective: Percutaneous nephrolithotomy (PCNL) is the standard of care for the treatment of large renal stones. Transfusion risk and other bleeding‐related complications are a major concern of PCNL. Tranexamic acid(TXA) has been studied as systemic(TXA‐S) or irrigation fluid(TXA‐I) in endourology as a method for reducing risk of bleeding complications.
This study aims to compare the effectiveness of irrigation and systemic TXA in reducing bleeding, transfusion and complications in PCNL
Methods: In February 2022, randomized controlled clinical trials on tranexamic acid as either systemic therapy or in irrigation fluid were identified. A Bayesian network was built using results from these studies to create models used to run 200000 Markov Chain Monte Carlo iterations. Results are reported as Mean Difference(MD) or Risk Ratio(RR). Treatments were ranked using Surface Under the Cumulative Ranking Curve(SUCRA)
Results: Ten RCTs were included. Eight RCTs compared TXA‐S vs placebo, 1 TXA‐I vs placebo and 1 TXA‐I vs TXA‐S. These provided a total of 1,761 patients of which 678 patients received TXA‐S, 280 received TXA‐I and 803 received placebo. TXA‐I had lower risk of transfusion (RR 0.63[0.47,0.84], SUCRA 0.950) than TXA‐S (RR 0.79[0.65,0.95] SUCRA = 0.545). TXA‐I had lower risk of complications (RR 0.38[0.21,0.67] SUCRA = 0.957 compared to TXA‐S (RR 0.55[0.39,0.78] SUCRA = 0.539. TXA‐I had lower postoperative decrease in Hb (MD ‐1.2[1.3,1.0] SUCRA = 0.849 compared to TXA‐S (MD‐0.97[‐1.0,‐0.93] SUCRA = 0.646].
Conclusions: Tranexamic acid regardless of route of administration is an effective intervention at decreasing bleeding, postoperative complications and risk of transfusion. TXA‐I appears to be more effective at decreasing risk of complications, transfusions and bleeding than TXA‐S. Further studies directly comparing these interventions are needed to validate these findings.
Safety and Feasibility of Percutaneous Nephrolithotomy (PCNL) in Septuagenarians and Older
L Mokool, C McCollum, S Nalagatla
University Hospital Monklands
Introduction & Objective: Urolithiasis is common with a prevalence between 5% – 9% in Europe. As life expectancy has increased so has the incidence of elderly patients undergoing treatment for urolithiasis and conservative management is no longer accepted as standard practice given the high risk of urinary tract infection. PCNL is currently the gold standard treatment for calculi larger than 2cm. In this study we aim to investigate the feasibility of PCNL as a management option for elderly patients with renal calculi.
Methods: A retrospective study of all PCNLs performed by a single consultant urologist from November 2009 to February 2020. Electronic records were analysed and patient demographics, imaging and operative data collected. Primary outcomes included length of stay, stone clearance rates and complications.
Results: A total of 73 patients were included in the study. The mean age was 75 and oldest patient was 89. PCNLs were performed for staghorn stones, 2 for encrusted stents, and the rest for either large renal pelvic, calyceal or multiple stones. There were no intra‐operative complications encountered in all 73 cases, however post‐operative complications were reported in 28 patients. Majority of complications (23) were defined as clavian dindo I or II. 1 mortality was reported in the 11 year study period. Age group and age‐adjusted Charlson Comorbidity Index (CCI) score did not have a statistically significantly impact on complication rates; p values of 0.3 and 0.4 respectively. Complete stone clearance was achieved in 59 cases with no statistical difference between age (p 0.6) or CCI (p 0.5). Complication and stone clearance rates were comparable to literature review.
Conclusions: PCNL is feasible in the over seventies population, however given increase in post operative sepsis more aggressive treatment and consideration of infection should be employed, especially when counselling patients. Careful planning and patient selection is essential as these elderly patients will have less physiological reserve to cope with potential complications compared to a younger population.
Stone Drainage during Supine and Prone Percutaneous Nephrolithotomy ‐ A Randomized Controlled Trial
R Perrella, F Vicentini, E Leite, G Marchini, F Torricelli, A Danilovic, C Batagello, P Mota, D Ferreira, D Cohen, C Murta, J Claro, W Nahas, E Mazzuchi
Division of Urology, HMASP, Sao Paulo, Brazil
Introduction & Objective: Percutaneous nephrolithotomy (PCNL) has been accepted as a good option for treating kidney stones in either supine or prone position. However, there are some concerns regarding the real advantages of supine position, and one of these could be better drainage of fragments, due to the gravitational effect.
The aim of this study is to prospectively evaluate the impact of patient position on the stone volume reduction.
Methods: A randomized controlled study of 112 patients scheduled to PCNL for complex kidney stones (Guy's Stone Score 3 or 4) from 2018 to June 2020. Patients were divided in 2 groups according positioning during PCNL: supine (SUP) in Bart´s Flank Free modified position or prone (PRO) position. All other surgical aspects were the same between groups. The variables analyzed were demographic (gender, age, body mass index (BMI), ASA score, Guy's Stone Score – GSS and Stone volume), operative (nephroscopy time) and success (immediate success evaluated on first postoperative CT, and stone volume reduction by nephroscopy time). A p‐value of <0.05 was considered statistically significant.
Results: We studied a total of 112 patients. The demographic and the baseline characteristics were comparable in both groups (Table 1). SUP had similar immediate success than PRO (62.5% vs 57.1%, p = 0.563), and had higher intraoperative stone clearance (stone volume reduction by nephroscopy time) (94.8 vs 67.8; p = 0.003, mm3/min) (Table 2).
Conclusions: In this randomized study, supine position showed higher stone volume reduction by nephroscopy time. This could lead to lower operative time and lower complication rates, important in complex cases, in complications are more frequent.
Impact of the Patient Positioning on Intrarenal Pressure during Percutaneous Nephrolithotomy – A Prospective Randomized Trial
R Perrella, M Turco, C Batagello, D Ferreira, P Mota, D Cohen, C Murta, J Claro, F Vicentini
Division of Urology, HMASP, Sao Paulo, Brazil
Introduction & Objective: (PRO) has been traditionally used, but in recent years the use of supine position (SUP) has increased globally. Both techiniques are efficient with similar success rates, but the most recent data shows a higher risk of fever and infectious complications in PRO. A possible cause could be an increased intrarenal pressure. The aim of this study was to evaluate the intrarenal pressure during prone and supine PCNL.
Methods: A randomized prospective controled analysis of 32 consecutive patients submitted to PCNL, from November 2020 to August 2021, including patients with non complex stones (Defined as Guys Stone Score 1 or 2). Were excluded cases were the ureteral catheter did not reach the renal pelvis. The variables analyzed were demographic (gender, age, body mass index (BMI), ASA score, Guy's Stone Score, and stone diameter), intrarenal pressure, and time of intrarenal pressure over 30 cmH2O (considering renal access, tract dilation and stone fragmentation). Intrarenal pressure was measured with an urodinamic device attached to the open ended uretheral catheter. Categorical outcomes were compared using Fisher's exact test or the chi‐square test. The means of continous outcomes were compared using the Student's t‐test or the Mann‐Whitney test. Statistical significance was set at p < 0.005.
Results: The demographic characteristics were comparable (Table1). Intrarenal preassure during renal access and during dilation was similar between groups (Table 2). During navigation and stone fragmentation intrarenal pressure and time of intrarenal pressure over 30 cmH2O were higher in PRO: 31.5 cmH2O (27.0 – 33.1) vs 38.6 cmH2O (35.5 – 41.0), p = 0.001; and 3.0 seconds (0 – 7.5) vs 32.5 seconds (20.0 – 58.0), p < 0.001 (Table 2).
Conclusions: During navigation and stone fragmentation iin PCNL, intrarenal pressure is higher in the prone position, this could lead to an increased pielovenous reflux and result in incread risk of infectious complications after PCNL.
Comparing Frailty Scores for Prediction of Complications after Percutaneous Nephrolithotomy in Elderly Patients
R Perrella, D Antunes, D Ferreira, C Batagello, P Mota, C Murta, J Claro, F Vicentini
Division of Urology, HMASP, Sao Paulo, Brazil
Introduction & Objective: Frailty is associated with higher risk of complications and worst outcomes aftersurgery. Literature data suggest that older patients subbmitted to percutaneous nephrolithotomy (PCNL) have the higher complication rates a longer hospital stay compared to younger patients, and the frailty accessment seems to be useful.
The aim of this study is to compare the predictive role of frailty scores for complications after PCNL.
Methods: Were studied 80 patients over 70 years old submitted to PCNL, between 2013 and 2021. The frailty scores used were the Modified 5‐item Fralty Index (mFI‐5), the G8 Geriatric Health Status screenig tool (G8), the Clinical Frailty Scale (CFS), and the Charlson Comorbidity Index (CCI). Variables analyzed were demographic (gender, age, body mass index (BMI), ASA score, Guy's Stone Score ‐ GSS), surgical parameters (Suprecostal access, mean operative time, hospitalization time) and complications (Clavien‐Dindo). The frailty scores were retrospectivelly applied and the area under the ROC curve (AUC) of the scores were compared to determine the most predictive frailty accessment.
Results: The demographic and surgical parameters characteristics were comparable between groups (Table1). Complications until 30 days after PCNL occurred in 32.5% of the patients. The G8 screening tool had greater accuracy to predict complications after PCNL (p = 0.003, AUC 0.698), better than mFI‐5 (p = 0.354, AUC 0.569), CCI (p = 0.522, AUC 0.544), and CFS (p = 0.1875, AUC 0.634) (Figure 1).
Conclusions: The G8 Geriatric Health Status screenig tool showed ability to predict complications after PCNL in patients over 70 years.
Predictive Factors for Hemorrhagic Complications after Percutaneous Nephrolithotomy – A Prospective Analysis
R Perrella, F Vicentini, E Leite, G Marchini, F Torricelli, A Danilovic, C Batagello, P Mota, D Ferreira, D Cohen, C Murta, J Claro, W Nahas, E Mazzucchi
Division of Urology, HMASP, Sao Paulo, Brazil
Introduction & Objective: Percutaneous Nephrolithotripsy (PCNL) is the gold standard to treat complex kidney stones. However there is still insecurity regards its complications. One of the most common complications is kidney hemorrhage. The aim of this study is to evaluate predictive factors for bleading complications after PCNL.
Methods: A prospective analysis of 112 consecutive patients submited to PCNL for complex stones, from May 2018 to June 2019. The variables analyzed were demographic (gender, age, body mass index (BMI), ASA score, Guy's Stone Score ‐ GSS), efficacy (number of punctures, calyx puncture site, supracostal access, mean operative time, hospitalization time) and safety (complications). All patients recieved tranexamix acid before surgery. Complex cases were defined as GSS 3 or 4 based on preoperative Computed Tomography (CT) scan analysis. Complications were graded according to the modified Clavien Classification. Univariate and multivariate analysis including all variables were performed to determine wich parameters were significantly important for haemoglobin drop.
Results: The demographic characteristics and the surgical parameters were presented on Table 1. The summary of complications is presented on Table 2, only 2 patients required transfusion after surgery. On univariate and multivariate analysis reanl parenchyma thikness (p < 0.001) and nephroscopy time (p = 0.012) influenced haemoglobin drop (Table 3). In a linear regression for each milimeter of renal parenchyma the haemoglobin drop was 0.0895 mg/dl, and for aech minute of nephroscopy the haemoglobin drop was 0.0081 mg/dL.
Conclusions: Renal parenchyma thickness and nephroscopy time are independent predictive factors for hemorrhagic complications after PCNL.
Optimization of Percutaneous Nephrolithotomy for a Free‐Standing Ambulatory Surgery Center: Outcomes from 1200 Cases
DC Rosen, M Drescher, NL Arias Villela, J Abbott, M Dunne, J Davalos
Introduction & Objective: Percutaneous Nephrolithotomy (PCNL) is frequently used as the primary treatment modality for patients with large stones or challenging anatomy. It has evolved from an inpatient procedure to one that is now routinely performed in the outpatient setting. We aimed to identify the patients who were able to be treated in a free‐standing ambulatory surgical center (ASC).
Methods: We analyzed patients who underwent PCNL or mini‐PCNL from 2015‐2021 by one of three surgeons. Patients were selected for ambulatory surgery if there was not a mandatory imperative for inpatient admission e.g. BMI >50 or severe cardiac or respiratory comorbidities. Patients were not excluded from the ASC based on stone burden or age. Generally, patients were administered an intercostal block and left with a double J stent at the end of the procedure and a foley catheter that was removed in the PACU. The tract was plugged with gelfoam/thrombin. Demographic, preoperative, and postoperative data was prospectively collected. Descriptive statistics were used for analysis.
Results: 1215 patients were available for analysis. Demographic and intraoperative characteristics of the patients are shown in Table 1. Operative technique progressed over time with the usage of primarily smaller percutaneous access sheaths (24Fr replacing 30Fr as standard, and the implementation of common usage of 17.5Fr mini sheaths for smaller stones). Patients were generally limited to a maximum of 2 access sites. 1.7% of patients required transfer to the hospital postoperatively.
Conclusions: PCNL can safely and routinely be done as an outpatient procedure with low risk of hospital transfer. Patients should be carefully selected for inpatient procedure and admission based on comorbidities and prior anesthetic complication history.
The Effect of COVID‐19 Pandemic on Stent Encrustations Requiring Percutaneous Surgical Intervention
C McCollum, M Alsawi, S Nalagatla
Monklands Hospital
Introduction & Objective: Stent Encrustation (SE) is a well‐recognised complication of ureteric stents and prolonged dwell‐time significantly increases risk. Covid‐19 has disrupted routine stent follow‐up and there is an anticipated rise in the incidence of SE requiring invasive intervention. Percutaneous Nephrolithotomy (PCNL) is indicted for severe proximal encrustation ( >1.5cm) or where ureteroscopy has failed. In this study we aim to investigate the effect of COVID‐19 delays and the efficacy of PCNL for removing severely encrusted stents.
Methods: A retrospective study of PCNL in a single health board between September 2017 and August 2021 was carried out. Operative database was examined and PCNL cases performed primarily for SE were included. Electronic records were analysed and patients' demographic, peri‐operative characteristics, operative, and post‐operative details were reviewed. Patients were dichotomised into two groups; those with PCNL performed before the UK national Lockdown of 23rd March 2020, and those performed after.
Results: 150 patients underwent PCNL between 1st September 2017 and 31st August 2021. In the pre covid period no PCNLs were performed for SE compared to 8 cases (27.6%) post lockdown. Most patients undergoing PCNL for SE were male (87.5%), mean age was 60 + 14.6 years, and the major indication for initial stent insertion was urolithiasis (70.5%). Average stent duration before re‐intervention was 9.8 months. 1 case (12.5%) proceeded directly to PCNL due to significant encrustation burden, the rest had failed initial ureteroscopic intervention. All encrusted stents were successfully removed at PCNL. 1 patient developed post‐operative fever and one patient developed post‐operative sepsis; both were defined as Clavien‐Dindo 2. No other post op complications were reported.
Conclusions: The covid‐19 pandemic has significantly impacted the incidence of SE requiring PCNL. Invasive intervention for the removal of encrusted stents comes with the risk of morbidity/mortality, and PCNL has a reported complication rate of 23‐80%. While follow up of ureteric stents is critical to avoiding complications, we have found PCNL to be a safe and effective means to remove SE that is severe, or that has failed ureteroscopic intervention.
Novel Robotic‐Assisted Electromagnetic Guidance for Precision Percutaneous Access: A Cadaveric Study of Novices versus an Expert
MR Humphreys, KM Wymer, BH Chew, J Zhen, F Elkhoury, S Sivalingam, M Dunn, M Borofsky
Mayo Clinic Arizona
Introduction & Objective: Percutaneous nephrolithotomy (PCNL) offers advantages over retrograde intrarenal surgery for large stone burdens. However, gaining optimal access into the renal collecting system can be challenging and requires advanced training. A minority of PCNL access is currently performed by urologists in the USA. The consequences of a suboptimal puncture and tract dilation can result in bleeding or the inability to treat stone burden efficiently or completely. This proficiency is developed over time and can be challenge for novices. In this study, we evaluate the success of gaining percutaneous renal access in a cadaveric model when using a novel robotic‐assisted electromagnetic (EM) guidance platform, compared to fluoroscopic guidance, among individuals that do not regularly perform their own PCNL access compared to experienced endourologists.
Methods: Seven novices (individuals who use IR for access, or gain percutaneous access <24 times/year, or have gained access <30 times after training) used robotic‐assisted EM guidance provided by the Monarch® Platform, Urology (Auris Health, Inc., Redwood City, CA) to obtain upper pole, mid kidney, and lower pole access in the supine position vs. the same tasks in a prone position using fluoroscopy in a cadaveric model. Measured variables were time to access, number of needle passes, fluoroscopy time and dosage, and the accuracy of access (location of the puncture). The novices were benchmarked against an expert ( >100 lifetime PCNLs including access) to contextualize the influence of the technology. Statistical comparisons were made using paired t‐tests.
Results: Successful access by the novices and expert was achieved in 100% of cases using robot‐assisted EM guidance in supine position, but only in 57% and 100% of cases, respectively, when using fluoroscopy in the prone position (Table 1). Time to access using fluoroscopy was 16.9 min vs 6.9 min (p < 0.05) using EM guidance for the novices, compared to <4 min with both methods by the expert. Mean number of needle insertions for the novices was 1.2 vs 3.0 (p < 0.05) with EM and fluoroscopy methods, and 1.0 vs 1.7 for the expert, respectively.
Conclusions: Robotic‐assisted EM‐guidance in the supine position offered a significant advantage to novices. It facilitated quicker and more accurate access to the renal collecting system with fewer attempts. These initial data suggest a potential to democratize the skill of gaining percutaneous access. Additional validation is needed to confirm the value of this tool to the surgeon's armamentarium.
Propensity‐Score Matched Analysis Comparing the Perioperative Outcomes of Supine vs. Prone Percutaneous Nephrolithotomy
R Babaoff, G Creiderman, R Gilad, A Darawsha, Y Erlich, D Lifshitz
Department of Urology, Rabin medical center
Introduction & Objective: To compare the perioperative outcomes of supine and prone percutaneous nephrolithotomy (PCNL) for kidney stones.
Methods: A retrospective propensity‐score matching analysis of perioperative outcomes in patients who underwent supine and prone PCNL between September 2015 and July 2020. Demographics, baseline clinical parameters, and stone burden were included as predictors in a logistic regression model generating a set of propensity scores. Operative time, perioperative complications, system complexity, and stone‐free rates were compared between the matched groups.
Results: A total of 517 patients who underwent PCNL in the supine (n = 91) and prone (n = 426) positions were included, of whom 140 patients were matched 1:1 based on their propensity scores. Matched cohort analysis showed a significantly shorter operative time (85.5 ± 25.2 vs 96.4 ± 25.8 min, p = 0.012) for supine PCNL. Low‐grade complexity systems were the most common (Grade I‐II: 85.6 vs 88.6%) in the supine and prone PCNL groups respectively, without a significant difference between all grade groups (p = 0.749). No significant differences were found in the perioperative complications rates (8.6 vs 4.3%, p = 0.301) and stone‐free rates (74.3 vs 65.7%, p = 0.356) between the supine and prone PCNL groups, respectively.
Conclusions: We used propensity‐score matching to compare the two treatment groups adjusting for selection bias. Supine PCNL demonstrated shorter operative time with no significant difference in complication rates and stone‐free rates between the two groups.
Comparison of the Efficacy and Safety of Percutaneous Nephrolithotomy and Retrograde Intrarenal Surgery for Single Renal Pelvis Stone Between 20 and 25mm in Size: Multicenter KSER Research Series
S Yang, K Choi, K Shim, W Kim, D Kim, S Paick, S Jeon, J Lee
Department of Urology, Chungnam National University College of Medicine, Daejeon, Korea
Introduction & Objective: Guidelines recommend that retrograde intrarenal surgery (RIRS) can be performed if percutaneous nephrolithotomy (PCNL) or shock wave lithotripsy is not possible for treatment of stones >2 cm. Thus, we compared the clinical outcomes and complications following PCNL and RIRS for single renal pelvis stone between 20 and 25 mm in size.
Methods: Total 2,127 patients who underwent surgery for kidney stones in 6 hospitals between January 2016 and December 2020, were examined retrospectively. Of these, 168 patients who underwent PCNL (104) and RIRS (64) with a maximal renal pelvis stone diameter of 20 to 25 mm were included in the study. Demographic data and operative outcomes were investigated. Success was defined as the absence of residual fragments larger than 4 mm.
Results: The mean operation time was similar between the both groups. The postoperative mean hemoglobin (P < 0.001) and hematocrit drop (P = 0.003) of the RIRS group were significantly lower than the PCNL group. Blood transfusions were required in 10 patients in the PCNL group and 0 patient in the RIRS group. Postoperative fever control was required in 25 patients in the PCNL group and 4 in the RIRS group (p = 0.003). Postoperative complication rates in PCNL group were higher, but the differences were not statistically significant. Hospitalization time was significantly shorter in the RIRS group (1.7 ± 1.0 vs 5.5 ± 3.8 days; P < 0.001). PCNL group showed higher efficacy (89%) in comparison with RIRS group (70%) in operation success rate (P = 0.002) (Table 1).
Conclusions: While PCNL group showed superior operation success rate, RIRS achieves acceptable operation outcomes with a high safety and low hospital stay. RIRS can be considered as an alternative option to PCNL for management of single renal pelvis stone between 20 and 25 mm in size. However, if RIRS is considered as the first treatment for renal stones larger than 20 mm, the explanation for second stage treatment can be necessary.
Efficacy and Safety of Kumpe Access Catheter for Pre‐Percutaneous Nephrolithotomy Renal Access in Modified Supine Percutaneous Nephrolithotomy
B Kim, J Park, J Chung, Y Ha, S Choi, J Lee, H Kim, T Kim, E Yoo, T Kwon, J Kang
Department of Urology, School of Medicine, Kyungpook National University
Introduction & Objective: Traditionally, percutaneous nephrostomy (PCN) using pig‐tail catheter was preferred for a pre‐percutaneous nephrolithotomy (PCNL) renal access. However, it can sometimes cause difficult situation for guidewire passage down to ureter and access tract loss can even occur during supine PCNL. For this reason, Kumpe Access catheter (KMP) has been recently used as a pre‐PCNL nephrostomy for easier guidewire passage to ureter during tract dilation at our institute. In this study, we aimed to analyze the efficacy and safety of KMP as a pre‐PCNL nephrostomy for the surgical outcomes of PCNL and compared with those of PCN.
Methods: From July 2017 to December 2020, a total of 232 patients underwent modified supine PCNL in a single tertiary center. Patients who underwent bilateral operation, multiple punctures or combined operation were excluded and 151 patients were enrolled in this study. Pre‐operative renal access was performed by two radiologists and pre‐PCNL nephrostomy catheter was selected by preference of each radiologist (Radiologist A: PCN and Radiologist B: KMP). All patients were divided into 2 groups according to the type of pre‐PCNL nephrostomy catheter and patients' characteristics and surgical outcomes, including stone‐free rate, operation time, radiation exposure time, and complications were compared.
Results: Of 151 patients, 53 patients underwent PCN and 98 patients underwent KMP insertion for pre‐PCNL nephrostomy. Patients' baseline characteristics were not significantly different between the two groups except the presence ratio of staghorn stone and multiple stones. Operation time, stone‐free and complication rate were not significantly different between both groups, whereas radiation exposure time was significantly shorter in KMP group.
Conclusions: Compared to the PCN, KMP insertion as a pre‐PCNL nephrostomy showed comparable surgical outcomes and shorter radiation exposure time during modified supine PCNL. This study demonstrated that it is feasible to place KMP for a pre‐PCNL nephrostomy, especially in terms of reducing radiation exposure time during surgery.
MP14: Clinical Stones: Ureteroscopy II
Ureteroscopy for Large Stone Volumes
N Coulthard, P Gravestock, M Shaw, A Rogers, A Moon, R Veeratterapillay
Newcastle upon Tyne Hospitals Foundation Trust
Introduction & Objective: To evaluate outcomes of patients undergoing ureterorenoscopy (URS) with large stone volumes.
Methods: Ureterorenoscopies performed for stone disease at the Freeman Hospital between 2015‐2019 were reviewed. Operation notes and/or preoperative imaging reports were interrogated and patients with a total unilateral stone volume of >1000mm3 from up to 3 contributing stones were included. Stone volume was calculated from CT measurements in the medial‐lateral, anterior‐posterior and cranial‐caudal planes. Stone free rates, post operative complications and re‐admission/re‐interventions were captured.
Results: 37 patients met the inclusion criteria. Median age was 67 (22‐86). 47% of patients had an ASA score of 3.
11 Patients had renal stones, 4 had ureteric stones and 22 had a mix of both. 57% (n = 21) had a single stone of >1000mm3 either solitary (n = 4) or alongside multiple calculi (n = 17). Mean total stone volume was 1946mm3 (1010‐6126mm3).
57% (n = 21) were admitted as an emergency prior to their URS, of these 95% were stented, 67% due to infection. The mean stent dwelling time prior to URS was 58 days (range 28‐111 days).
5 patients (14%) had post operative complications; UTI in 4 (11%), of which one was treated for sepsis on HDU and another required blood transfusion due to concomitant haematuria. A further patient was treated for pneumonia. 3 patients (8%) re‐attended within 30 days, 1 of which required admission for emergency stent reinsertion and 2 with stent symptoms were reviewed and discharged.
The number of URS performed per patient ranged from 1‐3 with 70% (n = 26) having only one treatment, the mean number of URS performed per patient was 1.37.
41% of patients (n = 15) were found to be completely stone free at initial radiographic follow up. 59% were stone free or had fragments of ≤3mm.
For those not stone free subsequent treatment included PCNL (n = 1), and surveillance (n = 21). Of those under surveillance 3 underwent repeat URS >1 year following their initial procedure (mean 775 days).
Conclusions: Whilst the indications for flexible URS are expanding, a large stone burden of >1000mm3 is associated with reduced stone clearance and increased need for repeat intervention. Patients should be carefully counselled regarding this.
Higher Case Volume and Endourology Fellowship Training are Associated with Improved Surgical Outcomes for Ureteroscopy: Internal Review of Providers in a Large Urban Health System
M Levy, C Chin, KA Moody, D Qian, S Hess, L Butler, M Palese
Icahn School of Medicine at Mount Sinai
Introduction & Objective: Surgical experience is associated with improved outcomes for complex urological procedures such as prostatectomy and nephrectomy. We investigated how physician experience affects outcomes for ureteroscopy (URS), a less complex minimally invasive procedure.
Methods: Medical records of patients who underwent URS between 2017‐2019 from providers at our health system were retrospectively reviewed. Surgical outcomes were compared based on physician case volume (< 19, 20 – 49, > 50 URS per year) and endourology fellowship training. Outcomes included operative time (OPT), length of stay (LOS), perioperative complications (PC), 90‐day ED visits and hospital readmissions (ED; HR), re‐operation rate (RO), stone free rate (SFR), and percentage of stone remaining (%SR). Multivariate analysis identified predictors of outcomes: age, gender, BMI, ASA score, smoking status, total stone burden, rate of lower pole involvement, case volume, and endourology fellowship. Outcomes were compared between groups based on case volume, and endourology fellowship.
Results: 415 records from 15 urologists were reviewed. Multivariate analysis showed higher case volumes and endourology fellowships to be significant predictors of greater SFR, (OR: 1.98, 95%CI 1.26 ‐ 3.16, OR: 3.64, 95%CI 1.66 ‐ 8.51) and lower %SR (OR: ‐0.08, 95%CI ‐0.12 ‐ ‐0.03, OR: ‐0.13, 95%CI ‐0.20 ‐ ‐0.05). Fellowship training also predicted fewer PC (OR: 0.17, 95%CI 0.01 – 0.86) and ED complications (OR: 0.30, 95%CI 0.09 – 0.81). Urologists with > 50 URS per year had a greater SFR (p < 0.001), lower %SR (p = 0.022), fewer ED complications (p < 0.001) and decreased OPT (p = 0.019,) compared to those with < 49 URS per year. Similarly, fellowship trained urologists had a greater SFR (p < 0.001), lower %SR (p = 0.013), fewer ED and HR complications (p = 0.026, p = 0.030), and a decreased OPT (p = 0.023) compared to non‐fellowship trained urologists. There was no difference in stone burden or rate of lower pole involvement in either analysis [Table 1].
Conclusions: This data suggests that more experienced physicians as defined by case volume and endourology fellowship have improved perioperative and post‐operative outcomes for URS. Though URS is a common and less complex minimally invasive surgery, it is important to recognize the value of physician experience on surgical outcomes.
Thulium Fiber LASER (TFL) vs Holmium LASER (HOL) for Kidney Stones in RIRS (Retrograde Intrarenal Surgery): A Randomised Controlled Trial
A Singh
Muljibhai Patel Urological Hospital Nadiad
Introduction & Objective: Aims and Objective: To compare the use of Thulium LASER fiber (TFL) with holmium LASER (HOL) in RIRS .
Methods: Materials and methods: It was a prospective , randomised, single centre study and included 62 patients with stone size between 1‐2 cm. Urolase‐SP 50 watt and Sphinx Junior 30 watt Holmium LASER machines were used in arm1 (TFL) and arm 2 (HOL) respectively. A 9Fr IndoscopeTM , 11/13 access sheath and 200 micron laser fiber was used in both groups. Laser energy settings in arm 1 were 0.05‐1 J energy and 50‐300 HZ frequency. In arm 2 , 0.2‐2 J energy and 10‐40 HZ frequency was used. Variable's analyzed included patient demographics , stone volume , operative time, lasing time, pain and complications. Primary end point was to compare the fragmentation rate. Secondary end point was to compare stone clearance rate and complications. Patients were followed up at 24 hours and 30 days with Xray KUB and USG KUB.
Results: Thirty patient in each group were included for analysis. Volume of the stone was significantly more in the arm 1 (503.05 ± 424.29)HU as compared to arm 2 (247.91 ± 227.01)HU (p value: 0.005). Stone Fragmentation rate was significantly faster (p: 0.003) in the TFL group(66.12 ± 46.05)mm3 as compared to the Holmium group(33.71 ± 31.79)mm3.
Complications were comparable and stone free rate was 86.6% in both the groups (26/30) .
Conclusions: The stone fragmentation rate for TFL ( Urolase ‐SP 50 watt) is more than 30 watt Holmium LASER in the settings of RIRS.
Ureteroscopy vs. Shockwave Lithotripsy for Lower Pole Renal Stones: Treatment Variation and Outcomes in a Surgical Collaborative
J DiBianco, S Daignault‐Newton, E Stockall, S Hiller, H Joon Kim, H Pimentel, C Dauw, K Ghani, f Surgery Improvement Collaborative
University of Michigan
Introduction & Objective: American Urological Association guidelines recommend ureteroscopy (URS) or shockwave lithotripsy (SWL) for lower pole (LP) renal stones ≤1cm, and URS for stones >1‐2cm. However, data guiding these recommendations are from select centers. We examined treatment variation, unplanned healthcare utilization and stone‐free rates (SFR) in the diverse practices comprising the Michigan Urological Surgery Improvement Collaborative (MUSIC).
Methods: Using the MUSIC registry we identified URS and SWL cases for LP stones ≤2cm from 2016‐2021. We assessed practice and surgeon frequency of performing URS or SWL. A treatment modality was considered favored if the procedure rate was >50%. Emergency department (ED) visits, hospitalization and SFRs were assessed according to stone size (≤1, >1‐2cm).
Results: 3,645 procedures were performed across 35 practices and 209 surgeons; 1358 (37.3%) URS and 2287 (62.7%) SWL. 80.2% of stones were ≤1cm. There was practice variation in performing URS (0 to 100%; p < 0.001) and SWL (0 to 100%; p < 0.001). 74.2% of surgeons favored SWL; 10% performed SWL, and 5.7% URS exclusively (Figure). For stones ≤1cm, ED visits (9.5% vs 2.5%, p < 0.001) and hospitalizations (3.5% vs 0.4%, p < 0.001) were higher after URS, as were SFRs (URS 56.4% vs SWL 38.8%; p < 0.001). There were no significant differences between URS and SWL for ED visits, hospitalizations, or SFRs, for >1‐2cm stones. Multivariable analysis revealed significantly increased odd of having an ED visit and being stone‐free for all LP stones ≤2cm and ≤1cm treated with URS (Table).
Conclusions: In Michigan, SWL is the favored treatment modality for LP stones ≤2cm. Over 15% of surgeons used one modality exclusively. URS provided better SFRs but with a 4‐fold increase in ED visits and hospitalization for stones ≤1cm but no difference for >1‐2cm stones. Our findings demonstrate the need for quality efforts to address treatment selection and improve outcomes.
Do Outcomes of Ureteroscopy and Laser Stone Fragmentation (URSL) in Patients with Morbid Obesity Match up to Non‐Obese Patients: Prospective Comparative Analysis over a 10 Year Period
V Massella, F Ripa, A Pietropaolo, M Mani, BK Somani
University hospital Southampton
Introduction & Objective: Obesity is a recognised risk factor for stone disease. We analysed the effect of morbid obesity in the outcomes of ureteroscopy and laser fragmentation (URSL) over a 10‐years period (March 2012‐December 2021).
Methods: We compared morbidly obese patients (BMI ≥40, group A) undergoing URS for stone disease to non‐obese patients (18.5< BMI <24.9, group B). We analysed and compared comorbidities, stone number, total length and location, anaesthetic risk (ASA grade), operative time, length of stay (LoS), complication rate (graded according to Clavein‐Dindo classification), pre and post‐operative eGFR and stone free rates (SFR). The analysis was performed on a prospective database in a single tertiary centre.
Results: 202 patients were included in the analysis (M:F 109:93, mean age:58), comprising of 29 and 173 patients in groups A and B respectively. Group A had more patients with multiple comorbidities (p = 0.007) and higher ASA grade (p = 0.005). There was no difference in prevalence of ureteric stones (34.2% and 42.3% in groups A and B, p = 0.62) and mean total stone length (17.3mm and 20.6mm in groups A and B, p = 0.75). The operative time was higher for group A (46.4 min vs 40.3 min, p = 0.26), with a median length of stay of <24 hours in both groups. Pre‐ and post‐operative renal function of group B was comparable, while it improved significantly post‐URSL in group A (mean eGFR difference of 4.3 ± 2.07 ml/min, p = 0.04). SFR was 89.3% and 90.6% (p = 0.74) in groups A and B respectively. While there were no complications in group A, there were 12 (7.2%) complications in group B.
Conclusions: Morbidly obese patients show multiple comorbidities and higher ASA score compared to non‐obese patients undergoing URS for stone disease. They required longer operative times, but SFR was comparable to normal weight patients. Renal function significantly improved after surgery and no
post‐operative complications were noted in this group suggesting that URSL is a safe and effective strategy in these patients with outcomes comparable to non‐obese group.
Cost Variation in Ureteroscopic Stone Management Throughout a Large Hospital System: Observations and Opportunities
WJ Brockway, P Anderton, P Lowry
Introduction & Objective: The lifetime incidence of renal stone disease is 13% in men and 7% in women. Technological advances have made ureteroscopy with laser lithotripsy one of the most common procedures performed by Urologists. Additional innovations have provided effective disposable instruments for stone removal including guide wires, access sheaths, baskets, stents, laser fibers, and disposable ureteroscopes. While making stone removal more effective, this advanced equipment increases cost. Urologists must become familiar with equipment costs and methods of reimbursement by insurance companies to maintain fiscal responsibility.
Our objective is to review the variation in insurance reimbursement across a six hospital system to highlight differences by company and even by individual hospital, and evaluate potential opportunities for cost savings.
Methods: Data was evaluated in a large central Texas Hospital system, and six individual hospitals with different contracting were included. Between 09/01/2017 – 08/31/2018, data was pulled from MIDAS, EPIC, and Project Manager. Only cases with a single CPT code, 52356, ureteroscopy with laser lithotripsy were included. 602 total cases were evaluated for supply cost by access sheath, stents, pharmacy cost (anesthesia), baskets, laser fibers, and guidewires. At one hospital, data was further analyzed by surgeon. Cost variation between the 6 hospitals was analyzed, and opportunity for savings were projected if all hospitals were on a single contract for lowest cost items.
Results: Significant variation in total cost and for each parameter was evaluated between the 6 hospitals under the same system. Additionally, variation between surgeons was significant between 9 individual Urologists at the largest of the hospitals.
Opportunity for cost savings was projected to be approximately $500 per case, or approximately $300,000 for the entire cohort of 602 patients.
Conclusions: Knowledge in variation in insurance reimbursement will help Urologists keep the cost of surgery under control. Urologists must be the driver in lowering unnecessary cost, and must perform fiscally responsible ureteroscopy while concurrently providing the best possible care for each patient.
Predicting Factors and Stone Free Rate of Impacted Ureteral Stones
T Oh, I Seo, S Park
Introduction & Objective: To evaluate predicting factors for impacted ureteral stone and describe stone free rates of ureteroscopic treatment for impacted compared with non‐impacted ureteral stones.
Methods: We retrospectively analyzed 179 patients who underwent ureteroscopic lithotripsy (URSL) for ureteral stones diagnosed by computed tomography (CT) between January 2019 and December 2020. Clinical and radiologic predictors of impacted ureteral stones were assessed using univariate and multivariate logistic regression analysis. Additionally, stone free rates of impacted ureteral stones and correlated factors were evaluated.
Results: All of 179 patients, 73(40.8%) patients were diagnosed with impacted ureteral stones. An impacted stone was defined as a through which a guidewire could not be passed at the ureter stone for URSL. The stone free rate was 71.2% for impacted stone, which is lower compared with 91.5% for non‐impacted stones (p < 0.001). Stone burden, hydronephrosis, C‐reactive protein (CRP), ureteral wall thickness (UWT) in patients with impacted ureteral stones was significant differences on univariate analysis. Multivariate analysis showed that stone burden, hydronephrosis, UWT (odds ratio 6.041, P < 0.001) were independent predictors of impacted ureteral stones. Additionally, preoperative percutaneous nephrostomy (PCN), stone burden, the using of flexible ureterorenoscope, hydronephrosis were independent predictors of affecting stone free rate for impacted ureteral stones.
Conclusions: The predictive factors such as stone burden, hydronephrosis, UWT may contribute to the preoperative diagnosis of impacted ureteral stone. Preoperative PCN and active using of flexible ureterorenoscope could be increase a stone free rate of ureteral impacted stone.
Predictors of Failed Access in Unstented Ureteroscopy
KN Morgan, H Possoit, C Frilot, Z Connelly, N Khater, A Gomelsky
LSU Health Shreveport
Introduction & Objective: While the AUA guidelines recommend against routine placement of a ureteral stent (PS) prior to ureteroscopy, PS is associated with higher stone free rates. The risk of failed access (FA) in unstented ureteroscopy ranges from 7.7%‐16%, with young females and those with prior ipsilateral stone surgery, narrow ureteral anatomy, and proximal ureteral stone location being at higher risk. Adjunct maneuvers utilized to overcome a narrow ureter have not been studied in this context. We aim to analyze the failure rate of unstented ureteroscopy and describe demographic and clinical predictors of FA.
Methods: We conducted an IRB‐approved, retrospective review of all unstented ureteroscopy procedures at our institution between January 2019 and June 2021. Pregnant women and those with non‐native bladders/urethrae were excluded. The primary endpoint was rate of FA, while secondary endpoints included demographic and procedural variables associated with FA. We also reviewed the operative record for adjunct (advanced) maneuvers used to improve access, including use of additional wires, access sheath placement, serial ureteral dilation, balloon dilation, use of a semirigid ureteroscope, and fiberoptic ureteroscope use. Statistical analysis was performed.
Results: Of the 407 ureteroscopy cases reviewed, there were 136 cases where unstented ureteroscopy was performed. Three of these cases were bilateral, and therefore 139 total renal units underwent ureteroscopy. Two of these patients underwent 2 unstented ureteroscopies during this time, bringing our number of patients to 134. Of these ureteroscopies, FA occurred in 21 (15.1%). FA was associated with procedures requiring multiple advanced maneuvers (p = 0.004). There was no association with race, sex, tobacco use, previous stone passage or intervention, diagnosis, surgeon, use of stiff wire or semi‐rigid ureteroscope, laterality, or stone/stricture/pathology location, or alpha antagonist use, as seen in Table 1 and Table 2.
Conclusions: Failed access occurred at a rate of 15.1% at our institution between January 2019 and June of 2021. Failure was associated with multiple different advanced maneuver attempts, indicating that anatomic complexity or irregularity is a chief predictor of FA.
Does Moses Technology Enhance the Efficiency and Outcomes of Regular Holmium Laser Lithotripsy? A Systematic Review and Meta‐Analysis of Comparative Studies
J Li, Q Wei, D cao
West China Hospital, Sichuan University
Introduction & Objective: Holmium laser lithotripsy is currently the optimum standard for surgical treatment of upper urinary calculi. This study aims to evaluate the clinical efficacy and safety of Moses compared with conventional holmium laser lithotripsy for the treatment of patients with upper urinary calculi.
Methods: This meta‐analysis complied with the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) criteria, and the study protocol was registered on PROSPERO (CRD42021292480). We conducted a systematic search using multiple databases (PubMed/Medline, Scopus, Web of Science, and ClinicalTrials.gov) until December 2021. Clinical trials comparing Moses and regular holmium laser lithotripsy were included. RevMan software v.5.4 was used for analysis.
Results: Four studies with 892 patients were included. There were no significant differences regarding stone‐free rate (mean difference [MD] 1.19, 95% CI 0.54, 2.56, p = 0.66), operative time (MD ‐9.31, 95% CI ‐21.11, 2.48, p = 0.12), fragmentation time (MD ‐1.71, 95% CI ‐11.81, 8.38, p = 0.74), total energy used (MD 1.23, 95% CI ‐0.44, 2.90, p = 0.15), auxiliary procedures (MD 0.38, 95% CI 0.08, 1.90, p = 0.24), and overall complications (odds ratio [OR] 0.70, 95% CI 0.30, 1.66, p = 0.42) between the groups. However, the laser working time (MD ‐0.94, 95% CI ‐1.20, ‐0.67, p < 0.001) of Moses technology was shorter than that of conventional technology.
Conclusions: Moses technology has similar outcomes to regular technology in terms of safety and efficacy. Given the higher cost of the Moses technology, further study is needed to determine whether there are benefits to this new technology.
Tubeless Ureterorenoscopy. Our Experience Using 120‐W Laser and Dusting Technique. Postoperative Pain, Complications and Readmissions
G Verhovsky, Y Yacobi, E Genessin, A Zisman, I Sabler
Shamir Medical Center
Introduction & Objective: Both double J stent (DJS) and ureter catheter (UC) drainage represent routine practice following ureterorenoscopy. In selected situations tubeless (T) approach is possible and safe. In tubeless cases we use sheathless dusting technique with Lumenis® MOSES Pulse™120H Holmium: YAG laser. We evaluated these three drainage subgroups, and compared postoperative complications, readmissions and pain.
Methods: Retrospective database of 269 consecutive patients that underwent primary ureterorenoscopy for treatment of upper urinary tract stones between October 2018 and August 2019. The cohort was divided according to post‐operative drainage as: T, UC and DJS. The choice as whether to leave or nor to leave drainage was left to the surgeon. Demographic parameters, stone location, number and burden, hydronephrosis grade, postoperative complications (fever, acute renal failure, obstruction of the upper urinary tract by stone street) were assigned, pain had been assessed by Visual Analog Scale (VAS) and use of analgesics by dose/case in each group.
Results: There were 70 (26%) T, 136 (50%) UC and 63 (24%) DJS cases. Patients that were drained with DJS had significantly higher stone burden, more severe obstruction and prolonged operative time. T and UC had same stone characteristics (table 1). Postoperative ER visits, readmissions, complications (table 1), VAS (table 2) and analgesic use (table 3) were significantly less in T group.
Conclusions: Tubeless approach is safe in selected cases. While DJS should be considered in complex cases, UC may be omitted since it does not appear to reduce immediate postoperative complications. Powerful laser dusting, may add to usefulness of postoperative drainage.Those fitted for tubeless procedure did better postoperatively in terms of analgesic use and complications, facilitating outpatient approach to upper urinary tract stones treatment and patient satisfaction
Are We Doing Enough Stent‐Free Ureteroscopies for Stones? A 3‐Year Review
E Hart, A Hashmi, F Kum, M Cynk, B Penev
Maidstone and Tunbridge Wells NHS Trust
Introduction & Objective: European Association of Urology (EAU) guidelines discourage routine ureteric stent insertion following uncomplicated ureteroscopy (URS) for stones. Temporary stenting is recommended in patients at greater risk of complications (ureteral trauma, ureteral stricture, residual stone fragments, bleeding, or single kidney). Despite this, practice is variable between centres. We assessed the frequency of stent insertion post‐URS at a single centre; compared Emergency Department (ED) re‐attendance following stented vs. stent‐free procedures; and explored the economic impact.
Methods: Retrospective review of all patients undergoing URS and laser stone fragmentation (LSF) for renal and ureteric stones during a 3‐year period.
Results: 334 patients underwent URS and LSF, of which 57.8% (192/332) had a ureteric stent inserted, and 42.2% (140/332) underwent a stent‐free operation. 5.2% of stented patients, and 8.6% of stent‐free patients returned to ED within 30 post‐operative days, most commonly for haematuria, ureteric/clot colic, or urinary tract infection. There was no significant difference in re‐attendance rate between stented and stent‐free patients (p = 0.22). Of the stented patients, 37.0% (71/192) had uncomplicated procedures documented, without a clear indication for stent insertion. The total estimated cost of stent placement and subsequent flexible cystoscopy stent removal in these patients was £15,007.
Conclusions: Stent‐free URS was not associated with a significantly increased re‐attendance rate at our centre, and those that did present most often had minor issues (Clavien‐Dindo I). Contrary to EAU guidelines, we appear to be inserting a greater number of stents following seemingly uncomplicated procedures. Limiting stent insertion in selected patients may reduce departmental expenditure, without incurring excess patient morbidity.
Treatment of Ureteric Stones with Lithoevo Device and Vapor Tunnel Tool
D Perri, M Maltagliati, L Berti, U Besana, C Buizza, S Micali, B Rocco, M Sighinolfi, C Sciorio, A Pastore, D Pushkar, A Govorov, J Romero Otero, G Bozzini
Sant'Anna Hospital Como
Introduction & Objective: The vapor tunnel (VT) technology is a result of the pulse modulation during holmium laser emission. This particular emission allows to reduce stone retropulsion. We present the outcomes of this new technology in the treatment of ureteral stones
Methods: 210 patients with ureteral stones were randomly assigned to holmium laser lithotripsy with or without VT technology (105 patients per group). The 35 W LithoEvo laser generator (Quanta System) was used for all cases. A 365 μm fiber was used in both groups. Energy and frequency settings were 1 J and 12 Hz. All procedures were performed by three experienced urologists. A ureteral stent was always positioned and removed 20 days later. We compared dusting time, total procedural time, and stone retropulsion, graded on a Likert scale from 0 (no retropulsion) to 3 (maximum retropulsion). We also compared postoperative ureteral lesions with the Posturetroscopic Lesion Scale (PULS), the success rates of the two techniques based on stone‐free rate at 1 month (defined as absence or presence of maximum 1 mm stone fragments at a computed tomography ‐scan) and postoperative ureteral strictures.
Results: The two groups were comparable in terms of age and mean preoperative stone size (1.1 vs 1.0 cm, p > 0.05). VT technology was associated with significantly lower dusting time (15.3 vs 9.7 minutes), total procedural time (37.2 vs 25.7 minutes), total delivered energy (19.9 vs 7.7 kJ) and retropulsion (Likert score 3 vs 0). Patients in the first group required stone fragments' retrieval with a Tipless Basket and presented a higher rate of PULS‐1 ureteral lesions than the VT group: 37 (35.2%) vs 8 (7.6%) patients. We registered six cases (5.7%) of postoperative ureteral strictures in the first group vs no cases in the VT group (p < 0.05). Stone‐free rate at 1 month was comparable between the two groups (88.6 vs 93.4%, p < 0.05).
Conclusions: The VT technology is associated with significantly lower dusting time and total procedural time, because of reduced retropulsion of the stone, which makes it more precise, quicker, and easier to perform. It also allows complete dusting with no need for fragments' retrieval, reducing ureteral lesions due to scratches on the ureteral wall
Determination of Stone Composition by Intraoperative Stone Characteristics: Can Urologists Predict Stone Composition and Make Stone Analysis Unnecessary?
S Hager, J Liao, TC Chang, S Conti
Stanford Medical Center
Introduction & Objective: Chemical stone analysis following surgery is recommended by the AUA and can cost approximately $450 per stone. We hypothesize that stone composition may be accurately predicted by surgeon identified, intraoperative visual cues. Our study reports on stone identification rates during ureteroscopic lithotripsy.
Methods: We retrospectively reviewed the charts of patients who underwent ureteroscopic lithotripsy at a single institution. Patients who had chemical stone analyses and prediction of the primary stone composition by the treating urologist based on intraoperative findings were investigated. Statistical analyses were performed to determine stone prediction agreeability with chemical analyses as well as correlations with and predictors of primary stone composition.
Results: We identified 101 procedures that met the inclusion criteria. Overall, there was moderate agreement between intraoperative prediction of the stone composition and definitive chemical analysis (Kappa value 0.559, p < .001). The prediction rates of calcium oxalate and uric acid were 86% and 100%, respectively (Table 1). Prediction of primary stone composition (0.633, p < .001) and stone Hounsfiled units (0.473, p < .001) were significantly correlated with chemical stone analysis (Table 2). Regression was then performed with significant correlates and was found to be a significant (p < .001) predictor of stone composition (Table 2). Prediction of a calcium based stone (p < .001) and Hounsfield units <500 (p < .05) were significant variables in the regression. A 100% positive predictive value was found when a calcium‐based stone was predicted and Hounsfield units were >750 or when stones were identified as uric acid.
Conclusions: Primary stone composition may be accurately predicted by experienced urologists using intraoperative visual cues. Combining clinical observations with other variables such as stone Hounsfield units can accurately predict of primary stone composition and potentially reduce healthcare expenditure associated with chemical stone analysis.
The Efficacy and Safety of Radiation‐Free Retrograde Intrarenal Surgery
B Kim, J Park, J Chung, Y Ha, S Choi, J Lee, H Kim, T Kim, E Yoo, T Kwon, J Kang
Department of Urology, School of Medicine, Kyungpook National University
Introduction & Objective: Retrograde intrarenal surgery (RIRS) has been commonly performed under the fluoroscopy guidance. Although fluoroscopy is necessary for safe and smooth procedure of RIRS, there is an increasing concern regarding the hazards of frequent radiation exposure to patients and surgeons. Thus, we established a technique for radiation‐free RIRS and retrospectively evaluated the efficacy and safety of radiation‐free RIRS for management of renal stone.
Methods: From January 2015 to December 2019, 462 patients who underwent RIRS for unilateral renal stone less than 2cm were enrolled in this study. The data was collected retrospectively and the patients were divided into two groups according to the usage of fluoroscopy during surgery. The patients' demographic data, operation time, hospital stay, complications, and stone‐free rate (SFR) were compared between fluoroscopy‐free and ‐usage groups.
Results: Of 462 patients, the initial consecutive 206 patients underwent RIRS under fluoroscopy guidance, and the other 256 consecutive patients underwent RIRS without fluoroscopy. The patients and stones characteristics were not statistically different between the two groups. Mean operation time was significantly shorter in fluoroscopy‐free group (103 ± 33.9 vs 110 ± 30.6 minutes, p = 0.022), while mean hospital stay (3.5 ± 2.0 vs 3.6 ± 2.5, p = 0.126), complication (18.4% vs 22.8%, p = 0.247) and stone‐free rate (85.2% vs 85.0%, p = 0.377) were not significantly different between both groups.
Conclusions: This study showed that there was no statically significant difference in stone‐free and complication rate after RIRS between fluoroscopy‐free and ‐usage groups. Radiation‐free RIRS can be safely and effectively performed with our established technique.
Retrograde Intrarenal Surgery Is a Safe Procedure in Severe Obese Patients: Is It Reality or Prediction? A Propensity Score‐Matching Analysis from RIRSearch Study Group
C Basatac, O Özman, H Çakır, □ Çınar, H Akgul, D Sıddıkoğlu, E Sancak, C Yazıcı, A Başeskioğlu, B Önal, H Akpinar
Demiroğlu Bilim University
Introduction & Objective: The aim of the study was to assess whether severely obese patients have an increased risk of complications during and after retrograde intrarenal surgery (RIRS).
Methods: The data of 639 consecutive patients undergoing RIRS for the treatment of upper tract urinary stones were analyzed retrospectively. The patients were divided into two groups according to their body mass index numbers (Group 1, < 35; Group 2, ≥35). The patients' demographics, stone characteristics, operative outcomes, and complication rates were compared between the groups. The primary objective was to examine whether the intraoperative and postoperative complication rates were higher in patients with a body mass index of ≥35 kg/m2.
Results: After matching of confounding factors, Group 1 comprised 135 patients, and Group 2 comprised 47 patients. The baseline characteristics were similar between the groups. There were no significant differences between groups for intraoperative complication rates (11.8% and 12.8%, respectively; p = 0.97). There was statistically significant difference in favor of Group 2 for postoperative complication rates (12.6% and 29.7%; respectively, p < 0.01), overall complication rates (22.9% and 38.2%; respectively, p = 0.02), mean operation time (56.15 vs 66.45 minutes; respectively, p = 0.01), and length of stay (1.4 vs 2.1 days; p = 0.03). Stone‐free rates (75.5% vs 85.1%; respectively, p = 0.17) did not differ between groups.
Conclusions: RIRS is an efficient and feasible treatment option for upper urinary tract stones in severe obese patients. However, higher possibility of postoperative, especially infectious, complication rates should be considered in these patients.
Risk Factors for Increased Stent‐Associated Symptoms Following Ureteroscopy for Urinary Stones
J Harper, H Yang, N Maalouf, JA Antonelli, A Desai, H lai, P Reese, G Tasian, H Wessells, H Al‐Khalidi, Z Kirkali, C Scales
Introduction & Objective: The USDRN STudy to Enhance uNderstanding of sTent‐associated Symptoms (STENTS) sought to identify risk factors for increased post‐ureteroscopic pain, urinary symptoms, and their interference with daily activities in a prospective multicenter observational cohort study.
Methods: Patients aged ≥12 years undergoing unilateral ureteroscopy with ureteral stent placement for stone treatment were enrolled at 4 U.S. clinical centers. Participants reported symptoms at baseline, on post‐operative days (POD) 1, 3, 5, at stent removal, and day 30 post‐stent removal using the Brief Pain Inventory short form and PROMIS measures for pain severity and pain interference, the Urinary Score of the Ureteral Stent Symptom Questionnaire, and Symptoms of Lower Urinary Tract Dysfunction Research Network Symptom Index (LURN SI‐10). Multivariable analyses using mixed‐effects linear models were implemented.
Results: 424 participants (396 adults) were enrolled. Median age (years) was 54 in adults and 15 in adolescents; 46.9% were female. Dominant stone location was ureteral in 56% and renal in 44% of participants. Mean ureteroscopy time was 39.7(SD ±24.8) min. There was a marked increase in pain and urinary symptoms from baseline to POD 1, with a gradual fall on days 3 to 5 and a decrease below baseline 30 days after stent removal. Regarding risk factors for postoperative symptoms, on multivariable regression analysis (Table), older age was associated with less postoperative pain intensity (p = 0.004). Having chronic pain conditions (p < 0.001), prior severe ureteral stent pain (p = 0.021), and depression at baseline (p < 0.001) were each associated with higher pain intensity. Neither stone location, ureteral access sheath use, nor stent size were associated with average pain intensity, pain interference, or urinary symptoms.
Conclusions: In this well‐characterized and multicenter prospective cohort, despite pain intensity decreasing over time, interference due to pain remained elevated. Patient characteristics such as depression, rather than surgical factors, impacted symptom severity. These findings provide a foundation for patient counseling and highlight potential targets for future efforts to mitigate the burden of stent‐associated symptoms.
Does Drainage Method After Flexible Ureteroscopy for Renal Stones Affect the Treatment Outcomes or Quality of Life?
AA Elsawy, N El‐Tabey, M Zahran, A Shoma
Mansoura University
Introduction & Objective: To prospectively study the impact of different drainage methods after FURS on treatment outcomes and health related quality of life (HRQoL) using validated questionnaire.
Methods: A prospective study on adult patients who underwent FURS for renal stones was carried out. Drainage at the end of the procedure was done either by ureteral catheter or double J (DJ) stent according to surgeon decision. We compared the perioperative characteristics, surgical outcomes, and HRQoL using Short Form 36‐Item Survey (SF‐36) questionnaire among the two groups.
Results: Between January 2020 and July 2021, 340 FURS procedures were performed. Ureteral catheter and indwelling DJ stent were utilized as the drainage method at the end of the procedures in 162 and 178 patients, respectively. There were no significant differences in patients' demographics such as age, gender, body mass index, stone burden, and kidney criteria. Operative time, perioperative complications, post‐operative pain and stone free rate were comparable did not show any significant difference between the two groups (all less than <0.05). Furthermore, unplanned visits and hospital readmission did not differ significantly between the two groups (P = 0.09). Only 303 patients who showed favorable stone free status at POD1 CT assessment were included in the final analysis of HRQoL. Preoperatively, both groups were comparable in all domains of SF‐36 survey with improvement of all domains of SF‐36 survey post‐operatively. On multivariate analysis, ureteral catheter group showed significant improvement as regard to general health impression and social health interference subdomains when compared to the DJ group (p = 0.02).
Conclusions: Our study suggested that the drainage types after FURS using a DJ stent or ureteral catheter were equally safe and efficacious, but patients who received a ureteral catheter had better HRQoL.
WITHDRAWN
Is There a Concordance Between Surgeon's Expectations and Post‐Operative Imaging Evaluation in Stone Patients Treated with Ureteroscopy? Results from a Tertiary‐Care Referral Center
L Villa, E Ventimiglia, A Briganti, F Montorsi, A Salonia
Department of urology, IRCCS Ospedale San Raffaele, Milan, Italy.
Introduction & Objective: In the current study we aimed at a) evaluating the concordance between the stone‐free status of stone patients treated with URS estimated by the surgeon at the end of surgery (SFSs) and the stone‐free status at post‐operative imaging (SFSi) and b) identifying predictive factors for estimating the reliability of surgeon's expectations.
Methods: We identified 307 patients treated with URS for ureteral/renal stones from January 2015 to June 2021 at a single tertiary‐care referral center. SFSs was defined as follows: a)no residual fragments, b)clinically insignificant residual fragments (CIRF) expected to pass spontaneously, c)relevant residual fragments. US, US+KUB or CT scan were used to evaluate the surgical outcome one month after surgery. Concordance of SFSi was defined as the confirmation of SFSs results (in this setting, CIRF were considered any residual fragments < = 3 mm). Descriptive statistics and Chi‐square test were used to detail patients' characteristics and to assess SFSi concordance. Uni‐ and multivariate logistic regression analyses (UVA and MVA) tested the impact of patients' characteristics (stone size, stone location), surgeon's experience and imaging technique on the rate of SFSi concordance according to the different SFSs.
Results: At the end of surgery, 137(44.6%), 108(35.2%) and 62(20.2%) patients were considered stone‐free, remained with CRF and had relevant residual fragments, respectively. One month after surgery, 187(60.9%), 40(13%) and 80(26.1%) patients were studied with US, US+KUB and CT scan, respectively. Overall, SFSi concordance was observed in 69.1% of the patients.
SFSi concordance in stone‐free (n = 137) and CIRF (n = 108) patients at the end of surgery was observed in 71(74%), 16(84,2%) and 13(59,1%) and 52(75,4%), 7(50%) and 11(44%) patients investigated with US, US+KUB and CT (p = 0.1 and p < 0.01), respectively. At UVA and MVA, none of the factors resulted associated with the rate of SFSi concordance in stone‐free patients at the end of surgery. In CIRF patients, imaging technique (US/US+KUB vs. CT scan, OR = 3.3;95%CI = 1.2‐9.1), stone location (ureter vs. kidney, OR = 7.6;95%CI = 1.8‐32.2) and surgeon experience (prolonged vs. regular training, OR = 3.7;95%CI = 1.3‐10.7) were independent predictors of SFSi concordance (all p< = 0.02).
Conclusions: The rate of SFSi concordance is roughly 70%. Although nothing seems to predict the imaging results in patients considered stone‐free at the end of surgery, stone location, surgeon experience and the choice of imaging technique may help to evaluate surgeon's expectations in patients considered to have CIRF at the end of surgery.
Prolonged Endourological Training Is the Key to Improve Surgical Outcomes of Stone Patients Treated with Flexible Ureteroscopy. Results from a Tertiary Care‐Referral Center
L Villa, E Ventimiglia, A Briganti, F Montorsi, A Salonia
Department of urology, IRCCS Ospedale San Raffaele, Milan, Italy.
Introduction & Objective: The learning curve of flexible ureteroscopy (URS) is considered quite short (n = 50 procedures). The aim of our study is to evaluate the impact of a one‐year clinical fellowship on the surgical outcomes achieved in a tertiary care referral center.
Methods: We identified 307 patients treated with URS for ureteral/renal stones from January 2015 to June 2021 at our center. All the procedures were performed by experienced surgeons (more than 50 procedures). Of those, two of them had a one‐year clinical fellowship at a stone referral center (Tenon Hospital, Paris, France). Optimal surgical outcome (OSO) was defined as the presence of residual fragments < = 3mm at one month post‐operative imaging (US, US+KUB or CT scan). We divided patients in two groups: a)patients treated by the two long trained surgeons, b)patients treated by the others surgeons (n = 5).
Descriptive statistics and Chi‐square test were used to explore patients' characteristics and to compare the OSO of the two groups of patients, respectively.
Uni‐ and multivariate logistic regression analyses (UVA and MVA) tested the impact of patients' characteristics (stone size, stone location), surgical data (presence of DJ stent at surgery, operative time, the use of ureteral access sheath), surgeon's experience and imaging technique on the rate of SFR. Sub‐analyses were made dividing patients according to the stone size ( ≤13 mm vs. >13 mm).
Results: Mean (Inter‐Quartile Range) stone size was 13 mm (8‐15 mm). Out of 307 patients, 211 (68.7%) were operated by the two prolonged trained surgeons. The overall OSO was 61.6%. OSO was achieved in 137 (65.6%) and 50 (52%) of patients treated by the long trained and regular trained surgeons, respectively (p = 0.02).
At UVA, prolonged training (OR = 1.75;95%CI = 1.07‐2.86), stone diameter (OR = 0.92;95%CI = 0.88‐0.96), stone location (kidney vs. ureter; 0.35;0.21‐0.58), imaging technique (TC vs. US/US+KUB, OR = 0.27;95%CI = 0.16‐0.47) predicted OSO achievement (all p < 0.03).
At MVA analyses, prolonged training remained significantly associated with OSO (OR = 2.22;95%CI = 1.29‐3.82;p< 0.01), along with the others aforementioned variables.
At MVA sub‐analyses performed according to the stone size, the effect of prolonged training resulted more evident in patients with large stone ( >13 mm), with a 4.78‐fold high likelihood of achieving OSO compared to patients treated by a regular trained surgeon.
Conclusions: A one‐year clinical fellowship in a stone treatment referral center positively affect surgeons performance, especially in patients with a high stone burden, with an almost 5‐fold high rate of OSO achievement compared to surgeons supposed to have already completed their learning curve.
Comparative Analysis of Ureteral Stent Dwell Time and Unplanned Emergency Room Visits: A Multi‐Institutional Retrospective Study
D Wenzler, P Yang, C Mcclure, E Eshaghian, J Boura, C Dauw, K Ghani
Michigan State University College of Human Medicine
Introduction & Objective: Ureteral stents are commonly placed and often recommended following minimally invasive urologic procedures including ureteroscopy for treatment of nephrolithiasis. It has previously been reported that stent placement can result in irritative symptoms in approximately 80% of patients. Previous studies have demonstrated that symptoms experienced after stent placement can lead to increased emergency department visits after surgery. Furthermore, overcrowding of emergency rooms and rising costs have placed an enormous burden on the U.S. healthcare system. Currently there are no guidelines for the optimal stent duration. This study aimed to analyze stent duration and its relation to emergency room visits across multiple institutions.
Methods: Data from the Michigan Urological Surgery Improvement Collaborative's Reducing Operative Complications from Kidney Stones (MUSIC ROCKS) clinical registry and identified ureteroscopy cases for treatment of nephrolithiasis between 2010 and 2021. Categorical variables were examined with a combination of chi‐square tests and Fisher's exact tests. All continuous variables were examined with Kruskal‐Wallis tests.
Results: We reviewed 16,759 unilateral stent procedures. Of those, 3,796 patients were included for analysis. Groups were categorized as stent dwell time 0‐3 days (23.5%), 4‐6 days (47.4%) and >6 days (29.1%). Stent dwell time ≤3 days resulted in increased incidence of ED visits within two days after removal (11.6%) compared to other groups. Stent dwell time >3 days demonstrated less incidence of flank pain in the ED.
Conclusions: Stent dwell time ≤3 days resulted in increased odds of ED visits within two days of removal, with flank pain being the most common complaint. Our results suggest it may be beneficial to remove ureteral stents in the 4‐6 day period to prevent unplanned visits to the ER while minimizing duration of irritative symptoms.
Retrograde Flexible Ureteroscopy versus Antegrade Mini Percutaneous Flexible Ureteroscopy for Treating Impacted Proximal Ureteric Stones ≥10mm
O Elgebaly, H Abdeldayem, A Fahmy
Alexandria University Faculty of Medicine, Egypt
Introduction & Objective: The standard treatment of patients with large impacted proximal ureteric stones remains challenging and controversial; the aim of the study is to prospectively compare between the safety and efficacy of retrograde flexible ureteroscopy (Flex URS) versus antegrade mini percutaneous (miniperc) Flex URS in treating this category of patients.
Methods: The study was conducted on 80 patients admitted to the Urology Department in Alexandria Main University Hospital, presenting with impacted proximal ureteric stone ≥10mm. Patients were randomly divided into two equal groups, Group A were treated with retrograde ureteroscopy using Flex URS going up to the stone, while Group B were treated by antegrade miniperc ureteroscopy, were a 14F renal tract was obtained to pass a ureteric access sheath, then Flex URS was used going from upside downwards to the stone. Holmium laser (Auriga XL, Boston, Germany) was used for stone fragmentation. DJ was inserted in all cases. Follow up with non‐contrast CT was performed after one month.
Results:Table (1): Results of both groups
Both groups were comparable in terms of demographics, stone criteria and lithotripsy time. Stone free rate (SFR) was significantly higher in Group B due to better riding of the stone on the other hand fragment migration was the reason for the lower SFR in Group A. Tract formation for the mini percutaneous route in Group B was associated with significantly increased mean operative time and more radiation exposure and mean hospital stay. Both groups were comparable in terms of minor complications with no major complications, however IV analgesia was required more in Group B. Surgeons reported better visualization and more easy lithotripsy in group B using a subjective questionnaire.
Conclusions: Antegrade miniperc Flex URS is more effective than retrograde Flex URS in treating large impacted proximal ureteric stones on the expense of operative time, radiation exposure and hospital stay.
Breakage Costs in Flexible Ureteroscopy: Digital vs. Fiberoptic
DA Igel, WE Ito, BB Whiles, W Molina
University of Kansas Medical Center
Introduction & Objective: While digital flexible ureteroscopes offer improved visualization and ergonomics relative to fiberoptic flexible ureteroscopes, the use of digital ureteroscopes has been limited at many centers due to the higher purchase and maintenance costs attributed to them. Indeed, with the annual cumulative financial impact of nephrolithiasis in the United States numbering in the billions of dollars, limiting the costs associated with the surgical management of stone disease is critical. Here we sought to compare the maintenance costs associated with breakage in digital and fiberoptic ureteroscopes in order to better understand the long‐term financial impact of the adoption of digital ureteroscopy.
Methods: Cumulative utilization and breakage data for fiberoptic and digital ureteroscopes at a single large academic institution from 2019 to 2021 was obtained from our endoscope vendor, Karl Storz. Repair costs were also obtained. Average repair costs per case for each scope type was calculated by multiplying the number of breakage events by the repair costs divided by the total number of cases. The T‐test was used to evaluate for significant differences between two independent sample means (fiberoptic and digital modalities). Statistical analysis was performed with SPSS.
Results: Flexible ureteroscopy was utilized 2,154 times at our institution from 2019‐2021, with 1,355 cases involving fiberoptic scopes and 799 involving digital scopes (p = 0.03). There were 197 scope breakage events during the study period, 124 in fiberoptic scopes and 73 in digital scopes (p = 0.06). No significant difference in aggregate average repair costs per case was identified between fiberoptic and digital ureteroscopy, with an average cost per case of $457.11 for fiberoptic ureteroscopy and $547.73 for digital ureteroscopy (p = 0.46).
Conclusions: Although digital ureteroscopes are typically more expensive to purchase and maintain on an individual basis than fiberoptic ureteroscopes, in this study, when averaged over a large number of cases, no significant difference was identified between the two in the per case cost associated with ureteroscope repair. This may be due to a decreased rate of breakage in digital scopes, which in this series approached but did not reach statistical significance. Further study is needed to better quantify the cost difference between these two platforms to help guide decision making in equipment acquisition and utilization.
Nationwide Evaluation of Oral Opioid Prescribing Patterns and Outcomes Following Ureteroscopy
R Alam, R Becker, A Alam, B Matlaga, E Katz
Johns Hopkins University School of Medicine
Introduction & Objective: Recent studies have demonstrated the efficacy of non‐opioid analgesics for pain control following ureteroscopy for urolithiasis. However, it is unclear to what extent these findings have affected real‐world practice. We sought to examine the nationwide practice patterns of analgesic medications following ureteroscopy, focusing on opioid versus non‐opioid administration, and the impact on return emergency room (ER) visits, persistent opioid use, and renal function.
Methods: TriNetX is a research enterprise which collects real‐time data from 92 healthcare organizations (HCOs) representing 212 million patients in the United States. We queried the TriNetX Research Network, a subset comprising 87 million patients in 58 HCOs, for adults who had ureteroscopy performed for urolithiasis between 2017 and 2021. Patients were stratified by receipt of oral opioid prescriptions to calculate the risk ratio (RR) of patients returning to the ER within 14 days and persistent opioid use ≥6 months from surgery. Creatinine values within 14 days and after 6 months were compared between the two groups. Propensity score matching was performed to control for confounders. The analysis was repeated in the full TriNetX database to test the generalizability of our results.
Results: We identified 84,423 patients in the Research Network who had a ureteroscopy performed for urolithiasis, of whom 28,301 (33.5%) were prescribed oral opioids. Patients receiving opioids were younger (53.9 years vs 55.3 years, P < 0.001), had lower creatinine values (1.06 mg/dL vs 1.08 mg/dL, P = 0.004), and were more likely to have a history of anxiety (25.2% vs 21.9%, P < 0.001) or previous opioid use (83.3% vs 76.2%, P < 0.001) compared to those who did not receive opioids. After propensity score matching, the opioid group demonstrated an increased risk of a return ER visit (RR 1.07, P = 0.03) and lower creatinine values (1.09 mg/dL vs 1.12 mg/dL, P = 0.03) within 14 days compared to the non‐opioid group. No difference in creatinine was seen after 6 months (1.06 mg/dL vs 1.05 mg/dL, P = 0.47). Patients who received opioids were at increased risk of persistent opioid use (RR 3.63, P < 0.001). The validation cohort (n = 260,701) yielded similar results.
Conclusions: Encouragingly, most patients undergoing ureteroscopy do not receive oral opioids for analgesia. These patients demonstrate a negligible decline in renal function in the immediate postoperative period, with a return to baseline after 6 months. Patients granted opioid prescriptions were more likely to return to the ER postoperatively and demonstrate long‐term opioid use.
The Social Impact of Surgery for Nephrolithiasis: Results from the Endourological Society TOWER Research Collaborative
AE Jones, B Schurhamer, C Rodriguez, G Lin, H Stambakio, BH Chew, J Stern, JB Ziemba
Division of Urology, University of Pennsylvania
Introduction & Objective: Nephrolithiasis is among the most common urological conditions. However, the social impact of the disease remains significantly understudied, particularly following surgical intervention. We prospectively captured patient‐reported ability to participate in social roles and activities in patients following ureteroscopy (URS) or percutaneous nephrolithotomy (PCNL) for nephrolithiasis.
Methods: Adults undergoing URS or PCNL for renal/ureteral stones were eligible for inclusion (10/2020‐02/2021). Patients prospectively completed PROMIS‐Ability to Participate in Social Roles and Activities instrument pre‐operatively (POD 0) and via email on POD 1, 7, 14 and 30. Scores are reported as T‐scores (normalized to US pop., mean = 50) with a change of 5 (0.5 SD) considered clinically significant. All post‐operative ureteral stents and/or nephrostomy tubes were removed by POD 7.
Results: A total of 180 patients completed enrollment, 132 of which underwent URS and 48 of which underwent PCNL. For URS, there was an acute worsening of social participation between POD 0 and 1, but this recovered and even improved to above the baseline between POD 7 and 14 (repeated measures ANOVA; p < 0.001) (Figure 1). For PCNL, there was a similar acute worsening of social participation between POD 0 and 1, but this did not recover and remained below the baseline even at POD 14 (repeated measures ANOVA; p < 0.001) (Figure 2).
Conclusions: Ability to participate in social roles and activities declines immediately post‐operatively for both patients undergoing URS and PCNL. However, there appears to be a relatively rapid recovery for patients undergoing URS between POD 7 and 14, but patients undergoing PCNL experience a greater impact with recovery beyond POD 14. Results offer meaningful insights to assist in counseling patients prior to the surgical treatment of nephrolithiasis.
Post‐Operative Pain and Recovery in Patients with Nephrolithiasis: Results from the Endourological Society TOWER Research Collaborative
AE Jones, B Schurhamer, C Rodriguez, G Lin, H Stambakio, BH Chew, J Stern, JB Ziemba
Division of Urology, University of Pennsylvania
Introduction & Objective: Nephrolithiasis is among the most common urological conditions. However, the impact of the disease on quality of life remains significantly understudied, particularly following surgical intervention. We prospectively captured patient‐reported pain interference in patients following ureteroscopy (URS) or percutaneous nephrolithotomy (PCNL) for nephrolithiasis.
Methods: Adults undergoing URS or PCNL for renal/ureteral stones were eligible for inclusion (10/2020‐2/2022). Patients prospectively completed PROMIS‐ Pain Interference instrument pre‐operatively (POD 0) and via email on POD 1, 7, 14 and 30. Scores are reported as T‐scores (normalized to US pop., mean = 50) with a change of 5 (0.5 SD) considered clinically significant. All post‐operative ureteral stents and/or nephrostomy tubes were removed by POD 7.
Results: A total of 180 patients completed enrollment, 132 of which underwent URS and 48 of which underwent PCNL. For URS, there was an acute increase in pain interference between POD 0 and 1, but this recovered and even improved to below the baseline between POD 7 and 14 (repeated measures ANOVA; p < 0.05) (Figure 1). For PCNL, there was a similar acute increase in pain interference between POD 0 and 1, but this was improved, although not completely recovered to the baseline even at POD 14 (repeated measures ANOVA; p < 0.05) (Figure 2).
Conclusions: Pain interference on work, family, and social obligations increases immediately post‐operatively for both patients undergoing URS and PCNL. However, there appears to be a relatively rapid recovery for patients undergoing URS between POD 7 and 14, but patients undergoing PCNL experience a less drastic recovery with continued pain interference, albeit minimal beyond POD 14. Results offer meaningful insights to assist in counseling patients prior to the surgical treatment of nephrolithiasis.
‘Boxing in the Corner’: A Modified Retrograde Approach for the Management of Proximal Ureteric Stones of 1–2 cm
O Elgebaly, H Abdeldayem, A Fahmy
Alexandria University Faculty of Medicine, Egypt
Introduction & Objective: To study a modification to the conventional retrograde ureteroscopic approach for treating proximal ureteric stones of 1–2 cm; we intentionally push the stone from the proximal ureter into a favourable calyx then the flexible ureteroscope is used to fragment the trapped stone using laser lithotripsy (‘boxing in the corner’).
Methods: The study was conducted in a randomised prospective manner and included 100 patients who presented with a single proximal ureteric stone of 1–2 cm. We randomised the patients into two equal groups: Group A (50 patients) underwent the conventional retrograde technique (CRT) and Group B (50 patients) underwent the modified retrograde technique (MRT) with the primary intention of relocating the stone into a favourable calyx. Intended relocation of the proximal ureteric stone in the MRT group was achieved in a stepwise manner. All intraoperative parameters and postoperative outcomes were recorded and compared between the two groups.
Results: There was no statistical significant difference in terms of the patients' demographics and stone criteria between the two groups. The stone‐free rate (SFR) was significantly higher in Group B (92%) compared to Group A (78%) (P = 0.049). Fluoroscopy time was significantly longer in Group B (P < 0.001), while operative time, lithotripsy time and hospital stay were comparable. There was no difference between the groups regarding complications.
Conclusions: The MRT was found to be safe and more effective than the CRT for treating proximal ureteric stones of 1–2 cm, with a significantly higher SFR.
MP15: Clinical Stones: New Technology II and Infection
Automated Segmentation of Kidney Stones During Ureteroscopy Using Computer Vision Techniques
S Setia, Z Stoebner, I Oguz, N Kavoussi
Vanderbilt University Medical Center
Introduction & Objective: Visualization and image quality during ureteroscopy is essential for stone tracking during fragmentation. However, this can be impacted by blood and debris intraoperatively. Novel applications of computer vision methods may augment endoscopic visualization and improve stone tracking. We sought to use computer vision techniques to automatically segment kidney stones in real‐time during ureteroscopy.
Methods: Twenty separate videos of ureteroscopy were collected with digital ureteroscopes (Karl Storz Flex Xc). Frames from each video were extracted at 20 frames per second (fps). The training data was manually annotated to identify the stone in each frame. Three established image segmentation computer vision models, U‐Net, U‐Net++, and DenseNet, were trained using the annotated frames. Different iterations of each model were compared via hyperparameter tuning for optimization. Eighty percent of the data was used to train the models with 10% being used for validation and 10% being used for testing. Outcomes included Dice similarity coefficient (DSC), accuracy (per pixel), and area under the receiver operating characteristic curve (ROC‐AUC).
Results: Mean duration of video was 22 seconds (SD ±13s). The U‐Net++ and U‐Net models demonstrated similarly strong performances for stone segmentation with DSCs of 0.92 and 0.91, accuracies of 0.95 and 0.96, and ROC‐AUC scores of 0.99 and 0.99, respectively. DenseNet had lower performance comparatively with a DSC of 0.73, accuracy of 0.87, and ROC‐AUC of 0.91 (Fig. 1). Additionally, we implemented a working system for the processing of real‐time video feeds with overlayed model predictions (Fig. 2). The models were able to intake real‐time video at 30 fps and annotate live at 1.8 fps on a laptop CPU.
Conclusions: Computer vision models demonstrate strong performance for automatic stone segmentation during ureteroscopy. Annotating new videos demonstrates the feasibility of their application real‐time during surgery. With further optimization with improved processing of live video, these models could augment ureteroscopic vision and improve stone treatment.
WITHDRAWN
Randomized Trial Comparing Holmium Laser with Moses Technology and SuperPulsed Thulium Laser System for Ureteroscopic Treatment of Renal and Ureteral Stones
MA Knoedler, C Haas, S Li, KL Penniston, S Best, S Nakada
University of Wisconsin, Department of Urology
Introduction & Objective: The primary objective of this study is to compare the laser efficiency between the two dominant but different modalities for ureteroscopic stone management: the Holmium Laser with Moses Technology and the Thulium Laser Fiber (TFL). Primary outcome was ureteroscope time (time from ureteroscope entering to leaving the ureter) required to adequately fragment stones to 1mm or less. Secondary outcomes were stone‐free rates and measures of laser efficiency including laser on time (LOT), ablation speed (stone volume / LOT), and ablation efficiency (total laser energy used / stone volume).
Methods: An IRB approved randomized clinical trial was conducted to randomize patients to outpatient treatment with either the Moses or Thulium laser in a 1:1 manner after stratification into groups based on the maximal diameter of treated stone (3‐9.9 mm or 10‐20 mm). Patient, stone, and operative parameters were collected and compared using the appropriate categorical/continuous and parametric/nonparametric statistical tests (SPSS 25). Stone free was defined as no fragments >2mm present on follow‐up KUB or CT.
Results: From 7/16/21 to 3/11/22, 106 patients have completed the protocol; 52 patients were randomized to Moses and 54 patients to TFL, of which 37% of the Moses cohort was between 10‐20mm and 38% of the TFL cohort was 10‐20mm. With the exception of the Moses group having a higher proportion of hydronephrosis than the TFL group (44% vs 26%, p = 0.04), there were no significant differences between groups for baseline patient demographics nor pre‐operative characteristics, including ureteral vs. renal stones (48% vs 35%, p = 0.15), mean number of stones treated (1.6 vs 1.8, p = 0.38), mean cumulative stone volume (319 vs 309mm3, p = 0.72), and mean stone Hounsfield units (1028 vs 993, p = 0.44). The primary outcome of ureteroscope time was not significantly different between modalities within the entire cohort (median Moses time 20m vs Thulium 17m, p = 0.65), or within subgroup analysis by stone group size. Secondary outcomes of stone free rates did not significantly differ with both at 84% for the 3‐9.9mm stone group size and 54% for the Moses 10‐20mm size and 61% for the TFL 10‐20mm size (p = 0.69). With the exception Moses laser having improved ablation efficiency over TFL (median 12kJ/mm3 vs 15kJ/mm3, p = 0.01) there were no other differences in laser efficiency measures.
Conclusions: Our randomized clinical trial suggests no significant clinical advantage of one laser technology over the other. Both are highly effective and safe, and thus surgeon and institutional preference is the best approach when selecting one or the other.
Utility of SOFA Score to Predict the Development of Septic Shock Post Renal Decompression Secondary to Urinary Lithiasis: A New Dimension
V Gauhar, Y Law, V Khor, W Chen, W Chen, P Durai, K Lie, K Lee
Ng teng Fong general hospital
Introduction & Objective: To identify predictive factors for the development of sepsis/septic shock post decompression of calculi‐related ureteric obstruction using Sequential Organ Failure Assessment (SOFA) score.
To compare the clinical outcomes and investigate the odd risks ratio of patients developing sepsis/septic shock following the insertion of percutaneous nephrostomy (PCN) versus insertion of retrograde ureteral stent (RUS).
Methods: Clinico‐epidemiological data of patients who underwent PCN and/or RUS in National University Hospital and Ng Teng Fong General Hospital for calculi‐related ureteric obstruction was retrospectively collected from January 2014 to December 2020. Patient demographics, characteristics of the obstructing ureteric calculus, clinical parameters 24 hours prior to procedure were recorded.
Results: Patients with PCN were generally older, had IHD and had poorer Eastern Cooperative Oncology Group status compared to patients with RUS. Patients with PCN had larger obstructive ureteral calculi, had longer durations of fever, persistence of elevated TWC and creatinine, and longer hospitalisation stays compared to patients who have undergone RUS. RUS at presentation had lesser probability of success compared PCN (8 patients (2.7%) in RUS versus 1 patient (0.4%) in PCN, p = 0.037). There were no significant differences in the change in SOFA score post‐intervention in all 6 organ systems and total SOFA score between the 2 interventions. In multivariate analysis, higher temperature just before the intervention (Odd ratios (OR):2.062, p = 0.002) and Cardiovascular SOFA score of 1 (OR:4.389, p = 0.006) were significant independent prognostic factors for the development of septic shock post decompression of ureteral obstruction
Conclusions: Post HD/ICU monitoring, inotrope support post decompression should be considered for patients with elevated temperature within 1 hour pre‐intervention and with cardiovascular SOFA score of 1.
Both interventions have similar overall risk of urosepsis, septic shock and mortality rate. Despite a marginally higher risk of failure, RUS should be considered in patients with lower risk as these patients can have faster recovery. Our study also validates older studies which show that PCN and RUS are safe decompression techniques
Obstructing Ureteral Calculi and Presumed Infection: Impact of Antimicrobial Duration and Time from Decompression to Stone Treatment in Developing Urosepsis
A Orr, M Awad, K Sternberg
University of Vermont Medical Center
Introduction & Objective: Obstructive urolithiasis with associated urinary infection is a urologic emergency requiring urinary tract decompression to decrease the risk of urosepsis. The management after decompression requires tailored antibiotic treatment, although the duration of antibiotics required and the amount of time to wait until proceeding with definitive stone surgery is unknown. Traditionally, longer periods of time were recommended to optimize urinary sterilization before surgery. This subjects the patient to the potential side effects of prolonged antibiotic use and whether this increased duration of antibiotics results in better clinical outcomes is unknown. Our goal is to review the clinical outcomes of patients requiring urgent decompression and identify associated risk factors for the development of complications after definitive stone surgery with focus on the timing and antibiotic usage between the initial and definitive intervention.
Methods: A retrospective review of patients with obstructive urolithiasis with a presumed infection and underwent urgent decompression with a ureteral double J stent or percutaneous nephrostomy (PCN) at our institution between 2012‐2018 was performed. Demographic, infection and antimicrobial data, and initial admission to stone treatment characteristics were collected. Factors associated with developing urosepsis post stone treatment were analyzed.
Results: Of 872 patients who underwent urgent decompression of obstructive urolithiasis during this period, 346 (39.7%) underwent definitive stone management at our institution, and 215 (62.3%) of these were performed for presumed infection and included in our analysis. The median antimicrobials duration post decompression was 13 days (IQR 8‐18). The median duration from decompression to stone treatment was 17 days (IQR 12‐27). 175 (81.4%) patients underwent ureteroscopy (URS) with laser lithotripsy/stone extraction and the rest underwent percutaneous nephrolithotomy (PCNL). 8 (4.6%) patients developed urosepsis post URS and 2 (5%) post PCNL. No factors were associated with developing urosepsis post stone treatment on univariate and multivariate logistic regression analyses.
Conclusions: This study demonstrates that in patients requiring urgent decompression for obstructing urolithiasis and suspected infection, the time between initial intervention and final stone treatment as well as the length of antimicrobial exposure did not impact rates of postoperative urosepsis. This highlights the importance of maintaining high clinical suspicion for prolonged use of antibiotics, to prevent overtreatment and possible exacerbation of antimicrobial resistance.
In Vitro Evaluation of Ablation Rates with Ho:YAG and TFL: Influence of the Stone Phantom Homogeneity
F Panthier, T Germain, L Berthe, S Doizi, L Dragos, O Traxer
Introduction & Objective: The in vitro study of lithotripsy efficiency(LE) requires artificial or human stone samples (AS, HS). With the development of Dusting lithotripsy, less ex vivo HS are available. We aimed to compare Thulium Fiber Laser(TFL) and HolmiumYAG(HoYAG)'s LE and to define the most accurate LE parameter according to AS homogeneity.
Methods: Hard and Soft homogenous‐ and heterogenous‐AS (Ho‐AS, He‐AS) were made to reproduce calcium‐oxalate monohydrate and uric acid stones, respectively by a rapid or slow brewing of BegostonePlus(Bego) and distilled water. 150 and 272μm laser fibers, connected to 50W TFLand 30W HoYAG generators, compared three settings for TFL “fine dusting”(FD:0.15J/100Hz); “dusting”(D:0.5J/30Hz); “fragmentation”(Fr:1J/15Hz) and two for HoYAG(D and Fr). An experimental setup consisting in immerged 10mm cubes of hard or soft Ho‐AS and He‐AS was used a 20 seconds' lasing spiral, in contact mode and repeated four times. Stones were dried, weighted and μ‐scanned. Ablation volumes (AV) were measured by 3D‐segmentation (Figure1).
Results: With He‐AS, Dusting AV were four‐ and three‐fold higher with TFL compared to HoYAG against hard and soft(p < 0,05). In Fragmentation, AV were two‐fold higher with TFL compared to HoYAG against hard(p < 0,05) and soft(p < 0,05) (Table1). Experiments with Ho‐AS were associated with non‐significant differences when comparing TFL‐150μm and TFL‐272μm. The ablation weight‐volume correlation (cAW‐AV) was higher with Ho‐AS than with He‐AS (p < 0,0001), and with hard than soft AS (Table 2). If the LE can be estimated by the AW with hard AS, this approximation is not consistent for soft AS.
Conclusions: TFL presented higher ablation rate than Ho:YAG, significant with He‐AS. If the AW is acceptable and less expensive for hard or Ho‐AS, AV are more accurate for He‐AS, which are suggested to imitate closely HS.
“Kidney Stone Calculator”: Predicting the Lithotripsy Duration and its Influencing Factors
F Panthier, I Duquesne, S Doizi, L Yonneau, T Lebret, M Timsit, L Berthe, A Méjean, O Traxer, F Audenet
Introduction & Objective: Kidney Stone Calculator(KSC) is a free, three‐dimensional (3D) planning software for flexible ureteroscopy(fURS) with Holmium:YAG(Ho:YAG) endocorporeal lithotripsy (EL). KSC provides the stone volume (SV) and expected duration of lithotripsy (ExDL) estimations based on non‐enhanced‐CT scan (NECT) DICOM series. We aimed to provide KSC ability to predic the EL duration and its influencing factors.
Methods: Between January 2020 and november 2021, a multicentric, prospective, observational double‐blind clinical evaluation was conducted in patients presenting with renal stones treated with Ho:YAG‐EL during fURS and preoperative NECT. Demographic and surgical data were collected. The primary endpoint was a significant median difference between ExDL and EffectiveDL (EfDL). Secondarily, efficiency (J/mm3) and efficacy (mm3/min) ratios were calculated and a multiple linear regression estimated the ExDL influencing factors.
Results: 45 patients were included in the clinical evaluation, with a median age of 55 years, Body Mass Index of 25,7(23,4‐30,7)kg/m2 and a 1.15 sex ratio (table1). In 82% of cases, there was a single stone located in the lower pole, with a density >1000 Hounsfield Unit observed in 58% and 31% of cases. A ‐8%(‐22%‐11%; p = 0,64%) median difference between ExDL and EfDL was noted(table2). Median values of 16.8 J/mm3 and 30,8mm3/s EL were reported. Surgeon's expertise, stone volume, utilization of a digital endoscope or a ureteral access sheath and the presence of significant residual fragments were influencing factors that increased the ExDL‐EsDL difference(table3). The laser source was not reported to influence the EsDL.
Conclusions: KSC is an accurate software that provides an ExDL for URSf. A larger cohort is needed to define the influencing factors of EL will improve its ExDL.
Intrarenal Pressure Using Vacuum Assisted Ureteral Access Sheaths
A Ostergar, DG Wong, A Shiang, S Ngo, J Jiang, L Elson, R Venkatesh, A Desai, K Sands
Washington University School of Medicine
Introduction & Objective: Vacuum assisted ureteral access sheaths (V‐UAS) are a new tool designed to evacuate dust or small fragments during ureteroscopy. There are reports of increased stone free rates, decreased infections and decreased operative time with V‐UAS usage. The optimal technique and setting for V‐UAS has yet to be described. Herein, we investigate real‐time intrarenal pressure (IRP) throughout a range of settings using V‐UAS in a porcine ureteroscopy model.
Methods: Using a LithoVue ureteroscope (Boston Scientific, MA) we performed ureteroscopy in 3 female porcine cadavers which had been sacrificed the same day. The back end of an Amplatz super stiff wire was used to reverse puncture the kidney. Then a Swan‐Ganz balloon catheter was pushed into the kidney over the tract and the balloon was inflated in the calyx to seal any leakage. The catheter was connected to a disposable pressure transducer for monitoring IRP. ClearPetra (Micro‐Tech Endoscopy, MI) V‐UAS was advanced retrograde over a wire to the UPJ. IRP was recorded with the ureteroscope positioned in the renal pelvis at different suction settings, inflow pressures, sheath sizes, and sheath distance from the UPJ. Measurements were taken over an average of 30 seconds after pressures had stabilized with each setting change. ClearPetra was connected to constant wall suction at 200 mmHg or max setting.
Results: IRP increased with inflow pressure and decreased with larger access sheath. IRP with no suction was consistently higher than suction without activation (suction on with side vent open) by about 2mmHg. IRP decreased when suction was activated. (Table 1) IRP paradoxically increased during several observations with suction activated. When this occurred, we observed a transient decrease in IRP followed by stable increase in IRP. This effect was significant at max wall suction compared with 200mmHg suction (p = 0.04). (Figure 1)
Conclusions: V‐UAS decreases IRP at a vacuum of 200mmHg, however, extended high vacuum can cause collapse of outflow tract resulting in paradoxical increased IRP. If high vacuum is needed, V‐UAS is best activated in short <3 second bursts. More testing is needed to determine optimal UPJ distance of sheath.
Robotic‐Assisted Percutaneous Nephrolithotomy and Ureteroscopy with the Monarch® Platform, Urology Compares Favorably Against Conventional Techniques
T Chi, L Hathaway, R Chok, M Stoller
University of California San Francisco.
Introduction & Objective: Robotic‐assisted percutaneous nephrolithotomy (PCNL) has not been previously described. Here we compare feasibility and safety of the novel robotic‐assisted device, the Monarch® Platform, Urology (Auris Health, Inc., Redwood City, CA), to conventional devices in completing both PCNL and ureteroscopy (URS) within a porcine model.
Methods: The Monarch® Platform robotic system was compared to conventional devices used for URS and PCNL in a live porcine model (n = 12) positioned in supine lithotomy. For URS, access sheaths were placed. For PCNL, serial dilators after renal access were used. Successful completion of distinct tasks within PCNL and URS was first assessed by two endourologists for ease of completion and scored on a Likert scale (1‐4). Sidedness was randomized between devices. Endourologists assessed safety by identifying any intra‐operative events and conducting post‐procedure retrograde pyelograms. Then, tissue specimens were evaluated by a board‐certified pathologist for gross and microscopic injury, and scored on a Likert scale (0‐4). Statistical comparisons were made using 1‐sided Mann‐Whitney U Tests, with p < 0.05 considered significant.
Results: Two endourologists performed 12 PCNL and 12 URS procedures in 24 renal units, and they observed no safety events during either the PCNL or URS procedures for both the robotic and conventional devices. Pathology assessment demonstrated no biologically significant nor clinically‐relevant differences between robotic and conventional devices in any category (Table 1A). Tasks within PCNL and URS exhibited comparable ease of completion scores between the devices (Table 1B). These data also suggest a trend of improved ease of completion of some tasks (e.g., renal access and ureteroscope maneuverability) using the Monarch® Platform.
Conclusions: This study demonstrates the Monarch® Platform to have a comparable safety and usability profile to that of conventional devices in performing PCNL and URS procedures. This foundational study demonstrates the feasibility of a single robotic platform to perform PCNL and URS as a new treatment paradigm for stone management.
Single‐Use Ureteroscopes Are Associated with Decreased Risk of Urinary Tract Infection After Ureteroscopy for Urolithiasis Compared to Reusable Ureteroscopes
R Unno, G Hosier, F Hamouche, D Bayne, M Stoller, T Chi
University of California, San Francisco, Department of Urology
Introduction & Objective: Although single‐use ureteroscopes have been shown to be comparable with reusable ureteroscopes in terms of intraoperative maneuverability, visual image quality, as well as stone‐related clinical outcomes, there are few large scale reports regarding clinical outcomes related to single‐use ureteroscopes. In the current study, we aimed to understand the impact of single‐use ureteroscopes on clinical outcomes for ureteroscopic stone removal and whether their use reduced postoperative urinary tract infection (UTI) risk.
Methods: This was a single‐center, retrospective cohort study designed to compare single‐use with reusable flexible ureteroscopes regarding peri‐ and postoperative outcomes between June 2012 and March 2021. The primary endpoint was postoperative UTI. The secondary endpoints were intraoperative outcomes (operative time and stone clearance), perioperative complications, hospitalization time, and re‐presentation to the hospital (telephone call, ED visit, and re‐admission) after URS.
Results: A total of 991 patients were analyzed, 500 patients in the single‐use URS group (50.4%) and 491 patients in the reusable group (49.6%). On univariate analysis, patients in the single‐use URS group were more often male and had lower BMI and presented with more bilateral stones than those in the reusable group. Single‐use URS was associated with a lower chance of postoperative UTI (6.5% vs 11.9%, p = 0.018) as well as a higher stone clearance rate (90.0% vs 83.9%, p = 0.005) and fewer postoperative telephone calls (19.2% vs 29.2%, p = 0.002). There were no significant differences in operative time, perioperative complications, ED visits, and re‐admission between the two groups. On multivariate analysis, single‐use URS remained a strong factor associated with stone clearance rate and decreased risk of postoperative UTI and postoperative telephone calls (Table 1). Postoperative sepsis, perioperative complications, and re‐admission were associated with a positive preoperative urine culture (odds ratio = 8.55; p = 0.005, 5.59; p < 0.001, 5.17; p < 0.001, respectively).
Conclusions: These data show that the single‐use URS is beneficial in reducing postoperative UTI and telephone calls as well as increasing the stone clearance rate. These results provide a clinical justification for their routine use during ureteroscopic stone removal.
Assessing the Clinical Force Threshold for the Safe Deployment of a Ureteral Access Sheath Using a Ureteral Access Sheath Force Sensor
M Vu, S Ali, RM Patel, P Jiang, J Landman, M Klopfer, RV Clayman
UC Irvine
Introduction & Objective: Ureteral access sheath (UAS) use in endoscopic procedures can result in ureteral injuries. An initial porcine study in our laboratory revealed that ureteral injuries from UAS deployment can be precluded by limiting insertion force to ≤6 Newtons (N) as measured by a force sensor developed at our institution specifically for use with an ureteral access sheath (UAS‐FS). We sought to assess if a similar threshold was clinically applicable.
Methods: The UAS‐FS provides a continuous read out of force measurements within a hundredth of a Newton. Initially, a 16Fr UAS was deployed; if 6N was reached, the UAS was recommended to be downsized to a 14Fr and, if 6N was again reached, a < 12.7F UAS was recommended. A post‐ureteroscopic lesion scale (PULS 0 = no injury 3 = visible splitting of the urothelium) was recorded after each case to assess for ureteral injury.
Results: Among 250 renal units (238 patients), a 16Fr UAS was successfully deployed in 58% of ureters at a mean maximal ureteral force of 5.47N (Table 1). Seventy‐five 14Fr UAS (30.0%) and thirty < 12.7F UAS (12.0%) were deployed at maximal forces of 5.28N and 4.22N, respectively. The highest PULS score was a 3 which occurred in two cases (0.8%); in both instances the force applied exceeded 8N (Table 1). The success rate of deploying a 16 Fr UAS was significantly increased in patients who had a preoperative stent in place (p = 0.004) and among patients with a history of bacteriuria and subsequent sterilization of the urine within 60 days prior to surgery (p = 0.046) (Table 2).
Conclusions: Keeping the force of UAS insertion < 6N precluded clinical ureteral injury; using this approach a 16Fr UAS was safely passed in 58% of our patients. Preoperative stents and a recent history of treated bacteriuria were independent predictors of the successful deployment of 16Fr UAS at ≤6N.
Assessing the Impact of Irrigation Temperature on SuperPulse Thulium Fiber Laser Lithotripsy with Optical Coherence Tomography
KL Morgan, P Jiang, N Katta, R Kim, R Bhatt, S Ali, RM Patel, T Milner, J Landman, RV Clayman
Department of Urology, University of California, Irvine
Introduction & Objective: During intrarenal laser lithotripsy, some energy is absorbed by the medium through which the laser is fired before reaching the target stone. Prior studies show that irrigation fluid temperature affects the energy absorption coefficient of water. We sought to evaluate the effect of irrigation temperature on renal stone ablation with the superpulse thulium fiber laser (sTFL).
Methods: Using optical coherence tomography (OCT) we analyzed the surface of 12 of each of the following human kidney stone compositions: Calcium Oxalate Monohydrate (COM), Calcium Oxalate Dihydrate (COD) and Uric Acid (UA). The stones were randomized and then submerged into baths of room temperature (20°C) or warm (37°C) 0.9% saline. At two locations on each stone, we used a 200 μm thulium laser fiber to administer a single pulse (0.5 J, 1.0Hz, 1.25ms) with the fiber tip touching the surface. Optical coherence tomography was repeated to analyze the cavitation created by each laser burst to calculate the volume of stone removed (Figure 1). The volume of stone removed in warm versus room temperature saline was compared with unpaired t‐tests for each stone composition.
Results: In all stone types, there was a significantly greater mean volume of stone removed during sTFL lithotripsy in warm irrigation compared to room temperature irrigation. A single fire of the sTFL removed 12.4% greater stone from COM stones when performed in warm irrigation compared to room temperature irrigation (p = 0.034). For COD stones, sTFL lithotripsy in warm irrigation removed 24.4% more stone than lithotripsy in room temperature irrigation (p = 0.014). UA stones had 28.6% more stone removed in warm irrigation compared to at room temperature irrigation. (Table 1)
Conclusions: The superpulse thulium fiber laser ablates significantly more stone per pulse energy when utilized in warm (37°C) saline compared to room temperature (20°C) saline for all stone compositions evaluated.
Evaluating Inner and Outer Ureteral Stent Coatings Efficacy to Prevent Uropathogen Adhesion
B Domingues, I Aroso, E Lima, A Barros, RL Reis
Introduction & Objective: Metal‐based coatings have gained prominence due to their ability to impair biofilm formation on biomedical implants, emphasizing silver (Ag)‐ and zinc (Zn)‐based strategies, which present intrinsic antimicrobial activity properties and biocompatibility. In urology, the bacterial infection is one of the main drawbacks associated with ureteral stents. Unlike most strategies that only have exterior coatings, we proposed the development of inner and outer coatings on polyurethane‐based stents in order to create a biomedical material with more efficient antimicrobial properties.
Methods: We performed electroless plating of metals on polyurethane stents' inner and outer surfaces, creating Ag, Zn, and zinc oxide (ZnO) coatings. Contact angle, scanning electron microscope (SEM), and X‐ray photoelectron spectroscopy (XPS) analyses were performed to characterize the modified surfaces properly. Adsorption level of bovine serum albumin (BSA) after immersing coated and uncoated stents on artificial urine was analyzed. To evaluate antimicrobial effects of coatings, stents were incubated, separately, with Escherichia coli ATCC 25922 and Staphylococcus aureus ATCC 25923, following an established biofilm formation protocol. Biocompatibility assays were carried out following ISO10993‐5, using L929 fibroblast and G/G uroepithelial cells. Mechanical properties were assessed following ASTM F1828.
Results: Following electroless plating of metals, four different coatings were created, as shown by SEM and contact angle analyses. By XPS, we proved the presence of the metals in both inner and out surfaces, confirming that the designed protocol was able to create internal and external coatings. After immersing stents in artificial urine, we reported a significant reduction in BSA per area on Ag‐, Zn‐, and ZnO‐coated stents compared to control. This indicates that those coatings could be less prone to form biofilms in the urological context. In terms of antibacterial effects, Ag coatings were effective for gram – and gram + bacteria, and Zn coatings were only effective for the tested gram + bacteria. After 1 h of incubation, Ag coatings were 99.999% efficient to prevent initial adhesion of E. coli (5 log reduction compared to control). Both Ag and Zn coatings exhibited antibacterial activity by lowering the adherence of both strains, without compromising cell viability or the mechanical properties of stents.
Conclusions: The development of inner and outer metal‐based coatings bestows antimicrobial properties to ureteral stents, conferring advantages compared to standard stents.
Clinical Measurement of Maximum Achievable Ureteral Internal Circumference Using a Novel Force Sensor
M Vu, AS Afyouni, S Ali, P Jiang, RM Patel, M Klopfer, J Landman, RV Clayman
UC Irvine
Introduction & Objective: The insertion and usage of larger ureteral access sheaths (UAS) may allow for improved ureteroscopic stone removal. Clinically, the largest UAS currently available is 16 French (F). To our knowledge, no studies have explored the maximum physiological diameter to which the human ureter can be safely sized. With the novel UC Irvine developed UAS force sensor, for the first time, we can safely explore the largest luminal diameter to which the human ureter could be dilated below 6 N (Newtons), a level of force that we have previously shown to be the threshold for avoiding ureteral injury when passing an ureteral access sheath.
Methods: Forty‐four ureters (15 male and 29 female patients) were sized during a ureteroscopic or percutaneous stone removal procedure. Force measurements were measured in 1/100ths of a Newton (N). Thirty‐five cm Cook® urethral dilators of 2 F increments (i.e., 12F, 14F, 16F, 18F, 20F, 22F, and 24F) were inserted until a force measurement of 6N was recorded. A similar size UAS, up to 16 F, was then placed.
Results: Among 44 ureters, 20% reached 6 N at ≤12F dilator, 25% at 14F, and 28% at 16F. 18% readily accepted a > 18F dilator (18‐24F) at <6N. In 4 cases (9%), 6N was reached at only 10F. The mean diameter was 14F. A 16F UAS was deployed in 41% of cases, while 14F and 12F UAS were deployed at <6N in 32% and 27%, respectively. Despite adhering to a 6N threshold, a Post‐Ureteroscopic Lesion Scale (PULS) score of 3 was individually noted in the proximal, mid, and distal ureter of 3 ureters (7%), all sized at ≥14 F. The presence of a pre‐existing stent alone or in combination with preoperative Tamsulosin (p = 0.023 and p = 0.049 respectively), was associated with passage of a larger dilator; however, tamsulosin by itself (23 patients) was not effective (p = 0.818). Prestented ureters allowed the insertion of dilators ≥16 F in 82% and ≥18 F in 36% of cases versus 33% and 12%, respectively, when the ureter was not prestented.
Conclusions: The human ureter can be safely sized to a maximum diameter of 24 F at ≤6 N. Most human ureters readily accepted a 14F dilator. Prestenting increased safe passage of a 16F dilator in 82% of cases and permitted the insertion of an 18F dilator in over one third of cases.
The Role of Presepsin as Predictive Factor for Sepsis in Patients with Urinary Tract Infection Associated with Urinary Calculi
K Oh, J Ha, R Lee, J Choi, Y Ko, P Song, K Moon, H Jung
Department of Urology, Chonnam National University Hospital, Gwangju, Korea
Introduction & Objective: Recently, many studies have reported that presepsin is useful inflammatory biomarker for early diagnosis of sepsis in pateints with urinary tract infection (UTI). However, few studies have reported the efficacy of presepsin for urosepsis associated with urolithiasis. We retrospectively investigated the efficacy of inflammatory biomarkers, including C‐reactive protein (CRP), procalcitonin, and presepsin for early diagnosis of urosepsis associated with urinary calculi.
Methods: From January 2021 to July 2021, a total of 94 patients with UTI associated urinary calculi included in this study. Sepsis was defined as 2 points or more quick Sequential Organ Failure Assessment (qSOFA) score for sepsis. We divided two groups (with (n = 24) and without (n = 70) sepsis) and assessed the clinical characteristics (age, sex, the past medical history), laboratory data, and stone characteristics of all patients. Also, we evaluated the predictive factors for urosepsis associated with urolithiasis, compared with inflammatory biomarkers.
Results: Mean age was 73.13+‐12.35 years and 67 patients were performed the ureteral stenting or percutaneous nephrostomy due to ureteral calculi with hydronephrosis. In univariate analysis, old cerebrovascular accident (CVA), high lactate, low albumin, high C‐reactive protein (CRP), presepsin, and procalcitonin were correlated with sepsis (p < 0.05). Multivariate logistic regression analysis showed that high lactate, low albumin, and high presepsin were independent factors associated with sepsis (Table 1). In receiver operating characteristic (ROC) curve for inflammatory markers, the area under the curve (AUC) of CRP, procalcitonin, and presepsis was 0.812, 0.851, and 0.824, respectively (p < 0.001).
Conclusions: This study demonstrated that high presepsin and lactate, and low albumin were predictive factors for sepsis with urinary calculi. Thus, we suggest that intensive care may be considered to prevent fatal outcomes in patients with these factors.
Superinfection of Perirenal Hematoma: A Case Series and Systematic Review
JM Gaines, EJ Macdonald, J James, N D'Souza, S Kivitz, E Lynch, AD Smith, A Rai
SUNY Downstate Health Sciences University, Brooklyn, New York.
Introduction & Objective: Perirenal hematoma (PRH), although often managed conservatively, may be complicated by several life‐threatening complications. Superinfection of PRH is a rarely reported outcome which requires urgent intervention.
Methods: A natural language processing search algorithm in Nuance mPower Clinical Analytics screened CT and MRI studies for “subcapsular renal" and "perinephric" hematomas from 2011 to 2021 at our institution. Patients whose hematoma became infected and had at least 3 cross‐sectional exams to track progression were included. Retrospective chart review assessed etiology of hematoma, interventions, and management. We then performed a systematic search of PubMed, Embase, and Cochrane Library according to PRISMA guidelines for reports of infected PRH.
Results: After identifying 136 patients with acute PRH, we identified 6 patients who developed an infected PRH from our institution with a median age of 65.5 (58‐76). After screening 335 articles, 17 (n = 19 patients) were included for analysis with a median age of 53 (21‐90). Case series and review data were pooled for a total of 25 patients. At presentation, median hemoglobin was 9.3 g/dL (7.2‐16.7), median WBC 16 (7.5‐24.97), fever was present 14 patients (56%), and pre‐treatment urine cultures were positive in 8 patients (32%). Etiologies of PRH were iatrogenic (13/25), spontaneous (11/25), and traumatic (1/25). Common comorbidities included hypertension (n = 12), diabetes mellitus (n = 7), chronic kidney disease (n = 8), and obesity (n = 4). Management with drainage and antibiotics was successful in most patients, however 5 required nephrectomy, 3 required ICU admission, and 7 were readmitted within 90 days of discharge.
Conclusions: Abscess formation following development of PRH, although rare, represents a serious complication which requires prompt identification and treatment. To prevent these, pre‐ operative urinary infections should be managed aggressively, especially in those with underlying kidney disease, at high risk for bleeding, and those who are immunocompromised. Drainage and antibiotics are effective and should remain first line therapy, however, patients should be adequately counseled about the risks for recurrent infection and other complications given the high rate of readmission.
Novel Endoscope Tip Designs for Aspiration of Renal Stone Fragments: An In‐Vitro Study
K Vo, A Shin, R Bhatt, KL Morgan, S Ali, A Peta, P Jiang, RM Patel, J Landman, RV Clayman
Department of Urology ‐ University of California, Irvine
Introduction & Objective: Basket removal of kidney stone debris after laser lithotripsy fails to clear the smallest (< 1.5 mm) remnants, leaving nidi for future stone formation. We evaluated the effectiveness of several novel endoscope tip designs with regard to aspiration of these finer stone remnants.
Methods: Six unique designs were created in CATIATM V5 (Dessault Systèmes®) and 3‐D printed using PrusaSlicer (Figure 1). To ease handling, all tip prototypes were scaled up to 27 Fr and attached to a suction apparatus (Aeros Moblvac III, Ardus Medical Inc.®). For each trial, one gram of pre‐measured stone fragments (1 mm, 1.25 mm, 1.70 mm, 2 mm, 2.50 mm, 3 mm, 3.55 mm, 4 mm, 5 mm) were sequentially placed in a basin and aspirated (suction pressure 100 mmHg). All tips were first evaluated using whole millimeter sized debris, and high performing tip designs (A ‐ batwing, C – power bar and E – half moon configuration) were compared using more targeted trials. Percent clearance, suction rate, and number of channel occlusions were recorded.
Results: All tips that were tested on fragment sizes up to 1.70 mm achieved 100% clearance and no occlusions. The fastest suction rates for 1 mm were tips A, C, and E at 266, 265, and 260 mg/sec, respectively. At 2 mm, only A, C, and E had 100% clearance. At 2.50 mm, tip A cleared all debris with the fastest aspiration rate (387 mg/sec) and no occlusions, while E and C encountered 1 and 4 occlusions, respectively. For both 3 mm and 4 mm, E had the highest percent clearance and suction rate (3 mm ‐ 86.2% at 53 mg/sec; 4 mm ‐ 18.87% at 16.3 mg/sec). At 3.55 mm, C had the highest clearance (14.55%), followed by A (13.17%), then E (9.48%) (Figure 2). At 3–5 mm all tips clogged equally; no tip successfully aspirated 5 mm.
Conclusions: Tips A, C, and E show promise as future aspiration‐enabled endoscope tip designs.
Thulium Laser Lithotripsy of Renal Calculi Augmented with a Novel Reverse Thermal Hydrogel in the Porcine Kidney
P Jiang, S Ali, R Bhatt, D Schneider, A Brevik, A Peta, RM Patel, J Landman, RV Clayman
Department of Urology, University of California, Irvine
Introduction & Objective: We sought to evaluate a novel reverse thermal Hydrogel (UroGen Pharma) for use during ureteroscopic thulium laser lithotripsy. Hydrogel is a liquid at room temperature and transforms into a viscous, semisolid gel at body temperature. We hypothesized that the gel would facilitate entrapment of stone fragments and enhance stone removal while possibly insulating the renal system from any laser‐induced thermal damage.
Methods: Four renal units in two anesthetized pigs were randomized to either the experimental (with Hydrogel) or control (without Hydrogel) arm. Via a pyelotomy, a pre‐weighed canine calcium oxalate stone (11‐12 mm in maximal dimension) was implanted into an upper pole calyx. A temperature probe was placed percutaneously into the calyx of interest. In the experimental kidneys, 5 cc of Hydrogel was instilled in the calyx with the stone through a 5 Fr molded ureteral catheter, such that the gel enveloped the stone and filled the calyx. Using a 14 Fr, 35 cm ureteral access sheath, an 8.5 Fr flexible video ureteroscope was passed into the affected calyx. Superpulse thulium fiber laser lithotripsy was performed by a single surgeon (PJ) using a 200‐micron fiber (settings: 0.2 J and 80 Hz) continuously with momentary pauses to target the stone. Once the stone was sufficiently dusted, any remaining fragments were basketed with a 1.7 Fr NCompass basket. In Hydrogel kidneys, an ureteroscopic brush was also utilized to remove residual fragments entrapped within the gel. After euthanizing the animals, the kidneys and ureters were harvested. The kidneys were bivalved and rinsed to capture all residual stone fragments within the collecting system. The stone fragments were then dried, sieved, and weighed.
Results: 99.3% of the stone's mass was removed from the experimental Hydrogel kidneys compared to 92.2% removed from the control kidneys. Peak intra‐calyceal temperature with Hydrogel was 36°C, in contrast, without Hydrogel the peak recorded temperature was 55°C and the system exceeded 44°C four times during laser lithotripsy.
Conclusions: The use of Hydrogel to augment ureteroscopic stone removal resulted in near‐complete stone removal at 99.3% while preventing high intra‐calyceal temperatures during thulium laser lithotripsy.
Urologic Perioperative Infection Outcomes and Prescribed Antibiotics
S Vallamkonda, XC Cortez, T Chi
UCSF
Introduction & Objective: Postoperative infection after surgical nephrolithiasis procedures is a significant morbidity concern. Preoperative antibiotics are recommended by multiple professional guidelines to prevent life‐threatening infection. However, the efficacy of different antibiotic approaches continues to be poorly understood. The primary objective of this study was to investigate the relationship between perioperative antibiotic regimens and incidence of postoperative urinary tract infection (UTI), systemic inflammatory response syndrome (SIRS), and urosepsis.
Methods: A retrospective analysis of prospectively collected data from the Registry for Stones of the Kidney and Ureter (ReSKU) was conducted in this case‐cohort study of patients who underwent nephrolithiasis surgery. Subjects whose stone surgery occurred between 2015 and 2021, had a definitive preoperative urine culture, received perioperative antibiotics, and completed a postoperative follow‐up visit were included. 25 subjects experienced postoperative UTI, SIRS, or sepsis. 240 did not have any infection‐related postoperative issues. Chi‐Square tests were performed to determine if there was a relationship between categorical variables of interest [sex, urine culture results, antibiotic regimen, and route of antibiotic administration (oral or intravenous)] and a postoperative infectious outcome.
Results: Postoperative infection was found to be significantly associated with sex [χ2 (1, N = 265) = 4.73, p = 0.030] but not with urine culture results [χ2 (1, N = 265) = 1.86, p = 0.17], antibiotic regimen [χ2 (29, N = 265) = 44.59, p = 0.77], or route of antibiotic administration [χ2 (3, N = 265) = 2.22, p = 0.53]. A likelihood ratio of 6.9 was seen between positive urine culture and postoperative infection.
Conclusions: The risk for postoperative infection after stone surgery is higher among women compared to men. Our data demonstrate no basis for specificity of antibiotic regimen to prevent postoperative infections after surgical nephrolithiasis treatment. To reduce risk of postoperative infection, more important than type of antibiotic, route of administration, or urine culture is simply the importance of consistently giving preoperative antibiotics. These data support AUA and EUA guidelines on the importance of preoperative antibiotics to reduce infectious morbidity after surgery.
Determinants of SuperPulsed Thulium Fiber™ Cumulative Laser Energy and Time During Ureteroscopic Lithotripsy
WE Ito, S Ghaffar, BB Whiles, N Choi, R Sivakumar, W Molina
The University of Kansas Medical Center
Introduction & Objective: Ureteroscopy (URS) has emerged as the preferred treatment for the majority of nephrolithiasis, helping stone‐free status to be achieved independently of the location of calculi in the ureter or body habitus. Stone fragmentation during URS can be achieved by different laser platforms, with SuperPulsed Thulium Fiber™ (SPTF) laser being one of the newest and most effective options available. Non‐contrast computed tomography provides preoperative insights in treatment planning, characterizing the stone, location, size, and density. This study aims to assess whether preoperative stone information can be correlated to SPTF cumulative energy and time required during laser lithotripsy.
Methods: A retrospective review (04/2020 ‐ 12/2021) was performed on patients who underwent ureteroscopy (semirigid and/or flexible) utilizing SPTF as the energy source for lithotripsy (150 or 200μm laser fiber; and settings limited to power of 8‐10W and 35‐40W for stones in the ureter and kidney, respectively) at a single tertiary care, academic medical center. Only patients with a single calculus and considered stone free at the end of the procedure by the surgeon were examined. The chosen parameters for analyses included patient and stone characteristics (location, size, volume, density, and composition); total laser time and energy; and surgical outcomes.
Results: A total of 45 patients met our inclusion criteria. Mean stone size was 1.04 ± 0.39 cm and volume 0.34 ± 0.40 cm3. Mean stone radiodensity was 898 ± 382 HU and Hounsfield units density (HUD) 87.53 ± 31.8 HU/mm. No complications were detected, and all patients were discharged ≤24 hours after surgery. Correlation analyses revealed a positive association between stone size and volume with total laser energy (R = 0.71, p < .001; R = 0.77, p < .001) and total laser time (R = 0.62, p < .001 R = 0.63, p < .001) – figure 1. In addition, a significant association was found between stone density with laser energy and time (R = 0.49, p < .001; R = 0.35, p = .018). In the univariate analysis, stone size, volume, and total operative time significantly increased laser energy and laser time. Interestingly, neither HU or HUD displayed a significant effect on laser time and energy. Stones in the kidney demanded more energy than stones in the ureter, but not time. Biochemical stone composition was not associated with the evaluated parameters – table 1.
Conclusions: Cumulative SPTF laser energy and time are incrementally affected by stone dimensions (size and volume), but not by stone density (absolute HU and HUD) or stone composition. This may represent a potential benefit of SPTF with its capability to fragment stones independently of stone composition.
A Randomized Clinical Trial Using Next‐Generation Bacterial Sequencing to Direct Antibiotic Selection Before Kidney Stone Lithotripsy Using an Interprofessional Model
MA Liss, K Revels, J Gelfond, T Tseng
University Of Texas Health San Antonio
Introduction & Objective: To determine if antibiotic selection prior to kidney stone lithotripsy using next‐generation sequencing (NGS) of bacterial genes prevents post‐operative infection more than standard of care antibiotic selection.
Methods: A prospective randomized clinical trial was conducted with a primary outcome of post‐operative infection within 2 weeks of surgery. The urine was collected at the time of pre‐operative culture collection and aliquoted to standard culture and NGS tubes. The culture was completed as part of standard of care and the NGS sample was sent to MicroGenDx for sequencing. Randomization took place at this time. If the culture was positive, the patient was excluded. For those with commensal bacteria or a negative report, the NGS report was sent to an infectious disease pharmacist. Patients were called 2 weeks after their procedure and their chart was reviewed for any infection complication that required additional antibiotics or a hospital stay.
Results: We enrolled 240 subjects that were randomized to the control (n = 121) and intervention (n = 119) arms. Of these subjects, 16 subjects had Percutaneous nephrolithotomy. After exclusion of positive urine cultures and moved/canceled surgery, 133 (55%) subjects completed the study with evaluable results. We had 58 subjects in the intervention group and 75 subjects in the standard of care group. However, 8 subjects in the intervention group were not given the NGS/Pharmacist recommendations. Therefore, 50 patients had completed the NGS‐directed therapy following pharmacist recommendations. None of the 50 NGS directed patients had a post‐operative infection ;whereas, six subjects (6/75, 8%) in the non‐directed group presented with an infection (n = 0 vs. 6, 0% vs 8%, p = 0.049, chi‐squared). A likelihood ratio of 5.8 (P = 0.02) would lead to a number needed to screen 14 patients. Of the 6 subjects in the control group who had infections two subjects were diagnosed with systemic inflammatory reactive syndrome (SIRS) and required intensive unit care. The three other subjects presented to the emergency room but were discharged with antibiotics. One patient had a fever and was called in for additional antibiotics.
Conclusions: In our randomized controlled study, the use of culture and NGS of urine to guide antibiotic prophylaxis prior to lithotripsy was able to prevent healthcare‐associated urinary infections and should proceed to a phase 3 clinical trial.
Holmium Laser Using Vapor Tunnel Pulse Emission Mode in the Treatment of Guy I Kidney Stones
L Rico, PN Contreras, F Frascheri, B Sofia, J Bujaldon, M Maqueda Vocos
Hospital Alemán
Introduction & Objective: Vapor Tunnel Pulse Emission Mode (VTEM) technology is a result of the pulse modulation during holmium laser emission: it consists of a single specific long pulse, using the minimum peak power in accordance with selected output settings. The first part of the pulse creates a vapor channel, whereas the remaining energy is discharged immediately after, passing through the previously created tunnel. We present the outcomes of this technology in the treatment of kidney stones.
Methods: A total of 38 patients consecutive patients with kidney stones were treated with flexible ureteroscopy (LithoVue BSCI) and holmium laser lithotripsy using VT technology. A 35 W‐LithoEvo laser generator (Quanta System) with 273 μm fibers were used for all cases. Using VTEM, Energy and frequency settings were 1 J and 10 Hz respectively. Stone complexity was classified according to Guy Score System (GSS) using preoperative imaging and solitary stones were included (GSS I). After the procedures, a ureteral stent was always positioned and removed 20 days later in 29 pacients (76.31%). Dusting time, total procedural time and total laser activity (kJ) was assesed. Patients were reported to be stone free if there were no stones on postoperative non‐contrast low dose CT scan. Results were compare with our previous 38 patients treated with our old Ho:YAG laser machine (Odissey, Cook Medical 30 W)
Results: The two groups were comparable in terms of age and mean preoperative stone size (1.1 vs 1.0 cm, p > 0.05). The VT technology was associated with significantly lower (p < 0.05) dusting time (15.3 vs 9.7 minutes), total procedural time (36.2 vs 26.7 minutes) and total delivered energy (15.9 vs 9.7 kJ). Stone‐free rate at 1‐month was comparable (88.6 vs 93.4%, p > 0.05).
Conclusions: In our series, the VTEM was associated with significantly lower dusting time and total procedural time.
Automated Segmentation of the Kidneys, Ureters and Bladder Using a Convolutional Neural Network Model to Create a “Urinary Tract Atlas”
KM Fischer, Y Li, B Schurhamer, E Choi, Y Fan, JB Ziemba, G Tasian
Children's Hospital of Philadelphia
Introduction & Objective: The management of urolithiasis relies heavily on stone features, such as size and location, and surrounding urinary anatomy on CT. Currently this requires human interpretation to identify and assess anatomic features, which is laborious and poorly reproducible. Automated analysis of images to perform these tasks can potentially increase accuracy, fidelity, and speed. Our aim was to create a deep learning model to automatically segment kidneys, ureters, and bladder from CT, thereby creating a “Urinary Tract Atlas.”
Methods: 122 CT urograms (CTUs) from adults undergoing imaging for hematuria or nephrolithiasis were manually segmented by labeling the kidneys, ureters, and bladder. These were randomly split into 98 images for training and 24 for testing. A novel deep learning model was developed using both transformers and convolutional neural networks (CNN) as encoders and convolutional blocks as decoders. This was trained with the AdamW optimizer in 1000 epochs with a batch size of 2 and image patches with a size of 160x160x96. Data augmentation was adopted including random flipping, scaling, and warping. Segmentation results using our model were assessed and compared to several previously described modeling approaches to medical images using Dice scores with 0 to 0.19 considered low, 0.20 to 0.39 low‐moderate, 0.40 to 0.59 moderate, 0.60 to 0.79 moderate‐high and 0.80 to 1.00 high.
Results: A novel machine learning model (ML‐TransUNet) was created and can automatically label the urinary tract on CTU. Figure 1 shows kidney, ureter, and bladder labels generated by our model compared with manual segmentation and original images. Dice score for the overall model was 0.8548+0.1205 with mean Dice scores of 0.9301+0.0291 for kidney, 0.7314+0.0974 for ureter, and 0.9029+0.1003 for bladder. When compared to previously described approaches our model's performance was superior in all aspects except for ureter.
Conclusions: We created a deep learning model that automatically segments the urinary tract with high precision. Our next step is to train the model to segment non‐contrast CT. Ultimately, this will be utilized to allow prediction of the probability of ureteral stone passage. Automation of imaging analysis has the potential to usher in personalized medicine for patients with stone disease where passage of ureteral stones and other outcomes could be predicted at the time of diagnosis.
Magnetic Retrieval of Kidney Stone Fragments: In Vitro Experience
TJ Ge, K Mach, S Conti, TC Chang, S Wang, K Sheth, J Liao
Introduction & Objective: Surgical management of stone disease aims for complete clearance, yet only 60‐75% of ureteroscopic treatments achieve complete stone‐free status. While residual fragments <2 mm in size are commonly deemed insignificant, up to 30% patients with “clinically insignificant fragments” experience stone‐related complications. We propose a system to improve ureteroscopic stone‐free rates and efficiency, in which fragments are rendered superparamagnetic and retrieved en masse with a magnetic guidewire.
Methods: Remaindered human stone fragments obtained from lithotripsy were separated by size. Fragments (10‐20 mg by dry weight) were rehydrated with normal saline in a 1.5 mL tube. Superparamagnetic iron oxide particles and a hydrogel‐forming polymer were mixed in vitro with the stones to form a magnetic hydrogel coating. A magnetic guidewire was fabricated and used to retrieve the magnetically labeled fragments. The fragments were dried and weighed to determine the capture efficiency. Magnetic hydrogel components were incubated with benign bladder or T24 urothelial cancer cell culture for up to 4 hours, and cytotoxicity was measured with an LDH release assay.
Results: The magnetic hydrogel system robustly captured stones up to 2 mm in size of a wide variety of compositions (calcium phosphate (CaPO4), calcium oxalate monohydrate (CaOxM) and dihydrate (CaOxD), uric acid, and struvite), and generally captured multiple stones in a single pass. In contrast, stones exposed to the magnetic nanoparticle alone experienced poor and unreliable magnetic capture. Magnetic hydrogel components did not lead to significant cytotoxicity in cell culture compared to negative controls.
Conclusions: Kidney stones could be magnetized with iron oxide nanoparticles. However, the reliable capture of larger stones required a more robust nanoparticle coating in order to achieve a magnetic force that counteracted gravitational force; this was achieved with a hydrogel coating. This system captured stones of many compositions, and did not exhibit cytotoxicity in cell culture. This approach can facilitate the efficient magnetic retrieval of stone fragments that are difficult or tedious to basket, and lead to improved stone‐free rates. The hydrogel components and wire can be introduced through the ureteroscope working channel. Further optimization of hydrogel properties and component delivery will allow for clinical translation.
Magnetic Retrieval of Kidney Stone Fragments: In Vitro Experience
DC Rosen, NL Arias Villela, M Drescher, J Abbott, M Dunne, J Davalos
Introduction & Objective: Mini‐Percutaneous Nephrolithotomy (mPCNL) utilizes a smaller tract size inherently limiting the diameter of the lithotripter that can be accommodated through the nephroscope while maintaining adequate fluid inflow. To compensate for the loss of sheath diameter compared to standard PCNL, a premium is placed on efficient and effective lithotripsy. We sought to evaluate and optimize the usage of the 1.9mm Trilogy probe (a larger probe compared to the available 1.5mm probe) compared to the MOSES Holmium Laser for treatment efficiency during mPCNL.
Methods: We prospectively analyzed patients who underwent mPCNL from September‐October 2021 and compared outcomes to our database of mPCNL performed with MOSES Holmium Laser from 2019 – 2021. The Storz 12Fr French nephroscope with the 16.5/17.5 Fr access sheath was used for both lithotripsy modalities. Demographic, preoperative, and postoperative data was prospectively collected. Stone volume was calculated both as the dominant single plane size as well as using 3D modeling with 3D Slicer. Treatment efficiency was calculated as stone size/treatment time. Fischer's exact test and two tailed t tests were used for statistical analysis.
Results: 27 consecutive patients who underwent mPCNL with the 1.9mm Trilogy probe were compared to 142 consecutive mPCNL patients who had undergone treatment with laser. Demographics and outcomes data is displayed in Table 1. The Trilogy 1.9mm probe was found to be overall comparable to the MOSES Holmium laser, with an average 3D stone burden removed of 455.8mm3, and 3D efficiency 34.2 mm3/min. Patients undergoing mPCNL with 1.9mm had larger stone sizes (24mm vs 19mm, p < .01) though this did not lead to a statistically significant change in lithotripsy time or efficiency.
Conclusions: The 1.9mm Trilogy lithotripter presents an efficient alternative to laser‐based modalities for mPCNL potentially allowing for the treatment of even larger stones with comparable lithotripsy times. Effective usage of retrograde and antegrade irrigation offers excellent visibility and efficient stone extraction allowing significant stone burdens to be treated using either modality requiring smaller tract size and renal sheaths compared to standard PCNL.
Stone Removal Should Be Offered to Patients Suffering from Recurrent UTI: Systematic Review of the Role of Kidney Stone Treatment in the Resolution of UTI
F Ripa, V Massella, A Pietropaolo, BK Somani
University Hospital Southampton NHS Foundation Trust
Introduction & Objective: The concomitant presence of urinary tract infections (UTI) and kidney stone disease (KSD) has been largely demonstrated. Eradication of kidney stones through surgical intervention might result in the clearance of infection for patients suffering from recurrent UTI or bacteriuria. We conducted a systematic review of literature to determine whether treatment should be offered to patients with kidney stones in order to clear recurrent UTI (rUTI) and to assess infection‐free rates after treatment.
Methods: A systematic review of literature was performed for studies reporting on patients with a history of recurrent UTIs or a positive pre‐operative urine culture who underwent either PCNL, URS or SWL for stone treatment. We reported stone‐free and infection‐free rates after surgery. Stone size, composition, type of procedure and causative bacteria were also reported.
Results: In a review of 269 patients, a strong association between KSD and UTIs was demonstrated, while clearance of stones (URS in 52.7%, PCNL in 39.7% and SWL in 7.6% of cases) led to resolution of UTI in the majority. Rates of infection clearance after stone removal ranged from 75% to 89% at 12 months follow up (p < 0.001). Among patients with stone recurrence, 80% also had a recurrence of UTI. An average of 3.1 UTIs in the year prior to surgical intervention vs 0.5 UTI in the year following intervention was reported (p < 0.001). There was a significant association of residual stones with rUTI compared to those without (p = 0.04). Among post‐operative UTI, 82% continued to have infections with the same preoperative organism, vs. 18% who had a change in bacterial species.
Conclusions: UTI and KSD are mutually coexisting and reciprocally causal. Evidence suggests that patients should be counselled for proactive intervention by stone removal especially when UTIs are recurrent or additional risk factors are present, irrespective of stone composition.
Comparison of Swiss LithoClast® Trilogy and ShockPulse‐SE as Energy Source in Percutaneous Nephrolithotomy for Staghorn Stones: A Matched Pair Analysis
RS Batra, K U. S, A Singh, A Ganpule, R Sabnis, M Desai
Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India
Introduction & Objective: High‐power lithotripters are required for staghorn stones as there is need of effective disintegration and faster stone‐clearance.This study aimed to evaluate efficacy of Swiss LithoClast Trilogy(Boston Scientific,USA) and ShockPulse‐SE(Olympus) in PCNL for staghorn stones.
Methods: We did a retrospective match pair analysis study comparing efficiency and outcomes of Trilogy and Shockpulse‐SE in patients with staghorn stones undergoing PCNL between January 2020 to December 2021. Primary objective was to compare stone fragmentation rates,with secondary objectives beings stone‐free rates,complications and instrument malfunction.
Results: 85 patients of staghorn stones underwent PCNL during the period.33 patients underwent PCNL with Trilogy and 42 patients with ShockPulse‐SE as energy source.Complete data was available for 27 patients of Trilogy. 27 patients of Shockpulse‐SE were match paired using propensity score with Trilogy with age, stone volume,stone density and staghorn morphometry score.Mean stone volume using 3D doctor imaging software from CT images and density were 22891 ± 45233 mm3, 22862 ± 42218 mm3 (p‐0.08) and 1153.6 ± 323.3 HU, 1146.5 ± 259 HU (p = 0.10) for Trilogy and Shockpulse‐SE,respectively. Staghorn morphometry classification was similar for both the groups(p‐0.78).Using probe‐activation time,stone‐fragmentation rate was 612.2 ± 287.7 mm3/min for Trilogy and 637.25 ± 543.4 mm3/min for Shockpulse‐SE (p‐0.08). Treatment time (combination of all stages) was 82.48 ± 45.39 min for Trilogy and 93.63 ± 38.56 min for Shockpulse‐SE (p‐0.3). Haemoglobin drop was 2.19 ± 0.76 gm/dl for Trilogy and 2.79 ± 1.1gm/dl for Shockpulse‐SE (p‐0.30).Trilogy had 81.48 % clearance and Shockpulse‐SE had 61.53% clearance at 48 hours in first stage PCNL. 18.51% patients of Trilogy and 38.46% patients of Shockpulse‐SE required subsequent staged PCNL. Trilogy had 92.59% stone free rate at 3‐month follow‐up while Shockpulse‐SE had 80.76% stone free rate. Trilogy had 4 Clavien‐Dindo grade‐II complications (1 PCN leak, 3 UTI with fever) while Shockpulse‐SE had 3 Clavien‐Dindo grade‐II complications(UTI with fever requiring antibiotics). There was no blood transfusion in either of arm. There were 3 instrument malfunctions(probe break) in Trilogy while there were 5 instrument malfunctions (3 probe breaks, 2 suction block) in Shockpulse‐SE.
Conclusions: Trilogy has comparable stone fragmentation rate with Shockpulse‐SE in managing staghorn renal stones. Complications and instrument malfunction were also comparable for Trilogy and Shockpulse‐SE. However, stone free rates at 3 months are better in Trilogy arm in comparison to Shockpulse‐SE.
MP16: BPH III
Laser Enucleation of the Prostate Remains Underutilized in the Frail Patient
KA Moody, E Garden, M Levy, C Chin, KT Ravivarapu, J Sewell‐Araya, M Palese
Icahn School of Medicine at Mount Sinai
Introduction & Objective: In frail adults, laser enucleation of the prostate (HoLEP) and photovaporization of the prostate (PVP) are safe and effective treatments for benign prostatic hyperplasia. These may be used as alternatives to transurethral resection of the prostate (TURP). We investigated trends in utilization of TURP, HoLEP and PVP in frail patients in a national cohort.
Methods: National Surgical Quality Improvement Program data files from 2015‐2019 were analyzed. All male patients aged 18‐89 with TURP, PVP, and HoLEP CPT codes were included. Clavien Dindo classifications were grouped as I/II, III, or IV. The modified 5‐item Frailty Index was calculated by assigning 1 point each for: impaired functional status, diabetes, chronic obstructive pulmonary disease, congestive heart failure, and hypertension. Frailty was defined as ≥2.
Results: A total of 54332 procedures were analyzed (TURP: 36764, PVP: 14267, HoLEP: 3301). From 2015‐2019 the percent of patients treated within each procedure group remained stable (TURP: 62.9‐70.4; PVP: 31.7‐23.7; HoLEP: 5.4‐7.8). Procedure groups differed significantly in race, age, and frailty. HoLEP patients were more often white than TURP and PVP patients (80.7% vs 62.6% and 67.6%, respectively; p < 0.001; Table 1). PVP patients were older (71.3) and HoLEP patients were younger (69.5; p < 0.001). HoLEP was most utilized in patients 50‐59 (7.1%) and least utilized in octogenarians (4.2%). HoLEP patients were less likely to be frail than TURP and PVP patients (19% vs 23.1% and 23.0%, respectively; p < 0.001). HoLEP patients had the fewest Clavien Dindo I/II (4.5%) and IV (1.1%) complications, UTIs (3.1%), occurrences of sepsis (0.4%), and unplanned readmissions (3.8%). HoLEP had the most patients discharged home (99.2%) and the fewest discharged non‐home (0.8%). HoLEP required longer operation times than TURP and PVP (100.4 minutes vs 56.7 and 55.4, respectively; p < 0.001).
Conclusions: The safety and improved outcomes of HoLEP in frail patients have been previously reported. Despite these findings, our study reveals that patients receiving HoLEP are more likely to be non‐frail adults. Frail adults are still more likely to receive TURP or PVP for treatment of benign prostatic hyperplasia.
Cost‐effectiveness of BPH Surgical Management for Patients with Large Prostates: A Comparison of Holmium Laser Enucleation and Simple Prostatectomy
KM Wymer, G Narang, A Slade, V Sharma, V Thao, B Borah, G Vedantam, S Cheney, MR Humphreys
Mayo Clinic
Introduction & Objective: For patients with benign prostatic hyperplasia (BPH) and large prostates ( >80g) requiring surgery, guideline options include Holmium Laser Enucleation of the Prostate (HoLEP) and simple prostatectomy (SP). Both have proven durability with low rates of retreatment, albeit with differences in short and long‐term complications, catheter requirements, and convalescence. Though they share excellent outcomes, costs vary for HoLEP and SP‐ both for the index procedure and follow up. This study compares the cost‐effectiveness of each approach.
Methods: A Markov model was used to perform a cost‐effectiveness analysis of HoLEP and SP for the management of a 65‐year old index patient with a prostate >80g. Data were drawn from randomized control trials and utility values were calculated from post‐op symptom scores. Base case analysis was performed at 5 years, with extrapolation to a lifetime horizon of 20 years. Outcomes included quality‐adjusted life years (QALYs), 2021 Medicare costs, and incremental cost‐effectiveness ratios (ICERs) with a willingness‐to‐pay (WTP) threshold of $100,000/QALY. Univariate and probabilistic sensitivity analyses were performed.
Results: At 5 years, HoLEP was less costly ($6,585 vs. $15,404) and as effective (4.654 QALYs vs. 4.650 QALYs) as SP, making HoLEP the most cost‐effective option. These findings remained true when varying follow‐up from 6 months to 20 years. Sensitivity analyses shoed that at least one of the following conditions would need to be met for HoLEP to no longer be cost effective: the cost of HoLEP increases by three‐fold, cost of SP drops by 65%, the probability of chronic stress incontinence following HoLEP increases ten‐fold, or the utility associated with post‐HoLEP symptoms decreases by 40%. In probabilistic sensitivity analyses, HoLEP was preferred in 55.9% of microsimulations. HoLEP remained cost‐effective at all WTP thresholds from $0‐$200,000/QALY (Figure 1).
Conclusions: HoLEP was more cost‐effective for patients with large glands ( >80g) due to significantly lower procedure costs and slight improvements in effectiveness. These data further support the increased use of HoLEP for the cost‐effective surgical management of patients with large gland BPH.
Water Vapor Thermal Therapy for BPH: Is Less More?
MV Nguyen, C Cerrato, S Bechis
UC San Diego School of Medicine
Introduction & Objective: Water vapor thermal therapy is an effective treatment for lower urinary tract symptoms (LUTS) from benign prostatic hyperplasia (BPH) but can be associated with short term post‐procedural irritative voiding symptoms. We sought to evaluate the effect of a minimal approach of water vapor thermal therapy (Rezum, Boston Scientific, Marlborough, MA, USA), defined as 1 vapor treatment per prostate lobe, on urinary symptoms and quality of life (QOL) compared to patients who received multiple treatments per lobe.
Methods: We performed a retrospective review of patients who underwent water vapor therapy for the treatment of symptomatic BPH from August 2017 to February 2022. Patients were divided into a cohort based on the number of treatments per lobe (1 per lobe including median lobe if present vs ≥2 per lobe). Primary outcome of interest was difference in the International Prostate Symptom Score (IPSS) and QOL sub score at baseline and at 1, 3, 6 and 12 months after the procedure.
Results: 174 patients were included, of which 52 patients received one vapor treatment per lobe and 122 patients received 2 or more treatments per lobe. 15 patients (8.7%) in the single treatment cohort had a median lobe that was treated. The mean PSA (1.59 vs 3.7, p = 0.054), percentage of patients with treated median lobes (8.8% vs 37.6%, p = 0.004), and time to post‐operative catheter removal (3.9 vs 4.4 days, p = 0.001) were significantly different between the cohorts (Table 1a). All other characteristics, including prostate volume and use of BPH medications, were not significantly different. There were no significant differences seen in IPSS scores between the two cohorts at baseline (p = 0.998). Patients undergoing the minimal treatment approach had significantly better total IPSS scores (10.8 vs 16.2, p = 0.046) and voiding sub‐scores (3.09 vs 7.90, p = 0.023) at 1‐month post‐procedure. No differences in IPSS or QOL scores were seen between the groups at 3‐, 6‐ and 12‐month follow‐up (Table 1b).
Conclusions: Minimal Rezum treatment approach with a single water vapor injection per lobe is a safe and effective option for patients undergoing long‐term treatment for BPH and is associated with improved IPSS and voiding symptom scores in the early period post‐procedure. Further studies are needed to investigate the effect of this minimal approach on longer term outcomes.
Impact of Patient Comorbidities on Short‐term Post‐operative Complications Following Holmium Laser Enucleation of the Prostate
KM Wymer, G Narang, J Vasilev, M Girardo, MR Humphreys, S Cheney
Mayo Clinic
Introduction & Objective: Holmium Laser Enucleation of the Prostate (HoLEP) is an effective, endoscopic surgical treatment for benign prostatic hyperplasia (BPH), regardless of prostate size. However, the procedure is not without risk of post‐operative complications. Accurately predicting these risks is important for patient counseling and decision making. In this study, we sought to identify patient comorbidities and clinical characteristics associated with short‐term post‐operative complications and urinary symptoms.
Methods: A retrospective review was performed using our institutional BPH registry and included patients who underwent HoLEP from 2007‐2019. Pre‐operative medical comorbidities were evaluated including age, cardiovascular disease, diabetes, neurologic disorders, transplant status, bleeding disorders, and therapeutic anticoagulation. Operative variables included prostate volume and procedure time. The primary outcome was 30‐day complications and 90‐day urinary symptoms as measured by IPSS. Logistic regression was performed to identify predictive variables and those that were significant in the univariate analyses were included in a multivariable model.
Results: A total of 1918 patients were included in the analysis with a mean age of 86 years, average prostate size of 97cc, and mean procedure time of 113 minutes. The rate of 30‐day UTI and urinary retention were 1.8% and 5.7%, respectively. 5.1% of patients had severe urinary symptoms at follow up based on IPPS responses. On logistic regression, patients with coronary artery disease (CAD) were significantly more likely to have post‐operative urinary retention [OR 1.81 (1.10‐2.90), p = 0.02] as were patients on pre‐operative therapeutic anticoagulation [(OR 1.65 (1.09‐2.50), p = 0.02]. CAD was also significantly associated with severe urinary symptoms [OR 1.78 (1.14‐2.80), p = 0.01]. Post‐operative UTI was not associated with any of the included comorbidities. Pre‐operative diabetes, prostate volume, and procedure time were not associated with post‐operative complications.
Conclusions: Post‐operative complications and urinary symptoms following HoLEP can have a significant impact on patient care. Pre‐operative comorbidities‐ particularly CAD and use of therapeutic anticoagulation, may significantly increase the risk of these complications‐ offering important information for more accurate pre‐operative patient counseling.
Lack of Diversity in BPH Procedures Among Urologists in the United States
F Munshi, A Shlimak, R Ortiz, E Hyams
Alpert Medical School of Brown University
Introduction & Objective: Diverse procedures are available for surgical management of benign prostatic hyperplasia (BPH) with significant overlap in clinical indications and scarce comparative data. It is unclear whether providers focus or diversify their surgical BPH practices, and how practice patterns trend across regions of the United States (US) with respect to procedure utilization and diversity. From the patient perspective, these are important issues to understand how and where to access different BPH procedures; from a more global perspective, to anticipate trends as technologies shift. This study examined practice patterns in the US to assess if urologists favor certain procedures and determine regional trends in surgical practice.
Methods: A retrospective analysis of BPH procedures for Medicare physicians across the US in 2019 was conducted using public Medicare data. The number of cases performed per provider was collected for transurethral resection of prostate (TURP, CPT 52601), Greenlight Laser Vaporization (52648), Urolift (52441), Rezum (53854), and Holmium Laser Enucleation (HoLEP, 52649). Data were analyzed regarding practice patterns by surgeon and region, as defined by the US Census. Low procedure rates were censored for privacy reasons.
Results: 2474 Medicare providers performed BPH procedures in 2019. 81% performed one type of procedure, 18% performed two, and 1% performed three. With one exception, no provider performed more than three procedure types (Table 1). Across all regions, the majority of providers favored TURP. Regional variation exists regarding the relative utilization of Greenlight and Urolift. The two least popular practices were HoLEP and Rezum (Table 2).
Conclusions: Urologists tend to focus on one procedure in the surgical management of BPH in Medicare patients. As of 2019, TURP is the most popular BPH procedure in the US. It remains unclear whether providers should focus on a specific procedure or diversify, what case volume is needed to maintain competence, and how to ensure appropriate patients counseling given the diversity of options for surgical management of BPH.
Outcomes of Same Day Discharge Following Holmium Laser Enucleation of the Prostate
J Badreddine, S Rhodes, D Chen, M Zell, I Jaeger, KL Stern
University Hospitals Cleveland Medical Center/ Case Western Reserve University
Introduction & Objective: Performing holmium laser enucleation of the prostate (HoLEP) as a same day surgery is a safe and feasible option for the majority of patients. Shortening postoperative hospital stays can minimize patient burden and increase accessibility to surgical care. We present our experience of 155 patients who underwent HoLEP during the pandemic last year. Admissions were limited to patients that required continuous bladder irrigation given the limited surgical bed availability and other restrictions imposed by the Covid‐19 pandemic.
Methods: From January 2021 till January 2022, 155 patients have undergone HoLEP surgery in which 135 were discharged on the same day and 20 patients were admitted. Perioperative data were retrospectively collected, and postoperative outcomes at least 2 months after the surgery were evaluated in terms of safety and efficacy and compared in both groups using chi‐square and t‐test. Multivariable logistic regression was also performed to identify factors associated with postoperative complications.
Results: The mean age of the same day discharge group (n = 135) is 71.2 (SD = 7.1). The mean prostate specific antigen(ng/dL) and prostate volume(mL) in the same‐day discharge group were 5.3 (range 0.16 ‐ 48.4) and 112.6 (range 52 ‐ 350), respectively, with 3.7% readmission rate and 9.6% emergency department visit rate. Our same‐day discharge rate was 87% of the total patients. Prostate Specific Antigen (P = .001), prostate volume (P < .001), and enucleated tissue weight (P = .04) were significantly higher in the admitted group. There was no difference in the rate of postoperative emergency department visits (P = .80), readmissions (P = 1), postoperative complications, and catheterization time (P = .98) between both groups. Patients using blood thinners had 3.35 (95% CI: 1.24‐9.08) greater odds of having postoperative complications.
Conclusions: Same‐day discharge following HoLEP is a safe and effective approach in most patients without an increase in postoperative complications.
Robotic‐assisted Simple Prostatectomy: A Comparison of Primary Simple Prostatectomy versus Salvage Simple Prostatectomy in Treatment of Lower Urinary Tract Symptoms
R Pathak, B Krol, N Crain, R Pak, A Hemal
Mayo Clinic
Introduction & Objective: Simple prostatectomy is indicated in patients with enlarged glands ( >80 grams) who present with lower urinary tract symptoms (LUTS) attributed to benign prostatic hyperplasia (BPH). Salvage simple prostatectomy (SSP) is defined as simple prostatectomy after failed transurethral procedure. The aim of this study is to evaluate the efficacy of primary simple prostatectomy (PSP) versus SSP in ameliorating LUTS.
Methods: We retrospectively reviewed 104 patients who underwent robotic simple prostatectomy (RSP) between 2013 and 2021. Indications for surgery were enlarged prostate, bothersome LUTS, or symptoms refractory to medical management and/or previous prostate surgery. PSP and SSP preoperative, perioperative, and postoperative variables were recorded. The severity of LUTS was assessed using the International Prostate Symptom Score (IPSS). Two‐tailed t‐tests were performed to compare primary vs. salvage RSP cohorts at a p‐value (p) of 0.05.
Results: Of 104 patients who underwent RSP, 87 were primary and 17 were in the salvage setting with 12 patients undergoing prior TURP, 3 status post TUMT, 1 status post TUNA, and 1 status post UroLIFT. Mean length of stay following RSP was 1.86 (days). At mean follow up of approximately 12 months, no patient required re‐operation for LUTS. Preoperative IPSS for primary and salvage RSP was 19.06 and 15.44, respectively (p = 0.36) and postoperative IPSS for primary and salvage RSP was 5.47 and 11.00, respectively (p = 0.43).
Conclusions: Regardless of primary or salvage indication, RSP remains a highly efficient and durable procedure for improvement in LUTS. RSP performed in the salvage setting greatly improved urinary function outcomes in patients after failure of previous transurethral procedures.
Transurethral Interventions and Influence on Types of Postoperative Urinary Incontinence: Results from a Systematic Review and Meta‐analysis
V Gauhar, D Castellani, E Rubilotta, ML Wroclawski, J Teoh, F Gomez‐Sancha, M Gubbiotti, M Pavia, M Maggi, A Fabiani, G Pirola
Ng teng Fong general hospital
Introduction & Objective: To perform a SR to assess the incidence of transient (< 6‐month) and persistent ( >6month) stress (SUI), urge (UUI), and mixed urinary incontinence (MUI) after transurethral surgeries for benign prostatic hyperplasia.Secondary outcome was to assess the difference in baseline prostate volume, surgical time, and resected/enucleated prostatic tissue.
Methods: This study was performed according to the 2020 PRISMA(Fig1) PICOSmodel was used to frame P: men with surgical indication for BPH; Intervention: transurethral procedures; Comparison: monopolar/bipolar TURP; Outcome: incidence of stress, urge, and mixed incontinence following surgery; Study type: Randomized, prospective nonrandomized, and retrospective studies. Baseline prostate volume, surgical time, enucleated/resected prostatic tissue were pooled using the inverse variance of the mean difference with a random effect, 95% CI, and p‐values. Incidence of stress, urge and mixed incontinence was assessed using Cochran‐Mantel‐Haenszel Method with the random effect model and reported as OR, 95% CI, and p‐values. Analyses were two‐tailed and the significance was set at p < 0.05 and a 95% CI.Meta‐analysis was performed using Review Manager The quality assessment using RoB 2 for randomized studies and ROBINS‐I for non‐randomized ones.28 studies were accepted.
Results: Incidence of:(fig12) transient SUI was 4.6%, 6.0%, 3.0%, 2.4% after ablation, enucleation, M‐TURP, and B‐TURP, respectively Persistent SUI was 1.1% after ablation, 1.7%, after enucleation and M‐TURP, 1.0% after B‐TURP. The Transient UUI was 2.0%, 7.3%, 4.4%, 2.8% after ablation, enucleation, M‐TURP, and B‐TURP Persistent UUI was 2.2% after M‐TURP Transient MUI was 5.1%, 0.8%, 5.4%, 0.9% after ablation, enucleation, M‐TURP, and B‐TURP, respectively Persistent MUI was 3.1% after ablation, and 4.8% after M‐TURP. The incidence of transient (OR 3.32, 95% CI 0.41‐26.65, p = 0.26) Persistent SUI (OR 4.79, 95%CI 0.5243.89,p = 0.17) was not significantly higher after ablation. Transient UUI was not significantly higher after ablation (OR 2.62, 95%CI 0.04‐166.01,p = 0.65), whilst persistent UUI did not differ Transient MUI was significantly higher after enucleation (OR 3.26, 95%CI 1.51‐7.05,p = 0.003)
Conclusions: Ablation, enucleation, and TURP have an impact on all forms of incontinence but this is transient in most cases with no difference between the groups, except for MUI which was higher after enucleation vs TURP. We also found that prostate volume and operative time did not correlate with the type of incontinence .
Effects of 5‐alpha Reductase Inhibitors Prior to Holmium Laser Enucleation of the Prostate: Does Increased Adenoma Density Resulting in Prolonged Morcellation Times?
MS Lee, M Ganesh, J Han, MA Assmus, AE Krambeck
Ohio State University
Introduction & Objective: 5‐alpha reductase inhibitors (5‐ARIs) are frequently used in the medical management of benign prostate hypertrophy as they reduce prostate volumes by 25%. The contraction of prostate epithelial and stromal elements increases the density of the prostate adenoma. Prior efforts studying the effect of 5‐ARIs prior to Holmium Laser Enucleation of the Prostate (HoLEP) have focused on enucleation difficulty or blood loss. To our knowledge, no one has examined if 5‐ARIs prolong morcellation times during HoLEP due to increased tissue density. Herein, we examine perioperative outcomes of patients on pre‐operative 5‐ARIs undergoing HoLEP.
Methods: A retrospective review of patients undergoing HoLEP by an expert surgeon from Jan – Oct 2021 was performed. We compared patients who received preoperative 5‐ARIs to those who did not. Statistical analysis was performed using SAS Studio (SAS institute, 2021). Student t‐tests and chi‐square tests were performed for continuous and categorical variables, respectively. Variables with a p‐value of <0.05 were deemed statistically significant.
Results: There were 322 patients who underwent HoLEP during the study period and 84 patients had preoperative 5‐ARI exposure. The preoperative prostate size was larger in the 5‐ARI group 140.2 ± 84.47 vs. 113.7 ± 55.04, p = 0.111. Procedure time and enucleation time were not statistically different between the two groups, but morcellation time was longer in the 5‐ARI group: 13.59 ± 13.46 vs. 9.18 ± 9.02, p = 0.0096. Morcellation efficiency was worse in the 5‐ARI group (7.77 ± 3.54 vs. 9.11 ± 5.72, p = 0.0212). There was no difference in: intraoperative complication rate, presence of hematuria, or ED visits at 1 week. A linear regression model including size and morcellation efficiency, found that only size remained significantly different between the two groups.
Conclusions: In this cohort, 5‐ARI use prior to HoLEP did not increase the intraoperative complication rate, procedure time or enucleation time, suggesting 5‐ARI use does not increase difficulty of dissection. Rates of post‐HoLEP hematuria were not statistically different between the two groups. Morcellation efficiency was worse in the 5‐ARI group on univariate analysis, but on multivariable analysis this difference was no longer seen. 5‐ARIs do not appear to change outcomes of HoLEP.
Comparison of Costs and Perioperative Outcomes Among Patients Undergoing Simple Prostatectomy and Laser Enucleation of the Prostate
SR Hawken, W French, H Kay, DP Viprakasit, DF Friedlander
University of North Carolina
Introduction & Objective: Simple prostatectomy (SP) and laser enucleation of the prostate (LEP) are treatments for symptomatic benign prostatic hyperplasia (BPH) in men with large glands (e.g. >80 grams). The decision between the two operations is often dependent on surgeon preference/experience and equipment availability. As the use of minimally invasive techniques, such as robotic assisted simple prostatectomy (RASP), has increased for the treatment of large gland BPH, studies comparing the outcomes and costs of these modalities in a contemporary cohort are lacking.
Methods: All‐payer data from Healthcare Cost and Utilization Project (HCUP) State Databases from Florida (FL), New York (NY), California (CA), and Maryland (MD) from 2016‐2018 were used to identify adults who underwent SP or LEP for BPH. Patient demographics, facility characteristics, revisit rates, and costs of the index hospitalization were examined. Multivariable logistic and gamma generalized linear regression models were utilized to compare predictors of the operation performed, 30‐day revisits, and index hospitalization costs amongst the two operations.
Results: Of the 2,032 patients in the cohort, 1,067 (46.4%) underwent LEP and 965 (41.9%) underwent SP. On multivariable logistic regression analysis, SP patients were younger, had higher comorbidity scores, and were more likely to be uninsured compared with LEP patients. 30‐day revisit rates amongst the operations were equivalent (OR 0.89, 95% CI 0.63‐1.27, p = 0.05).
The mean adjusted cost of the index hospital stay for LEP was significantly greater than that of SP ($7,291.23 vs $6442.32, p = 0.04). However, our sub‐group analysis examining high‐volume centers revealed no significant differences in costs ($6,183.93 vs $5352.97, p = 0.1).
Conclusions: Across the four states examined, SP and LEP were performed with comparable volume and had similar rates of 30‐day revisits. SP was less expensive than LEP overall; however, among high volume facilities the cost of both operations were reduced, such that they were equivalent.
Holep for LUTS Prior to Radiation for Prostate Cancer or While on Active Surveillance: Preliminary Results of a Prospective Observational Trial
BB Whiles, D Neff, C Valadon, K Glavin, W Parker, X Shen, M Mirza, DA Duchene, K Thurmon
Department of Urology, University of Florida, Gainesville, FL, USA
Introduction & Objective: The incidence of lower urinary tract symptoms(LUTS) and prostate cancer(PCa) increase with age. When both conditions are present concurrently, it is a complex clinical situation and the optimal management is not well described. The objective of our study was to evaluate the utility of Holmium laser enucleation of the prostate(HoLEP) in patients who are on active surveillance(AS) or who have elected for radiation therapy(RadTx) for management of PCa. Our objective is to describe intraoperative and post‐operative outcomes. We hypothesized that HoLEP would improve patient reported LUTS.
Methods: An IRB approved, prospective observational trial was developed for patients with PCa and bothersome LUTS, defined as International Prostate Symptom Score(IPSS) ≥15 and/or urinary retention. Patients were either on AS or planning for RadTx for PCa. Exclusion criteria included prior prostate surgery, radiation therapy, or metastatic PCa. The trial opened in 09/2019 and is ongoing. Surveys were obtained before and 3 months after surgery. Data analysis includes descriptive statistics.
Results: A total 11 patients have been enrolled in the study(Table 1). Total time in the operating room was 106 ± 24 minutes, lasering was 62.5 ± 27.6 minutes, and morcellation was 13.2 ± 10.0 minutes. PCa was detected in 3 (27%) specimens. All patients had 3‐month follow up. IPSS decreased from 21.7 ± 5.2 to 6.0 ± 3.4 (p < 0.01). Chronic urinary retention was present in 2 patients (18%), and both were voiding spontaneously postoperatively. During follow up ranging from 3 to 24 months, all patients on AS remained on AS after surgery. One patient planning for RadTx subsequently transitioned to AS after HoLEP. The other 4 patients planning for RadTx initiated this by 6 months (1 patient), 9 months (2 patients), and 12 months (1 patient). RadTx regimen was hypofractionated in 3 patients and sterotactic body in 1 patient. Post‐surgical complications included 1 (9%) urinary tract infection. One patient (25%) in the RadTx group developed a bladder neck contracture 1 year post‐HoLEP and 6 months post RadTx.
Conclusions: HoLEP is an effective procedure for bothersome LUTS in those with PCa who are on AS or planning for RadTx. Further studies are needed to evaluate long term outcomes in such patients as well as determine the optimal timing for radiation post‐operatively.
Outcomes After Holmium Laser Enucleation of the Prostate, Open Simple Prostatectomy, and Robotic Simple Prostatectomy: Experience from a Large Academic Medical Center
MS Lee, MA Assmus, M Ganesh, J Han, Q Mai, J Helon, AE Krambeck
Ohio State University
Introduction & Objective: Per AUA guidelines, large prostates (defined as < ![if !msEquation] >< ![if !vml] >< ![endif] >< ![endif] >80g in size) can be managed with Holmium Laser Enucleation of the Prostate (HoLEP), Open simple prostatectomy (OSP) or robotic simple prostatectomy (RSP). While these modalities have been previously compared to one another, one study only compared 32 RSPs to 600 HoLEPs. To our knowledge, the three modalitis have never been compared against each other in the same cohort. Furthermore, in any published studies, the authors were not performing same‐day catheter removal and discharge after HoLEP, indicating the studies must be updated. Herein, we present our experience performing HoLEP, OSP, and RSP for large prostates at a large academic medical center.
Methods: The Northwestern Enterprise Data Warehouse (EDW) is a system‐wide electronic medical record based data platform. We queried the EDW for all patients undergoing HoLEP, OSP, and RSP from Jan 2011 to Oct 2021 for prostates < ![if !msEquation] >< ![if !vml] >< ![endif] >< ![endif] >80g. Patients were identified by CPT code (52649, 55831/55821, 55899, respectively). Variables were abstracted from the EDW and medical record. Statistical analysis was performed using SAS studio (2021). Multiple comparisons for continuous variables were performed using ANOVA with Tukey's corrections. Chi‐square tests were used for categorical variables. P‐value <0.05 was determined to be statistically significant.
Results: The three cohorts were similar in age, BMI, and Carlson comorbidity index. There was no difference in preoperative Hgb, Cr or prostate volume. PSA was higher in the OSP group (p = 0.0077). Surgery duration, estimated blood loss (EBL), length of stay (LOS) and catheter duration were all shortest in the HoLEP group (p < 0.0001). OSP had the highest EBL and HoLEP had the lowest EBL (P < 0.0001) which also translated into less RBC transfusions for HoLEP and RSP compared to OSP (p < 0.0001). There were no differences in ED visits, but RSP had the highest readmission rate (p < 0.0001).
Conclusions: In this cohort where HoLEP patients underwent same‐day catheter removal and discharge, despite similar preoperative characteristics, HoLEP was associated with shorter surgery duration, LOS and catheter duration. HoLEP also had the lowest EBL and RBCs transfused with an increase in ED visits or readmissions.
Tranexamic Acid to Improve Same‐day Discharge Rates After Holmium Laser Enucleation of the Prostate: A Prospective Randomized, Controlled Trial
MA Assmus, MS Lee, J Helon, AE Krambeck
University of Calgary
Introduction & Objective: In a randomized, double blinded, controlled trial, 110 patients undergoing holmium laser enucleation of the prostate (HoLEP) were prospectively enrolled and randomized (1:1 ratio) to receive either one dose of tranexamic acid (TXA) (1g) or no‐TXA (control) after induction of anesthesia. Our objective was to assess safety and efficacy of single‐dose tranexamic acid on same‐day pathway outcomes for patients undergoing HoLEP. The primary outcome was rate of successful same day‐discharge (SDD). The secondary outcome measures included transfusion rate, length of catheter, length of stay (LOS), operative time and 90‐day Clavien‐dindo complications. ClinicalTrials.gov identifier: NCT05082142.
Methods: IRB approval (STU00215134) and registry with ClinicalTrials.gov (NCT05082142) was obtained and we began enrolling patients in a prospective, randomized controlled trial in September 2021. Patients were randomized to receive 1g of IV TXA at induction vs. control. Variables were collected prospectively. Our power analysis determined at least 98 patients should be enrolled to detect at 25% difference in SDD rate (accounting for drop out we will plan to enroll 110 patients). Statistical analysis was performed using SAS Studio (2021). Student t‐tests and chi‐square tests were performed for continuous and categorical variables, respectively. A p‐value of <0.05 was deemed statistically significant.
Results: In total, 110 patients were randomized 1:1 to the TXA and control groups with no significant difference in preoperative characteristics including age, ASA score, BMI, obesity, chronic kidney disease, diabetes, hypertension, COPD, history of chronic pain and mental health diagnoses (all p > 0.05). There was no difference in operative characteristics between groups including enucleation time, morcellation time and energy used (all p > 0.05). SDD was successful in 49/55 (89%) of patients in the control arm compared to 51/55 (93%) in the TXA cohort (p = 0.74). There was no difference in the proportion that had their catheter removed on the same day of surgery (Control ‐ 49/55 (89%) vs TXA – 50/55 (91%), p = 0.99). There was no difference in postoperative complications between groups (all p > 0.05).
Conclusions: Tranexamic acid administration is safe but did not significantly impact the rate of same day discharge after HoLEP.
Intravesical Prostatic Protrusion Length Is Associated with Postoperative Urinary Incontinence After Holmium Laser Enucleation of the Prostate
AI Khan, SN Rahman, BH Press, C Hayden, M Gardezi, SD Lokeshwar, M Siev, PC Sprenkle, DS Kellner
Yale School of Medicine
Introduction & Objective: Our objective was to assess the impact of preoperative measurements of intravesical prostatic protrusion length (IPPL) and membranous urethral length (MUL) on postoperative urinary incontinence after holmium laser enucleation of the prostate (HoLEP).
Methods: We retrospectively reviewed our institutional HoLEP database from April 2019 to March 2022 for patients with available preoperative magnetic resonance imaging (MRI) pelvis/prostate. MRIs were analyzed for IPPL and MUL. A binary logistic regression was performed defining urinary incontinence as <1 pad per day. Analysis was adjusted for age, body mass index, post‐void residual, preoperative incontinence, and preoperative prostate‐specific antigen (PSA). Separate analyses were performed using IPPL and MUL.
Results: A total of 114 patients were identified with preoperative MRIs that underwent HoLEP in our institution wide analysis. Out of these 114 patients, data regarding urinary incontinence data was available at 1 month and 3 months for 69 patients. In this cohort, the median age was 68.5 (61.5‐75.5) and median preoperative PSA of 10.2 (8.6‐14.3). At 1 month, IPPL and MUL were not found to be significantly associated with incontinence (p = 0.316 and p = 0.340). At 3 months, IPPL was found to be associated with urinary incontinence (OR = 1.09 [1.01‐1.29] p = 0.049). However, MUL was not associated with incontinence at 3 months (p = 0.712).
Conclusions: Preoperative measurement of IPPL is associated with postoperative urinary incontinence after HoLEP and can potentially be used to counsel patients about postoperative recovery. MUL was not found to be associated with postoperative urinary incontinence after HoLEP. Further studies are needed to assess the impact of anatomical dimensions on surgical outcomes after HoLEP.
Outcomes Following Surgical Treatment for Lower Urinary Tract Symptoms Due to Benign Enlarged Prostate in Patients with Neurological Diseases
N Nguyen, M Wahba, J Vetter, C Arett, CU Nottingham
Washington University School of Medicine in Saint Louis Physicians
Introduction & Objective: Clinical outcomes after treatment of Benign Prostatic Hyperplasia (BPH) are poorly defined in patients with neurologic deficits. The efficacy of treatments for BPH may be impacted by presence of neurologic bladder dysfunction, and the potential for complications such as incontinence may be a deterrent for surgery. We set out to define clinical outcomes for patients with neurologic deficits undergoing BPH treatment.
Methods: We conducted a retrospective review at a tertiary care center of patients with neurologic diseases undergoing surgical treatment of BPH surgery with either laser vaporization or transurethral resection of the prostate. We included patients with a chart diagnosis of cerebrovascular accident, spinal cord injury, myasthenia gravis, and Parkinson's from 2017 to 2019. We compare rates of urinary retention, use of medication, complications, and American Urological Association (AUA) symptom questionnaires before and after surgical intervention.
Results: We included 30 patients with a mean follow‐up of 5.7 months. Thirteen patients underwent transurethral electrosurgical resection of the prostate, whereas seventeen patients underwent transurethral laser vaporization of the prostate. Thirty‐three percent of patients had urodynamics performed preoperatively, whereas 10% of patients had urodynamics postoperatively. Urinary retention rates (48.3% vs 16.7%, p = 0.009) and use of alpha‐blocker medications (66.7% vs 26.7%, p = 0.002) were significantly lower after surgical treatment. The median AUA symptom score decreased from 23 to 19 postoperatively (p = 0.317), with half of patients experiencing an increase in their score. There was no impact of surgical treatment on infection rates, incontinence, or use of other medications.
Conclusions: Patients with neurologic disorders who underwent treatment of BPH had improvements in urinary retention and use of alpha‐blocker medications. However, there was no significant change in AUA symptom score. Larger studies are needed to determine which patients among this population may derive the most benefit or harm from surgical intervention.
Risk Factors and Management of Bladder Neck Contractures After Holep
A Hassan, O Noel, N Shah, J Moore, N Canvasser
University of California Davis, School of Medicine
Introduction & Objective: HOLEP is the most effective transurethral procedure to improve quality of life. Although significant complications are infrequent, developing a bladder neck contracture (BNC) after HOLEP requires a second procedure. Our objective was to evaluate risk factors for developing a BNC after HOLEP, and if additional bladder neck incisions (BNI) after enucleation are effective in preventing BNC. This is typically performed in smaller glands where, subjectively, the bladder neck is felt to be narrow.
Methods: We retrospectively reviewed our single‐institution HOLEP series. Patients who developed a symptomatic BNC were reviewed and compared to patients without BNC. A subset of patients with smaller glands were also compared to see if an additional 3 and 9 o'clock BNI after enucleation helped reduce the risk of BNC.
Results: A total of 193 patients underwent HOLEP from February 2020 – November 2021 with at least 6 months follow up. Four patients developed symptomatic BNC. These patients had smaller glands (p = 0.01), shorter enucleation times (p = 0.5), and slower enucleation rates (p = 0.007) (table 1). Each BNC underwent transurethral incision of the bladder neck at a median of 8 months after HOLEP. There has been no re‐recurrence of BNC, with median follow up of 9 months.
In a subgroup of patients with prostates <80 cc, additional BNI were performed in patients with smaller glands (p < 0.001) and slower enucleation rates (p < 0.007) (table 2). However, two patients still developed BNC (p = 0.6).
Conclusions: Gland size is a strong predictor of developing a BNC after HOLEP. Given smaller prostates can be a difficult enucleation, this is also reflected in slower enucleation rates. Subjectively added after enucleation in patients with narrow bladder necks, additional 3 and 9 o'clock BNI did not remove the risk of developing a BNC. In patients who develop BNC, a thorough laser transurethral incision is a successful procedure without any re‐recurrence in our series.
Antibiotic Prophylaxis Practice Patterns in Patients Undergoing Transurethral Resection or Vaporization of the Prostate with Preoperative Catheterization
MZ Gn, S Allu, T Wheeler, R Ortiz, P Caffery, C Tucci, E Hyams
Introduction & Objective: Patients undergoing transurethral resection of prostate (TURP) or Greenlight vaporization of the prostate (GLPVP) will often have an indwelling catheter or be on clean intermittent catheterization (CIC) prior to surgery. Urinary colonization is common in these patients and the optimal utilization of antibiotic prophylaxis prior to undergoing one of these procedures is unclear. We investigated antibiotic prophylaxis practice patterns at our institution for patients undergoing these procedures as well as infectious complications.
Methods: A single‐institution, retrospective review was performed to identify patients who underwent a TURP or GLPVP from 2020‐2021. Presence of a preoperative indwelling catheter or CIC regimen, preoperative urine cultures and antibiotics prescribed, and 30‐day re‐presentation secondary to a urinary tract infection (UTI) were recorded and analyzed.
Results: In total, 128 patients who underwent a TURP or GLPVP were identified. 50 patients (39.1%) had an indwelling catheter or were performing CIC preoperatively. Patients with an indwelling catheter or on CIC were more likely to have a positive preoperative urine culture (58.0% vs 15.4%; p < 0.01). They were also more likely to be treated with antibiotics preoperatively (68.0% vs 19.2; p < 0.01) even with a negative preoperative urine culture (28.6% vs 4.6%; p > 0.01). Patients with positive urine cultures were likely to be treated with antibiotics preoperatively (96.6% for patients with an indwelling catheter or on CIC vs 100% without; p = 0.51). Postoperative antibiotic prescribing rates were similar between the two groups (28.0% vs 26.8%; p = 0.89). 2 patients (4%) with an indwelling catheter or on CIC were readmitted within 30 days with a UTI versus no readmissions for patients without an indwelling catheter or on CIC (p = 0.08). There was no difference in 30‐day readmission rates with a UTI in patients with an indwelling catheter or on CIC who were placed on preoperative antibiotics versus those who were not (2.9% vs 6.3%; p = 0.58).
Conclusions: Patients with an indwelling catheter or on CIC are more likely to be treated with antibiotics preoperatively prior to undergoing a TURP or GLPVP, even with a negative preoperative urine culture. The benefit of antibiotic prophylaxis in patients with an indwelling catheter or on CIC remains unclear. Infectious disease consultation generally suggests perioperative prophylaxis only in these patients, though our practice patterns demonstrate more aggressive use of preoperative antibiotics. This issue warrants further attention in prospective studies to determine the optimal balance between effective prophylaxis and good antibiotic stewardship.
Perioperative Outcomes After Laser Enucleation of the Prostate: Comprehensive Analysis of 1693 NSQIP Patients
Z Dalimov, F Hennig, M Elhady, A Higgins, E Ghiraldi, A Houjaij, N Nader, O Darwish
Introduction & Objective: Laser enucleation of the prostate (LEP) is a size independent surgical treatment option for enlarged prostate with bothersome lower urinary tract symptoms. In this study, we aimed to analyze perioperative outcomes of LEP.
Methods: ACS‐NSQIP data was queried for patients who underwent LEP between the January 2015 and December 2017, which identified a total of 1693 patients (Table 1). Descriptive statistics were used to analyze patient characteristics and perioperative outcomes. History of bleeding disorders or chronic anticoagulation use was used to classify patients as increased bleeding risk. Multivariate analysis (MVA) was used to identify variables associated with any complication, return to operating room (OR), and hospital readmission.
Results: Of the 1693 cohort, only 86 (4.8%) patients experienced post‐operative complications within 30 days (Table 2). Post operative urinary tract infection (2.9%) and bleeding requiring transfusion (0.9%) were the two most common complications following LEP. On MVA, BMI (OR 1.05, 95% CI 1.01‐1.09, p = 0.008) and increased bleeding risk (OR 5.27, 95% CI 2.53‐10.97, p < 0.001) were associated with 30‐day complications (Table 3). 34 (2.0%) patients required return to OR that was related to their index procedure. The cystourethroscopy (35%) and cystourethroscopy with fulgurations (21%) were two most common procedures to return to OR (Table 2). The ASA 3 and above (OR 2.26, 95% CI 1.11‐4.65, p = 0.026) and having renal failure on dialysis (OR 11.25, 95% CI 2.16‐58.64, p = 0.004) were associated with return to OR. There were 61 (3.6%) re‐admissions related to the LEP surgery. The hematuria (28%) and urinary tract infection (16%) were two most common reasons for readmissions. The non‐Caucasian race (OR 1.82, 95% CI 1.08‐3.07, p = 0.026), ASA 3 and above (OR 2.37, 95% CI 1.43‐3.92, p = 0.001), increased bleeding risk (OR 3.26, 95% CI 1.49‐7.14, p = 0.003), and pre‐operative steroid use (OR 3.27, 95% CI 1.37‐7.80, p = 0.008) were associated with increased risk of re‐admissions following the LEP.
Conclusions: LEP is a relatively safe surgical treatment option for enlarged prostate with bothersome lower urinary tract symptoms. Urinary tract infection and blood transfusion are most common complications within 30 days. Small number of patients required reintervention and majority of them required cystourethroscopy. Hematuria and urinary tract infection were the most common reasons for readmissions related to LEP. History of bleeding disorders or chronic anticoagulation use was associated with increased risk of complications and re‐admissions following LEP.
Peri‐operative Outcomes of a New Holmium Laser Enucleation of the Prostate Program Using Moses 2.0 in a Safety‐net Hospital
M Rodriguez‐Homs, T Manalo, K Szymanski, D Gustafson, K Thurmon, R Donalisio Da Silva
University of Colorado
Introduction & Objective: Benign prostatic hyperplasia (BPH) with lower urinary tract symptoms (LUTS) results in a large healthcare and lifestyle burden. However, advancements in technology have continued to show improvement in patient outcomes. Studies highlighting bipolar plasma vaporization (BPV) versus transurethral resection of the prostate (TURP) demonstrate a significantly shorter catherization period, hospital stay, and retreatment rate for the BPV group. With holmium laser enucleation of the prostate (HoLEP), there is a growing acceptance of this modality as the new gold standard. Herein, we describe our initial six‐month experience starting a new HoLEP program with Moses 2.0 compared to our standard BPV procedure at our safety‐net hospital.
Methods: A retrospective study was done of 437 patients from 2012‐2022 who underwent surgery for symptomatic BPH. We compared both pre‐ and peri‐operative outcomes between HoLEP and BPV. The primary outcomes were same‐day discharge, hospital duration, operative time, and perioperative complications. A paired t‐test was performed to measure significance between groups for nominal data whereas a chi‐square test was used for ordinal data. Statistical significance was ≤0.05.
Results: In our study, 395 patients underwent BPV compared to 42 HoLEP patients. There was no difference in age, race/ethnicity, quality of life score, and uroflow data between groups. Pre‐operative IPSS scores were higher in the BPV group (19.5 + 9.7 vs 14.6 + 9.4, p ≤ 0.05). Prostate size was larger with HoLEP compared to BPV (102.7 grams + 52 vs 59.4 grams + 29.7, p ≤ 0.05). HoLEP was associated with longer operative time compared to BPV (118 minutes + 45 vs 77.2 minutes + 40.6, p ≤ 0.05). Patients who underwent HoLEP more often underwent same‐day discharges (25 vs 61 patients, p ≤ 0.05) and had less inpatient admissions (0.5 vs 1.2 days, p ≤ 0.05). Post‐operative catheter time in BPV compared to HoLEP was longer (8 vs 1 days, p ≤ 0.05). There were 0 complications for our HoLEP cohort and 10 (2.5%) for BPV.
Conclusions: A new HoLEP program using the Moses 2.0 laser at our safety‐net hospital is promising. HoLEP patients had more same‐day discharges, shorter hospital stays, less complications, and shorter post‐operative catheter duration despite longer operative time compared to BPV. Long‐term outcomes are needed given recent implementation of this technique and technology within our hospital.
Predictors of AUA Symptom Score Improvement Following Holmium Laser Enucleation of the Prostate
C Rogers, A Slade, E Sahm, T Large, G Vedantam
Indiana University
Introduction & Objective: Benign prostatic hyperplasia (BPH) symptom severity is often evaluated by filling out a symptom index from the American Urological Association (AUA). Holmium laser enucleation of the prostate (HoLEP) is considered the new gold standard for surgical treatment of BPH, and is a prostate size independent option. The aim of this study was to analyze any differences in AUA symptom score (AUA SS) improvement following HoLEP treatment related to preoperative prostate size, BMI, age, or a single component of preoperative AUA symptom score.
Methods: We included all patients who underwent a HoLEP procedure at our institution from 2018 through 2021 that had a completed record of preoperative prostate size, BMI, age at surgery, preoperative AUA SS, and postoperative AUA SS at least 3 months out from surgery. Patients with an indwelling catheter were excluded Patients were divided into a group of AUA SS improved (total reduction of at least 3 points) or AUA SS unimproved (reduction of less than 3 points). T‐test was used to compare variables between the two groups.
Results: There were 118 total patients included, 89 in the improved and 29 patients in the unimproved group. There was no significant difference in mean prostate size (100.0cc vs 100.7cc, p = 0.951), BMI (29.5 vs 29.4, p = 0.918), or age (68.0yrs vs 70.6yrs, p = 0.123) between the improved and unimproved groups respectively. Each component of the pre‐operative AUA SS (incomplete emptying, frequency, intermittency, urgency, stream, strain, nocturia and total score) was significantly higher in the improved group. Post‐operatively, the unimproved group experienced significant worsening in incomplete emptying, frequency, intermittency, urgency, and nocturia with improvement only in stream and strain (Table 1).
Conclusions: There exists a subset of patients who appear to not benefit from HoLEP. Having a higher preoperative score in any of the AUA SS components is associated with an increase in the likelihood of a significant total AUA symptom decrease following HoLEP. BMI, age, and even prostate size averaging over 100cc, may not be good prognostic indicators for symptomatic improvement following HoLEP. Further investigation is needed to identify patients who do not benefit from outlet procedures.
What Are My Patients Learning About BPH on Youtube? An Analysis of Patient Education Materials on Social Media
A Chen, JM Torres, H Perera, D Schulsinger
Stony Brook Medicine
Introduction & Objective: Benign prostatic hyperplasia (BPH) is a common diagnosis in the aging male population. Symptomatic BPH may drive patients to seek information from a variety of sources. YouTube is a popular platform for medical education, but the quality of information remains unevaluated.
Methods: A search was performed for the top 50 most viewed English‐language YouTube videos using the keywords ‘enlarged prostate treatment.’ Videos exceeding twenty minutes were excluded. Videos were graded based on user engagement, content, and metrics utilizing the DISCERN and Patient Education Materials Assessment Tool (PEMAT) standardized scores. Categorical variables were analyzed with chi‐square and continuous with ANOVA.
Results: The top 50 most popular videos accounted for 37,135,760 total views. 94% were produced by non‐medical institutions, 22% featured a physician, and 18% featured a urologist. Average DISCERN score was 2.9 with 68% of videos rated as moderate to poor quality (DISCERN ≤3).
Videos featuring a physician had a higher DISCERN quality score (2.7v3.3,p = 0.003). 70% of videos promoted home remedies/supplements for management of BPH. These videos were more actionable than ones without (0.37v0.26,p = 0.04). Saw palmetto was featured in 20% of videos and described positively (8), negatively (1), and with no effect (1). 69% of home remedy videos contained a link to purchase a featured product. 48% of videos featured surgeries. Videos featuring physicians were more likely to mention surgeries (8/11 = 73%v16/39 = 41%).
User comments/engagement was analyzed: 94% requested medical advice, 91% provided advice, 89% provided support. Videos featuring a physician had more user comments (640v401,p = 0.24).
Conclusions: Less than 25% of the 50 most popular videos on YouTube discussing BPH featured a physician. These videos were higher quality than those without. Home remedy videos were more likely to encourage patients to take action and most contained a link to purchase a featured product. Less than 50% featured surgeries. Patients appeared extremely engaged and desired more information. A stronger physician presence on social media platforms is needed to disseminate accurate and accessible information to the public.
MP17: Laparoscopy/Robotics: Prostate Cancer
Single‐port Robotic vs Open Radical Prostatectomy: A Comparison of Extraperitoneal Approaches
M Abou Zeinab, E Ferguson, A Kaviani, A Beksac, E Klein, J Kaouk
Cleveland Clinic
Introduction & Objective: The introduction of the “purpose‐built” single‐port (SP)robot adopted the same approach used in open radical prostatectomy (RP): the extraperitoneal approach. While both techniques avoid breaching of the peritoneal cavity and the need for the intraoperative Trendelenburg position, we sought to compare the outcomes between the two approaches.
Methods: From a single‐institution database, data of 69 consecutive patients who underwent open RP from January 2019 to January 2021 were prospectively collected. Similarly, data of 206 consecutive patients who underwent SP extraperitoneal RP were prospectively collected from November 2018 to October 2021. A 1:2 matched‐pair comparison for the National Comprehensive Cancer Network (NCCN) risk and preoperative Prostate Specific Antigen (PSA) was performed to assess the perioperative and early postoperative outcomes between the two groups. Continent patients were defined by using 0 or 1 pad for protection after the surgery.
Results: After matching, both groups were comparable in the baseline characteristics (Table 1). There was no difference in the median total operative time (p = .279). The open group had significantly more estimated blood loss, more transfusions despite the use of cell saver during the surgery (p < .001), and less nerve‐sparing (p < .001). The median lymph node yield was higher in the open group compared to the SP group (8 vs 5 nodes, p < .001). Postoperatively, the SP RP group required less opioid use(p < .001), were discharged during the same day of the surgery, compared to a median of an overnight hospital stay in the open group (p < .001), and had no difference in the postoperative complications (p = .103). 6 weeks post‐op, 30% of the open RP patients were continent compared to 54% in the SP group (p = .007) (Table 2).
Conclusions: The Single‐port RP technique offers patients a less invasive approach in terms of less blood loss, less opioid analgesics requirements, same‐day discharge, and quicker recovery. Open RP allows for more extensive lymph node dissection, which might be beneficial for high‐risk patients.
Transvesical versus Extraperitoneal Single‐port Robotic Radical Prostatectomy: A Matched‐pair Analysis
M Abou Zeinab, A Beksac, A Kaviani, E Ferguson, J Kaouk
Cleveland Clinic
Introduction & Objective: Single‐port (SP) transvesical radical prostatectomy (TVRP) was shown to be a feasible and safe procedure with excellent perioperative outcomes. In this study, we compared our perioperative and early postoperative outcomes with the SP extraperitoneal radical prostatectomy (ERP) approach
Methods: From December 2020 to October 2021, data of consecutive 69 patients who underwent SP TVRP were prospectively collected. Selection criteria for this approach were patients with extensive previous abdominal surgeries, patients with Gleason 7, or Gleason 6 with a significant family history of prostate cancer. Prospective data of consecutive 169 patients who underwent SP ERP prior to the introduction of the SP TVRP were included for comparison. To minimize selection bias, a matched‐pair analysis on PSA value, biopsy Gleason score, and prostate volume was performed with a 1:1 ratio. The median follow‐up is 9 and 5 months for ERP and TVRP, respectively
Results: After matching, all baseline characteristics were comparable between the two groups (Table 1). The median total operative time was longer in the TVRP compared to the ERP group (191 vs 210 min, p = .009) with less median estimated blood loss (125 vs 100cc, p = .05) (Table 2). The median Lymph node yield was higher in the ERP group (6 vs 2.5, p = .001). Both groups had minimal to no pain at discharge with minimal to no opioids use postoperatively. Median Foley catheter duration was 3 days in the TVRP group vs 7 days in the ERP group (p < .001). There were no differences in surgical margin status (19.1% vs 11.6%, p = .222), intraoperative or postoperative complications between the two groups. As for continence, 76% of the TVRP group had full urine control at 6 weeks postoperative compared to 57% in the ERP group (p = .001). Three months after surgery, there was no difference in the continence rate
Conclusions: TVRP is an alternative approach to ERP for patients with a hostile abdomen, or low to intermediate‐risk prostate cancer. In our initial series, TVRP allows for shorter Foley catheter duration and a faster urine control rate, without functional or oncological compromise
Positive Surgical Margins After Retzius Sparing Robotic Prostatectomy Are More Commonly Anteriorly Located Than After Traditional Robotic Prostatectomy
M West, A Wood, A Schulman, D Silver, E Teper
Maimonides Medical Center
Introduction & Objective: The Retzius Sparing (RS) approach to Robot Assisted Laparoscopic Radical Prostatectomy (RALP) has been described as an alternative technique for cancer control in patients with localized Prostate Cancer. Although data demonstrate equivalent perioperative outcomes and improved continence rates, little has been published about the location and extent of positive surgical margins (PSMs) in these patients. Our aim is to compare the characteristics of PSMs between the RS technique and previously established techniques.
Methods: We performed a retrospective cohort analysis of patients with PSMs following RALP at our academic medical center between January 2017 and July 2021. Review was conducted before and after adaptation of the RS technique by a high volume robotic surgeon. We assessed these characteristics for patients with PSMs: pre‐op PSA, DRE, Gleason score, Risk Category, anterior vs. posterior margin location, bladder neck or apical margin, limited vs non‐limited positive margin, multifocality, concomitant SVI or EPE, and first post‐operative PSA. Patients were split into RS and traditional RALP groups for analysis.
Results: 60 patients were included in the analysis, 20 PSMs after RS and 40 PSMs after traditional RALP. There was no difference in the distribution of preoperative NCCN risk stratification or pT3 status between the two groups. Anterior location of PSM was significantly more common in the RS group as compared with PSMs in the traditional RALP group (35% vs. 12.5%, p = 0.0399). Notably, 6 of the 7 patients with anterior PSMs in the RS group had an anterior lesion on Prostate MRI. In addition, PSMs after RS approach were more likely to involve the bladder neck (25% vs. 12.5%), be limited (50% vs. 40%) but multifocal (70% vs. 50%) in nature, and result in a non‐detectable post‐operative PSA (65% vs. 50%). However, these differences were not statistically significant.
Conclusions: PSMs in the anterior prostate are more common following RS approach to RALP. Clinicians should take this into account during operative planning, especially in patients with anterior lesions on Prostate MRI. Larger studies are needed to ascertain the impact of RS approach on biochemical recurrence after a PSM.
Using the Single‐port Robot to Solve Clinical Challenges in Prostate Cancer
A Levy, M Butaney, S Majdalany, GA Barayan, J Peabody, W Jeong, C Rogers
Henry Ford Health Systems
Introduction & Objective: Patients with prostate cancer who are poor candidates for multi‐port robotic surgery, but desire or require surgical management, can present a clinical challenge. Use of single port (SP) robotic technology may help overcome some of these challenges. We present our initial experience with robotic‐assisted radical prostatectomy (RARP) using the da Vinci SP robot for prostate cancer in patients who would otherwise not be good surgical candidates for conventional multi‐port transabdominal robotic surgery.
Methods: Fourteen of 41 patients who underwent SP‐RARP for biopsy confirmed, organ‐confined prostate adenocarcinoma at a single tertiary care institution qualified for inclusion in our study. Patient characteristics were collected prospectively and are highlighted in table 1.
Results: Nearly all patients had prior abdominal surgery (13/14, 93%) including aborted multi‐port RARP (2), hernia repair (5), bowel diversion (3), or peritoneal dialysis catheters (2) among others. Patients underwent extraperitoneal (9/14, 64%) or transvesical (5/14, 36%) approach. All patients underwent successful procedures without need to convert to multi‐port robotic or open approach. There were no intraoperative complications and one Clavien III post‐operative complication. Positive margin rate was 29%, most of which were microscopic (≤3mm, 3/4, 75%). Eighty‐five percent of patients had undetectable nadir PSA.
Conclusions: The SP robot can facilitate surgery for prostate cancer in some patients who might otherwise not be considered surgical candidates. In our experience, operative outcomes are not compromised despite a smaller incision and working space. We have found the SP system to be a valuable tool for carefully selected patients.
Feasibility and Safety of Outpatient Robot‐assisted Radical Prostatectomy: A Systematic Review and Meta‐analysis
J Li, D cao, Q Wei
Introduction & Objective: To provide a systematic analysis of outcomes comparing outpatient and inpatient robot‐assisted radical prostatectomy (RARP) for prostate cancer based on the best available evidence.
Methods: This present study has been reported following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta‐Analysis) statement and AMSTAR 2 guideline. A comprehensive search of electronic databases (PubMed, Web of Science, Scopus, and Cochrane Library) was conducted to determine eligible comparative studies as of February 2022. The Newcastle‐Ottawa scale was used to assess the quality of the included studies. Parameters including perioperative, oncological, and functional outcomes were collected.
Results: Nine studies with 2721 patients were included, of which 831 underwent outpatient RARP and 1890 underwent inpatient RARP. The combined results demonstrated that compared with the inpatient group, the outpatient group had shorter operation time (weighted mean difference [WMD] ‐8.59 95% CI ‐14.08 to ‐3.10, p = 0.002) and lower overall complication rate (odds ratio [OR] 0.64, 95% CI 0.44 to 0.95, p = 0.03). However, there were no significant differences regarding estimated blood loss, readmission rate, positive surgical margin, and urinary continence rates between the groups.
Conclusions: Outpatient RARP does not increase the incidence of complications and readmissions compared with inpatient RARP. This suggests that routine same‐day discharge after providing patients with RARP is safe and feasible.
Early Urinary Continence Recovery Following Robotic Radical Prostatectomy: Comparison of Single‐port Transvesical Retzius‐sparing versus Traditional Multi‐port Transperitoneal Approaches
A Beksac, M Abou Zeinab, N Abdallah, J Emrich Accioly, WR Jevnikar, E Ferguson, A Kaviani, J Kaouk
Glickman Urological & Kidney Institute, Cleveland Clinic
Introduction & Objective: Single‐port (SP) transvesical (TV) robot‐assisted radical prostatectomy (RARP) is a novel surgical technique with a rapid continence recovery. Herein, we sought to compare SP TV RARP with the traditional multi‐port (MP) transperitoneal RARP.
Methods: From a single‐surgeon series, we identified 165 patients (55 SP and 110 MP) who underwent RARP from 2015 to 2021. MP cases were from before the adoption of the SP approach in practice to avoid selection bias. All patients had more than 3 months of follow‐up. Continence was defined as requiring no pads or one safety pad per day. The primary outcome measure was urinary continence at postoperative 6 weeks and 3 months. A 1:2 matched‐pair analysis was performed. Univariate analysis was performed using Chi‐square, Fischer's exact, or Wilcoxon rank‐sum test.
Results: Median follow‐up was 8.8 months for the SP group and 30.7 months for the MP group. Baseline characteristics are comparable except for smaller prostate size (51 vs. 42 g, p < 0.001) and a higher rate of past surgical history (colectomy and or colostomy 18% vs. 0%, p < 0.001) in the SP group. Urinary continence recovery was superior in the SP group at 6 weeks follow up (72.7% vs. 50.9%, p = 0.007) and 3 months follow up (87.3% vs. 72.7%, p = 0.035). SP group had longer operative time (210.0 vs. 174.0 minutes, p < 0.001), shorter length of stay (4 vs. 26 hours, p < 0.001), lower morphine milligram equivalent (7 vs. 15, p < 0.001). The positive surgical margin rate was comparable (p = 0.057).
Conclusions: SP TV RARP resulted in improved early continence recovery, decreased postoperative pain, and faster postoperative recovery compared to traditional transperitoneal MP RARP.
Robotic‐assisted Radical Prostatectomy ‐ A Prospective Cohort Study of 232 Consecutive Cases Comparing Outcomes for Procedures Where the Trainee or the Consultant Were Primary Operator
J Saad, M Arianayagam, C Varol, I Thamgasamy, M Winter, R Ko, R Ferguson, M Khadra, B Canagasingham, A Goolam
Canberra Hospital
Introduction & Objective: We sought to compare the performance, pathological and peri‐operative outcomes for robotic‐assisted laparoscopic prostatectomy performed predominantly by a urology trainee to the outcomes achieved when the operation was performed predominantly by a consultant
Methods: This is a cohort study of prospectively collected data from December 2016 to August 2019. We assessed performance, peri‐operative parameters and pathological data. Each case was broken down into modules from port placement to specimen retrieval. If the registrar completed more than 75% of the steps from anterior bladder neck to forming the anastomosis, it was considered a registrar case. Fisher's exact test and the independent T test was used to assess categorical and continuous variables.
Results: A total of 232 cases were analysed. Overall, consultants completed 176 (75%) cases compared to 56 trainee cases (25%). Consultants were found to be completing the majority of the high‐grade cancers (88% of the ISUP 4/5 disease, Trainees completed 12%, P = 0.013) and extended lymph node dissections (Consultants: 80%, trainees: 20%, P = 0.47). The only statistically significant difference found was console time: consultants and trainees completed cases in 171 and 197 minutes respectively (p = 0.0049). There was no further statistically significant difference seen in surgical and pathological outcomes between consultants and trainees. This included blood loss (p = 0.79), margin rate (p = 0.5) and complication rate (p = 0.30).
Conclusions: Apart from an increased console time, similar outcomes can be achieved with good case selection, close supervision, and graded progression.
Single‐port Extraperitoneal vs Transperitoneal Robotic‐assisted Radical Prostatectomy: A Multi‐institutional Matched‐pair Comparison of Perioperative Outcomes
M Abou Zeinab, E Ferguson, A Kaviani, A Beksac, M Moschovas, L Morgantini, S Hemal, J Joseph, M Kim, S Crivellaro, V Patel, J Nix, J Kaouk
Cleveland Clinic
Introduction & Objective: The introduction of the ‘purpose‐built’ Single‐port (SP) robot successfully expanded the surgical approaches in the management of localized prostate cancer to include the extraperitoneal, in addition to the standard transperitoneal approach. We sought to compare the perioperative and early postoperative outcomes between SP extraperitoneal radical prostatectomy (EPRP) and transperitoneal radical prostatectomy (TPRP), in a multi‐institutional setting.
Methods: From February 2019 to October 2021, a prospective data collection from six different robotic centers was performed. Data of 412 patients who underwent EPRP and 238 patients who underwent TPRP were analyzed. All procedures were performed by surgeons with extensive robotic experience. A 1:1 matched‐pair analysis for body mass index (BMI), preoperative prostate‐specific antigen (PSA), prostate size, and National Comprehensive Cancer Network risk (NCCN) was performed. Baseline characteristics, intraoperative, postoperative and functional outcomes were evaluated.
From February 2019 to October 2021, a prospective data collection from six different robotic centers was performed. Data of 412 patients who underwent ERP and 238 patients who underwent TRP were analyzed. All procedures were performed by surgeons with extensive robotic experience. A 1:1 matched‐pair analysis for body mass index (BMI), preoperative prostate‐specific antigen (PSA), prostate size, and National Comprehensive Cancer Network risk (NCCN) was performed. Baseline characteristics, intraoperative, postoperative and functional outcomes were evaluated.
Results: After matching, 238 patients were included in each arm. The median follow‐up period was 7 and 6 months for EPRP and TPRP groups, respectively. The total operative time was longer in the EPRP group (median 206 minutes vs 155 minutes, p < .001). The EPRP group had a shorter length of hospitalization and same‐day discharge rate compared to the TPRP approach (p < .001). There was no difference in the overall intraoperative or postoperative complications rate between the two groups, nor positive surgical margin rates. Both groups had comparable continence rates at 6 weeks, 3 months, and 6 months postoperatively.
Conclusions: Both SP EPRP and TPRP are comparable surgical options for the treatment of localized prostate cancer. SP EPRP approach is more associated with a shorter hospital stay and a higher rate of same‐day discharge, with no difference in the surgical margin, complication, and short continence rates.
The Multi‐institutional Experience on Single‐port Extraperitoneal Robotic‐assisted Radical Prostatectomy
M Abou Zeinab, E Ferguson, A Kaviani, A Beksac, L Morgantini, J Joseph, M Kim, S Crivellaro, J Nix, J Kaouk
Cleveland Clinic
Introduction & Objective: Single‐port (SP) robotic‐assisted radical prostatectomy through the extraperitoneal approach has increased in popularity. We sought to evaluate the perioperative and postoperative outcomes in a multi‐institutional setting.
Methods: From February 2019 to October 2021, data of 412 patients who underwent SP extraperitoneal radical prostatectomy (ERP) in five different institutions were prospectively collected. All procedures were performed by surgeons with extensive robotic and SP experience. Baseline demographics, intraoperative, functional, and short oncological outcomes were evaluated.
Results: The median follow‐up was time was 8 months. The median cohort age, BMI, and preoperative PSA were 64 years, 29 kg/m2, and 6.6 ng/mL respectively. 23.8% of the cohort were at high‐risk prostate cancer according to the NCCN classification. Almost 30% of the patients had at least one previous abdominal surgery. The median operative time and estimated blood loss were 205 minutes and 150 cc, respectively. A nerve‐sparing approach was performed in more than 90% of the patients and 3 cases had peritoneal breach. On pathology, the positive surgical margins were 26.8% and the median lymph node yield was 6 nodes. Most of the patients were discharged a few hours after the surgery with a median pain score of 2. In the postoperative phase, 50% and 90% of the patients were continent within 3 and 6 months, respectively. 40% of the patients restored their sexual function by 6 months.
Conclusions: The Single‐port extraperitoneal robotic‐assisted radical prostatectomy is a minimally invasive approach in the management of localized prostate cancer. It is a suitable approach for patients with previous abdominal surgeries. This approach offers patients with promising outcomes in terms of single incision, minimal pain, and same‐day discharge without compromising the functional or oncologic outcomes.
Provider‐level and Regional Variation in Robotic‐assisted Laparoscopic Prostatectomy Volume
J Abraham, E Hyams, R Ortiz, A Homer, F Munshi
Introduction & Objective: There is a well‐established relationship between surgical volume and perioperative and oncological outcomes for robotic‐assisted laparoscopic radical prostatectomy (RALP). [1] However, there is limited recent evidence regarding variation in surgical volume at the surgeon and regional level.[2] In this study, we evaluated variation in RALP volume among Medicare patients to better understand recent practice patterns and inform discussions on centralization of care.
Methods: Using publicly available Medicare data (https://data.cms.gov/) we determined the number of RALPs (CPT 55866) performed by urologists in the United States from 2014‐2019. Providers were grouped into 4 United States regions by state: West, Midwest, Northeast, and South. The data were analyzed descriptively and using a multiple linear regression model with region fixed effects to determine the difference in provider RALRP volume across regions. Data were censored for provider volume <11 cases / year due to privacy concerns.
Results: During the study period, there were 1058 distinct providers performing RALP in Medicare patients. Mean surgical volume per provider per year was 21.09 (SD 16.46, IQR 11). The highest and lowest surgical volume per provider were 306 and 11 cases, respectively (Figure 1). There were significant regional differences in RALP volume per physician with highest volume in the Northeast (Figure 3A), despite outlying high volume providers (Figure 1). There was an increasing number of RALPs performed over time, but no change in procedures per physician per year (Figure 2/3).
Conclusions: In recent Medicare data, there is wide variation in RALP volume at the provider and regional level. While this is a subset of overall surgical practice, these data elicit questions regarding the frequency of lower volume surgery and the consideration of centralization to improve outcomes. [3] Further research is needed to determine how to centralize surgical treatment of prostate cancer most effectively.
no Pad Prostatectomy: A Comparison of Retzius Sparing and Posterior Urethral Suspension for the Reduction of Immediate Post‐prostatectomy Incontinence
HD Kominsky, J Gahan, J Cadeddu
UT Southwestern Medical Center
Introduction & Objective: Stress urinary incontinence (SUI) is a risk of radical prostatectomy that can be a frustrating problem for both surgeons and patients in the first few months following surgery. Different techniques have been described that attempt to reduce the incidence of post‐RP SUI including a Retzius‐sparing (RS) approach and the inclusion of a posterior urethral suspension (PUS) suture. We aim to compare short term continence outcomes between patients undergoing RS‐RP and those undergoing standard RP with inclusion of a PUS suture technique.
Methods: Eighty‐two patients who underwent robotic radical prostatectomy at our institution were included in the study. Demographic and perioperative data were collected from the electronic medical record. We were particularly interested in immediate functional status in terms of pad usage as a facsimile for SUI. Patients were first evaluated 2‐4 weeks following RP and again at 3 months. A strict continence definition of no pad or up to one safety pad was utilized.
Results: We compared 39 patients (mean age 63.9 years) who underwent RS‐RP to 43 patients (average age 62.8 years) who underwent PUS‐RP. There was no statistically significant difference in BMI, prostate volume, PSA, operative time, catheter duration and rate of complications between the two groups (all p > 0.05). There was a higher rate of a positive surgical margin in the RS‐RP compared to PUS‐RP (30% vs 12%, p < 0.05). At mean follow up of 4.3 weeks for PUS‐RP and 6.2 weeks for RS‐RP, there was no significant difference in frequency of continent men (78% vs 73%, p = 0.548). At mean follow up of 15.4 weeks for PUS‐RP and 13.25 weeks for RS‐RP, again, there was no significant difference in frequency of continent patients (84% vs 93%, p = 0.192).
Conclusions: Patients who underwent RS‐RP had similar rates of continence to those patients undergoing PUS‐RP in the short term post‐operative period. Use of a PUS stitch may provide equivalent short term urinary functional outcomes to RS.
M Abou Zeinab, A Beksac, E Ferguson, A Kaviani, J Kaouk
Cleveland Clinic
Introduction & Objective: Stress urinary incontinence is common morbidity and concern for patients after radical prostatectomy. In our initial limited series, we demonstrated the feasibility and safety of the single‐port (SP) transvesical, Retzius‐sparing radical prostatectomy (TVRP) with promising oncologic and functional outcomes. In this abstract, we sought to evaluate the perioperative and postoperative outcomes of the largest cohort to date
Methods: The data of a total of 100 consecutive patients who underwent SP TVRP at a single institution between December 2020 and March 2022 were prospectively collected. Inclusion criteria were patients with hostile abdomen or patients with low‐intermediate NCCN risk prostate cancer. All surgeries were performed by a single surgeon with extensive robotic experience. Baseline, intraoperative, functional, and short oncologic outcomes were evaluated
Results: The median follow‐up period was 8.5 months. 21% had surgery in the lower abdomen including gastrointestinal surgeries such as proctocolectomy with or without colostomy/J‐pouch (14%), kidney transplantation (2%), ventral hernia repair with mesh (3%), aborted open radical prostatectomy (1%), and abdominal aortic aneurysm repair (1%). The median PSA value and prostate size were 5 ng/ml and 40 grams, respectively. All cases were completed without intraoperative complications. The median operative time was 212.5 minutes, estimated blood loss (EBL) was 100 ml. The median length of stay was 5 hours, with 63% of patients discharged the day of surgery within a few hours of surgery, and 18% stayed less than 24 hours. The median Catheter duration was 3 days, Positive surgical margin rate was 16%. 46% had immediate urinary continence after catheter removal. Continence rate was 56% at one week, 64% at 2 weeks, 74% at 6 weeks, 88% at 3 months, and 96% at 6 months
Conclusions: SP TVRP results in promising outcomes and faster patient recovery. This approach offers same‐day discharge, minimal pain and narcotic use, short Foley catheter duration, and a significantly short time to full urine control without compromising the oncological outcomes
Laparoscopic versus Ultrasound Guided Transversus Abdominis Plane Block for Postoperative Analgesia After Radical Prostatectomy: A Randomized Controlled Trial
A Civitella, R Cataldo, F Esperto, F Prata, P Tuzzolo, R Scarpa, R Papalia
Department of Urology, Campus Bio‐Medico University of Rome
Introduction & Objective: To evaluate the efficacy of laparoscopic TAP block in relation to the US‐TAP block comparing: surgery time, operating room time, post‐operative pain, use of opioids and hospitalization in patients undergoing laparoscopic radical prostatectomy.
Methods: From January 2021 to June 2021, 60 consecutive patients undergoing laparoscopic radical prostatectomy were enrolled and randomized in two groups receiving US or Lap guided TAP block. The primary outcome was pain score expressed by a 0‐10 Visual Analogic Scale (VAS) evaluated in the first 72 hours after surgery. Secondary outcomes included postoperative opioid consumption, surgical time, complications, time to ambulation and total hospital length of stay.
Results: No statistically significant differences were observed between the two groups in surgery time, blood loss, time to ambulation, length of stay and pain after surgery. In the LAP tap‐block group the overall operating room time was significantly shorter than in the US tap‐block group (140’ vs 152’ P = 0,04).
Conclusions: Laparoscopic approach compared to US‐TAP block was equally safe, not inferior in reducing analgesic drugs use post operatively. Moreover the LAP tap block has proven to be a time sparing procedure. Further studies with a larger sample are expected to confirm the efficacy LAP guided TAP block in urologic surgery.
Single Port Transvesical Partial Prostatectomy for Localized Prostate Cancer: Initial Series with Functional and Oncologic Outcomes
E Ferguson, M Abou Zeinab, A Beksac, A Kaviani, J Kaouk
Glickman Urological & Kidney Institute, Cleveland Clinic Main Campus, Cleveland, OH
Introduction & Objective: Partial prostatectomy has recently been described as an alternative to focal therapy for management of localized low and intermediate risk prostate cancer in carefully selected patients. Preclinical studies show technical feasibility of single port (SP) transvesical partial prostatectomy. Here we describe the early outcomes for SP transvesical partial prostatectomy using the da Vinci SP surgical system.
Methods: SP transvesical partial prostatectomy was offered to nine patients as an alternative to focal therapy or whole‐gland treatment in patients with low volume, localized, and low to intermediate risk prostate cancer (Gleason 6 or 7). Through a 3cm suprapubic incision, the bladder was incised and a da Vinci SP access port was used for docking. Through the access port, robotic instruments, a 12 mm assistant port, and flexible suction tubing were introduced. Transrectal ultrasound fused with prostate MRI was used for intraoperative guidance.
Results: All cases were completed successfully without need for extra ports or conversion. There were no intraoperative complications, no transfusions, and no patients required an inpatient stay (median LOS of 3.8 hours). Pain scores at discharge were median 3/10 and no opioid prescriptions were used in opioid naive patients. There were no readmissions. Catheter duration was 3 days and all were able to void spontaneously, though two patients experienced hypercontinence requiring temporary foley catheter re‐insertion. Pathology reports showed GG1 in 1 patient and GG2 in 7 patients and GG3 in 1 patient. There were no positive margins on intraoperative margin assessment. The median PSA at 6 weeks was 0.50. Median SHIM score at 6 weeks was 17.5. All patients were continent with a median pad count of 0 at 6 weeks postop.
Conclusions: We demonstrated technical feasibility and reported the initial outcomes for SP robotic transvesical partial prostatectomy. To date, functional outcomes show impressive return to continence and erectile function. Continued attention to follow up will evaluate the long‐term oncologic outcomes.
Can the Degree of Extraprostatic Extension on Robotic‐assisted Radical Prostatectomy Predict the Oncological Outcomes?
Y Li, Y Lin, Y Ou, C Shu, M Tung
Division of Urology, Department of Surgery, Tungs' Taichung MetroHarbor Hospital
Introduction & Objective: Positive surgical margin(PSM) is well known as a marker of poor outcome after radical prostatectomy. However, research on extraprostatic extension(EPE) is seldom published and the available data was discussed only about image studies. We would like to evaluate the oncological outcomes based on EPE in pathology.
Methods: We retrospectively analyzed 62 patients with the diagnosis of prostate adenocarcinoma who received robotic‐assisted radical prostatectomy in one hospital. Other than PSA ≥0.2 ng/ml as biochemical recurrence, we defined a more strict definition as PSA undetectable(< 0.008 in our hospital) and detectable(≥0.008). If the PSA remained detectable in first follow‐ up, the patient was defined as "PSA persistence"; if PSA turned into detectable, he was "PSA recurrence". We followed the patient's PSA the first time within 3 month, the second time within 6 month and the third time in the 12 month. The pathologic report on presence of EPE, grade group and total length on EPE were reviewed. Statistical analysis with independent sample t test, logistic regression and survival was calculated using the Kaplan‐Meier method and compared using the log‐rank test.
Results: The EPE rate was 38.7%(24/62 patients). The patient number of PSA undetectable/ recurrence/persistence was 17/9/36. Independent sample t test showed statistically significant difference in presence of EPE with preoperative PSA(average PSA 34.76:13.41, p < 0.001). In the pathological report, univariate logistic regression revealed the presence of EPE(p = 0.01; OR, 8.38; 95% CI, 1.669‐42.1) and grade group(p = 0.011; OR, 1.87; 95% CI, 1.156‐3.047) were significant related to PSA persistence(PSA‐p) but not PSA recurrence(PSA‐r). The grade group and total length on EPE showed no statistical significance in both groups. Kaplan‐Meier analysis revealed that PSA‐p was significantly different among the presence of EPE (log rank = 7.966, P = 0.005).
Conclusions: In patients with prostate adenocarcinoma after robotic‐assisted radical prostatectomy, higher grade group and extraprostatic extension(EPE) were related to PSA persistence. For survival analysis, the presence of EPE may be independently associated with developing PSA‐p but not PSA‐r. More data was needed for trends of PSA and long term outcomes under patient following up.
Is Single Port Transvesical Radical Prostatectomy Feasible in Patients with a Hostile Abdomen?
E Ferguson, M Abou Zeinab, A Beksac, A Kaviani, J Kaouk
Glickman Urological & Kidney Institute, Cleveland Clinic Main Campus, Cleveland, OH
Introduction & Objective: Radical prostatectomy using the single port (SP) da Vinci surgical platform has been performed using extraperitoneal, transperineal, and transvesical (TV) approaches, all of which avoid entry into the peritoneal cavity. Among these, the TV approach is particularly well‐suited for use in patients with prior abdominal and pelvic surgery in that it avoids extensive dissection of the space of retzius and the working space is confined to the bladder and prostatic fossa. Here we aim to determine if SP TV radical prostatectomy is safe and feasible in patients with extensive prior abdominal surgeries.
Methods: Of the 68 initial patients who underwent SP TV radical prostatectomy, 29 patients with hostile abdomens were compared to the remaining 39 patients who served as controls. Hostile abdomen was defined as history of one or more of the following: lap (n = 1) or open (n = 6) colectomy, colostomy (n = 5), mesh ventral incisional hernia repair (n = 9), lap (n = 4) or open (n = 11) mesh inguinal hernia repair, J‐pouch (n = 2), renal transplant (n = 2), APR (n = 1), AAA repair (n = 1), attempted open prostatectomy (n = 1), and IPP (n = 1). We compared demographics characteristics and perioperative outcomes using descriptive statistics. P values were calculated based on median and interquartile range values for each outcome.
Results: Patients with hostile abdomens were significantly more likely to be older, have a higher ASA score, higher baseline SHIM scores, and higher Gleason scores at the time of diagnosis. A statistically significant difference was identified in narcotic prescriptions in the hostile abdomen group (2 vs 0, p = 0.007), otherwise there were no statistically significant differences in perioperative outcomes between groups. No patients in either group experienced intraoperative complications or required blood transfusions.
Conclusions: Single port transvesical radical prostatectomy in patients with extensive prior abdominal or pelvic surgery is feasible and is not associated with increased incidence of adverse perioperative outcomes.
Does Surgical Urethral Length Preservation Improve early Urinary Continence After LARP?
A Ragusa, F Esperto, F Tedesco, L Cacciatore, A Testa, N Deanesi, V Crimi, P Tuzzolo, F Prata, R Scarpa, R Papalia
Campus Biomedico University of Rome, Rome, Italy
Introduction & Objective: Several efforts in the last years have been done to predict and improve urinary continence after radical prostatectomy. Previous studies showed how membranous urethral length seems to be associated with continence rate after radical prostatectomy. The aim of our study is to investigate the impact of surgical urethral length preservation (SULP) on urinary continence after LARP (laparoscopic assisted radical prostatectomy).
Methods: We prospectively enrolled from 1 Nov 2020 to 1 nov 2021 42 patients diagnosed with prostate cancer who underwent LARP at our institution. Inclusion criteria were ISUP ≥1 and ≤3. Exclusion critera were BMI >30 or diabetes. Through a sterile ruler inserted by a 12 mm trocar,the length of the membranous urethra spared during LARP was assessed intra‐operatively from the pubic symphysis to the prostatic apex, where the urethral caudal surgical cut was made. We evaluated age, BMI, PSA, ISUP, estimated blood loss (EBL), Pads per week in incontinence patients and Continence rate at 3, 6, and 12 months of Follow‐up (FUP). Continence was considered reached when patients reported 0 PADS. Statistical analysis was performed with Mann‐Whitney U‐test for independent samples for non‐parametric quantitative variables, Pearson's Chi‐square test for non‐parametric qualitative variables, and Cox's regression with SPSS vers 27.
Results: Global continence rate at 1 year of Follow up was 81 %. Median SULP was statistically significant higher in continent patients compared to non‐continent ones at 1 year of follow up. Table 1 shows descriptive and variance analysis of our study. A Cox regression showed a 7% probability of earlier continence recovery every mm of urethra spared ((p < 0.008, Exp(B) 1.072, CI 1.018‐1.128)).
BMI: body mass index; PSA: Prostate specific antigen; EBL: estimated blood loss; SULP: surgical urethral length preservation; *Mann Whitney U test at independent samples; **Chi square Test.
Conclusions: Surgical urethral length preservation (SULP) seems to be associated with early continence recovery after LARP and with better overall continence rate. Further multicentric studies are needed to confirm our findings.
Intermediate‐term Oncological Outcome Assessment for Robotic Assisted Radical Prostatectomy Comparing Retzius Sparing to Standard Approach in a Randomized Control Cohort
GA Barayan, M Butaney, S Majdalany, D Dalela, A Levy, J Peabody, C Rogers, M Menon, W Jeong
Umm Al Qura University
Introduction & Objective: Retzius sparing prostatectomy is promoted with the early continence result, but criticized for higher positive surgical margin. The long‐term oncological outcome is still unknown. In this study, we aimed to compare the Intermediate‐term oncologic outcomes of these two approaches in a patient's cohort who was treated as part of a randomized controlled trial.
Methods: A total of 120 patients were previously randomized equally to receive retzius sparing (RS‐RARP) versus standard robotic assisted laparoscopic radical prostatectomy (S‐RARP) between January 2015 to April 2016. Baseline, surgical, and pathological characteristics as well as oncologic outcomes were assessed. The analysis was done based on the treatment received.
Results: Sixty‐three patients underwent S‐RARP while 57 patients underwent RS‐RARP. There was no statistically significant difference in the baseline nor surgical characteristics. The median follow up was 71.24 (IQR 59.75 ‐ 75.75). There were more pathological T3 diseases in RS‐RARP. There was no significant difference in the positive margin status nor the biochemical recurrence rate among both groups. After S‐RARP and RS‐RARP, 6 and 10 patients had biochemical recurrence and the 5‐years biochemical recurrence free survival were 91% and 85%, respectively. (p = 0.21)
Conclusions: In this cohort, there was no difference in biochemical recurrence in the patients who received either technique. Further mutli‐institutional studies with a larger sample size and longer follow‐up are required.
Artificial Intelligence‐enabled Automated Identification of Key Steps in Robotic‐assisted Radical Prostatectomy
K Abhinav, A Antolin, D Ben‐Ayoun, D Asselmann, T Wolf, M Tollefson
Mayo Clinic
Introduction & Objective: Analysis of surgical video allows surgeons to gain valuable insights. These include developing surgical best practices, identifying key pitfalls, developing situational awareness, and revisiting intraoperative decision‐making during key moments. However, surgical video review is laborious and time‐intensive. We developed a novel computer vision algorithm for automated identification of key surgical steps during robotic‐assisted radical prostatectomy (RARP).
Methods: Retrospective surgical videos from RARP performed at a single tertiary‐care academic referral center were manually annotated by a team of medical image annotators under the supervision of two fellowship‐trained urologic oncologists. Full‐length surgical videos were annotated with the following steps of surgery: preparation, adhesiolysis, lymph node dissection, Retzius space dissection, anterior bladder neck transection, posterior bladder neck transection, seminal vesicles and posterior dissection, lateral (including neurovascular bundle) and apical dissection, urethral transection, urethrovesical anastomosis, final inspection and extraction. Manually annotated videos were then utilized to train a computer vision algorithm to perform automated video annotation of RARP surgical video. Accuracy of automated video annotation was determined by comparing to manual human annotations as the reference standard.
Results: A total of 107 full‐length RARP videos [average 117 ± 40 minutes] were manually annotated with sequential steps of surgery. Of these, 70 cases served as a training dataset for algorithm development, 14 cases were used for internal validation, and 23 were used as a separate testing cohort for evaluating algorithm accuracy. Concordance between AI‐enabled automated video analysis and manual human video annotation was 88.5%. Algorithm accuracy was highest for the Vesico‐urethral Anastomosis step (98.5%) and lowest for the final inspection and extraction step (67.5%).
Conclusions: We present results of the first AI‐enabled computer vision algorithm for automated annotation of full‐length RARP surgical video. Automated surgical video analysis has immediate practical applications in retrospective video review by surgeons, surgical training, surgical quality assessment, and for the development of future algorithms to associate perioperative and long‐term outcomes with intraoperative surgical events.
Single‐port versus Multiport Robot‐assisted Radical Prostatectomy: A Meta‐analysis
T Nguyen, R Dobbs, H Vuong, K Quy, H Ngo, A Mai, M Tran Thi Tuyet, T Le, M Thai, H Tiong, S Choi, M Shahait, DI Lee
thanhtuan0131@gmail.com
Introduction & Objective: Several centers have reported their good experiences with the single‐port robotic approach in radical prostatectomy. However, these significant improvements in surgical outcomes are still debated. This meta‐analysis sought to compare the perioperative, oncological, and functional outcomes between single‐port robot‐assisted radical prostatectomy (SP‐RARP) and multiport robot‐assisted radical prostatectomy (MP‐RARP).
Methods: Three electronic databases, PubMed, Scopus, and Web of Science, were searched from their inception until December 15, 2021, for relevant articles. Two independent teams reviewed abstracts and extracted data from the selected manuscripts. A meta‐analysis has been reported in line with PRISMA 2020 and AMSTAR Guidelines. The risk ratio (RR) and weighted mean difference (MD) were applied for the comparison of dichotomous and continuous variables with 95% confidence intervals (CI).
Results: Of the 368 retrieved abstracts, 41 underwent full‐text review, and seven studies were included in the final analysis, comprising a total cohort of 1,934 cases of robot‐assisted radical prostatectomy (RARP). Compared to MP‐RARP, the SP‐RARP group had less postoperative pain score (MD = ‐0.7, 95% CI ‐1 to ‐0.4, p < 0.001), morphine milligram equivalents usage (MD = ‐3.8, 95% CI ‐7.5 to ‐0.1, p = 0.04), hospital stay (MD = ‐1, 95% CI ‐1.8 to ‐0.1, p = 0.019), and urinary catheterization time (MD = ‐1.1, 95% CI ‐1.9 to ‐0.3, p = 0.008). However, the SP‐RARP group had a longer console time compared to the MP‐RARP group (MD = 5.3, 95% CI 2.6 to 7.9, p < 0.001). There were no significant differences in other outcomes between the two techniques, including the operation time, estimated blood loss, postoperative complication, positive surgical margins, 3‐month continence, 6‐month continence, and 3‐month potency rates.
Conclusions: Our study results demonstrated the favorable postoperative results of the single‐port approach as a minimally invasive choice for radical prostatectomy. This technique could help to reduce the hospital stay and postoperative pain in the patients who underwent radical prostatectomy. However, further well‐designed studies will be needed to evaluate the role of single‐port robot‐assisted radical prostatectomy in long‐term oncological and functional outcomes.
Long Term Oncological Outcome of Radical Prostatectomy in High‐risk Prostate Cancer Patients
K Biswas, M Kusuma, J Corr, R Casey, R Pillai
Colchester General Hospital
Introduction & Objective: Radical prostatectomy (RP) is an established treatment option for high‐risk (D'amico) prostate cancer (CaP) as part of multimodal therapy. We aim to find out the overall survival (OS) and disease free/ bio‐chemical recurrence free survival (DFS/BCRFS) after RP in high‐risk CaP patients.
Methods: We analysed retrospectively the pre‐operative staging, histopathology, follow‐up data and subsequent additional treatment of all patients who had RP at out district hospital from 2007 to 2017. The OS and DFS of high‐risk CaP were analysed using Kaplan‐Meier survival analysis curve.
Results: Total 497 patients had RP in the study period of which 217 were high‐risk CaP patients. Positive surgical margin, extracapsular extension, seminal vesicle extension, lymph node involvement and Gleason's score 8‐10 cancer were 34.1%, 46%, 33%, 9% and 17.9% respectively. Median follow up was 82.5 months (13 months – 179 months). Fifteen patients (6.9%) had upfront adjuvant radiotherapy. Seventy‐eight patients (35.9%) had bio‐chemical recurrence at median time interval of 24 months (3 months – 120 months). Salvage radiotherapy and hormonal therapy only were offered to 57 (73.0%) and 4 (3.1%) patients respectively; whereas 17 patients (13.2%) were under observation. Total 76 patients (35.0%) required multimodal therapy. At 10 years, OS and DFS/BCRFS were 85% and 56% respectively.
Conclusions: RP in high‐risk CaP offers acceptable long‐term oncological outcome, however patients must be counselled about the requirement of multimodal therapy. Performed at a district general hospital, this is a real‐world representation of the long‐term outcome which is quite similar to most specialised center published data
The Effectiveness of a Criteria Led Discharge Initiative on the Length of Stay of Patients Who Underwent a Robotic Assisted Radical Prostatectomy
J Saad, I Thamgasamy, M Arianayagam, M Khadra, R Ko, R Ferguson, A Goolam, B Canagasingham, C Varol, M Winter
Canberra Hospital
Introduction & Objective: The purpose of this study was to review the effect of a criteria led discharge initiative on the length of stay (LOS) of patients undergoing a robotic assisted radical prostatectomy (RALP).
Methods: This is a cohort study of prospectively collected data completed at a major tertiary hospital (December 2016 to August 2019). Criteria led discharge consists of a drain output of less than 50ml, being hemodynamically stable 24 hours post operatively, presence of passing flatulence or bowel movement and the ability to tolerate an oral diet. We excluded 14 men that sustained a complication of Clavien Dindo grade 3 and above, as these men would not be suitable for discharge regardless of the presence of a CLD approach. Fisher's exact test was used to assess categorical variables and the independent T test to assess continuous variables.
Results: In this study there was 218 patients in total, with 100 being before implementation of the CLD and 118 being after. There was no statistically significant difference between the pre‐operative patient factors. The mean LOS was 1.8 days and 1.43 days for the pre and post CLD groups respectively (P = 0.0146, 95% CI: 0.07 to 0.66).
Conclusions: The criteria led discharge initiative significantly reduced the LOS of patients post RALP. Further investigations is required to assess the effect of patient factors on LOS.
Comparison of Retzius‐sparing versus Standard Approach Robotic Assisted Laparoscopic Prostatectomy for Localized Prostate Cancer: A Systematic Review and Meta‐analysis from KSER Update Series
D Chung, Y Moon, H Jung, D Kim, S Paick, S Jeon, J Lee
Department of Urology, Inha University School of Medicine, Incheon, Korea
Introduction & Objective: Robotic‐assisted radical prostatectomy (RARP) is widely used to surgically treat of localized prostate cancer. Among RARP, retzius‐sparing techniques (RS‐RARP) are implemented through douglas pouch, not the existing conventional approach(C‐RARP). Several comparative studies of the two methods have been published, but there are debates in conclusions. So, we conducted an updated systematic review and meta‐analysis including recent published papers.
Methods: Systematic review was performed following the PRISMA guideline. PubMed/Medline, Embase, and Cochrane Library were searched up to August 2021. We conducted meta‐analysis to outcomes between RS‐RARP and C‐RARP. Incontinence, positive surgical margins (PSM), complication, operation time and estimated blood loss (EBL) between two groups were analyzed.
Results: Thirteen studies with a total of 2,917 patients were included for meta‐analysis. Incontinence was analyzed with 0pad and safety pad, respectively. There showed a statistically significant advantage for RS‐RARP in terms of continence recovery at 1month(0Pad_odd ratios[OR]0.28, CI,0.16‐0.47;p < 0.00001, safety‐pad_OR,0.12; CI,0.07–0.22; p < 0.00001), as well as at 3months(0Pad_OR,0.31, CI,0.18‐0.53;p < 0.0001, safety‐pad_OR,0.23; CI, 0.14–0.40; p < 0.00001), 6months(0Pad_OR,0.29, CI,0.17‐0.51; p < 0.0001, safety‐pad_OR,0.13; CI,0.06–0.27;p < 0.00001). And after 12months, RS‐RARP showed better results only in the safety‐pad. (0Pad_OR,0.64, CI 0.35‐1.18;p = 0.15, safety‐pad_OR, 0.12; CI, 0.04–0.36;p = 0.0002). In PSM, there was no statistical difference between two group at overall stage(OR,0.87; CI,0.71–1.07;p = 0.69) and pT2 (OR,0.95; CI,0.58–1.56;p = 0.85), but RS‐RARP was observed to be higher than C‐RARP in pT3 subgroup analysis. (OR,0.74; CI,0.55–0.99;p = 0.047) Whereas, there was no significant difference between the two groups in complication(OR, 1.05; CI,0.65–1.70;p = 0.85), operation time(weighted mean difference[WMD],3.02; CI,‐32.03–38.06;p = 0.87), and EBL(WMD,8.80; CI,‐22.15–39.75;p = 0.87).
Conclusions: Our analysis showed that RS‐RARP is superior about early continence recovery than C‐RARP. However, RS‐RARP showed relatively high PSM in locally advanced PCa above pT3. Therefore, although RS‐RARP has few advantages about functional outcomes, we think that caution should be exercised when approaching patients with high‐risk local diseases.
Single Port Robotic Assisted Laparoscopic Radical Prostatectomy Advantages in Patients with Hostile Abdomen
S Agrawal, M Abou Zeinab, E Ferguson, A Beksac, A Kaviani, J Kaouk
Cleveland Clinic
Introduction & Objective: Patients with previous abdominal and bowel surgery are at risk for bowel injury in radical robotic assisted laparoscopic prostatectomy (RALP). The single‐port (SP) da Vinci surgical platform facilitates avoiding a previously violated intraperitoneal space and abdominal scar tissue encountered in multi‐port (MP) approach. The purpose of this study is to examine perioperative factors for postoperative outcomes between both approaches.
Methods: Patients who underwent RALP with or without pelvic lymphadenectomy were included. Hostile abdomen was defined as at least one previous abdominal open or laparoscopic surgery. T‐test and chi‐square analysis were done on disease characteristics among patients who underwent SP versus MP, as summarized in the table. Factors that impact postoperative complications were assessed with logistic regression analysis.
Results: We identified 181 patients (92 SP and 89 MP). Average age was 64 years (IQR 59‐68). At least 1 comorbid condition was present in 73% of patients. A majority of the patients had NCCN intermediate risk cancer (61%). Mean follow up was 37 months (IQR 11‐64). Biochemical recurrence occurred in 28 patients. SP approaches were: extraperitoneal in 27 (29%) patients, transvesical in 42 (46%), perineally in 22 (24%), and intraperitoneally in 1 (1%). Crohn's or ulcerative colitis was prevalent in 42 (23%) patients. MP or SP did not show a difference in complications on univariate analysis (OR 0.57, p = 0.13). On multivariable analysis, previous utilization of mesh for hernia repair (OR 0.23 (0.07 – 0.82), p = 0.02) correlated to decreased complications. Prior open abdominal surgery (OR 6.5 (95% CI 2.0 – 20.9) p = 0.002) and ostomy (OR 4.5 (95% CI 1.1 – 19.1), p = 0.04) demonstrated increased likelihood of postoperative complication.
Conclusions: Both MP and SP RALP approaches demonstrated favorable postoperative outcomes. The SP approach, which has been performed in more patients with a hostile abdomen, had lower estimated blood loss with no difference in complications. The SP RALP allows avoidance of the intraperitoneal space with transvesical and extrapertioneal approaches to minimize postoperative risks associated with an intraperitoneal approach, especially in patients who are not a candidate for MP RALP with a hostile abdomen.
Perioperative Outcomes of Robot Assisted Lap Radical Prostatectomy in Locally Advanced High Risk Prostate Cancer :A Prospective Evaluation
A Kumar, Y Prashanth, S Kumar, K kapoor, S Iyer, P Singh
Department of Urology, Robotics and Renal Transplant, SJH and VMMC, New Delhi
Introduction & Objective: The management of locally advanced high risk prostate cancer is challenging .The various guidelines have suggested radical prostatectomy ,as one of the options , in a multimodality approach .We prospectively evaluated the feasibility, safety and perioperative outcomes of Robot assisted laparoscopic radical prostatectomy(RARP), as a multimodality approach, in locally advanced high risk prostate cancer.
Methods: All consecutive patients undergoing RARP (using da‐Vinci Xi Robotic system)in locally advanced high risk prostate cancer, as a multimodality approach,by a single surgeon ,between Oct 2019 and November 2021, at our institution were included .The various clinical data were recorded and analyzed.
Results: A total of 71 patients with locally advanced and high risk prostate cancer were included. The mean age was 64.1 years with mean serum PSA of 13.9.The mean operating time and mean estimated blood loss were 147.8 min and 137.1 ml respectively. The intraoperative complications were seen in only 2(2.8% ) patients ,as Clavien 1‐2 .The mean catheterization time was 6.7 days .The postoperative complications were seen as Clavien 1‐2 in 2(2.8%) patients . In histopathology,19. 1% and 80. 9% patients had pT2 and < pT3a respectively. The Gleason score 7 ,8 and 9 were present in 9. 6%,71. 4%. and 19% patients respectively, in the final specimen. The positive surgical margins were present in only 3(4. 2%) patient. The mean number of lymph nodes removed was 18. The continence rate at 6 weeks and 3 months was 52(73. 2 % and 60(84.5%).
Conclusions: RARP in patients with locally advanced high‐risk prostate cancer can be offered as first intervention, followed by adjuvant treatment, as multimodality approach. It is feasible, safe with acceptable perioperative morbidity.
MP18: Laparoscopy/Robotics: New Technology & Reconstructive Surgery
Trends, Outcomes, and Predictors of Early Discharge After Minimally Invasive Pyeloplasty: A Case‐control Matched National Analysis, 2013‐2019
KT Ravivarapu, E Garden, C Chin, M Levy, O Omidele, AC Small, J Sewell‐Araya, M Palese
Icahn School of Medicine at Mount Sinai
Introduction & Objective: Minimally invasive surgery and enhanced perioperative care pathways have allowed earlier discharge after many urologic surgeries. Using a national sample, we sought to assess trends and predictors of early discharge (ED) following minimally invasive pyeloplasty (MIP), and compare outcomes between ED and non‐early discharge (NED) cohorts.
Methods: Using the American College of Surgeons National Quality Improvement database, we analyzed all MIP cases (CPT 50544) from 2013 to 2019 for patients older than 18 years. ED and NED were defined as length of stay ≤1 day and >2 days, respectively. Using case‐control matching, ED and NED patients were matched 1:1 based on age, BMI, ASA score, and modified Charlson Comorbidity Index. 30‐day outcomes including unplanned readmission, reoperation, and Clavien‐Dindo (CD) I/II and IV complications were compared between matched cohorts. Multivariate regressions controlling for demographic, operative, and patient‐level clinical characteristics were used to evaluate ED as an independent predictor of adverse outcomes. Similarly, we used multivariate analysis to identify factors correlated with increased likelihood of ED.
Results: 2051 MIP cases were included, of which, 883 were ED cases. The rate of ED went from 33.3% to 60.7% from 2013 to 2019 (p < 0.001). Comparison of 1610 matched ED and NED cases showed that ED cases resulted in lower rates of 30‐day readmission (2.9% ED vs. 5.5% NED, p = 0.009), reoperation (1.4% ED vs. 3.0% NED, p < 0.001), CDI/II (4.2% ED vs. 8.6% NED, p < 0.001), and CDIV complications (0.1% ED vs. 1.7% NED, p = 0.001). After controlling for demographic and clinical factors, ED was found to be a negative predictor of readmission, reoperation, CDI/II, and CDIV (Table 1). Predictors of ED included male sex (OR: 1.29 [1.08‐1.56], p = 0.007), surgery in 2018 (OR: 2.44 [1.68‐3.57], p < 0.001) and 2019 (OR: 2.36 [1.63‐3.44], p < 0.001), and non‐smoker status (OR: 1.35 [1.09‐1.69], p = 0.008).
Conclusions: ED after MIP did not confer increased risk of 30‐day readmissions, reoperations, or complications. Patient selection for ED is being done with appropriate safety, and further work can optimize and expand this initiative.
Laparoscopic Ureteric Reimplantation vs Robotic Assisted Laparoscopic Ureteric Reimplantation for Lower Ureteric Pathology: Single Institutional Comparative Study
RS Batra, A Agarwal, A Singh, A Ganpule, R Sabnis, M Desai
Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India
Introduction & Objective: To compare and analyze the results of laparoscopic ureteric reimplantation and robotic assisted ureteric reimplantation at our tertiary institute.
Methods: We retrospectively reviewed and analyzed the data of adult patients who underwent laparoscopic ureteric reimplantation and robotic assisted ureteric reimplantation between the year January 2000 and December 2020. Preoperative, intraoperative and postoperative parameters were analyzed for 19 patients in laparoscopic group and 47 patients in robotic group.
Results: The most common presentation was flank pain (67.89%) followed by recurrent UTI (21.05%) in both the groups. The baseline characteristics including age, gender, laterality, Charlson comorbidity index and BMI were comparable in both the groups. 5 patients(26.3%) in laparoscopy group had a history of endourological intervention while 3 patients(15.7%) had history of gynecological intervention. In the robotic group, 8 patients(17.07%) had history of endourological intervention, while 11(23.4%) patients had history of gynecological intervention. The time range from previous surgeries to presentation varied from 7 days to 5 years. Two patients in the laparoscopy group required boari flap and two patients required psoas hitch. Three patients in the robotic group required boari flap and five patients required psoas hitch. There is statistically significant difference between the operative time in laparoscopic (224.23 ± 76.61 min) and robotic group (187.06 ± 52.81 min) (p = 0.027). Hospital stay was significantly less in robotic group (9.07 days vs 6.0 days) (p = 0.001). There were no differences in the complication rate and post operative outcomes in both the groups. None of the patients had any significant serios intraoperative complications. 1 patient in the laparoscopic group had fever post operatively while 6 patients in the robotic group had post operative fever. The success rates in terms of symptomatic improvement, decrease in hydronephrosis and radiological success in the laparoscopic and robotic group were 94.73% and 95.45% respectively.
Conclusions: Robotic ureteric reimplantation and laparoscopic ureteric reimplantation are comparable in long term clinical outcomes. Robotic assisted laparoscopic ureteric reimplant is feasible, safe and faster with excellent outcomes, decreased hospital stay and minimal complication rates.
Robotic Uretero‐enteric Stricture Repair: Early Outcomes and Complications
E Bearrick, J Woods, J Alamiri, M Alom, B Findlay, F Balzano, A Potretzke, K Anderson, B Viers
Mayo Clinic
Introduction & Objective: Up to 10% of patients undergoing cystectomy with urinary diversion develop ureteroenteric stricture (UES). Open reconstruction is challenging and morbid, and therefore patients often elect for temporizing ureteral stenting which can carry significant burden. Herein, we aim to characterize our single institutional experience with robotic UES repair.
Methods: From our single surgeon ureteral reconstructive database of 221 patients between 2017‐2021, 14 patients underwent robotic UES repair. Prior to surgery, all ureteral stents were converted to nephrostomy tubes for ureteral staging. Complications, reconstructive success (uretero‐enteric patency), need for repeat intervention, and renal function were assessed in patients undergoing robotic UES reconstruction.
Results: UES repair was performed in 21 patients, of which 14 (67%) underwent robotic repair at a median age 68 years. Left‐sided repair was performed in 9 (64%), right‐sided in 3 (22%), and bilateral in 2 (14%) patients. Prior cystectomy was performed robotically in 5 (36%) patients and open in 9 (64%). Urinary diversion type was neobladder in 6 (43%) and ileal conduit in 8 (57%). Prior open or endoscopic intervention to address UES was performed in 3 (21%) and 3 patients had a history of radiation (21%). Median time from cystectomy to reconstruction was 9.0 months (IQR 7‐33). At ureteral staging, 10 (71%) had stage ≥3 CKD, with diminished differential function of the affected renal unit (median 34%).
Median operative time was 258 minutes with median EBL 100 ml. Median length of stay was 2 days. One (7%) procedure was converted to open due to significant adhesions. No patient experienced a major (Clavien ≥III) complication intraoperatively or within 90 days of surgery. At median follow‐up 11 months (IQR 3.3, 27.6), all repairs were successful as confirmed by patency on postoperative CT urogram or loopogram. At last follow up, there was no significant difference in serum creatinine, GFR, or worsening hydronephrosis. To date, no patients have required additional operations for treatment of UES.
Conclusions: Robotic assisted repair of uretero‐enteric stricture appears safe and well tolerated, with promising short‐term outcomes.
Multimodal Pain Control Utilizing Buprenorphine for Robotic Assisted Laparoscopic Prostatectomy: A Quality Improvement Comparison to Conventional Opioid Management
M Hajiha, S Wraich, J Sran, J Johnson, I Muchiutti, AS Amasyali, D Lien, G Stier, L Soloniuk, K Shete, R Belay, A Assidon, J Maldonado, M Keheila, A Li, B Hu, DD Baldwin, H Ruckle
Introduction & Objective: The purpose of this multidisciplinary study (urology, anesthesiology and surgical home) is to examine outcomes in patients who received standard mu opioid agonists (control) versus buprenorphine for perioperative pain while undergoing prostatectomy. Buprenorphine is FDA approved for postoperative pain and is uniquely a partial mu opioid agonist with potentially lower opioid side effects including constipation, respiratory depression, dysphoria, and substance abuse.
Methods: Two perioperative analgesic pathways were designed for patients undergoing robotic assisted laparoscopic prostatectomy (RALP). A quality improvement study with retrospectively collected data in a single institution over a 10‐month period was performed. The control group (n = 40) used standard mu opioid agonists and the intervention group (n = 40) used buprenorphine. The patients were surveyed five days after surgery. The primary endpoints were pain scores at discharge and total morphine equivalent dosage (MED). The secondary endpoints included length of stay (LOS), subjective pain control, ileus and patient satisfaction using a Likert scale of 1 (strongly agree) to 5 (strongly disagree). Statistical analysis included Mann‐Whitney U and Chi‐square, with p < 0.05 considered significant.
Results: Mean age (64.50 vs. 65.75, p = 0.483), BMI (28.9 vs. 29.1, p = 0.873) and race distribution (p = 0.851) were similar between groups. There was no difference between buprenorphine and the control groups in LOS (1.23 vs. 1.33 days, p = 0.158) and length of surgery (261 vs. 268 mins, p = 0.476). Buprenorphine had lower reported pain scores at discharge (4.7) compared to the control (5.4) although this did not reach significance (p = 0.242). While 74.4% of buprenorphine strongly agreed that their pain was adequately controlled in the hospital, this was 57.5% in the control (p = 0.261). There was no difference in overall satisfaction at postoperative day 5 (p = 0.313). When analyzing the primary endpoint of MED, buprenorphine received significantly less MED compared to control (15.19 vs. 47.53, p = 0.012). There was no significant difference in incidence of ileus between buprenorphine and control (40% vs. 33%, p = 0.485).
Conclusions: The use of buprenorphine reduced MED by 68% compared to the use of standard mu opioid agonists. This was achieved while maintaining higher patient satisfaction and pain control in buprenorphine compared to control.
Robotic Assisted Verses Laparoscopic Pyeloplasty
J Thompson, C Edgar, FE Rodger, R McLennan, JL Hendry, GM Oades
NHS Greater Glasgow and Clyde
Introduction & Objective: The outcomes of Robot Assisted Dismembered Laparoscopic Pyeloplasty (RALP) were compared with conventional Laparoscopic Pyeloplasty (LP) in a single centre.
Methods: Retrospective data were collected from June 2008 to June 2021 on 95 consecutive patients who underwent robot asisted dismembered laparoscopic pyeloplasty (RALP) or conventional dismembered laparoscopic pyeloplasty (LP). Operating time, perioperative outcomes and post‐operative results were compared. Comparison between groups was performed using TTest (SPSS v 26).
Results: 48 patients underwent RALP and 46 patients underwent LP. Procedures were performed in a single centre by a single surgeon. Mean operative time was significantly shorter at 122 minutes in the RALP group compared to 169 minutes in the LP group (p = < 0.01). Median length of hospital stay was significantly lower in the RALP group at 2 days compared to 4 days in the LP group (P = < 0.01). Post‐operative renography was available in 75 (79%) of patients. Improvement in drainage was demonstrated in 39 (81%) of patients in the RALP group and 36 (78%) patients in the LP group (p = 0.46). 46 (96%) patients reported complete resolution of symptoms in the RALP group and 41 (89%) patients in the LP group (p = 0.11).
There was one conversion to an open procedure in the RALP group due to adhesions preventing safe access. There was no significant difference in perioperative complication rates. In the RALP group the 30 day complication rate was 15% (Clavien‐Dindo I = 2, II = 5) and in the LP group it was 22% (Clavien‐Dindo I = 2, II = 4, IIIb = 2) (p = 0.36). There were no Clavien‐Dindo IIIa or greater complications in the RALP group.
Conclusions: RALP is a safe and efficient operation which reduces operating time and length of hospital stay, with equivalent outcomes to LP.
Robotic Assisted Ureteroneocystostomy and Substitution
MW Salkini, A Dahman
mhdsalkini@gmail.com
Introduction & Objective: Ureteroneocystostomy, occasionally with creation of Boari flap, is the best option to substitute for the loss of the distal ureter in both benign and malignant conditions. The procedure is usually performed through a large midline or Gibson incision. Utilizing the robotic da Vinci® surgical system made it feasible to achieve the objectives of the procedure with minimally invasive approach. Our aim is to report our experience with robotic assisted ureteral substitution with and without creation of Boari flap
Methods: We utilized de Vinci® robotic surgical system between September 2009 and February 2022 to reconstruct 45 distal ureteral units in 36 patients (9 patients needed bilateral ureteral reimplantation). 24 benign and 21 malignant conditions needed ureteral substitution. We prospectively collected the data with our institutional IRB approval. The distal ureter was excised with bladder cuff in cases of TCC involving the distal ureter. The proximal ureteral end was spatulated and re implanted to the bladder either directly or after developing Boari flap to enable tension free, leak proof anastomosis. Negative margin was insured in all the malignant cases.
Results: The average patient age was 59 years (ranging from 25‐80). We had 17 male and 19 female patients. All cases were completed robotically except one (2%) that needed to be converted to open due to adhesion. The patients were followed for an average of 45 months (ranging from 3 months to 84 months). Seven ureters (19 %) out of the 45 robotically reimplanted ureters developed stricture (Table 1). 4 ureters with TCC developed recurrence at the anastomosis. Only 2 patients out of the 15 patients with history of radiation developed structure.
Conclusions: Robotic ureteral reimplant is feasible with high success rate. High grade TCC, and creation of Boari flap were risk factor for failure.
WITHDRAWN
The Impact of Low‐pressure Pneumoperitoneum in Robot Assisted Radical Prostatectomy (RARP) During the COVID 19 Pandemic
NS Khan, A Cajucom, P Amoroso, P Dasgupta
The London Clinic
Introduction & Objective: In 2019, the airborne SARS‐CoV‐2 virus caused a global pandemic. This presented new challenges to safe operating for patients and staff. Patients requiring pneumoperitoneum had the increased risk of aerosol transmission of the virus. New recommendations were introduced to reduce surgical plume and pressure of pneumoperitoneum. We analysed the clinical outcomes of cases performed at a lower pressure of pneumoperitoneum of 8mmHg during the COVID 19 pandemic. The results were compared to cases performed prior to the pandemic at a pressure of 12mmmHg to assess if surgery at a lower pressure impacted outcomes.
Methods: Using the online Medsafe database at The London Clinic, we retrospectively collected data of patients undergoing RARP performed by a single surgeon between March 2019 and October 2021. A total of 34 patients had RARP under the standard pressure (SPP) of 12mmHg in the year prior to introduction of new recommendations. 27 patients had RARP at a lower pressure (LPP) of 8mmHg during the pandemic. Patient demographics, co‐morbidities, gleeson score and PSA were recorded. Data on intra‐operative and post‐operative parameters was collected.
Results: Mean weight was 87kg in both groups with a range of 71‐111.5kg in the LPP group and 59‐108kg in the SPP group. BMI was 27 (23‐36.5) in the LPP group and 26 (21.8‐40.2) in the SPP group. Gleeson score was 7 and ASA was 2 in both groups. Mean operative time was 104minutes (60‐180mins) in the LPP group and 102 minutes (70‐180mins) in the SPP group. Blood loss was 130mls (100‐500mls) in the LPP group and 106mls (0‐200mls) in the SPP group. Pain score at rest and movement was not statistically significant between groups. Length of stay was equivalent at 2.07 days (2‐3days) for the LPP group and 2.17 days (1‐3 days) for the SPP group. Post‐operatively peripheral oedema was noted in 1 patient in the LPP group and 4 patients in the SPP group. The rate of ileus, positive surgical margins and readmission rates were similar in both groups.
Conclusions: Lower pressure pneumoperitoneum in RARP during the COVID 19 pandemic did not show inferior results to the standard pressure pneumoperitoneum used prior to the pandemic. Post‐operative peripheral oedema and complications were lower in the LPP group. Therefore, we recommend continuing the use of LPP as a safer alternative to using SPP.
Is Retroperitoneal Robot‐assisted Partial Nephrectomy in Morbidly Obese Patients Safe and Feasible? Outcomes from a Multi‐institutional Cohort
AC Smith, G Rac, H Patel, G Gupta, P Gellhaus
University of Iowa Hospitals and Clinics
Introduction & Objective: The objective of the study is to evaluate the safety and feasibly of retroperitoneal robot‐assisted partial nephrectomy (RP RAPN) in the morbidly obese (BMI > 40).
Methods: The partial nephrectomy databases from two institutions that perform robotic RP surgeries frequently were reviewed. Thirty‐one morbidly obese patients who underwent RP RAPN from 2013‐2021 were identified, and their demographics, operative data, pathology and post‐operative courses were analyzed.
Results: The median BMI was 44.4 kg/m2 (interquartile range [IQR] 41.4‐48.1) and median age of the patients was 58 years. The median RENAL nephrometry score was 6 with a median tumor size of 3.1 cm (IQR 2.2‐3.9). The median surgical time was 185 minutes (IQR155‐244). 35% were performed off clamp. When clamped, median warm ischemia time was 23 minutes (IQR 15‐28). The median EBL was 50 ml (IQR 25‐150). Figure 1 summarizes the pathological data. One (3%) patient had a positive surgical margin. Three (9%) cases were converted to radical nephrectomy for locally advanced cancer. No intra‐operative or post‐operative transfusions were given. The median length of stay was 2 days (IQR 1‐3). There were two (6%) high‐grade complications. Two (6%) recurrences were documented at a median follow‐up of 7 months (IQR 4‐23).
Conclusions: RP RAPN appears safe and feasible in morbidly obese patients for the treatment of small renal tumors at institutions that perform RP RAPN frequently.
Uretero‐enteric Anastomotic Strictures Following Robotic Radical Cystectomy: Extracorporeal versus Intracorporeal Approaches in the Indocyanine Green Era
M Tuna, T Doganca, O Argun, I Tufek, C Obek, AR Kural
Acibadem Maslak Hospital, Urology
Introduction & Objective: The aim of this study is to compare the early period(6th week after the catheter removal) iatrogenic benign uretero‐enteric anastomotic stricture formation between robotic radical cystectomy with extracorporeal urinary diversion, robotic radical cystectomy with intracorporeal urinary diversion(without utilizing ICG) and robotic radical cystectomy with intracorporeal urinary diversion(with utilizing ICG)
Methods: A total of 30 patients(59 renal units) who underwent robotic radical cystectomy with intracorporeal and extracorporeal urinary diversion between 2014‐2021 in our clinic included in this study. We retrospectively reviewed the demographic and perioperative results. The primary endpoint of our study was uretero‐enteric stricture formation rate at the 6th week after the single J catheter removal.
Results: From our study cohort; 13 of these patients(26 renal units) underwent robotic radical cystectomy with extracorporeal urinary diversion, 10 of these patients(20 renal units) underwent robotic radical cystectomy with intracorporeal urinary diversion(without utilizing ICG) and 7 of these patients(13 renal units) underwent robotic radical cystectomy with intracorporeal urinary diversion(with utilizing ICG). The overall incidence of early period uretero‐enteric stricture formation(post‐operative 6th week after the single J catheter removal) was 8.5%(5 renal units); 11,5% (3 renal units) after extracorporeal approach; 10%(2 renal units) after intracorporeal approach(without utilizing ICG). None of the patients with intracorporeal approach (with utilizing ICG) had demonstrable uretero‐enteric stricture at post‐operative 6th week after the single J catheter removal.
Conclusions:: In the ICG era; robotic radical cystectomy with intracorporeal diversion is a promising approach in terms of preventing benign uretero‐enteric stricture formation when compared with robotic cystectomy with extracorporeal urinary diversion and intracorporeal urinary diversion without utilizing ICG. Larger prospective studies are required to confirm our outcomes.
Initial Experience and Operator Learning Curve Following the Introduction of Robot Assisted Dismembered Laparoscopic Pyeloplasty
J Thompson, FE Rodger, R McLennan, C Edgar, A Carrera, JL Hendry, GM Oades
NHS Greater Glasgow and Clyde
Introduction & Objective: We analysed our initial experience and operator learning curve following the introduction of Robot Assisted Dismembered Laparoscopic Pyeloplasty (RALP) in a single centre.
Methods: Retrospective data were collected on 48 patients undergoing RALP between June 2016 and June 2021. All operations were performed by a single experienced laparoscopic surgeon with no previous robotic experience. All patients underwent Anderson Hynes dismembered RALP using a da Vinci XI robotic surgical system with a 3 or 4 port technique. In each case an antegrade stent was placed and no abdominal drain. Successful outcome was defined as improvement in renography curve . To examine the learning curve cases were grouped into three blocks, Group 1; Case 1‐16, Group 2; Case 17‐32, Group 3; Case 33‐48. Statistical analysis was performed using a one‐ way ANOVA, and post hoc analysis using Tukey's correlation (IBM SPSS v26 )
Results: All patients presented with loin pain and were obstructed on MAG III renography. Post‐ operative renography was available in 44 (92%) of patients and showed partial or complete resolution of obstruction in 79%. 45 (94%) patients reported resolution of symptoms post procedure. There was one conversion and six complications (Clavien Dindo I/II). One patient had ongoing obstruction with no symptom resolution and underwent a successful redo procedure. The mean overall console time was 135 mins (SD 38 mins) with Group 1 = 150 mins, Group 2 = 143 mins and Group 3 = 110mins. There were significant differences between Group 1 and Group 3 as well as Group 2 and Group 3 ( p = 0.004 and p = 0.003) with no difference between Groups 2 and 3 (p = 0.99). Therefore the learning curve has plateaued between case number 33‐48. The median length of stay in group 1 was 3 days and this had fallen to 2 days in group 3.
Conclusions: Robotic pyeloplasty in the hands of an experienced renal surgeon is a rapid to learn procedure that can be performed safely. This is useful for training future upper tract surgeons to benchmark learning curve expectations.
Single Port Robotic Urologic Surgery: Fewer Ports, Higher Costs
BG Patel, MG Biebel, R Venkatesh, S Figenshau
Washington University in Saint Louis
Introduction & Objective: The robotic platform revolutionized urologic surgery. This is well characterized for robot assisted laparoscopic prostatectomy (RALP) and robot assisted partial nephrectomy (RAPN) for the Xi platform. With development of Single Port (SP) system, the operating room (OR) costs warrant analysis.
Methods: At a single academic medical center, we retrospectively analyzed billing data for SP and XI RALPs and RAPNs from 01/2019 – 01/2021. Due to institutional regulations, costs of instruments cannot be disclosed.
Results: Overall, 290 XI and 102 SP RALPs were performed. The mean OR cost per XI RALP was $2,271, while for SP RALP, it was $3,100. Per case, SP RALPs were $829 (36.5%) more expensive than XI RALPs.
For RAPNs, 223 were performed with the XI and 20 were performed with the SP platform. The mean OR cost per XI RAPN was $2,326, while for per SP RAPN it was $3,233. Per case, SP RAPNs were $907 (39%) more expensive than XI RAPNs.
SP monopolar scissors were $240 more expensive than their XI counterpart. The Maryland bipolar and needle drivers were $200 and $230, respectively, more expensive for the SP system. Non‐energized graspers were $215 more expensive for the SP system. Draping the SP system costs $207 more than the XI. Trocars for the SP system cost $78‐728 more than the XI, depending on usage and size of the Gelpoint.
Conclusions: Our analysis indicates that the OR costs for RALPs and RAPNs are approximately 40% more when performing them using the SP compared to the XI system. Further prospective studies are needed to additionally incorporate other hospital costs related to these surgeries.
Transperineal Robotic Prostate Biopsy with Prost
S Puliatti, A Piro, R Ferrari, M Amato, B Maris, M Fiazza, L Palladio, M De Piccoli, L Reggiani Bonetti, C Tenga, G Ligabue, P Fiorini, M Sighinolfi, G Bianchi, B Rocco, S Micali
University of Modena and Reggio Emilia, Department of Urology, Modena, Italy
Introduction & Objective: The PROST robotic system (Fig. 1) is an integrated platform to enable effective robot‐assisted prostate biopsies It offers MRI/US fusion, needle alignment and cognitive support for target selection and entry point planning. PROST prototype has been already validated in laboratory. The objective of this study was to assess PROST's positioning accuracy in a realistic anatomical environment.
Methods: To carry out the experimentation, 10 cadaver specimens were used for prostate biopsy. 12 sterile seeds were placed into the prostate of each cadaver, 6 target seeds and 6 reference seeds. The targets marked the position to be reached by the PROST system. The reference seeds were released when the physician performed needle insertion through a guide oriented by PROST. After the procedure, the prostate was removed and the distance between target seeds and reference seeds was assessed using CT scan images and histological examination (Fig.2).
Results: The distance between target seeds and reference seeds was approximately 2.25 ± 0.75 mm, with an estimated error due to needle deflection of 0.38 ± 0.12 mm (with a range of 0.29‐0, 59 mm).
Conclusions: PROST's accuracy is compatible with clinical requirements. Further studies need to be conducted for use in clinical practice
Nephrostomy Tube or Double J Ureteral Stent: As the Best Choice for patients with Malignant Ureteric Obstruction ? Lessons from a systematic Review and Meta‐analysis
V Gauhar, G Pirola, D Castellani, Y Law, S Scarcella, H Tiong, E Lim, E Rubilotta, C Giulioni, M De Angelis, M Gubbiotti, ML Wroclawski
Ng teng Fong general hospital
Introduction & Objective: To perform a meta‐analysis to assess perioperative outcomes, complications and survival when comparing ureteral stent and percutaneous nephrostomy in patients with malignant ureteral obstruction by understanding the nuances of both interventions and their bearing on quality of life. .
Methods: This systematic review was performed as per 2020 PRISMA framework. Comprehensive literature search was performed and the PICOS (Patient Intervention Comparison Outcome Study type) model was used to frame and answer the clinical question.
Outcomes were split into 3 domains: i) procedural data (operative time, fluoroscopy time, and the number of device replacements); ii) outcomes (postoperative creatinine, dislodgement, febrile episodes, and unplanned device replacement). hospital stay, and overall survival); iii) complications (device‐related, accidental ).Ten studies accepted after screening and excluding from 575 records
Results: 1)Mean procedure time was significantly shorter in the stent group (p < 0.00001)
2)No difference between the two groups in mean fluoroscopy time (p = 0.43).
3)No difference between the two groups in the mean interval time between the change of drainage tubes over time (p = 0.62).
4)No difference between the two groups in the decrease of the creatinine level after the procedure (p = 0.41)
5)Significantly shorter hospital stay in the stent group(p < 0.0001)
6)No difference in the mean overall survival (p = 0.17)
7)No difference in the number of febrile episodes after diversion (p = 0.96)
8)No difference in the overall number of complications after diversion (p = 0.49)
9)No of accidental tube dislodgments was significantly lower in the stent group (p < 0.0001)
10)No difference in unplanned device substitution between the two groups (p = 0.38)
Conclusions: Both percutaneous nephrostomy or ureteral stent can be deployed as a first‐line intervention in malignant ureteral obstruction and the decision is likely based on the availably of resources and ability to gain access. In patients with longer life expectancy, ureteral stents may be a better option for ease of maintaining as they had lesser issues like device dislodgment, shorter intraoperative time for placement, and overall shorter hospital stay
Robotic‐assisted Transperineal Mri‐us‐fusion Guided Biopsy of the Prostate ‐ Safety Profile and Side Effects
C Wetterauer, M Walter, P Trotsenko, D winkel, H Breit, H Seifert
Dept. of Urology, University Hospital Basel
Introduction & Objective: Robotic‐assisted transperineal MRI‐US‐fusion guided biopsy of the prostate is a novel and highly accurate procedure. Currently, there are only about 30 systems operating worldwide yet. The aim of this study was to evaluate the MonaLisa prostate biopsy system in terms of safety, tolerability, and patient‐related outcomes.
Methods: This prospective study included 135 patients, who had undergone robotic‐assisted transperineal MRI‐US‐fusion guided biopsy of the prostate at the University Hospital Basel between January 2020 and August 2021. Peri‐operative side effects, functional outcomes and patient satisfaction were assessed.Robotic‐assisted transperineal MRI‐US‐fusion guided biopsy of the prostate is a novel and highly accurate procedure. Currently, there are only about 30 systems operating worldwide yet. The aim of this study was to evaluate the novel MonaLisa prostate biopsy system in terms of safety, tolerability, and patient‐related outcomes.
Results: Mean pain score on the day of biopsy was 1.1 points on visual analogue scale. Pain remained constant on the day after biopsy. Overall, 18 of 135 patients (13.3%) developed grade I complications according to Clavien‐Dindo classification. No higher‐grade complications occurred. Gross haematuria, hematospermia and acute urinary retention occurred in 91/135 (68.9%), 66/135 (26.5%) and 17/135 (12.6%) patients, respectively. One patient (0.7%) developed urinary tract infection due to insufficient antibiotic treatment of urine culture results prior to biopsy.
Conclusions: Robotic‐assisted transperineal MRI‐US‐fusion guided biopsy of the prostate performed under general anesthesia is a safe and well tolerated procedure. This novel technique allows to omit perioperative prophylaxis and at the same time minimizes the risk of infectious complications. We attribute the favorable risk profile and tolerability to the minimal invasive approach via two entry points.
Operative Times with Robot‐assisted Laparoscopic Pyeloplasty Are Associated with Surgeon Experience Level and Trainee Level
BS Park, S Kim, HA Bachtel, C Koh
Baylor College of Medicine
Introduction & Objective: Robot‐assisted laparoscopic pyeloplasty (RALP) is the most commonly performed robotic procedure in pediatric urology. While the safety and efficacy of RALP has been demonstrated there is a paucity of data regarding procedure times, potentially reflecting quality outcomes and costs. We aim to examine surgeon and patient factors associated with pediatric RALP procedure times.
Methods: Prospectively collected quality improvement data was reviewed for all pediatric patients undergoing RALP at a tertiary care children's hospital (2013 – 2020). Descriptive statistics were utilized to compare total procedure and console times among cohorts.
Results: Among 285 pediatric patients, patient factors such as younger age at the time of the surgery (p < 0.005) and lower BMI (< 0.005) were associated with significantly lower total procedure and console times. Surgeon factors including surgeon experience level and trainee level were associated with significant differences in console time and total procedure time, where higher primary surgeon experience were associated with lower total procedure times (p < 0.005) and console times (p < 0.005). Of note, cases with fellow assistance had higher total procedure times (p < 0.005) and console times (p < 0.005), likely reflecting the educational activity time differences at most institutions.
Conclusions: Total procedure times and console times of RALP in children are influenced by surgeon and patient factors, with longer times associated with lower primary surgeon experience levels, higher trainee levels, as well as older patient ages and higher BMI. Consideration of such factors may allow for improved pre‐operative allocation of resources including operating room scheduling times and cost analyses.
Robot‐assisted Renal Sparing Segmental Ureteral Resection for Ureteral Tumors: Single Center Experience with Analysis of Outcomes of a Multitude of Options Based on Tumor Location
S Saini, A Hemal
Wake Forest University of Health Sciences, Winston‐Salem, NC, USA
Introduction & Objective: Radical nephroureterectomy with bladder cuff excision is the standard of care for all high‐risk upper tract urothelial carcinomas (UTUC). With continued advancements, robotic‐assisted segmental ureteral resection can be employed for ureteral tumors for renal preservation. Here in, we are presenting our experience of different techniques based on varying location of ureteral tumors along with peri‐operative and follow‐up data.
Methods: From January 2008 till June 2021, a total of 17 patients underwent robotic assisted renal preserving excisional procedures for ureteral tumors at our center. We collected and analyzed baseline, peri‐operative & follow up outcomes parameters from our prospectively maintained institutional database.
Results: Baseline characteristics are depicted in Table 1
Table 2: Peri‐operative & follow up parameters
Two patients were found to have non‐urothelial pathologies.
Table 3 elaborates the final pathological analysis (UTUC)
On follow up, 2 patients died secondary to non‐UTUC related causes, and 2 patients developed UTUC recurrences. At median follow up of 41 months (7‐156), overall survival of our study population is 88.23%.
Conclusions: Robot‐assisted renal sparing management for ureteral tumors is surgically feasible with several options based on tumor location. With acceptable oncological outcomes at intermediate‐long term follow up, these procedures may be considered in the management of localized ureteral malignancy to salvage the ipsilateral kidney
WITHDRAWN
Nineteen‐year Outcomes of the IRIS Procedure for Treatment of Female Stress Urinary Incontinence: Comparison with TVT Procedure
P Song, K Oh, J Choi, Y Ko, K Moon, H Jung
Department of Urology, Yeungnam University College of Medicine, Daegu, Korea
Introduction & Objective: We evaluated the long‐term efficacy and safety of the IRIS procedure and compared it with TVT (tension free vaginal tape) for the treatment of female stress urinary incontinence.
Methods: We included all 58 consecutive women who underwent IRIS (n = 30) or TVT (n = 28) between February 2002 and April 2003 and followed them up for at least 19 years postoperatively. We analyzed the 19‐year success rate and postoperative complications in the IRIS procedure and compared to the results of TVT procedure.
Results: The 19‐year success rate was 91.2% for the IRIS and 90.5% for the TVT, and the satisfaction rates were 88.5% and 85.7%, respectively. Intraoperative complications for the IRIS group included 3 cases of bladder perforation, and there were 3 cases of bladder perforation for the TVT group. The postoperative complications for the IRIS group included 3 patients with de novo urgency and one patient with mesh erosion. Six patients with the TVT developed de novo urgency. One case of each group showed temporary voiding difficulty.
Conclusions: On the basis of our results, the IRIS may be an effective and safe procedure as compared to the TVT for more than 19 years.
Surgical and Patient Reported Outcomes of Robotic Rectourethral Fistula Repair
E Bearrick, B Findlay, A Seyer, F Balzano, A Allawi, K Behm, S Kelley, B Viers
Mayo Clinic
Introduction & Objective: Transperineal rectourethral fistula (RUF) repair is standard of care. To achieve tension‐free reapproximation and fistula closure, this often requires advanced maneuvers not amenable to perineal approach alone. Herein, we aim to report our robotic RUF repair experience.
Methods: A single surgeon retrospective review of men undergoing robotic RUF repair from 2018‐2020 was undertaken. Complications, reconstructive success, urinary function, and quality‐of‐life(QOL) were assessed.
Results: Robotic RUF repair was performed in 14 men at a median age of 66. In total, 8 (57%) men had prior prostatectomy and 8 (57%) had prior radiation. Median time from fistula formation to reconstruction was 6 months and 4 (29%) had prior repair attempts.
Median length of stay was 6 days, with median blood loss 238 cc. A cystectomy with ileal conduit was performed in 5 (36%) men, prostatectomy in 2 (14%) and primary fistula closure in 7 (50%). There were 4 (29%) patients in group 1 (DE), 3 (21%) patients with posterior exenteration and 2 (14%) patients with anterior exenteration alone in group 2 (SO), and 5 men in group 3 (DO) including 3 (21%) transabdominal and 2 (14%) performed transanally. Tissue flap interposition was performed in 12 (86%) including omentum in 10 (71%), gracilis in 1 (7%), and rectus flaps in 1 (7%).
Major (grade 3 3) 30d complications occurred in 3 (21%) including return to OR for small bowel obstruction, ileus with neuropathy, and pubic osteomyelitis. RUF recurrence occurred in 1 (7%) and 2 (14%) patients required additional procedures. At median follow‐up 24 months, men with bladder preservation used a median 3 pads/day and 1 (7%) required artificial urinary sphincter. In 11 patients who completed QOL survey, 10 (91%) felt the surgery led to a positive change in their lives. Of those who underwent bladder preserving techniques, 2 (29%) would have rather had complete urinary diversion.
While there were no statistically significant differences observed between men with history of radiation and those without, men with radiation presented later after prostate therapy (115.0 months vs 39.6 months; p = 0.17), were more likely to have urethral stricture (50% vs 16.7%, p = 0.30), and undergo urinary diversion (50% vs 16.7%; p = 0.30). There was also an increased need for flap in irradiated men (100% vs 66.7%; p = 0.049) and these men were more likely to report that they would rather undergo a complete urinary diversion (66.7% vs 0%; p = 0.033).
Conclusions: Robotic assisted approaches for the treatment of RUF appears safe and feasible with acceptable short‐term outcomes. RUF in radiated men are complex and require thoughtful operative planning and patient counseling to restore QOL.
The Outcome of Robotic Reconstruction of the Radiated Ureter
AA Elbakry, K Aldabek, MW Salkini
West Virginia University Hospital
Introduction & Objective: The da Vinci® robotic surgical system revolutionized reconstructive urology as it enables us to perform complex procedures minimally invasive, and ureteral reimplantation is no exception. Here, we are reporting the outcome of robotic ureteral reimplantation of radiation induced ureteral structures.
Methods: We retrospectively identified all patients who underwent robotic reconstruction of the distal ureter in the last 10 years. Data collection included demographic data, preoperative baseline clinical data, operative data (operative time, EBL, conversion to open, surgical technique) and postoperative outcomes (early postoperative complications, hospital stay, 30‐days readmission, postoperative and delta eGFR, and reintervention rate). Analysis was done using IBM SPSS v24. Independent sample t test and Mann‐Whitney U test were used for continuous variables and Chi Square and Fisher's Exact tests were used for categorical variables.
Results: A total 45 ureteral units in 36 patients were subjected to distal ureteral reconstruction. Patients were categorized into 2 groups. Group 1 has 21 radiation naïve patients, and group 2 included 15 patents with history of pelvic radiation. The two groups were similar regarding baseline demographic data. Operative time, EBL, conversion to open, and length of stay were similar in both groups. There was no difference regarding early complications, 30‐days readmissions, and the duration of foley catheter or ureteral stent. Majority of patients in both groups reported symptoms improvement (100% in group 1 and 93.3% in group 2. Seven ureters (16%) out of the 45 robotically reimplanted ureters developed stricture after robotic reconstruction. The stricture developed in 5 patients from group 1 and 2 patients from group 2.
Conclusions: Robotic surgery is a feasible approach for post‐radiation distal ureteral reconstruction with a high success rate and relatively similar outcome to radiation naive patients. More studies with a larger number of patients are needed to fully evaluate the role of robotic surgery in post‐radiation sittings as an alternative for classic open surgery.
Safe Day of Surgery Discharge for Artificial Urinary Sphincters – No Change in Outcomes or Complications
R Vasan, J Myrga, B Chun, D Miller, C Taylor, C Morrill, E Hacker, P Rusilko
UPMC
Introduction & Objective: The necessity of overnight observation following artificial urinary sphincter (AUS) surgery has recently become scrutinized. The aim of this study was to evaluate our institutional experience of foley‐free same day discharges after AUS placement and to identify potential additional factors associated with surgical outcomes.
Methods: A single‐center retrospective review was performed of 102 AUS placements performed between 2016 and 2021. Outcomes included 3‐, 30‐ and 90‐day patient phone calls, emergency department (ED) visits, unplanned clinic visits and readmissions in addition to long‐term complication rates. Analysis was performed for associations between day of surgery discharge, patient demographics, case characteristics and surgical outcomes.
Results: Median age at time of AUS placement was 69 years, median duration of follow‐up was 26 months and median OR time 101 minutes. 88% of cases were post‐prostatectomy, 53% of patients had undergone prior urethral surgery, 43% of cuff placements were transcorporal and 27% of cases were revisions. 32 patients were discharged on the day of surgery without a foley catheter and 70 were discharged the following day, with no significant differences in patient or case characteristics between the two groups. The proportion of patients with satisfactory postoperative social continence defined as needing to use <1 pad per day at most recent follow‐up was 82%. Overall rates of AUS infection, revision and explant were 4%, 5% and 3% respectively. 50% of patients had a history of pelvic radiation and 20% had undergone >6 months of androgen deprivation therapy, neither of which was found to be associated with post‐operative phone calls, ED visits, unexpected clinic visits, readmissions, complications or continence rates, nor did any association exist between outcomes and OR time, cuff location or size, ethnicity, BMI, diabetes, cardiovascular disease, smoking, anticoagulation use or socioeconomic status. Crucially, there was no significant difference between those discharged on the day of surgery compared to the following day with regard to urinary retention, complications, outcomes or satisfaction rates.
Conclusions: The absence of a significant difference in outcomes following day of surgery discharge in the setting of diverse demographics and case characteristics supports the continued safe and successful practice of AUS placement in the management of male stress urinary incontinence for a wide range of patients without the need for overnight observation.
Robot Assisted Laparoscopic Vesico‐vaginal Fistula Repair with Omental Interposition : A Prospective Evaluation of Our Experience
A Kumar, Y Prashanth, S Kumar, K kapoor, S Iyer, P Singh
Department of Urology, Robotics and Renal Transplant, SJH and VMMC, New Delhi
Introduction & Objective: We prospectively evaluated our experience of Robot assisted laparoscopic VVF repair with omental interpositionin trigonal and supratrigonal VVF.
Methods: In this prospective study, all consecutive patients with trigonal and supratrigonal VVF ,from Oct 2019 to Feb 2021,requiring Robot assisted laparoscopic VVF repair with omental interposition(using da‐Vinci Xi Robotic system )were included.The patients with post radiotherapy and VVF with malignancy were excluded from the study.The various clinical data were recorded and analyzed.
Results: A total of 29 patients were included in the study. The mean age was 37.1 years .The fistula was post open abdominal hysterectomy in 52.6% and post lower segment caesarean section(LSCS) in 47.4% patients. The mean fistula size was 2.5 cm .The fistula location was trigonal in 36.8% and supratrigonal in 63.2% patients.The mean operating time and mean estimated blood loss were 109.3 min and 67.3 ml respectively .Six(31.5%) patients required simultaneous modified Lich Gregoir ureteric reimplantation There was no open conversion and intraoperative complications.The mean catheterization time ,mean hospital stay and mean convalescence were 10.9 days ,4.1 days and 1.9 weeks respectively.At mean follow up of 6 months ,postoperative complications were mainly clavien 1 ‐2 in only 5.2% patients .None of the patients showed recurrence of VVF or voiding symptoms .
Conclusions: Robot assisted laparoscopic VVF repair with omental interpositionin trigonal and supratrigonal VVF is feasible,safe with excellent efficacy,even in previously failed VVF repair.
Robotic Assisted Ureteroplasty with Buccal Mucosa Graft ‐ A Single Surgeon Experience
DT Lybbert, A Hertz, K Delfino, D Dynda, F Monn, BF Schwartz, A Jenks
Introduction & Objective: Ureteroplasty with buccal grafting is a relatively new approach to treating patients with complex ureteral stricture disease. To date, the data has been limited to case series and small multi‐institutional studies. Determining the optimal method of performing this repair is still relevant and evolving, particularly depending on surgeon familiarity with the procedure. We present our cohort of patients who underwent this procedure to assess outcomes and add to the growing literature for this approach to the management of ureteral stricture disease.
Methods: We performed a retrospective chart review of patients who underwent robotic assisted ureteroplasty with buccal mucosa grafting from 2019 to 2021. We differ slightly in surgical approach in that the bedside assistant performs ureteroscopy to assist in identifying the stricture and evaluating for patency intraoperatively. Primary endpoints were subjective responses concerning pain related to obstruction, imaging performed to evaluate for resolution of obstruction after surgery, complications related to procedure, and if there was a stricture recurrence.
Results: Ten patients underwent robotic assisted ureteroplasty with buccal mucosa grafting. There were six males and four females with a mean age at surgery of 47.9 (range – 21‐74 years). Average stricture length was 2.6 cm (range 1 – 6 cm). Eight patients had imaging that demonstrated patency within three months of surgery. Eight patients reported complete resolution of stricture related pain. Only two adverse events were observed within the 30‐day period following surgery—a urinary tract infection and an acute coronary syndrome, both of which were successfully treated.
Conclusions: Robotic assisted ureteroplasty with buccal mucosa graft is a recently adopted procedure for the treatment of ureteral strictures and can be coupled with concomitant ureteroscopy for assistance in identifying the strictured portion of the ureter during dissection. Our cohort of ten patients overall had positive outcomes comparable to larger case series done prior. Patients have also subjectively reported resolution of symptoms and satisfaction with the procedure.
WITHDRAWN
MP19: Laparoscopy/Robotics: Renal and Adrenal Tumors
Compare the Safety and Efficacy of Robot‐assisted Adrenalectomy (RA) and Laparoscopic Adrenalectomy (LA)
L Gan
Department of Urology, Nanchong Central Hospital, The Second Clinical College, North Sichuan Medical College (University), Nanchong, 63700, Sichuan, China.
Introduction & Objective: To compare the safety and efficacy of robot‐assisted adrenalectomy (RA) and laparoscopic adrenalectomy (LA).
Methods: We performed a systematic review and cumulative meta‐analysis of the primary outcomes of interest according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta‐Analyses) and AMSTAR (Assessing the methodological quality of systematic reviews) Guidelines. Five databases including Medline, PubMed, Cochrane Library, Scopus, and Web of Science were systematically searched. The time frame of the search was set from the creation of the database to December 2021.
Results: There were 26 studies including 2985 patients. Our study found that the robotic technique was superior to conventional laparoscopy for estimated blood loss [WMD = ‐18.25, 95% CI (−27.85, −8.65), P < 0.01], length of stay [WMD = ‐0.45, 95% CL (−0.57, −0.33), P < 0.01], and conversion to open [OR = 0.31, 95% CI (0.12, 0.78), P = 0.01], while complications and readmissions were comparable. Interestingly, there was no difference in operative time between the two surgical modalities, but subgroup analysis found that the retroperitoneal route robotic technique took longer [WMD = 14.64, 95% CL (0.04, 29.24), P < 0.05], whereas the study of the mixed surgical modality found that the robot required less time [WMD = ‐12.29, 95% CL (‐22.86, ‐1.72), P < 0.05]. For pheochromocytoma, RA was superior to LA in terms of length of stay [WMD = ‐0.49, 95% CI (‐0.83, ‐0.15), P < 0.01], with no difference in other indicators.
Conclusions: Robotics is a superior technique to conventional laparoscopy in the management of adrenal tumors, even in the case of a specific adrenal tumor ‐ pheochromocytoma.
Single‐port Robot‐assisted Kidney Transplantation: Comparison of Outcomes with Standard Open Kidney Transplantation
A Kaviani, Y Lin, M Abou Zeinab, A Beksac, E Ferguson, A Wee, M Eltemamy, J Kaouk
Glickman Urological & Kidney Institute, Cleveland Clinic Main Campus, Cleveland, OH
Introduction & Objective: To compare the perioperative and follow‐up outcomes of the initial series of patients who underwent single port (SP) robot‐assisted kidney transplantation (KTP) with the standard open KTP.
Methods: Using our institutional review board (IRB) approved databases, we compared a prospective cohort of 12 consecutive patients who underwent SP robotic KTP from Oct 2019 to Oct 2021 with a retrospective cohort of 12 matched patients who had open KTP. Patients were matched for donor type, the kidney donor profile index (KDPI) in deceased donors, recipient age, and history of diabetes. The comparison of normal data and percentages was performed using the T‐test and the "N‐1" Chi‐squared test respectively.
Results: Baseline, perioperative, and follow‐up data of both groups are presented in table 1. No patients in robotic arm were converted to open surgery. There were no perioperative complications ≥ Clavien grade 2 in either group. The mean (SD) inpatient morphine milligram equivalents (MME) score was 44.91 (40.15) and 149.16 (119.70) in SP and open groups respectively (P = 0.0091). 6‐, and 12‐month graft and patient survival were 100% in both arms. There was no significant difference in mean creatinine levels at 1, 6, and 12 months between groups.
Conclusions: Single port robot‐assisted kidney transplantation is associated with similar renal function compared to open kidney transplantation with the added benefit of less postoperative narcotics requirement. Larger comparative studies are required in this setting.
Comparison of Posterior etroperitoneoscopic adrenalectomy versus Lateral Transperitoneal laparoscopic Adrenalectomy for Adrenal tumors: a Systematic Review and Meta‐analysis
C Meng
Department of Urology, The affiliated Nanchong Central Hospital of North Sichuan Medical College (University)
Introduction & Objective: To discuss the differences in the effectiveness and security for adrenal tumors by posterior retroperitoneoscopic adrenalectomy (PRA) and lateral transperitoneal laparoscopic adrenalectomy (LTA).
Methods: We systematically searched PubMed, Embase, Scopus database and Cochrane Library, and the date was from above database establishment to November 2020. Stata 16 was used for calculation and statistical analyses.
Results: Nine studies involving eight hundred patients were included. The following differences were observed in favor of PRA vs LTA: less operative time (MD: ‐22.5; 95%CI ‐32.57 to ‐12.45; P = 0.000), Fewer estimated blood loss (MD: ‐15.17; 95%CI ‐26.63 to ‐3.72; P = 0.009), lower intensity of postoperative pain (MD: ‐0.56; 95%CI ‐1.05 to ‐0.07; P = 0.026), shorter length of hospital stay (MD: ‐1.15; 95%CI ‐1.94 to ‐0.36; P = 0.04). No differences were shown in conversion rate (OR 2.07; 95%CI 0.71 to 6.03; P = 0.181) and complications (OR 0.85;95% CI 0.46 to 1.56; P = 0.597).
Conclusions: Posterior retroperitoneoscopic adrenalectomy wasclinically superior to lateral transperitoneal laparoscopic adrenalectomy for adrenal tumors in operative time, estimated blood loss, length of hospital stay, and postoperative pain. Only in term of conversion rate and complications, both were similar
Do Positive Surgical Margins Following Robotic Partial Nephrectomy Matter?
S Hemal, M Abou Zeinab, A Beksac, A Fergany, R Stein, G Haber, J Kaouk
Cleveland Clinic Glickman Urological and Kidney Institute
Introduction & Objective: Robotic Partial Nephrectomy (RPN) is utilized as the standard of care for the surgical extirpation of localized renal masses of varying complexity while achieving efficacious oncologic outcomes. Its superiority to open and laparoscopic approaches is supported in literature citing decreased perioperative morbidity and complications, shorter hospital stay and faster convalescence. Given the success of RPN, the push to expand its application to the excision of complex and higher stage renal masses raises concerns for compromising oncologic efficacy. Therefore, we sought to evaluate the implications of positive surgical margins (PSM) following RPN.
Methods: A retrospective analysis of 1385 consecutive patients who underwent RPN from 2009‐2020 with at least 6 months follow‐up was performed. Two cohorts were generated and compared based on presence of PSM. Groups were compared using chi‐square for dichotomous variables and t‐tests for continuous variables. Kaplan‐Meier method was utilized to calculate the 4‐year overall survival rate. Distant metastasis was characterized as metastatic disease to brain, bone and lung. Associations between the captured baseline characteristics and oncologic outcomes were assessed between the two groups.
Results: 1385 patients were identified for analysis (102 PSM and 1283 negative surgical margin (NSM)). The PSM group had a greater incidence of previous partial nephrectomy and longer warm ischemia time (p‐value <0.05). From a pathologic standpoint, the PSM group exhibited a higher incidence of pT3a stage (30% vs 10%, p value <0.001) as indicated by higher rate of perirenal and sinus fat involvement (12.5% vs 3.4% and 31% vs 4% respectively, p value <0.001) and higher rate of lymphovascular invasion (5.7% vs 1 %, p value <0.001). From an oncological standpoint, PSM group had higher local recurrence rate (6% vs 2.3%, p value = 0.025) and greater distant metastasis rate (6% vs 2.4% p value = 0.034). In comparison to the NSM cohort, at a mean follow up of 51 months, the PSM group had higher overall mortality rate of 18.6% vs 4% (p‐value <0.001) and cancer specific mortality of 7.9% vs 1.6% (p‐value = 0.002).
Conclusions: A PSM on final pathological evaluation does have negative implications as not only is it associated with an overall higher pathologic stage, but it also confers a higher rate of local recurrence, distant metastasis and cancer specific mortality.
Comparison of Survival Outcomes After Radical or Partial Nephrectomy for Complex Renal Mass: Analysis from the ROSULA (Robotic Surgery for Large Renal Mass) Collaborative Group
C Cerrato, R Autorino, G Simone, B Yang, R Uzzo, F Porpiglia, U Capitanio, J Porter, A Minervini, C Lau, DD Eun, A Mottrie, L Schips, B Challacombe, O De Cobelli, C Mir, IS Gill, J Kaouk, C Sundaram, I Derweesh
Università degli studi di Verona, Urology Department UC San Diego Health
Introduction & Objective: Partial nephrectomy (PN) provides oncological equipoise to radical nephrectomy (RN) in for most T1 and T2 renal masses. Controversy continues with respect to oncological efficacy of PN for complex renal masses (CRM). We compared survival outcomes of PN and RN in CRM.
Methods: We performed retrospective analysis utilizing the ROSULA registry. CRM was defined as RENAL nephrometry score 10‐12. Primary outcome was all cause mortality (ACM)/overall survival (OS). Secondary outcomes were cancer specific mortality (CSM)/ cancer specific survival (CSS), recurrence/recurrence free survival (RFS), and complications. Cox proportional hazards multivariable analysis (MVA) was used to elucidate predictors for survival outcomes and complications. Kaplan Meier Analysis (KMA) was performed to analyze outcomes between the two groups stratified by pathological stage.
Results: 962 patients were analyzed (RN = 421, PN = 541; median follow up 24.0 months). MVA demonstrated increasing age (HR 1.06, p < 0.001), positive margins (HR 2.51; p = 0.024), and RN (HR 1.33, p = 0.03) to be independently associated with worsened ACM. Increasing age (HR 1.05, p < 0.001), positive margins (HR 5.17; p = 0.024), increasing tumor size (HR 1.06, p = 0.006), and higher BMI (HR 1.09, p = 0.043) were independent risk factors CSM. Positive margin (HR 2.61 p = 0.04) and increasing tumor size (HR 1.06; p < 0.001) were associated with increased risk of recurrence. Receipt of an intraoperative transfusion (HR 1.93; p = 0.012) was associated with increased rate of major complications, but not type of surgery (p = 0.151). For RN vs. PN, KMA revealed 5‐year OS for pT1 of 68% vs. 87%, (p < 0.001); pT2 of 65% vs. 88% (p = 0.221) and pT3 of 79% vs. 41% (p = 0.874). 5‐year CSS for pT1 was 86% vs. 98%, (p < 0.001); pT2 was 83% vs. 100% (p = 0.301) and pT3 was 85% vs. 79% (p = 0.867). 5‐year RFS for pT1 was 73% vs. 87%, (p < 0.001); pT2 was 61% vs. 91% (p = 0.273) and pT3 was 69% vs. 89% (p = 0.730).
Conclusions: In patients with CRM, PN was not associated with increased risk of complications or worsened oncological outcomes and may provide survival benefit in T1 RCC. PN may be considered as a preferred option when clinically indicated in CRM.
Kidney Volume Preservation During Robotic Partial Nephrectomy for Hilar Tumors: A Multi‐center Analysis
A Beksac, K Okhawere, M Abou Zeinab, A Kaviani, E Ferguson, K Badani, J Kaouk
Glickman Urological & Kidney Institute, Cleveland Clinic
Introduction & Objective: We aimed to analyze the outcomes of robotic partial nephrectomy (RPN) in the management of hilar renal masses with a focus on renal volume preservation.
Methods: From a multi‐center series, we have analyzed the data of 314 patients (47 hilar vs. 267 non‐hilar) who underwent RPN for a localized renal mass. All patients had preoperative and postoperative ipsilateral and contralateral kidney volumetric data available. Volumetric analyses were performed using a semi‐automated tissue segmentation tool. Tumor volume and bilateral kidney volumes were calculated preoperatively and postoperatively. The relationship between baseline characteristics as well as peri‐operative, oncological, and functional outcomes were evaluated using Chi‐square test or Fischer's exact test and Wilcoxon rank‐sum. A Kaplan Meier survival analysis with a log‐rank test was used to compare the recurrence‐free survival and overall survival between non‐hilar and hilar tumors.
Results: Baseline characteristics were comparable between the two groups, except for higher median RENAL score (9 vs. 7, p < 0.001) in the hilar group. Patients in the hilar group had longer warm ischemia time (22 vs. 16 minutes, p = 0.005), however, ipsilateral volume preservation (Hilar, 77.52% vs. non‐ Hilar, 89.72 %, p = 0.196) and contralateral hypertrophy (3.05% vs. 1.96%, p = 0.229) were comparable. Acute kidney injury (AKI) rate was similar (p = 0.827) and eGFR preservation did not differ between the two groups at either 12 months (87.1% vs. 89.2%, p = 0.817) or last follow up (88.6% vs. 89.7%, p = 0.765). Positive surgical margin rate (6.0% vs. 2.1%, p = 0.948) and recurrence rates (4.3% vs. 4.1%, p = 0.100) were comparable. RFS (p = 0.924) and OS (p = 0.922) were comparable.
Conclusions: With experience and optimal surgical excision, RPN yields comparable results between hilar and non‐hilar renal masses. Albeit, the warm ischemia time was longer in the hilar group, kidney volume preservation and eGFR preservation were similar in both groups.
Prevalence and Characteristics of Benign Renal Masses After Partial or Radical Nephrectomy in Caucasian Americans versus African Americans
SP Argade, J Vetter, J Palka, K Sands
Barnes Jewish Hospital/Washington University School of Medicine
Introduction & Objective: Benign and malignant renal masses can be challenging to differentiate using noninvasive techniques. Previous studies have shown that 10‐20% of excised renal masses are benign, but little is known about any racial disparities. This study aims to compare the prevalence and characteristics of benign renal masses in Caucasian Americans (CA) and African Americans (AA) on final pathology.
Methods: We reviewed all laparoscopic and robotic partial and radical nephrectomies performed at this institution between 2007‐2017 on patients self‐identifying as CA and AA. We compared patient characteristics including age, sex, body mass index (BMI), Charlson Comorbidity Index (CCI), and insurance type, tumor characteristics including tumor size and RENAL Nephrometry score, surgical characteristics including biopsy status, technique, and modality, and pathologic characteristics including histology, grade, cell type, and biopsy concordance. Groups were compared using Fisher's exact test.
Results: We identified 1154 CA patients and 171 AA patients. There was no significant difference in age, BMI, CCI, or insurance type between groups, but there was a higher proportion of women in the AA group (p = 0.03). Average tumor size and RENAL Nephrometry scores were not significantly different. Similar proportions of patients underwent preoperative biopsy, radical vs. partial procedure, and laparoscopic vs. robotic procedure. Pathologic analysis showed similar proportion of benign renal masses overall (12.4% CA vs. 9.4% AA, p = 0.254) and similar pathologic grade. However, there was a significantly higher proportion of angiomyolipoma (AML) (3.0% CA vs. 5.3% AA, p < 0.001), and lower proportion of oncocytoma (8.6% CA vs. 4.1% AA, p < 0.001) in AA patients. Biopsy concordance was 84.5% and 70.6% for CA and AA patients, respectively (p = 0.178) (Table 1).
Conclusions: Analysis of CA and AA patients undergoing renal mass excision showed similar patient, tumor, and surgical characteristics, but statistically significant differences in pathologic cell type. While similar proportions of patients in both groups were found to have benign renal masses, AML appears to be more prevalent and oncocytoma less prevalent in AA patients.
A Matched‐pair Analysis of Robotic Partial Nephrectomy for Single versus Multiple Ipsilateral Renal Masses
MG Biebel, BG Patel, J Vetter, R Venkatesh, S Figenshau
Washington University School of Medicine in St. Louis
Introduction & Objective: Nephron‐sparing surgery is important in patients with multiple renal tumors. Prior studies of partial nephrectomy (PN) for multiple, ipsilateral renal masses (mPN) showed preserved renal function and good oncologic outcomes, albeit with higher complications with more tumors. Here, we compare renal function changes, complications, and warm ischemia time (WIT) of robotic PN of a single mass (sPN) versus mPN.
Methods: We retrospectively reviewed our institution's multi‐surgeon PN database from 2011‐2018. We matched robotic sPN and mPN 3:1 using “nearest‐neighbor” propensity score matching based on age, Charlson Comorbidity Index (CCI), total tumor size, and nephrometry score. Multivariable models were fit controlling for these same variables.
Results: Fifteen mPN and 45 sPN patients were matched. The mean total tumor size was 4.2 and 3.8 cm, respectively (p = 0.278). The mean nephrometry score in both groups was 7.9 (p = 0.972). The mean number of tumors for mPN was 2.1. The mPN group had higher operative time (213.1 vs. 167.4 minutes, p = 0.003), estimated blood loss (EBL) (309 vs. 228 mL, p = 0.025), and WIT (26.3 vs. 21.1 minutes, p = 0.037). There was no difference in glomerular filtration rate change (mPN ‐19.0% vs. sPN ‐14.8%, p = 0.744). Complications (Clavien 2+) occurred in 20.0% of mPN and 17.8% of sPN (p = 1.000). Multivariable modeling predicts 9.8 minutes longer WIT for mPN (p = 0.003), and no difference in complication rates between groups (OR 1.05, p = 0.684).
Conclusions: Robotic PN in our matched comparison of mPN and sPN showed no difference in complications or renal functional outcomes. mPN was associated with increased operative time, EBL, and WIT.
Factors Influencing Warm Ischemia Time in Robot‐assisted Partial Nephrectomy Change Depending on the Surgeon's Experience
K Numakura, M Kobayashi, Y Sekine, S Kashima, R Yamamoto, T Nara, M Saito, S Narita, T Habuchi
Akita University
Introduction & Objective: Warm ischemia time (WIT) is a primary concern for robot‐assisted laparoscopic partial nephrectomy (RALPN) patients because longer WIT is significantly associated with postoperative deteriorating kidney function. Tumor complexity, determined by the RENAL nephrometry score (RENAL score), can help predict surgical outcomes, but it is unclear what RENAL score and clinical factors affect WIT. This study explored the clinical factors predicting long WIT in RALPN.
Methods: In our institute, 174 RALPNs were performed between November 2013 and February 2021, of which 114 were performed by a single surgeon and included in this study. Clinical staging and the total RENAL score were determined based on preoperative CT scans. The cases were divided into three groups based on experience: period 1: 1–38, period 2: 39–76, and period 3: 77–114. The clinical factors associated with longer WIT were analyzed per period.
Results: The overall median tumor diameter was 32 mm, and one patient had a positive surgical margin, but there were no cancer‐related deaths. In total, there were 18 complications (15.8 %). Periods 2 and 3 had larger tumor diameters (p < 0.01) and worse preoperative kidney function (p = 0.029) than period 1. A RENAL L‐component score of 3 was associated with longer WIT in period 3 (odds ratio: 3.900; 95 % confidence interval: 1.004–15.276; p = 0.044), but the tumor diameter and the total RENAL score were not.
Conclusions: A large tumor in the central lesion indicated by the RENAL L‐component score was associated with increased WIT in RALPN.
Mass Closure Renorrhaphy Reduces Warm Ischemia Robotic Partial Nephrectomy
MW Salkini, A Lamoshi
mhdsalkini@gmail.com
Introduction & Objective: Warm ischemia time (WIT) has been a concern in robotic partial nephrectomy (RPN). Multiple maneuvers have been tried to reduce WIT such as clampless RPN, early unclamping, internal cooling and using Laser. Separate closure of the collecting system is time consuming and is considered by many an essential step in renorrhaphy to prevent urine leak after RPN. We mass closed the renal parenchyma without dedicated closure of the collecting system to expedite renorrhaphy and reduce warm ischemia time. We report our own experience in omitting the closure of the collecting system
Methods: We did not specifically close the collecting system in the last 315 cases to speed the renorrhaphy. We left Jackson Pratt at the end of the procedure whenever we open the collecting system. To detect any urine leak, we sent the drainage fluid for analysis (checked the Cr)
Results: The average patients age was 67 years (28 ‐84). The average WIT was 13 min (5‐22). Average intraoperative blood loss was 175 ml (50‐750). Only 12 patients needed transfusion (4 %) and 4 needed intravascular intervention to stop delayed bleeding (1.2 %). Of note, one patient developed asymptomatic aneurism 12 months after surgery and that was embolized (0.4%). Two patients (0.6 %) developed urine leak caused by ureteral obstruction with clots. The leak resolved with stenting and bladder drainage.
Conclusions: Omitting the closure of the collecting system speed the renorrhaphy and decreases WIT and creatinine changes after surgery. The ratio of adverse event due to adoption of this technique was acceptable compared to the standard technique.
Outcomes of Eosinophilic Renal Neoplasms Following Renal Biopsy
J Shin, V Lynch, D Alcorn, S Sheridan, D Kay, N Umez‐Eronini
NHS Greater Glasgow & Clyde
Introduction & Objective: Use of renal biopsy in the evaluation of small renal masses is established practice. However, renal neoplasms with eosinophilic cytoplasm have many overlapping histological features with benign oncocytomas and distinguishing aggressive renal cell cancers (RCC) from biopsy specimens can be a challenge with significant implication on patient management. This is a single‐centre study evaluating the outcome of eosinophilic renal neoplasms and the value of renal biopsies in predicting clinical progression.
Methods: A prospectively maintained database of renal biopsies from 2015 to 2020 was used to identify patients with eosinophilic histology. Data on patient demographics, tumour characteristics and clinical outcome was collected from our electronic patient records.
Results: 59 renal biopsies were identified with eosinophilic neoplasm. Median patient age was 69 years with approximate gender ratio of 2:1 (m:f). Median number of biopsy cores was 3 (range 1‐6). Table 1 summarises the outcomes following renal biopsies. All biopsies favouring chromophobe RCC which subsequently underwent radical treatment had confirmed RCC. In biopsies favouring oncocytoma, no adverse outcome was reported during active surveillance of small lesions. However, significant cases resulted in active treatment due to growth kinetics, radiological concern, or patient choice (Figure 1). There was no report of disease recurrence or progression in patients undergoing cryoablation irrespective of histology.
Conclusions: Our data suggest renal biopsies can guide appropriate management of small renal lesions with eosinophilic histology. However, tumour size and growth kinetics remain key aspects in the overall interpretation of biopsy results and shared decision‐making process.
Perioperative Serum Cytokine Levels in Patients Treated with Robot‐assisted Laparoscopic Partial Nephrectomy
Y Sekine, S Narita, M Kobayashi, S Kashima, R Yamamoto, T Nara, H Mingguo, K Numakura, M Saito, T Habuchi
Department of Urology, Akita University Graduate School of Medicine
Introduction & Objective: We assessed the impact of the perioperative serum levels of six inflammatory cytokines on clinical outcomes in patients with renal cell carcinoma (RCC) treated with robot‐assisted laparoscopic partial nephrectomy (RAPN).
Methods: We included 138 patients who underwent RAPN for localized RCC between 2013 and 2020. We measured six inflammatory cytokines (interleukin [IL]‐10, IL‐6, IL‐8, IL‐1b, IL‐12p70, and tumor necrosis factor [TNF]‐a) using the BD Cytometric Bead Array Human Inflammatory Kit (BD, Tokyo, Japan), along with white blood cell count (WBC) and C‐reactive protein (CRP) level. Measurements were performed before the operation (pre‐OP), immediately after the operation (post‐OP), and at postoperative Day 1 (POD1). We statistically investigated the relationship between clinical outcomes and the levels of inflammatory mediators.
Results: The median age and body mass index were 64 years and 24. 5 kg/m2, respectively. The median tumor diameter was 30 mm; 116 (84.1%) and 22 (15.9%) patients had cT1a and cT1b disease, respectively. The median R.E.N.A.L. nephrometry score was 7. The levels of WBC, CRP, and IL‐10 at post‐OP and POD1 were significantly higher than those measured at pre‐OP (each, p < 0.05). The levels of IL‐6 and IL‐8 at post‐OP were significantly higher than those detected at pre‐OP (each, p < 0.05). The univariate analysis showed that the surgical approach, operative time, R.E.N.A.L. nephrometry score, and clinical stage were significantly associated with higher levels of IL‐6 and IL‐10 at POD1. The multivariate analysis showed that the retroperitoneal approach was an independent risk factor for a high IL‐10 level at POD1 (p = 0.031). Regarding the impact of cytokine levels on postoperative renal function, the patients with worse renal function had a significantly higher IL‐6 level at POD1 than those with better renal function (53. 3 pg/mL vs. 40. 4 pg/mL, respectively; p = 0.038). The multivariate analysis showed that a high IL‐6 level at POD1 was an independent risk factor for deterioration of renal function at 1 month (p = 0.039). There were no relationships between serum cytokine levels and oncological outcomes.
Conclusions: In RAPN, the retroperitoneal approach was linked to a risk for increased postoperative serum levels of inflammatory cytokines. The serum level of IL‐6 at POD1 was associated with postoperative renal deterioration in patients with RCC treated with RAPN.
Initial Experience of Senhanceò Assisted Laparoscopic Surgery for Renal Cell Carcinoma and Upper Urinary Tract Urothelial Carcinoma
G Kaneko, S Shirotake, M Oyama, I Koyama
Saitama Medical University International Medical Center
Introduction & Objective: The SenhanceÒ robotic system is a novel system with a telesurgical concept, and it consists of up to four independently positionable and controllable robotic arms, which are controlled by the surgeon via a console with attached laparoscopic handles. This system has several novel characteristics, such as an eye‐tracking camera control system and haptic feedback, and operations can be performed in comfortable seated position without neck strain. We herein describe our initial experience of SenhanceÒ assisted laparoscopic surgeries for renal cell carcinoma (RCC) and upper tract urothelial carcinoma (UTUC).
Methods: SenhanceÒ assisted laparoscopic radical nephrectomy (LRN) was performed in 10 RCC cases (clinical T1a in 3, T1b in 4, T2a in 2, and T3a in 1). Among them, nephrectomy was performed for cytoreduction after a combination immunotherapy in 2 cases. SenhanceÒ assisted laparoscopic partial nephrectomy (LPN) was performed in 1 RCC case (R.E.N.A.L nephrometry score 6). SenhanceÒ assisted laparoscopic nephroureterectomy (LNU) was performed in 7 patients with UTUC in clinical T stage ≤2. A kidney and a proximal ureter were laparoscopically dissected and mobilized, and a distal ureterectomy with a bladder cuff were performed in open procedures. All procedures were performed via transperitoneal approach in a similar manner to conventional LRN, LPN and LNU. Three robotic arms were used for several forceps (e.g. monopolar scissors, bipolar forceps, and ultrasonic instrument) and a camera, and 1 or 2 trocars were additionally inserted for an assistant. The peri‐operative data of surgeries performed between October 2020 and February 2022 were analyzed.
Results: In one case of SenhanceÒ assisted cytoreductive LRN after marked response to a combination immunotherapy, it was converted to conventional LRN due to severe adhesion around the renal hilum. In the remaining 9 cases of SenhanceÒ assisted LRNs, median console time and estimated blood loss (EBL) were 132 minutes and 53 mL, respectively. Postoperative intestinal obstruction (Grade 3b) was found in one case. In SenhanceÒ assisted LPN, console time, warm ischemic time, and EBL were 69 minutes, 21 minutes, and 5 mL, respectively, and the surgical margin was negative. In SenhanceÒ assisted LNU, median console time and EBL were 113 minutes and 55 mL, respectively.
Conclusions: SenhanceÒ assisted LRN, LPN, and LNU were safely and precisely performed. Furthermore, the operator was comfortable during the surgery. Although further surgical experience and long‐term follow‐up are required to assess surgical and oncological outcomes, SenhanceÒ assisted laparoscopic surgeries for RCC and UTUC may be promising procedures.
Association Between Abdominal Aortic Atherosclerotic Burden and predictors of Functional and Oncological Outcomes in patients Undergoing Partial Nephrectomy
A Tafuri, E Serafin, K Odorizzi, A Gozzo, G Di Filippo, C Cerrato, A Bianchi, M Borzi, G Zamboni, G Mansueto, A Porcaro, M Brunelli, M Cerruto, G Zaza, P Fiorini, B Maris, A Antonelli
Introduction & Objective: Cardiovascular disease and atherosclerosis are possible causes of renal disfunction and can lead to worse perioperative functional and oncological outcomes after partial nephrectomy (PN) for renal cell carcinoma. We aimed to assess the association between burden of aortic atherosclerosis described through an objective CT‐derived index (abdominal‐aortic atherosclerotic plaque index, API) and perioperative outcomes of PN.
Methods: Patients who underwent PN for renal tumor between April 2013 and March 2020 were included. We developed a user interface to calculate API from CT‐arterial‐contrast‐enhancement images, as the proportion of plaque volume over the total volume of abdominal aorta (Figure 1). API was investigated both as continuous as well as dichotomous variable, leveled as API = 0 (absence of atherosclerotic plaques) vs API >0. Demographic and clinical peri‐operative data were collected and their association with API was assessed by linear and logistic regression models.
Results: 142 patients were included [89(62.7%) males and 53(37.3%) females; median age of 67years]. Median follow‐up was 8 [4‐13] months. Median calculated API was 0.82% (IQR 0‐3.75). Univariate analysis showed that API was predicted by age (β = 0.47,p <0.01), pre‐operative eGFR (β = ‐0.39,p <0.01), use of antiaggregant‐anticoagulant therapy (β = 0.29,p <0.01), ASA score (β = 0.34,p = 0.01), Charlson Comorbidity Index (β = 0.32,p <0.01), hyperlipidemia (β = 0.30,p <0.01) and coronary artery disease (β = 0.38,p <0.01). API was a predictor of 1st post‐operative day (POD) eGFR (β = ‐0.32,p <0.01), 1st POD acute kidney injury (OR = 1.11, 95%CI 1.01‐1.23, p = 0.037), 1st POD Hb (β = ‐0.23,p <0.01), eGFR at discharge (β = ‐0.35,p <0.01), eGFR at follow‐up (β = ‐0.29,p <0.01). On logistic regression analysis, API >0 predicted a reduction of eGFR at discharge (OR = 3.31,p = 0.036) and at follow‐up (OR = 3.69;p = 0.047). Linear regression analysis showed that API >0 predicts a reduction of eGFR at 1st POD (β = ‐0.34,p <0.01), at discharge (β = ‐0.34,p <0.01) and at follow‐up (β = ‐0.36,p <0.01).
Conclusions: Patients undergoing preoperative CT staging in preparation for PN should be evaluated for abdomen aortic atherosclerosis plaques using API which is associated to clinical predictors of worse functional and oncological outcomes.
Safety and Efficacy of Minimally Invasive Technique Adrenalectomy versus Open Adrenalectomy in Patients with Large Adrenal Tumors (≥5 Cm): A Meta‐analysis and Systematic Review
L Gan
Department of Urology, Nanchong Central Hospital, The Second Clinical College, North Sichuan Medical College (University), Nanchong, 63700, Sichuan, China.
Introduction & Objective: To compare the safety and efficacy of minimally invasive technique adrenalectomy (MITA) with open adrenalectomy (OA) in patients with large adrenal tumors (≥5 cm).
Methods: We performed a systematic review and cumulative meta‐analysis of the primary outcomes of interest according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta‐Analyses) and AMSTAR (Assessing the methodological quality of systematic reviews) Guidelines. Five databases including Medline, PubMed, Cochrane Library, Scopus, and Web of Science were systematically searched. The time frame of the search was set from the creation of the database to March 2022.
Results: A total of 10 studies, including 843 patients, were included. Compared to OA, MITA is superior in LOS [WMD = ‐3.49, 95% CI (‐4.73, ‐2.26), P < 0.01], DT [WMD = ‐0.87, 95% CI (‐1.61, ‐0.12), P < 0.05] and FT [WMD = ‐0.95, 95% CI (‐1.40, ‐0.51), P < 0.01], EBL [WMD = ‐315.08, 95% CI (‐512.59, ‐117.58), P < 0.01] and transfusion [WMD = ‐416.73, 95% CI (‐703.75, ‐129.72), P < 0.01], while OT and complications are the same.
Conclusions: MITA offers advantages over OA in the management of large adrenal tumors.
Robot‐assisted Laparoscopic Donor Nephrectomy: The Cho Ray Hospital Technique
M Thai, Q Chau, K Hoang, X Ngo, T Tran, T Nguyen, K Thai, D Vu, L Dinh, D Pham, H Tiong, T Nguyen
thanhtuan0131@gmail.com
Introduction & Objective: This study sought to assess the safety and efficacy of introducing robotic‐assisted laparoscopic donor nephrectomy (RALDN).
Methods: Data were collected prospectively from 31 consecutive living kidney donors from February 2018 to December 2020. Donor baseline demographics, perioperative outcomes, and recipient outcomes were recorded, and these parameters were analyzed.
Results: The following data of RALDN was respectively recorded: operative time (216 ± 39 minutes), warm ischemic time (4.9 ± 1.4 minutes), postoperative complications (6.5%), hemoglobin (g/L) drop (9.7 ± 6.6), blood creatinine at six month (1.13 ± 0.24 mg/dL) and at one year (1.17 ± 0.28 mg/dL), opioid use after surgery (16.1%) and postoperative hospital stays (3.8 ± 2.2 day).
Conclusions: RALDN could be safely introduced into a living donor program experienced in laparoscopic donor nephrectomy.
Proposal for Reclassification of T1 and t2a Renal Cell Carcinoma: Results of a Multi‐institutional Analysis
MF Meagher, A Saidian, R Autorino, B Lane, Y Fujii, M Marchioni, H Tanaka, D Patil, F Porpiglia, R Nasseri, C Sundaram, J Porter, A Minervini, U Capitanio, F Montorsi, V Master, I Derweesh
Introduction & Objective: Outcomes of Stage 1 Renal Cell Carcinoma are heterogeneous and vary widely. We sought to investigate whether re‐alignment of T1 and T2 RCC would lead to a more rational consolidation of similar outcomes that may improve predictive ability of the T staging system.
Methods: We performed a retrospective multicenter analysis of patients undergoing radical (RN) or partial nephrectomy (PN) for pathologic T1‐T2aN0M0 RCC. The cohort was divided into tumor size ≤2cm, >2 cm or <5cm, >5cm or <7 cm, and >7 or <10cm. Primary outcome was all‐cause mortality (ACM)/overall survival (OS). Secondary outcomes were cancer‐specific mortality (CSM)/cancer‐specific survival (CSS) and recurrence/recurrence‐free survival (RFS). Cox proportional hazards multivariable analysis (MVA) was used to elucidate predictive factors for ACM, CSM, and RFS. Kaplan Meier Analysis (KMA) was performed to analyze 5‐year OS, CSS, and RFS. AUC/ROC analysis was utilized to compare the predictive capability of pT1 disease defined as <5cm and pT2a >5 and <10cm vs. the current pT1 <7cm and pT2a >7 and <10cm.
Results: 5126 patients were analyzed (median age 60.2 years, median follow‐up 40.9 months). MVA demonstrated increasing pathologic tumor size [vs. <2 cm (referent)] to be independently associated with ACM [ >5 to <7cm (HR 1.6, p = 0.02), >7 to <10 cm (HR 1.9, p = 0.004)], CSM [ >7 to <10 cm (HR 4.1, p = 0.002)] and recurrence pathologic tumor size [ >5 to <7 cm (HR 4.9, p < 0.001), >7 to <10 cm (HR 6.5, p < 0.001)]. Comparing ≤2cm, >2 cm or <5cm, >5cm or <7 cm, and >7 or <10cm groups, KMA (Figure) revealed significantly worsened: 5‐year OS with larger tumor size: (96% vs. 89% vs. 84%vs. 82%, respectively, p < 0.001); 5‐year CSS with larger tumor size (99% vs. 97% vs. 92% vs. 88%, respectively, p < 0.001); and 5‐year RFS with larger tumor size (97% vs. 95% vs. 86%, vs. 75%), p < 0.001). AUC analysis revealed greater predictive power for proposed pT1 as <5cm and pT2 > 5 and <10cm vs. the current pT1 <7cm and pT2 > 7 and <10cm for OS (0.549 vs. 0.528), CSS (0.675 vs. 0.617), and RFS (0.681 vs. 0632).
Conclusions: Revision of T1 RCC into <5 cm and T2a into >5cm and <10cm groups corresponds to distinctive tumor groups whose biological potential aligns more closely and may enhance risk stratification, refine pretreatment counseling, and augment postoperative follow‐up protocols.
Can Laproscopic Nephrectomy in Xanthogranulomatous Pyelonephritis Be Consider as Standard of Care? ‐ Retrospective Single Center Analysis
A Singh, D Shah, NJ Pathak, A Ganpule, R Sabnis, M Desai
Muljibhai Patel Urological Hospital Nadiad
Introduction and Objective: In the era of minimally invasive surgery, sparse literature is available which has evaluated the use of a laparoscopic approach in management of xanthogranulomatous pyelonephritis(XGPN) with variable results. This series aims to report the safety, efficacy , complications and techniques for successful laparoscopic nephrectomy (LN) in XGPN when compared to open approach. This represents one of the largest series to date comparing laparoscopic and open nephrectomy (ON) for XGPN.
Methods: A retrospective analysis of 117 and 50 patients who underwent laparoscopic and open nephrectomy respectively with a pathological diagnosis of XGPN from January 2001 to December 2020 was done. The demographic profile, clinical presentation, intraoperative techniques, post‐operative parameters, and complications were analyzed.
Results: LN was successfully performed with certain modifications from standard techniques in 120 patients out of which 3 patients were converted to open approach due to adhesion, bowel injury, and pleural injury respectively. There was significant difference in hospital stay (p = 0.004), wound infection (p = 0.008) and post‐operative drain placement (p = 0.00) between LN and ON groups. Operative time(minutes) was 101.46 ± 33.6 and 111.44 ± 47.96 in LN and ON groups, respectively(p > 0.05). Pre‐operatively Percutaneous nephrostomy (PCN) was kept in 60 and 33 patients in LN and ON groups, respectively (p > 0.05). Both groups were comparable in terms of hemoglobin drop(p = 0.21), post‐operative drain days(p = 0.16) and blood transfusion (p = 0.13).
Conclusion: Laparoscopic Nephrectomy for XGPN is comparable to open surgery in terms of blood loss and blood transfusion rate. Laparoscopic nephrectomy in XGPN results in shorter hospital stay and decreased incidence of wound infection as compared to open surgery.
Assessing Racial Disparity in Clinical Presentation and Utilization of Partial or Radical Nephrectomy for Patients Undergoing Minimally Invasive Surgery
I Saini, K Okhawere, B Ucpinar, A Deluxe, T Corse, R Abaza, DD Eun, A Bhandari, A Hemal, J Porter, K Badani, M Stifelman
Introduction & Objective: Racial disparities and access to health care have been well studied. Implications of which have led to poorer outcomes among minority groups presenting with multiple comorbidities. Hence, this study aims to determine whether disparities exist at clinical presentation and treatment received among black and white patients who underwent robotic‐assisted nephrectomy (RAN).
Methods: Data were obtained from a prospectively maintained multi‐institutional database of patient who underwent RAN between 2006 and 2021. Only patients who self‐identified as either non‐Hispanic (NH) black or white were included in the analysis. The main outcome of interest is the type of robotic nephrectomy received ‐ radical nephrectomy (RN) and partial nephrectomy (RN). Baseline demographic ‐, clinical ‐ and tumor‐ related characteristics were compared using the χ2 test, Fisher exact test, Mann Whitney U test, and logistic regression.
Results: Of the 1,815 patients included in this study, 14.16% (n = 257) were NH‐blacks and 76.86% (n = 1,213) had PN. The median age was 63 years. Compared to NH‐whites, NH‐blacks were younger [60 vs. 63 years; p = 0.002]. NH‐blacks had higher proportion of patients with hypertension [77.04% vs. 62.04%; p < 0.001], diabetes [29.96% vs. 22.72%; p 0.012], baseline chronic kidney disease (CKD) [27.24% vs. 20.41%; p 0.013], ASA score of 4 [10.12% vs. 3.59%; p < 0.001] and those who received RN [29.18%% vs. 22.14%; p 0.013]. Gender, body mass index, Charleston comorbidity index (CCI), tumor size and clinical stage were not significantly different between the two groups. In a multivariable analysis controlling for all covariates, NH‐blacks were more likely to receive radical nephrectomy (Odds ratio [OR]:1.50 95% CI: 1.01, 2.24). CKD, CCI, Tumor size, ASA score of 4 and clinical stage were associated with receiving RN.
Conclusions: Our study shows that NH‐black patients had higher co‐morbidities on presentation and were more likely to undergo a RN compared to PN. The factors that influence decision making and treatment will require future study.
Comparison of Functional Preservation After Robotic‐assisted Partial and Radical Nephrectomy in High‐complexity Renal Tumors
R Grauer, K Okhawere, B Ucpinar, S Razdan, R Abaza, DD Eun, A Bhandari, A Hemal, J Porter, M Stifelman, K Badani, I Saini
Mount Sinai Hospital
Introduction & Objective: To compare functional outcomes and rates of complications between patients that underwent robotic‐assisted partial nephrectomy (RAPN) and robotic‐assisted radical nephrectomy (RARN) for highly complex renal tumors.
Methods: Data were obtained from a prospectively‐maintained multi‐institutional database. Only patients who underwent robotic‐assisted nephrectomy for highly complex tumors (defined as R.E.N.A.L nephrometry score ≥10) were included in this study. All surgeries were conducted between 2008 and 2020. We excluded patients with prior ipsilateral, bilateral, or multiple renal masses. Overall, 133 RAPN (72.3%) and 51 RARN (27.7%) patients were included in the analysis. We defined percentage estimated glomerular filtration rate (eGFR) preservation as the percentage of eGFR preserved at the last follow‐up from baseline and defined de novo chronic kidney disease (CKD) as new‐onset CKD stage ≥3 after surgery. The baseline patient and tumor characteristics, perioperative and functional outcomes, and rate of complications were compared using chi‐square test, T‐test, Mann Whitney U test, and logistic regression.
Results: The mean age of patients was 58 years (SD = 13) and 59.2% were males. Compared to patients who had RARN, those who had RAPN were more likely to be younger (56 [12] vs. 64 [13] years; p = 0.0006) and have a smaller median tumor size [4.4 cm vs. 7.1 cm; p < 0.001]. Similarly, the proportion of patients with baseline hypertension [43.6% vs. 66.7%; p 0.005] and R.E.N.A.L score of 12 [1.5% vs. 21.64%; p < 0.001] was lower for patients that had RAPN. RAPN had a higher percentage of eGFR preservation and a lower proportion of de novo CKD at a median follow‐up of 7 months. All and major post‐operative complication rates were similar between the two groups. In the multivariable analyses controlling for covariates, patients who had RARN were more likely to have de novo CKD (odds ratio [OR]: 13.52, 95% confidence interval [CI]: 3.92, 46.68).
Conclusions: Our study suggests that irrespective of the degree of complexity, RAPN has better functional outcomes compared to RARN without an increase in complications. When feasible, partial nephrectomy should be considered even in high complexity tumors to optimize renal functional outcome.
Robotic Assisted Salvage Partial Nephrectomy for Local Recurrences After Thermal Ablation (Cryoablation & Radiofrequency Ablation) of Renal Masses: Single Center Experience with Analysis of Outcomes
S Saini, A Hemal
Wake Forest University of Health Sciences, Winston‐Salem, NC, USA
Introduction & Objective: Salvage partial nephrectomy for recurrences after thermal ablative therapies is technically challenging secondary to varying degrees of perinephric fibrosis. These cases pose additional problem secondary to prior surgical renal manipulation and treatment failure making salvage procedure more difficult. Here in, we are presenting our experience of robotic assisted salvage partial nephrectomy for thermal ablation failures.
Methods: Between January 2013 and April 2022, we reviewed data of patients with local recurrences (on follow up imaging) after thermal ablation of renal masses, from our prospectively maintained institutional database.
Results: We identified 17 renal lesions in 15 patients who underwent robotic‐assisted salvage partial nephrectomy for local recurrences. A second/new renal lesion was noted in 2 patients in the same kidney following initial cryoablation, on follow up. One case was converted to open partial nephrectomy secondary to dense perinephric fibrosis and blood loss (s/p re‐do cryoablation in solitary kidney).
Table: 1
Table: 2 (Peri‐operative & Follow up parameters)
Although subjective, dense perinephric adhesions were noted in 8 patients and in another 3 patients, mild‐moderate degree of perinephric fibrosis was observed. None of the patients developed major complications post‐operatively. None of the patients developed any recurrence and all patients are alive at the time of analysis of data. No statistically significant difference was noted between baseline & follow up creatinine and eGFR (p = 0.12 and p = 0.19, respectively).
Conclusions: Robotic‐assisted salvage partial nephrectomy following thermal ablation failure is technically feasible with excellent peri‐operative and oncological outcomes
Ethnic Disparities in Clinical Presentation and Surgical Outcomes for Hispanic Patients with Localized Renal Masses
T Iarajuli, R Sanchez De La Rosa, T Corse, H Hasley, M Malik, F Sheckley, S Sorin, S Gelman, M Billah, G Lovallo, R Munver, M Ahmed, M Stifelman
Hackensack University Medical Center
Introduction & Objective: We aim to determine if Hispanic patients differed in clinical presentation and surgical management of renal masses compared to Non‐Hispanic Caucasian patients in our Northern New Jersey catchment area.
Methods: We utilized an IRB‐approved renal mass database including 948 patients who underwent partial or radical nephrectomy at our institution between May 2017 and September 2021. We evaluated 926 patients who identified as either “Hispanic” or “Non‐Hispanic Caucasian.” Continuous data was analyzed using the Wilcoxon Rank Sum test. Categorical data was analyzed using Chi‐Squared and Fisher's Exact Tests where appropriate.
Results: 151 patients (16.31%) self‐identified as Hispanic and 775 (83.69%) identified as Non‐Hispanic Caucasian (Table 1). In terms of presentation, Hispanic patients were significantly younger on average (56.3 vs 63.6, p = 0.00001), more likely to be female (47.68% vs 30.84%, p = 0.0001), and less likely to have a history of tobacco use (33.77% vs 45.94%, p = 0.018). Non‐Hispanic Caucasian patients had higher incidences of hypertension (64.52% vs 52.98%, p = 0.0073). There was no significant difference in incidence of chronic kidney disease prior to undergoing surgery (13.25% vs 20.39%, p = 0.1170).
There was no significant difference in rates of undergoing radical nephrectomy between the two groups (33.77% vs 27.35%, p = 0.1182). There was no significant difference in changes from baseline preoperative eGFR (‐12.39 vs ‐12.1 mL/min/1.73 m2, p = 0.8752). Additionally, there was no significant difference in rate of perioperative complications (1.32% vs 1.81%, p = 1.0), readmissions (7.95% vs 6.19%, p = 0.4332), or mortality (1.99% vs 1.55%, p = 1.0).
Conclusions: In our Northern New Jersey population, we found that Hispanic patients presented with renal masses at younger ages with less comorbidities and less prior tobacco use in comparison to Non‐Hispanic Caucasian patients. We did not identify significant differences in surgical management, perioperative or long term outcomes between these cohorts. Our findings suggest that high volume, quaternary medical centers may reduce inequalities in access to care for patients from ethnic minorities.
MP20: Imaging and Thermal Ablation: Prostate
Transperineal Mr/ultrasound Fusion Guided Biopsy in Patients with Abdominoperineal Resection
G Krings, G Adans‐Dester, M Di Gregorio, F Lorge, L Tosco, J Van Damme
Department of Urology ‐ CHU UCL Namur
Introduction & Objective: In patients with clinical suspicion of prostate cancer,transperineal(TP) prostate biopsy approach is currently recommended by international guidelines due to lower risk of infectious complications compared to the transrectal(TR) approach. Management of patients who have undergone an abdominoperineal resection(APR) is challenging for urologists,because of the impossibility to perform a DRE and a TR prostate US imaging, due to the absence of anal canal. We describe a technique using an end‐fire 3D TR probe to acquire prostate images transperineally, in order to perform a MR/US fusion‐guided prostate biopsy in patients with no anus. We present the feasibility of the technique and the results of this initial series of 5 patients with APR who had an abnormal mpMRI of the prostate,performed for an elevated PSA.
Methods: A 3D Multimodal cartographer (TRINITY, KOELIS, Meylan, France) with a 3D end‐fire TR probe was used to obtain an US 3D volumetric acquisition of the prostate. A freehand positioning of the probe with a 45° angulation and a mild pressure on the perineum ensured good visibility of the prostate. It was contoured on the MRI and US images using the TRINITY PROMAP tool. Target lesions were indicated ont the MRI prostatic volume. Elastic fusion was finally obtained. Free‐hand TP biopsies with an 18G biopsy needle were performed,using the OBT(organ‐based tracking) and virtual biopsies to guide the needle insertion. All biopsy cores were processed separately and sent for pathological evaluation.
Results: All 5 patients were discharged on the same day and no short or long term postoperative complications occurred. The fusion procedure required some technical and habit adaptations,mainly because of the poorer image quality acquired from the prostatic apex,through the perineal skin. Though,the quality of obtained images through TP US was sufficient for a satisfying guidance and permitted OBT during the procedure. The quality was also indirectly controlled by the congruence of the prostatic volumes between US and MRI volumes. A volume difference of less than 5% was obtained in all patients. All biopsy cores revealed prostatic tissue. Pathological results showed 4 out of 5 patients with prostate cancer. Patients characteristics and pathology results are shown in Table 1.
Conclusions: MR transperineal US fusion‐guided prostate biopsies is a feasible, safe and reproductible procedure allowing men without anus to benefit of prostate MRI‐targeted biopsy. This procedure need further investigations to be validated.
Transurethral Vapor Ablation (TUVA) of Intermediate Risk Localized Prostate Cancer (PCa)
CA Warlick, R Levin, CM Dixon
University of Minnesota
Introduction & Objective: Definitive treatment of intermediate risk PCa may include side effects that can impact quality of life (QOL). TUVA utilizes thermal energy in water vapor to ablate prostate tissue and is currently used to treat BPH (Rezūm, Boston Scientific). We report 6 and 12 month results of a prospective, multicenter, safety study of TUVA for hemi‐ablation of prostate tissue with an investigational device in patients with intermediate risk PCa.
Methods: Men with biopsy confirmed unilateral, Grade Group 2 PCa, prostates 20‐80 cc, and PSA ≤15 ng/mL were enrolled. Water vapor was delivered to both the peripheral and transition zones of the prostate under cystoscopic and transrectal ultrasound (TRUS) guidance to complete a hemiablation. Multi‐parametric magnetic resonance imaging (mpMRI) was completed 7 days post‐treatment to assess ablation extent, and at 6 months to guide MRI/TRUS fusion surveillance biopsy. Validated questionnaires at 90 days, 6 and 12 months post‐treatment evaluated subject's urinary, sexual and bowel function, bother, and QOL. Cystoscopy, mpMRIs, and PSA were repeated at 12 months. Adverse events were assessed via Common Terminology Criteria for Adverse Events (CTCAE).
Results: 15 subjects, aged 49‐78, completed a single TUVA treatment targeting cancer in all regions of the prostate. There were no serious adverse events (primary outcome), and 14 AEs all <CTCAE grade 2 attributed to the procedure included urinary retention (n = 4), and erectile and ejaculatory dysfunction (1 each). At 7 days, mpMRIs revealed complete ablation of 14 of 17 (82%) MRI visible lesions. Biopsy at 6 months showed no Grade Group 2 PCa on the treated side in 13 of 15 (87%) subjects and no cancer on the treated side in 10 of 15 (67%) men. Median prostate size was reduced by 41% and PSA by 58% at 6 months (n = 15), and by 53% (n = 8) and 63% (n = 7), respectively at 12 months. QOL measures improved or remained stable at 6 months after TUVA in a majority of men.
Conclusions: This feasibility study supports initial safety of TUVA for ablation of prostate tissue in men with intermediate risk PCa. Preliminary results suggest encouraging cancer management rates with limited impact on QOL. Larger studies are warranted to further assess the benefit‐risk profile of TUVA.
Validation of Prostate Specific Antigen Doubling Time Kinetics Following Radical Prostatectomy to Guide Active Observation and Intervention
E Huang, L Huynh, A Gordon, R Chandhoke, B Morales, D Skarecky, J Tran, T Ahlering
University of California, Irvine
Introduction & Objective: Biochemical recurrence (BCR) after radical prostatectomy (RP) does not predict progression or prostate cancer specific mortality (PCSM). We previously established that a significant number of men with BCR have non‐lethal BCR without treatments of radiation (RT) and/or androgen deprivation therapy (ADT). This study validates the use of DT kinetics to direct active observation (AO) and intervention.
Methods: We conducted a retrospective cohort analysis on 1864 men undergoing RP between June 2002 and September 2019. BCR (PSA >0.2ng/dl, x2) patients were treated (RT and/or ADT) versus observation with DT kinetics. Our main outcome was no treatment in multivariate regression models for no treatment via ROC analysis. Secondary outcomes were PCSM via Kaplan‐Meier analysis.
Results: 407/1864 (21.8%) men experienced BCR (PSA >0.2 ng/dl, x2), with median follow‐up of 7.6 years (IQR 3.3‐11.9). There was no significant difference between treated and untreated patients in average age (63.7 ± 7.3 yrs) and follow‐up time (7.6 ± 4.3 yrs).
In multivariable analysis, DT >12 months (OR: 8.93, 95%CI: 4.53,17.6) and increasing DT (OR: 5.49, 95%CI: 2.81,10.71) were significant predictors for continued observation without treatment (p < 0.001), while pGGG, p‐stage, age, and preoperative PSA were not (Table 1). This model was an excellent predictor for continued no treatment (AUC = 0.83). No patients with DT >12 months and increasing DT experienced PCSM.
Conclusions: One third of patients with BCR were observed without RT and/or ADT, with 0% PCSM at median 7.6 years follow‐up. DT >12 months and the novel DT measure of increasing DT were excellent predictors of no need for treatment. We introduce this PSA kinetics model as a new method for guiding need and/or no need for treatment intervention.
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What Are We Missing in PI‐RADS 1 and 2 Prostate MRI?
L Rodriguez, RI Carey, MD PhD, X Chen, MD PhD, V Bird, MD
National Med. Assoc. and Research Group
Introduction & Objective: Data for PIRADS 1‐2 classification is limited in the literature. We aim to examine the effectiveness of diagnosing prostate cancer in PIRADS 1 and 2 mpMRI using BK/MIMs software to process, trace, identify, and biopsy suspicious lesions.
Methods: A retrospectively study at our institution from March 2019 and March 2022 included a cohort of patients who underwent MRI‐US guided fusion biopsies and standard sextant biopsies of the prostate. We selected patients with PIRADS designations 1 and 2. Age, PSA, PSA density, and AUA symptom scores (AUASS) were included in the analysis. All MRIs were designated with a PIRADS score by a board‐certified radiologist. Processing, tracing, and identification of suspicious prostatic lesions were performed by a board‐certified urologist using rigid registration software (MIMS 6.9 version on BK 3000 compatible hardware). T‐test statistical analysis was performed using Microsoft Excel V16.59.
Results: Of the 172 prostate biopsies in 157 patients, 24% had PIRADS 1‐2 designation. The mean age, PSA, PSA densities, and AUASS in patients with no cancer vs cancer in pathology were 63 vs 67 years old (p = 0.15); 4.6 vs 6.5 (p = 0.19); 0.10 vs 0.63 (p = 0.19); and 11 vs 8.24 (p = 0.76) In the PIRADS 1‐2 group, 95% were biopsy naïve patients and 5% had previously undergone biopsies with negative results at another facility. The cancer overall detection rate was 61.9%. Clinically significant prostate cancer was found in 24%. All nonbiopsy naïve patients were found to have prostate cancer. In this latter group, 50% of cancers were found on fusion cores; 26.9% were found in the same area as fusion cores (missed due to registration error) and 23.1% of cancers were found in areas not associated with fusion traced lesions.
Conclusions: In this population, we found that 50% of patients had identifiable lesions which were proven to be prostate cancer, with 24% of these lesions being csPCA. These findings suggest that urologists should continue developing skills in assessing possible lesions in mpMRI to identify possible cancers that may not fit the strict criteria for PIRADS classification. These findings may have implications when considering treatment options, including focal therapy.
Utility of Pre‐operative Positron Emission Tomography/computed Tomography in the High‐risk Prostate Cancer Patient
JC Jackson, DF Roadman, L Anderson, S Vourganti, CL Coogan, A Stephenson
Rush University Medical Center ‐ Department of Urology
Introduction & Objective: Positron emission tomography/computed tomography (PET/CT) has been increasingly used in patients with high‐risk and very high‐risk prostate cancer (HRCaP, VHRCaP) to assess for distant metastatic disease. The aim of this study was to assess the incidence of recurrent and/or metastatic disease in HRCaP and VHRCaP patients after curative loco‐reginal therapy.
Methods: A retrospective review was performed at a single institution for all patients with HRCaP or VHRCaP who underwent a robot‐assisted laparoscopic radical prostatectomy (RALP) between 1/2017 to 1/2021. HRCaP and VHRCaP were classified as having a Gleason score ≥8, PSA >15 ng/mL, or ≥ clinical stage T3 (cT3). Biochemical recurrence was categorized as a post‐operative PSA level >0.2 ng/mL or a post‐operative rise in PSA necessitating a secondary therapy to reach nadir. Descriptive analysis were then performed.
Results: A total of 66 patients met inclusion criteria. Average age at the time of RALP was 63.8 years old, while average pre‐operative PSA was 23.7. Average grade group (GG) on prostate biopsy was 3.3 with a mean of 13.9 cores taken and 6.9 cores being positive for disease. 55 patients (84.6%) underwent pre‐operative multiparametric magnetic resonance imaging of the prostate (mpMRI). Imaging displayed signs of extracapsular extension (ECE) in 11 patients (16.9%), seminal vesicle invasion in 5 patients (7.7%), and lymph node involvement in 5 patients (7.7%). Pre‐operative androgen deprivation therapy (ADT) was given to 7 patients (10.8%). Surgical pathology demonstrated an average GG of 3.6 with one specimen showing intraductal pathology and an additional three with cribriform changes. Positive margins were seen in 24 patients (36.9%), SVI in 25 patients (38.5%), and ECE in 41 patients (63.1%). An average of 8.8 lymph nodes were extracted per case with 9 cases positive for involvement (13.8%). Seven patients underwent post‐operative PET/CT with two showing positive local disease. Average post‐operative PSA nadir was 0.9 ng/mL. Evidence of biochemical recurrence was found in 24 patients (36.9%).
Conclusions: Patients with advanced prostate cancer are at an increased risk of extracapsular spread and subsequent distant metastasis; however, patients in this risk group were able to achieve low post‐operative PSA nadirs and often had no significant findings on post‐RALP PET/CT. Our study provides evidence that HRCaP and VHRCaP remains a predominantly local regional disease and the value of routine pre‐operative PET/CT imaging is unlikely to be of value. In our opinion, these patients should not be denied loco‐regional treatment by either RALP or local radiation therapy.
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Use of the Updated Uronav MR/US Fusion Ablation System During Nanoparticle Thermal Ablation of Prostate Cancer Decreases Treatment Duration
T Benjamin, T Williams, M Kuster, G Hautvast, J Schwartz, C Knauer, M Schwartz, A Rastinehad
The Smith Institute of Urology at Northwell Health
Introduction & Objective: As prostate cancer remains the second leading cause of death in men, much debate remains regarding its optimal treatment. Departing from the traditional strategies of prostatectomy and radiotherapy, evidence has shown focal therapy to be efficacious. AuroLase Therapy is a form of focal ablation in which gold nanoparticles are infused and preferentially accumulate within the tumor, followed by near infrared light excitation causing ultra‐focal tumor ablation.
The initial approach utilized a commercially available UroNav 3.0 fusion biopsy platform for guidance. Treatment planning was performed using cylindrical models for ablation and measuring via ultrasound guidance. Limitations included a lack of visual representation in the treatment field and underestimation of total energy deposition. To overcome these challenges, a novel protype of UroNav 4.0 magnetic resonance/ultrasound (MR/US) fusion ablation system was developed to fuse pre‐biopsy MR images with real‐time US images for 3D treatment planning, ablation zone predictive modeling, and navigation.
We aim to demonstrate that UroNav system 4.0 leads to decreased treatment time compared to UroNav 3.0 which did not have software support for focal therapy.
Methods: This was a retrospective study evaluating patients who participated in the IRB‐approved study of AuroLase Nanoparticle Ablation Therapy for low‐to‐intermediate‐risk prostate cancer (NCT02680535). The UroNav MR/US 3.0 fusion system was used until UroNav 4.0 was developed. Descriptive statistics were performed using SPSS.
Results: We included 21 patients, 10 treated with UroNav 3.0, and 11 treated with UroNav 4.0 (Table 1). Cases that utilized UroNav 3.0 had a higher number of focal laser treatments (p = 0.0041) while controlling for tumor volume treated. Additionally, patients treated with UroNav 4.0 had a shorter duration of laser treatment and a shorter time from initial US sweep to treatment conclusion (p = 0.0318 and p = 0.0485, respectively).
Conclusions: Focal therapy for prostate cancer remains an important treatment strategy. Using the UroNav 4.0 MR/US system in conjunction with nanoparticle focal thermal ablation of prostate cancer leads to decreased laser treatment time as well overall treatment duration.
Initial Outcomes of High Intensity Focused Ultrasound Focal Hemigland Ablation for Prostate Cancer
V Woranisarakul, M Ho, M Carpen, M Galocy, A Shalhav
Mahidol University
Introduction & Objective: High‐intensity focused ultrasound focal therapy (HIFUFT) is an evolving option for men with localized prostate cancer in the emerging treatment space between active surveillance and whole gland therapy. Although many have reported good oncologic control, excellent functional outcomes and minimal morbidity in selected patients undergoing this procedure, it remains outside the standard of care. Herein, we report the results of >2‐year experience with prostate HIFUFT at the University of Chicago.
Methods: From May 2019, eligible patients who elected HIFUFT were prospectively enrolled. HIFUFT was preferentially offered to patients who fit our protocol, defined as: prostate size <50 cm3, disease in the peripheral zone and not anterior to the urethra, all grade group (GG) ≥2 biopsies localized to one side of the gland with no cores > GG 3, and presence of cancer in <50% of biopsy cores. Using the Focal One® (EDAP TMS) platform, we employed cognitive MRI fusion and ultrasound targeting to focally ablate lesions. We preferentially spared the urethra and ipsilateral neurovascular bundle. During follow‐up, patients underwent PSA monitoring with mandatory prostate MRI and fusion biopsy 6‐12 months following HIFUFT.
Results: 71 HIFU procedures were performed on 65 patients, 48 of whom were on‐protocol. The median duration of follow‐up was 362 days. 15 patients (23%) had Clavien‐Dindo grade 1‐2 complications and 1 (2%) had a grade 3 complication. We observed no significant decline in IPSS or SHIM scores at 12 months follow‐up. There was a mean 64% decline in PSA at 12 months. 44 patients underwent post‐HIFUFT MRI. All in‐field recurrences and 69% of out‐of‐field recurrences were detected. 29 patients underwent post‐HIFUFT biopsy, of whom 16 (55%) had ≥ GG2 cancer. This was detected in‐field in 10 (34%) patients, out‐of‐field in 4 (14%), and both in‐ and out‐ of field in 2 (7%). There was no difference in recurrence rate between patients on‐ or off‐protocol. 6 (9%) patients had repeat HIFUFT procedures, and 3 (5%) had a RALP.
Conclusions: Short‐term results of HIFU hemigland ablation revealed excellent functional outcomes and few adverse events. Longer term follow‐up and a larger cohort will allow for further analysis in the future.
Reliability of a Combination of Targeted and Systematic Prostate Biopsies in Patients with Mri‐visible Lesions: Concordance Between Biparametric MRI, Combined Biopsies and Prostatectomy Pathology
T Noh, S Yun, T Park, C Hyun, H Kang, S Kim, J Shim, S Kang, S Kang
Introduction & Objective: We aimed to confirm the reliability of a combination of targeted and systematic prostate biopsies in patients with MRI‐visible lesions compared to radical robot‐assisted prostatectomy pahtology.
Methods: We retrospectively analyzed the records of 80 men who underwent bi‐parametric magnetic resolution imaging‐ultrasound fusion targeted and systematic biopsies (bpMRI‐US transperineal FTSB) transperineally with region of interest (ROI) and subsequent robot‐assisted radical prostatectomy. Changes in the grade group determined by MRI and biopsy versus surgical specimens were analyzed.
Results: 35 patients with insignificant prostate cancer and 45 with significant cancer were diagnosed using bpMRI‐US transperineal FTSB. Among those with insignificant PCa, 25 of 35 (71.4%) were upgraded to significant PCa in prostatectomy specimens: 9/12 (75.0%) with Prostate Imaging Reporting and Data System (PI‐RADS) 3, 12/16 (75.0%) with PI‐RADS 4, and 4/7 (57.1%) with PI‐RADS 5. In the PI‐RADS 3 group, the upgraded group showed higher prostate specific antigen (PSA) and PSA density (PSAD) than the concordance group; PSA 8.34(2.73) vs. 5.31(2.46) (p = 0.035) and PSAD 0.29(0.11) vs. 0.18(0.09) (p = 0.025).
Conclusions: The results of prostate biopsy and prostatectomy specimens were inconsistent and underestimated in patients with MRI‐visible lesions. Therefore, for precise and individualized treatment strategies for PCa with MRI‐visible lesions (PI‐RADS ≥3), careful interpretation of biopsy result is required, considering the high possibility of significant PCa, even if it is insignificant PCa.
Functional Outcomes of Focal Salvage MRI Fusion Guided HIFU for Localized Radiation Recurrent Prostate Cancer
A Kasraeian, M Alcantara, K Mola Alcantara, S Stephen
Kasraeian Urology
Introduction & Objective: Only two percent of men in the United States with localized radiation recurrence are offered local salvage therapy, often due to the high morbidity associated with whole gland salvage therapy for their recurrent prostate cancer. If, however, the recurrent tumor can be identified with advanced diagnostic techniques, such as MRI/US Fusion biopsy, and focally targeted, treatment morbidity can possibly be reduced. We discuss our experience with Focal Salvage MRI Fusion Guided HIFU with dose escalation (FS‐mfHIFU). Functional outcomes and data were prospectively collected, analyzed, and reported.
Methods: Between December 2015 and October 2019, 14 patients underwent FS‐mfHIFU. Median age was 65 years of age. Gleason Scores ranged from 6 to 10, with one low risk, 7 ik, and 6 h patients undergoing salvage focal therapy. Seven patients underwent focal HIFU of the MRI target with margin, four were treated with hemiablation, and three using a subtotal (urethral sparing) technique.
Results: A Foley catheter was used in all 14 patients who underwent FS‐msHIFU. Mean catheterization time was 7.25 days. Only 2 patients required catheter replacement due to urinary retention (14%). Only 2 (14%) required endoscopic intervention (due to urethral stricture). No rectal fistulae were noted in our series. Twelve of the 14 men treated reported pad free urinary continence (86%).
Functional outcomes included mean serial IPSS measurements of 8.6 (pre‐treatment), 9.78 (3 months), 7.4 (12 months). IIEF measures of mean erectile function demonstrated scores of 11.7 (pre‐treatment), 9.2 (3 months), and 7 (12 months). Additionally, mean PSA was 4 (pre‐treatment), 0.59 (3 months), 0.74 (6 months), and 0.67 (12 months).
Conclusions: With careful selection, advanced diagnostic techniques, and appropriate and honest counseling, focal salvage HIFU can offer men with localized radiation recurrence disease control with better preservation of their urinary and bowel function than whole gland salvage therapies for recurrent prostate cancer.
Early Single‐center Experience with TULSA‐PRO (outside of Clinical Trials): Initial United States Experience
A Kasraeian, M Alcantara, K Mola Alcantara, S Stephen
Kasraeian Urology
Introduction & Objective: Standard of care for the management of intermediate and high‐risk prostate cancer remains radical prostatectomy and radiation therapy. However, both are associated with serious potential side effects including urinary, bowel and erectile dysfunction. Transurethral Ultrasound Ablation of the Prostate (TULSA‐PRO) is a non‐surgical, non‐radiation therapy that combines real‐time MRI with a robotically‐driven transurethral ultrasound, and closed‐loop temperature feedback control, to facilitate a customizable, individualized, predictable and reproducible ablation of a surgeon‐defined prostate volume. Additionally, TULSA PRO can be used to treat men with prostate cancer and larger prostate size.
We report our initial US experience with TULSA‐PRO for the management of localized, organ‐confined prostate cancer.
Methods: Data was prospectively collected for twenty‐six men who underwent TULSA‐PRO for the management of their organ‐confined prostate cancer (PCa) between January 2020 and July 2020 at a single center. Twenty‐four men underwent whole gland ablation of their prostate, while 2 were treated with sub‐total ablation. Pre‐operative and early post‐operative oncological and functional outcomes (at 3 months) were prospectively collected and analyzed.
Results: Twenty‐six men underwent TULSA‐PRO between January and July of 2020. Average operative time was 94.5 minutes. Average age, prostate size and pre‐operative PSA were 63 years, 37.5 cc and 8.56 ng/mL, respectively.
The majority had a clinical stage of T1c (n = 14, 53.8%), followed by T2b (n = 8, 30.8%), T3a (n = 2, 7.7%), and T2a and T3b (n = 1 each, 3.8%). Most had intermediate risk PCa (GG2, n = 13 (50%), GG3, n = 6 (27%)), with an equal number with GG1 and GG4 disease (n = 3 each, 11.5%). Pre‐ and post‐operative PSA, IPSS (QOL) and IEF5 scores were collected (Table 1).
Of the 26, 23 had an indwelling Foley post‐operatively (average 12.6 days), while 3 were managed with suprapubic catheters (average 26.7 days). Of the latter, two had pre‐operative TURP. Early in the experience, 7 patients failed voiding trial requiring re‐catheterization.
Conclusions: TULSA‐PRO is an innovative technology that allows individualized, predictable and reproducible, non‐surgical and non‐radiation prostate ablation. We report the first experience with TULSA‐PRO in the United States (outside of clinical trials) with early outcomes showing it as a safe and effective alternative for men with organ‐confined prostate cancer, including those with larger prostate size. More studies and longer follow‐up are necessary to further assess intermediate to long‐term outcomes.
The Diagnostic Accuracy and Validity of the Vesical Imaging‐reporting and Data System in Predicting Muscle Invasion by Bladder Cancer: A Comparison Study of Biparametric and Multiparametric Mri
T Noh, S YUN, T PARK, C Hyun, H Kang, S Kim, J Shim, S Kang, S Kang
Introduction & Objective: This study aimed to compare the diagnostic accuracy and validity of biparametric magnetic resonance imaging (bpMRI) to those of multiparametric MRI (mpMRI) based on the Vesicle Imaging‐Reporting and Data System (VI‐RADS) in predicting muscle invasion by bladder cancer (BCa)
Methods: We retrospectively analyzed 357 patients with an initial diagnosis of BCa who underwent preoperative MRI: mpMRI (257) vs. bpMRI (100). One urogenitalradiologist evaluated all bpMRIs and mpMRIs using the VI‐RADS. The diagnostic validity of the VI‐RADS for predicting muscle invasion by BCa was analyzed based on the histopathology of the first and/or second transurethral resection of bladder tumors and radical cystectomy.
Results: Both groups showed optimal performance with a VI‐RADS ≥3. The bpMRI showed comparable diagnostic performance with that of mpMRI except for lower specificity (sensitivity 83.3% and 86.8% (p = 0.405), specificity 82.4% and 93.3% [p = 0.048], and the areas under the curve (AUC) 0.903 and 0.935 (p = 0.512) for bpMRI and mpMRI, respectively).
Conclusions: The current comparative study between bpMRI and mpMRI suggests that bpMRI shows comparable diagnostic performance and could be an alternative option to predict muscle invasion by BCa.
Targeted MRI/US Fusion and Standard TRUS Prostate Biopsy: 563 Patients ‐ Relationship Between PIRADS Score and Prostate Cancer Detection Rate: A Single Urologist's Experience
A Kasraeian, M Alcantara, K Mola Alcantara, J Yellin, A Brochert, J Cesaretti, A Kasraeian
Kasraeian Urology
Introduction & Objective: Multi‐parametric MRI (mpMRI) and targeted MRI/Ultrasound fusion prostate biopsy (tMRI/US FPB) are important tools in the diagnosis of prostate cancer (PCa). We report our experience with a total of 563 patients. Specifically, we report the relationship between PIRADS score and overall positive biopsy rate as well as detection rate of Gleason (G) 7 or higher PCa in men.
Methods: Data was prospectively collected and analyzed on 563 men undergoing tMRI/US FPB and TRUS standard biopsy between January 2017 and December 2020. In all patients, mpMRI was interpreted by a single radiologist using the PIRADS scoring system. 3D rendering of regions of interest was performed prior to tMRI/US FPB performed by a single urologist using the Invivo UroNav System. Concurrent standard 14 core biopsy (14Bx) was performed in all cases. Data was Prospectively collected and analyzed.
Results: Prostate biopsy was performed on 563 men between January 2017 and December 2020 of whom 62% (350/563) were diagnosed with PCa. Of men diagnosed, 63% (220/350) were diagnosed with G7 or higher disease. Among PIRADS 3 Fusion biopsies, the positive rate for PCa was 68% (127/178) with 46% (82/178) being G7 or higher disease (15% (26/178) G8‐9 PCa). Additionally, among PIRADS 4 Fusion biopsies, the positive rate for PCa was 95% (38/40) with 93% (37/40) being Gleason 7 or higher disease (38% (15/40) G8‐9 PCa). Lastly, among PIRADS 5 Fusions prostate biopsies 93% (14/15) were positive for a PCa with all but one being a G7 PCa or higher 87% (13/15) and 67% (10/15) being G8‐9 PCa.
The overall positive rate for MRI‐US Fusion prostate biopsies was found to be 74% (198/268). G7 or higher disease was found in 53% of those men (with 20% being G8‐9 PCa). The TRUS standard prostate biopsy positive rate was 51% (151/295) with 18% being G7 or higher disease (3.7%, G8‐9 PCa).
Conclusions: tMRI/US FPB is an important technology that increases the diagnostic yield of prostate biopsy when combined with 14Bx. In our series, the increased positive biopsy rate with combined tMRI/US FPB‐14Bx was statistically significant when compared to 14Bx alone. In addition, tMRI/US FPB‐14Bx found more Gleason 7 or higher PCa. Lastly, PIRADS 4 and 5 lesions on mpMRI were associated with higher rate of both overall and Gleason >7 PCA detection.
Racial Disparity in Prostate Cancer Diagnosis: A Comparison of Prostate Biopsy Results in African American and White Men Using an Mri‐based Biopsy Strategy
A Kasraeian, M Alcantara, K Mola Alcantara, J Cesaretti, A Kasraeian
Kasraeian Urology
Introduction & Objective: African American (AA) men in the United States have an increased burden of morbidity and mortality from prostate cancer (PCa). The roles of factors related to both racial disparities and intrinsic biological traits remain to be determined. We quarried our prospective database of standard and MRI fusion biopsies (tMRI/US FPB) to determine if any pre‐biopsy characteristics predicted adverse tumor pathology.
Methods: Between January 2017 and December 2020, 560 men underwent prostate biopsy (PBx) using an MRI based algorithm. Men with negative MRI underwent standard PBx (n = 293), while those with lesion on mpMRI underwent tMRI/US FPB (n = 267). All patients underwent mpMRI of the prostate, interpreted by a single radiologist using the PIRADS scoring system. 3D rendering of the regions of interest was performed by the radiologist prior to tMRI/US FPB performed by a single urologist using the Invivo UroNav Fusion Biopsy System. A standard 14 core PBx was performed at the same time in all tMRI/US FPB cases. Prospective data was collected and analyzed.
Results: Of 560 men who underwent standard and tMRI/US FP with 14Bx (tMRI/US FP‐14Bx), 422 presented with rise in PSA and 182 had a suspicious digital rectal exam. 256/418 (61%) of White men and 62/92 (67%) of AA men were found to have PCa (p = 0.29). 153/418 (37%) of White men and 46/92 (50%) of AA men had a Gleason score of 7‐10 (p = 0.019). Age, DRE status, PIRADS score and the incidence of Gleason 6 PCa were not found to be significantly different by race. 112/415 (27%) of White men and 10/91 (11%) of AA men had a PSA upon presentation of 0‐3.9 ng/ml (p = 0.001). The PSA levels of 4.0‐9.9 ng/ml and PSA >10 ng/ml at presentation were not significantly different. Of the 50/560 men who identify as not White and not Black no significant difference was found for any tested factor but interestingly 12/50 (24%) presented with a PSA between 0‐3.9 ng/ml (p = 0.053 NS) which was very close to the effect seen relative to White men.
Conclusions: In this dataset, it appears that AA men present with a higher PSA than White men. It is likely that this is related to disparities in access to care rather than biological intrinsic factors. We did observe a higher incidence of Gleason 7‐10 which one would expect in a cohort of patients who presented for biopsy in the community with a significantly higher PSA presentation. Continuing education of primary care providers regarding the importance of PSA testing in the AA community should be emphasized by both the urological and primary care professional medical societies.
Delay of Systemic Treatment Following Salvage Lymph Node and Pelvic Mass Dissection Identified by 68ga‐psma PET/CT with Reference to Lymph Node Removal at Time of Radical Prostatectomy
W Zhang, K Liang, E Huang, L Huynh, J Tran, T Ahlering
University of California, Irvine
Introduction & Objective: Previous publications suggest a lymph node dissection at the time of RP has an NNT of 200 that may decrease adverse oncologic events by 10%. 68 Ga‐PSMA PET/CT scan can identify BCR patients who may benefit from local therapy post‐RP, specifically lymph nodes or pelvic masses. This study assesses relative efficacy of robot‐assisted salvage pelvic lymph node dissection (sPLND) and salvage pelvic mass resection (sPMR) for patients with locally recurrent disease identified by PSMA PET/CT.
Methods: From September 2016 to June 2021, 80 patients underwent PSMA PET/CT imaging following post‐RP BCR (PSA values >0.2 ng/mL, x2). Of the positive findings (n = 61), patients underwent sPLND (n = 18) or sPMR (n = 10) based on recurrence location. Primary outcomes were efficacy of salvage surgery, assessed as failure (ADT and/or RT <6 mos), treatment delay, and success.
Results: Age and PSA was 65.9 yrs ±12.4 and 2.5 ± 2.11 ng/mL at salvage. Follow‐up is 15.1 yrs ±10.2 post‐RP and 1.26 yrs ±0.85 post‐salvage. Following surgery, PSA was 1.37 ± 2.17 ng/mL with 47% ± 54.9 percent decrease in PSA (Table 1). Of the 28 salvage procedures, 33% (6/18) sPLND versus 20% (2/10) sPMR patients failed (p = 0.47). 39% (7/28) sPLND versus 20% (2/10) sPMR patients delayed intervention by 18.2 mos (p = 0.31). 28% (5/18) sPLND versus 60% (6/10) sPMR patients did not require treatment (p = 0.10) at mean follow‐up of 11.5 (0.92‐34.1) mos post‐salvage.
Conclusions: PSMA PET/CT improved post‐RP recurrence location identification and selection for salvage procedures. A therapeutic benefit from salvage resection was seen as delayed treatment in 31% (9/28) and treatment avoidance in 38% (11/28) patients thus far. Compared to LND at time of RP, we demonstrated a therapeutic benefit in 28% of 18 salvage PLNDs.
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Structured Approach to Resolving Discordance Between PI‐RADS v2.1 Score and Targeted Prostate Biopsy Results: An Opportunity for Quality Improvement
D Seguier, R Arcot, S Sekar, S Kotamarti, Z Michael, M Krischak, W Foo, J Huang, TJ Polascik, MD, RT Gupta
Introduction & Objective: Prostate multiparametric magnetic resonance imaging (mpMRI) can identify lesions within the prostate with characteristics identified in Prostate Imaging Reporting and Data System (PI‐RADS) v2.1 associated with clinically significant prostate cancer (csPCa) or Gleason grade group (GGG) > 2 at biopsy. Our objective was to assess concordance (PI‐RADS 5 lesions with csPCa) of PI‐RADS v2/2.1 with targeted biopsy results and to examine causes of discordance (PI‐RADS 5 lesions without csPCa) with aim to provide a structured approach to resolving discordances and develop quality improvement protocols.
Methods: A retrospective study of 392 patients who underwent mpMRI at 3 Tesla followed by fusion biopsy. PI‐RADS v2/2.1 scores were assigned to lesions identified on mpMRI and compared to biopsy results expressed as GGG. Positive predictive value (PPV) of PI‐RADS v2/2.1 was calculated for all prostate cancer and csPCa. Discordant cases were re‐reviewed by a radiologist with expertise in prostate mpMRI.
Results: A total of 521 lesions were identified. Of these, 121/521 (23.2%), 310/524 (59.5%), and 90/521 (17.3%) were PI‐RADS 5, 4, and 3, respectively. PPV of PI‐RADS 5, 4, and 3 for all PCa and csPCa was 0.80, 0.55, 0.24 and 0.63, 0.33, and 0.09, respectively. We found 45 cases of discordant biopsy results for PI‐RADS 5 lesions. Of these, 27 were deemed “true” discordances or unresolved discordances where imaging re‐review confirm PI‐RADS appropriateness, while 18 were deemed “false” or resolved discordances due to downgrading of PI‐RADS scores based on imaging re‐review. Adjusting for resolved discordances on re‐review, the PPV of PI‐RADS 5 lesions for csPCa was deemed to be 0.74.
Conclusions: Although PIRADS 5 lesions are considered high risk for csPCa, a diagnostic dilemma occurs when targeted biopsy returns without csPCa. In our cohort, a proportion of discordances were resolved by mpMRI re‐review. We recommend a structured approach to discordance resolution using multi‐disciplinary re‐review of PI‐RADS 5 cases and needle tracking of archived biopsy images. Further work is needed to determine the value of re‐biopsy in cases of “unresolved” discordance and to develop robust QI systems for prostate MRI.
Initial Longitudinal Outcomes Following Implementation of Baseline Serum Prostate Specific Antigen Risk Stratification of Men in Their Forties Screening for Prostate Cancer
Z Michael, S Kotamarti, R Arcot, K Morris, D Seguier, A Shah, J Anderson, AJ Armstrong, RT Gupta, S Patierno, N Barrett, DJ George, GM Preminger, JW Moul, K Oeffinger, K Shah, TJ Polascik, MD
Duke University
Introduction & Objective: Prostate cancer (PCa) screening can be problematic due to potential over‐diagnosis/over‐treatment of indolent cancers. A baseline evaluation of prostate‐specific antigen (PSA) in a man's forties can assess risk for lethal prostate cancer (PCa) at a time in life when the PSA level should be low with few confounders. To address the need to optimize practices to better risk‐stratify patients, we examined initial longitudinal outcomes of mid‐life men with an elevated baseline prostate specific antigen (PSA) screened within a system‐wide network.
Methods: We assessed Duke Primary Care Network patients ages 40‐49 with a PSA measured following implementation of an electronic health record (EHR) screening algorithm from 2/2/2017‐2/21/2018. Outcomes of men with PSA > 1.5 ng/ml were evaluated through 7/2021. Statistical analyses compared PSAs between groups and identified factors associated with PCa detection. Clinically significant PCa (csPCa) was defined as Gleason Grade Group (GGG) > 2 or GGG1 with PSA > 10 ng/ml.
Results: The study cohort contained 564 patients, with 330 (58.5%) referred to urology for elevated PSA (Table 1). Forty‐nine (8.7%) underwent biopsy; of these, 20 (40.8%) returned with PCa. Eleven (2.0% of total cohort and 55% of PCa diagnoses) had csPCa. Referral timing and PSA were significantly associated with all PCa at biopsy on multivariable analysis. Referred patients had higher mean PSAs (2.97 vs 1.98, p = 0.001, Table 2).
Conclusions: Early PSA evaluation revealed PCa in a small, important percentage of mid‐life men, providing insight into baseline PSA measurement in men in their forties to provide early risk stratification and detection of csPCa in patients with otherwise extended life expectancy. Further follow‐up is needed to determine the prognostic significance of such mid‐life screening and optimize primary care physician‐urologist coordination.
Oncological and Functional Outcomes of Men Undergoing Primary Whole Gland Cryoablation of the Prostate: A Twenty‐year Experience
W Tan, S Kotamarti, E Chen, R Mahle, R Arcot, A Chang, A Ayala, Z Michael, D Seguier, TJ Polascik, MD
Introduction & Objective: We aim to report the oncological and functional outcomes in men with localized prostate cancer (PCa) who were treated with primary whole gland cryoablation (WGC) of the prostate.
Methods: We retrospectively reviewed our cryosurgery database between January 2002 and September 2019 for men who were treated with WGC of the prostate at our tertiary care center. Primary outcome included biochemical recurrence (BCR). Secondary outcomes included metastasis‐free survival (MFS) and adverse events. Kaplan‐Meier and multivariable Cox regression analyses were performed using a landmark starting at 3‐months of follow‐up.
Results: A total of 260 men were included in the study. Men having had prior treatment for PCa with another modality were excluded. Median follow‐up was 107 months (IQR: 68.3 – 132.5 months) (Table 1). AUA symptoms score and bother index were unchanged following cryoablation. Incontinence defined as requiring any protective pads only occurred in five patients (2%). No patient developed a fistula. Clavien‐Dindo >2 adverse events occurred in six (2.3%) patients (Table 2). BCR‐free survival and MFS at nine years was 87% and 97%, respectively. A higher D'Amico classification (p < 0.01), higher grade group score (p = 0.03) and higher pre‐cryoablation prostate specific antigen (PSA) (p < 0.01) were associated with worse BCR (Table 3). Patients who had high risk disease on D'Amico classification (p < 0.01), grade group 4 and 5 (p < 0.01) had a lower MFS.
Conclusions: WGC of the prostate achieves excellent oncological and functional outcomes in select men with localized PCa.
Video Session
VID1: Laparoscopy/Robotics: Non Prostate
Robot Assisted Salvage Partial Nephrectomy for Cryoablation Failure: Single Center Experience with Case Demonstration
S Saini, A Hemal
Wake Forest University of Health Sciences, Winston‐Salem, NC, USA
Introduction & Objective: Salvage partial nephrectomy for cryoablation failure is technically challenging. Variables like approach to the prior cryoablation, repeat cryoablation for failures and complexity of the renal lesion itself (based on nephrometry score), significantly adds to the challenges. Here in, we are presenting our experience with robot assisted salvage partial nephrectomy for cryoablation failures with video demonstrating a case with complex renal mass.
Methods: After reviewing our prospectively maintained database, between January 2013 and April 2022, we found 10 cases with local recurrences after initial cryoablation who underwent robot assisted salvage partial nephrectomy. Patient presented in this video is a 83 year old, diabetic and hypertensive women, who had received retro‐peritoneoscopic cryoablation for a 2 cm upper polar mass in the left kidney. CT Scan with contrast (Renal Protocol) at 4 years of follow up suggested increase in size and avid enhancement with nephrometry score of 10A.
Results: In this case, warm ischemia time was 25 minutes and blood loss was 50 ml. Despite dense peri‐nephric adhesions, there was no intra‐operative or post‐operative complication and the patient was discharged on post‐operative day 2 of the surgery. Histopathology revealed clear cell renal cell carcinoma with Fuhrman grade 3 and negative margins. In our whole cohort, 3 patients had single kidney, but in none of our patients, cold ischemia was required. The average ischemia time was 24.6 ± 3.8 minutes with median blood loss of 87.5 (30‐1300) ml. None of the patients had positive margins and no recurrences were encountered till the last follow up. Also, no statistically significant difference was noticed between baseline and follow up estimated GFR.
Conclusions: Although challenging, robot assisted salvage partial nephrectomy for cryoablation failure is technically feasible with excellent outcomes. This technique may frequently be employed for recurrent and complex renal masses at expert centers.
A Novel Approach to Targeted Lymphadenectomy
DE Bollinger, K Kiani, M Sawyer, G Lloyd
University of Colorado; VA Eastern Colorado Health Care System
Introduction & Objective: In this case, we highlight a unique approach for targeted lymphadenectomy. This technique leverages features of the robotic surgical platform to assist in the localization of nodal tissue suspected of harboring metastatic disease.
The patient is a 52‐year‐old male with high‐risk prostate cancer, Gleason Group Grade 5(4 + 5), and a PET avid pararectal lymph node identified prior to his initial surgical intervention. Previous attempts to resect the node, including with general surgical guidance during the initial robotic‐assisted prostatectomy, were unsuccessful. Given the pathology, there is a plan for adjuvant radiation therapy. Following a multi‐disciplinary review, it was hypothesized that surgical excision of the node would allow for increased precision and effectiveness of radiation dosing.
Methods: The patient underwent CT‐guided needle localization and injection of the lymph node 24‐hours prior to the procedure. One milliliter of 50/50 indocyanine green and methylene blue were administered by interventional radiology. Intraoperatively, the Firefly integrated fluorescence capability of the da Vinci robotic console was utilized to identify the suspicious nodal tissue. Methylene blue supplemented the visual guidance offered by the robotic platform to confirm proximity to the nodal tissue.
Results: The lymph node was successfully identified and removed. Pathology identified metastatic adenocarcinoma on frozen analysis of the lymph node.
Conclusions: This method of lymphadenectomy proved effective for a difficult‐to‐locate pararectal lymph node. In future utilization, it would be appropriate to use smaller volumes of fluorescence because the amount used during this procedure at times proved overpowering. However, we feel that this is a feasible and reproducible approach. This technique offers exciting potential for subsequent targeted lymphadenectomies.
Overcoming High Nephrometry Score Cases in True Single Port Robotic Partial Nephrectomy
MJ Davis, D Ali, M Ahmed, M Billah
Henry Ford Health System
Introduction & Objective: Currently, some urologists carefully select cases for single‐port partial nephrectomies or opt to use an assistant port in addition to the single operative port. We aim to describe urologic techniques for overcoming high nephrometry score cases in true single port robotic‐assisted partial nephrectomies.
Methods: We compiled pictures and video footage of true single port partial nephrectomy on a renal mass with a Nephrometry score of 10p after consent was obtained. The pictures and video footage were edited and spliced together using Adobe Premiere Pro. Narration and background music were overlaid as well.
Results: We performed a true single port partial nephrectomy on an 80‐year‐old patient with a right mid‐lateral 3.0 cm renal mass with a Nephrometry score 10p. This patient had an insignificant past medical history and a past surgical history of a right inguinal hernia repair over four decades ago. She underwent her partial nephrectomy using the Single Port robot without complication.
Conclusions: This video highlights the feasibility of performing minimally invasive single‐port surgery even with a complex renal tumor. The use of our described techniques can facilitate the completion of more difficult cases utilizing the single port without the need for an assistant port. We now perform all of our cases with a McBurney's point incision to facilitate better exposure of the target anatomy. Furthermore, we recommend the use of adjunct technologies such as ROSI and AirSeal as these may facilitate an easier transition to the single‐port partial nephrectomy.
Multiple Port Robotic Radical Cystectomy and Intracorporeal Neobladder: Modifications to Reduce Operative Time
A McCutchen, M Billah, M Ahmed, F Sheckley, A Saji
Hackensack Meridian School of Medicine
Introduction & Objective: The gold standard treatment for high‐risk or muscle invasive bladder cancer is a radical cystectomy with pelvic lymph node dissection. The multiport robotic cystectomy was presented by Menon in 2003, in effort to improve recovery and decrease patient morbidity. Although this procedure can be time consuming and technically difficult, many versions have emerged over time to further reduce the challenges that commonly become present in practice. We will demonstrate our experience completing the robotic assisted intracorporeal neobladder utilizing a modified Studer (U‐shape) technique to make the procedure faster and simpler.
Methods: From October 2019 to February 2022, we performed a multiport robot assisted cystectomy and created a modified U‐shaped intracorporeal neobladder for 10 patients. We utilized a mobile ileal segment of bowel with shorter length, ranging from 35‐40cm. We used fewer and simpler sutures by incorporating V‐Loc running stitches and created a more spherical reservoir by using off‐centered running stitches. We prospectively collected clinical data and retrospectively analyzed operative and follow up outcomes.
Results: The median follow‐up rate was 8 months (1‐ 26 mos.). The mean operating time, estimated blood loss, and post‐operative length of stay were 250 min (245‐316 min), 100mL (100‐150mL), and 5 days (4‐28d), respectively. There were no intraoperative complications or conversions to an open procedure. There were no early major complications. There was one late major complication consisting of a vesicovaginal fistula that was surgically repaired. At median follow‐up, out of 8 patients, functional outcomes include day continence rate of 62.5% and night continence of 25%. There was no presence of hydronephrosis or signs of increased bladder pressure for all patients.
Conclusions: The multiport neobladder creation can be challenging due to its required technical expertise and long operating time. In addition, there remains little consensus on how to perform this operation most effectively. Our technique results in an efficient, simpler case to improve operation time, while demonstrating patient outcomes that are comparable to those reported in literature, without compromising safety. Our approach is reproducible, allowing others to incorporate it in practice under the appropriate supervision. Further studies that include a larger patient population and longer follow up durations are needed to further confirm these results.
Robotic Partial Nephrectomy for Hilar Renal Tumor at Cho Ray Hospital
Q Chau, M Thai, X Ngo, A Tran, T Tran, L Dinh, T Tran, H Truong, T Hoang, T Nguyen
thanhtuan0131@gmail.com
Introduction & Objective: To evaluate the initial results of robot‐assisted partial nephrectomy in the treatment of kidney hilar tumor.
Methods: A 56‐year‐old woman presented to the hospital because of left flank pain without hematuria or a history of kidney disease. On presentation, her serum creatinine was 0.65 mg/dL and eGFR was 99 ml/min/1.73 m2. According to her renal scintigraphy, Split renal function: 50,9% for left kidney.. The computed tomography of the abdomen revealed the left kidney with a 3 x 3 × 4.1 cm hilar tumor. R. E. N. A. L. nephrometry score was 11PH and preoperative tumor staging was cT1bN0M0 in the left kidney. After discussion, the patient elected a minimally invasive approach to treating her malignancy. During the operation, both artery and vein were clamped using laparoscopic bulldog clamps. Once the hilum is occluded, the tumor is resected along the previously scored margin using cold scissor. Then, inner renorrhaphy layer was performed in a continuous fashion using 6‐inch 2‐0 V‐Loc barbed suture. After inner renorrhaphy, we used an early clamp release (ECR) technique. Outer layer renorrhaphy was performed in interrupted fashion using 1‐0 Vicryl sutures. The specimen was extracted through a 4‐cm left Gibson incision.
Results: The total operative time was 190 minutes. The warm ischemia time was 20 minutes. The estimated blood loss was 100 mL. The patient was discharged at postoperative day #4. Final pathologic examination of the tumor specimen revealed Fuhrman grade II clear cell renal cell carcinoma, with negative surgical margins. Local recurrence or metastasis was not detected by follow‐up CT imaging at 2 months after surgery. There was no hydronephrosis. The renal function was stable, her serum creatinine was 0.78 mg/dL and eGFR was 84 ml/min/1.73 m2
Conclusions: Robot‐assisted laparoscopic partial nephrectomy is feasible for the complex cases with the advantages of minimally invasive intervention.
Single Port Robotic Radical Cystectomy and Intracorporeal Neobladder: Modifications to Reduce Operative Time and Bring Parity to the Multiport Approach
A McCutchen, F Sheckley, M Ahmed, M Billah
Hackensack Meridian School of Medicine
Introduction & Objective: The best‐known treatment for muscle invasive bladder cancer is a radical cystectomy with pelvic lymph node dissection. The robot assisted radical cystectomy with neobladder creation is technically challenging as well as time consuming and while the use of a single port (SP) for this procedure is slowly emerging in practice, only a handful of experts are skilled enough to perform this effectively. We will describe our experience and outcomes completing the robotic intracorporeal neobladder utilizing a modified Studer (U‐shape) technique.
Methods: From October 2019 to February 2022, we created a modified U‐shaped intracorporeal neobladder for 15 patients. It was constructed with minimal tension, utilizing a mobile ileal segment of bowel with length ranging from 35‐40cm. We created a spherical reservoir and used fewer, simpler sutures by incorporating off‐centered V‐Loc running stitches. We prospectively collected demographic and clinical data and retrospectively analyzed intra‐ and peri‐operative, postoperative, and follow up outcomes.
Results: Our technique was done using the SP for 5 patients and the multiport for 10 patients. The median follow‐up rate was 8 months (1‐26 mos.). The median operating time, estimated blood loss, and post‐operative length of stay were 251 min (223‐370min), 100mL (100‐200mL), and 5 days (4‐28d), respectively. There were no intraoperative complications or conversions to an open procedure. There were no early major complications. There was one late major complication occurring at 90 days, consisting of a vesicovaginal fistula. We had one conversion to an ileal conduit and one death due to an unknown cause. At median follow up, out of 12 patients, functional outcomes include median day continence rate of 83.3% and night continence of 58.3%; GFR/Cr were calculated within normal range for 10/13 (76.9%) patients, and there was no presence of hydronephrosis or signs of increased bladder pressure.
Conclusions: The Studer neobladder technique, although well described, requires a long operating time and can be challenging. Our technique results in a safe, simpler, and more efficient case lending to decreased OR time, while demonstrating patient outcomes that are comparable to those reported in literature. Our approach is reproducible, allowing other surgeons to learn under the appropriate mentorship. Further studies that include this technique using a larger patient population, longer follow up durations, and the SP robot exclusively are needed to further confirm these preliminary results.
Robotic‐Assisted Partial Cystectomy and Ureteral Reimplantation for Lateral Bladder Wall Diverticulum Containing Bladder Cancer: Surgical Technique and Case Series of Outcomes
DF Roadman, JC Jackson, A Stephenson, A Chow
Rush University Medical Center
Introduction & Objective: Bladder tumor within an inaccessible diverticulum pose a challenge for endoscopic management. A lateral wall bladder diverticulum can be challenging due to its proximity to the ureteral orifice. Resection of the diverticulum with the ureteral orifice and concurrent reimplantation can be done. We present a series of three patients who underwent robotic‐assisted partial cystectomy and ipsilateral ureteral reimplantation.
Methods: Initially, cystoscopy was performed to curl glidewire into the diverticulum to aid robotic identification. Then robotic ports and AirSeal assistant were placed in standard pelvic configuration. The ipsilateral ureter was mobilized and secured with vessel loops. The Space of Retzius was developed. The diverticulum was widely excised with en‐bloc resection of the orifice and placed in a specimen bag to avoid tumor spillage. The cystostomy was closed. Two patients underwent pelvic lymph node dissections. The ipsilateral ureter was then re‐implanted in a running tension‐free anastomosis with 4‐0 PDS.
Results: Two patients were discharged on POD‐1 and one patient on POD‐2 due to need for psycho‐oncological consultation. Indwelling catheters were removed at 2‐weeks and ureteral stents were removed at 6‐weeks. Final pathology demonstrated pT2bN3, pT0, and T2bN0. Patients with T2 disease opted for surveillance and no tumor recurrence was seen at a mean follow up of 7‐months.
Conclusions: This case series demonstrates the feasibility of performing robotic‐assisted partial cystectomy and ureteral reimplantation for isolated bladder cancer within a diverticulum. A partial cystectomy is an excellent choice for tumor treatment, staging purposes, and to serve as a bladder sparing approach for pT2 disease. The accompanying video provides step‐by‐step demonstration of our technique.
Robotic Retroperitoneal Complex Partial Nephrectomy and Adjacent Cyst Decortication
WA Langbo, HD Kim, JT Emerson, A Chow
Rush Medical College of Rush University Medical Center
Introduction & Objective: This is a case of a 79‐year‐old gentleman who presented with an incidentally discovered right renal mass and large adjacent cyst. CT scan revealed an 8cm endophytic mass crossing midline, located at the posterior interpolar region and abutting the renal sinus. Adjacent to this mass was a 24cm simple cyst exerting mass effect on surrounding organs, concerning for primary renal malignancy. Our objective is to demonstrate the surgical steps of a retroperitoneal robotic‐assisted partial nephrectomy of a large renal mass and adjacent cyst.
Methods: Once port sites had been placed, the da Vinci Xi Surgical System Robot was docked. To initiate the procedure, the kidney and Gerota's Fascia were lifted anteriorly, allowing for quick identification of the renal artery. The tumor was identified in the interpolar region, adjacent to a large cyst. An ultrasound probe was utilized to confirm tumor and cyst identification, and the edges of the tumor were marked. Off‐clamp resection of the tumor proceeded, before ultimately clamping the renal artery. The tumor was then enucleated from the renal parenchyma. Once the tumor had been sufficiently reflected from the parenchyma, the interface of the tumor and the renal cyst was identified. The cyst was drained, and approximately 3 liters of fluid was evacuated. The interface of the tumor and the cyst was decorticated, and the freed tumor was placed into the cyst for later extraction. Part of the cystic wall was further decorticated to prevent cystic re‐accumulation. The renal artery was then unclamped, for a total clamp time of 30 minutes. The tumor and decorticated cyst wall were placed in a specimen bag inserted through the assistant port, the robot was undocked, and the specimen was extracted through the camera port. The lumbodorsal fascia was then reapproximated using 0 Vicryl suture and the skin using 4‐0 Monocryl suture.
Results: The patient tolerated the procedure well and was discharged on postoperative day 1. Estimated blood loss was 750mL. The specimen showed clear cell renal cell carcinoma measuring 8cm, staged T2aNX with negative margins. The excised cyst wall was benign.
Conclusions: A retroperitoneal approach offers a safe and effective route for resection of posteriorly located renal tumors, particularly in the context of an anteriorly located cyst. Cyst drainage can provide increased working space, however limited space requires comfort with retroperitoneal anatomy and special awareness of instrument location and traction. Despite the complexity of a renal mass, and particularly in the setting of moderate to several renal insufficiency, a retroperitoneal robotic approach can be considered if within the skillset of the surgeon.
Utilization of a 3D Model for Rehearsing Tumor Resection Prior to Robot‐assisted Partial Nephrectomy
P Kanabur, W Mayer, R Link
Introduction & Objective: Planning complex robotic‐assisted partial nephrectomies (RAPN) currently involves synthesizing a mental three‐dimensional (3D) representation of tumor anatomy from limited two‐dimensional images. Planning complex tumor resections that maximize cancer control and minimize nephron loss can be challenging. This can be an educational challenge for trainees. Partial nephrectomy of high complex tumors is associated with longer warm ischemia times, greater blood loss, renal dysfunction and high risk of conversion to radical nephrectomy. 3D printing is becoming an increasingly valuable tool for surgical education that affords the ability to visualize and teach complex tumor resections. We utilized a patient‐specific 3D printed model to facilitate rehearsals of tumor resection prior to the surgery to improve surgical preparation and perioperative outcomes.
Methods: Patient‐specific, cost‐effective 3D models of the affected kidney were created using an FDA‐approved technology (Prosure, Lazarus 3D) derived from preoperative imaging of two patients undergoing RAPN for complex renal masses. These models are composed of a soft material designed to simulate the tissue properties of kidney parenchyma and contain tumor, collecting system, veins and arteries. The model was placed into anatomical position in a robot training amphitheater and the tumors were resected using the DaVinci XI robotic surgical system first by the resident and then by an experienced attending surgeon. Resection time was documented and video was recorded to facilitate surgical preparation.
Results: The first patient was a 46 year old male with a 3.3 cm entirely endophytic left renal mass (nephrometry score = 10p) and the second patient was a 48 year female with a 4.5 cm endophytic hilar right renal mass (nephrometry score = 10ah). The rehearsal tumor resection times were 18 and 14 minutes, and surgical warm ischemia times were 28 and 26 minutes, respectively. Note that the surgical rehearsal times did not include renorrhaphy whereas the actual surgical times did reflect corticomedullary suturing. There were no perioperative complications. Final pathology was pT1a with negative margins for both patients
Conclusions: This video illustrates the utilization of a patient‐specific 3D kidney model to rehearse complex tumor resection prior to the surgery. The implementation of 3D models available to the surgeon prior to partial nephrectomy affords preoperative planning and improves the ability to anticipate intricacies of patient‐specific anatomy. Moreover, allowing the resident to demonstrate tumor resection capability on a model may increase trainee autonomy and focus teaching during the case.
M Lee (Temple University Hospital), J Jeong, J Sykes, DD Eun
Temple University Hospital
Introduction & Objective: Radical cystectomy with urinary diversion is the standard of care for surgical management of muscle invasive bladder cancer. In appropriately selected candidates, orthotopic neobladder formation may offer benefits to patients with regards to preserved body image and continence. We describe our approach to robotic intracorporeal orthotopic neobladder formation and highlight key aspects of our surgical technique.
Methods: We report the case of a 60‐year‐old male with history of high grade T2a muscle invasive bladder cancer who underwent a robotic radical cystectomy with intracorporeal orthotopic neobladder formation. Robotic ports are placed 6 centimeters more cephalad than the standard prostatectomy configuration and the left lateral 12 millimeter robotic fourth arm is placed one handbreadth toward the anterior superior iliac spine to allow for optimal operability of the robotic stapler. Intraoperatively, after the standard radical cystectomy and bilateral pelvic lymph node dissection, we construct the neobladder by forming a W‐shaped configuration of ileum with two troughs anchored to the foley catheter. The anti‐mesenteric side of the ileum is then detubularized and a posterior ileal plate is formed by suturing the cut edges of the anti‐mesenteric borders. A circumferential ileo‐urethral anastomosis is completed, and the anterior ileal plate is formed by suturing together the lateral most cut edges of the anti‐mesenteric borders. Ureteral stents are placed and the ileal neobladder is then taken out of continuity using a robotic stapler. Uretero‐enteric anastomoses are completed over the ureteral stents and intravenous indocyanine green is visualized under near infrared fluorescence to assess for adequate vascularization of the anastomosis.
Results: Intraoperatively, estimated blood loss was 300 milliliters and total operative time was 500 minutes. There were no intraoperative complications, and the patient was discharged on postoperative day 5 after an uncomplicated hospital course. The patient's foley and ureteral stents were removed on post op day 14. At 12‐months follow‐up, there were no major (Clavien >2) postoperative complications.
Conclusions: Robotic intracorporeal orthotopic neobladder formation can be an effective technique for urinary diversion in patients with muscle invasive bladder cancer.
Laparoscopic Partial Nephrectomy in Kidney Allograft
DF Kantimerov, RN Trushkin, AE Lubennikov, NE Shcheglov, OS Shevtsov
Moscow City Clinical Hospital 52
Introduction & Objective: The incidence of renal tumor on the allograft kidney is rare. There is no guidelines for the management of renal tumor in kidney allograft. To report the use of laparoscopic approach for removing tumor in kidney allograft.
Methods: A 46‐year‐old male with end‐stage renal disease secondary to chronic glomerulonephritis who underwent kidney transplantation in 1997. After 23 years, routine screening ultrasonography revealed a solid mass of 30‐mm diameter in the kidney allograft. Laparoscopic partial nephrectomy was performed.
Results: Ischemia time was 22 min. Blood loss was 50 mL. Postoperative period was unremarkable. There was no allograft dysfunction. Tissue histology revealed clear cell carcinoma with negative surgical margins. The patient was
discharged home after 7 days in hospital.
Conclusions: Laparoscopic partial nephrectomy can be carried out as a safe, effective and minimally‐invasive nephron‐sparing surgery procedure with less complications and less postoperative period in transplanted patietns.
Off‐clamp Robotic‐Assisted Partial Nephrectomy for Endophytic Renal Tumor
WM Hughes, TM Shelton, B King, EP Castle
Tulane
Introduction & Objective: With progressive advances in imaging technology, surgical instruments, and operative techniques, the urologic community continues to push the boundaries of what renal lesions can be successfully managed with nephron‐sparing approaches. Prolonged warm ischemia time during partial nephrectomy is associated with postoperative renal function. Many surgeons have begun to employ techniques such as selective arterial clamping to limit ischemic time. Here we demonstrate an advanced surgical technique for off‐clamp partial nephrectomy utilizing robotic ultrasound and enucleation of an endophytic cystic renal mass.
Methods: The patient is secured in a modified flank position allowing for maximum rotation of the operating table. The renal hilum is carefully dissected prior to off‐clamp resection and surgical clamps are placed near the renal vessels. Using a temporarily increased insufflation pressure of 20 mmHg, the renal mass is enucleated using the robotic vessel sealer device. A modified renorrhaphy with the sliding clip technique is utliized and hemostatic agents are applied to the surgical bed.
Results: Operative time for the procedure was 131 minutes. Estimated blood loss was 300cc and the patient was discharged on postoperative day 1. Pathology resulted as clear cell renal cell carcinoma, 3cm in greatest dimension, with negative margins. Creatinine and GFR at 3 months postoperatively are identical to preoperative labs and no complications occurred.
Conclusions: Off‐clamp partial nephrectomy is technically feasible in the hands of an experienced robotic surgeon, eliminating the concern of prolonged warm ischemia time. Complex, endophytic, cystic lesions can be successfully managed using the techniques outlined in this video.
Laparoscopic Retroperitoneal Heminephrectomy for Renal Cell Carcinoma in Horseshoe Kidney
T Nguyen, M Thai, Q Chau, X Ngo, T Tran, L Dinh, H Truong, T Tran, R Dobbs
thanhtuan0131@gmail.com
Introduction & Objective: We demonstrate our technique of a retroperitoneal laparoscopic heminephrectomy for a T1b right hilar tumor in a horseshoe kidney.
Methods: A 77‐year‐old woman presented to the hospital because of right flank pain without hematuria or a history of kidney disease. On presentation, her serum creatinine was 0.86 mg/dL and eGFR was 65.2 mL/min/1.73 m2. According to her renal scintigraphy, GFRs of the right and left moieties were 24.2 and 35.5 mL/min, respectively. Her computed tomography (CT) showed the horseshoe kidney with a hilar tumor (55 x 50 mm) arising from the upper pole of the right moiety kidney. Preoperative tumor staging was cT1bN0M0 in the right moiety. After discussion, the patient elected a minimally invasive surgery to treat her malignancy. The patient was placed in a flank position. Initial access was obtained through a 1.5 cm incision located below the tip of the twelfth rib. We used Gaur's balloon technique to create the retroperitoneal working space, and three more trocar ports were planned for operation. We identified the horizontal psoas muscle as the key anatomic landmark during the operation. Three arteries were dissected, including two arteries feeding the right moiety, one artery feeding the isthmus, and one vein, which was clipped and divided by Hem‐o‐lok. The isthmus connected to the lower poles was exposed, and the isthmusectomy was performed by the Endostapler. Consequently, the ureter was clipped and divided. Finally, the whole right segment of the horseshoe kidney was mobilized and taken out by the flank incision.
Results: The total operation time was 250 minutes. The estimated blood loss for the heminephrectomy was 200 ml. Serum creatinine of the patients after surgery was 1.08 mg/dl and eGFR was 49.47 mL/min/1.73 m2, with a decrease of 24% in renal function compared to the preoperative result. The patient was discharged on postoperative day #4. Final pathologic examination of the tumor specimen revealed a Fuhrman grade II clear cell renal cell carcinoma, capsular invasion, with negative surgical margins. After a three‐month follow‐up, the renal function was stable, with serum creatinine was 0.95 mg/dL, and eGFR was 57.7 mL/min/1.73 m2, with a decrease of 12% in renal function compared to the preoperative result. Local recurrence or metastasis was not detected by follow‐up CT imaging.
Conclusions: In conclusion, retroperitoneal laparoscopic heminephrectomy is feasible and may be a safe technique for patients with renal cell carcinoma in a horseshoe kidney.
Robot‐Assisted Laparoscopic Transperitoneal “No Clamp”‐ Zero Ischemia Time Partial Nephrectomy in Clinical T1a Renal Tumors
A Kumar, Y Prashanth, S Kumar, K kapoor, S Iyer, P Singh
Department of Urology, Robotics and Renal Transplant, SJH and VMMC, New Delhi
Introduction & Objective: The role of warm ischemia time(WIT) as modifiable predictor of postoperative renal function , has led to development of techniques to minimise WIT.The role of clampless robot assisted laparoscopic partial nephrectomy(RPN) in renal tumors is still not established . We prospectively evaluated the feasibility,safety , efficacy and Trifecta outcomes of RPN in clinical T1a renal tumors.
Methods: All consecutive patients undergoing clampless RPN(using da‐Vinci robotic system) for a clinical T1a predominantly exophytic renal tumors and normal contralateral kidney by a single surgeon between Oct 2019 and January 2021 at our institution were included .The various clinical data were recorded and analyzed. We are presenting video of one such case.
Results: A total of 21 patients were included in the study. The mean age was 56.5 years with mean preoperative serum creatinine and estimated glomerular filtration rate ( GFR) were 0.67 mg/dl and 72.7 ml/min/1.73 m 2 respectively.The mean tumor size was 3.1 cm.The tumor was superior polar in 42.8% patients,mesorenal 28.5% patients and inferior polar in 28.5% patients .The tumor growth pattern was cortical in 71.4%) patients and corticomedullar in 28.6% patients.The mean operating time and estimated blood loss were 81.3 min and 103 ml respectively . There was no conversion to open . The positive surgical margins were nil .In histopathology ,renal cell carcinoma was found in all patients.The intraoperative and postoperative complications were seen in nil and 1 patient respectively and mainly Clavien 1 ‐ 2 only .The mean estimated GFR at 1 month (70.9) was not significantly lesser than preoperative value( p = 0.54).
Conclusions: Robot assisted Laparoscopic Clampless partial nephrectomy for small predominantly exophytic renal masses (T1a), is feasible,effective with preservation of renal function ,acceptable complications and optimal Trifecta outcomes. However,it is a technically challenging procedure and should be done by surgeons of significant surgical expertise
A Prospective Evaluation of Perioperative and Trifecta Outcomes of Robot‐Assisted Laparoscopic Transperitoneal Partial Nephrectomy in Clinical T1b Renal Tumors
A Kumar, Y Prashanth, S Kumar, K kapoor, S Iyer, P Singh
Department of Urology, Robotics and Renal Transplant, SJH and VMMC, New Delhi
Introduction & Objective: We prospectively evaluated the feasibility,safety , efficacy and Trifecta outcomes of robot assisted laparoscopic transperitoneal partial nephrectomy(RPN) in clinical T1b renal tumors
Methods: All consecutive patients undergoing RPN(using da‐vinci Xi robotic system) for clinical T1b renal tumors and normal contralateral kidney by a single surgeon between Oct 2019 and October 2021 at our institution were included . Patients with absence of grade ≥2 Clavien‐Dindo complications, warm ischemia time (WIT) ≤25 minutes, ≤15% postoperative estimated glomerular filtration rate (eGFR) decrease and negative surgical margins were reported to achieve strict Trifecta outcomes. We are presenting video of one such case.
Results: A total of 91 patients were included in the study.The mean tumor size was 5. 9 cm. The tumor was upper polar in 30. 3% patients,mesorenal 25% patients and lower polar in 26 46.4% patients . The mean operating time and estimated blood loss were 117. 3 min and 127. 1 ml respectively . The mean ischemia time was 19. 3 min. The WIT was >25 min in 2 patients. The positive surgical margins were nil . The intraoperative and postoperative complications were 6. 2% and 6. 2% respectively and mainly Clavien 1 ‐2 only . The mean preoperative and 6 month postoperative eGFR were comparable(p = 0. 67). Two patients had a >15% postoperative eGFR decrease . The trifecta outcomes were achieved in 84.1% patients.
Conclusions: RPN for clinical T1b renal tumors,is feasible,effective with preservation of renal function , acceptable complications and optimal strict Trifecta outcomes.
A Prospective Evaluation of Robot Assisted Laparoscopic Anterior Exenteration in Females with Muscle Invasive Bladder Carcinoma
A Kumar, Y Prashanth, S Kumar, K kapoor, S Iyer, P Singh
Department of Urology, Robotics and Renal Transplant, SJH and VMMC, New Delhi
Introduction & Objective: Minimally invasive anterior exenteration is becoming very popular in females with muscle invasive bladder carcinoma. However ,this is technically challenging and confined to centers with advanced laparoscopic expertise. We prospectively evaluated the outcomes of robot assisted laparoscopic anterior exenteration (RALE) in females with muscle invasive bladder carcinoma.
Methods: All consecutive female patients undergoing RALE(using da‐Vinci Xi Robotic system) for muscle invasive bladder carcinoma by a single surgeon between Oct 2019 2020 and October 2021 at our institution were included . The various clinical data were recorded and analyzed. We are presenting video of one such case.
Results: A total of 69 patients were included in the study. The mean age was 62. 7years . The prior abdominal surgery was found in 28. 9% patients . The neo‐adjuvant chemotherapy was given in 33. 3% patients . The clinical stage was T2 in 56.4% and T3 in 43. 6% patients . The extracorporeal and intracorporeal ileal conduit was made in 68.1% and 21.9% respectively . The mean operating time and estimated blood loss were 145. 3 min and 153. 1 ml respectively . There was no conversion to open. The mean hospital stay was 4. 1 days . The introperative and postoperative complications were 4. 7% and 9. 5% respectively and mainly Clavien 1 and 2 only. In histopathology pT2,pT3, pN0 and pN1‐2 were found in 66. 8%,33. 3%,57. 1% and 42. 8% respectively . The mean number of lymph nodes removed were 19. There were no positive surgical margins in any patient.
Conclusions: Robot assisted Laparoscopic anterior exenteration (RALE) in females with muscle invasive bladder carcinoma is feasible,safe with acceptable perioperative morbidity . However,it is a technically challenging procedure and should be done by surgeons of significant surgical expertise.
VID2: Laparoscopy/Robotics: Benign Non Kidney
WITHDRAWN
Rendezvous Technique: Step by Step
A sierra, M Corrales, O Traxer
Hôpital Tenon
Introduction & Objective: The treatment of complete ureteral stenosis varies depending on the severity and location of injury but can include ureteral stent placement and surgical repair. Long‐term percutaneous nephrostomy (PN) drainage is another treatment option, but it leads to deterioration of the patient's quality of life. Therefore, as an alternative to surgery, the combined anterograde and retrograde approach, the so‐called rendezvous technique, is required.
Methods: A 52‐year‐old male with a history of prior flexible ureterorenoscopy for a 12 mm ureteral stone in the ureteropelvic junction presented with insidious onset complete ureteral stenosis. A nephrostomy tube was placed, and the patient was referred to our center. An anterograde and retrograde pyelography confirmed a diagnosis of ureteropelvic stenosis thought to be secondary to prior endoscopic procedure. A combined antegrade‐retrograde rendezvous dilation of stenosis was planned. A fiberoptic and digital ureteroscope were used through the left ureter and the nephrostomy tract, respectively, and allowed a careful visual examination of the ureteral lesion. The complete stenosis didn't allow the passage of a 0,035'' Terumo guidewire. Transillumination and fluoroscopy were used to direct the retrograde lasering of the tissue to create the new ureteral path.
Results: After reaching the pelvis through the retrograde access, a double J ureteral catheter (8 Fh) was placed to reduce the risk of restenosis and a nephrostomy tube. The nephrostomy tube was removed after 48 hours. The procedure was well tolerated and after 3 days the patient was discharged with the double J.
Conclusions: Combined antegrade‐retrograde rendezvous dilation offers a safe and viable alternative to high‐risk surgery in patients with complete ureteropelvic stenosis.
Robotic Retroperitoneal Debulking of an Obstructing Renal Myxoma
HD Kim, WA Langbo, DP Simon, JC Jackson, CL Coogan, A Chow
Rush University
Introduction & Objective: This is a case of a 51‐year‐old Caucasian male who presented with an incidental finding of bilateral renal masses causing obstructive uropathy in the left kidney. MRI revealed a large multiloculated left posterior renal mass measuring approximately 15 x 10 cm causing hydronephrosis. Two separate biopsies of the mass demonstrated spindle cell lesion with myxoid changes. Given the obstructive nature of the mass and continued concern for malignancy despite its benign‐appearing biopsy, surgical treatment was pursued. Our objective is to demonstrate the surgical steps of a robotic retroperitoneal debulking of biopsy‐proven renal myxoma.
Methods: Once robotic port sites had been established, the da Vinci Xi Surgical System Robot was docked. The psoas muscle was identified to maintain orientation and the kidney was positioned anteriorly. The renal artery was visualized to be displaced cephalad due to the large posterior mass. After the renal artery was confirmed using fluorescence, the interface of the renal mass was dissected to free the tumor circumferentially. An ultrasound probe was utilized to identify the tumor margin and its extent. During the process of enucleation, the decision to remove the mass in a piecemeal fashion was made due to poor mobility of the mass and its encapsulation of the renal hilum. The mass was divided down the middle and the caudal portion of the mass was first enucleated away from the kidney parenchyma without any bleeding. The remaining tumor was further divided into 3 separate pieces and safely enucleated from the normal kidney. A small remaining piece of the tumor encasing the renal artery was left intact given the high risk of iatrogenic injury. All four tumor pieces were extracted through the camera port in a specimen bag. The lumbodorsal fascia was reapproximated using 0 Vicryl and the skin using Dermabond.
Results: The patient tolerated the procedure well and was discharged on post‐operative day 1. The final pathology demonstrated bland spindle cells in fibrotic to myxoid stroma without cytologic atypia or mitoses. Follow up MRI at 3‐months revealed known residual mass in the hilum with a notable improvement of left hydronephrosis.
Conclusions: Renal myxoma is a rare but benign mesenchymal tumor of the kidney with good prognosis that can present with non‐specific urological symptoms like those of a malignant process. While total nephrectomy can be considered when presented with high level of suspicion for malignancy, minimally invasive debulking should be considered in biopsy‐proven renal myxoma to maximize kidney preservation. Robotic retroperitoneal debulking is a safe and effective treatment for obstructive uropathy caused by renal myxoma.
Robot‐assisted Ileocalicostomy for Complex Ureteral Stricture: A Novel Approach
C Floyd, R Bhalla, A Khan, N Kavoussi
Vanderbilt university medical center
Introduction & Objective: Ileal ureteral substitution has previously been demonstrated as a reconstructive option for complex ureteral strictures. However, certain anatomical considerations preclude anastomosis between the ureter and pelvis. We present a case describing the treatment of a complex ureteral stricture via robot‐assisted, intracorporeal ileocalicostomy.
Methods: A 26‐year‐old woman with a history of bladder exstrophy and repair with bladder augmentation and catheterizable channel presented to our institution with right flank pain and recurrent episodes of pyelonephritis after a recent ureteroscopy. Cross‐sectional imaging revealed severe hydronephrosis with a narrow‐appearing renal pelvis. A nephrostomy tube was placed for renal decompression. Subsequent imaging revealed a 5cm proximal ureteral stricture. Nuclear medicine imaging (i.e. dimercaptosuccinic acid) revealed 40% function of that kidney. Given the length and location of the stricture in a functioning kidney, she elected to undergo robot‐assisted ileocalicostomy. The procedure was done entirely intracorporeally using robot‐assisted laparoscopy. Colorectal surgery assisted in bowel mobilization and isolation of 20cm of ileum. A percutaneous nephroureteral tube was placed to ensure patency and drainage of the kidney postoperatively.
Results: The procedure length was 384 minutes and estimated blood loss was 100mls. Postoperatively, she was admitted for 4 days with a 12f catheter in her Mitrofanoff channel, a 20f catheter through her urethra, a 10f nephroureteral drain, and a 15f Jackson‐Pratt drain. A cystogram at 2 weeks showed no extravasation from her bladder and her catheters were removed. At 4 weeks, her nephroureteral stent was exchanged for a nephrostomy tube. Antegrade nephrostogram revealed adequate drainage of the kidney at 5 weeks, and the tube was removed. Follow‐up imaging at 3 months showed anastomotic patency. The patient has had no further episodes of pyelonephritis or flank pain.
Conclusions: Robotic ileocalicostomy is feasible for patients with complex ureteral strictures. The procedure should be considered carefully with other surgical options as a viable treatment.
Integral Pelvic Organ Prolaps Surgery (IPOP‐S): A New Laparoscopically Surgery Approach with Five Years Results
N Tola, M Barale, F Mele, P Gamba, R Migliari
Introduction & Objective: In this video we present a new laparoscopic lateral suspension of the symptomatic posthysterectomy vaginal vault prolapse using a mesh, named I‐POPS ( integral pelvic organ prolapse surgery).
Methods: We analyzed in a prospective cohort study 70 women treated by laparoscopic I‐POPS with mesh for symptomatic vaginal vault prolapse between January 2017 and September 2018. In this procedure, the four‐arm polypropilene mesh, is laterally suspended to the abdominal wall, about 8‐12 cm from the anterior superior iliac spine while the anterior arms are suspended 2 cm medially to the superior iliac spine . We performed systematic follow‐up examinations at 4 weeks, 6 months and yearly postoperatively. Clinical evaluation of pelvic organ support was assessed by the pelvic organ prolapse quantification (POP‐Q) grading system. Main outcome measures were recurrence rate, reoperation rate for symptomatic recurrence or de novo prolapse, mesh erosion rate, reoperation rate for mesh erosion, total reoperation rate.
Results: Of the 70 patients seen at a mean 48.4 months follow‐up, recurrent vaginal vault prolapse was registered in only one woman (success rate of 98.57 %). When considering all vaginal sites, we observed a total of 10 patients with recurrent or de novo prolapse (14,28 %). The non‐previously treated posterior compartment was involved in 12 cases (new appearance rate of 17,14 %). Of these women, only 6 were symptomatic, requiring surgical management (reoperation rate for genital prolapse of 8.6 %). 2 patients presented with mesh erosion into the vagina (2,85 %) that required partial vaginal excision of the mesh in the operating room apart from those there were no mesh‐related infections. The total reoperation rate was 11,4 %.
Conclusions: The new laparoscopic I‐POPS procedure shown in the video with a four‐ arm mesh interposition represents an alternative procedure to the laparoscopic sacrocolpopexy. This approach is a safe and effective technique for the treatment of vaginal vault prolapse.
Robotic Augmented Anastomotic Appendiceal Onlay for Ureteral Stricture
N Jones, CG Fakes, U Zareef, M Mikhail, A Kaldany, HV Patel, S Elsamra
Introduction & Objective: The management of ureteral strictures is challenging for urologists depending on the length and location of the stricture. Primary ureteroureterostomy is a potential surgical option for ureteral strictures, but can be challenging in strictures >2cm in length. Onlay grafts, such appendiceal onlay, have been described as safe and viable options for management of ureteral strictures. Here, we present a case where a right proximal ureteral stricture is treated with a robotic augmented anastomotic appendiceal onlay for ureteral reconstruction.
Methods: This procedure was performed using the da Vinci Xi® robotic system. Intraoperative ureteroscopy identified an 8cm ureteral defect with a ∼1cm obliterated ureteral segment. An augmented anastomotic appendiceal onlay was performed due to the length and location of the ureteral stricture.
Results: Estimated blood loss was 50 milliliters. There were no intraoperative or postoperative complications. As a part of the patient's follow up care, a renal‐bladder ultrasound 8 weeks after the procedure demonstrated resolution of right hydronephrosis and no obstruction was noted on MAG‐3 renal scan with Lasix.
Conclusions: In summary, robotic ureteral reconstruction with augmented anastomotic appendiceal onlay is a unique and innovative strategy for ureteral reconstruction.
Robotic Ectopic Ureterectomy of a Duplicated System with Firefly Assistance
JC Jackson, M Salkowski, JT Emerson, K Sinchek, A Chow
Rush University Medical Center ‐ Department of Urology
Introduction & Objective: We report on a 35‐year‐old male with right completed duplicated system and history of robotic partial nephrectomy of an obstructed upper pole moiety who presented to our clinic with recurrent UTIs. Computer tomography and retrograde pyelogram demonstrated a markedly dilated mid‐to‐distal ureteral remnant with ectopic insertion into the ejaculatory duct as the source of his UTI's.
Methods: The patient underwent robotic salvage ectopic ureterectomy. Both ipsilateral ureters were plastered within a desmoplastic common sheath which made it difficult to identify safe surgical planes. To aid in safe dissection intraureteral indocyanine green assisted in safe dissection of the healthy ureter off the ectopic ureter.
Results: Following this procedure, the patient experienced no complications post‐operatively. He was discharged from our hospital on post‐operative day one and has remained asymptomatic at a one month follow‐up.
Conclusions: In the presence of recurrent UTIs following partial nephrectomy, consider ectopic ureters and ureteral remnants as potential sources of infection. To reduce the risk of recurrent infection, ensure no remnant ureter is left behind by dissecting to site of insertion. Consider the use of intraureteral indocyanine green to aid in safe robotic dissection due to desmoplastic adherent tissue within the common ureteral sheath.
Single Position Robotic‐Assisted Laparoscopic Right Ileal Interposition
L Khizir, J Kim, CG Fakes, A Kaldany, HV Patel, J Khan, S Elsamra
Rutgers Robert Wood Johnson Medical School
Introduction & Objective: Ureteral stricture disease management is challenging for urologists and differs based on the location and length of the stricture, and ileal ureter reconstruction can be employed for extensive ureteral defects. The patient is a 45 year old woman with a history of cervical cancer in remission following treatment with surgery and radiation presenting with right panureteral stricture. Here, we present a single position robotic‐assisted laparoscopic right ileal ureter interposition.
Methods: Ports were placed similar to pelvic procedure with tilted axis, skewing the right‐sided ports up and skewing the left‐sided ports down to allow for better reach up towards the right ureteropelvic junction. Specific port placement used for this ileal ureter interposition allowed for better reach towards the right ureteropelvic junction and for the patient to remain in a single dorsal lithotomy position throughout the entire procedure.The ports were placed with right‐sided ports tilted up up and left‐sided ports down. Surgical footage highlights include isolation and division of the ileum, side to side bowel anastomosis, anastomosis of distal ureter to bladder and placement of a double‐j stent from distal to proximal part of ileal loop, incision of renal pelvis and side to side anastomosis between ileal segments and renal pelvis.
Results: Estimated blood loss was 50 milliliters with no intraoperative complications. Patient was stable with an unremarkable postoperative course, and post‐operative imaging demonstrated preserved renal function. Patient was discharged on post‐operative day two without complication.
Conclusions: The procedure was performed successfully without postoperative complications, showing how robotic ileal ureteral reconstruction is a viable strategy for definitive repair of extensive ureteral defects.
Ureteroscopic & Robot Assisted Ureteroplasty with Buccal Mucosa Graft
Y Deruyver, M Henckes, C Van Haute, F Van der Aa
University Hospitals Leuven
Introduction & Objective: In this video we present a case of a ureteroscopic and robot assisted redo‐ureteroplasty with buccal mucosa graft for a proximal ureteral stricture.
Methods: Here, we present a case of 72‐old female patient with a history of a right‐sided proximal ureteral stricture after ureteroscopic stone treatment. For this stricture she underwent robotic end‐to‐end ureteroplasty. Two years later, she presented with recurrence of the stricture for which she underwent balloon dilatation and tandemstenting. Unfortunately, the stricture recurred rapidly. A redo ureteroplasty with buccal mucosa graft was planned.
Results: Surgery and post‐operative course were uneventful. Six weeks after surgery the DJ stent was removed and 4 months post‐operative the patient is doing fine without evidence for recurrence of the ureteral stricture.
Conclusions: The video ilustrates how retrograde ureteroscopy in combination with FireFly fluorescence imaging can be a valuable contribution to identifying the ureter, which in redo cases is often surrounded by a lot of fibrotic tissue. Moreover, localisation of the stricture site is facilitated by retrograde ureteroscopy. After onlay of the buccal mucosa graft, patency and watertightness of the ureteroplasty can easily be controlled.
Single‐Port Transvesical Simple Prostatectomy for Big Median Lobe: Description of Technique
M Abou Zeinab, A Kaviani, E Ferguson, A Beksac, J Kaouk
Cleveland Clinic
Introduction & Objective: To present our updated technique and evaluate the perioperative and postoperative outcomes of Single‐port transvesical robot‐assisted simple prostatectomy (SP RASP)
Methods: Forty‐two consecutive patients with BPH indicated for surgery underwent SP RASP in a single institution. The procedure was performed in the following steps: 1‐ The Patient was positioned in a supine position. 2‐ A 3‐3.5 cm suprapubic midline incision is made, and a 2 cm vertical cystotomy was performed after bladder identification. 3‐ After insertion of the access port, the single‐port (SP) robot was docked. 4‐ Identification of the ureteral orifices. 5‐ Prostatic enucleation was performed using the prostatic capsule as a landmark. 6‐ Then a complete vesicourethral mucosal advancement flap was accomplished. Demographics, perioperative and postoperative data were prospectively collected. Mean follow‐up period was 12 months.
Results: All procedures were successfully performed with no conversion, additional port placement or intraoperative complication. The median prostatic volume was 170cc. 95% of the patients did not require opioids analgesia after discharge. 65% of the last consecutive patients were discharged a few hours after the surgery and had their Foley catheter removed 2‐3 days later. The Median IPSS score decreased from 23 before the surgery to 2.5 after the surgery. All patients had a significant postoperative improvement in maximum flow rate with a 200% improvement over baseline (19 vs. 6.5 mL/sec).
Conclusions: In our initial series, SP RASP allows for favorable perioperative and early postoperative outcomes including low complication same‐day discharge, short Foley catheter stay, minimal opioids use and quick recovery.
A Case of Obstructive Uropathy After Hip Arthroplasty Repaired with Robotic Assisted Laparoscopic Ureterolysis and Omental Wrap
EL Wood, PM Patel, M Dunn
Introduction & Objective: There are rare case reports of urologic complications following hip arthroplasty. In this case, a woman on chronic immunosuppression with multiple hip arthroplasties and revisions experienced extrinsic ureteral compression from migration of antibiotic‐soaked calcium sulfate into the retroperitoneum following her fifth left hip arthroplasty revision.
Methods: Permission was obtained from the patient who consented to share her medical history and video footage from surgery for academic purposes.
Results: The patient is a 69 year old woman with a history of acute myeloid leukemia who underwent allogenic stem cell transplant 5 years prior to presentation. The stem cell transplant was complicated by graft versus host disease (manifested with thrombocytopenia and transaminitis) and her graft was maintained on immunosuppression with prednisone, sirolimus, biweekly rituximab, belumosudil and monthly intravenous immunoglobulin. Avascular necrosis from her chronic immunosuppression led to the need for bilateral hip arthroplasty with multiple revisions and complications on the left side. Approximately one month following her fifth revision, she was admitted to the intensive care unit with a pressor requirement, found to have urosepsis and an obstructed left kidney requiring percutaneous nephrostomy tube. Nephrostogram revealed a 2.1cm left distal ureteral narrowing 8.5cm from the ureterovesical junction with externally compressing/migrated calcium sulfate beads. She underwent robotic assisted laparoscopic ureterolysis with omental wrap 3 months after her ICU admission. No ureteral stent was placed. Follow up imaging 1 month after surgery revealed complete resolution of hydronephrosis. See video for intraoperative technique.
Conclusions: Calcium sulfate beads may migrate across compartments and can cause extrinsic compression on the ureter in rare cases. When feasible, ureterolysis alone may be adequate to relieve the obstruction.
Using Mcburney's Incision for a Single Port Da Vinci Robotic Adrenalectomy and Simple Nephrectomy
R Huang, M Billah, M Stifelman, M Ahmed
New York Medical College
Introduction & Objective: Laparoscopic adrenalectomy was first described in 1992. A minimally invasive approach is the standard of care in benign adrenal disease and is increasingly used in adrenal malignancies. Robotic assisted laparoscopic surgery has greatly improved the technique by expanding the range of motion in a 3D environment. In 2018, the single port robotic system has further enabled advances in minimally invasive surgery. However, there is a higher learning curve to adopting single port robotics due to the physical limitations of operating multiple instruments in close proximity. There remains a paucity of educational videos on how to perform single port surgery, including in adrenal disease. We aim to demonstrate a single port right adrenalectomy and simple nephrectomy. We describe a novel and simple approach using the McBurney's incision to gain transperitoneal access to the adrenal gland and kidney.
Methods: This is a 33 year old female with refractory hypertension. Workup revealed a right adrenal aldosteronoma and an atrophic multicystic kidney. Due to the poor functioning ipsilateral kidney, she underwent a simultaneous single port robotic right adrenalectomy and simple right nephrectomy.
Results: The right adrenal gland and involuted kidney were removed en bloc in an efficient and safe manner. The total operative time was 60 minutes and the estimated blood loss was less than 10 mL. No drains were required. The patient's pain was minimal and she was discharged on the same day as surgery. The incision healed with excellent cosmetic results. No surgical site infections, incisional hernias or other postoperative complications were noted. Final pathology confirmed an adrenal gland with cortical hyperplasia and a multicystic dysplastic kidney.
Conclusions: A simultaneous single port robotic right adrenalectomy and simple nephrectomy is a safe and feasible technique when performed by an experienced surgeon. The McBurney's incision is a novel approach that provides excellent access and visualization. A distinct advantage is the improved cosmesis and reduced risk for midline hernias. Additionally, there is the potential for reduced post‐operative pain which may enable more same day discharges. Further refinement of the technique will hopefully add to the urologists' armamentarium against surgical adrenal disease.
Use of Intestinal Bowel Segments for Advanced Robotic Upper Tract Reconstructive Surgery
G Sanekommu, I Voznesensky, R Thomas, EP Castle
Tulane School of Medicine
Introduction & Objective: The use of bowel segments for reconstruction is an established technique for complex ureteral stricture management and urinary diversion. Traditionally, these surgeries have been performed using an open approach. The same surgical principles can be applied using laparoscopy and robotics with excellent outcomes. Here we demonstrate an advanced surgical technique for an ileal chimney in a patient with bilateral ureteral stricture disease using robotics. Even with a history of pelvic radiation and prior surgery, we show that the robotic approach is feasible.
Methods: A thirty‐two year old female was referred for bilateral ureteral strictures. She has a history of cervical cancer managed by surgery, radiation, and chemotherapy. After discussion of treatment options, the patient elected for robot‐assisted ileal chimney creation. The patient was secured in a dorsal lithotomy position. The ureters were carefully dissected. The left ureter was passed under the mesocolon. The stricture lengths were measured. The bladder was mobilized. The ileal segment was harvested. The bowel was placed back into continuity. Ureteroileal anastomoses were performed using absorbable suture. Ureteral stents were placed in antegrade fashion. Cystotomy was made. The ileovesical anastomosis was performed using a running absorbable barbed suture. Leak test was performed at the end.
Results: Estimated blood loss was 100cc. The patient went home on post‐operative day 5 with foley catheter, ureteral stents, and capped nephrostomy tubes. The foley catheter was removed 2 weeks post operatively. Nephrostomy tubes were removed 4 weeks post‐operatively. Ureteral stents were removed 8 weeks post‐operatively.
Conclusions: Advanced upper tract reconstruction using bowel segments is technically feasible. In the case presented, long bilateral ureteral strictures were successfully managed with an ileal chimney interposition.
Bilateral Robot‐Assisted Ureteral Reconstruction with Buccal Graft and Omental Wrapping
CS Mohan, A Rai, J Han
Introduction & Objective: The patient is a 52‐year‐old man presenting to urology with renal failure secondary to bilateral ureteral strictures managed with nephrostomy tubes. He taken to the OR for robotic bilateral repair of ureteral strictures.
Methods: Simultaneous bilateral nephrostograms and pyelograms demarcate the stricture burden at the start of case. The extent of stricture on the left was demarcated using ICG injected antegrade via the pre‐existing nephrostomy. The strictured portion of the left ureter was excised and a uretero‐ureterostomy primarily was performed. Next the right sided repair was performed. Using intraoperative ureteroscopy, the extent of the right proximal stricture was appreciated and a ureterostomy was made along it, approximately 2cm total. Given the length of the stricture, decision was made to perform a buccal graft ureteroplasty. An omental wrap was also used over the repair. Finally, a ureteral reimplantation was performed for management of the right distal ureteral stricture. Once the ureter was transected proximal to the strictured urethra, it was reimplanted into the bladder. Bilateral ureteral stents were left along with bilateral JP drains
Results: At two‐month follow‐up, the patient was noted to have complete patency of the left ureter without hydronephrosis. However, he was noted to have a new stricture on the right requiring replacement of stent on this side.
Conclusions: We demonstrated here that robot assisted upper tract reconstruction is a valuable tool for management of ureteral strictures and that buccal mucosa grafting can also help address long strictures that may otherwise be difficult to repair.
VID2: Laparoscopy/Robotics: Non Prostate
Robotic Ileal Ureteral Replacement
G Sanekommu, R Thomas, S Proctor, EP Castle
Tulane School of Medicine
Introduction & Objective: With wide spread and repeated use of ureteroscopy (rigid and flexible), long term complications such as ureteral strictures, multiple ureteral strictures and pan ureteral strictures have risen in incidence. Management of these patients is really challenging. Definitive management includes replacement of the ureter with an ileal bowel segment. Now the Da Vinci robot can be used for ileal replacement of the diseased ureter.
Methods: Since the ureter is strictured and adherent in the retroperitoneum, no valiant effort is made to remove the diseased ureter. The ileal segment is harvested as shown in the video and the bowel continuity is also reestablished using the Da Vinci robot. The open surgical technique and principles are mimicked with the robot.
Results: The patient did exceedingly well and long term results continue to show a well draining and unobstructed kidney.
Conclusions: Using the principles and techniques of bowel surgery and urologic reconstruction, the rare instance of having to replace the ureter with an ileal bowel segment can be done using the Da Vinci robot.
VID3: Pediatrics/Stone
Robotic Partial Nephrectomy in a Pediatric Patient
AA Elbakry, T Trump, C Crigger, K Aldabek, D Zekan, M Ost, O Al‐Omar
Introduction & Objective: To present a case demonstrating robotic partial nephrectomy in a pediatric patient.
Methods: 4 y.o. girl who presented with persistent hypertension and was found to have incidentally diagnosed right renal mass. US and CT scan were done and confirmed1.5 cm mass in the anterior aspect of the mid‐pole of the right kidney. Lab Workup: Urine Metanephrins (184 mcg\24 hr ↑), 24hr Urinary VMA (31.3 mg\g cr ↑). Multidisciplinary evaluation was done, and the consensus was to proceed with partial nephrectomy to exclude reninoma as a cause of hypertension. Also, we could not rule out AML or small Wilms' tumor. Decision was discussed with the family and they greed on proceeding with robotic partial nephrectomy.
Results: Robotic partial nephrectomy was done safely. Total operative time was 4 hours. ischemia time was 19 minutes. There was minimal blood loss. No known complications. pathology of the mass revealed cystic nephroma. Hypertension improved after the surgery.
Conclusions: Partial nephrectomy for renal masses can be done safely in pediatric age group using robotic approach.
Robotic Pyeloplasty in Malrotated Kidneys in Pediatric Patients
AA Elbakry, T Trump, K Aldabek, D Zekan, O Al‐Omar
Introduction & Objective: To demonstrate our approach for a challenging case of robotic pyeloplasty in a malrotated kidney in a pediatric patient.
Methods: Our patient is a 7 y.o. boy who presented for evaluation of incidentally diagnosed right hydronephrosis on an ultrasound that showed right grade 4 hydronephrosis which cortical thinning. Nuclear renal scan showed high grade of obstruction with split function of 50% of the right kidney. We proceeded with robotic right pyeloplasty. After mobilization of the hepatic flexure of the colon and exposure of the medial aspect of the kidney, the kidney was found to be malrotated with renal pelvis facing posteriorly. The Lower pole of the kidney was mobilized to gain access to the UPJ. Extracorporeal hitch stitch was placed through the renal pelvis for better exposure of the UPJ. Dismembered pyeloplasy was performed and a stent was placed in an antegrade fashion.
second patient is a 15 y.o. who was found to have right side grade 4 hydronephrosis that was ordered by her PCP for investigation of abdominal pain and US showed lower pole 10 x 5 mm stone. we followed the same approach as the first case for dissection and exposure of the UPJ. In this case, we did non‐dismembered approach "Y‐V Plasty". Also, the stone was removed using a flexible ureteroscope through the assistant port.
Results: Procedure was completed successfully in both patients with no complications. Operative time was around 2 hours and 30 minutes in both cases. Very minimal blood loss was estimated. Both patients were discharged home in less than 24 hours.
Conclusions: Robotic approach is a feasible option for pyeloplasty in pediatric patients with abnormal anatomy such as malrotated kidney.
Robotic Ureteral Reimplantation with Mitrofanoff Appendicovesicostomy Catheterizable Stomacreation in a Pediatric Patient
AA Elbakry, T Trump, K Aldabek, D Zekan, O Al‐Omar
West Virginia University Hospital
Introduction & Objective: To demonstrate our technique for simultaneous ureteral reimplantation for vesicoureteral reflux, and creation of Mitrofanoff "appendico‐vesicostomy" catheterizable stoma using robotic approach.
Methods: Our Patient is an 8 y.o. boy with a history recurrent febrile UTI, and severe dysfunctional voiding causing recurrent urinary retention. Urinary retention was initially managed with indwelling suprapubic catheter. US showing bilateral hydronephrosis (Grade 3 on the right and Grade 1 on the left), which slightly improved after SPT placement. VCUG showed bilateral vesicoureteral reflux (grade 4 on the right and grade 1 on the left). MRI spine was done and was negative. We decided to proceed with robotic right ureteral reimplantation for right grade 4 VUR, with catheterizable stoma creation foe management of urinary retention. The video demonstrates our approach in a stepwise fashion.
Results: The surgery was completed safely in overall time of 4 hours and 40 minutes. we estimated minimal blood loss. there was no complications intraoperatively and in the early postoperative period. Normal follow‐up US at 8 months post‐op with no hydronephrosis bilaterally. VCUG at 4 months post‐op showed complete resolution of bilateral VUR. No febrile UTI was reported after the surgery with follow up of 14 months.
Conclusions: Robotic approach is a versatile tool that can be employed in complex reconstructive surgeries in pediatric patients.
Treatment of Large Paediatric Stone with Flexible Ureteroscopy and Laser Lithotripsy (FURSL) and Ureteral Access Sheath (UAS)
F Ripa, V Massella, A Pietropaolo, S Griffin, BK Somani
University Hospital Southampton NHS Foundation Trust
Introduction & Objective: Urolithiasis in paediatric patients has dramatically increased in the last two decades. It has been demonstrated that flexible ureteroscopy and laser lithotripsy (FURSL) is an effective and safe procedure with high stone‐free rates for the management of large paediatric stones. The use of a ureteral access sheath (UAS) in paediatric patients with large renal stones is increasingly considered safe. UAS is intended to facilitate multiple passage of the flexible ureteroscope, to allow continuous drainage of renal cavities, better visibility and lower intra‐renal pressures and temperature.
Methods: We present a case of a 8‐year‐old female child suffering from recurrent UTIs and referring to our centre for a 17mm right renal pelvis, non‐obstructing calculus documented by urinary tract US. Her metabolic screening was normal and she presented with a borderline renal function (serum creatinine 63 micromol/L, eGFR 80mL/min).
Results: After standard cystoscopy, a safety guidewire was inserted via the ureteral orifice to right renal pelvis. A rigid ureteroscopy (6.5/8.5Fr) was performed and the ureter appeared easily able to accommodate ureteroscope. A working guidewire was then placed. A 9.5Fr ureteral access sheath (UAS) was inserted over guidewire under radiological guidance. Then, a 7.5Fr flexible ureteroscope was used to explore the renal cavities. A soft, infection‐type stone with a harder composition in the middle was found at renal pelvis. A 15 minutes laser lithotripsy was carried out (0.5‐0.8J, 30‐45Hz, total energy 15.9 kJ). Small fragments and debris were removed with NGage nitinol basket. Renal calyces were explored both endoscopically and with contrast. Only soft debris <2mm remained. Ureteric access sheath was removed under direct vision with good appearance of ureteral mucosa. A 5Fr overnight ureteric catheter was placed into renal pelvis. The overall operating time was 50 minutes. There was no intra‐ or post‐operative complications. The catheters were removed the next morning and the patient was sent home.
Conclusions: The use of a UAS in the setting of FURSL for large paediatric stone treatment is increasingly getting popular. Its benefits might overcome the concerns about potential ureteral damages. The use of UAS in the paediatric population is safe and achieves good outcomes for treatment of large kidney stones. Avoidance of excessive force and systematic visual assessment of the entire ureter on completion of the procedure are mandatory.
Simultaneous Bilateral Flexible Ureteroscopy Step by Step
R Marom, R Ben‐David, I Masarwe, N Bar‐Yaakov, Z Savin, H Herzberg, O Yossepowitch, M Sofer
Department of Urology, Tel Aviv Medical center
Introduction & Objective: Bilateral renal stones are encountered in up to 15% of patients with nephrolithiasis. Same‐session procedures, one side after the other, have been reported with good results, while simultaneous bilateral procedures have been reported mostly for flexible ureteroscopy (FURS) one side and percutaneous nephrolithotomy (PCNL) the other. We aimed this video to present a further extension of simultaneous bilateral endourological surgery, assessing our experience with simultaneous bilateral flexible ureteroscopy (SBFURS) and describing the approach step by step.
Methods: SBFURS was performed in 15 consecutive patients with bilateral urolithiasis between January 2020 and March 2022. Demographics, clinical data, and outcome of this group was compared with matched groups of same‐session bilateral and separate sessions bilateral FURS. Statistical assessment and video recording were performed.
Results: The results are presented in the table. SBFURS was a statistically significant shorter procedure than same‐session FURS (p = 0.002) and cumulative operating time of separate sessions (p = 0.00002). In comparison to separate sessions it also has a shorter hospital stay (p = 0.04E‐14) and obviously needs less anesthesia sessions (p = 0.01E‐12). SBFURS represents an excellent approach for teaching, allowing mentoring of two residents and adaption of the difficulty to their level of training. There were no differences between the comparison groups in terms of complications and stone free rates.
Conclusions: SBFURS is feasible, assuring shorter operative time, hospital stay, and fewer working days lost, without compromising safety and effectiveness. It provides excellent teaching advantages. SBFURS may be limited by the need for duplication of resources in terms of surgeons, instruments and appliances, and its cost effectiveness remains to be further determined. We hope that our presentation is contributing to the promotion and establishment of this procedure.
HTL Hybrid Thulium Laser miniECIRS with Enhanced Vacuum Cleaner Effect
F Mele, M Barale, R Migliari
Introduction & Objective: The “mini‐ECIRS” technique is a less invasive alternative to endoscopic combined intrarenal surgery (ECIRS). Recently, there has been renewed interest in mini‐ECIRS due to the emergence of next‐generation thulium lasers (HTL) that can rapidly pulverize large stones through these smaller tracts.
We developed a new reusable device, named Endo‐cleaner, which potentiates the adhesion of stone fragments in the eddy while the fluid flow is circulating around the stone offering a faster and better fragmentation and evacuation of the stones.
Methods: In this video we show the case of a patient with two left pelvic stones of 1.5 and 2.5 cm treated with a mini‐ECIRS approach with the Nagele nephroscope.
Patient was in Valdivia‐Uria modified supine position and the access to the stones was obtained using a mixed ultrasonic and X‐ray guidance to the lower left renal calyx. After fascial dilatation a 16 F working channel of the Nagele nephroscope was inserted.
Through the working channel of the nephroscope was inserted the Endo‐cleaner device containing a 550micron HTL fiber.
Results: The Endo‐cleaner is a laser holder fiber, shorter than the working channel of the nephroscope, with a lateral suction channel connected with a tube to a portable medical sucker. A plastic stopcock is used to adjust or cut off the suction.
The most common devices found in the market use irrigation to passively extract stones out of the sheath; depending on the system, stone extraction is aided by the Bernouilli vacuum cleaner effect, active suction, or baskets/ graspers.
Endo‐cleaner device, which allocate the laser fiber inside, can continuously suck stone debris during laser fragmentation. Suction during mini‐ECIRS has the advantage of keeping the stone close to the laser fiber, which can increase fragmentation efficiency.
Moreover, our suction device let to remove larger fragments when the scope is withdrawn past the working cannula as the suction through the laser fiber holder enhances the classic so called “vacuum cleaner effect”.
Finally, It helps to stabilize the laser fiber and gives a firm and better grip on it avoiding to manage the fiber with two fingers.
Conclusions: This video illustrates and explains the usefulness of our Endo‐cleaner device which potentiated the vacuum cleaner effect present in the Nagele nephroscope system, offering the benefit of quick and complete stone removal described.
Streamline Your Access: An Easy Ureteroscopically Guided Retrograde Approach to Achieving Reliable Through and Through Percutaneous Renal Access
RJ Brunner, A Antar, R Link, W Mayer
Baylor College of Medicine
Introduction & Objective: (Video Abstract)
Methods: (Video Abstract)
Results: (Video Abstract)
Conclusions: (Video Abstract)
Endoscopic Combined Intrarenal Surgery in Patients with Renal Calculi Using Suction and High Energy Laser Devices (Thulium and Holmium‐Moses)‐ Point of Technique and Video Demonstration of 2 Such Cases
NJ Pathak, A Singh, A Ganpule, R Sabnis, M Desai
Muljibhai Patel Urological Hospital, Nadiad
Introduction & Objective: Endoscopic Combined Intrarenal Surgery(ECIRS) is a combination of standard tract supine Percutaneous Nephrolithotomy (PCNL) and Retrograde Intrarenal Surgery (RIRS) procedure. With minor modifications of PCNL to mini PCNL with addition of suction and using high energy laser devices of Thulium and Moses Holmium laser systems, we aim to do a step‐by‐step video demonstration of 2 such cases to show better vision since suction and irrigation both are under surgeon control, reduced operating times and reduced sepsis incidence due to reduced intrarenal pressures, all translating into better stone free rates.
Methods: Out of the multiple cases undergoing ECIRS at a single tertiary center, 5 cases were selected where suction was used with mini PCNL and RIRS and stone lysis was done with high energy laser sources of Thulium and Moses Holmium laser system, out of them we have selected 2 cases for video demonstration. The patient preoperative and postoperative details were recorded with the intraoperative video recording.
Patients in Galdakao‐modified supine Valdivia (GMSV) position. Mini PCNL with Shah Suction sheath. Ureteral access sheath and Retrograde intrarenal surgery(RIRS) with Biorad Medisys Indoscope and Boston Scientific Lithovue as digital flexible disposable ureterorenoscope. Lithotripsy using Moses Lumenis 120 watt high‐power Holmium laser fibre and UROLASE SP SuperPulse Thulium laser fibre.
Results: ECIRS has advantages of PCNL done in supine position. Mini PCNL reduces tract size related patient morbidity. Mini PCNL with suction reduces operating time and intra‐renal pressure and improves field of vision. ECIRS also has benefits of RIRS as a supplement to PCNL which provides stone clearance in difficult to reach calyces, has access sheath which reduces intrarenal pressure. Using high energy laser devices such as Thulium and Moses Laser systems through both mini PCNL and RIRS simultaneously as mentioned above provides for faster stone fragmentation and reduces operating times along‐with the inherent benefits of laser lithotripsy versus other modalities of lithotripsy.
Conclusions: ECIRS using mini PCNL with suction and flexible disposable digital ureterorenoscope with high energy laser devices is an easy, safe, efficacious option for larger stones providing high clearance rates with a single surgery and minimal patient morbidity.
Miniaturized Surgical Treatment of Staghorn Stone. Active Suction Sheath and Reduced Caliber Flexible Nephroscope
JM Lopez, R Matheu, R Castañeda, L Peri, A Alcaraz Asensio
Clinic Hospital ‐ Barcelona University / Teknon Hospital ‐ Quiron Salud
Introduction & Objective: According to EAU/AUA guidelines Nephrolitotomy (PCNL) is the standard treatment for stones larger than 20 mm, staghorn and partial staghorn calculi. Bleeding is a major complication related to the sheath size and number of tracts. Miniaturization of the instruments allows a reduction of percutaneous sheath and the use of flexible instruments reduces the need of accessory percutaneous access. Mini‐PCNL has emerged since 1997 as an alternative to PCNL with potentially less bleeding complications. Due to the reduction of percutaneous access sheath, mini‐PCNL has some potential limitation as increased operating time or increased intra renal pressures. Sheaths with suction can decrease the risk of sepsis and increase the stone free rate. We present a video of a mini PCNL using a suction sheath and miniaturized single use cysto/nephroscope.
Methods: We present the surgery of a 54 years old woman with right flank pain caused by a 4 cm staghorn right calculi related to a proteus mirabilis infection. Urinary tract infection was treated previous to surgery. The procedure was performed using a 18 Fr suction sheath, a 12 Fr Rigid Nephroscope and 14,4 Fr single use cysto/nephroscope with a 550 um Holmium laser fiber.
Results: The active suction sheath increased the quality of vision during surgery and improved fragment removal faster and with almost no need for nitinol forceps or baskets. The use of a single‐use 14.4 Fr flexible cysto‐nephroscope made it possible to reach the upper and lower pole calyx without the need for accessory percutaneous access. Ho:YAG laser lithotripsy (2J 30 Hz, long pulse) was performed. Due to preoperatively documented urinary tract infection, a nephrostomy catheter was placed for 24 hours. Total operative time was 95 minutes. Preoperative Hb was 13.5 g/dL and postoperative 12.0 g/dL. The patient was discharged on the second postoperative day without incident.
Conclusions: Miniaturized suction sheaths may improve surgical outcomes and decrease bleeding risks of PCNL. This video demonstrates the feasibility of the suction sheath and the possibility of using a small‐bore cysto‐nephroscope to reduce the need for accessory percutaneous routes by reaching the peripheral renal cavities antegradely.
Ex‐Vivo Ureteroscopy for the Treatment of Nephrolithiasis in a Deceased Donor Kidney Prior to Transplantation
ml jamil, J Vernocke, P Etta, A Mohamed, M Butaney, M Bazzi, S Zetuna, L Malinzak, D Leavitt
Henry Ford Hospital
Introduction & Objective: There are over 100,000 adult patients awaiting renal transplantation in the United States, with less than 25% who undergo eventual transplantation. This disparity has motivated providers to seek ways to increase the number of kidneys available for transplantation. Historically, the presence of kidney stones in a renal allograft was a relative contraindication for renal transplantation. Ex‐vivo ureteroscopy, or, “back‐table ureteroscopy”, is a technique which has been employed as a potential solution to increase the total number of available kidneys which were initially deemed ineligible. We demonstrate our step by step technique for ex‐vivo ureteroscopy and to demonstrate its safety and efficacy as a method of stone removal prior to transplantation.
Methods: Following procurement and back table preparation of the donor kidney by the transplant surgery team, the kidney was replaced in an ice bath for ex‐vivo ureteroscopy. A combination of holmium laser lithotripsy and stone basketing were used to extract the stone. Following complete removal of the renal calculus, the renal allograft was reprepared and the renal transplantation was carried forth in the standard fashion by the transplant surgery team.
Results: The total operative time for the ex‐vivo ureteroscopy was 70 minutes. No intraoperative complications were identified during ex‐vivo ureteroscopy or during allograft transplantation. Six months following transplantation, the patients renal function remains normal.
Conclusions: Ex‐Vivo ureteroscopy can be a safe and effective treatment for the management of renal stones prior to transplantation. This method can be used with existing resources to increase the number of donor kidneys available for transplantation each year
Gradual Percutaneous Nephrolithotomy for Complete Staghorn Stone Can Reduce Complications and Improve Treatment Outcomes
J Feghali
KMC Hospital; Department of Urology; Jounieh Lebanon
Introduction & Objective: Standard Percutaneous Nephrolithotomy (PCNL) is the gold standard treatment for kidney stones larger than 2cm. Due to limited pyelocaliceal system space around a full staghorn stone, urologists might encounter difficulty to create a renal tract, bypass the stone and insert a guide wire down the ureter
Objective: Describe and evaluate a new technique that we call gradual PCNL defined as treating large stones in single procedure by MiniPCNL followed by standard PCNL through the same tract in order to reduce complications, perform the ideal tract and improve the stone rate (SFR).
Methods: From january 2019 to october 2021; 7 men with mean age of 60.6 years old, and complete staghorn stones were treated with gradual PCNL technique by single surgeon. Ureteral occlusion balloon cathter 34 Fr/100cm was inserted in lithotomy position in order to dilate the pyelocaliceal; followed by renal punction in prone position via an 18 gauge needle under fluoroscopic and/or ultrasound guidance. A 0.035 inch hydrophilic tip wire was then inserted in the pyelocaliceal system; followed by MiniPCNL technique in order to confirm appropriate punction, prevent traumatic dilation; open a stone window by laser or pneumatic lithotripsy and insert the wire down the ureter. Once the wire has reached the bladder, we removed the MiniPCNL operating sheath (15/18 Fr) and dilated the same tract with nephrostomy balloon catheter 30 Fr; then we switched to standard PCNL (using the nephroscope sheath 24 Fr) and removed the stone with ultrasonic lithotripsy. At the end of procedure a 7Fr/28cm ureteral stent was placed in an antegrade fashion, and 20 Fr nephrostomy tube was left in place.
Results: Mean Gradual PCNL operation time was 127 minutes; mean fluoroscopic time was 4.1min; nephrostomy tube was removed on day 1; all patients were discharged 48 hours after procedure; no blood transfusion was needed; mean hemoglobin drop after surgery was 1.12 g/dl; no major postoperative complications; SFR was 86% 1 month after surgery.
Conclusions: Gradual PCNL technique for complete staghorn stone is a single procedure that can facilitate renal access, prevent complications and improve stone free rate.
Optimization of 1.9mm Lithotripsy Probe in Mini‐percutaneous Nephrolithotomy
DC Rosen, M Drescher, NL Arias Villela, J Abbott, M Dunne, J Davalos
Introduction & Objective: Mini‐Percutaneous Nephrolithotomy (mPCNL) has gained greater acceptance in the United States in the past few years. Smaller tract size and further miniaturization of nephroscopes offer several potential benefits but may have limited efficiency due to the smaller diameter of the lithotripter that can be accommodated through the nephroscope while maintaining adequate fluid inflow. We sought to optimize the usage of a 1.9 mm lithotripsy probe within a 12Fr nephroscope, rather than the standard 1.5mm probe.
Methods: The Storz 12Fr French nephroscope with the 16.5/17.5 Fr access sheath was used and the procedure required three modifications in technique to maintain irrigation and accommodate the Trilogy 1.9 mm probe and handpiece. First, to provide adequate fluid inflow, a 11/13 Fr ureteral access sheath was placed retrograde into the ureter with a 10 French catheter placed inside the access sheath and attached to irrigation. Second, IV tubing was attached to the inflow of the nephroscope to accommodate the large Trilogy handpiece. Third, the 27001GG port was used to allow the 1.9mm probe to pass. Stones were extracted using a combination of the suction of the Trilogy and vacuum extraction via the renal access sheath.
Results: 27 patients underwent mPCNL with the 1.9mm Trilogy probe. An average 1D stone burden of 24mm and 3D stone burden of 455.8mm3 was removed, with 3D efficiency 34.2 mm3/min. Ergonomic and efficiency surgical satisfaction was rated a mean 4.75/5 by the operating surgeon. A sample case is presented in this video.
Conclusions: The 1.9mm Trilogy lithotripter presents an efficient alternative to laser‐based modalities for mPCNL potentially allowing for the treatment of even larger stones with comparable lithotripsy times. The lithotripters effect on irrigation inflow can be mitigated with procedural modifications that allow for excellent visibility and efficient stone extraction allowing larger stone burdens to be treated using smaller tract size and renal sheaths.
Continuous Monitoring of Intrapelvic Pressure Values During Flexible Ureterorenoscopy: A Technique Recommended by the RIRSsearch Working Group
□ Çınar, H Akgul, C Basatac, O Özman, H Cakir, E Sancak, A Gultekin, A Başeskioğlu, C Yazıcı, B Önal, H Akpinar
Introduction & Objective: Flexible ureterorenoscopy (F‐URS) is widely used in the treatment of upper urinary tract stones. Postoperative fever and urinary tract infection are the most common complications of F‐URS, and higher intrarenal pressure is thought be a factor in the formation of complications. The aim of this study was to measure in‐vivo intrapelvic pressure changes during F‐URS for upper urinary tract stones.
Methods: Pressure changes during F‐URS were recorded using a 6Fr angiography catheter (Boston Scientific, USA) placed over a guide wire (Sensor®, Boston Scientific, Natick, USA) that was advanced retrogradely from the ureteral orifice to the renal pelvis. Intrarenal pressures were monitored during standard continuous flow, during continuous flow with a laser probe (272 μm) in the working channel, and when using a hand pump. In addition, intrarenal pressures were monitored while dusting and pop‐corn methods were used for stone fragmentation.
Results: During F‐URS, intrapelvic pressure varied between 9‐70 mmHg (12.23‐95.16 cmH2O). The intrapelvic pressure was 9 mmHg (12.23 cmH2O) at the time of first entry into the renal pelvis, the highest pressure was measured as 70 mmHg (95.16 cmH2O) when the working channel was empty and the hand pump was pressed. Intrarenal pressure remained stable during stone fragmentation and was recorded as 14‐15 mmHg (19.03‐20.39 cmH2O).
Conclusions: During F‐URS, intrapelvic pressure monitoring was performed and recorded in‐vivo using a 6Fr angiographic catheter for the first time in the literature. Thanks to its easy application feature, this new technique can also be used in studies on RIRC and will contribute to the literature.
Ultra‐low‐dose Intraoperative CT Imaging During Endoscopic Stone Surgery
XG Glover, M Sawyer, E Ballon‐Landa
University of Colorado School of Medicine, Division of Urology
Introduction & Objective: Stone‐free status after percutaneous nephrolithotomy (PCNL) is a marker of treatment quality. Two groups described use of a robotic biplane fluoroscopy system (Artis Zeego, Siemens) for intraoperative CT during PCNL. A series of 20 prone PCNLs was reported with median CT effective radiation dose (ERD) of 6.7 mSv. We report initial results of an IRB approved QI study intended to reduce both need for further surgery and total radiation exposure.
Methods: Stone‐free status after percutaneous nephrolithotomy (PCNL) is a marker of treatment quality. Two groups described use of a robotic biplane fluoroscopy system (Artis Zeego, Siemens) for intraoperative CT during PCNL. A series of 20 prone PCNLs was reported with median CT effective radiation dose (ERD) of 6.7 mSv. We report initial results of an IRB approved QI study intended to reduce both need for further surgery and total radiation exposure.
Results: A series of 6 PCNLs and 5 retrograde ureteroscopy procedures were performed between 8/2021 and 02/2022 in a hybrid operating room with intention to perform intraoperative CT. In all cases, excellent 3D imaging was achieved with a median ERD for CTs of 1.66 mSv. Median stone burden was 2.35 cm in the cohort: 2.7 cm in the PCNL group and 2.3 cm in the URS group. Stone burden in all cases was > = 10 mm except for a stone in a transplant kidney (5 mm), who was included because percutaneous treatment was a consideration. Median BMI was 27.2 (20.4‐36.2).
Conclusions: We report the first experience for intraoperative ultra‐low dose CT imaging during endoscopic stone surgery. Extremely low doses reasonably allow additional CT scans during an initial procedure, if further treatment is indicated. Our facility is first in the world to establish intraoperative CT as a standard care for elective PCNL to reduce radiation for patients.
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VID4: BPH, Laser, Miscellaneous
Endoscopic Incisional Uses of Thulium Laser Fiber in Upper Urinary Tract Strictures
AS Sadiq, J Khusid, WM Atallah, M Gupta
New York University School of Medicine Long Island
Introduction & Objective: Endoscopic laser incision of upper tract strictures is a minimally invasive option usually utilizing the Holmium:YAG laser. The thulium fiber laser (TFL) has an effective ablation and coagulation profile that has been successfully applied for prostate enucleation and en bloc bladder tumor excision, and may make it a new option for laser incision of strictures. We review our experience and outcomes using the TFL for treatment of upper tract strictures.
Methods: Our prospectively maintained Endourology database was queried and 15 patients with mean age of 56 underwent endoscopic stricture incision with TFL from February 2020 to January 2021. Preoperative imaging consisted of CT scans, renal scans, and ultrasonography. The procedure was performed ureteroscopically using a 200u fiber with settings of 1J and 20 Hz. Only patients with a short (< 2cm stricture) were considered candidates. Post‐operative imaging was then compared to assess radiologic resolution, improvement, or worsening.
Results: Of the cohort, 3 had calyceal diverticula and 12 had ureteral/ureteropelvic junction (UPJ) strictures. Of these, 8 (53%) had a prior history of ureteroscopy or percutaneous nephrolithotomy, 2 (13%) had robotic reconstruction, and 2 (13%) had open reconstruction. The most common indications for surgery were stones (87%), hydronephrosis (80%), and pain (66%). Ureteral strictures were encountered at the UPJ (9), ureterovesicular junction (1), mid ureter (1), and ileal ureteral anastomosis (1). Of 12 patients with ureteral/UPJ strictures, 10 had a ten‐week post op CTU/ultrasound; 6 (60%) had resolution and 4 (40%) had improved hydronephrosis. Of 3 patients with calyceal diverticulum, all had resolution of symptoms with ten‐week post op ultrasound with no evidence of stone or diverticulum reformation. Of the entire cohort, 3 patients had six month post op imaging; all demonstrated maintained resolution of hydronephrosis. Every patient was discharged same day with no reported post‐operative complications.
Conclusions: Endoscopic laser incision of ureteral strictures using TFL may be a feasible method of managing strictures requiring a minimally invasive approach. It is versatile and can be applied to treating many areas of the upper tract including calyceal diverticula, UPJ obstruction, and strictures at ureteroenteric anastomosis. Preliminary results on short term outcomes are encouraging and more long term follow up will be required to better define the TFL's potential.
Robot Assisted Laparoscopic Adrenalectomy in Adrenal Masses: A Prospective Evaluation
A Kumar, Y Prashanth, S Kumar, K kapoor, S Iyer, P Singh
Department of Urology, Robotics and Renal Transplant, SJH and VMMC, New Delhi
Introduction & Objective: The minimally invasive approaches are becoming popular in treatment of adrenal masses,including complex adrenal masses . We prospectively evaluated the outcomes of Robot assisted laparoscopic adrenalectomy(RALA) in adrenal masses(including complex adrenal masses).
Methods: All consecutive patients undergoing RALA (using da‐vinci Xi Robotic system)for adrenal masses by a single surgeon between October 2019 and September 2021 at our institution were included . The various clinical data were recorded and analyzed. We are presenting video of one such case of a complex adrenal mass with retrocaval extension and adherent to renal hilum.
Results: A total of 37 patients were included in the study. The mean age was 51. 2 years with male /female distribution of 4/5 . The mean tumor size was 6. 1 cm. The indications for surgery included : Incidentaloma(Non functioning , more than 6 cm)‐ 42.1%,,Adrenal carcinoma −21%,Adrenal Cushing syndrome −10.5% ,Pheochromocytoma −33. 3%. The mean operating time and estimated blood loss were 101. 5 min and 137. 5 ml respectively . There was no conversion to open . The mean hospital stay was 2. 3 days. The intraoperative complication was seen in only 1 patient( Clavien 1 – 2) with no postoperative complications. In histopathology adrenal cortical carcinoma ,adenoma , pheochromocytoma and ganglioneuroma were seen in 21%,33. 3%,33. 3% and 11. 1% respectively
Conclusions: Robot assisted laparoscopic adrenalectomy adrenalectomy for adrenal masses is feasible,effective with acceptable complications and good perioperative outcomes. However,it is a technically challenging procedure and should be done by surgeons of significant expertise.
Single Port Robot‐assisted Laparoscopic Adrenalectomy via Mini‐Pfannenstiel Incision
J James, A Rai, JM Gaines, EJ Macdonald, M Vira
CUNY School of Medicine
Introduction & Objective: The field of urology has been increasing the use of robotic assistance in laparoscopic surgery for the past two decades. Particularly, single port robot‐assisted laparoscopic surgery has been performed more frequently because it minimizes the invasiveness of surgery, leads to fewer scars, less pain, and faster recovery. Previous studies have demonstrated the feasibility of such surgery for adrenalectomies; however, none of have reported this type of surgery using a mini‐Pfannenstiel incision.
Methods: A single port robot‐assisted laparoscopic left adrenalectomy was performed through a 2.5cm mini‐Pfannenstial incision on a 23‐year‐old female patient with a history of Cushing's syndrome secondary to a left adrenal adenoma. The patient had a full endocrine workup due to amenorrhea for one year and was referred by her endocrinologist to urology after magnetic resonance imaging revealed a 2.7cm left adrenal mass. The patient was positioned in a flank position with the left side up.
Results: Surgical steps were the same as standard single port robot‐assisted laparoscopic adrenalectomy except for the observed more caudal vantage point given the orientation of the robotic trocar through the mini‐Pfannenstiel incision. The adrenal gland and tumor were resected and extracted using a 10mm EndoCatch bag. The patient was discharged post operative day 3 with no complaints of pain and stable vitals with hydrocortisone and prednisone for one month. The pathology report was consistent with a 3.5cm adrenal cortical adenoma and reported negative resection margin for tumor.
Conclusions: The single port placement through a mini Pfannenstiel incision provides a less visible incision, which may be used for a variety of upper tract procedures. Care must be taken as this vantage point does have some alterations in tissue orientation when compared to standard port placement. With increasing popularity in single‐port urologic surgeries, this new technique further minimizes the invasiveness of surgery, the number of incisions, and increases the overall cosmesis.
Bilateral Retrograde Intrarenal Surgery (RIRS) in Patient with Bricker Heterotopic Urinary Diversion and Kidney Stones
Ej Politi, H Sanguinetti, M Lopez Silva, P Alvarez, S Battiston, M Colicigno, N Bernardo
Hospital de Clínicas
Introduction & Objective: Urolithiasis in patients with urinary diversions is rare and a true challenge for endourologists. The objective of this video is to show a Retrograde IntraRenal Surgery (RIRS) in a patient with Bricker heterotopic urinary diversion and bilateral kidney stones.
Methods: A 75‐year‐old man with a history of bladder cancer treated with radical cystoprostatectomy and Bricker (uretero‐ileal) urinary diversion presented three years after surgery with bilateral kidney stones. The patient complained of lumbar pain. Computed tomography scan showed a 16 x 4 mm lithiasis in the lower calyx of the left kidney and a staghorn lithiasis of the lower calyx with extension to the renal pelvis in the right kidney. Bilateral RIRS was performed simultaneously using a LithoVue™ single‐use digital flexible ureteroscope and holmium laser lithotripsy. The patient underwent two surgeries, with one month of difference between each one.
Results: Both surgeries were ambulatory. In both procedures, RIRS was first performed on the right kidney and then on the left. A limit of 60 minutes of surgery for each kidney was taken into account. After the first surgery, the patient was left with bilateral ureteral stent and in the second only with a left‐sided ureteral stent.
Conclusions: RIRS as management of kidney stones in patients with uretero‐ileal urinary diversion is a challenge and at the same time feasible, safe, and effective.
Combined HOLEP and Robotic Bladder Diverticulectomy for Recurrent Urinary Tract Infections and a Small Prostate
EJ Tavares, N Canvasser
UC Davis
Introduction & Objective: Bladder diverticuli are common in patients with bladder outlet obstruction. However, surgical removal is only warranted in patients who are symptomatic, most commonly with recurrent urinary tract infections. At the time of bladder diverticuli removal, performing a concurrent outlet procedure is typically recommended to correct the high pressure voiding and prevent recurrent diverticuli.
For patients with large prostates, a robotic simple prostatectomy can be performed at the time of robotic bladder diverticulectomy, but may require a separate cystotomy depending on the size and location of the diverticular os. Alternatively, for patients with small prostates, or if the diverticular os is not an ideal size or location, holmium laser enucleation of the prostate (HoLEP) could be considered, given similar functional outcomes to a simple prostatectomy.
Methods: We present a combined HoLEP and robotic bladder diverticulectomy.
Results: The patient is a 74 year old male with a large left bladder diverticulum, recurrent UTIs, and bladder outlet obstruction due to a small 18 g prostate. We first performed a two‐lobe HoLEP. Total enucleation time was 40 minutes and morcellation time was 3 minutes. A 3 and 9 o'clock bladder neck incision were made at the end of enucleation given the small gland size, to decrease the risk of bladder neck contracture. After morcellation, he was prepped for the robotic bladder diverticulectomy. During the initial part of this portion, his catheter was kept on mild traction as we did not want to run CBI during the robotic portion. The diverticulum was successfully excised. The os was approximately 5 cm in diameter, on the left lateral wall near the trigone. A 2 layer closure was performed. The patient was discharged home on post‐operative day (POD) #1. A CT cystogram on POD #6 confirmed no leak with an appropriate HoLEP defect in the prostate fossa. He passed a voiding trial and has remained without any further issues.
Conclusions: Combined HOLEP and Robotic bladder diverticulectomy is an appropriate procedure for patients with symptomatic bladder diverticulum, who have small prostates, or in patients where an additional cystotomy is required to perform a simple prostatectomy.
Indocyanine Green Assistance During Robot Assisted Radical Cystectomy: A Challenging Case in a Patient with a Transplanted Kidney
A Beksac, J Kaouk, S Hemal, M Abou Zeinab, A Kaviani, E Ferguson, M Eltemamy
Glickman Urological & Kidney Institute, Cleveland Clinic
Introduction & Objective: In this video, we are a challenging case of robot‐assisted radical cystoprostatectomy (RARC) in a patient with a transplanted kidney. The patient is a 59‐year‐old male with Bacillus Calmette‐Guerin refractory pT1 high grade urothelial carcinoma of the bladder. He has a past surgical history of kidney and pancreas transplantation. His graft was functioning very well and creatinine was 0.83 mg/dl.
Methods: The patient was positioned in the low lithotomy position with Trendelenburg. We started the case with dissection of the rectovesical pouch to the prostatic apex. Next, the Retzius space was entered from the right side without dropping the bladder. The right sided pedicle was taken down using a vessel sealer. The space of Retzius was then entered from the left side. At this point, a cystoscope was used to insert a ureteral catheter into the ureter and inject indocyanine green. The ureter was identified with the assistance of the Firefly mode. The ureter was then dissected circumferentially and the ureter was clipped as distally as possible. The plane between the bladder and the kidney was dissected and the left sided pedicle taken down with the vessel‐sealer. The bladder was then dropped, the dorsal venous complex was sutured and then transected. The urethra was clipped and transected and the specimen was free. Bilateral pelvic lymph node dissection was completed. Diversion was done via ileal conduit and anastomosis was performed using the Bricker technique. An 8F double J ureteral stent placed in the ureter.
Results: The surgery was completed successfully without intraoperative complications in a total of 3 hours for the cystectomy and 2 hours for the intracorporeal urinary diversion. No transfusions were needed. The patient was discharged on postoperative day 3 after drain removal. No complications were seen. Ureteral stent removed at postoperative one month. Postoperative 3 months imaging was unremarkable.
Conclusions: This video demonstrates a stepwise technique for the challenging scenario of RARC in a patient with a transplanted kidney. Indocyanine green is a useful tool for the identification of the ureter in complex surgical situations such as cystectomy in the presence of a transplanted kidney.
Ureteroscopic Removal of Fungal Balls Using ClearPetra Vacuum Assisted Access Sheath
DG Wong, R Venkatesh, K Sands
Washington University in Saint Louis
Introduction & Objective: Solid fungal masses, also known as fungal balls, can be difficult to eradicate from the urinary tract. ClearPetra vacuum assisted access sheaths are a new tool which has promising utility for removing dust and wispy debris.
Methods: Here we present a case in which we use a ClearPetra Ureteral Access Sheath to remove debris in a patient with persistent fungal balls and candiduria. 12‐14fr 46cm access sheath was used. Suction set to ‐200mmHg.
Results: Video as Shown. Total Case length 1 hour 25 minutes
Conclusions: ClearPetra ureteral access sheaths can help facilitate ureteroscopic removal of fungal balls. This can obviate the need for more invasive percutaneous removal.
A New Minimally Invasive Anatomic Enucleation of the Prostate with Hybrid Thulium Laser
F Mele, M Barale, R Migliari
Introduction & Objective: In this video we show our experience on symptomatic patients with BPH who underwent an innovative prostate enucleation technique seeking the preservation of ejaculatory function, using a low‐energy hybrid Thulium laser and a minimally invasive system with smaller caliber instruments.
Methods: The equipment included a Thulium pulsed laser (HTL Revolix) with a 550‐μm end fire laser fiber used through a slim (22 Ch) continuous‐flow resectoscope (RZ Medizintechnik GmbH) and a fiberoptic morcescope in combination with the outer sheath.
The technique adopted, with a special attention to preserving ejaculatory function, involves the following \steps in order to improve the ejaculatory outcomes: preservation of the bladder neck, preservation of the entire posterior urethral plate, and respect of the ejaculatory hood and of the external urethral sphincter.
The technique is based on low energy (0.5 J) laser emission for the incision and bleeding control. A mechanical blunt dissection is preferably used to clear the adenoma from the pseudocapsule.
Results: The surgical technique described has already been used in over 100 anatomic enucleation with continuous thulium laser and standard instruments, with excellent results in the voiding parameters and in the preservation of ejaculation.
We report the preliminary results of the advanced technique with the use of low‐energy HTL and miniaturized instruments performed on 5 patients.
Maximal flow rate and post‐void residual passed from an average of 8.1 ml/min and 120 ml pre‐operatively to 20.6 ml/min and 16 ml one month after. IPSS and QoL score dropped from 20.4 and 4.1 to 5.7 and 1.5 postoperatively. It has not yet been possible to evaluate the recovery of ejaculation for the premature follow‐up.
No significant complications were recorded in any surgery. There was no need to convert the intervention to a standard technique.
Conclusions: Our anatomical enucleation of the prostate shown in the video is a safe and innovative endoscopic procedure; it combines minimally invasiveness of the surgical technique with low total energy emission while offering to the patients optimal functional results .
Robot‐Assisted Repair of Benign Distal Ureteroenteric Strictures Following Radical Cystectomy
V Maxon, A Goh
Tripler Army Medical Center
Introduction & Objective: This video aims to provide a step‐by‐step approach for robot‐assisted repair of benign distal ureteroenteric strictures (UES) following radical cystectomy (RC).
Methods: We demonstrate the feasibility and safety of robotic repair through two clinical scenarios after different forms of diversion and open primary surgery. The cases demonstrate increasing complexity and advanced reconstruction including appendiceal interposition. UES repair is performed in the setting of an open Indiana pouch and a repeat repair after RC and ileal conduit (IC). The patients were placed in the modified lateral position with right side up. Port placement was directed at the right lower quadrant. The steps of the operation consist of extensive lysis of adhesions, mobilization of the diversion and ureter, identification of the UES, excision of ureteral scar tissue and spatulation, assessment of ureteral perfusion using indocyanine green (ICG) fluorescence and the creation of a tension‐free and watertight anastomosis.
Results: Both cases were completed successfully without the need for open conversion. There were no intraoperative complications. Operative times ranged from 180‐273 minutes. Estimated blood loss ranged from 10‐50ml. All patients were discharged on postoperative day 1. No major complications occurred within 90 days of discharge. Renal function remained stable in both patients at 6 weeks postoperatively. Patients were followed with functional renal imaging at 3 months postoperatively.
Conclusions: Robot‐assisted repair of UES is feasible and safe, even in the setting of extensive prior open abdominal surgery. This is the ideal approach for UES repair because it requires less mobilization of surrounding structures, allows for intraoperative ureteral assessment with ICG fluorescence and can successfully create a tension‐free and watertight anastomosis. Our patients recovered quickly and without complications.
Embolization Material Erosion into Renal Collecting System and Its Association with Nephrolithiasis
SQ Perkins, I Chen, M Butaney, S Schwartz, D Leavitt
Vattikuti Urology Institute, Henry Ford Hospital
Introduction & Objective: Renal angiomyolipomas (AML) are common, benign solid tumors of the kidney. Depending on the size and patients' symptoms, treatment options of AMLs consist of surveillance, nephron sparing surgery, or transarterial embolization. Embolization has been favored as it preserves renal parenchyma. Angioembolization for renal AML has a good safety profile however it has been associated with some complications including post embolization syndrome and embolic events. In this video, we demonstrate a previously undocumented phenomenon of erosion of embolization into the collecting system after renal AML angioembolization.
Methods: A 58‐year‐old female presented in 2018 for intermittent episodes of gross hematuria. She underwent computed tomography (CT) imaging which confirmed large macroscopic fat containing mass consistent with right renal AML. After joint decision‐making, the patient was recommended to Interventional Radiology (IR) and underwent a successful transarterial embolization with an admixture of Lipiodol® and 98% dehydrated ethanol. She continued to follow without any complications until she represented in 2020 with gross hematuria. CT imaging showed involution of right AML, however new hyper‐dense material within the collecting system was demonstrated. This was theorized to be nephrolithiasis versus extrusion of embolization material.
Results: Patient elected to undergo ureteroscopy, laser lithotripsy, and stone basketing. As the video demonstrates, shell like stones were found, as well as active erosion of what appeared to be embolization material into the collecting system. The embolization material had small calcifications stuck to it while swirling in the collecting system. Aspiration of the material was performed through the ureteroscope and sent for fluid analysis, but results were inconclusive.
Conclusions: Lipiodol® is known to remain in tissues for long periods of time; however, to the authors knowledge no prior videos of Lipiodol® eroding or migrating into the renal collecting system have been reported. Additionally, the embolization material appeared to have small calcifications attached to it and could have acted as a nidus for stone formation. This is an important consideration of the patient, urologist, and interventional radiologist when proceeding with selective embolization for renal AML.
Thulium Laser Fiber Performance for Simultaneous Treatment of a Ureteral Tumor, a Ureteral Stone, and a Kidney Stone: The Sky Is the Limit!
WE Ito, KE Schmanke, BB Whiles, W Molina
The University of Kansas Medical Center
Introduction & Objective: To demonstrate the versatility of the Thulium Laser Fiber (TLF) in the treatment of a simultaneous ureteral tumor, a ureteral stone, and a kidney stone.
Methods: A 44‐year‐old female patient was evaluated after an episode of right pyelonephritis. Past medical history was positive for morbid obesity (BMI 50.5), hypertension, and depression. She denied gross hematuria or weight loss. Family history was negative for malignancy. She had a history of multiple ureteral stents and six previous ureteroscopies/laser lithotripsy. She quit smoking 7 years ago but was still drinking alcoholic beverages (2 drinks/week). Ultrasound demonstrated right kidney hydronephrosis and two stones (1.5cm in the proximal ureter and 1.2cm in the lower pole). A CT‐Scan confirmed previous results. Ureteroscopy incidentally showed a distal ureteral tumor with papillary projections. Specimens were collected for pathology. For tumor ablation, we used TFL combined with a 200μm fiber, and settings to 1.0J, 10 Hz, and 10W of power. We continued with the same fiber to treat the ureteral stone, settings adjusted to 0.2J, 40 Hz, 8W. Next, a flexible ureteroscope was used to treat kidney stones. The ablation prevented the use of an access sheath. After stone repositioning, we continued using the same 200μm fiber, but with different settings: 0.3J, 120Hz, 36W. After stones treatment, a complete survey showed no additional tumors. Finally, a ureteral stent was placed.
Results: The pathology report revealed a benign urothelium, submucosal inflammation, and reactive changes. The Ho:YAG is the gold standard for most urological endoscopic procedures, but the TFL is a new technology, with numerous advantages over the Ho:YAG. The TFL offers a wider range of settings. Due to the electronic modulation, the pulse frequency in TFL can vary from 5 to 2400Hz and energy from 0.025 to 6J. TFL also allows smaller fibers (50 to 150μm), good precision, less retropulsion, and less back burn. Although the thermal threshold for ureteral lesions has been reported to be 42°C ‐ ∼20W with TFL ‐, less than 10W in power is recommended. Aiming for resection and hemostasis, we recommend a "high energy & low frequency" to ablate ureteral tumors. On the other side, stone treatment is best contemplated with "low energy & high frequency".
The problem with temperature is less significant when inside the pelvicalyceal system, and power up to 30‐36W is acceptable.
Conclusions: The goal of this video is to demonstrate how the TFL system can be adapted to manage three different but simultaneous endoscopic scenarios.
Metallic (Memokath™) Stent Removal: Tips and Tricks
F Ripa, V Massella, A Pietropaolo, BK Somani
University Hospital Southampton NHS Foundation Trust
Introduction & Objective: The positioning of a long‐term expandable metallic ureteral stent may be an appropriate and successful choice in dealing with ureteral obstructions resulting from malignant or benign strictures. Memokath™ is a thermo‐expandable, nickel‐titanium alloy spiral stent used to treat ureteric obstruction. We present a case of a challenging retrograde and antegrade approach for metallic stent removal.
Methods: A 59‐year‐old lady suffering from idiopathic retroperitoneal fibrosis resulting in a solitary functioning kidney and a total eGFR of 8 ml/min underwent a Memokath™ insertion in her right kidney in 2016. In 2020, due to stent obstruction and deteriorating renal function, a nephrostomy tube was placed. Despite this, her renal function did not improve and she was referred to our clinic for stent removal.
Results: A retrograde approach was attempted. However, the guidewire could not go beyond the mid part of the stent because of stent epithelisation. Therefore, a decision to proceed antegradely was made. In the interim, cold water was inserted through a ureteric catheter to the lumen of the stent in order to soften the coils. A 30Fr nephrostomy sheath was placed after balloon dilation. The proximal end of the stent was visualised and the stent removed with gentle traction through graspers. No active bleeding from the mucosa nor ureteral injuries were detected. A 10.2Fr nephrostomy was left in situ. 3 days after, an antegrade pyelogram showed ureteric passage of contrast; an antegrade standard stent insertion and nephrostomy removal were performed the same day.
Conclusions: The use of expandable metallic ureteral stents such as Memokath™ offers many advantages in selected cases of ureteric obstruction. Despite this, its encrustation and epithelisation might lead to stent malfunctioning and consequent impaired renal function. The retrograde removal of metallic stents might not be feasible due to stent encrustation and thus might require referral to high‐volume and experienced endourological centres for antegrade removal.
Management of Difficult Morcellation after Holmium Laser Enucleation of Prostate
N Leelani, M Elsaqa, MM El Tayeb
Cleveland Clinic Foundation
Introduction & Objective: Transurethral enucleation and morcellation of prostate has been used as an effective minimally invasive technique for the management of large prostates. We present different techniques that can be used to overcome difficult morcellation in some cases.
Methods: A case of significantly difficult morcellation was encountered after Holmium laser enucleation of Prostate (HoLEP).
Results: We present the different techniques used in this case to overcome difficult morcellation of prostatic tissue. Laser and Bipolar resection of the morcellated prostate tissue were used to cut the dense fibrous prostatic tissue.
Conclusions: Morcellation of prostatic tissue can be hard in some situations. Resection of morcellated Prostate tissue using both laser and bipolar electrocautery can be considered a safe alternative in complex cases.
Indocyanine Green ‐ Guided Laparoscopic Partial Nephrectomy for a 5.5 Cm Renal Mass
F Prata, A Civitella, P Tuzzolo, V Crimi, F Tedesco, A Ragusa, N Deanesi, L Cacciatore, A Testa, A Minore, F Esperto, R Scarpa, R Papalia
Department of Urology, Campus Bio‐Medico University of Rome
Introduction & Objective: Partial nephrectomy (PN) is the standard of care for renal masses, whenever the surgical procedure is feasible. In the majority of cases, it is performed by expert surgeons clamping the renal hilum, resulting in possible worsening of post‐operative renal function. Indocyanine green (ICG) is a sterile anionic water‐soluble molecule that rapidly binds to plasma proteins. In this video we evaluate the feasibility and safety of an entirely off‐clamp laparoscopic partial nephrectomy using ICG.
Methods: A 68 years old man was admitted to our department for a 5.5 cm left renal mass showed by CT scan. Preoperative serum creatinine was 1.43 mg/dl and eGFR was 80.4 ml/min. The patient was placed in right flank position. A transperitoneal approach was adopted. The left paracolic gutter was incised with monopolar scissors, exposing the renal profile. The renal hilum was not hisolated, but we only exposed the part of the kidney necessary to perform the tumor enucleation. The renal mass was exposed circumferentially, trying to respect the anatomical planes that surround the kidney. 25 milligrams of ICG were diluted with 20 milliliters of saline solution and 10 milliliters of the solution were intravenously in bolum injected thorugh periferal line 2‐3 minutes before enucleation. Then, the renal parenchyma was incised with monopolar scissors and the enucleation of the mass was completed with the use of Ligasure, without the need of clamping the renal hilum. The procedure was carried out smoothly, and following the green light as a carpet we were able to easily distinguish between healthy tissue and the tumour during resection. The bleeding was controlled using the monochromatic vision, which allowed an intraoperative angiography and a point‐specific hemostasis. A single transfix stitch was used and hemostasis perfected with the use of Tabotamp.
Results: The procedure was successfully completed. Operative time was 80 minutes. Estimated blood loss was 200 cc. No intraoperative and postoperative transfusions were necessary. The patient was discharged 2 days after surgery. Serum creatinine and eGFR at discharge were 1.07 mg/dl and 107.5 ml/min, respectively. No complications or adverse events were registered due to the use of ICG.
Conclusions: Despite off‐clamp partial nephrectomy is a challenging procedure, it can be safely performed, even in non‐expert hands, using the ICG to better identify the cleavage plane.
Intraoperative Recognition & Management of an Iatrogenic Clipping of the Superior Mesenteric Artery During Robotic Left Cytoreductive Nephrectomy
BG Patel, DF Roadman, N Barashi, MG Biebel, A Chow, R Venkatesh, S Figenshau
Washington University in Saint Louis
Introduction & Objective: Ligation of the superior mesenteric artery (SMA) is a very rare, and often fatal complication of minimally invasive left nephrectomy (MILN). Despite its rare occurrence, urologists must be cautious when dissecting the left renal artery (RA) and vein (RV) in cases where surgical planes and vascular anatomy are distorted. We present a case of a 77 year old male with metastatic renal cell carcinoma who underwent a cytoreductive robotic left nephrectomy following immunotherapy.
Methods: The patient was placed in standard right decubitus position with the left flank flexed. Pneumoperitoneum was achieved with a Veress needle, and 4 robotic 8 mm ports were placed in a straight line along the lateral edge of the rectus with a 12 mm assistant port in the midline. After the colon was medialized, hilar dissection started with identifying the RV. A pulsation was seen cephalad and parallel to the RV. This vessel was dissected and presumed to be the RA. After the RA was ligated with one clip, the distal aspect of the vessel continued to pulsate. The left kidney and hilar region behind this clipped vessel continued pulsating, raising suspicion that we clipped the SMA. Adding to this suspicion was the anterior location of the artery, in contrast to the normal posterior location relative to the RV. Immediately, two needle drivers were inserted and the clip prongs were pulled in opposite directions to dislodge the locking mechanism. Total ischemia time was less than ten minutes, and the rest of the case was completed without incident. The specimen was extracted through a Gibson incision, and the patient was awoken from general anesthesia and brought to recovery in stable fashion.
Results: Procedure time was 4 hours and 2 minutes. Pathology revealed clear cell RCC, Furhman grade 4 with rhabdoid features and negative surgical margins. On the evening of POD#0, the patient's pain was well controlled, vital signs were stable, and abdominal exam was reassuring. On POD#1, the patient remained stable with no clinical deterioration. He was monitored and discharged on POD#2.
Conclusions: Ligation of the SMA during MILN is exceedingly rare, but can occur in several scenarios: post‐systemic therapy operative fields, cytoreductive settings, and large tumors distorting anatomy via mass effect. In such cases, the path of the SMA can be distorted and appear to head laterally towards the kidney. We favor clip placement over stapling to permit removal of the clips should such a complication arise. Urologists must know techniques to remove clips, including using the laparoscopic clip remover, cutting the locking mechanism off the clip, and pulling the prongs of the clip in opposite directions to dislodge the locking mechanism.
Prostatic Pockets: “REZUMing” Normal Voiding via HoLEP
WE Ito, BB Whiles, M Larson, DA Duchene, W Molina, D Neff
Department of Urology, University of Florida, Gainesville, FL, USA
Introduction & Objective: Water vapor thermal therapy (REZŪM) is a minimally invasive surgical option that utilizes convective thermal energy to destroy prostatic tissue. Likely secondary to low rates of surgical retreatment, little is described in the current literature regarding causes of persistent outlet obstruction. We demonstrate a rare REZŪM side effect and the feasibility of holmium laser enucleation (HoLEP) to treat it. We hypothesized this occurred due to differential blood supply to the prostatic urethral mucosa vs. the adenomatous tissue.
Methods: This is a video report that demonstrates identification, and treatment of intraprostatic pockets after REZŪM resulting in persistent obstruction. Due to its intrinsic rarity, surgical steps, materials, and intraoperative findings are described in a single patient.
Results: We present a case of a 70‐year‐old male with a long history of bothersome urinary symptoms with a 62g prostate, and a REZŪM procedure completed 2 years prior. After appropriate preoperative workup, treatment options were discussed and the patient opted for HoLEP as therapy. In lithotomy position, cystoscopy confirmed indirect signs of bladder obstruction. After assessing the landmarks, we proceeded with HoLEP incisions at 5 and 7 o'clock positions. This revealed a large empty pocket within the prostate. After excision of the mucosa, additional adenomatous tissue in the prostatic fossa was exposed and ablated. Effective laser settings were 2J, 50Hz for excision/ablation and 1J, 20Hz for hemostasis. The operation was completed in 38 minutes with total laser time of 17 minutes and energy of 81.4kJ.
The patient was discharged home on post‐operative day #0. At follow up, he reported significant improvement of symptoms and quality of life (AUA‐SS 28 to 11 and IPSS‐QoL 4 to 2).
Conclusions: If urinary symptoms persist after REZŪM, patients need to be evaluated for persistent obstruction. Although the transitional tissue can be adequately vaporized, residual mucosal tissue can act as a membrane over empty prostatic cavities and result in persistent obstruction. Although, REZŪM can significantly alter the internal prostatic architecture, holmium laser enucleation is feasible after thermal water vaporization of the prostate with acceptable outcomes.
VID5: Laparoscopy/Robotics: Oncology Prostate
Feasibility of Robotic Partial Prostatectomy for Isolated Anterior Prostate Cancer Lesions
MG Biebel, GL Andriole, BG Patel, R Venkatesh, S Figenshau, EH Kim
Washington University School of Medicine in St. Louis
Introduction & Objective: Ablative focal therapy for prostate cancer (PCa) is becoming more prevalent. Few studies have explored focal therapy via surgical excision (i.e. partial prostatectomy). We describe our initial experience with robotic partial prostatectomy (RPP) for isolated anterior PCa lesions.
Methods: We identified five patients with anterior low or intermediate‐risk PCa. The lesion was identified with magnetic resonance imaging (MRI) and targeted biopsies were performed. All biopsy cores outside of the MRI lesion were benign. Informed consent was obtained. During the operation, the lesion was localized by ultrasound‐guided transperineal placement of spinal needles around the lesion. Robotically, we dropped the bladder, incised endopelvic fascia, ligated the dorsal venous complex, excised the lesion, cauterized the defect, and closed bladder neck over the defect. Follow‐up includes PSA at 6 weeks, MRI at 3 months, and repeat biopsy at 1 year.
Results: Mean patient age was 72.6. Mean preoperative PSA was 4.4. Mean lesion size was 2.0 centimeters. Four RPPs were done with the DaVinci XI and one was done with the DaVinci SP (extraperitoneal). Mean operative time was 129.2 minutes. Pathology showed Gleason 7 PCa in all cases and a positive margin in three (60%) cases (see table 3 for margin details). No patients reported incontinence or erectile dysfunction thus far. Mean post‐operative PSA was 1.5.
Conclusions: RPP is feasible for isolated anterior PCa. It completely preserves functional outcomes; however, oncologic outcomes need further investigation, particularly considering the positive margin rate. Further follow‐up and improved intraoperative margin localization are needed to determine if RPP is a viable alternative to ablative focal therapy.
Robotic‐assisted Bladder Neck Sparing Prostatectomy After Neoadjuvant Hormone Therapy for High‐risk Prostate Cancer
H Yang, W Chen, L Chang, S Hung, K Chiu
Department of Urology, Division of Surgery, Taichung Veteran General Hospital
Introduction & Objective: Bladder neck sparing (BNS) during radical prostatectomy (RP) has been shown as a technique to improve early and long‐term recovery of urinary continence after radical prostatectomy. However, this technique has been mainly used in low and intermediate‐risk patients because of the concern for the risk of compromising oncological outcomes due to positive surgical margins. The purpose of this video is to demonstrate the technique of bladder neck sparing robotic‐assisted laparoscopic radical prostatectomy and to show that in selected high‐risk patients, preservation of bladder neck without compromising oncology outcome is feasible.
Objective: To demonstrate the technique and feasibility of bladder neck sparing robotic‐assisted laparoscopic radical prostatectomy on high‐risk patients through a case. A literature review for surgical technique and outcomes is also included in the video.
Methods: A 63‐year‐old male was diagnosed with high‐risk prostate cancer (cT2c at least, PSA = 90ng/ml, Gleason score:4 + 5 = 9) without distant metastasis. There was no evidence of cancer near the bladder neck on pre‐operative MRI. After neoadjuvant hormone therapy, the patient underwent bladder neck sparing robotic‐assisted radical prostatectomy (BNS‐RALRP). Surgical video clips as well as pathology, along with searches in the available literature are included in the video.
Results: The bladder neck sparing (BNS) radical prostatectomy was first proposed in the 1990s to achieve a quicker and better continent after surgery. The advance of the robotic surgical system help decreases surgery complexity. During a BNS‐RALRP, the identification of bladder neck fiber and its transition into the prostatic urethra was crucial. Various studies have shown that the bladder neck sparing technique during radical prostatectomy leads to a quicker continent after surgery and a better long‐term continent rate. In the systemic review by Kim et al., the BNS technique leads to the early return of urinary continence and long‐term urinary continence without increased incidence of positive surgical margin over bladder neck in patients undergoing BNS‐RALRP. While most of the study in this meta‐analysis includes patient with low to intermediate‐risk disease, we demonstrate that in selected high‐risk patient, the bladder neck sparing technique is feasible.
Conclusions: Through this video, we demonstrate that in carefully selected high‐risk patients without evidence of cancer involvement near bladder neck, preservation of the bladder neck facilitates continence restoration without compromising oncology outcome.
Single Port Robotic Radical Prostatectomy: Toolbox and Accessory Instruments
E Ferguson, A Beksac, M Abou Zeinab, A Kaviani, J Kaouk
Glickman Urological & Kidney Institute, Cleveland Clinic Main Campus, Cleveland, OH
Introduction & Objective: The Single Port (SP) da Vinci surgical system was introduced in 2018. Since that time, it has been adapted for use in radical prostatectomy including perineal, transperitoneal, extraperitoneal, and transvesical approaches. In this video we aim to list and demonstrate the use of important tools and accessories used during single port radical prostatectomy.
Methods: Important tools and instruments utilized during single port robotic radical prostatectomy are shown including: 1. SpaceMaker Kidney Shaped Balloon Dissector, 2. SP Single Port Access Kit, 3. GelSeal Cap, 4. AirSeal, 5. ROSI, 6. Robotic Instrument Tray, and 7. Accessory Tray.
Results: Demonstrations of instruments and examples of accessories are shown.
Conclusions: This instructional video is designed to help providers understand the instruments commonly used when performing single port robotic radical prostatectomy.
Indocyanine Green ‐ Guided Laparoscopic Radical Prostatectomy: Urethra and Bladder Neck Sparing
F Prata, A Civitella, P Tuzzolo, V Crimi, F Tedesco, A Ragusa, N Deanesi, L Cacciatore, A Testa, A Minore, F Esperto, R Scarpa, R Papalia
Department of Urology, Campus Bio‐Medico University of Rome
Introduction & Objective: Prostate cancer is the most common cancer in men. Due to the increasing number or surgeries, more and more patients are suffering from post‐operative urinary incontinence. The preservation of urethra and bladder neck are key factors for urinary function recovery after radical prostatectomy (RP). Indocyanine green (ICG) has been used during RPs for extended lymphnode dissection. In this video we evaluate the feasibility and safety of an ICG‐guided laparoscopic radical prostatectomy (LARP) for the preservation of urethra and bladder neck.
Methods: A 62 years‐old man, was admitted to our department, for Gleason score 6 (3 + 3) prostate cancer of the right lobe (4/12 positive cores). Preoperative PSA was 4.8 ng/ml. Before placing laparoscopic trocars, 25 milligrams of ICG were diluted with 20 milliliters of saline solution and 10 milliliters of the solution were transrectally injected for each lobe from the base to the apex, under ultrasound guidance. Then the patient was placed in steep trendelemburg position. A transperitoneal approach was used, the space of retzius was developed and the prostate visualized. LARP was performed using Ligasure. This instrument is excellent for dissection and hemostasis, and its blunt tip provides a gentle separation of cleavage planes. The ICG, allowed to better identify and isolate the urethra from the prostatic border. Then, prostatic edge was easily visualized following the green light. The bladder neck was carefully transected with monopolar scissors. Thanks to the ICG, the bladder neck was enhanced by the green light and perfectly spared. The vesicourethral anastomosis was performed in a running fashion using 2 pretied sutures.
Results: The procedure was successfully completed. Operative time was 70 minutes. Estimated blood loss was 100 cc. No intraoperative and post‐operative complications were registered. The patient was discharged on post‐operative day 2 after drainage removal. The bladder catheter was removed on post‐operative day 11. The pathological report confirmed the Gleason score 6 prostate cancer (pT2a) of the right lobe. After 3 months, PSA was <0.02 ng/ml and the patient resulted to be almost perfectly continent.
Conclusions: Urethra and bladder neck preservation could be a challenge during LARP, even in expert hands. ICG allowed to better identify the cleavage planes and to safely spare urethra and bladder neck, improving post‐operative urinary incontinence recovery.
Radio‐guided Surgery Experience During Robotic Radical Prostatectomy
T Doganca, M Tuna, O Argun, I Tufek, C Obek, AR Kural
Acibadem Maslak Hospital, Urology
Introduction & Objective: Robot‐assisted radical prostatectomy and lymph node dissection is an essential step for the treatment of prostate cancer. Lymph node dissection in high‐risk patients are recommended in guidelines. Appropriate staging and survival advantage may provided with appropriate lymph node dissection. Today, Ga68 PSMA PET is frequently used for lymph node staging. In order to find and remove suspicious lymph nodes, marking can be done with Tc99m at the preoperative period, especially for the nodes that are not in standard dissection template. In this video, we share our experiences with our 2 patients.
Methods: First case: 58‐year‐old patient with a PSA value of 9.5 ng/ml had undergone prostate biopsy for PIRADS 5 lesion detected in mpMRI. Gleason 9 (4 + 5) adenocancer reported. Suspicious lymph nodes were detected in the left obturator fossa and anterior of the bladder with Ga68 PSMA PET. These lymph nodes were labeled with Tc99m macro aggregated albumin (MAA). During the surgery, after their excision of these nodes, they were checked with gamma probe and confirmed for radionuclide presence Frozen examination of these nodes showed adenocarcinoma metastasis. Second case: 69‐year‐old patient with a PSA value of 24 ng/ml underwent prostate biopsy for a PIRADS 5 lesion at mpMRI. A Gleason 7 (4 + 3) adenocancer was detected. A pathological lymph node was detected in the right obturator fossa with Ga68 PSMA PET scan. This lymph node was labeled with MAA. Excised lymph node checked with gamma probe and confirmed for radionuclide presence . Likewise, frozen section analysis of the excised lymph node confirmed metastasis.
Results: Final pathology analysis of both excised lymph nodes was found to be compatible with metastasis.
Conclusions: Radio‐guided surgery can ease excision of metastatic lymph nodes located outside the standard lymphadenomectomy templates.
Single Port Transvesical Radical Prostatectomy in Patients with Prior Kidney Transplantation
E Ferguson, M Abou Zeinab, A Beksac, A Kaviani, J Kaouk
Glickman Urological & Kidney Institute, Cleveland Clinic Main Campus, Cleveland, OH
Introduction & Objective: Prostate cancer in patients with previous kidney transplantation is challenging to manage surgically. In limited published case series, robotic radical prostatectomy has previously been shown to be feasible with a transperitoneal multiport approach, but has not yet been evaluated in patients undergoing prostatectomy using the single port da Vinci surgical platform. Transvesical radical prostatectomy allows for direct access to the bladder and prostate that completely avoids the peritoneal cavity and allows for minimal disturbance to the extraperitoneal space or the iliac fossa. We sought to evaluate the safety and effectiveness of a singe port transvesical approach in treatment of patients with prior kidney transplantation.
Methods: Single port transvesical radical prostatectomy was performed in two patients with prior kidney transplantation, including one patient with two prior kidney transplants. Flexible cystoscopy was used for assistance in accessing the bladder intraoperatively in the patient with two prior transplants to avoid injury to either transplant ureteral orifice. Both patients were admitted postoperatively for observation.
Results: Both patients had similar preoperative pathology, operative times, EBL and hospital stay. There were no intraoperative or postoperative complications in either patient. While both patients showed high risk pathology, surgical margins were negative in both cases and initial postoperative PSA at 6 weeks was undetectable. Both patients had good recovery of continence after surgery, with 0 and 1 pads per day at 6 week follow up.
Conclusions: Single port transvesical radical prostatectomy is safe and feasible in patients with prior renal transplantation.
Single Port Transvesical Partial Prostatectomy for Localized Prostate Cancer
E Ferguson, M Abou Zeinab, A Beksac, A Kaviani, J Kaouk
Glickman Urological & Kidney Institute, Cleveland Clinic Main Campus, Cleveland, OH
Introduction & Objective: Cross‐sectional imaging guided prostate biopsy has allowed for more accurate diagnosis of clinically localized prostate cancer. Appropriately counseled patients with low or intermediate risk localized disease may opt for focal or ablative therapies. Recently, partial prostatectomy has been shown to be safe and effective for anterior prostate tumors. The single port da Vinci surgical platform with a transvesical approach allows for anterograde dissection of the prostate gland with minimal disturbance to the space of retzius and has recently been adapted for simple and radical prostatectomy. In 2018, cadaver studies demonstrated that partial prostate gland excision was feasible using a single port transvesical approach. Here we present the case of a patient undergoing single port transvesical partial prostatectomy.
Methods: A patient with localized Gleason 3 + 4 prostate cancer in the left lateral peripheral zone diagnosed on MRI fusion prostate biopsy. The procedure was performed with intraoperative MRI fusion using the KOELIS mobile fusion imaging platform. The following surgical steps were described: (1) anterograde bladder neck dissection, (2) endopelvic fascia incision, (3) unilateral vascular pedicle ligation, (4) partial DVC ligation, (5) lateral lobe excision, (6) surgical margin assessment, (7) bladder neck reconstruction.
Results: The patient underwent an uncomplicated single port robotic partial prostatectomy with removal of the left lateral lobe and seminal vesicle. Intraoperative frozen sections of medial and lateral margins were negative for malignancy. He was discharged after spending 3.8 hours in recovery and did not require narcotics at discharge. His foley catheter was removed on postoperative day 3 and he was fully continent within 7 days of foley removal. He had good erectile function preoperatively and was fully potent within seven days of surgery. Six month follow up data shows stable PSA of 0.88 and no lesions on prostate MRI.
Conclusions: Single port transvesical partial prostatectomy is feasible and safe in carefully selected men with localized prostate cancer. Close attention to ongoing postoperative follow up is imperative to determine long‐term oncologic outcomes.
Retrograde Paraaortocaval Lypmphadenectomy During Robotic Radical Prostatectomy in a Patient Followed by Neoadjuvant Chemo‐hormonal Treatment
M Tuna, T Doganca, O Argun, I Tufek, C Obek, AR Kural
Acibadem Maslak Hospital, Urology
Introduction & Objective: This video presents a retrograde paraaortocaval lymphadenectomy procedure performed after super extended lymphadenectomy and robotic radical prostatectomy in a patient with very high risk prostate cancer.
Methods: The patient was a 67 years old gentleman with a PSA of 28 ng/ml. Prostate biopsy revealed Gleason 9 (4 + 5) prostate cancer in 12 of 12 cores. Ga68 PSMA PET showed multiple lymph only metastasis of paraaortocaval region up to the renal hilum. The patient received 6 cycles of chemohormonotherapy prior to the surgical treatment. After completion of radical prostatectomy and super extended lymphadenectomy an additional suprapubic camera port was inserted in the midline for retrograde access. Robotic crane was turned 180 degrees facing cranial. Lymphadenectomy template was extended up to the level of renal pedicle. First posterior peritoneum was opened from caecum to Treitz ligament , and right ureter was identified. Posterior peritoneum was lifted up on both sides via externally placed stay sutures. Upper limit of the lymphadenectomy template was identified. Caval and paracaval lymph nodes were excised with blunt and sharp dissection and using Weck clips. Great attention was paid to occlude large lymphatic vessels with Weck clips. Next step was identification of left ureter through mesosigmoideum. Left common iliac lymph nodes were removed below the mesenteric artery. Interaortocaval lymph nodes were excised with blunt and sharp dissection. Large lymphatic vessels were occluded with Weck clips. During interaortocaval lymph node dissection extra care must be paid no‐t to damage lumbar branches. Right renal artery was identified and preserved precisely. Then aortic and paraaortic lymph node dissection was started. During paraaortic lymph node dissection inferior mesenteric artery was identified and preserved carefully. Again, Weck clips were used to occlude large lymphatic vessels. After completion of paraaortocaval and interaortocaval lymph node dissection, surgical field was controlled carefully for potential bleeding.
Results: Estimated blood loss was 250 ml. and the operation time was 300 minutes. The drain was removed on postoperative second day and the patient was discharged on postoperative fifth day. On final histopathology, there was T3B N1 prostate cancer. Six out of 68 lymph nodes were positive for metastasis. Three of positive lymphs were in the paraaortocaval region.
Conclusions: At postoperative 12 month follow‐up, the patient is still on antiandrogen treatment and has a nadir PSA level.
Tips and Tricks of Super Extended Lymphadenectomy During Robotic Radical Prostatectomy
T Doganca, M Tuna, O Argun, I Tufek, C Obek, AR Kural
Acibadem Maslak Hospital, Urology
Introduction & Objective: In this video, we present some tips and tricks for succesful and safe results in robotic surgery.
Methods: We present our recommendation as follows: Anatomical structures and landmarks should always be considered. When dissecting the peritoneum on the ureter, the use of thermal energy should be avoided.In paraaortic lymphadenectomy, the clip should be placed at the upper limit whenever possible. Attention should be paid to the mesosigmoid plan in the detection of the left ureter. In the left side lymphadenectomy, the left ureter should always be considered. IMA is the dissection limit and care should be taken not to damage it. Dissection of presacral lymph nodes may facilitate external iliac lymphadenectomy. On the right side, the 4th robotic arm can assist retraction. Robotic arm movements' parallel to the obturator nerve should be applied in Fossa Marseille dissection. We prefer to fix the peritoneal surface of the bladder to the suprapubic anterior abdominal wall to prevent the development of lymphocele.
Results: Taking care of anatomic structures and using some simple techniques during robotic surgery may provide more successful and safer results.
Conclusions: It is possible to perform safer and effective robotic surgery by paying attention to the above mentioned.
Pelvic Lymphadenectomy with Indocyanine Green During Laparoscopic Radical Prostatectomy
A Civitella, F Esperto, F Prata, P Tuzzolo, P Calle, V Crimi, R Scarpa, R Papalia
Department of Urology, Campus Bio‐Medico University of Rome
Introduction & Objective: The recent introduction of new technologies in video visualization such as ICG is making a great contribution to intraoperative decision making during surgical procedures The aim of this video is to show our experience in using indocyanine green (ICG) in laparoscopic lymphadenectomy.
Methods: From April to October 2021 we performed at our center, (an high volume tertiary university hospital with high experience laparoscopic surgeon) 30 lymphadenectomies in the course of laparoscopic radical prostatectomies for patient with grade group 3 3 using indocyanine green. All the procedure were performed by a single high experienced laparoscopic surgeon. 25 mg of ICG diluted with 20 ml of saline solution were injected, 10 ml for each lobe, trans‐rectally from the base to the apex of the prostate before the sterile draping.
Results: No intraoperataive or injection‐related adverse effects were reported. the use of the intensity map of the karl storz 4k tower allowed a good visualization of the anatomy associated with an excellent visualization of the lymph nodes and of the lymphatic ducts.
In our department, the median value of nodal yield at pelvic lymph node dissection during laparoscopic radical prostatectomy is 17.4 nodes (s2 = 4.17) and the most prevalent surgical complication is Lymphocele/lymphorrea with a rate of 3%. Using indocyanine green in laparoscopic lymphadenectomy we had a median nodal yield at pelvic lymphadenectomy of 19.25 (s2 = 4.49) and no lymphocele/lymphorrea occurred.
Conclusions: In our experience, the ICG fluorescence imaging system seems to be simple, safe, and useful. The technique may well become a standard in the near. Larger studies and more specific evaluations are needed to confirm its role and to address its disadvantages.
Multi‐modalities to Achieve Early Return of Continence and Potency in Robotic‐assisted Radical Prostatectomy by Techniques of Preservation, Reconstruction and Regeneration
W Hu, Y Lin, Y Ou, M Tung
Tungs' Taichung Metroharbor hospital
Introduction & Objective: Robotic assisted radical prostatectomy (RARP) has brought great advantages in neurovascular bundle (NVB) sparing. Despite of well‐preserved NVB, recovery of continence and potency is still a great task and it sometimes takes a long convalescent period. We aim to present our experience to achieve early return of continence and potency in robotic‐assisted radical prostatectomy by multi‐modalities.
Methods: We presented a 72‐year‐old man with localized prostate adenocarcinoma. He elected to undergo a robotic assisted radical prostatectomy. We planned to preserve nerve function with aids of ice‐packing, nerve allograft and dehydrated human amnion chorion membrane. We conducted with trans‐peritoneal 4‐arm approach. (A 12‐mm trocar for camera and three 8‐mm trocars for robotic arms added with two trocars for assistant.)
We used the 12‐mm assistant trocar to facilitate introduction of ice pack and utilized the ice pack to protect the neurovascular bundle from thermal injury. During dividing the prostatic capsule, we minimized the use of thermal instrument. After the prostate was fully mobilized, hemostasis of was achieved by suture instead of clips. We made end‐to side anastomosis of nerve allograft to the neurovascular bundle before urethrovesical anastomosis. We placed the dehydrated human amnion chorion membrane beside the neurovascular bundles at the end of surgery.
Results: The operative time was 100 minutes and the estimated blood loss was 50 ml. The continence recovered in 6 weeks. The post operative international index of erectile function (IIEF) score was 19 three months after the surgery.
Conclusions: This video demonstrates how early return of continence and potency can be achieved by multi‐modalities in Robotic‐assisted radical prostatectomy. Preservation of NVB can be maximized by ice‐packing and avoiding thermal injury. Reconstruction is accomplished by aid of nerve allograft. Placing the dehydrated human amnion chorion membrane beside the NVB may help regeneration of nerve function.
A Prospective Evaluation of Neurovascular Bundle Preservation in Robot‐Assisted Laparoscopic Radical Prostatectomy in High Risk Localized Prostate Cancer
A Kumar, Y Prashanth, S Kumar, K kapoor, S Iyer, P Singh
Department of Urology, Robotics and Renal Transplant, SJH and VMMC, New Delhi
Introduction & Objective: We report short term oncologic and functional outcomes in patients with preoperative EAU high risk prostate cancer, undergoing nerve sparing robot‐assisted radical prostatectomy (RARP).
Methods: All consecutive patients undergoing RARP (da‐Vinci Xi Robotic system) in high risk localized prostate cancer, by a single surgeon ,between Oct 2019 and Feb 2021, at our institution were included .
The various clinical data were recorded and analysed. We are presenting video of one such case.
Results: Out of 101 patients with high risk localized prostate cancer(EAU classification), 41 underwent complete (group 1), 37 underwent partial (group 2), and 23 patients underwent non‐nerve‐sparing procedure (group 3).There were no difference in preoperative characteristic between the groups, but group 3 had higher Gleason score sum (p = 0.001), positive cores on biopsy (p = 0.001) and higher t stage (p = 0.001).Side specific positive surgical margins (PSMs) rates were higher for non‐nerve‐sparing (p < 0.001); Continence rate at 3 month was significantly higher in complete NS group(p = 0.01), however, difference was not statistically significant at 1 year. The Potency rate was significantly higher and mean time to potency was significantly lower in complete NS group in comparison to non‐NS group (p = 0.02 and 0.03, respectively).
Conclusions: In high risk prostate cancer patients, selective nerve sparing during RARP, using the preoperative clinical variables (clinical stage and positive cores on biopsy) and surgeon's intraoperative perception, could provide reasonable short term oncologic, functional outcomes with acceptable perioperative morbidity and positive surgical margins rate.
Laparoscopic Radical Prostatectomy versus Robotic‐assisted Laparoscopic Radical Prostatectomy: Single Surgeon, Similar Technique, Similar Results?
RH Kalbit, ES Lorenzo
Jose R. Reyes Memorial Medical Center
Introduction & Objective: The treatment of localized or locally advanced prostate cancer has evolved throughout the years with the goal of achieving the best oncologic outcome. Radical prostatectomy (RP) is considered the standard of treatment for localized prostate cancer. Historically, open prostatectomy gained its popularity up until the use of laparoscopy and robots come into fruition.
Experienced surgeons have described the various advantages of laparoscopy. The approach remains a technically demanding procedure requiring a high learning curve. Meanwhile, the use of the robotic system reduces the issues on difficulty performing complex laparoscopy and the learning curve compared doing laparoscopy alone.
Methods: Patient positioned according to approach. Supine on LRP while lithotomy position on RALP. Port placement was done starting from the umbilicus using the Veress needle and drop test technique. Insufflation of the abdomen and inspection was done. Trocar placement was done accordingly. Surgical approach will be presented according to highlights of the procedure: Defattening of the prostate; dissection of the endopelvic fascia; Incision of puboprostatic ligaments; Ligation of dorsal venous complex; Bladder neck dissection; Posterior dissection; Identification of vas deferens and seminal vesicles; lateral pedicle dissection; apical dissection; urethrovesical anastomosis; retrieval of specimen and extraction.
Results: On LRP the total operative time was 288 minutes with total blood loss of 250cc. No complications were noted. The patient was discharged after 3 days. Return of continence was noted on the 3rd month post‐operation. Patient was maintained on PDE5 inhibitors. Follow‐up PSA was 0.00 (6weeks). Meanwhile on RALP, the total operative time was 360 minutes including the lymph node dissection time. Total blood loss was 200cc. No complications were noted and the patient was discharged after 3 days. Return of continence and erection was noted on the 3rd month post‐operation. Patient was maintained on PDE5 inhibitor.
Conclusions: In terms of oncologic outcome LRP is at par with RALP.
Single‐port Transvesical Robotic Radical Prostatectomy: An Extraperitoneal Retzius Sparing Approach That Facilitates Early Continence Recovery
A Beksac, M Abou Zeinab, E Ferguson, A Kaviani, J Kaouk
Glickman Urological & Kidney Institute, Cleveland Clinic
Introduction & Objective: In this video, we are presenting our single‐port (SP) transvesical robot assisted radical prostatectomy (RARP) technique.
Methods: A total of 100 consecutive patients underwent SP transvesical RARP at an academic center by a single surgeon, between December 2020 and March 2022. The patient was positioned in a supine position. A 3.5 cm suprapubic incision is made and access is made directly into the bladder. Da Vinci SP access kit was used and the robot is docked using the floating docking technique. RARP was performed using a transvesical anterior Retzius‐sparing approach. Surgical steps are in the following order. 1) Posterior bladder neck dissection, 2) Seminal vesicle and vas deferens dissection, 3) Posterior dissection, 4) anterior bladder neck dissection, 5) Prostatic pedicle and neurovascular bundle dissection, 6) Lymph node dissection, 7) Vesicourethral anastomosis. Bilateral limited pelvic lymph node dissection was performed in 31% of patients.
Results: Surgery was completed in 179 minutes. Estimated blood loss was 50 ml. Patient was discharged on the day of surgery. Urethral catheter was removed at postoperative day 3. Patient was continent upon catheter removal. Pathology showed pT2 disease, Gleason 3 + 4 disease with negative surgical margins. In our initial series, continence rates at postoperative 6 weeks, 3 months, and 12 months were 70.1%, 89%, 94% respectively. The median length of stay 5 (4‐21.8) hours, catheter time 3 days (3‐4). 4% required opioid analgesics after discharge. The positive surgical margin rate was 16%. Two patients had Clavien III complications, one hematoma, and one lymphocele.
Conclusions: SP transvesical RARP results in a high rate of early continence recovery and same‐day discharge; and low rate of positive surgical margins, complication rate, and opioid analgesia requirement.
Visible Air Embolism in the External Iliac Vein During Robotic Prostatectomy Using a Valveless Insufflation System
T El‐Ghazaly, K Perry, Jr
Northwestern University
Introduction & Objective: Air Embolism is a rare but potentially lethal complication of laparoscopic or robotic surgery. We describe a first reported case of persistent visible air embolism occupying the entirety of the left external iliac vein, early on during a robotic radical prostatectomy before transecting the dorsal venous complex.
Methods: Our patient is a 58‐year‐old man with Gleason 4 + 3 Prostate Cancer and a pelvic lymphadenopathy risk of 16%. With the patient in reverse Trendelenburg, a posterior dissection of the seminal vesicles and bladder take down was carried out using both cautery and blunt dissection, with our suctioning device set at a low continuous setting. Upon taking down the tissue overlying the left external iliac vein, many visible medium‐sized air bubbles can be seen occupying the entirety of the vein, moving in a loop from the bottom to the top of the vein. Durant's maneuver was carried out, and transesophageal echocardiocardiogram revealed air in the hepatic vein. As the visible air bubbles remained persistent, in the absence of a clear source, and with most of the procedure yet to be completed, the procedure was aborted.
Results: While the high solubility of carbon dioxide renders most cases of venous air embolism harmless, valveless insufflation devices have been shown to introduce insoluble non‐medical room air into the surgical cavity, especially when coupled with the use of a suctioning device in the operative field.
Conclusions: This case describes a first‐reported case of visible persistent air embolism while performing a robotic pelvic lymph node dissection as part of a radical prostatectomy, with a valveless system used for insufflation. Given the gravity of such a complication, caution is advised when using continuous intraoperative suction coupled with a gasket‐less insufflation device.
VID6: Laparoscopy/Robotics: Benign Kidney
A Safer Method for Identifying the Dysplastic Upper Pole Moiety of a Duplex Kidney Using Near‐infrared (NIR) Fluorescence Imaging with Intravenous Indo‐cyanine Green (ICG) During a Laparoscopic Left Hemi‐nephrectomy
NW Seng, W Chong, S Yeo, C Yew Lam
Ministry of Health Holdings
Introduction & Objective: We present a case of a laparoscopic left hemi‐nephrectomy for bilateral duplex kidneys with completely duplicated ureters, complicated by recurrent left pyelonephritis. This video demonstrates the utilisation of indo‐cyanine green (ICG) intraoperatively to distinguish between the viable lower pole moiety from the dysplastic upper pole moiety after selective renal artery clamping.
Methods: Our patient is a 42‐year‐old lady with a background history of bilateral duplex kidneys, with multiple hospital admissions due to recurrent left pyelonephritis.
A prior rigid cystoscopy with bilateral retrograde pyelogram revealed both the ectopic ureters to be emptying into the urethra, below the sphincter mechanism, with the right ectopic ureter entering the urethra at the 7 O clock position and the left at the 2 O clock position. Despite this aberrant anatomy, the patient did not report any stress urinary incontinence, possibly suggesting the lack of function from both the upper pole moieties. A CT urography revealed bilateral complete duplicate collecting systems, with bilateral hydronephrosis and significant cortical atrophy of the upper pole moieties. Both lower pole moieties were normal, though displaced laterally by the upper pole moiety, and had distinct ureters exiting from them and inserting into the bladder at the trigone.
The lower moiety ureter was first stented to allow ease of intra‐operative identification of the lower moiety ureter and to facilitate the subsequent dissection of the upper moiety ureter. A renal artery to the upper moiety and an aberrant lower renal moiety artery were identified separately and isolated. Before transection, the upper moiety renal artery was selectively clamped with a laparoscopic bulldog clip and 5 mls of intravenous ICG was administered. Using NIR fluorescence imaging on a Karl Storz Spies ICG laparoscopic camera system, the demarcation between the unperfused upper moiety and the perfused lower moiety was clearly visualised. This gave us the confidence to staple the upper pole renal vessels and commence the left hemi‐nephrectomy. Nearing the end of the case, intravenous ICG was re‐administered to demonstrate that the perfusion to the lower pole moiety had been well maintained.
Results: The total operative time was 370 minutes and estimated blood loss was 200mls. The patient recovered well after surgery without complications and was discharged on post‐operative day 4.
Conclusions: Laparoscopic hemi‐nephrectomy in duplex kidneys with duplicated ureters can be performed safely with the aid of intraoperative NIR fluorescence imaging with ICG allows clearer differentiation of the upper and lower pole moiety for resection.
First Robot Assisted Laparoscopic Ureterolithotomy with Hugo RAS System
V Elorrieta, J Salvadó, A Velasco, R Olivares, □ Kompatzki
Universidad Finis Terrae
Introduction & Objective: We report the case of a patient afflicted by a 2.5 cm long and high density mid left ureteral stone. This challenging case was discussed due to the broad range of surgical interventions available. Based on the size of the stone and density, we considered the low likelihood of success and high risk of both intraoperative and postoperative complications. We also considered that an endourological approach would require multiple interventions. After consideration, we performed a robot‐assisted surgery (RAS) laparoscopic ureterolithotomy. The patient was discharged on the third postoperative day with no complications. The objective of this case was to evaluate how emerging technologies facilitate the management of complex cases.
Methods: A 60‐year‐old female whose medical background included hypertension and a remitted breast cancer, was afflicted by intermittent left flank pain for the last two months. Her blood Creatinine levels were 1.17 mg/dL. A Computed Tomography (CT) scan revealed a 2.5 x 1 x 1 centimeters and 1700 Hounsfield Units stone in her medium left ureter. We performed a RAS laparoscopic ureterolithotomy, after considering the shorter recovery time and lower morbidity.
Results: The surgical procedure lasted 150 minutes (console 110 minutes). A two‐centimeter‐long longitudinal ureterotomy was performed and the stone was removed. We proceeded with a longitudinal ureterotomy closure, leaving a double‐J stent as a tutor. After confirming hermeticity we placed a drain and proceeded with closure. The patient had an excellent postoperative evolution. The double‐J stent was removed after 4 weeks, with complete resolution of the clinical symptoms.
Conclusions: Indications for ureterolithotomy are rare in the modern era of endourology. Current indications include stones with a low likelihood of treatment success using extracorporeal shock wave lithotripsy, ureteroscopy, or percutaneous techniques. We opted for a safe and effective option, assisted by the recently acquired Hugo RAS system. Due to its versatility, mobility and cost effectiveness, this system could make a meaningful difference in expanding access to care to more patients worldwide. We safely resolved a complex case and removed a large, dense stone by performing the first Hugo RAS laparoscopic ureterolithotomy.
S Jayaprakash, M Thangarasu, J Soni, R Paul, D Kannan, P Taur, N Jain
Apollo Hospitals
Introduction & Objective: Autosomal dominant polycystic kidney disease (PCKD) represents one of the most common genetic disorders affecting kidneys (approximate incidence 1 in 500 to 1000), characterised by the presence of large number of fluid filled cysts in both kidneys. Patients usually present around the fourth decade of life and develop end‐stage renal disease after about 5 to 10 years of diagnosis of renal impairment. Nephrectomy is indicated for patients with large kidneys causing pressure symptoms, pain, infection, bleeding, hypertension, erythrocytosis, recurrent UTI and suspicion of malignancy. Nephrectomy is also indicated in these patients to create space for renal allograft. Historically, open bilateral nephrectomy (BN) performed through the midline laparotomy has been associated with a high rate of postoperative complications and high risk of a lethal outcome. The first description of laparoscopic nephrectomy for PCKD was by Elashry and colleagues.
Methods: The technical difficulties that would be encountered are due to the size of kidneys, distorted anatomy, difficulty in handling the kidney due to its weight and size, port placement, space constraints in the abdomen, difficulty in approaching the renal hilum, occasional intense perinephric inflammatory reaction making dissection of tissue planes more challenging and the risk of bleeding from coagulopathy secondary to CKD.
Results: We share our tips and tricks for successful outcomes which has been demonstrated and discussed in the video. The advantages of laparoscopic surgery includes lower estimated blood loss as pneumoperitoneum itself gives the tamponade effect, lesser transfusion rates, shorter length of hospital stay, single pfannensteil incision for specimen extraction, in azotemic patients especially, larger abdominal incision adds to existing co‐morbidities and prolongs the convalescence period, lower pain scores, lesser need of analgesia and early bowel recovery, smaller incision, better cosmesis, similar postoperative complication rates to open surgery, lower morbidity, lesser wound related complications and rapid decrease in symptoms related to PCKD.
Conclusions: Laparoscopic bilateral nephrectomy for PCKD is a challenging procedure, however it is safe for the patients. The disadvantages are higher conversion rates for larger kidneys ( >3500cm3), longer operative times, higher chance of bowel injury, spillage of cyst contents and fluid in the peritoneal cavity has been associated with pain and peritonitis with subsequent ileus. When in difficulty the safety of the patient should not be compromised and there should not be any hesitation to convert to open surgery.
Robotic Pyeloplasty and Pyelolithotomy in a Pelvic Kidney – Technical Considerations
D Jivanji, A Wood, A Sandozi, A Schulman
Maimonides Medical Center
Introduction & Objective: This case involves a 41‐year‐old male with no past medical history who presents with intermittent umbilical pain for the last two years. Workup CT imaging reveals a left pelvic kidney with severe hydronephrosis and three‐centimeter renal caliculi. Here we describe the technical considerations for the use of robotic pyeloplasty and pyelolithotomy as surgical management.
Methods: The DaVinci Surgical System was successfully docked once the patient was placed in lithotomy and steep Trendelenburg. Incision of the line of Toldt and subsequent reflection of the left colon superior‐medially allowed for the exposure of the pelvic kidney. Ureter was identified, dissected from surrounding structures, and mobilized proximally toward the renal pelvis. After adequate exposure to the ureteropelvic junction, a wide incision was made, allowing for the retrieval of an intact caliculi. Lastly, a YV pyeloplasty technique was used to reconstruct the renal pelvis.
Results: Postoperative findings revealed successful retrieval of a three‐centimeter spiculated renal caliculi. The remainder of the hospital course was unremarkable. Follow‐up ultrasound showed preservation of renal parenchyma and reduction of hydronephrosis.
Conclusions: There is clinical utility of robotic pyeloplasty and pyelolithotomy in pelvic kidney for management of upper tract stone disease.
Bilateral Laparoscopic Nephrectomy in a Patient with Horseshoe Kidney
DF Kantimerov, RN Trushkin, NE Shcheglov, OS Shevtsov, AE Lubennikov
Moscow City Clinical Hospital 52
Introduction & Objective: o report the use of the laparoscopic technique for removal of a horseshoe kidney in a patient with autosomal dominant polycystic kidney disease (ADPKD).
Methods: Hospital and outpatient records were reviewed for a 59‐year‐old female with end‐stage renal disease secondary to ADPKD who underwent bilateral nephrectomy of her's horseshoe kidney due to reccurent acute pyelonephritis. She underwent kidney transplantation in 2018. The surgical method is described.
Results: It was completed successfully with an operative time of 115 minutes and an estimated blood loss of 180 mL. After 4 days th patient was discharged.
Conclusions: Bilateral nephrectomy can be considered as an option for surgical removal of very large polycystic horseshoe kidneys.
Single Port Robotic Kidney Transplantation: Extraperitoneal Approach
A Kaviani, M Abou Zeinab, E Ferguson, A Beksac, A Wee, M Eltemamy, J Kaouk
Glickman Urological & Kidney Institute, Cleveland Clinic Main Campus, Cleveland, OH
Introduction & Objective: We introduced the single‐port robotic extraperitoneal kidney transplantation in 2019. In this video, we provide detailed tips and tricks for the surgical steps of this procedure.
Methods: Fourteen patients underwent single‐port robotic kidney transplantation with kidneys placed in the right iliac fossa. Patients are placed in the supine position with the bed slightly flexed, tilted toward the left side, and put in a 15° Trendelenburg position. A 5‐cm infraumbilical incision is made and the extraperitoneal space is developed. The da Vinci SP robot (Intuitive Surgical, Sunnyvale, CA, USA) is docked per the floating docking technique using a GelPOINT access platform (Applied Medical Resources Corp, Rancho Santa Margarita, CA, USA). The external iliac artery and vein are dissected using monopolar scissors. Benching of the kidney is performed using the LigaSure device (Medtronic, Dublin, Ireland). The posterior surface of the artery and the vein are marked. A 14 cm ureteral stent is placed. A 3‐0 chromic suture is placed in the lower pole for nephropexy. The kidney is wrapped with a blue glove with cut‐off fingers covering the lower pole. A 12 mm port is placed through the GelSeal® cap and 400 mL of ice is introduced. The kidney is introduced through the same incision. The venous and arterial anastomoses are performed using one 6‐0 GORE‐TEX® suture (Gore Medical, Flagstaff, AZ, USA) for each of them and in a running fashion. Each suture is tied to itself at the distal and proximal corners. Bulldog clamps (Scanlan, Saint Paul, MN, USA) are used for vascular control. Arteriotomy is made using a sleeve‐protected scalpel. An aortic punch is introduced directly through the abdominal wall. After completion of the anastomosis, the kidney is repositioned to the space above the psoas muscle. Ureteroneocystostomy is performed using 4‐0 Vicryl sutures. The kidney is fixed to the lateral abdominal wall. The robot is undocked and the wound is closed.
Results: Surgery was completed in all patients without conversion to open surgery. There were no intra or postoperative complications ≥ Clavien grade 2. Median (IQR) vein and artery anastomosis times were 26 (24‐28) and 37 (33‐40) minutes. Patients were discharged home in 2–3 days. Mean (SD) creatinine at 6 and 12 months were 1.31 (0.24) and 1.30 (0.16) mg/dL.
Conclusions: We demonstrated tips and tricks for surgical steps of the single‐port robotic extraperitoneal kidney transplantation.
Heminephrectomy on the Left Side
DF Kantimerov, AE Lubennikov, RN Trushkin, NE Shcheglov, OS Shevtsov
Moscow City Clinical Hospital 52
Introduction & Objective: Calculus conditioned hydronephrosis of the inferior pole of the left kydney is rare complication of kidney stone disease. To evaluate th feasibility of the laparoscopic heminephrectomy.
Methods: We performed laparoscopic partial neprhectomy of the left kidney with hydronephrotic transformation of the inferior pole.
Results: There was no need for conversion. Blood loss was 110 mL. Ischemia time was 18 min. There was no significant decrease of kidney function. The patient was discharged home on 4th day.
Conclusions: Laparoscopic heminephrectomy seems technically feasible, safe, and reliable for benign diseases.
Robotic Partial Nephrectomy in Transplanted Kidney
A Kaviani, M Abou Zeinab, J Kaouk, M Eltemamy
Glickman Urological & Kidney Institute, Cleveland Clinic Main Campus, Cleveland, OH
Introduction & Objective: To demonstrate the technical considerations for performing a robotic partial nephrectomy in a transplanted kidney.
Methods: Robotic Partial Nephrectomy of the transplanted kidney was performed for 2 patients. Ports were placed in a W‐shaped configuration with the camera port placed 4 fingerbreadths above the umbilicus, 2 robotic ports placed on the left side, and one robotic port and one 12 mm assistant port were placed on the left side. After lysing the adhesion and dissecting the bowel and the female genital organs off the kidney, the psoas muscle was identified and followed medially to identify the common iliac artery which was then carefully dissected off the common iliac vein. Margins of the tumor were marked using intraoperative ultrasound. A Bulldog clamp (Scanlan, Saint Paul, MN, USA) was placed on the common iliac artery and the tumor was excised. Renorrhaphy was performed in 2 layers with early unclamping after suturing the deep layer. After retrieving the specimen and placing a drain, the robot was undocked and the 12 mm port site was closed.
Results: Baseline characteristics and transplant history of patients have been summarized in table 1. Perioperative information of patients has been summarized in table 2. The mass size was 7 and 2.2 cm in the first and second patients. There were no perioperative complications. Margins were negative in both patients.
Conclusions: Robotic partial nephrectomy is feasible in transplanted kidneys. The common iliac artery control is a safe alternative in patients with a complex vascular reconstruction.
Fraley's Syndrome: A Novel Robotic Nephron‐sparing Vasculopexy Surgical Approach
DG Ortega, J Kim, EI Rojas, MA Lizana, E Forsyth, A Chang, G Fuchs, IS Gill
Department of Urology, University of Southern California
Introduction & Objective: Fraley's Syndrome, a rare entity, is characterized by obstruction of the renal upper pole infundibulum by an anatomically variant segmental renal artery. Surgical treatment options include open/laparoscopic partial nephrectomy, infundibuluo‐infundibulostomy, infundibulo‐pyelostomy, vasculopexy, or a combination thereof. To our knowledge, we report the initial robotic repair of Fraley's Syndrome using a novel nephron‐sparing approach.
Methods: An 18‐year‐old female presented with four‐month history of severe right flank pain and right nephrolithiasis. The pain persisted despite resolution of urolithiasis and recurrent UTI. MAG‐3 renal scan showed obstruction with hydronephrosis of the upper pole moiety of the right kidney with a T1/2 after Lasix of 27.3 minutes (Fig 1). CT Angiogram revealed crossing vessel at the upper right pole calyx, suggestive of Fraley's Syndrome. There were 3 renal veins draining into the IVC, and 2 renal arteries with the superior artery bifurcation located retro‐caval. The superior apical segmental renal arterial branch passed posterior to the upper pole infundibulum, and the anterior superior segmental renal artery crossed in front of the upper pole infundibulum, causing impingement (Fig 2). We performed robotic anterior vasculopexy of the anterior superior segmental renal artery and vein, with adipose flap interposition between the superior infundibulum and the posterior branch of the superior segmental renal artery, relieving the obstructed upper pole calyx. Operating room time was 215 minutes, blood loss was minimum, hospital stay was one day.
Results: Four months post‐operatively, the patient reported pain relief and MAG‐3 scan showed stable right renal function with improved post‐Lasix T1/2 of 10 minutes (Figure 1).
Conclusions: A unique case of robotic nephron‐sparing management of Fraley's syndrome is presented. Longer follow‐up is needed
“Six by Six” Technical Guide for Laparoscopic Living Donor Nephrectomy; Impact of Perioperative Outcomes and Learning Curve
AA Elsawy
Mansoura University
Introduction & Objective: Laparoscopic living donor nephrectomy (LLDN) is currently adapted as a standard procedure for harvesting the kidney in living donation. Despite its minimally invasive nature, LLDN could be limited by its lethal hemorrhagic complications that might occur and the need for highly qualified, competent, and well‐trained surgeons.
Methods: In this video, we present a simple technical guide for LLDN that can provide the surgeon with a helpful tool to improve the peri‐operative outcomes as operative time, intraoperative complications and graft function. In addition, this guide could optimize the learning curve of this highly‐competent procedure.
Results: Our technical guide consists of SIX major steps (Exposure, Opening the ways to the hilum, Hilar dissection, Preharvesting, Harvesting, Post‐harvesting to do). In each major step, we illustrate SIX points to achieve or consider.
Conclusions: Currently, we are investigating the impact of this technical guide application in our transplantation program on peri‐operative outcomes and learning curve during LLDN.
Robotic Left Pyelolithotomy and Y‐V Pyeloplasty
WM Hughes, R Thomas, I Voznesensky, M Wong
Tulane
Introduction & Objective: Management of certain renal calculi can be challenging, especially considering the size, high H.U. and intervening bowel making PCNL fraught with danger. This video will go through the best treatment option.
Methods: Using standard robotic technique and positioning patient and robot as for a robotic pyeloplasty, the Da Vinci robot was used to approach and extract, intact, a large left renal pelvic calculus with minimum branching into the calyces. After the pyelotomy was performed using the Da Vinci robot, and the large calculus was extracted, a robotic Y‐V plasty for associated UPJ obstruction was performed. Ureteral stent was placed along with JP drain.
Results: The patient healed nicely and the patient was stone free. The pyeloplasty was successful on Post‐Op evaluation.
Conclusions: Difficult calculi cases call for unusual remedies. In this case, when PCNL was not possible because of intervening bowel, the robotic pyelolithotomy and pyeloplasty saved the day!
Single‐Port Retroperitoneal Robotic Pyeloplasty: Description of Technique
A Beksac, M Abou Zeinab, E Ferguson, A Kaviani, J Kaouk
Glickman Urological & Kidney Institute, Cleveland Clinic
Introduction & Objective: We are presenting a novel technique to perform single‐port (SP) extraperitoneal dismembered pyeloplasty using a modified mini‐Pfannenstiel incision.
Methods: Our case is a 31‐year‐old female with a history of right‐sided flank pain and recurrent urinary tract infections. Her flank pain required consistent use of analgesic medication. A preoperative MAG‐3 scan demonstrated 30% function of the right kidney and there was no response to furosemide administration on the right side. The patient underwent right ureteral J stent placement prior to referral and her pain improved significantly with ureteral stent placement. The decision was made to treat the patient with SP extraperitoneal right robotic dismembered pyeloplasty. The access was made through a 3.5 cm modified Pfannenstiel incision and with blunt dissection, the extraperitoneal space was created. Da Vinci SP access kit was used, along with an 8 mm assistant port, and the remotely operated suction irrigation system. After access, surgical steps in order were 1) Ureteral Dissection, 2) Renal pelvis dissection, 3) Excision of the ureteropelvic junction, 4) Spatulation of the ureter, 5) Anastomosis.
Results: The surgery was completed successfully without any need for additional port placement. Operative time was 175 minutes and estimated blood loss was 20 ml. The patient was discharged home on the day of surgery. She did not require opioid analgesics after discharge. The Ureteral J stent was removed 4 weeks after surgery and the patient has been without right flank pain since ureteral stent removal. Postoperative MAG‐3 scan showed resolution of obstruction.
Conclusions: Retroperitoneal SP dismembered pyeloplasty is safe and feasible using a modified mini‐Pfannenstiel incision. This approach is applicable to any patient without a past history of pelvic surgery.
Robotic Right Radical Nephrectomy and Ureteroduodenal Fistula Repair
M Lee (Temple University Hospital), G Limardo, N Houston, DD Eun
Temple University Hospital
Introduction & Objective: A ureteroduodenal fistula is an uncommon diagnosis that has been associated with significant patient morbidity including recurrent urinary tract infections, pneumaturia and flank pain. Surgical management may be complex due to the extensive fibrosis and scarring surrounding the ureteroduodenal fistula site secondary to chronic inflammation. We describe our robotic surgical approach for repair of a ureteroduodenal fistula in a patient with an associated ipsilateral atrophic kidney.
Methods: We report the case of a 42‐year‐old female with history of a right ureteroduodenal fistula secondary to iatrogenic injury during a ureteroscopy and laser lithotripsy procedure one year prior. The fistula connected the proximal right ureter to the third part of the duodenum. The patient was previously managed with ureteral stent exchanges but desired definitive management as she experienced recurrent urinary tract infections and intermittent fevers. A percutaneous nephrostomy tube was placed four weeks prior to her procedure. A preoperative renal scan showed 10% function in the right kidney and the patient elected to undergo a robotic total right nephrectomy and ureteroduodenal fistula repair. Intraoperatively, extensive retroperitoneal fibrosis and purulent debris was evident surrounding the right renal hilum and pelvis. Antegrade injection of intraureteral indocyanine green was visualized under near infrared fluorescence to aid in dissection. A total right nephrectomy was performed, leaving a 2‐centimeter margin of kidney parenchyma and ureter that remained connected to the duodenal fistula. The general surgery team then performed a duodenotomy and primary repair with omental patch.
Results: Intraoperatively, estimated blood loss was 400 milliliters and robotic console time was 200 minutes. A small injury to the inferior vena cava during dissection was repaired primarily. An upper GI series was performed on postoperative day 3 that demonstrated no duodenal leak. The patient was discharged on postoperative day 4 after an uncomplicated hospital course. At 11‐months follow‐up, there were no major (Clavien >2) postoperative complications, and the patient has not experienced any urinary tract infections.
Conclusions: Robotic total nephrectomy and ureteroduodenal fistula repair may be performed effectively in a patient with a ureteroduodenal fistula and associated ipsilateral atrophic kidney.
< ![endif] >< ![endif] >80g in size) can be managed with Holmium Laser Enucleation of the Prostate (HoLEP), Open simple prostatectomy (OSP) or robotic simple prostatectomy (RSP). While these modalities have been previously compared to one another, one study only compared 32 RSPs to 600 HoLEPs. To our knowledge, the three modalitis have never been compared against each other in the same cohort. Furthermore, in any published studies, the authors were not performing same‐day catheter removal and discharge after HoLEP, indicating the studies must be updated. Herein, we present our experience performing HoLEP, OSP, and RSP for large prostates at a large academic medical center.
< ![endif] >< ![endif] >80g. Patients were identified by CPT code (52649, 55831/55821, 55899, respectively). Variables were abstracted from the EDW and medical record. Statistical analysis was performed using SAS studio (2021). Multiple comparisons for continuous variables were performed using ANOVA with Tukey's corrections. Chi‐square tests were used for categorical variables. P‐value <0.05 was determined to be statistically significant.
