Single Cell Transcriptional Profiles of Benign Prostatic Hyperplasia
Rei Unno2, Heiko Yang1, Kazumi Taguchi2, Shuzo Hamamoto2, Atsushi Okada2, Takahiro Yasui2, Thomas Chi1, Franklin Huang1
1Department of Urology, University of California, San Francisco, 2Department of Nephro‐urology, Nagoya City University Graduate School of Medical Sciences
Presented By: Rei Unno, MD, PhD
Introduction: Benign prostatic hyperplasia (BPH) affects the majority of aging men and leads to lower urinary tract symptoms. Based on histological characteristics and bulk sequencing data, the pathophysiology and underlying mechanisms of BPH are poorly understood. The aim of this study was to investigate the transcriptional profile of BPH at single cell resolution to improve our understanding of the molecular features of BPH.
Methods: Fifteen BPH specimens were collected from patients undergoing holmium laser enucleation of the prostate. Cells from each specimen were isolated, captured, and sequenced using a bead‐based single‐cell RNA sequencing platform (Seq‐well). Transcriptomic analysis of the gene expression matrices was performed. The absence of malignant pathologic diagnoses was independently confirmed.
Results: 16,234 cells from 15 BPH specimens were analyzed. By canonical cell type markers, we annotated three major cell types (epithelial, stromal, and immune cells). Using significantly upregulated genes in BPH compared to normal prostates previously derived from a bulk RNA sequencing comparison, bulk sequencing highlighted only the fibroblast populations. After performing a sub‐clustering analysis of the 6249 epithelial cells, we identified four luminal cell subclusters showing similar levels of luminal epithelial markers KLK3, KLK2, and NKX3‐1, as well as one distinct basal and one club cell population. Analysis of the differentially expressed genes among the four luminal subclusters revealed that luminal subcluster 4 was enriched in a specific signature gene set, including ribosomal genes and KLK4, which has been shown to be abundant in BPH, compared to the other subclusters. Gene ontology analysis using this gene set demonstrated that luminal subcluster 4 was associated with pathways such as oxidative phosphorylation and adipogenesis. Analyses of the BPH immune microenvironment showed a larger proportion of pro‐inflammatory cells, such as M1 macrophages, compared to anti‐inflammatory cells within the myeloid cell population.
Conclusions: Single cell profiling identified epithelial cells, stromal cells, and immune cells. We confirmed the upregulation of previously derived BPH‐associated genes in the fibroblast population and the enrichment of pro‐inflammatory myeloid cells in the immune microenvironment. Within the epithelial cell population, we identified a luminal epithelial subcluster that may represent a cell state associated with BPH.
Funding: None
MBD2 Promotes Bladder Fibrosis Via Macrophage‐Myofibroblast Transition
Wei Wang1, Lede Lin1, Huiling Chen1, Liang Zhou1
1Department of Urology, Institute of Urology (Laboratory of Reconstructive Urology), West China Hospital, Sichuan University, Chengdu, Sichuan, P.R. China
Presented By: Wei Wang, MD
Introduction: Unresolved inflammation can lead to tissue fibrosis and impaired organ function. Macrophage–myofibroblast transition (MMT) is one newly identified process to generate collagen‐producing myofibroblasts in fibrotic disease. However, the mechanisms underlying MMT remain to be determined. Here, we investigated the potential role of methyl‐CpG binding domain 2 (MBD2)‐mediated MMT in bladder fibrosis with bladder outlet obstruction (BOO) mice.
Methods: Male C57BL/6 mice were subjected to a surgical operation for BOO as previously reported. Bladder tissues were harvested for assays of flow cytometry, western blot, histological examinations, immunohistochemistry staining and immunofluorescence. In vitro, bone marrow‐derived macrophages (BMDM) were isolated from mice by flushing the femur and tibia with DMEM/F12 medium, dispersing the cells and isolating F4/80+ cells via FACS (> 99% purity). Generation of MMT cells from BMDMs was stimulated by TGF‐β1 as described previously.
Results: The expression of MBD2 was abnormally increased in the BOO group, accompanied by MMT cell accumulation. Interestingly, we found that MBD2 was highly expressed by macrophages undergoing MMT in sites of bladder fibrosis. In vitro study demonstrated that TGF‐β1 treatment significantly upregulated the expression of collagen‐1, fibronectin, α‐smooth muscle actin and MBD‐2 in macrophages. Furthermore, systemic knockout of MBD2 alleviated bladder fibrosis and pathological damage. MBD2 deficiency significantly attenuated MMT cell infiltration in the bladder following BOO induction.
Conclusions: Our findings establish a role for MBD2 in MMT and bladder fibrosis and suggest that MBD2 may be a therapeutic target for BOO with progressive bladder fibrosis.
Funding: This study was supported by the National Natural Science Foundation of China (Grant No. 81800667, 82270811), and the Project of Science and Technology Department of Sichuan Province (Grant No. 22NSFSC1447).
Associations Between the Prostatic Microbiome and Prostate Size in BPH
1Case Western Reserve University School of Medicine, 2Cleveland Clinic
Presented By: Aaron Miller, PhD
Introduction: Though benign prostatic hyperplasia (BPH) affects an estimated 70% of men between the ages of 60‐69, the etiology is not well understood. Recently, the human urinary tract microbiome has been associated with a variety of urologic diseases, especially those mediated by an inflammatory pathway. Here, we sought to determine associations between age‐independent prostate size and microbiome.
Methods: Men over 18 years old undergoing Holmium Laser Enucleation of the Prostate (HoLEP) for BPH were recruited if they had no history of prostate cancer, prostate surgery, or pelvic radiation. Patients were excluded if they had a positive preprocedural urine culture, recent UTI requiring antibiotics, bladder stones, or if they were catheter‐dependent due to obstruction. Prostate tissue samples, catheterized urine, and urethral and specimen container swabs were collected from each patient. All non‐prostate samples were used as contamination controls. Patient data such as age, prostate‐specific antigen (PSA) level, BPH symptoms, and prostate size were recorded. All samples underwent DNA extraction, 16S sequencing, and analysis in R statistical software. After quality control, reads associated with the controls were removed. High‐quality, decontaminated data were assessed for diversity (alpha, beta, taxonomy). The correlation between amplicon sequence variants (ASVs) and patient metrics were quantified through Sparcc correlations, which was designed for count matrix correlations.
Results: 20 patients qualified, consented, and were analyzed in this study. Mean age, PSA, and prostate size were 68.6 years, 3.4 ng/mL, and 107.9 g, respectively. After bioinformatic decontamination of samples with the negative controls, diversity analyses identified distinct microbiomes: site‐specific differences between the urine, urethral swab, and prostate microbiomes were greater than inter‐individual variability. Common uropathogens were positively associated with prostate size. These included five ASVs belonging to Enterobacter cloaceae (p = 0.02‐0.03), four Planococcaceae ASVs (p = 0.008‐0.03), and four Acinetobacter (p = 0.014‐0.026). Only one ASV in the Ralstonia genus exhibited a significant association with age (p = 0.015).
Conclusions: This study is the first to characterize the prostatic microbiome in BPH and to link prostate size to specific common bacterial uropathogens, while controlling for age and contamination. Further research with a larger sample size and culturomics will provide insight into the mechanisms of how the prostate microbiome contributes to enlarged size.
Funding: Endourological Society Summer Student Scholarship
WITHDRAWN
Toward Ultrasound‐Guided Trans‐Perineal High Intensity Focused Ultrasound Treatment of Benign Prostatic Hyperplasia Pre‐Clinical Validation
1Hebrew University, 2NINA Medical, 3Technion, Israel Institute of Technology, 4Shamir Medical Center
Presented By: Ehud Willenz, DVM
Introduction: The trans‐perineal (TP) approach to the prostate for Ultrasound (US) imaging and for focal therapy using High Intensity Focused Ultrasound (HIFU)offers several advantages over alternatives. TP US‐ guided HIFU could become a completely non‐invasive treatment for Benign Prostatic Hyperplasia (BPH), in contrast to the existing minimally invasive ones.We present the results of pre‐clinical studies demonstrating US‐guided HIFU ablation with real‐time tracking of the focal point prior to and during the ablation process.During pre‐clinical phase of the TP US‐guided HIFU ablation system, experimental treatment was suggested to dog owners for dogs diagnosed with prostate cancer. Prior to dog treatment, a safety in‐vivo experiment was performed ina pig model.
Methods: NINA Medical's (Nazareth, Israel) HIFU system was used for the ablation. The pre‐clinical safety experiments were approved by local Helsinki committee 14/2020 (Shamir Medical Center) and experimental treatments for dogs were approved by local Helsinki committee MD‐21‐16565‐3 (Hebrew University). Two treatment attempts were applied to two different dogs. Figure depicts the HIFU beam visualization as was observed in‐situ (pig's thigh) in real‐time with schematic drawings of the system location.During sonication, a fused display of the anatomy and HIFU imaging is presented to the physician. (1) schematics of transducer location on the skin, (2) a water balloon coupled to the skin, (3) the skin interface, (4) real‐time visualization of the focal point.
Results: Four different lesions were created in pig's thigh during the safety experiment, using various HIFU parameters, under US guidance.During treatment, dogs were under general anesthesia, and the prostate was approached via the abdomen due to the lack of substantial perineum. The prostate capsule, the urethra (catheterized) and the HIFU beam were observed with US, including US imaging of the focal point within the prostate.No skin burns or any damage to the surrounding tissue including the urethra was observed following the treatments.
Conclusions: New HIFU imaging technology provides real‐time feedback from the focal point within the body prior to and during ablation, paving the way for TP non‐invasive treatment of BPH.
Funding: NINA Medical Ltd.
Analysis of the Top‐Down HoLEP Learning Curve: A Single‐Centre Experience of Two Clinical Fellows
Introduction: Holmium laser enucleation of the prostate (HoLEP) is known to have a steep learning curve. The top‐down technique was introduced to lessen the number of procedures required to master HoLEP. The objective of our study was to present the experiences of two successive clinical fellows with the top‐down HoLEP learning curve and to compare the fellows' performance with their supervisor.
Methods: We conducted a prospective study of 40 patients that underwent top‐down HoLEP performed by two successive clinical fellows at our institution from September 2020 to July 2022. Prior to data collection, each fellow observed three top‐down HoLEP procedures and assisted with seven additional cases before independently performing top‐down HoLEP under supervision. We collected data from each fellow's first 20 consecutive top‐down HoLEP procedures. All patients included in the study had a prostate size > 80 g. The learners' cases were grouped according to chronological order (Cases 1‐10 and 11‐20). The primary outcome was defined as the number of cases before the clinical fellow could independently complete all steps of top‐ down HoLEP without any major intraoperative complications. The secondary outcomes included the intraoperative and postoperative outcomes of both groups. The 40 cumulative cases of the clinical fellows were then compared to 148 procedures performed by their supervisor in terms of efficiency, outcomes, and complications.
Results: There were no significant differences in baseline patient demographics for both clinical fellows. Each learner performed the first 20 cases independently without needing the supervisor to intervene. There were no major intraoperative complications recorded and no statistically significant differences in intraoperative and postoperative outcomes between fellows' cases (Table 1). There was a statistically significant difference between the fellows and their supervisor in terms of operative efficiency and enucleation efficiency (p = 0.000). We did not find a significant difference between the fellows and the supervisor regarding intraoperative complications, major postoperative complications, or postoperative subjective and objective parameters.
Conclusions: Top‐down HoLEP shows promising and reproducible results in shortening the HoLEP learning curve. Further comparative and multi‐institutional studies with additional learners are needed to verify our preliminary findings.
Funding: None
Initial Experience of Smart Phone Based AI Generated Uroflowmetry in Post‐HOLEP Patients
James Johannes1, Alexis Brown1, Jaylon Hartley1
1Lehigh Valley Health Network
Presented By: james johannes, MD
Introduction: Remote medical monitoring and testing is rapidly developing due to medical access challenges and emphasis on value based care. We tested a novel machine learning based smartphone app for following post‐HOLEP patients uroflowmetry and IPSS.
Methods: Patients within the first year of HOLEP recovery performed at home uroflowmetry using the Emano Flo app (EF). These results were compared to digital weight sensor uroflowmetry in the office.EF is a smartphone based app using AI to generate a flow curve based on acoustics of a urine stream contacting the toilet bowl water. Prior to voiding into a toilet, the patient opens the app on his phone and presses record. The phone is placed on any surface. After the void is complete, the patient answers standard IPSS questions. Data is accumulated over a 7‐10 day period of voids, aggregated, and reported to the ordering physician.
Results: 11 patients underwent both in‐office uroflowmetry/PVR/IPSS and remote EF. 8 patients performed at the 1 month post‐op visit, 3 at 3 months, 1 at 12 months postop. Results are in Table 1. Patients performing the EF averaged 47.4 voids per report. The average voided volume (VV) was lower in the EF patient population, 164.3 vs 204.3. Qmax and Qmean between EF vs In‐Office were almost identical, 23.3 vs 20.7 and 12.0 vs 11.0 respectively. Excluding flows < 125ml, EF VV increased to 215.1, Qmax 24.4, and Qmean 13.1. Similarly, the > 125ml office patients had an average VV 362, Qmax 28.1, and Qmean 16.3. For the 4 patients who had > 125ml voided with both modalities, the average VV EF vs office was 261.1 vs 351, Qmax 25.1 vs 26.9, Qmean 14.4 vs 15.4. One more patient achieved a VV of 125 using the app vs in office.IPSS scores were similar between EF and office, 7.6 total/QOL 0.9, vs 7.9 total/QOL 1.6 and consistent regardless of VV.
Conclusions: Using a smartphone based app to perform at home uroflowmetry has many potential applications. In our post‐HOLEP patients, we found the EF results were similar to in office‐based uroflowmetry. Further study is necessary to determine if smartphone based uroflowmetry can supplant in‐ office studies. This has potential impact in reducing patient visits to the office which can help improve access and reduce healthcare costs.
Funding: none
How Mirabegron Affects the Human Ureter: An in Vitro Study
Ahmet Gudeloglu1, Meylis Artykov1, Esin Ozcelebi2, Mehmet Yildirim Sara2, Alper Bektas Iskit2, Fazil Tuncay Aki1
1Department of Urology, Hacettepe University, 2Department of Pharmacology, Hacettepe University
Presented By: Ahmet Gudeloglu
Introduction: In this study, we aimed to investigate the effects of Mirabegron (MRB), a β3‐ adrenergic receptor agonist with current widespread clinical use in the treatment of overactive bladder disease, on isolated healthy human ureter.
Methods: The approval of review board of the ethical committee was obtained prior to the study. This prospective study was designed as series of in vitro tissue experiments. Graft kidney's ureteral tissues of living donors who underwent surgery at our center between December 2020 and June 2021 were preferred. Informed consent was obtained from all patients. Ureters were transected harvested at the level of just above iliac crossing. Tissue transfer took place in the sealed flask containing pre‐gassed Krebs solution. Ureters were eventually detubularized and stripes were suspended in organ baths. The tissue activity was recorded after stripes were left to rest until spontaneous contractions were observed. Consequently, tissue responses were recorded by adding increasing concentrations of Mirabegron. The myogenic activity was recorded via electro‐mechanical transducer set‐up and AcqKnowledge® 4.2 (BIOPAC Systems, Inc.) software. Data analysis was performed with software SPSS 24.0 (IBM Corp., Chicago, USA) and GraphPad Prism 6 (GraphPad, La Jolla, CA, USA).
Results: The total of 24 tissue strips from 16 ureters were prepared and studied. Of these, only 15 strips exhibited spontaneous or inducible activity. The effect of Mirabegron was examined in tissues with spontaneous activity. The data of strips without detectable activity was excluded from the study. It was determined that MRB lowered the frequency of spontaneous ureteric contraction in the concentration‐ dependent manner (Figure 1; A sample trace visualizing the effect of MRB in cumulative concentration on isolated ureteral strips. Molar concentrations are depicted in means of logarithmic value). The decrease in frequency was statistically significant in presence of MRB at 10‐6.5 ‐ 10‐4.5 M (Figure 2; Response values were proportioned with baseline contraction. All data in graphs is presented as arithmetic mean ± standard error of the mean. a p < 0.05, b p < 0.005). Also, the decrease in spontaneous contraction frequency in terms of percentage change was statistically significant at 10‐8 ‐ 10‐4.5 M. The MRB lowered the spontaneous ureteric contractile force in a dose‐dependent manner compared to the baseline contractile force. The decrease in amplitudes was statistically significant at 10‐7 ‐ 10‐4.5 M concentrations.
Conclusions: The Mirabegron shows suppressive properties on the human ureter activity in vitro. This effect could be achieved in the dose‐dependent fashion in isolated tissue strips showing spontaneous activity.
Funding: This study was financially supported by the Scientific Research Unit of Hacettepe University, Turkey.
Randall's Plaque‐Associated Macrophages Receive Chemokine Signaling from the Loop of Henle
Heiko Yang1, Hanbing Song1, Thomas Chi1, Marshall Stoller1, Franklin Huang1, Sunita Ho1
1UCSF
Presented By: Heiko Yang, MD, PhD
Introduction: We recently identified an embryonically derived tissue resident subpopulation of macrophages associated with Randall's plaques. These macrophages typically reside in the renal cortex in normal kidneys, so how they arrive at the papillary tip in stone formers is unclear. The objective of this study was to use our single nuclear RNA sequencing dataset to identify which cells at the papillary tip may be responsible for chemokine signaling to these macrophages.
Methods: Randall's plaque and renal papillary tissues were collected from adult patients undergoing stone surgery. Randall's plaque tissue was obtained from endoscopic biopsies while whole renal papilla tissue were obtained from fresh nephrectomy specimens. Single nuclear RNA sequencing was performed using the 10X Genomics platform and Illumina NovaSeq S4. Additional tissue was saved for immunohistologic staining. Analysis was conducted using R Studio and Seurat. Intercellular molecular interactions were predicted using CellphoneDB.
Results: CXCR4‐mediated chemokine signaling was found originating from epithelial cells in the loop of Henle. This interaction was highly specific to RP‐associated macrophages and was not predicted to originate from other epithelial or stromal cell types. Adhesion interactions via P‐selectin and E‐selectin were notably absent between vascular endothelial cells and RP‐associated macrophages, reinforcing a non‐hematologic origin.
Conclusions: Epithelial cells at the loop of Henle may be responsible for attracting RP‐associated macrophages to the papillary tip. While the role of these macrophages in biomineralization is still being investigated, these results support the hypothesis that the loop of Henle is the functional location of Randall's plaque pathology.
Funding: California Urology Foundation (HY), Program in Biomineralization Studies (SH)
Development of a Realistic Mouse Model of Urosepsis
Dirk Lange1, Roman Herout1, Sreeparna Vappala2, Sarah Hanstock1, Igor Moskalev3, Ben Chew1, Jayachandran Kizhakkedathu2, Dirk Lange1
1The Stone Centra at Vancouver General Hospital, Department of Urologic Sciences, University of British Columbia, 2Department of Pathology and Laboratory Medicine and Centre for Blood Research, The University of British Columbia, 3Vancouver Prostate Centre, Department of Urologic Sciences, University of British Columbia
Presented By: Dirk Lange, PhD
Introduction: Murine models of sepsis, such as the cecal ligation and puncture (CLP) model, are typically polymicrobial and associated with a high mortality within hours after the specific intervention. To date, nomodels exist that follow the natural course of development from initial infection to sepsis, meaning that current models are not suitable to test the effiacy of interventions to prevent development to sepsis. To address this shortcoming, we developed a high‐throughput, murine model that mimics a slow‐paced, monomicrobial sepsis originating from the urinary tract.
Methods: Twelve (12)‐week‐old male C57Bl/6 mice (n = 23) underwent percutaneous insertion of a 4mm catheter piece into the urinary bladder. The following day mice were divided into three groups differing in the number of bacteria introduced into the bladder of animals:group 1 ‐ 50 μl of a 1x10^8 CFU/ml solution (n = 10), group 2 ‐ 50 μl of a 1x10^7 CFU/ml solution (n = 10), and group 3 (sham mice) ‐ 50 μl of sterile saline (n = 3). On day 4 mice were sacrificed. The number of bacteria in urine, colonizing bladder catheters, adherent to/invaded into the bladder tissue as well as a set of (32) sepsis‐associated pro‐/anti‐inflammatory cytokines and chemokines were analyzed.
Results: All 23 mice survived the postinterventional period. Mean weight loss was 11% in group 1, 9% in group 2 and 2% in the control group. Mean urine CFU counts were highest in group 1 and all sham mice had negative urine cultures. All infected mice had high catheter‐adhered bacterial counts. 18/20 infected mice had CFU counts in homogenized splenic tissue indicating septicemia. Cell‐free DNA and D‐Dimer was highest in group 1 and lowest in the control group. Serum levels of G‐CSF were significantly increased in group 1 when compared to controls. Serum levels of IL‐6, TNF‐a, IFN‐? and IL‐1ß were all elevated (1.5 to 30‐fold) compared to control mice.
Conclusions: We present a monomicrobial murine model of urosepsis that follows the natural progression to sepsis from an initial urinary tract infection originating from an indwelling catheter. This model does not lead to rapid deterioration and death and can therefore be used as a model to test the efficacy of novel interventional strategies to prevent sepsis development.
Funding: Roman Herout was funded by the Deutsche Forschungsgemeinschaft (DFG, German Research Foundation) – 447437311.
Composition and Structure of a Cystine Bladder Stone
Amy Gosling1, Roanne Causey1, Chandra Shekhar Biyani2, Robert Simpson3, Ben Holley3, Antonia Borissova3, Andrew Scott3
1School of Medicine, Worsley Building, University of Leeds, 2Urology Department, St James's University Hospital, 3School of Chemical and Process Engineering, University of Leeds
Presented By: Amy Gosling
Introduction: Cystinuria is an autosomal recessive condition resulting in the supersaturation of cystine in the urine and subsequent crystallisation. Despite only accounting for 2% of all urolithiasis, the 5‐year recurrence rate for cystine stones is high at approximately 83%. The current understanding of the growth mechanisms of urinary stones is limited. Characterisation of urinary stones is essential to improve understanding of the formation of urolithiasis, allowing for the identification of major and trace components and morphological features and structure. The existing standard analysis technique is Fourier‐transform infrared spectroscopy (FT‐IR), however, a wider range of characterisation techniques is advisable for a thorough understanding of stone composition and growth. These results will be used to suggest a protocol for stone analysis.
Methods: Three intact stones were removed from an 80‐year‐old male, undergoing treatment for prostate cancer. The stones were removed by an open cystolithotomy because of the size. There was no positive family history of cystinuria. The three ovoid stones (two ∼6 cm, one ∼3 cm in length) were superficially similar. One stone was cut in half to reveal the internal structure. The surface of the stone was imaged using stereo and reflected light microscopy. Higher‐resolution imaging and elemental information were performed using scanning electron microscopy (SEM). Crystalline phases were identified by X‐ray diffraction (XRD). Results were compared with FT‐IR spectra. A 30‐micrometre thin section of the smaller stone was produced to enable polarised transmitted light microscopy.
Results: Light microscopy visualised a central core of large crystals surrounded by concentric growth rings emanating from the centre of the stone (Fig.). XRD revealed a single, crystalline phase, cystine. SEM imaging and elemental analysis (EDX) showed hexagonal crystals (cystine) together with amorphous, spherical calcium phosphate particles (∼5 μm) clustered near the core and in concentric rings within the stone. FT‐IR spectra were consistent with cystine and calcium phosphate.
Conclusions: We have demonstrated that a wide range of characterisation techniques is necessary to clearly understand the structure and composition of cystine stones. Protocols for the analysis of urinary tract stones should combine multiple methods of characterisation to aid in the understanding of stone formation.
Funding: Nil
When Does Pyelovenous Backflow Occur? the Effect of Raised Intrarenal Pressures on an Ex Vivo Animal Model
Anne Hong1, Justin Du Plessis1, Greg Jack1, Cliodhna Browne1, Damien Bolton1
1Austin Health
Presented By: Anne Hong, MD
Introduction: Elevated intrarenal pressures (IRPs) are common during ureteroscopies and may have implications for post operative complications. However, little is known about the microscopic processes that transpire during pathogenesis complications. We aimed to document the histological changes observed in renal units subjected to elevated IRPs and postulate the possible mechanisms of infectious complications.
Methods: 21 ex vivo porcine kidney models were used. Each ureter was cannulated with a 10Fr dual lumen ureteric catheter (Boston Scientific, Massachusetts, United States) with the proximal end at the pelviureteric junction. The distal end of the ureter was secured to form a leak‐proof seal around the ureteric catheter. A 0.014” pressure sensing wire (Comet II Pressure Guidewire®, Boston Scientific, Massachusetts, United States) was inserted through one lumen and with the sensor positioned in the renal pelvis for IRP measurement. Undiluted India ink stain (Royal Talens, Apeldoorn, Netherlands) was irrigated through the second lumen. Each renal unit was subjected to India ink Irrigation at target IRPs of 5mmHg (control), 30mmHg, 60mmHg, 90mmHg, 120mmHg 150mmHg and 200mmHg. 3 renal units subjected to each target IRP. After irrigation, each renal unit was processed by a uropathologist with haematoxylin and eosin, and examined under low and high power magnification.
Results: India ink stain was observed in the collecting ducts at 5mmHg. Signs of pressure as represented by collecting duct dilatation was first observed at 60mmHg (Figure A). Stain was consistently observed in the distal convoluted tubules at ≥60mmHg, all renal units showed renal cortex involvement. At ≥90mmHg, stain was observed in venous structures (Figure B). At 200mmHg, stain was observed in supportive tissue, peritubular capillaries and glomerular capillaries.
Conclusions: Demonstration of vascular involvement is required to account for septic complications. This occurred at IRP of ≥90mmHg in ex vivo porcine models.
Funding: The authors did not receive any funding for this research
Transcriptomic Workflow for Microbiome Profiling of the Genitourinary Tract
Jose Agudelo1, Sromona Mukherjee1, Mangesh Suryavanshi1, Ava Adler1, Thien Dang1, Aaron Miller1
1Cleveland Clinic
Presented By: Jose Agudelo, MD
Introduction: Multiple studies have revealed the presence of viable microorganisms in the urinary tract designated as the urobiome.Dysbiosis of the urobiome has been associated with a number of urologic diseases. The purpose of the present study was to characterize and compare the trans‐domain microbiome in diverse genitourinary tract tissue.
Methods: The sequence read archive (SRA) was searched for human transcriptomic data derived from human genitourinary tissue. An automated workflow was developed and run for studies that fit the above criteria, as follows: downloading raw sequencing data, filtering, and mapping to the GRCh38 human genome. Then nonhosts reads were mapped to a database that contains > 45,000 full‐length Prokaryotic, Protozoan, Viral, and Fungal genomes downloaded from the NCBI. The resulting microbial taxonomic profiles were used to quantify differences and similarities in the microbial profiles of different regions of the genitourinary tract.Additionally, when applicable, patient‐specific analyses were conducted to determine the factors that shape the urobiome and possible disease‐specific dysbioses.
Results: Ten studies fit our criteria and included samples from urine, semen, prostate tumor, upper tract urothelium, testicle, kidney, bladder tumor, and laser micro dissected tubuli and glomeruli. Five studies used shotgun metagenomics, with four RNA‐seq, and one exome‐seq. We were able to identify taxa from all domains in all tissue types, with Prokaryotes dominating the microbiome in all tissues (Figure 1). A trans‐ domain species richness analyses show variable microbial loads between tissue types, which was in part driven by sequencing platform and depth.
Conclusions: Our findings provide evidence of the presence of a diverse microbiome in tissues that span the length of the genitourinary tract. These results provide a baseline microbial profile of the urobiome that can be used for future targeted studies on health and disease of the genitourinary organs.
Funding: Lerner Research Institute
Dynamics of Inflammatory Reaction Markers in Patients under Endourological Interventions: A Single‐Center Cohort Study
Vigen Malhasyan5, Dmitry Pushkar1, Yuriy Kim2, Sergei Sukhikh3, Tasin Mahmudov3, Igor Grickov4
1Academician of RAS, Prof., Head of the Department of Urology, A.I. Evdokimov Moscow State University of Medicine and Dentistry, 2Urologist at the Department of Urology, A.I. Evdokimov Moscow State University of Medicine and Dentistry, 3urologist at the Department of Urology, A.I. Evdokimov Moscow State University of Medicine and Dentistry, 4Resident at the Department of Urology, A.I. Evdokimov Moscow State University of Medicine and Dentistry, 5Professor of the Department of Urology, A.I. Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russian Federation. Head of Urology Department №4, S.I. Spasokukotsky City Clinical Hospital
Presented By: Vigen Malhasyan, MD
Introduction: Urolithiasis is one of the most widespread urological diseases and infectious complications remain one of the most common adverse events after surgical interventions for urolithiasis. Currently, in routine clinical practice in most clinics in the country, for the purpose of postoperative control and detection of infectious complications is used: a clinical blood test with assessment of the dynamics of the blood leukocyte count. Unfortunately, the current edition of the clinical guidelines does not contain recommendations on what indicators of postoperative follow‐up examinations the clinician should focus on in order to identify infectious and inflammatory complications. For this reason, the study of the value of other markers of the inflammatory response appears to be an actual task.
Methods: The prospective cohort study included 217 patients diagnosed with urolithiasis and underwent surgical removal of stones by endoscopic method. Of total patient numbers, 43 patients underwent ureteroscopy (URS) with lithotripsy, 152 patients underwent percutaneous nephrolithotripsy (PNL), and 22 patients underwent flexible ureterolithotripsy with lithotripsy. An analysis of demographics, clinical parameters and postoperative complications was performed as a descriptive analysis. Patients underwent a standard list of laboratory and instrumental examination methods. The mandatory control of body temperature was carried out 3 times a day, every day. Before surgical treatment, indicators of the content of white blood cell (WBC), lymphocytes (LYMP), C‐reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were recorded on the 1st and 2nd day after surgical treatment.
Results: In the postoperative period, an increase in (CRP) and (ESR) was noted both in the fever group and in the normal temperature group, exceeding the reference values already on the first day. At the same time, in the fever group, a significantly higher increase in these indicators was observed (685% vs. 323%) for (CRP) and (146% vs. 80%) for (ESR). According to the results obtained in our study, (CRP) and (ESR) indicators demonstrate the most clinically significant dynamics, increasing by more than 500% and 100%, respectively.
Conclusions: Endoscopic urinary calculus removal is a safe treatment option in patients with sterile urine cultures. After endoscopic stone removal, all patients experience such reactive changes in peripheral blood parameters as: an increase in the level of leukocytes, lymphopenia, an increase in (ESR) and (CRP) levels. Indicators of (CRP) and (ESR) demonstrate the most clinically indicative dynamics.
Funding: No
Visualising the Effects of Raised Intrarenal Pressure on the Renal Cortex
Anne Hong1, Justin Du Plessis1, Cliodhna Browne1, Greg Jack1, Damien Bolton1
1Austin Health
Presented By: Anne Hong, MD
Introduction: Complications after pyeloscopy have been attributed to raised intrarenal pressures. Pyelovenous backflow has been reported as a possible mechanism of ascending infection. However, the urothelium is lined with umbrella cells connected by tight junctions, forming a robust barrier. Thus, the exact mechanism of pathogen passage to the renal parenchyma and the vasculature remains a question. We examine ex vivo animal models and describe some possible mechanisms.
Methods: 21 ex vivo porcine kidney models were used. Each ureter was cannulated with a 10Fr dual lumen ureteral catheter. A Comet Pressure Guidewire (Boston Scientific, Massachusetts, USA) for pressure measurement was inserted through one lumen and positioned in the renal pelvis, with irrigation fluid flowing through the second lumen. The irrigation fluid used was undiluted India ink (Royal Talens, Netherlands). The kidney models were irrigated for 5 minutes at intrarenal pressures of 5, 30, 60, 90, 120, 150 and 200 mmHg. At the conclusion of irrigation, the renal units were bivalved and macroscopically examined for location of India ink.
Results: The control renal units subjected to 5mmHg demonstrated no staining of the renal parenchyma. From 30mmHg onwards, the renal parenchyma is unevenly affected, with each renal unit containing areas that are macroscopically unstained. The number of renal pyramids and percentage of renal cortex affected is summarised in Table 1.
Conclusions: Staining of the renal cortex is demonstrated at IRPs of 30mmHg and higher, suggesting that backflow may affect the renal parenchyma from 30mmHg. However, this appears to be significantly greater from 90mmHg. These may contribute to infectious complications after pyeloscopy.
Funding: The authors received no funding for this research
A Rare Cause of Cystolithiasis: Intravesical Migration of Intrauterine Device
Jan Ernest Guy Yadao4, Eli Paulino Madrona1, Brian Severo Blas2, Meliton Alpas3, Karl Marvin Tan1
1veterans memorial medical center, 2Eastern Visayas Medical Center, 3Veterans Memorial Medical Center
4Veterans Memorial Medical Center
Presented By: Jan Ernest Guy Yadao, MD
Introduction: Intrauterine devices ( IUD) are one of the most reliable and cheapest contraception methods. Although IUDs are effective, various complications, including bleeding, infection, ectopic pregnancy and uterine perforation, have been identified. Migration of IUD to the bladder through partial or complete perforation has been rarely reported. Herin, a case is presented where cystolithiasis was found 11 years after inserion of an IUD.
Methods: The case report describes the patients clinical presentation, laboratory and radiological findigns, as well as the management approach, which involved cystolithotripsy to remove the bladder stones and IUD
Results: The radiographic imaging revealed a 5x5cm radiopaque calculus encrusting a T‐shaped material identified as IUD. Cystoscopy confirmed the presence of bladder calcui and the copper IUD. The patient underwent successful cystolithotripsy and the postoperative period was uneventful.
Conclusions: Bladder stones are the most common manifestation of lower urinary tract lithiasis, accounting for 5% of all the urinary stone diseases, and approximately 1.5% of urologic hospital admissions. Traditionally, the bladder stones are classified as migrant, primary idiopathic, or secondary. Secondary bladder stones are always associated with underlying bladder pathology, such as a migrated intrauterine contraceptive device, which can act as the nidus for the formation of a secondary bladder stone. Radiography and ultrasonography provide adequate imaging for the diagnosis of intravesical migration of intrauterine devices. Prompt removal of the stone must be done to prevent recurrent urinary tract infection.
Funding: none
Safety of Hypoxic Preconditioned Allogeneic Bone Marrow‐Derived Mesenchymal Stem Cells in Acute Kidney Injury: An Open‐Label Phase 1 Clinical Trial
Dalsan You2, Myoung Jin Jang1, Joomin Aum2, Yu Seon Kim2, Ha Chul Shin3, Nayoung Suh4, Choung‐Soo Kim5
1Asan Institute for Life Sciences, Asan Medical Center, 2Department of Urology, Asan Medical Institute of Convergence Science and Technology, Asan Medical Center, University of Ulsan College of Medicine, 3Pharmicell Co. Ltd., 4Department of Pharmaceutical Engineering, College of Medical Sciences and Department of Medical Sciences, General Graduate School, Soon Chun Hyang University, 5Department of Urology, Ewha Womans University Mokdong Hospital
Presented By: Dalsan You, MD, PhD
Introduction: Treatment using stem cells, a key tool of regenerative medicine, has emerged due to limitations in surgical efforts to reduce ischemic time or premedication during partial nephrectomy. The preclinical study using hypoxic preconditioned allogeneic bone marrow‐derived mesenchymal stem cells
(HP‐BMSCs) to treat renal ischemia‐reperfusion injury has shown promising results. The authors conducted a phase 1 clinical trial evaluating the safety and potential efficacy of renal arterial injection of HP‐BMSCs to prevent renal ischemia‐reperfusion injury‐induced acute kidney injury.
Methods: The patients who temporarily blocked blood flow to the kidney and underwent partial nephrectomy for renal tumor were enrolled. The clinical trial protocol was authorized by the Ministry of Food and Drug Safety, Republic of Korea (31769), and approved by the institutional review board of Asan Medical Center, Seoul, Republic of Korea (2018‐0438), and conformed to the tenets of the Declaration of Helsinki. The brief study protocol was registered on the Clinical Research Information Service site of the Korea Centers for Disease Control and Prevention (KCT0003417). The primary outcome was the safety of renal arterial injection of HP‐BMSCs, and the secondary outcome was the protection of renal function.
Results: Of the 13 patients screened, 10 were registered in the clinical trial. Of them, eight were injected with HP‐BMSCs into the renal artery and completed the clinical trial. Seven patients experienced seventeen treatment‐emergent adverse events (TEAEs). None of them experienced serious TEAEs, and all TEAEs were considered not to be related to injection of HP‐BMSCs. In addition, no clinical significance was identified related to other safety measures, such as laboratory tests, vital signs, and physical examination. The mean value of serum creatinine increased significantly at 1 month versus baseline (1.04 mg/dL versus 0.91 mg/dL, P = 0.0068). However, there was no statistically significant change until 12 months later.
Conclusions: This phase 1 clinical trial confirmed the safety of HP‐BMSCs in patients undergoing partial nephrectomy for renal tumor. The potential efficacy of HP‐BMSCs needs to be confirmed by a phase 2 clinical trial including a control group.
Funding: This study was supported by a contribution of the Korea Health Technology R&D Project through the Korea Health Industry Development Institute (KHIDI), funded by the Ministry of Health & Welfare, Republic of Korea (grant number: HI18C2414).
BASIC SCIENCE POSTER SESSION 2: ONCOLOGY
Trancriptional Landscape in ccRCC and pRCC: The Future of Clinical Biomarker Signature Use in Kidney Cancer
Ketan Badani1
1Icahn school of medicine, Mount Sinai
Presented By: Ketan badani, MD
Introduction: RNA analysis to get Gene expression profiles (GEPs) has been widely use in oncology to assess tumor aggressiveness, risk of disease progression, and anticancer drug sensitivity. Sample collection, storage, and RNA extraction is a process that requires specialized infrastructure and can influence the outcome. We aimed to evaluate the feasibility of utilizing aRNASeq platform in archival formalin‐fixed paraffin embedded (FFPE) to describe the main cancer related signatures in clear‐cell renal cell carcinoma (ccRCC) and papillary renal cell carcinoma (pRCC).
Methods: Regions of interest were identified in FFPE kidney tumor samples, using H&E staining from 18 ccRCC and 10 pRCC. RNA was extracted and next‐generation sequencing (NGS) was performed with Illumina sequencing. Differences in 38 cancer hallmark pathways between ccRCC and pRCC were assessed using student's t‐test. Differences in gene expression were assessed using DESeq2. Gene ontology analysis of differentially expressed genes was generated via Metascape.
Results: To compare transcriptional landscape between ccRCC and pRCC we evaluated gene expression across 38 cancer hallmark pathways (Figure 1). Hypoxia was the most upregulated pathway in ccRCC (p < .001). NF‐κB, TNF, IL‐2, and other immune signatures were also found upregulated in ccRCC (p < .001). pRCC was found to have upregulated p53 pathway (p = .004) and DNA repair (p < .001). We performed ontology analyses with top 300 dysregulated genes (Figure 2). A strong enrichment for hypoxia and angiogenesis pathways including HIF‐1, vasculature development, endothelium development (p < .001) was found for in ccRCC tumors. In contrast, genes upregulated in pRCC tumors were enriched for metabolic processes such as amino acid or lipid metabolism (p < .001).
Conclusions: RNASeq analysis of FFPE samples comparing ccRCC and pRCC showed adequate technical performance and the observed underlying biology was in agreement with the literature. This shows that kidney FFPE archival samples are usable for high quality NGS‐based interrogation of molecular mechanisms and biomarker identification, anticipating their future use in the clinic.
Funding: None
A New Paradigm for the Risk Stratification of Newly Diagnosed Prostate Cancer Using MRI Parameters
Goh Jia Ling1, Lee YM Alvin1, Lee Han Jie1, Cheng WS Christopher1, Ho SS Henry1, Yuen SP John1, Ngo Nye Thane1, Law Yan Mee1, Tay Kae Jack1, Chen Kenneth1
1Singapore General Hospital
Presented By: Goh Jia Ling, MBBS
Introduction: Despite the advent of multi‐parametric MRI, risk stratification of prostate cancer is still based on traditional parameters of PSA, clinical stage and grade group at biopsy. Prior studies have demonstrated that size of index lesion and MRI tumour stage were predictive of early biochemical recurrence (BCR). The objective of our study is to incorporate mpMRI parameters into risk stratification of prostate cancer and to compare this risk model with other existing models.
Methods: Clinico‐pathological data from our single‐institution, prospectively maintained, electronic radical prostatectomy database was extracted. The primary outcome evaluated was BCR‐free survival (defined as PSA > / = 0.2 ng/mL). Cox's proportional hazard model was used to identify risk factors for BCR and receiver‐operating‐curves (ROC) were used to compare a MRI based risk model with other established model.
Results: A total of 1063 men had radical prostatectomy data available with 589 having MRI parameters available. On unadjusted analyses, biopsy grade group (p = 0.00), MRI tumour stage (p = 0.00), PSA (p = 0.00) and size of index lesion (p = 0.001) were significant predictors of BCR. On adjusted analyses, only size of index lesion (p = 0.039), grade group (p = 0.00) and were significant. ROC analyses demonstrate that the MRI‐ based model had greater AUC (0.693) compared to EAU (0.669) and NCCN (0.669) risk groups but was comparable to CAPRA risk group (0.703) in predicting early BCR (< 3 years).
Conclusions: Incorporation of MRI‐based parameters show promise in improving risk stratification of prostate cancer compared to prior established models. However, more external validation studies are warranted.
Funding: nil
Renal Cancer Exosomes Promote Platelet Activation and Thrombosis
Tejasvi Dudiki1
1Cleveland Clinic
Presented By: Tejasvi Dudiki, PhD
Introduction: Platelet activation and thrombosis are common complications in renal cancer patients, affecting up to 25% of cases. However, the mechanisms underlying renal cancer‐induced thrombosis remain poorly understood, and targeted therapeutic interventions are lacking. This study aimed to investigate the impact of exosomes derived from renal cancer cells on platelet activation and thrombosis, with the potential for developing targeted therapies.
Methods: In vitro and in vivo experiments were conducted using exosomes derived from renal cancer cell lines to evaluate platelet activation and the uptake of exosomes. The presence of renal cancer‐specific biomarkers in patient samples and the mechanisms underlying platelet activation were analyzed.
Results: Rapid uptake of exosomes derived from renal cancer cells by platelets was observed within 15 minutes of co‐incubation in vitro, indicating a preferential uptake compared to exosomes from non‐cancer cells. This uptake of renal cancer exosomes resulted in robust platelet activation after 60 minutes, suggesting the involvement of a non‐canonical mechanism with a time delay between exosome uptake and platelet activation. Translational inhibitors, such as cyclohexamide and puromycin, effectively inhibited cancer exosome‐induced platelet activation, highlighting the role of translation in this process and explaining the time delay. Blocking CD63, a key exosome surface protein, successfully rescued both the uptake of exosomes by platelets and platelet activation. Furthermore, elevated levels of KIM1, a renal cancer‐specific biomarker, were detected in platelets from renal cancer patients.
Conclusions: Exosomes derived from renal cancer cells play a role in stimulating platelet activation and enhancing thrombosis through CD63 and translation‐mediated mechanisms. These findings provide valuable insights into the mechanisms underlying renal cancer‐associated thrombosis and suggest potential biomarkers and therapeutic targets for managing thrombotic complications in patients with renal cancer.
Funding: NIH grants R01HL142772American Heart Association grant 18POST34030159
Comparison of Bladder Microbiome Composition Between Urothelial Cell Carcinoma and Benign Pathology Using Gene Sequencing of Tissue Specimens
Jacob Emerson1, Phillip Engen1, Ankur Naqib2, Stefan Green1, Ali Keshavarzian1, Christopher Coogan1
1Rush University Medical Center, 2Rush Univeristy Medical Center
Presented By: Jacob Emerson, MD
Introduction: There is emerging evidence that bladder microbiome composition may play a role in urothelial cell carcinoma (UCC); however the majority of data is derived from analyzing urine specimens. We have previously demonstrated that microbial 16S ribosomal amplicon sequencing from transurethral resection of bladder tumor (TURBT) specimens is a reliable method of assessing microbiome composition. Here we analyzed the species diversity and richness of TURBT specimens in patients with non‐muscle invasive UCC in comparison to patients with benign TURBT pathology.
Methods: Formalin‐fixed paraffin‐embedded (FFPE) TURBT specimens from 42 patients with non‐muscle invasive UCC as well as 17 patients with benign pathology were identified. We additionally identified 6 UCC patients who subsequentially underwent BCG treatment with additional TURBT specimens available after treatment had been completed. All patients had a negative standard urine culture. Microbial 16S ribosome amplicon sequencing with the 515F/806R primer set was performed. Differential abundance analyses at the taxonomic level of genus were performed using DESeq2 software.
Results: There was significantly increased alpha diversity based upon Simpson Index (p = 0.03) and Pielou's Evenness Index (p = 0.01) in the UCC cohort; however Shannon Entropy was not significantly different (p = 0.086). Significant differential abundances of Actinomyces, Streptococcus, and Staphylococcus were observed in the benign pathology cohort, while abundances of Enhydrobacter and Yersiniaceae were observed in the UCC cohort. BCG treatment resulted in significantly reduced Shannon Entropy (p = 0.04) and Simpson Index (p = 0.02) relative to baseline.
Conclusions: Significantly increased alpha diversity was observed in the UCC cohort. Although the sample size was relatively small, there was a significant reduction in alpha diversity following BCG treatment. Our findings suggest that increased bladder microbiome diversity may be a marker of UCC, and that following successful BCG treatment there may be a reduction in diversity.
Funding: Departmental
Reduced p63 Expression is Linked to Unfavorable Prognosis in Muscle‐Invasive Urothelial Carcinoma of the Bladder
Kira Kornienko1, Henning Plage1, Thorsten Schlomm1, Tobias Klatte1, Martina Kluth2, Niclas Blessin2, Maximilian Lennartz2, Guido Sauter3, Michael Rink4, Margit Fisch4, Steffen Hallmann5, Thorsten Ecke5, Sefer Elezkurtaj6, David Horst6, Marcin Slojewski7, Andreas Marx8, Henrik Samtleben8, Henrik Zecha9
1Department of Urology, Charité ‐ Universitaetsmedizin Berlin, 2Department of Pathology, University Medical Center Hamburg‐Eppendorf, 3Department of Pathology, University Medical Center Hamburg‐ Eppendorf, 4Department of Urology, University Medical Center Hamburg‐Eppendorf, 5Department of Urology, Helios Hospital Bad Saarow, 6Department of Pathology, Charité ‐ Universitaetsmedizin Berlin, 7Department of Urology and Urological Oncology, Pomeranian Medical University, 8Department of Pathology, Academic Hospital Fuerth, 9Department of Urology, Albertinen Hospital
Presented By: Kira Kornienko, MD
Introduction: There is ashortage of establishsd biomarkers in bladder cancer. One candidate is the Tumor protein 63 (p63),a transcription factor of the p53 gene family which is regularly expressed in the normal urothelium in the basal layer. It is commonly involved inthe growth and development of epithelial tissues.p63 immunohistochemistry (IHC) is used in diagnostic pathology to differentiate urothelial carcinomas from adenocarcinomas of the prostate infiltrating the bladder. Various studies have proposed a prognostic role of p63 expression in urothelial carcinomas, but the results are highly conflicting.
Methods: Using tissue microarrays (TMAs), we investigated the expression p63 in over 2700 bladder carcinomas, including non‐muscle invasive pTa tumors and muscle‐invasive pT2‐pT4 tumors.The sample collection was carried out in accordance with guidelines, depending on the tumor stage, during transurethral resection (TUR) or radical cystectomies in various urological clinics in Germany and Poland between 2003 and 2021. Additionally, we examined the correlation between p63 pathological parameters, patient outcome and pre‐existing data about the transcription factor GATA3 of the same study cohort.
Results: Nuclear p63 staining was seen in all cells of normal urothelium and at elevated levels in pTaG2 tumors. The rate of p63 positive cases and the staining intensity was lower in pTaG3 tumors (93.2%, p < 0.0001 for pTaG3 vs pTaG2) and markedly lower in pT2‐4 carcinomas (83.5%, p = 0.0120 for pT2‐4 vs. pTaG3). Within 1,018 pT2‐4 carcinomas treated by cystectomy, low p63 expression was linked to nodal metastasis (p = 0.0028) and overall survival (p = 0.0005). The association with survival was independent of pT and pN (p = 0.0081).p63 expression was associated with GATA3 expression (p < 0.0001). A joint analysis of p63 and GATA3 did not suggest that GATA3 could provide additional prognostic information.
Conclusions: In summary, the independent prognostic role of reduced p63 expression in advanced urothelial carcinomas suggestthat p63 could be a useful biomarker to distinguish pT2‐4 urothelial carcinomas.
Funding: Supported by a Ferdinand Eisenberger grant of the Deutsche Gesellschaft für Urologie (German Society of Urology), grant ID PlH1/FE‐23
Is Drain Fluid PSA Associated with Positive Surgical Margin and Recurrence in Prostate Cancer?
Rifat Ergül3, Faruk Özcan1, Rifat Burak Ergül2, Serdar Turan2, Anil Tantekin2, Selcuk Erdem1, M. Oner Sanli1
1Division of Urologic Oncology, Department of Urology, Istanbul University Istanbul Faculty of Medicine, 2Department of Urology, Istanbul University Istanbul Faculty of Medicine, 3Istanbul University Istanbul Faculty of Medicine Department of Urology
Presented By: Rifat Ergül, Resident
Introduction: Prostate‐specific antigen (PSA) is produced in prostatic ducts and it is a component of seminal plasma. Any inadvertent penetration to prostatic ducts during surgical procedure may cause PSA extravasation to periprostatic area. In this report, we aimed to investigate any possible association of value in drain fluid PSA with positive surgical margin and biochemical recurrence in patients who underwent robotic‐ assisted radical prostatectomy (RARP) for prostate cancer.
Methods: Drain fluid PSA values measured in eighteen patients who underwent RARP for prostate cancer in a tertertiary center.Results were retrospectively reviewed. Drain fluid PSA values were determined from a sample taken from the drain on the morning of the first postoperative day. Since the relationship between drain PSA and surgical margin positivity/biochemical recurrence has not been previously reported, cut off values for surgical margin positivity and biochemical recurrence were calculated with Youden index. The patients were divided into two groups according to defined cut off values. Chi‐square test was performed for statistical analysis.
Results: Drain fluid PSA‐ the cut off value for biochemical recurrence was calculated according to Youden index as 29.5 ng/mL. 11 (61%) patients were categorized above the cut off value. There was no difference between the categorized groups in terms of biochemical recurrence. (p > 0.05) The cut off value for drain PSA‐ surgical margin positivity was found to be 50 ng/mL. 9 of the patients (50%) were above the cut off value. There was a significant difference in surgical margin positivity between these two groups. (p < 0.05)
Conclusions: Our results showed that there was a significant correlation between PSA value in drain fluid and surgical margin positivity according to the cut off value of 50 ng/mL. Our results will be further evaluated with increasing patient number and may indicate the group of patients that should be followed more closely.
Funding: None
Correlation of Post‐Prostatectomy Decipher Genomic Classification to Disease‐Specific Mortality in Prostate Cancer over 8‐Year Follow‐up
Genesis G. Dolgetta1, Tonya S. King1, Robert I. Carey2, Benjamin J. Behers3, Maximilian S. Carey1, Karim Ghazli2
1Sarasota Memorial Health Care System Research Institute, 2Sarasota Memorial Health Care System
3Florida State University College of Medicine
Presented By: Genesis G. Dolgetta, BS
Introduction: Decipher genomic classification (DGC) has been developed to predict disease severity in prostate cancer. This study seeks to evaluate how well Decipher scores, as well as individual genes, predicted disease‐specific mortality in 197 patients that underwent robotic prostatectomy (RALRP) with 8‐year follow‐ up of survival outcomes.
Methods: Data was collected from an IRB‐approved, prospectively maintained database of 197 patients who underwent RALRP with DGC testing of the post‐prostatectomy specimens with mean 8‐year follow‐up outcomes. The Decipher prediction signatures were Metastasis Risk, Androgen Deprivation Therapy (ADT) Response, Post‐Operative Radiation Response, Docetaxel Sensitivity, Seminal Vesicle Invasion, Genomic Gleason Score of Primary 4 or 5, Genomic CAPRA‐S Score of High (> 5), Pathology Stage T3 (pT3 Disease), Tumor Cell Proliferation, and Androgen Receptor (AR) Signaling Activity. Proportional hazards regression analyses evaluated these signatures, as well as 36 individual genes, with the actual clinical outcome of disease‐specific mortality (DSM).
Results: Patients were an average of 67.8 years old with mean prostate weight 55.7 g and mean percent tumor 35%. Patient T stage was T2 62.9% and T3/T4 37.1% and Gleason Grade Group (GGG) 1 (8.1%, GGG 2 (52.8%), GGG 3 (18.3%), GGG4 (5.6%), and GGG 5 (15.2%).Decipher risk groups divided into high (38.1%), average (19.3%), and low (42.6%) with a mean DGC risk score 0.51.DSM was not significantly different among Decipher risk groups (p = 0.37) or Gleason grade groups (p = 0.14). Specific individual genes Top2A, KLK3, KLK2, SRD5A1, AURKA, and PARP1 were identified for further investigation as potential predictors of disease‐specific mortality, along with the Decipher prediction signatures. Of these, only AURKA and AR Signaling Activity were significant in a multivariable proportional hazard's regression model; DSM was 6.4 times greater for every 25‐unit increase in AURKA (95%CI 1.51‐26.83, p = 0.012), and 0.15 times lower for every 25‐unit increase in AR Signaling Activity (95% CI 0.03‐0.75, p = 0.021). Conclusions were unchanged after adjustment for T‐stage, which was not significant (p = 0.11). A threshold of ≥ 71 of AURKA was found to be the best threshold for predicting DSM (p = 0.007).
Conclusions: This study finds correlation between Decipher genomic predictions with actual clinical outcomes at 8‐year post‐prostatectomy follow‐up. Not only was AURKA the best individual gene predictor of DSM, AURKA was found to be a better predictor of DSM at 8‐year follow‐up than T stage, GGG, or the DGC risk score itself. Aurora Kinase A (AURKA), a threonine kinase associated with mitosis, is a critical step in the transmutation of prostate cancer into its fatal neuroendocrine form.It stands to reason that pre‐ existing high expression of AURKA in post‐prostatectomy genomic analysis is associated with early death from prostate cancer. This study demonstrates that evaluation of the genomic data after a patient has a prostatectomy can more accurately assess the risk of prostate cancer DSM than clinical T‐stage or Gleason grade.
Funding: None.
Post‐Prostatectomy Genomic Classifier and Individual Gene Prediction of Freedom from Progression with no Further Treatment over 8‐Year Follow‐up
Genesis G. Dolgetta1, Tonya S. King1, Robert I. Carey2, Benjamin J. Behers3, Maximilian S. Carey1, Karim Ghazli2
1Sarasota Memorial Health Care System Research Institute, 2Sarasota Memorial Health Care System
3Florida State University College of Medicine
Presented By: Genesis G. Dolgetta, BS
Introduction: Genomic classifier (GC) data has been used to predict risk of metastasis and this risk has been extrapolated to recommend salvage radiation therapy (aRT) and androgen deprivation therapy (ADT). We posit that many of these patients may not need these adjunctive therapies. In this work we present GC data that predicts freedom from progression (FFP) for 8 years without any adjuvant radiation therapy (aRT), salvage radiation therapy (sRT) or androgen deprivation therapy (ADT).
Methods: Data was collected from an IRB‐approved prospectively maintained database of robotic prostatectomy (RALRP) in a tertiary care hospital. 197 consecutive patients underwent RALRP with GC (Decipher) testing of the post‐prostatectomy specimens. Individual genes were evaluated relative to freedom from progression in patients with no treatment over 8 years. A logistic regression analysis was performed to examine what genes were significant in the prediction of FFP with no treatment.
Results: Gleason grade group (GGG), the percentage of cancer in the prostate specimen, and the individual genes AR (Androgen Receptor) and PCA3 were all significant predictors of FFP.The odds of FFP were 0.62 times lower for every 1‐unit increase in grade group (95%CI 0.45‐0.87, p = 0.005), 0.52 times lower for every 25‐unit increase in % of cancer (95%CI 0.31‐0.87, p = 0.012), 0.64 times lower for every 25‐unit increase in AR (95%CI 0.43‐0.96, p = 0.030), and 1.5 times greater for every 25‐unit increase in PCA3 (95%CI 1.03‐2.15, p = 0.032).The best thresholds for decipher risk score to predict FFP with different GGGs were 0.55 for GG = 2 and 0.8 for GG 3‐5.The odds of high risk (GG = 5 or T stage greater than or equal to T3b) and no progression were 1.7 times greater for every 25 unit increase in PD1 (95%CI 1.04‐2.89, p = 0.036), and 2.4 times greater for every 25 unit increase in SVI genomic signature (95%CI 1.42‐4.03, p = 0.001).
Conclusions: The best individual gene predictor for freedom from progression in high‐stage/high‐grade prostate cancer after RALRP was PD1 and the best genomic signature SVI.Thresholds of the Decipher risk score to predict FFP can be established for each GGG.The expression of genes AR and PCA3 were both significant predictors of FFP in post‐prostatectomy specimen GC analysis.This study indicates that more thorough analysis of DCR individual genes and genomic signatures can help identify patients likely to remain with FFP at 8 years and avoid unnecessary adjuvant treatments.
Funding: None.
Outcome of Radical Prostatectomy in High‐Risk Prostate Cancer
Krishnendu Biswas1, Rajiv Pillai1, Murthy Kusuma1, Rowan Casey1, John Corr1
Introduction: Radical prostatectomy (RP) is an established treatment option for high‐risk (D'amico) prostate cancer (CaP) as part of multimodal therapy. We aimed 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 Colchester 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 ISUP ≥3 cancer were 34.1%, 52.9%, 15.2%, 5.5% and 47.5% respectively. Median follow up was 82.5 months (13 months – 178 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 (5.1%) patients respectively; whereas 17 patients (21.7%) were under observation. Total 76 patients (35.0%) required multimodal therapy. At 10 years, OS and DFS/BCRFS were 92% and 55% 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 centre published data.
Funding: None
PneuTUR and Gen‐Plot as Novel Techniques to Improve Treatment and Molecular Characterization in Bladder Cancer
Jörg Neymeyer1, Jörg Neymeyer1, Thorsten Schlomm1, Katharina Mala1, Nicolas Hertzsprung1, Annika Fendler1, Henning Plage1, Antonia Franz1, Tobias Klatte1, Sebastian Hofbauer1, Michela de Martino1, Bernhard Ralla1, Joachim Weischenfeldt1, Sefer Elezkurtaj2, Simon Schallenberg2
1Charité ‐ Universitätsmedizin Berlin, Klinik für Urologie, 2Charité ‐ Universitätsmedizin Berlin, Klinik für Pathologie
Presented By: Jörg Neymeyer, MD
Introduction: Bladder cancer (BCa) is the seventh most common cancer in Western societies. The clinical course of bladder cancer is highly variable and mostly depends on the initial stage of presentation. Transurethral resection of bladder tumor (TURBT) is the gold standard for the diagnosis and therapy of BCa but the technique holds pitfalls. Transurethral dissection into pieces of the tumor and removal from the bladder contravene basic oncological principles and hamper pathological examination. En bloc in toto resection overcomes these hurdles and using air (PneuTUR) instead of irrigation fluid allows for better visibility. In combination with the transurethral surgery‐ natural orifice transluminal endoscopic surgery (TUS‐NOTES) technique intramural tumor spread can be accurately accounted for by injection of indocyanine green (ICG) and unraveling intratumor spatial heterogeneity by complete genetic characterization of the tumor (Gen‐Plot).
Methods: This project is a single‐center randomized controlled clinical trial of 215 patients comparing in a first step PneuTUR in combination with TUS‐NOTES and ICG to conventional TURBT. In addition, the tumor will be freshly dissected after pathology examination and the different layers of the tumor will be divided into a superficial (transitional cell), mid‐layer (muscle of bladder wall), and an invasive biopsy (figure 1). After a standardized fresh frozen protocol, WGS will be performed to characterize the spatial heterogeneity by Gen‐Plot genetically. By including ctDNA, longitudinal tissue sampling and detailed clinical metadata a comprehensive characterization of BCa will be established.
Results: Our novel technique PneuTUR in combination with TUS‐NOTES and intramural ICG injection will enable accurate transurethral full‐bladderwall resection and suture in a minimally invasive procedure.
Conclusions: Therefore, it will reform the treatment of BCa patients and impede incomplete resection, clinical progression, and eventually the quality of life in patients who would have undergone cystectomy. The molecular landscape of BCa will be spatially resolved and allowing for a detailed spatial map and has the potential to develop a molecular cancer classification and evolution algorithm in order to find novel biomarkers and therapeutic options.
Funding: internal
Evaluating Urinary Cancer Tissue and Adjacent Normal Renal Tissue Microbiome in Patients with Clear Cell Renal Carcinoma: Results of a Pilot Study
Joao Porto1, Jonathan Katz1, Harrys Jacob1, Praveen Singh1, Sanoj Punnen1, Chad Ritch1, Bruno Nahar1, Mark Gonzalgo1, Kryvenko Oleksandr1, Sabita Roy1, Dipen Parekh1, Hemendra Shah1
1Desai Sethi Urology Institute, University of Miami
Presented By: Joao Porto, MD
Introduction: Next‐generation sequencing has allowed us to investigate previously unknown microbes. Hence, our study explored microbiomes in clear cell renal carcinoma (ccRCC).
Methods: After IRB approval, 10 adult patients who underwent partial or radical nephrectomy for ccRCC were included in study. We excluded patients with history of nephrolithiasis and recent positive urine culture. Samples of renal tumor tissue, adjacent normal tissue (ANT), and bladder urine were collected. DNA extraction was performed using DNeasy PowerSoil kit (Qiagen) and NEBNext microbiome DNA enrichment kit. The sample then underwent 16S/18S/ITS sequencing. The statistical analysis was done to compare the microbiome of renal cancer, ANT, and bladder urine.
Results: Due to the low bacterial biomass in the samples, extended PCR cycling was employed for 16S amplification. At the phylum level, when comparing the microbiome composition of renal cancer tissue with that of ANT and bladder urine, Firmicutes were found to be significantly more abundant (p = 0.04) in cancer tissue and ANT, whereas Proteobacteria were significantly lower (p = 0.04) in bladder urine as compared to renal cancer tissue and ANT. Moreover, beta diversity analysis revealed a significant difference (p = 0.006) among the three sample groups, indicating distinct microbial compositions (Figure 1A). Additionally, alpha diversity analysis using the Shannon and Chao1 methods showed a significant difference between healthy renal tissue and bladder urine, indicating variations in microbial richness and evenness between these sample types (Figure 1B). To further explore the differential microbial enrichment in each specimen, Lefse analysis was conducted, demonstrating diverse enrichment patterns unique to each sample category.
Conclusions: Our pilot study highlights an association between microbial diversity and ccRCC. Further investigation is needed to elucidate the relationship of microbiomes and ccRCC.
Funding: N/A
Detection of Bladder Cancer Using Quantitative Interferometric Flow Cytometry – An in Vitro Study
Introduction: Non muscle invasive bladder cancer (NMIBC) has nearly 60% 1 year recurrence rate. Cystoscopic surveillance allows for early detection of recurrences and progression, however, it causes significant morbidity and hinders patients quality of life as well as increases health care costs. Quantitative phase imaging is an optical 3D imaging method which provides significant morphologic information of cells and tissues. QPI is able to classify benign and malignant bladder tissues and differentiate between low and high grade NMIBC. Our aim is to develop a QPI system able to image flowing cells in urine and classify them into benign or malignant classes.
Methods: The system is based on a Mach‐Zahnder interferometer. The interference is caused between a sample beam and a reference beam, which are projected on the camera plane and processed to an optical path delay heatmap. The sample is composed of blood (WBC, RBC) and urothelial cell lines (benign and malignant, different grades) flowing through a microfluidic channel and imaged by the QPI system.
Classification is performed by a deep learning (DL) algorithm, trained, and tested on the QPI imaged cells. Model performance was assed with ROC curve and decision curve analyses.
Results: Approximately 20000 cells were imaged (16,000 used for training and 4000 for testing the DL algorithm). Sensitivity, specificity, negative predictive value, and accuracy were 0.99, 0.98, 0.98 and 0.98 respectively. The AUC was 0.99 and the model showed increased net benefit across all threshold probabilities(figure 1).
Conclusions: QPI is accurate for identifying BC cells in simulated urine with high NPV. This system may supplant surveillance cystoscopy.
Funding: Israeli Innovation Authority research grant
Localization of Surgical Margin Positivity in Radical Prostatectomy Specimens
Serdar Turan4, Faruk Özcan1, Serdar Turan2, Aydan Malçok3, Reşat Aydin2, Selçuk Erdem1, M. Oner Sanli1
1Division of Urologic Oncology, Department of Urology, Istanbul University Istanbul Faculty of Medicine, 2Department of Urology, Istanbul University Istanbul Faculty of Medicine, 3İstanbul university biostatistics department, 4Istanbul University, Istanbul Faculty of Medicine, Department of Urology
Presented By: Serdar Turan, resident
Introduction: We evaluated the surgical margin localization in radical prostatectomy specimens
Methods: Pathology reports of 433 patients who underwent radical prostatectomy between 2005 and 2022 were evaluated retrospectively. Incidence of positive surgical margins studied in emphasis to apical tissue. Margin positivity is further classified anterior or posterior according to transverse plane.
Results: Out of 433 patients who underwent radical prostatectomy, pathologic tumour mapping is reached in 191 patients. Surgical margin was positive in 78/191 (%40) patients. 38/78 (%48) patients had positive surgical margin at the apex of the prostate. 29/78 patients (%37) had anterior margin positivity whereas 49/78 (%62) had posterior margin positivity. (p: 0,07)
Conclusions: Apex of the prostate is prone to surgical margin positivity and this should be considered during apical dissection in radical prostatectomy. Margin positivity is also more commonly occurred at the posterior plane indicating posterior dissection of the prostate from rectal surface should also be performed delicately.
Funding: none
Primary Ewing Sarcoma/Primitive Neuroectodermal Tumors of the Kidney: Case Series of Eight Cases from a Single Center with Follow‐up Details.
1MPUH, Department of urology, Nadiad (Gujarat), 2Muljibhai Patel Urological Hospital, Nadiad (Gujarat, India)
Presented By: Akshay Nathani, Fellow in World Endourology Society
Introduction: Primitive neuroectodermal tumor (PNET) rarely presents as a primary renal tumor. They are aggressive tumors affecting young adults, presenting at an advanced stage. Diagnosis is made on histopathological examination with confirmation by immunohistochemistry and cytogenetics. Management has to be equally aggressive with multimodality treatment. The present study aims to present our experience in the diagnosis and management of PNET of the kidney.
Methods: We retrospectively reviewed the data of all the patients treated for PNET of the kidney from a single center. Eight patients were treated for PNET of the kidney. We present their clinical features, imaging findings, diagnosis, treatment, and follow‐up.
Results: Of the eight patients who were included in the studyonly one was female. The mean age at presentation was 26.5 years (range 4‐46 years). All cases had large tumors with tumor sizes more than 4 cm, one patient had tumor thrombus extension into IVC, one patient presented with metastases, and two patients presented with tumors extending to paranephric space. All patients had small round blue cell neoplasm and immunohistochemistry staining with CD 99 was positive in all cases. All patients underwent radical nephrectomy with three patients undergoing laparoscopic surgery and the patient with IVC tumor thrombus undergoing IVC thrombectomy in addition. Postoperatively, two patients had a prolonged postoperative ileus of four days or more, and two patients required blood transfusions making two patients with Clavien‐Dindo grade 2 and remaining patients with Clavien‐Dindo grade 1 complications. Chemotherapy was given with VAC/IE regimen {Vincristine, Adriamycin and Cyclophosphamide (VAC) /Ifosfamide and Etoposide (IE)} in all patients for 1 year, with a total of 16 courses, with one patient undergoing chemotherapy. Local radiotherapy to tumor bed was given in three patients, two for residual disease, and one for recurrent disease. One patient developed metastasis and expired at three and half years and One patient expired at 6 years post‐ surgery due to malignant cachexia in metastatic disease
Conclusions: Renal ES/PNET is an uncommon neuroectodermal malignant soft tissue tumor. Presentation is late at an advanced stage with a poor prognosis resulting from tumor aggressiveness. Radiological features are not specific to renal PNET. Diagnosis is confirmed only on Histopathological examination with immunohistochemistry. Treatment is multimodal with surgery and chemotherapy, with/without adjuvant radiotherapy.
Funding: NIL
Multifocal Renal Cell Carcinoma with Partial Staghorn Calculi in a Solitary Kidney Due to Renal Agenesis: A Case Report
Jan Ernest Guy Yadao3, Eli Paulino Madrona1, Meliton Alpas2
1Veternas Memorial medical center, 2Veternas Memorial Medical Center, 3Veterans Memorial Medical Center
Presented By: Jan Ernest Guy Yadao, MD
Introduction: Renal cell carcinoma (RCC) is a malignant neoplasm originating from the renal parenchyma,accounting for 3% of all adult malignancies. Multifocal RCC with assocaited partial staghorn calculi is an uncommon phenomenon. This report describes a rare case of multifocal RCC with partial staghorn calculi in a patient with a solitary kidney due to renal agensis,who underwent partial nephrectomy.
Methods: We present a case report of a 60‐year‐old male patient with renal agenesis who was diagnosed with multifocal RCC with partial staghorn calculi in the left solitary kidney. The patient underwent partial nephrectomy, and histopathological examination was performed to confirm the diagnosis.
Results: A 67 year old male patient with history of renal agenesis was referred to our hospital for an incidental finding of multiple renal masses and partial staghorn calculi in the solitary kidney on ultrasound. Further imaging studies, including CT and MRI,confirmed the presence of multiple renal masses and partial staghorn calculi. The patient underwent partial nephrectomy and histopathological examination revealed Multifocal Renal Cell Carcinoma
Conclusions: Multifocal RCC with associated partial staghorn calculi is a rare phenomenon, especially in patients with a solitary kidney due to renal agenesis. Timely and accurate diagnosis of RCC is essential in these patients to ensure appropriate management. Partial nephrectomy can be a suitable treatment option for multifocal RCC in these patients, provided that the tumors are localized, and the remaining renal parenchyma is functioning adequately. Further studies are needed to determine the optimal management strategy for these rare cases.
Funding: none
Pathological Effects of Renal Ischemia After Partial Nephrectomy in the Rabbit (Oryctolagus cuniculus) Model
Chloe Michel2, Nicholas Rocco1, Matthew Christman2, Michael Santomauro3
1Camp Pendleton Naval Hospital, 2Naval Medical Center San Diego, 3Genesis Healthcare Partners
Presented By: Chloe Michel, MD
Introduction: Renorrhaphy suture depth and suture compression pressure have an unknown effect on renal ischemia after partial nephrectomy. These modifiable renorrhaphy techniques could be unaccounted factors in nephron preservation for partial nephrectomies. We sought to evaluate these factors in a rabbit model.
Methods: Left, lower pole, partial nephrectomies were completed in 14 rabbits with a standard diameter and depth of 1cm. Renorrhaphies were performed at a depth of 5mm or 10mm, and with a compression pressure of either 0.04lbs or 0.08lbs. Rabbits were survived for 14 days after the partial nephrectomy and then returned to the operating room where the left kidney was harvested for histologic evaluation.
Results: Depth of ischemia was significantly associated with a lower pressure (0.04lbs) renorrhaphy (p < 0.05). Depth, width, and area of ischemia were not significantly associated with depth of renorrhaphy.
Conclusions: This study introduces two variables of renorrhapy reconstruction that affect degree of nephron ischemia. Our results showed that a lower pressure renorrhaphy technique is associated with greater depth of ischemia after partial nephrectomy. Further studies are warranted to validate and evaluate the clinical implications of our histologic findings.
Funding: No funding was received for this abstract.
TULA in Outpatient Settings: Tolerability, Safety and Side Effects Assessed through VAS Score and EORT Validated Questionnaires
Simone Giona2, Samer Jallad1, Neil Barber2, Ahmed Ali2
1Wexham Park Hospital, 2Frimley Park Hospital
Presented By: Simone Giona, MD, MRCS
Introduction: Tula(Trans urethral laser ablation) hasrevolutionised the management of NMIBC and helpedurology departments indealingwith the growing demand of theatres, post covid pandemic.The mainadvantagesof TULAare:the possibility of treating NMIBCinoutpatient settings, underlocalanaesthesiaand with minimalmorbidity. The Despite the end of COVID pandemic, many urology services have struggled to keep up with significant backlogs of bladder cancer follow up and new GP referrals. This issue has led Us to rethink about how to improve our bladder cancer services by prioritising aggressive diseases and new diagnosis while contextually keep providing safe management of small recurrences and follow up. The aimof our study wasto assessproceduralpainbyVAS score,patient satisfaction and side effects byvalidated EORT questionnairesC30 (Quality of Life) and NMIBC24 (side effects).We set up an outpatient service where those who had a history of recurrent Low grade TTC and/or or were considered high risk for GA could be treated with TULA under Local Anaesthetic and rather than undergoing the process of pre‐op assessment and Cystoscopy under General Anaesthetic. By doing so, we prioritised the use of main theatre for new diagnosis and large recurrent disease which could not be treated under local anaesthesia.
Methods: For each treatment, we collected anagraphic data, basic cancer history (ASA grade, Previous Histology, results, Number of previous TULA) and prospective cancer data (Biopsy taken, Cytology, Number or lesions, Complete resection or not). At the end of procedure patient was asked to rate the degree of discomfort/pain by the use of a VAS score (0‐10). Two validated EORT questionnaires were also handed to the patients before leaving the clinic: The QLQ‐C30 and QLQ‐NMIBC24.The former has 30 questions on cancer patients QoL, with answers rated 1‐4 (1‐Not at all, 2‐A little, 3‐Quite a bit, 4‐Very much) while the latter investigate Urology related side effects (Frequency, urgency, incontinence, dysuria, fever, sexual function) with the same method used by the C30.Phone calls or emails were used to collect the feedbacks 3/52 after the procedure.
Results: Information was collected prospectively for 25 patients.Average Age was 76y, Median ASA 2, 44.4% of the patients were at least on 1 blood thinner, 8% on double. The most common referred histology type was recurrentG2pTa. The Median VAS score registered was 2 (Very low pain) and the average energy used 383.9J. Median number of lesions treated was 1, with an average of 1.9 per patient. Complete ablation was achieved in 80% of the cases. 2 cases had to be abandoned; one for pain and one for bleeding. 2 Patients had significant complications which required a bladder washout under GA in one case and 24h of bladder irrigation in the second.In terms of follow up. 28% of patient had visible haematuria for less the 24h, the median score for Pain and Fatigue was 1 (No at all) whereas the average scoring was respectively 1.5 and 1.1.The most common post‐operative symptoms were Day frequency (Median score, 2 A Little bit) and Urine leak (Median score 1, Not at all)with respectively 66.7% and 44.8% of patients affected. 38.9% of patients had nocturia (Median score 1, Not at all). All these symptoms completely settled within 48h from the procedure.
Conclusions: TULA is an extremely well tolerated and safe procedure that allows the management of small bladder lesions under local anaesthetic in both healthy and frail/complex patientsin outpatient settings. Post‐ operative symptoms are present, but usually not severe and self‐settling in less than 72h.Therefore, we believe that the use of TULA could be extended to an increasingly higher number of selected patients, helping the specialist to free main theatre slots to higher priority cases while helping to reduce the backlog of patients waiting for treatment or follow up.
Funding: None
The Clinical Presentation and Outcome of Patients with Sarcomatoid Renal Cell Carcinomas‐ A Single Centre Experience Form India
Introduction: Sarcomatoid dedifferentiation is a rare characteristic that can appear in the majority of renal cell carcinomas (RCCs) histological subtypes and carries a very bad prognosis. The median survival time for sarcomatoid RCCs (sRCCs) is typically 6 to 13 months, and standard treatments have historically had limited success. The mechanisms causing sarcomatoid dedifferentiation, which was first identified in 1968, are still poorly understood, and patients and doctors have few informational resources and therapeutic alternatives. Regular imaging or biopsy for preoperative diagnosis is unreliable, and the majority of patients have advanced disease and systemic symptoms when they arrive.With at least a one‐year follow‐up for our patients, we sought to assess our data of 15 cases of sarcomatoid RCCs.
Methods: Retrospective observational record‐based study included 15 patients who were operated for primary renal cell carcinoma with sarcomatoid differentiation in the department of urology of a tertiary care hospital in India. Detailed structured proforma including the demographic, surgical and follow‐up details were filled out for all the patients. The clinical characteristics, including age at diagnosis, year of diagnosis, tumor grade, tumor size, nodal status, subtype, and treatment was analyzed.
Results: There were a total of 15 patients who were diagnosed with sRCC at the time of the analysis. 11 were male and 4 were female. The ages of the patient ranged from 55 years to 92 years. There were 13 left sided tumors and and 2 right sided. 9 of these tumors were pre‐dominantly clear cell RCC, 5 were papillary and 1 was a chromophobe RCC. The percentage of sarcomatoid differentiation ranged from 22 % to 43%. There were 10 tumors that were staged as T3a and 2 each as T2a and T1b, with a single one staged as T1a. Nodal involvement was seen in 5 cases and tumor thrombus was seen in 3 cases. There were 6 patients who had metastases at the time of the diagnosis. Three patients received chemotherapy and 2 received immunotherapy. 4 patients had passed away and 11 were still alive at the time of the analysis.
Conclusions: The survival rate of the patients is 100% upto 8 months of age, after which, to 50% after 15 months of age. Higher number of patients present with Large tumor size,have nodal involvement and Metastasis at presentation.Ultimately, large collaborative efforts are needed to improve our understanding of sRCCs in order to devise more effective treatments for this lethal disease.
Funding: NIL
Role of MMP‐9 and TIMP‐1 in Disease Prognosis of Renal Cell Cancers in Terms of Clinico‐ Pahtological Corelation. Possible Tumor Markers in RCC
Introduction: Renal cell cancers defy the one size fits all approach with heterogenous groups including different morphologies and unpredictable clinical disease trajectories and prognosis. With the current discerepancies and refinements in tumour grading and stage which currently form the basis of prognosis and management, there is a need for objective and simplistic markers in adjunct. Matrix metalloproteinases (MMPs) are implicated in tumour infiltration and metastasis by degradation of extracellular matrix. Tissue inhibitor of metalloproteinases (TIMPs) traditionally considered to inhibit enzymes of the MMP family also have paradoxical functions in terms of tumour progression. Our study focuses on the role of these novel markers, already seen to be involved in several human cancers, in RCCs and to establish any correltaions with tumour grade, stage and recently included architectural patterns.
Methods: We conducted a combined retrospective and prospective study over 100 patients with RCC. Immunohistochemical staining with TIMPs and MMPs was done over their surgically resected tissue specimens and were correlated with tumour staginggrading including Furhman's , WHO/ISUP grading(2016) and architectural patterns. The predictability in terms of overall survival and recurrence free survivalwas analyzed by the Kaplan‐Meier method and compared by the log rank test.
Results: MMP‐9 and TIMP‐1 showed strong expression in 55/100 (55%) and 17/100 (17%) of the cases Overall survival was significant withboth MMP‐9 and TIMP‐1 expression (p = 0.025, p < 0.0001). In Univariate analysis, MMP‐9 expression was seen to be significant in terms ofadvanced stage (p value‐0.038), architectural grading (p value‐0.047) while TIMP‐1 correlation was seen with advancing stage and high grade disease though it was statistically significant only in terms ofarchitectural pattern grading (p value – 0.023)
Conclusions: Our study establishes the positive association of MMP‐9 and TIMP‐1 expression with advanced tumour grades and stages alongwith prediction in terms ofoverall survival and disease progression. Though proven in other neoplasms, further validation of their role in RCC prognosis and management needs to be established with large sample, multi‐institutional studies.
Funding: No Funding was required
A Rare Triple Concurrence of a Ureteric Calculus and Renal Cell Carcinoma in a Horseshoe Kidney
Kale Munien1, Adib Rahman1
1Toowoomba Hospital
Presented By: Adib Rahman
Introduction: Horseshoe kidneys are a rare congenital abnormality of mostly low clinical concern. They can however, lead to significant complications in clinical decision mHorseshoe kidneys are a rare congenital abnormality of mostly low clinical concern. They can however, lead to significant complications in clinical decision making and operative management when coinciding with other pathologies. We report a rare case of concurrent diagnoses of a renal cell carcinoma and ureteric calculus in a horseshoe kidney and the subsequent treatment rationale based upon current literature.
Methods: A 70‐year‐old female presented to the Emergency Department (ED) with left upper quadrant pain associated with nausea and vomiting.A non‐contrast Computed Tomography (CT) scan revealed a horseshoe kidney with a hydronephrotic left renal moiety secondary to an obstructing 4.5mm calculus in the proximal left ureter. Co‐incidentally, a 4cm renal mass at the left lower pole cortex, suspicious for a renal cell carcinoma (RCC) was found.Bloodwork revealed a mild acute kidney injury with an eGFR of 54ml/min/1.73m2, down from a baseline of 80. Her white cell count was mildly increased at 12.8/nl, and her CRP was < 1. A urine dipstick had erythrocytes and leukocytes but no nitrites.She remained haemodynamically stable, afebrile and her symptoms resolved with oral analgesia and antiemetics. The patient was discharged from the ED with a four‐week trial of medical expulsive therapy for the calculus, and a follow up Urology clinic appointment with a Multiphase Renal CT and repeat blood tests.At follow‐up, while the position of the left ureteric calculus was unchanged, the hydroureteronephrosis had resolved. The renal mass was radiologically staged as T1bn0m0. The patient's renal function had returned to baseline with an eGFR of 84ml/min/1.73m2
Results: A left heminephrectomy and proximal ureterectomy was performed to treat both the calculus and likely left lower pole RCC. A midline laparotomy approach was chosen because of the ectopic vascular and ureteric anatomy in the horseshoe kidney. The left ureter was tied and transected distal to the calculus which was palpable within the ureteric lumen. Two left renal arteries, and one left renal vein were divided.Histology revealed an ISUP grade 2 Clear Cell Renal Cell Carcinoma confined to the renal cortex of the left lower pole measuring 42mm. Surgical resection margins were clear, and no lymphovascular, renal sinus, perirenal fat, or pelvi‐calyceal system invasion were noted. The TNM staging (AJCC 8th edition) was pT1b Nx. The calculus measured 5.5mmThe postoperative course was uneventful and the patient was discharged without complications.
Conclusions: Horseshoe kidneys are an uncommon anatomical variant that complicates the clinical management of coexisting pathologies like calculi and tumours. These come with specific diagnostic and operative concerns because of the highly variable anatomy of the vasculature and excretory tract. This is a rare case in which an ipsilateral ureteric calculus and renal cell carcinoma in a horseshoe kidney were diagnosed concurrently and treated in a single procedure.
Funding: nil
BASIC SCIENCE POSTER SESSION 3: STONES 1
E.Coli Phages as a Novel Method to Treat Recurrent, Ureteral Stent Associated Infections of the Urinary Tract
Leonid Boyarsky2, Ortal Yerushalmi1, Ronen Hazan1, Amitay Lorber2, Vladimir Yutkin2, Ofer Gofrit2, Shunit Coppenhagen‐Glazer1, Mordechai Duvdevani2
1Institute of Biomedical and Oral Research (IBOR),Faculty of Dental Medicine, Hebrew University, 2Department of Urology, Hadassah Ein Kerem Medical Center
Presented By: Leonid Boyarsky, MD
Introduction: Ureteral stents are devices commonly used for kidney drainage. After insertion, the stent provides a surface for biofilm forming. In case of infection, antibiotics only partially affect the pathogens within the biofilm, and resistant strains emerge. The phages are one of the most promising solutions for antibiotic resistance crisis today. The aim of our study was to assess the ability of E. coli phages to eradicate biofilms built on ureteral stent.
Methods: Phages were grown on isolated E.coli cultures. Phage host range of infection was determined with plaque assay method. The urine stability of phages was assessed. Biofilm model was built separately on 96 well plates and on ureteral stent. Following biofilm infection, the phage lytic activity with and without ampicillin was assessed by CFU test and scanning electron microscopy (SEM).
Results: Ampicillin resistant, E.coli strain O5, was found as sensitive to a group of phages designated ECOY 1‐8 and was therefore selected as a study strain. ECOY5 was found to be stable in urine and was selected as a study phage. In the study group, the CFU test showed 10‐ fold and 100‐ fold decrease in E.coli CFU growth for well plate and stent models respectively. The lytic effect of phage treatment was clearly visualized on SEM images
Conclusions: This is the first study that shows the bacteriological and microscopic effect of phage on E.coli biofilm built on ureteral stents. Our results showed the lytic effect of phage on E.coli biofilm contaminated ureteral stents. ECOY5 phage demonstrated the ability to eradicate 90% of the E.coli within the ureteral stent biofilm. A synergistic effect of phage and antibiotics was noticed. Incorporating phage therapy as a potential treatment option for stent associated UTI's could offer a solution to antibiotic‐resistant infections and enhance treatment outcomes.
Funding: None
Gut Microbiota Dependent Effects of Oxalate as a Driver of Urinary Stone Disease and Atherosclerosis
Jose Agudelo1, Lucas Osborne1, Beckey DeLucia1, Mark Brown1, Jan Claesen1, Ava Adler1, Sromona Mukherjee1, Mangesh Suryavanshi1
1Cleveland Clinic
Presented By: Jose Agudelo, MD
Introduction: Previous studies have shown a positive relationship between cardiometabolic syndrome and increased risk of urinary stone disease (USD).However, the underlying mechanisms that leads to synchronous development of these co‐morbidities are unknown. In the current study, we aimed to determine microbiome and diet dependent effects on atherosclerosis and calcium oxalate stone formation in a mouse model.
Methods: Sixty‐six female ApoE null mice were randomly assigned to either a basal or 3% oxalate diet. Half of the animals received sterile water and half received sterile water with a cocktail of antibiotics. Mice consumed dietsad libitumfor 8‐weeks. Fecal pellets were collected at 3 timepoints for 16S rRNA quantification. Blood samples were obtained at necropsy for lipids, cytokines, creatinine and oxalate. Kidneys, aortas and liver were also collected. Kidneys and aortas were visualized with polarized light to quantify calcium oxalate content. Kidneys were also assessed for calcium oxalate deposition/stones after Von Kossa and Alizarin red staining. Aortas were assessed for atherosclerosis plaque quantification. Livers were used for quantification of bile acids. Results were compared on a one‐way and two‐way ANOVA analyses.
Results: Histological aortic root analysis of sequential sections and stained with oil red O revealed a significant increase in atherosclerotic plaque area in animals under oxalate diet, both with or without antibiotics compared to controls, with a higher oxalate content in the plaque of animals receiving antibiotics.Dietary oxalate also enhanced hypercholesterolemia with antibiotic treatment. Renal histopathological analysis revealed either the development of obstructive uropathy and stone development in animals fed oxalate, without antibiotics, or oxalate nephropathy in mice under both interventions. Oxalate diet was associated with an increase of microbial derived secondary cardiotoxic bile acids.
Conclusions: Our results support the hypothesis that oxalate enhances the pro‐atherogenic potential in dyslipidemic animals and simultaneously leads to the development of urinary stones, exacerbated by a loss of function dysbiosis driven by gut microbiota disturbance. Importantly, the APOE‐/‐mice may serve as a more appropriate mouse model for kidney stones that what has previously been used.
Funding: NIH: DK121689‐01A1
Radiant Energy Transmission Efficiency through Saline and Pressure Transient Comparison: Diode‐Pumped Thulium Fiber Laser vs Flash Lamp Pumped Holmium Laser
Seyedamirvala Saadat1, Allen Rojhani1, Nitesh Katta2, Seyedamirvala Saadat1, Kalon Morgan1, Andrei Cumpanas1, Andrew S. Afyouni1, Kelvin Vo1, Sohrab N. Ali1, Zachary E. Tano1, Pengbo Jiang1, Roshan M. Patel1, Jaime Landman1, Ralph V. Clayman1, Thomas E. Milner2
1Department of Urology, University of California, Irvine, 2Beckman Laser Institute, University of California, Irvine
Presented By: Seyedamirvala Saadat
Introduction: We sought to study the fiber‐to‐target radiant energy transmission efficiency (RETE) through saline and retropulsion pressure transients of the thulium fiber (TFL) compared to the Ho:YAG laser.
Methods: RETE and pressure transients were compared between the TFL and Ho:YAG lasers. RETE and peak pressures were recorded under 24 test conditions: three laser dosimetries (i.e., popcorn (0.5 J and 40 Hz), dusting (0.3 J and 60 Hz) and fragmentation (1.0 J and 10 Hz)), four fiber diameters (i.e., 272, 365, 550, and 940 μm) and two fiber to target separation distances (1 mm and 2 mm) (Figure 1).
Results: For a 1 mm distance in saline: TFL RETE was significantly greater than Ho:YAG RETE at six test conditions (p‐values < 0.01); while Ho:YAG RETE was significantly greater than TFL RETE at four test conditions (p‐values < 0.0001)(Table 1). At a 2 mm fiber‐to‐tip target distance in saline, TFL RETE was greater than Ho:YAG RETE at all 12 test conditions. Ho:YAG RETE demonstrated an inverse relationship with increased fiber size. In all tested conditions, TFL yielded lower amplitude retropulsion pressure transients (p‐value = 0.0002).
Conclusions: TFL RETE is greater than Ho:YAG RETE at all 2 mm distances and at 1mm for popcorn settings with 365 μm and 940 μm fibers, and fragmentation settings with 940 μm fiber; moreover, TFL displayed less retropulsion at all test conditions. On the other hand, the Ho:YAG provided better RETE at 1mm with the 272 μm fiber for popcorn, dusting, and most markedly, for fragmentation settings.
Funding: None.
Oxalate Induces Colitis through MyD88‐Specific Inflammatory Pathways, Dependent on the Presence of Specific Gut Microbes
Sromona Mukherjee1, Thien Dang1, Mangesh Suryavanshi1, Jose Agudelo1, Ava Adler1, Aaron Miller1
1Cleveland Clinic
Presented By: Sromona Mukherjee, PhD
Introduction: Hyperoxaluria plays a direct role in urinary stone disease (USD), with 80% of kidney stones comprised primarily of calcium oxalate. Studies show Oxalobacter formigenes, an oxalate‐degrading specialist, alone is not sufficient to mitigate USD. The MyD88 gene produces an innate immune signal transduction adapter protein for the Toll/IL‐1R and is involved in numerous inflammatory responses. MyD88 adapter protein regulates tight junction permeability in renal and intestinal tissue. To understand the impact of oxalate on intestinal permeability and the influence of the gut microbiota, we utilized tamoxifen inducible intestinal epithelium cell specific (IEC) MyD88 wild type and knock out (MyD88WT or MyD88KO) mice maintained under germ‐free conditions. We determined the impact of dietary oxalate on systemic inflammation, oxalate absorption, and colitis. We also tested whether oxalate‐degrading bacteria alone are sufficient to reduce oxalate absorption or if other gut microbes are required to modulate host responses to oxalate.
Methods: Mice were orally gavaged with one of 5 groups of microbes to determine if there are synergistic interactions among microbes that influence gut permeability and oxalate absorption: 1) No bacteria 2) Oxalate‐degrading bacteria 3) oxalate‐degrading and acetogenic, methanogenic, and sulfate‐reducing microbes, 4) all microbes 5) All but O. formigenes. Control and 1.5 % oxalate diets were provided to mice for 14days. Necropsies were performed to collect tissue and plasma. Multiplex Elisa's were performed to quantify circulating cytokines. Colon tissue was stained with H&E for assess colitis severity.
Results: Results indicate that a 1.5% oxalate diet had a significant exacerbating effect on colitis assessed by decreasing crypt density and goblet cells, increased inflammatory infiltrates, abscess formation etc. The conditional knockout of MyD88 in the intestinal epithelial cells mitigated the adverse effects of the oxalate‐ rich diet. Importantly, we observed that inoculation of mice with our complete microbial consortium successfully rescued the oxalate‐induced colitis. The high oxalate diet led to elevated levels of IL‐4 and IL‐5 in the plasma of MyD88KO mice, suggesting a systemic inflammatory response was attributed to the impact of high oxalate levels in other organs such as kidneys.
Conclusions: Our study demonstrates the detrimental impact of a 1.5% oxalate diet on colitis in mice. Targeted knockout of MyD88 in intestinal epithelial cells or microbial inoculation rescues oxalate‐induced colitis, indicating a protective role of the microbes working synergistically and highlighting their therapeutic potential against urinary stone disease.
Funding: NIH funding to Dr. Miller: 1 R01 DK121689‐01A1
A 3d Kidney Spheroid Model to Study Calcium‐Containing Crystal Formation
Jennifer Bjazevic6, John Chmiel1, Wongsakorn Kiattiburut1, Aaron Kwong2, Priyanka Prabhu3, Hassan Razvi4, Leonard Luyt3, Jeremy Burton5
1Department of Microbiology & Immunology, Western University, London, Ontario, Canada; Canadian Centre for Human Microbiome and Probiotic Research, London, Ontario, Canada, 2Department of Medicine, Western University, London, Ontario, Canada, 3Department of Chemistry, Western University, London, Ontario, Canada, 4Division of Urology, Department of Surgery, Western University, London, Ontario, Canada, 5Department of Microbiology & Immunology, Western University, London, Ontario, Canada; Canadian Centre for Human Microbiome and Probiotic Research, London, Ontario, Canada; Division of Urology, Department of Surgery, Western University, London, Ontario, Canada, 6Division of Urology, Department of Surgery, Western University, London, Canada
Presented By: Jennifer Bjazevic, MSc, MD, FRCSC
Introduction: Approximately 10% of North Americans suffer from nephrolithiasis; with rising incidence rates, there is a strong need for models to study the pathophysiology of stone disease. In vitro cell culture models are essential for mechanistic and high‐throughput analysis of stone formation and drug treatment; however, there are no suitable cell models that adequately represent stone disease pathophysiology. Using a renal cell line, we developed a hollow 3D kidney spheroid (cysts) that produces intraluminal calcium‐based kidney stones after long‐term culture.
Methods: Madin‐Darby canine kidney (MDCK) cells were cultured in growth factor‐reduced Matrigel® to generate hollow spheroid cysts. Crystal formation was induced by culturing cysts in a custom crystal‐forming media for two weeks. Immunofluorescent staining was used for characterizing and visualizing the three‐ dimensional structure. Alendronate‐fluorescein, a fluorescently labelled bisphosphonate that specifically binds to calcium‐containing crystals, was used along with plain polarized light to visualize crystal structures.
Results: Immunofluorescent imaging demonstrated that the luminal spheroids that displayed have basal‐to‐ apical polarization were successfully formed under culture conditions. Alendronate‐fluorescein staining confirmed the presence of calcium‐containing crystals in the lumen of the cyst. Birefringent structures crudely resembling calcium oxalate dihydrate and calcium phosphate crystals were observed embedded along the apical (inner) face of the spheroid and protruding into the lumen.
Conclusions: We have demonstrated that hollow kidney spheroids cultured with crystal‐forming media can generate calcium‐containing crystals in the spheroid lumen. This model is the first cell‐based model to reliably develop calcium‐based crystals and can be used for high‐throughput drug screening or pathophysiology investigation. It also begins to set the foundation for personalized medicine, whereby renal tissue can be harvested and cultured to identify individual intrinsic risk factors that might contribute to stone development.
Funding: Lawson Internal Research Fund (IRF) and Northeastern Section of the American Urological Association (NSAUS) Datta G. Wagle Young Investigator Award
Kymora Scotland1, Reyhaneh Nazarian1, William Schmidt1, Jiahui Li2, Neil Lin1, Aaron Celestian3, Qian Chen2, Gerard Wong1
1UCLA, 2University of Illinois, 3National History Museum of Los Angeles
Presented By: Kymora Scotland, MD, PhD
Introduction: Kidney stone disease prevalence is increasing worldwide. Our current incomplete understanding of kidney stone pathogenesis hinders the development of effective stone prevention interventions. Approximately 80% of kidney stones are composed of calcium oxalate (CaOx). Recent studies suggest that bacteria may play an active role in CaOx stone pathogenesis. This study aimed to investigate the effect of biofilm‐forming bacteria on the formation and propagation of CaOx crystals.
Methods: CaOx crystals were formed in‐vitro in the presence and absence of E. coli and P. aeruginosa, biofilm‐forming bacteria frequently observed in stones collected from patients. Confocal and scanning electron (SEM) microscopy were used to assess the (1) size, (2) morphology, and (3) formation kinetics. In addition, Raman (RS) and Energy Dispersive X‐ray Spectroscopy (EDAX) were employed to identify the chemical composition of the formed crystals. A microfluidic kidney model was developed to recapitulate the physiology of the urinary tract. We evaluated the mechanism of CaOx crystallization in the presence of bacteria in this microenvironment.
Results: SEM images show that the morphology of bacteria‐influenced crystals differs substantially from control crystals; RS and EDAX confirmed CaOx composition in both groups. P. aeruginosa mediated up to 280% increase in CaOx crystal size over 10 days, with a growth rate 2.5 times that of controls. Using the 3‐ dimensional kidney model, we found that P. aeruginosa and E. coli secretions significantly enhance CaOx crystallization, growth, and aggregation compared to controls (p < 0.05 for all paramenters).
Conclusions: Our results suggest that biofilm‐forming bacteria significantly promote CaOx crystal growth, propagation, and aggregation and that bacterial secretions extensively enhance CaOx crystal formation. Collectively, these findings give more explicit insight into the pathogenesis of bacterial‐influenced CaOx crystallization.
The Protective Effects of Butyrate in Kidney Stone Disease
Dirk Lange1, Sarah Hanstock1, Demian Ferreira1, Hans Adomat2, Felipe Eltit2, Qiong Wang3, Dalia Othman1, Roman Herout1, Breanna Nelson1, Alina Reicherz1, Rizhi Wang4, Aaron Miller5, Ben H. Chew1, Genelle Lunken3, Dirk Lange1
1The Stone Centra at Vancouver General Hospital, Department of Urologic Sciences, University of British Columbia, 2Vancouver Prostate Centre, Department of Urologic Sciences, University of British Columbia, 3University of British Columbia, 4The University of British Columbia, 5Lerner Research Institute, Cleveland Clinic
Presented By: Dirk Lange, PhD
Introduction: Microbiome dysbiosis is suggested as a risk factor for kidney stone disease (KSD). As such, a few studies including ours have reported that individuals with KSD have a lower abundance of intestinal butyrate‐producing bacteria. The present study aims to examine the role of microbe‐derived short chain fatty acids (SCFAs), primarily butyrate, in calcium oxalate (CaOx) kidney stone formation. We hypothesize that SCFAs modulate oxalate processing and transport pathways to attenuate hyperoxaluria, and thus are protective for KSD.
Methods: We developed a novel diet‐inducedin vivomurine model of hyperoxaluria to assess the effect of supplementing inulin (prebiotic) and tributyrin (butyrate prodrug) in combination with sodium oxalate on CaOx crystal formation. Urine, blood, and stool samples were collected for oxalate measurements using isotope dilution‐high performance liquid chromatography/mass spectrometry (ID‐HPLC/MS). Stool samples and cecal contents were collected for 16S sequencing and SCFA analysis. Renal tissue was collected for histology to quantify crystal deposits. Renal and intestinal tissues were to collected for real‐time quantitative polymerase chain reaction (RT‐qPCR) to measure expression of oxalate transporters and inflammatory markers.
Results: Histology results indicate efficacy of our in vivo model, specifically showing renal calcium oxalate crystal formation in mice on the high oxalate diet. Supplementation of tributyrin in animals fed a high oxalate diet resulted in a significant decrease in CaOx crystal formation versus animals on the oxalate diet alone (p < 0.001). Inulin supplementation did not attenuate crystal formation. SCFA analysis revealed that inulin supplementation was able to significantly increase butyrate concentration in stool (p < 0.001), however in combination with oxalate this increase was not seen. ID‐HPLC/MS analysis revealed that urine oxalate levels were significantly higher in animals fed the combination tributyrin and oxalate diet, versus that of animals on the oxalate diet alone (p < 0.05).
Conclusions: Tributyrin appears to attenuate crystal formation in mice that are on a high oxalate diet and may do this by modulating oxalate transport. Findings from this study may provide insight into the etiology of KSD, and inform the development of novel diet‐based strategies to prevent KSD.
Funding: None
Thulium Fiber Laser vs. Holmium MOSESTM Laser in Flexible Ureteroscopy for the Management of Kidney Stones: Preliminary Single‐Center Results
Hazem Elmansy1, Parsa Nikoufar1, Amr Hodhod1, Moustafa Fathy1, Ahmed S. Zakaria1, Ruba Abdul Hadi1, Loay Abbas1, Husain Alaradi1, Waleed Shabana1, Prashidhi Pathak1, Ahmed Kotb1, Walid Shahrour1
1Northern Ontario School of Medicine
Presented By: Hazem Elmansy
Introduction: The primary objective of the study was to compare the laser efficiency of two widely used systems, the holmium MOSESTM laser and the thulium fiber laser (TFL), in the management of kidney stones. The secondary outcomes were to evaluate the impact of stone composition on laser efficacy.
Methods: We conducted a retrospective review of patients that underwent flexible ureteroscopy (F‐URS) for renal calculi and had a 3‐month postoperative CT scan between 2020 and 2022 at our institution. Patient demographics and stone parameters, including stone site, size, volume, and density, were recorded. Intraoperative data, including total operative time, lasing time, lasing technique, and total energy delivered, as well as stone composition, were collected and analyzed. All patients underwent a CT scan at 3 months follow‐up. We recorded the presence of residual stones and the percentage of stone volume reduction. Laser efficacy was calculated by dividing the energy utilized (J) by the stone volume (mm3). The ablation speed was calculated by dividing the stone volume (mm3) by the lasing time (sec). Patients with a stone size < 4 mm were deemed stone‐free.
Results: The MOSESTM and TFL groups consisted of 62 and 49 patients, respectively. Patient characteristics, perioperative, and postoperative data are presented in Table 1. There were no significant differences between groups for baseline patient demographics or stone characteristics. The two modalities had comparable total energy used, laser time, laser efficacy and laser ablation speeds. Sub‐analysis of the impact of stone composition on laser efficacy is presented in Table 2. We observed that the lasing time was significantly shorter with MOSESTM than TFL in calcium phosphate stones [7.95 vs. 10.85 min, respectively (p = 0.01).
Conclusions: MOSESTM and TFL laser systems were comparable in terms of efficacy for lithotripsy of renal calculi during F‐URS; however, calcium phosphate stones had a longer lasing time with TFL.
Funding: None
Unveiling the Thulium Fiber Laser Power Play: High Energy/Low Frequency vs. Low Energy/High Frequency Settings for a Human Kidney Stone: An in‐Vitro Evaluation
Robert Medairos1, Robert Medairos1, Francois Soto‐Palou1, Junquin Chen2, Arpit Mishra2, Jodi Antonelli1, Glenn Preminger1, Michael Lipkin1, Pei Zhong2
1Duke University Medical Center, 2Duke University Department of Mechanical Engineering and Materials Science
Presented By: Ezra Margolin, MD
Introduction: The optimal settings for laser lithotripsy with the Thulium Fiber Laser (TFL) are not clearly defined, and there is limited understanding of the efficacy in human stones. Our aim was to compare the treatment outcomes of high‐energy/low‐frequency settings to low‐energy/high‐frequency settings of the TFL for dusting calcium oxalate monohydrate (COM) human kidney stones within an anatomical kidney model.
Methods: A transparent 3D anatomical kidney model, accurately replicating similar acoustic and mechanical qualities to renal tissue (Fig a), was utilized. COM stones were placed in an upper pole calyx and underwent laser lithotripsy using a 200 μm TFL laser fiber. The procedure was performed through a single‐channel flexible ureteroscope with continuous flow irrigation. Two different settings were evaluated: high energy/low frequency (0.8 J/12 Hz) and low energy/high frequency (0.2 J/50 Hz). Additionally, six PFA K‐type thermocouples were inserted through the kidney phantom to reach the inner boundary of the upper pole calyx. The thermal dose, measured as cumulative equivalent minutes at 43 °C (CEM43°C), was calculated to assess the potential risk of thermal injury. Stone fragment residuals were retrieved and segregated into different sizes as fine dust (< 0.25 mm), dust (< 1 mm), small (1‐2 mm) and large (> 2 mm) fragments.
Results: The average initial stone mass was similar between the two groups, measuring 260.49 ± 27.81 mg (p = 0.30). The high energy/low frequency setting of 0.8 J/ 12 Hz was superior, showing a two‐fold increase in stone ablation speed (p < 0.001). The 0.8 J/ 12 Hz setting resulted in a higher percentage of fine dust (77.0% vs 62.5 %, p = 0.003) and a smaller proportion of large fragments (13.8% vs 24.2 %, p = 0.048) [Fig b]. The maximum temperature rise was statistically similar in both settings in all thermocouple locations (p = 0.49).
Conclusions: In COM stones, high‐energy/low‐frequency settings demonstrated a superior ablation speed and finer dust profile compared to low‐energy/high‐frequency settings. Further studies are warranted to determine the most effective settings in stones of varying chemical compositions.
Funding: N/A
The Kidney Stone Microbiome is Comprised of Antibiotic‐Resistant, Biofilm‐Forming Bacteria, Which Has Implications for the Etiology of Lithogenesis
Aaron Miller1, Mangesh Suryavanshi1, Prajit Khooblall1, Ava Adler1, Sromona Mukherjee1, Jose Agudelo1, Smita De1, Naveen Kachroo2
1Cleveland Clinic Foundation, 2Henry Ford Health System
Presented By: Aaron Miller, PhD
Introduction: Evidence suggests that urinary stone disease (USD) is associated with the urinary tract microbiome, termed urobiome. We and others have shown a strong association between USD and past antibiotic use. Furthermore, there is increasing evidence that active biofilm formation is present in calcium‐ based stones. These data present the hypothesis that antibiotic resistant, biofilm‐forming bacteria promote the lithogenesis of calcium‐based stones.
Methods: To test our hypothesis, we obtained calcium oxalate or calcium phosphate stones surgically extracted through percutaneous nephrolithotomy or ureteroscopy. Stone fragments were rinsed with sterile PBS to remove non‐adherent surface bacteria, crushed aseptically, serially diluted, and inoculated onto five different culture media. Resulting colony‐forming units were isolated for identification and plate‐based assays to quantify biofilm formation and antibiotic resistance. Eleven antibiotics were chosen for testing, which included common surgical prophylaxes and colistin, considered an antibiotic of last resort.
Results: From five calcium oxalate and five calcium phosphate stones, we obtained 75 bacterial isolates comprised of Kocuria, Escherichia, Micrococcus, Staphylococcus, Bacillus, Actinomyces, Brevibacterium, Rothia, and Dermacoccus genera. Out of 44 isolates tested, 42 exhibited strong biofilm formation, with one each exhibiting moderate or no biofilm formation. The strongest biofilms were from K. rhizophila, Bacillus spp. and M. luteus. Most isolates (38 out of 44) exhibited complete resistance at least one antibiotic. Thirteen isolates exhibited complete resistance to four different antibiotics. A total of 6 of the 11 antibiotics exhibited at least moderate effectiveness against all isolates, which included amoxycillin‐clavulanic acid, ciprofloxacin, gentamicin, cefazolin, levofloxacin, and vancomycin. Colistin was the least effective, with only nine of 44 isolates exhibiting susceptibility.
Conclusions: Our study presents strong evidence for biofilm formation in stone‐associated bacteria and moderate evidence for antibiotic resistance. Unexpectedly, most isolates were resistant to colistin, which suggests that this antibiotic is not effective as a last resort. More work is needed to understand the mechanisms of how biofilm formation promotes lithogenesis.
Funding: NIH R01DK121689
Impact of Irrigation Fluid Temperature on Thulium Fiber Laser Stone Ablation: An In‐ Vitro Study
Andrei Cumpanas2, Nittesh Katta1, Antonio R.H. Gorgen2, Thao N. Vu2, Mariah C. Hernandez2, Yi Xi Wu2, Kelvin Vo2, Sohrab N. Ali2, Pengbo Jiang3, Zachary E. Tano3, Roshan M. Patel3, Thomas Milner4, Jaime Landman3, Ralph V. Clayman3
1Beckman Laser Institute, University of California, Irvine, 2Department of Urology, University of California Irvine, 3Department of Urology, University of California, Irvine;, 4Beckman Laser Institute, University of California, Irvine;
Presented By: Andrei Cumpanas, MD
Introduction: Prior laser studies have shown that as the temperature of the medium increases, less energy is lost into the surrounding medium. Accordingly, we sought to investigate the role of irrigation fluid temperature on ablation of the six major clinical uroliths.
Methods: In this in vitro study, 360 stones were divided according to their chemical composition: calcium oxalate monohydrate, cystine, struvite, calcium phosphate, uric acid, and calcium oxalate dihydrate. With the tip of a 200 mm superpulse Thulium fiber laser (sTFL) in contact with each stone, while immersed in 0.9%NaCl at four different temperatures (25°C, 37°C, 44°C, and 60°C), a single laser pulse with distinct energy settings (0.1 J, 0.5 J, 1.5 J) was applied. Optical coherence tomography was used to assess the volume of the resulting ablation cone. The difference in mean stone volumes was evaluated using an ANOVA test. A multivariate generalized linear model was also developed to assess the data.
Results: With the exception of uric acid stones, a higher fluid temperature was associated with a higher volume ablation cone (b 0.096, 95% CI 0.060‐0.133, p < 0.001), at each energy level (Figure 1) (Table 1). When accounting for the individual chemical compositions, calcium oxalate monohydrate and cystine stones were found to benefit the most from increasing the temperature of the irrigation fluid (Table 1).
Conclusions: For nonuric acid stones, the sTFL ablation efficiency increased with the use of warmer fluid. The effect was most notable for calcium oxalate monohydrate and cystine stones.
Funding: None.
Uremic Toxins Enhance Calcium Oxalate Stone Formation In Vitro and In Vivo
Gerrit Stuivenberg1, Jennifer Bjazevic1, John Chmiel1, Polycronis Akouris1, Wongsakorn Kiattiburut1, Jeremy Burton1
1Western University
Presented By: Gerrit Stuivenberg, PhD Candidate
Introduction: The prevalence of kidney stones is on the rise, highlighting the need for a better understanding of their underlying causes. The gut 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. Interestingly, the gut microbiota of calcium‐based stone formers is primed with bacterial species that produce these uremic toxins. As such, this study aimed to investigate the relationship between uremic toxins and calcium oxalate (CaOx) stone formation. Specifically, we examined the impact of uremic toxins on crystal formation both in vitro and in vivo, using multiple models.
Methods: The direct effect of uremic toxins on CaOx crystallization and adherence was assessed in vitro using a standard gel‐based assay, artificial urine, and cell culture. Next, a Drosophila melanogaster model of nephrolithiasis was used to determine if the uremic toxins promote CaOx crystallization, ROS production, and gut microbiota changes in vivo.
Results: Indoxyl sulfate, p‐cresyl sulfate, and their precursors directly promoted CaOx crystal production in vitro. Uremic toxin exposure significantly increased CaOx adherence to mammalian kidney cells. In addition, indoxyl sulfate promoted the monohydrate morphology during the syntheses of CaOx crystals. D. melanogaster exposed to uremic toxins had increased stone burden within the Malpighian tubules (i.e., fly kidney). An increased stone burden was associated with more ROS production both locally within the Malpighian tubules and systemically. Uremic toxin exposure was also associated with a reduction of short‐ chain fatty acid producing bacteria, like lactobacilli, which is a common observation in human stone formers.
Conclusions: This is the first study to investigate the role of uremic toxins in kidney stone disease and it demonstrated that gut microbiota‐derived uremic toxins directly promote CaOx crystallization. Uremic toxins also enhanced stone burden in vivo by stimulating ROS production in the renal environment of Drosophila. These findings suggest that uremic toxins may augment stone production and adherence to kidney cells, which we confirmed in cell culture. These findings may potentially help to develop novel therapeutic and preventive strategies targeting uremic toxin accumulation to combat kidney stone disease.
Funding: Canadian Institutes of Health Research ‐ Canada Graduate Scholarship DoctoralOntario Graduate Scholarship ‐ Doctoral
Differences in Papillary Morphology Between Black and White Stone Formers
Luke Reynolds1
1University of Chicago
Presented By: Luke Reynolds, MD, FRCSC
Introduction: Nephrolithiasis is common and incidence is increasing faster among Blacks (B) compared to Whites (W). Recent evidence suggests that many stone formers (SF) form calcium oxalate stones on the base of a Randall plaque (RP), but this has only been studied in W SF. We sought to compare the renal papillary anatomy of B and W to improve our understanding of stone pathogenesis in the two groups.
Methods: SF undergoing ureteroscopy for the treatment of symptomatic and asymptomatic stone disease were prospectively enrolled. Patients with a systemic or anatomic cause for stone disease were excluded. Race was self‐identified. Two blinded independent reviewers who had undergone standardized training on papillary grading used digital videos from ureteroscopy to assign scores of 0, 1 , or 2 for plugging, plaque, pitting, and loss of contour. Scores were averaged across all papillae graded per kidney for each category, as well as the combined total score, and compared using Mann‐Whitney U test. ANCOVA models were used to evaluate differences in these scores with adjustments for sex, age, BMI, and recurrence status (RS).
Results: Thirty‐three B and 47 W patients were enrolled. Age was similar between groups but B had higher BMI (Table 1). The majority of patients were recurrent SF (66% W/83% B). B had significantly lower scores for plugging and plaque, as well as lower total scores (Table 1, Figure 1). In multivariate models, race was the only significant factor contributing to RP score, while race, age, and RS were significant for plugging. For total score, race and RS were significant contributors, and there was no interaction between race and RS.
Conclusions: This study is the first to describe the papillary anatomy of B SF. Compared to W SF, B have significantly less RP and tubular plugging, suggesting potentially different mechanisms for stone formation.
Funding: P01 DK056788 (Worcester, Coe, Zisman)
Understanding the Clinical Genetics of Kidney Stone Disease Using a Kidney‐Disease Specific Genetic Test Panel
Kavita Gupta3, Rutul Patel1, Kevin Labagnara2, Benjamin Green2, Michael Zhu2, Andrea A. Asencio3, Deep Sharma3, Wei Chen3, Dima Raskolnikov3, Jillian Donnelly3, Kara L. Watts3, Alexander C. Small3
1Montefiore Medical Center Department of Urology, 2Albert Einstein College of Medicine, 3Montefiore Medical Center
Presented By: Kavita Gupta, MD
Introduction: The etiology of kidney stone disease (KSD) is multifactorial. Emerging data suggest that genetics may play a larger role than previously thought. 11% to 56% of KSD has heritable stone‐related genetic mutations. We aimed to better understand the genetics of KSD using a kidney disease focused genetic test at our diverse, urban academic center.
Methods: A single‐center, prospective study was conducted on patients with recurrent stones or a single stone with family history. Those with known causes of urolithiasis, active UTI or acutely passing a stone were excluded. All underwent standard stone analysis, serum metabolic evaluation, 24‐hour urine studies and buccal DNA screen for 385 kidney disease‐linked genes using the Natera RenasightTM kit. Variants were categorized as “positive” if pathologic, “carrier” if autosomal recessive, or of “uncertain significance” (VUS).
Results: 89 patients were enrolled. 55% were female, 60% were Hispanic, and 30% reported a first‐degree family history. Median (IQR) patient age was 49 years (IQR 41‐60) with 2 (IQR 1‐3) stone episodes in the prior 5 years. 61% formed calcium oxalate stones.7 (8%) subjects were positive for amyloidosis (TTR), Alport syndrome (COL4A3), cystinuria (SLC7A9), polycystic kidney disease (PKD1), or FSGS (APOL1). 39 (44%) were carriers for 30 unique genes and all patients had multiple VUS spanning 247 unique genes. Positive/carrier patients were similar to negative patients in demographics, comorbidities, stone analysis and 24‐hour urine studies. They had lower median vitamin D (22.3 vs 29.7 ng/ml; p = 0.041) and higher potassium (4.4 vs 4.2 mEq/ml; p = 0.090).
Conclusions: Our study sheds light on potential genetic variants in recurrent stone formers in our diverse patient population. The initial wide range of results support the complex and polygenetic expression of KSD.
Funding: Natera
Genetic Susceptibility of Urolithiasis: up‐to‐Date Results from Genome‐Wide Mendelian Randomization and Colocalisation Analysis
Lede Lin1, Yucheng Ma1, Kang Ning2, Liang Zhou1
1West China Hospital, 2Sun Yat‐sen University Cancer Center
Presented By: Lede Lin
Introduction: The pathogenesis of urolithiasis is multi‐factorial and genetic factors have been shown to play a significant role in the development of urolithiasis. We tried to apply genome‐wide Mendelian randomization (MR) analysis and figure out reliable gene susceptibility of urolithiasis from the largest samples to date in two independent genome‐wide association studies (GWAS) database of European ancestry.
Methods: We extracted summary statistics of expression quantitative trait locus (eQTL) from eQTLGen consortium. Urolithiasis phenotype information was obtained from both FinnGen Biobank and UK Biobank.Multiple two‐sample MR analysis with a Bonferroni‐corrected P threshold (P < 2.5e‐06) was conducted.The primary endpoint was the causal effectcalculated by random‐effect inverse variance weighted (IVW)method. Sensitivity analysis, colocalisation analysis, Steiger tests and phenome‐wide association study(PheWAS) analysiswere also performed.
Results: After multiple MR tests between 19942 eQTLs and urolithiasis phenotype from both cohorts, thirty common eQTLs with consistent effect size direction were found to be causally associated with urolithiasis risk. After colocalisation analysis between those 30 eQTLs and urolithiasis phenotype from both cohorts, only one gene LMAN2 was colocalised with both cohorts (OR: 1.966, 95% CI: 1.844‐2.096 and OR: 1.004, 95% CI: 1.003‐1.006 for FinnGen Biobank and UK Biobank respectively).
Conclusions: We for the first study integrated MR, colocalisation, Steiger tests and PheWAS analysis to investigate the genetic susceptibility of urolithiasis in general population of European ancestry. Our results provided novel insights into common genetic variants of urinary stone disease, which was of great significance for subsequent researches.
Funding: Not applicable.
BASIC SCIENCE POSTER SESSION 4: STONES 2
Battle of the Bots: A Comparative Analysis of ChatGPT and BING AI's Ability to Respond to Kidney Stone Treatment‐Related Questions in Accordance with AUA Guidelines
Amber Mcmahon2, Terry Russell1, Wilson Molina2, Willian Ito2, Bristol Whiles2
1University of Florida, 2University of Kansas Medical Center
Presented By: Amber McMahon, MD
Introduction: Artificial intelligence (AI) has become more prevalent within healthcare, including an increased interest in its ability to answer healthcare‐related questions. ChatGPT™ (Open AI®) and Bing AI™ (Microsoft®) are two popular AI‐powered chatbots with such capability. Both are trained to provide human‐like responses to a prompt. However, unlike ChatGPT, Bing AI utilizes Microsoft internet search engine to include current information. The purpose of this study is to compare each model's responses for kidney stone treatment‐related questions. This will help us to better understand the strengths and limitations of these chatbots and future directions within urology.
Methods: We developed 20 kidney stone evaluation and treatment related questions based on the AUA Surgical Management of Stones guidelines. Questions were asked within ChatGPT and Bing AI. We compared their responses utilizing the brief DISCERN tool, a validated instrument to assess quality of health‐ related information, as well as response appropriateness. Scores were described by mean ± standard deviation and analyzed using paired t‐test (significance level < 0.05).
Results: ChatGPT significantly outperformed Bing AI for DISCERN questions 1‐3, which evaluate if the response aims were clear, if aims were achieved, and if the response was relevant. The total score for DISCERN questions 1‐3 was 12.65 ± 1.95 for ChatGPT™ vs. 10.2 ± 3.31 for Bing AI (p = < 0.01). In contrast, Bing AI always provided references, whereas ChatGPT never did. Therefore, the results for DISCERN questions 4‐6, which evaluated the quality of the sources, were consistently low for ChatGPT and high for Bing AI with a mean of 4.43 vs 11.7, respectively. ChatGPT provided more appropriate responses than Bing AI (75% vs. 42.5%), mentioned the importance of consulting with a provider more often (100% vs 85%) but never apologized for patient condition (0% vs 45%)(p‐values ≤0.01). ChatGPT, also had less responses give advice against guidelines (20% vs 30%) and stated that it cannot give medical advice more often(15% vs 10%)(p > 0.05).
Conclusions: ChatGPT significantly outperformed Bing AI in terms of providing responses with clear aim, achieving such aim, and relevant and appropriate responses based on AUA surgical stone management guidelines. However, Bing AI automatically provides references, allowing evaluation of the quality of information. Additional studies are needed to further evaluate these chatbots and their potential use by healthcare providers and patients.
Funding: N/A
How Much Energy Do We Need to Ablate 1 Cubic Millimeter of Stone During Thulium Fiber Laser Lithotripsy? An in Vitro Study
Frederic Panthier9, Marie Chicaud1, Steeve Doizi2, Stessy Kutchukian3, Catalina Solano4, Luigi Candela5, Laurent Berthe6, Mariela Corrales7, Olivier Traxer8
11 GRC n°20, Groupe de Recherche Clinique sur la Lithiase Urinaire, Hôpital Tenon, Sorbonne Université, 75020, Paris, France. 2 Service d'Urologie, Assistance‐Publique Hôpitaux de Paris, Hôpital Tenon, Sorbonne Université, 4 rue de la Chine, 75020, Paris, France. 3 PIMM, UMR 8006 CNRS‐Arts et Métiers ParisTech, 151 bd de l'Hôpital, F‐75013 Paris, France 4Service d'Urologie, CHU Limoges, 21 GRC n°20, Groupe de Recherche Clinique sur la Lithiase Urinaire, Hôpital Tenon, Sorbonne Université, 75020, Paris, France. 2 Service d'Urologie, Assistance‐Publique Hôpitaux de Paris, Hôpital Tenon, Sorbonne Université, 4 rue de la Chine, 75020, Paris, France. 3 PIMM, UMR 8006 CNRS‐Arts et Métiers ParisTech, 151 bd de l'Hôpital, F‐75013 Paris, France, 31 GRC n°20, Groupe de Recherche Clinique sur la Lithiase Urinaire
Hôpital Tenon, Sorbonne Université, 75020, Paris, France. 2 Service d'Urologie, Assistance‐Publique Hôpitaux de Paris, Hôpital Tenon, Sorbonne Université, 4 rue de la Chine, 75020, Paris, France. 3 PIMM, UMR 8006 CNRS‐Arts et Métiers ParisTech, 151 bd de l'Hôpital, F‐75013 Paris, France 5 Department of Urology, Poitiers University Hospital, 2 Rue de la Milétrie, 86000 Poitiers, France, 41 GRC n°20, Groupe de Recherche Clinique sur la Lithiase Urinaire, Hôpital Tenon, Sorbonne Université, 75020, Paris, France. 2 Service d'Urologie, Assistance‐Publique Hôpitaux de Paris, Hôpital Tenon, Sorbonne Université, 4 rue de la Chine, 75020, Paris, France. 6Department of endourology, Uroclin SAS Medellin, Colombia, 51 GRC n°20, Groupe de Recherche Clinique sur la Lithiase Urinaire, Hôpital Tenon, Sorbonne Université, 75020, Paris, France. 2 Service d'Urologie, Assistance‐Publique Hôpitaux de Paris, Hôpital Tenon, Sorbonne Université, 4 rue de la Chine, 75020, Paris, France. 7Division of experimental oncology/unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy; Vital‐Salute San Raffaele University, Milan, Italy, 63 PIMM, UMR 8006 CNRS‐Arts et Métiers ParisTech, 151 bd de l'Hôpital, F‐75013 Paris, France, 71GRC n°20, Groupe de Recherche Clinique sur la Lithiase Urinaire, Hôpital Tenon, Sorbonne Université, 75020, Paris, France. 2Service d'Urologie, Assistance‐Publique Hôpitaux de Paris, Hôpital Tenon, Sorbonne Université, 4 rue de la Chine, 75020, Paris, France., 81 GRC n°20, Groupe de Recherche Clinique sur la Lithiase Urinaire, Hôpital Tenon, Sorbonne Université, 75020, Paris, France. 2 Service d'Urologie, Assistance‐Publique Hôpitaux de Paris, Hôpital Tenon, Sorbonne Université, 4 rue de la Chine, 75020, Paris, France., 9Tenon Hospital APHP‐Sorbonne University
Presented By: Frederic Panthier, MD MSc
Introduction: Holmium:yttrium‐aluminium‐garnet(Ho:YAG) and Thulium Fiber(TFL) lasers are used for lithotripsy. Stone composition and stone volume are major lithotripsy determinants. This TFL in vitro study evaluated the ablation volume per pulse (AVP) and energy needed to ablate 1mm3 (J/mm3) of various stone types at different laser settings.
Results: AVP for COM stones were significantly greater than those for CYS stones and similar to UA stones (p = 0.02 and p = 0.06, respectively). If AVP increased with PE against COM and UA stones, AVP decreased against CYS stones. 1J PE resulted in a threefold lower J/mm3 compared to 0.5J and 0.8J for COM stones. Required J/mm3 for UA stones were similar, despite PE. For CYS stones, RE were increasing with PE. TFL was associated with greater AVP for COM, but lower for UA and CYS stones compared to Ho:YAG laser.
Conclusions: This in‐vitro study reports of TFL's efficiency by the ablation volume per pulse on human stone samples, according to various pulse energies. The stone composition could be considered when choosing the laser source for lithotripsy.
Funding: None
Comparison of Encrustation Between Silicon Covered and Polytetrafluoroethylene Covered Metallic Stent, in Vitro Experimental Study
Jun Seop Kim2, Seong Soo Jeon1, Jae Hoon Chung1, Deok Hyun Han1
1Samsung Medical Center, 2Samsung Medical Center, Seoul, Korea
Presented By: Jun Seop Kim, MD.
Introduction: Covered metallic ureteral stents (MUS) have many advantages compared with uncovered MUS or double‐J stents, such as a lower rate of tissue ingrowth and higher patency rate. There are some materials used to cover the MUS, include silicon and polytetrafluoroethylene (PTFE). However, no research has been reported on which cover material is more suitable for MUS. In present study, we compared the encrustation between silicon and using biofilm reactor.
Methods: 26 pieces of silicon covered ‐ and PTFE covered ‐ MUS were used respectively. Each piece was immersed in artificial urine (AU) with proteus mirabillis. Immersion test was performed for 48 hours using Biofilm reactor (Figure 1). After 48 hours, pieces of MUS were analyzed. Weight difference between pre‐ and post‐immersion test, A Scanning Electron Microscope (SEM), Energy Dispersive X‐ray Spectometer (EDS) and AU culture was assessed.
Results: Weight difference after immersion test was 9.50 ± 5.77 in silicon covered ‐ MUS, 16.75 ± 10.61 in PTFE covered – MUS (p = 0.004). Weight difference per length was 0.76 ± 0.45 in silicon covered ‐ MUS, 1.30 ± 0.81 in PTFE covered – MUS (p = 0.004) (Table 1). SEM images were taken at × 50 and × 5000 (Figure 2) magnifications. In addition, for qualitative analysis, EDS was performed on × 10000 magnification of SEM (Figure 3). In SEM, the intact surface and encrustation were confirmed. On the × 10000 SEM image with EDS, the calcium salts deposition and sulfate was identified.
Conclusions: Silicon covered ‐ MUS showed more resistance to encrustation than PTFE covered – MUS in AU immersion test.
Funding: None
Investigating Optimal Settings and Thermal Injury Risk of the Thulium Fiber Laser in An Anatomical Kidney Model
Robert Medairos1, Robert Medairos1, Francois Soto‐Palou1, Junquin Chen2, Arpit Mishra2, Jodi Antonelli1, Glenn Preminger1, Michael Lipkin1, Pei Zhong2
1Duke University Medical Center, 2Duke University Department of Mechanical Engineering and Materials Science
Presented By: Ezra Margolin, MD
Introduction: Despite the increasing usage of the novel Thulium Fiber Laser (TFL), comprehensive evaluation of settings which maximize treatment efficacy while minimizing the risk of thermal injury is limited. We aim to identify the optimal laser settings for stone dusting while assessing the potential thermal injury risk associated with the TFL in an anatomical kidney model.
Methods: A 3D‐printed anatomical kidney model, designed from human computed tomography scans, was used. A 6 x 6 mm cylindrical soft Begostone was positioned in an upper pole calyx, and TFL lithotripsy was performed using a 200 μm fiber inserted through a flexible ureteroscope with continuous flow irrigation. The stone ablation speed (mg/s) of the complete treatment was evaluated across various energy (Ep) (0.2 – 1.5 J), frequency (F) (6 to 150 Hz), and power settings (W) (10 W to 30 W). Additionally, temperature changes were recorded by placing multiple thermocouples near the tissue boundary, and the risk of tissue injury was determined by calculating the thermal dose as cumulative equivalent minutes at 43 °C (CEM43°C). The experiments were timed from the start of treatment until completion, and the remaining Begostone fragments were collected and weighed to calculate ablation speed.
Results: A total of 5 experiments were conducted for each setting, with an average initial stone mass of 259.57 ± 13.21 mg. High‐power settings exhibited the fastest ablation speed (Fig a). When power was controlled, increasing the Ep resulted in higher ablation speeds (Fig a). Ureteral thermal injury risk was observed with 20 W and 30 W power settings (Fig b), but not with the 10 W power settings. Lastly, the low Ep and high F combination led to faster temperature increases, reaching the thermal dose for tissue injury (t43 = 120 min) more rapidly than the high Ep / low F combination.
Conclusions: High Ep, low F settings demonstrates the maximum efficacy without excessive thermal toxicity for stone dusting using TFL. High power settings demonstrate considerable risk for possible thermal injury.
Further studies are needed to accurately quantify the size of dust particles generated during ablation in these settings with different types of urinary stones.
Funding: N/A
Association Between Gut Microbiota and Nephrolithiasis: A Two‐Sample Mendelian Randomization Study
Kunjie Wang1, Ya Li1, Zhongyu Jian1, Linhu Liu1, Menghua Wang1
1West China Hospital, Sichuan University
Presented By: Li Ya, MD
Introduction: It is reported that change in gut microbiota among nephrolithiasis patients by 16S rRNA microbial profiling analyses. Many ongoing animal studies and in vitro studies are also trying to establish the association between the disease and some specific bacteria. Nevertheless, whether there is a true causal relationship between gut microbiota and nephrolithiasis is still debated.
Methods: We performed a two‐sample Mendelian randomization analysis. Pooled statistics of gut microbiota was retrieved from the GWAS study (n = 14306). Pooled statistics of nephrolithiasis were from the FinnGen R8 data (8597 cases with 333128 controls). Seven different statistic methods were used to examine the causal effect between gut microbiota and nephrolithiasis. Heterogeneity were also quantified. Mendelian randomization analysis of the opposite direction was conducted for the bacteria that were statistically causally associated with nephrolithiasis.
Results: Twelve bacterial genera, namely, Clostridiumsensustricto1, Gordonibacter, Haemophilus, Howardella, Hungatella, Intestinimonas, Lachnospira, LachnospiraceaeUCG008, Odoribacter, RuminococcaceaeUCG004, RuminococcaceaeUCG010, Subdoligranulum, were associated with nephrolithiasis. IVW estimates suggested that Clostridiumsensustricto1 (OR = 0.82) and Intestinimonas (OR = 0.86) had a protective effect on nephrolithiasis. The protective role of Clostridiumsensustricto1 still existed after pleiotropy analysis (cML‐MA OR = 0.83). However, results of reverse MR suggest nephrolithiasis may also have some effect on Clostridiumsensustricto1 (cML‐MA OR = 0.96). RuminococcaceaeUCG010 could be a risk factor of nephrolithiasis according to IVW, cML‐MA, NL, MR‐PRESSO estimates (IVW OR = 1.36, 95% CI: 1.04‐1.76).
Conclusions: This two‐sample Mendelian randomization study identified RuminococcaceaeUCG010 as a potential risk factor that are causally associated with nephrolithiasis. Eleven other bacterial genera may also play some role in the development of the disease. Further animal or in vitro studies are required to clarify the mechanism behind and clinical trials should verify the protective effect of microbiota.
Funding: not applicapable
What Are the Optimal Laser Settings for Stone Dusting Using the Popcorn Technique
1Sheba Medical Center, 2Dorit.Zilberman@sheba.health.gov.il
Presented By: Oleksandr Chepeliuk, MD
Introduction: When evoking stones with a laser (Dusting) it is common to use the “popcorn” technique to complete the dusting. Today there are advanced and much more powerful laser machines, which allows the use of a variety of intensities, rates, and modulations. The purpose of the study is to check what are the most effective holmium laser settings while performing the popcorn technique.
Methods: Stones were brewed from gypsum mixtures in three density levels. Their density was measured by CT imaging. 5 stones of size 2.8‐3.3 mm were filtered and put into test tubes, and their weight was measured. Under continuous washing, “popcorn” stone dusting was performed with a holmium laser using a 272 micron fiber, using the popcorn technique for 2 minutes at intensities 0.3J/80Hz, 0.5J/40Hz, 1J/20Hz, 1J/ 30Hz, 1.5J/20Hz. With/without Moses modulation (distance). 3 repetitions were performed for each intensity. The mass of the remaining stone was weighed, and the stones larger than 1 and 2 mm were counted. The efficacy and evaporation rates of the stones were compared.
Results: The density of the hard, medium and soft stones was 2095,995,548 HU respectively. The average rate of evaporation in soft, medium and hard stones was 68%, 50%, 47%. In soft stones it was found that the rate of vaporisation was the largest in the laser settings of 1J/30Hz without Moses (93%). There were no stones > 2 mm left, and the number of crumbs between 1‐2 mm was 3. In medium density stones, the rate of vaporisation was the greatest in the settings 1.5J/20Hz with Moses (71%). No stones > 2 mm remained, and the number of stones between 1‐2 mm was 3. In hard stones, it was found that the rate of vaporisation was the greatest in the laser settings of 1J/30Hz with Moses (76%). There were no stones > 2 mm left, and the number of stones between 1‐2 mm was 7. Moses modulation did not change the total vaporisation rate (p = 0.256).
Conclusions: When using the “popcorn” technique for laser dusting of kidney stones, we found different efficiency rates between the different laser settings. The most effective laser settings were in soft stones 1J/30Hz without Moses, in medium 1.5J/20Hz with Moses, and in hard stones 1J/30Hz with Moses.
Funding: Sheba Medical Center
The Measurement of Intrarenal Pressure in Ureteroscopy with Laser Lithotripsy: A Prospective Trial
Jonathan Katz1, Jamie Finegan1, Jonathan Berger1, Seth Bechis1, Manoj Monga1, Roger Sur1
1UC San Diego Health
Presented By: Jonathan Katz
Introduction: Intrarenal pressure (IRP) during Ureteroscopy with laser lithotripsy (URS) is believed to be a major adjustable risk factor for post‐operative sepsis. The objective of our study was to show that continuous IRP measurement with a pressure guidewire during URS is safe and feasible alongside a ureteral access sheath (UAS).
Methods: We performed an analysis of a single institutional prospective data collection of patients with renal and/or ureteral stones who underwent URS. We collected demographic data as well as intraoperative data including UAS size and IRP (continuously measured using the Comet II pressure guidewire, Boston Scientific Marlborough, MA). We calculated the mean, median, and maximum pressures, and the area under the curve during treatment (a surrogate for total pressure experienced by the kidney) for each patient. Data was collected at baseline (just before access sheath placement) and continued until the removal of the access sheath at the end of treatment. Finally, we tracked intraoperative complications and episodes of post‐ operative sepsis.
Results: A total of 16patients were analyzed with a median age of 61 and 12.5% male, 87.5% female. One patient was excluded due to a Comet II pressure guidewire breaking in the renal pelvis (single fragment removed with a basket). Regarding the procedures in total, we found a mean pressure of 40.9 (14.6‐136.6) mmHg, median pressure of 18.2 (13.7‐115.4) mmHg, max pressure of 346.4 mmHg, standard deviation (SD) of 36.7 mmHg, and median area under the curve of 4803.0 mmHg*second, across all patients (Table 1). UAS sizes were 11/13Fr (n = 6), 12/14Fr (n = 6), and 13/15Fr (n = 3). There was one intraoperative complication (patient mentioned above) and no episodes of post‐operative sepsis.
Conclusions: Intraoperative monitoring of IRP is safe and feasible. The Comet II guidewire provides a mechanism to monitor the impact of alterations in surgical technique (sheaths, irrigation systems) on intrarenal pressures; and the correlation of intrarenal pressures and patient outcomes. We found that pressures varied substantially not only between patients, but during various stages of URS.
Funding: Boston Scientific
WITHDRAWN
Characterisation is Key ‐ Composition and Structure of Oxalate Kidney Stones
May Schymczyk1, Armaan Ali1, Chandra Shekhar Biyani2, Robert Simpson3, Katie Bolger3, Lourenz Pervera3, Antonia Borissova3, Andrew Scott3
1School of Medicine, Worsley Building, University of Leeds, 2Urology Department, St James's University Hospital, 3School of Chemical and Process Engineering, University of Leeds
Presented By: May Schymczyk, 4th Year Medical Student
Introduction: Urinary calculi are chemically heterogeneous and 45% of stones are composed of two or more compounds. Calculi, classified by composition, are calcium oxalate (80%), calcium phosphate (50%), struvite (10%), uric acid (9%) and cystine (1%). Calcium‐binding proteins have been found to promote the formation of calculi.There is no widely adopted international urolithiasis classification system, despite its increasing global prevalence. Within the UK, consistent biochemical characterisation and analysis are not always routinely performed on calculi. Fourier‐transform infrared spectroscopy (FT‐IR) is the standard method for calculi composition analysis. The aim of this work is to apply a range of materials characterisation techniques to fully determine the chemical and structural composition of intact stones, enabling a better understanding of nucleation and growth mechanisms.
Methods: Ten intact stones, similar in appearance and size (∼6 mm diameter), were obtained from a male patient using percutaneous nephrolithotomy. One calculus was cut in half, revealing its internal structure and the surface was then imaged using stereo and reflected light microscopy. Higher‐resolution imaging and elemental information were performed using scanning electron microscopy (SEM). Crystalline phase information was obtained via X‐ray diffraction (XRD) and the results were compared with FT‐IR spectra. A fluorescent marker (Fast Green FCF) was added to the surface of the calculus to preferentially stain regions of a protein. Confocal fluorescence microscopy was then used to image the specimen.
Results: Figure 1 shows the layer structure of the section of the stone. XRD revealed the stone to be calcium oxalate monohydrate (COM), which is further confirmed via FT‐IR. SEM clearly shows the plate‐like COM crystals. Initial fluorescence microscopy results show promise of potentially being able to identify proteins and their distribution within the calculi.
Conclusions: We have identified a methodology for thoroughly analysing intact urolithiasis by demonstrating concordance between structural (microscopy) and chemical characterisation (XRD, FT‐IR). This implies that structural analysis could potentially be used to routinely classify stones and help determine the pathogenesis of urolithiasis in recurrent stone formers.
Funding: Nil
Comparison of the Intestinal Microbiota of Patients with Primary Hyperparathyroidism with and Without Urinary System Stone Disease
1Hacettepe University Faculty of Medicine Department of Urology, 2Hacettepe University Faculty of Medicine Department of Endocrinology, 3Hacettepe University Faculty of Medicine Department of General Surgery
Presented By: Ahmet Gudeloglu, MD
Introduction: Primary Hyperparathyroidism (PH) is a common endocrine disorder characterized by hypercalciuria and increased parathormone level. Although hypercalcemia and hypercalciuria were detected in metabolic analysis, urinary system stone disease (USSD) is seen only in 10‐20% of these patients. The mechanism of why USSD does not occur in all PH patients still needs to be fully understood. The differences inintestinalmicrobiota could be one of the potential explanations. Our goal was to demonstrate if there are any differences in the intestinal microbiota of patients with PH who develop or do not develop USSD.
Methods: A total of 40 PH patients were included in the study from October 2021 to October 2022. While 15 of them had a history of USSD, 25 of them had never experienced it. The exclusion criteria were a history of antibiotic medication in the last 3 months, bariatric surgery, inflammatory bowel disease, and secondary or tertiary hyperparathyroidism. The stool samples were obtained from each participant and were kept at ‐ 80 degrees. The determination of microorganisms in the gut microbiota was done by a metagenomic study.
Results: We have identified 9 phyla, 14 classes, 23 orders, and 37 families in both groups. When the gut microbiota of the two groups were compared, there was no difference at the phylum level. However, Clostridia (p = 0.024) class ratio and Lachnospirales (p = 0.015) order ratio were higher in the stone‐developing group at the class and order levels, respectively. Further analyses at the family level revealed that Lachnospiraceae (p = 0.015) family ratio and Bacteroidaceae (p = 0.030) family ratio were found to be higher in the stone‐developing group (Graph 1).
Conclusions: This study showed that there was a significant difference in the class, order, and family levels in the gut microbiota of patients with PH who develop or do not develop USSD.These differences may play a role in the development of USSD in patients with PH. However, there is a need for comparative studies with a larger number of patients to demonstrate the relationship between intestinal microbiota and USSD in this particular patient group.
Funding: None
Surgical Treatment of Urolithiasis in Patients with Musculoskeletal Disorders and Complex Renal Anatomy
Sarit Cohen1, Ilan Kafka1, Boris Chertin1
1Shaare Zedek Medical Center
Presented By: Sarit Cohen, MD
Introduction: Urolithiasis in patients with skeletal and anatomical disorders has a multifactorial etiology that includes, among other things, immobility, recurrent infections, and urinary stagnation. Its surgical treatment can be challenging. This study details our surgical experience with kidney stones in this patient population.
Methods: In this retrospective study patients with kyphoscoliosis, cerebral palsy, horseshoe kidney, ectopic kidney, double collecting system, multiple sclerosis, sacral agenesis, spina bifida, muscular dystrophy and ankylosing spondylitis who underwent surgery to treat urinary tract stones were included and their medical records were reviewed. Imaging (CT, US, KUB) was used to determine stone‐free rates following the procedure. Univariate statistical analysis was also performed on demographic, surgical, and follow‐up data.
Results: Seventy‐nine patients between 2005 and 2023 were reviewed. Nine patients with kyphoscoliosis, 15 patients with cerebral palsy, 15 patients with horseshoe kidneys, 5 patients with ectopic kidneys, 10 patients with incomplete double collecting systems, 6 patients with multiple sclerosis, 2 patients with sacral agenesis, 4 patients with spina bifida, 2 patients with muscular dystrophy, and 11 patients with ankylosing spondylitis.Median patient age was 50 years (10‐80 years), and the median stone size was 10 mm (4‐40 mm). 16 patients underwent PCNL, 37 flexible ureteroscopy, and 20 ureteroscopy. Median operative time was 42 minutes (8‐165 min.) and a median hospital stay was 1 day. Four patients remained with a nephrostomy after the procedure and 55 patients with a double‐J stent. There were no anesthesia or surgical complications recorded and no blood transfusion was required. Statistically significant differences between the surgical approaches were not detected. In Univariate logistic regression analyses, however, stone size and the length of the procedure were associated with the need for 13 auxiliary procedures (1 ESWL, 4 ureteroscopy, 7 PCNL). The auxiliary procedures were performed on two patients with kyphoscoliosis, five with cerebral palsy, three with horseshoe kidneys, two with multiple sclerosis, and one with ankylosing spondylitis.
Conclusions: While endourological procedures were found to be safe and effective in patients with skeletal muscle disorders and complex renal anatomy, we found risk factors for the need for auxiliary procedures, such as stone size and procedure length.
Funding: None
Analysis of Association Between Klotho Protein and Kidney Stones: A Cross‐Sectional Study Based on NHANES
Yu Liu1, Menghua Wang1, Kunjie Wang1
1Department of Urology, Institute of Urology, West China Hospital, Sichuan University
Presented By: Yu Liu
Introduction: Klotho gene is an anti‐aging gene. Previous studies suggested that Klotho protein might inhibit the formation of kidney stones, but relevant studies were few. The purpose of this study was to investigate the correlation between Klotho protein and kidney stones using the NHANES.
Methods: NHANES is a biennial survey of people across the United States. In this study, we selected 10 years of data from 2007 to 2016 to increase the sample size and statistical efficiency as much as possible. In this study, we screened the study population with complete kidney stones and serum Klotho protein content for further study, and then divided into quartile groups based on Klotho protein content for subsequent analysis. We used univariate and multivariate Logistic regression to explorethe relationshipbetween Klotho protein content and kidney stones. All data analyses were performed using STATA and P < 0.05 was considered statistically significant.
Results: Atotal of 13,516 subjects were included in this study, including 1,519 patients with kidney stones. No association was found between Klotho and kidney stones in single‐factor studies. In the multivariate Logistic regression, Q2 (OR 1.02, 95%CI 0.82‐1.27, P = 0.885), Q3(1.13, 95%CI 0.89‐1.42, P = 0.309), Q4
(1.10, 95%CI 0.87‐1.39, P = 0.434) also showed no statistical differencewhen compared with Q1.
Conclusions: In this study, no correlation was observed between Klotho protein and kidney stones. Prospective studies are needed to further analyze the correlation and causation between Klotho protein and kidney stones.
Funding: None
Exploring the Microbiome of the Renal Papilla in Calcium Oxalate Stone Formers: A Pilot Study
Joao Porto1, Jonathan Katz1, Harrys Jacob1, Praveen Singh1, Oleksandr Kryvenko1, Sabita Roy1, Ramgopal Satyanarayana1, Robert Marcovich1, Hemendra Shah1
1Desai Sethi Urology Institute, University of Miami
Presented By: Joao Porto, MD
Introduction: Little is known about the influence of microbiomes in calcium oxalate (CaOx) stones. To evaluate this relationship, we performed analysis on the renal papillary (RP) tissue from both CaOx stone formers and controls.
Methods: We included 7 patients with stones scheduled for percutaneous nephrolithotomy and 7 patients scheduled for radical nephrectomy for renal cell carcinoma (RCC). Patients on anticoagulants, with recent positive urine culture, or with ureteral stents/nephrostomy tubes were excluded. We collected mid‐stream voided and bladder urine, renal stone fragments, and RP biopsy from each patient. DNA extraction was performed using DNeasy PowerSoil kit (Qiagen) and NEBNext microbiome DNA enrichment kit. The sample then underwent 16S/18S/ITS sequencing. The statistical analysis was performed to compare the microbiome of RP, kidney stone and bladder urine specimen. We also compared the microbiome of RP with healthy renal tissue biopsy from nephrectomy specimen from RCC. Moreover, microbiome of voided urine with bladder urine specimens was compared.
Results: Bacterial biomass was low in all specimens, and 16S amplification results were obtained only with extended PCR cycling. Comparing the microbiome diversity between CaOx formers and controls, no difference was found in alpha diversity. However, beta‐diversity analysis at the genus level showed a significant difference in the abundance of Bacillus genome in favor of CaOx stone formers (p = 0.033). ANCOM‐BC analysis revealed higher abundance of Alishenwanella, Bacillus, BCP, Corynebacterium, Staphylococcus, and Streptococcus in the CaOx RP tissue (Figure 1). Similarly, E. coli and Okhensis were statistically more abundant at the species level in the CaOx RP. There were no differences in alpha diversity between specimens (RP, kidney stones, catheterized urine) of CaOx formers, but RP and kidney stone specimens clustered together with lower diversity compared to catheterized urine. No differences were found in alpha diversity between clean‐catch midstream urine and urine collected directly from the bladder intraoperatively. At the genus level, Prevotella was more abundant in catheterized urine (p = 0.032), while Escherichia‐Shigella was more common in voided urine (p = 0.044).
Conclusions: We found difference between RP of CaOx stone formers and controls, which suggests that microbial diversity could play possible role in CaOx stones.
Funding: N/A
Effects of Renal Access Angle and Speed of Nephroscope Retrieval Movements on the Vortex Effect for Stone Retrieval
Crystal Valadon1, Wilson Molina1, Willian Ito1, Dillon Prokop2, Bristol Whiles1, Donald Neff1, David Duchene1
1The University of Kansas Health System, 2University of Kansas School of Medicine
Presented By: Crystal Valadon, MD
Introduction: The vortex effect (VE) is widely utilized in mini‐percutaneous nephrolithotomy (mini‐PCNL), although its physical components are still poorly understood. This study aimed to analyze the influence of different renal access angles and nephroscope retrieval speeds on the VE's efficacy during mini‐PCNL.
Methods: A Pexiglas™ (KUS®) model was built based on the dimensions of a 15/16Fr mini‐PCNL set (Karl Storz®). The flow rate was continuous via an automatic pump and calibrated to achieve hydrodynamic equivalence to the real equipment. One experiment consisted of retrieving all 30 stone phantoms (3mm diameter) utilizing only the VE. Cumulative time to retrieve all stones was measured. An accelerometer recorded instant speeds every 0.08s, and 3 experiments were performed at each angle (0°, 45°, and 90°). We classified the effectiveness of the VE in each experiment (Figure 1). A logistic regression model was built utilizing maximum speeds and access angles (AA) to predict the effectiveness of the VE.
Results: Mean cumulative time was 28.1s at 0° vs. 116.5s at 45° vs. 101.4s at 90°(p < 0.01). We noted significantly higher speeds at 0° in comparison to 45° and 90°(p < 0.01); however, differences between 45° and 90° were not statistically significant (Table 1).The regression model demonstrated a negative association between increased maximum speeds and VE's effectiveness (OR 0.547,CI 95% 0.350‐0.855,p < 0.01). When controlling for speeds, the 0° angle had a nearly 100‐fold increased chance of obtaining at least a partiallyeffective VE (OR 0.017,CI 95% 0.002‐0.141,p < 0.01), when compared to 90°.
Conclusions: Increasing the renal access angle negatively impacts the nephroscope retrieval speeds. This significantly increased procedure time in the laboratory model, suggesting that the VE is less effective at higher sheath angles.
Funding: None
Evaluation of Char Formation Using the Thulium Fiber Laser: The Standoff Between High versus Low Energy
Francois Soto‐Palou1, Francois Soto‐Palou1, Robert Medairos1, Junquin Chen2, Arpit Mishra2, Jodi Antonelli1, Glenn Preminger1, Michael Lipkin1, Pei Zhong2
1Duke University Medical Center, 2Duke University Department of Mechanical Engineering and Materials Science
Presented By: Ezra Margolin, MD
Introduction: Char formation on stones during lithotripsy can significantly impede treatment efficacy. The current understanding of char formation on stones when using the Thulium fiber laser (TFL) is limited. Our aim was to assess the factors that may contribute to the char formation on a Calcium Phosphate (CaP) stone under two distinct different pulse energy/frequency combinations using the TFL.
Methods: A 6 x 6 x 4 cm 100% calcium phosphate stone was cold‐mounted, bisected, and polished using 1200‐grit sandpapers to create a flat surface (Fig a). The chemical composition of the stone was determined at the Mayo Clinic (Rochester, MN) by infrared spectroscopy. The stone sample was fixed in a water tank filled with degassed water at room temperature and treated by the TFL at two different pulse energy/frequency settings: 0.2 J/100 Hz and 0.8 J/12 Hz. A 200 μm fiber was placed perpendicularly to the stone surface. Laser pulses were delivered at various pulse numbers (PNs) at standoff distances (SDs). Each combination of laser PNs and SDs were repeated five times at a different localized area of the stone. The resultant stone damage was then quantified by optical coherence tomography (OCT).
Results: Charring, defined as the carbonization of stone materials, was observed more frequently using the 0.2 J/100 Hz setting at all SDs compared to 0.8 J/12 Hz (Fig b). As a result, no significant rise in the crater volume was observed as the pulse number increased from 25 to 100 under 0.2 J/100 Hz, except for SD = 1.0 mm. In contrast, more crater damage was produced under 0.8 J/12 Hz setting, and the crater volume increased progressively with the PN at all SDs (Fig c).
Conclusions: At a low pulse energy, TFL treatment efficiency of CaP stone may significantly decrease due to the charring. Our results suggest that a high pulse energy level may help to avoid the charring and improve the treatment efficiency. The physical mechanisms of char formation and stone damage at different energy levels warrant further investigation.
Funding: N/A
MODERATED POSTER SESSION
MODERATED POSTER SESSION 1: LAPAROSCOPIC AND ROBOTIC PROSTATE CANCER 1
The Relevance of Nomograms for Prediction of Pelvic Lymph Node Metastases in the PSMA‐PET/CT Era
Ofer Gofrit2, Marina Orevi1, Simona Ben Haim2, Tzahi Neuman2, Nordechai Duvdevani2, Guy Hidas2, Vkadimir Yutkin2
1Hadassah Hebrew UniversityHospital, 2Hadassah Hebrew University Hospital
Presented By: Ofer Gofrit, MD. PhD
Introduction: Current guidelines suggest that the indication for pelvic LN dissection (PLND) during radical prostatectomy (RP) should rely on nomograms predicting their involvement. PET/CT with prostate specific membrane antigen (PSMA) radioligand is gaining acceptance as routine diagnostic test before RP in patients with intermediate/high‐risk prostate cancer (PC). In this study we examined the effect of preoperative PET/CT on the accuracy of the nomograms.
Methods: Patients with intermediate/high risk PC with PET/CT‐ PSMA showing no extra prostatic disease underwent RP with PLND and were followed postoperatively for at least 6 months. Reevaluation with PET/CT‐PSMA was done in patients with detectable (> 0.1 ng/ml) postoperative PSA levels. Minimal postoperative follow‐up was 6 months.
Results: A total of 70 patients underwent RP for intermediate (34 patients) or high‐risk disease (36 patients). According to the Partin, MSKCC and Briganti 2012 nomograms, in this case‐mix, positive LNs were expected in 7, 13, and 12 patients, respectively. At PLND, one positive LN was found in a single patient (p < 0.05 compared to the expected number of patients from all nomograms). Post‐operatively, 10 patients developed detectable PSA levels. Radioligand uptake that could indicate LN involvement was noted in one patient. Considering these two patients as failures, the negative predictive value of PSMA‐PET/CT for predicting LN involvement is 97.1%.
Conclusions: Pre‐operative PSMA‐PET/CT with no extra‐prostatic uptake prior to RP in patients with intermediate to high‐grade PC is highly accurate for ruling out LN involvement, superior to the routinely used nomograms. Its use induced stage migration, rendering predicting nomograms irrelevant.
Funding: None
Use of Peritoneal Interposition Flap for the Prevention of Lymphocele Formation After Pelvic Lymph Node Dissection During Robotic‐Assisted Laparoscopic Radical Prostatectomy: Systematic Review and Meta‐Analysis
Angela Estevez1, Utsav Bansal1, Joseph Wagner2, Sumedh Kaul1, Aaron Fleishman1, Paul Bain3, Peter Chang1, Andrew A. Wagner1, Boris Gershman1
1Beth Israel Deaconess Medical Center, 2Hartford Healthcare Medical Group, 3Countway Library, Harvard Medical School
Presented By: Angela Estevez, MD
Introduction: The use of a peritoneal interposition flap (PIF) has been proposed as a promising technique to reduce the rate of lymphocele formation after pelvic lymph node dissection (PLND) in robotic‐assisted laparoscopic radical prostatectomy (RARP).Herein, we conducted a systematic review and meta‐analysis to evaluate the association of PIF with lymphocele formation and postoperative complications after RARP.
Methods: We conducted a systematic search of MEDLINE, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials through January 18, 2023 with a professional librarian. Two investigators independently selected studies for inclusion. A random effects meta‐analysis was then performed to evaluate the associations of PIF with the following outcomes: symptomatic/asymptomatic lymphocele and non‐lymphocele postoperative complications.
Results: Four randomized controlled trials (RCTs) and five retrospective studies, including 2,476 patients, were included in the final analysis. Compared to a standard technique, the use of PIF was associated with a reduced risk of 90‐day symptomatic lymphocele formation after RARP when examining only RCTs (pooled OR 0.46, 95% CI 0.23‐0.93; I2 = 24%, Figure 1a) and both RCTs and observational studies (OR 0.37, 95% CI 0.18‐0.74; I2 = 43%, Figure 1b). Similarly, use of PIF was associated with a reduced risk of 90‐day any lymphocele formation (OR 0.46, 95% CI 0.34‐0.64, I2 = 4%; Figure 2). There were no statistically significant differences in postoperative complications (OR 0.98; 95% CI 0.73‐1.32; I2 = 11%; Figure 3).
Conclusions: Use of the PIF is associated with an approximately 50% reduced risk of symptomatic and any lymphocele formation within 90‐days of surgery, and it is not associated with an increase of postoperative complications.
Funding: None
Peritoneal Window Technique During Extended Pelvic Lymph Node Dissection is Associated with Reduced Symptomatic Lymphocele Formation After Robotic Radical Prostatectomy
Eric Qualkenbush1, Amanda Myers1, Yeonsoo Lee1, Sarah Hapton1, Jared Schommer1, Raymond Pak1
1Mayo Clinic Florida
Presented By: eric qualkenbush, MD
Introduction: Extended pelvic lymphadenectomy during robotic prostatectomy carries the risk of lymphocele formation, which can cause complications such as infection, deep vein thrombosis, and pain. Peritoneal window is an easy, single step technique performed during lymph node dissection. Therefore, the objective of this study was to evaluate whether the peritoneal window technique would be associated with reduced incidence of symptomatic lymphocele formation after extended pelvic lymphadenectomy.
Methods: Patients who underwent a robotic prostatectomy with extended pelvic lymph node dissection by a single surgeon from 2018 to 2022 were identified. The exposure of interest was peritoneal window technique. The peritoneal window was created by excising the portion of peritoneum overlying the pelvic lymph nodes and iliac vessels at the time of lymphadenectomy. The surgeon documented peritoneal window technique in the operative note when performed. The primary outcome was symptomatic lymphocele. Statistical analysis was performed using Kruskal‐Wallis test for continuous variables and chi squared test for categorical variables with p < 0.05 considered significant.
Results: Between 2018 and 2022, we identified 147 patients who underwent robotic assisted radical prostatectomy with extended pelvic lymph node dissection. Of whom, 101 (69%) received the peritoneal window technique, while 46 (31%) did not. Clinicopathologic variables are summarized in table 1. Five patients developed symptomatic lymphocele at a median of 23 days postoperatively (IQR 12‐46 days). No patients with a peritoneal window developed a symptomatic lymphocele (P = < 0.001).
Conclusions: The creation of a peritoneal window during an extended pelvic lymphadenectomy for prostate cancer was associated with a significant reduction in symptomatic lymphoceles. The peritoneal window is an easy, one‐step technique that potentially prevent lymphoceles and warrants further study.
Funding: none
Comparing Different Methods of Lymphogenic Complications Prophylaxis During Robot‐Assisted Radical Prostatectomy
Dmitry Pushkar1, Konstantin Kolontarev1, Alexander Govorov1, Konstantin Skrupskiy1
1Moscow State Medical and Dental University named after A.I. Evdokimova of the Ministry of Health of the Russian Federation
Presented By: Dmitry Pushkar, PHD
Introduction: Pelvic lymphadenectomy is a therapeutic and diagnostic manipulation that allows to evaluate lymph nodes metastasis, but also to provide the most accurate staging after radical prostatectomy. Lymphocele is the most common complication after pelvic lymphadenectomy robot‐assisted radical prostatectomy.
Methods: Objective: To develop prophylaxis lymphogenic complications after robot‐assisted pelvic lymphadenectomy.Design, setting, and participants: prospective randomized single‐center study including patients with prostate cancer (cT1‐3N0M0) who underwent robot‐assisted radical prostatectomy with pelvic lymphadenectomy between September 2022 and December 2022. Patients were randomized into 3 groups:1. A group of patients with fixation of a free peritoneal flap to the pubic bone;2. A group of patients use of the lymphostatic drug «Lymphoblock»;3. Control group.Measurements: The main objective of the study was to assess the frequency lymphocele during follow‐up period.
Results: 79 patients included in the study. The median follow‐up was 90 d. There were no differences between the groups regarding clinical and pathological variables. The patients were divided into 3 groups: group 1 ‐ fixation group (n‐26), group 2 ‐ «Lymphoblock» (n‐26); group 3 – control group (n ‐ 27). After surgery, lymphocele was diagnosed in 8 (10.1%) patients: group 1 ‐ 2 (2.5%) patients, group 2 ‐ 1 (1.3%), group 3 ‐ 5 (6.3%). Lymphocele in the fixation groups and use of the lymphostatic drug «Limfobok» was asymptomatic and had absolutely no clinical symptoms. Symptomatic lymphocele was diagnosed in 2 (2.5%) patients of the comparison group.
Conclusions: The surgical method of a free peritoneal flap fixation to the pubic bone during robot‐assisted radical prostatectomy and pelvic lymphadenectomy and the use of the lymphostatic drug Lymphoblock can reduce the incidence of lymphocele formation compared to the standard technique. The use of preventive measures complex can be recommended for routine use in patients who underwent robot‐assisted radical prostatectomy and pelvic lymphadenectomy.
Funding: Not fundidng
Prediction of Urinary Incontinence After Robot‐Assisted Radical Prostatectomy Based on Pre‐ Surgery Patient's Characteristics
Andrei Shvedov1, Dmitrii Pushkar1, Konstantin Kolontarev1
1Federal State Budgetary Educational Institution of the Higher Education “A.I. Yevdokimov Moscow State University of Medicine and Dentistry” of the Ministry of Healthcare of the Russian Federation
Presented By: Dmitrii Yu Pushkar, MD
Introduction: Radical prostatectomy is the gold standard localized prostate cancer treatment. Continued innovation of the robot‐assisted radical prostatectomy (RARP) since 2001 has resulted in an effective, high quality surgical treatment for prostate cancer. Complete recovery of urinary continence, however, remain challenging to achieve. It is crucial to assess the risks of incontinence preoperatively and, if necessary, choose a different treatment method
Methods: We conducted a prospective cohort study that included 127 patients who underwent radical robot‐ assisted prostatectomy. Several risk factors for urinary incontinence were found. Then using logistic regression an online nomogram of the probability of urinary incontinence was created
Results: In the early postoperative period, urinary incontinence occurred in 88 (70.3%) patients, but by the 12th month of follow‐up, this number had decreased to 14 (11%). Seventy (79,5%) patients noted a significant decrease in the quality of life after surgery. Age, body mass index, length of the membranous urethra, size of m. levator ani, a history of prostate surgery and symptoms of an overactive bladder were urinary incontinence predictors. Using the logistic regression method, the data obtained in a specific time interval was analyzed, after which the logistic regression equation was constructed. Then, based on these equations, an online nomogram was created to calculate the probability of urinary incontinence on the 7th day and 1,3,6,12 months after removal of the urethral catheter. Urologists can use this nomogram on regular base
Conclusions: Despite the development of surgical techniques and understanding of the anatomy urinary incontinence after robot‐assisted prostatectomy is a frequent functional complication. The negative impact of urinary incontinence on the quality of life is obvious. Searching of risk factors and the ability to calculate the probability of urinary incontinence will help to choose the optimal method of treatment.
Funding: The study was not sponsored
Simple Prostatectomy Followed by Radiation vs Radical Prostatectomy: A Propensity Score Matched Analysis of a Novel Treatment Pathway for Men with Prostate Cancer and Prostatomegaly
Hal Kominsky1, Samuel Gold1, Ross Gillum1, Caleb Ashbrook1, Isaac Palma Zamora2, Daniel Segal2, Tara Morgan3, Ramy Goueli1, Jeffrey Gahan1
1UT Southwestern Medical Center, 2isaacpalmazamora@gmail.com, 3Duke University
Presented By: Hal Kominsky
Introduction: Treatment of prostate cancer (PCa) in men with prostatomegaly is challenging due to the increased risk of stress urinary incontinence (SUI) post‐radical prostatectomy (RP) and worsening lower urinary tract symptoms (LUTS) or retention post‐radiation therapy (RT). We propose that simple prostatectomy (SP) followed by RT improves symptomatic LUTS, treats cancer, and minimizes SUI versus RP alone. This is an initial analysis of oncologic and functional outcomes for men who underwent SP with RT versus RP
Methods: A retrospective review was conducted in which men with prostatomegaly (> 80 mL) on magnetic resonance imaging (MRI) and biopsy‐proven PCa were treated with RT after robotic‐assisted SP (RASP). These men were compared against a 1:1 propensity score matched cohort of men treated with robotic‐assisted RP (RALP) based on prostate volume, age, and body mass index (BMI).
Results: Thirteen men were included in both RASP+RT and RALP cohorts. Between the two cohorts (Table 1), there were no significant differences in age (73.0 vs 73.0, p = 0.88), volume (135.0 mL vs 135.0 mL, p = 0.92), BMI (30.7 kg/m2 vs 28.4 kg/m2, p = 0.53), or PSA (13.0 ng/mL vs 10.3, p = 0.53). RASP operative time was less than half that for RALP (126 min vs 315 min, p < 0.001). Full, partial, and non‐nerve sparing was performed in 4 (31%), 5 (38%), and 4 (31%) RALP patients. No men experienced SUI in the RASP+RT group while 92% and 88% experienced SUI in the RALP group at 3 and 6 months. One man had an artificial urinary sphincter placed after RALP. There were no high‐grade complications in the RASP+RT group although 2 men required bladder irrigation for clot retention. One RALP patient experienced ileus requiring nasogastric tube and deep vein thrombosis requiring anticoagulation. Another RALP patient developed a pelvic abscess requiring drain placement. Metastases developed in 2 (15%) men after RASP + RT and in 2 (15%) men after RALP; 2 (15%) others had biochemical recurrence after RALP.
Conclusions: For men with prostatomegaly and PCa, staged treatment with RASP followed by RT offers an alternative to RALP with shorter operative times and better urinary control at 6 months. Further oncologic and functional data will help evaluate the durable success of this novel treatment pathway.
Narmina Khanmammadova1, Rafael Gevorkyan1, Narmina Khanmammadova1, Maria Epino1, Tuan Thanh Nguyen2, Sohrab Naushad Ali1, Andrei D Cumpanas1, Jacob Basilius1, Antonio Gorgen1, Jaime Altamirano1, Mohammed Shahait3, Thomas Ahlering1, David I Lee1
1University of California, Irvine, Department of Urology, 2University of Medicine and Pharmacy at Ho Chi Minh City, 3Clemenceau Medical Center, Department of Surgery
Presented By: Narmina Khanmammadova, MD
Introduction: The complex language used in clinical reports, such as prostate biopsy results, often poses a challenge to patient comprehension. As artificial intelligence (AI) continues to evolve, its potential for facilitating patient understanding has been explored. This study set out to assess the quality of patient‐ centered reports generated by ChatGPT, with evaluations provided by urological surgeons.
Methods: 25 original prostate biopsy reports, 5 from each Gleason Grade group, were transformed into patient‐centered versions using ChatGPT‐3.5. The generated reports were evaluated by 7 urological surgeons using a 7‐item questionnaire that focused on structure, clarity of diagnosis, accuracy of biopsy result description, extent of disease explanation, Gleason grade interpretation, comparative effectiveness for patient understanding, and willingness to use AI‐generated reports in practice. Ratings were scored on a 5‐point Likert scale. We utilized 2 readability measures, the Flesch Reading Ease and the Flesch‐Kincaid Grade‐ Level, to evaluate and compare the readability of each ChatGPT‐generated report against its respective original pathology report.
Results: The ChatGPT‐generated patient‐centered reports exhibited significantly higher Flesch Reading Ease Scores (49.05 ± 4.75) compared to the original biopsy reports (31.15 ± 14.62; p < 0.001). Flesch‐Kincaid Grade Levels were similar between the two (p = 0.940). Surgeons' evaluations of the ChatGPT‐generated reports indicated favorable responses across the seven‐item criteria. Surgeons strongly agreed with the generated reports' use of patient‐friendly language (48.6%), accuracy of biopsy results (54.9%), disease extent explanation (56.6%), and Gleason grade interpretation (58.9%). Surgeons indicated a neutral to positive agreement that the ChatGPT reports' structure and potential to improve patients' understanding of their disease, yet a strong agreement for willingness to use them in their practice (76.0%).
Conclusions: The evaluation of ChatGPT‐generated patient‐centered reports demonstrated improved readability compared to the original biopsy reports. As the field of AI continues to advance, tools like ChatGPT may play a key role in patient‐centered care.
Funding: No funding.
Unlocking Patient‐Centered Narratives: Evaluating the Feasibility and Effectiveness of ChatGPT in Generating Surgical Pathology Reports for Radical Prostatectomy
Narmina Khanmammadova1, Rafael Gevorkyan1, Mohammed Shahait2, Maria Epino1, Narmina Khanmammadova1, Tuan Thanh Nguyen3, Sohrab Naushad Ali1, Jacob Basilius1, Jaime Altamirano1, Antonio Gorgen1, Andrei D. Cumpanas1, Thomas Ahlering1, David I Lee1
1University of California, Irvine, Department of Urology, 2Clemenceau Medical Center, Department of Surgery, 3University of Medicine and Pharmacy at Ho Chi Minh City
Presented By: Narmina Khanmammadova, MD
Introduction: The potential of Artificial Intelligence (AI) to translate complex medical reports into patient‐ friendly language has been of interest. This study aims to assess the clinical utility of ChatGPT in generating patient‐centered surgical pathology reports for patients who underwent radical prostatectomy.
Methods: The study encompassed 25 original surgical pathology reports evenly distributed across each Gleason Grade group. The reports were converted into patient‐centered versions using ChatGPT‐3.5. These generated reports were reviewed by 7 urological surgeons. An 8‐item questionnaire was designed to evaluate the quality of these reports, with each item scored on a 5‐point Likert scale. The items assessed the structure, readability, accuracy of pathology results, disease extent explanation, Gleason grade interpretation, surgical margin explanation, patient understanding improvement, and the surgeons' willingness to use these AI reports in their clinical practice. The Flesch Reading Ease score and the Flesch‐Kincaid Grade‐Level score were computed and compared between the ChatGPT‐generated and original reports to assess the relative readability and comprehension level.
Results: The Flesch Reading Ease score improved in the ChatGPT‐generated reports (49.64 ± 3.39) compared to the original reports (41.39 ± 16.82; p = 0.020). However, the Flesch‐Kincaid Grade Level was higher in the ChatGPT‐generated reports (10.47 ± 0.70) than the original reports (8.72 ± 2.17; p < 0.001). Surgeons' evaluations of the ChatGPT‐generated reports indicated favorable responses across the eight‐item criteria. Surgeons strongly agreed with the generated reports' structure (71.4%), readability (80.0%), accuracy of pathology results (78.9%), and disease extent explanation (53.7%). Neutral to positive responses were observed for surgical margin explanation and Gleason grade interpretation. A strong agreement existed for the ChatGPT‐generated reports' potential to improve patient understanding (63.4%) and surgeons' willingness to use them in their practice (87.4%).
Conclusions: Our results suggest that ChatGPT‐generated reports may enhance patient comprehension and have the potential to be utilized in clinical settings. There is strong willingness among surgeons to use these reports in their practice.
Funding: No funding,
Long Term Management of Biochemical Recurrence Following Radical Prostatectomy: Avoiding Aggressive Treatment Using PSA Doubling Time Kinetics.
Thomas Ahlering1, Joshua Tran1, Nick Hassas1, Rafael Gevorkyan1, Erica Huang2, Catherine Fung1
1University Of California, Irvine, 2University of Massachusetts Medical School
Presented By: Thomas Ahlering, MD
Introduction: Prostate cancer (PC) biochemical recurrence (BCR) is best described as being in slow motion as most men will die with PC rather than of PC. Most BCRs don't result in PC mortality suggesting an opportunity for observation and either obviating or delaying radiation and/or androgen deprivation (RT/ADT) intervention.In 2022 we published that 1/3 of men with BCRs are either benign (non PC‐mortal) or have minimal PC mortality potential. We showed that ADT/RT initiation was best based on PSA doubling time (DT) kinetics over surgical pathology. In the present study we look at men who did not undergo castrating ADT/RT with 9‐21 year progression outcomes.
Methods: 287/1400 (20.5%) men undergoing RARP between 2002‐2014 had BCR. Men with early rapid progression underwent ADT/RT and are not included (n = 182). PSA observation began 8 weeks post‐op. PSA levels were entered into a spreadsheet that calculated DT and DT patterns. Men with non‐detectable PSAs or slowly rising PSAs were managed expectantly (AO, n = 105).
Results: Figure 1 presents the overall outcomes since surgery (avg ‐ 14.6 yrs). Of the 105 AO, 86 (82%) were “success” (avg. 11.1 yrs no ADT/RT). AO success had 61 men with increasing DTs (70.9% avg 10.8 yrs) managed without ADT/RT (Fig 2). AO decreasing (n = 25, 29.1%) typically had prolonged periods of DTs slowly decreasing (Fig 3). 18 (17.1%) died of other causes (avg 9.3 yrs). Of the 105 AO, 19 experienced failure (avg. 8.24 yrs ADT/RT 18%) and to date just 1 death of which was due to PC.
Conclusions: In men 9‐21 years post‐RP, 36.6% of men with BCR were managed with AO in order to avoid ADT/RT. To date we have been able to avoid ADT/RT in 86 of 287 BCRs (30%). Also, 86 of 105 (82%) have safely avoided ADT/RT and just 1 of 105 AO candidates (0.9%) died of PC. DT pattern has been key.
Funding: None
Comparison of da Vinci Single Port & da Vinci Transperitoneal Multiport Cases in a Tertiary Care Center: Intraoperative Quality & Patient Safety Standards Should Be Established & Mandated
Tonya S. King4, Genesis G. Dolgetta1, Robert I. Carey2, Christopher W. Guske2, Benjamin J. Behers3, Maximilian S. Carey2, Karim Ghazli2
1Sarasota Memorial Health Care Research Institute, 2Sarasota Memorial Health Care System, 3Florida State University College of Medicine, 4Sarasota Memorial Health Care System Research Institute
Presented By: Tonya S. King, PhD
Introduction: Although da Vinci single port prostatectomy (SPP) has been reported to have equivalent outcomes to da Vinci Xi transperitoneal prostatectomy (XiTPP) in selected institutions with expert surgeons who are performing both procedures, less is known about how well SPP compares to XiTPP when implemented into a hospital system with surgeons of varying degrees of training, expertise, and experience.
Methods: Data was collected from an IRB‐approved prospectively maintained database of robotic prostatectomy (RALRP) in a tertiary care hospital.From December 15, 2022, to June 1, 2023, 148 consecutive patients underwent XiTPP with fellowship‐trained surgeons, each with more than 15 years of experience with XiTPP.In the same time period, 22 patients underwent SPP with a different surgeon.Operative and peri‐operative data were collected and analyzed with SAS statistical software.
Results: Median age was 70 for SPP and 72 for XiTPP.Median surgery time was 242.5 min (167‐655 min to max) for SPP and 105 min (61–169 min to max) for XiTPP, p < 0.001.SPP patients were more likely to have a positive margin > 3mm than XiTPP (38.1% vs. 8.5%, respectively, p = 0.001). Transfusion rate was 2/21 (9.5%) for SPP and 1/148 (0.68%) for XiTPP, p = 0.044.Risk of having a hospital length of stay of more than two nights was 16.7% for SPP and 0% for XiTPP, p = 0.001.Median estimated blood loss was 300 cc (50‐1700 cc) for SPP and < 50 cc for XiTPP, p < 0.001.The median prostate weight was larger for XiTPP (52 g) than SPP (45.5 g), although not statistically significant, p = 0.06, and there was a higher percentage of EPE and SVI in the XiTPP patients, although not statistically significant.There was no significant difference in preoperative hemoglobin or Gleason Grade Group, but XiTPP patients were higher stage (T2 58% and > T3 42%) than SPP (T2 73% and > T3 0%), p < 0.001.The presence of a surgical margin greater than 3 mm is significantly higher for SPP (38.1%) than XiTPP (8.5%).
Conclusions: This study reveals a marked statistically significant difference between operative quality and outcomes for patients undergoing XiTPP vs SPP at a large county hospital.XiTPP patients fare better than SPP patients in all intra and perioperative parameters.Although SPP patients were lower stage than TPP patients, SPP patients were 10.7 x more likely to have a positive margin > 3 mm (95% CI 2.5‐45.2), with adjustment for stage; 13.5 x more likely to have a transfusion (95% CI 1.3‐142.3), 131% longer median time under general anesthesia, 500% larger median blood loss, and more likely to have a prolonged hospital stay.When such discrepancies are apparent between SPP and XiTPP, hospitals should establish and enforce standards for the protection of patient safety and oncologic outcomes.
Funding: None.
Improved Therapy of Vesicourethral Anastomosis Stricture After Radical Prostatectomy through Monopolar Stricture Opening and Fully Covered Stent Insertion
1Kocaeli University Hospital ‐ Department of Urology, 2Medical University Charite ‐ Berlin ‐ Department of Urology
Presented By: Joerg Neymeyer, Dr.
Introduction: The development of a stricture of the vesicourethral anastomosis is a serious complication after radical prostatectomy. Strictures occur in 5‐8% of patients after radical prostatectomy. Classic anastomosis resection alone carries the risk of recurrent stenosis. Improved modified high‐precision stricture opening and subsequent continence‐preserving stent placement should reduce restenosis rates and minimise damage to the sphincter.
Methods: From 01/2018 till 01/2023 36 patients with vesicourethral anastomosis stricture who underwent a radical prostatectomy (DaVinci RPX n = 14, Laparoscopic RPX n = 4, retropubic RPX n = 18) were treated with modified high‐precision stricture opening carfully without damaging the sphincter muscle by using a monopolar hook or wire electrode. For subsequent healing and to reduce re‐stenosis to provides wide lumen opening, a continence‐preserving stent placement (RPS stent 3cm or 4cm) was inserted. We looked at the incidence of anastomotic re‐strictures. The diagnostic workup is similar to the procedure for typically vesicourethral anastomosis stricture. In addition to clinical examination, questionaire, urethrocystoscopy, uroflowmetry, perineal‐ and transrectal ultrasound, a cystourethrogram or, if necessary, a micturating cystourethrogram can be performed.
Results: Patient age (54‐81, mean age = 72.3). Based on prospective X‐ray studies, we were able to show that the site of stricture is located below the bladder neck musculature in most cases well above the distal urethral sphincter and pelvic floor. Stent length of stay (28‐314 days, mean length of stay = 131.8d around 4 months). No continence problems were encountered in a follow‐up of 12‐72 months determined by a questionnaire and clinical examination. An anastomotic re‐stricture was found in 7 cases requiring the same endoscopic treatment again.
Conclusions: Endourological procedure by using monopolar stricture opening and healing stent insertion are a good treatment option. The protective large‐lumen sealing polymer coating of the stent minimised restenosis by improving tissue healing.
Funding: none
Prostate Specific Antigen Response to Neoadjuvant Lutetium‐177‐PSMA Treatment in High‐ Risk Localized Prostate Cancer Patients
Michael Frumer1, Daniel Kedar1, Jack Baniel1, David Groshar1, Hanna Bernstine1, Maxim Yakimov1, Eli Rosenbaum1, Shay Golan1
1Rabin Medical Center
Presented By: Michael Frumer, MD
Introduction: Recently, the added‐value of Lutetium‐177‐PSMA (LuPSMA) was demonstrated in metastatic castration‐resistant prostate cancer patients. A decrease in PSA was observed among 70% of the patients who were treated with LuPSMA in addition to standard hormonal treatment. However, the dynamics of prostate specific antigen (PSA) in response to LuPSMA‐only treatment in localized high risk prostate cancer (HRPCa) has not been described in the literature.
Methods: We analyzed data from a phase I neoadjuvant LuPSMA trial of HRPCa patients who underwent radical prostatectomy (RP). Each patient received 2 or 3 LuPSMA, two weeks apart at a dose of 7.4 Gbq per treatment until one month before RP. Serum PSA level was measured before and after each LuPSMA dose. We described PSA response to treatment and compared the clinical and histological characteristics between patients with > or < 50% decrease in PSA.
Results: 14 patients with a median baseline PSA value of 11.8 ng/dL (IQR 9, 17) were included, of which 6 patients were treated with two doses of lutetium and 8 patients with three doses.A decrease in PSA of at least 0.3 ng/dl was observed in 57% of patients after the first lutetium dose and in 93% of patients after the second lutetium. The median percentage of change after the second dose was ‐17% (IQR ‐9, ‐50). After the third dose, 100% of patients showed a decrease in PSA and the median percentage of change was ‐34% (IQR ‐11, ‐60).PSA decreased in > 50% and < 50% in 4 (30%) and 10 (30%) patients, respectively. There were no differences in the baseline median PSA between these subgroups (9.5 and 12.7 ng/dL, respectively (p > 0.05)).At final surgical histology down‐grading was observed in 3 of 4 patients with > 50% PSA decrease and in none of the patients with < 50% decrease (P = 0.02). No differences were found between the subgroups in terms of demographic characteristics, clinical staging or the biochemical response after surgery.
Conclusions: This study shows that neadjuvant LuPSMA in localized HRPCa is associated with a dose‐ dependent decrease in PSA that can reach 34% after 3 LuPSMA doses. Although a decrease of > 50% in PSA predicted down‐grading on RP final histology, the long term implications are not clear.
Funding: Dr. Adolph and Klara Brettler Endowment Fund in Urology, Sackler Faculty of Medicine, and Tel Aviv University.
Early Oncological Outcomes of Neoadjuvant 177‐Lu‐PSMA‐I&T Radionuclide Treatment Before Radical Prostatectomy
Michael Frumer1, Daniel Kedar1, Jack Baniel1, David Groshar1, Hanna Bernstine1, Maxim Yakimov1, Eli Rosenbaum1, Shay Golan1
1Rabin Medical Center
Presented By: Michael Frumer, MD
Introduction: Neoadjuvant lutetium‐177‐prostate‐specific membrane antigen (LuPSMA) therapy before definitive local therapy may improve oncological outcomes by targeting the primary tumor and micro‐ metastatic disease. The safety of LuPSMA has already been reported. This study aims to describe early oncological outcomes of LuPSMA in patients with High‐risk prostate cancer (HRPCa).
Methods: Patients with HRPCa and increased uptake on PSMA‐PET/CT were enrolled in an open‐label, single‐arm clinical trial. Two or three LuPSMA doses (7.4 GBq) were given at two‐week intervals. Robotic‐ assisted laparoscopic radical prostatectomy (RALP) with lymph node dissection was done 4 weeks after the last LuPSMA dose. The oncological outcomes including histological findings, biochemical response, biochemical recurrence free survival and overall survival, were descriptively analyzed.
Results: Thirteen patients were treated with LuPSMA followed by RALP (median age, 67). Final whole‐ mount pathology showed significant (≥3 mm) positive margins in 4 patients (30%) and downgrading to ISUP 3 in 3 patients (23%). At 5 weeks after surgery, 12 patients (92%) had undetectable PSA (< 0.1 ng/ml).During median follow‐up of 26.3 months (IQR 21‐33), 6 patients (46%) experienced biochemical recurrence and were referred to early salvage radiation and androgen deprivation Therapy. Median time from surgery to biochemical recurrence was 14 months (IQR 11‐17). On follow‐up PSMA‐PET/CT, among those 6 patients, 2 had positive lymph nodes and 1 had positive lymph nodes and abnormal uptake in femur bone. Regarding functional outcomes, 12 patients (92%) required one or less pad/day.
Conclusions: In this first report of early oncological after neoadjuvant LuPSMA in HRPCa patients, about half experienced biochemical recurrence and required salvage therapy. Additional follow up is required to assess long term outcomes.
Funding: Dr. Adolph and Klara Brettler Endowment Fund in Urology, Sackler Faculty of Medicine, and Tel Aviv University.
Factors Associated with Surgical Complications in Robotic‐Assisted Laparoscopic Prostatectomy: Insights from Contemporary NSQIP Data
Alexander Homer1, Borivoj Golijanin1, Phillip Schmitt1, Vikas Bhatt1, Elias S. Hyams1, Gyan Pareek2
1The Minimally Invasive Urology Institute, The Miriam Hospital, Urology Division, Warren Alpert Medical School of Brown University, Providence, RI, USA, 2Brown Medical School
Presented By: Alexander Homer, AB
Introduction: Robotic‐assisted laparoscopic prostatectomy (RALP) is the surgical standard of care for localized clinically significant prostate cancer (PCa). The National Surgical Quality Improvement Program (NSQIP) initiated collection of RALP‐specific data in 2019. Though RALP boasts a generally low rate of complications, continued assessment of morbidity is necessary for ongoing quality assurance (QA), particularly given a growing trend towards same‐day discharge.
Methods: NSQIP was queried for patients with PCa undergoing RALP from 2019‐21. Multivariate logistic regression was used to explore the association of risk factors and postoperative complications. Risk factors included ASA class, age, operative time, BMI, and from the extended dataset, PLND, number of nodes evaluated, perioperative antibiotic use (PAU), postoperative VTE prophylaxis use, history of prior pelvic surgery (pPS), and history of prior radiotherapy (pRT). Outcomes included infection, pulmonary embolism (PE), deep venous thrombosis (DVT), acute renal failure, pneumonia, or any surgical complication.
Results: Among 11,811 patients undergoing RALP, 3.0% (354/11,811) of patients experienced complications. Of the complications, 60% were infections, 20% PEs, 16.7% DVT, 3.3% acute renal failure, and 10% pneumonia. Factors associated with increased risk of complications were older age, higher BMI, longer operative time, absence of PAU, and pRT. Infection risk was higher among patients with a history of pRT, longer operative time, and higher BMI. PAU only decreased the occurrence of organ space infections. The absence of PAU and higher BMI were associated with a higher risk of PE. Older age was a significant risk factor for DVT. Acute renal failure was more likely in patients with a history of pRT. The absence of PAU was linked to a higher risk of pneumonia.
Conclusions: In recent NSQIP data, RALP has low complication rates, but operative time, BMI, age, pRT, and absence of PAU are associated with postoperative complications. Accounting for these risk factors and possible future development of predictive tools are important to reduce morbidity and re‐presentation in the age of same‐day discharge.
Funding: None
Modified Apical Dissection Improves Early Continence in Robot‐Assisted Laparoscopic Radical Prostatectomy: Comparative Study Between Modified Apical Dissection and Anterior Suspension Stitch
Sung Goo Yoon1, Seok Ho Kang1, Sung Gu Kang1, Hwang Jae Young1, Seong Woo Yun1, Tae Young Park1, Chang Wan Hyun1, Tae Il Noh1
1Department of Urology, Korea University College of Medicine, Seoul, Korea
Presented By: Sung Goo Yoon, MD
Introduction: Recently, the modified apical dissection (MAD) technique in robot‐assisted laparoscopic radical prostatectomy (RARP) has shown excellent functional outcomes but has never been rigorously validated at various institutions. This study aimed to evaluate the effect of MAD on early continence and potency compared with the anterior suspension stitch (SS) technique.
Methods: A total of 100 patients who underwent RARP with SS and 100 who underwent RARP with MAD by a single surgeon were propensity score matched and retrospectively compared for continence and potency recovery at 1 week and 1, 3, 6, 9, and 12 months.
Results: Continence was reached in 20.6%, 33.3%, 67.2%, 74.1%, 81.1%, and 83.0% of patients in the SS group, compared with 49.2%, 73.3%, 86.8%, 96.6%, 100.0%, and 100.0% in the MAD group at postoperative 1 week and 1, 3, 6, 9, and 12 months, respectively. In the SS group, potency rates were 0.0%, 20.0%, 50.0%, 66.7%, 75.0%, and 83.3%; in the MAD group, the rates were 50.0%, 90.0%, 88.9%, 100.0%, 100.0%, and 100.0%. Recovery of continence was higher in the MAD group within the first 6 months (p = 0.005, < 0.010, 0.041, 0.016 at 1 week, 1, 3, and 6 months). There were no significant differences in potency recovery rates between the two groups (all p ≥ 0.05).
Conclusions: The MAD technique results in earlier recovery of continence compared with the SS technique.
Funding: This research was supported by the Korea University College of Medicine.
Early Postoperative Functional Outcomes Following Hood Technique Compared to Standard Nerve Sparing Approach
Narmina Khanmammadova1, Narmina Khanmammadova1, Mohammed Shahait2, Tuan Thanh Nguyen3, Rafael Gevorkyan1, Jacob Basilius1, Ruth Hwang1, Catherine Fung1, Caroline Nguyen1, Sohrab Naushad Ali1, David I Lee1
1University of California, Irvine, Department of Urology, 2Clemenceau Medical Center, Department of Surgery, 3University of Medicine and Pharmacy at Ho Chi Minh City
Presented By: Narmina Khanmammadova, MD
Introduction: Several modifications of the surgical technique applied during robot‐assisted radical prostatectomy (RARP) were proposed to hasten and improve urine continence recovery rate. Recently, the hood technique was introduced which aims to preserve periurethral anatomical structures in Space of Retzius including endopelvic fascia, puboprostatic ligaments, anterior vessels, detrusor apron and some detrusor muscle.In this study, we sought to compare early functional outcomes of the hood technique and standard nerve sparing (NS) technique applied during RARP.
Methods: Our prospectively maintained RARP database was quired between January 2019 & February 2023 and identified 127 consecutive patients who underwent RARP with the hood technique and 130 consecutive patients with the standard technique. The decision to proceed with the hood technique was based on the surgeon's preference.Patient characteristics and functional outcomes at 3 months were compared between the two groups. Early continence was defined as using a 0‐1 safety pad. The percentage of erection fullness is the patient‐reported ability to have a full and hard erection.
Results: There were no differences in the preoperative patient and tumor characteristics between the two groups. (Table 1) Estimated blood loss and operation time was lower in a group undergoing RARP with hood technique compared to the group following standard technique (50 (50 – 100) vs. 75 (50 – 100), p = < 0.001; 140.7 ± 25.4 vs. 148.8 ± 28.9, p = 0.018). Patients undergoing RARP with hood technique had higher early continence rates and SHIM scores at 3 months compared to patients underwent standard technique (78.1% vs. 66.1%, p = 0.041; 10 (3.25 – 20) vs. 5 (3 – 15.5), p = 0.004, respectively). No perioperative complications, blood transfusion, or conversion to open surgery were reported in both groups. Positive surgical margin rates were comparable in both groups (p = 0.374).
Conclusions: This is the first prospective study to compare the early functional and oncologic outcomes of the hood technique for RARP to standard NS surgical technique. The hood technique improved the early continence rate without compromising perioperative or early oncological outcomes.
Funding: No funding.
Assessing the Feasibility of the Hood Technique for Robot‐Assisted Radical Prostatectomy in Patients with Large Prostates
Narmina Khanmammadova1, Narmina Khanmammadova1, Mohammed Shahait2, Tuan Thanh Nguyen3, Jacob Basilius1, Sohrab Naushad Ali1, Catherine Fung1, Caroline Nguyen1, David I. Lee1
1University of California, Irvine, Department of Urology, 2Clemenceau Medical Center, Department of Surgery, 3University of Medicine and Pharmacy at Ho Chi Minh City
Presented By: Narmina Khanmammadova, MD
Introduction: Hood technique was developed to improve postoperative functional outcomes following the robot‐assisted radical prostatectomy (RARP). The main goal is to preserve periurethral structures that are essential for urinary continence: endopelvic fascia, puboprostatic ligaments, detrusor apron, some detrusor muscle, and anterior vessels. However, the working space for large prostates might be limited. Here, we evaluate whether the hood technique is feasible for large prostates (> 80 mL).
Methods: Between March 2022 and March 2023, 121 patients underwent RARP with the hood technique. Twenty patients had prostate > 80 mL & 101 patients had prostate size <80 mL. Preoperative and perioperative as well as postoperative characteristics were compared between the two groups.Urinary continence was defined as using no pads or 1 security pad. The ability to have a firm erection enough for penetration was described as the percentage fullness of erection reported by patients.
Results: Patients with prostate size > 80 g had significantly higher mean BMI (29.71 ± 5.68, p = 0.018), higher Gleason scores on biopsy (p = 0.004), and higher preoperative median AUA Symptom Scores (AUASS, 17 (8.5 ‐ 22.5), p = 0.020). There were no differences between the two groups in terms of estimated blood loss, overall operation time, console time, and dissection time. There was no need for early control of DVC or to convert to the conventional approach. Postoperative length of hospital stay, length of catheterization, readmission rates in 30 and 90 days, Gleason Score on surgical pathology, surgical margins, pathologic grades, postoperative complications, and PSA levels at 3 months were comparable between the two groups. No difference was observed in postoperative functional outcomes at 3 months including AUASS, continence rates, SHIM scores as well as percentage fullness of erection. Same‐day discharge rates were comparable in both groups with prostate size > 80 g and < 80 g. (85%, 91.2%, p = 0.396, respectively).
Conclusions: Hood technique is feasible and safe in patients with large prostate volumes, without compromising early oncological outcomes and intermediate postoperative functional outcomes.
Funding: No funding.
Feasibility of Hood Technique with Large Prostates Compared to Standard Nerve Sparing Technique
Narmina Khanmammadova1, Narmina Khanmammadova1, Mohammed Shahait2, Tuan Thanh Nguyen3, Jacob Basilius1, Catherine Fung1, Caroline Nguyen1, Sohrab Naushad Ali1, David I Lee1
1University of California, Irvine, Department of Urology, 2Clemenceau Medical Center, Department of Surgery, 3University of Medicine and Pharmacy at Ho Chi Minh City
Presented By: Narmina Khanmammadova, MD
Introduction: Hood technique was developed recently for robot‐assisted radical prostatectomy (RARP) to enhance postoperative functional outcomes. The main scope of this technique is to preserve periurethral anatomical structures including anterior vessels, puboprostatic ligament complex, endopelvic fascia, detrusor apron, some detrusor muscle and arcus tendineus.We sought to compare perioperative and early postoperative outcomes of hood technique to standard nerve sparing (NS) technique in patients with prostate size > 80g to demonstrate the feasibility of the hood technique with large prostates.
Methods: Data from 45 patients who underwent RARP either with standard NS (n = 20) or hood technique (n = 25) between January 2019 and March 2022 were collected prospectively in IRB approved database.Continence was defined as using no or 1 security pad. The percentage fullness of erection reported by patients was recorded to evaluate the erectile function.
Results: Basic patient demographics and preoperative characteristics including the prostate size were comparable in between two groups. No differences were observed regarding the mean operative time, console time and dissection time. The median estimated blood loss was significantly lower in a cohort who underwent RARP with hood technique (100 (75 – 150), p = 0.047). Patients who had RARP with hood technique had better early urinary continence at 3 months as 64.2% of patients reported to be continent (p = 0.039). There was an upward trend in group with hood technique compared to the standard NS in terms of percentage fullness of erection and SHIM scores at 3 months (80 (35 – 80) % vs. 15 (10 – 20) %, p = 0.432, and 8 (1 – 15) vs. 16 (3.5 ‐ 24.5), p = 0.259, respectively). There were no differences in length of hospital stay and catheterization as well as surgical margins, postoperative complications and readmission rates.
Conclusions: This is the first study evaluating the applicability of the hood technique during RARP in patients with prostate size > 80g. Our results demonstrate that it is safe and feasible for large prostates with promising postoperative functional outcomes without compromising early oncological outcomes.
Funding: No funding.
WITHDRAWN
.
Prospective Randomized Evaluation of Organ Retrieval Site for Hernia Development Following Robot Assisted Laparoscopic Radical Prostatectomy
Tunkut Doganca3, Omer Burak Argun1, Mustafa Bilal Tuna2, Ilter Tufek1, Can Obek1, Ali Riza Kural1
1Acibadem University, School of Medicine, Urology, 2Acibadem Maslak Hospital, 3Acibadem Taksim Hospital, Urology
Presented By: Tunkut Doganca, MD
Introduction: Minimally invasive techniques are gradually being used for surgical treatment of prostate cancer. However, the incisional hernia development after these techniques are yet to be evaluated. In this study, we compared 3 different organ retrieval site for the risk of incisional hernia development following robot assisted laparoscopic radical prostatectomy.
Methods: Between January 2020and May 2021, 149 patients were enrolled for the study. In the first,second and third group, organs were retrieved through supraumbilical, right abdominal (through the assistant port) and Pfannenstiel incisions respectively. Patients were grouped according to the penultimate number of the social security numbers. In the postoperative period, the area where the organ was removed was evaluated by ultrasonography. Valsalva maneuver was applied during the ultrasonographic examination.
Results: We observed hernia in 20 patients. The frequency of hernia development for operations with different incision locations are as follows: Supraumbilical 9/49, Assistant port 10/49, Pfannenstiel: 1/51
Conclusions: Hernia development is significantly associated with incision location, we see that it is lower for pfannenstiel incision compared to supraumbilical and assistant port incision. We did not observe any other factor associated with hernia development.
Funding: None
MODERATED POSTER SESSION 2: STONES - MEDICAL MANAGEMENT 1
The Effect of Tamsulosin in Ureteroscopic Surgery in Dilation of Ureter and Improvement of Stent‐Related Symptom: A Randomized, Double‐Blind, Placebo‐Controlled Trial
1Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea, 2Urology Institute, Ewha Womans University Mokdong Hospital, Seoul, Republic of Korea, 3Department of Urology, Gangneung Asan Medical Center, University of Ulsan College of Medicine, Gangneung, Republic of Korea
Presented By: Kyeng Hyun Nam, MD
Introduction: The aim of this study was to investigate the effect of taking tamsulosin prior to surgery on the successful insertion of a 14 French (F) ureteral access sheath (UAS) during the procedure, as well as the impact of pre‐ and post‐operative tamsulosin use on symptoms related to the ureteral stent.
Methods: This was a randomized, single‐center, double‐blind, placebo‐controlled trial with a total of 200 patients underwent retrograde intrarenal surgery. Patients received either tamsulosin (0.4 mg) or placebo from 1 week before the surgery until the day when ureteral stent was removed. The patients were randomly assigned to one of four groups: Group 1 (G1) received tamsulosin throughout the entire study period; group 2 (G2) received tamsulosin before surgery and placebo after surgery; group 3 (G3) received placebo before surgery and tamsulosin after surgery; and group 4 (G4) took placebo before and after surgery. The ureteral stent symptom questionnaire (USSQ) was completed between postoperative day 7 and 14.
Results: In total, 160 patients were included in the analysis (G1: 40, G2: 43, G3: 36, G4: 41). Mean age was 55.0 ± 11.0 years, and 48 were female (30.0%). In the group receiving pre‐tamsulosin (G1+G2), the success rate of 14F UAS deployment was significantly higher compared to the pre‐placebo (G3+G4) group (88.0 vs. 75.3%, p = 0.038). Regarding the USSQ, no significant intergroup differences were found between four subgroups in domains of urinary (p = 0.110), pain (p = 0.185), sexual matters (p = 0.523), and additional problems (p = 0.511). The analysis of variance for the general health (p = 0.047) and work (p = 0.035) were statistically significant results, however, post‐hoc analysis did not reveal statistical significance.
Conclusions: Our results revealed that preoperative administration of tamsulosin improved the success of larger sized UAS, while pre‐ and postoperative tamsulosin use did not significantly alleviate symptoms related to ureteral stent.
Funding: none.
Design and Application of ROS Scavenging Alloy Metal Nanoparticles for the Kidney Stone Disease Prevention and Treatment
Yushi He1, Zhaofa Yin1, Shijian Feng1, Xi Jin1, Hong Li1, Kunjie Wang1
1Department of Urology, Institute of Urology (Laboratory of Reconstructive Urology), West China Hospital, Sichuan University, Chengdu, Sichuan, P.R. China.
Presented By: Yushi He, MD
Introduction: Kidney stone disease, also named as nephrolithiasis, is one of the most common disease in Urology. In China, the incidence was reported to be 5.1%, which is highest incidence in Asia. But even clinical guideline and technique have been mature and the stone flow rate is satisfying, the recurrence rate is still high and increasing. So, to design a special agent to prevent stone formation or recurrence may be a possible way.
Methods: We used 100 CaOx DMEM to make cell model and glyoxylate to acquire the mouse kidney stone model by intraperitoneal injection. Four groups (Group 1: no nanoparticles or glyoxylate; Group 2: only nanoparticles; Group 3: only glyoxylate; Group 4: nanoparticles+glyoxylate) were set and we detected cell death, ROS generation, osteogenesis, inflammation and immune response through flow cytometry, immunofluorescence, WB, PCR, histologic section and etc.
Results: Significant decrease was found in crystal formation and kidney injury after nanoparticle treatment according to mouse kidney section. And the nanoparticle alone didn't lead to damage to the main organs. Flow cytometry and immunofluorescence indicate that nanoparticles significantly decrease ROS concentration, cell death, inflammation and immune response and increase SOD activity, cell viability compared with the kidney‐stone‐modelling group (p < 0.05). WB and PCR found decrease in cell death (BAX, NGAL, HMGB1; p < 0.05), inflammation (IL‐1β, IL‐6, TNF‐α; p < 0.05) and osteogenesis (BMP2, BMP4, SMAD4, RUNX2, OPN, fetuin‐A; p < 0.05) after nanoparticles treatment. The inflammation inhibitive factor was found increase after kidney stone modelling, meaning the negative feedback exists and it can be inhibited by nanoparticles.
Conclusions: ROS can contribute to the stone formation by increasing renal epithelial apoptosis, damage, and ectopic osteogenesis, while the nanoparticles treatment can inhibit these pathways and decrease stone formation in mouse models.
Funding: Sichuan University West China Hospital Excellent Development 1 · 3 · 5 Project (ZYGD18011）
Use of Sodium‐Glucose Cotransporter 2 (SGLT2) Inhibitors in Stone‐Naïve Diabetics is Associated with a Decreased Risk of Urolithiasis Compared to Other Antihyperglycemics
Ridwan Alam2, Jared Winoker1, Brian Matlaga2, Naren Nimmagadda2
1Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 2Johns Hopkins University School of Medicine
Presented By: Ridwan Alam, MD, MPH
Introduction: Secondary analysis of pooled randomized controlled trials suggests that empagliflozin, a sodium‐glucose cotransporter 2 inhibitor (SGLT2i), may reduce the risk of urolithiasis in diabetics by 38% when compared to placebo. We compared the risk of urolithiasis among stone‐naïve diabetic patients prescribed SGLT2i versus other antihyperglycemics using a longitudinal, nationwide database.
Methods: TriNetX is a collaborative research enterprise with real‐time data from over 70 healthcare organizations with more than 100 million patients. We queried the database for stone‐naïve adult patients with type 2 diabetes mellitus between 1/1/2016 and 1/1/2021. Patients receiving SGLT2i therapy were compared against two groups: (1) patients receiving dipeptidyl peptidase 4 (DPP‐4i) or glucagon‐like peptide‐1 receptor agonist (GLP‐1‐RA) and (2) all patients not receiving SGLT2i. Propensity score matching was performed on age, sex, race, hemoglobin A1c, glomerular filtration rate (GFR), and body mass index to control for confounding.TheKaplan‐Meier method was used to estimate freedom from a stone event and the Cox proportional hazards regression was performed to estimate the risk of urolithiasis over time.
Results: SGLT2i was prescribed to 101,485 patients, DPP‐4i or GLP‐1‐RA to 463,233 patients, and any non‐ SGLT2i to 3,924,446 patients. After matching, each group contained 101,484 patients with balance achieved on almost all baseline parameters. GFR was comparable among the groups at roughly 81 mL/min/1.73 m2 (P > 0.10). The 5‐year freedom from stone rate was 95.3%, 93.7%, and 94.6% for the SGLT2i, DPP‐ 4i/GLP‐1‐RA, and non‐SGLT2i groups, respectively (P < 0.001) [Figure]. Compared to the SGLT2i group, patients taking DPP‐4i or GLP‐1‐RA demonstrated a 35% increased risk of urolithiasis (HR 1.346, 95% CI 1.276‐1.420,P < 0.001), and those taking any non‐SGLT2i demonstrated an 18% increased risk (HR 1.176, 95% CI 1.112‐1.244,P < 0.001).
Conclusions: Compared to other antihyperglycemics, SGLT2i is associated with the lowest risk of urolithiasis among diabetic patients without a prior history of stones.
Funding: None.
Workload Burden and Nephrolithiasis: The Occupational Impact on Stone Disease.
Michael Pasherstnik1, David Dothan1, Dolev Peretz1, Boris Chertin1, Ilan Kafka1
1Shaare Zedek Medical Center
Presented By: Michael Pasherstnik, MD
Introduction: Urolithiasis is a common condition and its worldwide prevalence has been rising over the past few decades. It has been shown to have a complex etiology influenced by genetic, metabolic, environmental, and lifestyle factors including occupation. The effect of occupational risk on urolithiasis has not been thoroughly studied but has been linked to both sedentary and labor‐intense occupations. The present study aims to establish a correlation between stone composition and occupational workload.
Methods: Data from patients who underwent an endourological procedure for stone disease at our department, where stone analysis was available, were collected retrospectively from 2018‐2020. Patients < 18 of age were excluded from the analysis.Stones were classified as calcium oxalate monohydrate (COM), dihydrate (COD), carbapatite stones (CAP), and uric acid (UA). Stones containing any struvite, brushite, cystine, calcite, or xanthine, were classified as “other”.Patient's occupation was stratified into strength levels (Sedentary, Light, Medium, Heavy, and Very Heavy) according to the amount of force or physical effort.
Results: 628 patients were included, 454(72.3%) male and 174(27.7%) female, with a mean age 51.4 ± 15.1. Occupational workload: Sedentary 291(46.33%), light 239(38.05%), medium 62(9.87%), and heavy 36(5.73%). We found no statistically significant association between occupational workload and specific stone composition, P = 0.57, although an inverse correlation was found between occupational workload and stone formation, R squared 0.9, P = 0.04. This association is most prominent in COM, R squared 0.92, P = 0.04.
Conclusions: In the populationstudied, we did not identify a connection between occupational workload and stone composition. An inverse relationship was identified between occupational workload and stone formation in patients requiring stone lithotripsy, which may imply that more active, non‐sedentary patients may have a lower chance of requiring surgery for stone disease and may have higher rates of spontaneous stone passage; however, further research is required to confirm these findings.
Funding: none
Do Clinical and Radiological Prostate Characteristics Predict Distal Ureteral Stone Passage?
Dor Rubinshtein3, Efrat Yashno1, Brian Berkowitz2, Ishai Dror2, Roy Croock3, Dan Leibovici3, Yaniv Shilo3
1Kaplan medical center, 2Weizmann Institute of Science, 3Urology department, Kaplan medical center
Presented By: Shir Tiger
Introduction: Early identification of patients with distal ureteral stones that are less likely to pass spontaneously is important to avoid complications. In this study, we aimed to clarify whether an enlarged prostate and, in particular, an enlarged median lobe, can be a risk factor for spontaneous stone expulsion due to anatomical changes in the ureterovesical junction.
Methods: A retrospective review was conducted on the medical records and CT imaging of 224 consecutive patients diagnosed with distal ureteral stones. Prostate volume and median lobe size were calculated from CT scans for each patient. Additionally, relevant prostate‐related parameters such as PSA levels, history of prostate surgery, and usage of medication for BPH were collected. A comparative analysis assessed the characteristics of patients who underwent surgical intervention compared to those who received conservative treatment. To further investigate the factors associated with ureteral stone passage, a logistic regression model was performed.
Results: Among the 224 patients included in the study, conservative treatment was administered to 175 patients (78%), while 49 patients (22%) underwent surgical intervention. In the univariate analysis, several parameters emerged as significant predictors for spontaneous passage including prostate volume (P = 0.02), symptoms duration (P = 0.02), stone length and width, stone density, and distance from the stone to the bladder (P < 0.001). Parameters found to be significantly correlated with prostate volume were patient age (R = 0.52; P < 0.001), stone length (R = 0.22; P = 0.001), stone width (R = 0.15; P = 0.02), PSA value (R = 0.46; P = 0.01), median lobe size (R = 0.59; P = 0.004) and presence of urinoma (P = 0.004[ID1]). In a multivariate analysis, no prostate‐related parameters were found to be significant, but stone width (OR 2.13, P < 0.001) and distance from the bladder (OR 1.03, P = 0.009) remained significant.
Conclusions: No correlation was found between prostate volume or the presence of a median lobe and the likelihood of spontaneous passage of a distal ureteral stone. Further studies in elderly populations where an enlarged prostate is more common may be more suitable to clarify whether prostate size affects stone passage.
Funding: none
What is the Compliance Rate with Metabolic Evaluation in Surgically Treated Nephrolithiasis Patients?
Sagi A. Shpitzer1, Hadar Tamir1, Yaron Ehrlich1, Abd E. Darawsha1, David Lifshitz1
1Rabin Medical Center
Presented By: Sagi A. Shpitzer, MD
Introduction: Metabolic evaluation (ME) in renal stone disease helps to identify underlying metabolic abnormalities and guide personalized treatment. However, only a relatively low proportion (around 10‐20%) of patients with kidney stones undergo a ME despite its importance. Surgically treated stone patients may be more inclined to undergo ME. We studied the compliance rate and the findings of ME in a large cohort of surgically treated stone patients.
Methods: All surgically removed stones in the largest HMO in Israel are analyzed since 2013 in one centralized laboratory using Fourier‐transform infrared spectroscopy (FTIR). Utilizing the stone analysis cohort we queried a centralized data base assessing the rate of urine collection for calcium, uric acid, citrate, oxalate and sodium as well as relevant demographic data. A complete urine collection was defined as results available for ≥4 urine collection results.
Results: 11,979 patients with stone composition analysis were identified. 7,067 patients (59%) had at least one urine collection result available during the study period and 4,668 patients (39%) had a complete urine collection. Demographic factors increasing the likelihood of completing a urine collection included female gender, age group 60‐69 years, Jewish ethnicity and a high socioeconomic level. Cystine and calcium phosphate stone formers had the highest rate of any urine collection completion (78% and 72%, respectively). Of patients with a complete urine collection 63% had at least one metabolic abnormality, with hypercalciuria and hypocitraturia being the most frequent (24% each).
Conclusions: Surgically treated stone patients are more likely to complete a ME, yet the majority (61%) do not have a complete workup suggesting further patient education is required.
Funding: None
Exploring Risk Factors for Nephrolithiasis: A Complementary Analysis of Umbrella Review and Mendelian Randomization Study
Introduction: Nephrolithiasis is prevalent and burdensome worldwide, but its risk factors remain unconsolidated. We aim to map risk factors of nephrolithiasis from observational studies with the validation of causation by two‐sample Mendelian randomization (MR).
Methods: We conducted an umbrella review of meta‐analyses of observational studies investigating the association of potential risk factors and nephrolithiasis to assess the strength and validity of the association between risk factor candidates and nephrolithiasis and performed the causal relationship through two‐sample MR. We obtained the genome‐wide association studies summary data of the risk factor candidates identified in the umbrella review from the UK Biobank (6,536 cases and 388,508 controls) and that of nephrolithiasis from FinnGen (4,969 cases and 213,445 controls), respectively.
Results: Our study included 17 meta‐analyses regarding 46 risk factors, 34 of which (73.9%) showed statistically significant association with nephrolithiasis. Among the 46 associations, we found that only nine (19.6%) and seven (15.2%) were supported by high and moderate evidence certainty, respectively. Next, the MR analyses supported that obesity/central obesity and type 2 diabetes (T2D), higher levels of circulating calcium, urinary calcium, circulating vitamin D, and urinary sodium to be causally or suggestively causally associated with a higher risk of nephrolithiasis. Caffeine/coffee/tea and alcohol/beer consumption, and higher urinary magnesium levels were causally or suggestively causally associated with a lower nephrolithiasis risk.
Conclusions: People with obesity and/or type 2 diabetes should note their increasing risk of nephrolithiasis. People should balance the benefits and risk of nephrolithiasis when taking external calcium and/or vitamin D supplementation. Although taking more coffee/tea and alcohol/beer may help prevent nephrolithiasis, people should balance their potential harms on other organs especially for alcohol consumption.
Funding: None
Brushite Stones: A Comparative Study
Muhammad Krenawi1, David Lifshits1, Abed Elhalim Darawsha1, Ron Gilad1, Yaron Erlich1, Michael Frumer1, Saeedian Daniel1
1Hasharon Rabin Medical Center
Presented By: Muhammad Krenawi, MD
Introduction: Brushite stones make up approximately 2‐4% of all renal stones, and patients with brushite stones present specific challenges. In this study, we aimed to compare the clinical, surgical, and metabolic characteristics of brushite patients (BP) who were treated endoscopically to non‐brushite patients (NBP).
Methods: Using a retrospective database of patients who underwent endoscopic stone removal between 2013 and 2020, we identified patients with a brushite stone composition of over 10%. We compared the clinical, surgical, and metabolic characteristics of BP and NBP who underwent endoscopic stone removal.
Results: Forty‐three (1.7%) patients with a mean brushite content of 60% (SD‐24) were compared to 2509 NBP. BP were younger (42.9 vs. 53.1, p < 0.001) and had a similar gender distribution (68% male, 32% female) compared to NBP. The mean surgery time for ureteroscopy and PCNL was higher in BP (66.7 and 135.4 min vs. 49 and 101 min, respectively; p = 0.003). The rate of significant residual stones following PCNL was significantly higher in BP compared to NBP (33.3% and 8.2%, respectively; p = 0.001). BP underwent a mean of 3.75 (range 1‐10) procedures during the study period. BP exhibited distinct metabolic features compared to NBP. The rate of hypercalciuria and hypocitraturia was significantly higher in BP compared to NBP (62.1% vs. 35%, p < 0.001 and 45.5% vs. 29%, p = 0.02, respectively), while the rate of hyperuricosuria was lower (16% vs. 31%, p = 0.04).
Conclusions: The presence of more than 10% brushite in renal stone analysis has a significant clinical impact. BP patients tend to be younger and require frequent interventions, which may result in longer surgery times and higher rates of residual stones.
Funding: Therefore, preventive treatment targeting the typical metabolic findings of hypercalciuria and hypocitraturia is crucial.
Sodium‐Glucose Cotransporter 2 (SGLT2) Inhibitors Are Associated with a Reduced Risk of Future Stone Events in Diabetic Stone Formers
Ridwan Alam2, Jared Winoker1, Naren Nimmagadda2, Brian Matlaga2
1Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 2Johns Hopkins University School of Medicine
Presented By: Ridwan Alam, MD, MPH
Introduction: Sodium‐glucose cotransporter 2 inhibitors (SGLT2i) have emerged as a treatment for diabetes mellitus with additional cardiovascular and renal benefits over other classes of antihyperglycemics.
Promising data suggests that SGLT2i may also reduce the risk of urolithiasis. We compared the risk of urolithiasis among diabetic patients with a history of stones prescribed SGLT2i versus other antihyperglycemics.
Methods: TriNetX is a collaborative research enterprise with real‐time data from over 70 healthcare organizations with more than 100 million patients. We queried the database for adult patients presenting between 1/1/2016 and 1/1/2021 with type 2 diabetes mellitus and a prior history of urolithiasis. Patients receiving SGLT2i therapy were compared against two groups: (1) patients receiving dipeptidyl peptidase 4 (DPP‐4i) or glucagon‐like peptide‐1 receptor agonist (GLP‐1‐RA) and (2) all patients not receiving SGLT2i. Propensity score matching was performed to control for confounding. TheKaplan‐Meier method was used to estimate freedom from a stone event and the Cox proportional hazards regression was performed to estimate the risk of urolithiasis over time.
Results: Among diabetics with a history of stones, SGLT2i was prescribed to 3,302 patients, DPP‐4i or GLP‐ 1‐RA to 17,952 patients, and any non‐SGLT2i to 131,592 patients. After matching, each group contained 3,297 patients and were balanced on all baseline characteristics. At 5 years, the freedom from a stone event was 52.4%, 46.8%, and 49.0% for the SGLT2i, DPP‐4i/GLP‐1‐RA, and non‐SGLT2i groups, respectively (P < 0.001)[Figure]. Compared to the SGLT2i group, the risk of urolithiasis was 21% higher inpatients taking DPP‐4i or GLP‐1‐RA(HR 1.208, 95% CI 1.119‐1.303, P < 0.001) and 17% higher in patients taking any non‐SGLT2i (HR 1.172, 95% CI 1.086‐1.265,P < 0.001).
Conclusions: When managing diabetic patients with a history of stones, the use of SGLT2i presents an attractive option due to the significantly decreased risk of future stone events when compared to other antihyperglycemic medications.
Funding: None.
WITHDRAWN
Short‐Term Outcomes of Observation for Non‐Obstructive Urinary Tract Calculi in Patients with Pain
Ukrit Rompsaithong2, Thomas Chi1, Wilson Sui1, Heiko Yang1, David Bayne1, Justin Ahn1, Marshall Stoller1
1Department of Urology, University of California, San Francisco, San Francisco, California., 2Division of Urology, Department of Surgery, Khon Kaen University, Khon Kaen, Thailand.
Presented By: Ukrit Rompsaithong, MD
Introduction: Management of non‐obstructive urinary tract calculi represents a clinical quandary as both surgical intervention and observation are reasonable options. It is unknown whether observing symptomatic patients leads to poorer outcomes such as more frequent visits to the emergency department or clinic or higher rates of emergent surgery as compared to asymptomatic patients.Our objective is toassessthe short‐ term outcomes of observation for non‐obstructive urinary tract calculiin patients presenting with pain.
Methods: We retrospectively analyzed prospectively collected data from consecutive patients diagnosed with non‐obstructive urinary tract calculi who opted for observation as a management strategy from the Registry for Stones of the Kidney and Ureter (ReSKU) between 2015 and 2022. Patient and stone characteristics were compared between those with and without initial pain. Symptomatic events, surgical events, and emergency department (ED) visits were analyzed over a 6‐month follow‐up period. Mean survival time and event incidence were compared between the two groups using the log‐rank test.
Results: Among 247 patients,166 (67.2%) initially presented with pain. The median stone burden did not differ significantly between the two groups with and without pain at presentation (6 vs 8 mm, p = 0.06). The stone location and laterality were comparable in both groups. During the 6‐month follow‐up, there were no significant differences between the groups in symptomatic events (16.9% vs 14.8%, p = 0.681), surgical events (12.1% vs 8.6%, p = 0.421), or ED visits (5.4% vs 3.7%, p = 0.756) (Figure1). 40% (6/15) of patients in the pain group who experienced surgical events underwent ureteroscopy due to persistent pain. The mean cumulative time until symptomatic events (167.6 vs. 160.1 days, p = 0.622) and surgical events (171.9 vs. 166.8 days, p = 0.414) showed no statistically significant difference between the two groups.
Conclusions: In patients with non‐obstructive urinary tract calculi, short‐term observation of those presenting with pain resulted in comparable outcomes in terms of symptomatic events, surgical events, and ED visits compared to patients without pain. These findings provide valuable information for clinical decision‐making, supporting the consideration of observation as an alternative management strategy for selected patients.
Funding: None
Conservative Management of Patients with Staghorn Stones: A Retrospective, Single‐Center, 15‐Year Experience
Anindyo Chakraborty2, Iman Sadri1, Hend Alshamsi1, Sero Andonian1
1Department of Urology, McGill University, 2Faculty of Medicine and Health Sciences, McGill University
Presented By: Anindyo Chakraborty, BSc
Introduction: Staghorn stones are associated with significant morbidity including worsening renal function, renal scarring, recurrent urinary tract infections (UTI), and sepsis. Thus, surgical intervention and stone clearance is considered standard of care. However, conservative management with watchful waiting and medical therapy has emerged as a viable option in select patients with staghorn stones, particularly those deemed unfit for surgery or at a high risk of complications. The aim of this study is to elucidate the safety and efficacy of conservative non‐operative management of staghorn stones by presenting our single‐center experience spanning 15 years.
Methods: A retrospective chart review of a single surgeon's cohort of staghorn stone patients managed conservatively was executed. Reviewed data include patient's demographic and baseline clinical information, stone characteristics, medical management, and clinical outcomes including renal deterioration, need for dialysis, infectious complications, and disease‐specific mortality.
Results: Twenty‐one patients with unilateral staghorn stones were included in the study, with an average follow up of 8.76 years. Among the 16 (76%) patients on medical therapy, 14 received prophylactic antibiotics, 4 were prescribed allopurinol, 2 were administered thiazide diuretics and 6 patients received alkalization agents. Progressive renal deterioration occurred in 2 (10%) patients, with one (5%) patient requiring eventual dialysis due to medical renal disease. We noted recurrent UTIs among 13 (62%) patients, with pyelonephritis occurring in 4 (19%) patients and urosepsis in 3 (14%) patients. Although the all‐cause mortality rate was 14% (3 patients), no patient died from a stone related complication in our cohort.
Conclusions: In selected high‐risk patients, non‐operative management of staghorn stone is possible. Full metabolic workup and medical management with antibiotic prophylaxis are adjuncts for long‐term follow up.
Funding: No source of funding was seeked out or received for this project.
Real‐World Effectiveness of Preventive Pharmacological Therapy in Patients with Urolithiasis
John Hollingsworth5, Mary Oerline1, Ryan Hsi2, Joseph Crivelli3, John Asplin4, Vahakn Shahinian1
1University of Michigan, 2Vanderbilt University, 3University of Alabama at Birmingham, 4Litholink Corporation, 5NorthShore University HealthSystem/University of Chicago Pritzker School of Medicine
Presented By: John Hollingsworth, MD, MS
Introduction: Because most efficacy results supporting preventive pharmacological therapy (PPT) to reduce urolithiasis recurrence are driven by imaging findings with unclear clinical significance, we conducted an observational cohort study to determine whether its use was also associated with fewer symptomatic stone events.
Methods: We identified patients with urolithiasis who were enrolled in the United States' largest health insurance program, Medicare, and had a 24‐hour urine collection processed by a central laboratory. We then linked these patients' clinical data with their medical claims. For the subset with at least one urine chemistry abnormality, we distinguished patients who were prescribed PPT and adhered to it from those who were prescribed PPT but were nonadherent and untreated patients. We used multivariate regression to estimate symptomatic stone event (i.e., emergency department [ED] visit, hospitalization, or stone‐directed surgery) risk as a function of PPT use.
Results: Among 13,942 patients meeting inclusion criteria, 31.0% were prescribed PPT. Compared to untreated patients, those prescribed PPT who adhered to it had a 13% lower hazard of a symptomatic stone event (hazard ratio [HR], 0.87 [95% confidence interval {CI}, 0.76‐0.99]; P = 0.032), whereas the hazard was significantly higher for those who were nonadherent (HR, 1.20 [95% CI, 1.09‐1.34]; P < 0.001). In terms of PPT's effect size, the adjusted two‐year predicted probability of a symptomatic stone event among concordant/adherent patients was 14.0% (95% CI, 12.4‐15.5%), compared to 18.9% (95% CI, 17.3‐20.4%) and 15.9% (95% CI, 15.1‐15.6%) among concordant/nonadherent and untreated patients, respectively (P < 0.001 for overall comparison). When compared to concordant/nonadherent and untreated patients, concordant/adherent patients also had significantly lower adjusted two‐year predicted probabilities of ED visit, hospitalization, and stone‐directed surgery (Figure).
Conclusions: Our findings help strengthen the evidence base for PPT use, providing real‐world data on its clinical effectiveness.
Funding: National Institute of Diabetes and Digestive and Kidney Diseases
Nomogram to Predict “Pure” vs “Non‐Pure” Uric Acid Kidney Stones
Liran Zieber1, Muhammad Krenawi1, Gherman Creiderman1, Daniel Rothenstein1, Yaron Ehrlich1, Abd Elhalim Darawsha1, Ruth Tor2, David Lifshitz1
1Rabin Medical Center, 2Chemical Laboratory, Rabin Medical Center
Presented By: Liran Zieber, MD
Introduction: Oral chemolysis is an attractive and non‐invasive treatment for non‐obstructive uric acid (UA) stones. However, the success of this therapy relies on patients' adherence to a long‐term medication regimen. Therefore, it is crucial to identify individuals who are most likely to benefit from this approach. Specifically, patients with pure UA stones have a higher chance of successfully dissolving the stones orally compared to those with mixed (heterogeneous) stones. While the measurement of Hounsfield Units (HU) can indicate the presence of UA composition, it does not adequately represent the stone's purity. Previous research has not focused on identifying pure UA stones. The aim of this study is to develop a nomogram that can differentiate between pure and mixed UA stones.
Methods: We retrospectively queried our data base of all stones analyzed using Fourier transform infrared spectroscopy. Included were patients with a predominant (> 50%) UA stone composition and a preoperative non‐contrast CT as well as KUB or CT‐ scout. The stone density and opacity were analyzed by an independent observer blinded to the stone analysis results. The patient's data were obtained from our prospectively maintained data base and computerized charts. Patients were divided into 2 groups based on UA stone content: mixed (50‐90%) and “pure” UA stones (95‐100%).
Results: The study cohort included 135 patients. Fifty one in group 1 (50‐90% UA component) and 84 in group 2 (95‐100% UA component). Diabetes was more prevalent in group 2 (63% vs 41%, p = 0.013). The mean stone density and the number of radiopaque stones in group 2 was significantly lower (450 HU vs 600 HU and 23% vs 58%, respectively). A stepwise multivariate logistic regression revealed that lower stone density, bigger stone size, older age and decreased stone opacity are predictive variables for pure UA stones. Next, a nomogram was generated (Figure 1). The ROC curve showed an area under the curve of 0.78. A patient with a total score = > 156 has a probability of > 95% of “pure” UA stone.
Conclusions: Predicting “pure” UA stones is feasible utilizing a nomogram that includes stone density (HU) as well as stone opacity, stone size and age. This tool may help to better select patients suitable for oral chemolysis.
Funding: None
“Silent Stones” Can Persist After Initial Presentation of Ureteric Colic with no Hydronephrosis or Symptoms
Shiv Sarna2, Eric Edison1, Daniela Velinova1, Siobhan Price1, Alberto Melchionna1, Simon Choong1, Sian Allen1, Daron Smith1, Vimoshan Arumuham1
1University College Hospital, London, 2University College hospital, London
Presented By: Shiv Sarna
Introduction: There are no recognised follow‐up guidelines for ureteric stones managed conservatively. Urologists often assess for resolution of hydronephrosis (on ultrasonography) and symptoms as markers for ureteric stone passage. This study aims to assess the validity of this.
Methods: The weekly Colic MDT was used as a platform for a prospective, observational study from June 2022 to May 2023. Patients presenting through A&E, referred with CT‐confirmed ureteric stones, appropriate for conservative management, underwent a repeat CT KUB in 3 weeks. This was reviewed for presence of ureteric stone and hydronephrosis. Symptoms were assessed using a template via telephone consultation, assessing for pain, urinary symptoms and presence of haematuria.
Results: A total of 251 patients had a follow up CT scan following 3 weeks of conservative management. Of these, 171 had spontaneous passage of the stone and 80 had persistent stone on follow up. Of the persistent stones, 78% (62/80) had hydronephrosis at the initial presentation. Of these, hydronephrosis resolved in 50% (31/62), symptoms resolved in 35% (22/62), and 21% (13/62) had neither hydronephrosis nor symptoms despite a persistent ureteric stone ie a silent stone.For patients with resolution of hydronephrosis, ongoing symptoms conferred a 47% sensitivity for predicting ongoing stone presence.
Conclusions: Of the stones that originally presented with hydronephrosis and persist in the ureter, up to one fifth can have resolution of hydronephrosis and symptoms – ie become a “silent stone”. This implies that CT scan should be considered for follow up of all patients with ureteric colic.
Funding: None
The Effect of Vitamin C Supplements on Urinary Parameters: A Systematic Review and Meta‐Analysis
Ala'a Farkouh1, Ala'a Farkouh1, Matthew Buell1, Akin S. Amasyali1, D. Duane Baldwin1
1Loma Linda University Health
Presented By: Ala'a Farkouh, MD
Introduction: With the increased intake of vitamin C supplements during the COVID pandemic, physicians have reported a rise in the number of urinary stone cases and larger stone sizes. Oxalate is an end‐product of vitamin C breakdown and many studies have investigated the risk upon stones. The purpose of this study was to systematically review the available literature and perform a meta‐analysis on the effect of vitamin C supplements on 24‐h urine parameters associated with stone formation.
Methods: A comprehensive review was performed on PubMed, Embase, Web of Science, and the Cochrane Library databases, to retrieve relevant articles published from inception until Feb 2023. Criteria for study inclusion were set according to the PICO framework, with the population being stone formers (SF) or non‐ stone formers (NSF), the intervention being oral vitamin C supplements, the comparison being baseline before supplementation, and the outcome of interest being 24‐h urinary parameters. Exclusion criteria included reviews, non‐interventional studies, studies measuring spot urine as the outcome, and studies using invalid methods to measure 24‐h parameters. Relevant data were extracted from each study and meta‐ analyses were performed to calculate the mean difference (MD) measuring the effect of vitamin C supplements on urinary parameters.
Results: Initial database search yielded 808 titles. After duplicate removal and initial screening, 70 articles underwent full‐text screening and 8 studies met inclusion criteria. All articles reported on urinary oxalate and pooled analysis revealed a significant increase in urinary oxalate after vitamin C supplementation (MD = 9.72 mg/24h, 95% CI [5.94, 13.5]; p < 0.001). Stratified analysis revealed that vitamin C increases urinary oxalate excretion in both SF (MD = 13.5 mg/24h, 95% CI [6.71, 20.2]; p < 0.001) and NSF (MD = 6.64 mg/24h, 95% CI [3.42, 9.85]; p < 0.001). Three studies met inclusion criteria for citrate and there was no significant effect of vitamin C on citrate (MD = 17.6 mg/24h, 95% CI [‐46.1, 81.3]; p = 0.589). Five studies reported on calcium, which was not affected by vitamin C overall (MD = 27.4 mg/24h, 95% CI [‐4.99, 59.7]; p = 0.097), however stratified analysis showed that vitamin C increases urinary calcium in SF (MD = 51.6 mg/24h, 95% CI [4.97, 98.3]; p = 0.03).
Conclusions: Vitamin C supplements significantly increase urinary oxalate excretion in both SF and NSF, and also increase urinary calcium in SF. These factors contribute to stone formation and may worsen stone presentation among those who consume vitamin C supplements.
Funding: None
Consumption of Whole Grains and of Fruits and Vegetables Combined, But Not Fruits or Vegetables Alone, is Associated with Higher Urinary Citrate Excretion
Kristina L. Penniston2, Melanie V. Betz1
1University of Chicago, 2University of Wisconsin School of Medicine and Public Health
Presented By: Kristina L. Penniston, PhD, RDN
Introduction: Fruits and vegetables (FV) provide organic acids that undergo hepatic conversion to bicarbonate, which increases urine citrate and prevents calcium nephrolithiasis. Of all food groups, FV are the greatest sources of dietary alkali and oppose the significant acid load conferred by the typical Western dietary pattern. Nutrition therapy to reduce dietary acid load is important in medical management of calcium stones. We identified foods correlated with urine citrate in order to be able to more precisely target nutrition recommendations for stone prevention.
Methods: Food records and 24h urine collections from patients seen by a registered dietitian nutritionist in the nephrology clinic of a large academic center were collated. Multiple‐day food records were analyzed using the Nutrition Data System for Research (University of Minnesota, 2017). Patients were divided by quartiles for 24h urine citrate. Urine pH and nutrient data were then assessed for each quartile. Comparisons were made using ANOVA.
Results: Patients (n = 85) were 48 ± 15 years, 53% female, and had nephrolithiasis or polycystic kidney disease. Their 24h urine citrate is shown by quartile (Table). Within each quartile, dietary consumption of food groups, including FV, is shown. Urine pH was significantly correlated with citrate excretion as were FV, whole grains, and non‐cheese dairy foods.
Conclusions: Urinarycitrate excretion was most associated with consumption of FV and whole grains. There was no association with urine citrate for fruits alone nor vegetables alone. While the association of urine citrate with FV consumption was expected, the association with whole grains was not, especially because grains are known to confer an acid load. The association of whole grains with higher urinary citrate excretion should be further explored.
Funding: None
Finding Phytate ‐ What Foods Contribute the Most to Phytate Among Patients with a History of Calcium Urolithiasis?
Kristina L. Penniston2, Melanie V. Betz1
1University of Chicago, 2University of Wisconsin School of Medicine and Public Health
Presented By: Kristina L. Penniston, PhD, RDN
Introduction: Dietary phytate consumption is associated with higher urinary phytate excretion, which forms a soluble complex with calcium in urine, thus inhibiting calcium stone formation. Additionally, phytate consumption was shown to reduce calciuria in patients with hypercalciuria secondary to bone resorption. We identified dietary sources of phytate among patients with a history of calcium urolithiasis.
Methods: Patients seen in a multidisciplinary kidney stone prevention clinic (n = 83) were 66% male and 57 ± 12 years of age. Patients' 4‐day food‐records were analyzed by a registered dietitian nutritionist using the National Data System for Research (University of Minnesota, 2017). Pearson's correlations were calculated to identify food groups and specific nutrients that correlated with phytate. Foods that contributed more than 100 mg of phytate per portion consumed were identified as significant phytate sources.
Results: Controlling for energy intake, dietary phytate was strongly correlated with consumption of vegetable protein, magnesium, and fiber (R > 0.70, P < 0.001 for all) and moderately with oxalate and potassium (R > 0.30, P < 0.01 for both). Phytate was inversely correlated with animal protein (R = ‐0.35, P < 0.01) and calculated dietary acid load (R = ‐0.25, P = 0.03). Of all foods consumed, 8% accounted for 71% of all phytate consumed (Figure). Interestingly, these same foods accounted for 42% and 41% of total fiber and oxalate consumed, respectively.
Conclusions: Whole grains, cereals, nuts, and beans provided the majority of phytate in patients with a history of calcium urolithiasis and also provided significant fiber and magnesium. Consumption of higher amounts of these foods may prevent calcium urolithiasis by multiple mechanisms and should be part of nutrition counseling.
Funding: None
Retrospective Evaluation of Patients Undergoing KidneyseqTM Genetic Testing in the Evaluation of Nephrolithiasis and Nephrocalcinosis
Ryan Steinberg1, Zubin Shetty1, Meenakshi Sambharia1, Melissa Swee1, Mycah Kimble2, M Adela Mansilla2, Margaret Freese2, Christie Thomas3, Chad Tracy1
1University of Iowa Health Care, 2Iowa Institute of Human Genetics, 3University of Iowa Health Care, Iowa Institute of Human Genetics
Presented By: Ryan Steinberg, MD
Introduction: Recent literature has suggested that up to 15% of all stone disease may have a monogenic cause with the most prevalent condition being cystinuria. KidneySeqTM is a clinically approved comprehensive renal gene panel which tests for over 120 renal diseases, including nephrolithiasis (NL) and nephrocalcinosis (NC). We sought to assess the positive diagnosis rate in patients who have undergo genetic testing for NL/NC using KidneySeqTM.
Methods: An IRB‐approved retrospective review of all patients who underwent KidneySeqTM genetic testing between 10/2015 and 4/2023 was performed. Only patients with a clinical history of NL or NC, as specified in the indication for testing, or who only had the NL/NC sub‐panel ordered (available separate from the full test after 10/2017) were eligible for analysis. Basic demographic information and genetic results were reviewed. Descriptive statistics were generated.
Results: A total of 44 patients (23 males) with median age 15 years (range 21 days ‐ 62 years) underwent testing. 17 (39%) reported a family history of stone disease. 26 patients (59%) were reported to have genetic variants, of which 9 had multiple variants (Table 1). 11 (25%) patients had pathogenic or likely pathogenic variants supporting a NL‐related genetic diagnosis, of which 5 were also heterozygous carriers of recessive diseases. 15 (34%) patients were found to be heterozygous carriers, of which 11 (25%) were for NL‐related conditions. 9/15 carriers had variants of uncertain significance (VUS). Sub‐analysis of the 23 patients with a history of NL alone found 11 (48%) to have genetic variants, of which 3 had pathogenic or likely pathogenic variants with s supporting genetic diagnosis and 8 were heterozygous carriers.
Conclusions: In our cohort, 25% of patients were considered to have causal variants supporting a genetic diagnosis. The effect of carrier status and VUS in stone risk in an additional 25% remains unclear. Our results confirm that genetic testing has a high yield when clinical suspicion is strong.
Funding: None
Citralith™ Powder Supplement as a Treatment for Hypocitraturia in Patients with Nephrolithiasis
Jennifer Lu1, Eric Wang1, Kelley Zhao1, David Schulsinger1
1Stony Brook University Hospital
Presented By: Jennifer Lu, MD
Introduction: Potassium citrate is commonly given to stone‐forming patients to alkalinize urine and increase urinary citrate levels because both hypocitraturia and low urine pH are associated with calcium oxalate stones. TheraLith®, a nutritional supplement in tablet form, contains potassium citrate and has been shown to increase urinary citrate to levels above the normal threshold (> 550mg/L for females, > 450mg/L for males) within one month of administration. The large size of TheraLith® tablets, however, makes it difficult for some patients to comply with daily administration. This study aims to investigate the efficacy and tolerability of CitraLith™, a powder supplement containing potassium citrate, magnesium citrate and sodium citrate.
Methods: A retrospective study of patients who were started on CitraLith™ between April 2022 and April 2023 at a single institution was conducted. Only patients with known history of calcium oxalate stones and hypocitraturia proven by 24‐hour urine studies were included. Using univariate analysis, results of 24‐hour urine studies collected before CitraLith™ initiation were compared against those collected > 3 months after initiation. Patients were also surveyed about user experience.
Results: 15 patients were included. There was a significant difference between mean urinary citrate levels prior to starting CitraLith™ of 310.9mg/L and follow‐up urinary citrate level at 3‐6 months of 586.3 mg/L (p = 0.001). Urinary magnesium level was also significantly improved from 104.6mg/L pre‐supplement to 150.5mg/L post‐supplement (p = 0.003). All subjects tolerated the supplement well, and none discontinued its use. When asked about their experiences using the supplement, 73% of respondents felt the supplement was easy to ingest and found the taste of the supplement acceptable. The most common complaints were a slight metallic taste and occasional difficulty in dissolving the supplement in water
Conclusions: CitraLith™ significantly increased 24‐hour urine citrate and magnesium concentrations in this cohort. CitraLith™ was well tolerated, effective and could potentially be safely offered as an alternative to those unwilling or unable to take other citrate supplements.
Funding: none
MODERATED POSTER SESSION 3: EPIDEMIOLOGY, SOCIOECONOMIC AND HEALTH CARE POLICY 1
Race Influences Prostate Cancer Screening in America, Results from a Large National Survey
Borivoj Golijanin1, Vikas Bhatt1, Alexander Homer1, Gyan Pareek1, Elias Hyams1
1Minimally Invasive Urology Institute of the Miriam Hospital and Warren Alpert Medical School of Brown University
Presented By: Borivoj Golijanin
Introduction: Social determinants of health (SDOH) have been well documents to be a barrier to equal and quality healthcare. In prostate cancer in America, racial disparities are associated with higher incidence and mortality in black men compared to white men. It is unclear if this disparity exists at the level of prostate cancer screening with prostate‐specific‐antigen (PSA) testing and shared‐decision‐making (SDM), a requirement in guidelines for prostate cancer screening.
Methods: This study identifies men aged 50‐75 in the 2020 Behavioral Risk Factor Surveillance Survey and assesses how SDOH influence the likelihood of PSA testing and SDM.
Results: 54,396 respondents with average age of 62 at time of responding to the survey were included. 62% of respondents had PSA testing. Patients who had PSA testing identified as: 81. 3% White, 7.6% Black, 6.6% Hispanic, 1.6% Asian, 1.1% Multiracial, 0.8% American Indian/Pacific‐Islander, 0.2% Native Hawaiian, and 1.1% Other. For every year older than 50, odds of PSA testing increased (AOR = 1.03, CI = 1.03 ‐ 1.03). Any level of college education was found in 85.3% of individuals with SDM, and in 79.2% of those without had; in 85.5% of those with history of PSA testing, and in 76.7% of those without PSA testing. Any college‐level education was associated with higher odds of SDM (AOR = 1.93, CI = 1.92 – 1.94) and PSA screening (AOR = 3.38, CI = 3.36 – 3.39). Compared to White, Black patients had higher odds of SDM (AOR = 1.6, CI = 1.59 – 1.6) and decreased odds of PSA testing (AOR = 0.94, CI = 0.94 – 0.95). Hispanic patients had increased odds of SDM (AOR = 1.16, CI = 1.15 – 1.16) and PSA screening (AOR = 1.05, CI = 1.05 – 1.06). Compared to residents of the Northeastern United States, there were lower odds of SDM and PSA testing in the Western US, Southern US, and Midwestern US.
Conclusions: SDOH mediate the likelihood of SDM and PSA testing in age eligible men. Specifically, racial disparities suggest that Black men undergo PCa screening at lower rates. These findings suggest that higher incidence and mortality in this patient population might be related to screening efforts. Improving the quality of SDM in this patient population can improve prostate cancer detection.
Funding: None.
Clinical Significance of Preoperative Thrombocytosis in Patient with Urothelial Carcinoma from Renal Calyx to Distal Ureter
Phil Hyun Song1, Jae Young Choi1, Tae‐Hwan Kim2, Kyung‐jin Oh3
1Department of Urology, College of Medicine, Yeungnam University, 2Department of Urology, School of Medicine, Kyungpook National University, 3Chonnam National University Hospital
Presented By: Phil Hyun Song, MD.PhD.
Introduction: 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 110 patients undergoing NUx for UC between 2005 and 2022 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.
Funding: None
Evaluation of the Effectiveness of Transrectal Prostate Biopsy under the Control of Histoscanning in a Day Stay Unit
Yuriy Kim5, Dmitry Pushkar1, Alexander Govorov2, Alexander Vasilyev3, Anton Sadchenko4
1Academician of RAS, Prof., Head of the Department of Urology, A.I. Evdokimov Moscow State University of Medicine and Dentistry, 2Associate Professor at the Department of Urology, A.I. Evdokimov Moscow State University of Medicine and Dentistry, 3PhD, Teaching Assistant at the Department of Urology, A.I. Evdokimov Moscow State University of Medicine and Dentistry, 4Urologist at the Department of Urology, A.I. Evdokimov Moscow State University of Medicine and Dentistry, 5Yu.A.Kim
Presented By: Yuriy Kim, PhD
Introduction: The effectiveness of a standard 12‐point prostate biopsy is largely dependent on the experience of the specialist. One of the most promising, non‐invasive methods of additional imaging in prostate biopsy is histoscanning. Using the True Targeting software allows you to perform a targeted biopsy in real time. The purpose of the study is to evaluate the effectiveness of performing prostate biopsy under the control of hostoscanningin the day stay unit.
Methods: From May 2019 to April 2022. In the day stay uniton the basis of the S.I.Spasokukotsky state clinic2800 patients with suspected prostate cancer underwent transrectal histoscanning prostate biopsy inreal‐ time.
Results: The average prostate‐specific antigen value was 14,23 ng/ml (varied from 0,5to 1900 ng/ml). The average age of the patients was 66 years, the average prostate volume was 53,89 cm3. The average time of a transrectalhistoscanning prostate biopsyis 17 minutes. The average number of biopsies taken was 16 (of which4 were targeted). Primary biopsy was performed in 1296 patients (82%), repeated ‐ in 504 patients (18%). The presence of prostate cancer in close relatives was noted in 84 patients (3%). Among them, prostate cancer was detected in 69 patients, which is 82%. Suspicious sites were mainly located in the anterior sections of the prostate, which are usually missed when performing a standard transrectal biopsy. The overall incidence of prostate cancer was 59%, and with a standard biopsy this figure was 17%, while with a hostoscan‐targeted biopsyprostate cancer was diagnosed in 6% of cases.
Conclusions: The conducted study showed high efficiency of prostate biopsy under histoscanning control in conditions of day stay unit. The use of this method allows to increase the incidence of clinically significant prostate cancer and influence the choice of further treatment tactics.
Funding: No
The Initial Management of Clinically Significant Prostate Cancer after HoLEP
Ali Antar1, Tudor Borza1, Glenn Allen1, Margaret Knoedler1, Chris Manakas1, Matthew Grimes1, Dan Gralnek1
1University of Wisconsin
Presented By: Ali Antar, MD
Introduction: Rates of incidental prostate cancer (iPCa) after Holmium Laser Enucleation of the Prostate (HoLEP) are higher than in other bladder outlet surgeries. Management presents a challenge considering the effects of HoLEP on anatomy and other causes of mortality in the older population. We examined cancer characteristics and initial management of patients with iPCa after HoLEP to understand the significance of these incidentally discovered cancers
Methods: Patients with iPCa were identified over a 4 year period from a prospectively maintained institutional database. Clinical data collected included preoperative PSA levels, cancer stage, grade, initial management, post operative PSA, staging imaging or biopsy. We defined clinically significant cancers as those where treatment other than watchful waiting was recommended by NCCN guidelines based on predicted life expectancy, which was estimated using the Social Security Life Expectancy Calculator.
Results: 183/913 (20%) patients were diagnosed iPCa after HoLEP. 133 patients (73%) had clinically significant and 50 patients (27%) had clinically insignificant iPCa. Of clinically significant cancers, 7 patients with high risk PCa were managed with upfront local treatment and the rest underwent PSA surveillance (Figure). 11 experienced a PSA increase and underwent local treatment after confirmatory biopsy: 3 underwent RALP, 7 underwent XRT and one underwent ADT, all with appropriate PSA response to treatment. The clinically insignificant population underwent PSA observation. 9 were lost to follow up and 5 experienced a PSA increase triggering intervention: 4 underwent XRT and 1 underwent ADT with appropriate PSA response. At a mean follow‐up of 16.3 months (IQR 7.9 – 13.4 months), there were 6 deaths, all from non‐cancer related causes.
Conclusions: Despite the low risk nature of many post‐HoLEP iPCA, the majority were classified as clinically significant cancers based on NCCN guidelines. Data driven guidelines for pre‐operative screening evaluation and post‐operative management of iPCa after HoLEP are critical given the frequency and clinical implications these cancer diagnoses.
Funding: None
Transurethral Resection of Bladder Tumor Outcomes are Predicted by a 5‐Item Frailty Index
Christopher Connors1, Micah Levy1, Krishna Ravivarapu1, Juan Sebastian Arroyave1, Chih Peng Chin1, Olamide Omidele1, Francisca Larenas1, Michael Palese1
1Icahn School of Medicine at Mount Sinai
Presented By: Christopher Connors, BA
Introduction: The modified 5‐item frailty index (mFI‐5) has been shown to have predictive value for adverse outcomes following various urologic procedures. This study evaluated mFI‐5 as a predictor of post‐operative outcomes following transurethral resection of bladder tumor (TURBT).
Methods: The National Surgical Quality Improvement Program database was queried for TURBT cases from 2015‐2019. Cases with concurrent major procedures were excluded.mFI‐5 scores were calculated by assigning a point to each of the following: COPD, CHF, dependent functional status, hypertension, and diabetes. Patients were stratified by mFI‐5 scores.Demographics and 30‐day outcomes including Clavien‐ Dindo (CD) I/II and IV complications, mortality, and increased healthcare resource utilization (HCRU) were compared. HCRU outcomes included prolonged (> 2 days) length of stay (PLOS), unplanned readmission (UR), and discharge to continued care (DCC). Multivariate regression assessed the predictive value of mFI‐5 score on outcomes.
Results: 41,109 TURBT cases were identified (mFI‐5 = 0: 12,640, mFI‐5 = 1: 17,575, mFI‐5 = 2: 9,445, mFI‐5 ≥ 3: 1,449). Patients with higher mFI‐5 scores were more likely to be older, male, White, have higher ASA scores, and have larger tumors, all p < 0.05. Increasing mFI‐5 scores resulted in increased frequency of all adverse outcomes, all p < 0.001 [Figure 1]. On multivariate analysis, mFI‐5 ≥ 3 classification was a significant predictor of all outcomes including CD I/II (OR = 1.280), CD IV (OR = 2.539), mortality (OR = 2.202), HCRU (OR = 2.094), PLOS (OR = 2.136), DCC (OR = 3.401), and UR (OR = 1.705), all p < 0.05 [Table 1]. A mFI‐5 score of 2 was an independent risk factor for HCRU (OR = 1.220), PLOS (OR = 1.224), DCC (OR = 1.770), and UR (OR = 1.176), all p < 0.05. A mFI‐5 score of 1 was not a significant predictor for any outcomes studied.
Conclusions: The mFI‐5 is an easily ascertainable pre‐operative risk assessment tool that is a predictor of adverse clinical and HCRU outcomes following TURBT.
Funding: None
Percutaneous Nephrostomy for the Treatment of Malignant Ureteric Obstruction: A Walk on the Narrow Strait Between Beneficence and Maleficence
Sharon Fihsberg1, Conor Brown1, Vladimir Yutkin1, Mordechai Duvdevani1, Amitay Lorber1, Guy Hidas1, Ofer Gofrit1
1Hadassah Medical Center and The Hebrew University of Jerusalem
Presented By: Sharon Fihsberg, MD
Introduction: Malignant ureteric obstruction (MUO) is common in patients with advanced malignancy and percutaneous nephrostomy (PCN) is its ultimate solution. Yet PCN insertion is painful and living with PCN is marked by a decrease in quality of life, and frequent complications. Urologists and oncologists were often blamed for overusing this procedure potentially violating the core ethical principle of nonmaleficence. In this study, based on a three‐month survival threshold, we attempted to find whether PCN is justified in current patients with MUO.
Methods: The study analyzed data of 34 patients treated with PCN for MUO. Information regarding the indication for PCN and the survival after PCN insertion was collected.
Results: Average patients age was 64.17 years( ±15.81). The etiology of the obstruction was: urothelial carcinoma in 13 patients, prostate cancer in 7 patients, colorectal cancer in 6 patients, and other malignancies in 8 patients. The indications for PCN: were acute renal failure in 29 patients (79.4%), infection in 10 patients (29.4%), pain in 3 patients (8.8%), and hydronephrosis in 3 patients (8.8%). Out of the 34 patients, 26 patients (76.5%) met the three months survival threshold. The average survival after PCN insertion was 391 days ( ±479.4), demonstrating the long‐term beneficial effect of this intervention.
Conclusions: PCN is an effective palliative intervention for patients with MUO. Currently inserted PCNs are done almost always for good reasons (renal failure, infection, and pain) and not for the management of hydronephrosis and most patients meet the three‐month survival threshold.
Funding: No funding was recieved for this work
Temporal Trends of “Shared Decision‐Making” and Prostate Cancer Screening from 2018 to 2020: Findings from the Behavioral Risk Factors Surveillance Survey (BRFSS)
Borivoj Golijanin1, Vikas Bhatt1, Alexander Homer1, Gyan Pareek1, Elias Hyams1
1Minimally Invasive Urology Institute of the Miriam Hospital and Warren Alpert Medical School of Brown University
Presented By: Borivoj Golijanin
Introduction: In 2018, the United States Preventative Services Task Force (USPSTF) updated its recommendations for prostate cancer (PCa) screening, encouraging “shared decision‐making” (SDM) with patients rather than discouraging screening altogether. This study aims to assess whether there was an increase in SDM following the 2018 guidelines change as well as an increase in screening for different socioeconomic groups.
Methods: Responses of age‐eligible men were extracted from the 2018 and 2020 Behavioral Risk Factors Surveillance Survey (BRFSS), a national survey on health behaviors. Sociodemographic traits including socioeconomic status, race, participation in other health behaviors, and previous medical history were captured. Hierarchical classification of records was used to identify similar clusters based on the traits. Rates of SDM and prostate cancer screening were compared. All results were weighted.
Results: Four similar clusters were identified for each of the years: low‐diversity low‐socioeconomic status (LD‐LS), low‐diversity high‐socioeconomic status (LD‐HS), high‐diversity low‐socioeconomic status (HD‐ LS), and high‐diversity high‐socioeconomic status (HD‐HS).In 2018, rates of SDM were similar between the groups with 25% in LD‐LS, 24% in LD‐HS, 22% in HD‐LS, and 21% in HD‐HS (Table 1). In 2020, rates of SDM were comparable torates seen in 2018 for each of the groups with 22%,23%, 20%, and 20%, respectively.PSA screening rates were 56% for LD‐LS, 51.5% for LD‐HS, 50.5% in HD‐LS, and 45% in HD‐ HSin 2018, versus 48.5%, 49.5%, 39.5%, and 40%, respectively, in 2020.
Conclusions: Between 2018 and 2020, there was no increase in SDM for all racial and socioeconomic groups, despite a change in guidelines recommending this practice. PCascreening rates decreased for all groups and remained lowest in minority groups. This can be explained by a possible lack of utility of screening from prior guidelines, or insufficient time for guideline adoption. SDM was equally low acrosssocioeconomic levels, and the decrease in screening was comparable. These data may demonstrate a delay in behavior adjustment after guidelines change, or rigidity in practice, particularly when practices from prior more categorical recommendations (screening is “discouraged”) may have become instilled in the medical culture.
Funding: None
Partcipation in Preventative Health Behaviors Predicts Shared‐Decision Making and Prostate Cancer Screening
Borivoj Golijanin1, Vikas Bhatt1, Alexander Homer1, Gyan Pareek1, Elias Hyams1
1Minimally Invasive Urology Institute of the Miriam Hospital and Warren Alpert Medical School of Brown University
Presented By: Borivoj Golijanin
Introduction: There is stronger evidence for colorectal cancer (CRC) screening and vaguer recommendations for prostate cancer screening with prostate‐specific‐antigen (PSA) testing. Evidence suggests that involvement in prior preventative health behaviors, like CRC screening, improves the likelihood of shared‐decision‐making (SDM) and compliance with medical recommendations. It is unclear how participation in CRC screening influences the likelihood of PSA testing.
Methods: This study identifies age‐eligible men in the Behavioral Risk Factor Surveillance Survey who underwent PSA testing between 2019 and 2020 and assesses their participation in health behaviors, exercise, CRC screening, and PSA testing, and SDM with their healthcare provider. Participation in these preventative health behaviors is used to establish the likelihood odds of SDM and PSA testing.
Results: In age eligible men (n = 54,396), screening rates were 62% for PSA and 88% for CRC. Rates of SDM were 39.1% in those with PSA screening, and 16.2% in those without. Odds of PSA screening were higher when SDM was present (AOR = 2.68, CI = 2.67 – 2.68). There was a positive association between SDM and history of colonoscopy (AOR = 1.16, CI = 1.15 – 1.16), sigmoidoscopy (AOR = 1.26, CI = 1.25‐1.26), stool DNA (AOR = 1.23, CI = 1.22 ‐ 1.23), and stool blood testing (AOR = 1.05, CI = 1.05 ‐ 1.05). VR colonoscopy is associated with lower odds of SDM (AOR = 0.98, CI = 0.98 ‐ 0.99) and PSA testing (AOR = 0.95, CI = 0.95 ‐ 0.95). There were higher odds of having a PSA test when there was history of receiving colonoscopy (AOR = 1.94, CI = 1.94 ‐ 1.95), sigmoidoscopy (AOR = 1.23, CI = 1.23 – 1.23), stool DNA testing (AOR = 1.11, CI = 1.11 – 1.11), and stool blood testing (AOR = 1.11, CI = 1.11 – 11). Health behaviors, like regular exercise are associated with increased odds of SDM (AOR = 1.14, CI = 1.13 – 1.14) and PSA testing (AOR = 1.28, CI = 1.28 – 1.29). History of flu vaccination in the last twelve months was associated with higher odds of SDM (AOR = 1.29, CI = 1.29 – 1.3) and PSA testing (AOR = 1.36, CI = 1.35 – 1.36). Increased SDM was associated with history of pneumonia vaccination (AOR = 1.19, CI = 1.19 – 1.2). The history of current or prior smoking was negatively associated with SDM (AOR = 0.86, CI = 0.85 – 0.86) and PSA testing (AOR = 0.93, CI = 0.92 – 0.93).
Conclusions: Participation in health behaviors is associated with more SDM which appears to be a proxy marker for quality preventative healthcare, both in terms of following PSA screening guidelines, as well as its' association with other appropriate cancer screenings. SDM may be a trackable metric that can strengthen the patient‐doctor relationship and lead to wider preference‐sensitive care and improved preventative care.
Funding: None.
The Influence of Shared Decision Making on Prostate Cancer Screening Rates in the USA is Mediated by the Complex Interactions of Social Determinants of Health
Borivoj Golijanin1, Vikas Bhatt1, Alexander Homer1, Gyan Pareek1, Elias Hyams1
1Minimally Invasive Urology Institute of the Miriam Hospital and Warren Alpert Medical School of Brown University
Presented By: Borivoj Golijanin
Introduction: Cancer screening choices may be influenced by more complex interactions of known social determinants of health (SDOH) including race, socioeconomic status (SES), and general health behaviors. In addition to SDOH, shared decision‐making (SDM), required for responsible, guideline‐concordant prostate‐specific antigen (PSA) testing for prostate cancer screening, may augment screening rates. This study assesses the influence of SDOH and SDM on PSA screening rates.
Methods: Responses of individuals meeting the eligibility criteria for PSA screening based on current recommendations were extracted from the 2020 Behavioral Risk Factors Surveillance Survey (BRFSS). Records containing definitive history of SDM and PSA testing were included for analysis. Hierarchical classification of records was used to identify similar clusters. Multivariable interactions were calculated. All results were weighted.
Results: Four distinct clusters were identified within the 30,958 records that met inclusion criteria (Table 1): less diverse, low SES (LD‐LS); less diverse, high SES (LD‐HS); more diverse, low SES (MD‐LS); more diverse, high SES (MD‐HS). Rates of SDM were similar: 22% in LD‐LS, 23.36% in LD‐HS, 20.34% in MD‐ LS, 19.9% in MD‐HS. For the four groups, LD‐LS, LD‐HS, MD‐LS, and MD‐HS, PSA screening rates were significantly different with 48.6%, 49.5%, 39.59%, and 39.52%, respectively; colorectal carcinoma screening rates were similar with 81.6%, 84.1%, 78.5%, and 77.2%, respectively. SDM increased odds of PSA testing in all groups, MD‐LS demonstrated the highest increase (OR = 4.64, CI = 4.63 – 4.65), followed by MD‐HS (OR = 3.69, CI = 3.68 – 3.69), LD‐LS (OR = 3.21, CI = 3.21 – 3.21), and LD‐HS (OR = 3.06, CI = 3.06 – 3.06).
Conclusions: Naturalistic analysis identified unique groups with distinct healthcare behaviors representing differences between PSA screening‐eligible patients. SDOH and preventative health behaviors interact with SDM, which remains low across all groups, and affect cancer screening rates. Importantly, differences in SDM and PSA screening exist within the same racial groups when considering SES and within the same SES level when considering race. Additional investigation into the interplay of SDOH and lifestyle can further elucidate how cancer screening practices may be improved.
1Loma Linda University Health, 2Hadassah Hebrew University Hospital, 3Penn State Hershey Medical Center, 4University College London Hospital, 5Duke University, 6Palmetto Health, USC
Presented By: Ala'a Farkouh, MD
Introduction: As part of the Endourological Society's initiative to continuously enhance the field of endourology, the second annual census was circulated after the World Congress of Endourology and Technology (WCET) 2022. This report presents the results of this census.
Methods: An anonymous survey was created using Qualtrics XM and was disseminated via email to all Endourological Society (ES) members (n = 1502) between Oct 4th, 2022 and Jan 26th, 2023. A total of 46 questions were included in the survey and covered different aspects including demographics, practice patterns, satisfaction, impact of COVID, WCET 2022 attendance, and future opportunities.
Results: A total of 404 (27%) ES members, representing 63 different countries participated in the survey. The demographics of this survey echoed those of the inaugural census, with women constituting an integral part of the society (8.2% of responses) and the mean participant age was 48.9 years. Fellowship‐trained endourologists constituted 58.9% of respondents. The most common practice setting was academic (55.2%), while 30.9% were in some form of private practice and 7.7% were government employed, with 28.5% considering a change in practice setting. The most common practice scope was surgical and medical management of urolithiasis (> 70%). Laparoscopy and robotic surgery were performed by 57.4% and 43.8% respectively. Work schedules were variable with 51.1% working 40‐60 hours/week and 35.3% working more. No call is taken by 14.7%, while 28.4% take 4‐6 calls, and 24.5% take ≥7 calls per month. More than 80% were satisfied with their practice, however 42.4% indicated that COVID made satisfaction worse. This was mainly attributed to staff shortages and decreased efficiency, as 60.4% found it more challenging to manage patients after COVID, with 41.9% reporting an increase in case volume. Of participants, 49.5% were satisfied with their compensation and 7.3% plan to retire within the next 5 years. When asked about the future of endourology, 92.9% had a positive outlook.
Conclusions: These survey results report important trends within the field of endourology and demonstrate the robust outlook of the society members for the future. By demonstrating important practice patterns and member needs, this information can be used to improve the responsiveness of the society to its members and to continually strengthen the Endourological Society.
Funding: None
Analysis of Seasonal Variations in 24‐hour Urine Studies
T. Max Shelton1, Najash Abdishkur1, Joel Green1, Luke Vandeventer1, Rj Caras1, Austen Slade1, Marcelino Rivera1
1Indiana University School of Medicine
Presented By: T. Max Shelton, MD
Introduction: Nephrolithiasis is a common medical issue affecting an estimated 1 in 11 people in the United States. Inadequate fluid intake has been shown to play a role in stone development. There is a lack of consensus regarding seasonal variations in urine volumes and little published on seasonal variations in urine electrolytes. This study evaluates seasonal variations in 24‐hour urine parameters among a large cohort of stone‐formers at a single institution.
Methods: Data from 2,779 24‐hour urine tests from 2017‐2022 was used to calculate seasonal averages for urine testing variables. Subsequently, an ANOVA single factor test was used to determine the statistical significance of the results using a p‐value of 0.05.
Results: Urine volumes, urine chemistries and super‐saturations were analyzed for a total of 2,779 24‐hour urine studies. Urine sodium and chloride were statistically lower during summer months (June‐August) at 154.6 vs. 170.5 mmol/d (p = 0.00003) and 157.2 vs. 170.4 mmol/d (p = 0.0008). This seasonal variation was also reflected with urine urea nitrogen (p = 0.0346), magnesium (p = 0.0357), and phosphorus (p = 0.0266). The remainder of analyzed factors showed no statistically significant difference.
Conclusions: This study shows statistically significant decreases in urine sodium, chloride, magnesium, and phosphorus during the summer season compared to other yearly averages. The decreases in these parameters may be due to electrolyte losses from perspiration, although other dietary factors warrant study. Interestingly, no significant seasonal variations were noted in urine volumes, super‐saturations, or other urine electrolytes.
Funding: None
The Effects of Age and Gender on Ureteral Stones Treatment Costs
Amit Shemesh1, Dor Golomb1, Hanan Goldberg2, Eyal Hen1, Fahed Atamna1, Amir Cooper1, Orit Raz1
1Samson Assuta Ashdod University Hospital, 2SUNY Upstate Medical University
Presented By: Amit Shemesh, MD
Introduction: The growing incidence of urolithiasis is reflected in a significant financial burden with increasing direct and indirect costs. The aim of this study is to evaluate the direct health care expenditure of ureteral stone management in Emergency Department (ED) patients in relation to their age and gender.
Methods: A retrospective analysis was conducted on all patients admitted to the ED and found to have a ureteric stone on CT. Clinical, laboratory, and imaging parameters were collected, along with data regarding admissions, ED readmissions, surgical procedures, and the total cost of treatment. The different cost rates were compared with regard to different stone parameters and characteristics, patient clinical presentation, laboratory results, and demographics.
Results: Between January 2018 and January 2020, an abdominal CT‐proven ureteric stone was found in 805 patients during an ED visit in a single institution. Of those, 773 patients met the inclusion criteria. Seventy‐ eight percent (609) were males, and 22% (169) were females, with a mean age of 50 years. Treatment costs were inversely related to age, costing $4,025, $5,116, $6,058, and $9,225 in the 18‐30, 31‐50, 51‐70, and older than 70 age groups, respectively (p < 0.001). Older age was related to unfavorable stone features and poorer presentation characteristics, with a larger stone size (p < 0.001) and rate of proximal location (p = 0.024), as well as higher creatinine level (p < 0.001), higher inflammatory marker levels (CRP: p < 0.001, WBC: p = 0.0015), positive urine culture (PUC) (p < 0.001), and fever (> 37.8°C) (p = 0.029). Older patients had a high rate of surgical procedures (p < 0.001), a higher hospital admission rate (p = 0.018), and a longer length of hospital stay (p = 0.026). Female gender was associated with increased treatment costs, averaging at $6,831 compared to $5,450 in males (p = 0.03). There were no differences between the genders in stone features (size p = 0.18, proximal location p = 0.13), the type of surgical procedure (p = 0.5), or in hospital stay (p = 0.1). However, female patients underwent more surgical procedures (p = 0.016). The female population had predominantly higher rates of infection and increased inflammatory markers (PUC: p < 0.001, fever: p = 0.032, CRP: p = 0.001).
Conclusions: Treatment costs were significantly affected by age and gender. Older age and female gender were both found to be associated with increased direct treatment costs in the management of ureteric stones.
Funding: None
Ammonium Urate Urinary Stones – a Rare Subtype of Unknown Significance
Sagi A. Shpitzer1, Yaron Ehrlich1, Abd E. Darawsha1, David Lifshitz1
1Rabin Medical Center
Presented By: Sagi A. Shpitzer, MD
Introduction: Ammonium urate (AU) crystals are a rare component of urinary stones. In general AU appears primarily in mixed composition stones while pure AU stones are rare. The clinical significance of AU is unclear. In this study we sought to investigate the clinical as well as the metabolic characteristics of patients with an AU stone component.
Methods: A large healthcare database was searched for adult patients with laboratory results of a stone composition analysis between the years 2013‐2020. A stone was considered as having an AU component if it consisted on analysis of > 10% AU. AU stone formers were subdivided according to the additional predominant stone component. Results were compared to patients with similar predominant stone compositions without an AU component.
Results: Out of 11,979 patients with a stone composition analysis in our database 141 stones (1.2%) were classified as AU stones. None of the stones were pure ammonium urate. Patients were divided into uric acid (UA, n = 51), calcium oxalate (CaOX, n = 56) and infection stone (IS, n = 34) subgroups. The UA group had a higher proportion of female patients (47% vs. 25%, p < 0.001) and of patients with inflammatory bowel disease (IBD) (5.9% vs. 1.8%, p = 0.045). The CaOX group had similar findings with 45% females vs. 22% (p < 0.001) and 8.9% IBD patients vs. 2.4% (p < 0.001). The IS group had more patients from low socioeconomic groups (39% vs. 14%, p < 0.001) but no difference regarding gender (47% vs. 58% female, p = 0.19). When comparing the results of metabolic evaluation differences were found only in the UA group which had a higher prevalence of hyperoxaluria (41.2% vs. 17.1%, p < 0.001) and a trend towards hypocitraturia (50% vs. 33%, p = 0.09). Average spot urine pH was acidic in all 3 subgroups ‐ 5.67, 5.86 and 6.3 in the UA, CaOX and IS groups respectively.
Conclusions: Patients with AU containing stones are more likely to be women and to suffer from IBD, but in most other respects are similar to patients with matching stone composition without an AU component. It is unclear whether patients with AU containing stones should be treated any differently than patients without AU stones.
Funding: None
24‐Hour Urine Collections for Sodium in Nephrolithiasis Patients – a Possible Link with Ischemic Heart Disease
Sagi A. Shpitzer1, David Lifshitz1, Yaron Ehrlich1, Abd E. Darawsha1, Ron Gilad1
1Rabin Medical Center
Presented By: Sagi A. Shpitzer, MD
Introduction: Numerous studies have identified a connection between nephrolithiasis and ischemic heart disease (IHD). Increased sodium intake has been linked to both of these conditions. The purpose of this study was to investigate sodium excretion in a large cohort of nephrolithiasis patients, aiming to identify a potential link between nephrolithiasis and IHD.
Methods: We analyzed a comprehensive healthcare database encompassing all adult patients from the largest health maintenance organization (HMO) in our country. The database was examined for patients who underwent stone analysis between 2013 and 2020, and among them, those who also had results from a 24‐hour urinary sodium collection were included. Demographic and clinical parameters, including the presence of IHD, were analyzed.
Results: Our database included 11,979 patients, of whom 4,611 had results available for urinary sodium collection within the study period. Among the cohort, 73% were male, with an average age of 55 ± 14 years. The average 24‐hour urinary sodium excretion was 167 ± 86 mEq/day, with 20% of patients exceeding the upper limit of normal (220 mEq/day) as defined by our laboratory. Higher urinary sodium excretion was associated with male gender, non‐Jewish ethnicity, higher BMI, diabetes, and hypertension. A total of 23% of patients had a diagnosis of IHD. Patients with urinary sodium levels exceeding the normal range were more likely to have a diagnosis of IHD, with an odds ratio of 1.19 (95% CI, 1.01‐1.41).
Conclusions: Excessive urinary sodium excretion is a prevalent finding in the metabolic evaluation of stone disease and is associated with a diagnosis of IHD. This association may offer insights into the link between nephrolithiasis and IHD.
Funding: None
Lost to Follow‐up: A Prospective Risk Factor Analysis of Forgotten Ureteral Stents
Danna Raslan1, Mark Wille1, Jonathan Alcantar1, Alicia Roston1
1John H. Stroger, Jr. Hospital of Cook County
Presented By: Jonathan Alcantar, MD
Introduction: In contemporary urologic practice, routine stent maintenance is an important preventative measure to minimize ureteral stent encrustation. There is a lack of data exploring risk factors that make patients less likely to follow up for routine ureteral stent management. This is the first prospective study to identify risk factors associated with patients in whom stents were retained beyond the intended maximal stent life.In addition, our study is the first of its kind to explore the impact of retained stents on quality of life measures.
Methods: This is a prospective analysis of patients who underwent first‐time ureteral stent placement between 2018 and 2023 by a single‐surgeon experience at a single‐institution. Patients with stents beyond the intended maximal stent life of 6 months were considered to have retained stents (n = 34). The control group consisted of patients who followed up for timely ureteral stent maintenance (n = 30). All study participants were consented to complete a 17‐item study questionnaire developed by the authors and the validated EQ‐ 5D‐5L questionnaire to assess health‐related quality of life.
Results: The factors that were previously shown to be significantly different between the two groups still hold true with the updated data with increased statistical significance: the retained stent group is still more likely to have no symptoms (p = 0.0006), less likely to have private insurance (p = 0.03), and more likely to have changed urologist (p = 0.01). The retained stent group was more likely to rate their instructions on stent maintenance as unsatisfactory (p = 0.03). Regarding the EQ‐5D‐5L questionnaire, the overall health index scores did not significantly differ between the two groups (p = 0.08). The two groups significantly differ in their responses on difficulty with self‐care (p = 0.018) and anxiety/depression (p = 0.0414). When the Euroqol data is dichotomized, the retained stent group is more likely to report some degree of difficulty with self‐care (slight, moderate, severe, unable) than the control group (p = 0.0046) and more likely to report moderate, severe, or extreme levels of anxiety/depression (p = 0.0108).
Conclusions: This prospective study emphasizes identifiable patient risk factors for developing retained ureteral stents as well as defined the impact on quality of life associated with this problem. The treatment retained stents is fraught with expensive and complicated urologic interventions. In identifying such predisposing factors, we may be able to develop preventative measures to allow for more timely ureteral stent follow up in order to minimize complex urologic sequelae of retained ureteral stents.
Funding: None
Steerable Ureteroscopic Renal Evacuation: Implications on Cost‐Effectiveness for the Treatment of Large Renal Stones
Kevin Wymer1, Daniel Heidenberg1, Victoria Edmonds1, Nicolette Payne1, Mouneeb Choudry1, J. Stuart Wolf1, Karen Stern1
1Mayo Clinic
Presented By: Kevin Wymer, MD
Introduction: Although PCNL is the standard for management of stones > 2cm, the approach has technical barriers and often requires advanced training. Conversely, ureteroscopy alone can prove ineffective. The CVAC aspiration system (Calyxo, Inc.) has shown promising results as an adjunct to URS. Herein, we assess the economic and quality of life impact of the CVAC system.
Methods: A decision‐analytic Markov model was used to assess the cost‐effectiveness of URS alone, URS + CVAC, and PCNL for the treatment of 2‐3cm renal stones. The model included stone free rates, retreatment, auxillary procedures, complications, and residual stone events. Primary outcomes included Medicare costs, effectiveness (quality adjusted life years (QALYs)), and incremental cost‐effectiveness ratios (ICERs) with a willingness‐to‐pay (WTP) threshold of $100,000/QALY. Univariable and multivariable sensitivity analyses were performed.
Results: At 3 years following the index procedure, costs per patient were $6,259, $9,741, and $11,343 for URS, URS+CVAC, and PCNL, respectively. Similarly, URS resulted in the lowest QALYs (2.89), followed by URS+CVAC (2.93), and PCNL (2.94). Although more effective, both URS+CVAC (ICER = $108,505) and PCNL (ICER = $112,905) were not cost‐effective relative to URS alone. However, with an ICER near the WTP threshold, the model was sensitive to slight changes in multiple variables. Specifically, URS+CVAC became cost‐effective if the SFR with CVAC was 22% higher than URS alone (base difference of 20%) or if the cost of CVAC decreased by 3%. On multivariable analysis with 100,000 microsimulations, URS was most commonly favored (42%), followed by URS+CVAC (30%), and PCNL (28%) (Figure).
Conclusions: Based on a Markov model, URS+CVAC led to higher quality of life relative to URS alone and lower costs relative to PCNL‐ occupying a middle ground between these two procedures for patients with large (2‐3cm) sized stones. Such models can be used to help guide patient, provider, health system, and reimbursement‐level decision making for these complex patients.
Funding: No Funding
Evaluation of Private Payer and Patient Out of Pocket Costs Associated with the Surgical Management of Benign Prostatic Hyperplasia
Kevin Wymer1, Viengneesee Thao1, Gopal Narang2, Vidit Sharma1, Bijan Borah1, Nicolette Payne1, Victoria Edmonds1, Mouneeb Choudry1, Scott Cheney1, Mitchell Humphreys1
1Mayo Clinic, 2University of North Carolina
Presented By: Kevin Wymer, MD
Introduction: Despite the high prevalence of benign prostatic hyperplasia (BPH) treatment and its significant economic impact, limited data are available comparing the financial burden of specific surgical interventions.
Methods: We identified commercially insured men with a diagnosis of BPH who underwent a procedure of interest (SP, TURP, HoLEP, PVP, PUL, or WVTT) between 2015‐2021 with the OptumLabs Data Warehouse. Primary outcome was total healthcare costs (THC) which included both patient out‐of‐pocket (OOP) and health plan paid (HPP) costs for the index procedure and combined follow‐up years 1‐5. A generalized linear model was used to estimate adjusted costs controlling for demographic and clinical characteristics. Patients undergoing WVTT were excluded from extended follow‐up analyses due to limited data.
Results: Among 25,407 patients with BPH, 10,117 (40%) underwent TURP, 6,353 (25%) underwent PUL, 5,411 (21%) underwent PVP, 1,319 (5%) underwent SP, 1,243 (5%) underwent WVTT, and 964 (4%) underwent HoLEP. Index procedure costs varied significantly with WVTT being the least costly [THC: $2,637 (95% CI: $2,513 – $2,761)], and SP being the costliest [THC: $14,423 (95% CI: $12,772 – $16,075)]. For aggregate index and 5‐year follow‐up costs, HoLEP ($31,926 [95% CI: $29,704–$34,148]) was the least costly and PUL ($36,596 [95% CI: $35,369‐37,823]) was the costliest (Figure).
Conclusions: BPH surgical treatment is associated with significant system‐level healthcare costs. The level of impact varies between procedures. Minimally invasive options, such as WVTT, may offer initial cost reductions; however, HoLEP and SP are associated with lower follow‐up costs.
Funding: This work was supported in part by the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery
Trends in Opioid and Nonsteroidal Anti‐Inflammatory Drug Use for Patients with Kidney Stones in United States Emergency Departments
Richard Berman3, Juliana Villanueva1, Ezra Margolin2, Ojas Shah2
1Columbia University Mailman School of Public Health, 2Columbia University Department of Urology
3Columbia University Vagelos College of Physicians & Surgeons
Presented By: Richard Berman, BA
Introduction: Kidney stones commonly result in emergency department (ED) visits due to high levels of associated pain. Opioids are frequently prescribed due to their potency and rapid onset; however, overuse of opioids can lead to dependence and abuse. Nonsteroidal anti‐inflammatory drugs (NSAIDs) are also effective in managing renal colic with a different risk profile. This study aims to examine recent national trends in opioid and NSAID use for ED encounters related to kidney stones in the United States (US).
Methods: Kidney stone ED encounters were identified within National Hospital Ambulatory Medical Care Survey data from 2015 to 2020. National estimates were derived from a multistage survey weighting procedure to account for selection probability, nonresponse, and population weights. Trends in medication use were estimated from logistic regression on the year of the encounter, adjusting for selected demographic and clinical characteristics. Results were considered statistically significant with two‐sided p‐values < 0.01.
Results: There were an estimated 8,033,609 ED encounters for kidney stones in the US from 2015 to 2020. The mean age was 47 (± 17) years, 54% of patients were male, and 75% were White. Overall, 5,481,326 (68%) patients received opioids and 5,199,967 (65%) patients received NSAIDs. Opioid use decreased significantly during the study period (annual odds ratio [OR]: 0.84, 99% confidence interval [CI] 0.71‐0.99, p = 0.006), and there was no significant change in NSAID use (annual OR: 1.09, 99% CI 0.91‐1.30, p = 0.214) (Figure). There was regional variation in opioid use, with opioid use more common in the West than in the Northeast (OR: 3.15, 99% CI 1.15‐8.62, p = 0.004). 4,198,607 (52%) patients received opioids during their ED visit, and 3,498,702 (48%) patients were prescribed opioids at discharge. Overall, 37% of patients were given opioids that were stronger than morphine, including oxycodone (20%), hydromorphone (19%), and fentanyl (4%).
Conclusions: Although opioids are still frequently used to manage renal colic in the ED, opioid use has decreased in recent years. These results may suggest improved national opioid stewardship from ED physicians in response to the opioid epidemic. Ongoing high rates of opioid use underscore opportunities for continued efforts.
Funding: None
Multi‐Institutional Implementation of the Registry for Stones of the Kidney and Ureter
Wilson Sui1, Kevin Chang1, Ian Metzler2, Brian Duty2, Roger L. Sur3, Heiko Yang4, Michelle Li4, Catherine Arevalo4, David Bayne4, Justin Ahn4, Marshall Stoller4, Tom Chi4
1University of California San Francisco, 2Oregon Health & Science University, 3UCSD, 4UCSF
Presented By: Wilson Sui, MD
Introduction: High‐quality data on long‐term outcomes is essential for advancing our understanding of stone disease, but much of stone research exists in silos. Prior attempts at stone registries have relied on inefficient, manual data entry with limitations in reliability. The Registry for Stones of the Kidney and Ureter (ReSKU) is an automated electronic health record (EHR)‐based longitudinal registry of patients with stone disease initially developed and implemented at our institution. Herein we describe our early experience with multi‐ institution implementation.
Methods: Prospectively identified demographic, intraoperative, and perioperative variables were incorporated into standardized data collection instruments reflecting new patient encounters, surgery specific measures, post‐operative outcomes and longitudinal follow up data. Automated data extraction into a HIPAA‐ complaint database was performed from the EHR. The registry infrastructure was disseminated to other high volume stone centers for technical build and implementation with data sharing capabilities. Initial data from completed builds were integrated in an automated fashion.
Results: 17 medical centers across the United States (US), Canada, and China are in various phases of implementation of ReSKU, with 4 centers (3 USA, 1 China) having functioning builds with data sharing capabilities. Across these four institutions, 7439 patients have been recruited as of 2022. Patients at US institutions had significantly different body mass index and rates of symptomatic presentations than patients at the Chinese institution. The Chinese institution had patients with larger mean cumulative stone burden (32.7 mm vs 18.9 mm, p < 0.001) and had a greater rate of percutaneous nephrolithotomy (PCNL) for surgical management (61% vs 22%, p < 0.001) compared to the US institutions (Table 1). Patients undergoing 24‐hour urine testing at US institutions also displayed significant differences in urinary calcium and uric acid compared to those at the Chinese institution (Table 1).
Conclusions: The Registry for Stones of the Kidney and Ureter is a growing multi‐institutional registry with infrastructure supporting automated data extraction at a single institution and data integration across institutions. Further development and expansion of this resource will facilitate multi‐institutional, high impact stone research.
Funding: NA
MODERATED POSTER SESSION 4: STONES - PCNL 1
Preoperative Immersive Virtual Reality: A Safer, More Effective Approach to Percutaneous Stone Removal
Andrei Cumpanas3, Kalon L. Morgan1, Antonio Gorgen1, Allen Rojhani1, Rohit Bhatt1, Candices M. Tran1, Kelvin Vo1, Sohrab N. Ali1, Pengbo Jiang1, Zachary E. Tano1, Roshan M. Patel2, Jaime Landman2, Ralph V. Clayman2
1Department of Urology, University of California, Irvine;, 2Department of Urology, University of California, Irvine, 3Department of Urology, University of California, Irvine; Orange, CA, USA
Presented By: Andrei Cumpanas, MD
Introduction: A complete understanding of the CT‐based perirenal anatomy, stone size and stone location in the collecting system is of the utmost importance for a safe and successful PCNL. Accordingly, in a randomized clinical trial, we assessed the impact of using a pre‐operative immersive, interactive virtual reality (iVR) model on surgical planning and outcomes.
Methods: Between 2019‐2022, 150 PCNL patients were randomized preoperatively into either a CT only group (n = 75) or a CT+iVR group (n = 75). CT scans were rendered into iVR models that allowed the urologist to visualize and manipulate the relevant anatomical landmarks, while also simulating the percutaneous approach to the selected calyx of entry (Figure 1). Complications were classified according to the Clavien‐ Dindo system while postoperative CT scans with 2‐3 mm cuts were used to evaluate stone‐free status (i.e., absolute stone free, no remnants (Grade A), stone remnants < 2 mm (Grade B), or stone remnants 2.1 mm to < 4 mm (Grade C).
Results: After viewing the iVR model, the urologist changed the initial CT‐based calyx of choice in 28% of the cases. Moreover, in the iVR group, there was an enhanced understanding of the intra‐renal anatomy, stone location, stone size, stone shape, and orientation of the stone‐bearing (all p < 0.01). In addition, among the iVR patients, there was a statistically significant improvement in absolute‐stone free rate (11 % vs. 23%, p = 0.031) and in the < 2 mm remnant rate (12% vs. 25%, p = 0.036). Lastly, in the iVR group, there was a reduction in Clavien‐Dindo II and IIIa complications (3% vs. 12%, p = 0.037) (Figure 2).
Conclusions: Preoperative viewing of an immersive, interactive iVR model by the operating urologist, resulted in a safer, more effective percutaneous stone removal procedure.
Funding: None.
Prospective Comparison Between a Pulsed Solid State Thulium:YAG Laser and a Holmium:YAG Laser for Lithotripsy During Mini‐PCNL
Benedikt Becker1, Benedikt Becker1, Julius Bergmann1, Christopher Netsch1, Clemens M. Rosenbaum1, Andreas J. Gross1
1Department of Urology, Asklepios Hospital Barmbek
Presented By: Benedikt Becker, MD
Introduction: Laser lithotripsy is one of the standard fragmentation procedures during mini‐PCNL. In this study, a holmium:YAG laser was compared with a new pulsed solid state thulium:YAG laser with special consideration of operative time and stone‐free rates (SFR).
Methods: Between September 2020 and August 2022, all patients (n = 100) who underwent mini‐PCNL were prospectively included. In all patients, either a Ho:YAG laser (Sphinx Jr, Lisa Laser) (group 1) or a new pulsed thulium:YAG laser (RevoLix HTL, Lisa Laser) (group 2) was used as the energy source for lithotripsy. 50 patients were included in each of the two groups and all patients were treated by one surgeon. Primary endpoints were operative time and SFR. On the first postoperative day, all patients underwent either computed tomography or kidney/ureter/bladder radiography with antegrade filling to determine SFR.
Results: Both groups were comparable in terms of age (p = 0.21), gender (p = 0.84), stone size (p = 0.75), and stone density (p = 0.78). The SFR at 24 hours was 90% in the holmium group and 92% in the thulium group (p = 0.73). All patients with residual stones underwent retrograde intrarenal surgery (RIRS) for definitive stone clearance. In all of the five patients from group 1 and in one of the five patients from group 2, a residual stone was removed by RIRS. In the remaining patients of group 2, only stone dust was seen without the possibility to extract any stone material. Laser time (10.35 vs. 7.1 min; p = 0.03) was significantly shorter in group 2. Total operating time from puncture to insertion of the nephrostomy also showed a significant difference between the two groups (39.2 vs. 30.6 min; p < 0.05) with advantages on the side of the thulium:YAG laser. Intraoperative and postoperative complication rates were not significantly different.
Conclusions: The novel pulsed solid state thulium:YAG laser showed significant advantages over the holmium:YAG laser in terms of laser time as well as operative time. However, when comparing the initial SFR as well as the complication rates, there were no significant differences between the two lasers.
Funding: Not applicable.
The Impact of Percutaneous Nephrolithotomy for Nephrolithiasis on Post‐Operative Pain Interference and Social Ability
1University of Pennsylvania, 2Children's Hospital of Philadelphia
Presented By: Justin Ziemba, MD, MSEd
Introduction: Urolithiasis is among the most common urological conditions, however, the quality‐of‐life impact of those with the disease remains significantly understudied, particularly following surgical intervention. We prospectively captured patient‐reported outcomes related to pain interference and social participation in the short term post‐operative period to better understand the quality‐of‐life impact of percutaneous nephrolithotomy (PNL).
Methods: Adults undergoing PNL for renal/ureteral stones were eligible for inclusion (10/2020‐03/2023). Patients prospectively completed PROMIS—Pain Interference and PROMIS—Ability to participate in social roles and activities instruments in‐person 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 and higher score equates to more of the concept being measured.
Results: Total of 60 patients completed enrollment at POD 0 (POD 1 = 15, POD 7 = 23, POD 14 = 13, POD 30 = 17). There were statistically significant differences in pain interference (Figure 1‐A) and social participation (Figure 1‐B) scores between select point comparisons: POD 0‐1 (mean diff. +14.66 pain and ‐8.81 social; p < 0.05), POD 1‐14 (mean diff. ‐12.20 pain and +9.71 social; p < 0.05), POD 1‐30 (mean diff. ‐10.43 pain and +9.00 social; p < 0.05), and POD 7‐30 (mean diff. ‐10.43 pain and +7.37 social; p < 0.05). Black race (β = 9.8, CI: 2.1‐17.0; p < 0.05) and ureteral stone location (β = 7.5, CI: 2.3‐13; p < 0.05) were associated with more baseline pain interference. Increasing age (β = 0.60, CI: 0.09‐1.1; p < 0.05) was associated with greater social participation at POD #1, while female gender was associated with worse social participation at POD #14 (β = ‐12, CI: ‐23‐ ‐0.83; p < 0.05) and more pain interference at POD #30 (β = 14, CI: 4.4‐24; p < 0.05).
Conclusions: Pain interference sharply increases immediately post‐operatively, while ability to participate in social roles declines. Patients return to baseline social participation and see resolution of pain interference by POD 14. Results offer meaningful insight to assist in counseling and setting expectation for patients in the post‐operative period.
Funding: None
Prone versus Supine Percutaneous Nephrolithotomy: Does this have an Effect on Renal Pelvic Pressures?
Kai Wen Cheng3, Kyu Park1, Nicole Mack2, Cliff DeGuzman2, Toby Clark2, Matthew Buell2, Kanha Shete2, Rose Leu2, Akin S. Amasyali2, Ala'a Farkouh2, Elizabeth Baldwin2, Kai Wen Cheng2, Zhamshid Okhunov2, D. Duane Baldwin2
1Loma Linda University School of Medicine, 2Loma Linda University Health, 3Loma Linda
Presented By: Kai Wen Cheng, MD
Introduction: Recently, the influence of renal pelvic pressure (RPP) on surgical outcomes following percutaneous nephrolithotomy (PCNL) has been studied. However, the effect of patient position on RPP has not been published. The aim of this study was to compare RPP between prone and supine PCNL in a benchtop model.
Methods: Six identical silicone 3D‐printed kidney models were placed into anatomically correct prone or supine torsos constructed from an actual prone or supine patient CT scan. A 30 Fr renal access sheath was placed in either the upper, middle, or lower pole calyx of each kidney model for both prone and supine positions. Two 9 mm BegoStones were placed in the respective calyx prior to each trial and RPP was measured in 3 conditions: baseline, during ultrasonic lithotripsy using a 26 Fr rigid nephroscope (RN), and laser lithotripsy using a 16 Fr flexible nephroscope (FN). Five trials were conducted for each of the upper, middle, and lower pole accesses in both prone and supine positions. Statistical comparisons were performed using the Wilcoxon test and a Kruskal‐Wallis test followed by a Dunn's test, with p < 0.05 considered significant.
Results: The average baseline RPP in the prone position was significantly higher (9.1 mmHg) compared to the supine position (2.7 mmHg; p < 0.001). Similarly, the average RPP in the prone position was significantly higher (19.1 mmHg) than in the supine position (5.3 mmHg; p < 0.001) when using the RN. Again, the average RPP in the prone position was significantly higher (13.6 mmHg) compared to the supine position (1.6 mmHg; p < 0.001) when using the FN. When comparing RPPs for upper, middle, and lower pole access site, the lower pole had lower pressure in the supine position, but all access sites were similar in the supine position. Overall, when combining all RPPs at baseline and with irrigation, with all access sites and types of scopes, the mean RPP was significantly higher in the prone position (14.0 mmHg) compared to the supine position (3.2 mmHg; p < 0.001).
Conclusions: RPPs were significantly higher in the prone position compared to the supine position in all three conditions tested. These higher RPPs seen in prone PCNL, could in part explain the increased incidence of fever and sepsis that has been reported in prone compared to supine PCNL.
Funding: None
Antimicrobial Prophylaxis for Percutaneous Nephrolithotomy: Contemporary Practice Patterns
Jeffrey Johnson4, Ojas Shah1, Prakash Gorroochurn2, Miyad Movassaghi1, David Han1, Juliana Villanueva3, Michael Schulster1
1Columbia University Irving Medical Campus, 2Columbia University Department of Biostatistics, 3Columbia University Mailman School of Public Health, 4Weill Cornell Medicine
Presented By: Jeffrey Johnson, MD
Introduction: Updated in 2019, the American Urological Association's (AUA) Best Practice Statement on Urologic Procedures and Antimicrobial Prophylaxis outlines prophylaxis recommendations for percutaneous nephrolithotomy (PCNL). Recent studies have challenged these Best Practice Statements. We hypothesized endourologists do not routinely follow the AUA's statement on antibiotic use during PCNL and assessed their prescribing patterns.
Methods: A 25‐question survey was distributed to members of the Endourological Society. The primary outcome was adherence to the AUA's recommendations. Multivariable logistic regression analysis was performed to assess predictors of Best Practice Statement adherence.
Results: 51.4% of endourologists follow the AUA Best Practice Statement for antimicrobial prophylaxis of uncomplicated PCNL. No demographic data was predictive of following the AUA. 90.9% and 83.6% reported they have “never” used the first‐line recommendation options of metronidazole and aztreonam, respectively. Preferred antibiotics were cephalosporins (uncomplicated 60%, complicated 52.6%), fluoroquinolones (13.3%, 7.2%), aminoglycosides (12.7%, 17.8%), penicillins (7.9%, 11.2%), carbapenems (0.6%, 0.7%), trimethoprim‐sulfamethoxazole (2.4%, 5.9%), fosfomycin (0.6%, 0.7%), nitrofurantoin (2.4%, 2.6%), aztreonam (0%, 0.7%), and clindamycin (0%, 0.7%). For uncomplicated PCNL, 37.9% prescribe > 24 hours of perioperative antibiotics. For complicated PCNL, 16.2% prescribe ≤24 hours of perioperative antibiotics while 20.4% begin antibiotics 7 or more days prior.
Conclusions: Nearly half of respondents do not follow the AUA's recommendations for antibiotic choice for PCNL. Few endourologists prescribe 7 days of preoperative antibiotics for complicated PCNL despite supporting data. Metronidazole and aztreonam are rarely used as a first line antibiotic choice for PCNL and their roles needs to be further evaluated as first line prophylaxis recommendations. Updates on antibiotic recommendations for PCNL are needed based on current literature, antimicrobial stewardship, and contemporary practice patterns.
Funding: None
Comparing Anterior and Posterior Calyx Approach in Supine Percutaneous Nephrolithotomy
Raymond Khargi2, Anna Ricapito1, Alan J. Yaghoubian2, Christopher Connors2, Kavita Gupta2, Samuel Yim3, Blair Gallante2, Johnathan A. Khusid2, William M. Atallah2, Mantu Gupta2
1University of Foggia, Department of Urology, 2Icahn School of Medicine at Mount Sinai, 3SUNY Downstate Health Sciences University
Presented By: Anna Ricapito, MD
Introduction: Percutaneous Nephrolithotomy (PCNL) has traditionally been done in the prone position on which a posterior calyx is designated target for puncture. Modified supine PCNL has gained increasing popularity amongst urologists. Both anterior and posterior calyces are potential targets for access in modified supine positions. However, historically urologists have been reluctant to access anterior calyces due to proximity to adjacent organs and longer access tract. To date, no study has compared the anterior to the posterior calyceal access in supine ultrasound‐guided PCNL. Accordingly, the main objective of this study is to compare the safety and efficacy of anterior and posterior approaches in supine PCNL.
Methods: Consecutive patients undergoing supine PCNL with ultrasound‐guided access were prospectively enrolled. Demographic information and S.T.O.N.E. scores were collected. The decision to access an anterior or posterior calyx was left to surgeon discretion. Intraoperative measurements such as access location, total access time, puncture operator, needlestick attempts, tract length, fluoroscopy time, and operative time were collected. Outcomes included stone‐free rate, 30‐day complications and ED visits and/or readmissions.
Categorical variables were compared between groups using Chi‐square of Fisher's exact tests while continuous variables were analyzed using Mann‐Whitney U‐tests.
Results: Thus far 35 patients were enrolled. 29 underwent anterior and 6 underwent posterior access. There was a greater total stone burden in the anterior group (27 vs 15 mm, p = 0.020). Age, BMI, gender, diabetes, prior PCNL rates, S.T.O.N.E. scores, preoperative hydronephrosis or stent usage did not differ between groups. Location of access was mostly lower pole (89.7% vs. 83.3%, p = .546) and started below the 12th rib (89.7% vs. 66.7%, p = .195). Fewer needlestick attempts were required in anterior approach although this difference was not statistically significant (p = .054). Other intraoperative measures did not differ. Postoperative transfusion rates were greater in the posterior than anterior group (33.3% vs. 0%, p = .025) while stone‐free rate, 30‐day complications, ED visits and readmissions were similar.
Conclusions: There were some differences found in patients who underwent anterior and posterior approach in supine PCNL although the contrast in group size should be noted. Patients who underwent anterior approach had required fewer puncture attempts and had similar complications. Our preliminary data suggest that an anterior calyceal access appears to have a non‐inferior safety and efficacy profile compared to a posterior approach.
Funding: None
An Intraoperative Methylene Blue Test May Help Guide Patient Selection for Totally Tubeless Mini‐Percutaneous Nephrolithotomy
Heiko Yang1, Wilson Sui1, Justin Ahn1, David Bayne1, Marshall Stoller1, Thomas Chi1
1UCSF
Presented By: Heiko Yang, MD, PhD
Introduction: The practice of performing totally tubeless percutaneous nephrolithotomy has been demonstrated to be feasible and safe, especially when smaller access diameters are used (mini‐PCNL). Having an objective test to guide patient selection could improve confidence and enable broader adoption of this practice. The purpose of this study was to evaluate the utility of an intraoperative methylene blue test to predict candidacy for a totally tubeless procedure.
Methods: We performed a pilot study in adult patients undergoing mini‐PCNL at our institution (enrollment began in May 2023 and is ongoing). Patients with anatomic abnormalities or a history of reconstructive surgery (e.g. strictures, ileal conduits), and cases requiring a ureteral access sheath were excluded. After stone clearance, 10 mL methylene blue dye was injected into the percutaneous access tract. A positive test was defined as visualization of blue dye in the bladder catheter within 1 minute of injection. In the case of a positive test, no upper tract drainage tubes (ureteral stent or nephrostomy tube) were inserted. Post‐operative obstructive complications (flank pain, nausea, vomiting, fever) were evaluated as the primary outcome.
Results: The intraoperative methylene blue test was performed in 5 mini‐PCNL cases. Median stone size was
2.2 cm, and the median operative time was 93 minutes. All 5 had positive tests and received no postoperative drainage tubes. Four of 5 patients were discharged same day, while one patient was a planned overnight admission. There were no obstructive or infectious complications on follow‐up.
Conclusions: An intraoperative methylene blue test could be a simple and cost‐effective way to predict candidacy for totally tubeless mini‐PCNL. We are currently increasing the sample size for this study to produce more robust results.
Funding: None
Ultra‐Mini PCNLs Result in Significantly Fewer Bleeding Related Complications as Compared to Standard Approach PCNLs
Conner Brown2, Eli Heifetz1, Amitay Lorber2, Leonid Boyarsky2, Mordechai Duvdevani2
1The Jerusalem College of Technology, 2Hadassah Medical Center
Presented By: Conner Brown, MD
Introduction: Since the advent of the percutaneous nephrolithotomy (PCNL) complications such as bleeding, need for blood transfusion, the risk of pseudoaneurysm have driven many Endourologists to seek improvements to the techniques and methods used during these procedures. One major shift in recent years has been the introduction of the “ultra‐mini” PCNL, a technique that utilizes percutaneous access of 12‐14Fr as compared to 26‐30Fr used during a standard PCNL. The objective of this study is to compare bleeding related complications between standard PCNLs and ultra‐mini PCNLs.
Methods: A retrospective analysis on a database of patients who underwent standard or ultra‐mini percutaneous nephrolithotomy procedures from 2006 to 2022 (n = 807) was performed to identify patients who developed any post‐operative complications, Clavien‐Dindo grade 1‐5, (n = 121). A subset of data was then identified in which the patient had any bleeding complication (n = 22), required a blood transfusion, and/or eventually required selective angio‐embolization (n = 8), then further delineated into standard PCNL and ultra‐ mini PCNL groups.
Results: Of the total complications (n = 121), 98 where in the standard group and 20 where in the ultra‐mini group, while the balance of 3 developed complications after the case was aborted prior to tract dilation. Standard PCNLs were more likely to result in a bleeding complication as compared to ultra‐mini (n = 21 vs n = 0, P = 0.002). The standard PCNL group also required significantly more blood transfusions when compared to the ultra‐mini group (n = 17 vs n = 0, P = 0.009). No statistical difference was observed between the standard and ultra‐mini groups when comparing rates of selective angioembolization (n = 8 vs n = 0, P = 0.12). No deaths in either group were observed.
Conclusions: Ultra‐mini PCNLs result in fewer bleeding related post‐operative complications and blood transfusions when compared to standard PCNLs. While the rate of pseudoaneurysm requiring selective angioembolization is statistically insignificant, none of the ultra‐mini PCNLs performed during this time frame went on to undergo this intervention. Further analysis of the rates of selective angioembolization in ultra‐mini PCNLs as compared to standard PCNLs is warranted once the sample size has increased by a sufficient margin.
Funding: None
Ambulatory Tubeless Mini‐Percutaneous Nephrolithotomy (Mini‐PCNL) versus Retrograde Intrarenal Surgery (RIRS) in Treatment of 1‐2 cm Lower Calyceal Renal Stones: A Randomized Controlled Clinical Study
Husain Alaradi1, Hazem Elmansy1, Moustafa Fathy1, Amr Hodhod1, Amer Alaref1, Parsa Nikoufar1, Ahmed S Zakaria1, Abdulrahman Alkandari1, Ruba Abdul Hadi1, Loay Abbas1, Waleed Shabana1, Ahmed Kotb1, Walid Shahrour1
1Northern Ontario School of Medicine
Presented By: Sai Vangala, MD
Introduction: We compared the safety and efficacy of flexible ureteroscopy (F‐URS) and ambulatory tubeless mini‐percutaneous nephrolithotomy (mini‐PCNL) in the treatment of 1‐2 cm lower calyceal renal stones.
Methods: Patients who underwent F‐URS and mini‐PCNL for the treatment of 1‐2 cm lower calyceal renal stones between October 2020 and July 2022 were evaluated in a randomized controlled trial. Sixty‐four participants were included in the study thus far. All participants underwent a CT renal colic scan preoperatively, on postoperative day one (POD 1), and at 3 months follow‐up. Outcome measures including stone characteristics, operative time, hospital stay, stone‐free rate (SFR) in addition to complication rates were collected and compared. All patients were discharged home on the same operative day.
Results: There were no significant differences in preoperative baseline data between the two surgical groups. A significantly longer median operative time was reported in the mini‐PCNL group (p = 0.04). The median hospitalization time was 5 hours and 4 hours in the mini‐PCNL and F‐URS groups, respectively (p = 0.14). The SFR on POD‐1 was 23.5% in the F‐URS group and 80% in the mini‐PCNL group (p < 0.001). At 3 months follow‐up, the SFR was 67.6% in the F‐URS group and 90% in the mini‐PCNL group (p = 0.03). There was no significant difference in hemoglobin drop or postoperative complications between the two groups. One patient in the F‐URS group required retreatment.
Conclusions: Ambulatory mini‐PCNL and F‐URS are effective treatment options for 1‐2 cm lower calyceal stones. Both techniques have comparable hospital stay and complication rates, with a significantly better stone‐free rate with mini‐PCNL.
Funding: None
Opioid‐Free Percutaneous Nephrolithotomy: An Initial Experience
Raymond Khargi1, Alan J. Yaghoubian1, Ryan M. Blake1, Anna Ricapito2, Christopher Connors1, Kavita Gupta1, Blair Gallante1, Johnathan A. Khusid1, William M. Atallah1, Mantu Gupta1
1Icahn School of Medicine, 2University of Foggia
Presented By: Kavita Gupta, MD
Introduction: The opioid epidemic in the United States is an ongoing public health crisis that is in part fueled by excessive prescribing by physicians. Percutaneous nephrolithotomy (PCNL) is a procedure that conventionally involves opioid prescriptions for adequate post‐operative pain control. We aimed to evaluate the feasibility of a non‐opioid pain regimen by evaluating post‐operative outcomes in PCNL patients discharged without opioids.
Methods: As a quality improvement measure to reduce opioid consumption our department began routinely prescribing oral ketorolac instead of oxycodone‐acetaminophen for pain control after PCNL. We retrospectively compared patients undergoing PCNL who had received ketorolac prescriptions (NSAID) to those who received oxycodone‐acetaminophen prescriptions (NARC). Demographic, operative, and post‐ operative factors were obtained and compared in both groups. peri‐operative factors and demographics were compared using either Chi‐square tests, Mann Whitney U tests. Surgical outcomes were compared between the two groups using Chi‐square tests and Fisher's exact tests. Multivariate logistic regression analysis was performed to determine whether ketorolac use was an independent predictor of post‐surgical pain‐related encounters. Primary outcome was unplanned pain‐related healthcare encounters inclusive of office phone calls, unscheduled office visits, and emergency department (ED) visits. Secondary outcome measures were non‐pain‐related healthcare encounters, hospital readmissions, pain‐related rescue medications prescribed, and post‐op complications.
Results: There were similar demographics and peri‐operative characteristics amongst patients in both cohorts. There was no significant difference identified between NSAID and NARC regarding unplanned pain‐related encounters (8/70, 11.4% vs. 10/70, 14.3%, p = 0.614). However, NARC experienced more unplanned phone calls (42, 60% vs. 24, 34.3%, p = 0.004). Multivariate analysis revealed only prior stone surgery was predictive of pain‐related encounters after PCNL (p = 0.035).
Conclusions: Our results show that there were no significant differences in pain‐related encounters between those who received ketorolac and oxycodone‐acetaminophen following PCNL. A non‐opioid pathway may mitigate the potential risk associated with opioid prescription without compromising analgesia. Prospective comparative studies are warranted to confirm feasibility.
Funding: No Funding
Prospective Randomised Controlled Trial Comparing the Infectious Complications Using Miniperc with and Without Suction for Renal Stones of Size Less than 3 Cm
Introduction: To do a study to compare infectious complications in patients operated for MiniPerc or Minimally invasive Percutaneous Nephrolithotomy (MPCNL) using Storz MIP system without suction and MPCNL with suction using Shah Superperc sheath for medium sized renal stones less than 3 cm in size. The primary objective of this study wasto compare the infectious complications and the secondary objectives wereto compare stone free rates, complication rates and operative times
Methods: A prospective randomized controlled trial with patients having proximal ureteral and renal stones of 10‐30 mm size and planned for MPCNL done at a single institute. Total of 80 consecutively admitted patients with written informed consent were included for randomization with 40 patients in each arm of MPCNL and suction MPCNL.
Results: Median age in MPCNL and suction MPCNL arms were 48 and 49 years, median stone sizes were15.45 and 16.7 cm, Median stone volume were1576.2 vs 1752 mm3, and median stone density was1258 and 1250 Hu respectively, median hospital stay of 3 days in both arms were comparable. Infectious complications were comparable in both the arms. Operative time was significantly less in the suction MPCNL group (26.5 min,IQR 17‐34.8) than in MPCNL group (34.8 min,IQR 20‐45), p = 0.021 and Stone free rates were more in Suction MPCNL arm at 97.5% than in MPCNL at 87.5%, p = 0.04. Overall, the complication rates were comparable in both the arms.
Conclusions: Suction MPCNL procedure resulted in shorter operating times and more stone free rates than conventional MPCNL with comparable complication rates.
Funding: None
Efficacy for Robot‐Assisted Fluoroscopic Renal Puncture in Mitigating Learning Curve for Percutaneous Nephrolithotomy
1Nagoya City University, 2Wakayama Medical University
Presented By: Kazumi Taguchi, MD,PhD
Introduction: We previously reported the efficacy of robot‐assisted fluoroscopy‐guided (RAG) puncture in percutaneous nephrolithotomy (PCNL).In the current study, we compared ultrasound‐guided (USG) puncture with RAG puncture by 1) determining the learning curve for surgical outcome from a pooled clinical trial data, then 2) by using the improved version of robot system for percutaneous renal puncture (ANT‐X@), which enabled us to perform horizontal puncture in the supine position (Figure1).
Methods: 1) The surgical outcomes of RAG PCNL were analyzed to calculate the learning curve and then compared with the 300 USG PCNL database. 2) We conducted a multicenter prospective benchtop study with a renal phantom model using the improved version of ANT‐X®. The participants were 17 urologists who punctured the renal phantom model using RAG and USG techniques. The single puncture success rates, time from device setup to puncture, puncture time, and fluoroscopic usage time were recorded, and the surgeon's self‐assessment using the NASA‐Task Load Index was conducted for the analyses.
Results: 1) In the RAG group, the learning curve for percutaneous access duration and surgical time was steeper than that in the USG group. The stone‐free rate and complications significantly improved as cases accumulated per resident in the USG group, whereas there was no statistical difference in these outcomes by case accumulation in the RAF group. 2) A total of 32 urologists participated in this study. The single‐ puncture success rates of the RAG and USG techniques were 91% and 56%, respectively (p < 0.01). In the RAG technique, the median device setup time was longer (146 and 25 s, p < 0.01), whereas the median needle puncture time (18 and 34 s, p < 0.01) and the deviation from the target center (16 and 26 mm, p < 0.01) were shorter than those in the USG technique, respectively. The results of the surgeon's self‐ assessment showed that the Mean Weighted Workload Score was lower in the RAG technique than in the USG technique (25 and 60, p < 0.01); the mental workload was significantly smaller in the RAG technique.
Conclusions: The RAG technique showed higher accuracy rates of puncture and smaller mental workload than the USG technique for renal puncture.
Funding: None
Comparison of Radiation Exposure in Urologic‐ vs Interventional Radiology‐Guided Access in Percutaneous Nephrolithotomy
Daniel Marchalik1, Kenneth Lim1, Sarah Fashakin2, Dar Yoffe2
1MedStar Georgetown University Hospital, 2Georgetown University School of Medicine
Presented By: Daniel Marchalik, MD, MBA
Introduction: Radiation exposure from percutaneous nephrolithotomy (PCNL) can vary widely between institutions and surgeons. The purpose of this study was to compare radiation exposure (fluoroscopy time and dose) during PCNL when renal access is obtained by interventional radiology (IR) versus urology.
Methods: A retrospective chart review was conducted of consecutive patients undergoing unilateral PCNL, categorized by the method of renal access, by three endourologists from January 2020 to January 2023. Two of the endourologists use IR assistance to obtain renal access prior to PCNL while the other endourologist performed PCNL with endoscopic combined intrarenal surgery (ECIRS). Patient characteristics along with fluoroscopy times, fluoroscopy doses, and operative times were compared using a two‐independent sample student's t‐test and multivariable linear regression analysis.
Results: Thirty‐one patients underwent unilateral PCNL with IR renal access (group 1 (IR)) while 66 patients underwent urology‐guided ECIRS (group 2 (URO)). The two groups were similar based on mean age, BMI, sex, and stone size. Fluoroscopy dose (39.6 vs. 327 mgy, p < 0.001) and fluoroscopy time (1.46 vs. 10.9 min, p < 0.001) were significantly lower in the URO group. Total operative time (1.97 vs. 3.00 hours, p < 0.001) was also lower in the URO group. With each unit increase in BMI, fluoroscopy dose was increased by 28.93 mgy (p < 0.001) in the IR group. However, this correlation was not noted in the URO group.
Conclusions: Endoscopic guided renal access by a urologist resulted in a significant reduction in radiation exposure and operative time. Interestingly, BMI was associated with increased operative times within the IR renal access group, but not the urology renal access group. As these patients are likely to undergo multiple procedures requiring fluoroscopy and given the negative potential effects of radiation exposure, it is important to continue to find ways to decrease total radiation dose in percutaneous urologic surgery.
Funding: none
Ambulatory Percutaneous Nephrolithotomy is a New Standard of Care: An Analysis of Over 1600 Cases
Natalia L. Arias Villela1, Max R. Drescher1, Andy J. Martinez Morales1, Suneet Waghmarae2, Daniel C. Rosen1, Meagan M. Dunne1, Joel E. Abbott1, Julio G. Davalos1
1Chesapeake Urology, 2University of Maryland School of Medicine
Presented By: Natalia L. Arias Villela, MD
Introduction: Percutaneous nephrolithotomy (PCNL) has traditionally been considered an inpatient surgery due to the risk of bleeding and systemic infection. The evolution of technology and surgical approaches, such as the application of endoscopic combined intrarenal surgery (ECIRS) and mini‐PCNL (mPCNL), have increased the safety of this procedure. In this series, we show that ambulatory PCNL (aPCNL) may be safely and efficaciously performed in most patients.
Methods: We analyzed patients who underwent aPCNL, including standard PCNL (24‐30Fr) and mPCNL (14‐23Fr), at two free‐standing ambulatory surgery centers (ASCs) between 2015‐2022. Patient exclusion criteria for the ASC included BMI > 50, severe cardiopulmonary conditions, and history of prior anesthetic complication. Patients were positioned either prone or in the Galdakao‐modified Valdivia supine position. Standard practices included ECIRS technique for renal access, ureteral stent only for drainage with a thrombin‐soaked hemostatic plug in the access tract, and surgeon‐administered intercostal rib block to optimize pain control. Patients were observed in the post‐anesthesia care unit (PACU) for 90 minutes and were sent home without a Foley catheter. Patient demographic, pre‐operative, and post‐operative data were prospectively collected. Descriptive statistics were used for data analysis.
Results: A total of 1610 cases were available for analysis (Table 1). The mean age of patients was 57.4, mean BMI was 33.1, and mean ASA score was 2.3. 27% of patients had diabetes and 59% had hypertension. 17% of patients had a positive urine culture treated pre‐operatively. The mean stone burden was 31.4mm. Standard tract PCNL was used in 66% of cases and 92% of cases were done through a single tract. 99% of cases had a ureteral stent as the only form of drainage. The mean treatment time was 18 minutes and mean PACU time was 84 minutes. There was no planned second look in 90% of cases. The average estimated blood loss was 41mL. 1.9% of patients had a Clavien‐Dindo complication > grade 2, but none were grade 5. Only 1.7% of patients required hospital transfer.
Conclusions: aPCNL is efficacious and safe in appropriately selected patients. In our high‐volume series, we found a low morbidity rate and low risk for hospital transfer. Unless there are medical or social factors precluding same day discharge, PCNL should be routinely performed as an ambulatory procedure.
Funding: None
Stone Burden Volume as Predictor of Outcomes After Mini‐Percutaneous Nephrolithotomy
Connie Chen1, Austen Slade1, Elisa Sarmiento1, Thomas Max Shelton1, RJ Caras1, Marcelino Rivera1
1Indiana University School of Medicine
Presented By: Connie Chen, BS
Introduction: Surgical decision making for kidney stones is often performed by visual estimation of stone burden, but as the quantity and size of stones increases, estimation becomes challenging as there is no standardized method for obtaining this measurement. Advances in artificial intelligence (AI) have allowed for automated calculation of stone volume; however, no study has evaluated how AI models compare with standard estimates or if true stone volume can predict outcomes after mini‐PCNL. We aimed to compare stone volume with other methods of measuring stone burden in their predictive value for outcomes after mini‐ PCNL.
Methods: Patients undergoing unilateral mini‐PCNL at our institution between 2019 and 2021 were included in this retrospective analysis. Stone burden was assessed through three ways: cumulative stone diameter, maximum diameter of largest stone, and total stone volume measured on pre‐operative CT scan using a web‐ based AI segmentation tool. Mini‐PCNL was defined as access sheath ≤22 French in size. A patient was stone‐free if there were no fragments > 3mm on post‐operative CT scan. Primary outcome was stone‐free status (SFS) at discharge. Secondary outcome was operative time. Pearson correlation was used to determine if stone volume correlates with cumulative stone diameter and/or maximum diameter. Logistic regression and linear regression were used to compare the predictive value for SFS and operative time.
Results: A total number of 57 CT scans were analyzed. Pearson correlation revealed that stone volume had a positive correlation with cumulative stone diameter (r = 0.99, p < 0.001) and maximum diameter (r = 0.97, p < 0.001). Logistic regression revealed that cumulative stone diameter (OR 0.966, 95% CI 0.909‐1.028), maximum diameter (OR 1.014, 95% CI 0.887‐1.158), and stone volume (OR 1.351, 95% CI 0.483‐3.777) did not predict SFS. Linear regression revealed that cumulative stone diameter was a predictor of operative time (estimate 1.917, 95% CI 0.859‐2.975, p < 0.001). Maximum diameter (estimate 1.479, 95% CI ‐0.810‐ 3.768) and stone volume (estimate 14.365, 95% CI ‐0.054‐28.784) did not predict operative time.
Conclusions: In a cohort of mini‐PCNL patients, operative time was best predicted by cumulative stone diameter. Both total stone diameter and maximum stone diameter correlate very well with stone volume. Further refinement of AI software measuring large stone burden volume and operative measures is needed to determine predictive value of stone‐free rate and operative time in more complex stone procedures.
Funding: None
Ergonomics in Prone vs. Supine Percutaneous Nephrolithotomy: Electromyographic and Emotional Analysis of Lithoclast Master vs. Lithoclast Trilogy
Belén Giménez1, Juan Fulla1, Diego González1, Tomás Gatica2, Pablo Chamorro1, Nicolás Urnía3, Sebastián Arroyo1, José Salvado2, Felipe Pauchard4, Gastón Astroza5, Sofía Astorga1, Catherine Sanchez6
1Universidad de Chile, 2Universidad Finis Terrae, 3Universidad de Desarrollo, 4Universidad de Valparaíso, 5Pontificia Universidad Católica de Chile, 6Clinica las Condes
Presented By: Belén Giménez, MD
Introduction: Percutaneous nephrolithotomy (PNL) is considered the treatment of choice for large and staghorn renal stones. Stone fragmentation can be performed using lithotripters, where Lithoclast Master (LM) and Trilogy (LT) stand out. The surgical approach for PNL can be performed prone or supine, with debate on the optimal position. Our aim was to compare the physical and mental fatigue produced by PNL in the urologist when the patient is in the prone vs. supine position, comparing the use of both lithotripters, through an ergonomic analysis of the procedure.
Methods: Urologists experts in endourology were evaluated when performing simulated PNL in 4 different conditions that combined each of the approaches (prone or supine) with each of the lithotripters (LM or LT). Muscular fatigue was measured by electromyography and assessed by the mean percentage of muscular activation using root mean square method. Heart rate was used to analyze emotional fatigue. Besides, a surgical workload measure questionnaire, Surgery Task Load Index (SURG‐TLX), was applied for each condition, comparing physical and temporal demands, situational stress, task complexity and distractions. Data was analyzed using STATA 11.
Results: Four urologists were recruited for the study. The analysis of fatigue did not show relevant overall differences in the evaluated muscles in the 4 conditions, despite the existence of differences in specific muscles. In the analysis of emotional fatigue, a greater increase in heart rate was observed when LM was used in both positions. The SURG‐TLX questionnaire analysis highlighted higher physical demand, temporal demand, task complexity, and distraction for prone position compared to the supine position, mainly when using LT. The higher score for distraction was observed when using LM, in the supine position. Regarding mental demand and situational stress, there were no major differences between both approaches or lithotripters.
Conclusions: This study provides the first analysis of physical and emotional fatigue in different PNL approaches. The overall findings indicate no significant differences in terms of physical fatigue between the two lithotripters and approaches. However, variations in emotional fatigue were observed across the different conditions. These findings should be taken into consideration when selecting the appropriate surgical techniqueforurologists.
Funding: None
Characterization of Intrarenal Pressures During Mini Percutaneous Nephrolithotomy: A Randomized Trial Comparing Suction to Non‐Suction Sheaths
Raymond Khargi1, Alan J. Yaghoubian1, Anna Ricapito2, Christopher Connors3, Kavita Gupta1, Samuel Yim1, Blair Gallante3, Johnathan A. Khusid1, William M. Atallah1, Mantu Gupta1
1Icahn School of Medicine at Mount Sinai, 2University of Foggia, Department of Urology, 3Icahn School of Medicine
Presented By: Kavita Gupta, MD
Introduction: In recent years, there has been a growing emphasis on the intrarenal pressure generated during Mini‐Percutaneous Nephrolithotomy (PCNL) due to its connection with renal damage and the potential for sepsis. We aimed to assess the range of pressures created in the urinary collecting system of patients undergoing Mini‐PCNL.
Results: A total of fifteen patients were enrolled in the study and randomly assigned to either the suction group (8/15) or the non‐suction group (7/15). Maximum and average pressure was found to be similar during access sheath dilation and nephroscopy in both groups. However, during the lithotripsy component, the suction group demonstrated a significantly lower maximum pressure measurement compared to the non‐ suction group (9.5 mmHg vs. 34.3 mmHg, p = 0.037). Conversely, the average lithotripsy pressure did not show a statistically significant difference between the two groups.
Conclusions: Based on our preliminary findings, the average intrarenal pressure during Mini‐PCNL appears to remain unchanged regardless of the utilization of a suction system. However, it is noteworthy that the maximum pressure experienced during lithotripsy is significantly lower when employing a suction sheath.
Funding: This work was supported by a grant from the New York Academy of Medicine.
Laser‐Guided Renal Access for PCNL: A Comparison to Conventional Fluoroscopy
Sikai Song1, Alphie Rotinsulu1, Ala'a Farkouh1, Matthew Buell1, Akin S. Amasyali1, Rose Leu1, Kanha Shete1, Carter Ware1, Vance Gentry1, Sikai Song1, Grant Sajdak1, Cliff DeGuzman1, D. Duane Baldwin1
1Loma Linda University Health
Presented By: Sikai Song, MD
Introduction: Fluoroscopic‐guided renal access exposes patients and staff to substantial radiation. The Laser Direct Alignment Radiation Reduction Technique (DARRT) is a hybrid technique utilizing fluoroscopy, ultrasound, endoscopic vision, and laser targeting to reduce fluoroscopy use and improve outcomes. The purpose of this study was to compare Laser DARRT to conventional fluoroscopic‐guided PCNL.
Methods: A retrospective review was performed of all patients undergoing PCNL at a single academic institution from January 2017 to March 2023. Patients with pre‐existing nephrostomy tubes used for access and only ultrasound‐guided access were excluded. Renal access was categorized into either fluoroscopy or Laser DARRT. The primary outcomes of interest were total fluoroscopy time and fluoroscopy time used for renal access. Secondary outcomes were stone‐free rates (SFR), complication rates, procedure time, length of stay, and need for additional procedures. The independent samples t‐test was used to compare continuous variables and the Chi‐squared test was used to compare categorical variables between groups, with p < 0.05 significant.
Results: A total of 292 patients met inclusion criteria. Baseline patient characteristics were similar between groups (Table 1). There was no significant difference in stone laterality, stone volume, and Hounsfield units, however there was a higher percentage of staghorn calculi in the Laser DARRT group (84.6% vs 67%; p = 0.001). The Laser DARRT technique resulted in significantly lower total fluoroscopy time (21.8 vs 597.7 sec; p < 0.001) and fluoroscopy time for access (10.8 vs 551.7 sec; p < 0.001). There was no significant difference in total procedure times, length of stay, blood loss, or complication rates between groups (Table 1). SFR was significantly higher for the Laser DARRT group (84.1% vs 64.1%; p < 0.001).
Conclusions: Laser DARRT reduced mean renal access fluoroscopy time by 98% and total fluoroscopy time by 96.4% during PCNL. Despite reduced fluoroscopy time, laser DARRT had higher stone‐free rates and similar operative times, estimated blood loss, and complication rates.
Funding: None
Supine Mini Percutaneous Nephrolithotomy in Horseshoe Kidney
Eugenio Di Grazia5, Orazio Maugeri1, Letterio D'Arrigo2, Roberta Agliozzo1, Gianluca Calvano3, Federica Trovato1, Sebastiano Diego Cimino4
1“G.Rodolico ‐ San Marco” Polyclinic University Hospital, 2Emergency Hospital, Cannizzaro, 3ARNAS Garibaldi, 4G.Rodolico ‐ San Marco” Polyclinic University Hospital, 5MaterDei Hospital
Presented By: Eugenio Di Grazia, Medical Doctor
Introduction: The percutaneous nephrolithotomy (PCNL) in Horseshoe kidneys (HSK) is usually performed in the prone position, allowing entry through the upper pole and providing good access to the collecting system. However, in patients with normal kidney anatomy, the supine position is reliable and safe in most cases, but it is unknown whether the supine position is adequate in patients with HSK. The purpose of this study was to describe the results of PCNL in HSK in three different surgical institutions and to evaluate the impact of supine position during surgery, comparing pre‐operative and post‐operative data, complications, and stone status after surgery.
Methods: Between 2017 and 2022, a total of 10 patients underwent percutaneous renal surgery for stone disease in HSK. All patients were evaluated pre‐ and post‐ operatively with non‐contrast CT. We evaluated patients (age and gender), stones characteristics (size, number, side, site and density ), and outcomes. The change in haemoglobin, hematocrit, creatinine and eGFR were assessed between the most recent preoperative period and the first postoperative day. Procedure success was defined as stone‐free or presence of ≤4 mm fragments (Clinically Insignificant Residual Fragments – CIRF). Complications were registered and classified according to Clavien‐Dindo Grading System, during the 30 ‐ day postoperative period and Clavien scores ≥3 were considered as major complications. Statistical analysis was performed using “R 4.2.1” software, with a 5% significance level. We also compared pre‐operative and post‐operative data using “Wilcoxon signed‐rank test”.
Results: No statistical difference was observed between pre‐operative and post‐operative renal function data. At one post operative day CT scan, an overall success rate of 100% was registered. 9/10 patients were completely free from urolithiasis (stone‐free rate: 90%), while 1/10 patients had ≤4 mm stone fragments residual(CIRF rate: 10%). No cases of intraoperative complications were registered. Post‐operative complications were reported in 1/10 patients. The patient developed urosepsis (defined as SIRS with clinical signs of bacterial infections involving urogenital organs ‐ Clavien‐Dindo Grade II) after procedure, that was treated with intravenous antibiotic therapy successfully.
Conclusions: This study shows that in patients with HSK Mini‐PCNL in supine position allows to achieve good stone free rate with a very low morbidity. According to our series, the described technique for PCNL in HSK should be an option. Nevertheless these results must be confirmed by further studies.
Funding: None
Monopolar Electrocautery in Providing Hemostasis During Tubeless Miniaturized Percutaneous Nephrolithotomy
1Department of Urology, Seoul National University Hospital, Seoul National University College of Medicine, 2Division of Urology, Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 3Department of Urology, Seoul National University Hospital
Presented By: Sung Yong Cho, Professor
Introduction: Kidney hemorrhage is one of the most common and significant complications of tubeless miniaturized percutaneous nephrolithotomy (mPCNL). This study aimed to evaluate the effectiveness and safety of hemostasis in mPCNL using monopolar electrocautery in the percutaneous tract bleeding.
Methods: We prospectively enrolled 200 consecutive patients (presenting to a single institution and) classified them into two groups. The experimental group consisted of 28 patients receiving monopolar coagulation for the percutaneous tract. The control group included 172 patients in whom fulguration was not done. Perioperative outcomes were compared between the groups.
Results: There was no statistical difference in operative times and transfusion rates between the two groups. However, patients who received electrocauterization demonstrated a statistically significant decrease in the rate of angiography procedures. Additionally, these patients experienced a significantly shortened duration of double J stent placement and rapid recovery of hemoglobin levels, particularly in cases of significant bleeding. Notably, no significant complications were observed in either group.
Conclusions: These findings suggest that the use of monopolar electrocauterization effectively reduces the risk of postoperative bleeding and alleviates the burden on patients who may require additional blood transfusions by providing effective hemostasis during tubeless mPCNL.
Funding: This work was supported by the National Research Foundation of Korea(NRF) grant funded by the Korea government(MEST) (No. 2022R1F1A1059835) andthe Korea Medical Device Development Fund grant funded by the Korea government (the Ministry of Science and ICT) (Project Number: 1711194216,
Risk Factors for Urinary Septic Shock Following Ureteroscopy for Stone Disease
Ameer Nsair1, Michael Mullerad1, Oleg Goldin1, Gilad Amiel1
1Rambam Health Care Campus
Presented By: Ameer Nsair, MD
Introduction: Urinary tract infections (UTIs) are a common complication of endourological procedures for stone fragmentation. In a recent meta‐analysis, the risk of postoperative urosepsis after ureteroscopy for stone disease is 5%. Risk factors for postoperative urosepsis were older age, diabetes mellitus, ischemic heart disease, preoperative stent placement, a positive urine culture, and longer procedure time.Septic shock is a life‐threatening subset of sepsis and It's identified with a clinical construct of sepsis with persisting hypotension requiring vasopressors to maintain MAP ≥65 mmHg and having a serum lactate level > 2 mmol/L (18 mg/dL) despite adequate volume resuscitation. With these criteria, hospital mortality is more than 40%.The aim of this study is to identify clinical and surgical risk factors for the development of septic shock following ureteroscopy.
Methods: Between January 2010 to December 2021, 5000 patients underwent ureteroscopy in our academic medical center. 20 cases of postoperative septic shock were identified and evaluated retrospectively. A control group of 115 patients were identified that consecutively underwent ureteroscopy during 2021 at our academic medical center and did not develop septic shock. Septic shock was defined as those requiring vasopressors admission due to sepsis following the procedure.Several preoperative and intraoperative factors have been collected: age, gender, medical history including presence of hypertension, diabetes, ischemic heart disease, malignancy, chronic kidney disease, baseline glomerular filtration rate, baseline creatinine levels and body mass index (BMI). Presence and type of pre‐operative and post‐operative drainage, duration of pre‐operative drainage, pre‐operative culture status and operating time.All patients completed preoperative workup including complete blood count, blood chemistry and urine culture. In addition, all patients underwent a preoperative non‐contrast CT examination of the urinary tract. The stone numbers, location and size were identified.
Results: The demographic and clinical factors of both groups are presented in Table 1. The septic shock group was significantly older, females comprising about 65% of the group which is about twice the females in the control group. In addition, they had significantly higher BMI, twice as much hypertension and far greater percentage of preoperative positive urine culture with 6 times that of the control group. In addition, the septic shock group had a higher percentage of preoperative drainage and their preoperative drainage duration was significantly higher than their controls. No pattern was identified in the other compared factors.Multivariate analyses was applied on gender, age, BMI, history of diabetes, hypertension, ischemic heart disease, duration of preoperative drainage and positive urine culture. Multivariate analysis indicated that advanced age, higher BMI and positive preoperative urine culture were statistically significant. The data are presented in Table 2.
Conclusions: Risk factors for the occurrence of urinary septic shock following ureteroscopy include advanced age, higher BMI and previously positive culture. This information can assist in risk stratifying patients for developing this severe infectious complication following ureteroscopy and therefore diagnose septic shock more efficiently in order to provide prompt treatment. Further research preferably multi‐centred with a larger cohort is needed to better characterise the risk factorsfor septic shock following ureteroscopy.
Funding: None
Predicting Success in Primary Ureteroscopy for Proximal Ureteral Stones
Hadar Tamir1, Sagi A. Shpitzer1, Shayel Bercovich1, Abd E. Darawsha1, Ron Gilad1, Yaron Ehrlich1, David Lifshitz1
1Rabin Medical Center
Presented By: Hadar Tamir, MD
Introduction: The treatment of choice for proximal ureteral stones is ureteroscopy or shock wave lithotripsy. When discussing primary ureteroscopy (pURS) with a patient it is important to recognizethe scenario of a tight ureter requiring ureteral stent placement. To our knowledge, a comprehensive model that utilizes potentialpredictors to determine the presence of a tight ureterhas not yet been developed.
Methods: We retrospectively reviewed 168 patients undergoing pURS for proximal urolithiasis from 2014 to 2023 in RMC. The primary outcome was the completion rate of the URS. We collected patients' demographic, medical history, and surgical factors from medical records. We trained 3 classical learning multi‐feature machine learning classifiers to predict pURS success relying on patient's characteristics.
Results: To develop predictive models, we employed three machine learning classifiers: naive Bayes, decision trees, and logistic regression. These models achieved accuracy rates of 73.5%, 88.2%,and 79.4% respectively. Interestingly, certain features that were initially deemed insignificant in the single‐feature analysis played a significant role in predicting the outcome of pURS. Factors that were included in the most accurate predictive model were Cr, age, BMI, largest ureteral stone diameter, Hb, and previous ipsilateral procedure.In a multivariable analysis, the highest rate of success was found in male gender with previous procedure and stone expulsion(p = 0.024).
Conclusions: pURS has shown a high success rate for treating proximal ureteral stones. Utilizing machine learning techniques, clinicians can accurately assess the likelihood of completing the treatment in a single procedure based on patient features. This has the potential to significantly impact pre‐procedure discussions with patients, providing valuable insights into the chances of requiring a two‐procedure treatment approach.
Funding: None.
A Novel Nomogram to Stratify Risk of Septic Shock in Patients Undergoing Ureteral Stent Placement for Obstructing Stone and Presumed Urinary Tract Infection
Brian Eisner1, Michal Segall1, Jason J. Lee2, Christina S Kottooran1, Kate Hanson3, Nikil Uppaluri3, Micheal Borofsky3
1Massachusetts General Hospital, 2Yale, 3University of Minnesota
Presented By: Brian Eisner, MD
Introduction: Kidney stones areone of the most common urologic causes of emergency room (ER) visits. Patients with obstructing stones and concomitant infection, have an increased risk of developing infection, pyelonephritis, and urosepsis. The current study aimsto create a predictive risk stratification score through generation of a nomogram which incorporates these risk factors which can be used as a clinically useful tool to predict urosepsis in this group of patients.
Methods: An IRB approved retrospective chart review was performed to identify consecutive patients undergoing emergent retrograde ureteral stent placement at two different sites between the dates July 2016 through April 2020. Patients were included if they had unilateral obstruction from ureteral or renal pelvic stones with a documented concern for concomitant urinary tract infection who underwent ureteral stent placement within 24 hours of emergency room arrival.Collected patient data was run through sequentialsingle and multiplelogistic regressions in order to identify variables related to the outcome of interest (septic shock). Outcomes are reported using a Response Operator Curve (ROC) analysis with Area Under the Curve (AUC). Values over at least 600 were considered marginally adequate.
Results: The following variables were identified as significant predictorsdeveloping septic shock: age, purulent urine, history of recurrent UTIs, WBC count, lactate and qSOFA status.Each of the variables was weighted to up to a 100 points, with lactate having the highest maximum score and point accrual (100) and history of recurrent UTI having the lowest maximum score (30). Overall, the sum of the results are weighted in a score ranging from 0‐350, with 110 being the lowest combined score with assigned risk of 10% and 270 being the highest combined score with an assigned risk of 90%. Nomogram is displayed in figure 1. AUC value is 81.1%.
Conclusions: Using the risk factors identified, our nomogram can predict up to a 90% risk of developing septic shock due to an obstructive stone with concomitant UTI. This finding offers a potentially useful clinical tool in evaluating patients so that escalation of care is preemptively prepared where necessary.
Funding: No funding was received
Preoperative Antibiotic Duration Has no Impact on Postoperative Infectious Complication Rate After Ureteroscopy in High Risk Patients
Wilson Sui1, Ukrit Rompsaithong1, Lejla Pepic1, Heiko Yang1, Kevin Chang1, Ashwin Balakrishnan1, David Bayne1, Justin Ahn1, Marshall Stoller1, Tom Chi1
1University of California, San Francisco
Presented By: Wilson Sui
Introduction: Postoperative infections after ureteroscopy are common and potentially devastating complications. The AUA and EAU guidelines recommend treatment of symptomatic positive urine cultures, but how to apply these guidelines to high risk patients, who are often asymptomatic, remains unclear. To examine whether antibiotic duration impacts the infection rate, we evaluated our institutional practices and outcomes with regard to preoperative antibiotic use in high risk ureteroscopy patients.
Methods: Our prospectively collected database, the Registry for Stones of the Kidney and Ureter, was queried for all patients undergoing ureteroscopy between 2015 and 2022. Perioperative urine culture results and antibiotic duration/choice were abstracted. Patients with a high likelihood of urinary colonization were identified (history of spinal cord injury, stroke, MS, paraplegia, bowel diversion, indwelling SPT or foley, or a stent/percutaneous nephrostomy in place for > 30 days). Our primary outcome was postoperative infection, which was defined by urinary tract infection, pyelonephritis, systemic inflammatory response syndrome or fever within 30 days of surgery.
Results: A total of n = 884 patients met our inclusion criteria, 57% of whom were low risk while the rest were high risk. Duration of preoperative prophylactic antibiotic utilization was categorized into none, 1‐3 days, 3‐10 days and > 10 days before the day of surgery for patients. The proportion of patients in each category were similar (Figure 1a). For all high‐risk patients, the infectious complication rate ranged from 10% to 20% and there were no differences detected on univariate analysis. On multivariable analysis of predictors of postoperative infectious complications, only female sex (OR 1.938, 95% CI 1.183‐3.324) was statistically significant.
Conclusions: The duration of preoperative antibiotics prior to ureteroscopy, even in high risk patients with positive urine cultures, did not reduce postoperative infectious complication rates. Further research is needed to identify alternative interventions to prevent postoperative infectious complications
Funding: None
Quality of Life After Urinary Stone Surgery Based on Japanese Wisconsin Stone Quality of Life Questionnaire
1Department of Nephro‐urology, Nagoya City University Graduate School of Medical Sciences, 2Department of Urology, Gyotoku General Hospital, 3Department of Urology, Hara Genitourinary Hospital
Presented By: Shuzo Hamamoto, MD, PhD.
Introduction: Health‐related quality of life (HRQOL) assesses the impact of health conditions and symptoms on daily lifeof stone formers.However, no study has yetcomparedthe HRQOL pre‐and post‐operation for urinary stones and the factors associated withthesechanges by HRQOL.Weevaluated the impact of surgical treatment for urinary stones on perioperative health‐related quality of life (HRQOL)usingthe Japanese Wisconsin Stone Quality of Life questionnaire (J‐WISQOL), anHRQOL measure designed for patients with urinary stones.
Methods: This study prospectively enrolled 123 patients with urinary stones who visited three academic hospitals for stone treatment. The participants completed the J‐WISQOL within four weeks before and aftertheurinary stone treatment. Treatmentsincluded shock wave lithotripsy (SWL), ureteroscopy lithotripsy (URSL), and endoscopic combined intrarenal surgery (ECIRS). J‐WISQOL was assessed for age, stone size and location, type of treatment, stone‐freestatus, postoperative ureteral stent placement, hospital stay, and complications in all patients.
Results: Inthepreoperative J‐WISQOL, patients with stones in the ureter had significantly greater social impact D1 (p = 0.005) and disease impact D3 (p = 0.045) than those with stones in the kidney. In a comparison of pre‐ and postoperative J‐WISQOL, patients without postoperative ureteral stent placementscoredsignificantly higher social impact D1 (p = 0.007) and disease impact D3 (p < 0.001).Patientswith less than the medianlength of hospital stayhad significantly higher social impact D1 (p = 0.001) and disease impact D3 (p < 0.001) compared to those with longer hospital stay.SWL significantly improvedthetotal score (p = 0.015), social impact D1 (p = 0.017), and disease impact D3 (p = 0.004) comparedwithother treatments.
Conclusions: In this study, we evaluated,the pre‐ and postoperative changes in HRQOL of SWL, URSL, and ECIRSinpatients with urinary stones using J‐WISQOL. Perioperative HRQOL in patients with urinary stones is particularly affected by the type of treatment, ureteral stent placement, and hospital stay,whichshould be considered in surgical selection and patient decision‐making.
Funding: none
Patient‐Reported Pain and Quality of Life after Ureteroscopy Vary by Stone Location and Stenting
Russell Becker1, Stephanie Daignault‐Newton1, Andrew Higgins1, Mahin Mirza1, Bronson Conrado1, Golena Fernandez Moncaleano1, Mahmoud Hijazi1, Karla Witzke2, Jeremy Konheim3, Richard Sarle4, Kandis Rivers5, William Roberts1, Khurshid Ghani1, Casey Dauw1
1University of Michigan Medicine, 2MyMichigan Health Midland, 3IHA Urology, 4Sparrow Hospital, 5West Bloomfield Hospital
Presented By: Russell Becker, MD PhD
Introduction: Studies of ureteroscopy outcomes have historically centered on efficacy (stone‐free rates) and safety (complications). However, the patient's own subjective experience, including pain and health‐related quality of life (HRQOL), are gaining recognition as additional important factors. Empirical data on these are severely lacking. We have previously reported that ureteral stent placement after ureteroscopy increases unplanned healthcare encounters. However, less is known about the impact of stent placement on HRQOL.
Methods: The Michigan Urological Surgery Improvement Collaborative (MUSIC) Reducing Operative Complications from Kidney Stones (ROCKS) group launched a patient‐reported outcomes (PRO) program in 2021 which includes assessments of pain (PROMIS Pain Intensity and Pain Interference), lower urinary tract symptoms (LURN), and treatment satisfaction (ICIQ). This automated system distributes electronic questionnaires preoperatively and at 7‐10 days and 4‐6 weeks postoperatively. We compared postoperative day 7‐10 (POD7) PROs for stented versus not stented patients based on stone location (renal versus ureteral) with linear regression models adjusting for preoperative score, age, gender, pre‐stenting, and stone size.
Results: Clinical and PRO data were collected on 338 patients (64% ureteral, 36% renal stones). Overall 251 (74.3%) had a stent placed at the time of surgery. Stented patients had larger stones in both the ureteral (8 vs 6mm, p < 0.001) and renal (10 vs 7mm, p < 0.001) subgroups. Stent omission in patients with ureteral stones resulted in improved PROMIS Pain Interference (52.7 vs 57.4, p < 0.01), PROMIS Pain Intensity (48.9 vs 53.6, p < 0.01), LURN urinary symptoms (6.3 vs 10.3, p < 0.001), and ICIQ treatment satisfaction (21.1 vs 18.5, p < 0.01) at POD7 (Figure). For patients with renal stones, stent omission resulted in improved PROMIS Pain Interference (55.8 vs 61.1, p = 0.02) and LURN urinary symptoms (6.9 vs 10.7, p < 0.001), without significant differences in PROMIS Pain Intensity (52.9 vs 56.6, p = 0.1) or ICIQ treatment satisfaction (20.0 vs 17.6, p = 0.07).
Conclusions: Stent omission at the time of ureteroscopy was associated with significantly better PROs at POD7 for patients with both ureteral and renal stones.
Funding: MUSIC is funded by Blue Cross Blue Shield of Michigan
First‐in‐Human Experience Using the LithoVue Elite Single Use Ureteroscope to Measure Intrarenal Pressure: The Canadian Experience'
Naeem Bhojiani4, Kyo Chul Koo1, Abdulghafour Halawani2, Victor K.F. Wong3, Ben H. Chew3
1Yonsei University, 2King Abdulaziz University, 3University of British Columbia, 4University of Montreal
Presented By: Naeem Bhojiani, MD, FRCSC
Introduction: Intrarenal pressure (IRP) is thought to play a role in complications following ureteroscopy. This area is poorly studied because of the difficulty in routinely measuring IRP. We report on our first‐in‐ human experience using the LithoVue EliteTM ureteroscope (Boston Scientific).
Methods: A single‐arm retrospective observational analysis was performed in 46 consecutive patients undergoing ureteroscopic lithotripsy using the LithoVue Elite™ system with pressure sensing capability between April‐October, 2022 at 2 centres. A pressure bag set at 150mmHg or hand irrigation with a 60cc syringe was used for irrigation and a ureteral access sheath (UAS) was placed at the physician's discretion. Median and maximum IRPs, and relative cumulative time exceeding 20, 40, 60, 80, 100, 120, 140, 160, and 200 mmHg per total procedure time were analyzed. The two‐sample Mann‐Whitney U‐test was used with a statistical significance set at p < 0.005.
Results: Median patient age and body mass index (BMI) were 62.5 (IQR 47.8–72.0) years and 29.4 (23.3– 32.8) kg/m2 (Table 1). During the median total procedure time of 31.9 (IQR 17.4–44.9) minutes, median and maximum IRPs were 30.0 (IQR 21.0–51.5) and 177.0 mmHg (IQR 129.0–266.0), respectively. IRP remained below 60 mmHg 91.3% of the procedure times. Patients with Asian ethnicity and hypertension had higher pressures and a longer relative cumulative time ≥20 mmHg compared to others, while patients with tight ureters and without UAS use exhibited longer cumulative times ≥60 mmHg . The smaller 10/12 Fr UAS did not lower pressures as much as the 11/13 Fr and 12/14 Fr UAS (p < 0.001). Age, pre‐stenting, preoperative α‐blockade, and BMI did not show any statistically significant associations with IRP.
Conclusions: IRP can now be routinely measured during ureteroscopy. Patients had a median IRP of 30 mmHg and a maximum of 177 mmHg. The use of a smaller UAS (< 12/14 Fr), Asian ethnicity, hypertension and tight ureters were found to have higher IRPs in our study.
Funding: Boston Scientific Corporation provided the LithoVue Elite ureteroscopes in‐kind. No other contributions, monetary or otherwise were distributed to any of the investigators or sites.
Ureteral Access Sheath is Not Associated with Reductions in Infection‐Related Hospitalization: Real‐World Data from a Surgical Collaborative
Russell Becker1, Andrew Higgins1, Golena Fernandez Moncaleano1, Sung Yong Cho1, Mohammad Jafri2, Jessica Phelps3, Jeremy Konheim4, Bronson Conrado1, Monica Van Til1, Stephanie Daignault‐Newton1, Casey Dauw1, Khurshid Ghani1
Introduction: Elevated intrarenal pressure during ureteroscopy (URS) may result in pyelovenous backflow, which is hypothesized to increase the risk of sepsis. When treating renal stones, the ureteral access sheath (UAS) is considered a pressure mitigation strategy, yet evidence on whether a UAS reduces infectious complications is unclear. Prior studies are limited by small cohorts, heterogenous inclusion criteria, ambiguous endpoints, or lack adequate risk adjustment. We examined UAS use when treating renal stones and its association with infection‐related hospitalization in a statewide registry.
Methods: Using the Michigan Urological Surgery Improvement Collaborative (MUSIC) registry, we identified all patients undergoing single‐stage unilateral URS for renal stones, with or without the use of a UAS. We assessed variation in UAS in practices with > 10 cases. We evaluated demographic differences between cases with or without UAS. A multivariable logistic regression model was constructed to examine the impact of UAS use and other patient, stone, and surgical factors on 30‐day infection‐related hospitalization.
Results: Among 6,142 patients undergoing URS by 233 urologists across 34 practices, 152 (2.5%) had an infection‐related hospitalization within 30 days. Overall 59% of cases utilized UAS, with significant variation between practices (4.1% to 99.5%, p < 0.0001). Patients with UAS had significantly larger stones, more positive preoperative urine culture, and higher comorbidity. Infection‐related hospitalization rates were no different for cases with (2.6%) vs. without (2.3%) UAS use (p = 0.5). On multivariable analysis (Figure), infection‐related hospitalizations did not differ by UAS (OR 0.8; 95% CI 0.6 ‐ 1.2; p = 0.4), but were associated with higher Charlson Comorbidity Index (CCI 1 vs. 0, OR 1.9; 95% CI 1.2 ‐ 2.9; CCI 2+ vs. 0, OR
2.3; 95% CI 1.4 ‐ 3.6; p < 0.001), history of recurrent UTI (OR 2.4; 95% CI 1.4 ‐ 4.0; p < 0.01), larger stones (OR per 5mm 1.1; 95% CI 1.0 ‐ 1.3; p = 0.04), and positive preoperative urine culture (OR 1.8; 95% CI 1.2 ‐ 2.7; p < 0.01).
Conclusions: Utilization of UAS when treating renal stones varies widely across practices within Michigan. UAS was not associated with differences in infection‐related hospitalization following URS for renal stones.
Funding: MUSIC is funded by Blue Cross Blue Shield of Michigan.
Dusting versus Fragmentation/Basketing for Renal Stones: Real World Utilization and Outcomes
Russell Becker1, Alex Zhu1, Andrew Higgins1, Monica Van Til1, Stephanie Daignault‐Newton1, Sung Yong Cho1, Richard Sarle2, Eric Stockall3, Casey Dauw1, Khurshid Ghani1
1University of Michigan Medicine, 2Sparrow Hospital Urology, 3Capital Urological Associates
Presented By: Russell Becker, MD PhD
Introduction: Dusting technique for ureteroscopy (URS) laser lithotripsy has become popular, but there remains a knowledge gap about how often it is performed compared to fragmentation with basketing. Prior studies of outcomes for dusting vs. fragmentation are from expert single centers and may not reflect real‐ world practice. We assessed practice patterns and outcomes of the two techniques in Michigan.
Methods: Using the Michigan Urological Surgery Improvement Collaborative (MUSIC) clinical registry, we identified all single‐stage cases of URS laser lithotripsy performed for renal stones between 2016‐2022. Data was collected by independent abstractors at each practice using standardized definitions. Stone‐free rate (SFR) was defined as zero fragments on imaging reports (ultrasound, x‐ray, CT scan) within 60 days. We assessed urologist‐level utilization of dusting vs. fragmentation/basketing. Using multivariable regression we assessed the association of each technique with stone‐free rate and 30‐day postoperative emergency department (ED) visits accounting for patient, stone, and surgical characteristics.
Results: Among 4,772 ureteroscopy procedures for renal stones performed by 230 surgeons across 34 practices, 2,838 (59%) were performed with a dusting technique. Significant variation in use of dusting was observed across urologists (0‐100%, p < 0.001) (Figure 1A). Dusting was used more frequently for larger stones (median [IQR]: 9mm [7‐13] vs 8mm [6‐11], p < 0.001) and stones in multiple locations (30% vs. 20%, p < 0.001). Ureteral access sheaths (55% vs 72%, p < 0.001) and post‐operative stents (79% vs 86%, p < 0.001) were used less frequently with dusting. Dusting approach was associated with higher ED visits on multivariable analysis (OR 1.4, 95% CI 1.1‐1.8, p = 0.006). Post‐operative imaging was performed in 48% of patients; SFR was lower with dusting (OR 0.6, 95% CI 0.5‐0.7, p < 0.001) (Figure 1B).
Conclusions: Six of ten patients with renal stones undergoing URS are treated with a dusting technique in Michigan. Real‐world practice indicates dusting is associated with higher post‐operative ED visits and lower stone‐free rates.
Funding: MUSIC is funded by Blue Cross Blue Shield of Michigan.
Introduction: We aimed to evaluate operative time with the outcomes of ureteroscopy (URS) and investigate the relationship between these factors, and assess if longer operative times were associated with a higher risk of complications.
Methods: This study aimed to investigate various factors influencing stenting requirements in patients undergoing retrograde intrarenal surgery (RIRS) and/or ureteroscopic surgery (URS). A comprehensive analysis was conducted on a sample of 2432 patients. The patients were divided into two groups: with ana without preoperative ureteral stent. The operative time, duration of prior stent placement, total stone volume were respectively compared.
Results: The impact of time elapsed since the prior stent on subsequent stenting in the current procedure was examined. Results indicated a positive relationship, suggesting that longer intervals between prior stenting procedures were associated with an increased likelihood of requiring a new stent. Additionally, the influence of stone volume on the need for stenting in the current procedure was explored. Findings demonstrated a positive correlation, indicating that larger stone volumes were associated with a higher probability of requiring a stent. Furthermore, the correlation between the time passed from the last stenting procedure and the duration of the current procedure was investigated. Statistical analysis revealed no significant correlation between these variables (the average procedure time for patients without a prior stent was 26 minutes, whereas patients with a prior stent experienced a similar or even longer duration (29 minutes). Lastly, a comparison was made between patients with and without prior stents to determine stenting rates in the current procedure. The results showed differing percentages of patients requiring a new stent based on their prior stenting status.
Conclusions: These findings emphasize the importance of considering factors such as timing of prior stenting, stone volume, and prior stent presence in decision‐making for stenting during RIRS and URS procedures. This research contributes to enhancing surgical decision‐making and optimizing patient outcomes in urological interventions.
Funding: Hadassah University Hospital
The Impact of Ureteroscopy for Nephrolithiasis on Post‐Operative Disease Specific Quality of Life
Justin Ziemba1, Jay Fuletra1, Amanda Jones1, Zili Zong2, Jing Huang1
1University of Pennsylvania, 2Children's Hospital of Philadelphia
Presented By: Justin Ziemba, MD, MSEd
Introduction: Urolithiasis is among the most common urological conditions, however, the quality‐of‐life impact of those with the disease remains significantly understudied, particularly following surgical intervention. We prospectively captured patient‐reported outcomes related to disease‐specific quality of life in the short term post‐operative period following ureteroscopy (URS) for nephrolithiasis.
Methods: Adults undergoing URS for renal/ureteral stones were eligible for inclusion (10/2020‐8/2022). Patients prospectively completed Wisconsin Stone Quality of Life (WISQOL) instrument in‐person pre‐ operatively (POD 0) and via email on POD 30. Scores are reported as a total score and 4 domain scores: social, emotional, disease, and vitality impact. A higher score equates to a better quality of life.
Results: Total of 178 patients completed enrollment at POD 0 (POD 30, N = 67). There were statistically significant improvements for the total score and each of the 4 domain scores between POD 0 and 30 (Wilcoxon rank sum test, all p < 0.001) (Figure 1 A‐E). On univariate analysis, age (β = 0.32; CI: 0.11, 0.53), African American race (β = ‐11; CI: ‐20, ‐2.5), and BMI (β = ‐11; ‐1.1, ‐0.18) were all associated with the total score at POD 0, while only African American race (β = ‐22; CI: ‐41, ‐2.0) remained associated at POD 30. On multivariate analysis, both age (β = 0.28; CI: 0.08, 0.49) and BMI (β = ‐0.67; CI: ‐1.1, ‐0.21) remained associated with the total score at POD 0, while no demographic variables were associated with the total score at POD 30 after adjusting for stone and surgical characteristics. A prediction model revealed that only an intraoperative kidney stone location (ref. lower ureter) predicted a profound recovery (> 10 points) (OR 0.14; CI: 0.02, 0.87; p < 0.035) for the total score.
Conclusions: Ureteroscopy results in significant improvement in disease specific quality of life by 30‐days. Both age and BMI may have a modifying influence on recovery. Kidney as opposed to ureteral stone removal may result in a more profound recovery. Results offer meaningful insight to assist in counseling and setting expectation for patients in the post‐operative period.
Funding: None
Comparison of Ureteoroscopy and Laser Stone Fragmentation Between Holmium:YAG Laser with MOSES vs Non‐MOSES Technology: Prospective Single‐Centre Propensity Score‐Matched Analysis Using Similar Laser Settings
Victoria Jahrreiss4, Francesco Ripa1, Clara Cerrato2, Carlotta Nedbal3, Amelia Pietropaolo2, Bhaskar Somani2
1Department of Stones and Endourology, University College London Hospitals, 2University Hospital Southampton NHS Trust, 3University Hospital Southampton NHS Trust, Università Politecnica delle Marche Ancona, Italy, 4University Hospital Southampton NHS Trust, Southampton, UK; Department of Urology Medical University Vienna, Austria
Presented By: Victoria Jahrreiss, MD
Introduction: In‐vitro studies have shown that the holmium MOSES technology can lead to an increase of efficacy in lithotripsy and a reduction of retropulsion, but clinical evidence comparing it to Non‐MOSES technology is still scarce. We did a comparison of ureteoroscopy and laser stone fragmentation (URSL) between Holmium:YAG laser with MOSES vs Non‐MOSES technology.
Methods: Patient data and outcomes were prospectively collected and analyzed regarding patient demographics, stone parameters and clinical outcomes. Patients undergoing URSL with standard high power holmium laser (100W) without MOSES technology (group‐1) were compared to 60W holmium laser with MOSES (group‐2) using the same clinical laser settings (0.4‐1J, 20‐40Hz) with dusting and pop‐dusting technique. The independent t‐test, Mann–Whitney‐U test and Chi‐squared test were used, with a p‐value of < 0.05 as significant. Given the different size of the cohorts, we performed a propensity score 1:1 matched analysis.
Results: A total of 206 patients (1:1 matched) with a male:female ratio of 94:112 and a median age of 56 (range: 39‐68) years were analyzed. Group 1 and 2 were matched for ureteric stones (27.7% and 22.3%, p = 0.42), pre‐stenting (37% and 35%, p = 0.66), mean number of stones (1.76 ± 1.3) and 1.82 ± 1.4,p = 0.73) and ureteral access sheath (37% and 35%,p = 0.77) respectively.While there was no significant difference in clinical outcomes, the stone size was slightly larger in group 2, 14.8mm ±10.8 vs 11.7mm ±8.0, for a lower operative time 42.7min ±30.6 vs 48.5min ±25, lower perioperative complication rates 3.9% vs 4.9% and a higher stone free rate 90.3% vs 87.4%.
Conclusions: While the use of MOSES technology was slightly beneficial for treatment of stones in terms of clinical outcomes, this was not statistically significant. As this debate continues, there is a need for high quality randomized studies to show if there is a true difference in these outcomes.
Funding: None.
Negative Ureteroscopy in Ureteral Stone Management: Identifying Predictive Factors and Implementing Solutions
Ukrit Rompsaithong2, Thomas Chi1, Wilson Sui1, Heiko Yang1, David Bayne1, Justin Ahn1, Marshall Stoller1
1Department of Urology, University of California, San Francisco, San Francisco, California, 2Division of Urology, Department of Surgery, Khon Kaen University, Khon Kaen, Thailand
Presented By: Ukrit Rompsaithong, MD
Introduction: Negative ureteroscopy (URS), characterized by the unexpected absence of detecting stones during surgery, is an uncommon but known outcome in the management of ureteral stones. This outcome potentially exposes patients to unnecessary surgical interventions and complications. However, these risks should be weighed against the risk of leaving ureteral stone untreated. This study aims to identify predictive factors associated with negative URS and propose solutions to improve stone detection rates.
Methods: In this cohort study, we retrospectively analyzed prospectively collected data on consecutive patients who underwent URS for unilateral ureteral stone disease from the Registry for Stones of the Kidney and Ureter (ReSKU) between 2015 and 2022.Exclusion criteria included concomitant kidney stone procedures, and staged procedures. Patient characteristics, preoperative imaging, operative data, and complications were compared between positive and negative URS cases. Univariable and multivariable logistic regression analyses identified factors associated with negative URS.
Results: A total of 307 renal units were included, with a negative URS rate of 12.1%(95%CI 8.6‐16.2%). Negative URS cases had significantly shorter operative times compared to URS cases where stones were found (39 vs 51 minutes, p < 0.001) and a lower frequency of postoperative stent placement (43.2% vs 80.4%, p < 0.001). No significant differences were observed in the length of hospital stay and complication rate between the two groups. Factors significantly associated with negative URS were absence of microscopic hematuria (OR 30.62), ureterovesical junction stone location (OR 28.54), stone size < 6 mm (OR 16.53), interval symptomatic presentation (OR 13.50), interval since computed tomography (CT) scan > 2 months (OR 7.54), and right‐side stone location (OR 5.62) (Table 1).
Conclusions: Optimizing preoperative imaging protocols and careful patient selection can help reduce negative URS rates. Patients should be counseled about the risk of a negative ureteroscopy and repeat imaging should be considered when these associated factors are present.
Funding: None
Characterizing Pain Location and Intensity Following Ureteroscopy for Stones – Results from the USDRN STudy to Enhance uNderstanding of sTent‐Associated Symptoms (STENTS)
Jonathan Harper1, Andrew Rabley1, Naim Maalouf2, Hongqiu Yang3, Alana Desai1, Peter Reese4, Gregory Tasian5, Hunter Wessells1, Hussein Al‐Khalidi3, Henry Lai6, Michele Curatolo1, Jodi Antonelli7, Matthew Sorensen1, Rob Sweet1, Ziya Kirkali8, Charles Scales9
1University of Washington, 2University of Texas Southwestern Medical Center, 3Duke Clinical Research Institute, 4University of Pennsylvania, 5Children's Hospital of Philadelphia, 6Washington University in St. Louis, 7Duke Urology, 8National Institute of Diabetes and Digestive and Kidney Diseases, 9Duke Clinical Research Institute, Duke Urology
Presented By: Jonathan Harper, MD
Introduction: Previously published data from STENTS reported the time course of stent‐associated symptoms (SAS) and factors associated with increased pain. However, there remains a paucity of information regarding the location and site‐specific intensity of stent‐associated pain. We hypothesized that differences in these factors may exist between sexes due to dissimilar genitourinary anatomy and voiding patterns, and that differences may exist based on stone location. The objective of this analysis was to characterize pain location and intensity after URS and ureteral stent, and to describe differences between sexes and primary stone location.
Methods: STENTS participants completed questionnaires at baseline and on postoperative day (POD) 1, 3, 5, 7‐9, and 30 days after stent removal. Pain distribution and intensity were characterized with the Brief Pain Inventory, in which participants localized specific sites of pain using a detailed body map, indicating the site of most intense pain at each time point. These findings were stratified by sex and primary stone location.
Results: 424 participants enrolled in STENTS at five US health systems; 47% were female and mean age was 49 years (SD 17). The dominant stone location was 50% renal and 50% ureteral. The most frequent sites of pain were the back followed by abdomen and pubic region, all ipsilateral to the stone. Of these 3 sites, the site of most intense pain on POD 1 was equally reported in the ipsilateral back (38%) and abdomen (38%) followed by pubic region (24%). On POD 5, 42% reported pain in the ipsilateral back as most intense, followed by abdomen (34%) and pubic region (24%).Men were more likely to report ipsilateral back as the most intense pain site on POD 1 (p = 0.003) and POD5 (p = 0.007), independent of dominant stone location. Women more often reported pain in the abdominal region on POD1 (p = 0.008) and in the pubic region on POD3 (p = 0.003). Compared to those with ureteral stones, those with a dominant renal stone were more likely to: 1) have ipsilateral back pain on POD 1‐5 (p < 0.05) and 2) report a higher pain intensity score at various sites and timepoints.
Conclusions: Pain distribution after URS with ureteral stent, including location of most severe pain, changed over time, and differed between sexes and by stone location. These results facilitate counseling and may contribute to a better understanding of the patient experience and identification of patient pain phenotypes.
Funding: US National Institutes of Health/NIDDK
What is the Most Favourable Modality of Treatment for Children with Ureteral Stones ≤10 mm2?
Muhammet Demirbilek2, Elif Altınay Kırlı1, Engin Dereköylü2, Feyyaz Irmak2, Bülent Önal2
1Istanbul University‐Cerrahpasa, Cerrahpasa Faculty of Medicine, 2Istanbul University‐Cerrahpasa, Cerrahpasa School of Medicine
Presented By: Muhammet Demirbilek, MD
Introduction: We compared the effectiveness of shock wave lithotripsy (SWL) and ureterorenoscopy (URS) in the treatment of ureteral stones ≤10 mm2.
Methods: Children presented ureteral stone ≤10 mm2stone burden, and whom had been treated either with SWL or flexible/semirigid URS were included in the study(1998‐2021). Factors related with outcome (detection of no stone in radiological evaluations a month after the treatment was accepted as stone‐free, and any size of stone fragment regarded as failure) and complication (determined according to Satava and modified Clavian classifications) were evaluated regarding the patients, stones and treatment characteristics.
Results: Of 153 patients with a median age of 7(1‐17) were treated with SWL(n = 89;58%) and URS(n = 64;42%). According to comparison based on treatment protocols (SWL/URS) patients have similar gender distributions(p = 0.869), stone locations(distal/proximal;p = 0.869)and stone burden(p = 0.869). Patients that underwent URS are relatively younger (p = 0.008), and have a higher rate of a previous history of stone surgery(p = 0.003).According to comparison based on outcome; the age(p = 0.655), gender(p = 0.229), side (p = 0.304), and stone burden (p = 0.304) were similar for the patients that had a stone free status and residual stones. Stone free status is similar for SWL and URS (91% vs 83%; p = 0.129). Nevertheless; success rates are lower for distal ureter stones treated with URS (67%;p = 0.009). Complication rates were found to be higher in the group with residual stones (26%;p = 0.035).
Conclusions: We conclude that SWL was found to be effective for the treatment of ureter stones ≤10 mm2in children. Lower stone free status rates in the treatment of distal ureter stones with URS was surprising. The factors related to the patient and ureter, independent of localization and size, may be effective in this result, that we should focus on further studies.
Funding: None.
Steerable Ureteroscopic Renal Evaluation Achieves Higher Stone Clearance and Lower Residual Stone Volume Compared to Ureteroscopy with Basketing
Tom Chi7, Brian Matlaga1, Thomas Mueller2, Brett Johnson3, Jay Page4, Stuart Wolf5, Glenn Preminger6
1Johns Hopkins, 2Summit Urology, 3University of Texas Southwestern, 4Arizona Urology, 5University of Texas, 6Duke University, 7University of California San Francisco
Presented By: Tom Chi, MD
Introduction: Recent studiesdemonstrated thatsteerable ureteroscopic renal evacuation (SURE)using the CVAC® Aspiration Systemis safe and effective, even in complex patients with large stone burden.ASPiration toImproveRenal Calculi RemovalEffectiveness (ASPIRE) is a prospective, randomized, multi‐center study to evaluate the safety and efficacy of SURE compared to ureteroscopy with basketing (URS).Herein, we report the 30‐day efficacy and safety outcome.
Methods: 132 subjects from 11 US institutions were enrolled in the study between June 2021 and February 2023, and 104 subjects qualified for the efficacy analysis. All subjects had baseline CT and post‐operative CT. Post‐operative CT was standardized to 1.25mm CT slice thickness at 30‐days post‐op, reviewed by a central lab radiologist, and overread by an endourologist. Three‐dimensional volumetric analysis was performed. This data was used for efficacy endpoints including stone clearance, residual stone volume (RSV), and stone free rate (SFR) defined as zero fragments.
Results: SURE demonstrated statistically significant higher stone clearance (96.8% vs. 92.9%, p = 0.034) and lower RSV (15.0 ± 31.1 vs. 70.2 ± 144.9, p = 0.01) than URS. These results were independent of the baseline stone volume, in contrast to that of the standard URS (Figure 1).SURE also minimized the RSV in the lower pole vs. URS (25.7 ± 37.9 vs. 97.4 ± 147.3, p = 0.046). There was no significant difference in SFR or safety between SURE and URS.There were 3 CVAC‐related events that were managed without intervention.
Conclusions: SURE is safe and delivers higher stone clearance and minimizes residual stone volume, independent of the baseline stone burden. ASPIRE will assess future stone events and retreatments thru the 2‐ year duration.
Funding: Calyxo
WITHDRAWN
Urereteroscopy for Nephrolithiasis: Cost Effectiveness of Pre‐Stented Ureteroscopy vs Non‐ Stented Ureteroscopy
Reut Shashar1, Lihi Blumen1, Boris Lebedenko1, Michael Mullerad1, Oleg Goldin1, Gilad Amiel1, Azik Hoffman1
1Rambam Medical Center
Presented By: Reut Shashar, MD
Introduction: Ureteroscopy (URS) for treating stone disease involves the cost of the procedure, as well as additional costs involving the perioperative period, hospitalization, and expenses due to common complications. Real‐life expenses for achieving stone‐free status involves the cost of URS, hospitalization days, insertion and removal of ureteral stents, and extra costs for possible complications such as emergency room (ER) visits and additional procedures.Primary URS compared to post‐stent URS are both accepted treatments for renal and ureteral calculi, without any proven clinical superiority of one over the other. In this study we compared the cost of the two options in a public healthcare system, incorporating real‐life expenses and clinical outcomes.
Methods: Clinical data regarding patients treated for ureter and kidney stones were collected retrospectively: demographic details, stone characteristics, information regarding ER visits, hospital admissions, and treatment in the pre and post‐operative period. Total treatment cost was calculated by summing the cost of URS (5,896$), stent insertion (892$) and removal (1,652$), need for additional ureteroscopies, ER visits (262$), and hospitalization stay (952$ per day) in the perioperative period (30 days post OP). A statistical analysis was made to compare both treatment options.
Results: 299 patients underwent URS between 2019‐2022, 145 had primary URS and 154 had URS following prior stenting. Age and sex did not differ among groups. Stone size was larger in the pre‐stented group: 9 mm (IQR [6‐15mm]) vs 7 mm (IQR [5‐10mm], p = 0.019. In the pre‐stented group, 70% (108/154) had a proximal stone (kidney or upper ureter), and 30% (46/154) had a distal stone (middle or distal ureter), compared to 54% (79/145) proximal stone, and 46% (66/145) in the non‐stented group. The mean cost of the treatment was lower for proximal stones in 1,176$, comparing to the pre‐stented group (8,807 USD vs 9,983
USD, p‐value = 0.035). In distal stones, there was no significant difference in the overall cost between pre‐ stented and non‐stented patients, regardless of stone size. The overall stone‐free rate after 3 months was similar in both groups (87% vs 86%, respectively).
Conclusions: Stenting before ureteroscopy for renal and upper ureteral stones may lower the overall cost of the treatment with a similar stone‐free rate.
Funding: N/A
Assessing the Safety of Ureteral Stent Placement for Obstructive Urolithiasis in Patients During the COVID‐19 Pandemic
Thomas Martin1, Ankur Choksi1, Soum Lokeshwar1, Mursal Gardezi1, Christopher Hayden1, Amir Khan1, Timothy Tran1, Dinesh Singh1, Piruz Motamedinia1
1Department of Urology, Yale School of Medicine
Presented By: Thomas Martin, MD
Introduction: Patients with an active SARS‐CoV‐2 infection are at a higher risk of post‐operative mortality as well as pulmonary and cardiovascular complications. In this study, we analyze the post‐operative safety of patients undergoing cystoscopy with ureteral stent placement for an obstructing ureteral calculi that tested positive for COVID‐19.
Methods: We retrospectively identified patients who underwent cystoscopy and ureteral stent placement between June 5, 2020 and December 31, 2022 as an add‐on case for an obstructive ureteral stoneafter presenting to the Emergency Department. Patients were stratified by whether they had a positive COVID‐19 test on admission. Baseline characteristics were compared using Students t‐test for continuous variables and Pearson chi‐square test for categorical variables. Univariate and multivariate logistic regression analysis was performed to identify predictors of postoperative 30‐day mortality.
Results: A total of 1,408 patients underwent add‐on cystoscopy with ureteral stent placement for an obstructing calculus, of which 55 (3.9%) patients had a positive COVID‐19 test. When stratified by COVID‐ 19 status, both groups were similar with regards to age, sex, race, co‐morbidities, indications, procedure duration, and type of anesthesia administered. Patients without COVID‐19 had a higher prevalence of chronic lung disease. Of the 137 patients that were admitted to the ICU, 9 patients were COVID‐19 positive (16.4% vs. 9.4%, p = 0.09). On multivariate logistic regression, patients with COVID‐19 had a higher odds of 30‐day mortality (OR 7.06, 95% CI: 2.03 – 24.47, p = 0.002) when controlling for age, co‐morbidities, vaccination status, anesthesia type, and indication for ureteral stent placement.
Conclusions: Patients that underwent cystoscopy and ureteral stent placement for an obstructing ureteral stone with a concurrent COVID‐19 diagnosis had an increased risk of 30‐day perioperative mortality.
Funding: None
MODERATED POSTER SESSION 6: UROTHELIAL CARCINOMA
Open vs Robotic/Laparoscopic Nephroureterectomy: Contemporary Trends from a Wide National Population‐Based Database
Francesco Ditonno1, Antonio Franco1, Morgan R. Sturgis1, Celeste Manfredi1, Daniel Roadman1, Jamie Yoon1, Adan Z Becerra1, Srinivas Vourganti1, Ephrem O Olweny1, Riccardo Autorino1
1Rush university medical center
Presented By: Francesco Ditonno
Introduction: The existing literature on nephroureterectomy (NU) primarily relies on studies conducted at single institutions, which typically report outcomes from experienced surgeons at high‐volume centers and teaching hospitals. However, it remains unclear whether similar outcomes can be reproduced at a broader national level. Our primary objective was to investigate overall complication rates among open and robotic/lap partial nephroureterectomy, including impact of social determinants of health (SDOH) on postoperative outcomes.
Methods: Patients who underwent open and robotic/lap NU between 2011 and 2021 were retrospectively analyzed by using PearlDiver‐Mariner, an all‐payer insurance claims database. International Classification of Diseases diagnosis and procedure codes were used to identify the type of surgical operation, patient's characteristics, postoperative complications and SDOH. Outcomes were compared using multivariable regression models.
Results: Overall, 15,240 patients underwent open (n = 7,675) and robotic/lap (n = 7,565) nephroureterectomy. The 60‐day postoperative complication rate was 23% for open and 19% for robotic approach. Approximately 5% and 9% of patients reported at least one SDOH at baseline for open and robotic/lap NU, respectively. SDOH were associated with slightly higher odds of postoperative complications (Open = OR:1.09, 95% CI:0.84‐1.40; Robot/Lap = OR:1.17, 95% CI:0.95‐1.43). Open approach showed a significantly higher risk of postoperative complications (OR:1.33, 95% CI:1.20‐1.48) compared to the minimally invasive approach. Utilization of nephroureterectomy outlined opposite timeline trends when comparing open to robotic/lap approach, from 57% in 2011 to 13% in 2021 (p = 0.05) and from 24% to 35% (p = 0.05), respectively. There were not significant differences in terms of insurance plane's adoption between the two groups.
Conclusions: Contemporary trends are showing a shift towards minimally invasive nephroureterectomy, which is gradually replacing the open counterpart, due to a less invasiveness and lower complication rates. SDOH seems to have slight impact on postoperative outcomes.
Funding: None
Long‐Term Follow‐up and Efficacy of Endoscopic Treatment for Low‐Grade Upper Tract Urothelial Carcinoma (LG‐UTUC)
Hen Hendel1, Yaron Ehrlich1, Abd Elhalim Darawsha1, Chen Shenhar1, Ron Gilad1, David Lifshitz1
1Rabin Medical Center
Presented By: Hen Hendel, MD
Introduction: The endoscopic treatment of LG‐UTUC has gained significant momentum as a therapeutic approach in recent years. The choice of appropriate treatment requires a thorough evaluation of the treatment's long‐term effectiveness, utilizing data from the literature as well as real‐world outcomes. In this study, we present long‐term follow‐up data after endoscopic treatment for LG‐UTUC.
Methods: We retrospectively identified patients who underwent endoscopic treatment for LG‐UTUC in our department until 2022. Clinical follow‐up was conducted, and medical records were reviewed up until the beginning of 2023. Data on laboratory parameters, pathology, and morbidity were collected and analysed.
Results: The study cohort comprised 62 patients who underwent endoscopic treatment for LG‐UTUC, including 5 patients (8.1%) with bilateral disease. The median age at presentation was 70.5 years (range: 51‐ 89), and risk factors such as cardiovascular disease and hypertension were present in 43.3% of patients. Prior bladder tumor history was observed in 51.6% of cases, with 45.1% of patients having a low‐grade pathology and 8.1% having a high‐grade pathology. The average tumor size during the initial surgery was 13.14 mm.The median follow‐up period was 5 years (interquartile range: 2.8‐8). Over the follow‐up period, patients underwent an average of 6.83 ureteroscopies (range: 1‐24), with an average of 1.39 ureteroscopies per year. The average hospitalization duration was 16.27 days (range: 2‐56). Monitoring of GFR levels revealed an average decrease of 9.86 ml/min/1.73 m2.During follow‐up, tumor recurrence in the upper urinary tract was observed in 83.3% of patients, while 8.1% exhibited a transformation to a higher‐grade malignancy. Nephroureterectomy was required in 20.1% of patients at an average of 3.45 years from diagnosis. Metastatic spread occurred in 4.8% of patients, with an average time to detection of 2.62 years. The average time to death from any cause was 6.83 years.
Conclusions: Renal preservation treatment for LG‐UTUC demonstrates a success rate of 79.9% in our patient cohort, based on a median follow‐up of 5 years. Although the risk of metastatic spread is relatively low, the recurrence rate in the upper urinary tract remains high. Further research and strategies are warranted to address these challenges and optimize patient outcomes
Funding: None
Retrograde Intrarenal Ablation of Upper Urinary Tract Urothelial Carcinoma with Thulium Laser: A Reliable Alternative to Nephroureterectomy
Roman Andreev2, Konstantin Kolontarev1, Dmitriy Pushkar1, Elena Lazareva1
1Moscow State University of Medicine and Dentistry named after A.I. Evdokimov, 2The S.I. Spasokukotsky City Clinical Hospital, Moscow, Russia
Presented By: Roman Andreev, FACS
Introduction: Upper urinary tract urothelial carcinoma (UTUC) is a rare and dangerous disease that requires serious treatment. Radical nephroureterectomy has long been the gold standard treatment for UTUC, but it should only be used for large tumors because it can lead to serious complications. In this regard, small tumors of low malignancy are the most promising to operate with flexible ureteroscopic laser ablation, which allows to save the organ and avoid the development of complications. Various types of lasers for the treatment of UTUC are discussed in the literature, but the efficacy and safety of the Thulium (Tm:YAG) laser for ureteroscopic ablation of UTUC has not yet been studied.The aim of the study:to evaluate the safety and efficiency of the Thulium laser in ureterorenoscopic ablation of UTUC to improve the treatment outcomes of patients with this disease.
Methods: To achieve this goal, a retrospective single center study of patients diagnosed with UTUC was performed between January 2018 and December 2022. All patients underwent ureterorenoscopy to visualize the tumor process, as well as a biopsy of the UTUC. Depending on the histopathological grade of the tumor, patients were recommended to undergo either radical nephrectomy (in case of high grade of malignancy) or retrograde intrarenal ablation of the tumor and follow‐up (in case of low grade of malignancy).The study was conducted to evaluate the results of retrograde intrarenal ablation of urothelial carcinoma using the Thulium laser. Forty patients participated in the study, 23 of whom underwent radical nephrectomy surgery, while the remaining 17 patients who underwent laser Tm:YAG ablation alone were followed up for 15 months.
Results: The study demonstrated high safety and efficacy of retrograde intrarenal ablation of urothelial carcinoma using the Thulium laser. Among the 17 patients who underwent laser ablation of UTUC, reoperation was required only in one case (5.9% of cases), which was due to the original size of the tumor. It is worth noting that hemostatic drugs and hemotransfusions were not used in any of the cases. The use of this method allows preserving the organ and minimizing the development of complications associated with renal failure.
Conclusions: Evaluation of the results of retrograde intrarenal ablation of urothelial carcinoma using Thulium laser showed its high efficiency and safety. The use of this technique allows not only preserving the organ, but also avoiding complications in the form of renal failure. However, an additional study with a larger number of patients and a prospective study design is required to assess these results more accurately.
Funding: no funding
Endoscopic Ablation versus Nephroureterectomy for Low‐Grade Favorable and Unfavorable Upper Urinary Tract Malignancies: Mid‐term Results
Hen Hendel1, Shayel Bercovich1, Asaf Shvero2, Nir Kleinman3, David Lifshitz1
1Rabin Medical Center, 2sheba medical center, 3Sheba medical center
Presented By: Hen Hendel, MD
Introduction: Endoscopic ablation is currently the preferred treatment for low‐grade, favorable upper urinary tract tumors (UTUC) and may be offered to patients with unfavorable low‐grade UTUC. In this study, we analyzed the oncological outcomes of endoscopic treatments compared to nephroureterectomy (NU) and evaluated the favorable and unfavorable low‐risk subgroups within the endoscopic group.
Methods: We conducted a retrospective review of medical records from two institutions, covering the periods 1998‐2022 and 1996‐2021 for endoscopic treatments and NU, respectively, focusing exclusively on patients with low‐grade disease. Demographic information, tumor characteristics, and surgical follow‐up data, including metastatic progression and overall survival, were collected. Kaplan‐Meier curves and the Log rank test were used to compare the outcomes between the two treatment modalities.
Results: The study included a total of 109 patients who underwent endoscopic treatment and 56 who underwent NU. Among them, 45 patients (27.2%) were women, with a median age of 72 (IQR 61‐80) and 68 (63‐74) in the endoscopic and radical resection groups, respectively (p = 0.623). The median tumor size was 14 mm (10‐20) and 25.5 mm (20‐34.15) in the endoscopic treatment and NU groups, respectively (p < 0.001).The median follow‐up duration was 29 months (12.75‐57.25) for the endoscopic group and 55 months (24‐93) for the NU group. Metastatic progression was observed in 3 patients (5.3%) in the NU group compared to 5 patients (4.5%) in the endoscopic group, with no statistically significant difference (p = 0.891). The median overall survival was 178 and 143 months for the endoscopic and NU groups, respectively, with no statistically significant difference (p = 0.382). Within the endoscopic treatment group, a subgroup analysis revealed no statistically significant differences in terms of all‐cause mortality, metastatic disease, and eventual NU between the favorable and unfavorable low‐risk subgroups. However, the unfavorable group was associated with a higher number of ureteroscopies.
Conclusions: The mid‐term oncological outcomes of NU and endoscopic ablation for low‐grade UTUC favorable and unfavorable groups are similar.
Funding: None
Comparison of Ureteroscopic Biopsy for Frozen Pathology and Permanent Pathology in Staging of Upper Tract Urothelial Carcinoma
Tal Cohen1, Kevin Koo1, Sharma Vidit1, Potretzke Aaron1
1Mayo Clinic
Presented By: Tal Cohen, MD
Introduction: Upper tract urothelial carcinoma (UTUC) represents 5% of all urothelial malignancies. Accurate pathologic diagnosis is key and may direct treatment decisions. Current ureteroscopic biopsy techniques include cold‐cup, backloaded cold‐cup and stone basket. The study objective was to compare frozen section pathology with final permanent pathology to determine correlation. This would help determine whether intraoperative decision making can be based on frozen section results.
Methods: We performed ureteroscopic biopsy using the “form tackle” technique as previously described by Klett et al. Int Braz J Urol. 2022. Eligibility criterium was an upper tract lesion ≥1 cm concerning for urothelial carcinoma. Each tumor was biopsied four times: two biopsies for frozen section and two biopsies for final permanent section. Concordance of frozen and permanent section was assessed.
Results: 10 procedures performed on 10 patients between January of 2023 and June of 2023. Within the cohort there were 5 concordant pathology results, 2 disconcordant pathology results, 3 nondiagnostic frozen section interpretations. (Table 1) Permanent section yielded a diagnosis in all 10 patients. Final extirpative surgical pathology was available in 1/10 patients and was concordant. There were no complications related to biopsy.
Conclusions: Frozen pathology may yield concordant pathology results when compared to permanent pathology which could allow for intraoperative decision‐making. Further work is needed to ontinue to improve frozen pathology diagnostic yield.
Funding: N/A
Pre‐Operative Ureteral Stenting of the Upper Urinary Tract Increases the Risk for Lower Urinary Tract Urothelial Carcinoma Recurrence Following Radical Nephroureterectomy
Mohammad Zuaiter2, Mohammad Zuaiter1, Saifelislam Awida1, Baidar Yousif Khalabazyane1, Aran Nanthakumar1, Kumar Priyadarshi1
Introduction: Radical nephroureterectomy with the excision of the bladder cuff remains the gold standard for managing high risk upper urinary tract urothelial carcinoma (UTUC). Pre‐operative management of high risk (UTUC), however, is yet not standardizedas obtaining a histological diagnosis and drainage of the obstructed upper tract may or may not be carried out pre‐operatively. We review lower urinary tract recurrence rates post radical nephroureterectomy for high grade (UTUC) at our institution over a 7‐year period with particular attention to pre‐operative stenting of upper tract system.
Methods: In this retrospective observational study, a total of 109 patients underwent radical nephroureterectomy from the year 2015 to 2022. Of these cases, 65 patients were eligible for the study. All eligible patients had high grade (UTUC) on post‐operative histopathology with at least one follow‐up cystoscopy done within 12 months post nephroureterectomy. Patients with low grade (UTUC) or non‐ urothelial tumours on histopathology, or who had simple cystectomy done prior to radical nephroureterectomy, or had a history of high grade lower tract urothelial carcinoma, or had no follow up cystoscopy, or died within 3 months post‐operatively were excluded from the study. Post nephroureterectomylower urinary tract recurrence and histopathology were observed. Time taken for first lower tract recurrence to occur was also reviewed. Patients were divided into two main groups, those who were stented pre‐operatively vs. those who were not. Furthermore, patients with hydronephrosis (n = 48) were subdivided into two distinct subgroups, those who had hydronephrosis and were stented pre‐operatively (n = 15) vs. patients who had hydronephrosis but were not pre‐stented (n = 33). Post nephroureterectomy lower urinary tract recurrence was then compared in both subgroups. All patients underwent either laparoscopic or robot assisted radical nephroureterectomy. Pre‐operative biopsy was done percutaneously in two cases with the rest having ureteroscopic biopsies (n = 21).Data were evaluated for significance by two‐tailed unpaired t test, withP ≤0.05 considered significant. Calculations were performed using GraphPad Dotmaticssoftware (Graph‐Pad Software, Inc., San Diego, CA).
Results: Nineteen (29.2%) of the 65 patients had at least one lower urinary tract recurrence within 36 months post‐operatively. Eleven patients (57.9%) out of 19 pre‐stented had post‐operative lower tract recurrence compared to eight (17.4%) out of 46 patients who were not pre‐stented (p‐value = 0.0008). Fifty three percent out of those who had hydronephrosis and stent insertion pre‐operatively developed lower urinary tract recurrence compared to (24.2%) who had hydronephrosis but were not pre‐stented (p‐value = 0.048). Mean time to first recurrence was 10.1 months. Mean time to first recurrence in patients who were pre‐stented was 6.1 months compared to 16 months in those not pre‐stented (p‐value = 0.0144). Majority of the recurrences (73.6%) occurred in the first 12 months post‐operatively. Fifty‐two percent of those who underwent a pre‐ operative biopsy plus stent insertion had post‐operative lower tract recurrence compared to (16.7%) who were not biopsied pre‐operatively (p‐value = 0.002). Sixteen patients out of those who had hydronephrosis (33.3%) had recurrence compared to only three patients (17.6%) who did not have hydronephrosis. Ten patients (52.6%) out of the lower tract recurrence cases were Ta high grade (TCC), while five (26.3%) were T1 high grade (TCC), two (10.5%) were T2 high grade (TCC), and one had isolated carcinoma in situ. Nineteen (29.2%) of the 65 cases had a ureteral stent inserted pre‐operatively. Twenty‐three (36.4%) of the 65 patients underwent pre‐operative diagnostic biopsy. Sixteen (24.6%) cases had pre‐operative biopsy plus stent insertion pre‐operatively. Forty‐eight patients (73.8%) had hydronephrosis. Thirty‐five patients had left sided radical nephroureterectomy. Mean age at diagnosis was 70.8 years, male to female ratio was 1.5 to 1, with visible haematuria being the most common presentation (69.2.5%), followed by incidental radiographic finding and visible haematuria (13.8%) & (9.2%), respectively, while two patients presented with non‐ visible haematuria and two more with acute kidney injury, in addition to one patient who presented with weight loss. Only 37 cases (56.9%) had pre‐operative cytology checked with (35.1%) being positive. Mean pre‐ and post‐operative creatinine were 98.9 and 131.9 mmol/L, respectively. The most common tumour site occurrences were pelvis & calyces 33 occasions, followed by midureter 22 occurrences, distal ureter 19 occurrences, and proximal ureter 17 occurrences. All tumours were high grade urothelial carcinoma with a mean size of 4.35 cm, and multifocal in (32.3%) of the cases. Regarding post‐operative histology, twenty patients (30.8%) had Ta high grade (TCC), four (6.2%) had T1 high grade TCC, eleven (16.9%) had T2 high grade TCC, twenty‐three (35.4%) had T3 high grade TCC, five (7.7%) had T4 high grade TCC, one had isolated carcinoma in situ (CIS) and one more had T0. Nine patients had variant histology while 46 had tumour invasion. Thirty‐six patients (55.4%) had associated upper tract CIS while one had isolated upper tract (CIS). Out of 24 lymph nodes dissected only 2 were found positive.
Conclusions: In the context of high grade (UTUC), pre‐nephroureterectomy ureteral stenting increases the overall risk for post operative lower tract recurrence and shortens the time taken for first postoperative bladder recurrence to occur significantly. Furthermore,the combination of hydronephrosis and pre‐operative stenting almost doubles the overall risk for postoperative bladder recurrencecompared to hydronephrosis alone.
Funding: None.
Is Bladder Cuff Excision Essential During Nephroureterectomy for Upper Tract TCC?
Ben Sionov1, Jeffry Mattar1, Abraham Ami Sidi1, Alexander Tsivian1
1Department of Urology, The E. Wolfson Medical Center, Holon and Sackler Faculty of Medicine, Tel Aviv University, Israel
Presented By: Ben Sionov, MD
Introduction: Radical nephroureterectomy (RNU) with bladder cuff excision (BCE) is widely regarded as the most effective surgical intervention for managing upper urinary tract urothelial carcinoma (UTUC). However, to mitigate the potential complications associated with BCE, such as urine leakage, scarring, reduced bladder capacity, and suture line dehiscence, we have developed an approach for distal ureterectomy during RNU, involves the excision of the intramural portion of the ureter, without opening the urinary tract, eliminating the need for bladder cuff removal.
Methods: To evaluate the oncological safety of RNU with BCE compared to RNU without BCE with a focus on local and distant disease recurrence.
Results: Between 2008 and 2021, 107 patients with primary UTUC underwent RNU. Fifty‐three patients with a follow‐up of at least 12 months were included in the study. The database of the patients with and without BCE was reviewed. Demographic data, medical background, tumor characteristics, histopathology, cystoscopic and imaging results were recorded. Bladder tumor recurrence incidence and occurrence of distant metastatic disease were compared in the 2 groups.
Conclusions: Of the patient's cohort, 23 underwent RNU with BCE (group A), and 30 underwent RNU without BCE (group B). There was no statistical difference in demographics and pathologic characteristics between the groups. At a median follow‐up of 39 and 28 months in groups A and B, respectively, intra‐ vesical disease recurrence was detected in 56% in group A versus 43% in group B, (p = 0.21). Median time to first recurrence was 16 and 18 months in group A and B, respectively. Metastatic disease was diagnosed in 13.4% and 16.7% of groups A and B, respectively (p = 0.71).
Funding: Laparoscopic RNU with dissection and detachment of the intramural ureter, while avoiding BCE, offers comparable oncologic outcomes to the more complex procedure involving BCE. This approach not only minimizes the risk of potential complications associated with BCE but also eliminates the need for transurethral/intraureteral instrumentation and patient repositioning.
Simultaneous Laparoscopic or Robotic Nephroureterectomy and Robot‐Assisted Radical Cystectomy for Patients with Both Invasive Bladder Cancer and Upper Urothelial Carcinoma
1Department of Urology, Akita University Graduate School of Medicine
Presented By: Taketoshi Nara, MD
Introduction: Patients presenting with invasive bladder cancer and concurrent upper urinary tract malignancy must prefer simultaneous nephroureterectomy (NU) and radical cystectomy. However, few reports of robotic‐assisted radical cystectomy (RARC) and laparoscopic or robotic NU performed in a single stage have been available. We report 4 cases of simultaneous RARC and laparoscopic or robotic NU.
Methods: We performed 4 cases of simultaneous laparoscopic unilateral NU (3 laparoscopic, one robotic) and RARC at our hospital between 2019 and 2022. Clinical factors and preoperative and postoperative parameters were retrospectively analyzed.
Results: The median age of the four patients was 66.5 years（range 45‐75）, two males and two females. The median operative time was 664 minutes (range 576‐845 minutes), and estimated blood loss was 412 ml (range311‐1910 ml). The intracorporeal technique of urinary diversion was applied for all four cases. According to the Clavien‐Dindo Classification system, Grade IIIA of wound dehiscence occurred in one patient. The patient's position was changed from lateral to supine after finishing NU. Eight or nine ports were used in each NU＋RARC. At the RARC part, three or four NU ports were shared as RARC ports.
Conclusions: By positioning the trocar placement, the number of trocars used in laparoscopic or robotic NU and RARC could be reduced, allowing for a minimally invasive procedure. Simultaneous laparoscopic or robotic NU and RARC should be feasible and safe surgical options.
Funding: The authors have no conflicts of interest directly relevant to the content of this article.
Robotic Distal Ureterectomy for High‐Risk Distal Ureteral Urothelial Carcinoma: A Retrospective Multicenter Comparative Analysis (ROBUUST Collaborative Analysis)
Francesco Ditonno19, Savio D. Pandolfo1, Antonio Franco2, Ithaar H. Derweesh3, Vitaly Margulis4, Firas Abdollah5, Matteo Ferro6, Hooman Djaladat7, Georgi Guruli8, Giuseppe Simone9, Reza Mehrazin10, Mark L. Gonzalgo11, Zhenjie Wu12, Francesco Porpiglia13, Daniel D. Eun14, Andreas Correas15, Andrea Minervini16, Chandru P. Sundaram17, Riccardo Autorino18
1Department of Neurosciences and Reproductive Sciences and Odontostomatology, University of Naples “Federico II”, 80131 Naples, Italy., 2Department of Urology, Rush University, Chicago, IL 60612, USA, 3Department of Urology, University of California‐San Diego Health System, La Jolla, CA, USA, 4Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA, 5Vattikuti Urology Institute, Henry Ford Hospital, Detroit, MI, USA, 6Division of Urology, European Institute of Oncology (IEO)‐IRCCS, Milan, Italy, 7Norris Comprehensive Cancer Center, Institute of Urology, University of Southern California, Los Angeles, California, USA, 8Division of Urology, VCU Health, Richmond, VA, USA, 9Department of Urology, IRCCS “Regina Elena” National Cancer Institute, Rome, Italy, 10Department of Urology, Icahn School of Medicine at Mount Sinai Hospital, New York, New York, USA, 11Desai Sethi Urology Institute, University of Miami Miller School of Medicine, Miami, FL, USA, 12Department of Urology, Changhai Hospital, Naval Medical University, Shanghai, China, 13Division of Urology, University of Turin, San Luigi Gonzaga Hospital, Turin, Italy, 14Department of Urology, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA, 15Fox Chase Cancer Center, Philadelphia, PA, USA, 16Department of Urology, University of Florence, Florence, Italy, 17Department of Urology, Indiana University, Indianapolis, IN, USA, 18Dept of Urology, Rush University, Chicago, IL, USA, 19Department of Urology, Rush University, Chicago IL, USA
Presented By: Francesco Ditonno, MD
Introduction: The role of kidney‐sparing surgery (KSS) in patients with high‐risk upper urinary tract urothelial carcinoma (UTUC) is controversial. The aim of this study was to assess the outcomes of robotic distal ureterectomy in patients with high‐risk distal ureteral tumours.
Methods: Three hundred and sixty‐five patients with high‐risk UTUC of the distal ureter were retrieved from the ROBUUST (ROBotic surgery for Upper Tract Urothelial Cancer Study) multicenter international (2006‐ 2019). The study population was divided in two subgroups according to the type of surgical approach: 38 patients treated with robotic distal ureterectomy and 135 treated with robotic nephroureterectomy (RNU). Time to recurrence, defined by urinary cytology, CT scan or cystoscopy at last follow‐up, was the primary endpoint. Secondary endpoint was the post‐operative renal function, calculated as eGFR at last follow‐up. A Mann‐Whitney U test was performed to compare mean (± SD) of each outcome between the two populations.
Results: In the overall population, mean age was 70.4 years (±9.3), with a mean preoperative Cr of 1.2 (±0.8) mg/dL and a mean tumour size of 3.3 (±2.1) cm. No significant difference was observed in terms of time to recurrence (13.3 months vs 14.3 months, p = 0.8) between patients treated with distal ureterectomy and RNU. Post‐operative eGFR, instead, was significantly better in patients treated with distal ureterectomy (63.4 mL/min/1.73m2vs 51 mL/min/1.73m2,p = 0.01).
Conclusions: Within the limitations related to the retrospective study design, our findings suggest comparable outcomes in terms of time to recurrence between distal ureterectomy and RNU, and an advantage of in terms of post‐operative renal function preservation. KSS might be considered as a potential option for selected high‐risk patients.
Funding: None
Clinical Features and Prognosis of Invasive Parenchyma Pyelocaliceal Urothelial Carcinoma with Venous Thrombus.
Yu Zhang1, LuLin Ma1
1Peking University Third Hospital
Presented By: Yu Zhang, MD
Introduction: To demonstrate the clinical, pathological and prognostic features of invasive parenchyma pyelocaliceal urothelial carcinoma (pUC) with venous thrombus (VT).
Methods: We conducted a propensity‐matched retrospective cohort study containing 23 patients with pUC‐ VT and 104 patients with pUC only from January 2014 to January 2021. We reported the characteristics of pUC‐VT and compared the surgical and oncological outcomes with pUC only. The Pearson chi‐square test and Fisher exact test, Wilcoxon rank sum test, Coxproportional hazards regression model and log‐rank testwere used.
Results: After matching, 20 patients were matched in each group and no significant differences were found in most baseline characteristics except for tumor diameter (7.5cm vs 4.5 cm, P = 0.004). Patients with pUC and VT had more blood loss (400ml vs 50 ml, P = 0.004) and higher complication rate (35% vs 5%, P = 0.04) than that with pUC only. After a median follow‐up of 48.0 mon (IQR 41.0‐ 59.0 mon) in the pUC with VT group and 58.0 mon (IQR 41.0‐ 62.0 mon) in the pUC group, the median OS of pUC patients with renal vein thrombus or inferior vena cave thrombus were 13.0 mon (IQR 3.5‐13.0 mon) and 4.5 mon (IQR 2.5‐13.0 mon), respectively. Patients with pUC and IVC thrombus had worse OS than patients with pUC only (Adjusted HR 2.67, 95%CI 1.06‐6.82; P = 0.04).
Conclusions: Radical nephroureterectomy and thrombectomy of pUC with VT is feasible with acceptable surgical outcomes. Long‐term survival of pUC with VT patients is poor and multimodality treatment is needed to improve the prognosis.
Funding: None
Retroperitoneal Single‐Port Robot Assisted Nephroureterectomy with Bladder Cuff Excision: Initial Experience and Description of Technique
Sung‐Hoo Hong1
1Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea
Presented By: Sung‐Hoo Hong, MD,PhD.
Introduction: To investigate the feasibility of single port (SP) robotic retroperitoneal(RP) nephroureterectomy(NUx) with bladder cuff excision.
Methods: We sequentially analyzed 20 patients who were performed SP robot NUx from January 2021 to December 2022. All patients were diagnosed with upper tract urothelial carcinoma (UTUC) and were operated by a single expert with da Vinci SP platform.
Results: Total of 20 patients underwent SP robotic NUx with bladder cuff excision. The mean age of the patients was 69.45 ± 8.68 years, and the mean body mass index (BMI) was 25.37 ± 3.00 kg/m2. The mean tumor size was 2.42 ± 1.03 cm on CT scan, with right tumors in 8 patients (40%) and left tumors in 12 patients (60%). The median console time was 106 minutes 40 seconds and the expected blood loss was 122.50 ± 75.18 ml. Final pathology showed all of patients diagnosed as urothelial carcinoma and 1 was Ta (5.00%), 3 were T1(15.00%), 7 were T2(35.00%), 8 were T3(40.00%) and 1 was T4(5.00%). None of the 20 patients showed complications with Clavien‐Dindo scale.
Conclusions: SP robotic NUx via with retroperitoneal approach offers feasible perioperative and postoperative outcomes for UTUC.
Funding: not applicable
is Robotic Radical Cystectomy with Intracorporeal Urinary Diversion (RRC‐ICUD) Feasible in Patients Who Have Had Prior Abdominal Surgery (i.e. the “Hostile” Abdomen)?
Sij Hemal1, Michael Eppler1, Aref Sayegh1, Monish Aron1, Mihir Desai1, Inderbir Gill1, Giovanni Cacciamani1
1University of Southern California ‐ USC Institute of Urology
Presented By: Sij Hemal, MD
Introduction: Previous abdominal surgery (PAS) is considered a relative contraindication to subsequent complex robotic oncologic urologic surgery such as RRC‐ICUD. We compared outcomes of patients undergoing RRC‐ICUD with a history of PAS vs those without PAS.
Methods: From 07/2010 to 12/2021, 445 consecutive patients underwent RRC‐ICUD. Patients were divided into no PAS vs PAS, the latter further sub‐stratified into 1 PAS and ≥2 PAS. Outcomes of interest were operative time (OT), overall 30‐day complication rate, readmission rate and presence of genitourinary (GU) complications. Multivariate analysis assessed the impact of PAS on the outcome of interest controlled by clinical stage, gender, urinary diversion type and BMI (p < 0.05 significance level). Cox‐regression was performed for overall survival (OS) and recurrence free survival (RFS).
Results: Of 445 patients undergoing RRC‐ICUD, 266 had no history of (h/o) PAS and 179 had h/o PAS. No significant differences were noted in Operative Time (OT), Estimated Blood Loss (EBL), hospital stay, early complications (cardiac, gastrointestinal, GU, DVT, infection, neuro). Significant differences were observed in early post‐op transfusion rate (20 vs 30%, p = 0.02). No significant differences were observed in overall complications at 30 and 90 days. Higher 30‐day readmission rate was noted for the PAS group (18 vs 26%, p = 0.03). Positive surgical margin rates were similar. On multivariate analysis, h/o PAS and increasing number of PAS (0 vs 1; 0 vs ≥2; 1 vs ≥2) were independent predictors for readmission and 30‐day GU complications. On comparing number of PAS, PAS ≥2 was an independent predictor for a higher 30‐ day readmission % (RR 2.4, p = 0.01) and GU complication rate (RR 1.8, p = 0.01). BMI independently predicted longer OT (est. 0.03, p = 0.03), higher readmission rate (RR 1.06, p = 0.01), and increased overall 30‐day complication rate (RR 1.04, p = 0.03). No differences were found for the OS (p = 0.29, p = 0.68) and RFS (p = 0.82, p = 0.6).
Conclusions: RRC‐ICUD is a feasible procedure in patients with a history of prior abdominal surgery, yielding similar overall complication rates, surgical margin rates, and survival to those with no PAS. However, patients with PAS should be counseled on a slightly greater risk of readmission and need for perioperative transfusion.
Funding: No sources of funding were utilized. This was an IRB approved study.
Minimally Invasive Partial Cystectomy: A Safe Alternative to Open Surgery in Pediatric Patients.
Christopher Connors1, Micah Levy1, Daniel Wang1, Juan Sebastian Arroyave1, Francisca Larenas1, Jeffrey Stock1, Michael Palese1
1Icahn School of Medicine at Mount Sinai
Presented By: Christopher Connors, BA
Introduction: Partial cystectomy (PC) is a rare procedure in the pediatric population that is most often utilized to treat urachal cysts. PC has traditionally been an open procedure, but technological advancement has led to minimally invasive surgery (MIS) becoming more commonplace. Herein, we present the first study comparing post‐operative outcomes between MIS and open PC in children.
Methods: The Pediatric NationalSurgical Quality Improvement Program (pNSQIP) database was queried for PC from 2012 to 2020. Patients were stratified by MIS or open surgical approach. Demographics, perioperative information, and rates of 30‐day surgical outcomes including surgery‐related readmissions (SRR), prolonged length of stay (PLOS), and Clavien‐Dindo (CD) complications, including reoperations (CD III) were compared between groups. Multivariate regression analysis was used to determine whether aMIS approach was an independent predictor of the surgical outcomes studied.
Results: 253 cases of PC were identified (Open = 191; MIS = 62). Patients undergoing MIS PC were more likely to be older (5.74 years [2.15 – 9.19] vs. 4.28 years [1.85 – 7.37], p = 0.030) and be female (71.0% vs 53.9%, p = 0.018). All post‐operative outcomes of interest were less common in the MIS group when compared to an open approach including CD I/II (1.6 vs 8.9%), reoperations (1.6 vs 4.7%), CD IV (1.6 vs 2.1%), PLOS (22.6 vs 34.0%), and SRR (3.2 vs 5.2%), but these differences were not significant [Figure 1]. Additionally, following multivariate analysis, aMIS approach was not found to be a significant predictor of CD I/II or CD IV complications, PLOS, reoperations, or SRR [Table 1].
Conclusions: MIS and open PC demonstrate comparable post‐operative outcomes, suggesting that a MIS approach does not confer additional risk to pediatric patients undergoing PC. Additional research should confirm the safety and efficacy of MIS PC as minimally invasive approaches become more common.
Funding: None
Impact of Types of Previous Abdominal Surgery on Perioperative Outcomes in Patients Undergoing Robotic Radical Cystectomy with Intracorporeal Urinary Diversion
Sij Hemal1, Michael Eppler1, Aref Sayegh1, Monish Aron1, Mihir Desai1, Inderbir Gill1, Giovanni Cacciamani1
1University of Southern California‐ USC Institute of Urology
Presented By: Sij Hemal, M.D.
Introduction: Patients with prior lower abdominal/pelvic surgery may harborpost‐surgical intra‐abdominal adhesions that may distort surgical planes making future dissection challenging. Such a “hostile” abdomen isconsidered to be a relative contraindication for subsequent complex robotic urologic surgery, such as robotic radical cystectomy with intracorporeal urinary diversion (RRC‐ICUD). Herein, we evaluated outcomes of patients undergoing RRC‐ICUD with a history of prior lower abdominal/pelvic surgery stratified by type of previous abdominal insult.
Methods: From 07/2010 to 12/2021, 445 consecutive patients underwent RRC‐ICUD for bladder cancer. Patients with previous abdominal surgery (PAS) were divided into 4 cohorts: PAS within surgical Region of Interest (sROI); pelvic vs abdominal PAS; major vs minor PAS; and approach of PAS [minimally invasive (MIS) vs open]. Outcomes of interest were operative times (OTs), overall 30‐day complication rate, readmission rate and genitourinary (GU) complications. Multivariate analyses was utilized to assess impact of the type of PAS on the outcomes of interest (p < 0.05 significance level).
Results: Our cohort included 445 patients: 266 with no PAS and 179 with PAS; 156 (89%) with PAS in sROI vs 19 (11%) with PAS not in sROI; 113 (64%) Major vs 63 (36%) Minor PAS; 82 (47%) with Pelvic PAS vs 93 (53%) with abdominal PAS; 22 (37%) with prior MIS vs 38 (63%) with open PAS. Oncologic outcomes: no significant differences between soft tissue positive margins amongst all 4 cohorts. Multivariate analysis: previous pelvic surgery and type of approach of PAS did not adversely impact perioperative outcomes (all p > 0.05). PAS in sROI trended towards a higher overall GU complication rate (RR = 3.8, p = 0.08). Prior major PAS trended towards a higher 30‐day complication rate (RR = 1.9, p = 0.06) and higher GU complication rate (RR = 2.1, p = 0.07). Across the models, BMI independently predicted longer OT (p = 0.02)(Fig. 1).
Conclusions: RRC‐ICUD is feasible in a previously operated abdomen with relatively noninferior perioperative and oncologic outcomes. However, patients with PAS in the sROI or major PAS should be counseled on a higher peri‐ and post‐operative complication rate. Obese patients are likely to have prolonged operative times and may be counseled on preoperative weight loss.
Funding: No sources of funding were utilized. This was an IRB approved study.
Pembrolizumab for BCG Refractory Non‐Muscle Invasive Bladder Cancer: Poor Recurrence‐Free Survival and High Toxicity
Borivoj Golijanin1, Vikas Bhatt1, Galina Lagos2, Kamil Malshy1, Ali Amin3, Anthony Mega2, Dragan Golijanin1
1Minimally Invasive Urology Institute of the Miriam Hospital and Warren Alpert Medical School of Brown University, 2Lifespan Cancer Institute at the Miriam Hospital and Warren Alpert Medical School of Brown University, 3Department of Pathology and Laboratory Medicine at the Miriam Hospital and Warren Alpert Medical School of Brown University
Presented By: Borivoj Golijanin
Introduction: Pembrolizumab was approved in January 2020 for treatment of patients with high‐risk, BCG refractory non‐muscle invasive bladder cancer (NMIBC) with carcinoma in situ (CIS) with or without papillary tumors who received adequate BCG therapy and were ineligible for or opted out of radical cystectomy. This study reports our single institutional experience using pembrolizumab for this indication.
Methods: Records of patients with NMIBC treated by pembrolizumab from 01/2020‐01/2023 were retrospectively reviewed for key demographic and clinical information. Kaplan‐Meier curves were used to calculate progression free (PFS) and treatment specific survival (TSS), and combined positivity score (CPS) of PD‐L1 on immunochemistry was assessed.
Results: Out of 250 screened records of NMIBC, 18 records with median age of 74.1, male to female ratio of 3.5:1, and a median follow‐up of 17.5 months (IQR = 8.1 – 22.5) were included. All had a history of CIS and were treated with intravesical chemotherapy after they became BCG refractory. At start of pembrolizumab, 1/18 (5.6%) was cTa, 6/18 (33.3%) had CIS, and 11/18 (61.1%) had cT1. After an average of 8.9 cycles (SD = 6.3), 72.2% of patients (13/18) discontinued. Five patients (38.5%) are still in treatment with an average of 12.6 cycles (SD = 10.4 cycles). One patient out of thirteen who stopped treatment had a sustained complete response at 19 cycles. Discontinuations were due to: Grade 2 or higher toxicity in 7/13 (53.8%), disease progression in 4/13 (30.8%), , and 1/13 stopped due to disease recurrence. Recurrence‐free survival rates at 3‐, 6‐, and 12‐months were 16.7%, 11.1%, and 5.6%, respectively. 6‐ and 12‐month PFS rates were 94% and 77.7%, respectively. Kaplan‐Meier revealed a PFS of 19.5 months (SD = 2.4) and a TSS of 26.5months (SD = 2.9). Four patients required radical cystectomy and were pTa (n = 1), pTis (n = 1), pT1 (n = 1), and pT4 (n = 1). PD‐L1 positivity, defined as CPS > 10, was noted for only one patient.
Conclusions: High toxicity leading to early withdrawal from treatment was common in this cohort. This study does not confirm previously reported high response rates beyond one year. Early discussion on radical surgery remains an important part of our guidelines for treatment of BCG refractory NMIBC. Additional research is warranted to better identify patients who are likely to benefit from this agent.
Funding: None
The Effects of Surgical Approach and Enhanced Recovery Protocol on Cost Effectiveness of Radical Cystectomy
Miki Haifler1, Eyal Kord1, Moshe Leshno1
1Tel Aviv University
Presented By: Miki Haifler, MD, MSc
Introduction: Radical cystectomy (RC), which is the gold standard therapy for localized MIBC, provides excellent local control, However, it is highly morbid, with lengthy hospital stay and high complication rate. Enhanced recovery protocols and robotic approach to radical cystectomy are known to reduce perioperative complications, however, the most cost‐effective strategy is unknown. We aim to assess cost effectiveness of radical cystectomy with different surgical techniques and perioperative treatment protocols.
Methods: We performed a meta‐analysis of studies comparing open radical cystectomy (ORC), robotic assisted radical cystectomy (RARC) using extracorporeal (ECUD) or intracorporeal urinary diversion (ICUD) and enhanced recovery after surgery (ERAS) protocol. Operative time, transfusion, complication, Ileus, length of stay and re‐admission rates were extracted. US costs for surgery, treatment, hospitalization, and complications were obtained from the literature. Israeli costs were obtained from hospital administrative data. Two cost effectiveness models (US and Israel) were developed. The primary output of the models was quality adjusted life years (QALY). QALY together with costs were used to calculate the incremental C/E ratio (ICER) between each two strategies. A sensitivity analysis was performed to address the variability of data collected from different studies using tornado analysis.
Results: The two most cost‐effective strategies in both models were ORC/ERAS and RARC/ICUD/ERAS (figure 1). RARC/ERAS produced the two most effective strategies with ICUD being dominant over ECUD. All strategies implementing the ERAS protocol were more effective than their parallel non‐ERAS strategies. RARC/ICUD/ERAS is cost effective compared to ORC. ERAS protocol improves treatment effectiveness and lowers overall costs. ICUD was shown to be more effective and less costly in comparison to ECUD.
Conclusions: RARC with ICUD and an ERAS protocol is cost effective in comparison to ORC in the US model. Implementation of ERAS protocols improve treatment effectiveness and lowers overall costs. ICUD was shown to be more effective and less costly in comparison to ECUD.
Funding: None
Laparoendoscopic Surgery for Urachal Remnant with Extraperitoneal Approach through An Umbilical Port
Tsukasa Masuda1, Hiroki Ishikawa1, Ryohei Takahashi1, Satoshi Tamaki1, Jun Hagiuda1, Ken Nakagawa1
1Tokyo Dental College Ichikawa General Hospital
Presented By: Tsukasa Masuda
Introduction: Recently, laparoendoscopic single‐site surgery (LESS), in which a single incision is used to remove the remnant ureter, has been shown to be useful. In addition, preservation of the peritoneum is important to control infection and reduce invasiveness to the intraperitoneal organs. In this report, we describe a laparoscopic ureteral duct excision using the retroperitoneal approach, including the single incision method, that was performed at our hospital.
Methods: Thirteen patients who underwent laparoscopic ureteral duct excision by the retroperitoneal approach at our hospital from November 2013 to March 2023 were included in the study. We reviewed the surgical outcomes and complications retrospectively. For cases performed with reduced port surgery, we used an articulated instrument because its configuration provides a wide range of movements.
Results: Among these 13 patients, five underwent conventional laparoscopy (cLap) with three ports, and eight patients underwent LESS through an umbilical port. In all cases, umbilical infections were completely controlled with antibiotics and/or drainage. Regarding our patients' backgrounds, the mean age was 26.8 (range, 13–36) years, and all cases were male. The mean operative time in the cLap group were 152（range, 111‐201） minutes and in the LESS group were 172（range, 135‐210）minutes. Although there were variations in operative time among the surgeons, no major intraoperative complications were observed.
Moreover, we placed a urethral catheter and it was left in place for 3–5days after surgery.Because the patients had no complications, such as wound infection, the catheter was removed and they were allowed to be discharged from our hospital in average 5.5 (range, 4‐9) days.
Conclusions: The laparoendoscpic surgery for urachal remnant with extraperitoneal approach through an umbilical port was a safe procedure, especially LESS using the single port technique, was an effective procedure with good postoperative cosmetic results.
Funding: None
Impact of Ergonomics on Pelvic Surgery: A Single‐Institution, Tri‐site Survey on Academic Surgeon Well‐Being and Sequela of Workload Demand
Eric J Regele1, Raymond Pak1, Ram a Pathak1, Hamid Norasi2, M Susan Hallbeck2, Eric a V Qualkenbush1
1Mayo Clinic Florida, 2Mayo Clinic Rochester
Presented By: Eric J Regele, MD
Introduction: Ergonomic impact on surgeon longevity and surgeon well‐being is understudied. Like other physically demanding jobs, surgery can have a significant impact on surgeon wellbeing, occupational longevity, and economics. This study aims to characterize the impact of ergonomics on pelvic surgeons.
Methods: A tri‐site (Mayo Clinic Arizona, Florida & Rochester) internal survey was sent to all pelvic surgeons at a single enterprise. A total of 129 surgeons received an electronic anonymous survey‐based questionnaire characterizing ergonomic impact on surgeon wellbeing.
Results: Of 129 surveys provided, 48 (32.1%) responses were completed (62.5% male, 37.5% female). Mean age, career duration, and BMI were 48.1 years old, 13.3 years, and 25.5, respectively. 39.6% were urologists, 45.8% gynecologists, and 14.6% colorectal surgeons. Dominant modality with respect to surgical approach was defined as the approach where > 10 % of all surgeries were performed. The cohorts were as follows: 25% open, 18.6% robotic, 18.6% endoscopic, 14.6% laparoscopic, 16.7% had no dominant modality, and 6.3% vaginal/hysteroscopic. Average OR days/week were 2.1 and percentage of cases > 3 hours were 35.5%. Twenty five percent of surgeons had baseline pain not attributed to surgery, and 100% reported acute on chronic pain exacerbation with surgery. On a scale of 1 (least) to 10 (greatest), open surgery on average was reported as the most physically demanding (6.10), followed by laparoscopy (5.55), endoscopy (3.72), and robotics (3.69). Figure 1 shows surgeon reported musculoskeletal (MSK) pain by dominant surgical modality. With the exception of endoscopic surgery (30‐60 min), surgical approach was irrespective of onset of pain (1‐2 hrs). 50% of pelvic surgeons noted pain will influence their ability to perform future surgery.
Conclusions: Ergonomics play an impactful role on surgeon wellbeing and ability to perform future surgery. 1 in 2 pelvic surgeons will report MSK pain attributed to surgery. On average, pelvic surgeons associate open and laparoscopic surgery as the most physically demanding. However, surgeons who perform robotic surgery report no MSK pain attributed to surgery. A rise in minimally invasive alternatives to open surgery may be an untoward benefit to surgeon longevity.
Funding: None
Randomized Controlled Trial on Single Dose Perioperative Instillation of Intravesical Gemcitabine versus Mitomycin‐C Following Complete Resection of Non Muscle Invasive Bladder Cancer
Brusabhanu Nayak2, Nitish Aggarwal1, Amlesh Seth1, Prabhjot Singh1, Rishi Nayyar1, S N Dwivedi1
1All India Institute of Medical Sciences, 2All India Institute of Medical Sciences, New Delhi
Presented By: Brusabhanu Nayak, MD
Introduction: Bladder cancer (BC) is one of the most common urological malignancy. The current international guidelines recommend a single instillation of intravesical Mitomycin C in the immediate postoperative period following TURBT . The recent NCCN guidelines recommends gemcitabine as preferred agent for immediate intravesical therapy . Till date no randomized trial is available comparing the intravesical gemcitabine with intravesical MMC
Methods: It was a 2 arm randomized controlled trial. Patients were followed for efficacy(recurrence) and tolerance (side effects). The consort diagram is provided in the figure 1
Results: During the 2 years of accrual (one year of enrolment and one year of follow up) total 0f 215 patients were screened, out of which 54 patients met eligibility criteriaOut of the 26 patients in gemcitabine group and 27 in the Mitomycin group, 3 patients in the gemcitabine arm(11.53%) and 3 patients in the Mitomycin arm(11.11%) experienced a recurrence at 1 year follow up. Out of these 6 recurrences , one patient in mitomycin C arm showed progression in T stage on Re TURBT. No progression was seen in respect to grade of tumour.Injection gemcitabine was found to be slightly less costly than Injection mitomycin C. ($24.47 vs $26.559)There was no grade 3 or above adverse events. Dysuria /voiding pain were the most common adverse events (more in mitomycin arm ) followed by haematuria and culture positive UTI.
Conclusions: Gemcitabine was found to be aseffective as Mitomycin C in decreasing bladder cancer recurrenceand progression especially in low grade/low risk tumour over short follow up period. Intravesical gemcitabine is better tolerated than mitomycin. Cost and availability of these drugs is not an important issue in Indian setup. Larger multi‐institutional prospective randomized studies with longer follow up are required to establish superiority of one intravesical agent over other.
Funding: None
Randomized Trial on Single Dose Perioperative Instillation of Intravesical Gemcitabine versus Mitomycin‐C Following Complete Resection of NMIBC: Evaluation of Efficacy and Tolerance
Nitish Aggarwal2, Brushabhanu Nayak1
1aiims new delhi, 2AIIMS NEW DELHI
Presented By: Nitish Aggarwal
Introduction: Bladder cancer (BC) is one of the most common urological malignancy. The current international guidelines recommend a single instillation of intravesical Mitomycin C in the immediate postoperative period following TURBT . The recent NCCN guidelines recommends gemcitabine as preferred agent for immediate intravesical therapy . Till date no randomized trial is available comparing the intravesical gemcitabine with intravesical MMC
Methods: It was 2 arm randomized controlled trial. Patients were followed for efficacy(recurrence) and tolerance (side effects).
Results: During the 2 years of accrual (one year of enrolment and one year of follow up) total 0f 215 patients were screened, out of which 54 patients met eligibility criteriaOut of the 26 patients in gemcitabine group and 27 in Mitomycin group at 1 year , 3 patients in the gemcitabine arm(11.53%) and 3 patients in the Mitomycin arm(11.11%) experienced a recurrence . Out of these 6 recurrences , one patient in mitomycin C arm showed progression in T stage on Re TURBT. No progression was seen in respect to grade of tumour.Injection gemcitabine was found to be Slightly less costly than Injection mitomycin C. ($24.47 vs $26.559)There was no grade 3 or above adverse events. Dysuria /voiding pain was the most common adverse event(more in mitomycin arm ) followed by haematuria and culture positive UTI
Conclusions: It can be said that gemcitabine is as effective as Mitomycin C in decreasing recurrence rate and progression especially in low grade/low risk tumour over short follow up period. Intravesical gemcitabine is better tolerated than mitomycin. Cost and availability of these drugs is not an important issue in Indian setup. Larger multi‐institutional prospective randomized studies with longer follow up are required before we label any one agent superior to other
Funding: None
Surgical Duration is a Predictor of TURBT Outcomes: A National Analysis from 2015 – 2019
Christopher Connors1, Micah Levy1, Krishna Ravivarapu1, Olamide Omidele1, Francisca Larenas1, Michael Palese1
1Icahn School of Medicine at Mount Sinai
Presented By: Christopher Connors, BA
Introduction: Past studies have identified increased operative time (OT) as a predictor of complications following urologic surgeries, including transurethral resection of bladder tumor (TURBT). We build on this work with the largest study on the impact of OT on post‐operative outcomes of TURBT while also accounting for tumor size.
Methods: The National Surgical Quality Improvement Program was queried for TURBT cases from 2015 to 2019. Cases were grouped as small (< 2 cm), medium (2 – 5 cm), or large tumors (> 5 cm) using CPT codes. Within each tumor size group, cases were stratified by OT quartile.Demographics and outcomes including unplanned readmissions (UR), unplanned reoperations (URO), prolonged (> 2 days) length of stay (PLOS), and Clavien‐Dindo (CD) complications were compared. Multivariate analysis was used to determine if OT was an independent predictor of adverse outcomes.
Results: 17649 small, 14460 medium, and 9000 large TURBT cases were identified.Mean OTs were 25 mins (SD 22) for small, 33 mins (SD 24) for medium, and 52 mins (SD 38) for large tumors. Higher OT quartiles were associated with older age, Black race, higher BMI, and general anesthesia for all tumor size groups, all p < 0.001. On multivariate analysis for small tumors, a 4thquartile OT was a significant predictor of all outcomes including CD I/II and IV complications, urinary tract infection, bleeding requiring transfusion (BRT), sepsis, UR, PLOS, and URO, all p < 0.005 [Table 1]. Similarly, a 4thquartile OT was a significant predictor of all outcomes for medium‐sized tumors (all p < 0.005) and for large tumors except URO (all p < 0.005). Of note, for all tumor sizes, a 4thquartile OT was the strongest predictor of BRT (small: OR = 10.693, medium: OR = 6.260, large: OR = 4.429) and PLOS (small: OR = 7.367, medium: OR = 4.921, large: OR = 4.485), all p < 0.001. Additionally, an OT ≥25thpercentilewas an independent risk factor for CD I/II complications and PLOS when compared to the 1stquartile for all tumor sizes, all p < 0.05.
Conclusions: Patients undergoing TURBT with a prolonged OT may experience significantly increased risk for PLOS, UR, and clinical complications including a particularly heightened risk for BRT. Further studies using OT to predict clinical outcomes may assist in future surgical decision making.
Funding: None
MODERATED POSTER SESSION 7: LAPAROSCOPIC AND ROBOTIC PROSTATE CANCER 2
Retzius‐Sparing vs. Posterior Urethral Suspension: Similar Early‐Phase Post‐Robotic Radical Prostatectomy Continence Outcomes
Hal Kominsky1, Mohannad Awad1, Isaac Palma Zamora1, Daniel Segal1, Jeffrey Gahan1, Jeffrey Cadeddu1
1UT Southwestern Medical Center
Presented By: Hal Kominsky
Introduction: Stress urinary incontinence (SUI) is a risk of robotic‐assisted radical prostatectomy (RP) that can be a frustrating problem for both surgeons and patients. We aim to compare short term continence outcomes between patients undergoing Retzius Sparing RP (RS‐RP) and those undergoing standard RP with inclusion of a PUS suture technique and suprapubic tube (PUS‐RP).
Methods: A retrospective review of 105 consecutive patients who underwent RP was performed, comparing patients who underwent RS‐RP and PUS‐RP. Our main outcome was pad usage as a surrogate for SUI. Patients were evaluated 4 weeks following RP and again at approximately 3 months. Continence was defined as no pad usage or up to one safety pad per day. Risk factors associated with not being continent were identified using univariate and multivariate analyses.
Results: In our cohort, 52 patients underwent RS‐RP and 53 patients underwent PUS‐RP. The two groups had similar patient demographics. Although not statistically significant, there was a higher rate of a positive surgical margin in the RS‐RP compared to PUS‐RP (25% vs 15%, p = 0.204). At one month follow up for PUS‐RP and RS‐RP, there was no significant difference in frequency of continent men (69.2% vs. 76.9%, p = 0.302). At 3 month follow up for the two groups of patients, again, there was no significant difference in frequency of continence for PUS‐RP and RS‐RP (86.2% vs 88%, p = 0.824).
Conclusions: Patients who underwent RS‐RP had similar rates of continence to those patients undergoing PUS‐RP in the short term post‐operative period.
Funding: None.
The Association Between Pathologic Neuromuscular Characteristics and Incontinence After Robotic‐Assisted Radical Prostatectomy ‐ A Pilot Study
Tomer Bashi1, Jonathan Margalioth1, Ziv Savin1, Ibrahim Fahoum2, Rabab Naamneh3, Roy Mano1, Ofer Yossepowitch1
1Department of Urology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel, 2Pathology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel, 3Pathology Department, Rabin Medical Center, Petah Tikva, Israel
Presented By: Tomer Bashi, MD,PhD
Introduction: Incontinence after RALRP has been associated with older age, longer operative time,BMI, membranous urethral length and preoperative erectile function. In the current study we describe theneurologic characteristics observed in radical prostatectomy specimens and evaluate their association with postoperative urinary incontinence.
Methods: Radical prostatectomy specimens from 28 men who underwent RALRP between 10/21 to 03/22 were reanalyzed by dedicated genitourinary pathologists who specifically assessedtheir neuromuscular characteristics. Urinary incontinence was evaluatedwith the International Consultation on Questionnaire‐ Short Form (ICIQ‐SF).Linear and logistic regression analyses were performed to assess the relationship between the neuromuscular characteristics and incontinence severity controlling for clinical variables including age, prostate size, and pathological stage.
Results: At a median follow‐up of 11 months (IQR 9‐12), 11 patients (40%) reported severe incontinence (> 12 ICIQ‐SF score). Median number of peripheral nerves observed at the base and apex of the specimens were 48 (IQR 11‐154) and 55 (IQR: 26‐143), respectively (Figure 1). Ganglia were present in 13 patients (46%) at the base and 12 patients (43%) at the apex. Additionally, the median proportional area of detrusor smooth muscle fibers at the base was 0.54 (IQR 0.31‐1), while the median proportional area of striated muscle fibers at the apex was 0.13 (IQR 0.08‐0.24).A non‐significant association between prostate size and peripheral nerve concentration and ganglia presence was observed (p ≤ 0.1). No associations were found between the pathological neuromuscular characteristics and postoperative urinary incontinence (Table 1).
Conclusions: Pathologic neuromuscular characteristics were not associated with postoperative incontinence. Larger‐scale studies with comprehensive assessments including myelin staining as well as intraoperative evaluation of the neurovascular bundle may improve prediction of postoperative urinary incontinence.
Funding: ‐
Long‐Term Outcomes of Testosterone Replacement Therapy Delaying Biochemical Recurrence Post‐RARP: Frequency‐Matched Case‐Control Study
Joshua Tran1, Mai Xuan Nguyen1, Muhammed Hammad1, Rafael Gevorkyan1, Catherine Fung1, Faysal Yafi1, Linda My Huynh2, Thomas Ahlering1
1University of California, Irvine, 2University of Nebraska Medical Center
Presented By: Joshua Tran, MS
Introduction: Testosterone Replacement Therapy (TRT) is known to improve functional and sexual outcomes in hypogonadal men. TRT historically has been contraindicated for the management of hypogonadism in men with prostate cancer (PC). In 2020, we demonstrated in a cohort of 850 men that TRT reduced biochemical recurrence (BCR) by 50% (median follow‐up 3.5 yrs.). The present study extends the follow up to 5.25 years.
Methods: A retrospective review of prospectively collected data between December 2009 and June 2018 undergoing robotic radical prostatectomy by a single surgeon was conducted. 152 patients were administered TRT post‐RP with a calculated free testosterone (cFT; below the 25%) and were frequency matched to 420 patients not receiving TRT with respect to pathological stage (p‐stage) and Gleason Grade Group (GGG). Biochemical recurrence (BCR) was defined as two consecutive prostate specific antigen (PSA) blood tests > 0.2 ng/mL. An adjusted Kaplan‐Meier (KM) graph was used to analyze rate and time to BCR.
Results: Baseline differences in demographics were observed in BMI (p = 0.006) and follow up time (p = 0.0023), and cFT (p = 0.0156). While overall BCR was not significantly different between the two groups, a difference was observed in time to recurrence. In adjusted KM analysis, patients with a higher calculated free testosterone were less likely to have a BCR (p = 0.05). In the same analysis, patients with a higher GGG, p‐ stage, and preoperative PSA (p < 0.01) were more likely to have a BCR. Patients receiving TRT had similar rates of BCR ( p = 0.676). However, if they recurred, there was an average delay of 1.4 years.
Conclusions: TRT was observed to have a continuing protective effect in preventing and delaying BCR in patients post‐RARP when compared to patients who did not receive TRT.
Funding: None
Does Local Availability Influence Choice of Radical Treatment for Prostate Cancer?
Brian Ho1, Jemini Vyas1, Jenny Branagan1, Stuart Duggleby1, Aakash Pai1, Chandran Tanabalan1
1Northampton General Hospital
Presented By: Brian Ho, MBBS, MRes, MRCSEd
Introduction: Radical prostatectomy (RP) and radiotherapy (RR) are both viable options for the treatment of localised prostate cancer. Over the years, medicine has evolved towards a patient‐centred approach. Patient decision‐making is not motivated by clinical outcomes alone. Geographical location and ease of access to treating clinician are contributory factors.With the development of robotic surgery, RP had been centralised into tertiary centres. Since then, robotic surgery has become more readily available and patients are now having their RP more locally. Northampton General Hospital has been performing RP since June 2022. This study aims to compare whether local availability influences choice of radical treatment.
Methods: A single centre retrospective study over a 11‐year period looking at pre‐centralisation, post‐ centralisation then subsequent decentralisation.All patients with localised prostate cancer, undergoing RP or RR were collected pre‐centralisation between January 2012 and July 2014.This was compared to those undergoing these treatments post‐centralisation between January 2018 and March 2020 in addition to decentralisation between June 2022 and April 2023.
Results: Pre‐centralisation, both RP and RR groups had to travel a median of less than five miles for treatment.Post‐centralisation, prostatectomy patients had a median of more than 40 miles to travel, whilst travel distance for the radiotherapy group was unchanged. In the pre‐centralisation cohort, there was a mean number of 5.1 patients undergoing RP per month compared with 13.3 patients undergoing RR per month. Post‐centralisation, RP group had mean of 1.9 patients per month whilst RR group had 18.8 patients per month. Since decentralisation, RP group had mean of 7.2 patients per month and RR group had 16.1 patients per month.
Conclusions: Choice of radical treatment in localised prostate cancer is multifactorial.This study infers that local availability can influence choice of radical treatment. It is imperative that efforts are made to maintain accessibility to all viable options for prostate cancer patients, so that patient choices are not compromised.
Funding: None
Robot‐Assisted Radical Prostatectomy with Same‐Day Discharge Pathway
Narmina Khanmammadova1, Narmina Khanmammadova1, Tuan Thanh Nguyen2, Rafael Gevorkyan1, Maria Epino1, Jacob Basilius1, Catherine Fung1, Caroline Nguyen1, Sohrab Naushad Ali1, Mohammed Shahait3, David I Lee1
1University of California, Irvine, Department of Urology, 2University of Medicine and Pharmacy at Ho Chi Minh City, Department of Urology, 3Clemenceau Medical Center, Department of Surgery
Presented By: Narmina Khanmammadova, MD
Introduction: Robot‐assisted radical prostatectomy (RARP) is the standard surgical treatment for localized prostate cancer in the United States. Same‐day discharge (SDD) pathway for a variety of urologic surgeries including RARP has been shown to significantly reduce overall costs, have comparable complication rates, peri‐operative outcomes and patient satisfaction. Herein, we describe our outcomes of RARP with SDD pathway.
Methods: 76.8% of RARP from May 2021 to February 2023 was done with the SDD pathway (n = 182). All data was compiled in the IRB‐approved prospective database.Detailed explanation as well as educational materials were provided to all patients scheduled to undergo RARP with SDD pathway. Calls or text messages to the healthcare providers as well as visits to the urology clinic or the Emergency Department during the first week of postoperative period were recorded. Continence was described as using no pads or 1 security pad.
Results: Mean age of the cohort was 66.1 ± 7.7 years, mean BMI was 27.82 ± 4.4 kg/m2, median preoperative PSA was 7.3 (5.24 ‐ 11.15) ng/mL, median prostate volume was 40.3 (29 – 60) mL, median preop AUASS was 8 (3.5 ‐ 14) and median preop SHIM Score was 18 (11 – 24). 98.4% of patients had clinical stage 1 cancer. Mean operation time was 143.2 ± 26.4 mins and mean console time was 92.8 ± 26.7 mins. There were no perioperative complications, need for blood transfusion or conversion to open. Median estimated blood loss was 50 mL, median length of hospital stay was 159.6 ± 63.5 mins, median patient reported pain score 1 hour after surgery and at discharge time was 3 (0 – 7) and 2 (0 – 3.75), respectively. 30.7% (n = 27) of patients reported using opioid during the postoperative period while 7.5% (n = 7) of patients were chronic opioid users. Only 7.7% (n = 14) of patients needed to visit urology clinic or ED during the postoperative 1st week while calls and text messages were received from 23.8% (n = 43) of patients. 76.9% (n = 123) of patients reported being continent at postoperative 3 month.
Conclusions: With a comprehensive explanation of the SDD RARP and communication between patients, patients' familiesand healthcare providers; experienced centers can transition to the SDD protocol for RARP which will mitigate the cost burden of overnight stay without affecting patient outcomes.
Funding: This study received no fundings.
Routine Postoperative Laboratory Tests After Laparoscopic Prostatic Surgery
Bernardo Afonso1, Gonçalo Mendes1, João Cabral1, Maria Rocha1, Mariana Madanelo1, Sofia Mesquita1, Miguel Monteiro1, João Vital1, Avelino Fraga1
1Centro Hospitalar Universitário de Santo António
Presented By: Bernardo Afonso, MD
Introduction: Post operative protocols, including blood tests, are frequently implemented to standardise care and as guarantees of safety before discharge. They might however be unnecessary after minimally invasive surgery. Our objective was to determine the clinical utility of routine postoperative blood test after laparoscopic prostate surgery.
Methods: A retrospective review of 235 patients who underwent laparoscopic prostatectomy was conducted. The primary outcome was clinically significant blood loss, defined as a drop in haemoglobin level of 4 g/dL or the need for a blood transfusion. A logistic regression model was developed for both outcomes.
Results: Final review included 235 patients. Forty‐five patients (19.5%) had at least one abnormal blood test parameter on the first post operative day. Eleven patients (4.7%) had clinically significant blood loss, with four patients (1.7%) overall requiring a blood transfusion. All patients requiring a transfusion had a significant complication that was clinically evident; all other abnormal blood tests were mild and did not change routine care. Signs of haemodynamic instability were the main predictors of clinically significant blood loss on multivariable regression analysis, with an OR of 4.14 (95% CI 1.12 – 15.35; p = 0.034).
Conclusions: Routine post operative blood tests have very low yield, seldomly changing care. Clinical signs of hemodynamic instability were the main predictors of significant blood loss and can be used as the main trigger for laboratory testing. Reducing routine laboratory tests could improve patient experience, diminish cost and hospital stay. Our results provide evidence to perform radical prostatectomies in a one day surgery setting.
Funding: None
Survey of International Practices of Robot‐Assisted Radical Prostatectomy
Narmina Khanmammadova1, Narmina Khanmammadova1, Muhammed A Moukhtar Hammad1, Tuan Thanh Nguyen2, Sohrab Naushad Ali1, Jacob Basilius1, Catherine Fung1, Caroline Nguyen3, Mohammed Shahait4, David I Lee1
1University of California, Irvine, Department of Urology, 2University of Medicine and Pharmacy at Ho Chi Minh City, 3University of California, Irvine. Department of Urology, 4Clemenceau Medical Center, Department of Surgery
Presented By: Narmina Khanmammadova, MD
Introduction: Numerous modifications have occurred with the evolution of robot‐assisted radical prostatectomy (RARP). In this survey, we aim to provide a snapshot of RARP practice variation among surgeons.
Methods: A multidimensional questionnaire was conducted internationally from February toMay 2023 via the Endourological Society to assess surgeons' training status & preferred RARP practices.
Results: Of the 75 surgeons participated, 43.2% were from the USA, and 59.6% were from 30 other countries. 66.7% received fellowship training: 46% in robotic and laparoscopic surgery, 26% in urologic oncology, and 22% in endourology. The distribution of the prostatectomies done per month was as follows: 20% of surgeons > 10; 17.3% 6‐10; 40% 3‐5; 18.7% 1‐2 and 4% none.Preferred approaches during RARP were as follows: 58.6% using transperitoneal anterior approach, 28.6% practicing transperitoneal posterior approach, 4.3% using extraperitoneal approach, and 7.1% utilizing the Retzius‐sparing approach. 65.7% preferred standard insufflation pressure (12‐15 mmHg), while 25.7% favored low (10‐11 mmHg), and 8.6% opted for ultra‐low pressure. Rates for preferred technical points during vascular control and nerve‐sparing were as follows: 37.3% electrocautery; 20% suture ligatures for NVB dissection; 6.7% ultrasonic shears; 78.7% clips for vascular pedicle ligations. 62.9% of surgeons preferred the right‐side assistant while 37.1% reported having left side assistant.44.9% preferred cut & suture ligation for DVC control while 5.8% reported utilizing endoscopic stapling, 40.6% reported applying suture ligation with suspension and 8.7% reported using other methods such as electrocautery. 64.2% reported not using hemostatic agents. 48.6% of surgeons opted for the standard approach to perform routine pelvic lymph node dissection (PLND), and 28.4% reported performing extended PLND routinely. 64% prescribed postop non‐opioid oral analgesics. 23.6% preferred same‐day discharge for most of their patients, 5.6% reported discharging patients on postop day 2 and 16.4% preferred keeping patients in the hospital for ≥3 days.
Conclusions: There are notable variations in the practice of the RARP globally. Our results might inform future global data registry designs to capture these nuances of RARP.
Funding: No funding.
Preemptive Use of Beta‐Agonists in Patients with Type II Diabetes Mellitus Hastens the Return of Urinary Continence Post Robotic‐Assisted Radical Prostatectomy
Sneha Parekh3, Shirin Razdan1, Sanjay Razdan2
1Icahn School of Medicine at Mount Sinai,, 2International Robotic Institute for Prostate Cancer, 3Larkin Palm Springs Hospital, Miami, FL, USA
Presented By: Sneha Parekh, MD
Introduction: Diabetes mellitus (DM) is associated with delayed recovery of urinary continence following robotic‐assisted radical prostatectomy (RARP).(1) Beta‐agonists are often prescribed to diabetic patients who have overactive bladder symptoms.(2) The objective of this study was to evaluate the efficacy of beta‐ agonists in patients with type 2 diabetes mellitus (DM2) undergoing RARP for early return of continence.
Methods: We prospectively recruited 120 men with localized prostate cancer who were scheduled to undergo RARP. Group A consisted of 30 patients with DM2 who were started on beta‐agonists at the time of foley removal, group B consisted of 30 patients with DM2 who were not started on beta‐agonist, and Group C consisted of 60 patients without DM2 with no beta‐agonist. All men underwent our maximal urethral length preservation (MULP) technique to maximize the early return of urinary continence. (3) All men in Group A were started on post‐operative beta‐agonist (Mirabegron 50 mg) upon foley removal and continued for 3 months. These patients were followed up at 10 days, 3 months, and 6 months after surgery and their degree of continence was measured. A 1‐month telephonic interview was also conducted. Continence was defined as the use of no pads in a 24‐hour period.
Results: There was a significant difference in return to continence between Group A and Group B. Median number of days until the return of urinary continence in Group A was 24days whereas it was 54 days in Group B (p < 0.01). There was no significant difference in the median number of days until the return of continence between Group A and Group C (22 days, p < 0.01). By the 3‐ month follow‐up, 95% of all patients had a return of urinary continence. By the 6‐month follow‐up, 99% of all patients had a return of continence.
Conclusions: Comorbid DM2 results in a delay in the return of urinary continence post RARP. The use of postoperative beta‐agonists helps hasten the return of continence in this group of men undergoing RARP.
Funding: None
Erectile Function Recovery in Hypogonadal Men Aged ≥60 Post‐Radical Prostatectomy: A Retrospective Concomitant Nonrandomized Comparison of Testosterone Replacement Therapy Versus No Treatment
Joshua Tran1, Rafael Gevorkyan1, Muhammed Hammad1, Catherine Fund1, David Barham1, Faysal Yafi1, Thomas Ahlering1
1University of California, Irvine Medical Center
Presented By: Joshua Tran, MS
Introduction: We, and others, have shown that testosterone replacement therapy (TRT) can be safely applied in men with low calculated free testosterone (cFT) following radical prostatectomy (RP). Further, in our experience, we found that older men (> 60), regardless of their calculated free testosterone (cFT) levels, tend to experience a diminished degree of EF recovery compared to younger men (< 60). Hence in this study we assess TRT versus no TRT 2‐yrs potency outcomes in hypogonadal men aged ≥60.
Methods: Retrospective concomitant nonrandomized comparison of 70 hypogonadal men, aged 60 or older, were stratified by TRT post‐RP. Baseline demographics, total testosterone (TT), cFT, and comorbidities prior to RP were measured from October 2016 – October 2020. EF was assessed at 3, 9, 15, and 24 months post‐ RP defined as erections sufficient for penetration and satisfying (EPIC), International Index EF 5 on Q1 (IIEF‐5; confidence) and/or erection fullness > 75%. T‐tests, chi‐square, and regression analyses were performed.
Results: There were no statistically significant differences in baseline factors (age and Grade) between groups. EF at 2 yrs was 63.6% (TRT) versus 35.1% (No TRT; p = 0.017). Regression analysis showed that TRT was a predictor of EF 2 yrs post‐RP (OR: 3.33; 95% CI: 1.16‐10.3; p = 0.029) after adjusting for age and Gleason Grade Group. Kaplan Meier analysis demonstrated a trend towards a significant improvement in time to BCR (p = 0.078).
Conclusions: In hypogonadal men aged ≥60, TRT significantly improved EF outcomes 2‐yrs post‐RP. The 5‐yrs risk of BCR in men receiving TRT was trending lower (p = 0.078).
Funding: None
Challenges of Renal Transplantation in Patients with Prior Robotic Prostatectomy
Kai Wen Cheng1, Ala'a Farkouh1, Cheryl Wang1, Matthew I. Buell1, Akin S. Amasyali1, Kai Wen Cheng1, D. Duane Baldwin1
1Loma Linda University Health
Presented By: Kai Wen Cheng, MD
Introduction: Patients with end stage renal disease (ESRD) who are candidates for transplantation are often screened and treated for prostate cancer prior to renal transplant. Robot assisted laparoscopic prostatectomy (RALP) is sometimes performed in these patients and may increase the complexity of subsequent renal transplantation. The purpose of this study was to review the surgical outcomes in patients undergoing renal transplantation following RALP.
Methods: A retrospective review of prostate cancer patients with ESRD, who underwent RALP at a single academic institution followed by renal transplant, was performed. For all patients, oncologic, functional, and surgical outcomes were recorded. Particular attention was paid to challenges arising from the prior RALP at the time of transplant.
Results: Sixteen patients underwent RALP followed by transplant. The mean age at time of RALP was 60 years and the mean duration between RALP and subsequent renal transplant was 38 (range: 6‐130) months. At the time of RALP, 75% of patients were undergoing dialysis and 7 (43.8%) were anuric. On RALP specimens the pathological local stage was T2 in 81.3% and T3 in 12.5%. No patient had positive lymph nodes and no recurrence was reported in any patient at a mean follow‐up of 66 (13‐206) months. The transplant mean operative time was 304 minutes and 50% of the cases required an intraoperative urologic consultation. In 4 cases, intraoperative consultation was for difficult catheterization secondary to meatal stenosis (1), false passage (1), bladder neck contracture (1), and distal urethral stricture (1). In 4 cases, the transplant team required urologic assistance to identify and mobilize the small contracted bladder. In one of these cases, urology also assisted in ureteral reimplantation. Additionally, intraoperative challenges with bladder identification or mobilization were recorded and managed by transplant surgeons in 5 cases, without urology consultation. After transplant, 4 patients experienced voiding dysfunction (2 stress incontinence, 1 urge incontinence, and 1 incomplete voiding due to stricture), 3 of which were newly evident in previously anuric patients.
Conclusions: RALP is a suitable treatment option for patients with localized prostate cancer and ESRD, but may result in increased complexity at the time of the subsequent renal transplant, requiring urologic assistance. Transplant surgeons and urologists should anticipate these unique challenges. In anuric patients, voiding dysfunction may not manifest until after transplantation.
Funding: None
Assessing Decision Regret in Patients with Same‐Day Discharge Pathway after Robot‐ Assisted Radical Prostatectomy
Narmina Khanmammadova1, Narmina Khanmammadova1, Tuan Thanh Nguyen1, Rafael Gevorkyan1, Joshua Tran1, Jacob Basilius2, Catherine Fung1, Caroline Nguyen1, Sohrab Naushad Ali1, Mohammed Shahait3, David I Lee1
1University of California, Irvine, Department of Urology, 2University of California, Irvine, 3Clemenceau Medical Center, Department of Surgery
Presented By: Narmina Khanmammadova, MD
Introduction: After the introduction of the same‐day discharge (SDD) pathway for a variety of surgeries it was found to have comparable complication rates as well as reduced overall cost of care. While outpatient RARP is feasible in high‐volume centers, patients' perspectives on being discharged the same day following the operation need to be elucidated.
Methods: A multidimensional questionnaire consisting of 24 questions to assess socioeconomic status, presence of caretaker at home, preferred transportation to the emergency room and the Likert Decisional Regret Scale was distributed to patients who underwent robot‐assisted radical prostatectomy between June 2020 and August 2022. Decision regret score was calculated as described in the literature before. We used 15 as a cut‐off point for differentiating the high and low regret rates.
Results: During our study, 80 men (49.6%) undergoing outpatient RARP from a single high‐volume center completed the survey. Patients who completed < 80% of the survey (n = 8) were excluded from the final analysis. Forty‐four (65.7%) patients felt no regret about their decision of choosing SDD RARP protocol and 65 men (90.3%) stated that they would have chosen the same decision while 68 (97.1%) patients would also recommend this procedure to others. Median decisional regret score of the cohort was 0 (0 – 10). Fifty‐four (80.6%) patients had low regret scores while 13 (19.4%) had high regret scores. Patient rate with low household income (< $30.000 a year) was higher (7.7%) in high regret score group compared to the patients with lower regret scores (1.9%). Patients in the high regret score group reported postoperative pain more frequently than patients in the low regret score group (61.5% vs. 38.9%, respectively).
Conclusions: While most of the patients did not regret their decision to choose SDD pathway post‐RARP, further research is necessary to identify patients who might be prone to have high decision regret for choosing SDD pathway post‐RARP.
Funding: No funding.
WITHDRAWN
WITHDRAWN
Uncovering Robotic‐Assisted Laparoscopic Prostatectomy (RALP)‐Specific Complications: Lessons from Contemporary NSQIP Data
Alexander Homer1, Borivoj Golijanin1, Phillip Schmitt1, Vikas Bhatt1, Elias S. Hyams1, Gyan Pareek2
1The Minimally Invasive Urology Institute, The Miriam Hospital, Urology Division, Warren Alpert Medical School of Brown University, Providence, RI, USA, 2Brown Medical School
Presented By: Alexander Homer, AB
Introduction: Robotic‐assisted laparoscopic prostatectomy (RALP) is commonly used to treat localized clinically significant prostate cancer (PCa). The National Surgical Quality Improvement Program (NSQIP) started collecting RALP‐specific data in 2019. Although RALP has a low complication rate, continued assessment of risk factors for complications is necessary for quality assurance (QA), particularly in the era of same‐day discharge.
Methods: PCa patients who underwent RALP were identified within the 2019‐2021 NSQIP database. Patient identifiers were merged with the RALP‐specific NSQIP data file. Multivariate logistic regression was performed to evaluate the association between risk factors and outcomes specific to RALP and pelvic lymph node dissection (PLND). Input variables included ASA class, age, operative time, and BMI. Additional variables from the extended dataset with PLND information were the number of nodes evaluated, perioperative antibiotic use, postoperative VTE prophylaxis use, history of prior pelvic surgery, and history of prior radiotherapy. Outcomes of interest were lymphocele and urinary/anastomotic leak.
Results: Complete records of 11,811 patients were identified. Following RALP, 2.0% developed lymphocele, and 2.5% experienced urinary/anastomotic leaks. The odds of developing lymphocele were higher with a history of prior pelvic surgery (OR:1.57, CI:1.16 ‐ 2.13), increasing number of nodes evaluated (OR:1.02, CI:1.01 ‐ 1.03), and undergoing PLND (OR:3.05, CI:1.64 ‐ 5.7). Perioperative antibiotic use (OR:0.45, CI:0.29 ‐ 0.71) was associated with a lower likelihood of urinary/anastomotic leaks. On the other hand, prior radiotherapy (OR:5.52, CI:2.92 ‐ 10.42), longer operative time, higher BMI, and prior pelvic surgery (OR:1.4, CI:1.06 ‐ 1.84) were associated with an increased risk of urinary/anastomotic leak.
Conclusions: Although the risk of developing lymphoceles or anastomotic leak is low, consideration of prior treatments, operative course, and extent of PLND is warranted in patients undergoing RALP. Attention to these risk factors can improve perioperative care and help identify patients who may benefit from additional risk reduction efforts.
Funding: None
Single Port Robot‐Assisted Extra‐Peritoneal Radical Prostatectomy: Evaluation of Learning Curve
Jennifer L Nguyen2, Teona Iarajuli1, Katherine Kim1, Cairo Stanislaus1, Aamirah McCutchen1, Meghana Singh1, Ruchir Chaturvedi1, Mutahar Ahmed2, Michael Stifelman2
1Hackensack Meridian School of Medicine, 2Department of Urology, Hackensack University Medical Center
Presented By: Jennifer L Nguyen, BS
Introduction: To evaluate the learning curve of single port (SP) robotic‐assisted extraperitoneal radical prostatectomy (RARP) by two surgeons at a single institution.
Methods: We utilized a prospective, single center database and selected patients who underwent SP RARP between 2021 and 2022 by two surgeons. Demographics and clinical characteristics were analyzed. Cases were divided into four groups based on chronological order of operative date: group 1 included cases 1‐24, group 2 had cases 25‐48, group 3 had cases 49‐72, and group 4 had cases 73‐97. Outcomes between the groups were compared with Wilcoxon rank sum test for continuous variables or Fisher's exact test for categorical variables. Qualitative assessments were made based on least squares regression line.
Results: We analyzed 97 patients who underwent SP RARP. There was no statistically significant difference in age, BMI, pre‐op gleason, and PIRADS scores between the four groups. The median prostate size was significantly larger in groups 3 (50.5 cc) and 4 (44.5 cc) than in groups 1(31.0 cc) and 2 (35.0cc) (p = 0.0144). Figure 1. is suggestive of an overall trend of a slow decrease in operative time as the case numbers increase.
Conclusions: At our institution, experienced robotic surgeons did not demonstrate a steep learning curve in SP extraperitoneal RARP. Of note, average prostate size increases over time, which may suggest more complex cases and partly explain these results. Further analysis of less experienced robotic surgeons should be evaluated to depict a more accurate learning curve.
Funding: No funding was received for this article
Androgen Deprivation Therapy versus Active Observation: Incidence of Adverse Cardiovascular
Joshua Tran1, Rafael Gevorkyan1, Erica Huang2, Robert Wilson3, Sheldon Greenfield1, Linda Huynh4, Catherine Fung1, Thomas Ahlering1
1University of California, Irvine Medical Center, 2University of Massachusetts Medical School, 3University of California, Irvine, 4University of Nebraska, Medical Center
Presented By: Joshua Tran, MS
Introduction: Secondary treatment of prostate cancer recurrence following a radical prostatectomy (RP) consists of androgen deprivation therapy (ADT) and/or radiation therapy (RT). A major complication associated with ADT use is an adverse cardiovascular event (ACE). Current literature outlines a disagreement between the relationship of ADT and its effects on ACEs. The present study describes the relationship of ACE in men undergoing ADT following RP.
Methods: 1895 men between June 2002 and September 2019 underwent RP performed by a single surgeon. Patients were included if they had a BCR, defined as two prostate specific antigen blood tests > 0.2 ng/mL, with adequate follow‐up. 308 men were included in our analysis. 189 men in the “treatment group” (TG) received either ADT or RT/ADT. A comparator group of 119 men were in the active observation group (AO) and were observed without treatment. Student t‐test and chi square analyzed differences between the groups. Logistic regression and Kaplan‐Meier survival curves found predictors of ACE and time to ACE.
Results: Age, CCI, body mass index (BMI), treatment status (AO vs TG), and smoking status (previous vs non‐smoker) were significant predictors of ACE in univariate regression analysis. 15‐year Kaplan‐Meier (KM) analysis showed a statistically significant increase in ACEs (TG 54.4% and AO 41.8%, p = 0.02). Multivariate regression analysis found CCI and BMI to be significant predictors of ACE with treatment status trending toward significance.
Conclusions: Treatment status was associated with an increased risk of cardiovascular morbidity (measured by ACE). We also noted the importance of BMI and CCI as a prognosticating tool for ACE.
Funding: None
Robotic Radical Prostatectomy in Prostate Cancer: Oncologic Results of Our First 102 Cases
Serdar Turan3, Faruk Özcan1, Serdar Turan2, Rifat Ergül2, İlker Teke2, Yasin Ates2, Selcuk Erdem1, M. Oner Sanli1
1Division of Urologic Oncology, Department of Urology, Istanbul University Istanbul Faculty of Medicine, 2Department of Urology, Istanbul University Istanbul Faculty of Medicine, 3Istanbul University, Istanbul Faculty of Medicine, Department of Urology
Presented By: Serdar Turan, Resident
Introduction: We aimed to evaluate the post‐operative oncological results of our patients who underwent robot‐assisted radical prostatectomy (RARP) for localized prostate cancer.
Methods: Demographic data, PSA values, pathology and follow‐up data of our first102 patients who underwent RARP for localized prostate cancer between April 2018 and September 2022 in a tertiary center, were retrospectively analyzed.
Results: The mean age of the patients was 62.8(55.8‐69.8) . The mean PSA value of the patients was 9.6 ng/ml (range 2,6‐16,7). In biopsies of the patients, 19 (18%) ISUP grade 1, 48 (47.1%) ISUP grade 2, 19 (18.6%) ISUP grade 3, 9 (8.8%) ISUP grade 4, 7 (6.9%) ISUP grade 5 tumors were detected. When the patients were classified according to the EAU risk classification, 2 (1.9%) patients were classified as low risk, 68 (66.6%) patients with intermediate risk, 32 (31.3%) patients with high risk prostate cancer. Surgical margins were negative in 53 patients (52%), positive in 38 patients (37.3%), and contiguous in 11 patients (10.8%). 58 patients had organ confined disease (%56).35 patients (34.3%) had extra prostatic extension, 9 (8.8%) patients had seminal vesicle invasion. 9% lymph node positivity was detected in patients who underwent lymph node dissection. In radical prostatectomy material, 2 (2%) patients had ISUP grade 1, 36 (35.3%) patients had ISUP grade 2, 34 (33.3%) patients had ISUP grade 3, 23 (22.5%) patients had ISUP grade 4, and 7 (6.9%) patients had ISUP grade 5 tumors. A cribriform pattern was detected in 16 (15.7%) patients. Lymph node dissection was performed in 97 (95%) patients. Lymph node metastasis was detected in 8 of 97 patients who underwent lymph node dissection. Follow‐up data was available in 91 patients. Biochemical recurrence occurred in 15 (14.7%) of 91 patients during the mean follow‐up time of 28 months.
Conclusions: RARP can be performed with safe oncological outcome in urology clinics even in early periods of newly started robot‐assisted radical prostatectomy program.
Funding: None
MODERATED POSTER SESSION 8: STONES - MEDICAL MANAGEMENT 2
Can Artificial Intelligence Help Our Patients Prevent Kidney Stones?
Matthew Steidle2, Rajat Jain1, Steven Hassig1, Scott Quarrier1
1URMC Urology, 2University of Rochester Urology
Presented By: Matthew Steidle, MD
Introduction: Recent advances in artificial intelligence have led to the creation of chatbots, such as ChatGPT. Chatbots function as alternatives to search engines by providing detailed and articulate responses in easy to understand, conversational prose, to make information easier to digest. However, there are rising concerns that AI‐powered chatbots can sometimes present invented information that is false. These are called “hallucinations.” We predict that, similarly to searching for information on the internet, as chatbots improve and become increasingly prevalent, patients will turn to them to provide information on how to prevent kidney stones. We tested several of the currently publicly available chatbots to test if they provide accurate dietary advice to patients for kidney stone prevention.
Methods: The AUA guidelines on medical management of kidney stones include statements 8‐11 which are labeled diet therapies. Several publicly available chatbots were tested. The question: “how do you prevent kidney stones by changing your diet?” was entered. The responses were then evaluated to see if they covered guidelines statements 8‐11. The responses were subjectively evaluated for accuracy of content, quality of sources, ease of understanding, and functionality. The chatbots were given an opportunity to provide further detail with the prompt: “can you elaborate on that further?”
Results: With only 1 exception, all of the chatbots gave dietary advice that covered the AUA dietary guidelines for kidney stone prevention. Some gave more specifics and quantifiable targets. For example, You.com Chat recommended drinking enough fluid to produce 2‐2.5L of urine while Chat GPT gave a list of specific oxalate rich foods to avoid. See table for further details.
Conclusions: We demonstrated that by and large, AI‐powered chatbots provide helpful, general information about kidney stone prevention, including hydration, a healthy balanced diet, weight loss, and avoidance of animal protein. In the present study, we found the chatbots to be easy to use and a good starting point for patient education at minimal cost. They all recommended speaking with a dietary professional or urologist for further information. This is important as nuances of kidney stone prevention relies heavily on stone analysis, blood work and 24‐hour urinalysis.
Funding: None
Association of Obesity with Different Metabolic Risk Factors in Nephrolithiasis Patients
Mark I Sultan1, Mark I Sultan1, Pengbo Jiang1, Sohrab N Ali1, Roshan M Patel1, Ramy Youssef1
1University of California, Irvine
Presented By: Mark I Sultan, MD
Introduction: 24‐hour urine collections are obtained as part of the metabolic workup for nephrolithiasis to identify modifiable abnormalities for stone prevention. We sought to discern trends in the prevalence of metabolic abnormalities based on body habitus.
Methods: All Litholink 24‐hour urine collections for nephrolithiasis patients obtained at our institution between 2004 and 2020 were retrospectively reviewed. Only the first 24‐hour urine collection prior to therapy for each patient was included the analysis. Patients were classified according to Body Mass Index (BMI)as underweight (< 18.5), normal (18.5 ‐ 25), overweight (25‐30), and obese (> 30). Litholink's gender specific reference ranges were used to define abnormalities.
Results: 1372 patients were included. The mean age was 56 ± 15.3 (53.5% male, 46.5% female). Overall, the most common metabolic abnormality was elevated urine sodium (52.8%), while the least common was a low urine pH (15.6 %). Table 1a reports the prevalence of metabolic abnormalities among the groups, table 1b reports the median value and significance of variation between the groups. On subgroup analysis, obese stone formers compared to normal patients were more likely to have hypercalciuria OR = 1.36 [1.036‐1.794], hyperoxaluria OR = 1.85 [1.40‐2.45], elevated urine sodium OR = 2.60 [1.98‐3.41], hyperuricosuria OR = 3.09 [2.22‐4.31], low urine pH OR = 3.86 [2.60‐5.75], and high uric acid supersaturationOR = 3.20 [2.37‐4.34].
Conclusions: Body weight differences are associated with different risk profiles on a 24 hour urine collection. Obese patients are more likely to harbor metabolic derangements on a 24‐hour urine analysis compared to normal patients. These findings highlight the importance of lifestyle and dietary modifications to correct obesity in addition to directed medical therapy for stone formers.
Funding: None
Grounded: A Retrospective Study of Aviation Pilots Undergoing Treatment for Nephrolithiasis
Hal Kominsky1, Mohannad Awad1, Isaac Palma Zamora1, Alaina Garbens1, Vineeth Komiddi1, Brett Johnson1, Margaret Pearle1
1UT Southwestern Medical Center
Presented By: Hal Kominsky
Introduction: Nephrolithiasis represents a significant societal burden with respect to overall healthcare cost and decreased work productivity. Pilots are particularly vulnerable as they are prohibited from flying by the Federal Aviation Association until they can demonstrate documented stone clearance. The goal of our study was to examine the clinical characteristics, in addition to metabolic and surgical outcomes in a cohort of aviation pilots with nephrolithiasis.
Methods: We performed a retrospective chart review of a cohort of aviation pilots with a radiographically confirmed diagnosis of nephrolithiasis who received care at our institution between 2006 and 2022. Demographic information, prior history of stone disease at the time of presentation, baseline metabolic parameters, stone size and location, as well as surgical and metabolic interventions were obtained from the electronic medical record. The clinical outcomes of interest included initial stone burden, type and rate of intervention, stone composition, serum chemistry and 24‐hour urine parameters.
Results: In total, we identified 39 pilots (median age of 44, one female) who met study criteria. Twelve patients (31%) were referred from an Emergency Department encounter for a symptomatic stone episode. We found that 72% of patients reported a history of at least one previous stone episode, and 51% had previously undergone some form of stone surgery. Average symptomatic stone size at presentation was 5.0mm while mean cumulative stone burden was 10.2mm. The rate of bilateral stones was 51%. Ureteroscopy was performed at least once in 72% of patients, and two patients required a secondary procedure to clear remaining fragments. One patient underwent percutaneous nephrolithotomy, and one patient underwent shock wave lithotripsy. All patients were initially deemed to be stone free at their first follow up after surgery, determined by CT, KUB and/or renal ultrasound. Stone composition was primarily calcium oxalate in 82% of patients who underwent surgical treatment while 11% had calcium phosphate stones. Metabolic management or dietary modification was initiated in 28 patients (72%). Medical management included initiation of indapamide, potassium citrate, and allopurinol prescribing in 28%, 44%, and 5% of patients, respectively. Baseline 24‐hour urine analysis revealed mean urine volume 2.42L, pH 6.2, sodium 219.7mg/TV, calcium 287.5mg/TV, citrate 660.2mg/TV, uric acid 738.2mg/TV, and oxalate 44.6mg/TV. At median follow up of 13.5 months, mean urine volume was 2.62 (p = 0.028), pH 6.7 (p = 0.148), sodium 175mg/TV (p = 0.199), calcium 256.8mg/TV (p = 0.807), citrate 353mg/TV (p = 0.116), sodium 741.8mg/TV (p = 0.976), and oxalate 41.5mg/TV (p = 0.352). Four patients (10%) had a recurrent stone event. Three patients (8%) were treated with ureteroscopy, all of whom had previously been on medical management.
Conclusions: We observed a high rate of surgical intervention from outpatient referrals for aviation pilots with nephrolithiasis. These patients did not appear to have any baseline serum metabolic abnormalities and commonly had bilateral stones. Most of these patients were advised on dietary modification and or initiated on drug therapy, emphasizing that aggressive stone prevention is paramount for pilots with nephrolithiasis.
Funding: None.
Development of a Novel Mobile Health Platform for Surveillance of Kidney Stone Formers: A First Look
Jenny Guo2, Mark Assmus1, Nicholas Dean2, Jessica Helon2, Amy Krambeck2
1University of Calgary, 2Northwestern University
Presented By: Jenny Guo, MD
Introduction: Usage of mobile health (mHealth) applications in management of urolithiasis is becoming increasingly more prevalent. We developed a comprehensive stone prevention mobile care plan that addresses the current lapses in dietary/medical adherence and misinformation to improve stone‐related quality of life (QOL).
Methods: We created a care plan for kidney stone formers in partnership with GetWell Loop, an interactive mHealth application. The plan incorporates 24‐hr urine collection results to provide custom recommendations regarding dietary management, fluid intake, medications for each individual patient. The main feature of the app includes check‐in surveys every 3 months, which act as a refresher regarding medical management of stones and incorporate patient satisfaction, stone‐related health, and Wisconsin QOL (WISQOL) questionnaires. Other features include monthly fluid and medication adherence reminders, an activity feed where patients can review custom‐created stone handouts, and a secure messaging chat. Eligible patients included those over 18 years who are first‐time or recurrent stone formers.
Results: A total of 153 patients were eligible for the study, and 46 patients have been enrolled into the application thus far. Mean patient age is 55.5 years (range 24‐81), and 50% were female. Feedback received include that it is “streamlined,” “easy to use,” and “not too lengthy.” Patients report that they enjoy having access to resources at their convenience and feel that the app has helped them remain more compliant with provider recommendations. Figure 1 depicts screenshots of the check‐in process.
Conclusions: We designed a novel kidney stone mHealth care plan that incorporates patient‐specific data to reinforce dietary management, fluid intake, and medication adherence in chronic stone formers. Usage of this application may improve patient QOL and compliance with recommendations.
Funding: Urology Care Foundation Residency Research Award
Urinary Alkalization: Exploring the Efficacy of Alkaline Water and a Systematic Review of Other Beverages and Supplements
Paul Piedras1, Andrei Cumpanas1, Amanda McCormac1, Seyed Amiryaghoub Lavasani1, Antonio Gorgen1, Allen Rojhani1, Rohit Bhatt1, Minh‐Chau Vu1, John Asplin2, Zachary Tano1, Jaime Landman1, Ralph Clayman1, Roshan Patel1
1UCI, 2Litholink Corporation, Labcorp®
Presented By: Paul Piedras, BS
Introduction: Alkaline water with a pH range of 8‐10 has been considered as a possible therapeutic approach to urinary alkalinization among patients suffering from uric acid urolithiasis. The general starting recommendation for urinary alkalization is the daily ingestion of 30 mEq of alkali. For any fluid to have an alkalinizing effect on urine, it must contain organic anions such as bicarbonate or citrate. Common therapies targeted for uric acid stone patients, either prescribed or purchased over the counter, may present a significant financial burden (i.e., $200/month). Accordingly, we conducted an analysis of the electrolyte and organic anion composition of five commercially available alkaline water products. Furthermore, we implemented a systematic review of previously reported beverages and supplements that might facilitate urinary alkalinization.
Methods: Five commercially available alkaline water brands (Essentia®, Smart Water® Alkaline, Great Value™ Hydrate Alkaline Water, Body Armor® SportWater, and Perfect Hydration®) underwent anion chromatography and direct chemical measurements to determine their mineral contents. A comprehensive review of 49 additional over‐the‐counter beverages and supplements was done to detail their alkali, sodium, and caloric content per serving.
Results: The pH levels of the five alkaline waters ranged from 9.69‐10.15; however, the physiologic alkali content was uniformly < 1 mEq (Table 1). There were only 12 out of 49 supplements or beverages which with 3 servings/day or fewer, provided an alkali content equal to the AUA and EAU 30 mEq daily intake recommendations for alkalinizing the urine among uric acid stone formers (in green on Table 2).
Conclusions: Despite its high pH, alkaline water fails to provide the necessary alkali to raise the urine pH. Among 49 other sources of urinary alkali, only sodium bicarbonate (i.e., baking soda) and Now® potassium citrate have the dual benefit of low cost and sufficient alkali content.
Funding: N/A
The Internet vs Kidney Stones: What is the State of Online Kidney Stone Prevention Information?
Bassel Salka2, Roshan Patel1, Antonio Gorgen1, Nadir Al‐Saidi2
1University of California Irvine, 2University of Michigan
Presented By: Bassel Salka, Student
Introduction: The incidence of kidney stones continues to increase despite strong evidence of medical prevention of stone formation. As a result, patient education has emerged as a primary tool of urologists to prevent recurrence. With many patients seeking health information online, little is known regarding the quality of kidney stone prevention information available today. The purpose of this study was to evaluate the quality of kidney stone prevention information online.
Methods: We analyzed the first 50 results of the search term “kidney stone prevention” on the most popular search engine (Google), long‐form media player (YouTube), short‐form media player (TikTok) and social media platform (Instagram). Only content in English, related to the topic, and with greater than 1,000 views (when available) were included. Video quality was assessed utilizing DISCERN, a tool used to appraise consumer health information, and the proportion of content that accurately represents AUA medical management guidelines.
Results: The average DISCERN score was statistically greatest on Google (60.1) followed by Youtube (40.4), TikTok (26.6) and Instagram (28.8). The most common type of content creator was Health Systems on Google (72%), physician personal creator on YouTube (56%), and non‐physician personal creator on TikTok (84%) and Instagram (56%). TikTok shows a significantly different DISCERN score between healthcare/physician creators and non‐physician creators. Table 1 shows the percent of videos that accurately describe AUA guidelines.
Conclusions: Kidney stone prevention content on the Internet is strongest on Google. The majority of videos on TikTok and Instagram are of low quality and fail to address AUA guidelines. Increased engagement on these platforms by urologists can improve education.
Funding: No funding
Demographic and Clinical Characteristics of Pure and Mixed Uric Acid Stone Formers
Sagi A. Shpitzer1, Hadar Tamir1, Yaron Ehrlich1, Abd E. Darawsha1, David Lifshitz1
1Rabin Medical Center
Presented By: Sagi A. Shpitzer, MD
Introduction: Uric acid (UA) stone formers are commonly defined as patients with a predominant (> 50%) UA component. However when considering stone dissolution, it is important to differentiate between pure and mixed UA stone formers. In this study we sought to investigate the differences between these two populations in a large cohort of surgically treated nephrolithiasis patients.
Methods: A large healthcare database was searched for adult patients with laboratory results of a stone analysis between the years 2013‐2020. Pure and mixed UA stones were defined as stones containing ≥95% and > 50% UA respectively. Demographic, clinical, and laboratory results were compared between the groups.
Results: Out of 11,979 patients with a stone composition analysis in our database 1,366 stones (11.4%) were classified as UA stones of which 904 were pure and 462 were mixed. The male‐to‐female ratio was 3:1 in both groups. Pure UA stone formers were older (63.8 vs. 61.1 years, p < 0.01) and more likely to be of Jewish ethnicity (82% vs. 76.6%, p < 0.01). Comorbidities including diabetes, ischemic heart disease, hypertension and chronic kidney disease were significantly more frequent in the pure UA group, with the highest difference observed in the diagnosis of diabetes (62.7% vs. 51.5%, p < 0.01). No significant difference in BMI was found between the groups (30.56 vs. 30.93, p = 0.267). Blood uric acid levels were slightly higher in the pure UA group (6.56 vs. 6.38 mg/dL, p = 0.04) while urinary uric acid levels as well as calcium and citrate did not differ. Urinary pH in the pure group was slightly higher (5.53 vs. 5.47, p = 0.03).
Conclusions: Mixed and pure uric acid stone formers differ in certain demographic and clinical aspects. Older patients with diabetes are more likely to present with pure UA stones. Urine pH and 24‐hour urine collection do not allow differentiation between the groups.
Funding: None
Cystine and Brushite Stone Formers Lack of Compliance with Follow up and Treatment
Ilan Klein2, Alex Blinzovski1, Ilona Pilosov Solomon2, Yuval Freifeld2, Rani Zreik2, Mahran Kabaha2, Gazi Fares2, Yoram Dekel2
1Ruth & Bruce Rappaport faculty of medicine, Technion, 2Carmel Medical Center
Presented By: Ilan Klein, MD
Introduction: Cystine and Brushite (C/B) stones are notorious for high recurrency rates. Therefore, follow up of these stone formers should be strict and preventive measures should include specific diet and medications.
Methods: A large IsraeliHMO database we created (over 10K stone patients) was used to identify patients with C/B stones treated between 2014 and 2019. A telephone survey was conducted evaluating patient understanding of stone composition, follow up, urine collection, treatment compliance etc. Patients' data, emergency room (ER) visits, admissions procedures and urologist visits were compared to 100 random Calcium Oxalate patients at the same time period.
Results: Thirty three Cystine patients out of 62 and 39 Brushite patients out of 84 participated. In the Cystine group 75.7% were aware of their stone type and 27.2% had at least 3 stones passed in the last year but half of them did not see their urologist in the previous year. Medication [YF1][2קכ]compliance was only at 57.5%. The Brushite group had only a 28.2% stone awareness, 43.5% did not visit their urologist in the previous year and only a quarter complied with medication. When comparing ER visits, 14% of the control group had 3 times or more in comparison to 41% of the C/B group. 37% of C/B group were admitted more than once a year in comparison to only 14% in the control group.
Conclusions: Poor compliance of C/B patients should urge urologists to improve their follow‐up in order toreduce recurrent stone events.
Introduction: Urine metabolic abnormalities are considered the etiology of nephrolithiasis, and as so it is recommended in both the EAU and AUA guidelines to perform a metabolic evaluation for recurrent stones formers. However, certain patients present with recurrent unilateral renal stones, while the mate kidney consistently remains stone free. The purpose of this study was to explore whether metabolite differences between urine samples of mate kidneys can explain lifetime unilateral renal stone formation.
Methods: We retrospectively reviewed our registry database of nephrolithiasis return patients in an attempt to compare 24‐hour urine compositions obtained under regular diet and daily activities. Three groups of stone formers were detected: Bilateral stone formers (BSF) and unilateral formers (USF) whereby 24‐hour urine collection reflected two mate kidneys, and past‐USF (PUSF) whereby the stone‐forming kidney has been resected or declared as non‐functioning per renal scan. In the latter group, the urine collection reflected the stone‐free kidney.
Results: There were 618 patients in the BSF group, 22 in the USF group, and 8 in the PUSF group. The total median follow‐up length was 83 months. In the USF group there were higher citrate levels compared to the BSF group (669 mg/24hr vs. 486 mg/24hr, p = 0.03), however in the USF group there were unexpectedly higher levels of calcium, uric acid, and oxalate (269 mg/24hr vs 184 mg/24hr p = 0.03; 623 mg/24hr vs. 597 mg/24hr p = 0.03; 36 mg/24hr vs. 32 mg/24hr p = 0.04, respectively). A sort of “correction” was seen in the PUSF group, whereby normal levels of calcium, uric acid, and oxalate levels were detected (123 mg/24hr; 446 mg/24hr; 24 mg/24hr, p < 0.05), yet lower‐than‐expected levels of citrate were seen (218 mg/24hr, p < 0.05). Sodium level was highest in the BSF group and lowest in the PUSF group, however without statistical significance (170 mg/24hr, 158 mg/24hr, 142 mg/24hr, respectively p = 0.6).
Conclusions: 24‐hour urine composition differences between mate kidneys may not serve as a single etiology for lifetime unilateral‐renal stone formation. The solution for this enigma may lie at the molecular/genetic level.
Funding: None.
Baseline Diet Compared to Ideal Kidney Stone Prevention Diet: Implications for Dietary Counseling
Connor Forbes2, Anna Black1, Ghizlane Moussaoui1
1University of British Columbia, 2University of British Columb ia
Presented By: Connor Forbes
Introduction: Dietary interventions can help prevent kidney stone recurrences. Understanding the differences between a population's baseline diet and the ideal diet for kidney stone prevention can help clinicians and patients focuson dietary interventions with the highest yield. Therefore, the aim of this study was to compare the Canadian population's diet to dietary recommendations for kidney stone prevention.
Methods: The 2015 Canadian Community Health Survey – Nutrition (CCHS‐Nut), a national cross‐sectional instrument administered by Statistics Canada and Health Canada was queried. Total daily intake of relevant nutrients were compared to kidney stone recommendations according to Canadian Urological Association patient information materials.
Results: The CCHS‐Nut included data for 14 275 participants, of whom only 34% consume > 2L of fluid per day. This varies across Canada, with almost 10% more adults in Western Canada and the Prairies consuming > 2L per day compared to Central and Eastern Canada. Only 9.4% of the population had 1000‐ 1200mg of dietary calcium and 53.9%consumed too much sodium. Interestingly, 61% of the population had the recommended protein intake.
Conclusions: In this study, 73% of the population reported inadequate fluid intake. Furthermore, most patients consumed too little calcium and magnesium, but too much sodium. Most of patients had appropriate protein intake. While only a subset of these patients will develop stones, this study suggests that clinicians may wish to focus more of their motivational interviewing time on fluid intake and appropriate calcium/ sodium intake, and less on protein intake.
Funding: None
Natural History of Symptomatic Isolated Lower Pole Kidney Stones: A Study from ReSKU
Heiko Yang4, Kevin Chang1, Leslie Charondo1, Gregory Hosier2, Fadl Hamouche3, David Bayne1, Wilson Sui1, Marshall Stoller1, Tom Chi1
1UCSF, 2University of Manitoba, 3McGill University Health Centre, 4University of California San Francisco
Presented By: Heiko Yang, MD,PhD
Introduction: The natural history of isolated lower pole stones has not been well characterized in symptomatic patients. The goal of this study is to describe the outcomes for symptomatic patients with newly diagnosed lower pole stones managed with surgery or observation.
Methods: Prospective data on patients enrolled in the Registry for Stones of the Kidney and Ureter (ReSKU) between 2015 to 2021 with symptomatic isolated lower pole stones [YH1]and followed up accordingly were reviewed. Patients were stratified into those managed with upfront surgery vs observation. The presence of symptoms, defined as pain, hematuria, and nausea or vomiting, during the follow‐up period was the primary outcome. Secondary outcomes were other stone‐related events during the observation period including any of stone passage, stone growth, or need for surgery. Univariate statistics were used to compared outcomes between the two groups. A multivariate model was constructed to identify risk factors associated with symptoms.
Results: 115 patients with symptomatic isolated lower pole kidney stones and follow‐up were identified with a median stone burden of 10 mm and median time to first follow‐up of 3.3 months. 65 patients underwent surgery and 50 patients opted for observation. Patients in the observation group were more likely to remain symptomatic within a 12‐month follow‐up period (36% vs 17%, p = 0.03). No patient‐associated risk factors were identified for symptom persistence aside from the decision to undergo observation. In patients who elected for observation, 11 (22%) ultimately underwent surgery, 5 (10%) had spontaneous stone passage, and 11 (22%) had increase in size of their lower pole stone. In patients who underwent surgery, 4 (6%) underwent another surgery and 3 (5%) had spontaneous stone passage.
Conclusions: Patients with symptomatic lower pole stones are twice as likely to remain symptomatic if they choose observation compared to upfront surgery. An understanding of these outcomes should be used during the shared decision‐making process.
Funding: NA
Effects of a Commercial Lemonade Beverage and Potassium Citrate on Urinary Stone Risk Factors: A Preliminary Analysis
Jenny Guo1, Nicholas Dean1, Mark Assmus2, Xinlei Mi1, Jessica Helon1, Amy Krambeck1, Matthew Lee3
1Northwestern University, 2University of Calgary, 3The Ohio State University
Presented By: Jenny Guo, MD
Introduction: Potassium citrate (KCit) is commonly prescribed to patients with recurrent nephrolithiasis, however medication compliance is poor due to gastrointestinal side‐effects. Crystal light (CL) sugar‐free lemonade is a low‐calorie beverage alternative that has been shown to increase urinary citrate and pH levels. In this study, we aimed to compare the effects of potassium citrate and Crystal light on 24‐hour urine collections
Methods: We performed a randomized crossover trial of 5 patients with isolated hypocitraturia on 24‐hour urine collections. Patients completed one week trials of KCit (15mEq daily), CL (1L daily), and combination CL and KCit (500mL +10mEq daily) followed by immediate 24‐hour urine collections after each weekly treatment. Statistical analysis was conducted with p < 0.05 representing significance.
Results: The CL regimen led to the greatest increases in urinary volume (CL: 0.69 vs KCit: 0.16 vs Combo: 0.38, p = 0.4) and urinary citrate (CL: 316 vs KCit: 120 vs Combo: 190, p = 0.5) from baseline, however these differences did not reach statistical significance. The Combo regimen led to a mean increase in pH of 0.53 compared to 0.41 with CL and 0.07 with KCit (p = 0.4). There were similar increases in supersaturation (SS) of calcium phosphate in all groups (CL: 0.28 vs KCit: 0.25 vs Combo: 0.27, p > 0.9). The SS of calcium oxalate (CaOx) decreased by 0.91 in the CL group but showed slight increases in the KCit (0.78) and combo groups (0.07, p = 0.7). Figure 1 depicts the stone risk factor plots comparing all groups.
Conclusions: CL was associated with the greatest increases in urine volume and urinary citrate and decreases in SS CaOx compared to KCit. However, these differences did not meet statistical significance. Further multi‐ institutional studies are needed to determine clinical significance.
Funding: none
Does Kidney Stone Treatment Impact Subsequent Obstetric Outcomes? Analysis of a Contemporary Nationwide Cohort
Morgan Sturgis1, Jamie Yoon1, Daniel Roadman1, Antonio Franco1, Riccardo Autorino1, Adan Becerra1, Ephrem Olweny1
1Rush University Medical Center
Presented By: Morgan Sturgis, MD
Introduction: Kidney stones diagnosed during pregnancy are associated with an increased risk of maternal complications, but little is known about the risk of obstetric complications in patients conceiving shortly after nephrolithiasis treatment. We evaluated the association between upper tract stone (UTS) treatment and obstetric outcomes of pregnancies occurring within 2 years of treatment.
Methods: Women of childbearing age (18‐52), diagnosed or treated for UTS in 2010 ‐ 2021, who subsequently achieved pregnancy within 2 years of treatment, were identified from the PearlDiver‐Mariner database, a nationwide all‐payer claims database. UTS interventions and obstetric complications were identified using the appropriate ICD 9/10 and CPT codes. UTS interventions were categorized as operative (URS, PCNL, SWL, open/laparoscopic/robotic, ancillary procedures (stent or nephrostomy tube) vs non‐ operative. Associations between UTS intervention and obstetric complications were evaluated with uni‐ and multivariable analyses (MVA).
Results: A total of 139,759 patients who achieved a pregnancy episode within 2 years of UTS diagnosis or treatment were identified. 113,604 (81.3%) were managed non‐operatively. URS was the most common operation (18469/26155, 70.6%). Overall obstetric complication rate for those undergoing non‐operative management was 19.3% vs 20.6% for operative management (p < 0.0001). On MVA, operative management was associated with significantly greater odds of obstetric complications (OR 1.08; 95% CI 1.05‐1.12), while Charlson comorbidity index, treatment year and treatment region were significant predictors. Compared with obstetric complication rate after non‐operative management, complication rates following URS and ancillary procedures were significantly greater (p < 0.0001 for each), while complication rates following each of the other surgical modalities were similar.
Conclusions: Our findings suggest that obstetric complication rates in women achieving pregnancy within 2 years of UTS diagnosis are significantly higher for those undergoing URS and ancillary procedures prior to pregnancy. Further studies to confirm these findings are needed.
Funding: No funding was utilized to execute this study.
Review of Common Nephrolithiasis Home Remedies
Conner Brown1, Mordechai Duvdevani1
1Hadassah Medical Center
Presented By: Conner Brown, MD
Introduction: Nephrolithiasis is a common medical condition worldwide. While medical and/or surgical interventions are often necessary, some people turn to home remedies to alleviate symptoms and promote the passage of stones. This review aims to evaluate the effectiveness of various home remedies for the treatment of nephrolithiasis.
Methods: A PubMed database and Google Scholar search was performed for articles published between 2010 to 2022, using the following terms: “kidney stones,” “nephrolithiasis,” “home remedies,” “alternative treatments,” and “herbal remedies.” Studies reporting the effectiveness of home remedies for the treatment of kidney stones were included in this review.
Results: The literature search resulted in 12 articles reporting the effectiveness of home remedies for kidney stones. Various remedies were studied, including herbal preparations, dietary modifications, and alternative treatments like acupuncture. The most commonly studied remedies included lemon juice, apple cider vinegar, and herbal teas. Some studies reported positive results with the use of these remedies in aiding the passage of kidney stones and reducing pain, while others showed no significant effects. Some remedies, such as consuming large amounts of cranberry juice, may have adverse effects on the urinary system and overall health.
Conclusions: While some home remedies may provide symptomatic pain relief or aid in the passage of renal stones, evidence to support their effectiveness is limited. Also, some remedies may even have adverse health effects so caution should be exercised while using them. Patients suffering from nephrolithiasis should seek medical advice from a Urologist who can develop a safe and effective treatment plan.
Funding: None
Systematic Review of Alternative Treatments for the Prevention of Calcium Oxalate Stones
Christopher Lo5, Qian Hui Khor1, Victor Abdullatif2, Cesar Delgado3, Yadong Lu4, Jonathan Katz3, Roger Sur3
1Changi General Hospital, 2Urology, Ascension Macomb Oakland Hospital, 3Department of Urology, UCSD Health, 4Department of Urology, Singapore General Hospital, 5Duke‐NUS Medical School
Presented By: Christopher Lo
Introduction: Many supplements have been trialed to prevent calcium oxalate (CaOx) kidney stone recurrence. The aim or our study was to summarize current knowledge and identify promising alternative therapies for the prevention of CaOx stones.
Methods: A literature search was conducted using the following databases: MEDLINE, EMBASE, Web of Science, and Google Scholar. Studies were included in this systematic review if researchers evaluated adults with a history of CaOx kidney stones. Studies that implemented pharmacotherapy or herbal supplements or uncategorized research chemical that are not in current AUA guidelines as an effective modality for treating or preventing CaOx stones were included. Review papers, case reports, pilot studies, study protocols, and conference proceedings were excluded.
Results: Our search included 6,155 articles. After exclusion, 42 articles were included in the final analysis, which yielded six distinct categories of interventions used in the study of CaOx stone prevention. These included “medications”, “herbal supplements”, “food products and macronutrients”, “minerals and micronutrients”, “enzymes/probiotics”, and “other uncategorized”. The most promising modalities included rice‐bran (decreased urinary calcium (p < 0.005); stone episode rate decreased from 1.439 to 0.151/patient/year), Phyllanthus niruri (decreased urinary oxalate (p < 0.001); decreased number and size of stones (p < 0.001)), empagliflozin (decreased stone episode rate from 1.01 to 0.63 per 100 patient years), magnesium citrate (increased CaOx metastable limit (p < 0.05); decreased urinary oxalate (p < 0.05)), calcium‐rich and magnesium‐rich mineral water (increased urinary citrate (male stone formers p = 0.01); decreased urinary oxalate (male stone formers p < 0.01, female stone formers p = 0.01); decreased CaOx relative supersaturation (male stone formers p < 0.01, female stone formers p = 0.02)).
Conclusions: This systematic review is a comprehensive summary of a wide variety of modalities for the prevention of CaOx stones. We have identified several preventative therapies that may benefit CaOx stone formers with urinary abnormalities, however they have not yet been incorporated into AUA guidelines. Future research should focus on how and when to incorporate these treatments to prevent recurrent CaOx stones.
Funding: None.
Evaluation of the Treatment Management Survey Results in Children's Urinary System Stone Diseases
Nebil Akdogan2, Mutlu Deger1, Mert Hamarat2, Volkam Izol2, Nihat Satar2, Ibrahim Atilla Aridogan2
1cukurova unıversıty urology department, 2Cukurova University Urology Department
Presented By: Nebil Akdogan, MD
Introduction: Although urinary system stone disease is perceived as an adult disease, it is a disease that is seen in all children, including infancy, and its incidence is increasing.In this study, we aimed to evaluate the treatment approaches of urologists for pediatric urinary system stone disease.
Methods: We divided pediatric stone patients into 3 age groups as 0‐2, 2‐6 and 6‐18. In order to compare these groups, we prepared a 42‐question survey based on the EAU 2022 Guidelines and sent this survey to urologists working in the country via the social network.
Results: Our survey was evaluated by 96 urologısts.While SWL was applied at a rate of 35.42% in patients aged 0‐2 years, a statistically significant difference was found in the comparison made according to title in this group (p:0.013). While microPNL was applied at a rate of 19.79% in this age group, a statistically significant difference was found in the comparison made by title (p:0.030). Again, the rate of those who did not perform surgery in this age group was 31.25%, while a statistically significant difference was found in the comparison made according to title (p:0.038).While SWL was applied with a rate of 36.46% in 2‐6 year old patients, a statistically significant difference was found in the comparison made according to title in this group (p:0.004).While SWL was applied with a rate of 58.33% in patients aged 6‐18 years, a statistically significant difference was found in the comparison made according to title in this group (p:0.011). While miniPNL was applied with a rate of 65.63% in the same group, a statistically significant difference was found in the comparison made according to title (p:0.002).While there was a statistically significant difference in the application of the RIRS method in the 0‐2 age group (p:0.029) and 2‐6 age group (p:0.049) according to the institution, a high level of significant difference was observed in the application to the 6‐18 age group (p:0.01). .A statistically high significant difference was observed in the comparison made by title among those who underwent surgical treatment in this 3‐year‐old group for Staghorn kidney stones (p:0.007).
Conclusions: It was observed that there were statistically significant differences in the treatment management of pediatric urinary system stone patients with different localization and size according to age groups, according to the institution and title. However, it is necessary to carry out comprehensive studies with more domestic and international participation in this regard.
Funding: no funding
Current Prevalence and Aspects of Urolithiasis Metaphylaxis in Russia: A National Survey
1Moscow state university of medicine and dentistry named after A.I. Evdokimov, 2National medical research urological center, 3A.I. Burnazyan SRC FMBC, 4N.I.Pirogov High Medical Technologies Clinic
Presented By: Sergey Sukhikh, Phd
Introduction: Urolithiasis is one of the most common urological diseases in adults. Due to the high risk of recurrent stone formation causing repeated surgical interventions, the issue of effective urinary stone metaphylaxis is very important.
Methods: To study the current state of the problem of urolithiasis metaphylaxis among Russian urologists, an anonymous questionnaire was applied. 1,238 specialists completed the questionnaire. The database compiled from the received responses was processed and presented with descriptive statistics in the form of tables and charts.
Results: According to the survey, more than half of the 831 (67.1%) specialists specialized in the treatment of urolithiasis. Only 521 (69.6%) urologists specializing in surgical treatment of urolithiasis give a patient a stone fragment to analyze its chemical composition. At the same time, half of the respondents reported that less than 10% of patients come to them for further metaphylaxis. One of the main reasons for not analyzing the chemical composition of the stone was the fact that 877 (70,84%) specialists indicated the inaccessibility of analysis under the state guarantee program, 503 (40,63%) specialists indicated the patient's satisfaction with the results of minimally invasive surgical treatment. 1180 (96,8%) respondents practiced the prophylaxis of recurrent calculi formation, but only 336 (28,47%) performed comprehensive metabolic examination of all patients followed by prescription of drug therapy and appropriate diet.
Conclusions: Our survey revealed low involvement of urologists at the outpatient level in the process of conservative treatment and metaphylaxis of urolithiasis, low activity of urologists in performing complex metabolic study and comprehensive prevention of recurrent stone formation, low percentage of performing chemical composition analysis of stone and low activity of urologists in performing primary litholytic therapy of urate stones. Based on this analysis of the responses of most Russian urologists, it is possible to formulate recommendations to remove the obstacles to providing patients with urolithiasis with quality medical care in terms of conservative therapy and metaphylaxis of urolithiasis.
Funding: No
The Role of Genetic Testing in Nephrolithiasis
Robert Pearce1, Wilson Sui1, Heiko Yang1, Thomas Chi1, Marshall Stoller1
1University of California, San Francisco, Department of Urology
Presented By: Wilson Sui, MD
Introduction: There are no established guidelines regarding indications for genetic testing in stone formers. 24‐hour urine testing has long been utilized to identify downstream urinary abnormalities to target for treatment in hopes of preventing recurrent kidney stones. However, few studies have explored the relationship between genetic mutations and 24‐hour urine results. In this study, we hypothesized that patients with abnormal 24‐hour urine analytes would be more likely to test positive for genetic abnormalities.
Methods: We retrospectively identified patients who underwent genetic testing to assess etiology of nephrolithiasis between 2020 and 2022 at a single institution using the PerkinElmers specialized genomics panel for nephrolithiasis. The most common reason for genetic testing was hyperoxaluria (> 40mg/day) without enteric etiology. Analyses were performed to compare patient characteristics with and without genetic abnormalities. We also performed cutpoint analysis to identify candidate thresholds for genetic testing.
Results: 14 of 36 patients who underwent genetic testing had identifiable mutations. The most commonly found mutations were associated with cystinuria, xanthinuria and primary hyperoxaluria. Of the 29 patients tested with hyperoxaluria, the mean oxalate level was 71mg/day (± 32) and three were found to have primary hyperoxaluria types 2 and 3. Cutpoint analysis showed that using a urinary oxalate value greater than 80mg/day, 60% of patients were found to have a genetic abnormality (Figure 1). A trend was noted toward a higher proportion of genetic mutations with increasing oxalate cutoffs. A similar cutpoint analysis for calcium revealed that 60% of patients with urinary calcium > 120mg/day had a genetic abnormality; most of these patients were found to have cystinuria, xanthinuria, or primary hyperoxaluria.
Conclusions: Genetic testing in patients with nephrolithiasis remains controversial due to the unknown yield of positive results and the time and energy required to discuss these with our patients. This preliminary report identifies potential cut‐offs that may help guide the clinician to decide when a genetic profile should be undertaken to help determine optimal therapy. In our practice, this was used to identify and confirm candidates for clinical trial enrollment for cystinuria and primary hyperoxaluria.
Funding: None
Trends in Usage and Cost of Potassium Citrate and Alternative Alkalizing Agents for Nephrolithiasis
Benjamin Lichtbroun1, Kevin Chua1, John Pfail1, Ji Hae Park1
1Rutgers Robert Wood Johnson Medical School
Presented By: Benjamin Lichtbroun, MD
Introduction: The rising incidence of nephrolithiasis places a hefty financial burden on the U.S. healthcare system. Potassium citrate, a mainstay in the medical management of nephrolithiasis, is cost‐prohibitive for patients and further exacerbates this burden. Alternative alkalinizing agents have demonstrated similar efficacy and are less expensive. This study aims to examine urologists' prescribing patterns for alkalinizing agents over time.
Methods: The Medicare Part D Prescribers Database was used to identify prescriptions by urologists for alkalinizing agents including potassium citrate, potassium bicarbonate, sodium citrate, and sodium bicarbonate. The total annual expenditure, number of claims, and cost per claim from 2013 to 2020 were analyzed.
Results: Potassium citrate represented > 99% of claims and costs each year for alkalinizing agents. Expenditure for potassium citrate increased from $13,711,645.99 in 2013 to $27,189.128.66 in 2020 (Table). Claims for potassium citrate also increased from 97,734 in 2013 to 152,450 in 2020. The percentage of branded potassium citrate prescribed, which was $49.49–$170.80 more expensive per claim than the generic version, declined from 2.23% in 2013 to 0.02% in 2020. The yearly cost per claim was $140.30–$209.37, $27.00–$47.35, $18.17–$42.69, and $21.75–$70.56 for potassium citrate, potassium bicarbonate, sodium citrate, and sodium bicarbonate, respectively. Potassium citrate was $118.54–$155.04 more expensive per claim than the next most expensive alternative and $122.09–$185.84 more expensive per claim than the cheapest alternative. Prescribing the next most expensive alternative instead of potassium citrate would have resulted in cost savings ranging from $11,585,492.14–$23,573,029.70 per year.
Conclusions: Urologists can generate significant cost savings by prescribing alternative alkalinizing agents. Lowering the cost of alkali therapy is essential to reducing financial toxicity for patients and improving equitable access to preventative stone treatment.
Funding: None
Building a Virtual Multidisciplinary Kidney Stone Clinic – Structure and Patient Satisfaction
Ian Metzler1, Michael Lin‐Brande1, Celia Janoff1, Tyler Chase1, Raghav Wusirika1, Brian Duty1
1Oregon Health & Science University
Presented By: Ian Metzler, MD, MTM
Introduction: Our objective was to develop a totally virtual multidisciplinary kidney stone clinic and assess patient satisfaction of this format.
Methods: The virtual multidisciplinary stone clinic began July 2021 and continued monthly. Prior to the beginning of each clinic, providers from the urology, nephrology, and dietitian teams meet virtually to discuss the patients. Patients would then log into WebEx virtual platform and providers would subsequently log into the patient's virtual room, to review radiology, laboratory results, and dietary logs then provide counseling. Patients were then sent a survey via electronic mail regarding their experience. A 5‐point Likert scale was used for responses ranging from strongly disagree to strongly agree. Scores were averaged to rank results.
Results: A total of 122 patients were sent surveys, and a total of 31 surveys were completed. Sixty‐one percent of patients strongly agree and 13% agree that they felt comfortable using the virtual platform. When asked if they prefer using the virtual platform for their visit, 70% of patients agreed or strongly agreed and only 16% of patients disagreed or strongly disagreed. In regards to potential advantages of a virtual visit, the Likert scores were averaged and ranked from most to least important with improved timeliness (3.7) and ease of scheduling into day (3.6) the highest rated advantages (Table 1). Most patients did not find any concerns using the virtual platform, however the ability to see the provider in‐person and connecting personally was of highest concern with an average Likert score of 2.3. Overall 83% of patients agreed or strongly agreed that the multidisciplinary stone clinic satisfied their kidney stone related questions regarding treatment and prevention.
Conclusions: A virtual multidisciplinary kidney stone clinic can be implemented with high patient satisfaction scores and help overcome the limitations of physical clinic space and provider schedule coordination. There are few disadvantages to using the platform.
Funding: None
MODERATED POSTER SESSION 9: EPIDEMIOLOGY, SOCIOECONOMIC AND HEALTH CARE POLICY 2
Ureteroscopy, Percutaneous Nephrostomy or Ureteral Stent for the Urgent Management of Obstructive Urolithiasis – Which is the Most Economic Approach?
Catarina Laranjo Tinoco1, Andreia Cardoso1, Eliana Pereira2, Ricardo Matos Rodrigues1, Catarina Laranjo Tinoco1, Ana Sofia Araújo1, Mariana Dias Capinha1, Luís Pinto1, João Pimentel Torres1, Paulo Mota1
1Urology Department, Hospital de Braga, Portugal, 2School of Medicine, University of Minho, Braga, Portugal
Presented By: Catarina Laranjo Tinoco, MD
Introduction: Urolithiasis is a major health problem worldwide, affecting adult patients, with high socioeconomic burden. It is a major motif for urgent admission in urologic departments, and it can present complications requiring urgent urinary decompression. Double‐J ureteral stents (JJ) or percutaneous nephrostomy (PN) placement are the most frequently used methods, while ureteroscopy (URS) is usually reserved for urolithiasis' elective treatment, though it can be performed in selected urgent cases. Thus, our goal was to compare the economic costs of these treatments, in the setting of urgent management of obstructive urolithiasis.
Methods: Retrospectively, we divided patients submitted to urgent treatment of obstructive urolithiasis in our department, from January 2019 to December 2021, in 3 groups, according to the decompressing treatment applied: JJ, PN or URS.We collected baseline demographic and clinical data, and analyzed hospital costs from the 1st urgent intervention, until the 1st attempt of definitive urolithiasis' surgical treatment. Cost analysis included: hospital readmissions, imaging and laboratorial exams performed, type of initial and definitive interventions.
Results: A total of 349 patients were included. JJ was the preferred option for 1st intervention (JJ n = 281; PN n = 23; URS n = 45). Infection was the main reason for PN placement, while for URS it was refractory pain. The mean length of the 1st hospital stay was: 4.2 (JJ) vs 6 (PN) vs 2.8 (URS) days. Emergency department readmissions were: 33.45% (JJ) vs 56.52% (PN); and for hospital stay: 6.05% (JJ) vs 34.78% (PN). However, the mean length of hospital readmissions was: 10 (JJ) vs 4.2 days (PN). There were some differences on the definitive urolithiasis treatment between groups. Table 1 presents results' details.Estimated overall cost was: 7140.82€ for URS, 14422.45€ for JJ, and 15430.54€ for PN.
Conclusions: URS seams the most cost‐effective decompressing method in the setting of obstructive urolithiasis. However, we recognize it requires ideal conditions not always present in emergency departments (material, time), as well as patients' selection (not for sepsis or high stone burden cases). Socioeconomic burden and patient‐related outcomes were not evaluated but it will possibly reinforce the benefits of URS. Despite suggesting more quality studies, we stress out the benefit of URS for urgent decompression and definitive treatment of obstructive urolithiasis.
Funding: None.
Do “Heat Extremes” Affect Urinary Stone Characteristics?
Dor Rubinshtein3, Noa Eliezer1, Dan Haberman2, Roy Croock3, Brian Berkowitz4, Ishai Dror4, Shir Tiger3, Alexey Kovalyonok3, Dan Leibovici3, Yaniv Shilo3
1Kaplan medical center, 2Heart institute, kaplan medical center, 3Urology department, Kaplan medical center, 4Weizmann Institute of Science
Presented By: Dor Rubinshtein, MD
Introduction: Studies report an association between high ambient temperatures and urinary stone formation, as well as emergency room admissions for renal colic during warm months and periods of fasting. Data regarding stone characteristics under such conditions are scarce. We explored the difference in stone characteristics that were diagnosed during heat waves in comparison to periods with average temperatures.
Methods: We retrospectively collected data between 2018‐2021, for patients who had a positive computer tomography finding of urinary stones. Patients diagnosed with urolithiasis during a two‐week period starting from a heat wave were included in group 1. The remaining patients with urolithiasis who were diagnosed during two weeks prior to or following the heat wave period and having average monthly temperatures were included in group 2. Heat waves were defined as days with a temperature five degrees Celsius or higher than the multi‐year monthly average, and lasting longer than 3 days. We collected demographic, clinical and radiographic data and compared the two groups.
Results: Of 229 patients who met the inclusion criteria, group 1 (heat waves) included 121 patients and group 2 (average temperatures) included 108 patients. No statistical difference was found between the groups in term of age (51 vs. 52), gender (76% vs. 73% men), average number of stones (1.6 vs. 1.8) and ureter stone rates (72% vs. 66%), respectively. In group 1, 73% of patients (88 of 121) had stones under 5 mm, in comparison to 60% in group 2 (P = 0.04). In a multivariate analysis, adjusting to duration of symptoms and stone location, heat waves were a risk factor for presence of stones under 5 mm (OR = 1.8, P = 0.04).
Conclusions: There is a higher probability of finding small urinary stones during heat waves, compared to periods with average temperatures. This finding may provide insight into the mechanism of stone formation and can assist the decision‐making process in the ER.
Funding: none
Kidney Stone Rates in Cirrhotic and Liver Transplant Patients; SPARCS Analysis (2004‐2017)
Micah Levy1, Aaron Walt1, Christopher Connors1, Daniel Wang1, Juan Arroyave Villada1, Hasan Bilal1, Francisca Larenas1, Michael Palese1
1Icahn School of Medicine at Mount Sinai
Presented By: Micah Levy
Introduction: With rising rates of kidney stones, cirrhosis, and liver transplants, it is important to understand the possible association between liver failure, management with transplantation, and the formation of kidney stones.
Methods: The 2004‐2017 New York Statewide Planning and Research Cooperative System database was queried for patients in 4 groups: controls (Co) representing the general population who had received a medical exam regardless of the reason or any normal or abnormal findings, cirrhosis (Cr), liver transplant (Lt), and stone risk factors (Rf) representing anyone with at least one of the following: obesity, hypertension, or diabetes. The first 100,000 patients in each group were queried. Though duplicates were removed to minimize overlap within groups, some Co, Cr, or Lt patients may still have the above stone risk factors. Differences in stone rates (SR) between each group and within groups before and after their coded diagnosis were analyzed.
Results: 196,737 cases were analyzed (Co: 45,890, Cr: 42,694, Lt: 19,129, Rf: 89,024). SR were 1.76% (Co), 2.72% (Cr), 4.30% (Lt), and 4.81% (Rf) with significant differences between all 4 groups (p < 0.001, p = 0.002 for Lt vs. Rf), suggesting higher SR in Cr and Lt compared to the general public, but not as high as those with known risk factors. There was no significant difference in the pre‐diagnosis SR between Co and Cr (1.85% vs. 1.95%, p = 0.271), suggesting the onset of Cr is associated with an increased SR as before the diagnosis of Cr, these patients had similar SR to controls. When comparing SR within groups before and after diagnosis, Co showed no significant difference before or after their general medical exam (p = 0.333), while Cr, Lt, and Rf showed significantly higher SR following their diagnoses (p < 0.001). This too suggests that compared to Co, the onset of liver failure and liver transplant may be associated with higher SR.
Conclusions: Patients with Cr and those managed with Lt have significantly higher SR compared to general public controls, but significantly lower SR compared to patients with stone risk factors. Interestingly, as SR were higher in Lt compared to Cr, this may suggest that transplantation may not reduce, but may in fact increase this association.
Funding: None
Estimating the Risk of Symptomatic Stone Events Associated with Topiramate and Zonisamide Use in Older Americans
David Nusbaum4, Bassel Salka1, Mary Oerline1, John Asplin2, Vahakn Shahinian1, John Hollingsworth3
1University of Michigan, 2Litholink Corporation, 3NorthShore University HealthSystem, 4University of Chicago Medical Center
Presented By: David Nusbaum
Introduction: With expanding indications like treatment of alcohol dependence, obesity, and migraines, rates of topiramate and zonisamide prescription have increased in the United States. Given the effects that these medications have on urine chemistries, we conducted an observational study to estimate the risk of symptomatic stone events associated with their use.
Methods: We identified older adults enrolled in the United States' largest health insurance program, Medicare, who were prescribed topiramate or zonisamide between 2008 and 2019, as well as age‐ and sex‐ matched controls. We then measured the frequency of symptomatic stone events (defined as an emergency department visit, hospitalization, or surgery for stones) in these two groups. Finally, we fit multivariate Cox proportional‐hazards regression models to estimate the risk of a symptomatic stone event as a function of topiramate or zonisamide use, both overall and stratified by treatment indication.
Results: A total of 237,217 patients met study inclusion criteria, including 39,518 who were prescribed topiramate or zonisamide. Unadjusted rates of symptomatic stone events occurred more frequently among topiramate and zonisamide users than controls during the three months to 9 years after their initial prescription fill (1.9% versus 0.8%, respectively [P < 0.001]). After controlling for a variety of sociodemographic factors and level of comorbid illness, topiramate and zonisamide users had a 77% higher hazard (hazard ratio, 1.77 [95% confidence interval, 1.60 to 1.97]) than controls of a symptomatic stone event. When stratifying by treatment indication, this association persisted.
Conclusions: Regardless of treatment indication, topiramate and zonisamide use is associated with a higher hazard of a symptomatic stone event. Prescribing physicians and the patients for whom they care will need to determine whether the benefits of these medications are outweighed by their stone risk.
Funding: National Institute of Diabetes and Digestive and Kidney Diseases
Incomplete Distal Renal Tubular Acidosis in Stone Formers: An Overlooked Risk Factor
Mario Basulto‐Martinez4, Fernanda Gabringa‐Berto1, Nabil Sultan2, Elie Gharib2, Eduardo Gonzalez‐ Cuenca3, Hassan Razvi3, Jennifer Bjazevic3
1Division of Urology, Schulich School of Medicine & Dentistry, Western University, 2Division of Nephrology. Schulich School of Medicine & Dentistry. Western University, 3Division of Urology, Schulich School of Medicine & Dentistry. Western University, 4Division of Urology, Schulich School of Medicine & Dentistry, Western University,
Presented By: Mario Basulto‐Martinez, MD, MSc
Introduction: Distal tubular renal acidosis (dTRA) is characterized by the distal nephron's inability to acidify urine and is associated with calcium phosphate (CaP) urinary stones, nephrocalcinosis and bone disease. However, in the incomplete form of dTRA (idTRA), the biochemical traits are often less conspicuous, unrelated to systemic acidosis, and usually underrecognized. Therefore, this study aimed to evaluate stone‐formers (SF) with features of idTRA to identify the prevalence and better characterize their clinical features compared to SFs without dTRA/idTRA.
Methods: A prospectively collected metabolic stone clinic database was reviewed. Patients with incomplete data or incorrectly collected 24‐h urine studies were excluded. SF with urinary pH ≥6, hypocitraturia (< 1.6 mmol/d), and serum potassium < 3.8 mmol/L were considered as suggestive for idTRA and compared to SF without evidence ofdTRA[JB1].
Results: A total of 1170 SF were included, and 5.2% had suggestive features of idTRA. Sex was similar between groups (p = 0.428); however, median age (p = 0.003) and body mass index (BMI, p = 0.032) were significantly lower in patients with idTRA. Stone composition was available in 682 SF, of which 12% had predominantly CaP stones, but no association between CaP and idTRA was observed (p = 574). Moreover, idTRA was associated with lower vitamin D (p = 0.023), urinary phosphate (p = 0.001) and calcium (p = 0.02). Furthermore, 6.6% of patients with idTRA had nephrocalcinosis and 7 subjects (11.5%) had bone mineral densitometry performed with 4 (57%) showing below normal bone mass.
Conclusions: idTRA is an underdiagnosed risk factor for urinary stone disease and may be found in up to 5% of stone‐formers. Patients with idRTA may present at a younger age, with lower BMI, low vitamin D levels and lower urinary calcium compared to SF without features of idTRA. Recognition of idTRA is essential to providing optimized care for SF.
Funding: None
Rates of Genitourinary Symptoms After the COVID‐19 Vaccine – Are They Different from Other Common Vaccines?
Benjamin Lichtbroun1, Kyle Moore1, Aravind Rajagopalan1, Kevin Chua1, Danielle Velez‐Leitner1
1Rutgers Robert Wood Johnson Medical School
Presented By: Benjamin Lichtbroun, MD
Introduction: There has been a concern in mainstream media about adverse effects of the COVID‐19 vaccine including those on the genitourinary system. Our objective was to evaluate the rate of patient‐ reported genitourinary symptoms after the COVID‐19 vaccine. We hypothesized rates of genitourinary side effects was not different compared to other commonly used vaccines.
Methods: We queried the Vaccine Adverse Events Reporting System database for all genitourinary symptoms reported after receiving the COVID‐19, influenza, shingles, and pneumonia vaccines. Symptoms were placed into one of five categories – lower urinary tract symptoms (LUTS), sexual side effects, infectious, hematuria, or other disorders of the penis/scrotum/testis. Rates of genitourinary symptoms were compared between the vaccines. Data collection occurred7‐8/2022. Since the shingles and pneumonia vaccines are given to elderly patients, we comparedCOVID‐19 vaccine adverse events for those 60‐years or older between those groups.
Results: Out of 13,568,650 symptoms reported after the COVID‐19 vaccine, 9,022were genitourinary (0.066%). Genitourinary symptoms included LUTS (39.71%), infectious (32.38%), hematuria (17.42%), disorders of the penis/scrotum/testis (5.99%), and sexual side effects (4.50%). Rates of genitourinary symptoms after the COVID‐19 vaccine was significantly lower than the influenza (0.128%) (Table 1) but higher than the shingles (0.030%) and pneumonia (0.037%) vaccines (Table 2). There was no significant differences in the penis/scrotum/testis symptoms category.
Conclusions: Genitourinary symptoms from the COVID‐19 vaccine are rare. The rate of side effects is lower than the influenza vaccine, and while higher than the pneumonia and shingles vaccines, these rates are overall very low and unlikely to be clinically significant.
Funding: None
The Effect of Opiates on Patient Reported Outcomes After Ureteroscopy
Russell E. N. Becker1, Andrew M. Higgins1, Stephanie Daignault‐Newton1, Golena Fernandez Moncaleano1, John K. Ludlow2, Hector Pimentel3, Brian D. Seifman4, David L. Wenzler5, Bronson Conrado1, Karla Witzke6, Khurshid R. Ghani1, Casey A. Dauw1
1University of Michigan, 2Western Michigan Urological Associates/Holland Hospital, 3Corewell Health, 4Michigan Institute of Urology, 5Michigan State University College of Human Medicine, 6MyMichigan Health
Presented By: Russell E. N. Becker, MD, PhD
Introduction: The outcomes of kidney stone surgery have long been focused on stone‐free rates and safety, yet patient reported outcomes (PRO) are often lacking. In 2018 the Michigan Urological Surgery Improvement Collaborative (MUSIC) Reducing Operative Complications from Kidney Stones (ROCKS) group initiated a pain optimization pathway using an opioid‐free multi‐modal pain regimen. This has resulted in a decline in opioid prescription rates after ureteroscopy (86 to 19%). We used a comprehensive PRO system to understand the initiative's impact on patients' experiences of treatment pain and satisfaction.
Methods: MUSIC ROCKS instituted its patient‐reported outcomes (PRO) program in 2020 which included an assessment of patient pain (PROMIS Pain Intensity short form and Pain Interference short form) and overall treatment satisfaction (ICIQ‐S). This system is automated and distributes questionnaires preoperatively and at 7‐10 days and 4‐6 weeks following ureteroscopy (URS). We compared patients who were prescribed opiates after URS to those who were not. After adjusting for observed demographic differences (age, gender, pre‐stent status, stone location/size, and preoperative pain), we evaluated PRO pain intensity and interference, with linear mixed models. A clinically meaningful difference in PROMIS scores is 2.5‐3.5 points. Treatment satisfaction scores were compared with Wilcoxon rank tests.
Results: A total of 292 patients completed all questionnaires (258 non‐opioid and 34 opioid). There was no significant difference between non‐odxzpioid and opioid cohorts with regards to age (60 vs 59 years), gender (50 vs 53% male), pre‐stenting status (76 vs 65%), stone location (64 vs 59% ureteral), and stone size (8.0 vs 7.2 mm). After adjustment, there was no significant difference in preoperative pain intensity scores between the groups at pre‐URS (p = 0.06), 7‐10 days postop (p = 0.87), and 4‐6 weeks postop (p = 0.99, Figure). Pain interference followed a similar pattern, with no significant differences observed at any timepoint. There was no difference in satisfaction scores, as measured both 7‐10 days (p = 0.46) and 4‐6 weeks (p = 0.47) after URS.
Conclusions: Rates of opiate prescription have declined after ureteroscopy in Michigan. Using a novel PRO system, we confirmed that URS of opioid‐free pathways has not resulted in increased pain nor decreased patient satisfaction.
Funding: Blue Cross Blue Shield of Michigan
The Effects of Honeybee Mite Treatment on Dietary Oxalate Levels
Introduction: Mankind likely started harvesting honey from the European honey bee, Apis mellifera, at least 10,000 years ago while domestication of this species has been in effect for at least 5,000 years. Due to the crop pollination services these insects provide throughout North America, a great deal of research has gone into their greatest known threat to date: Varroa destructor. Varroa mites are a major pest affecting honeybees, leading to up to 80% losses in some apiaries when first introduced to North America in 1987. Oxalic acid treatment has been widely used to control the infestation of varroa mites in honeybee colonies. The treatment involves the application of oxalic acid by vaporization, dusting, or evaporation. It has been found to be an effective method for controlling varroa mite infestation in honeybee colonies, while having almost no impact on the overall health of the honeybees. It is reasonable to be concerned that the use of oxalic acid treatment and its potential contribution to dietary oxalate levels. Oxalate is a naturally occurring compound found in many plants and is known to form kidney stones when consumed in excess.
Methods: A PubMed and Google Scholar search was performed with the keywords, “varroa”, varroa destructor”, “oxalic acid treatment”, “per capita honey consumption” between the years of 1990 and 2021. The resulting papers and publications were analyzed for relevant data.
Results: If and to what degree oxalic acid treatments contribute to oxalate levels in honey is somewhat contested, however some sources clam it is between 68mg/kg and 119mg/kg. The 2021 per capita honey consumption was 0.87 kg in the USA, 1.55 kg in Greece, and 2.03 kg in New Zeeland. Respective annual oxalic acid intake per capita in these countries may be as high as 103.5mg, 184.5 mg, and 241.6 mg.
Conclusions: Although the potential impact of oxalic acid treatment on dietary oxalate levels is a concern, it should be noted that the contribution of honey to overall oxalate intake is generally low. With the average recommended oxalate intake levels for stone formers with known hyperoxaluria being 100mg or less, the levels found in honey are negligible. Although oxalate is metabolized differently in insects than in vertebrates, there is enough concern that the US Food and Drug Administration banned the use of oxalic acid treatment on hives in which honey gathering “supers” have been added for the season. Overall, the use of oxalic acid treatment remains an important tool for controlling varroa mite infestation in honeybee colonies and its contribution to human oxalate consumption is of little impact.
Funding: None
Work Absence and Productivity Loss of Patients Undergoing a Trial of Passage for Ureteral Stones
Ian Berger1, Robert Medairos1, Alexandria Spellman1, Vishnukamal Golla2, Michael Lipkin1, Gary Faerber1, Jodi Antonelli1, Charles Scales1, Deborah Kaye1
1Duke University Medical Center, 2Durham Veterans Affairs Medical Center
Presented By: Ezra Margolin, MD
Introduction: Ureteral stones commonly affect patients of working ages and disrupt daily activities. Patient reported outcomes during a trial of passage have been understudied which leads to difficulty in setting patient expectations. We sought to characterize work productivity losses among individuals passing a ureteral stone.
Methods: We identified employed, English speaking patients between the ages of 18‐64 and discharged from Duke University Health System emergency departments with unilateral ureteral stones from February 7, 2022 to February 7, 2023. Patients were contacted by phone 4 weeks after discharge and administered the Institute for Medical Technology Assessment Productivity Cost Questionnaire which evaluates three domains of productivity loss over a four week period: absenteeism (missed work), presenteeism (decreased productivity at work), and volunteerism (help with unpaid work or domestic tasks). Patients were determined to have passed their stone if they noticed it in the toilet or identified a day where symptoms resolved and did not return.
Results: 112 patients completed the survey. 62% (69/112) of participants reported passing their stone, with a median of 3 days until passage (interquartile range [IQR] 1—7 days). 13% (14/112) of participants had surgery before survey completion. In total, 68% (76/112) of participants reported missing work (Figure 1), with a median absence of 2 days (IQR 1—5 days). Participants who passed their stone missed a median of 50% (IQR 21%—100%) of working days until their stone passed. 46% (52/112) of participants endorsed decreased productivity when they returned to work, reporting their effectiveness at a median of 70% (IQR 50%—80%). 55% (62/112) of participants reported requiring unpaid work, or help with tasks around the house.
Conclusions: Missed work and decreased productivity when returning to work is common among patients undergoing a trial of passage for ureteral stones. However, many patients only miss a couple days of work. While direct comparative data for ureteroscopy is lacking, this suggests that immediate surgical treatment during an acute stone episode may not significantly decrease work absence over a trial of passage. This information will be important to appropriately counsel patients in EDs on options for management during an acute stone episode.
Funding: None
The Effects of Stone Characteristics and Imaging Features on Ureteral Stones Treatment Costs
Amit Shemesh1, Dor Golomb1, Hanan Goldberg2, Eyal Hen1, Fahed Atamna1, Amir Cooper1, Orit Raz1
1Samson Assuta Ashdod University Hospital, 2SUNY Upstate Medical University
Presented By: Amit Shemesh, MD
Introduction: The growing incidence of urolithiasis is reflected in a significant financial burden, with increasing direct and indirect costs. The aim of this study is to evaluate the direct healthcare expenditure of ureteral stone management in Emergency Department (ED) patients in relation to stone characteristics and imaging features.
Methods: A retrospective analysis was conducted on all patients admitted to the ED and found to have a ureteric stone on CT. Clinical, laboratory, and imaging parameters were collected, along with data regarding admissions, ED readmissions, surgical procedures, and the total cost of treatment. The different cost rates were compared with regard to different stone parameters and characteristics, patient clinical presentation, and laboratory results.
Results: Between January 2018 and January 2020, an abdominal CT‐proven ureteric stone was found in 805 patients during an ED visit in a single institution. Of those, 773 patients met the inclusion criteria. The mean stone size was 4.73 mm, with 31% (238) located proximally and 69% (535) located distally. Treatment costs were inversely related to stone size, costing $3,133, $9,181, and $15,525 for stones smaller than 5 mm, between 5‐10 mm, and larger than 10 mm, respectively (p < 0.001). Treating proximal stones carried a higher expenditure rate of $9,864 on average, compared to $3,919 for treating distal stones (p < 0.001). Stone composition was available for only 240 patients. Struvite stones were the most expensive to treat at $14,251, followed by Calcium phosphate stone (CaPh) at $13,135. Uric acid (UA) stones incurred costs of $10,758, Calcium oxalate monohydrate (COM) $9,697, Calcium oxalate dihydrate (COD) $9,373, and Cystine, with only a single patient with this stone composition, cost $278 (p < 0.001). The presence of renal stone, hydronephrosis, and urinoma were associated with higher expenditure rates ($6944 vs $4878, p < 0.001; $5871 vs $1581, p = 0.007; $8767 vs $5458, p < 0.001, for renal stone, hydronephrosis, and urinoma, respectively).
Conclusions: Treatment costs were significantly affected by stone size, location, and composition. Ureteral stones with unfavorable expulsion features and/or surgical complexity, such as infectious state, denser stone, and concomitant renal stones, are associated with increased direct treatment costs in the management of ureteric stones.
Funding: None
Flipping the Paradigm: Should Metabolic Management of Stone Disease Begin Before a Patient's Initial Stone Event?
Jonathan Katz1, Roger Sur1, Henry Horita1, Cesar Delgado1, Seth Bechis1
1UCSD/Department of Urology
Presented By: Jonathan Katz
Introduction: Metabolic evaluation and treatment for the prevention of nephrolithiasis in individuals with increased risk of kidney stones due to a family history of a first‐degree relative with nephrolithiasis has not been explored. To better characterize this clinical scenario and potential patient interest, we surveyed patients with nephrolithiasis.
Methods: With IRB approval, we conducted telephone surveys of50 patients being treated for nephrolithiasis at the UCSD Comprehensive Kidney Stone Center regarding demographics, number of first‐degree relatives whose medical histories they were familiar with, and the number and age of onset of kidney stones within these family members. We compared the age of onset of nephrolithiasis in first‐degree family members to determine if there was a trend towards earlier stone‐disease in progeny. Finally, we asked patients if they would have been interested in metabolic testing and treatment prior to their initial stone event.
Results: The median age of our patient's first kidney stone was 43 (25.5, 58) years. 60% of patients were female. 40% had a first‐degree relative with a kidney stone and within these families 83% had stones occurring earlier in successive generations (Figure 1). 10% of patients had children already affected by nephrolithiasis. Overall 66% of patients would have been interested in the option for metabolic testing prior to their first kidney stone had this been offered and of patients with a first‐degree family member with kidney stones this number increased to 89%.
Conclusions: Our data suggests that not only are progeny at increased risk for nephrolithiasis, but that they are also at risk at an earlier age. These individuals may be interested in metabolic evaluation and treatment prior to having their first stone, which offers a novel opportunity for intervention to stop nephrolithiasis before it starts.
Funding: None
Urinary Stone Disease Burden and Risk Factors in Mexico
Mario Basulto‐Martinez1, Eduardo Gonzalez‐Cuenca1, John Denstedt1
1Western University Schulich School of Medicine & Dentistry
Presented By: Mario Basulto‐Martinez, MD, MSc
Introduction: Mexico holds the second highest population in both North America and Latin‐American. Mexico's population, however, is remarkably underrepresented on the mainstream scientific literature on urinary stone disease (USD). We aimed to gather and systematically review the literature on USD prevalence and risk factors in Mexico including grey literature and Official Data.
Methods: The dataset from the 2018 Health and Nutrition National Survey (HNNS) data was reviewed. In addition, we screened English and Spanish literature on USD prevalence and risk factors from Mexico since 2012, including grey literature. The resulting manuscripts were systematically appraised. This is a PRISMA statement compliant study.
Results: The HNNS included 43,070 participants nationwide and USD prevalence per 1,000 persons was 33.2, with Yucatan state and Mexico City holding the highest prevalence (72.2 and 61.5, respectively). The Gulf Coast had the highest burden of USD (Figure 1). Median age was higher for SF (p < 0.0001]) and peak age‐prevalence was 60‐70 years (49.6). Moreover, 11 manuscripts reporting 2791 stone‐formers (SF) and 112 non‐stone‐formers (NSF) controls were included for review. Obesity [1.69 (1.51 – 1.89), p < 0.0001], Type 2 diabetes (T2D) [1.68 (1.45 – 1.94), p < 0.0001] and hypertension (HTN) [2.04 (1.82 – 2.29), p < 0.0001] were associated with USD. Obesity rates in SF ranged from 33 ‐ 62.7% and extracted data from manuscripts reporting T2D and HTN rates in SF was 23.1% and 27.5%, respectively. Menopause was not associated with USD [0.76 (0.57 – 1.01), p = 0.061]. The most frequent metabolic abnormalities were hypocitraturia (39.4 – 98%), hypercalciuria (21.3 – 42.1%), hyperoxaluria (31 – 36.5%) and hyperuricosuria (13.1 – 26.6%).
Conclusions: USD literature in Mexico is scarce. The Gulf Coast holds the highest prevalence with 1 in every 13 persons, similar to that reported in North America (7‐13%) and Europe (5‐9%). Obesity, T2D and HTN are significant risk factors, and hypocitraturia was the most frequent metabolic abnormality.
Funding: None
The Use of Genetic Testing for the Management of Nephrolithiasis: Knowns and Unknowns
Nicolette Payne2, Sayi Boddu1, Kevin Wymer2, Daniel Heidenberg2, Charles Van De Walt3, Lanyu Mi3, Mira Keddis4, Karen Stern2
1Mayo Clinic Alix School of Medicine, 2Mayo Clinic Arizona, Department of Urology, 3Mayo Clinic, Department of Qualitative Health Sciences, 4Mayo Clinic Arizona, Department of Nephrology
Presented By: Nicolette Payne, MD
Introduction: Recent studies have shown that up to 10% of adult stone formers have an underlying monogenic cause. Over 30 genes contributing to stone formation have been identified, but additional clinically significant genetic variants remain unidentified. We sought to describe genetic and clinical characteristics for patients undergoing genetic testing at a large urology practice with a multi‐disciplinary stone clinic
Methods: A retrospective review was performed on patients evaluated in our multi‐disciplinary stone clinic and referred to our nephrolithiasis genetics clinic between 2018 and 2022. Patient demographic, clinical, stone, and genetic data were included. Specifically, we included stone history, composition, as well as the presence or absence of a genetic variant and its associated pathogenic significance if known.
Results: Of 825 patients seen in the multi‐disciplinary stone clinic from 2018‐2022, 50 patients were referred to the nephrolithiasis genetics clinic. Among these patients, 33 (66%) underwent genetic testing and were included in analysis. Genetic testing identified a variant in 19 (58%) patients of which 6 (32%) had a variant with a known pathogenic association. For patients with a variant identified, the majority had a family history of stones (68%), a prior stone event (95%), calcium‐based stones (68%), and had undergone medical (79%) or surgical (79%) management prior to testing. A large proportion (37%) had their first stone episode prior to age 18. There were no significant differences in demographic or clinical parameters between patients with pathogenic variants vs. variants of unknown significance (VUS). Solute‐carrier (SLC) gene abnormalities were the most common variants identified among both groups.
Conclusions: Among a high volume, multidisciplinary stone practice, more than half of the patients referred for a genetics consultation were found to have a genetic variant. However, the majority of these variants were of unknown significance. Further evaluation into associations of these VUS with clinical indicators/outcomes is warranted.
Funding: None
Pre‐Operative Opioid Exposure is Associated with Higher Post‐Operative Opioid Prescribing Following Kidney Stone Procedures
Emily Serrell1, Tudor Borza1, Jessica Schumacher1, Manasa Venkatesh1, Randi Cartmill1, Robert Tyllo1, Margaret Knoedler1, Stephen Nakada1
1University of Wisconsin
Presented By: Emily Serrell, MD
Introduction: In opioid naïve patients, experts recommend prescribing 0‐10 opioid doses following common kidney stone procedures. It is unclear to what extent patients are exposed to narcotics preoperatively. We aim to quantify pre‐ and post‐operative opioid prescribing patterns in patients undergoing ureteroscopy (URS) and shock wave lithotripsy (SWL) and measure the association between pre‐operative opioid exposure and post‐ operative prescribing.
Methods: We used the Wisconsin Health Information Organization database, which captures over 75% of Wisconsin's population. We collected demographic data on adult patients undergoing URS and SWL between 1/1/2017 and 12/31/2021. We evaluated pre‐ and post‐operative opioid prescriptions, quantified opioid exposure in morphine milligram equivalents (MME), and compared prescribing characteristics between opioid naïve and opioid exposed patients (defined as those with a filled prescription in 6 months before surgery).
Results: We identified 14,075 patients (10,886 URS, 3,189 SWL). Overall, 45% of patients filled a pre‐ operative prescription with similar proportion for the URS (45%) and SWL (45%) patients. The majority of fills occurred in the 3 weeks prior to surgery (63%; Figure) at a median time of 16 days (IQR 8‐40) with 18% fills occurring > 8 weeks prior. Patients filled 1 prescription (IQR 1‐3) with a median dose of 150 MME (IQR 90‐337). Post‐operatively, 50% of patients filled a prescription with a median first fill dose of 120 MME (IQR 75‐210), equivalent to sixteen 5mg oxycodone tablets. Opioid exposed patients had a significantly higher 2 week post‐operative dose (171 vs 131 MME, p < 0.001) and number of prescriptions (1.43 vs 1.35, p < 0.001).
Conclusions: Nearly half of patients undergoing kidney stone procedures are not opioid naïve, with the majority filling prescriptions in the three weeks before surgery. After surgery, more than half of patients filled an opioid prescription. For all patients, pre‐ and post‐operative prescribing remains significantly higher than recommended. Patients with prior opioid exposure had significantly higher number and dosage of opioid prescriptions. Incorporating opioid exposed patients into guideline recommendations is imperative to inform real world care.
Funding: None
Visualizing Episode‐Specific Costs for Renal Colic: A Model for Bundle Payment Reform
Hannah Kay1, Matthew E. Nielsen1, Charles D. Scales2, David F. Friedlander1
1University of North Carolina at Chapel Hill, 2Duke University
Presented By: Hannah Kay, MD
Introduction: Bundled payments are value‐based reimbursement models that link payments to providers for episodes of care related to inpatient admissions for certain conditions. What remains a limitation of episode‐ based payments, however, is their inability to account for health care expenditures that may accrue prior to the inciting inpatient admission. Renal colic is uniquely suited to evaluate the association between pre‐ and post‐operative events given high levels of variation in the timing and type of treatment. The objective of this study is to better understand how pre‐operative costs may relate to operative and post‐operative costs for a renal colic episode.
Methods: Using 2018 all‐payer claims data from the Healthcare Cost and Utilization Project, we identified individuals in Florida, New York, Wisconsin, and Maryland who had a renal colic diagnosis, a subsequent definitive surgical episode after diagnosis, and a post‐operative acute care encounter within 90 days of surgery. We categorized individuals into quartiles based on incurred costs during the pre‐operative, operative, and post‐operative periods and plotted the number of individuals in each quartile across the care time horizon using a Sankey diagram. Ordered logistic and linear regression were utilized to identify predictors of episode‐ related costs.
Results: A total of 2,736 individuals met inclusion criteria during the study period. Among individuals in the highest pre‐op cost quartile, 42% (n = 288) remained in the two highest post‐op cost quartiles. In multivariable analyses higher pre‐operative costs predicted experiencing higher post‐operative costs (OR 1.19, 95% CI 1.11‐1.27; P < 0.001). Drivers of higher pre‐operative cost included delays in surgery (OR 1.85, 95% CI 1.69‐2.01; P < 0.001) and Medicaid vs. private insurance (OR 1.11, 95% CI1.03‐1.20; P = 0.007).
Conclusions: Our findings suggest that pre‐operative spending influences post‐operative expenditures for an episode of renal colic, and accounting for this relationship may help inform future iterations of surgical payment bundles.
Funding: American Urological Association Research Scholars Grant
Claims‐Based Approach to Defining Episodes of Care Associated with Acute Renal Colic
Hannah Kay1, Matthew E. Nielsen1, Charles D. Scales2, David F. Friedlander1
1University of North Carolina at Chapel Hill, 2Duke University
Presented By: Hannah Kay, MD
Introduction: Central to United States (US) efforts to reduce healthcare spending are alternative payment models (APMs) that seek to link provider incentives to performance measurements/the cost of care. Surgical APMs largely consist of bundled payments, whereby providers are given a lumpsum payment for a single surgical episode and all related care over a pre‐specified time period. However, debate exists over how to accurately define the time horizon of a surgical episode of care. We use renal colic as a model surgical condition to validate a novel claims‐based approach to defining surgical episodes of care more broadly.
Methods: We queried the 2015‐2020 Carolina Cost and Quality Initiative claims dataset to identify patients presenting to an emergency department (ED) with a primary diagnosis of renal colic. Clinical and sociodemographic data was collected as were weekly charges stratified by surgery status in the 13 weeks preceding and following the initial ED encounter. Non‐parametric bootstrapping was performed to calculate changes in mean weekly charges and their accompanying 95% confidence intervals (CI). An episode was defined as the period of time where the 95% CIs for the change in mean weekly charges did not contain a zero value.
Results: We identified 34,515 individuals experiencing 38,196 index renal colic episodes over the study period. Males comprised 53.1% of the cohort, while the median age at time of the index encounter was 46.0 years (IQR 36.0‐55.0 years). 19.0% (n = 6,566) of individuals subsequently underwent definitive surgery within 90 days, with median time to surgery being 8 days (IQR 2‐36 days). Procedures performed included ureteroscopy (14.7%) followed by shockwave lithotripsy (4.2%), and percutaneous nephrolithotomy (0.3%). Average episode duration was 6 weeks for individuals not requiring surgery compared to 12 weeks for those requiring surgery.
Conclusions: To our knowledge this is the first study to use a claims‐based approach to defining an episode of renal colic. We show that episodes requiring surgery are twice as long as those that don't require surgery, and that episode onset precedes the index ED visit by 2 weeks. Our findings have important implications for ongoing APM reforms taking place in the US.
Funding: American Urological Association Research Scholars Grant
Incident Kidney Stones among U.S. Commercial Aviation Pilots
M. Reza Roshandel3, Anthony P. Tvaryanas1, Michael Ding2, Kevin Koo3
1Federal Aviation Administration (FAA), Civil Aerospace Medical Institute, 2Federal Aviation Administration (FAA), Health Safety Information, 3Mayo Clinic, Department of Urology
Presented By: M. Reza Roshandel, MD
Introduction: Occupational factors may increase the risk of kidney stone disease. Aviation pilots may be susceptible due to work‐related low fluid intake and physical inactivity. However, limited research exists on nephrolithiasis in contemporary pilots. This study investigates incident stone disease and potential risk factors among pilots.
Methods: We reviewed the United States Federal Aviation Administration (FAA) database between 2002 and 2022. Medical exams obtained for FAA certificate renewal were reviewed to assess incident stone events and associations with certificate types, flight hours, medical history, medications, labs, and reported stone events and procedures. Data were summarized for epidemiological analysis.
Results: A total of 7,615,939 visits for medical license renewal were included, encompassing 1,583,565 pilots evaluated over a span of 20 years. Among these pilots, 859,226 held class I and II [RMRM1]medical licenses. 10,903 unique pilots were reported to have experienced stone events: 2,820 reported prior stones during their initial medical exam during the study period, while 8,127 reported initial stone events during the study period. The average prevalence of kidney stones among the total pilot population was found to be 1.5%. This prevalence remained consistent among class I pilots (1.5%), while among female pilots, it was lower at 0.5%. Over the study period, the prevalence of kidney stones exhibited a steady increase from 1.4% in 2002 to 2.5% in 2022. Among female pilots, this increase was observed from 0.5% to 1.8%. Several factors were found to be associated with stone formation, including male gender, advanced age, and metabolic syndrome (evidenced by higher BMI, hypertension, and diabetes). Additionally, significant relationships were identified between urolithiasis and occupational circumstances, such as increased total flights hours and increased pilot hours in the 6 months prior to the exam (P < 0.05).
Conclusions: In this national cohort of commercial aviation pilots, the prevalence of kidney stones has increased steadily of the past 20 years, mirroring disease trends in the general population. However, the magnitude of stone prevelance was noted to considerably lower, suggesting that the impact of occupational risk factors may be attenuated relative to rising prevalence of general medical risk factors in the population.
Funding: N/A
Comparing mFI‐5, ASA Class, and mCCI as Predictors of Postoperative Outcomes Following Endoscopic Treatment of BPH
1Sophie Davis School of Medicine, 2Northwell Health, 3Northwell
Presented By: Arun Rai, MD, MBA
Introduction: While frailty has emerged as a predictor of morbidity following urological surgery, it remains difficult to measure. A new frailty index (modified Frailty Index‐5(mFI‐5)) has emerged for endoscopic treatment of benign prostatic hyperplasia (BPH); however, its discriminatory abilities for postoperative complications has not been investigated. Therefore, we compared mFI‐5 to two most commonly used indexes, the American Society of Anesthesiologists physical classification (ASA) and modified Charlson Comorbidity Index (mCCI) using the National Surgical Quality Improvement Program (NSQIP) database.
Methods: We retrospectively queried the 2015‐2020 NSQIP datasets for patients who underwent endoscopic treatment for BPH using CPT and ICD codes. Patients were stratified by procedure type (transurethral resection of the prostate (TURP), laser vaporization (LVP) and enucleation (LEP) of the prostate). Risk indexes were calculated and compared as predictors of postoperative outcomes using C‐statistics (AUC).
Results: 38,128 patients were included with a mean age of 71[RA1]. In aggregate, ASA Class, mFI‐5, and mCCI were fair models of mortality (AUC > 0.7) and not superior to the other (p > 0.05). ASA Class (AUC = 0.605) and mCCI (AUC = 0.635) were poor models for any readmissions and surgical complications; [RA2]however, all other indexes failed to model any other postoperative outcomes (AUC < 0.6).Upon stratifying by endoscopic procedure, all three indexes were fair models of mortality (AUC > 0.7) and not superior to the other (p > 0.05). When stratifying for patients undergoing TURP, mFI‐5 and ASA class were poor models of surgical complications (AUC = 0.638) and readmission (AUC = 0.600), respectively, but were superior to other indexes (p < 0.05). For LVP, mCCI (AUC = 0.636) and ASA (AUC = 0.600) were poor models of length of stay ≥2 days, but mCCI was superior (p < 0.05). Additionally, all indexes were poor models of readmission, but mCCI was superior (AUC = 0.626, p < 0.05) for Greenlight. Lastly, for LEP, ASA and mCCI were poor models of any complication and surgical complication (AUC > 0.6), respectively, but not significantly different (p < 0.05). All three indexes were poor models of readmission (AUC > 0.6) and not significantly different for LEP.
Conclusions: All three indexes are fair models of mortality for endoscopic treatment of BPH. However, these indexes were inadequate models for all other postoperative outcomes, despite previous studies demonstrating an association. Endoscopic treatment of BPH needs better risk indexes to predict post‐operative complications.
Funding: None
The Role of ‘Artificial Intelligence, Machine Learning, Virtual Reality and Radiomics' in PCNL: A Review of Publication Trends Over the Last 30 Years
Carlottac Nedbal5, Victoria Jahrreiss1, Clara Cerrato2, Daniele Castellani3, Amelia Pietropaolo4, Andrea Benedetto Galosi3, Bhaskar Kumar Somani4
1Department of Urology, University Hospitals Southampton, NHS Trust, Southampton, United Kingdom AND Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria., 2Department of Urology, University Hospitals Southampton, NHS Trust, Southampton, United Kingdom, 3Urology Unit, Azienda Ospedaliero‐Universitaria delle Marche, Polytechnic University of Marche, Ancona, Italy., 4Department of Urology, University Hospitals Southampton, NHS Trust, Southampton, United Kingdom., 5Urology Unit, Azienda Ospedaliero‐Universitaria delle Marche, Polytechnic University of Marche, Ancona, Italy., AND Department of Urology, University Hospitals Southampton, NHS Trust, Southampton, United Kingdom.
Presented By: carlottaC Nedbal, MD
Introduction: To analyze the trend of publications in a period of 30 years from 1994 to 2023, on the application of “Artificial Intelligence (AI), Machine Learning (ML), Virtual reality (VR) and Radiomics in PCNL”. We conducted this study looking at published papers associated with AI and PCNL procedures, including simulation training, with preoperative and intraoperative applications.
Methods: Though a MeshTerms research on PubMed database, we performed a comprehensive review of the literature from 1994 to 2023 for all published papers on “AI, ML, VR, Radiomics” in “PCNL”, with papers in all languages included in the final review. Papers were divided into three 10‐years periods according to year of publication: Period‐1 (1994‐2003), Period‐2 (2004‐2013), Period‐3 (2014‐2023).
Results: Over a 30‐year timeframe, 143 papers have been published on the subject with 116 (81%) published in the last decade, with a relative increase from Period‐2 to Period‐3 of +427% (p = 0.0027). There was a gradual increase of areas such as automated diagnosis of larger stones, automated intraoperative needle targeting and VR simulators in surgical planning and training. This increase was most marked in Period‐3 with automated targeting with 52 papers (45%), followed by application of AI, ML and radiomics in predicting operative outcomes (22%, n = 26) and VR for simulation (18%, n = 21). Papers on technological innovations in PCNL (n = 9), intelligent construction of personalized protocols (n = 6) and automated diagnosis (n = 2) accounted for 15% of publications. Comparing Period‐2 and Period‐3, the rise in publication on automated targeting for PCNL was significant at +247% (p = 0.0055). Similarly, an increasing trend by +200% was seen in publication on PCNL training (p = 0.0161).
Conclusions: An interest in the application of AI in PCNL procedures has increased in the last 30 years, and a steep rise has been witnessed in the last 10 years. As new technologies are developed, their application in devices for training and automated systems for precise renal puncture and outcome prediction seems to play the leading role in modern day AI based publication trends on PCNL.
Funding: None
Clinical Impact of Electronic Health Record Patient Portal Distribution of the International Prostate Symptom Score Questionnaire
Scott Quarrier1, Denzel Zhu1, Kaela Mali2, Jathin Bandari1, Rajat Jain1
1Department of Urology, University of Rochester Medical Center, 2University of Rochester School of Medicine & Dentistry
Presented By: Scott Quarrier, MD, MPH
Introduction: Recent American Urological Association (AUA) guidelines for the initial evaluation of benign prostatic hyperplasia (BPH) recommend the routine collection of symptom score data by validated questionnaires. We hypothesize that distribution of questionnaires through an electronic patient portal (EPP) will increase patient completion of the questionnaires allowing for improved institutional adherence to AUA guidelines.
Methods: We performed a retrospective, cross‐sectional study of men undergoing a new patient visit (NPV) for a chief complaint of lower urinary tract symptoms (LUTS) at an academic medical center. On January 2021, we initiated distribution of International Prostate Symptom Score (IPSS) questionnaires through the EPP 7 days prior to the NPV; previously, IPSS was distributed in paper at the NPV. Primary outcome measure was the completion of the IPSS; secondary outcomes included new BPH medication or surgery scheduled within 6 months of the NPV. The χ2‐test was used to compare outcomes.
Results: We reviewed 494 NPV for BPH, 255 NPV occurred prior to EPP collection and 239 NPV occurred after. Pre‐EPP collection, only 37% (N = 93) of IPSS scores were collected; this increased to 57% (N = 136) following EPP collection (p < 0.0001). The prevalence of severe LUTS based on IPSS (≥20) was higher post‐EPP (41%) compared to pre‐EPP (29%) collection (p = 0.04). Following routine EPP collection of the IPSS, fewer patients (4%) had new BPH medications ordered during the NPV (10.2%, p = 0.014); however, more patients had BPH surgery scheduled within 6 months (19% vs 9%, p = 0.001).
Conclusions: Our study demonstrated that distribution of validated questionnaires via EPP significantly increased completion rate of the IPSS in patients undergoing evaluation for LUTS, increasing compliance with AUA guidelines. Routine EPP collection may help detect more severe disease and reduce time‐to‐ intervention. Limitations include the COVID‐19 pandemic possibly confounding surgical management, as well as its retrospective nature.
Funding: No external sources of funding supported this research.
MODERATED POSTER SESSION 10: STONES - PCNL 2
A Novel Preoperative Scoring System for Predicting Successful Renal Access for Ultrasound‐ Guided Percutaneous Nephrolithotomy
Ukrit Rompsaithong2, Thomas Chi1, Wilson Sui1, Heiko Yang1, David Bayne1, Justin Ahn1, Marshall Stoller1
1Department of Urology, University of California, San Francisco, San Francisco, California, 2Division of Urology, Department of Surgery, Khon Kaen University, Khon Kaen, Thailand
Presented By: Ukrit Rompsaithong, MD
Introduction: Renal access remains a challenging but important step in successful percutaneous nephrolithotomy (PCNL). Understanding factors that predict successful access will help operative planning. With ultrasound guidance for renal accessbeing adopted for widespread clinical practice, this study aimed to develop and validate a novel preoperative scoring system for predicting renal access difficulty for ultrasound‐guided PCNL.
Methods: We analyzed consecutive patients undergoing ultrasound‐guided PCNL from the Registry for Stones of the Kidney and Ureter(ReSKU)between 2015 and 2022. A risk model was created using a randomized data‐ splitting approach, using 70% for model development and 30% for model validation. Ultrasound‐guided access failure was defined as the inability to puncture the renal calyx of choice using ultrasound‐only guidance. To create a multivariate model, the preoperative variables were determined using forward selection and modified according to clinical judgment. The predictive scores were created by weighting the coefficients of each significant factor. The total scores were classified into three risk groups according to the incidence and the correlation of difficult renal access. The final model was validated.
Results: Three hundred renal units were used for model development and 90 for validation. Four significant factors were identified in the final model and scored: body mass index ≥40kg/m2 (2 points), none/mild hydronephrosis (4 points), staghorn (5 points), and diverticular stone (7 points) (Table 1). The total scores were categorized into low (0‐4 points), moderate (5‐8 points), and high difficulty (9‐18 points), with a failure rate of 4.1%, 15.4%, and 50% in each group, respectively. This scoring system had a sensitivity of 78.1% and specificity of 80.7% in predicting failures over the moderate difficulty cut‐point. The area under the receiver‐operating characteristic curve (AUC) in the final model and the validation group were 85.5% and 87.7%, respectively.
Conclusions: Ournovelscoring system may be an effectivescreening tool to identify difficult cases for ultrasound‐guided access. In these patients, we suggest having backup imaging modalities available for alternate means of achieving access.
Funding: None
Comparative Outcomes in Patients with Pre‐Existing Nephrostomy Tube Prior to Percutaneous Nephrolithotomy (PCNL): Retrospective Analysis of Tract Reutilization vs New Intraoperative Access
T. Max Shelton1, Kameron Bell1, Nicholas Crowe1, William Stanton1, RJ Caras1, Austen Slade1, Marcelino Rivera1
1Indiana University School of Medicine
Presented By: T. Max Shelton, MD
Introduction: Percutaneous nephrolithotomy (PCNL) is indicated for the treatment of large renal calculi. At our institution, percutaneous access into the kidney is performed by urologists the majority of the time, however, in some instances, patients already have a percutaneous nephrostomy (PCN) tube placed by interventional radiology (IR) prior to the PCNL surgery. This study aimed to evaluate outcomes of PCNLs in patients with pre‐existing nephrostomy tubes and focused on pre‐existing PCN tract utilization versus new urology‐obtained intraoperative access.
Methods: A retrospective study was performed to identify patient who underwent unilateral PCNL with preoperative nephrostomy tube placement by interventional radiology at a single institution from 2017 to 2022. Patient demographic data, surgical outcomes and 30‐day postoperative data was analyzed.
Results: A total of 79 patients met inclusion criteria. In 63 patients (79.7%), the existing nephrostomy access was used to perform PCNL, while in 16 (20.3%) patients new intraoperative access was obtained. No differences were noted in postoperative stent or nephrostomy tube placement, residual stone burden, same‐ day discharge rate, or ipsilateral secondary surgery at 90 days. 30‐day complication rates and emergency department visits were higher in the PCN tract set at 29 (46.03%) vs 1 (6.25%).
Conclusions: Our findings reveal a statistically significant increase in the 30‐day complication rate when the PCN tract was reused compared to when new intraoperative access was obtained (46% vs. 6.3%, respectively). This observation suggests a potential advantage in establishing new intraoperative access during PCNL in patients with a pre‐existing nephrostomy tubes. Further studies are warranted to substantiate these results and to identify the underlying factors responsible for the increased complication rate.
Funding: None
Battle of the Fibers: A Comparison of Thulium Fiber Laser vs. High Powered Holmium Laser in Miniature Percutaneous Nephrolithotomy (mPCNL)
Julio Chong1
1Colorado Urology
Presented By: Julio Chong, MD
Introduction: High‐powered lasers have been marketed by many major device companies that support endourological procedures. The newest high‐powered lasers include improvements on the 120‐watt holmium laser (HPH‐M, MOSES 2.0, Lumenis) and the thulium fiber laser (TFL, Soltive, Olympus). With its reduced sheath size, miniature percutaneous nephrolithotomy (mPCNL) can be an optimal delivery modality of these lasers in stone treatment that still require the power of percutaneous stone extraction. Previous randomized studies have only compared TFL to lower wattage holmium lasers and little data exists comparing TFL vs HPH‐M in a mPCNL setting.
Methods: A retrospective analysis of mPCNL procedures done by one surgeon from August 2021 to May 2023 was performed. mPCNL with TFL (n = 23) and mPCNL with HPH‐M (n = 15) were identified. All fibers used were 200 micron (um). Treatment specific parameters such as laser energy, treatment/laser times and laser efficiency were compared using a two‐tailed paired t‐test.
Results: There were no differences in patient and stone demographics such as age (52.3 vs 53.7, p = 0.891), sex, procedure side, stone size (14.3 vs 17.93 mm, p = 0.093), or stone locations between TFL and HPH‐M groups. Stone location and stone predominant type were similar in both groups. Treatment time (all manipulation required to clear stones, 13.87 vs 20.47 min, p = 0.165), operative time (71.48 vs 78.47 min, p = 0.345), laser time (293 vs 328 sec, p = 0.725), laser total energy (4.53 vs 4.65 kJ, p = 0.95) and treatment efficiency (laser time/treatment time, 0.39 vs 0.3, p = 0.305) tended to favor the TFL group but were not statistically significant. Stone‐free rates on a renal ultrasound six weeks post‐operatively were also similar between groups (82.6 vs 86.7%, p = 0.112). One patient in the TFL arm required post‐operative oxygen needing admission and one patient in the HPH‐M arm had stent migration that necessitated stent exchange. No complications related to laser usage were noted in either arms.
Conclusions: 200 um TFL and HPH‐M fibers perform similarly in a mPCNL setting. Both laser types result in good stone‐free rates, even in complex mPCNL cases. There were no laser related complications noted in this study. A surgeon performing mPCNL should expect to achieve excellent stone clearance in a safe manner with either high powered lasers.
Funding: None
Risk Factors for Postoperative Sepsis in Elective Percutaneous Nephrolithotomy
Brian H Eisner2, Juliana Villanueva1, Michal Segall2
1Columbia, 2Massachusetts General Hospital
Presented By: Brian H Eisner, MD
Introduction: Percutaneous nephrolithotomy is one of the most common procedures to treat large kidney and upper ureteric stones. Although there have been improvements in the procedure technique, there is still a risk of severe infectious complications. Urosepsis and septic shock correlated to percutaneous nephrostomy have an incidence of 0.3‐4.7%. However, the mortality rates of these patients can be as high as 80%. This study aims to determine possible risk factors for post‐intervention sepsis.
Methods: With prior IRB approval data was gathered prospectively at multiple participating centers of patients undergoing PCNL. Data was analyzed in SPSS v 25. Continuous data was assessed for normality of distribution using the Kolmogorov‐Smirnov test. Single logistic regressions were performed for associated variables to establish their possible relation with positive quick Sequential Organ Failure Assessment status(qSOFA) after the intervention. Models were assessed with Omnibus' test of model coefficients as well as Hosmer and Lemeshow's test of model fit. Results are presented in Odds Ratios(OR) with 95% confidence intervals(CI).
Results: A total of 320 patients were analyzed. Of these, 23 met qSOFA criteria after the intervention, suggesting a 7.18% rate of postoperative sepsis. Of analyzed variables, the ones found to have significant ORs for developing +qSOFA were: High ASA Score(4‐5), Positive Preoperative Urine Culture and Underlying Renal Anatomic Abnormalities such as horseshoe kidneys. Table 1 displays odds ratios for these variables.
Conclusions: Higher comorbidity scores, positive cultures as well as renal anatomic abnormalities may be significant predictors of infectious complications after elective PCNL. These findings should be validated in external cohorts.
Funding: No funding
SuperPulsed Thulium Fiber versus High‐Power Holmium:YAG Laser in Mini‐Endoscopic Combined Intrarenal Surgery for Treatment of Kidney Stones: A Practical Comparison
Bristol Whiles1, Wilson Molina1, Willian Ito1, Nicholas Choi2, Crystal Valadon1, Donald Neff1, David Duchene1
1The University of Kansas Health System, 2University of Kansas School of Medicine
Presented By: Crystal Valadon, MD, MBA
Introduction: Miniaturized endoscopic combined intrarenal surgery (mini‐ECIRS) comprises the simultaneous use of two different but complementary surgical techniques to treat kidney stones: miniaturized percutaneous nephrolithotomy and retrograde intrarenal surgery. This study aims to address the literature paucity regarding the outcomes of the utilization of the high‐power Holmium:YAG (HoYAG) and the thulium fiber laser (TFL) in mini‐ECIRS.
Methods: Data on patients undergoing supine mini‐ECIRS was prospectively collected from 08/2021 to 09/2022, regardless of stone size or complexity. Exclusion criteria included patients with urinary diversion (e.g., ileal conduit), simultaneous utilization of > 1 laser platform, cases using any other form of energy fragmentation, and patients with ureteral stones. The utilized HoYAG platform was the Lumenis Pulse P120H™ (120W, Boston Sci®), while the TFL comprised the Soltive SuperPulsed Thulium Fiber (SPTF, 60W, Olympus®). Perioperative antibiotics were managed per EDGE consortium criteria. Stone‐free status (SFS) was defined as the absence of stone fragments (i.e., 0% residual fragments) after assessing a CT scan performed on the first postoperative day.
Results: A total of 74 patients met the study criteria, including 25 patients in the HoYAG and 49 in the SPTF groups. Table 1 exhibits patients' demographic features and stones characteristics, with no significant differences between groups. HoYAG utilized less energy and time, resulting in higher ablation efficiency and speed (p < .001 and p = .039, respectively), with no reflection on total operative time (p = 0.29). Overall, we observed no difference in SFR between HoYAG and SPTF (OR 0.52, CI 95% 0.19 – 1.40, p = 0.19) – Table 2.
Conclusions: Although we observed an equivalence in operative time and immediate postoperative SFRs, this study depicts a higher intraoperative laser efficiency of the HoYAG over the SPTF in mini‐ECIRS.
Funding: No funding.
Bilateral Simultaneous Percutaneous Nephrolithotomy ‐ Does it Worth the Risk? High‐ Volume Endourology Center Experience and a Systemic Review of the Literature
Sergiu Bistritzky1, Oleg Goldin1, Jonatan Aguinaga1, Michael Mullerad1, Gilad Amiel1
1Rambam Health Care Campus
Presented By: Sergiu Bistritzky, MD
Introduction: Bilateral simultaneous percutaneous nephrolithotomy (BS‐PCNL) has the potential to reduce hospital visits and psychological impact compared to staged procedures. However, it is still considered adventurous, time‐consuming, and risky. This study aims to evaluate the outcomes of BS‐PCNL cases and review existing literature to assess the risk‐benefit profile of this approach.
Methods: Over a 20‐year period (2003‐2023), 85 patients underwent 89 BS‐PCNL procedures. Epidemiological and clinical data were collected, and treatment outcomes were assessed retrospectively. Successful treatment was defined as a stone‐free kidney or insignificant stone fragments (< 5 mm) without
the need for further interventions within one year. Data from other relevant studies were included for comparison.
Results: Mean age: 53.2 years (range: 1.5‐87). 42 women, 43 men. Mean hospitalization: 11 days. Stone burden per kidney: 23 cm3 (5‐169). Median operating time: 185 (120‐315) min. Complications in 64 patients: Grade I: 20% (13), Grade II: 44% (28), Grade III: 33% (21), Grade IV: 0%, Grade V: 3% (2). Serious complications: bleeding requiring transfusion: 25% (21), pneumothorax necessitating drainage: 6% (5), pleural effusion requiring drainage: 13% (11), sepsis: 4.7% (4), 2 deaths (urosepsis, pulmonary emboli). 75% of operated kidneys and 63% of procedures achieved stone‐free or insignificant state. Other studies: synchronous PCNL stone‐free rate: 92.4%, average operating time: 171 min, mean hospital stay: 3.9 days. Some reported shorter operating times with BS‐PCNL (83 min/renal unit, 120 min/bilateral) and less blood loss compared to staged PCNL. Most BS‐PCNL studies reported higher residual stone rates and a complication range of 12.1%‐53.2%, mostly low‐grade.
Conclusions: BS‐PCNL is a feasible approach for the complete treatment of bilateral renal stone burden in a single session. However, it carries a high rate of complications, including mortality. Comparative data indicate relatively high stone‐free rates but also higher complication rates compared to the staged approach. Patient selection and performing the procedure in high‐volume endourology centers are crucial for minimizing risks.
Funding: No funding.
Complications of Tubeless versus Standard Percutaneous Nephrolithotomy
Hayden Hill1, Rebekah Keller1, Susan Talamini1, Joel Vetter1, Charles Nottingham1
1Washington University School of Medicine in St. Louis
Presented By: Hayden Hill, MD
Introduction: The necessity of nephrostomy tube after percutaneous nephrolithotomy (PCNL) has been called into question in modern series. We sought to examine differences in post operative complications and outcomes of tubeless PCNL versus standard PCNL at our institution.
Methods: A retrospective review of our institutional stone database was conducted from January 2016 to December 2021 for patients who had undergone either tubeless PCNL, defined by placement of only an internal ureteral stent, or standard PCNL, which involved placement of an externalized nephrostomy tube. Patients were excluded if they underwent totally tubeless PCNL.
Results: A total of 438 patients were included for analysis: 329 patients underwent tubeless PCNL and 109 patients underwent standard PCNL. Between tubeless and standard groups there was no difference in readmission rates 6.1% vs 9.2% (p = 0.268), clavien 2 or > complications 18.5% vs 19.3% (p = 0.923), and clavien 3 or > complications 4.0% vs 7.3% (p = 0.151). The tubeless group experienced shorter operative duration 121.5 vs 144.8 minutes (p = 0.012), shorter length of stay 2.5 vs 3.8 days (p = 0.002), higher stone free rates 72.3% vs 60.2% (p = 0.014), but also increased blood transfusion rates 6.4% vs 0.9% (p = 0.022).
Conclusions: In comparing tubeless with standard PCNL there was no difference inreadmission rates,or significant clavien complication rates. Patients undergoing tubeless PCNL experienced higher stone free rates, but more required post operative blood transfusion. The decision to leave a nephrostomy tube after PCNL appears unlikely to impact overall complication rates and can be left to surgeon experience and case‐ based discretion.
Funding: None
Impact of the Timing of Percutaneous Nephrostomy on the Prognosis in Patients with Obstructive Urolithiasis with Sepsis
Ji Eun Yu1, Ye Chan Joo1, Jae Hyun Baik1, Young Seop Chang1, Jin Bum Kim1, Hong Wook Kim1, Hyung Joon Kim1, Dong Hoon Koh1
1Konyang University College of Medicine
Presented By: Ji Eun Yu, MD
Introduction: In patients with obstructing ureteral stone, immediate renal decompression using percutaneous nephrostomy (PCN) or cystoscopic double‐j stent indwelling are standard of care if infection is suspected.Previous study has shown that the timing of ureteral stent placement impact on the clinical outcome of patients with obstructing ureteral stones with sepsis.Even though PCN is alternative option for renal decompression, the impact of timing of PCN on the patient outcome is not well understood.
Methods: Using a database from 2017 to 2021, we evaluated patients who visited emergency department with obstructive uropathy due to urinary stones and underwent percutaneous nephrostomy insertion. We classified patients in two groups, whom met quick sequential organ failure(qSOFA) score of lesser than two, and qSOFA score of two or more, and retrospectively investigated patients.The aim of this study is to understand how time to percutaneous nephrostomy insertion affects the prognosis, including total length of stay, need for intensive care unit.
Results: Total 96 patients met the criteria. 70 patients had qSOFA score of lesser than two, and 26 patients had qSOFA score of two or more. Overall, 37 patientshave positive urine culture. Mean time to percutaneous nephrostomy insertion was 229 minutes, and mean length of stay was 18.11 days. There was no difference between groups in clinical values. In group of qSOFA score of lesser than two, there was no correlation between the time to procedure and length of stay, but in group of qSOFA score of two or more, hospitalization days was significantly shorter in patients of percutaneous nephrostomy before 4 hours than patients whom underwent procedure after 4 hours.
Conclusions: In patients with obstructive uropathy with high risk of sepsis, length of stay would be decreased as time to percutaneous nephrostomy insertion shortened.
Funding: NO
Percutaneous Nephrolithotomy for Renal Stones in a Paediatric, Enbloc Transplant Kidney
Amy Nagle1, Mohammed Zain Adhoni1, Zubeir Ali1
1Royal London Hospital
Presented By: Amy NAGLE, MBBS
Introduction: Percutaneous nephrolithotomy (PCNL) is an accepted and widely used approach to extract large renal calculi. Treatment for symptomatic calculi in the transplanted kidney can be problematic.Percutaneous nephrolithotomyhas routinely been used but concerns exist about potential injury to adjacent organs using a percutaneous access technique. We describe a successful case of mini percutaneous nephrolithotomy in a paediatric enbloc transplant kidney.
Methods: We describe the case of a percutaneous nephrolithotomy (PCNL) in a transplant kidney. Our patient was a 42‐year‐old female who received a cadaveric kidney transplant in March 2019 on a background of Ig A nephropathy and ESRF.In September 2019 she attended the accident and emergency department complaining of lower urinary tract symptoms, haematuria and right flank pain with fevers. She consequently had computed tomography scan of the kidneys, ureter and bladder (CT KUB) which confirmed evidence of renal calculi in the pelvis and lower pole of the left, medial transplant kidney. The calculus in the pelvis measures approximately 12 mm. The calculus in the lower pole measures approximately 5 mm. There was no hydronephrosis.
Results: Transplant PCNL was performed and full stone clearance achieved endoscopically and radiologically. The estimated blood loss 150ml.Urolithiasis is an uncommon, but potentially catastrophic complication of renal transplantation. The risk of ureteral obstruction and subsequent graft compromise contribute to the urgent manner in which management is required. Additionally, patients are chronically immunosuppressed following transplantation predisposing them to sepsis should infection complicate the stone.The extra‐anatomical location of a renal allograft becomes an important consideration when planning stone extraction. Extracorporeal shock wave lithotripsy can be used; however, targeting the shock wave directly onto the stone can be difficult due to the proximity of the bony pelvis, and there is risk of bleeding and haematoma. Ureteroscopic approaches are also possible, but can be challenging as the neo‐ureteric orifice is often superior in the bladder and difficult to access.
Conclusions: Percutaneous nephrolithotomy is safe and effective in the transplanted kidney. Minimal postoperative complications were noted and stone‐free status was achieved in this patient. 4 years post‐ surgery, she remains stone free with no stone recurrences and with stable graft function after the procedure.
Funding: Nil
Effect of Access Sheath Diameter Used in Percutaneous Nephrolithotomy on Renal Functions: A Prospective Randomized Study
Deniz Noyan Özlü1, Mithat Ekşi1, Selçuk Şahin1, Alev Kural1, Murat Sipahi1, Taner Kargı1, Alper Bitkin1, Ali İhsan Taşçı1
1University of Health Sciences Bakırköy Dr. Sadi Konuk Training and Research Hospital
Presented By: Deniz Noyan Özlü, MD
Introduction: We aimed to determine the effect of access sheath diameter used in percutaneous nephrolithotomy (PNL) on kidney functions. We also investigated the predictors of impaired renal function.
Methods: Data were prospectively collected from patients who underwent PNL from December 2020 to December 2021. Patients were randomized according to access sheath diameter as Group 1 (22Fr, n = 44) and Group 2 (28Fr, n = 44). Relative renal function (RRF) was calculated by technetium‐99m dimercaptosuccinic acid (DMSA) scintigraphy and glomerular filtration rate (GFR) was calculated by diethylenetriamine pentaacetic acid (DTPA) scintigraphy. A difference of 5% or more in RRF was considered a significant functional change. Preoperative and postoperative Kidney Injury Molecule‐1 (KIM‐1) levels were measured. Perioperative factors were compared between the groups.
Results: Preoperative demographic data and stone characteristics were similar when Groups 1 and 2 were compared. There was no statistically significant difference between the groups in terms of the operation time, postoperative mean Hemoglobin (Hg) decrease, stone‐free rate, presence of complications, scar development, changes in RRF, GFR and KIM‐1/Creatinine (Cr) (p > 0.05). Significant deterioration in RBF was detected in a total of 6 (6.8%) patients, 3 in each group. The factors predicting loss of function were analyzed by regrouping the patients without loss of function as Group A (n = 82) and those with loss as Group B (n = 6). When groups A and B were compared, there was a significant difference in terms of preoperative hydroureteronephrosis grade, stone volume, Hounsfield Unit, operation time, postoperative mean Hg decrease, scar development and presence of complications (p < 0.05). Only stone volume was statistically significant in multivariate analysis (p = 0.002). The Area Under Curve (AUC) value for the stone volume was 0.907 (0.830‐0.983), and the AUC value was 0.878 (0.797‐0.959) when the stone volume was taken as 4750 mm3, and the sensitivity,positive predictive, specificity, and negative predictive were 100%,23.1%, 75.6%, and 100%, respectively.
Conclusions: There was no significant effect of access sheath diameter on kidney function after PNL. Preoperative stone volume was found to be an independent predictor of loss of function after PNL.
Funding: The authors declared that this study has received no instutitional financial support.
Utilization of MOSES™ Lumenis Holmium Laser in Mini‐Percutaneous Nephrolithotomy
Cassidy Lleras1, Maytal Babajanian1, Max R. Drescher2, Natalia Arias Villela2, Andy Martinez3, William Meeks4, Emily Galen4, Joel Abbott5, Meagan Dunne3, Daniel C. Rosen1, Julio G. Davalos3
1New York Medical College, 2University of Maryland School of Medicine, 3Chesapeake Urology Associates
4American Urological Association, 5Pacific West Urology
Presented By: Cassidy Lleras, BS
Introduction: Percutaneous nephrolithotomy (PCNL) is the preferred treatment for large and complex kidney stones. Miniaturization of the PCNL (“mini‐PCNL”) has shown promising outcomes through a smaller incision. There is limited data regarding the use of MOSES™ Lumenis holmium laser in mini‐PCNL, specifically in regards to stone composition and location. We aim to explore outcomes in patients with renal calculi of varying composition and location who underwent mini‐PCNL using theMOSES™ holmium laser.
Methods: We retrospectively reviewed records of patients who underwent mini‐PCNL with the MOSES™holmium laser from July 2018 to April 2022. Patient demographics, comorbidities, and preoperative demographics were extracted. Treatment time was defined as time from stone removal initiation until completion, including lithotripsy, basketing, and extraction, while lithotripsy time was defined as time spent on fragmentation. Kruskal‐Wallis tests were used for statistical analysis.
Results: A total of 251 patients were included. Postoperatively, the majority of patients (95%) were stone free, while 12 patients had residual stone. Complication rate was low at 1% (n = 3). Median stone treatment time was 8.2 min while median lithotripsy time was 1.75 min. Overall treatment efficiency (diameter of stone/treatment time) was 0.48 mm/min. Median lithotripter efficiency (diameter of stone/lithotripsy time) was 9.3 mm/min. Lithotripsy efficiency was similar among primary stone locations (p = 0.113) and primary compositions (p = 0.075). After taking time spent evacuating stone fragments into account, treatment efficiency was also similar among stone locations (p = 0.182) and compositions (p = 0.131).
Conclusions: The laser was clinically equivalent across stone type and location. With high stone free rates and minimal complications, our study provides evidence for the effective use of MOSES™ holmium laser in mini‐PCNL in kidney stone treatment, to which future lasers/lithotripters may be compared.
Funding: Statistical analysis was funded by LUMENIS.
Implementation and Outcomes of the 1.9mm Trilogy Lithotripter in Mini Percutaneous Nephrolithotomy
Daniel Rosen1, Arsha Venkat1, Rebecca Kindler1, Natalia Arias Villela2, Andy Martinez3, William Meeks4, Emily Galen4, Joel Abbott5, Meagan Dunne3, Julio Davalos3
1New York Medical College, 2University of Maryland School of Medicine, 3Chesapeake Urology Associates
4American Urological Association, 5Pacific West Urology
Presented By: Arsha Reddy Venkat, BA
Introduction: Mini Percutaneous Nephrolithotomy (mPCNL) is widely used for complex stone disease but is limited by the size of lithotripter that can be used. We aim to evaluate the use of a larger 1.9mm Trilogy probe with varying locations and composition of renal stones.
Methods: We prospectively enrolled patients to undergo mPCNL procedures using the 1.9mm Trilogy probe technique from Aug 21‐ Apr 22. Adjunctive irrigation measures including retrograde irrigation were used to accommodate the larger probe. Patient preoperative demographics, and real‐time surgical data were extracted. Stone volume was calculated with 3D Slicer, when DICOM images were available, or manually using an ellipsoid formula. Treatment time was from start of lithotripsy to total elimination of relevant stone from kidney. Lithotripsy time was total lithotripter‐on time. Stone treatment efficiency was size of stone/total treatment time and treatment efficacy as lithotripter time/treatment time. Lithotripter efficiency was diameter (or volume in 3D)/lithotripter time in min. Statistical analysis was with a Kruskal‐Wallis Test to compare both stone type and location.
Results: 110 patients were treated with 109 endoscopically stone‐free after treatment. Median total treatment time was 6.8 min, median lithotripsy time was 3.3 min, median stone treatment efficacy was 0.34 mm/min, and treatment efficacy was 50.4. Overall median lithotripter efficiency was 104.6 mm3/min. Treatment efficiency was similar among stone composition (p = 0.245) and location (p = 0.263). Lithotripter 3D and 1D efficiency was also similar among stone composition (p = 0.637 and 0.766). Lithotripter 1D efficiency was nearly twice as fast in the lower pole compared to other stone locations (p = 0.010). 5 patients had minor complications, including one patient that required admission to the hospital for postoperative pain management. Broken probe rate was 12%, mostly at the beginning, suggesting a learning curve.
Conclusions: The 1.9mm Trilogy Lithotripter can be effectively used in mPCNL procedures with the use of easily implementable adjunctive irrigation techniques, decreasing the gap between lithotripsy time and total treatment time.
Funding: EMS supplied the probes used in the study and provided administrative support.Julio Davalos is a Consultant for BSC, Storz, and EMS
Mini PCNL in a Spinal Deformity Patients— Our Experience in 92 Patients
Introduction: Patients with spinal deformity (SD) pose specialchallenge in stone management due to altered anatomy andcompromised respiratory function. Retrograde intrarenalsurgery (RIRS) is an established standard of care in the modernliterature. However, this is not a viable options in remote areasof India due to large stone burden and limited economic andtechnologicalresources. Under these circumstances mini PCNL(mPNL) yields an alternative minimally invasive treatmentoption as a treatment for stone disease. We seek to evaluatesafety and efficacy of this approach in large renal stone burdenin patients with spinal deformity.
Methods: Wehave studied 92 patients with spinal deformitiesbetween 2000 to 2023. Large total stone burden was defined as allpatient with a stone greater than 1.5 cm. Spinal deformitieswere‐ varying amount( scoliosis,kyphosis,lordosisand Kyphoscoliosis). Stone size was calculated with the help of CTIVP after confirmingtheir operative fitness. All children andelderly population deemed medically unfit for surgery wereexcluded. General anesthesia was used in all cases. Allpercutaneous access was established via use of Fluoroscopyguide puncture using standard technique and the percutaneoustract was dilated up to 14F, 16For18F dilators. All stones werefragmented to dust with the help of the 30 wt holmium laser 365fiber aswells as mini pored lithoclast. 5.0Fr double J stent andpercutaneous drain was placed and all patients were evaluatedwitha KUB on post operative day 1and were discharged on day2.
Results: There were a total of92 patients and70(76.3%)were male . Mean age was 45yrs (32‐62 yrs). Stone location wasas follows: renal pelvis 45(48.9%);Pelvis and calyx ‐29(31.6%), only calyx 18cases(19.6%). Four patients werecompletestaghorn. Mean operative Timewas: 50 minute (20‐120) min. Complete clearance was 84 (91.4%), remainingrequired relookmPCNLfor clearance . Minor complications in11patients (12.2%) (minorbleeding in 7, culture positiveinfection in 4) occurred 14( 15.2%) , major complications in 10patients (11%) (bleedingrequired transfusion in 6patients, persistenturine leak from surgery site in 2, hydrothorax in 1andcolonic rupture in 1)
Conclusions: ThemPCNLis safe effective in patientswith spinal deformities and large renal stones. Stringent patientselection and pre‐operative stone mapping is very important.Financial conflicts and Disclosure statement ‐ NoneSource of funding ‐ None
Funding: None
Enhanced Recovery after Percutaneous Nephrolithotomy with an Erector Spinae Plane Block and Opioid Minimization
Scott O. Quarrier1, Aaron Saxton1, David Song1, Christopher Wanderling1, Austin Lee1, Timothy Campbell1, Stephen Hassig1, Sarah Jaffe1, Kaitlyn Mitchell1, Rajat Jain1
1University of Rochester
Presented By: Scott O. Quarrier, MD, MPH
Introduction: Optimizing analgesia after a percutaneous nephrolithotomy (PCNL) is not standardized. At our institution we instated an enhanced recovery after surgery (ERAS) pathway centered on a preoperative erector spinae plane (ESP) block to improve pain control post‐operatively and minimize opioid consumption.
Methods: In association with the Department of Anesthesiology, an ERAS pathway was created for patients undergoing PCNL. This pathway involved a preoperative ESPblock and the replacement of opioids with multi‐modal analgesia post‐operatively. After IRB approval, patient charts were retrospectively reviewed and placed into two cohorts – one cohort participated in the ERAS pathway while the other did not and received traditional pain control. Opioids were available for patients in the ERAS group if their pain was not controlled. Patients were excluded if they were currently on opioid analgesics, unable to receive a preoperative block, significant non‐ESP related intra‐operative complication requiring further surgical intervention. Data collected included baseline demographics, morphine equivalents (MEs) received post‐ operatively, nursing pain scores, if an opioid was prescribed for home, and the need for any refills. Descriptive statistics were performed by unpaired student's t‐test and Chi‐squared test for continuous and categorical variables, respectively.
Results: 33 patients were identified in the ERAS cohort versus 66 in the traditional pain control cohort. Baseline demographics are stated in Table 1. There was a statistically significant difference in average postoperative nursing pain scores between the ERAS and traditional cohorts (2.7 vs 3.5, p = 0.04), as well as a significant difference in average postoperative MEs received (19.8 vs 38.9, p < 0.01). 67% (22/33) of patients in the ERAS cohort received an opioid prescription for home compared to 80% (53/66) in the historical cohort (p = 0.15). There was no significant difference in length of hospital stay between the ERAS and traditional cohorts (1.3 vs 1.1, p = 0.1). No adverse patient events resulted from the block.
Conclusions: An ERAS pathway centered on a preoperative ESP block and multi‐modal analgesia reduced nursing pain scores postoperatively and decreased MEs received. Future randomized prospective studies with the ERAS protocol can be considered.
Funding: N/a
Workload Profiles of Urology Residents when Obtaining Ultrasound vs. Fluoroscopic Percutaneous Renal Access on Benchtop Models
Spencer Mossack2, Matthew Greydanus2, Luke Reynolds1, Alexander Chow2, Christopher Coogan2, Ephrem Olweny2
1University of Chicago, 2Rush University Medical Center
Presented By: Spencer mossack, MD
Introduction: The learning curve for residents in training for obtaining percutaneous renal access during PCNL is steep. Simulation models may help supplement clinical training for this complex skill. We evaluated NASA‐TLX workload profiles of urology residents during simulated percutaneous renal access with ultrasound or fluoroscopic guidancein bench top models.
Methods: During the 2023 Chicago Urologic Society meeting, a PCNL simulation workshop was held for urology residents from programs across the city and state. It included modules for obtaining fluoroscopic and ultrasound‐guided percutaneous renal access with guidance from Endourology fellowship trained faculty. Each participant subsequently completed a general questionnaire, as well as a NASA‐TLX questionnaire for each model. NASA‐TLX domain scores for fluoroscopy vs. ultrasound models, and junior (PGY1‐3) vs. senior (PGY4‐6) residents were compared using standardized t‐tests.
Results: A total of 22 junior and 13 senior residents participated in the workshop. Only senior residents reported being exposed to > 20 PCNL cases in training. The majority of residents found both simulations to be “very” or “extremely” useful. The highest mean (SE) TLX domain score for the ultrasound model was for “performance” (43.06 (4.2)), compared with “temporal demand” for the fluoroscopy model (47.03 (3.7)). There were no statistically significant differences in any of the mean NASA‐TLX domain scores for the ultrasound vs. fluoroscopy models. Similarly, there were no differences in mean NASA‐TLX domain scores for junior vs. senior residents. The models were rated equally with respect to overall perception, ease, usefulness, and real‐life representation.
Conclusions: Bench top models for ultrasound and fluoroscopic guided PCNL access appear to provide value for resident training, with residents reporting positive overall perceptions of their experience. Urology resident workload during the simulation exercises was low, with each of the NASA‐TLX domain scores < 50.
Funding: None
Operative Times and Surgical Outcomes are Comparable between “Mini” 17.5 Fr and “Standard” 34 Fr ECIRS for Renal Stones up to 33 mm
Victor Abdullatif4, Joel Abbott1, Julio Davalos2, Mark Silva3
1Pacific West Urology, 2Chesapeake Urology, 3Plymouth Care Center, 4Ascension Macomb Oakland Hospital
Presented By: Victor Abdullatif, DO
Introduction: To compare our experience with minimally invasive Endoscopic Combined Intrarenal Surgery (mini‐ECIRS) and standard percutaneous Endoscopic Combined Intrarenal Surgery (standard ECIRS) for stones of comparable size.
Methods: A stone database was queried for percutaneous stone‐extraction procedures performed between July 2017 and May 2018 for stones between 8 and 33 mm from a free‐standing ambulatory surgical center. Demographic profiles were adjusted and similar in both arms. Among the 120 procedures reviewed, 73 patients (61%) underwent standard ECIRS (34/30 Fr) and 47 patients (39%) underwent mini‐ECIRS (17.5/15.5 Fr). Student's t test was used for statistical analysis of quantitative variables, and χ2 was used for qualitative variables.
Results: Mean stone‐free rate (SFR) was slightly higher in the standard ECIRS group compared to the mini‐ ECIRS group (97.2% vs 95.7%, respectively), but this difference was not statistically significant (p > 0.05). There were no statistically significant differences between mini‐ECIRS and standard ECIRS in overall complications (6.4% vs 6.8%, respectively; p > 0.05). Additionally, there were no statistically significant differences in mean operative time (89 vs 91 mins; p = 0.655), renal access time (5 vs 5 mins; p = 0.691), intracorporeal time (36 vs 41 mins; p = 0.186), treatment time (16 vs 18 mins; p = 0.443), fluoroscopy time (75 vs 75 sec; p = 0.997), and PACU time (98 vs 96 mins, p = 0.834) between mini‐ECIRS and ECIRS.
Conclusions: Mini‐ECIRS is non‐inferior to standard ECIRS and demonstrates comparable efficacy in the management of renal stones 8 to 33 mm in size, with a similar stone‐free rates, complication rates, and operative time parameters. Our findings indicate that mini‐ECIRS may be a suitable alternative to standard ECIRS in patients with a stone burden up to 33 mm as no significant difference between the two techniques was observed.
Funding: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work.
Post PCNL Embolization: Who Actually Needs it?
Charan Mohan1, Gregory Mullen1, Jared Winoker1, David Hoenig1, Zeph Okeke1, Arun Rai1, Tareq Aro1
1The Smith Institute for Urology, Northwell Health
Presented By: Charan Mohan
Introduction: Severe bleeding following percutaneous nephrolithotomy (PCNL) is a complication that has significant impact on morbidity, readmissions and length of stay. This study seeks to describe the true incidence of severe bleeding related complications following PCNL and identify risk factors that may help predict the need for intervention
Methods: A retrospective data query was performed for all PCNL's performed over an 18‐month period (6/2020 to 12/2021) across a large health system. Analysis included all patients requiring angiography with or without embolization. Patient, surgeon, and procedure specific details were analyzed to examine any predictors of severe bleeding complications requiring intervention.
Results: A total of 778 surgeries were identified across 9 different hospitals. The median age was 61 (IQR 50‐69) and median length of stay was 1 day (IQR 1‐3). 12 patients had bleeding requiring angiography (1.5%), performed at a median time of POD4. Only 7 patients (0.9%) required embolization with 5 due to pseudoaneurysm, and 2 for injured renal vasculature. There was no patient factor which predicted which patients undergoing angiography would need embolization (Table 1). . Patients who needed embolization had higher rates of pre‐operative anticoagulation use compared to all non‐embolized PCNL patients (29% vs 6%, p = 0.04). When looking at patients who underwent angiography only, embolization rates were still higher among those on anticoagulation (29% vs 0%); however, this difference was not statistically significant (p = 0.4).
Conclusions: Severe bleeding complications requiring angiography are rare following PCNL mirroring estimates in the literature at 1.4%. Furthermore only 0.9% of all patients across this large health system required embolization, comprising 58% of all patients undergoing angiography. The only statistically significant difference in our study was the use of pre‐operative anti‐coagulation. Due to the rarity of this condition, further work is needed to better identify at‐risk patients and expedite treatment when needed and reduce unnecessary contrast load in patients unlikely to benefit from intervention.
Funding: n/a
Does Being Truly Stone‐Free After a PCNL Decrease the Risk of Unplanned Stone Procedures?
Rajat Jain1, Christopher Carlisi1, Karen Doersch1, Galen Cheng1, Scott Quarrier1
1University of Rochester
Presented By: Rajat Jain, MD
Introduction: Stone‐free status (SF) is considered important to achieve in percutaneous nephrolithotomy (PCNL), as it may affect risk for unplanned stone procedures. PCNL literature has traditionally defined SF to be < 2 mm on post‐op CT scan. However, we know from URS studies that the reoperation rate can be as high as 17% within 1 year. We analyzed whether being truly SF with a post‐op stone burden of 0 mm confers a lower risk of unplanned stone procedure following PCNL.
Methods: We performed a retrospective review of adults undergoing PCNL by a single surgeon between 10/11/2018 and 7/7/2022. Patients underwent PCNL in the prone split‐leg position with endoscopic‐guided access, using a 24 Fr access sheath. A post‐op day 1 CT (POD1 CT) was routinely performed. Exclusion criteria included no POD1 CT, planned secondary procedure intraoperatively or after POD1 CT, known residual stones with no plans to treat, and patients undergoing PCNL with a pre‐op CT scan over 1 year old. Stone burden was defined as the sum of the longest dimensions of all stones or fragments. Patients were classified as SF if there were no residual fragments identified. Univariate and multivariate logistic regression was performed.
Results: We identified 209 subjects undergoing PCNL. 130 of them were included (51.5% female, mean BMI 31.2, mean age 59.8). 45 patients were excluded due to no POD1 CT, 22 due to planned secondary procedure, and 12 for other reasons. The median preop stone burden was 34.45 mm (IQR 23.8‐52.65). 38 patients (29.2%) were SF. 50 patients (38.5%) would be considered SF by the 2 mm cutoff. The median post‐ op stone burden was 3.5 mm (IQR 0‐7.7), and median size of largest residual stone fragment was 2.3 mm (IQR 0‐4.1). At a median follow up period of 23 months (IQR 14‐31), there were 3 (7.9%) and 13 (14.1%) patients who underwent unplanned secondary procedures in the SF and residual stone groups, respectively. However, this was not statistically significant (OR = 1.48, p = 0.66). Median length of time to secondary procedure was 15 months (IQR 12‐18.25).
Conclusions: There is a very low rate of unplanned secondary procedures following PCNL at a median follow up time of 23 months, suggesting that small residual stone burden does not negatively impact the patient in this time frame. Being completely SF may be important with longer follow up, but more data is needed to confirm this.
Funding: None
Comparison of Fluoroscopic Radiation Exposure Between Standard, Mini, and Ultramini Percutaneous Nephrolithotomy
T. Max Shelton1, Nicole Jansen1, Christoper Schorr1, Peyton Robinson1, RJ Caras1, Austen Slade1, Marcelino Rivera1
1Indiana University School of Medicine
Presented By: T. Max Shelton
Introduction: Advances in endoscopic technology have broadened surgical treatment options for patients with large renal stone burdens. In addition to standard percutaneous nephrolithotomy (PNL), more minimally invasive approaches with mini (MPL) and ultra mini PCNL (UPL) have gained favor. This study evaluates differences in intraoperative fluoroscopic radiation exposure between these three procedures in a retrospective single institution analysis.
Methods: A retrospective review of a all MPL and UPL procedures performed at a single institution between January 2021 and January 2023 was performed. Bilateral surgeries and cases performed with ultrasound guidance or incomplete fluoroscopy records were excluded. In total, 36 MPL and 10 UPL cases were identified. An additional 36 age and gender matched PNL patients were also identified within this same period. Radiation exposure was compared between all 3 procedures using two‐tailed T‐tests.
Results: Among the age and gender‐matched cohort, no significant difference was noted between the average radiation exposure in SPL 69.8 mGy, MPL 90.6 mGy, and UPL 48.8 mGy (p = 0.5622). Although there were marked differences in exposure averages—wide variations in standard deviation limited significance. There were no statistically significant differences in patient BMI or case duration between the procedures.
Conclusions: There appears to be no difference in radiation exposure between SPL, MPL, and UPL in this retrospective cohort. Future prospective studies focusing on procedural radiation exposure are warranted to evaluate for comparison among these techniques.
Funding: None
Shockpulse vs Holmium Laser in Mini‐Percutaneous Nephrolithotomy
Jonathan Wagmaister1, Jonathatn Wagmaister1, Nicola Mabjeesh1, Muhammad Jabareen1, Rabea Moed1, Basel Abu Ganem1, Aviad Korman1
1Soroka University Medical Center
Presented By: Jonathan Wagmaister, MD
Introduction: Percutaneous Nephrolithotomy (PCNL) is the Gold Standard treatment for large renal stones. During the last few years, miniaturized PCNL has gained popularity, being Holmium Laser (HL) most used for stone treatment, while small‐bore ballistic and ultrasonic lithotripters are thought to be less effective. Still, it is unclear which method is more effective for lithotripsy and if stone composition can affect the choice of one modality over the other. We thought of conducting a comparative study that may aid in optimizing lithotripsy modality choice according to the expected stone composition.
Methods: This retrospective study included charts review of patients aged 18 years and above who underwent mini‐PCNL for removal of kidney stones using either 100‐w HL or 1.83 mm Shockpulse SE (SP) (Olympus®) between 01/01/2019 and 08/01/2021. Patients with renal anatomical variations, those who underwent surgery using both the SP and the HL methods during the same procedure, and patients under the age of 18 were excluded. Statistical analyses were performed, including the χ^2 test, Fisher‐Exact test, Mann‐ Whitney non‐parametric test, and logistic regression.
Results: This study involved 74 participants, 29 in the SP group and 45 in the HL group. There was no significant differences in baseline and demographic data between the groups, including stone burden, staghorn and stone density measured by Hounsfield Units (HU). The SP group had a significantly higher stone‐free rate (96.6% vs. 75%, p = 0.034) and less stone residue on average (0.27 vs. 0.86) (p = 0.051) than the HL group. The SP group also had a lower percentage of basket usage compared to the HL group (64.3% vs. 84.4%) (p = 0.048). No significant difference was observed in terms of duration of surgery, length of hospitalization, hemoglobin drop, need for blood products or complications. Stones exhibiting HU values below 1000 displayed a 9.6‐fold higher likelihood of achieving stone‐free status in the Shockpulse group compared to the Holmium laser group (OR: 1.002, 95% CI: 1.002‐91.964, p = 0.05). Conversely, no significant disparity was observed between the two treatments for stones with HU per‐CT values above 1000.
Conclusions: According to our study, the mini‐SP was shown to be more effective than Holmium laser in achieving stone‐free status and reducing the need for basket usage during urinary stone removal in mini‐ PCNL, especially for non‐calcium stones with Hounsfield units below 1000. Further research is necessary to fully determine the effectiveness of these modalities in mini‐PCNL.
The Dynamic Patient Experience of Pain and Ability to Work after Ureteroscopy and Stenting
Russell Becker2, John Michael Dibianco1, Golena Fernandez Moncaleano2, Andrew Higgins2, Eduardo Kleer3, David Leavitt4, Andre King5, Naveen Kachroo4, Sami Majdalany4, David Gandham2, Bronson Conrado2, Stephanie Daignault‐Newton2, Casey Dauw2, Khurshid Ghani2
1University of Florida, 2University of Michigan Medicine, 3IHA Urology, 4Henry Ford Health System
5Chelsea Hospital Urology
Presented By: Russell Becker, MD PhD
Introduction: Ureteral stents can cause significant patient discomfort, yet the temporal dynamics of symptoms and impact on social activities remain poorly characterized. We employed an automated text message tool to collect daily ecological momentary assessments (EMA) following ureteroscopy with stenting regarding pain and ability to work. Our aim was to assess the feasibility of capturing EMA data, and better characterize the postoperative patient experience.
Methods: As an exploratory endpoint within an ongoing pragmatic clinical trial (NCT05026710), patients undergoing ureteroscopy and stone intervention with stenting (without a tether) were asked to complete daily EMAs for 10 days postoperatively, or until the stent was removed, whichever was longer. Stents were removed in the office. Questionnaires were distributed via text message and included a numeric pain scale (0‐ 10) and a single item from the validated PROMIS Ability to Participate in Social Roles and Activities instrument, as well as days missed from work or school. Responses from postoperative day (POD) 1 through the day of stent removal (up to POD10) were analyzed for the first 59 participants in EMAs.
Results: Median patient age was 58 years (interquartile range [IQR] 50‐67), 56% were female. Stones were 54% renal and 46% ureteric, with median stone diameter 9 mm (IQR 7‐10). Median stent dwell time was 7 days (IQR 6‐8). Pain scores were highest on POD1 (median score 4/10) and declined with each subsequent day, reaching median score 2/10 on POD5. 63% of patients on POD1 reported they had trouble performing their usual work at least sometimes, but by POD5 this was < 50% of patients. Patients who work or attend school reported a median of 1 day missed (IQR 0‐2).
Conclusions: An automated daily text message EMA system for capturing patient reported outcomes was demonstrated to be feasible with sustained excellent engagement. Patients with stents reported the worst pain and interference with work on POD1 with steady improvements thereafter, and by POD5 the majority of patients had minimal pain or trouble performing their usual work.
Funding: MUSIC is funded by Blue Cross Blue Shield of Michigan.NCT05026710 is funded by Coloplast.
Which Stone Fragments are Left Behind after Ureteroscopy? An in Vitro Model
Bingyuan Yang2, Aditi Ray1, James Zhang1, Ben Turney2
1Boston Scientific Corporation, 2University of Oxford
Presented By: Bingyuan Yang, MB BChir
Introduction: Residual stone dust and fragments following ureteroscopy are a problem for clinicians and patients. They are thought to contribute to lower stone‐free rates and higher rates of recurrence. There is little evidence on the effectiveness of intraoperative irrigation in removing these fragments. Furthermore, opinion is divided as to whether all stone fragments should be extracted surgically, or whether fine particles may be left to wash out of the kidney naturally. We present an in vitro model using canine urinary stone investigating the effectiveness of ureteroscopic irrigation at evacuating stone fragments of known size.
Methods: Stone dust was produced from canine struvite stone using a Ho:YAG laser at 2J 30Hz. This dust was then wet sieved into fractions consisting of particles of < 63um, 63‐125um, 125‐250um, 250‐500um, 500‐1000um and 1000‐2000um. Equal dry masses of each fraction were combined to form 0.5g of dry uniform stone dust mix.The uniform stone dust was introduced into the mid‐pole calyx of an anatomical kidney and ureter model (Pulse Medical Demonstration Models, USA). The model was filled with water and placed supine, and a single‐use digital flexible ureteroscope (LithoVue, Boston Scientific Corp, USA) introduced to the kidney and aimed towards the dust. The dust was irrigated via the scope for 30 minutes at 15 ml/min using a pump, after which the model was brought into a vertical position. All remaining particles in the model after this final manoeuvre were deemed to be residual. These residual particles were collected and wet sieved to categorise them by size.
Results: Particles of size > 250um predominantly remained in the kidney, with 83‐88% of these particles remaining after irrigation. Particles < 250um washed out more effectively but 40‐48% of these particles still remained after irrigation.
Conclusions: The size of particles has a major impact on the effectiveness of irrigation, with a sharp contrast above and below 250um. Despite 30 minutes of targeted irrigation at clinically representative rates, over 83% of particles > 250um remained in the kidney. The size and large number of these particles would make them both technically challenging and extremely time‐consuming to extract clinically using a stone basket.
Further work will be done to investigate the effect of irrigation rate and duration on particle washout.Disclaimer: Bench test results may not necessarily be indicative of clinical performance.
Funding: Boston Scientific Corporation: research grant
Initial Clinical Experience with the Pulsed Solid‐State Thulium YAG Laser from Dornier : First 25 Cases
Frederic Panthier8, Catalina Solano1, Marie Chicaud2, Stessy Kutchukian3, Luigi Candela4, Steeve Doizi5, Mariela Corrales6, Olivier Traxer7
11 GRC n°20, Groupe de Recherche Clinique sur la Lithiase Urinaire, Hôpital Tenon, Sorbonne Université, 75020, Paris, France. 2 Service d'Urologie, Assistance‐Publique Hôpitaux de Paris, Hôpital Tenon, Sorbonne Université, 4 rue de la Chine, 75020, Paris, France. 4Department of endourology, Uroclin SAS Medellin, Colombia, 21 GRC n°20, Groupe de Recherche Clinique sur la Lithiase Urinaire, Hôpital Tenon, Sorbonne Université, 75020, Paris, France. 2 Service d'Urologie, Assistance‐Publique Hôpitaux de Paris, Hôpital Tenon, Sorbonne Université, 4 rue de la Chine, 75020, Paris, France. 3 PIMM, UMR 8006 CNRS‐ Arts et Métiers ParisTech, 151 bd de l'Hôpital, F‐75013 Paris, France 4Service d'Urologie, CHU Limoges, 31 GRC n°20, Groupe de Recherche Clinique sur la Lithiase Urinaire, Hôpital Tenon, Sorbonne Université, 75020, Paris, France. 2 Service d'Urologie, Assistance‐Publique Hôpitaux de Paris, Hôpital Tenon, Sorbonne Université, 4 rue de la Chine, 75020, Paris, France. 3 PIMM, UMR 8006 CNRS‐Arts et Métiers ParisTech, 151 bd de l'Hôpital, F‐75013 Paris, France 5 Department of Urology, Poitiers University Hospital, 2 Rue de la Milétrie, 86000 Poitiers, France, 41 GRC n°20, Groupe de Recherche Clinique sur la Lithiase Urinaire, Hôpital Tenon, Sorbonne Université, 75020, Paris, France. 2 Service d'Urologie, Assistance‐Publique Hôpitaux de Paris, Hôpital Tenon, Sorbonne Université, 4 rue de la Chine, 75020, Paris, France. 7Division of experimental oncology/unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy; Vital‐Salute San Raffaele University, Milan, Italy, 51 GRC n°20, Groupe de Recherche Clinique sur la Lithiase Urinaire, Hôpital Tenon, Sorbonne Université, 75020, Paris, France. 2 Service d'Urologie, Assistance‐Publique Hôpitaux de Paris, Hôpital Tenon, Sorbonne Université, 4 rue de la Chine, 75020, Paris, France. 3 PIMM, UMR 8006 CNRS‐Arts et Métiers ParisTech, 151 bd de l'Hôpital, F‐75013 Paris, France, 61GRC n°20, Groupe de Recherche Clinique sur la Lithiase Urinaire, Hôpital Tenon, Sorbonne Université, 75020, Paris, France. 2Service d'Urologie, Assistance‐Publique Hôpitaux de Paris, Hôpital Tenon, Sorbonne Université, 4 rue de la Chine, 75020, Paris, France., 71 GRC n°20, Groupe de Recherche Clinique sur la Lithiase Urinaire, Hôpital Tenon, Sorbonne Université, 75020, Paris, France. 2 Service d'Urologie, Assistance‐Publique Hôpitaux de Paris, Hôpital Tenon, Sorbonne Université, 4 rue de la Chine, 75020, Paris, France., 8Tenon Hospital, APHP‐Sorbonne University
Presented By: Frederic Panthier, MD, MSc
Introduction: Holmium:yttrium‐aluminium‐garnet(Ho:YAG) and Thulium Fiber(TFL) lasers are currently the two laser sources recommended for endocorporeal laser lithotripsy. Recently, the pulsed‐ Thulium:YAG(Tm:YAG) laser was proposed for ELL, answering to both Ho:YAG and TFL limitations. We aimed to evaluate Tm:YAG in terms of efficiency, safety, and laser settings in laser lithotripsy during retrograde intrarenal surgery (RIRS).
Results: A total of 25 patients were analyzed(Table 1). The median(IQR) age was 55(44‐72)years old. Median(IQR) stone volume was 2849(916‐9153)mm3. Median (IQR) stone density was 1000(600‐1174)HU. Median (IQR) pulse energy, pulse rate and total power were 0.6(0.6‐0,8)J, 15(15‐20)Hz and 12(9‐16)W, respectively. All procedures used “Captive Fragmenting” pulse modulation(Table 2). The median(IQR) J/mm3was 14,8(6‐21). The median(IQR) ablation rate was 0,75(0,46‐2)mm3/s. One postoperative complications occurred(streinstrasse). SFR and ZFR were 95% and 55%, respectively.
Conclusions: We reported the first clinical experience with pulsed‐Tm:YAG, as a safe and effective laser source for lithotripsy during RIRS, using low pulse energy and low pulse frequency, and “Captive Fragmenting” mode as preferred settings. Further comparative studies are required to define its place in the laser sources pipeline.
Funding: None
WITHDRAWN
Comparative Analysis of TFL, Ho:YAG, and pTm:YAG Lasers in Dusting Lithotripsy: In Vitro Study
Catalina Solano1, FréDeric Panthier1, Marie Chicaud2, Luigi Candela3, Mariela Corrales1, Olivier Traxer4
1GRC n20, Groupe de Recherche Clinique sur la Lithiase Urinaire, Hôpital Tenon, Sorbonne Université, 2Department of Urology, Limoges University Hospital, 3Division of Experimental Oncology/Unit of Urology, URI‐Urological Research Institute IRCCS Ospedale San Raffaele, 4GRC n20, Groupe de Recherche Clinique sur la Lithiase Urinaire, Hôpital Tenon, Sorbonne Université, Service d'Urologie, Assistance‐Publique Hôpitaux de Paris, Hôpital Tenon, Sorbonne Université,
Presented By: Catalina Solano, MD
Introduction: In this study, our aim was to compare the efficiency of the thulium fiber laser (TFL), the holmium: yttrium–aluminum–garnet (Ho:YAG) laser, and the pulsed thulium:yttrium aluminum garnet laser (pTm: YAG) by evaluating the stone mass loss after lithotripsy using different lasers on BegoStones and human stones in an in vitro model.
Methods: We utilized a Ho:YAG laser (30 W; Rocamed), a TFL Drive (60W; Coloplast), and a pTm:YAG (100 W; THULIO Dornier) for our experiments. The laser parameters for TFL were set as follows: (10 W = 0.5 J x 20 Hz; short pulse). For Ho:YAG, we used (10 W = 0.5 J x 20 Hz), employing both short and long pulses. pTm:YAG was set at (12.5 W = 0.6 J x 20 Hz, long pulse and 0.5 J x 25Hz dusting). We performed contact lithotripsy on phantoms (BegoStones) and human stones with different compositions, including uric acid (UA) and calcium oxalate monohydrate (COM) in water environments. Laser ablation was carried out with a total energy of 3000 J. Mass loss was determined by calculating the difference between the initial phantom mass and the final ablated phantom mass for both phantoms and human stones.
Results: The median mass loss for TFL laser configurations was 22 mg for uric acid (UA) stones and 36 mg for calcium oxalate monohydrate (COM) stones. For Ho:YAG, the median mass loss was 10 mg for UA stones and 24 mg for COM stones, while for p‐Tm:YAG, it was 25 mg for UA stones and 24 mg for COM stones. Statistical analysis revealed a significant difference in ablated weight between TFL and Tm:YAG laser devices (p‐value = 0.03) for UA stones (88 mg vs. 50 mg), whereas no significant difference was observed between Ho:YAG and TFL, or Ho:YAG and pTm:YAG lasers.
Conclusions: In our in vitro study, employing dusting settings, TFL lithotripsy demonstrated higher efficiency in terms of achieving greater mass loss compared to Ho:YAG and pTm:YAG lithotripsy.
Funding: none
Mirabegron versus Tamsulosin Comparison for Sexual and Urinary Catheter‐Related Symptoms After Ureteroscopy (URS) for Urinary Stones – a Prospective Study
Ana Sofia Araújo1, Ricardo Rodrigues1, Catarina Tinoco1, Andreia Cardoso1, Mariana Capinha1, Luís Pinto1, Paulo Mota1, Carlos Oliveira1, João Torres1, Sara Anacleto1, Jorge Ribeiro1, Emanuel Dias1, Miguel Mendes1, Mário Alves1, Vera Marques1
1Hospital de Braga
Presented By: Ana Sofia Araújo, MD
Introduction: Routine stenting after URS is not recommended but may be necessary and might increase postoperative morbidity and costs. Although no drugs have been licensed for this use, alpha‐blockers can improve catheter tolerability. Mirabegron is a beta‐3 adrenergic agonist approved for overactive bladder. Thus, we aim tocompare mirabegron with tamsulosin for sexual and urinary catheter‐related complaints after URS with double‐J catheter placement.
Methods: We conducted a prospective single‐center study including 108 patients who underwent URS with double‐J catheter placement and took tamsulosin or mirabegron between November 2022 and April 2023. Four validated questionnaires ‐International Consultation Incontinence Questionnaire Female Lower Urinary Tract Symptoms (ICIQ‐FLUTS), Female Sexual Function Index (FSFI), ICIQ‐Male LUTS (MLUTS), International Index of Erectile Function (IIEF‐5) and one subjective questionnaire were used. Statistical analysis was done with IBM®SPSS®, version 27.0.
Results: A total of 55 patients received mirabegron and 53 tamsulosin, including 55 women and 53 men.Patient and surgery aspects as well as median time to catheter removal were not statistically different between drugs for women and men (all p > 0.05). There were no differences in FLUTS/MLUTS dimensions (filling, voiding, incontinence), FLUTS/MLUTS total score, and bother between drugs. However, median bother and total scores were higher in the tamsulosin group (FLUTS‐bother 47.0 vs 20.0 p = 0.156and FLUTS total score 20.0 vs 12.0p = 0.407; MLUTS‐bother 22.0 vs 18.5 p = 0.993 and MLUTS total score 8.0 vs 7.0p = 0.838). Women's median FSFI total score was 2.0 in both drug groups, indicating that the majority didn't have sexual intercourse. In men, about 1/3 of patients in both drug groups also didn't try it. Of those who attempted, there were no differences (p = 0.868) but mirabegron had a higher prevalence of no erectile dysfunction (ED) (34.6% vs 33.3%), and tamsulosin had a higher prevalence of some ED (33.3% vs 26.9%). The subjective questionnaire showed that although mirabegron patients reported more lumbar and suprapubic discomfort (67.3% vs 60.4% p = 0.456, 65.5% vs 60.4% p = 0.585 respectively), tamsulosin patients experienced more dysuria (30.2% vs 23.6% p = 0.514) and haematuria (9.4% vs 5.5% p = 0.806).
Conclusions: We conclude that mirabegron was not statistically distinct from tamsulosin in improving sexual and urinary catheter‐related symptoms; in fact, in some variables, mirabegron has better results than tamsulosin.
Funding: None
As Time Goes by. Changing the Lithotripsy into an Outpatient Surgery Room
Alejandro García Sánchez2, Carmen Arai Valladares Ferreiro1, Pedro Blasco Hernández2
1Hospital Virgen e Valme, 2Hospital Virgen de Valme
Presented By: Alejandro García Sánchez, MD
Introduction: Since we introduced lithotripsy in our unit in 1986 (first public health service lithotripsy in Spain) treatment paradigm of lithiasis has changed, decreasing number of cases treated with lithotripsy with an increase of cases solved endoscopically.We present our experience in the surgical treatment of lithiasis in the Lithotripsy room of our center.Our main objective is to evaluate the results after the procedures, complications rate, needing of second surgical time and the hospital stay.
Methods: We retrospectively analyzed 181 procedures performed between March 2016 and November 2022, including retrograde intrarenal surgery (RIRS)and ureteroscopy (URS). Variables analyzed were age, history of lithiasis, type of surgery, laterality and lithiasis location, hardness and previous urinary diversion, lithiasis‐ free rate, complications, needing of a second surgical time and hospital stay.
Results: Mean age was 53 years. 65% had a history of lithiasis: 21 (11.6%) previous endoscopic lithiasis surgery. 66.8% were classified as ASA II, followed by ASA III. No ASA IV were included.181 interventions were performed. 134 URS (74%), 44 RIRS (24.3%) and 3 combined surgeries: Lithiasis in distal ureter (51.4%), proximal ureteral stones (12.7%). In 2018, 21% were RIRS and 79% URS. In 2022, RIRS and URS were 43% and 55.4%, respectively.That means increasing complexity of cases treated. Bilateral lithiasis accounted for 3%. Mean lithiasis size and hardness varied between successive years. 48 patients required preoperative ureteral catheterization. 95.6 % of the procedures were completed in their entirety in one time, while in 8 cases surgery was not completed due to ureteral or meatal strictures. 97% of the patients underwent some complementary test to evaluate the lithiasis‐free rate. Computed tomography was the most frequently performed.155 patients (85.6%) were free of lithiasis (no lithiasis in radiography or lithiasis remnant < 3 mm in tomography) after the first procedure. 17 patients required a second procedure. We achieved a total lithiasis‐free rate of 95%.Complications appeared in 12 cases (6.6%). 5 grade IIIb of Clavien Dindo. There was no mortality associated.181 patients meant performing 17% of lithiasis procedures in 2022 in major ambulatory surgery environment and 12.5% in 2018.
Conclusions: Using lithotripsy room in the surgical treatment of urinary lithiasis is safe, effective, and efficient. Our experience has allowed us to increase the number of combined surgeries performed a year, increasing complexity with an adequate lithiasis‐free rate and a low percentage of complications.
Funding: .
Ureteroscopy with CVAC Aspiration System for the Surgical Management of Large Renal Stones
Mouneeb Choudry1, Victoria Edmonds1, Daniel Heidenberg1, Kevin Wymer1, Benjamin Borgert2, Karen Stern1, Stuart Wolf Jr.3
1Mayo Clinic Arizona, 2Florida State University School of Medicine, 3The University of Texas at Austin
Presented By: Mouneeb Choudry, MD
Introduction: The surgical management of large stone burdens is a challenge which often necessitates staged ureteroscopy or a more invasive percutaneous nephrolithotomy. The CVAC Aspiration System is a novel, steerable catheter using irrigation and aspiration to evacuate stone debris after laser lithotripsy. Our study aims to evaluate the effectiveness of CVAC for treating large renal stones and, in particular, the effectiveness of CVAC in treating complex patients.
Methods: A retrospective, multi‐institutional review was performed on patients from 2 major urologic centers with stones larger than 10 mm who underwent ureteroscopy with laser lithotripsy and CVAC outside of an ongoing randomized clinical trial. A sub‐analysis was performed on all patients on active anticoagulation at the time of surgery and patients with neurologic conditions significantly limiting mobility (cerebral palsy, muscular dystrophy, spina bifida, quadriplegia). Categorical variables were summarized using relative frequencies and percentages. Continuous variables were summarized using mean ± standard deviation, median, and minimum and maximum.
Results: 43 patients underwent the procedure. Mean pre‐operative stone burden was 29 ± 12 mm and mean stone volume 3092 ± 5002 mm3. 24 patients had CT imaging at follow‐up, and of those, up 33.3% (8) had no residual stone, 91.7% (22) had > 90% stone volume removed, 95.8% (23) had > 80% removed and 100% (24) had > 60% removed.Mean stone volume reduction based on baseline stone burden varied between 93.8% and 98.9%.21 patients were anticipated pre‐operatively to need a secondary procedure. Of those, only 2 (9.5%) required a secondary procedure. 22 patients were deemed high‐risk, 12 on anticoagulation or antiplatelet therapy and 10 with neurologic conditions. There was a 97% stone volume reduction in the anticoagulated cohort with postoperative CT imaging and an 83% stone volume reduction in the neurologic condition cohort with CT imaging. There were no complications secondary to the device and no post‐operative admissions.
Conclusions: CVAC is a safe and effective procedure for large stone burdens, especially in high‐risk patients, and should be considered to avoid the morbidity associated with repeat ureteroscopy or PCNL.
Funding: Calyxo, inc.
To Stent or Not to Stent – Is it Really a Question?
Rami Ludyansky1, Conner C. Brone1, Amitay Lorber1, Mordechai Duvdevani1
1Hadassah University Hospital
Presented By: Rami Ludyansky, MD
Introduction: Ureteroscopy (URS) has emerged as a valuable minimally invasive technique in urology, especially for the management of stone disease. The optimization of surgical outcomes and the reduction of post‐operative complications remain ongoing challenges. Double‐J stenting (DJS) after URS is still debated, however its use is considered mandatory by many in order to prevent postoperative pain or infection due to an obstruction in the form of residual fragments or edema. A counterargument to routine post‐operative stenting is the affect it can have on the patient's quality of life in the form of LUTS, hematuria, and social/sexual repercussions. Stent migration, encrustation, pyelonephritis, and retained stent can occur after stent placement. In this study, we aim to evaluate prestenting as factor affecting the success of URS.
Methods: Patients who underwent URS were evaluated retrospectively. Age, stone size, stone localization, Hounsfield Unit (HU), stone‐free rate (SFR) and complications (total, fever, acute kidney failure AKF, steinstrasse) were evaluated.
Results: We analyzed 2068 patients treated with URS between October 2013 and January 2023 – these patients were split into two groups: those who had a stent inserted and those who were tubeless post‐ operatively. A comparison of showed that 2.42% of patients experienced complications in the stent group, compared to 1.47% in non‐stented group, indicating a 64% high rate of complications in the stented group. Post‐operative fever was significantly higher in stented patients, 2.17%, compared to only 0.6% in non‐ stented patients (a tubeless procedure), representing a 249% difference. Additionally, we found no incidences of steinstrasse in the stent group and 0.78% in the non‐stent group, representing a 100% higher risk in the non‐stent group. The occurrence of post‐acute renal failure (ARF) was explored, with 0.5% of stented patients developing post‐ARF compared to 1% in non‐stented patients, a 49% difference. Finally, we analyzed stone‐free rates and found that 25% of stented patients achieved a stone‐free status following URS, compared to 30% in non‐stented patients, representing a 15% difference.
Conclusions: An understanding of how routine peri‐URS stenting affects post‐operative complications, fever, ARF, steinstrasse formation, and stone‐free rates can help refine surgical decision‐making and guide the development of personalized approaches to enhance patient outcomes. Ultimately, this research has significant implications for improving the effectiveness and safety of future surgical procedures in urology, leading to enhanced patient care and better treatment outcomes.
Funding: Hadassah University Hospital
Can Failure to Insert a Ureteral Access Sheath During Ureteroscopy for Unstented Patients be Predicted Using a Non Contrast Computed Tomography?
Sobhi Khoury1, Ilan Klein1, Mohammad Ali1, Mohammad Shalabi1, Yuval Freifeld1, Rani Zreik1, Maharan Kabha1, Gazi Fares1, Natalia Goldberg1, Yoram Dekel1
1Carmel Medical Center, Haifa, Israel
Presented By: Sobhi Khoury, MD
Introduction: Ureteral access sheath (UAS) has become an invaluabletool inretrograde intrarenal surgery (RIRS). However it's insertion may sometimes fail, usually due to a tight ureter. We aimedto assess whether UAS insertion failure can be predicated based on ureteral diameter measured on non‐contrast computerized tomography (NCCT) and to identify demographic, clinical, and operative risk factors associated with failure.
Methods: This is a single centre retrospective study, the study group included all previously unstented patients who underwent primary RIRS with failure of UAS insertion between 2017 and 2022and agroup of randomly selected patients with successful UAS insertion. Demographic and clinical data were collected, as well as radiographic characteristics, operative data and complications. Ureteral diameter was measured by a single radiologist at predefined points on axial NCCT images.
Results: There were 33 consecutivecases of UAS insertion failure included in the study,and 71 successful cases that were randomly selected. No statistically significant differences were found regarding age, sex, BMI and previous history of ipsilateral procedures between the groups. The ureteral diameterat thecrossinglevel of the iliac vessels and the ureterovesical junction (UVJ)was significantly smaller in the study group (p = 0.02), with cut‐off values of 4 mm at the level of theiliac vessels(88 % sensitivity and 62% specificity) and 3 mm at theUVJ level (84 % sensitivity and 58% specificity).
Conclusions: Measuring the ureteral diameter on NCCT at thecrossinglevel of the iliac vessels and the UVJ can indicate failure in UAS insertion during ureteroscopy for unstented patients.
Funding: None
Clinical Evaluation of Operative Planning Software for Stone Surgeries: “Kidney Stone Calculator” with the Thulium Fiber Laser, Comparison with the Holmium:YAG Laser (KSC‐2 Study)
1Service d'urologie, CHU Poitiers, 2Service d'Urologie, Assistance‐Publique Hôpitaux de Paris, Hôpital Européen George Pompidou, 3PIMM, UMR 8006 CNRS‐Arts et Métiers ParisTech, 4Service d'urologie, Hôpital Foch, 5Service d'Urologie, Hôpital Foch, 6Service d'urologie, APHP, Hôpital Tenon, 7Division of experimental oncology/unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy; Vital‐Salute San Raffaele University, 8Service d'Urologie, CHU de Limoges, 9Service d'urologie, CHU Limoges
Presented By: Marie Chicaud, MD
Introduction: Kidney Stone Calculator (KSC) is a free software that estimates the duration of endocorporeal laser lithotripsy (ELL) during flexible ureteroscopy (fURS), based on the stone volume. This tool has been previously clinically evaluated with Holmium:YAG (Ho:YAG). We aimed to evaluate the clinical performances of KSC withThulium Fiber Laser (TFL) and to compare these results with those obtained with Ho:YAG.
Methods: This prospective multicenter clinical study included patients with kidney and ureter stones treated by fURS with ELL and preoperative non‐contrast computed tomography(NCCT), in 4 centers, between January 2020 and April 2023. Demographic, urolithiasis and peri‐operative data were prospectively collected. The correlations between estimated and effective ELL durations overall then according to the laser source(LS) were calculated. Univariate and multivariate analyzes on the pre‐(volume, location, stone density, presence of anatomical anomaly) and per‐operative (laser adjustment, operator level, relocation, use of a basket) criteria were then carried out according to the LS.
Results: A total of 89 patients were included (Ho:YAG; TFL). The groups were comparable except for presence of urolithiasis pathology, anatomical abnormalities, kidney stones location and previous surgical urolithiasis history (Table 1). A significant correlation (r = +0.89) between estimated and effective ELL durations was found overall(p < 0.001), and within the two groups (TFL: r = +0.95, p < 0.001; Ho:YAG = r = +0.81,p < 0.001). Mean efficiency and ablation rates were 18.22 and 15.68J/mm3 and 0.71 and 0.53mm3/s for TFL and Ho:YAG, respectively (Table 2). In multivariate analysis, the difference between estimated and effective ELL durations was influenced by preoperative criteria (volume > 2000mm3 for Ho:YAG, volumes (500‐750mm3) and calicial diverticula for TFL) and on operative criteria (fragmentation setting (p > 0.001) and use of a basket (p = 0.05) for Ho:YAG, no factor found for TFL).
Conclusions: Kidney Stone Calculator is a reliable tool for ELL estimation for both TFL and Ho:YAG. Various criteria, which differ depending on the LS, can lead to underestimating the effective duration of ELL (volume > 2000mm3, use of a basket, fragmentation setting for Ho:YAG and volumes (500‐750mm3) and calicial diverticula for TFL).
Funding: None
Success Rate of Ureteral Access Sheath Insertion During Primary Retrograde Intrarenal Surgery ‐ A Retrospective Asian Cohort Analysis
Yadong Lu1, Jeremy Tay1
1Singapore General Hospital
Presented By: Yadong Lu, MD
Introduction: Ureteral access sheath (UAS) has definite advantage during Retrograde Intrarenal Surgery (RIRS) but cannot be deployed in all cases at first instance. We retrospectively analysed the success rate of UAS insertion during primary RIRS.
Methods: All procedures with RIRS code performed in Singapore General Hospital in 2016 were screened. Only primary RIRS performed for renal/PUJ stones (with no prior instrumentation) were included in the final analysis. All secondary procedure and treatment/surveillance for upper tract tumors were excluded. Insertion rate and factors affecting UAS insertion were studied using Chi square and binary logistic regression analysis.
Results: 138 cases were screened and 73 met inclusion criteria. Mean age was 54.5 ± 13.1 years. Mean operative time was 81.4 ± 34.1 min. The success rate of UAS insertion during primary RIRS was 63% (46/73), of which 93.5% (43/46) used 11/13F UAS, 4.3% (2/46) used 10/12F and 2.2% (1/46) used 9/11F. Those who failed UAS insertion, 77.8% (21/27) were stented with 6F double‐J. 22.2% (6/27) were stented with 7F double‐J. Stone free rate in primary successful insertion group were 52% (24/46) while it was 44% (12/27) in the stented group with subsequent RIRS. No preoperative factors (age, gender, race, BMI, stone location, and stone number) were associated with increased rate of successful insertion of UAS in logistic regression analysis.
Conclusions: The success rate of UAS insertion during primary RIRS was 63% in this cohort. Our efforts to increase this rate (e.g. preoperative tamsulosin) in randomized controlled trials are awaited.
Funding: NA
Repeated Manual Bolus Irrigation Leads to Critical Intrarenal Pressures During Ureteroscopy
Anne Hong1, Greg Jack1, Cliodhna Browne1, Damien Bolton1
1Austin Health
Presented By: Anne Hong, MD
Introduction: Uretero‐renoscopy has become the dominant method of managing urolithiasis. Various methods of irrigation can be utilized to maintain clear views. One such method is the manual bolus irrigation, whereby a bolus of fluid is delivered from a chamber or syringe in the irrigation system. Raised intrarenal pressures (IRPs) will logically ensue from such fluid instillation, and this is of concern due to associated post‐ operative complications. Deaths have been reported as a consequence of sepsis related to uretero‐renoscopy. We aim to characterize the fluctuations and maximal IRPs produced by manual bolus irrigation used during uretero‐renoscopy.
Methods: A pressure guidewire was used for IRP measurement during routine flexible uretero‐renoscopy, including manual bolus irrigation when required to maintain vision. The fluid bolus was either as a single manual bolus or a series of manual boluses in quick succession. The baseline IRPs, maximal IRPs and the difference between the two were calculated.
Results: 10 procedures in 9 patients were analyzed. 20 single manual boluses were observed. The median baseline IRP was 31.23mmHg, the median rise in IRP was 28.79mmHg, and the median maximal IRP achieved was 50.85mmHg. 24 serial manual boluses were analyzed with the median baseline 39.66mmHg. After serial manual boluses, the median rise in IRP was 64.82mmHg, with the median maximum IRP achieved being 110.5mmHg. These results are summarized in Table 1.
Conclusions: Both single and serial manual bolus irrigation – but particularly serial boluses – produces significant rises in IRPs and could logically result in pyelovenous backflow and sepsis. Our results suggest that this maneuver should be avoided to reduce complications during uretero‐renoscopy.
Funding: The authors received no funding for this project
Comparative Analyses and Ablation Efficacy of Thulium Fiber Laser by Stone Composition
Jeffrey Johnson5, Ojas Shah1, Miyad Movassaghi1, David Han1, Srinath‐Reddi Pingle1, Justin Lee1, James Williams2, Michael Schulster1, Prakash Gorroochurn3, Yinming Shao4, Dmitri Basov4
1Columbia University Irving Medical Center, 2Indiana University School of Medicine, 3Columbia University Department of Biostatistics, 4Columbia University Physics Department, 5Weill Cornell Medicine
Presented By: Jeffrey Johnson, MD
Introduction: There is limited data on ablation effects of thulium fiber laser (TFL) settings with varying stone composition. Little is known surrounding the photothermal effects of TFL lithotripsy regarding the chemical and structural changes with charring. We aim to identify ablation settings that predict optimal ablation efficiency across stone types and to better understand the photothermal effects of TFL lithotripsy.
Results: Across all settings and stone types, 0.05J x 1000Hz was the most efficient ablation setting. When selected for more clinically relevant laser settings (i.e. 10‐20W), 0.2J x 100Hz short pulse (SP) proved the most efficient ablation setting for COD, cystine, and struvite stones, 0.4J x 40Hz SP for COM, 0.3J x 60Hz SP for UA and CA, and 0.5J x 30Hz SP for brushite. Pulse duration impacted ablation effectiveness greatly with 6/8 (75.0%) of inadequate ablations occurring in medium or long pulse settings. The average percent of mass lost after ablation was 56.9%; cystine stones averaged the highest percent mass lost at 70.8%. Charring was observed in 39.5% specimens, most often in UA, cystine, and brushite stones across all laser settings. EM of char demonstrated a porous melting effect different to that of brittle fracture. FTIR spectroscopy of brushite char demonstrated a chemical composition change to amorphous calcium phosphate.
Conclusions: We describe the optimal ablation settings of TFL lithotripsy by stone composition. For patients with unknown stone composition, lasers can be pre‐set to target common stone types. We recommend using short pulse for TFL lithotripsy.
Funding: Coloplast
Prospective Evaluation of Efficacy, Safety, Cumulative Laser Energy, and Stone‐Free Rates in the Post‐Market SOLTIVE™ Superpulsed Laser System Registry: Insights from the T.O.W.E.R.
Research Consortium
Ben H Chew6, Kyochul Koo1, Mitchell R. Humphreys2, Wilson R. Molina3, Bodo E. Knudsen4, Mantu Gupta5, Victor K.F. Wong6, Abdulghafour Halawani7, Peter Kronenberg8, Palle Osther9, Olivier Traxer10
1Yonsei University, 2Mayo Clinic, 3Kansas University, 4Ohio State University, 5Mt. Sinai, 6University of British Columbia, 7King Abdulaziz University, 8KUB, 9University of Southern Denmark, 10Sorbonne Université
Presented By: Ben H Chew, MD, MSc FRCSC
Introduction: Thulium fiber laser (TFL) has emerged as an effective tool for endoscopic laser lithotripsy since its introduction in 2019. In this prospective, international clinical registry, the Endourological Society's T.O.W.E.R. Research Consortium evaluated the ablative performance, stone‐free rates (SFRs), and safety of the first commercially available TFL system, SOLTIVE™ SuperPulsed Laser System (Olympus, Southborough, MA)) in a large patient cohort.
Methods: 413patients undergoing ureteroscopy for ureteral and/or renal stones using the SOLTIVE™ TFL laser were prospectively recruited and treated across eight international institutions between 12/2021‐ 4/2023. Baseline clinical characteristics, intraoperative lithotripsy efficiency, (adverse events, and post‐operative outcomes were collected up to 90 days post‐procedure. Kidney and ureteral stones were analyzed according to stone volume. Adverse events, re‐interventions, and SFRs were assessed at 1 and 3 months.
Results: Laser lithotripsy was performed by dusting, fragmentation, and by combination in 68.1%, 2.5%, 28.3% and 48.3%, 13.6% and 33.9% of kidney and ureteral cases, respectively. The overall SFRs for kidney and ureteral stones were 66% and 80% at 1 month, and 67% and 85% at 3 months. Lower SFRs were observed with the highest quartile energy delivery in both kidney and ureter (p < .001). This also correlated with stone size as larger stones required more energy. Kidney stones > 9.7 mm and ureteral stones > 12.1 mm resulted in lower SFR (p < 0.001). If ≥17.2 kJ of laser energy was used in the kidney and ≥3.39 kJ in the ureter, this resulted in lower SFR (p = 0.001). Across the cohort, the mean ablation rate was 4.2 ± 18.1mm3/s for renal stones (mean 855.6 ± 400.7 HU), and 2.4 ± 6.7 mm3/s for ureteral stones (mean 790.5 ± 358.5 HU). No ureteral perforations occurred across all procedures. Post‐procedure serious adverse events (11) occurred in 2.91% (UTI 5, Sepsis 1, fever 2, pyelonephritis 1, acute kidney injury 1, stricture 2) and 7.02% re‐intervention rates (salvage SWL, URS or PCNL) throughout the 90 day follow‐up period.
Conclusions: The SOLTIVE™ SuperPulsed Laser System is effective in ureteroscopic lithotripsy for stone disease, with low complication and re‐intervention rates and comparable SFRs to Ho:YAG lasers.
Funding: Olympus Medical
Prospective Randomized Double Blind Clinical Trial to Compare Holmium Laser Lithotripsy with and Without Moses Technology for the Ureteroscopic Treatment of Nephrolithiasis
Naren Nimmagadda7, Nicole Miller1, Amy Reed1, Ryan Hsi1, Seth Bechis2, Mitchell Humphreys3, Michael Lipkin4, Manoj Monga2, Ojas Shah5, Karen Stern3, Roger Sur2, Sriharan Sivalingam6
1Vanderbilt University Medical Center, 2University of California San Diego, 3Mayo Clinic Arizona, 4Duke University, 5Columbia University, 6Cleveland Clinic, 7Johns Hopkins University
Presented By: Naren Nimmagadda, MD
Introduction: The clinical impact of Moses pulse‐width modulation in decreasing stone retropulsion and increasing lithotripsy efficiency remain debated. We sought to evaluate the potential of Moses 2.0 pulse‐ width modulation to reduce operative time compared to non‐Moses settings for ureteroscopic treatment of nephrolithiasis.
Methods: In this multi‐institutional, randomized, double‐blind clinical trial, 150 patients were randomized and underwent unilateral ureteroscopy for stones 8‐20mm in size at or above the ureteropelvic junction. Patients were randomized to Moses or Non‐Moses settings. Stones were treated by attending endourologists with standardized dusting settings to maintain blinding. A validated survey (NASA Task Load Index) was completed afterwards. Stents were maintained for 4‐10 days, and CT imaging was obtained 6 weeks postoperatively. The primary outcome was to compare total operative times. Secondary outcomes included blinded measures of stone retropulsion, stone‐free rate, and surgeon workload.
Results: 143 patients were included in the analysis. Demographics and stone characteristics were similar between groups. Moses setting led to shorter ureteroscopy time overall on average, but difference was not statistically significant. Intraoperative outcomes did not reach statistical significance but Moses setting trended towards shorter ureteroscopy time overall (29.5min v 30.7min, p = 0.60761). When stratified for stone size, total stone burden between 8‐12mm demonstrated shorter operative times (‐3.5 min, p = 0.41) compared to longer operative times for stone burden 12‐16mm (+1.0min, p = 0.82583), and 16‐20mm (+9.5min, p = 0.132). Amongst 112 patients reaching 6 week follow‐up, no difference in stone‐free status was seen with and without the Moses setting (42.3% v 38.9%). Surgeons correctly perceived the Moses setting in 57.7% of cases compared to 48.6% of cases without Moses. After using Moses, surgeons experienced less mental burden, physical burden, temporal demand, frustration, and less required effort. Perception of operative performance was higher when using the Moses setting. These findings remained significant on multivariable analysis (Table 1).
Conclusions: No significant differences were seen in total operative time, ureteroscopy time nor stone‐free rate. However, use of Moses settings remained a significant predictor across NASA task load domains after controlling for factors that increase surgeon workload during ureteroscopy.
Funding: This study was funded by a grant from the Endourology Disease Group for Excellence courtesy of Lumenis. Study data were collected and managed using REDCap electronic data capture tools hosted at Vanderbilt University.
Endourology Surgeries. General Anesthetist vs. Specialized Endourology Anesthetist: Does An in‐House Anesthetist Make a Difference?
Eyal Riemer2, Amitay Lorber1, Leonid Boyarsky2, Ofer Gofrit2, Mordechai Duvdevani1
1Hadassah Hospital Jerusalem, Dept. of Urology, Endourology Unit., 2Hadassah Hospital Jerusalem, Dept. of Urology.
Presented By: Eyal Riemer, MD
Introduction: Ureteroscopy for the treatment of urolithiasis is one of the most common procedures in the world of endourology. This study seeks to compare several operating room time measurements between a general anesthetist and aspecialized endourology anesthetist in holmium laser lithotripsy ureteroscopy procedures.
Methods: A retrospective observational study was performed over a database of 2380 ureteroscopy procedures collected since October 2013 by the endourology unit of a single tertiary center. The data was divided into two categories according to the performing anesthetist: procedures performed with a specialized endourology Anesthetist (SA) and procedures performed with a general non‐specialized Anesthetist (GA). The two outcomes analyzed were Total Operation Time (TOT), which was measured from patient intubation to patient extubation, and Surgical Time (ST), which was measured from the beginning of the surgeon's performance to it's end. A secondary outcome measured was the proportion of ST from TOT (PST).Statistical analysis was performed using IBM SPSS version 29.
Results: 2260 procedures were analyzed, 1887 in the SA group and 373 in the GA group. Significant difference was found across all outcomes analyzed.Mean ST was30.07 ± 17.49 minutes for the SA group, vs. 32.40 ± 19.90 minutes in the GA group p_val = 0.018). Mean TOT was 49.89 ± 22.97 minutes for the SA group, vs. 61.85 ± 31.57 minutes in the GA group (p_val < 0.001).Mean PST was 60.17 ± 19.05 in the SA group vs. 54.54 ± 20.48 minutes in the GA group (p_val < 0.001).
Conclusions: A constant specialized endourology anesthetist as part of the endourology O.R team had a statistically significant advantage in both TOT and ST, and also in the proportion of time in the O.R spent performing surgery. Our findings suggest that not only is anesthesia timeshorter in such a team,but it alsoallows the surgeons to be more time efficient.
Funding: None
The Impact of Endourology Fellowship in High Volume Ureteroscopy Outcomes
Micah Levy1, Daniel Wang1, Christopher Connors1, Aaron Walt1, Jacob Stifelman1, Olamide Omidele1, Francisca Larenas1, Michael Palese1
1Icahn School of Medicine at Mount Sinai
Presented By: Micah Levy
Introduction: Studies have shown that surgeon experience, as determined by both case volume and endourology fellowship training significantly impact surgical outcomes for ureteroscopy (URS). We analyzed the differences in surgical outcomes of URS performed by high volumes urologists with and without endourology fellowship training.
Methods: Patients receiving URS for stone management from a high‐volume urologist (> 50 URS per year) at our institution between 2017 ‐2019 were retrospectively reviewed. Demographics, stone characteristics, and surgical outcomes including stone free rate (SFR), complications, and imaging follow up were recorded. Analysis compared outcomes of those high‐volume urologists with endourology fellowship training (FT) and those without (NFT).
Results: 581 cases performed by 6 high‐volume urologists (FT: 3, NFT: 3) were reviewed. Compared to FT urologists, those that were NFT operated on older patients (61 vs. 57, p = 0.001), a higher rate of patients with American Society of Anesthesiology (ASA) score of III/IV (38.28% vs. 26.50%, p = 0.016), patients with statistically significant but clinically insignificant larger primary stone sizes (0.8 cm vs. 0.7 cm, p = 0.001) and total stone burden (1.1 cm vs. 0.8 cm, p = 0.002), and patients with a higher rate of prior stenting (39.62% vs. 22.29%, p = 0.010) and prior failed stone procedures (21.09% vs. 13.36%, p = 0.045). However, FT urologists had a significantly higher SFR for primary (90.10% vs. 75.00%, p < 0.001) and secondary stones (91.29% vs. 80.95%, p = 0.023). They also had fewer total complications (3.75% vs. 13.28%, p < 0.001) though there was no difference in reoperation rates (5.52% vs. 4.69%, p = 0.827). While FT complications were all Clavien‐Dindo (CD) I/II, the difference in CD III/IV rates was not statistically significant (0.00% vs. 17.65%, p = 0.227). Lastly, though there was no difference in the rate of 365‐day imaging follow up (63.58% vs. 65.62%, p = 0.747), FT patients had a higher rate of imaging follow up within the recommended 90‐day post‐operative period (65.92% vs. 41.46%, p < 0.001).
Conclusions: Even amongst high‐volume urologists, those with endourology fellowship training had improved surgical outcomes compared to those without fellowship training, suggesting that fellowship training may provide an added expertise that case volume alone does not.
Funding: Partial funding by the Endourology Society Summer Scholarship awarded to Micah Levy.
The Efficacy and Safety of Retrograde Intrarenal Surgery Over 250mmHg Pressure Assisted by Automated Irrigation Pump
Homin Kang1, Wook Nam1, Han Gwun Kim1, Jong Yeon Park1, Sung Jin Kim1, Han Kyu Chae1, Kyeng Hyun Nam1
1Department of Urology, Gangneung Asan Medical Center, University of Ulsan College of Medicine, Gangneung, 25440, Republic of Korea
Presented By: Kyeng Hyun Nam
Introduction: We retrospectively evaluated the safety of high pressure automated irrigation pump (AIP) during retrograde intrarenal surgery (RIRS) by evaluating postoperative infectious complications and the impact of long‐term renal function.
Methods: We included 155 RIRS cases conducted in Gangneung Asan Hospital from June 2020 to December 2021 with AIP pressure setting > 250mmHg using disposable flexible ureteroscope (LithoVueTM). All enrolled patients checked vital signs every four hours and lab data twice (six hours and next day after RIRS) to evaluate postoperative inflammatory complications after RIRS. To evaluate the long‐term effect of RIRS on renal function, eGFR and serum creatinine were additionally measured one month after surgery. Patients are categorized into two groups according to postoperative infectious complication; no infectious complication and patients with infectious complication including systemic inflammatory response syndrome (SIRS), sepsis and septic shock.
Results: After RIRS, complications of grade II or higher occurred in 11 patients (7.1%) according to the Clavien‐Dindo classification. Infectious complications occurred in 13 (8.3%) patients postoperatively, all of which improved with appropriate intravenous antibiotics and fluid resuscitation and were discharged safely. Linear mixed model demonstrated that white blood cell (WBC) increased six hours after RIRS, but improved the next day (p < 0.001). ln (CRP) increased in statistical significance after six hours and the day after RIRS from baseline (p < 0.001), but all within the normal range. When analyzing the changes in renal function after one month compared to baseline, ln (Creatinine) decreased from baseline (p = 0.037), and eGFR was significantly improved from baseline (p = 0.006). In subgroup analysis, renal function change between no infectious complication group and infectious complication group showed no significant differences (p = 0.29).
Conclusions: RIRS using a single channel flexible ureteroscope can be performed without increasing the risk of infectious complications with the high pressure AIP setting > 250 mmHg. In addition, the occurrence of infectious complications is estimated to have little relevance to long‐term renal damage after RIRS.
Funding: I have no conflict of interest to disclose.No funding.
Ureteroscopy and Lasertripsy with Pop Dusting Using High Power Holmium Laser for Large Urinary Stones >15 mm: 6.5‐Year Prospective Outcomes from a High‐Volume Stone Centre
Victoria Jahrreiss1, Francesco Ripa1, Clara Cerrato1, Carlotta Nedbal1, Virginia Massella1, Amelia Pietropaolo1, Bhaskar Somani1
1University Hospital Southampton NHS Foundation Trust
Presented By: Victoria Jahrreiss, MD
Introduction: The role of ureteroscopy in stone treatment has expanded over the last decades, proving its efficacy and versatility even in difficult clinical scenarios. Dusting and pop‐dusting techniques with Holmium:YAG laser represent an excellent surgical option to treat large renal stones. Our aim was to assess safety and efficacy of dusting and pop‐dusting for renal and ureteric stones > 15 mm using a high power Holmium laser.
Methods: We analysed a cohort of patients with stones > 15mm treated with either a 60W Moses or 100 W Holmium:YAG laser from 2016 to 2022. Patients were treated with a standardised approach including the use of ureteral access sheath(UAS) according to the surgeon's preference (9.5/11.5F or 12/14F). The pop‐ dusting technique combines an initial dusting modality (0.4‐0.8J, 20‐30Hz) with a subsequent non‐contact lithotripsy (0.5–0.7J, 30–50Hz). A 6 Fr JJ ureteric stent was placed in most cases. Primary outcomes were stone free rate(SFR) and complication rate(CR). The effect of pre‐ and intra‐operative variables on the primary outcomes was also evaluated. SFR was defined as complete endoscopic stone clearance or ≤2 mm fragments on postoperative imaging.
Results: Overall, 201 patients and 222 procedures were included with a median age of 60. Single and cumulative stone size were 18mm and 22.4mm respectively with 136 patients(67.8%) having multiple stones. The initial and final SFR was 84.5% and 94% respectively with 20(9%) needing a completion ureteroscopy. The median operative time was 54 minutes (37‐64.5) and a UAS was inserted in 44.8%. Over a median follow up of 12 months (1‐24) the overall CR was 3.4% (7/201), including 6 urosepsis requiring IV antibiotics (Clavien Dindo II) and 1 urosepsis requiring intensive care (Clavien Dindo IVa).A binomial logistic regression was performed to assess the effects of age, pre‐operative stenting, total stone length, UAS use and post‐operative stenting on SFR and CR. Pre‐operative stented patients had 3.26 times higher chances of being stone free (p = 0.011); the use of UAS added 0.34 likelihood to SFR (p = 0.015). Having a positive urine culture added a risk of 8.5 on the onset of complications (p < 0.01).
Conclusions: Our study confirms the safety and effectiveness of ureteroscopy and pop‐dusting technique in treatment of large upper urinary tract stones with excellent outcomes.
Funding: None
Surgical Management of Renal Colic During Pregnancy: A Systematic Review of Different Techniques
Catarina Laranjo Tinoco2, Maria João Braga1, Andreia Cardoso2, Ana Sofia Araújo2, Mariana Capinha2, Ricardo Rodrigues2, Paulo Mota2, Carlos Oliveira2, João Pimentel Torres2
1School of Medicine, University of Minho, 2Hospital de Braga
Presented By: Catarina Laranjo Tinoco
Introduction: Renal colic is the most common non‐obstetric cause of abdominal pain during pregnancy. Although urolithiasis is not more common in pregnant women, it is associated with a higher risk of complications. When invasive treatment is required, possible options are temporary drainage with ureteral stent (JJ) or percutaneous nephrostomy (PCN), or immediate definitive treatment with ureteroscopy (URS). Our goal was to evaluate the safety and efficacy of these techniques in the treatment of renal colic during pregnancy.
Methods: The review was elaborated according to the PRISMA checklist. PubMed, Embase, and Scopus database were browsed for articles containing data on the efficacy and complications of the 3 procedures in pregnant women. The quality of evidence and risk of bias of the selected articles was evaluated with the critical appraisal tools from the Critical Appraisal Skills Programme and the Institute of Health Economics
Results: This review included 45 articles (cohort studies and case series) with a total of 3174 interventions in pregnant patients ‐ 2491 URS, 715 JJ and 512 PCN. The mean age varied from 22 to 30.49 years and the renal colic was more common in the second trimester.Regarding the treatment success, primary URS seems the more efficient than temporary drainage in which most patients need a second procedure after delivery. The stone‐free rates reported for URS varied between 86 and 100%, and were not different from URS in non‐ pregnant patients, as showed by one comparative study.The few comparative studies did not report statistically significant differences in post‐operative complications between procedures. The most frequent complications of URS were lower urinary symptoms and urinary infections, with 13 cases of urosepsis (0.5%). Ureteral stenting complications were bladder irritability in most patients, encrustation and stent migration. PCN complications were fever, bacteriuria, catheter obstruction and hematuria. Concerningobstetric complications, there were 184 cases of preterm labor with 23 premature births. A comparative study showed no statistically significant differences in preterm labors between URS and JJ patients, while another reported a higher rate of preterm induction of labor in JJ patients due to catheterintolerability.
Conclusions: Despite the lack of high‐quality studies, the current evidence suggests that URS, JJ and PCN are all safe and effective in pregnant women that require invasive treatment. Primary ureteroscopy has a high efficacy rate, while the remaining options usually require a second procedure after delivery.
Funding: None
MODERATED POSTER SESSION 12: ABLATIVE THERAPY
Primary Whole Gland Ablation for the Treatment of Clinically Localized Prostate Cancer: A Focal Therapy Society Best Practice Statement
Sriram Deivasigamani1, Srinath Kotamarti1, Eric S. Adams1, Thomas J. Polascik1, Members of Focal Therapy Society2
1Duke University Medical Center, 2Focal Therapy Society
Presented By: Sriram Deivasigamani, MBBS
Introduction: Whole‐gland ablation is a feasible and effective minimally‐invasive treatment for localized prostate cancer (PCa). Previous systematic reviews supported evidence for favorable functional outcomes, but oncological outcomes were inconclusive owing to limited follow‐up.To evaluate real‐world data on mid‐ to‐long‐term oncological and functional outcomes of whole‐gland cryoablation and HIFU (High Intensity Focused Ultrasound) in patients with clinically localized PCa.
Methods: We performed a systematic review of PubMed, Embase, and Cochrane Library publications through February 2022 according to the Preferred Reporting Items for Systematic Review and Meta‐Analysis (PRISMA) statement. As endpoints, baseline clinical characteristics, oncological and functional outcomes were assessed. To estimate the pooled prevalence of oncological, functional, and toxicity outcomes, and to quantify and explain the heterogeneity, random‐effect meta‐analyses and meta‐regression analyses were performed.
Results: Twenty‐nine studies were identified, including 14 cryoablation and 15 HIFU with median follow‐up of 72 months. Most were retrospective (n = 23), with IDEAL stage 2b (n = 20) being most common. Biochemical recurrence‐free survival, cancer‐specific survival, overall survival, recurrence‐free survival, and metastasis‐free survival rates at ten years were 58%, 96%, 63%, 71‐79%, and 84%, respectively. Erectile function was preserved in 37% of cases, and overall pad‐free continence was achieved in 96% of cases, with one year rate of 97.4‐98.8%. Stricture, urinary retention, urinary tract infection, recto‐urethral fistula, and sepsis are observed at rates of 11%, 9.5%, 8%, 0.7%, and 0.8%, respectively.
Conclusions: The mid‐to‐long‐term real‐world data, the safety profiles of cryoablation and HIFU are sound to support and offer as primary treatment for appropriate patients with localized PCa. When compared to other existing treatment modalities for PCa, these ablative therapies provide nearly equivalent intermediate‐ to‐long‐term oncological and toxicity outcomes, as well as excellent pad‐free continence rates in the primary setting. This real‐world clinical evidence provides long‐term oncologic and functional outcomes that enhance shared decision‐making when balancing risks and expected outcomes that reflect patient preferences and values.
Funding: None
Selective Minimally Invasive Cryoablation of Penile Nerves as a Treatment for Premature Ejaculation
Yakov Mirkin1
1URO‐PRO Clinics
Presented By: Yakov Mirkin
Introduction: Premature (early) ejaculation is the second most common type of male sexual dysfunction, which has significant negative impact on the quality of life. Nowadays there is no satisfactory treatment for premature ejaculation despite its obvious need. Conservative therapy for premature ejaculation is based on the sensory decrement of the glans penis with topical anesthetics. Pharmacological effects on serotonin receptors of the central nervous system are also used with selective serotonin reuptake inhibitors. Surgical methods of treatment are based on sensory decrement of the glans penis by various methods, the main of which for the moment is selective dorsal neurotomy. The method has demonstrated good efficacy; however, it is invasive and is accompanied by the risk of complications, also the result of the intervention is not predictable. Recently, minimally invasive methods have been developed to reduce excessive sensitivity of the glans penis by temporary demyelination of the dorsal nerve of the penis using radiofrequency or cryoablation. This abstract presents the results of selective minimally invasive cryoablation of the penile nerves as a treatment for premature ejaculation.
Methods: The retrospective study included 28 patients aged 22 to 35 years (mean age 28.7 years). All patients met CriPE (Criteria for Premature Ejaculation). The median Intravaginal Ejaculation Latency Time was 75.8 seconds (range 25 to 118 seconds). Patients completed the Premature Ejaculation Profile with a mean score of 3.6 (range 0 to 6) indicating extremely poor ejaculation control, high levels of distress, and an apparent negative impact on relationships with sexual partners. All participants underwent selective minimally invasive cryoablation of the dorsal nerves of the penis.Method for prersize localization of penile nerves was electrical stimulationat a frequency of 50 ‐ 100 Hz, which causes paresthesias in the region of innervation of the penile sensory nerves.With electrical stimulation of the dorsal nerve of the penis, paresthesias (tingling, etc.) appear in the region of the glans penis. The cryoablation devicehas a built‐in electrical stimulator. Cryoablation of the dorsal nerves of the penis is currently performed under electrical stimulation navigation and is as follows:1. Local anesthesia of the skin with 0.5 cc 1% lidocaine solution2. Penetration of the cannula for intravenous injection of 14G through the skin into the region of the dorsal neurovascular bundle at the 2 o'clock position – perpendicularly axis of the penis.3. Insertion the isolated cryoprobe 18 G through the cannula.4. Electrical stimulation with a frequency of 50 Hz to find the dorsal nerve5. After localization of the nerve (the cryoprobe is located in the zone of maximum sensory response to stimulation), an additional anesthetic portion of 1 ml is injected through the cannula port6. Nerve freezing: 2 freeze cycles with 2 minutes exposure and 1 minute defrost time7. Repetition of points 4 ‐ 6 in the position at 11 o'clock. Three months after the procedure, participants filled the Premature Ejaculation Profile again and measured their Intravaginal Ejaculation Latency Time.
Results: Average Intravaginal Ejaculation Latency Time increased from of 75.8 seconds to 227.6 seconds (+298%), the average Premature Ejaculation Profile score increased from 3.6 to 11.35 points (+315%). No significant complications were recorded.
Conclusions: Selective minimally invasive cryoablation is a promising treatment for premature ejaculation in patients who have positive response with topical anesthetics. However, additional studies with a larger number of participants are recommended.
Funding: No conflict of interest
Nerve Protection During Prostate Cryosurgery
Franz Schmidlin3, Pegah Ranjbartehrani1, Qi Shao1, Michael Etheridge1, David Ramirez2, Paul Iaizzo2, John Bischof1
1Department of Mechanical Engineering University of Minnesota, 2Department of Surgery University of Minnesota, 3Urology Center Clinic Hirslanden Grangettes
Presented By: Franz Schmidlin, MD
Introduction: A major side effect of focal prostate cryosurgery is injury to the neurovascular bundle (NVB). Cryoinjury halts conduction of action potential (APs) in the nerve that may lead to erectile dysfunction and hence diminish the patients quality of life. The objective of this study was to analyze the feasibility of usinga gel containing cryo protective agents (CPA) that is applied directly to the regions of the nerves exposed to the cold to minimize non‐recovery loss of APs conduction there by preserving the neuronal function.
Methods: We modeled cryosurgical procedures based on data taken during clinical cases by measuring temperature profiles at specific locations of the NVB during cryosurgical procedures.The same temperature profiles were applied ex‐vivo to porcine phrenic nerves and rat sciatic nerves in a controlled experimental setting (cryostage). The APs were measured before and after the CPA exposure alone and in combination with a gel during 3 hours of recovery. Threshold for nerve injury was considered loss of 70% or more of AP amplitude. To determine the temperature profiles of the NVB 3D temperature distribution was calculated by numerical modeling for different clinical tumor locations.
Results: The modeling of the coldest temperature (‐100C) on the NVB for most (anterior and lateral) tumor locations is consistent with clinical measurements. Comparisons of AP amplitude recovery with various CPA compositions reveal that certain CPAs (e.g., 5% DMSO +7.5% Trehalose and 5% M22 for porcine and rat nerves, respectively) showed little or no toxicity and effective cryoprotection from freezing (on average 48% and 30% of respective AP, respectively). Good nerve protection was also achieved with CPA‐containing gel (2% hydroxyethyl cellulose). Diffusion modeling showed more than 50% CPA penetration in the nerve after 45 min. No AP recovery was observed in nerves not protected by CPA compositions.
Conclusions: This work demonstrates the feasibility of a nerve‐sparing approach to employ cryoprotective agents embedded in a gel to prevent cryoinjury around the NVB during prostate cryoablation and hence reduce ereftile dysfunction. This method appears to be effective and easy to implement clinicallyas the gel may be injected by a perineal approach under ultrasound guidance similar to saline injections we perform presently to increase the space between the prostate and the rectum. Preoperative 3D cryosurgery modeling may also become a helpful tool to predict and hence prevent possible cryosurgical side‐effects in the future.
Funding: Research Fund Medical Immersion Technology
Intermediate‐Term Oncologic and Functional Outcomes After Salvage Cryoablation for Localized, Biopsy‐Proven Recurrent Prostate Cancer Following Primary External Beam Radiotherapy versus Primary Cryotherapy
Sriram Deivasigamani1, Scott P. Campbell1, Rohith Arcot2, Eric S. Adams2, Hazem Orabi3, Ahmed Elshafei4, Wei Phin Tan5, Leah Davis1, Yuan Wu1, Andrew Chang6, J Stephen Jones7, Thomas J Polascik1
1Duke University Medical Center, 2Duke Medical Center, 3Assiut University, 4University of Florida Health, 5NYU Langone Health, 6Moffit Cancer Center, 7Inova Health System
Presented By: Sriram Deivasigamani, MBBS
Introduction: Local prostate cancer recurrence following radiotherapy (XRT) or cryoablation (CRYO) may be addressed with salvage cryotherapy (SCT), although little is known about how the main treatment modality affects SCT results. Oncologic and functional outcomes of patients who underwent SCT after primary XRT (XRT‐SCT) or cryoablation (CRYO‐SCT) were studied.
Methods: Data was collected using the Duke Prostate Cancer database and the Cryo On‐Line Data (COLD) registry. The primary outcome is biochemical progression‐free survival (BPFS). Urinary incontinence, rectourethral fistula, and erectile dysfunction were all secondary outcomes. To compare BPFS rates and identify impacting factors, the Kaplan‐Meier log‐rank test and Cox proportional hazards models were utilized. Logistic regression analysis (LR) was used to identify factors that predict biochemical recurrence (BCR).
Results: 419 XRT‐SCT and 63 CRYO‐SCT patients met inclusion criteria, that were reduced to 63 patients in each cohort after propensity matching. On survival analysis of the propensity‐matched cohort, the Kaplan‐ Meier log‐rank test demonstrated no significant difference between groups for BPFS at 2 years (p = 0.85) or 5 years (p = 0.58). In LR analysis, the BCR rate was higher in the high (OR = 36.38; p = 0.03) and intermediate‐ risk (OR 8.26; p = 0.01) D'Amico risk categories compared to low‐risk. No differences were noted between groups (CRYO‐SCT vs XRT‐SCT) in the functional outcomes such as pad‐free rates (4.9% vs.16%, p = 0.06), erectile function (26% vs.14%, p = 0.06), and recto‐urethral fistula (5% vs.3%, p = 0.3).
Conclusions: Following primary cryotherapy, salvage cryoablation provides comparable intermediate oncological outcomes and functional outcomes compared to primary radiotherapy. The D'Amico risk group predicts oncologic outcomes, underlining significance of close monitoring after initial therapy in individuals with high or intermediate‐risk PCa to detect early recurrence and salvage treatment.
Funding: None
Intermediate‐Term Oncological and Functional Outcomes of Salvage Cryotherapy for the Management of Prostate Cancer Recurrence After Primary Brachytherapy versus Primary Cryotherapy: A Propensity Score‐Matched Analysis
Sriram Deivasigamani4, Hazem Orabi1, Ahmed El‐Shafei2, Eric S Adams3, Srinath Kotamarti4, Ali Aminsharifi5, Leah Davis4, Yuan Wu4, J Stephen Jones6, Thomas J. Polascik4
1Assiut University, 2University of Florida Health, 3Duke University Medical Center, 4Duke University Medical Center, 5Penn State Health Mission S.Hershey Medical Center, 6Inova Health System
Presented By: Sriram Deivasigamani, MBBS
Introduction: Salvage cryotherapy (SCT) is widely used to treat prostate cancer (PCa) recurrence after radiotherapy (RT). Our objectives were to determine intermediate oncological and functional outcomes of patients who underwent SCT after primary brachytherapy (BT‐SCT) or cryoablation (CRYO‐SCT), as well as the effects of primary therapy on its outcome.
Methods: An IRB‐approved retrospective cohort study utilizing patient data from the Cryo On‐Line Data (COLD) Registry and the Duke PCa database between 1992 and 2016.Biochemical recurrence (BCR) using Phoenix criteria was the primary endpoint assessed at 2‐ & 5 years post SCT. Secondary endpoints assessed functional outcomes including urinary continence, erectile function and recto‐urethral fistula. Association between treatment and biochemical progression‐free survival (BPFS) was assessed using inverse probability weighted (IPTW) Cox proportional hazards regression. The differences in the secondary functional outcomes were assessed by Pearson's χ2 test or Fishers exact test, corrected for IPTW.
Results: 194 patients met inclusion criteria. There was no statistical difference in 2‐year BCR (HR 0.9; 95% CI, 0.5–1.7, p = 0.7) or 5‐year BCR (HR: 0.86; 95% CI, 0.5‐1.5, p = 0.6) between the groups. On survival analysis of the propensity‐matched cohort, the Kaplan‐Meier log‐rank test demonstrated no significant difference between groups for BPFS at 2 years (p = 0.63) or 5 years (p = 0.39).The functional outcomes like urinary incontinence (p = 0.4), erectile function (p = 0.1) and recto‐urethral fistula (p = 0.3) were not statistically different.
Conclusions: CRYO‐SCT appears to be well tolerated, with comparable oncological and functional outcomes to patients failing primary brachytherapy. The findings also demonstrated that SCT can render a significant number of patients biochemically free of disease after initial cryotherapy with minimal morbidity.
Funding: None
Focal Treatment for Prostate Cancer‐ Oncologic and Functional Outcomes
David Margel2, Yaara Ber1
1Raphael Hospital, 2Raphael Hospital, Israel
Presented By: David Margel, MD,PhD,MBA
Introduction: Focal treatment for prostate cancer by ablative energies is an innovative approach to treatment. Our goal was to examine the oncological and functional results of focal treatments and test predictors of its success.
Methods: 748 patients with low‐ or intermediate‐risk prostate cancer were treated by focal therapy between May 2014‐May 2023. The technologies we used were HIFU, nanoknife and cryotherapy. Oncologic follow‐ up protocol included PSA once every 3‐6 months, annual MRI and fusion‐ biopsy if necessary. Functional outcome was assessed prospectively using questionnaires for sexual function (IIEF), leakage and LUTS (IPSS).
Results: Median Patients' age was 68 years (IQR 64‐72). 262 patients (35%) had low‐risk prostate cancer (GG1 but tumor volume greater than 6 mm on biopsy or tumor volume greater than 1 cm on MRI) and 486 patients (65%) had intermediate‐risk prostate cancer (GG2 and GG3). 246 patients were treated with HIFU, 28 with nanoknife and 474 with cryotherapy.Oncologic Outcomes‐ At a median follow‐up of 38.3 months, the median PSA decreased by 63% (IQR 48.3%‐82.1%) MRI and normal PSA dynamics were observed in 561 (74%). Follow‐up biopsy showed recurrence in the ablation area in 51 patients (6.8%), and recurrence outside the ablation area was diagnosed in 96 (13%). 80% of the patients (n = 601) without evidence of active disease, 10% (n = 72) underwent additional focal treatment, 5% needed treatment for the entire prostate (17 underwent surgery and 21 radiation).Functional outcome ‐ Mild urinary leakage was observed in 2 patients (0.004%). Baseline IPSS ((9, IQR 4‐16) improved (7, IQR 3‐12). Overall, baseline IIEF (19, IQR 14‐23) decreased by 16%. However, 12 months post‐treatment 78% returned to base‐line sexual function.On multivariable Cox regression, Independent predictors for disease recurrence, were Grade Group (HR 1.5 9.5%CI 1.2‐2.1) and tumor location (HR 0.8 9.5%CI 0.82‐0.95)
Conclusions: At a median follow‐up of over 3 years, focal treatments in low‐ or intermediate‐risk prostate cancer patients demonstrate oncological successes while maintaining a good quality of life.
Funding: None
Evaluating the Safety and Efficacy of Focal Ultrasound Guided Cryo‐Ablation Using UroNav/DynaCAD on Low to Intermediate Risk Prostate Cancer
Peter Tricarico1, Thomas Williams1, Karen Huang1, Tavya Benjamin1, Cynthia Knauer1, Scott Thompson2, Samuel Coons2, Michael Schwartz1, Ardeshir Rastinehad1
1Northwell Health, 2Philips
Presented By: Peter Tricarico, Clinical Research Coordinator
Introduction: The urologic landscape for prostate cancer has transitioned to image‐based approach using mpMRI of the prostate for patients at risk for prostate cancer. Combining MRI with MR/US fusion technology aids in creating an optimal and accurate plan for both biopsies and focal therapy. This study details using UroNav software (v 4.0) and DynaCAD software (v 5.0) to perform cryoablation of prostate cancer in men with localized prostate cancer diagnosed using MR/US fusion guided prostate biopsies.
Methods: A prospective, single‐center clinical trial was conducted, evaluating the use of the UroNav 4.0 and DynaCAD 5.0 Urology systems as adjunctive software tool during ultrasound‐guided cryoablation of the prostate. 37 men with focal MRI visible Gleason Grade ≤3 undergoing focal cryoablation were included.The primary endpoint was to determine safety of UroNAV Ablation system‐aided cryo‐ablation for focal treatment of low to intermediate‐risk MR visible disease. Incidence and severity of device/treatment‐related complications were evaluated from the treatment day visit through the 24‐month follow‐up. The secondary endpoints included results of a 12‐month MR/US fusion‐guided prostate biopsy with a standard 12‐core biopsy template. Metrics for oncologic and clinical success included serial PSAs, interval MRI assessments, post‐ablation prostate biopsy (pBx), International Prostate Symptom Score (IPSS), Sexual Health Inventory for Men (SHIM), and the Expanded Prostate Cancer Index Composite short form 26 (EPIC 26) scores.
Results: To date, 18 subjects have completed the 12‐month post‐therapy follow‐up visit. 17 patients underwent MR/US fusion‐guided post‐ablation prostate biopsy 12 months post‐therapy. 16 subjects did not have recurrent disease (94%). 1 subject had recurrent GG2 disease (6%). PSA values had a significant decrease confirming a biochemical response. IPSS, SHIM, and EPIC scores were not clinically significant, indicating that the treatment is not causing adverse effects [Table 1].
Conclusions: The MR/US fusion technology is a potentially more accurate method to focally treat localized prostate cancer compared to a typical cognitive approach using ultrasound only. The UroNav and DynaCAD systems provide a safe, effective, and streamlined process that allows for precise focal cryoablation of the prostate in men with localized prostate cancer.
Funding: None
Can PSMA‐11 PET/CT Detect Prostate Cancer Local Recurrence after HIFU?
1Nuclear Medicine, Rambam Health Care Campus, Haifa, Israel, 2Department of Urology, Rambam Health Care Campus, Haifa, Israel, 3Department of Urology, Rambam Health Care Campus, Haifa, Israel
Presented By: Omer Sadeh, MD
Introduction: High‐intensity focused ultrasound (HIFU) is gaining increased popularity as a minimally invasive therapy for low to intermediate risk prostate cancer (PCa). Optimal recommendations for follow‐up after treatment have yet to be defined. Currently, prostate‐specific antigen (PSA), multiparametric magnetic resonance imaging (mpMRI) and biopsies are used. However, mpMRI after intervention is often inaccurate.We aimed to investigate whether prostate‐specific membrane antigen (PSMA‐11) positron emission tomography (PET)/CT could be used to detect and localize recurrent disease.
Methods: HIFU for PCa is performed in our institution under an ongoing investigational trial. Hemi‐gland ablation is applied to the entire prostate lobe diagnosed with PCa on pre‐treatment biopsy. Per protocol, patients complete an mpMRI and PSMA PET/CT 1 year after treatment. Repeat biopsy is left at physician discretion. Interim analysis was performed for the findings from the first 4 years of the trial. PSMA PET/CT scans were read by a masked nuclear radiologist. A 5‐point Likert scale was defined to rate the suspicion for recurrence from very low risk (1) to very high risk (5) in each prostate lobe, with 4 used as a cutoff for suspected disease. Results were compared with template biopsy findings.
Results: 35 patients underwent HIFU in our institution from 04/2018 to 01/2022. Of them 15 patients completed both PSMA PET/CT and biopsy at 1 year. The hemi‐gland based sensitivity, specificity, positive and negative predictive values for PSMA PET/CT were 50%, 44%, 37 and 57% for in‐field recurrence, and 66%, 91%, 66%, and 91% respectively for out‐field recurrence. PSMA PET/CT was negative in one case with grade group (GG) 3 disease, and in 3 cases with GG 2 disease.
Conclusions: Our preliminary results indicate that PSMA PET/CT as a single modality is not sensitive enough for detection of in‐field PCa recurrence after HIFU. Combination with mpMRI results may improve detection rates.
Funding: None
Do Urine Cytology and FISH Analysis Have a Role in the Follow‐up Protocol of Upper Tract Urothelial Carcinoma?
Introduction: Current guidelines recommend a stringent follow‐up regimen that includes interval cystoureteronephscopy, CT urography, and selective urine cytology sampling for upper tract urothelial carcinoma (UTUC) patients undergoing endoscopic treatment and management. There are no recommendations regarding FISH analysis. Our purpose was to assess the efficacy of cytology and FISH as part of the follow‐up protocol and its significance to clinical decision‐making in this scenario.
Methods: The medical records of all patients who managed endoscopically for UTUC at our institute between 2014 and 2022 were retrospectively analyzed. Demographic and clinical data, histology, cytology, and FISH results were collected. FISH analysis was considered malignant according to Paris criteria.
Results: During the study period, 62 patients underwent 561 ureteroscopies as part of the treatment and follow‐up regimen of UTUC. Urine from the affected upper tract was sampled for cytology in 377 procedures, and FISH analyses were performed in 273. In 75.4% of FISH analyses, the result was different from the cytology results: FISH found malignant aberrations in 15.5% of cases where cytology was benign. Furthermore, FISH classified all the cells that were defined as atypical via cytology as either benign or malignant. In only one case, the urinary cytology report changed the follow‐up regimen accepted at our department.
Conclusions: Cytology and FISH may be omitted from the follow‐up protocol of UTUC in most cases. In the specific cases where cytology is obtained, FISH analysis has added value, particularly when cytology reports cellular atypia.
Funding: None.
Feasibility & Outcomes of Gold Nanoparticle Focal Ablation of Low‐to‐Intermediate Risk Prostate Cancer
Tavya Benjamin1, Thomas Williams1, Cynthia Knauer1, Michael Schwartz1, Alejandro Sanchez2, Lance Mynderse3, William Ellis4, Arjun Sivaraman5, Christopher Weight6, Eric Klein6, Thomas Polascik7, Arvin George8, Steven Canfield9, Ardeshir Rastinehad1
1The Smith Institute for Urology ‐ Northwell Health, 2University of Utah, 3Mayo Clinic, 4University of Washington, 5Washington Univerity, 6Cleveland Clinic, 7Duke University, 8University of Michigan, 9University of Texas ‐ Houston
Presented By: Tavya Benjamin, MD
Introduction: As prostate cancer remains the most frequently diagnosed cancer in men, there has been a strong impetus to offer men less invasive treatments for localized disease while not compromising oncologic outcomes or quality of life metrics. One such focal treatment modality is Nanospectra Biosciences' Aurolase Therapy ablation system. Patients are infused with gold nanoparticles the day prior to the ablative procedure allowing time for the nanoparticles to preferentially accumulate within the tumor. Utilizing a transperineal approach, near infrared lasers are inserted into the lesion with magnetic resonance/ultrasound (MR/US) fusion guidance. We aimed to determine the feasibility of this focal technology, as well to define its oncologic & safety outcomes.
Methods: A prospective, open‐label, single dose study of AuroLase Therapy was conducted at 10 tertiary‐ care centers. Men ≥45 years with organ‐confined prostate cancer with Gleason Score ≤7 & ≤ 2 lesions were included. Success was defined as no evidence of Gleason ≥7 or ≥3mm of Gleason 6 at biopsy. All treatments utilized the UroNav MR/US fusion biopsy & the Nanospectra's Aurolase Therapy ablation systems. Descriptive & inferential statistics were calculated as indicated.
Results: Of the 100 patients included, mean baseline PSA was 8.4 ng/dL (± 3.9), & the baseline incidence of Gleason Grade Groups 1, 2, & 3 were 24%, 63%, & 13%, respectively. Patients were biopsied at 6‐months & 1‐year post‐ablation (Table 1). Overall success rate at 1‐year, accounting for 7 failures that withdrew for salvage therapy, was 71% (65 successful of 92 evaluated). Marginal differences were seen in baseline & 1‐year Sexual Health Inventory for Men & International Prostate Symptom Scores, & no change was seen in baseline to 1‐year Quality of Life scores, though the sample size of the reported functional outcomes was not sufficient for significance to be evaluated. No serious adverse events were reported.
Conclusions: Focal therapy is an important treatment option for men with clinically significant prostate cancer in which whole gland therapy, & the side effects that often accompany it, seem too radical. This study shows that gold nanoparticle focal laser ablation is a safe & effective treatment modality in men with low‐to intermediate risk prostate cancer. Source of Funding: Nanospectra Bioscience Inc
Funding: Nanospectra Bioscience Inc
Preliminary Results of Cryotherapy for Non Muscle Invasive Bladder Cancer
Azik Hoffman2, Eyal Kochavi1, Omri Nativ2, Kamil Malshy2, Omer Sadeh2, Michael Mullerad2, Gilad E Amiel2
1Vessi Medical, 2Rambam Medical Center
Presented By: Azik Hoffman, MD, MHA
Introduction: Initial treatment for non‐muscle invasive bladder cancer mostly remains the same over many years. Utilizing cryotherapy with CO2 is commonly used to treat superficial papillary lesions of the skin for many years. Recently, we have proven its potential in treating urinary epithelial lesions in an animal model. Therefore, we present our preliminary phase 1 clinical results in treating low grade papillary lesions of the bladder.
Methods: Following local IRB approval, 10 patients with up to 3 papillary lesions and a maximum of 10 mm in size were recruited. No patient had previous high‐grade disease nor positive cytology. Following the initial routine cystoscopy, the bladder irrigation medium was replaced with CO2 insufflation, and each lesion was treated with direct visual CO2 spraying for 15 seconds twice and allowing 10 seconds of thawing after every treatment cycle. Follow‐up cystoscopy and treatment site biopsy were performed 4‐6 weeks later, and routine surveillance was performed every 3 months for 1 year.
Results: 8 men and 2 women were included (age 57—89 years). Overall, 14 lesions were treated. No complications were noted during treatment nor follow‐up (range 2‐14 months). Pathological analysis of the treatment site 4‐6 weeks later detected residual low grade TCC only in the first patient, attituded to suboptimal lesion freezing due to our initial learning curve.
Conclusions: Initial results of cryotherapy utilizing CO2 spraying for small low grade NMIBC is safe and feasible. Pathological analysis confirms efficacy in tumor eradication. This potential treatment offers a potential paradigm shift in NMIBC treatment.
Funding: none
is it Safe and Effective to Perform Renal Cryoablation in Patients with Chronic Liver Disease?
Kai Wen Cheng2, Matthew Buell1, Matthew Wilson1, Daniel Jhang1, Jason Smith1, Vance Gentry1, Akin S. Amasyali1, Rose Leu1, Kanha Shete1, Ala'a Farkouh1, Katya Hanessian1, Kai Wen Cheng1, D. Duane Baldwin1
1Loma Linda University Health, 2Loma Linda
Presented By: Kai Wen Cheng, MD
Introduction: Patients with chronic liver disease are high‐risk surgical candidates given their coagulopathic state and risk of metabolic complications. Cryoablation may be a less invasive option for these high‐risk patients with small renal tumors. While renal cryoablation has been shown to be successful in the general population, little information exists regarding outcomes in patients with chronic liver disease. The study's purpose was to evaluate the outcomes of renal cryoablation in patients with chronic liver disease.
Methods: A retrospective review was performed on patients who underwent renal cryoablation at a single academic institution from April 2013 to October 2022. Patients were compared based on the presence or absence of chronic liver disease/cirrhosis. The primary endpoints were recurrence‐free and overall survival. Secondary endpoints included complication rates, hospital stay, blood transfusions, and ICU admission. Chi Square test and Wilcoxon rank sum test were used to compare outcomes between patients with and without chronic liver disease. The Kaplan‐Meier log rank test was used for recurrence‐free and overall survival, with p ≤ 0.05 considered significant.
Results: A total of 131 cryoablations were analyzed, and out of these 14 (10.7%) had chronic liver disease/cirrhosis, with a mean MELD score of 9.6. Patients were followed for a mean of 19.3 ± 28.6 months. Liver disease patients were younger (64 vs 70 years, p = 0.019), but there were no significant differences in preoperative tumor characteristics, including nephrometry score (5.9 vs 6.4; p = 0.16), mean tumor grade (1.7 vs 1.7; p = 0.88), and mean tumor size (2.9 vs 3.1 cm; p = 0.28) in the no liver disease and chronic liver disease groups, respectively. Overall survival in patients with chronic liver disease was lower (p = 0.050; Figure 1a), but there was no difference in recurrence‐free survival between groups (p = 0.096; Figure 1b). There were no post‐operative patient mortalities and transfusion rates were similar between groups (p > 0.05).
Conclusions: In patients with reasonable life expectancy or patients needing renal tumor treatment prior to liver transplantation, renal cryoablation is feasible and safe, with acceptable procedural and oncologic outcomes.
Funding: None
Preliminary Results of a Novel Non‐Invasive Treatment for Benign Prostatic Hyperplasia Using Focused Ultrasound: Histoblast
Carlos A. Garcia Becerra1, Carlos M. García Gutierrez1, Naren Sanghvi2, Natalia Garcia Becerra1, Sunao Shoji3, Leonardo Fernandez Avila4, Habid Becerra Herrejon1
1UROVALLARTA Urology Center, 2Sonablate Co., 3Tokai University School of Medicine, Department of Urology, 4CIBO IMSS
Presented By: Carlos A. Garcia Becerra, MD
Introduction: Benign Prostatic Hyperplasia (BPH) is a disease that affects one‐third of men older than 50 years and is histologically evident in up to 90% at 85 years. Men with this pathology suffer from Lower Urinary Tract Symptoms (LUTS) in approximately 50% of men in the sixth decade of life and 80% in the ninth decade.In this epidemiological context, this protocol aims to evaluate the efficacy and safety of a new Focused Ultrasound Surgery (FUS) modality named Histoblast and evaluate as a new minimally invasive therapy for BPH.
Methods: A prospective clinical study was conducted, with nine patients enrolled until now. The traditional tissue ablation function of the FUSdevice was modified by changing the treatment plan, energy delivery and implementation of prostate compression.At treatment, the cavitation phenomenawas verified with the FUSDevice. Qmax assessment, IPSS, and IIEF‐5 questionnaires were conducted pre‐ and post‐treatment, with a follow‐up of 2 months. Magnetic resonance Image (MRI), ultrasoundand histopathological analyses were conducted at post‐treatment time.A Kruskal‐Wallis ANOVA test and a Mann‐Whitney t‐Student test were conducted for the statistical analysis.
Results: During treatment, a significant increase of the amount of cavitation phenomena was registered in every treatment with > 80%, with less dissipation of ultrasound energy due to tissue compression.The IPSS and Quality of Life results demonstrated a significant improvement in the scoring, throughout the 2‐month follow‐up. The IIEF‐5 score shows no significant change among the patients, due totreatment. The Qmax assessment showed a significant improvement. The MRI and ultrasound scans showed precise ablation to the BPHarea, with preservation of the urethra and peripheral zone. The histologic analysis demonstrated complete destruction of the tissue architecture in the treated area.
Conclusions: The image guidance during the treatments, confirmed, that this new FUS treatment modality increases the boiling cavitation ablative phenomena, instead of the thermo ablation produced by the original protocols. Keeping the same safety parameters approved in several countries, for prostate ablation. The preliminary results confirmed the efficacy of BPH ablation, with good clinical improvement. We concluded that Histoblastis a very safe, precise, and repetitive treatment, positioning it as a promising alternative in the Minimally Invasive SurgicalTreatmentsforBPH.
Funding: UROVALLARTA Urology Center
Comparative Analysis of Prostate Cancer Detection by Cognitive, mpMR/US‐Fusion and Saturation Biopsy
Vladislav Petov1, German Krupinov1, Andrey Bazarkin1, Timur Ganzha1, Sergey Danilov1, Yaroslav Chernov1, Denis Chinenov1, Ramin Rzayev2, Alexander Suvorov3, Alexander Amosov1, Dmitry Enikeev4
1Institute for Urology and Reproductive Health, Sechenov University, 2University Clinical Hospital №2, Department of Radiology, Sechenov University, 3“Digital Biodesign and Personalized Healthcare” World‐ Class Research Center, Sechenov University, 4Department of Urology and Comprehensive Cancer Center, Medical University of Vienna
Presented By: Vladislav Petov, MD
Introduction: Currently, prostate biopsy remains the only reliable method for PCa diagnosis. Taking into consideration the variety of prostate biopsy methods, the issue of indications for each of them remains unresolved. Current EAU guidelines recommend combining MR‐targeted biopsy with systematic biopsy for high yield of PCa diagnosis. Nevertheless, it remains unclear which biopsy is more accurate for PCa detection. The aim of the study: to compare PCa detection rate among the transrectal cognitive biopsy (COG‐ TB), transperineal mpMR/US‐fusion biopsy (FUS‐TB) and transperineal template mapping biopsy (TPMB).
Methods: Inclusion criteria were as follows: PSA > 2 ng/mL, and/or positive digital rectal examination, and/or suspicious lesion on TRUS or MRI (according to Pi‐RADSv2.1 ≥ 3 score). All patients underwent mpMRI (Siemens Magneton Skyra 3T, protocol – T2WI, DWI, ADC map, T1WI, DCE). Then one of 3 experienced urologists performed TPMB (> 20 cores) or one of the targeted biopsy methods: COG‐TB or FUS‐TB (MIM Software, MIM Symphony).
Results: Totally 475 patients were enrolled into the study: 102 of them underwent COG‐TB, 176 – FUS‐TB and 197 – TPMB. Median PSA level (6.7 ng/ml – in COG‐TB group, 6.4 ng/ml – in FUS‐TB group, 6.9 ng/ml – in TPMB group (p = 0.36)), prostate volume (46; 46 and 48 cm3; p = 0.76) and PSA density (0.13; 0.13 и 0.13 ng/ml/cm3; p = 0.89) did not differ significantly among biopsy groups. Suspicious lesions classification by Pi‐RADS v2.1 score did not show statistically significant difference among groups: Pi‐ RADS 3 (p = 0.73), Pi‐RADS 4 (p = 0.99), Pi‐RADS 5 (p = 0.56). Overall PCa detection rate was higher for TPMB, but the result was not statistically significant (COG‐TB – 42.1% vs FUS‐TB – 50.5% vs TPMB – 56.3%; p = 0.06). CsPCa (ISUP ≥2) detection rate was higher for COG‐TB among biopsy methods, also not statistically significant (30.3%, 25.0%, 27.4%; p = 0.61). Less was detected cisPCa [A О1]by COG‐TB compared with other biopsy methods (11.8%, 25.5%, 28.9%; p = 0.004). Median maximum cancer core length did not differ significantly among biopsy methods (7.6; 6.6 and 4.8 mm; p = 0.42). Percentage of positive cores significantly increased for targeted biopsy methods (29.5%, 30.5%, 9.67%; p < 0.001).
Conclusions: Targeted methods did not show an increase in detection of csPCa as well as overall PCa detection over TPMB. Wherein less CisPCa was detected by targeted biopsy methods in comparison with TPMB. Another advantage of targeted methods is increased sampling efficiency.
Funding: None.
High Intensity Focused Ultrasound with “Focal‐One” Robotic Device: Evaluation of 3‐Year Results
Artem Alaverdyan2, Dmitry Pushkar1, Alexander Govorov1, Konstantin Kolontarev1, Alexander Vasilyev1
1Moscow State University of Medicine and Dentistry named after A.I. Evdokimov Department of Urology, 2Moscow City Hospital named after S.I. Spasokukotsky
Presented By: Artem Alaverdyan, Resident
Introduction: The aim of our trial was to assess treatment of localized prostatecancer (PCa) using HIFU with «Focal One» device (with the possibility of fusion technology combining intraoperative ultrasound and preoperative MRI data).
Methods: From November 2019 to April 2023, HIFU using the “Focal One” device (EDAP, France) was performed in 145 patients with PCa.Total ablation was carried out in 95 cases, focal ablation in 50 cases. The mean ageof the patients was 62.7 (51‐80) years, total PSA level 9.3 (3.2‐15.5) ng/ml, prostate volume 32.0 (11‐55) cc, Qmax 13.3 (6.3 ‐ 36) ml/s, total IPSS score 7 (3‐25), IIEF‐5 18 (4‐25). Clinical stage T1cN0M0 was established in 118 patients,T1bN0M0 in 10 and T2N0M0 in 17 patients. In 49 cases transurethral resection ofthe prostate was performed 4‐6 weeks before total HIFU.
Results: In all cases HIFU was performed under general anaesthesia. The average operation time was 96 (56‐ 147) minutes. The course of the postoperative period was without any serious (Clavien‐Dindo > 2) complications. All patients received antibiotic therapy (14 days) and treatment with alpha‐adrenoblockers (1 monthafter surgery). After urethral catheter removal on the 4th day, natural urination wasrestored in all patients. Twenty five patients required an additional single catheterization during 24 h after Foley removal. One year after HIFU 100 patients were fully examined: mean total PSA level in patients who underwent totalablation (n = 65) was 0,96 ± 0,11 ng/ml, IPSS score was 6,9 ± 0,6 points (no difference from the initial level), at control biopsy the prostatic adenocarcinoma was revealed in 9 patients; in the remaining cases the prostatic tissue fibrosis wasrevealed. Sexual function was not preserved in men who underwent total HIFU and the median IIEF score remained the same in those after focal therapy. Evaluation of other results is ongoing.
Conclusions: Treatment of localized prostate cancer using HIFU with the «FocalOne» robotic complex is promising and safe minimally invasive type of therapy, which has demonstrated good oncological results after a short follow‐up period.
Funding: Source of Funding – none.
Profile of Ethnic Minorities Undergoing MRI Fusion Ultrasound Prostate Biopsy in a Safety Net Hospital Post COVID Era
Fernando J. Kim2, Sharon White1, Kyle Szymanski1, Ian McComb1, Connie Wolf1
1Denver Health, 2Denver Health Medical Center
Presented By: Fernando J. Kim, MD, MPH
Introduction: Ethnic minorities often face disparities in access to healthcare and are underrepresented in prostate cancer research. The emergence of advanced techniques, such as MRI fusion ultrasound prostate biopsy system, has revolutionized the diagnosis and management of prostate cancer and it may be pivotal to address healthcare disparities and tailor effective strategies for early detection and treatment.
Objective: This study examines the profile of ethnic minorities undergoing MRI fusion Ultrasound Prostate biopsy using the Koelis system in our safety net hospital post COVID era.
Methods: From August 2022 and February 2023 a total of 65 individuals medical charts were reviewed in the study, including 14 Black individuals, 17 Hispanic individuals, 5 other individuals, and 29 Caucasian individuals.
Results: The average age of the participants was 63.8 ± 7.4 years. The study also investigated the types of health insurance among the participants. Among the Black participants, 3 individuals had indigent insurance, 7 had Medicaid/Medicare, qand 4 had private insurance. Among the Hispanic participants, 4 had indigent insurance, 12 had Medicaid/Medicare, and 1 had private insurance. The other participants all had Medicare insurance. Among the Caucasian participants, 23 had Medicaid/Medicare, and 6 had private insurance.Prostate size was measured in cubic centimeters (cm3), with an average size of 59.4 cm3 across all participants. Black participants had an average prostate size of 52.3 cm3, Hispanics 68.5 cm3, other 64.6 cm3, and Caucasian 56.8 cm3.Clinically significant Pirads scores (4 or 5) were observed in the majority of participants. Among the Black participants, 8 had a Pirads score of 4 and 2 had a score of 5. Among the Hispanic participants, 6 had a score of 4 and 6 had a score of 5. The other participants had 1 with a score of 4 and 3 with a score of 5. The Caucasian participants had 15 with a score of 4 and 12 with a score of 5.Gleason scores were analyzed, with the majority of G3 + 3 scores observed in Caucasian participants (13) compared to Black (5), Hispanic (5), and other (1) participants. Black participants had scores of 3 + 4 (3) and 4 + 3 (2), Hispanic participants had scores of 4 + 3 (2) and 4 + 5 (1), and Asian participants had Gleason scores no higher than 3 + 3.The International Prostate Symptom Score (IPSS) was assessed, with an average score of 8.3. Other participants had a significantly higher average score of 16.7 compared to the other ethnic groups.Prostate‐specific antigen (PSA) levels were measured, with an average level of 8.5 ± 6.3 ng/ml across all participants. Black participants had an average PSA level of 11.2 ± 7.1 ng/ml, Hispanic participants had an average level of 6.7 ± 3.2 ng/ml, other participants had an average level of 5.5 ± 3.1 ng/ml, and Caucasian participants had an average level of 8.9 ± 7.3 ng/ml.
Conclusions: In summary, this study provides insights into the profile of ethnic minorities undergoing MRI fusion Ultrasound Prostate biopsy using the Koelis system. It highlights variations in prostate size, Pirads scores, Gleason scores, IPSS, and PSA levels among different ethnic groups, indicating potential differences in prostate health characteristics and the need for further investigation.
Funding: none
MODERATED POSTER SESSION 13: LAPAROSCOPIC AND ROBOTIC RENAL 1
Small Renal Mass Management in Latin America: Why is a Preoperative Biopsy Not (Yet) Standard of Care?
Antonio Rebello Horta Gorgen1, Jaime Altamiro1, Andrei D. Cumpanas1, Zachary E. Tano1, Roshan M. Patel1, Ralph V. Clayman1, Jaime Landman1
1University of California, Irvine
Presented By: Bruce Gao, MD
Introduction: Across the globe, renal mass biopsy (RMB) is not routinely performed for the management of small renal masses (SRM), despite an ongoing 20% rate of incidental nephrectomy/partial nephrectomy (i.e., benign histopathology). Recent literature has clearly dispelled cited reasons by U.S. urologists for not doing a RMB and thus the AUA guidelines have been accordingly amended. This study aimed to assess the use of preoperative RMB for SRM among Latin American urologists.
Methods: A survey was distributed through the Sociedade Brasileira de Urologia, Confederación Americana de Urología, Sociedad Argentina de Urología, Sociedad Chilena de Urología, and Sociedad Colombiana de Urología. The survey consisted of three parts: demographic information, management of five clinical SRM scenarios in each of which a RMB would be well within the stated AUA guidelines, and a list of potential reasons for rejecting a preoperative SRM.
Results: The survey was completed by 174 urologists: 75 from Brazil, 53 from Chile, 30 from Colombia, and 18 from Argentina. Among the respondents, 24% were urologic oncologists, 5% were endourologists and 12% were residents or fellows. The survey included urologists from academic practice (25%), private practice (27%), or both (49%). Most urologists (58%) considered RMB in fewer than 10% of the five scenarios (never (24%)). Only 3.4% of the urologists recommended RMB in the majority (> 50%) of their SRM cases. The most common reasons for a nonbiopsy strategy were: no alteration in management (46%), risk of false negative results (45%), and complication due to RMB (24%). (Table 1). In the five clinical scenarios, a preoperative RMB was recommended by 2%, 8%, 6%, 12%, and 4% of the urologists, respectively (Table 2).
Conclusions: RMB for SRM in Latin America is rarely performed. The reasons cited by Latin American urologists are similar to reports in the U.S. literature. Despite current AUA guidelines supporting RMB in a variety of clinical scenarios, a nonRMB approach persists.
Funding: None.
Initial Experience in Urological Surgery with a Novel Robotic Technology: Magnetic‐Assisted Robotic Surgery in Urology
Belén Giménez4, Juan Fulla1, Francisca Larenas1, Isidora Flores1, Cristobal Roman2, Christian Martinez1, Tomas Gatica2, Catherine Sanchez3
1Universidad de Chile, 2Universidad Finis Terrae, 3Clinica las Condes, 4Urology Department, Universidad de Chile, Hospital Clínico San Borja Arriarán
Presented By: Belén Giménez, MD
Introduction: Magnetic Assisted Robotic Surgery (MARS) platform, developed by Levita Magnetics (California, USA), has been developed to maximize the patient benefits of minimally invasive surgery while enhancing surgeon control and visualization. The objective of this study was to evaluate the safety and efficacy of the MARS platform in laparoscopic renal and adrenal surgery for the first time.
Methods: A prospective, single‐arm, open‐label, ethics committee‐approved study was performed. Clinical Trials Identifier: NCT05353777. Fifteen cases of patients with renal or adrenal pathology, who were submitted to laparoscopic surgery between April and June 2022 were included. All patients were followed up to 30 days after surgery. Preoperative, intraoperative, and postoperative data were recorded. Polynomial regression was used to determine the learning curve for docking time.
Results: Ten females and five male cases were included (mean age, 55 years‐old and mean BMI, 29 cm/m2). No cases required conversion to open surgery and all patients were discharged on the first or second postoperative day. No complications or re‐admissions were reported within the first 30 days. All oncological cases had negative margins. Learning curve was achieved by the 4thcase, diminishing docking time from 5.22 (range 2.6‐11.5; SD 2.9) to 2.68 minutes (2.1‐3.8; SD 0.67) (p = 0.002). The learning curve was fitted to a cubic regression and obtained a R2 = 0.714.
Conclusions: This is the first clinical study that demonstrates the safety and versatility of the MARS Platform in urological surgeries. The robot was especially useful for tissue retraction, avoiding additional incisions and obviating the need for a surgical assistant, while increasing surgeon control and visualization. The learning curve was fast, achieving a short docking time after the fourth case. Further studies are required to assess its applicability in other surgical areas of this promising new technology.
Funding: None
Renal Mass Biopsy: Risk of Complications and Discordance with Final Surgical Pathology
M. Reza Roshandel2, Christopher L. Welle1, Thomas D. Atwell1, Kelly S. Lehner2, Austin J. Martin2, Stephen A. Boorjian2, John J. Schmitz1, Anil Nicholas Kurup3, Vidit Sharma2, Bradley C. Leibovich2, Aaron M. Potretzke2
1Mayo Clinic, Department of Radiology, 2Mayo Clinic, Department of Urology, 3Mayo Cinic, Department of Radiology
Presented By: M. Reza Roshandel, MD
Introduction: Renal mass biopsy (RMB) may be used to determine histology and risk stratification but may be limited by a nondiagnostic result. RMB has a low reported risk of complications. We evaluated potential associations of RMB characteristics and discordance to final pathology and complications.
Methods: We retrospectively reviewed medical records of patients who underwent RMB from 2003‐2017. Data were collected regarding patient and tumor characteristics, biopsy technique, and histopathology. Diagnostic rates, concordance with nephrectomy pathology, and complications were analyzed. Multivariable logistic regression analyses were performed to assess for associations of RMB characteristics with discordant final pathology and complications.
Results: Of the 835 biopsies performed on 778 patients, 792 (95%) were diagnostic, and 627 (75%), 165 (20%), and 43 (5%) demonstrated malignant, benign, and nondiagnostic findings, respectively. Among the malignant pathology, there were 451 renal cell carcinoma, 79 urothelial carcinoma, 68 metastasis, and 29 others.A total of 313 patients (40%, 325 biopsies) underwent partial or radical nephrectomy. Final pathology was concordant with RMB regarding tumor type (excluding subtype and grade) in 280/302 (92.7%). 25 patients underwent surgery for benign RMB, of which 5 (20%) had final malignant pathology. No significant associations were observed between concordance of biopsy pathology to the final pathology and variables such as BMI, tumor size and location, needle size, and number of needle passes.Complications by Common Terminology Criteria for Adverse Events (CTCAE) classes of I, II, III, and IV occurred in 14 (1.7%), 10 (1.2%), 11 (1.3%), and 4 (0.5%) of biopsies. There was a single case with concern for tract seeding. After adjusting for other characteristics, BMI (OR = 1.04) and %‐extent of necrosis on imaging (OR 0.98) were independently associated with complication rate (p < .05) (Table).
Conclusions: RMB is associated with a low rate of complications. The diagnostic yield of RMB is high along with a considerable concordance between RMB and final pathology regarding tumor type. However, clinicians should be mindful of the possibility of a false negative biopsy.
Funding: N/A
Complex Renal Tumors: A Comparative Analysis Between Robotic Assisted Partial Nephrectomy and Robotic Assisted Radical Nephrectomy
Ketan Badani1
1Icahn school of medicine, Mount Sinai
Presented By: Ketan Badani, MD
Introduction: We aim to compare functional outcomes and complication rates between patients undergoing robotic‐assisted partial nephrectomy (RAPN) and robotic‐assisted radical nephrectomy (RARN) for highly complex renal tumors.
Methods: Patients from our multi‐institutional database with highly complex renal tumors (R.E.N.A.L nephrometry score ≥10) undergoing RAPN or RARN between 2008‐2021 were included. Patients with prior ipsilateral, bilateral, or multiple renal masses were excluded. Inferential statistics were used and multivariable logistic regression was performed to evaluate de novo chronic kidney disease (CKD) defined as new‐onset CKD stage ≥3 after surgery.
Results: Of 320 patients 195 were (60.9%) male, 125(39%) females; 209(65.3%) underwent RAPN while 111 (34.7%) underwent RARN. Mean (SD) age was smaller in RAPN [59 (12) vs. 63 (12), p = 0.003]. The RAPN group had a larger mean baseline eGFR [84.7 (22.2) vs. 78.8 (20.9), p = 0.021], smaller tumor size [4.48 (2.18) cm vs. 6.67 (2.43) cm, p < 0.001] and fewer R.E.N.A.L scores of [12 (3 (1.44%) vs. 19 (17.12%), p < 0.001]. Other baseline characteristics were comparable. RAPN had a smaller delta eGFR [‐11.32 (14.64) vs. ‐23.04 (14.98), p < 0.00] and incidence of de novo CKD [35 (16.75%) vs 47 (42.3%), p < 0.001] at a 12 (6‐25) months follow‐up with similar perioperative morbidity and postoperative complications. In multivariate analysis controlling for covariates, the RAPN group was less likely to have de novo CKD (OR: 0.31, 95% CI: 0.17, 0.57).
Conclusions: Patients undergoing RAPN had better functional outcomes compared to RARN without increased complications. When feasible, RAPN should be considered in high complexity tumors to optimize kidney functional outcomes.
Funding: None
Robot‐Assisted Radical Nephroureterectomy Using a Hinotori Surgical Robot System: Report of First Series of Four Cases
1Division of Urology, Department of Surgery, Tottori University Faculty of Medicine
Presented By: Ryutaro Shimizu, MD, PhD
Introduction: We have been routinely performing RANU using the da Vinci surgical robotic system since July 2019. Recently first made in Japan, the HinotoriTMsurgical robot was introduced in our center. Now we are performing RANU using both the da Vinci and the HinotoriTMsystem. To report our initial experience of Robot‐assisted radical nephroureterectomy (RANU) using the HinotoriTMsurgical robotic system and to compare the perioperative outcomes with the cases performed using the da Vinci system.
Methods: An 8‐mm robotic port was placed two finger widths below the costal margin at the lateral edge of the rectus muscle, the third arm was placed as close to the midline as possible, and the camera and robotic another arm ports were placed 7 cm apart from each robotic arm port. The 12‐mm assistant port was placed at least 5 cm median from the camera port. This retrospective study included 21 cases with the da Vinci and 5 cases with hinotori, in which the RANU was performed from April 2019 to April 2023. Five hinotori cases were reported in detail and retrospectively compared to the da Vinci for comprehensive perioperative outcomes.
Results: For the da Vinci and hinotori, respectively, the median age was 67 (range: 35‐84) and 74 (range: 62‐ 87) years. Retroperitoneal approach was performed in 5 cases (23.8%) using the da Vinci system and 0 cases using the Hinotori system, lymph node dissection was performed in 18 (85.7%) cases using the da Vinci system and 0 cases using the Hinotori system. The median operative time was 329 min (range: 216‐420 min) and 261 min (range: 234‐344 min), median blood loss was 50.0 ml (range: 5‐175 ml) and 15.0 ml (range: 5‐ 80 ml), postoperative Hb loss was 1.9 g/dL (range: 0.4‐3.7 g/dL), 2.1 g/dL (range: 1.1‐3.5 g/dL), postoperative CRP elevations were 5.71 mg/dL (range: 0.24‐14.98 mg/dL) and 10.98 mg/dL (range: 6.90‐ 22.91 mg/dL) respectively using the da Vinci and the Hinotori system. Clavien Grade III or higher complications were 1 (4.8%) in the da Vinci and 0 in hinotori. There was no open conversion and need for blood transfusion in either group.
Conclusions: Despite being a small case series, this is the first study focusing on RANU using the hinotori surgical robot system. Hinotori surgical robotic system was found to be safe and efficacious in performing RANU with comparable perioperative outcomes to those performed with the da Vinci system.
Funding: Nothing
Feasibility of Respiratory Adjustment for Laser Lithotripsy and Stone Removal Using Robotic Retrograde Intrarenal Surgery System Zamenix™ in a in‐Vitro Model
1Department of Urology, Seoul National University Hospital, Seoul National University College of Medicine, 2ROEN Surgical. Inc, 3Division of Urology, Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 4ROEN Surgical, Inc., 5Department of Urology, Seoul National University Hospital, 6Department of Mechanical Engineering, Korea Advanced Institute of Science and Technology, KAIST / CEO, ROEN Surgical, Inc., 7Department of Urology, Severance Hospital, Urological Science Institute, Yonsei University College of Medicine
Presented By: Sung Yong Cho, Professor
Introduction: This study aimed to investigate the improvement of stone fragmentation rate and safety in robotic retrograde intrarenal surgery (RIRS) systems that automate the adjustment mechanism for respiratory motion in vitro.
Methods: Stone fragmentation was performed in three groups: manual procedure (M), robotic procedures without respiratory adjustment (RNR), and robotic procedure with respiratory adjustment (RR). The study assessed the total procedure, number of mucosal contacts, total energy used, and number of pulses. We evaluated the impact on the parameters according to surgeons' experience.
Results: The average procedure times for groups M, RNR, and RR were 1,698.2 ± 370.9sec, 1,270.9 ± 269.2sec, and 1,103.7 ± 157.9sec, respectively. The RR group achieved stone‐free status the fastest. The RNR group showed a 25% decrease in procedure time compared to group M, while group RR decreased by up to 35% to achieve stone‐free status. There were no significant differences between the RNR and RR groups. The average number of mucosal contacts during each procedure was 0.89 ± 1.4. The total energy used was 3.17kJ ±0.72, and the number of pulses was 15,091.61 ± 3283.11. None of these parameters showed significant differences across the groups. The number of mucosal contacts was reduced in both the RNR and RR groups compared to group M. There were significant differences in procedure times between the two surgeons. However, the number of mucosal contacts was significantly reduced with the help of the robotic system for less experienced surgeon.
Conclusions: Robotic RIRS systems enhanced the stone fragmentation rate. Furthermore, it improves the safety for less experienced surgeon.
Funding: This work was supported by the National Research Foundation of Korea(NRF) grant funded by the Korea government(MEST) (No. 2022R1F1A1059835) andthe Korea Medical Device Development Fund grant funded by the Korea government (the Ministry of Science and ICT) (Project Number: 1711194216, RS‐2020‐KD000010).
Surveillance of cT1 Renal Masses is Common in Patients with CKD
Samantha Wilder2, Allison May1, Neil Vaishampayan1, Samantha Wilder2, Ji Qi1, Mahin Mirza1, Anna Johnson1, Sabrina L. Noyes3, Mohit Butaney2, Yuzhi Wang2, Craig G. Rogers2, Michael Levin4, Todd Morgan1, Brian R. Lane3
1University of Michigan School of Medicine, 2Henry Ford Health, 3Spectrum Health Hospital System
4Beaumont Hospital ‐ Comprehensive Urology
Presented By: Samantha Wilder, MD
Introduction: Patients with chronic kidney disease (CKD) and T1 renal masses (T1RM) represent a difficult group to treat. Most published data support the important role of partial nephrectomy (PN) in this context, however real‐world decision making is complex and most published series use intervention as the trigger for inclusion. This selection bias has likely led to under‐reporting of surveillance. We aim to describe GFR outcomes and treatment trends in patients with CKD and T1RM within practices participating in MUSIC‐ KIDNEY.
Methods: We reviewed the MUSIC‐KIDNEY registry for patients undergoing urologic evaluation for T1RM from 9/2017 to 1/2022. Patients were categorized as having CKD if pre‐existing GFR was < 60 ml/min/1.73m2, or without CKD when GFR ≥60. Inclusion criteria mandated that GFR data was available at ≥6 months post‐diagnosis. The primary outcome was “substantial GFR decline,” defined as a drop of > 15% and to GFR < 45. Trends in treatment and GFR outcomes were compared between patients with or without CKD and between treatment categories.
Results: We identified 3,036 patients evaluated for T1RM. 839 (28%) had pre‐existing CKD. Similar rates of ablation and RN were seen between the CKD and no‐CKD groups. Interestingly, rather than an increase in rate of PN in the CKD group, a decline was seen (17% in CKD vs. 34% in no‐CKD). A concomitant increase in rate of surveillance was observed (61% in CKD vs. 47% in no‐CKD) (Figure 1a). Among CKD patients, active surveillance was more likely to be used in older patients (76 yr vs. 67 yr) with greater comorbidity (48 with CCI ≥2 vs. 47% with CCI = 0) and smaller masses (2.3 cm vs. 3.2 cm) when compared to PN. Of the 822 patients with 6 month follow up, 102 (12%) had a substantial decline in GFR: 27% of those with pre‐existing CKD and 7% without CKD. PN and RN led to notably higher rates of GFR decline in those with pre‐existing CKD compared to those without (Figure 1b).
Conclusions: Despite the long‐held notion that patients with T1RM and CKD have an imperative indication for nephron‐sparing interventions, predominately PN, our study suggests urologists and patients commonly choose to avoid intervention altogether. This may reflect an under‐recognition or shift towards non‐operative management of T1RM, particularly in patients at high risk for significant renal functional decline.
Funding: Blue Cross Blue Shield of Michigan
A Meta‐analysis Comparing Safety and Efficacy of Ablation Therapy versus Partial Nephrectomy for Renal Masses in a Solitary Kidney
Mark I Sultan1, Mark I Sultan1, Ahmad Abdalaziz1, Nina Kar1, Muhammed A Hammad1, Pengbo Jiang1, Greg E Gin1, Roshan M Patel1, Mark L Jordan1, Jaime Landman1, Ramy Youssef1
1University of California, Irvine
Presented By: Mark I Sultan, MD
Introduction: A renal mass poses a clinical dilemma for patients with a single functional kidney due to the need for preserving renal function to prevent End Stage Renal Disease (ESRD). As both thermal ablation and partial nephrectomy are recommended nephron‐sparing approaches, this systematic review and meta‐analysis aims to evaluate the outcomes of ablative therapy compared to partial nephrectomy in patients with a solitary functional kidney.
Methods: A comprehensive search was undertakento identify relevant studies. Only clinical studies reporting outcomes of patients with ablative therapy compared to partial nephrectomy in the setting of a solitary functional kidney were included. A random effects model was used,effect sizefor continuous variables (Tumor size, glomerular filtration rate (GFR)) wasprocessed using Cohen's D statistic and the effect size for dichotomous outcomes (complications, recurrence, and metastasis) were calculated based on the natural log transform of the risk ratio.
Results: 14 studies were elected to assess the impact of ablative therapy (n = 727) compared to partial nephrectomy (n = 1380). Table 1 summarizes the weighted means of each treatment group, the estimated effect size, and the significance in difference. Lesions treated by ablative therapy were smaller compared to partial nephrectomy (p < 0.001). The pretreatment GFR was lower in the ablation cohort (p < 0.001). Ablative therapy demonstrated a higher rate of local recurrence (p = 0.013) however no significant difference in the rate of metastasis were observed (p = 0.062). Ablative therapy demonstrated superior functional outcomes compared to partial nephrectomy with a lower percent reduction in GFR after intervention (p = 0.006). Complications, defined as Clavien‐Dindo grade 3 or greater, were more frequent for patients undergoing partial nephrectomy (p < 0.001).
Conclusions: In a solitary kidney with a renal mass, patients treated by thermal ablation tend to have smaller masses and a lower pretreatment GFR. Ablative therapy, for masses less than 3.4cm, was associated with less complications and more preservation of kidney function. Though there was a greater risk of local recurrence with thermal ablation, there were no significant difference in the rate of metastasis. Thus, legitimizing the safety and efficacy of thermal ablation in the setting of a solitary kidney.
Funding: None
Technical Skill of Partial Nephrectomy on Patient Outcomes: A Video Review Project
Samantha Wilder1, Samantha Wilder1, Yuzhi Wang1, Mahmoud Hijazi2, Mahin Mirza2, Monica Van Til2, Khurshid R. Ghani2, Thomas Maatman3, Alice Semerjian4, Bradley Rosenberg5, Brian Seifman6, Brian R. Lane7, Craig G. Rogers1
1Henry Ford Health, 2University of Michigan School of Medicine, 3Michigan Urological Clinic, 4IHA Urology, St. Joseph Mercy Hospital, 5Beaumont Hospital ‐ Comprehensive Urology, 6Beaumont Hospital ‐ Michigan Institue of Urology, 7Spectrum Health Hospital System
Presented By: Samantha Wilder, MD
Introduction: It is unknown if technical skills of surgeons performing robotic partial nephrectomy (RPN) are linked to patient outcomes. We conducted a peer surgeon video review exercise in a surgical collaborative to understand if aspects of the procedure could be identified for improving patient outcomes.
Methods: RPN surgeons participating in a statewide quality improvement collaborative (MUSIC‐KIDNEY) were invited to submit and review RPN videos. Videos were segmented into 6 steps: exposure of kidney, identification of ureter and gonadal, hilar dissection, tumor localization, clamping and resection, and renorrhaphy. Video clips were deidentified and distributed to blinded peer reviewer surgeons who provided written feedback and scores using a previously published evaluation tool: Scoring for Partial Nephrectomy (SPaN), 1 = lowest and 5 = highest. Outcomes from MUSIC registry for all submitting surgeons were assessed for length of stay (LOS), estimated blood loss (EBL) > 500, warm ischemia time (WIT) > 30 min, positive surgical margin (PSM), and readmission. Surgeons were stratified into low scoring (score ≤ median score) and high scoring (score > median). Outcomes were compared between cohorts through Chi squared and Fisher's exact test with p‐value < 0.05. Score card and written comments were provided to all participants. Participant survey results were collected 2 months after video review.
Results: 11 surgeons submitted a total of 127 video clips; 379 total reviews were performed by 24 reviewers over the span of 2 months. The average score for reviewed clips was 4.1, with surgeon averages ranging between 3.6 and 4.7. Low‐scores overall as well as in tumor resection and renorrhaphy were significantly associated with several outcomes including PSM, 30 day readmissions, EBL, and LOS (Figure). Surveys indicated submitters and reviewers found the process and score card valuable for identifying areas of improvement, learning different RPN techniques, and educating trainees.
Conclusions: Video review of RPN demonstrated that surgeons with higher technical skill had a significantly lower frequency of intraoperative and post‐operative complications. Given these results, the MUSIC‐ KIDNEY collaborative are in the process of developing interventions to address technical aspects of RPN with the goal to reassess and improve outcomes.
Funding: Blue Cross Blue Shield of Michigan
Robotic Nephrectomy with the CMR Versuis System in the Highest Volume Centre in the United Kingdom: from Conception to Delivery
Sachin Veer1, Amal Baby1, Tharani Mahesan1, James Henderson1, Shahid Khan1
1East Surrey Hospital
Presented By: Sachin Veer, Specialty Registrar in Urology
Introduction: In 2019, A decision was taken to incorporate Robotics as a part of our treatment options for Urology patients requiring laparoscopic surgery. At the time, other surgical specialities were exploring the option of procuring a robot, and a joint decision was made to obtain the CMR Versius Robot.
Methods: Training commenced for two consultant robot naïve urologists and theatre staff in Cambridge in May 2021. The surgeons also completed 60 hours of training modules each. The first case was performed on May 26th 2021. To date we have performed 43 robotic renal cases, currently making us the highest volume centre on the CMR Versius in the UK.Between May 2021 and May 2023 patients who were diagnosed with renal tumour , ureteric tumour and were fit for minimally invasive surgery, underwent robotic radical nephrectomy and nephroureterectomy with CMR Versius robotic platform. 8 nephroureterectomies, 1 Nephrectomy + Adrenalectomy along with thirty four radical nephrectomy were performed. Surgical data were retrospectively reviewed from a prospectively collected database.
Results: Twenty nine men and fourteen women, with a median (range) age of 57 (47‐ 86) years underwent surgery with average BMI 28.1 kg/m2 ( 21‐ 48) and average ASA 2 (2‐3). Average size of tumour was 7.45 cm ( 11‐ 3.0cm) , with mean skin to skin operating time at 279.7 mins and average blood loss at 105.4mls. Average length of stay was 2.4 days. No patient required conversion to open, blood transfusion or re‐ exploration. There was 1 Clavien‐ Dindo grade II , 1 grade III and 1 grade V complication noted.Subjectively, surgeons reported improved spatial awareness, reduced dissection time at the hilum and improved ergonomics throughout as compared to standard laparoscopy .As with any new technique, there was a learning curve. Initially we performed one case (average 345 mins), however as surgical time reduced (average 210 mins), including the time for docking Robot, now we are performing two renal robotic surgeries in a day.
Conclusions: Since the introduction of CMR Versius robotic system, robot naïve surgeons have voiced satisfaction with regards to reduced stress, ease of access and ergonomics, while maintaining excellent clinical outcomes.
Funding: The funds were provided by the NHS trust
Accuracy and Readability of Common Patient Questions for Small Renal Masses: Artificial Intelligences versus Accredited Patient Information Materials
Connor Forbes1, Anna Black1, Connor Forbes1
1University of British Columbia
Presented By: Connor Forbes, MD, FRCSC
Introduction: Artificial intelligence (AI) has introduced an alternative platform for patients to inquire about health‐related matters, potentially influencing care‐related decisions. Patients are often provided with Patient Information Materials (PIMs) from respected bodies like the CUA, AUA, and EAU for self‐reading. Recently, ChatGPT has emerged as an open‐access AI platform that generates outputs in simple language. In this study, we compared the accuracy and readability of ChatGPT's responses to PIMs published by accredited bodies regarding the diagnosis of a small renal mass (SRM).
Methods: We identified the most commonly asked clinical questions by patients about SRMs and posed them to ChatGPT. Two independent reviewers evaluated the accuracy of each response using accredited PIMs as the reference standard (rated on a scale of 1 to 5, with 1 = inaccurate and 5 = accurate). Readability scores of each ChatGPT response were assessed and compared with the CUA PIM using standardized SMOG and Gunning Fog readability assessments with descriptive statistics.
Results: Readability scores ranged from 11.6 ‐ 18.5 and 8.8 ‐ 19.8 for ChatGPT responses, compared to 12.5 ‐ 14.8 and 12.9 ‐ 15.3 for CUA PIMs on the SMOG and Gunning Fog scales, respectively. Accuracy assessment for ChatGPT answers regarding general information, treatment options, and long‐term care scored 4.5, 4.7, and 4.4, respectively. This indicates accurate information with minor detail omitted. On average, the CUA PIM was more “readable” compared to the ChatGPT outputs (CUA average readability 13.9 vs ChatGPT average readability 15.1). All categories were found to have a statistically significant difference in readability, favoring the CUA PIM.
Conclusions: Overall, ChatGPT provided accurate answers that omitted minor details to common patient questions regarding SRMs. ChatGPT answers did not compare favorably to the CUA PIM regarding readability. ChatGPT provides a novel way to access information from a patient perspective, but it should not replace PIMs from accredited institutions such as the CUA. Limitations to the information provided by ChatGPT are important to understand by clinicians to appropriately counsel patients.
Funding: None to disclose
Surgical Technique and 14‐Year Follow‐up of Oncologic and Renal Function Outcomes: Radiofrequency Ablation of Renal Tumors 3‐7 cm
Tonya S. King1, Genesis G. Dolgetta1, Robert I. Carey2, Benjamin J. Behers3, Maximilian S. Carey2, Karim Ghazli2
1Sarasota Memorial Health Care System Research Institute, 2Sarasota Memorial Health Care System
3Florida State University College of Medicine
Presented By: Tonya S. King, PhD
Introduction: In this study,we describe the 14‐year follow‐up of oncologic and renal function outcomes for a cohort of patients who underwent laparoscopic radiofrequency ablation (LRFA) of SERMs with real‐time temperature monitoring of the ablation zone with non‐conducting fiberoptic thermistors.
Methods: All patients undergoing LRFA for SERM were prospectively entered into an IRB‐approved database. Renal function was assessed at 3 months and annually thereafter. Changes in GFR were calculated using the Modification of Diet in Renal Disease formula. LRFA was performed with a Covidien Cooltip probe system using multiple probes and multi‐pass technique. Direct real‐time, fiberoptic temperature monitoring was performed for each case with temperature goals of greater than 60 degrees C achieved at the deep and peripheral margins.
Results: The mean patient age was 73.3 years (SD 9.52), mean tumor size of 3.5 cm (SD 1.14), median tumor volume of 17.2 cm3 (1.77, 203.69), and mean RENAL nephrometry score of 6.8 (SD 1.36).Median creatinine was 1.0 (0.6, 3.4) pre‐surgery, 1.1 (0.7, 3.8) at 3 months, and 1.2 (0.8, 2.4) at 3 years.Mean estimated GFR was 60.2 (SD 19.8) pre‐surgery, 55.7 (SD 20.20) at 3 months, and 51.0 (SD 15.84) at 3 years.Thirty‐one patients were female (41.3%), laterality was left 39 (52.0%) and right 36 (48.0%), all tumors were solid and enhancing.Pathology showed clear cell 36 (48.0%), papillary 11 (14.7%), chromophobe 1 (1.3%), oncocytic 19 (25.3%), malignant fibrous histiocytoma 1 (1.3%), angiomyolipoma 3 (4.0%), lung cancer metastasis 1 (1.3%), and nondiagnostic 2 (2.7%).Over the 14‐year follow‐up, 3 patients required a partial nephrectomy for locally recurrent RCC and 4 patients required a radical nephrectomy for locally recurrent RCC. Only one of the local recurrences developed metastasis. Overall, there were 4 instances of metastasis after LRFA leading to DSM, two of which were in T1a tumors which resulted in death 5 and 7 years after the ablation, one of which was a T1b tumor with DSM 3 years after RFA, and one of which was in solitary kidney with T1b tumor and history of contralateral nephrectomy for RCC.There were two instances of metastasis without DSM, a T1b patient alive with metastasis 15 years after RFA and a T1b tumor that died of metastatic lung cancer ten years after RFA but also had documented low‐volume metastatic RCC.The 14‐ year overall survival rate was 0.53, and the disease‐specific survival rate was 0.94. The risk of overall mortality in this study was 0.26 times lower for ASA 2 vs. 3/4 (95%CI 0.12‐0.58), p = 0.001, 2.1 times greater for every 1 unit increase in log‐transformed tumor volume (95%CI 1.18‐3.58), p = 0.011, 0.64 times lower for every 20‐unit increase (1 SD) in calculated pre‐GFR (95%CI 0.45‐0.92), p = 0.015, with adjustment for nephrometry score. Nephrometry score was the most significant predictor of salvage therapy (OR 4.0 for every 1‐unit increase, 95%CI (1.74‐9.0), p = 0.001), and metastasis (OR 2.4 for every 1‐unit increase, 95%CI (1.25‐4.55), p = 0.009).
Conclusions: This study documents the natural history of LRFA patients with 3‐7 cm SERMs followed for 14 years. Although LRFA is feasible with overall excellent preservation of kidney function and 94% DSS,preservation of renal function andrecurrence‐free‐survivaldecline inversely with tumor size and RENAL nephrometry score.Local tumor bed recurrence, metastasis, and DSM occur over long‐term follow‐up with these large tumors despite independent temperature monitoring.Long‐term follow‐up identified four deaths from metastatic RCC, one of which had pre‐existing metastasis but two of which were in T1a patients.
Funding: None.
Trends in Minimally Invasive Surgery for Kidney Cancer: A National Population‐Based Study
Celeste Manfredi1, Antonio Franco1, Morgan R. Sturgis1, Francesco Ditonno1, Daniel Roadman1, Jamie Yoon1, Adan Z. Becerra1, Srinivas Vourganti1, Riccardo Autorino1, Ephrem O. Olweny1
1Rush University Medical Center
Presented By: Celeste Manfredi
Introduction: Nephron‐sparing surgery (NSS) has revolutionized the field of urology by offering a conservative approach to the management of renal masses. However, current knowledge on clinical trends and utilization of renal minimally invasive surgery (RMIS) across different socioeconomic groups and different regions of USA is sparse. Our primary objective was to investigate overall complication rates among renal ablation, robotic partial and radical nephrectomy, including impact of social determinants of health (SDOH) on postoperative outcomes. Secondary analysis was to report frequencies across sociodemographic variables.
Methods: Patients who underwent robotic partial nephrectomy (n = 41,948), robotic radical nephrectomy (n = 26,004) and renal ablation (n = 12,869) between 2011 and 2021 were retrospectively analyzed by using PearlDiver‐Mariner, an all‐payer insurance claims database. International Classification of Diseases diagnosis and procedure codes were used to identify the type of surgical procedure, patient's characteristics, postoperative complications and SDOH. Outcomes were compared using multivariable regression models.
Results: Overall, 80,821 patients underwent RMIS. The 60‐day postoperative complication rate was 9% for partial nephrectomy, 10% for radical and 9% for renal ablation. Approximately 9% of patients reported at least one SDOH at baseline. SDOH were associated with higher odds of postoperative complications (Partial N = OR:1.31, 95% CI:1.18‐1.46; Radical N = OR:1.17, 95% CI:1.01‐1.36; Ablation N = OR:1.56, 95% CI: 1.28‐1.88;). Ablation appeared to be the safest procedure among the others, whereas robotic radical nephrectomy showed a higher risk of postoperative complications (OR:1.20, 95% CI:1.13‐1.27 and OR:1.15, 95% CI:1.08‐1.22) compared to the other two techniques. Opposite timeline trends were reported when comparing robotic partial to radical nephrectomy, from 24% in 2011 to 34% (p = 0.05) in 2021 and from 36% to 23% (p = 0.05), respectively. To note, patients who underwent ablation technique presented higher age (mean age: 67.45 ± 9.89), higher Charlson Comorbidity Index (mean CCI:5.24 ± 3.22) and higher adoption of Medicare insurance (29.8%). All RMIS were mainly adopted in the South Region, whereas West Region distribution presented the lowest rate.
Conclusions: NSS is definitively gaining momentum among treatment options for kidney cancer. SDOH disparities have significantly higher risk of postoperative complications following any type of RMIS.
Funding: None
Robotic Partial Nephrectomy in a Community Hospital Setting: One Surgeon's Ten Year Experience
David Price1, Tina Price1
1Ochsner Louisiana State University Health Shreveport
Presented By: David Price, MD
Introduction: To evaluate the operative and postoperative outcomes of patients undergoing robotic partial nephrectomy in the community hospital setting by a single experienced robotic surgeon, and to compare outcomes with those reported in the literature from higher volume centers of excellence.
Methods: The medical records of 60 attempted robotic partial nephrectomies performed in 3 community hospitals by a single experienced robotic surgeon between December 2007 and January 2017 were retrospectively reviewed. All patients underwent transperitoneal robotic partial nephrectomy with clamping of either renal artery only or both renal artery and vein individually.
Results: Results: 57 patients underwent successful robotic partial nephrectomy. One patient converted to an open partial nephrectomy and two patients electively converted to open nephrectomy were excluded from analysis. The most recent 26 renal masses where characterized using R.E.N.A.L. nephrometry scoring. Mean age of patients was 61.3 years. Mean tumor size was 2.9 cm. Mean surgical and warm ischemic time were 196 minutes and 23.1 minutes. Mean estimated blood loss was 155.8 mls. Pathology demonstrated 43 renal cell carcinomas, 13 benign lesions. Tumor stages were 37 T1a and 6 T1b. One patient had a microscopic positive surgical margin. Fifteen patients experienced complications and three patients received blood products. Mean increase serum creatinine at discharge was 0.15 mg/dl. Mean hospital LOS was 2.4 days. Comparison ofthis series with a high volume center of excellence during initial and later series of patients is demonstrated in table format.
Conclusions: In spite of the overall low number of cases performed per year, these data demonstrate that robotic partial nephrectomy can be performed safely and efficiently by private practice physicians in community hospitals with excellent outcomes. However, an experienced robotic surgeon, robotic team and careful patient selection is required.
Funding: None
Decision‐Making Regarding Conversion from Partial to Radical Nephrectomy in MUSIC‐ KIDNEY
Samantha Wilder1, Mohit Butaney1, Samantha Wilder1, Yuzhi Wang1, Mahmoud Hijazi2, David Gandham2, Monica Van Til2, Benjamin Goldman3, Ji Qi2, Mahin Mirza2, Anna Johnson2, Michael Rudoff4, David Wenzler5, Craig G. Rogers1, Brian R. Lane6
1Henry Ford Health, 2University of Michigan School of Medicine, 3Ascension Macomb‐Oakland Hospital
4Beaumont Hospital ‐ Comprehensive Urology, 5Comprehensive Urology, 6Spectrum Health Hospital System
Presented By: Samantha Wilder, MD
Introduction: Partial nephrectomy (PN) has emerged as the standard of care for localized small renal masses. Its use has expanded to include larger and more complex masses, with increasing potential for conversion to radical nephrectomy (RN). Limited data exists regarding specific reasons for conversion to RN. We evaluated incidence and reason for conversion in patients undergoing robotic PN (RPN) using data from a statewide quality improvement (QI) collaborative.
Methods: MUSIC‐KIDNEY maintains a prospective statewide registry of newly diagnosed T1RM. All patients with a plan to undergo RPN at initial visit with the urologic surgeon were queried and then stratified based on actual procedure performed (RPN vs. RN). Pre‐operative and intra‐operative records were obtained for each patient to confirm conversion from RPN to RN, determine preoperative assessment of PN difficulty, and assess reason for conversion. Patient, tumor, and practice variables were obtained via the MUSIC registry and compared between cohorts via Wilcoxon rank sum test. Pathologic data and postoperative renal function were assessed.
Results: A total of 650 patients were identified with an initial plan to undergo RPN. The rate of conversion from RPN to RN was 4.7% (27/650). No open conversions were documented. Patients undergoing conversion had larger (4.4 cm vs 2.8 cm) and higher complexity (63.0% with intermediate/high RENL score vs 51.6%) tumors. Patients who underwent conversion had significantly higher rates of pT3/T4 disease (28% vs 8.7%, p = 0.006) and lower postoperative renal function (Cr 1.3 vs 1.0, p < 0.001). Review of the 27 cases that underwent conversion found that 24 conversions were performed due to tumor complexity and/or oncologic concerns for locally‐advanced disease, with only 5 (0.9%) conversions secondary to intraoperative bleeding. Only 63.0% (17/27) of converted cases had preoperative documentation regarding assessment of PN difficulty and/or likelihood of conversion. 88% (15/17) of converted cases with preoperative documentation available indicated increased surgical complexity (‘PN vs. RN’, ‘complicated PN, etc.).
Conclusions: MUSIC‐KIDNEY has identified a low rate of conversion (< 5%) from RPN to RN within the collaborative that likely reflects the increased proportion of surgeries for tumors with increased oncologic risk, in which the plan may better be termed PN vs. RN. The rate of intraoperative conversion for uncontrolled bleeding was < 1%. These findings provide further data to justify the safety of PN, even in higher complexity tumors. We have identified QI opportunities to standardize preoperative documentation regarding PN difficulty, and multiple initiatives within MUSIC‐KIDNEY exist to improve this and other aspects of surgical care for patients with renal masses.
Funding: Blue Cross Blue Shield of Michigan
Does Fuhrman Grade 3‐4 Affect Oncologic Outcomes in Pathology T1a Renal Cell Carcinoma after Surgical Treatment?
Courtney Yong1, Courtney Yong1, Chinade Roper2, Morgan Black2, William Zhang2, Elise Patrick2, Kelly DeMichael2, Troy Wesson2, Sean O'Brien2, Rowan Farrell2, Chandru Sundaram2
1Indiana University, 2Indiana University School of Medicine
Presented By: Courtney Yong, MD
Introduction: We compared outcomes of T1a low grade (Fuhrman grade 1 or 2) and T1a high grade (Fuhrman grade 3 or 4) renal cell carcinoma (RCC) after surgical treatment.
Methods: With IRB approval, we conducted a retrospective review to identify patients undergoing surgical treatment for pT1a RCC at a single institution between 2000‐2017. Patient demographics, nephrometry score, biopsy results, surgical pathology, and recurrence data were collected. Time‐to‐event analysis was utilized to calculate hazard ratios (HR) for cancer‐specific (CSS), overall (OS), and recurrence free survival (RFS).
Results: The cohort included 743 patients. Patients with high grade masses were slightly older than those with low grade masses (56 vs 59, p = 0.001). The average nephrometry score was 7 for low grade and 8 for high grade pT1a. The positive margin rates for low and high grade pT1a were 5.2% and 7.5% respectively (p = 0.22). CSS, OS, and RFS were not significantly different between groups (Figure 1). Median follow up was 41 months.
Conclusions: The findings of this study suggest there is no significant difference in CSS, OS, and RFS when comparing patients with T1a low and high grade RCC. Alternative surveillance schedules based on tumor grade after surgical resection of pT1a RCC are not required.
Funding: None
Outcomes of Pathologic T3 Renal Cell Carcinoma: Does Size Matter?
Courtney Yong1, Courtney Yong1, Chinade Roper2, Morgan Black2, William Zhang2, Elise Patrick2, Kelly DeMichael2, Troy Wesson2, Sean O'Brien2, Rowan Farrell2, Chandru Sundaram2
1Indiana University, 2Indiana University School of Medicine
Presented By: Courtney Yong, MD
Introduction: We sought to determine the importance of tumor size on oncologic outcomes after surgical treatment of pT3 renal cell carcinoma (RCC).
Methods: A retrospective review identified patients undergoing surgery for pT3 RCC at a single institution from 2000‐2022. Data was gathered on demographics, tumor size, surgical pathology, and outcomes. Student's t‐test or chi‐squared analysis were performed. Recurrence‐free, overall, and cancer‐specific survivals (RFS, OS, CSS) were calculated using the Kaplan‐Meier method.
Results: 783 patients had pT3 RCC with preoperative imaging available for review. 78% had pT3a, 18% had pT3b, and 4% had pT3c. 13% had masses ≤4 cm. Ages were similar between masses > 4 cm and masses ≤4cm (61.8 ± 0.47 vs 63.0 ± 1.3), as was the positive margin rate (18% vs 11%, p = 0.08). RENAL scores were only different by the amount expected from the difference in mass size (10 vs 7.5). RFS was found to be associated with mass size but not T stage (Figure 1). OS and CSS were associated with both mass size and T stage (Figure 1). Median follow up was 15 months.
Conclusions: For pT3 RCC, size < 4 cm may be more beneficial in predicting outcomes than pathologic T stage, especially RFS and CSS. Size should be considered in risk stratification for the post‐surgical management of pT3 RCC.
Funding: None
Conversion from Laparoscopic Partial to Radical Nephrectomy in a Mid Volume Center
Ragaee Atamna3, Alexander Tsivian1, A.Ami Sidi2
1Edith Wolfson Medical Center, Holon, Israel. The Sackler Faculty of Medicine, Tel Aviv University., 2Edith Wolfson Medical Center, Holon, Israel . The Sackler Faculty of Medicine, Tel Aviv University, 3Edith Wolfson Medical Center, Holon, Israel . The Sackler Faculty of Medicine, Tel Aviv University.
Presented By: Ragaee Atamna, MD
Introduction: Conversion from a planned partial to radical nephrectomy is uncommon and occurs in approximately 5% in high volume centers. Herein we present a detailed analysis of causes for conversion to radical nephrectomy in a mid volume center.
Methods: Data base review of the patients who underwent partial nephrectomy using a minimally invasive approach between 07.2005 and 07.2022 identified patients who were converted to radical nephrectomy. Demographic data, tumor characteristics (size and location) were gathered, and the factors that caused conversion were analyzed.
Results: A total of 476 patients who underwent laparoscopic partial nephrectomy were reviewed. Most of the patients were men (65.3%).The median age was 72.5 years (range 24–84 years). Of those stage T1a, T1b and T2 was in 297, 139, and 40 patients accordingly.In 35 patients there were multiple tumors.The overall conversion rate to radical nephrectomy was 2.7% (13 patients). In 10 patients ( 77% ) the reason for conversion was bleeding, in 5 due to uncontrollable intraoperative and the other 5 – postoperative one. Of those central tumor was in 7 patients, multiple tumors ‐ in 2 and hilar ‐ in one. Oncological consideration, such as suspicion for positive margins, tumor thrombus and tumor undetection intraoperatively (1 patient in every case) were reasons for conversion. Of note, in this subgroup two tumors were more than 6 cm.
Conclusions: Low and conceivable conversion rate (2.7%) is achievable in a mid volume center. Preoperative characteristics such as hilar, central locations, tumor size and multiplicity were associated with conversions.
Funding: NO FUNDING
Robot‐Assisted Partial Nephrectomy for Complex (Padua Score ≥10) Tumors: Results from a High Volume Single Center
Tunkut Doganca3, Mustafa Bilal Tuna1, Omer Burak Argun2, Ilter Tufek2, Can Obek2, Ali Riza Kural2
1Acibadem Maslak Hospital, Urology, 2Acibadem University, School of Medicine, Urology, 3Acibadem Taksim Hospital, Urology
Presented By: Tunkut Doganca, MD
Introduction: The aim of this study is to compare the preoperative and peroperative outcomes of RAPN in PADUA score ≥10 and PADUA < 10 renal tumors in our center.
Methods: Between April 2008 and February 2023 a total of 354 patients had undergone RAPN. Demographic (Table 1), clinical (Table 2), preoperative, peroperative outcomes (Table3) of the patients were collected retrospectively. All of the procedures were performed with Da Vinci Si and Xi surgical system (Intuitive Surgical, Sunnyvale, CA, USA). Comparisons between the groups were evaluated with Mann– Whitney U test for continuous variables and with Chi‐squared test for categorical variables. A p‐value below 0.05 was considered significant.
Results: Of our study cohort 124 patients(35%) had PADUA score ≥10 (Group 1), and 230 patients (65%) had PADUA score < 10 tumors (Group 2). Group 1 (PADUA score ≥10) had a significantly lower mean age when compared to Group 2 (PADUA score < 10) (p = 0.003). No significant difference was found in terms of sex, BMI and surgical margin positivity between Group 1 (PADUA score ≥10) and Group 2 (PADUA score < 10). Tumor size, operation time, blood loss, need for collecting system repair, ischemia time and hospitalization time were significantly higher in Group 1 (PADUA score ≥10) when compared to Group 2 (PADUA score < 10)(p < 0,001, p = 0.002, p = 0.001 p < 0.001, p < 0.001, p < 0.001, p = 0.005 respectively).
Conclusions: Although increasing tumor complexity may affect the surgical outcomes; RAPN can be considered as an effective treatment option in complex (PADUA score ≥10) renal tumors.
Funding: None
The Camparative Study of Robot Partial Nephectomy for Renal Tumors; Transperitoneal versus Retroperitoneal Approach
Taek Sang Kim2, Yong Deuk Seo1, Dong Ha Kim2, Sung Bin Kim1, Won Tae Seo1, Su Hwan Kang1
1Deparment of Urology, Kosin University Hospital, 2Department of Urology, Kosin University Hospital
Presented By: Taek Sang Kim, MD PhD
Introduction: We analysed robotic partial nephrectomy ‐ transperitoneal (transperitoneal robotic partial nephrectomy, TRPN) and retroperitoneal (retroperitoneal robotic parthal nephrectomy, RRPN) approaches and compared the results.
Methods: We retrospectively investigated patients who underwent robotic partial nephrectomy at our hospital from November 2019 to May 2022. In a total of 70 patients, 35 TRPN and 35 RRPN performed. We reviewed the perioperative data such as age, hospital stay, operation time, warm ischemic time (WIT), estimated blood loss (EBL) during surgery, positive surgical margin, tumor size, renal nephrometry score(RNS), tumor location, post‐operative estimated glomerular filtration rate (eGFR) and complications.
Results: There were statistically significant differences in operation time, EBL, tumor size, RNS. In TRPN, tumor size was larger and RNS was higher. Operation time was shorter and EBL was less in RRPN. Tumor locations were also statistically different between two groups. In RRPN group, tumors were more tend to be located posterior and lower pole (Table).
Conclusions: In our study, RRPN had advantages for operation time and EBL than TRPN. RRPN was usually selected in posterior or lower pole located renal masses. However, there was a tendency to perform TRPN rather than RRPN in cases that were more complex in terms of tumor size or RNS. Although the choice between RRPN and TRPN depends on the surgeon's preference, when appropriately selected, RRPN can be effective choice for treatment of small renal masses.
Funding: none
MODERATED POSTER SESSION 14: EPIDEMIOLOGY, SOCIOECONOMIC AND HEALTH CARE POLICY 3 AND HISTORY
Ureteral Stone Surgical Treatment Costs: A Retrospective Analysis of 296 Procedures
Amit Shemesh1, Dor Golomb1, Hanan Goldberg2, Eyal Hen1, Fahed Atamna1, Amir Cooper1, Orit Raz1
1Samson Assuta Ashdod University Hospital, 2SUNY Upstate Medical University
Presented By: Amit Shemesh, MD
Introduction: Surgical interventions play a significant role in the direct treatment costs associated with urolithiasis. This study aims to evaluate the expenditure related to surgical treatment in patients presenting with ureteral stones at the Emergency Department (ED).
Methods: A retrospective analysis was conducted on all patients admitted to the ED and found to have a ureteric stone on CT. Clinical, laboratory, and imaging parameters were collected, along with data regarding admissions, ED readmissions, surgical procedures, and the total cost of treatment. The different cost rates were compared with regard to different stone parameters and characteristics, patient clinical presentation, laboratory results, admissions and surgical intervention.
Results: Between 2018 and 2020, a total of 805 patients visiting a single institution's ED were identified with CT‐proven ureteral stone. Of them, 296 patients underwent surgical procedures. Eleven patients (3.7%) underwent kidney drainage (KD) only (ureteral stent/nephrostomy), 260 (87.8%) ureteroscopy (URS) with or without retrograde internal renal surgery (RIRS), 4 (1.4%) percutaneous nephrolithotomy (PCNL), 4 (1.4%) extracorporeal shockwave lithotripsy (ESWL) and 17 (5.7%) patients underwent multiple procedure (MP). PCNL patients had the highest treatment cost (30,776$), followed by MP (21,016$), KD (16,326$), URS (12,435$) and ESWL (11,165$) [p < 0.001]. The average hospital stay was longest for PCNL patients with 15.75 days, followed by KD (15.7 days), MP (8.4 days), URS (6 days) and ESWL (4.25 days) [p < 0.001]. PCNL patients had larger stones (p < 0.001) and higher rate of proximal stone (0.003). Patients underwent KD, had higher inflammatory markers (CRP p < 0.001, WBC p = 0.02), positive urine culture rate (p = 0.026) and ICU admissions (p < 0.001). On logistic regression, length of stay was the sole parameter correlating with treatment costs (pearson correlation 0.937). A number of 188 patients underwent kidney drainage prior surgery. 171 (91%) ureteral stent (US), 11 (6%) nephrostomy (PCN), 3 (1.5%) multiple PCN and 3 (1.5%) multiple US and PCN. Pre‐drainage increased the total treatment cost, with patient underwent multiple PCN having the highest expenditure (52,290$), followed by multiple US and PCN (29,503$), PCN (18,893$), US (13,257$) and without drainage (11,274$) [p < 0.001].
Conclusions: Surgical treatment costs for ureteral stone are chiefly affected by hospital length of stay, which is dictated by stone burden, infectious state, and patient general health.
Funding: None
Can Remote Administration of Wisconsin Stone Quality of Life Survey Replace in‐Person Stone Symptom Surveillance in Telemedicine Era?
Emily Serrell1, Stephen Nakada1, Emily Davidson1, Christopher Haas2, Margaret Knoedler1, Scott Quarrier3, Rajat Jain3, Rachael Sherrer1, Shuang Li1, Kristina Penniston1
1University of Wisconsin, 2Tufts University School of Medicine, 3University of Rochester
Presented By: Emily Serrell, MD
Introduction: The Wisconsin Stone Quality of Life (WISQOL) is a stone‐specific health‐related quality of life (HRQOL) survey that is validated for in‐person use. Telemedicine has increasingly replaced in‐person visits. We compared the feasibility and reliability of remote administration of WISQOL.
Methods: WISQOL responses of patients from 4/1/2020 to 12/31/2022 from 2 institutions were collected. Patients completed WISQOL in‐person in clinic or remotely by telephone, mail, or electronic medical record (EMR). Univariate analysis was used to compare responses. Internal consistency was assessed with Cronbach alpha coefficient.
Results: WISQOL was completed by patients in clinic (n = 90) or by telephone (n = 90), mail (n = 90), or EMR (n = 90). Telephone surveys were completed in mean 8.3 ± 2.4 minutes, compared to 5 minutes in clinic (prior study). Mail respondents (mean age 62.6 years) were significantly older than clinic (54.1y) and telephone (56.6y; p < 0.05); EMR (59.4y) were older than clinic (p < 0.05).All survey methods demonstrated reliability with high Cronbach alpha coefficients > 0.97.No significant differences were seen in stone symptoms by survey method (yes symptoms: 32% clinic, 37% telephone, 27% mail, 22% EMR, p > 0.05). In asymptomatic patients, no significant differences across methods were seen in total WISQOL scores. Except lower vitality reported by EMR vs telephone (77.9 vs 88.4 score, p < 0.05), there were no other differences for WISQOL domain scores.Compared to asymptomatic patients, patients with symptoms reported worse HRQOL across all survey methods (p < 0.001 for all groups). Symptomatic patients surveyed by mail had lower total WISQOL scores than other methods (45.1 vs 62.7 telephone, 69.7 EMR, 56.5 clinic; all p < 0.05); no differences in WISQOL domains were seen between clinic, telephone, and EMR group responses. This was consistent across all domains (Figure).
Conclusions: WISQOL responses were reliable and internally consistent for in‐person and remote administration. Remote surveillance of stone symptoms is a practical option in the telemedicine era. Patients responding by mail were more likely to report lower HRQOL than by other survey methods. Further investigation should examine difference in response rates between methods and mail respondents' HRQOL.
Funding: None
Access to Care and Healthcare Utilization Among Patients with Nephrolithiasis
Kevin Wymer1, Mouneeb Choudry1, Sayi Boddu1, Gopal Narang2, Daniel Heidenberg1, Marlene Girardo1, Mitchell Humphreys1, Karen Stern1
1Mayo Clinic, 2University of North Carolina
Presented By: Kevin Wymer, MD
Introduction: Despite the high prevalence of kidney stones, little data exist regarding the prevalence of barriers to obtaining care. We sought to use a diverse dataset to evaluate and characterize the impact of nephrolithiasis diagnosis and treatment on healthcare utilization and identify predictors of barriers to care in the patient population.
Methods: We conducted a retrospective cohort study using the All of Us Database, an NIH database targeting recruitment of underrepresented populations. Patients with a diagnosis of kidney stones were included and matched to a control group. Primary outcomes were patients' self‐reported healthcare access and utilization. Univariable and multivariable regression analyses were performed.
Results: 9,173 patients with a diagnosis of nephrolithiasis were included and matched to 9,173 controls. Patients with kidney stones were less likely to have had > 1 year since last provider visit (1.7% vs. 3.8%, p < .001), but did not report increased delays obtaining care (31%), inability to afford care (11.4%), or higher likelihood of skipping medications (12.9%). Among patients with stones, 1,208 (13.2%) had been treated surgically. On multivariable analysis, younger age, female sex, lower income, lower education, non‐ insured status, and lower physical and mental health were all associated with delays obtaining care, difficulty affording care, skipping medications, and/or prolonged time since seeing a provider (Table).
Conclusions: A diagnosis of nephrolithiasis and subsequent surgical intervention were not associated with an increase in patient‐reported barriers to care. However, among patients with nephrolithiasis, younger, comorbid, female patients from lower socioeconomic status are at significant risk of being unable to access and utilize treatment.
Funding: This work was supported in part by the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery
Impact of COVID‐19 Outbreak on Consultation and Radiological Exams for Urinary Stones in the Largest Public Health System in the World
Oscar Fugita1, Carolina Correa1, Barros Jacson2, Jose Otoch1, Joao Amaro3
1Hospital Universitario ‐ Universidade de Sao Paulo, 2Universidade de Sao Paulo, 3Faculdade de Medicina de Botucatu ‐ Universidade Estadual Paulista
Presented By: Oscar Fugita, MD, PhD
Introduction: The Brazilian Public Health System (SUS) is the largest and one of the most complex public health systems in the world. It allows any person living in Brazil to have universal access to the Brazilian public health system, guaranteeing health support to more than 170 million people. The Brazilian Public Health Information System (DATASUS) is a publicly available database that comprises information from SUS including those from all public health hospitals throughout the country.Some previous papers evaluated the impact of the COVID‐19 outbreak on acute urinary stone presentation, hospitalizations and management. However, to the best of our knowledge, no previous publication addressed the impact of the COVID‐19 pandemia on the access of patients with urinary stones to the health system. The aim of this paper is to present the impact of the COVID‐19 outbreak onconsultations and radiological exams for urinary stones in the SUS.
Methods: This is a cross‐sectional study reviewing health system access (urgent and elective consultation) and access to radiological exams (CT‐scans and Ultrasounds) from de DATASUS. All gathered information associated with the urolithiasis diagnosis (ICD‐10 N20) between January 2018 and December 2022 was analysed. Urgent and elective consultations and radiological (CT‐scans and US) exams were differentiated in the statistics. There was no need for IRB or informed consent as DATASUS uses secondary data.Covid‐19 vaccination in Brazil started in January/2021. In January/2022, about 70% of the Brazilian population was fully vaccinated. For data analysis, 2020/2021 (COVID‐19 outbreak) data were compared to the 2018/2019 data (pre‐COVID‐19 outbreak). The 2022 data were used to discuss the impact of vaccination on the number of consultations and radiological exams performed for urinary stones in the Brazilian Public Health System.
Results: A total of 2.224.902 consultations for urinary stones (ICD‐10 N20) were performed from January 2018 to December 2022 in the Brazilian Public Health System (SUS). 51.8% of patients were female and 64.4% ranged from 31 to 60 years of age.During the COVID‐19 outbreak (2020‐2021), there was a significant decrease (20.4%) in urinary stone‐related elective consultations compared to the preceding years (2018‐2019). There have been 344.957 and 351.620 consultations in 2018 and 2019, respectively (total of 696.577), compared to 266.996 and 287.251 in 2020 and 2021, respectively (total of 554.247). In 2022, there have been a total of 331.867 consultations. On the other hand, the number of urgent consultations due to urinary stone disease increased progressively during the same period. (Figure 1).The total number of consultations (urgent and elective) per year was as follows: 433.851 (2018), 450.603 (2019), 386.111 (2020), 435.437 (2021) and 518.900 (2022). A drop of 7.1% in the total number of consultations was observed comparing the 2018‐2019 (pre‐COVID) to the 2020‐2021 (COVID outbreak) periods.In 2018 and 2019, 72.288/49.292 (121.580 total) and 74.554/52.317 (126.871 total), CT scans/US were performed, respectively. In 2020 and 2021, 67.028/39.986 (107.014 total) and 72.232/38.829 (111.061 total) CT scans/US were performed, respectively. A drop of 22.4% and 5.1% in the total number of US and CT scans, respectively, was observed comparing the 2020‐2021 (COVID outbreak) period to the 2018‐2019 (pre‐COVID) period.A drop of 12.2% in the total number of radiological exams was observed comparing the 2018‐2019 (pre‐ COVID) to the 2020‐2021 (COVID outbreak) periods.In 2022, 85.619 CT scans and 37.676 US (123.295 total) were performed.
Conclusions: During the COVID‐19 outbreak, the elective (20.4%) and total number of consultations (7.1%) for urinary stones in the Brazilian Public Health System decreased, despite of an increase of the urgent consultations (42%). This may have impacted the number of surgical procedures, as stated by other authors worldwide and in Brazil as well. Regarding the radiological exams, the impact of the COVID‐19 outbreak was even more evident (12.2%), because of the lower number of US (22.4%) performed during this period (2020‐2021) compared to the pre‐COVID outbreak (2018‐2019) period.In 2022, more than 80% of the Brazilian population had been fully vaccinated for COVID‐19. This may have positively impacted the number of consultations and radiological exams performed for urinary stones during the year of 2022.
Funding: None
A Reimbursement Paradox for Ureteroscopy: The Higher the Risk, the Lower the Payment
Victoria S. Edmonds1, Kevin M. Wymer1, Mitchell R. Humphreys1, Karen L. Stern1
1Mayo Clinic Arizona
Presented By: Victoria S. Edmonds, MD
Introduction: Ureteroscopy for stone treatment carries higher risk of complication in comorbid patients. In the United States, hospital and facility payments for stone treatment episodes are now risk‐adjusted to account for patient complexity. However, this is not reflected in surgeon payment. We compared surgeon
reimbursement among patients with differing risk profiles undergoing ureteroscopy with laser lithotripsy stones.
Methods: The publicly available “2021 Medicare Physician and Other Provider” file was used to collect demographics and comorbidities for the patient panels of US urologists, including mean age and rates of atrial fibrillation (AF), chronic kidney disease (CKD), diabetes (DM), and congestive heart failure (CHF). The mean patient hierarchal condition category (HCC) risk score was collected, which is a standardized metric with score of 1.0 representing an average patient. This data was linked to all procedures billed to Medicare in 2021 under CPT code 52356 and Medicare surgeon reimbursement for all episodes. Student T‐ tests and Chi‐squared analysis were used to compare variables in patients with HCC risk score of less than and greater than 1.5.
Results: In 2021, 52,816 procedures under CPT code 52356 were billed to Medicare. Mean physician reimbursement was $338.24. Patients with HCC risk scores greater than 1.5 had higher rates of comorbidities compared to patients with HCC less than 1.5 (Table 1). The mean payment for patients with HCC greater than 1.5 was $329.77, which was significantly lower than the mean payment of $340.47 for patients with HCC less than 1.5 (p < 0.001).
Conclusions: Although risk‐adjustment exists for hospital reimbursement in the US, there is currently no risk‐adjustment for surgeon fees. We demonstrate that mean surgeon reimbursement for ureteroscopy for stone treatment is lower for more comorbid patients. Risk‐adjustment for surgeon reimbursement should be considered to incentivize surgeons to treat complex patients who will likely require increased surgeon time and resources.
Funding: None.
Analysis of 24‐Hour Urine Studies in Hispanic Stone Formers
T. Max Shelton1, Christian Karcher1, Varun Rao1, Rj Caras1, Austen Slade1, Marcelino Rivera1
1Indiana University School of Medicine
Presented By: T. Max Shelton
Introduction: 24‐hour urine testing provides valuable feedback on risk factors affecting kidney stone formers. This study focused on variations in 24‐hour urine study parameters in Hispanic patients to identify unique risk factors among this patient population to support preventive strategies and tailored clinical interventions.
Methods: A retrospective analysis of self‐identified Hispanic patients was performed at two separate hospital systems within a single academic institution. Patients with 24‐hour urine testing were included in the study. An age and sex matched non‐Hispanic patient cohort was used for comparison. 24‐hour urine data variables analyzed included: volume, calcium, chloride, citric acid, creatinine, magnesium, oxalate, urine pH, phosphorus, potassium, sodium, and uric acid. Two‐tailed T‐tests were performed to analyze differences between these groups.
Results: A total of 118 patients were included in this study, 59 Hispanic and 59 were non‐Hispanic who were sex and age matched in comparison to the Hispanic group. Significant differences in 24‐hour urine calcium and uric acid levels were identified (P < 0.05). No significant difference in urine volume, chloride citric acid, creatinine, magnesium, oxalate, urine pH, phosphorus, potassium, or sodium.
Conclusions: Hispanic patients in this cohort demonstrated statistically significant elevations in 24‐hour urine calcium and uric acid levels when compared to an age and sex matched non‐Hispanic population. These differences may be due to factors such as dietary patterns, genetic predisposition, and metabolic abnormalities; however, further study is needed to investigate these differences.
Funding: None
Demographic Variation in the Prevalence of Metabolic Risk Factors for Nephrolithiasis Patients
Mark I Sultan1, Mark I Sultan1, Sohrab N Ali1, Pengbo Jiang1, Roshan M Patel1, Ramy Youssef1
1University of California, Irvine
Presented By: Mark I Sultan, MD
Introduction: 24‐hour urine collections are obtained as part of the metabolic workup for nephrolithiasis to identify modifiable analyte abnormalities for stone prevention. We sought to discern trends in the prevalence of metabolic abnormalities based on age and gender.
Methods: All Litholink 24‐hour urine collections for nephrolithiasis patients obtained at our institution between 2004 and 2020 were retrospectively reviewed. Only the first 24‐hour urine collection prior to intervention for each patient was included in the analysis. Patients were grouped by age (< 50, > 50) and gender. Litholink's gender specific reference ranges were used to define abnormalities.
Results: 1477 patients were included. The mean age at collection was 56 years (53.5% male, 46.5% female). Table 1a shows the prevalence of each abnormality after stratification for age and gender. Table 1b shows the prevalence of the analyte abnormality and the significance in difference between demographic groups. Male patients (particularly older men), demonstrated higher rates of hyperoxaluria (OR = 2.93 [2.34‐3.68]), in addition to (in particularly younger men) hyperuricosuria (OR = 2.55 [1.96‐3.32]) and an elevated urine sodium (OR = 2.33 [1.89‐2.88]). Female patients, particularly younger stone formers, demonstrated an increased prevalence of low urine volume (OR = 1.46 [1.16‐1.83]) and hypercalciuria (OR = 1.73 [1.39‐2.14]); meanwhile, older females demonstrated higher rates of hypocitraturia (OR = 2.19 [1.78‐2.70]). Older patients were more likely to have low urine pH (OR = 2.37 [1.65‐3.41]) compared to younger patients.
Conclusions: Metabolic risk factors for nephrolithiasis vary significantlybetween different genders and age groups.These variations canbe attributed to hormonal factors, diet, and lifestyle habits.Thesefindings maydemonstratethe importance of 24 h urine evaluation to tailor specific dietary intervention and directed medical therapybased on abnormalities.More studies are needed to better understand the complex pathogenesis of nephrolithiasis and its relation to gender and age.
Funding: None
Associated Factors for Hospital Admission and Surgical Intervention in Adult Emergency Department Patients with CT‐Confirmed Ureteral Stones
Amit Shemesh1, Dor Golomb1, Hanan Goldberg2, Eyal Hen1, Fahed Atamna1, Amir Cooper1, Orit Raz1
1Samson Assuta Ashdod University Hospital, 2SUNY Upstate Medical University
Presented By: Amit Shemesh, MD
Introduction: Urolithiasis is one of the most common urology related admissions in the Emergency Department (ED). However, only a small proportion necessitate hospital admission or urologic intervention. Our objective is to identify and describe the factors that can predict the need for hospital admission or urologic intervention.
Methods: A retrospective analysis was conducted on all patients admitted to the ED and found to have a ureteric stone on CT. Clinical, laboratory, and imaging parameters were collected, along with data regarding admissions, surgical procedures. Need for urology intervention and admission was assessed with relation to patients presenting parameters in the ED.
Results: Between January 2018 and January 2020, an abdominal CT‐proven ureteric stone was found in 805 patients during an ED visit in a single institution. Of those, 773 patients met the inclusion criteria. A total of 304 (39%) were admitted to the hospital of them 210 (69%) underwent surgical procedure. Of 469 discharged patients 86 (18%) required surgical intervention.Parameters associated with hospitalization were older age, stone size, stone location, inflammatory markers, creatinine level, fever, positive urine culture, personal history of urolithiasisParameters associated with surgical intervention were older age, female gender, stone size, stone location, presence of renal stone, creatinine level, inflammatory markers, fever, positive urine culture and history of prior procedure
Conclusions: The majority of hospitalized ureteral stone patients require intervention with overlapping in the associated factors for surgical intervention and admission. Older age, infectious status and stone parameters are significant factors for intervention and admission, with personal history of urolithiasis associated with admission and female gender and prior surgery associated with surgical intervention.
Funding: None
Neighborhood Social Vulnerability is Correlated with Worse Quality of Life in Kidney Stone Patients
Scott Quarrier2, David Song1, Karen Doersch2, Timothy Campbell2, Christopher Wanderling2, Nathan Schuler2, Rajat Jain2, Scott Quarrier2
1University of Rochester School of Medicine, 2University of Rochester Medical Center
Presented By: Scott Quarrier, MD
Introduction: Socioeconomic factors contribute to kidney stone prevalence, impacting the quality of life of affected individuals. The Social Vulnerability Index (SVI), developed by the CDC using US census data, assesses various socioeconomic factors to determine the level of vulnerability within a particular community. This study aims to explore the association between social vulnerability and patient‐reported quality of life in kidney stone patients, utilizing the Wisconsin Stone Quality of Life Questionnaire (WISQOL), a validated disease‐specific questionnaire.
Methods: A retrospective review was conducted for new urolithiasis patients who completed the WISQOL questionnaire upon their initial visit to a kidney stone clinic between 1/16/2019, and 4/13/2023. Patients were categorized into quartiles based on their census tract SVI scores, representing varying levels of vulnerability (quartile 1: least vulnerable, quartile 4: most vulnerable). Statistical analysis using the one‐way ANOVA test in Python3 was performed to assess the disparity in WISQOL total score and subscores.
Results: The study included a total of 1696 patients, distributed across quartiles 1‐4 as follows: 662 (39%), 639 (38%), 291 (17%), and 104 (6%). WISQOL total scores decreased (indicating worsening QOL) as social vulnerability increased, with a statistically significant difference observed among the SVI quartiles (p < 0.001). Several SVI sub‐scores showed negative correlations with lower WISQOL scores, including socioeconomic factors (p < 0.001), minority status and language (p < 0.01), housing type and transportation (p < 0.05), and household composition and disability (p < 0.01). Furthermore, significant differences were noted in all WISQOL subdomains between the SVI quartiles, encompassing social impact, emotional impact, disease impact, and impact on vitality (p < 0.01).
Conclusions: Our findings highlight the association between neighborhood‐level socioeconomic vulnerability and diminished quality of life among new kidney stone patients attending a kidney stone clinic. The incorporation of SVI measures may prove valuable for clinicians and researchers in identifying patients who are most likely to benefit from preventive and clinical interventions.
Funding: None
Review of Nephrolithiasis Rates in Arid and Semi‐Arid Regions
Conner Brown1, Mordechai Duvdevani1
1Hadassah Medical Center
Presented By: Conner Brown, MD
Introduction: Nephrolithiasis prevalence varies geographically due to differences in climate, diet, and lifestyle. Arid regions are known to have higher rates of nephrolithiasis due to the high temperatures, low humidity, and low water intake. We aim to review the rates of nephrolithiasis in arid and semi‐arid regions.
Methods: A search was conducted using the PubMed and Google Scholar databases for articles published between 2010 to 2022 that contained the following terms: “nephrolithiasis,” “kidney stones,” “arid regions,” “prevalence,” and “incidence.” Studies reporting the prevalence or incidence of nephrolithiasis in arid regions were included in this review.
Results: We selected 15 articles reporting on the rates of nephrolithiasis in arid regions. These studies were conducted in different arid regions worldwide, including the Middle East, North Africa, Australia, the Mediterranean, and the Southwestern United States. The prevalence rates of nephrolithiasis in these regions ranged from 5% to 20%, with higher rates observed in males and the elderly. This is compared to the reported prevalence rates in more temperate regions of 10% or less. The incidence rates of nephrolithiasis also varied, with higher rates reported during the summer months and in individuals with a prior history of nephrolithiasis.
Conclusions: This review highlights the high rates of nephrolithiasis in arid regions, which can be attributed to various environmental factors and lifestyle habits. Awareness campaigns promoting proper hydration and dietary modifications may help reduce the incidence and prevalence of this condition in these regions as the decreased productivity and increased healthcare cost represent a sizable burden upon the healthcare system.
Funding: None
Distribution of Occupational and Geographical Risk Factors for Kidney Stones in Canada: Guidance for Resource Planning
1Department of Urologic Sciences, University of British Columbia
Presented By: Connor Forbes, MD, FRCSC
Introduction: Elevated ambient temperature is a known risk factor for development of kidney stones that can be affected by seasonal changes or by heat stress especially in indoor spaces. Other understudied exposures including heavy metals have also been associated with increased incidence of nephrolithiasis. We assessed the distribution of known kidney stone risk factors including occupational heat stress; occupational cadmium, lead, and arsenic exposures; and elevated ambient temperature secondary to seasonal variations across Canadian regions. This may aid in establishing targeted resource planning and risk mitigation strategies.
Methods: Data on the number of working Canadians employed in occupations with heat and heavy metals exposures was obtained from Statistic Canada from the year 2021. Number of Canadians working in these high‐risk industries were mapped across Canada to create easily interpretable risk maps. Regional daily temperatures of all Environment Canada recording stations in 2021 was averaged over the hottest 3 months of the year to determine the warmest provinces/territories in the year. Significance of the results was evaluated based on 95% confidence interval difference from the null hypothesis.
Results: Warmest summers were experienced in provinces in lower latitudes, with the hottest summers being recorded in Ontario (Fig. 1A). Most regions had similar rates of occupational heat stress ranging from 619‐ 865 people per 10,000 working age Canadians except for Nunavut at a lower rate of 375 per 10,000 (Fig. 1B). Data on the combined occupational cadmium, lead, and arsenic exposures indicated significantly higher exposure rates in Yukon and Northwest territories with non‐overlapping 95% confidence intervals compared to the remaining Canadians regions (Fig. 1C).
Conclusions: An ambient‐temperature‐based approach to preventative counselling merits consideration given the looming climate crisis. Occupational exposures to cadmium, lead, and arsenic were higher in Northern Canada, suggesting the potential benefit in risk reduction strategies through safe work practices in these areas. Due to multiple confounders, direct causation of stone occurrence from these exposures cannot be measured; however, distribution of these risk factors has implications for resource allocations as none of the Canadian territories have access to permanently stationed urologists.
Funding: No funding was received for this project.
Survey of Habits of Patients with Urinary Lithiasis: Unmasking the Risks of Water and Salt Consumption in a Chilean Population
Belén Giménez5, Juan Fulla1, Nicolás Urnía2, Vicente Cornejo1, Pablo Chamorro1, Pablo Mardones1, Tomás Gatica3, Catherine Sanchez4
1Universidad de Chile, 2Universidad del Desarrollo, 3Universidad Finis Terrae, 4Clinica las Condes
5Urology Department, Universidad de Chile, Hospital Clínico San Borja Arriarán
Presented By: Belén Giménez, MD
Introduction: Urolithiasis present a high degree of recurrence, significantly affecting the quality of life of patients. Its occurrence has been associated with dietary habits. The objective of this study was to describe the water and salt consumption habits in relation to the risk of developing urolithiasis in a population of Chilean patients.
Methods: A cross‐sectional observational study was conducted. A comprehensive questionnaire was implemented to collect data from patients over 18 years of age, healthy or that had been diagnosed with kidney stones in the last 12 months, as part of a machine learning project to predict risk of urolithiasis through artificial intelligence. Information included demographic data, medical history, dietary and occupational habits, as well as laboratory test results. Data related to hydration (exposure to high temperatures, sensation of thirst, hours without water, amount of water consumed per day, and urine color) and salt consumption were evaluated to determine the degree of risk of stone development. The data was analyzed using SPSS for logistic regression analysis with a 95% confidence interval (CI).
Results: Data from 958 patients (46.9% female and 53.1% male) with a mean age of 47 years were analyzed. Logistic regression analysis indicated that not experiencing thirst during the day (OR = 0.645; CI 0.421‐0.989) and not going more than 4 hours without drinking water (OR = 0.048; CI 0.007‐0.351) are protective factors for the development of urolithiasis. On the other hand, it was found that dark urine color (OR = 1.321; CI 1.132‐1.541) and consumption of salt close to half a teaspoon per day (OR = 2.873; CI 1.076‐7.671) are risk factors for the development of urolithiasis. A significant portion of the respondents reported going more than 4 hours without drinking water and experiencing thirst, despite not being exposed to high temperatures.
Conclusions: Our results indicate that certain factors related to water and salt consumption are associated with the risk of developing urolithiasis in a Chilean population. These findings emphasize the importance of maintaining proper hydration and controlling salt intake to prevent urolithiasis, highlighting the need for increased awareness and education to promote healthier habits and improve the quality of life for individuals at risk of urolithiasis in Chile.
Funding: None
Vulnerability to Financial Toxicity after Renal Stone Surgery
Justin Ziemba1, Katharine Michel1, Benjamin Schurhamer1, George Lin1, Hanna Stambakio1
1University of Pennsylvania
Presented By: Justin Ziemba, MD, MSEd
Introduction: The financial burdens that healthcare places on patients is termed financial toxicity. The vulnerability to experiencing financial toxicity was assessed in a cohort of patients undergoing surgical stone management.
Methods: Adults undergoing ureteroscopy or nephrolithotomy for renal/ureteral stones were eligible for inclusion (1/2022 – 1/2023). Patients prospectively completed a modified version of the Commonwealth Biennial Health Insurance questionnaire, which measures health insurance coverage, affordability, and financial impact of medical bills. The questionnaire was completed electronically pre‐operatively (POD 0).
Results: Total of 88 participants were enrolled with a median age of 50 (IQR 40‐60), 52% male, and 77% white. The majority underwent ureteroscopy (73/88; 83%), unilateral (85/88; 97%), and with the dominant stone in a kidney only stone location (40/88; 45%). Participants were mostly employed full‐time (53/88; 60%), had a high education level (52/88; 59% 4‐year college or more), and a wealthy median household income (38/88; 43% $100,000 or more). All participants were insured (68/68; 100%) with the majority having private insurance through an employer (60/88; 68%). Figure 1 shows the insurance cost associated with deductible and out‐of‐pocket costs. Figure 2 shows the impact of insurance and healthcare costs on personal decisions and finances. Figure 3 shows the burden of medical debt. There was no difference in these impact measures between those with and without private insurance.
Conclusions: Despite our patient population being well educated and universally insured, a significant subset of patients are highly vulnerable to financial toxicity and have low financial literacy.
Funding: None
Social Determinants of Health and Postoperative Outcomes After Major Uro‐Oncological Surgery: A National Population‐Based Study
Antonio Franco1, Morgan R. Sturgis1, Francesco Ditonno2, Celeste Manfredi1, Jamie Joon3, Daniel Roadman3, Adan Z. Becerra3, Srinivas Vourganti3, Riccardo Autorino3, Ephrem O. Olweny3
1Rush University Medical Center, 2Rush University Medical center, 3Rush university medical center
Presented By: Antonio Franco, MD
Introduction: Socioeconomic determinants of health (SDOH) are often unvalued during surgery risk stratification; therefore, they might be a major source of disparity that can jeopardize outcomes related to urological surgery. Hence, the aim of our study is to evaluate the impact of SDOH on postoperative outcomes following uro‐oncology surgery.
Methods: Patients who underwent major uro‐oncology procedures between 2011 and 2021 were retrospectively analyzed by using PearlDiver‐Mariner, an all‐payer insurance claims database. International Classification of Diseases diagnosis and procedure codes were used to identify the type of surgical operation, patient's characteristics, postoperative complications and SDOH. Outcomes were compared using multivariable regression models.
Results: Overall, 275,696 patients (mean age = 62.8 ± 10.6) were identified [Radical Prostatectomy = 135,358 (49%), Radical Cystectomy = 22,670 (8%), Nephrectomy = 98,259 (36%), Nephroureterectomy = 8,981 (3%), Adrenalectomy = 10,428 (4%)]. The 60‐day postoperative complication rate was 14.3%. Approximately 7% of patients reported at least one SDOH at baseline. SDOH were associated with higher odds of 60‐day postoperative complications (OR:1.21, 95% CI:1.16‐1.27), including urinary tract infection (OR:1.30, 95% CI:1.23‐1.37) leakage/hematoma (OR:1.10, 95% CI:0.97‐1.25), pneumonia (OR:1.26, 95% CI:1.15‐1.40), deep vein thrombosis (OR:1.22, 95% CI:1.10‐1.36), sepsis (OR:1.08, 95% CI:0.99‐1.17), wound defect (OR:1.23, 95% CI:0.97‐1.54), acute kidney injury (OR:1.20, 95% CI:1.14‐1.27) and pulmonary embolism (OR:1.14, 95% CI:1.01‐1.29).
Conclusions: SDOH minorities have significantly higher risk of postoperative complications following uro‐ oncological surgery. Early identification of these disparities may help stratifying high‐risk patients undergoing major uro‐oncological procedures.
Funding: None
Social Determinants of Health and Postoperative Outcomes After Robotic Radical Prostatectomy: A National Population‐Based Study
Antonio Franco1, Morgan R. Sturgis1, Francesco Ditonno1, Celeste Manfredi1, Jamie Yoon1, Daniel Roadman1, Adan Z. Becerra1, Srinivas Vourganti1, Ephrem O. Olweny1, Riccardo Autorino1
1Rush university medical center
Presented By: Antonio Franco
Introduction: Socioeconomic determinants of health (SDOH) are often unvalued during surgery risk stratification; hence, they might be a major source of disparity that can jeopardize outcomes related to urological surgery. The aim of our study is to evaluate the impact of SDOH on postoperative outcomes following robotic radical prostatectomy (RARP).
Methods: Patients who underwent RARP between 2011 and 2021 were retrospectively analyzed by using PearlDiver‐Mariner, an all‐payer insurance claims database. International Classification of Diseases diagnosis and procedure codes were used to identify patient's characteristics, postoperative complications and SDOH. Outcomes were compared using multivariable regression models.
Results: Overall, 100,035 patients (mean age = 63.24 ± 7.07) underwent RARP. The 60‐day postoperative complication rate was 11%. Approximately 6% of patients reported at least one SDOH at baseline. SDOH were associated with higher odds of 60‐day postoperative complications (OR:1.24, 95% CI:1.15‐1.34), including urinary tract infection (OR:1.32, 95% CI:1.20‐1.45), pulmonary embolism (OR:1.21, 95% CI:0.95‐ 1.52), acute kidney injury (OR:1.31, 95% CI:0.98‐1.29) and postoperative urethral stricture (OR:1.37, 95% CI:0.92‐1.98).
Conclusions: Patients with SDOH have significantly higher risk of postoperative complications following RARP, especially urinary infection and acute kidney injury. Early identification of these groups may help stratify high‐risk patients diagnosed with prostate cancer, in order to accurately counsel them.
Funding: None
The Historical Origins and Contemporary Role of Endoluminal Treatment for Urethral Stricture Disease
Kunal Jain1, Thomas Southall1, Suvig Dua2, David Chung1, Ryan Ramjiawan1, Jasmir Nayak1, Premal Patel1, Umesh Jain3
1University of Manitoba, Section of Urology, 2University of Manitoba, Max Rady College of Medicine
3University of Toronto, Department of Urology (St. Joseph's Health Centre)
Presented By: Kunal Jain, MD
Introduction: We explore the historical origins and developments in dilation and urethrotomy for the treatment of urethral stricture disease (USD).
Methods: Primary and secondary sources related to USD were reviewed and put into perspective within current practices.
Results: The earliest known treatment for USD is from the Ayurveda, when its founder used urethral dilators lubricated with ghee. By 200 BC, Erasistratus of Greece developed S‐shaped metal catheters. These catheters were adapted and modernized by the Romans who used lead and bronze dilators. It was not until the first recorded epidemic of gonorrhea in 1520 AD when a renewed focus on USD arose and a primitive form of internal urethrotomy was developed. The introduction of the lanceolate‐shaped catheter in 1795 AD allowed for successful internal urethrotomy and paved the future for the development of later internal urethrotomes. It was only in 1996 AD when Freid and Smith described a method which used a guidewire for cannulation of the urethra and then dilation overtop with a Seldinger technique. In 1997 AD, Steenkamp et al. published a landmark trial demonstrating equivalent outcomes between filiform dilation and direct visual internal urethrotomy. In 2007, Herschorn of Canada introduced S‐shaped coaxial urethral dilators, and four years after that, Gelman et al. described direct vision balloon dilation. Recently, drug‐coated balloon dilation is being investigated.
Conclusions: The origins of endoluminal treatment of USD can be traced back to over twenty‐six centuries ago. Current guidelines rely on limited and dated evidence. We demonstrate that this field is ripe for further advancements.
Funding: None.
Penile Enhancement Surgery – the Short and the Long of it
Kyle T. Moore1, Melinda Z. Fu1, Benjamin J. Lichtbroun1, Danielle Velez1
1Rutgers Robert Wood Johnson Medical School
Presented By: Kyle T. Moore, BA
Introduction: Society has long been preoccupied with penis size. As a result, penis enlargement strategies provide examples of mankind's ingenuity in addressing the issues troubling them most. From snake bites to complex cosmetic surgery, this essay summarizes the lengthy history of penile augmentation.
Methods: Existing literature was reviewed to provide a history on penile enhancement. Beginning with a discussion on ancient attitudes and practices, landmark studies are summarized to portray the evolution of penile augmentation strategies into thetechniques being investigated today. This paper also provides analysis on the effectiveness of various techniques and the quality of evidence available in the field of penile augmentation.
Results: Weights, herbal remedies, and jelqing represent examples of ancient penile enlargement strategies. In the modern era, girth enhancement began with Robert Gersuny's mineral injections, and now numerous injectable fillers are approved for cosmetic use and under investigation for penile girth enhancement. Fat injections and dermal fat grafts are other examples of strategies for girth enhancement. Recently, the Penuma® implant became the first FDA‐cleared penile implant for cosmetic male penile enhancement. Meanwhile, modern penile lengthening strategies can be traced back to Cantwell's 1895 description of reconstruction of an epispadic penis. Since then, V–Y advancement and suspensory ligamentolysis have become foundational techniques for penile lengthening. Other approaches have also arisen over recent years, including suprapubic fat pad reduction, penile disassembly, and sliding elongation. However, while many techniques exist, weaknesses in the field such as unstandardized methodology and publication bias make it difficult to develop clear guidelines on penile augmentation. Furthermore, studies have found mixed psychological outcomes and patient satisfaction even if there are measurable increases in penile length or girth.
Conclusions: Penile augmentation has a history dating back thousands of years. Penis size is of great importance to many men, and advancements in this field may provide relief for those suffering from penile dysmorphophobia. However, the evidence behind these techniques is incomplete, and more research is needed before the benefits of penile augmentation can be compared to those of procedures such as breast augmentation. However, given mankind's relentless pursuit of penile enlargement, we can expect continued advancements in the field for the foreseeable future.
Funding: None
The Life and Works of Rhazes: Contributions to Urology and Medicine
Ahmad Alam1
1John Hunter Hospital, Newcastle, Australia
Presented By: Ahmad Alam, MBBS, MS
Introduction: Abu Bakr Muhammad Ibn Zakariya al‐Razi, also referred to as Rhazes in Latin, was a prominent philosopher, alchemist, and physician who lived during the Abbasid Caliphate and was born in the 8th century near Tehran, which is presently located in Iran. With an early emphasis on the importance of experimental medicine, he demonstrated expertise in this field and subsequently secured the role of chief physician at both the hospitals in Baghdad and Ray, leading to a highly accomplished medical career.
Methods: Rhazes made significant contributions to the field of urology by advancing the understanding and management of various urological conditions. His work included the first description of the differences between renal colic and abdominal colic, with specific attention given to the localization of pain. In addition, he advocated for a thorough examination of urine, encompassing analysis of its clarity, color, sediment, and consistency, in order to discern underlying pathologies. Rhazes' recommendations for the prevention of renal calculus formation emphasized dietary and lifestyle modifications, such as avoidance of heavy foods and drinks and use of natural diuretics. These recommendations are consistent with contemporary advice centered around the principles of diet, hydration, and diuresis.
Results: Rhazes' surgical innovations in urology were groundbreaking. He championed the crushing of stones within the bladder before retrieval, thereby reducing the required size of incisions. In addition, he advocated for preoperative enemas prior to lithotomy for bladder stones. Rhazes also made important contributions to the refinement of urological instruments. He promoted the use of lead in the manufacture of catheters to enhance their pliability and safety. Moreover, he advocated for the replacement of the catheter tip opening with eyelets located on the sides which enabled safer and more effective catheterization procedures.
Conclusions: Rhazes was a prominent physician whose lasting impact on medicine in Europe can be attributed to his seminal work, Kitab al‐Hawi (Liber Continens). This magnum opus served as a foundational teaching text for medical schools, exerting a significant influence on medical education and practice for centuries following his passing.
Funding: None
Historical Involvement of the Medical Profession in the Development and Promotion of Anti‐Masturbation Devices
Sindhu Sankaran1, Alberto Coscione1
1Addenbrookes Hospital
Presented By: Sindhu Sankaran, MBBS
Introduction: Masturbation, a natural sexual behaviour, has been a topic of interest and controversy throughout history. Various social, cultural, and religious factors have led to the creation of devices aimed at curbing this behaviour, and the medical profession has played a notable role in this regard. This abstract delves into the development of anti‐masturbation devices, the involvement of physicians, and the implications of medical intervention in sexual behaviour.
Methods: A literature search was done on Pubmed Central, Google Scholar and archive.org for both modern and historical manuscripts relating to Anti‐masturbation devices and role of physicians.
Results: The origins of anti‐masturbation devices can be traced to the late 18th and early 19th centuries, a period marked by increased awareness and anxiety about masturbation. Medical professionals of the time believed that excessive masturbation was a cause of physical and mental health problems, leading them to advocate for preventive measures. This mindset gave rise to a wide array of devices designed to hinder or discourage the act of self‐stimulation, ranging from simple restraints to more complex contraptions like genital cages, four‐point urethral ring and mechanical bed frames.Doctors, relying on their authority and medical knowledge, contributed to the popularization of these devices through publications, lectures, and consultations, some claiming that masturbation could lead to serious illnesses or death.While the intentions of the medical profession were often driven by a desire to protect and improve public health, the use of anti‐ masturbation devices raises questions about bodily autonomy, sexual repression, and the potential for psychological harm.This abstract recognizes the historical context of the medical profession's involvement in anti‐masturbation devices. It acknowledges that societal attitudes towards sexuality have evolved over time, and contemporary medical professionals no longer endorse or promote such interventions.
Conclusions: This abstract provides an overview of the involvement of the medical profession in anti‐ masturbation devices throughout history. It explores the motivations behind their development, the active role of physicians in their promotion, and the ethical implications of medical intervention in sexual behaviour. By shedding light on this historical aspect, the abstract contributes to a broader understanding of the relationship between medicine, sexuality, and societal attitudes.
Funding: None
Ureteroureterostomy: A Century of Advancements
Ezra Shoen1, Jeffrey Stock1, Shirin Razdan1
1Icahn School of Medicine at Mount Sinai
Presented By: Ezra Shoen, MD
Introduction: A review of the literature supporting ureterureterostomy (UU) for treatment of duplicated ureteral systems in children and the current state of minimally invasive techniques.
Methods: A literature search was performed. Original publications dating back to 1886 were identified. Over 100 years of clinical descriptions of ureteroureterostomy and its utilization to treat duplicated ureters were reviewed.
Results: The first ureteroureterostomy for a duplicated system was performed in 1928. It was not until 1965 that a series was published for ureteroureterostomy in children. The shift to minimally invade techniques occurred in 2007.
Conclusions: Regardless of the technique (open, laparoscopic, robotic) 100 years of experience demonstrates that Ureteroureterostomy is a highly successful surgical option. The refining the robotic technique has added the benefits of minimally invasive surgery to the Ureteroureterostomy.
Funding: No disclosures
MODERATED POSTER SESSION 15: BPH 1
12‐Month Outcomes from a Randomized, Double‐Blind, Sham Controlled Study Evaluating a Novel Drug Coated Balloon for the Treatment of Benign Prostatic Hyperplasia
Dean Elterman2, Steven Kaplan1
1Mount Sinai, 2University of Toronto
Presented By: Dean Elterman, MD, MSc, FRCSC
Introduction: The PINNACLE study is a prospective, randomized, double‐blind, sham controlled study evaluating the Optilume BPH System. Optilume BPH is a novel minimally invasive surgical therapy (MIST) that combines mechanical dilation with the delivery of paclitaxel for the treatment of lower urinary tract symptoms (LUTS) secondary to benign prostate hyperplasia (BPH). Mechanical dilation with Optilume BPH achieves an anterior commissurotomy, while delivery of paclitaxel is intended to maintain luminal patency during healing.
Methods: 148 subjects were randomized in a 2:1 fashion at 18 centers in the US and Canada. Subjects and evaluating personnel were blinded to the treatment received through 12‐months. 12‐month follow‐up is complete. Symptom improvement was measured utilizing the International Prostate Symptom Score (IPSS) and BPH Impact Index (BPH‐II), functional improvement measured by peak urinary flow rate (Qmax) and post‐void residual volume (PVR). Erectile and ejaculatory function were evaluated utilizing validated questionnaires. Adverse events were prospectively collected and relatedness to treatment was adjudicated by an independent, blinded clinical events committee.
Results: Subjects treated with Optilume BPH showed a sustained and significant reduction in IPSS from baseline to 12‐months (23.4 vs 10.9, p < 0.001). Improvement was seen with both voiding and storage symptoms (Figure 1). Improvement in IPSS at 12 months was significantly greater for Optilume BPH compared to Sham in the intent‐to‐treat population (11.5 vs 4.8, p < 0.001) (Figure 2). Qmax improved 113%, from 8.9 mL/sec at baseline to 19.0 mL/sec after treatment with Optilume BPH, while average PVR decreased from 84 mL to 58 mL (p = 0.004). Improvement in PVR at 12‐months was significantly greater for Optilume BPH compared to Sham (26.6% vs ‐4.6%). There were no changes in perceived sexual or ejaculatory function. The most reported treatment related adverse events after treatment with Optilume BPH included hematuria (39/98 [39.8%]), urinary tract infection (11/98 [11.2%]), and dysuria (8/98 [8.2%]).
Conclusions: Treatment with Optilume BPH resulted in significant, immediate symptomatic and functional improvements and to date the highest Qmax reported in BPH MIST trials. Durability of these outcomes was shown through 12‐month follow‐up, demonstrating the intended effect of an immediate mechanical benefit that is sustained long‐term by the delivery of paclitaxel. Long‐term outcomes will be verified with 5‐year follow‐up for Optilume BPH.
Funding: Urotronic
Holmium Laser Enucleation of the Prostate (HoLEP) in Octogenarian Patients: Characteristics and Clinical Outcomes
Sagi A. Shpitzer1, Abd E. Darawsha1, David Lifshitz1, Gherman Creiderman1, Ron Gilad1, Michael Frumer1, Tzach Aviv1, Muhammad Krenawi1, Tomer Weizman1, Shayel Bercovich1, Nadav Dekel1, Hadar Tamir1, Tal Wax1, Tomer Hasdai1, Yossi Ventura1, Niv Segal1, Hen Hendel1, Liran Zieber1, Dmitry Enikeev2, Yaron Ehrlich1
1Rabin Medical Center, 2Medical University of Vienna
Presented By: Sagi A. Shpitzer, MD
Introduction: Holmium laser enucleation of the prostate (HoLEP) is a relatively new surgical technique used for treating benign prostatic obstruction. The increasing experience in this technique has made it possible for older and frailer patients, who were previously considered non‐operative candidates, to undergo HoLEP more frequently. This study aims to analyze the characteristics and clinical outcomes of HoLEP in the octogenarian population.
Methods: We conducted a retrospective analysis of all HoLEP surgeries performed at our institution between 2016 and 2022. We compared clinical, demographic, and surgical parameters between patients aged 80 and above and those below the age of 80.
Results: The study included 704 patients, of whom 113 were aged 80 and above and 591 were younger patients. The median age in the elderly group was 83 years (IQR = 81‐86 years) and in the younger group was 70 years (IQR = 65‐74 years). Preoperatively, the elderly group had a larger prostate volume (118 vs. 110 ml, p = 0.03) and a higher likelihood of having an indwelling catheter (65% vs. 40%, p < 0.001). Despite the larger prostate size operative time did not differ between the groups (118 vs. 115 minutes, p = 0.36) although the elderly patients were more likely to undergo surgery under spinal anesthesia (14.2% vs. 7.5%, p = 0.02). On the first postoperative day elderly patients had a lower catheter‐free rate (75% vs. 85%, p = 0.01), but the rates of catheter‐free discharge were similar between the elderly and the younger group (94.7% vs. 97.2%, p = 0.18). During the 30‐day follow‐up period, there was no significant difference in emergency room visits (9.5% vs. 10.6%, p = 0.71) or hospital readmissions (6.8% vs. 9.7%, p = 0.27) between the two groups.
Conclusions: HoLEP in octogenarian patients yields comparable results to those of younger patients, with similar catheter‐free rates on discharge, despite a higher rate of indwelling catheterization preoperatively. Age alone should not be a factor for excluding this population from undergoing HoLEP surgery.
Funding: None
Holmium Laser Enucleation of Prostate in Patients with Indwelling Catheter: A Retrospective Study from a High‐Volume Endourology Center
Tzach Aviv1, Yaron Ehrlich1, Abd Elhalim Darawsha1, Ron Gilad1, Michael Frumer1, Sagi Shpitzer1, Muhammad Krenawi1, Tomer Weizman1, Shayel Bercovich1, Nadav Dekel1, Hadar Tamir1, Tal Wax1, Tomer Hasdai1, Yossi Ventura1, Niv Segal1, Hen Hendel1, Liran Zieber1, Iyad Khamaisi1, David Lifhshitz1, Dmitry Enikeev2, Gherman Creiderman1
1Rabin Medical Center, 2Medical University of Vienna
Presented By: Gherman Creiderman, MD
Introduction: Patients with indwelling catheters (IC) due to chronic urinary retention constitute a large subgroup of individuals undergoing surgical treatment for benign prostatic hyperplasia. Previously, both high post‐void residual (PVR) volume and long‐term catheterization were regarded as indicators of increased risk for perioperative complications and surgical outcomes. In this study, we compare the complication rates and treatment success of holmium laser enucleation of prostate (HoLEP) in the (IC) group with patients treated for lower urinary tract symptoms (LUTS) without catheter.
Methods: We retrospectively analyzed data from 704 patients who underwent (HoLEP) at our institution between 2016 and 2022. We compared patient cohorts with and without (IC). All surgeries were performed by senior urologists at different stages of the learning curve using a high‐power holmium laser (Lumenis/Quanta). Patients with (IC) received perioperative antibiotics based on culture results. Those with negative cultures received a combination of penicillin and an aminoglycoside in the operating room according to the institution policy. Treatment success was defined as a successful trial to void after surgery, with no need for catheter placement upon discharge.
Results: Out of 704 patients, 309 (44%) had (IC). Patients with (IC) were older with higher enucleated tissue weight [mean±SD; 74 years ±8.5 and 92 g± 44.8] than LUTS patients [70.4 years ±7.08 and 81.1 g± 38.6] (p < 0.01). The median (PVR) prior to surgery in the (IC) cohort was 875cc (357.5‐1200), compared to 123cc (46‐233.2) in the (LUTS) cohort. Urinary culture results were positive in 57.3% of (IC) patients, compared to 9.4% in the (LUTS) cohort. Both groups had similar postoperative catheter duration and hospitalization time, with a median of 1 day for both parameters. The (PVR) on discharge was lower in the (LUTS) group ‐ 51.5 cc (27.7‐90.25) vs 70 cc (36.2‐124) (p < 0.001). The febrile urinary tract infection rate was higher in the (IC) group compared to the LUTS group – 12 (3.8%) vs 4 (1%) (p = 0.01). There was no statistically significant difference in the percentage of patients discharged with a catheter (13 [4.2%] in (IC) vs 11 [2.8%] in (LUTS) group), urinary retention rate, emergency room visits, and the rate of rehospitalization after discharge.
Conclusions: (HoLEP) in patients with (IC) is a safe procedure with a high success rate, comparable to that of patients with (LUTS). It provides patients with chronic urinary retention and high preoperative (PVR) with an opportunity to void spontaneously with low residuals on the next day after surgery. The higher potential for infection complications should be addressed through proper perioperative antibiotic treatment.
Funding: None
Assessing Peri‐Operative Antibiotic Administration Practices Amongst Urologic Surgeons Performing Holmium Laser Enucleation of the Prostate
Mohammad Mohaghegh1, Tasha Posid1, Nicholas Dean2, Bodo Knudsen1, Amy Krambeck2, Matthew Lee1
1The Ohio State University, Department of Urology, 2The Northwestern University
Presented By: Mohammad Mohaghegh, MD, FRCSC
Introduction: Holmium laser enucleation of the prostate is a size‐independent surgical treatment for benign prostatic hypertrophy. As with many outlet procedures, UTI and sepsis are feared complications and antibiotics are given with this procedure. Currently, there is a lack of data on peri‐operative antibiotic prescribing patterns for HoLEP and, thus, no consensus on optimal practices. We set out to determine what the current prescribing practices are for peri‐operative antibiotic therapy for HoLEP in various clinical scenarios.
Methods: Members of the Endourologic Society (n = 3000) were invited through the endourologic society email list to complete a REDCap survey. The study was exempt from IRB approval. The survey included questions about surgeons' practice setting, training, surgical volume, antibiotic prescribing practices and different factors affecting their choices of what antibiotic to administer. Data was tabulated an analyzed using SAS v9.4.
Results: Urologists (n = 70, 66 male, 4 female) reported that they performed an average of 108 HoLEPs per year with mean clinical experience of 11 years. More surgeons were based out of the United States, and worked at an academic center (36%, 69%, respectively). HoLEP training for the cohort consisted of fellowship training (39%), self‐taught (33%) andcourse‐based training (17%). Urologists consider a variety of factors when determining the type and duration of antibiotic therapy with HoLEP, Figure 1. In the case of a negative pre‐operative urine culture and the patient is not catheterized/self‐catheterizing (C/ISC), most urologists would only give a single dose of antibiotic on the day of the procedure (96%). However, this did not hold true if patient is C/ISC (Figure 1). If the pre‐operative urine culture resulted “mixed‐flora”, 34% of surgeons will request further speciation and 42% will treat in the absence of further speciation (Figure 1). If the pre‐operative urine culture is negative 39% of surgeons will prescribe postoperative antibiotics if the patient is not catheterized vs 64% if the patient is catheterized (Figure 1).
Conclusions: There remains significant variability amongst surgeons for perioperative antibiotic prescribing practices for HoLEP. In general, more antibiotic are prescribed if the patient has a history of catheterization or infection. Further clinical studies are needed to identify the best antibiotic prescribing protocols when HoLEP is performed.
Funding: NA
Contemporary Trends in BPH Reoperation Rates; A SPARCS Analysis (2004 – 2021)
Micah Levy1, Christopher Connors1, Daniel Wang1, Juan Arroyave Villada1, Aaron Walt1, Hasan Bilal1, Francisca Larenas1, Michael Palese1
1Icahn School of Medicine at Mount Sinai
Presented By: Micah Levy
Introduction: With improvements in the surgical management of benign prostatic hyperplasia (BPH) leading to increased indications and rising surgical rates, it is important to understand contemporary trends in reoperations in BPH surgical management.
Methods: The 2004 – 2021 New York Statewide Planning and Research Cooperative System (SPARCS) database was queried for patients receiving BPH surgical management via transurethral resection of the prostate (TURP), laser therapies, prostatic ureteral lift (PUL), and other minimally invasive surgery therapies (MIST). Reoperation rates (RR) and the reoperation surgery method were analyzed between groups stratified by initial surgery method.
Results: 135,349 cases were analyzed (TURP: 58.97%, laser therapies: 34.94%, PUL: 4.44%, MIST: 1.66%). Across all cases the RR was 2.70%, 5.96%, 7.20%, 8.79%, and 9.21% for 1, 3, 5, 10, and 17 years following initial operation respectively, with 29.35%, 64.72%, 78.20%, and 95.47% of reoperations occurring within the first 1, 3, 5, and 10 years respectively. Laser therapies had the highest RR (10.34%), followed by MIST (9.85%), then TURP (8.81%) and finally PUL (5.28%), recognizing that the more recent PUL data has limited postoperative data to analyze and that laser therapies are a combination of several unique procedures. The laser therapy RR was significantly greater than that of TURP and PUL (p < 0.001) but not significantly different to that of MIST (p = 0.453), while the TURP RR was significantly greater than that of PUL (p < 0.001) but not that of MIST (p = 0.0872). TURP was the most common reoperation procedure making up 69.46% of all reoperations, suggesting patients are more likely to switch to TURP rather than to repeat the same initial surgery method. Despite this, rates of reoperations with laser, PUL, and MIST were higher when they were repeat procedures rather than a new surgery method (repeat laser: 41.10%, repeat PUL: 22.71%, repeat MIST: 14.03%), suggesting that patients are most likely to switch to a TURP or repeat the same surgery method as their initial procedure.
Conclusions: BPH reoperation rates reach up to 10% depending on the initial surgery type, with the highest rates amongst those initially treated with laser therapies. Though TURP remains the gold‐standard, making up a large majority of reoperation surgeries, a significant proportion of patients choose to repeat the same surgery method for laser, PUL, and MIST reoperations
Funding: None
is Laser Enucleation of the Prostate the Safest BPH Procedure for Octogenarians? A 2013 – 2019 National Analysis
Christopher Connors1, Micah Levy1, Juan Sebastian Arroyave1, Evan Garden1, Olamide Omidele1, Francisca Larenas1, Michael Palese1
1Icahn School of Medicine at Mount Sinai
Presented By: Christopher Connors, BA
Introduction: The safety of surgical options for benign prostatic hyperplasia (BPH) in octogenarians (OGN) is not fully understood. This is the first study to compare post‐operative outcomes of transurethral resection of the prostate (TURP), photoselective vaporization of the prostate (PVP), and laser enucleation of the prostate (LEP) among OGNs using a national database.
Methods: The NSQIP database was queried from 2013 to 2019 for males undergoing TURP, PVP, and LEP. Patients were grouped as OGN or younger (< 80 years old) and stratified by procedure. Demographics and 30‐day surgical outcomes includingsurgery‐related readmissions (SRR), prolonged length of stay (PLOS), and Clavien‐Dindo (CD) complications were analyzed using chi‐square and multivariate analysis.
Results: 71,283 BPH cases were identified (TURP = 47,704; PVP = 18,539; LEP = 5,040). OGNs were more likely to experience SRR, CD I/II, and bleeding requiring transfusion (BRT) for all BPH procedures when compared to younger patients. OGNs undergoing TURP or PVP were also more likely to experience PLOS, CD IV, and urinary tract infections. On multivariate analysis for TURP and PVP, being an OGN was a predictor of SRR (TURP: OR = 1.289; PVP: OR = 1.483), PLOS (OR = 1.554; 1.794), CD I/II (OR = 1.290; 1.297), and CD IV (OR = 1.230; 1.797), all p < 0.05 [Table 1]. However, for LEP, OGN classification was not a significant risk factor for any surgical outcomes studied. Among OGNs only, PVP was an independent risk factor for CD IV (OR = 1.511) and sepsis (OR = 1.684) but a negative predictor of SRR (OR = 0.615), PLOS (OR = 0.370), and BRT (OR = 0.377) when compared to TURP, all p < 0.05 [Table 2]. Compared to TURP, LEP was a negative predictor of PLOS (OR = 0.386), CD I/II (OR = 0.611), and CD IV (OR = 0.380), all p < 0.05.
Conclusions: LEP is used less frequently than TURP or PVP but demonstrates a more favorable safety profile for OGNs undergoing BPH surgery.Further studies are needed to confirm the safest BPH surgical options for OGNs given the advent of new procedures.
Funding: None
Comparing mFI‐5, ASA Class, and mCCI as Predictors of Postoperative Outcomes Following Endoscopic Treatment of BPH
1Smith Institute of Urology, 2SUNY Downstate, 3Smith Institute for Urology, 4CUNY School of Medicine
Presented By: Justin James, BS
Introduction: While studies have reported many risk indexes for predicting morbidity following urological surgery, it is difficult to determine which risk indexes are better utilized in the clinical space. A new frailty index (modified Frailty Index‐5(mFI‐5)) has emerged for endoscopic treatment of benign prostatic hyperplasia (BPH); however, its discriminatory abilities for postoperative complications has not been investigated. Therefore, we compared mFI‐5 to two most commonly used indexes, the American Society of Anesthesiologists physical classification (ASA) and modified Charlson Comorbidity Index (mCCI), and total number of comorbidities using the National Surgical Quality Improvement Program (NSQIP) database.
Methods: We retrospectively queried the 2015‐2020 NSQIP datasets for patients who underwent endoscopic treatment for BPH using CPT and ICD codes. Patients were stratified by procedure type (transurethral resection of the prostate (TURP), laser vaporization (LVP) and enucleation (LEP) of the prostate). Risk indexes were calculated and compared as predictors of postoperative outcomes (all cause complication, surgical/medical complications, unplanned reoperation, unplanned readmission, length of stay, and complication severity) using logistic regressions and C‐statistics (AUC).
Results: 38,128 patients were included with a mean age of 71. The overall complication rate was 10.6%, but upon stratifying by procedure, the complication rates were 11.0%, 10.3%, and 7.6% for TURP, LVP, and LEP, respectively. Discriminatory ability of risk indexes was mostly comparable between risk indexes but differed based on procedure type and postoperative outcome. mCCI was found to be superior in predicting surgical complications for TURP, and in predicting unplanned reoperation and increased length of stay for LVP. ASA Class was found to be superior in predicting all cause complication, unplanned reoperation, and complication for LEP. mFI‐5 was not superior to any index in predicting any postoperative outcome.
Conclusions: mCCI and ASA Class have utility in predicting postoperative outcomes for LVP and LEP, respectively. Most risk indexes are comparable and therefore can be utilized at the ease of the provider.
Funding: None.
Device Related Adverse Events During Benign Prostatic Hyperplasia Surgery: Review of the Manufacturer and User Facility Device Experience Database
Mouneeb Choudry1, Daniel Heidenberg1, Ethan Nethery2, Kevin Wymer1, Nathaneal Judge3, Scott Cheney1, Mitchell Humphreys1
1Mayo Clinic Arizona, 2Virginia Tech Carilion School of Medicine and Research Institute, 3Michigan Technological University
Presented By: Mouneeb Choudry, MD
Introduction: Our aim was to evaluate the proportion of clinically significant complications for patients who underwent BPH surgical interventions based on procedure type. The Manufacturer and User Facility Device Experience (MAUDE) database is an FDA maintained public database that contains anonymous, voluntary medical device reports. Herein, we review device‐related adverse events reported in the MAUDE database associated with BPH surgeries using a standardized classification system. We then sought to determine the factors contributing to these adverse events.
Methods: The MAUDE database was queried for “Aquablation, Greenlight Laser, Holmium Laser, Morcellator, Rezum, Loop Resection, and Urolift” from 2018 through 2021. The circumstances and patient complications associated with each surgical technology were identified. A complication classification system (Level I‐IV) based on the Clavien‐Dindo system was used to categorize events based on outcomes. These events were then correlated with device malfunctions and classified as “device related” and “non‐device related.” Chi squared analysis was performed to identify associations between BPH surgery type and complication classification distribution.
Results: A total of 873 adverse events were identified. The adverse events were classified into level I (minimal harm) vs levels II‐IV (clinically significant). Overall, most complications were associated with minimal patient harm. Aquablation (p < 0.017) and Rezum (p < 0.012) were associated with the highest relative incidence of Level II‐IV complications compared with other procedure types. Overall, device related malfunctions were not more likely to be associated with level II‐IV complications relative to non‐device related malfunctions (p = 0.212).
Conclusions: Based on the MAUDE database, among common BPH surgical devices, Aquablation and Rezum were associated with a higher proportion of clinically significant complications. However, this did not appear to be driven by device‐related malfunctions ‐ highlighting other factors as a potential source for adverse events with newer products.
Funding: None
Holmium Laser with MOSES (Molep) vs Thulium Fibre Laser Enucleation of Prostate (Thuflep) in the Real‐World. A Multicentre Propensity Score Analysis from REAP Database
Vineet Gauhar8, Daniele Castellani1, Fernando Gómez Sancha2, Dmitry Enikeev3, Nariman Gadzhiev4, Abhay Mahajan5, Mohammed Taif Bendigeri6, Moisés Rodríguez Socarrás2, Thomas R.W. Herrmann7
1Urology Unit, Azienda Ospedaliero‐Universitaria delle Marche, Università Politecnica delle Marche, 2Department of Urology and Robotic Surgery, ICUA‐Clínica CEMTRO, 3Institute for Urology and Reproductive Health, Sechenov University, 4Saint‐Petersburg State University Hospital,, 5Department of Urology, Mahatma Gandhi Mission's Medical College and Hospital, 6Asian Institute of Nephrology and Urology, 7. Department of Urology, Kantonspital Frauenfeld, Spital Thurgau AG, 8Ng teng fong general hospital
Presented By: Vineet Gauhar, MCh uro, Dip MIS Uro
Introduction: The Refinement in Endoscopic Anatomical Prostate enucleation database (REAP) retrospective registry was created to understand and identify the nuances and preferences in global practice of prostate enucleation by inviting experienced surgeons from centres around the world. This study aims to compare and contrast the Holmium laser with MOSES (MoLEP) and Thulium fibre laser enucleation of the prostate (ThuFLEP) in term of surgical and functional outcomes,
Methods: A retrospective analysis of all patients who underwent either procedures in 5 centres (January 2020‐January 2022). Exclusion criteria: previous urethral/prostatic surgery, radiotherapy concomitant surgery. Propensity score matching (PSM) analysis was performed to adjust for the bias inherent to the different characteristics at baseline. Differences between procedures were estimated for international prostate symptom score (IPSS), quality of life (QL), maximum flow rate (Qmax).
Results: PSM retrieved 118 patients in each. Baseline characteristics were similar except for PSA and number of men on indwelling catheter (higher in MoLEP group). Median surgical time was significantly longer in the MoLEP.Median catheter dwelling time and postoperative stay were similar. Early complications were mainly Clavien ≤2.Rate and type of early and persistent incontinence (> 3 months) was similar. At 12‐month patients reaching a decrease (Δ) of IPSS ≥18 from baseline was significantly larger with MoLEP.
Conclusions: This is the first real‐world study reporting outcomes up to 1 year comparing MoLEP vs ThuFLEP. Both were safe and efficacious with similar short‐term operative and functional outcomes. At 1‐ year, MoLEP patients had a sustained reduction of IPPS score. This information can help in counselling patients.
Funding: nil
The Initial Experience with HoLEP Program Implementation of a Non‐Fellowship Trained Urologist
Gregory Lacy II2, Daniel Kellner1
1Yale New Haven Hospital, 2Yale New Hven Hospital
Presented By: Gregory Lacy II, MD, FACS
Introduction: Holmium laser enucleation of the prostate (HoLEP) is an effective treatment for benign prostatic hyperplasia, but by most accounts, has a steep learning curve. We report the experience of a non‐ Fellowship trained single surgeon'sinitialexperience of more than 400 holmium laser enucleation of the prostate procedures at a single institution.
Methods: From April 2019 to February 2022 holmium laser enucleation of the prostate was performed on more than 400 patients. An institutional review board approved database was used to analyze the experience.
Results: In the first 400 patients (mean age 68.3 years), 381 patients underwent standard (N = 138) or en‐bloc (N = 243) HoLEP procedures. As the surgeon's experience rose, average pathology volumeincreased (p = .035) and overall operation time decreased (p < .001). Mean hospital stay also decreased from the first 100 patients to the last 100 (p < .001). 6‐month incontinence rates decreased from 10.8% (first 100 patients) to 5.5% (patients 301‐400) as the surgeon gained experience. When reviewing complications, there was not a significant difference in hematuria, UTIs, orurinary retention complications as the case numbers grew. When stratifying incontinence outcomes across various prostate sizes we identified significant decline in 3‐ and 6‐ month incontinence rate from second to third quartile of cases for 50‐100g prostates and 100 + g prostates (p < 0.005, 11.2% to 6.3% and 10.8% to 5.0% from first to fourth quartile in 50‐100g and 100g+ cases respectively). This decline in incontinence was not present in smaller sized prostates.
Conclusions: Holmium laser enucleation of the prostate can be implemented safely in the practice of community urologists despite a lack of specific procedural training in residency or Fellowship, in a properly supported environment. Improved operative efficiency, lower complication rates, and incontinence values can be expected as procedural case volume increase even as prostate volume and case complexity increase, with the adoption of the en‐bloc enucleation technique.
Funding: None
Temporal Trends of BPH Medications and Procedures ‐ Contemporary Medicare Database Analysis from 2013‐2020
Kevin Chua1, Jake Drobner1, John Pfail1, Rachel Passarelli1, Benjamin Lichtbroun1, Sai Krishnaraya Doppalapudi1, Hiren Patel1, Elias Hyams2, Sammy Elsamra1, Danielle Velez‐Leitner1, Ji Hae Park1
1Rutgers Robert Wood Johnson Medical School, Department of Surgery, Division of Urology, 2Brown University Medical School Division of Urology
Presented By: Kevin Chua, MD
Introduction: There has been rising usage of minimally invasive techniques for treatment of symptomatic benign prostatic hyperplasia (BPH) including water vapor thermal therapy (WVTT) and prostatic urethral lift (PUL). We hypothesized that the increased adoption of such technologies would lead to a decrease of BPH medication prescriptions and costs.
Methods: The 2013‐2020 Medicare Part D Public Use File was used to identify the number of claims and annual expenditure of alpha blockers (AB), 5‐alpha reductase inhibitors (5ARI), tamsulosin‐dutasteride combination pill, and tadalafil by urologists. Medicare Part B National Summary Data File was used to calculate the number of each BPH procedure per year.
Results: From 2013 to 2020, total BPH medication claims increased from 5,682,443 in 2013 to 6,874,329 in 2017 but decreased each year afterward to 6,565,868 in 2020 (Figure). Annual expenditure increased from $324,545,652 to $353,369,600 from 2013 to 2015, but then decreased to $167,365,641 by 2020. Dutasteride expenditure decreased by about $100 million from 2014 to 2020. Number of BPH procedures decreased from 106,016 to 100,963 from 2013 to 2015, but then increased to 129,958 in 2019. PUL increased from 0 to 35,639 from 2014 to 2019. WVTT increased from 0 to 7,611 from 2017 to 2019. There was a decrease in procedures in 2020 which is likely due to COVID.
Conclusions: BPH medication prescribing was seen to decrease after 2017 which may demonstrate the effect of increased surgical treatment. The economic burden of BPH medications has also been decreasing over time.
Funding: n/a
Evaluating Perioperative Antimicrobial Management in High‐Risk Patients Undergoing HoLEP: A Multi‐Institutional, Retrospective Study
Fabrice Henry1, Nikhil Pramod1, Suruchi Ramanujan1, Will Jevnikar1, James Bena2, Ryan Schwartz3, Jaxon Jeffery4, Samuel Sorkhi4, Ruben Sauer5, Shannon McNall6, Samantha Freeman6, Kevin Wymer4, Jessica Mandeville6, Simone Civellaro5, Mitchell Humphreys4, Naeem Bhojani3, Smita De2
1Cleveland Clinic Glickman Urological Institute, 2Cleveland Clinic Glickman Urologic Institute, 3University of Montreal, 4Mayo Clinic Arizona, 5University of Illinois Chicago, 6Lahey Clinic
Presented By: Fabrice Henry, MD
Introduction: There are minimal data to guide antibiotic management of patients undergoing holmium laser enucleation of the prostate (HoLEP) for benign prostatic hyperplasia (BPH), specifically patients at high risk of infection. Also, management of these patients varies widely. We therefore aim to evaluate the effect of preoperative antibiotic duration on infectious complications in high‐risk patients undergoing HoLEP.
Methods: A multi‐institutional retrospective review of patients undergoing HoLEP between 2018‐2023 at five institutions with differing antibiotic protocols was performed. Patients were defined as high risk if they were catheter‐dependent (indwelling urethral catheter, self‐catheterization, or suprapubic tube) or had a positive preoperative urine culture. These patients were categorized into long course (> 3 days) or short course (≤ 3 days) of pre‐operative antibiotics. The primary outcome was 30‐day infectious complications defined as a positive urine culture. A t‐test or Wilcoxon rank‐sum test was used for continuous variables and Fischer's exact test was used for categorical variables.
Results: Our cohort included 409 patients, of which 146 (35.7%) and 263 (64.3%) were categorized as short course and long course of pre‐operative antibiotic use, respectively. Median pre‐operative antibiotic duration was 1 day (IQR: 0‐3 days) and 7 days (IQR: 5‐7 days) in the short and long cohorts, respectively. 30 day post‐op infectious complications occurred in 11 (7.59%) of the patients who received a short course of antibiotics and 5 (1.94%) patients who received a long course of antibiotics (OR (95% CI) = 0.24 (0.08, 0.71); p = 0.007). There was no significant difference in prostate size, catheter‐dependence, and length of procedure between the two groups though enucleation time was longer in the long course cohort. Postoperative antibiotics use was noted to be more common in the long course cohort.
Conclusions: In our multi‐institutional study of high‐risk patients undergoing HoLEP, infectious complications were significantly lower on long‐course vs. short‐course of antibiotics. Prospective trials are needed to identify optimal pre‐ and post‐operative antibiotic regimens for HoLEP.
Funding: None
Diabetes Mellitus Affects Continence Recovery After HoLEP
Jonathan Modai1, Parth Patel1, Roi Babaoff2, James Lee1, Dong Ho Shin1, Kymora Scotland1, Matthew Dunn1
1UCLA, 2Rabin Medical Center
Presented By: Jonathan Modai, MD
Introduction: Transient postoperative urinary incontinence (UI) is a known complication of holmium laser enucleation of prostate (HoLEP). Patients suffering from this complication are reassured about the expected continence recovery but the timeline for this recovery is poorly understood. Studies assessing risk factors for prolonged transient UI found several risk factors, prostate size being one of them. No study to date has evaluated the effect of prostate dimensions on continence recovery after HoLEP. We hypothesize that the torque applied on the external urinary sphincter during HoLEP is influenced by prostate dimensions and affects continence recovery after the procedure.
Methods: We performed a prospective observational cohort study of patients undergoing HoLEP by a single surgeon from 2020 to 2022. Demographic, clinical, and radiographic variables were collected for analysis. Patients were followed post‐operatively until they regained urinary continence. Univariate and multivariable logistic regression analyses were performed to identify predictors of early (< 1 month) versus delayed (> 1 month) continence recovery after HoLEP.
Results: A total of 244 patients were included in the analysis, 40% of whom took longer than one month to regain continence. Average age, body mass index (BMI), and prostate volume were 70 (44‐92), 25 (20.56‐ 32.05), and 120 (18‐382), respectively. On univariate analysis, diabetes mellitus, BMI, length of surgery, and weight of resected tissue were all associated with delayed continence recovery. On multivariable analysis, patients with diabetes mellitus (DM) were three times more likely to experience delayed continence recovery (OR 3.02, CI 1.48‐6.18). Patients with higher BMI were statistically less likely to experience late continence recovery (OR 0.869, CI 0.76‐0.98), but the difference in mean BMI between the groups was only 0.66 and was deemed clinically non‐significant. Prostate dimensions were not found to affect continence recovery in neither uni nor multivariate analysis.
Conclusions: Patient‐related factors affect post‐operative urinary continence recovery after HoLEP. Our findings indicate that DM triples the risk for prolonged incontinence after HoLEP, while prostate dimensions were not found to have such an effect. These findings can help when counseling patients on their expected continence recovery after HoLEP.
1Institute of Urology, Rabin Medical Center ‐ Hasharon Hospital
Presented By: Tomer Hasdai, MD
Introduction: Holmium laser enucleation of the prostate (HOLEP) is a commonly performed procedure for the treatment of benign prostatic hyperplasia (BPH), particularly in cases involving large prostates. Compared to open prostatectomy, HOLEP has demonstrated advantages such as less complications, shorter hospital stays, reduced bleeding, and faster recovery. However, HOLEP is associated with a steep learning curve and potential complications that may necessitate a conversion to an open surgical procedure. This study aimed to present HOLEP cases which underwent conversion to open approach in our institution.
Methods: We conducted a retrospective analysis of patients who underwent HOLEP at our institution and required conversion to open surgery. We collected demographic and clinical data, as well as intraoperative and postoperative characteristics.
Results: Among 890 patients who underwent HOLEP surgery at our institution between 2016 and 2023, 6 patients (0.67%) required conversion to open surgery. The mean age at the time of surgery was 75 years (range: 70‐87), and the mean body mass index (BMI) was 30. Five patients were referred for surgery due to intractable lower urinary tract symptoms (LUTS), while one patient had obstructive uropathy. The mean prostate size was 101 cc (range: 80‐174). The indication for conversion included bladder perforation during morcellation (2 cases), operational difficulties (2 cases), uncontrolled arterial bleeding (1 case), and a narrow urethra impeding resectoscope insertion (1 case). In patients with bladder perforation, exploration and cystotomy suturing were performed, while the remaining patients underwent standard Suprapubic prostatectomy (SPP) with hemostasis as needed. No correlation was observed between surgeon experience and the need for conversion to open. The mean duration of the operation was 221 minutes (range: 141‐253), and the average length of hospital stay was 8.5 days (range: 5‐11). Two patients experienced urinary tract infections during the postoperative period, two patients required intensive care unit admission, and one patient needed drainage of a contaminated collection. No patient required reoperation.
Conclusions: Although the risk of conversion to open surgery during HOLEP is low, it does exist. HOLEP surgeons should be aware of this potential complication and acquire proficiency in the open surgical approach for situations when it is necessary.
Funding: non
Holmium Laser Enucleation of the Prostate as a Treatment Option for Patients with Concurrent Outlet Obstruction and Bladder Diverticulum
Michael Frumer1, Iyad Khamaisi1, Tzach Aviv1, Sagi Arieh Shpitzer1, Tomer Weizman1, Hen Hendel1, Gherman Creiderman1, Ron Gilad1, Krenawi Muhammad1, Shayel Bercovich1, Nadav Dekel1, Hadar Tamir1, Tal Wax1, Tomer Hasdai1, Yossi Ventura1, Niv Segal1, Liran Zieber1, Dmitry Enikeev1, Abd Elhalim Darawsha1, Yaron Ehrlich1
1Rabin Medical Center
Presented By: Michael Frumer, MD
Introduction: Bladder diverticulum can be secondary to prostatic enlargement with bladder outlet obstruction and be a source of high postvoid residuals prompting surgical intervention. This study aims to describe the early and intermediate‐term outcomes of patients with bladder diverticulum undergoing holmium laser enucleation of the prostate (HoLEP).
Methods: Preoperative, perioperative, and postoperative patients' variables were assessed retrospectively. The study group included patients with at least one diverticulum of 2 cm or more in diameter. Only those operated on until the end of 2021 were included to allow for a relatively long follow‐up.
Results: Among the 596 patients who underwent HoLEP at our institution until the end of 2021, 26 patients (4%) had diverticula measuring 2 cm or larger. The median prostate size was 92 cc (IQR 76, 121), and the median diverticulum size (largest if multiple) was 3.7 cm (IQR 2.5, 5). Preoperatively, 11 patients (42%) required an indwelling urinary catheter. In the rest, the median preoperative post‐void residual was 180 ml (IQR 68, 338). Perioperatively, no patient had a fever and one patient (4%), with prostate size of 210 g and long‐term use of blood thinners, required blood transfusion. Emergency department visits within 30 days included three hematuria (12%), one dysuria with negative urine culture (4%), and one transient urinary retention (4%). In a median follow‐up of 34 months (IQR 25, 53), all patients were voiding with no residual urine, four patients (16%) had urinary tract infection events, two patients (8%) required more than one pad per day, and none required diverticulectomy.
Conclusions: HoLEP is an effective treatment method for outlet obstruction in patients with bladder diverticula. Following the alleviation of the outlet obstruction, most patients do not require additional treatment and can avoid more invasive surgical interventions.
Funding: none
An Autonomous Continuous Bladder Irrigation System
Kai‐Ho Fok6, Sufyan Shaikh1, Ray Jayatunga2, Shamir Malik3, Jonguk Lee3, Brian Carrillo4, Monica Farcas5
1University of Toronto, 2University of Toronto, Institute of Biomedical Engineering, 3University of Toronto, Temerty Faculty of Medicine, 4WellSpring Research, 5University of Toronto, Temerty Faculty of Medicine, Institute of Medical Science, St. Michael's Hopsital, 6St. Michael's Hospital
Presented By: Egor Parkhomenko, B.Sc, MD
Introduction: Continuous bladder irrigation (CBI) is used in a variety of clinical settings including post‐ transurethral surgery and the emergency department. Currently, CBI administration relies on nurses to diligently monitor and switch irrigation bags, as well as titrate the inflow rate based on effluent color.
Inappropriate administration can result in discomfort to patients, clot urinary retention, repeat injury to the pathological or surgical site, extended hospital stays, and even operative management. Our objective was to create an autonomous CBI system that decreases the incidence of disrupted irrigation flow and monitors the outflow to alert clinicians of critical events.
Methods: 3D printing and off‐the‐shelf microcontrollers were used to design a device to fit the needs identified by stakeholders at our institution. Anin vitromodel of the bladder was created to test our design. The mechanical, electrical, and software subsystems were adjusted accordingly to meet our design requirements.
Results: Ourin vitroCBI model was able to simulate routine CBI administration with sudden bleeding. Bovine blood was used to simulate the bleeding events. A device was created that met identified stakeholder needs. Accurate detection of critical bleeding events, catheter blockage, and empty irrigation bags were achieved. The device responds to bleeding appropriately by increasing the irrigation rate. When the catheter is blocked, it stops the irrigation and alerts the nurse. Our system accurately titrated the irrigation rate to match a set outflow blood level parameter; conserving irrigation and minimizing nursing workload.Continuous monitoring of CBI effluent was recorded.
Conclusions: We anticipate our device will decrease the cognitive load on nurses in busy clinical settings and improve workflow.Moreover, the detection of critical events will likely decrease patient morbidity. Continuous monitoring of the CBI outflow may prove to be a new clinical decision‐making tool for ongoing hematuria. Clinical trial is pending.
Funding: This work was supported by the St. Michael's Foundation, Toronto, Ontario, Canada through the Angels' Den competition and the Keenan Foundation, as well as Alayne and Ron Metrick.
Predictors of Health‐Related Quality of Life Improvement for Water Vapor Thermal Therapy (REZUM) After 12‐Months of Follow‐up. A Prospective Cohort Study
Belén Giménez4, Juan Fulla1, Ragheb Massouh1, Diego González1, Sebastián Arroyo1, Tomás Gatica2, Sofía Astorga1, Catherine Sanchez3
1Universidad de Chile, 2Universidad Finis Terrae, 3Clinica las Condes, 4Urology Department, Universidad de Chile, Hospital Clínico San Borja Arriarán
Presented By: Belén Giménez, MD
Introduction: Water Vapor Thermal Therapy (WVTT)is an effective minimally invasive surgical treatment of bladder outflow obstruction. We aimed to identify pre and perioperative factors associated with health‐ related quality of life (HRQoL) positive changes after12‐months of WVTT.
Methods: Patients who underwent WVTT between 2020‐2022 in a Chilean clinical center were eligible for inclusion. Changes in urinary symptoms and HRQoL were assessed using the International Prostate Symptom Score (IPSS) questionnaire, and only patients with IPSS‐QoL ≥3 at baseline were included. Demographics, perioperative, and clinical outcomes data were obtained at baseline. The patients were assessed at 6 weeks and 3, 6, and 12 months after procedure. An improvement greater than 50% in IPSS score or an IPSS‐QoL score less than or equal to 2 points after procedure, was considered as a satisfactory treatment. Logistic regression analysis was used to determine potential predictors of a satisfactory treatment.
Results: A total of 130 men were treated and followed for a median of 13.1 months. The median age of included patients was 61.9 years (50‐87) with a mean prostate volume of 52.3cc (35‐81). Regarding the severity of the symptoms, 65.4% of patients reported moderate (IPSS 12‐23), 28.8% severe (IPSS 24‐35) and 5.4% mild lower urinary tract symptoms (IPSS 0‐11). At 12 months follow‐up, IPSS improved by 22.1%, 65%, 66.5% and 65.5% at 6 weeks, and 3, 6 and 12 months, respectively (P < 0.03). IPSS Quality of Life (QoL) scores improved by 55.5%, 61%, 63.2% and 66.6% % at these same time points (P < 0.001). Maximum flow rate (Qmax) improved by 6.9 mL/s at 12 months (p = 0.01). According to the definition of satisfactory procedure, 61.5% of patients improved their IPSS score, and 86.2% their quality‐of‐life score. Age ≤60 years‐old, expected prostate volume ≤60cc and a total number of injections ≤5, were independently associated on logistic regression analysis with improvement on IPSS‐QoL (OR 1.25, 1.87 and 1.55 respectively).
Conclusions: The WVTT was effective in improving the quality of life of the patients one year after the intervention. In this study, we demonstrated that age (≤60 years‐old), prostate volume (≤60cc) and a small number of treatments during WVTT (≤5 injections) were predictors of a significant 12‐month improvement of HRQoL in patients undergoing WVTT.
Funding: None
Global Variations in Transurethral Resection of the Prostate in the 21st Century: A Systematic Review and Meta‐Analysis
1Seth GS Medical College and KEM Hospital, 2Desai Sethi Urology Institute, University of Miami
Presented By: Joao Porto, MD
Introduction: To assess differences between TURP results in distinct parts of the world and comprehend the variations of this procedure in the last decades.
Methods: A systematic review and meta‐analysis of PubMed from 2000 to 2022 were conducted to assess randomized clinical trials (RCT) related to TURP. We found 126 studies with 8431 patients that were divided by continents: Europe, Asia, Africa, and Others (North America, South America, and Australia). The articles were also divided based on year period: 2000‐2004, 2005‐2009, 2010‐2014, and 2015‐2022. We assessed baseline and follow‐up visits (3, 12, and 36‐months) for International Prostate Symptom Score, Peak Flow (Qmax), Post‐void residue of urine (PVR), Prostate‐Specific Antigen (PSA), prostate volume, Sexual Health Inventory for Men (SHIM) score, and post‐operative complications. We evaluated the overall heterogeneity (OH) of all studiesin the analysis, differences between continents and year‐groups, and heterogeneity within each continent and year‐group.
Results: We found high OH for Qmax at 3 and 12‐months, PVR during the entire follow‐up, and PSA at 3‐ months. We also found significant elevated OH for bleeding, clot evacuation, incontinence, irritative symptoms, retrograde ejaculation, UTI, and diagnosis of cancer. Significant differences were found between continents for Qmax at 12‐months, PVR at 12 and 36‐months, SHIM at 3‐months, PSA at 3 and 36‐months, and prostate volume at 3 and 12‐months. Significant continent differences were also found for bleeding, blood transfusion, clot evaluation, and cancer diagnosis. Furthermore, Europe had significantly higher heterogeneity compared to other continents.
Conclusions: In the last 20 years there has not been a clear trend in the results of TURP. The heterogeneity within continents may indicate a lack of standardization in TURP, however, the symptom improvement among patients is relatively uniform, what may explain why TURP is the best available option for BPH, even with variation in the way it is performed across different regions.
Funding: N/A
Emergency HoLEP (eHoLEP): Holmium Laser Enucleation of the Prostate for Refractory Gross Hematuria (GH) in Men with Benign Prostatic Hyperplasia (BPH)
Nicholas Dean1, Jenny Guo1, Eric Li1, Perry Xu1, Matthew Lee1, Amy Krambeck1
1Northwestern University
Presented By: Perry Xu, MD
Introduction: BPH can be a common cause of GH. Men experiencing BPH‐related GH, especially those on therapeutic anticoagulation (AC), often require admission secondary to urinary retention and blood loss. The objective of our study was to examine the safety and efficacy of performing eHoLEP at time of cystoscopy and clot evacuation in men presenting with refractory GH in the setting of BPH.
Methods: We retrospectively identified men who underwent eHoLEP for prostate glands > 80 cc with refractory GH from our BPH database. Continuous variables were expressed as a mean (range). All HoLEP procedures were performed with MOSES 2.0 laser technology.
Results: We identified 11 patients who underwent eHoLEP between Jan 2021 and April 2023. The mean patient age was 77.0 (58‐92) years and the mean pre‐operative prostate size was 262.8 (126‐550) cc. Most patients were on baseline therapeutic AC (63.6%, n = 7/11) and had pre‐admission indwelling catheters (90.9%, n = 10/11). AC could not be held in 18.2% (n = 2/11) of patients. The mean duration of inpatient treatment for GH prior to eHoLEP was 4.7 (1‐14) days and 45.5% (n = 5/11) of patients had transfusion‐ dependent hematuria. At least one attempt at cystoscopy and clot evacuation failed in 36.4% (n = 4/11) of patients. The mean procedure duration was 109.7 mins (65‐182) and a mean 204.4 g (116‐393) of tissue was resected. The mean post‐operative LOS was 2.2 days (1‐4). Most patients were discharged without a foley catheter (81.8%, n = 9/11) and all patients are catheter free at last follow‐up. The 30‐day complication rate was 27.3% (n = 3/11), with all being CD grade 1 or 2. No patient required re‐admission or re‐operative intervention.
Conclusions: HoLEP can safely be offered to men admitted with refractory BPH‐related GH and is associated with satisfactory post‐operative outcomes in a co‐morbid cohort. Definitive emergency BPH treatment may hasten patient recovery and has the potential to reduce morbidity associated with treatment delays.
Funding: None
Prostate Biopsy Prior to Holmium Laser Enucleation of the Prostate: Effect on Perioperative Outcome and Complications
Jonas Herrmann1, Friedrich Hartung1, Britta Grüne1, Maren J Wenk1, Paul Patroi1, Marie‐Claire Rassweiler‐Seyfried1, Maximilian C Kriegmair1, Maurice S Michel1
1University Medical Centre Mannheim
Presented By: Jonas Herrmann, MD
Introduction: Prostate biopsy (PBx) may be necessary prior to surgical treatment of benign prostatic enlargement if there is suspicion of prostate cancer. It has been a matter of academic debate whether PBx influences the results of holmium laser enucleation of the prostate (HoLEP). Therefore, our aim was to analyse perioperative outcomes and complication rates in patients following HoLEP with vs. without previous PBx in a high volume center.
Methods: Perioperative data and 30‐day complication rates of 524 patients receiving HoLEP from 01/2021 to 01/2023 were analysed from a prospective database. Complications were recorded and evaluated using the Clavien Dindo Classification (CDC) and the Comprehensive Complication Index (CCI). The cohort was divided into patients who received PBx 6 months prior to HoLEP (group A) vs. patients who received PBx > 6 months prior to HoLEP or did not receive PBx at all (group B).
Results: The median prostate volume in group A (N = 76) was 100 cm3, which was greater than in group B (N = 448), which was 80 cm3 (p = 0.0431). Significant bacteriuria prior to HoLEP was more common in group A than in group B. (51.3 % vs. 27.7 %, p < 0.0001). Group A patients were younger (median 66 years vs. 72 years, p < 0.0001) and had higher preoperative PSA levels (7.5 ng/mL vs. 4.2 ng/mL, p < 0.0001). Enucleation efficiency (1.73 g/min vs. 1.8 g/min, p = 0.868), median hemoglobin drop (1 g/l vs. 0.8 g/l, p = 0.521), and median hospital stay (2 days in both groups) did not differ significantly between groups. Intraoperative complications occurred in 1.32 percent of group A patients versus 1.34 percent of group B patients (p = 1.00).
Conclusions: Prostate biopsy within 6 months of HoLEP did not show an effect on perioperative outcomes or complications, both intra‐ and postoperatively. Patients who received PBx 6 months before surgery had a larger prostate volume, a higher pre‐operative PSA, were younger, and significant bacteriuria was observed more frequently.
Funding: No funding was received.
MODERATED POSTER SESSION 16: BPH 2
Holmium Laser Enucleation of the Prostate in Men with Prostate Cancer and Bladder Outlet Obstruction
Michael Frumer1, Abd Elhalim Darawsha1, Gherman Creiderman1, Ron Gilad1, Tzach Aviv1, Sagi Arieh Shpitzer1, Muhammad Krenawi1, Tomer Weizman1, Shayel Bercovich1, Nadav Dekel1, Hadar Tamir1, Tal Wax1, Tomer Hasdai1, Yossi Ventura1, Niv Segal1, Hen Hendel1, Liran Zieber1, Dmitry Enikeev1, Yaron Ehrlich1
1Rabin Medical Center
Presented By: michael Frumer, MD
Introduction: The surgical treatment of men with enlarged symptomatic prostate and concurrent prostate cancer (PCa) is not well defined. This study aims to compare the surgical complications and success rate in men undergoing holmium laser enucleation of the prostate (HoLEP) with and without prostate cancer.
Methods: The medical records of patients treated with HoLEP between 2016 to 2023 at a single institution were assessed retrospectively. The study group included patients who already had PCa diagnosis or incidentally detected PCa at HoLEP. The control group included patients without pre‐existing PCa and with benign surgical pathology. Peri‐ and postoperative variables were compared between the groups using Pearson's chi‐squared test for categorical variables and Mann–Whitney test for continuous variables.
Results: Included were 704 men with a median age of 71.5 years (IQR 66, 77) and a median prostate size of 102 cc (IQR 85, 130). The study group included 37 (5%) patients: 16 patients with pre‐existing PCa and another 21 with incidentally detected PCa. Overall, 28 (76%) patients had ISUP grade 1, and 9 (24%) patients had grades ≥2. The control group included 667 (95%) patients without PCa. The surgical time and the resected prostate tissue volume were similar. No significant difference was found between the groups when comparing peri‐ and postoperative complications and surgical outcomes (Table 1).At a median follow‐up of 18.3 months (IQR 16, 27), all patients who underwent cancer treatment post‐HoLEP survived without cancer progression.
Conclusions: Patients with PCa can safely undergo HoLEP with a notably high catheter‐free rate. Postoperative monitoring and treatment are feasible and can detect disease progression requiring definitive treatment. Further research is needed to optimize surveillance strategies and long‐term cancer‐specific outcomes.
Funding: None
Defining the Best Metric for Evaluating Early Holmium Laser Enucleation of the Prostate (HoLEP) Learning Curve Progression
Rajat Jain1, Alexander Chait1, David Song1, Karen Doersch1, Scott Quarrier1
1University of Rochester Medical Center, Department of Urology
Presented By: Rajat Jain, MD
Introduction: Holmium laser enucleation of the prostate (HoLEP) has been proposed as the “Platinum Standard” for BPH therapy. The steep learning curve of HoLEP compared to other modalities has led to its lack of utilization. The objective of this study is to determine the best metrics for assessing the early learning curve progression of HoLEP.
Methods: The first 40 HoLEP cases of two surgeons were evaluated using the following metrics: total OR time, enucleation time, total OR time/prostate volume preop, total OR time/prostate weight resected, enucleation time/prostate volume preop, enucleation time/prostate volume weight resected, enucleation time/laser time, and prostate volume preop/prostate weight resected. Scatter plots for both surgeons were created of the number of cases vs the metric of the HoLEP learning curve being evaluated. A best‐fit line was calculated using least squares regression and the goodness‐of‐fit was compared using R2 (Table 1).
Results: Enucleation time/laser time was the most strongly correlated measure of the learning curve for both surgeons: Surgeon A (R2 = 0.26) and Surgeon B (R2 = 0.5) (Figure 1). There was no or very weak correlation with other learning curve metrics.
Conclusions: Studies estimate it takes 25‐50 cases to become acquainted with the steep learning curve associated with HoLEP. Different aspects of the procedure have variable learning curves. Identifying early metrics associated with the learning curve may aid in tracking a surgeon's competency. Our study demonstrates enucleation time/laser time, a measure of the efficiency of active laser use compared to total enucleation time, as a metric to track proficiency and identify surgeons who need additional attention in enucleation efficiency. Metrics related to volume or specimen weight are thought to add difficulty to the procedure but are not correlated in this early learning phase.
Funding: None
Comparative Analysis of Holmium Laser Enucleation of the Prostate (HoLEP) in Obese and Non‐Obese Patients
Shayel Bercovich1, Hen Hendel1, Abed Elhalim Darawsha1, Sagi Arieh Shpitzer1, Michael Frumer1, Yosi Ventura1, Liran Zieber1, Yaron Ehrlich1
1Rabin Medical Center
Presented By: Shayel Bercovich, MD, MPH
Introduction: Holmium laser enucleation of the prostate (HoLEP) has emerged as a minimally invasive surgical technique that offers excellent outcomes and improved quality of life for patients suffering from symptomatic BPH. However, the impact of obesity on surgical outcomes and the overall efficacy of HoLEP in the management of BPH remains a subject of debate. We aimed to compare the surgical results, perioperative parameters, and postoperative complications of HoLEP in obese and non‐obese patients.
Methods: We retrospectively assessed data of patients who underwent HoLEP from July 2016 to September 2023 in our institution. All the procedures were done by or in the presence of a senior Urologist. Patients were assessed as obese or non‐obese by BMI greater or lower than 30. Obese patients were categorized in which morbid obesity was defined as a BMI of 40 or higher.
Results: One hundred sixty‐eight patients with BMI greater than 30 were compared to all 536 other patients.Patients' demographics and clinical characteristics were similar, with a median age of 72 vs. 70 years, median prostate size of 100 vs. 110 CC, and percentage of indwelling catheter before surgery of 45% vs. 40% in non‐obese and obese patients, respectively. No significant difference was found in the procedure length (median: 110 vs. 112 min), post‐operative hospitalization length (median: 1 vs. 1 day), post‐surgical urinary retentions (6% vs. 7%), or post‐operative ER visits (10% vs. 10%), comparing obese to non‐obese patients respectively. Sub‐categorial analysis of obese patients showed no difference in the post‐operative parameters; however, the procedure length was longer in the morbidly obese (BMI > 40) patients (median: 135 vs. 110 min [p = 0.02]).
Conclusions: HoLEP in obese patients is similar to HoLEP in non‐obese patients regarding in‐op and immediate post‐op results. While obesity is a well‐established risk factor for various health conditions and poor surgical outcomes, we showed that HoLEP in obese patients is effective and safe.
Funding: none
MRI Transition Zone Volume is Highly Concordant with Enucleated Volume after HoLEP Due to Variation in Transition Zone Index
Emily Serrell4, Matthew Grimes1, Jordan Krieger2, Margaret Knoedler3, Shane Wells4, Ali Antar4, Ethan Richmond3, Trevor Everett4, Alex Thomas4, Daniel Gralnek4, Christopher Manakas5
1university of wisconsin, 2University of SWisconsin, 3University of WIsconsin, 4University of Wisconsin
5University of wisconsin
Presented By: Emily Serrell
Introduction: Holmium laser enucleation of the prostate (HoLEP) aims to remove the entire prostate transition. Preoperative imaging estimates of whole gland volume (WGV) are often used to predict HoLEP enucleated volume. However, WGV and enucleated volume are sometimes discordant, implying variability in the ratio of TZV to WGV (transition zone index, TZI). We aim to evaluate the TZI and WGV relationship assess the concordance between HoLEP enucleated volume and MRI‐estimated WGV and TZV.
Methods: A prospective HoLEP database was queried to identify patients with MRI within one year of HoLEP. TZI was calculated by dividing TZV by WGV. Patients were categorically stratified based on ellipsoid WGV, as measured by a radiologist. The ratio between TZI and WGV was assessed using stratified analysis and regression. Concordance was defined as the ratio of enucleated volume to WGV and TZV, with mean values compared using ANOVA.
Results: We analyzed 218 patients with mean WGV of 101g (range 16.7 ‐ 388) and TZV of 63.6g (range 6.06 ‐ 346). Specimen weight was more concordant with TZV than WGV (mean 0.98 (SD 0.3) vs 0.56 (SD 0.19); p < 0.001) Both TZV and WGV were positively correlated with specimen weight (r = 0.91 vs 0.88, p < 0.001). Mean TZI and enucleated specimen concordance all varied significantly when stratified by prostate volume (Table). Regression analysis revealed a significant, positive, non‐linear moderate relationship between WGV and TZI, but with high variability among individual patients (r = 0.62) (Figure).
Conclusions: MRI‐estimated TZV measurements are concordant with HoLEP enucleated volumes, especially when compared with WGV measurements. Larger prostates have a higher TZI, but TZI is highly variable between individuals and may not be accurately predicted by WGV alone. Therefore, preoperative transition zone measurement with MRI provides a valuable, accurate, and non‐invasive tool for estimating enucleated volume prior to HoLEP.
Funding: None
Holmium Laser Enucleation of the Prostate for Acute and Non‐Neurogenic Chronic Urinary Retention: How Effective is it? Results from a Single Surgeon Cohort
1Nottingham NHS Foundation Trust, 2Cambridge University Hospitals NHS Foundation Trust
Presented By: Tevita Aho, FRACS(Urol)
Introduction: Little is known about the outcomes of HoLEP for the subtypes of urinary retention (UR): Acute (AUR = painful UR of any volume with relief on catheterisation) and non‐neurogenic chronic (NNCUR = painless UR with PVR > 300ml in men able to void and painless with > 1,000ml on initial catheterisation in men unable to void).
Methods: A prospectively maintained database of the first 500 HoLEP cases performed under the care of a single surgeon was used to evaluate the three month post‐operative catheter status of patients with pre‐ operative UR. Long‐term serum creatinine was evaluated for those with high pressure chronic urinary retention (HPCUR = painless UR with associated renal dysfunction that improves following catheterisation).
Results: 280/500 (56%) had pre‐operative UR, of which 195 had AUR and 85 NNCUR, including 22 with HPCUR. Urodynamic assessment did not play a role in the surgical decision‐making process for those with UR. 98.9% of those with AUR and 98.8% with NNUR were catheter‐free three months following HoLEP. Those with NNCUR were statistically less likely to pass their first post‐operative trial without catheter (58.8%) compared to those with AUR (84.6%) and those undergoing HoLEP. for lower urinary tract symptoms (87.7%). No patients with HPCUR had a clinically significant deterioration in serum creatinine at a median of 60. months (IQR 36‐82 months).
Conclusions: HoLEP has excellent catheter‐free outcomes for those with pre‐operative UR in those not pre‐ selected by urodynamic assessment. It is a durable long‐term treatment for those with HPCUR.
Funding: Nil
Effectiveness and Safety of HoLEP Surgery for Extremely Large Prostates (>200 cc)
Hen Hendel1, Yaron Ehrlich1, Abd Elhalim Darawsha1, Gherman Creiderman1, Ron Gilad1, Michael Frumer1, Tzach Aviv1, Sagi Arieh Shpitzer1, Krenawi Muhammad1, Shayel Bercovich1, Tomer Weizman1, Nadav Dekel Dekel1, Hadar Tamir1, Tomer Hasdai1, Yossi Ventura1, Niv Segal1, Liran Zieber1, Dmitry Enikeev2, David Lifshitz1
1Rabin Medical Center, 2Medical University of Vienna
Presented By: Hen Hendel, MD
Introduction: Laser enucleation of the prostate (HoLEP) is an established endoscopic treatment modality for benign prostatic hyperplasia (BPH), primarily targeting prostates with significant volumes (> 80 cc). However, the existing literature on the effectiveness and safety of HoLEP surgery in patients with extremely large prostates (> 200 cc) is limited. Therefore, this study aims to evaluate the efficacy and safety of HoLEP surgery in this specific patient population.
Methods: Through a retrospective analysis, we identified a total of 704 patients who underwent HoLEP surgery at our department between 2016 and 2022. The study group comprised patients with prostates exceeding 200 cc, while the control group consisted of patients with prostates sized between 80‐199 cc, who underwent surgery in close proximity to the research group.
Results: We compared 28 patients with prostates larger than 200 cc (average 213.1 cc, range 200‐270 cc) to 56 patients with prostates sized between 80‐199 cc (average 135.3 cc, range 80‐190 cc). Apart from prostate size, there were no significant differences in the characteristics of the groups, except for the presence of a preoperative catheter (53.6% in the study group vs. 41.1% in the control group) and general risk factors.The duration of the surgery was longer in the study group compared to the control group (median 160 minutes vs. 110 minutes, respectively, p = < .001). However, there were no significant differences in postoperative haemoglobin drop (median 1.15 g/dL per mol 0.75, respectively) or time until catheter removal (96% of the study group and 91% of the control group had catheters removed on the first postoperative day).All patients in the study group were discharged home without a catheter, in contrast to 92.9% in the control group. Additionally, all patients were successfully weaned from the catheter within 7 days after surgery. Notably, one patient (3.5%) in the study group and three patients (5.3%) in the control group visited the emergency room within 30 days post‐surgery.No significant difference was observed between the study group and the control group in terms of the rate of surgical complications (0% vs. 3.9%, respectively).
Conclusions: This study demonstrates that HoLEP surgery is effective and safe for patients with prostates larger than 200 cc, comparable to HoLEP surgery in smaller prostates, with the exception of a longer surgical duration. These findings support the utilization of HoLEP as a viable treatment option for patients with prostates exceeding 200 cc.
Funding: None
'do as I Say, Not as I Do', a Survey on Physician Prescribing Preferences in the Management of Male Lower Urinary Tract Symptoms.
Ijeoma Nnorom1, Francesca Kum1, Gordon Muir1
1King's College Hospital London
Presented By: Ijeoma Nnorom, MBBS, MRCS
Introduction: This study aims to compare the prescribing choices of medications for male lower urinary tract symptoms (LUTS) to self‐administration preferences of Urologists and associated practitioners across the globe. The medications included in the survey are recommended by guidelines including European Associsation of Urology, British Association ofUrology, as well asNorth American sources.There is a paucity of data regarding the physicians' take on these medications in light of existing data on efficacy and side effect profile, as well as (guideline) recommendations for their use. The personal (self prescription) preferences discoveredmay throw some light on clinicians'approval of these medicines.We also wanted to assess the tendencies of our colleagues in other parts of the globe who may use a different set of guidelines and/or have a varying array of medications accessible in comparison to those commonly used in United Kingdom (UK) practice.
Methods: An electronic survey of Urologists and allied practitioners, practicing within the United Kingdom (UK) and globally was conducted. On a 10‐point Likert scale, respondents were asked 3 questions about these medications:‘Likelihood of prescribing’; the ‘perceived efficacy’, and ‘the likelihood of the respondent taking them’.10 medications from a total of 5 drug classes were looked at‐ Alfuzocin, Tamsulosin, Finasteride, Dutasteride, Solifenacin, Fesoterodine, Oxybutinin‐ Immediate Release(IR), Oxybutininin Extended Release (ER), Mirabegron, andTadalafil.
Results: Of the 210 respondents, most were from the UK (65%). 92% were Urologists or Urology trainees.Tamsulosin was the most preferred prescription with 96% being ‘Extremely likely’ to prescribe it, whereas nearly half were ‘Extremely unlikely’ to offer Oxybutynin‐immediate release. Next most preferred (for patients) was Finasteride. Interestingly Alfuzocin which is reported to havean overall better safety profile than tamsulosinremained a significantly less preferred prescribing choice than the latter. Furthermore,practitioners preferred taking Tamsulosin over Alfuzosin despite both being deemed similarly effective (mean rating 6.9).Overall, Solifenacin was deemed the most effective medication for male LUTS, and Oxybutinin IR, thought to be the least effective.Most practitioners would not take 5‐alpha‐reductase inhibitors, and Finasteride was a favoured prescription choice (64% rating > / = 7) over dutasteride (54% rating < / = 4) despite similar perceptions of efficacy.Daily Tadalafil was an ‘Unlikely’ prescription (48% rating < / = 4), however, many practitioners would be ‘Very Likely’ to take it (43% rating > / = 7).Similar patterns were noted in the patient prescription and self prescription patterns with some of the antispasmodics, though Mirabegron tended to be a favored choice in both instances over Solifenacin; 65% and 62% of clinicians would take Mirabegron and Solifenacin respectively if they were apporpriate patients, while 62% and 61% wouldprescribe Mirabegron and Solifenacin respectively.Solifenacin remained thefavorite forself prescription among antimuscarinincs. Percentages were compared with the weighted averages in each instance.
Conclusions: The prescribing choices of Urologists for male LUTS management do not necessarily mirror their personal preferences. The results obtained from this study can drive future studies on the actualfactors which dictate prescribing choices in various climes‐ side effect profile, cost and payment methods, demographics, prevalent local prescriptions and more.Furthermore, more robust studies may provide much needed information which could drive development of future medication and prescribing climates that enhance desireable characteristics and minimize unfavorable ones.
Funding: None (Self funded)
Comparison of EEP and TURP Long‐Term Outcomes. Systematic Review and Meta‐Analysis.
Andrey Morozov1, Mark Taratkin1, Anastasia Shpikina1, Yaron Ehrlich2, Jonathan McFarland3, Vasiliy Kozlov4, Harun Fajkovic5, Juan Gomez Rivas6, Lukas Lusuardi7, Jeremy Yuen‐Chun Teoh8, Thomas Herrmann9, Jack Baniel2, Dmitry Enikeev5
1Institute for Urology and Reproductive Health, Sechenov University, 2Division of Urology, Rabin Medical Center, 3Faculty of Medicine, Universidad Autónoma Madrid, 4Department of Public Health and Healthcare, Sechenov University, 5Department of Urology, Medical University of Vienna, 6Department of Urology, Clinico San Carlos University Hospital, 7Department of Urology, University Hospital Salzburg, 8S.H. Ho Urology Centre, Department of Surgery, The Chinese University of Hong Kong, 9Department of Urology, Hannover Medical School
Presented By: Andrey Morozov, MD, PhD
Introduction: Endoscopic enucleation of the prostate (EEP) has been previously shown to result in a lower postoperative prostate volume as well as a decreased PSA level compared to transurethral resection of the prostate (TURP). However, patients' outcomes with long term follow‐up are still to be determined in order to assess durability of the effect. The study objectives were to compare long‐term reoperation rate and functional outcomes between EEP and TURP.
Methods: We undertook a systematic literature review using three databases (Medline, Scopus, and Web of Science).The detailed search strategy is available at Prospero (CRD42021269261). According to PICO process (Patient, Intervention, Comparison, Outcomes) the scope of the review is as follows: P ‐ patients with BPH; I – EEP; C – TURP; O – reoperation rate due to BPH regrowth, functional outcomes (Qmax, IPSS, QoL, IIEF‐5, PVR), prostate volume, PSA level with follow‐ up longer than 3 years. The level of evidence for each study was estimated according to the Oxford Centre for Evidence‐based Medicine scale. RoB2 tool was applied to assess risk of bias in randomized studies. The primary outcome was reoperation rate at > 3 years. Secondary outcomes included long‐term functional outcomes or related values (prostate volume, PSA level, etc.).
Results: The final sample consisted of 5 trials (4 prospective randomized controlled trials and one retrospective analysis) with long‐term follow‐up 4‐7 years. EEP reoperation rate ranged from 0% to 1.27%, while – from 1.7% to 17.6% for TURP. Meta‐analysis showed significantly lower OR for EEP, 0.27 (95% CI 0.24 – 0.31), with notable homogeneity of the results, I2 = 0%. Long‐term Qmaxand IPSS were significantly better for EEP. Qmaxpooled mean difference was 1.79 (95% CI 1.72 – 1.86) ml/s with a high concordance amongst the studies, I2 = 0%. IPSS mean difference ‐1.24 (95% CI ‐1.28 – ‐1.2) points, I2 = 57% but QoL did not differ, with mean difference being 0.01 (95% CI ‐0.02 – 0.04), I2 = 0%. The residual urine volume measured by ultrasound was presented in 2 trials: while the first study showed significantly less PVR for EEP, the second one showed no difference (data was not suitable for meta‐analysis). IIEF‐5 score was also significantly better for EEP, mean difference 1.08 (95% CI 1.03 – 1.13), but heterogeneity was high, I2 = 70%. PSA level and prostate volume were only reported in one study and favored EEP slightly yet statistically significantly.
Conclusions: EEP had a significantly lower reoperation rate and better functional outcomes (Qmax and IPSS) at long term compared with TURP. It may also be beneficial in terms of IIEF‐5, PVR, and PSA level.
Funding: None
Evaluating Postoperative Holmium Laser Enucleation of the Prostate Outcomes in Benign Prostatic Hyperplasia Patients with Hypocontractile Bladders
Smita De4, Suruchi Ramanujan1, Nikhil Pramod2, William Jevnikar3
1Case Western Reserve University School of Medicine, 2Cleveland Clinic Lerner College of Medicine
3Wright State University Boonshoft School of Medicine, 4Cleveland Clinic
Presented By: Smita De, MD, PhD
Introduction: Holmium Laser Enucleation of the Prostate (HoLEP) has become a popular surgical treatment for benign prostatic hyperplasia (BPH) given that it is size‐independent and is associated with shorter hospital stays and less blood loss compared to traditional techniques. We evaluated outcomes of patients with hypocontractile bladders and BPH who underwent HoLEP as counseling these patients can be challenging. Our objective was to compare 6‐week and 6‐month post‐HoLEP outcomes in patients with hypocontractile bladders to those with normocontractile bladders.
Methods: We conducted a retrospective review of all HoLEP patients who had preoperative urodynamics at a single institution between December 2019 and June 2022. Bladder contractility index (BCI) was used to categorize patients into two groups: normocontractile and hypocontractile (BCI < 100 or inability to urinate). Post‐void residual (PVR) was assessed as the primary outcome at 6 weeks and 6 months. Secondary outcomes include catheterization status, AUASS, and urinary quality of life.
Results: Of 92 HoLEP patients with complete urodynamic evaluation, 44 had hypocontractile bladders. In the hypocontractile group, the mean PVR at 6 weeks post‐op was 57.05 mL versus 35 mL in the normocontractile group (p = 0.36). At 6 months post‐op, the mean PVR in the hypocontractile group was
27.6 mL versus 42 mL in the normocontractile group (p = 0.57) (Figure 1). 95.5% (21/22) of patients who were catheter‐dependent pre‐op in the hypocontractile group were catheter‐free following surgery compared to all (13/13) who were catheter‐dependent in the normocontractile group. At 6 weeks post‐op, there was no significant difference between mean AUASS (p = 0.75) and urinary quality of life (p = 0.74) in the hypocontractile and normocontractile groups. At 6 months post‐op, there was no significant difference between mean AUASS (p = 0.44) and urinary quality of life (p = 0.85) between the two groups.
Conclusions: HoLEP is an effective surgical option in BPH patients with hypocontractile bladders, including those who are catheter dependent. Similar results were seen 6 weeks and 6 months postoperatively in patients with hypocontractile and normocontractile bladders.
Funding: None
Rezum for BPH: Results from a Large Retrospective Multicenter Study
Clara Cerrato8, Mimi Vi Nguyen1, Vi Nguyen1, Savio Domenico Pandolfo2, Michelle Leach1, Raffaele Balsamo3, Francesco Uricchio3, Juan A. Fulla4, Dean Elterman5, Kevin C. Zorn6, Naeem Bhojani6, Bilal Chughtai7, Seth K. Bechis1
1University of California San Diego, 2University of Naples Federico II, 3Monaldi Hospital, 4Clinica Las Condes, 5University of Toronto, 6Centre Hospitalier de l'Universite de Montreal, 7Weill Cornell Medicine, 8University Hospital Southampton NHS Trust, Southampton, United Kingdom
Presented By: Clara Cerrato, MD
Introduction: We sought to determine predictors of post‐operative outcomes and adverse events for patients who underwent Rezum treatment for BPH.
Methods: We performed a multi‐institutional retrospective review of patients who underwent Rezum procedure for symptomatic BPH between April 2019 and November 2022. Patients' demographics, pre‐ and peri‐operative data, prostate volume (PV) and total international prostate symptoms score (IPSS) were evaluated. Primary outcomes were predictors for development of post‐operative adverse events (AEs) at one month follow up (persistent irritative symptoms [PIS], de novo UTI, retention or bleeding, or surgical retreatment by one year).Patients with pre‐operative urinary retention requiring catheterization were excluded.
Results: 798 patients were included in the analysis, with 177 (22.2%) having AEs, the majority of which was retention (12.3%)(Table 1). 42 (4.3%) patients had persistent irritative symptoms at one month postop (PIS), and 22 (2.8%) patients required retreatment within one year. AE group showed older age, larger prostate volumes, more treatments and longer post‐operative catheterization (all significant). On multivariate analysis (MVA), decreasing pre‐operative IPSS was associated with a higher overall probability of AEs (B ‐0.005, p = 0.044) and PIS(B ‐0.003, p = 0.020).Absence of median lobe (B ‐0.040, p = 0.039) and decreasing PV/treatment ratio (more treatments per unit volume) (B ‐0.004, p = 0.033) were independently associated with higher probability of de‐novo UTI, whereas presence of median lobe (B 0.070, p = 0.004), decreasing pre‐op IPSS (B ‐0.004, p = 0.035) and decreasing PV/treatment ratio (B ‐0.005, p = 0.046) were associated with higher risk of development de‐novo urinary retention. Higher preop IPSS scores were associated with higher postop IPSS scores at 1, 3‐6 and 12 months (p > 0.001).
Conclusions: Our results confirm that Rezum is a safe and effective option for patients undergoing treatment for BPH with low AEs and retreatment rates. Pre‐op IPSS, PV/treatment ratio, and presence of median lobe may help predict the development of postoperative AEs, but our study is limited by overall low numbers of AEs. Further analyses and longer follow‐up are needed.
Funding: None.
Large Prostate Practice Patterns and Outcomes: Single Center Experience of Holmium Laser Enucleation of the Prostate and Robot Assisted Simple Prostatectomy
Carl A Ceraolo1, Scott O Quarrier1, Karen M Doersch1, Anthony J Pamatmat2, Laena T Hines1, Jodi Erler1, Thomas P Frye1, Guan Wu1, Hani H Rashid1, Ahmed Ghazi1, Jean V Joseph1, Rajat K Jain1
1University of Rochester Medical Center, Department of Urology, 2University of Rochester School of Medicine and Dentistry
Presented By: Carl A Ceraolo, MD, MPH
Introduction: Holmium Laser Enucleation of the Prostate (HoLEP) and Robot assisted Simple Prostatectomy (RASP) are standard of care for management of large gland (> 80cc) benign prostatic hyperplasia (BPH). RASP can be performed using a traditional multiple port suprapubic approach (MP‐ RASP) or more recently a single port approach (SP‐RASP). This retrospective study aims to compare RASP surgical and postoperative metrics across approaches with HoLEP at a single institution.
Methods: Data were queried from a consented and prospectively maintained database for patients with large gland (> 80cc) BPH who underwent HoLEP between January 2022 and March 2023 at a single institution. Data were also retrospectively queried by manual chart review for patients with large gland BPH who underwent RASP in the same time period. Variables were analyzed using median and interquartile ranges for continuous variables, and proportions were obtained for count data. The Kruskal‐ Wallis test was used to compare continuous variables among RASP and HoLEP, and sub‐analyses were performed comparing RASP approaches with HoLEP. A chi‐square test was used to compare count data, and the fisher exact test was used for low count data. Linear regression was performed to obtain unadjusted and adjusted mean differences. P‐ values were reported with a pre‐determined alpha of 0.05. Statistical analyses were performed with R version 4.3.0.
Results: The study included 74 patients who underwent HoLEP and 30 patients who underwent RASP, of which 16 underwent SP‐RASP and 14 underwent MP‐RASP. Baseline, operative, and outcome analysesare reported in Table 1. Preoperative metrics were not significantly different among surgical groups except for prostate size. Operative time and catheter duration were greater in RASP groups compared to HoLEP (p < 0.05) in both tabular analysis and linear regression.
Conclusions: This study contributes to literature comparing HoLEP with RASP and is one of the first studies comparing HoLEP with SP‐RASP. Notably, our practice tends to send larger prostates for RASP. However, catheter duration, OR time, and hematuria were greater with RASP across approaches. Outcomes were favorable for all groups.
Funding: None
The Impact of Standard vs Early Apical Release HoLEP Technique on Postoperative Incontinence and Quality of Life
Mouneeb Choudry1, Daniel Heidenberg1, Nicholas Parker1, Jeffery Stagg1, Kevin Wymer1, Scott Cheney1, Mitchell Humphreys1
1Mayo Clinic Arizona
Presented By: Mouneeb Choudry, MD
Introduction: Early apical release has been reported to improve mucosal preservation of the external sphincter mucosa of the urethra. However, clinical implications remain relatively understudied. This is a single center, retrospective review to compare the standard and early apical release techniques for Holmium Laser Enucleation of the Prostate (HoLEP).Our aim was to investigate the difference in postoperative incontinence and quality of life for BPH patients treated with HoLEP using the standard vs apical release technique.
Methods: A retrospective review was performed to identify patients who underwent HoLEP from December 2021 to July 2022. A total of 114 patients underwent HoLEP, 60 patients using an early apical technique and 54 patients using a standard technique. Preoperative assessments included American Urological Association symptom score (AUASS), American Urological Association QoL score, serum prostate‐specific antigen (PSA), and prostate volume. Perioperative parameters included total operating time, total laser time, total morcellation time, and duration of postoperative catheterization. Postoperative evaluations were obtained at 6 weeks and3 months. These evaluationsincludedAUASS, AUASS QoL, and number of pads used per day.Wilcoxon and chi‐squared tests were used to evaluate differences between the two surgical groups in terms of continuous and categorical variables, respectively. A logistic regression was used to evaluate the usage of pads post‐operatively, when controlling for age and prostate size, between the two surgical groups.
Results: Pre‐operatively, there was no significant difference between the two groups in regard to AUASS, with a median overall score of 22.00 [IQR, 16.25‐26.75]. Post‐operatively, at 6 weekfollow up, the apical release cohort reported greater improvement in AUASS (p‐value: 0.034) and Quality of Life (p‐value: 0.001) relative to the standard technique group.The apical release group also reported significantly lower incontinence rates at 6 weeks post‐operatively(p‐value: 0.001), with 96.7% of men reporting the use of 1 pad or less per day compared to 42.6% in the standard technique group. Likewise, when controlling for prostate size and age, the apical release cohort was less likely to require 1 pad or more post‐operatively at 6 weekswhen compared to the standard HoLEP cohort, with an OR 0.59 (95% CI 0.51‐0.67, p = .001).
Conclusions: Compared to standard technique, early apical release HoLEP technique promotes improved return of continence and quality of life within 3 months of surgery.
Funding: None
An Audit on Readmissions Following TURP
Ahmad Alam1
1John Hunter Hospital, Newcastle, Australia
Presented By: Ahmad Alam, MBBS, MS
Introduction: Benign prostatic hyperplasia (BPH)is a common condition causing lower urinary tract symptoms in Australian men. BPH accounts for 228,000 general practice visits per year. The purpose of this retrospective chart review study was to investigate the major reasons for readmission of patients who underwent Transurethral resection of the prostate (TURP) surgery in an Australian Centre.
Methods: Data from 311 patients who underwent TURP for Benign Prostatic Hyperplasia from January 2019 to September 2020 were retrospectively analysed. Demographic information, patient factors, and intra‐ hospitalization characteristics were collected from online data records, including age, anticoagulant or antiplatelet therapy, preoperative catheterization, American Society of Anaesthesiologists (ASA) score, and preoperative urine culture. Perioperative factors, such as length of stay and days to readmission since the procedure, were also collected. Two patients were excluded from the analysis; one was readmitted for non‐ urological reasons (social reasons) two weeks after the procedure, and the other was excluded due to a lack of data.
Results: Of the 309 patients included in the analysis, 35 were readmitted within 30 days of discharge. The readmission rates for 2019 and 2020 were 13.17% (26 out of 205 surgeries) and 9.43% (9 out of 106 surgeries), respectively. The major reasons for readmission were clot retention from haematuria (40.6%), urinary retention (21.8%), infection (15.6%) and catheter complications (15.6%). The overall 30‐day ward readmission rate was 11.2%, which is consistent with previous studies reporting readmission rates ranging from 4.24% to 14.4%. Factors associated with readmission in our study included higher ASA score (infection), preoperative catheterization (infection), and the presence of antiplatelet/anticoagulants (clot retention).
Conclusions: The study recommends implementing a standardized protocol for preoperative optimisation of TURP patients. To further advance in the field, upcoming research should prioritize the creation of comprehensive guidelines for discontinuing and administering antiplatelet or anticoagulant medications. Additionally, there is a need for research into better patient selection based on their ASA scores.
Funding: This study was unfunded.
Comparison Between Thulium Fiber Laser and High‐Power Holmium Laser for Anatomical Endoscopic Enucleation of the Prostate: A Propensity Score‐Matched Analysis from the REAP Registry
Carlotta Nedbal17, Vineet Gauhar1, Daniele Castellani2, Khi Yung Fong3, Mario Sofer4, Rodríguez Socarrás5, Azimdjon Tursunkulov6, Lie Kwok Ying7, Dean Elterman8, Abhay Mahajan9, Tanuj Bhatia10, Dmitry Enikeev11, Nariman Gadjiev12, Mallikarjuna Chiruvella13, Jeremy Teoh14, Andrea Galosi2, Fernando Gómez Sancha5, Bhaskar Somani15, Thomas Herrmann16
1Department of Urology, Ng Teng Fong General Hospital, NUHS, Singapore., 2Urology Unit, Azienda Ospedaliero‐Universitaria delle Marche, Università Politecnica delle Marche, Ancona, Italy., 3Yong Loo Lin School of Medicine, National University of Singapore, 4Department of Urology, Tel‐Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel‐Aviv University, Tel‐Aviv, Israel., 5Department of Urology and Robotic Surgery, ICUA‐Clínica CEMTRO, Madrid, Spain, 6Urology Division, AkfaMedline Hospital, Tashkent, Uzbekistan, 7Department of Urology, Ng Teng Fong General Hospital, NUHS, Singapore, 8Division of Urology, Department of Surgery, University Health Network, University of Toronto, Toronto Canada, 9Department of Urology, Sai Urology Hospital and MGM Medical College, Aurangabad, India., 10Department of Urology, Sarvodaya Hospital and Research Centre, Faridabad, Haryana, India, 11Department of Urology, Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russian Federation, 12Department of Urology, Saint‐Petersburg State University Hospital, Saint‐Petersburg, Russia., 13Department of Urology, Asian Institute of Nephrology and Urology, Hyderabad, TG, India., 14S.H.Ho Urology Centre, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China, 15Department of Urology, University Hospital Southampton NHS Trust, Southampton, UK, 16Department of Urology, Kantonspital Frauenfeld, Spital Thurgau AG, Frauenfeld, Switzerland, 17Urology Unit, Azienda Ospedaliero‐Universitaria delle Marche, Università Politecnica delle Marche, Ancona, Italy AND Department of Urology, University Hospital Southampton NHS Trust, Southampton, UK.
Presented By: Carlotta Nedbal, MD
Introduction: To compare surgical and functional enucleation outcomes in a real‐world multicentre practice using high‐power Holmium laser (HP‐HoLEP) and Thulium fiber laser enucleation of the prostate (ThuFLEP) for different prostate sizes.
Methods: 4216 patients who underwent HP‐HoLEP or ThuFLEP in 8 centers from 7 countries between 2020 and 2022 were included. Exclusion criteria were previous urethral or prostatic surgery, radiotherapy, concomitant surgery.
Results: Propensity score matching (PSM) analysis retrieved 563 patients in each cohort to adjust for the bias inherent to different characteristics at baseline. Outcomes included incidences of postoperative incontinence, early complications (30‐day), and delayed complications; and measurements of the International Prostate Symptom Score (IPSS), quality of life (QoL), maximum flow rate (Qmax), and post‐void residual (PVR). After PSM, 563 patients in each arm were included. Total operative time was similar, but enucleation and morcellation times were significantly longer for ThuFLEP. Postoperative acute urinary retention was higher in the ThuFLEP arm (3.6% vs 0.9%, p = 0.005), but 30‐day readmission was higher in the HP‐HoLEP arm (22% vs 8%, p = 0.016). There was no difference in postoperative incontinence rates (HP‐HoLEP:19.7%, ThuFLEP:16.0%, p = 0.120). Rates of other early and delayed complications were low and comparable. ThuFLEP had higher Qmax (p < 0.001) and lower PVR (p < 0.001) than HP‐HoLEP at 1‐year follow‐up. This study is limited by its retrospective nature.
Conclusions: This real‐world study shows that early and delayed outcomes of enucleation with ThuFLEP are comparable to HP‐HoLEP, with similar improvement in micturition parameters and IPSS. As lasers become readily available, urologists should focus on performing a good anatomical prostate enucleation, with the laser only an adjunct for good surgery. Patients should be counseled about long‐term complications even in experienced hands.
Funding: None
Efficacy of GreenLight Laser Prostatectomy in the Management of Acute and Chronic Urinary Retention: A Retrospective Study
Sai Vangala1, Parsa Nikoufar1, Amr Hodhod1, Moustafa Fathy1, Sai K Vangala1, Ahmed S Zakaria1, Ruba Abdul Hadi1, Vahid Mehrnoush1, Loay Abbas1, Waleed Shabana1, Owen Prowse1, Prashidhi Pathak1, Ahmed Kotb1, Walid Shahrour1, Hazem Elmansy1
1Northern Ontario School of Medicine
Presented By: Sai Vangala, MD
Introduction: The objective of our study was to evaluate the efficacy and durability of GreenLight laser prostatectomy for the management of acute urinary retention (AUR) and chronic urinary retention (CUR) and to determine outcomes compared to patients without preoperative urinary retention.
Methods: We conducted a retrospective study of prospectively collected data from individuals who underwent GreenLight laser prostatectomy at our institution from May 2018 to July 2022. Patient demographics and outcome measures were recorded, including indications for the procedure, median urinary volume drained or median post‐void residual urine volume (PVR) before catheterization or GreenLight laser prostatectomy. Chronic urinary retention (CUR) was defined as PVR > 300 mL in males able to void and initial catheter drainage > 1,000 mL in males unable to void, in the absence of pain. All patients had postoperative follow‐up visits at 1, 3, 6, and 12 months. Our evaluation included the International Prostate Symptom Score (IPSS), quality‐of‐life (QoL) assessment, maximum urinary flow rate (Qmax), PVR, and catheter‐free status.
Results: One hundred sixty‐eight males who underwent GreenLight laser prostatectomy were included in our study. The urinary retention (UR) group consisted of 88 patients (50 AUR and 38 CUR), and the lower urinary tract symptoms (LUTS) group was comprised of 80 individuals. There were no statistically significant differences between the AUR and CUR subgroups regarding demographics. The CUR group had a significantly higher PVR at 1, 3, and 6 months than the AUR group. Other outcome measures were similar between the two groups. The UR group had a significantly higher age and duration of postoperative catheterization (p = 0.000 and 0.000, respectively) than the LUTS cohort. During the 3 and 6‐month follow‐up visits, the UR group had a significantly higher PVR than the LUTS cohort. At 12 months follow‐up, the LUTS group had a higher catheter‐free rate than the UR group (p = 0.008), and other outcome variables were comparable between the two cohorts. The successful first trial of void (TOV) rate for the UR and LUTS groups was 83% and 80%, respectively. At 12 months postoperative, the catheter‐free rate for the UR and LUTS cohorts was 87.5% and 100%, respectively.
Conclusions: GreenLight laser prostatectomy is an effective and durable treatment for urinary retention with a high catheter‐free rate and comparable outcomes when performed to manage LUTS.
Funding: None
Use of Temporary Prostatic EXIME Stent for Men with Urinary Retention ‐ Single Institution Experience
Keng Ng2, Jirayr Ajzajian1, Neil Barber1
1Frimley Health NHS Foundation Trust, 2Frimley Health NHS Foundatiuon Trust
Presented By: Keng Ng, BSc(Med), MBBS, MS, FRCS(Urol) , PhD
Introduction: Urinary retention is a common presenting issue to urologists. Conventional per urethral catheters have often been the main stay of treatment for the acute setting and also in men with chronic retention. Lately a novel new temporary prostatic stent has been utilised to treat urinary retention, allowing the patient to pass urine spontaneously without need of catheters and its associated catheter related complications (blockages, UTI, bladder spasms). We presentour single centre experience for Exime stent in men with both acute and chronic retention.
Methods: Retrospective data was collected for men who had Exime stent inserted form 2021‐2022 in one single institution. These were men who had acute retention, chronic retention and also a cohort of men post rezum surgery who had Exime instead of the usual catheter.Exime stnets were placed under aseptic technique with installation of local anaesthetic urethral gel with ease. Baseline clnical parameters, efficacy, safety, complications andtolerability were collected post insertion.
Results: 30 male patients (mean age of 77.4 years) with benign prostatic enlargement as cause of their retention were included over 1 year period. 7 patients had Exime stent post Rezum surgery while 23 had acute or chronic urinary retention. 22 patients had successful outcomes with Exime stent (voided spontaneously with no significant post void residuals) and remain catheter free. 8 patients had early complications ‐ 5patients were from post Rezum arm(urinary retention), while 2 patients had blockages due to debris and 1 patinet had urinary incontinence. These patients had stent removal and replacement with urinary catheters. the patient s with successful exime outcomes describe no pain or LUTS while maintaining spontaneous voluntary micturition. there were no reports of UTI in these men while the stent were in situ. A cohort of men with chronic retention were delighted to have regular 12 weeks Exime stent changes as their preferred choice over urinary catheters.
Conclusions: Exime stent is a safe and easy procedure to relieve urinary retention in men performed under local anaesthesia. It avoids the discomfort and complicationsof urinary catheters placed per urethrally and allows the patient to pass urine naturally and be catheter free. Further long term data will need to be collected to further evaluate the efficacy and cost effectiveness of Exime over urinary catheters.
Funding: None
Holmium Laser Enucleation of the Prostate in Men with Refractory Lower Urinary Tract Symptoms on Active Surveillance for Prostate Cancer: An Updated Cohort Analysis
Adam Wiggins1, David Canes1, Alireza Moinzadeh1, Jessica Mandeville1
1Lahey Hospital and Medical Center
Presented By: Adam Wiggins, MD
Introduction: The safety and feasibility of surgical treatment for BPH and lower urinary tract symptoms in men on active surveillance (AS) for known low‐risk prostate cancer (PCa) is not well studied. We previously reported 20 patients with low risk PCa on AS who underwent holmium laser enucleation of the prostate (HoLEP). Herein, we provide an updated and expanded cohort analysis, to assess the safety and feasibility of HoLEP in this population.
Methods: Men on AS who underwent HoLEP between 2013 and 2023 were identified. Data was collected and analyzed, with a focus on oncologic and functional outcomes.
Results: Thirty‐nine patients were included in this expanded cohort analysis. The average patient age was 66 years (std dev = 5.4 years), with a mean Body Mass Index of 28 Kg/m2 (std dev: 9.2 Kg/m2). The mean pre‐ operative max flow rate was 8.4 ml/s (std dev = 3.4 ml/sec), with a median postvoid residual of 79cc (interquartile range [IQR]: 57 ‐ 269) and a mean prostate size of 101cc (std dev = 32cc). Patients had a median adjusted preoperative PSA of 9.5 ([IQR]: 4.5‐13.5) ng/ml. All men had undergone a prior prostate biopsy, with most men having had one core positive for PCa (median 1; [IQR 1‐2]. Concerning post‐ operative functional data, the mean resected tissue weight was 79g (Std dev = 43) with improved postoperative flow rate (median improvement = 11 ml/s, [IQR] 6 ‐ 21) and decreased post‐void residual (median improvement = 85cc, ([IQR] 35 – 245). A total of 10 (26%) men had PCa in the HoLEP specimen (all Gleason Grade Group 1). Regarding oncologic outcomes, the median postoperative PSA nadir was 1ng/ml ([IQR]: 0.5‐1.4) at a median of 4 months. At last follow‐up (median 17 months, IQR: 4‐48), median PSA was 1.8 (IQR: 0.5‐1.5) ng/ml. Twelve men underwent postoperative multiparametric magnetic resonance imaging (mpMRI) with the identification of a new Prostate Imaging Reporting and Data System 5 lesion in four patients, who ultimately underwent prostate biopsy. Of these men, three had progression of disease, of which two decided to undergo treatment.
Conclusions: This updated and expanded analysis of 7 years of follow up data provides further evidence that, while postoperative monitoring with PSA, mpMRI, and biopsy remains necessary to detect disease progression that may require definitive treatment, men on AS for low‐risk PCa can safely and feasibly undergo HoLEP with significantly improved voiding parameters.
Funding: No specific funding.
Are All Fellowships Created Equal? Variation in Prostate Enucleation Case Volumes During Endourology Fellowships
Garrett Ungerer1, Kelly Lehner1, Reza Roshandel1, Aaron Potretzke1, Li‐Ming Su2, Kevin Koo1
1Mayo Clinic ‐ Rochester, 2University of Florida
Presented By: Kelly Lehner, MD
Introduction: There is growing interest in training opportunities that offer proficiency in enucleation procedures for BPH, which offers considerable advantages when treating large volume prostate glands. With an estimated learning curve of 25 cases, many trainees seek out fellowships to become proficient. We aimed to characterize variation in surgical training experience in prostate enucleation during endourology fellowships.
Methods: We analyzed surgical case logs submitted to the Endourological Society for all graduating fellows in 2020‐2022. Case logs were cross‐referenced with a list of verified fellowship graduates to ensure accuracy. Based on contemporary training literature, we defined the threshold for technical proficiency as 25 enucleation procedures.
Results: Case logs for 131 certified endourology fellows were analyzed. 48 (37%) fellows in 29 fellowship programs reported performing at least 1 prostate enucleation case during fellowship (Figure). The average number of cases performed was 52 (range 1‐334). 8 (17%) of fellows were women, corresponding to 112 of 2503 (4%) enucleation cases. 26 of the 29 (90%) programs offering enucleation training were based in the United States. The average number of cases performed in a 2‐year fellowship was 98 cases, compared to 27 cases in 1‐year programs. 23 (48%) of fellows met the minimum threshold of 25 cases during fellowship to reach proficiency (dotted line in Figure). Among different fellowship tracks, 2‐year stone track fellowships offered the largest volume of enucleations, averaging 145 cases per fellow, compared to 38 cases for 1‐year stone track programs, 30 cases for 2‐year combined stone/robotics track programs, and 7 cases for 1 year robotics track programs. No enucleations were reported at 2‐year robotics track programs.
Conclusions: There is substantial variation in enucleation case volumes between fellows and institutions. Roughly half of fellows who performed enucleation cases surpassed the proficiency threshold of 25 cases. Expanding advanced training for BPH including enucleation may help improve access to care for this problem.
Funding: None
Endoscopic Enucleation of the Prostate: Outcomes in Patients with Enormous Prostates (≥ 200 cc)
Vladislav Petov4, Alexander Androsov1, Andrey Morozov2, Dmitry Enikeev3
1Institute for Clinical medicine, Sechenov University, 2Institute for Urology and Reproductive Health, Sechenov University, 3Department of Urology, Medical University of Vienna, 4Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia
Presented By: Vladislav Petov, MD
Introduction: Current EAU and AUA guidelines suggest endoscopic enucleation of the prostate (EEP) for all the patients with BPH regardless of the prostate volume. However, in patients with enormous prostates (≥ 200 cc) EEP is associated with prolonged surgery duration and sometimes looks like herding cats for unexperienced surgeon. Some surgeons prefer simple prostatectomy in such cases. The aim of our study is to evaluate efficacy and safety of EEP in patients with BPH ≥200 cc and to make a conclusion on its reasonability in such difficult setting.
Methods: A retrospective single‐center study was conducted in the Institute for Urology and Reproductive health of Sechenov University between 2020‐2023 years. Inclusion criteria were as follows: preoperative prostatic volume ≥200 cc; the management of BPH was performed using Holmium laser enucleation of the prostate (HoLEP) or Thulium fiber laser enucleation of the prostate (ThuFLEP). Exclusion criteria: previous surgical interventions for BPH, no postsurgical follow‐up data.
Results: A total of 53 participants were enrolled in the study: 28 of them underwent HoLEP and 25 – ThuFLEP. The baseline stats were as follows: mean age ‐ 68.4 ± 6.9 years, median prostatic volume – 210 (200;236) cc, mean PSA – 6.4 ± 3.7 ng/ml, mean Qmax – 8.3 ± 1.8 ml/sec, median PVR – 60 (50;72.5) ml, median IPSS – 23 (22;24), median QoL 4 (3;5). Median operation duration was 81 (59;126) min, median enucleation weight – 97 (68;169) g, catheterization time – 1 (1;2) days, hospital stay 3 (3;4) days. Transient stress urinary incontinence was observed in 4 patients; injury of the bladder wall – in 1 patient;injury of the ureteral orifice – in 1 patient(Clavien‐Dindo I); clot retention– in 4 patients (Clavien‐Dindo II); acute urinary retention – in 1 patient; clot retention with surgical revision – in 2 patients; delayed morcellation – in 1 patient(Clavien‐Dindo III);death due to thromboembolia of the pulmonary artery (Clavien V) – in 1 patient with the prostatic volume 310 cc. At 3‐months follow‐up all functional parameters significantly improved: prostatic volume reduced to 20 (15;30) ml; PSA – 1.1 ± 0.2 ng/ml; Qmax – 21.8 ± 2.7 ml/sec; PVR – 10 (0;20) ml; IPSS – 4 (3;7); QoL 2 (1;2), p < 0.01. Among late complications there were stress urinary incontinence in 1 patient and bladder neck sclerosis in 1 patient.
Conclusions: The results of our study affirm that EEP is a size independent BPH management procedure and it should be considered as a viable optional for surgical treatment in patients with prostates ≥200 cc too.
Funding: None
How Good Are We Really? Retrospective Study of Postoperative Bleeding Requiring Intervention and the Need for Intraoperative Electrocoagulation After Thulium Laser Enucleation of the Prostata
Simon Filmar1, Andreas Gross1, Clemens Rosenbaum1, Benedikt Becker1, Christopher Netsch1
1Asklepios Klinik Barmbek
Presented By: Simon Filmar, Dr. med.
Introduction: Laser enucleation of the prostate with the thulium laser (ThuLEP) is a procedure for the surgical treatment of benign prostate hyperplasia(BPH).
Methods: A collective of 503 patients who received ThuLEP in the period from August 1st, 2021 to July 31st, 2022 in the urological department of the Asklepios Klinik Barmbek for BPH were examined retrospectively. Preoperative and intraoperative parameters were defined and their influence on the occurrence of postoperative bleeding requiring intervention and the need for intraoperative electrocoagulation was evaluated.
Results: In 41.2% (n = 207) of all cases, intraoperative electrocoagulation was necessary for ThuLEP. Independent risk factors for intraoperative electrocoagulation in ThuLEP were the occurrence of an intraoperative capsular perforation (p = 0.005) and a higher resection weight (p = 0.002). In 4.2% (n = 21) of the cases, secondary bleeding requiring intervention was observed. There was statistically significant secondary bleeding requiring intervention with a higher preoperative prostate volume (p = 0.004), a higher resection weight (p = 0.004) and intraoperative electrocoagulation in ThuLEP (p = 0.048).
Conclusions: The need for intraoperative electrocoagulation in ThuLEP was associated with an increased rate of postoperative bleeding requiring intervention. Independent risk factors for the need for electrocoagulation were intraoperative perforation of the prostate capsule and increased resection weight.
Funding: None.
MODERATED POSTER SESSION 17: PEDIATRIC UROLOGY
Minimally Invasive Bladder Augmentation: A Safe Alternative to Open Surgery in Pediatric Patients
Christopher Connors1, Micah Levy1, Daniel Wang1, Francisca Larenas1, Jeffrey Stock1, Michael Palese1
1Icahn School of Medicine at Mount Sinai
Presented By: Christopher Connors, BA
Introduction: Augmentation enterocystoplasty (AEC) is a complex reconstructive procedure used to increase bladder capacity often in children experiencing neuropathic bladder dysfunction. While traditionally an open procedure, minimally invasive (MIS) approaches have become more common. Currently, no studies compare outcomes between open and MIS AEC. This study evaluated surgical outcomes between open and MIS AEC in pediatric patients using a national database.
Methods: The Pediatric NationalSurgical Quality Improvement Program (pNSQIP) database was queried for AEC from 2012 to 2020. Patients were stratified by open or MIS approach. Demographics, perioperative information, and rates of 30‐day surgery‐related readmissions (SRR), prolonged length of stay (PLOS), and Clavien‐Dindo (CD) complications, including reoperations (CD III) were compared between groups via chi‐ square and multivariate analysis.
Results: 769 AEC cases (MIS = 80; Open = 689) were identified. MIS patients were more likely to be older (10.58 vs 10.11 years) and male (59% vs 49%), but these differences were not significant. Additionally, operative time was significantly longer in the MIS group (407 vs 375 mins, p = 0.008). All surgical outcomes studied were more common in the open group including CD I/II complications (23.8 vs 22.5%), CD IV complications (4.4 vs 1.3%), reoperations (10.4 vs 10.0%), PLOS (31.7 vs 25.6%), and SRR (15.1 vs 7.5%), but these differences were not significant [Figure 1]. However, on multivariate analysis, MIS was a negative predictor of unplanned SRR(OR = 0.323 [0.114 – 0.914], p = 0.033) [Table 1]. MIS was not a significant predictor of CD I/II or CD IV complications, reoperations, PLOS, or SRR.
Conclusions: AEC is a major surgery with relatively high instances of post‐operative complications and SRR. A MIS approach for AEC does not confer additional risk to patients and may in some cases be associated with improved surgical outcomes such as fewer unplanned SRR.
Funding: None
A Machine Learning Model for Predicting Surgical Intervention in Children with Ureteral Stones ≤10mm
Paz Lotan8, Hen Hendel1, Subhy Khoury2, Kamil Malshy3, Yarden Zohar4, David Ben‐ Meir5, Roy Morag5, Nir Kleinmann6, David Lifshitz7, Miki Haifler6
1Department of Urology, Rabin Medical Center, Petah‐ Tikva, Israel, 2Department of Urology, Carmel Medical Center, Haifa, Israel, 3Department of Urology, Rambam Health Care Campus, Haifa, Israel, 4Department of Urology, Soroka Medical Center, Beer‐ Sheva, Israel, 5Pediatric Urology Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel, 6Department of Urology, The Chaim Sheba Medical Center at Tel Hashomer, Ramat‐Gan, Israel, 7Department of Urology, Rabin Medical Center, Petach Tikva, Israel, 8Department of Urology, Rabin Medical Center, Petah‐ Tikva, Israel and Department of Urology, Roswell Park Comprehensive Cancer Center, Buffalo, New York
Presented By: Paz Lotan, MD
Introduction: The increasing prevalence of pediatric urolithiasis highlights the importance of identifying patients presenting to the emergency department (ED) who will ultimately require surgical intervention. This is crucial for efficient management and reducing the healthcare burden. Our objective was to develop a machine learning (ML) model that can predict the need for surgical intervention in children with ureteral stones ≤10mm.
Methods: We conducted a retrospective review of a multi‐institutional cohort comprising children aged 1‐18 who presented to the ED with ureteral stones ≤10mm between 2004 and 2021. We collected data on various factors, including age, gender, ethnicity, urolithiasis history, symptoms, visual analog scale (VAS) scores, imaging findings such as hydronephrosis, stone size, location and side, laboratory measures, and management approaches.Continuous and categorical variables were compared using the Wilcoxon and Fisher exact tests, respectively.We fitted a tree‐based extreme gradient‐boosting ML model to predict the need for surgical intervention based on clinical parameters. Each variable's importance was assessed using Shapley additive explanations values. The cohort was divided into training (80%) and test (20%) sets. The model was fitted on the training set and evaluated using the test set by receiver operating characteristic curve and decision curve analyses.
Results: Of a total of 164 children (median age 15 [IQR 10,16.7]) included in the study, 60 (37%) underwent surgical intervention. The model accuracy predicting the need for surgical intervention was 0.89 (Figure 1). The most important features, collectively contributing 65% of the model's predictive power, were the stone size and location, presence of renal stones, ethnicity, and neutrophil‐to‐lymphocyte ratio. The model demonstrated significant clinical benefit across all probability thresholds.
Conclusions: Our ML model can assist in the decision‐making process between conservative treatment and surgery for ureteral stones ≤10mm in children presenting to the ED. The model exhibited high accuracy and generalizability. It has the potential to identify patients who will likely require surgical intervention early on, thus reducing the burden of expectant therapy.
Funding: None
Laparoscopic Fixation of Testis with or Without Spermatic Vessels Division
Eyal Atias2, Noy Tandler1, Yehezkel Landau2, Gabriel Molineros2, Leonid Boyarsky2, Guy Hidash2
1Sackler Faculty of Medicine, 2Hadassah Medical Center
Presented By: Eyal Atias, MD
Introduction: Available data suggest that whenever possible, the primary laparoscopic fixation of the undescended testis without dividing the testicular vessels is a preferred procedure. Recent studies have challenged this long‐standing perception. These studies recommend performing a single‐stage laparoscopic orchiopexy with division of the testicular vessels (single‐stage laparoscopic Fowler‐Stephens orchiopexy) for all patients, regardless of the location of the testis. Our aim is to describe the outcomes of the procedure with and without dividing the testicular vessels in our institution.
Methods: We performed a retrospective cohort study and obtained demographic, clinical, and surgical data about infants with undescended testis. Comparison of results between primary surgery or Fowler‐Stephens (FS) in one stage. The decision regarding the type of surgery was made intraoperatively based on the testis location and the degree of vascular mobility. Surgical success was defined as the testis being properly positioned in the scrotum during follow‐up.
Results: Ninety‐nine diagnostic laparoscopies were performed. Undescended testis was identified, and laparoscopic fixation was performed in 62 patients. Among them, 52 patients (63 testis) were included in the study. Forty‐eight testes underwent primary fixation while preserving the testicular vessels, and 15 testes underwent FS. The median age at surgery was 1.2 years (range: 0.5‐6.1 years). The median follow‐up duration was 3.2 months (range: 0.2‐37.7 months). The success rate of primary laparoscopic fixation was 97.9%, while the success rate of FS was 80%.
Conclusions: Despite the retrospective nature and the selection bias of the study, similar to other comparable series, this study also demonstrates that primary laparoscopic fixation of undescended testis without division of the testicular vessels is possible in a large proportion of cases, and its outcomes are superior to those of the procedure with division of the testicular vessels. We recommend, whenever possible, performing primary laparoscopic fixation of undescended testis without division of the testicular vessels.
Funding: Non
Comparison Between Contrast Enhanced Voiding Urosonography (CEVUS) with Standard Cystography under Fluoroscopy (VCUG) for Detection of Vesicoureteral Reflux in Pediatric Patients
Omri Nativ1, Ehud Berger1, Nikola Fazza1, Fadi Zu'bi1, Imad Kassis1, Halima Dabaja‐Younis1, Gharam Salame1, Amir NSair1, Anat ILivitzki1, Akram Assadi1
1Rambam Medical Center
Presented By: Omri Nativ, MD
Introduction: The gold standard diagnostic test to evaluate pediatric febrile urinary tract infections (UTI) is cystography under fluoroscopy (VCUG). Despite the advantages of the standard cystography in identifying anatomical anomalies and vesicoureteral reflux (VUR), the examination exposes the patients to ionizing radiation and its invasive nature can cause UTI at significant rate. In recent years a novel diagnostic test called Contrast Enhanced Voiding Urosonography (CEVUS) allows performing a dynamic and anatomic evaluation of the urinary system under US guidance by using contrast media that is based on small air bubbles. This new technology can avoid the patient's exposure to ionizing radiation. In the current study we aim to evaluate the efficacy in diagnosing VUR and the periprocedural infection rate of CEVUS compared with VCUG.
Methods: This retrospective study included pediatric patients that were referred to a cystographic evaluation of the urinary system during years 2012‐2022. The indication for referral included: first febrile UTI below one year of age, recurrent febrile UTI, antenatal diagnosed hydronephrosis and children with posterior urethral valves or neurogenic bladder. Periprocedural UTI was defined as culture positive UTI within 30 days of the examination. All patients received periprocedural antibiotic prophylaxis. According to the diagnostic test (CEVUS or VCUG), patients were divided into two groups.
Results: Results are presented in Table 1: the study included 873 patients of which 759 in the VCUG group and 114 in the CEVUS group. As shown in the attached table, patients referred to the CEVUS group were female with UTIs. In addition, the proportion of high grade VUR (4‐5) was nearly twice more often in the CEVUS group. In the VCUG group there were more tests with no pathological finding (54% vs 36%).
Conclusions: Compared to VCUG, CEVUS test had a higher detection rate of high‐grade reflux (4‐5) and a lower diagnosis of grade 1 reflux. This difference might be attributed to the subjective nature of the US examination. Although there were twice more UTIs in the CEVUS group it was not found to be statistically significant.
Funding: None
Efficacy of Bladder Neck Injection to Achieve Continence after Failed Bladder Neck Repair in Exstrophy Patients
Ilhami Surer1
1The University of Health Sciences, Gülhane Medical School, Department of Pediatric Urology
Presented By: Ilhami Surer, MD,FEBPS,FEAPU
Introduction: To evaluate the efficacy of bladder neck injection technique (BNIT) with a bulking agent in patients with previously failed bladder neck repair in exstrophy‐epispadias complex patients.
Methods: From January 2000 to January 2023, 29 exstrophy children were treated for incontinence due to failed bladder neck repair by endoscopic submucosal BNIT with a Dx/HA copolymer bulking agent. The median age was 11 years (7‐19 years). The procedure was performed as an out‐patient procedure under general anesthesia and injection sites were 3 and 9 o'clock position at the bladder neck. The follow –up assessment of the continence was performed by voiding charts, urodynamic evaluation and VCUG. The mean follow‐up period was 60 months (9‐144 months).
Results: After single injection, at 3‐months follow‐up 20 of the 29 patients were dry completely and overall success rate was 68.9% . The median injected volume was 9 ml (5‐13 ml). Overall success rate decreased to 48,2 % at the end of one year follow‐up. Three years after the injection achieved success rate decreased to 34.4% and five years later only four patients were continent(13,7%). There was no complication related to the injection during the follow‐up period
Conclusions: Treatment of incontinence in exstrophy patients that previously failed bladder neck repair can not be managed successfully by endoscopic submucosal BNIT technique in long term period.
Funding: None
Geographic Distribution of Hypospadias in Rhode Island Iis Not Related to Pollution: A Study of a Small State with a Stable Population
Borivoj Golijanin1, Emily Barry1, Rachel Greenberg1, Anthony Caldamone1, Hsi‐Yang Wu1
1Minimally Invasive Urology Institute of the Miriam Hospital and Warren Alpert Medical School of Brown University
Presented By: Borivoj Golijanin
Introduction: It is thought that in‐utero exposure to environmental factors may have a role in the pathogenesis of hypospadias through hormonal dysregulation. Endocrine disrupting environmental factors can be found in superfund sites (SS), leaking underground storage tanks (LUST), sanitary waste sites (SWS), and active solid waste facility sites (ASWFS). This study investigates whether hypospadias in Rhode Island has a geographic distribution that is dependent on pollution.
Methods: Pediatric hypospadias cases in Rhode Island (RI) treated at a single hospital system from 2015 to 2018 were retrospectively reviewed. Type of hypospadias (proximal, midshaft, distal) was assessed for each record after which the records were geocoded and mapped. Geographic distribution of these cases was assessed for clustering and outliers using Global Moran's I and Local Moran's I. Correlation of the formed clusters with the proximity of pollution sites including SS, LUST, SWS, ASWFS was calculated.
Results: 113 cases of hypospadias, including 20.4% proximal (23/113), 10.6% midshaft (12/113), and 69% distal (78/113), were included. Regardless of type, Global Moran's I did not find significant incidence clustering (Moran's Index = 0.073, z‐score = 1.82, p = 0.067). Considering the types of hypospadias, Local Moran's I identified 31 significant clusters (Table 1). 48.4% (15/31) of clusters were comprised of distal hypospadias cases only, they were found along the Blackstone River Valley in Northern RI. Proximal and midshaft were found in 48.4% (15/31) of clusters; they were all found in central RI and areas around the capital. One outlier was found between Northern RI and Central RI and was comprised of all three types of hypospadias. There were no significant correlations between proximity of any of the pollution sites and hypospadias incidence.
Conclusions: There is a clear geographic separation of the type of hypospadias found in RI that is unrelated to proximity of pollution sources. Northern RI bordering Massachusetts has significant incidence of distal hypospadias whereas proximal and midshaft were found in central RI surrounding the capital. Additional study of the causes of hypospadias, including timing and amount of exposure, and genetic factors, are warranted to explain the etiology of this developmental malformation.
Funding: None
Antegrade Endourological Technics for Diagnosis and Treatment of Congenital Obstruction of Female Reproductive System
Yitzhak Elkis1
1Hadassah Medical Center
Presented By: Yitzhak Elkis, MD
Introduction: Antegrade imaging, nephrostomy tube insertion, and dilation of the path to the kidney are accepted techniques in urology when the upper urinary tract is obstructed. Here We describe the use of these techniques for the diagnosis and treatment of congenital obstructive defects in the female reproductive system.
Methods: A prospective collection of data on patients in whom we used endourological techniques to diagnose and treat congenital obstructions of the female reproductive system. In brief: After cystoscopy and vaginoscopy, a diagnostic laparoscopy was performed in which we identified the uterus. Under laparoscopic guidance, and with assistance of fluoroscopy and laparoscopic probe ultrasound, we performed a trans‐ cutaneous puncture and injection of contrast material into the uterine cavity.
Results: Four female patients are described. In two patients, no evacuation of contrast material from the uterus was seen at all, and no uterine cervix was demonstrated – which supported the diagnosis of Cervical Agenesis and absence of a proximal vagina (Image 1). A third 9‐day‐old female patient with urogenital sinus and urinary retention due to a pelvic mass blocking the urethra. Ultrasound scan was performed which raised the suspicion that the obstruction was due to external compression from the uterus. During the operation, a vaginoscopy was attempted in which it was not possible to advance in the vagina and therefore Distal vaginal agenesis was diagnosed. Dilation of the tract was performed and drainage of contaminated hematometra by nephrostomy tube. A fourth patient with OHVIRA syndrome (obstructed hemivagina and ipsilateral renal anomaly), and with a transverse vaginal septum blocking one of the hemivagina, which caused the formation of a pelvic cyst that compresses the urinary bladder. A cut of the transverse septum was made using the Bugbee electrode.
Conclusions: antegrade endourological techniques are not familiar in the field of gynecology but may be useful in the evaluation and treatment of congenital obstructive problems of the female reproductive system. We recommend cooperating with our gynecologist colleagues in the treatment of these children.
Funding: None
Trends in Emergency Department Admissions Due to Renal Colic in the Pediatric Population – A Multicenter Study
Dor Golomb8, Hanan Goldberg1, Paz Lotan2, Ilan Kafka3, Stanislav Kotcherov3, Guy Verhovsky4, Asaf Shvero5, Ron Barrent6, Ilona Pilosov Solomon7, David Ben Meir6, Ezekiel H. Landau8, Amir Cooper8, Orit Raz8
1State University of New York Upstate Medical University, 2Rabin Medical Center, 3Shaare Zedek, 4Shamir Medical Center, 5Sheba Medical Center ‐ Tel Hashomer, 6Schneider Children's Medical Center, 7Carmel Medical Center, 8Assuta Ashdod Hospital
Presented By: Dor Golomb, MD
Introduction: Pediatric urolithiasis is relatively uncommon and represent only 2% to 3% of all patients known to have urinary stones . The etiology of adult kidney stones is multi‐factorial, with observed geographic and seasonal differences affecting the rate of stone formation. The etiology of pediatric urolithiasis is not as clear.Our goal was to analyze trends in emergency department (ED) admissions due to renal colic in a pediatric population (≤18 years old) and to assess the possible effect of climate on ED admissions.
Methods: A retrospective, multicenter cohort study, based on a computerized database of all ED visits due to renal colic in patients ≤18 years old. Included in the study were patients found to have urolithiasis on imaging during their ED admission. Exact climate data was acquired through the Israeli Meteorological Service (IMS).
Results: Between January 2010 and December 2020, 609 patients, under the age of 18 years, were admitted to ED's in 5 medical centers with renal colic. 318 (52%) were males and 291 (48%) were females. The median age was 17 (range 1‐18). ED visits oscillated through the years, peaking in 2012 and 2018. A downward trend in ED admissions of 6% was noted between 2010 and 2020. The number of ED admissions in the different seasons was 179 (30%) in the autumn, 134 (22%) in winter, 152 (25%) in spring and 144 (23%) during the summer (p = 0.8). Logistic regression multivariable analysis assessing for factors associated with ED visits did not find any correlation between climate parameters and ED admissions due to renal colic in the pediatric population.
Conclusions: ED admissions oscillated during the period investigated and had a downward trend. Unlike previously published data in the adult population, the rate of renal colic ED admissions in the pediatric population does not seem to be affected by neither seasonal changes nor the rise in maximum ambient temperature.
Funding: None.
Retrograde Pyelogram Serves as a Diagnostic and Therapeutic Tool for a Blocked Ureter in Two Sites
Eyal Atias1, Yehezkel Landau1, Leonid Boyarsky1, Guy Hidash1
1Hadassah Medical Center
Presented By: Eyal Atias, MD
Introduction: Double obstruction at the ureteropelvic junction (UPJO) and the ureterovesical junction (OMU) in the same ureter is a challenging diagnostic and therapeutic condition. Simultaneous correction of both obstruction sites is not recommended due to the risk of compromising blood supply to the ureter. Traditionally, it is accepted to primarily address the distal obstruction to avoid pressure on the proximal segment. However, is it necessary in all cases? We know that OMU often resolves without surgery in most cases, and UPJO can be secondary to distal obstruction and can improve after distal surgery. In this study, we describe the use of retrograde pyelogram for accurate diagnosis of the more severe obstruction site and accordingly decide regarding the type of surgery.
Methods: A retrospective review of surgeries performed between 1/2014 and 1/2022 for UPJO or OMU repair was conducted. Cases with retrograde imaging demonstrating double obstruction were included. In these cases, the more severe obstruction was surgically corrected. Success was defined as improvement in the sonographic appearance of the kidney after surgery and the absence of the need for additional surgery.
Results: A total of 252 surgeries were examined. Fourteen cases of double obstruction were identified. The median age at surgery was 13 months (range: 3‐60). The median follow‐up time was 24 months (range: 9‐79). Nine patients underwent pyeloplasty, and five underwent ureteral reimplantation. Postoperative sonography showed improvement in hydronephrosis in 12 (86%) cases, and they did not require additional surgery. One patient underwent surgery at the second obstruction site, and another patient is awaiting surgery. Retrograde imaging led to a change in the preoperative diagnosis in three cases (21%).
Conclusions: The use of retrograde imaging can recognize a ureter with more than one obstruction and also allows for precise assessment of the severity of obstruction. Surgical intervention at the more severe obstruction site and close postoperative monitoring result in improvement in hydronephrosis and can help avoid additional surgery in most cases.
Funding: Non
Long Term Results of Double HIT Technique in High Grade Vesicoureteric Reflux
Ilhami Surer1
1The University of Health Sciences, Gülhane Medical School, Department of Pediatric Urology
Presented By: Ilhami Surer, MD,FEBPS,FEAPU
Introduction: Primary aim in this study was to evaluate single surgeon's experience and the long term efficacy of double hydrodistension and injection technique(d‐HIT) in children with high grade primary vesicoureteric reflux(VUR)
Methods: Between December 2004 and December 2022 d‐HIT was performed by single surgeon using dextranomer and hyaluronic acid complex(Dexell®) in 337 cases (536 ureter) due to high grade VUR in children. 270 ureter have Gr III, 177 ureter Gr IV and 89 ureter Gr V VUR. Median age was 35 months (7mo.‐16yrs), median follow‐up period was 56 months (6 mo.‐17 yrs). Efficacy of the technique was determined by postinjection voiding cystourethrography at 3‐12‐24‐36 and 60 months sequentially. VCUG was repeated only in symptomatic cases beyond that time.
Results: Success rates were described due to time/reflux grading as follows.3rd months: Overall % 73 GrIII‐ %90 GrIV‐%78 GrV‐ %5212th months: Overall %67 GrIII‐ %82 GrIV‐%70 GrV‐ %4924th months: Overall %63 GrIII‐ %79 GrIV‐%66 GrV‐ %4536th months: Overall %60 GrIII‐ %77 GrIV‐%63 GrV‐ %4060th months: Overall %58 GrIII‐ %75 GrIV‐%62 GrV‐ %38In 17 cases (26 ureter)(5%) symptomatic urinary tract infection was diagnosed after 5 years follow up program. In all cases Gr V reflux recurrence was diagnosed by VCUG. During cystoscopic exam total loss of bulking agent in 7 cases and migration of bulking agent caudally at the trigone in 10 cases were diagnosed.
Conclusions: Minimally invasive endoscopic correction of primary high grade VUR by using d‐HIT technique in children is successful. To obtain reliable results, experience with this technique plays an important role besides re‐reflux may occur in late period especially in grade 5 reflux patients. This technique can be considered as a first choice due to low morbidity and invasiveness when compared with the other methods in the treatment of high grade VUR.
Funding: None
Surgical Scar, Robotic or Open? What Do the Patients and Parents Prefer?
Gabriel Alejandro Molineros Mayorga1, Guy Hidas1
1Hadassah Ein Kerem
Presented By: Gabriel Alejandro Molineros Mayorga, MD
Introduction: Robotic surgeries have been proven to be safe and effective in pediatric urology. The surgical scar appearance is of great influence on the decisions of the surgeon and the family prior to surgery. As usually assumed, robotic surgeries have a cosmetic advantage over open surgery because the incisions and scars are smaller, but do parents and their children really prefer these scars over wider scars after open abdominal surgery? Our goal in this study is to answer this question.
Methods: An online questionnaire was distributed by social media. In this questionnaire three pictures were shown. The first one of Pyeloplasty surgery scar after dorsal lumbotomy approach and after laparoscopic/robotic incisions. The second one of Pyeloplasty surgery scar after abdominal flank approach and after laparoscopic/robotic incisions. And the third one of ureteral reimplantation surgery with an open suprapubic incision (Pfannenstiel) and the same surgery with laparoscopic/robotic incisions. The respondents were asked to choose between the two options with the following question: In case you (or your child) were to have this surgery, which scar would you prefer to have?
Results: 750 persons participated in the study, 74% female and 26% male, the average age was 41.27 years old (7‐78 years old). On the first question (dorsal lumbotomy pyeloplasty vs laparoscopic/robotic pyeloplasty), 65% of the respondents preferred dorsal lumbotomy, 22% laparoscopic/robotic, 13% didn't have preference. When asked the second question (flank incision pyeloplasty vs laparoscopic/robotic pyeloplasty) 74 % preferred laparoscopic/robotic incisions, 18% flank incision and 8% didn't have preference. And on the last question (Pfannenstiel incision vs laparoscopic/robotic incisions) 48% preferred laparoscopic/robotic incisions, 44% Pfannenstiel incision and 8% didn't have preference.
Conclusions: Surgeons and parents prefer an open surgery scar with a dorsal approach over a robotic surgery scar for repair of stenosis on the ureteropelvic joint. And robotic/laparoscopic approach over abdominal flank approach. Opinions were divided when asking about bladder surgeries (ureteral reimplantation), on which about half of the patients prefer suprapubic Pfannenstiel open approach. Because the appearance of the scar has a great influence on the decision of the parents and patients it should be discussed when presenting the surgical treatment.
Funding: N/A
Caveats Against the Use of Ultrasound as the Primary Imaging Modality in Pediatric Urolithiasis.
Mahmoud Abbas1, Jawdat Jaber Jaber1, Stanislav Kocherov1, Galiya Raisin1, Boris Chertin1, Ilan Kafka1, Ruth Cytter‐Kuint2, Elena Zahrkov3
1Department of urology and pediatric urology, Shaare Zedek Medical Center, jerusalem, israel, 2Department of pediatric Radiology, Shaare Zedek Medical Center, 3Department of Radiology, Shaare Zedek Medical Center
Presented By: mahmoud abbas, MD
Introduction: The incidence of pediatric nephrolithiasis has risen over the past few decades leading to a growing public health burden. Children and adolescents represent a unique patient population secondary to their higher risks from radiation exposure as compared to adults, high risk of recurrence, and longer follow up time given their longer life expectancies. EAU and ESPU guidelines strongly recommend abdominal ultrasound (US) as a first approach to identify nephrolithiasis reserving non‐contrast helical CT scanning (NCCT) for equivocal cases.The aim of the study, to Identify differences in the possible management outcomes of the pediatric patient with suspected urolithiasis in whom US was performed as the primary imaging modality.
Methods: We have conducted a retrospective study to identify pediatric patients (< 18 years old) who were initially evaluated for suspected urolithiasis by US and in whom NCCT was performed within 72 hours of the initial renal ultrasound at our institution between 2008 and 2023. All US were performed by two board certified pediatric radiologists. The presence number, size, and location of kidney stone were compared between the two imaging modalities based on the reviewed imaging reports. We also looked at the change in the management following wrong or delay diagnosis and if it adversely impacted downstream care..
Results: We have identified51patientswith ameanageof 10.2 ± 4.6 (mean ±SD). In 25 (49%) of the 51 patients there were significant differences in stone characteristics. Of these 25 patients, 15(60%) had stone missed by US that was detected by CT, 6(24%) had differences in stone location, 4 (16%) in stone size (> 3mm size difference). Of these 25 patients, 16 (64%) received conservative acute management and later on underwent different procedures for stone removal. Eleven underwent ureteroscopy and the remaining 5 PCNL . Wrong diagnosis by US led to sepsis in 6 (26%) patients, acute renal obstruction in 3(12%) who required renal drainage by nephrostomy in 3 patients, and JJ stent insertion in 6 remaining patients. Three patients underwent “stoneless” ureteroscopy following calculus diagnosis on US, subsequent confirmative NCCT was also negative for nephrolithiasis. The amount of radiation for all patients who underwent a CT scan was 182 + 95.2 mGYcm 3 .
Conclusions: Our data show that primary US for detection of pediatric nephrolithiasis might lead to wrong or delayed diagnosis in 49% of cases, moreover, in 36% a delay in the diagnosis caused life threatening complications which required emergency intervention. In spite of guideline recommendations, there is still a high incidence of false negative finding even in the experience hands. In spite of the known possible risks from ionizing radiation of NCCT we have to treat cautiously the US finding. When there is a high clinical index of suspicion for life‐threatening urolithiasis, a low dose abdominal scan can affect the clinical course without significantly increasing the patient radiation exposure.
Funding: When there is a high clinical index of suspicion for life‐threatening urolithiasis, a low dose abdominal scan can affect the clinical course without significantly increasing the patient radiation exposure.
Comparison of the Clinical Results of Pedıatric Patıents Who Were Opened and Laparoscopic Pyeloplasty Due to Ureteropelvic Conjunction Stricture
Nebil Akdogan1, Nebil Akdogan1, Mutlu Deger1, Tunahan Ates1, Mert Evirgen1, Ismail Onder Yilmaz2, Ali Borekoğlu3, Volkan İzol4, İbrahım Atılla Aridogan4, Nihat Satar, Prof1
1Cukurova University, Faculty of Medicine, Department of Urology, Adana, Turkey
2Ceyhan Devlet Hastanesi, Adana, Türkiye, 3Mersin City Hospital, 4Cukurova Üniversitesi, Tip Fakültesi, Üroloji Bölümü, Adana, Türkiye
Presented By: Nebil Akdogan, MD
Introduction: Minimally invasive applications in the treatment of ureteropelvic junction stenosis (UPD) have developed significantly in the last 10 years. The aim of our study is to compare the surgical and functional results of laparoscopic and open pyeloplasty performed in children in the last 8 years in our clinic.
Methods: In this study, it was planned to evaluate the results of patients who were diagnosed with ureteropelvic junction stenosis and underwent surgical treatment in the urology clinic of Çukurova University between 2012 and 2020. Patients treated with laparoscopic and traditional open surgery methods were evaluated as the study group. 194 cases were performed over an 8‐year period, were retrospectively analyzed.The patients were compared as laparoscopic group and open surgery group. 164 patients were treated with open surgery (OP) and 30 patients with laparoscopic approach (LP). Demographic characteristics, clinical appearance, functionality of the affected kidney, and length of hospital stay of the cases in both groups were compared. The results were statistically analyzed.
Results: Of the patients included in the study, 111 (57.2%) were boys and 83 (42.8%) were girls. There was no difference between the two groups in terms of gender distribution (p = 0.564). The mean age of the patients included in the study was 35 ± 47,2 month in the OP group. In the LP group, it was 147,6 ± 46.4 months. Patients were grouped according to their symptoms at admission to the clinic. The most common complaints were 102 (53%) flank pain, 37 (19.07%) abdominal pain, 41 (21.13%) febrile urinary tract infection (UTI), 14 (7.2%) antenatal hydronephrosis. When both groups were compared in terms of operation time, the mean operation time was 122 ± 35.2/min in the OP group and 200 ± 66.7/min in the LP group. When the length of hospital stay was compared, the median was 3.5 days in the OP group and 3.2 days in the LP group.
Conclusions: As a result of the study performed in our clinic, it has been shown that the results of the laparoscopic and open surgery groups in the surgical treatment of UPD in the pediatric age group are similar.
Funding: NONE
Lower Urinary Tract Symptoms in Boys After Cardiac Surgery
Sharon Fishberg1, Mordechai Duvdevani1, Ofer Gofrit1, Eldad Erez1, Guy Hidas1
1Hadassah Medical Center and The Hebrew University of Jerusalem
Presented By: Sharon Fishberg, MD
Introduction: Cardiac surgery in adults is a well‐known risk factors for a urethral stricture and Lower urinary tract symptoms(LUTS). The etiology is speculated to be a low urethral tissue perfusion during surgery combined with urinary tract infection and traumatic catheterization. Pediatric cardiac surgery of a congenital heart defect is complexed surgery but, no information exists regarding the association between cardiac surgery and urethral stricture and LUTS in the pediatric population.
Methods: Prospective study was conducted including pediatric toilet trained boys who underwent open heart surgery because of a congenital heart defect. The children and their parents were asked to fulfil a validated pediatric LUTS questionnaire (ICIQ‐CLUTS), physical examination was conducted and uroflowmetry study was done. The uroflowmetry results were compared with age adjusted nomograms of healthy boys.
Results: 24 patients were examined; the median age is 7.3 years. On physical examination meatal stenosis was seen on 11 patients (46%). The average ICIQ‐CLUTS score is 13 (the questionnaire score ranges 10‐38, score above 20 is considered as moderate severity and above 30 as severe). 1 patient with moderate symptoms and non with severe symptoms. The average Qmax in the study population was 14.2 (±4.5) ml/sec compared to the expected of 15.3 (±4.5) ml/sec (p value = 0.2391). the average Qmean in the study population was 8.9 (±3.2) ml/sec compared to the expected 7.7 (±3.2) ml/sec(p value = 0.1991).
Conclusions: As opposed to the adult population, pediatric patients underwent major cardiovascular surgery, are not prone to urethral stricture and LUTS. High incidence of meatal stenosis was observed in those children. We recommend evaluating for meatal stenosis during the follow up of these patients.
Funding: No funding was recieved for this work
Preoperative Factors Associated with the Development of Distal Ureteral Stump Syndrome After Upper Pole Heminephrectomy
Eric Kurzrock1, Hansen Lui1
1UC Davis School of Medicine
Presented By: Hansen Lui, MD
Introduction: For children with duplex systems and severe hydroureteronephrosis of the upper pole, open or laparoscopicheminephrectomy is one of many suitable treatments, particularly if there is no associated lower pole reflux. Distal ureteral stump syndrome (DSS) is a very difficult complication and manifests as stump empyema, urinary tract infection and/or vulvar discharge and can occur months to years later in 10 to 20 percent of patients. Secondary distal ureterectomy is an extremely difficult surgery due to inflammation and adhesions. To avoid DSS, distal ureterectomy at the time of heminephrectomy can be performed concurrently but carries a risk of lower pole ureter devascularization and injury. Current literature on DSS has shown associations with subtotal ureterectomy or long ureteral stumps. We hypothesized that there may be preoperative variables prior to heminephrectomy that are associated with the development of DSS.
Methods: Retrospective analysis of pediatric patients who underwent upper pole heminephrectomy at a single, academic institution from 1999 to 2021. Pre‐operative patient age, gender, history, imaging, and lab results were extracted from patient charts to assess for factors that may predict the development of DSS. Patient groups with and without DSS were comparedusing Fischer's Exact Test.
Results: Thirty‐six patients who underwent upper pole heminephrectomy for a duplex kidney were included in the study with a mean age of 19 months and female predominance (69%). Indications included severe hydronephrosis and/or febrile UTI. All had excision of the upper pole ureter to the level of the superior pelvic brim. Median follow up after surgery was 38 months (range 1—229).Patients who developed DSS underwent secondary open distal ureterectomy at a median time of 22 months (range 3—34) after heminephrectomy. The presence of ureteral debris on preoperative ultrasound (p < 0.001), reflux into the upper pole (p = 0.005), and mucus discharge (p < 0.001) were found to be significantly associated with those who developed DSS, compared to those who did not. These three pre‐operative factors had high specificity (97‐100%) and negative predictive value (94‐97%).
Conclusions: Substantial experience has shown that less than 20% of patients benefit from distal ureterectomy during upper heminephrectomy. Whether using an open or laparoscopic approach, selection of at‐risk patients should lower operative time and avoid injury and devascularization of the lower pole ureter for most patients.
Funding: None
Outpatient Robotic Surgery in Pediatric Urology: Are We Ready to Take the Leap?
Osama Al‐Omar1, Ahmad Dahman1, Amr Elbakry1, Ahmed Abdelhalim1
1Department of Urology, West Virginia University
Presented By: Osama Al‐Omar, MD, MBA, FEBU, FACS
Introduction: Most pediatric urologic surgeries are routinely done as outpatient procedures with same day discharge. Despite the expanding use of robotic surgeries in the field of pediatric urology, the usual practice is to admit patients for observation post‐operatively. Our objective is to report our initial experience in exploring the safety and feasibility of outpatient robotic surgery in pediatric urology.
Methods: We retrospectively identified all patients (< 18 years) who underwent robotic‐assisted urologic surgeries as outpatient procedures at a single center. Data were collected regarding patient age, gender, operative details and follow‐up. We also collected information regarding 30‐day complications, phone calls to the urology care team, unplanned clinic or ED visits, readmissions or reoperation.We started transitioning to outpatient robotic surgery in 2019 with select procedures. Since 2022, outpatient robotic surgery became the standard for all noncomplex pediatric robotic surgeries, unless medically necessary for postoperative admission, like patients under the age of 4 months. All our patients are managed with zero‐narcotic approach for outpatient pain management. Patients are generally discharged without Foley catheters except in the case of ureteral reimplantation with history of severe voiding dysfunction. No drains were placed in all patients.
Results: A total of 26 patients (15 males) were identified between 2019 and 2023. Median age at surgery was 45 (7‐214) months. Surgical procedures included partial cystectomy for urachal anomalies in 3 patients, ureteral reimplantation in 7, pyeloplasty in 8, uretero‐ureterostomy in 3, nephrectomy in 1, Bilateral orchiopexy in 1, Mitrofanoff in 1, and ureterolysis in 2. No intraoperative complications were reported, and all patients were discharged from post anesthesia care unite (PACU). Follow‐up duration ranged from 1 to 22 months. Four (15%) patients presented to the emergency department (ED) within 30 days postoperatively (1 for fever, 2 for urinary retention, and 1 for port site erythema). The urology team received Phone calls from 7 (27%) patients, none of which resulted in unplanned clinic or ED visits. The reasons for phone calls included wound/dressing questions in 3, dysuria, fever, hematuria, and a medication reaction in one each. No readmission or reoperation was required within 30 days of surgery.
Conclusions: Our initial experience indicates the safety and feasibility of outpatient pediatric urologic surgeries. Further studies with larger number of patients are needed to support this conclusion.
Funding: None
Subductal Dextranomer and Hyaluronic Acid Complex Injection in Recurrent Epididymo‐Orchitis
Ilhami Surer1
1The University of Health Sciences, Gülhane Medical School, Department of Pediatric Urology
Presented By: Ilhami Surer, MD,FEBPS,FEAPU
Introduction: To present a case which is suffering from recurrent epididiymo‐orchitis after perineal hypospadias repair
Methods: One year old boy admitted to the hospital due to abnormal genitalia. In physical examination both testes were undescended, scrotum was bifid,phallus was rudimentary and external meatus located at the perineum. Chromozomal analysis was 46XY and genetic testing was revealed androgen insensivity. The baby boy otherwise healthy and no other anomalies. Penoscrotal transposition and bilateral orchidopexy were performed as a first stage. Six monts later under anrostenedion stimulation perineal hypospadias repair and scrotoplasty were performed in a single stage. Postoperative period was uneventfully and the patient was able to urinate easily from external meatus that located at the tip of the glans. Four months later the patient has first epididymo‐orchitis attack that treated with sefixim due to sensitive antibiogram testing. All symptoms and signs were revealed completely after 7 day treatment course. However same clinical condition repeated 3 times more within 1 year follow‐up period. In cystoscopic exam revealed that veru montanum was hypertrophic and left ductal opening was quite large. 0,2 cc bulking agent(Dexell) was injected submucosally as a sting procedure to prevent urine reflux to the ductal system possibly during micturation.
Results: During two years follow up period, the patient is doing well no sign and symptoms regardingepididymo‐orchitis. Ultrasonographic examination revealed bilateral normal testicular parenchyma.
Conclusions: To the best of my knowledge, this is the first epididymo‐orcitis case in the literature treated by subductal injection technique to prevent recurrent infection.
Funding: None
is Paediatric ‘Pop‐Dusting’ with High Power Laser a New Standard for Treatment of Ureteroscopy and Laser Lithotripsy (FURS): Prospective Outcomes from a University Teaching Hospital
Victoria Jahrreiss1, Francesco Ripa1, Clara Cerrato1, Carlotta Nedbal1, Virginia Massella1, Amelia Pietropaolo1, Bhaskar Somani1
1University Hospital Southampton NHS Foundation Trust
Presented By: Victoria Jahrreiss, MD
Introduction: Thanks to technological advancements and miniaturisation of surgical armamentarium, ureteroscopy and laser lithotripsy(FURS) indications and applicability in the paediatric population have expanded, showing excellent outcomes in terms of efficacy and safety. We wanted to assess the outcomes of high‐power Holmium:YAG laser for stone treatment in a paediatric population from a tertiary referral hospital using the dusting and pop‐dusting techniques.
Methods: We prospectively analysed a cohort of paediatric patients(< 18 years) submitted to flexible ureteroscopy for stone treatment over a 5‐year period. We collected data on patient demographics, stone characteristics, operative details, procedural outcomes and complications. Our technique entails a safety guidewire, a semirigid ureteroscopy with a 4.5–6F scope, followed by flexible ureteroscopy(FURS). A ureteral access sheath(UAS) was used per surgeon discretion(9.5‐11.5F, 35 cm). We used either a 100W or a 60W Ho:YAG Moses laser (Lumenis, Inc.). We started with dusting setting(0.3–0.5 J; 40–50 Hz) and switched to pop‐dusting(0.5–0.6 J; 20–40 Hz). A 4.7F ureteric stent was inserted at the end of the procedure in some cases. Stone free rate(SFR) was defined as complete absence of stones endoscopically and ≤2 mm fragments on post‐operative imaging.
Results: Overall, 35 patients underwent 43 procedures (1.2 procedure/patient). Mean age was 9.4 (1‐16). Mean stone size was 18mm (10‐39mm), pre‐ and post‐operative stent rates were 32.5% and 55.8% respectively. A UAS was used in 19(44.1%) procedures. Overall SFR was 94.2% (n = 33), with no intra‐ or post‐operative complications. We sub‐divided the patients into 3 groups based on cumulative stone size of 10‐15mm(n = 18), 16‐20mm(n = 8) and > 20mm(n = 9). For a mean stone size of 12.1mm, 17.9mm and 29.4mm, the mean number of procedures/patient were 1.16, 1.25 and 1.33, with a SFR of 94.4%, 87.5% and 100%. Staged procedures were required in 4(22%), 2(25%) and 2(22%) patients in the three groups.
Conclusions: Paediatric FURS using a high‐power laser achieves a high SFR with no complications noted in our prospective series. Dusting and pop‐dusting could set a new benchmark for treating large, multiple and complex stones even in the paediatric setting. Parents must however be counselled about staged procedures which might be needed.
Funding: None
Pediatric Patient‐Centered Perspectives on Single Port Robotic Surgery Compared to Open and Multi‐Port
Jason P. Joseph2, Alexandra Hernandez1, Daniel Reich1, Romano Demarco1, Christopher Bayne1
1University of Florida, 2University of Florida College of Medicine
Presented By: Jason P. Joseph, MD
Introduction: Early reports of the da Vinci single port (SP) robot's utility in pediatric urology are limited. As our pediatric experience with the SP robot has expanded, we sought to define the value of this approach to patients and their families by assessing reported surgery experience and cosmetic satisfaction with postoperative scars.
Methods: We identified patients < 18 years who underwent upper tract urological reconstruction or extirpative surgery by a single surgeon at our institution. Patients were divided into cohorts based on surgical approach: open, multi‐port robotic (MP), and single port robotic (SP). Families were recruited at time of follow‐up encounter. All parents were administered two validated surveys; the Surgical Satisfaction Questionnaire (SSQ‐8), and Patient Scar Assessment Questionnaire (PSAQ‐9). Additionally, patients ≥10 years were given the surveys to provide patient‐specific feedback. Survey responses were directly recorded into a REDCap database. Data were summarized by median and interquartile range (IQR) for continuous data and counts and percentage (%) for categorical data.
Results: 31 families were enrolled in the study, with patient ages ranging from 11 days to 17 years. Eight children had open surgery (median age5 months). Nine children underwent MP robotic surgery (median age5 years). Fourteen underwent SP robot assisted surgery (median age 12 years). Twenty‐six (84%) underwent pyeloplasty. Median time between surgery and survey was 11 months (IQR 4, 17). Surgical success was high in all cohorts. Median SSQ‐8 scores (range 8‐40; lower scores indicating better experience) were 12.5 (IQR 10, 13) for open, 8 (IQR 8, 9) for MP, and 8 (IQR 8, 10) for SP. Median PSAQ‐9 scores (range 6‐25; lower scores correlating with better scar perception) were 8 (IQR 7, 9) for open, 9 (IQR 8,10) for MP, and 6 (IQR 6, 7) for SP. We did not perform inferential statistics secondary to sample sizes.
Conclusions: In this pilot study, patients and families undergoing pediatric urological surgery with the SP robot rate their experience and scars favorably. The median scar score for the SP cohort was the lowest possible PSAQ‐9 score (6), indicating the highest satisfaction. An important limitation is that incisions within each cohort are not uniform and varied within the cohorts. Overall, we believe these data provide impetus for continued use and patient‐centered outcome investigation of the SP robot in pediatric urology. Future studies should include larger sample sizes with standardized incisions within each cohort.
Funding: None
Comparative Analysis of Ureteral Calculi Presentation and Management in Children and Adults
Shayel Bercovich2, Hen Hendel1, Yossi Ventura1, Paz Lotan1, Mohamed Keadan1, Elia Baransi1, Roy Morag1, David Ben‐Meir1, David Lifshitz1
1rabin medical center, 2Rabin Medical Center
Presented By: Shayel Bercovich, MD, MPH
Introduction: The prevalence of children presenting with renal colic is significantly lower than adults. The presentation, as well as the chances of spontaneous expulsion and the rate of intervention, may differ between the age groups. The aim of the current study was to assess such potential differences.
Methods: We retrospectively assessed data from a consecutive group of children and adults presenting to the emergency department and diagnosed with a ureteral stone. The presence of a ureteral stone was confirmed by computed tomography (CT) or ultrasonography (US) exam. Clinical characteristics, radiological exams, and the rate of intervention spontaneous stone expulsion were compared between the adult and children cohorts.
Results: 106 children were compared to 99 adults who visited the ER for symptomatic ureteral stones. In the adult group, all stones were diagnosed by a CT exam. In the children group, CT was utilized in 36% of the patients (X2 p < 0.001). The median stone size was similar between the children and adult groups (5 vs. 4.5 mm [IQR 3‐6 mm], respectively), as well as the ureteral stone location distribution. In the children and adult groups, 59% and 60% presented with distal ureteral stones, respectively. Flank pain as the presenting symptom was less common in children compared to adults (67% vs. 88% [X2 p < 0.001]), while moderate or severe hydronephrosis was observed more frequently in children compared to adults (35% vs.17% [X2 p < 0.001]). In patients treated conservatively, the rate of spontaneous stone expulsion was similar between the groups (72% and 73% in the children and adult population, respectively [X2 P = 0.8]). However, the rate of immediate intervention was higher in the children group (36% vs. 11%, respectively [X2 p < 0.001]).
Conclusions: The current study highlights differences between children and adults presenting to the ER with a ureteral stone. Diagnosis in children requires a higher index of suspicion as the presentation may be less typical, as evident by the lower rate of flank pain and a higher rate of hydronephrosis that may suggest delayed diagnosis. Children are more likely to undergo immediate intervention, probably due to difficulties in pain management. However, when allowed expectant therapy, the rate of spontaneous stone expulsion is similar between the groups.
Funding: none
MODERATED POSTER SESSION 18: KIDNEY AND MISCELLANEOUS IMAGING
Inter‐Observer and Inter‐Package Evaluation of MRI Radiomics Features for the Characterization of Small Renal Masses: Preliminary Results
Ketan Badani1
1Icahn School of Medicine, Mount Sinai
Presented By: Ketan Badani, MD
Introduction: While radiomics analysis based on magnetic resonance imaging (MRI) sequences has shown promise for small renal mass (SRM) characterization, clinical translation is challenging as radiomic feature stability, effect of observer and software package, and model performance remains uncertain. This has motivated our interest to evaluate radiomic features' stability using inter‐observer and inter‐package measurement analysis in SRMs based on clinical MRI sequences and to employ machine learning (ML) statistical models for tumor characterization.
Methods: Thirty‐one patients (21M/10F; age 60.9 ± 10.4y) with SRMs (18 clear cell renal cell carcinoma (ccRCC)/6 non‐clear cell (non‐cc)RCC/7 benign; mean size, 3.2 ± 1.8cm) undergoing surgery were recruited in a single‐center prospective study. SRM volume‐of‐interest (VOI) regions were manually segmented on T2‐ WI, DWI/ADC, and T1‐WI pre‐/post‐contrast imaging at 1 and 3‐minutes using two separate radiomics software packages. Inter‐observer measurements were obtained in a subset of 26 patients. A 3rd observer performed a qualitative assessment including clear cell likelihood score (ccLS). Intra‐class correlation coefficients (ICC) were calculated to assess inter‐observer and inter‐package reproducibility of radiomics measurements. Random forest models of radiomics and qualitative features were employed to distinguish RCC from benign SRM and ccRCC from non‐ccRCC.
Results: Inter‐observer comparison of radiomics measurements found that T1‐WI pre/post‐contrast and T2‐ WI yielded the greatest proportion of features with good/moderate ICC, while ADC measurements yielded low/moderate ICC. Inter‐package comparisons demonstrated that most features had moderate/poor ICC, with the greatest stability found for measurements extracted from T1‐WI post‐contrast. ML radiomics models generated validation set AUCs range of 0.54‐0.69 for RCC vs. other SRM and range 0.66‐0.70 for ccRCC vs. non‐ccRCC.
Conclusions: Radiomics features extracted from T1‐WI pre/post‐contrast demonstrates greater stability across observers and software packages, with fair/good accuracy in distinguishing RCC from benign SRM and ccRCC from non‐ccRCC. Careful consideration to study design and methodology is required when conducting radiomics studies in MRI; data must be interpreted with caution when comparing radiomics analysis results using different software packages.
Funding: none
Diagnostic Accuracy of Contrast‐Enhanced Ultrasonography for the Assessment of Small Renal Mass: A Prospective Study
Bum Soo Kim2, Young Jun Moon1, Jae‐Wook Chung2, Yun‐Sok Ha2, Seock‐Hwan Choi2, Jun Nyung Lee2, Hyun Tae Kim2, Tae‐Hwan Kim2, Eun Sang Yoo2, Tae Gyun Kwon2, Tae Heon Kim3
1Department of Urology, Kyungpook National University Hospital, 2Department of Urology, School of Medicine, Kyungpook National University, 3Departments of Urology, CHA Bundang Medical Center, CHA University
Presented By: Bum Soo Kim, MD, PhD
Introduction: This study was conducted to validate the diagnostic accuracy of contrast enhanced ultrasonography (CEUS) for the assessment of small renal mass (SRM) (≤ 4 cm) compared with kidney dynamic computed tomography (KDCT) and magnetic resonance imaging (MRI).
Methods: A total of 62 patients with SRM who underwent renal biopsy or nephrectomy (partial or radical) between September 2020 and April 2023 were prospectively included. All patients underwent KDCT, MRI and CEUS prior to renal biopsy or nephrectomy. All images were interpreted by a single expert uro‐ radiologist. Imaging results were compared with histological data.
Results: Mean tumor size and renal score was 20.5 ± 10.1 mm and 7.0 ± 1.8, respectively. Of 62 patients, 50 patients underwent partial nephrectomy, 1 patient underwent radical nephrectomy and 11 patients underwent renal biopsy. Renal cell carcinoma (RCC) was confirmed in 46 patients, while 16 patients showed benign tumor (angiomyolipoma: 8, oncocytoma: 2, other benign tumor: 6). There were no significant differences in clinicopathologic variables between RCC and benign group. Diagnostic accuracy for RCC of KDCT, MRI and CEUS was 72.6%, 69.4% and 72.6%, respectively (p > 0.05). While the sensitivity was slightly higher in KDCT (93.5%) and MRI (91.3%) than in CEUS (82.6%), the specificity, positive and negative predictive values were higher in CEUS (43.8%, 80.9% and 46.7%) compared to those of KDCT (12.5%, 75.4% and 40.0%) and MRI (6.3%, 73.7% and 20.0%).
Conclusions: The present results demonstrated that CEUS could be useful in improving the assessment of SRM. In particular, CEUS showed the highest specificity, positive and negative predictive values. Therefore, CEUS can be a good option counseling patients who are planned to undergo nephrectomy or renal mass biopsy.
Funding: None
Re‐VASC: A Novel Retroperitoneal Neovascularity Scoring System for T1a Small Renal Masses Characterization
Andrei Cumpanas4, Cameron Fateri1, Bradley Roth1, Sriram Rao1, Akhil Peta2, Luke Limfueco2, Thahn‐Lan Bui1, Andrei Cumpanas2, Nina H. Kar3, Justin Glavis‐Bloom1, Jaime Landman2, Roozbeh Houshyar1
1Department of Radiology, University of California Irvine, 2Department of Urology, University of California Irvine, 3Burrell College of Osteopathic Medicine, New Mexico State University, 4Department of Urology, University of California, Irvine,
Presented By: Andrei Cumpanas, MD
Introduction: When pre‐operative small renal mass (T1a) biopsy is not performed, up to 20% of surgically extracted tissues display benign histological features. However, up to 32% of urologists report that they would never perform a biopsy for T1a renal cortical neoplasms. Thus, we sought to evaluate the potential application of the Re‐VASC retroperitoneal neovascularity score as an adjunct or potential replacement for renal biopsy in patients with T1a renal masses (Figure 1).
Methods: Patients who underwent surgical treatment of T1a renal cell carcinoma between 2014 and 2020, had pre‐operative CT scans and post‐operative pathology reports, were retrospectively included in our study. The population was divided into two‐groups: the malignant group (pT1a) and the benign group (angiomyolipomas or oncocytomas). Re‐VASC tumor scores were compared and analyzed between the two‐ groups. A multivariate logistic regression model was run to assess the effect of different covariates on predicting the malignancy of the tumor (age, gender, BMI, tumor size, tumor laterality, Re‐VASC score of the tumor‐bearing side as well as the contralateral kidney).
Results: 64 benign and 69 malignant T1a renal tumors were included in this study. Tumors in the malignant group had a statistically significantly higher Re‐VASC score than the benign group (p < 0.001). On the multivariate logistic regression analysis, only the tumor size (OR: 1.686, p = 0.0245) and the Re‐VASC score of the tumor‐bearing kidney (OR: 2.737, p = 0.0079) were found to be independent predictors of malignancy.
Conclusions: There is significant difference in the Re‐VASC score between benign and malignant T1a renal masses. The Re‐VASC score has the potential of being an adjunct or potential replacement of renal biopsy, contributing to the reduction in T1a renal mass over‐treatment. Further, larger cohort multi‐center studies are needed to validate the neovascularity system's validity.
Funding: None.
GA68‐FAPI PET/CT for the Primary Evaluation of a Localized Renal Mass; a Pilot Study
Tzach Aviv2, Hana Bernstine1, Andrei Nadu2, David Groshar1, Jack Baniel2, Shay Golan2
1Department of Nuclear Medicine, Rabin Medical Center ‐ Beilinson Hospital, 2Institute of Urology, Rabin Medical Center ‐ Beilinson Hospital
Presented By: Tzach Aviv, MD
Introduction: Conventional imaging studies (i.e. CT or MRI) cannot reliably differentiate between benign and malignant renal masses. Recently, FAPI (fibroblast activating protein inhibitor) based PET/CT has been investigated in lung, breast, and GI cancers with promising results. We assessed the role of GA68‐FAPI PET/CT in the evaluation of renal masses.
Methods: A prospective case series of patients with enhancing localized renal mass who were referred for partial or radical nephrectomy. All patients completed GA68‐FAPI PET/CT before surgery. The scans were interpreted by two nuclear medicine specialists. Demographic, clinical, and histopathological data were extracted. The standardized uptake values (SUV) were compared between benign and malignant lesions. The local institutional review board approved the study and all patients provided written informed consent to participate in the study.
Results: We evaluated 12 renal masses in 10 patients. The average age was 60 ± 8 years and the median mass size was 2.3 cm (IQR 1.7‐3.9). 70% of the tumors were malignant. Until the submission of this abstract, 9 patients with 10 renal masses underwent surgery. 70% of the tumors were malignant, including 4 (40%) Papillary RCC, 2 (20%) Clear cell carcinoma, and 1 (10%) chromophobe RCC. Of 3 benign lesions 2 (20%) were angiomylipomas and 1 (10%) oncocytoma. Increased tracer uptake was subjectively visualized in the tumors and was stronger in benign lesions. The median SUVmean and SUVmax of benign and malignant lesions were 5.4 (IQR 4.7‐8.4) and 1.9 (IQR 1.6‐2.3), p = 0.02; and 10.1 (IQR 8.3‐15.6) and 2.6 (IQR 2.3‐4), p = 0.02, respectively.
Conclusions: This is the first study to highlight GA68‐FAPI uptake in localized renal masses.We observed increased tracer uptake in benign versus malignant renal tumors. This supports further assessment of this tracer in a larger patient cohort.
Funding: None
Statistical Spatial Mapping Atlas of Kidney Stones Derived from CT Scans
1University of Pennsylvania, 2Children's Hospital of Philadelphia
Presented By: Justin Ziemba, MD
Introduction: Limited information exists on the spatial distribution of stones within the kidney. Spatial mapping of kidney stones offers a quantitative and visual tool to assess the location and frequency of kidney stones in individuals and populations. This study evaluated the feasibility of creating a statistical spatial mapping atlas through CT scan analysis using image segmentation and registration algorithms.
Methods: Non‐contrast CT scans of 122 patients with kidney stones were retrospectively identified. A deep learning (DL) image segmentation model was built to segment kidneys automatically. Kidney stones were automatically identified as outlier voxels with Hounsfield Unit (HU) larger than mean plus 5‐sigma of HUs of all voxels within the kidney, and a kidney stone image was generated to have unit intensity value at locations of stone voxels and zero otherwise. Bilateral kidney atlases were created by registering all individual images to a common image space using affine‐transformation and diffeomorphic deformable image registration algorithms subsequently. The kidney stone image of each kidney was spatially transformed to the corresponding left or right kidney atlas with the same image deformation information obtained for creating the atlases. Statistical spatial maps of the kidney stones were generated for the bilateral kidneys separately to quantify frequency of the stones at every voxel of the kidney atlases.
Results: The DL image segmentation model segmented the kidneys with an average dice value of 0.96. The automatic stone identification algorithm detected individual stones with 100% sensitivity. Statistical spatial maps of the kidney stones quantified spatial frequency of the kidney stones across subjects, with frequency up to 6%.
Conclusions: The statistical spatial mapping of kidney stones provides a quantitative and visual means to characterize frequency of stones within the kidneys at both the individual and population level. Precisely characterizing stones in terms of size and location can facilitate effective treatment planning and ensure no stones are “missed” for an individual patient and assess patients' stone location as compared to the group atlases. In the future we hope to incorporate stone registration and spatial mapping into clinical care as well as better evaluate its performance and utility in this setting.
Funding: NIDDK P20 CHOP/ Penn Center for Machine Learning in Urology (P20DK127488) AUA Care Foundation and SPU Sushil Lacy Research Scholar Award (KMF)
Can Pregnant Surgeons Safely Perform PCNL?
Akin S. Amasyali1, Akin S. Amasyali1, Toby Clark1, Kyu Park1, Nicole Mack1, Cliff De Guzman1, Matthew I. Buell1, Rose Leu1, Kanha Shete1, Ala'a Farkouh1, Elizabeth Baldwin1, Sikai Song1, D. Duane Baldwin1
1Loma Linda University Health
Presented By: Akin S. Amasyali, MD
Introduction: There has been little study of radiation safety among pregnant healthcare workers, but current occupational recommendations limit fetal dose to 1 mSv. No prior study has investigated surgeon uterine radiation dose during percutaneous nephrolithotomy (PCNL). With the increased gender diversity in urology, understanding uterine radiation exposure is important. The purpose of this study was to determine surgeon uterine radiation dose during PCNL and the efficacy of radiation reduction techniques.
Methods: A coronally bisected cadaver, with an 8‐week sized uterus, was positioned standing at bedside, similar to a surgeon performing PCNL. An ion chamber was placed behind the anterior wall of the uterus to measure radiation dose. A second complete cadaver was positioned prone on the operating table to produce scatter radiation. Three different methods for reducing exposure were studied: pulsed fluoroscopy (1, 4, 8, 15, 30 pps), low dose (LD) fluoroscopy, and surgeon shielding (none, 0.35, 0.50, 0.70 mm lead equivalents). Using an image intensifier C‐arm, 20 trials were conducted for each of 40 comparison groups to determine dose/second. For calculations, PCNL exposure time was assumed to be 5 minutes and the case number prior to reaching the 1 mSv limit was determined. Statistical analysis was performed using the Wilcoxon test, and Kruskal Wallis with Dunn's test
Results: Decreasing pulse frequency from 30 to 1 pps resulted in a 96% dose reduction (p < 0.001). Compared to automatic exposure control (AEC), the low‐dose setting decreased dose by 56% (p < 0.001). Using continuous fluoroscopy with AEC and without shielding resulted in 0.086 mSv per PCNL to the uterus. Addition of a standard (0.35 mm) lead vest resulted in a 94% dose reduction (p < 0.001). Compared to the 0.35 mm lead, the 0.50 and 0.70 mm lead vests further reduced dose by 12% and 47%, respectively. At AEC (30 pps) with no lead and 0.35 mm lead, a surgeon could perform 12 and 189 PCNLs respectively, prior to reaching the 1 mSv limit.
Conclusions: Pregnant surgeons performing PCNL with conventional fluoroscopy settings and no lead could reach unsafe fetal exposure levels after 12 cases. By employing shielding, low‐dose, and pulsed fluoroscopy, pregnant surgeons can safely perform PCNL without exceeding safe uterine exposure levels. Surgeons, especially those considering pregnancy, are strongly encouraged to implement dose reduction strategies.
Funding: None
The Rise of Ultrasound: Kidney Stone Imaging Trends in the Emergency Department.
Christopher Connors1, Micah Levy1, Chih Peng Chin1, Olamide Omidele1, Francisca Larenas1, Michael Palese1
1Icahn School of Medicine at Mount Sinai
Presented By: Christopher Connors, BA
Introduction: Concern for radiation exposure has increased interest in ultrasound (US) for imaging of upper urinary tract calculi (UUTC) in the emergency department (ED). However, it is still unclear how practice patterns have evolved in the United States. We evaluated recent UUTC imaging trends using a national database.
Methods: The National Hospital Ambulatory Medical Care Survey was queried from 2010 to 2020 for ED visits of adults with a UUTC diagnosis. Trends in frequency of US, computerized tomography (CT), and X‐ ray imaging were analyzed using logistic regression. Multivariate analysis identified predictors of US, CT, and X‐ray imaging.
Results: 2199 UUTC visits were identified, representing a national estimate of 1.2 million annual ED visits with a UUTC diagnosis. 73% of visits used CT, 13% used X‐ray, and 7% used US. Linear trendlines from 2010 to 2020 estimate that CT use decreased by 0.4% (p = 0.812), X‐ray use decreased by 5.1% (p = 0.013), US use increased by 10.5% (p < 0.001), and the use of US only (no additional CT or X‐ray) increased by 2.6% (p = 0.036). On multivariate analysis, Hispanic ethnicity (OR = 1.857) was a significant predictor of US while age between 60 and 70 (OR = 0.256) or 70+ years (OR = 0.046), no insurance (OR = 0.442), and pain on a level of 8‐10 on a 10‐point scale (OR = 0.531) were negative predictors, all p < 0.05. Age greater than 70 (OR = 2.371) and an 8‐10 pain level (OR = 1.577) were predictors of CT, while Black race (OR = 0.666) was a negative predictor, all p < 0.05. Medicare or Medicaid (OR = 1.542) predicted receiving an X‐ray, while an 8‐10 pain level (OR = 0.637) was a negative predictor, all p < 0.05.
Conclusions: The utilization of US in the diagnosis of UUTC in the ED has significantly increased while X‐ ray use has decreased, but this has not corresponded with a change in CT imaging. Race, age, pain, and insurance type may play a significant role in imaging selection. Future studies should identify imaging strategies that ensure accurate diagnosis of UUTC while minimizing radiation exposure for all patient populations.
Funding: None
A New‐Old for the Evaluation of Upper Tract Obstruction ‐ Non‐Contrast Computerized Tomography Radiodensity Changes in An Obstructed Kidney
Sharon Fihsberg1, Gabriel Molineros1, Eliyahu Heifetz2, Amitay Lorber1, Guy Hidas1, Ofer Gofrit1, Mordechai Duvdevani1
1Hadassah Medical Center and The Hebrew University of Jerusalem, 2Department of Accounting and Data Management, Lev Academic Center
Presented By: Sharon Fihsberg, MD
Introduction: The gold standard study for evaluating suspected obstructed kidney is non contrast computerized tomography (CT). However, hydronephrosis, especially when the cause can not be identified, is not always a sign of obstruction. Obstructed kidney becomes edematous, a pathological process represented by increasing amount of fluid inside the kidney parenchyma and in the adjacent perirenal fat. The radiodensity of the obstructed kidney parenchyma and perirenal fat is measured in Hounsfield units.The objective of this study is to compare the density of an obstructed kidney to the a non‐obstructed counterpart during acute one sided ureteral calculi obstruction.
Methods: This is a retrospective comperative study. The study group included patients admitted with renal colic due to one sided obstructing ureteral calculi (group1), and the control group included patients with non‐ obstructing kidney stone (group 2). In each group clinical and radiological characteristics were collected. The radiodenisty of 3 parenchymal areas (upper pole, interpolar and lower pole) were measured and averaged, and then compared with the contralateral kidney. The average parenchymal density difference was calculated by subtracting the average parenchymal density of the obstructed kidney from the parenchymal density of the non‐obstructed kidney, we repeated this process for the perirenal fat.
Results: One hundred patients, 50 in each group were included in this study. Femal to male ratio was 11/39 and 13/37 in group 1 and 2 respectively. The average age in group 1 was 47.1 years compared to 52.5 years in the control. The average parenchymal density difference in group 1 was 4.38 HU compared to 1.12 HU in the control group (p value < 0.0001). An even more significant difference was found comparing the average perirenal fat density difference – in group 1, the average perirenal fat density difference was 11.13 HU compare to only 2.06 HU in the control group (p value < 0.0001). We didn't find any significant difference comparing age, gender, stone size and stone location.
Conclusions: In case of a single side ureteral obstruction, the obstructed kidney and the perirenal fat are characterized by a significant lower density than the contralateral kidney. These radiological signs from a non‐contract abdominal CT, can help the clinician to differentiate anatomical‐ hydroneprosis without obstruction from functional obstruction. This data is usually available on the first admission to emergency department, saving time and expenses when the diagnosis is uncertain.
Funding: No funding was recieved for this work
Limitations of Ultrasound Compared with CT for Kidney Stone Surveillance
Ryan Sun2, Elijah Sommer1, Calyani Ganesan2, Alan Pao2, John Leppert2, Helena Chang3, Simon Conti1, Timothy Chang2
Introduction: Renal ultrasound is an imaging modality used for kidney stone surveillance that does not expose patients to the risks of radiation associated with computed tomography (CT). However, US has lower sensitivity and specificity for the diagnosis of kidney stone disease compared with CT. Additionally, US may overestimate stone size, which could prompt unnecessary surgical treatments. To date, studies have reported varying results regarding US performance for kidney stone surveillance and it remains unclear if US is sufficient to inform clinical‐decision making for patients with known kidney stone disease. In this study, we aim to assess the accuracy of US for kidney stone surveillance, using CT as reference, and to identify factors that affect US performance.
Methods: This was a retrospective review at a single large volume academic medical center of patients with known kidney stone disease who were seen in the Urology clinic and who underwent both renal US and CT within 90 days for surveillance from January 2022 to December 2022. Patients with stone passage and interventions were excluded. Stone characteristics were recorded based on formal radiology reports, and statistical analysis was performed comparing the diagnostic accuracy of US and CT.
Results: A total of 107 patients and 128 stones were included, with a mean time difference of 25.7 ± 23.7 days between US and CT. The sensitivity was 77% and positive predictive value (PPV) was 75% for detection of stone by US. The PPV of stone diagnosis by US was only 59% for stones that are measured to be > 4mm by CT. The mean stone size on US was 8.7 ± 6.2mm, compared with 5.5 ± 6.4mm on CT (p = 0.02). This overestimation was more pronounced in patients with smaller stones and greater BMI (p < 0.05). Subgroup analysis showed no significant difference in US performance when stones were categorized by location, laterality, or time between US and CT scans. The individual technologist who performs the US exam, and not the radiologist who interprets the US exam, was associated with differences in stone detection (p = 0.01) or stone size (p = 0.03).
Conclusions: US performance is limited by worse detection of kidney stones as compared with CT and is dependent on stone size, patient BMI, and technologist. US significantly overestimated stone size, and if used alone to guide management, up to two in five patients with stones measuring > 4mm may undergo unnecessary intervention.
Funding: None
Enhancement of X‐Ray Imaging for Kidney Stones Using Single‐Exposure Dual Energy Subtraction: A Proof‐of‐Concept Study
Mario Basulto‐Martinez1, Eduardo Gonzalez‐Cuenca1, John Denstedt1
1Division of Urology, Schulich School of Medicine & Dentistry, Western University
Presented By: Mario Basulto‐Martinez, MD, MSc
Introduction: Patients with kidney stone are often exposed to repeated imaging. Computed tomography (CT) scan is the most accurate modality but is associated with ionizing radiation. Conventional X‐Ray of kidney, ureters, and bladder (KUB) are often underutilized due to lower sensibility and specificity when compared to CTs, however, the ionizing radiation dose is more than 20 times lower. Dual energy subtraction involves a low‐energy and a high‐energy spectrum for differentiating structure. Spectra/DR™ is a novel technology that utilizes a Reveal™ X‐Ray dual energy detector. This allows dual energy subtraction for any X‐ray source using single exposure and keeping the same dose of a standard KUB. The single exposure prevents motion artifacts by avoiding movement of several exposures. This technology has been proved to enhance chest X‐ rays identifying pathologies not seen without it. In this proof‐of‐concept study we explore the Spectral/DR™ technology using the Reveal™ detector in kidney stones
Methods: Human kidney stones were placed inside an anatomical phantom model and placed over the Reveal™ dual energy detector. A single exposure was obtained with fluoroscopy and imaging subtraction was performed with Spectra/DR™.
Results: Dual energy subtraction enhanced the imaging detail of stones within the anatomical phantom. The stones were visualized and easy discriminated from the phantom. The level of detail of stones was notably better from the conventional KUB.
Conclusions: Enhanced X‐ray with single‐exposure dual‐energy subtraction increased the detail of conventional X‐ray KUB. This is a promising alternative for improving image quality and accuracy while maintaining low dose of ionizing radiation and can be a helpful tool in follow up of patients with kidney stones.
Funding: None
Growth Rate of Kidney Stones Based on Computed Tomography Findings ‐ a Retrospective Cohort Study
Dor Rubinshtein4, Sharon Shreiber1, Dan Haberman2, Brian Berkowitz3, Ishay Dror3, Dan Leibovici4, Yaniv Shilo4
1Kaplan medical center, 2Department of Cardiology, Kaplan Medical Center, 3Weizmann Institute of Science
4Urology department, Kaplan medical center
Presented By: Dor Rubinshtein, MD
Introduction: Kidney stones are a common health problem with nearly 10% prevalence in the Western world. Studies of natural history of asymptomatic nephrolithiasis report that nearly 20% of kidney stones require surgical intervention within 3‐4 years of their detection. Nevertheless, the clinical outcomes of untreated asymptomatic kidney stones remain uncertain, and evidence‐based reports regarding their growth rate are scarce. This study aims to assess the growth rate of kidney stones based on multiple CT scans.
Methods: We retrospectively searched for all patients who were diagnosed with nephrolithiasis by non‐ contrast computed tomography (NCCT) from June 2020 to April 2023 and had a previous NCCT imaging, separated by at least 6 months, demonstrating the same renal stones. We reviewed the demographic, laboratory, and radiological data of all patients included in the cohort. Measurement of stone growth for the entire cohort was done initially, followed by comparing stone growth in patients with lower calyx stones to those with kidney stones in any other calyx. We referred to stone size by either the maximal length or by stone volume.
Results: Our cohort included 77 patients with 94 renal stones. The average growth rate for all kidney stones in this cohort was 1.3 mm/yr for the maximal stone length and 81 mm3/yr by stone volume. Of the 94 renal stones, 40 were in the lower calyx (group 1), and the remaining 54 were in non‐lower kidney calyces (group 2). There were no differences between the groups comparing the following parameters: average patient age (52 yr in group 1 and 51 yr in group 2), gender (87% males and 13% females vs. 89% males and 11% females, respectively), diabetes mellitus (20% and 10%), serum calcium (9.2 ± 0.55 and 9.2 ± 0.53), and urine pH (5.8 ± 0.8, 6.1 ± 0.7). The median stone size and volume for group 1 were 7.3 mm and 114 mm3, respectively, and 5.7 mm and 74.7 mm3 for group 2 (P = 0.04). Group 1 displayed higher Hounsfield unit attenuation of 885 ± 310 compared with 718 ± 262 in group 2 (P = 0.05). The mean growth rate in group 1 was 1.43 mm/yr, while in group 2, the growth rate was 1.1 mm/yr (P = 0.06).
Conclusions: In this cohort, an overall average growth rate of 1.3 mm/year for kidney stones was observed. Lower calyx stones were significantly larger and exhibited a faster growth rate than stones in other kidney calyces. This observation holds potential clinical significance in terms of surveillance protocols and patient counseling.
Funding: none
An Audit of Patient Radiation Dose Exposure During Computed Tomography Imaging for Urolithiasis
Mario Basulto‐Martinez2, Cameron Dawson1, Eduardo Gonzalez‐Cuenca2, Justin Amann3, Hassan Razvi4
1Western University Schulich School of Medicine and Dentistry, Department of Medical Imaging, London Health Sciences Centre, 2Western University Schulich School of Medicine and Dentistry, Division of Urology, 3Department of Diagnostic Imaging, Schulich School of Medicine and Dentistry, Western University, 4Western University, Schulich School of Medicine and Dentistry, Division of Urology
Presented By: Mario Basulto‐Martinez, MD, MSc
Introduction: Patients with urinary stone disease (USD) are often exposed to repeated computed tomography (CT) scans. While CT is the most accurate imaging for USD allowing a comprehensive evaluation, it is also associate with ionizing radiation. The low‐dose CT scan protocols reduce this exposure and must be adopt whenever possible. We aimed to audit doses from CT scans performed for USD in London, Ontario.
Methods: The CT records for the 3 University affiliated hospitals in London, Ontario were audited and those non‐enhanced performed for USD were identified. The total dose was calculated from every study performed in January every other year from 2011 – 2021. The dose was compared between sites. The Kruskal‐Wallis test with Bonferroni correction was utilized for comparison between sites.
Results: A total of 663 CT scans were audited; n = 152, n = 154, and n = 357 at Victoria Hospital (VH), University Hospital (UH), and St. Joseph's Health Care (SJHC), respectively. The overall median dose was significantly different between VH: 10.6 (6.5 – 15.8) mSv, UH: 6.6 (5.0 – 11.1) mSv, and SJHC: 3.9 (3.4 – 7.4) mSv, p < 0.001. The CT dose trends from 2011 – 2021 are presented in Figure 1.
Conclusions: Low‐dose CT scans for USD must be preferred whenever feasible. This audit study demonstrated that SJHC, the center where endourologists are based, had lower CT scan dose of more than half compared to the other centers. This may be explained by more awareness of radiation exposure and acquaintance with low‐dose protocols. Reducing radiation exposure in patients with USD is paramount.
Funding: None
Cranberry Reduces Urinary Symptoms Associated with Radiation Cystitis in Patients Undergoing Pelvic Radiation Therapy: A Systematic Review and Meta‐Analysis
Zheyu Xiong2, Chi Yuan1, Kunjie Wang1
1Department of Urology and Institute of Urology (Laboratory of Reconstructive Urology), West China Hospital, Sichuan University, Chengdu, People's Republic of China., 2Department of Urology and Institute of Urology (Laboratory of Reconstructive Urology), and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, People's Republic of China.
Presented By: Zheyu Xiong, MD
Introduction: Urinary symptoms associated with radiation cystitis (RC) are common in patients receiving pelvic radiotherapy (RT). There are still conflicting conclusions regarding the effectiveness of cranberry in preventing urinary symptoms associated with RC. This study was designed to determine whether cranberry products can prevent urinary symptoms associated with RC.
Methods: Randomized controlled trials (RCTs) and cohort studies that investigated the effectiveness of cranberry in the prevention of urinary symptoms associated with RC were included. The secondary outcome was reported as the number of patients who developed urinary tract infection (UTI) after RT. Random effect or fixed effect models were chosen for statistical analysis based on the heterogeneity.
Results: Five RCTs and one cohort study were included in this study. The results showed that cranberry products could reduce the risk of urinary symptoms associated with RC after pelvic RT by 24% (P = 0.02, RR = 0.76, 95% CI = 0.60‐0.96). However, cranberry products couldn't reduce the risk of UTI after pelvic RT(P = 0.11, RR = 0.57, 95% CI = 0.29‐1.13). Subgroup analyses showed that the protective effect of cranberry on urinary symptoms was seen only in studies that used placebo controls and not in studies that might have used active controls.
Conclusions: Our meta‐analysis indicated that cranberry could reduce the risk of urinary symptoms associated with RC but not reduce the risk of UTI after pelvic RT.
Funding: This study was supported by National Clinical Research Center for Geriatric, West China Hospital, Sichuan University (Y2021LC005).
An Overlooked Complication of the Clean Intermittent Catheter; Prostate Calculi
Gökhan Ecer2, Arif Aydin1, Mehmet Giray Sönmez1, Muzaffer Tansel Kilinc2, Selçuk Güven1, Mehmet Balasar1
1Necmettin Erbakan University Meram Medical School, Konya, Turkey, 2Konya State Hospital, Konya, Turkey
Presented By: Gökhan Ecer, MD.
Introduction: Although the clinical importance of prostate calculi has been understood over time, it is a urinary system disease that can cause different symptoms and can be ignored by urologists sometime. Clean intermittent catheter (CIC) is the gold standard method for bladder rehabilitation and urinary drainage in patients with neurogenic bladder. The aim of this study was to compare the incidence of prostate calculi and related pathologies between patients using CIC and not using CIC.
Methods: A total of 314 neurogenic bladder patients who were followed up and treated in our urology clinic were included in this study. The patients were divided into two groups as patients non‐using CIC (Group‐1, n:154) and patients using CIC (Group‐2, n:160).Presence of prostate calculi, the number of CIC used per/day, plasma uric acid levels, urine parameters, mean‐stone‐density (MSD) and calculi sizes were retrospectively scanned from patient records.
Results: In this study, no significant difference was observed between the parameters such as age, uric acid level, MSD, urine parameters, and other electrolyte levels (Table 1) While the incidence of prostate calculi in Group 1 was 23.4%; The incidence of prostate calculi in group 2 was 37.5(p = 0.007) .
Conclusions: In this study, it was tried to show the relationship between the use of CIC and prostate calculi that cause LUTS and dysuria, which are generally ignored in clinical evaluation but do not pass in patients. As a result of this study, it was determined that the incidence of prostate calculi increased in patients using CIC.
Funding: The authors did not receive support from any organization for the submitted study.
Kidney Stone Growth ‘Rings' Visualized Using Micro CT and Fluorescence Microscopy: Similarities in Growth of Randall's Plaque Calcium Oxalate Stones from the Same Kidneys
James C. Williams, Jr.1, James E. Lingeman1
1Indiana University School of Medicine
Presented By: James C. Williams, Jr., PhD
Introduction: Recent work has shown that mechanisms of stone growth can be demonstrated at the microscopic level using fluorescence microscopy. The objective here was to study multiple stones to observe patterns of mineral and organic deposition within and between patients.
Methods: Stones were removed by basket during endoscopic procedure, and a total of 12 stones were studied from 3 patients. All stones were verified by micro CT as having grown on Randall's plaque by residue visible on the stone. Each stone was mounted on polystyrene and ground down to reveal a planar surface inside the stone. The stone was then imaged using confocal microscopy (Leica SP8) with a water immersion lens (20x, 0.75 NA). Each stone was ground repeatedly to collect as many interior planes as possible, with micro CT verification of each plane of section and mineral regions exposed.
Results: Within a patient, similarities of layering (both thickness and color) were apparent in stones from the same kidney. Deposition of calcium oxalate monohydrate showed variable patterns of fluorescence even in adjacent layers.Several stones showed evidence of episodic growth by deposition of aggregates of dihydrate crystals, and dihydrate crystals showed only scattered regions of fluorescence in the blue region. Regions of apatite adjacent to Randall's plaque showed yellow fluorescence distinctly different from apatite deposited in later stone overgrowth. Randall's plaque showed fluorescence in the deep blue range as previously reported.
Conclusions: The unique fluorescence of apatite laid down as the first overgrowth on Randall's plaque is suggestive of special urine molecules deposited at the initiation of stone growth. Outside of this consistent finding, fluorescent molecules laid down with mineral in calcium oxalate stones are not universal among patients, but stones from the same kidney showed similar fluorescence patterns.
Funding: NIH P01DK056788; NIH R01DK124776
Augmented Reality for PCNL Access ‐ a Proof‐of‐Concept Study
Adib Rahman3, Kale Munien1, Aiyapa Ajjikuttira1, Chris Camilleri2
1Toowoomba Hospital, 2University of Queensland, 3Toowoomba hospital
Presented By: Adib Rahman
Introduction: PCNL is the preferred treatment of kidney stones > 20mm in diameter, with Fluoroscopy employed to achieve access. THis can be challenging to conceptualise the 3D anatomy especially in difficult cases, and multiple punctures often required to gain entry to correct calyx. Augmented reality involves overlaying digital information onto real world objects/places to enhance user experience. This can be achieved using optical see‐through head mounted display (OST‐HMD) such as the HoloLens.Augmented reality may allow access into the collecting system during PCNL. We aim to use AR as an adjunct for PCNL, especially in difficult cases.
Methods: We conducted a prospective, scoping proof‐of‐concept trial. We constructed patient‐unique models of the kidney and associated stones and used augmented reality to achieve puncture into the collecting system and confirm entry intraoperatively with fluoroscopy.Pre‐operative CT IVP was used to generate 3D model of the patient's kidney and stones. Blender (Blender Foundation) and Unity (Unity Technologies) used to create final models and user interface, subsequently uploaded onto HoloLens unit.
Results: Five patients have undergone successful supine AR guided PCNL. All were able to achieve puncture into renal calyx using AR guidance on a first attempt. There were nocomplications encountered in achieving entry. 1patient underwent asubsequent laser lithotripsy to clear small fragments.
Conclusions: We were able to establish proof‐of‐concept and able to enter calyx and achieve stone clearance. We foresee this being a useful adjunct for, assisting trainees in learning PCNL, visualising complex anatomy and stone burden.
Funding: Toowoomba Hospital Foundation
Evaluating the Perceptions of Urology Residents and Program Directors Regarding the Current Training in Genitourinary Imaging
David Bouhadana13, Sarah Elbaz1, Rose Diioa2, Anne Xuan‐Lan Nguyen3, Diana Benea4, David‐Dan Nguyen5, Paul Perrotte6, Samuel Lagabrielle7, Jason Lee8, Peter Metcalfe9, Isabelle Hardy10, Rehana Jaffer11, Naeem Bhojani12
1Faculty of Medicine, Laval University, Montreal, QC, Canada, 2Division of Radiology, McGill University, Montreal, QC, Canada, 3Division of Opthalmology, University of Toronto, Toronto, Ontario, Canada, 4Division of Neurology, McGill University, Montreal, QC, Canada, 5Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada, 6Division of Urology, University of Montréal, Montreal, QC, Canada, 7Division of Urology, Sherbrooke University, Sherbrooke, QC, Canada, 8Division of Urology, University of Toronto, Toronto, Ontario, Canada, 9Division of Urology, University of Alberta, Edmonton, AB, Canada, 10Department of Ophthalmology, University of Montréal, Montreal, QC, Canada, 11Department of Diagnostic Radiology, McGill University, Montreal, QC, Canada, 12Division of Urology, Centre hospitalier de l'Université de Montréal, Montreal, QC, Canada, 13Division of Urology, McGill University, Montreal, QC, Canada
Presented By: Sarah Elbaz
Introduction: Competency in interpreting genitourinary (GU) imaging is an important skill for urologists. However, no nationally accredited GU imaging curriculum exists for urology residency training programs. The main objectives of our study were to 1) characterize GU imaging training in Canada; (2) evaluate residents' self‐perceived competencies in interpreting GU imaging; (3) explore program directors' (PD) and residents' perceptions regarding the current imaging curriculum and suggestions for future directions.
Methods: From November to December 2022, a survey examining current imaging education in residency, perceived resident imaging knowledge, avenues for improvement in imaging education, and the role of point‐ of‐care ultrasound within urology was distributed to all Canadian urology PDs and residents.
Results: All PDs (13/13) and 40% (72/178) of residents completed the survey. Only two programs had a formal GU imaging curriculum. PDs and residents reported trainees were least comfortable interpreting Doppler ultrasound of renal, gonadal, and penile vessels. PDs reported that residents were most comfortable with non‐contrast computed tomography (CT) scans(9.5/10),CTurogram(9.3/10), and retrograde pyelography(9.3/10). All but one PD favoured increasing imaging training in their program.PDs highlighted the lack of time in the curriculum (n = 3) and lack of educators (n = 3) as the primary barriers to increasing imaging training in their program.
Conclusions: The majority of both PDs and residents believed that there needed to be more imaging training offered at their institution. However, addressing this is challenging due to the limited time in the curriculum and the need for available educators.
Funding: None
MODERATED POSTER SESSION 19: LAPAROSCOPIC AND ROBOTIC RENAL 2 AND ADRENAL
Laparoscopic Partial Nephrectomy on Central Tumors
Murat Gülşen2, Murat Gülşen1, Mehmet Necmettin Mercimek3, Ertuğrul Köse1, Ender Özden1, Yakup Bostancı1, Yarkın Kamil Yakupoğlu1, Şaban Sarıkaya1
1Ondokuz Mayıs University, School of Medicine, Department of Urology, Samsun, Turkey, 2Ondokuz Mayıs University, School of Medicine, Department of Urology, 3Atasam Hospital Urology Clinic, Samsun, TURKEY
Presented By: Mehmet Necmettin Mercimek, MD
Introduction: Our objective in this study is to compare functional and oncological outcomes in patients with central kidney tumors versus polar kidney tumors.
Methods: Prospectively collected data of 597 consecutive patients undergoing laparoscopic partial nephrectomy (LPN) by a single surgeon in a tertiary‐care center from November 2009 to March 2023 were retrospectively evaluated. Patients with bilateral or multiple renal tumors, graft, and horseshoe kidney, and missing data were excluded. 517 patients included in the study. R.E.N.A.L. nephrometry score was implemented to determine the complexity and localization of the tumors. The cohort was allocated into two groups. Group 1: 168 patients with centrally located renal tumors, group 2: 344 patients with polar renal tumors. Tumors exhibiting deep parenchymal involvement and demonstrating contact with or invasion into the collecting system or renal sinus were classified as central tumors. Tumors based at the renal hilum, in proximity to the hilar arteries, veins, or renal pelvis within a 5 mm range, also were categorized as central tumors. Demographics, perioperative and postoperative variables were compared between 2 groups.
Results: Age and gender were comparable between two groups. However, RENAL score and tumor size was higher in group 1. We favor transperitoneal access for the majority of central tumors. Warm ischemia time (WIT) was significantly higher in central tumors. Trifecta achievement rate and complication rate were comparable for both groups.
Conclusions: Although LPN is a more challenging approach in patients with central tumors. In high‐volume centers, it may be achieved similar surgical outcomes as in patients with polar tumors.
Funding: None
Which is Better to Assess Postoperative Complications in Patients Undergoing Laparoscopic Partial Nephrectomy?: Clavien‐Dindo Classification Versus Comprehensive Complication Index
Mehmet Necmettin Mercimek1, Mehmet Necmettin Mercimek1, Ender Özden2, Murat Gülşen2, Ertuğrul Köse2, Yakup Bostancı2, Yarkın Kamil Yakupoğlu2, Şaban Sarıkaya2
1Atasam Hospital Urology Clinic, Samsun, TURKEY, 2Ondokuz Mayıs University, School of Medicine, Department of Urology, Samsun, TURKEY
Presented By: Mehmet Necmettin Mercimek, Associate Professor
Introduction: This study aims to compare the strength of the classical Clavien‐Dindo classification system (CDCs), which is a Likert scale analysis versus the comprehensive complication index (CCI), a new quantitative evaluation system, in patients undergoing laparoscopic partial nephrectomy (LPN).
Methods: Prospectively collected data of sixty‐two patients undergoing LPN with postoperative complications from November 2009 to August 2020 were evaluated retrospectively. Postoperative complications were classified according to the CDCs and calculated using CCI‐calculator (https://www.assessurgery.com) quantitatively. Major complications were determined as ≥ grade 3 complications according to the CDCs. The complexity of the renal mass was defined according to the RENAL nephrometry score. The cut‐off value for CCI was analyzed by ROC analysis technique. Significance level was taken as p < 0.05.
Results: The sensitivity and specificity were found at 21.43% and 91.11% according to the CDCs to integrate postoperative complications, respectively. However, the AUC (95% CI) value is 97.4% in differentiating major complications with a CCI cut‐off value of 31.55 and above. Moreover, sensitivity was 86.67%, specificity was 97.87%, PPV value was 92.86%, NPV value was 95.83% and accuracy was 95.16%.
Conclusions: The study reveals that CCI has been found to evaluate both minor and major complications more accurately in patients undergoing LPN. Besides, it also has been shown that CDCs evaluate only minor complications more accurately.
Funding: none
The Learning Curve: Transitioning from Multiport to Single Port Robot‐Assisted Partial Nephrectomy
Jennifer L Nguyen2, Teona Iarajuli1, Angelo Cadiente1, Katherine Kim1, Allison Brown1, Ruchir Chaturvedi1, Meghana Singh1, Ali Mahkdoom1, Simon Gelman1, Fahad Sheckley2, Mutahar Ahmed2, Michael Stifelman2
1Hackensack Meridian School of Medicine, 2Department of Urology, Hackensack University Medical Center
Presented By: Jennifer L Nguyen, BS
Introduction: To evaluate the learning curve of single port robotic‐assisted partial nephrectomy (PN) between two experienced robotic surgeons at a single institution.
Methods: We utilized a single center, prospective database, and selected patients who underwent single port partial nephrectomy between May 2017 and October 2022 by two experienced surgeons. Demographics and clinical characteristics were analyzed for those with complete data. Outcomes between surgeons were compared with Wilcoxon rank sum test for continuous variables or Fisher's exact test for categorical variables. Operating times were used as a surrogate endpoint for learning curve and were plotted against case numbers separately for each surgeon and fitted with LOESS curves.
Results: There were 93 patients in this study, with 21 (22.6%) for surgeon 1 and 72 (77.4%) for surgeon 2. There was no significant difference in age, sex, BMI, or smoking status between the two surgeons. In regards to perioperative outcomes, there was no difference in EBL or intraoperative and major postoperative complications. In terms of learning curve, it suggests a decrease in OR time between cases 5 and 15 for surgeon 1, followed by a rebound in operative time in cases 15‐22. For surgeon 2, there is a decrease in OR time at case 35.
Conclusions: We did note a decrease in operative time in both surgeons within the first 5‐35 cases and a rebound toward their most recent experience. This rebound may reflect the surgeons tackling more complex cases. Further analysis of this and other factors is needed to delineate proficiency in single‐port robotic PN.
Funding: No funding was received for this article.
Open vs Robotic Partial Nephrectomy: Comparative Trends from a Wide National Population‐Based Database
Francesco Ditonno1, Antonio Franco1, Morgan R. Sturgis1, Celeste Manfredi1, Daniel Roadman1, Jamie Yoon1, Adan Z Becerra1, Srinivas Vourganti1, Ephrem O Olweny1, Riccardo Aurtorino1
1Rush university medical center
Presented By: Francesco Ditonno
Introduction: Our objective was to investigate overall complication rates among open and robotic partial nephrectomy (PN), including impact of social determinants of health (SDOH) on postoperative outcomes.
Methods: Patients who underwent partial nephrectomy between 2011 and 2021 were retrospectively analyzed by using PearlDiver‐Mariner, an all‐payer insurance claims database. International Classification of Diseases diagnosis and procedure codes were used to identify the type of surgical operation, patient's characteristics, postoperative complications and SDOH. Outcomes were compared using multivariable regression models.
Results: Overall, 65,325 patients underwent open (n = 23,377) and robotic (n = 41,948) PN. The 60‐day postoperative complication rate was 14% for open and 9% for robotic approach. Approximately 16% and 11% of patients reported at least one SDOH at baseline for open and robotic PN, respectively. SDOH were associated with higher odds of postoperative complications (Open = OR:1.11, 95% CI:0.99‐1.25; Robot = OR:1.31, 95% CI:1.18‐1.46). Open approach showed a significantly higher risk of postoperative complications (OR:1.62, 95% CI:1.54‐1.70) compared to the robotic approach. Utilization of PN outlined opposite timeline trends when comparing open to robotic approach, from 32% in 2011 to 26% (p = 0.05) in 2021 and from 24% to 34% (p = 0.05), respectively. There were no significant differences in terms of insurance plane's adoption between the two groups.
Conclusions: Our findings confirm that robotic PN is gradually replacing open PN. Open PN carries a higher risk of complication. SDOH are associated with significantly higher risk of postoperative complications following PN, regardless of the approach.
Funding: None
Predictive Factors of Renal Function After Robot‐Assisted Partial Nephrectomy in Clinical T1b Tumors
1Department of urology, Akita university school of medicine
Presented By: Ryuichiro Sagehashi, MD
Introduction: Robot‐assisted partial nephrectomy (RAPN) allows for a safe dissection and precise tumor resection. Although RAPN also applies for even clinical T1b renal cell carcinoma (RCC), little is known about renal function after RAPN for cT1b renal tumor.
Methods: Fifty patients who underwent RAPN for cT1b renal tumor from November 2017 to September 2022 in Akita University Hospital were entered in this retrospective study. The estimated glomerular filtration rate (eGFR) was assessed at baseline and postoperative days (PODs) 180. A significant decline of renal function was defined as ≥15 % reduction from baseline eGFR. Uni‐ and multivariable logistic regression analyses (including age, sex, R.E.N.A.L nephrometory score, and perioperative factors such as operative time and estimated blood loss) were performed to elucidate the risk factors of renal function.
Results: The median age was 62 years (IQR: 55‐70). The median tumor diameter and R.E.N.A.L nephrectomy sore were 44 mm (IQR: 43‐50) and 8 (IQR: 7‐9), respectively. 82% of patients achieved Trifecta. The median eGFR at baseline and PODs180 were 70 mL/min/1.73m2 (IQR: 60‐78) and 61 mL/min/1.73m2 (IQR: 53‐71), respectively. The significant renal functional decline in at POD 180 was observed in 19 (38%) of 50 patients. By multivariable analysis, R.E.N.A.L nephrectomy score (HR 11.07; 95% CI [1.67‐22.99]; p = 0.012) and estimated blood loss ≥200 ml (HR 6.279; 95% CI [1.35‐19.02]; p = 0.019) were significant risk factors of renal functional decline. A subgroup‐analysis of the component of R.E.N.A.L nephrectomy score showed that the L component (location relative to the polar lines) significantly impacted renal functional decline (HR 3.03; 95% CI [1.33‐6.92]; P = 0.008).
Conclusions: RAPN was a safe and feasible approach for cT1b RCC. R.E.N.A.L nephrometory score, especially the L component, is a significant predictive factor of renal function decline after RAPN for cT1b renal tumors.
Funding: Non.
Prognostic Significance of the Site of Invasion in pT3a Renal Cell Carcinoma
Ray Lee1, Kyeng Hyun Nam1, Jungyo Suh1, Cheryn Song1, Minyong Kang2, Seong Il Seo2, Chang‐Wook Jeong3, Cheol Kwak3
1Department of Urology, Asan Medical Center, 2Department of Urology, Samsung Medical Center
3Department of Urology, Seoul National University Hospital
Presented By: Ray Lee
Introduction: Pathological T3a renal cell carcinoma (RCC) encompasses three different types of locally advanced features and hence the debate on prognostic heterogeneity and need for reclassification persists. We aimed to identify the prognostic significance of the site of invasion.
Methods: Data of 1,606 patients with pT3aN0M0 RCC who underwent nephrectomy between 1988 and 2020 at three institutions were grouped according to the site of invasion: perinephric fat invasion (PFI), sinus fat invasion (SFI), renal vein invasion (RVI), PFI and SFI without RVI (PFI+SFI), and RVI with PFI and/or SFI (RVI+FI). Clinicopathological characteristics and recurrence‐free (RFS) and cancer‐specific survival (CSS) were compared to identify prognostic factors. Median follow‐up was 59.8 months (IQR 28.1, 93.7).
Results: Groups with PFI+SFI, RVI and RVI+FI had significantly poorer characteristics: larger tumor size, higher nuclear grade, more frequent sarcomatoid differentiation and lymphovascular invasion. Five‐year RFS were 75.8%, 66.9%, 61.7%, 60.9%, and 47.9% for SFI, PFI, PFI+SFI, RVI and RVI+FI groups, respectively (p < 0.001). On multivariate analysis, site of invasion was an independent prognostic factor in addition to tumor size, histologic subtype, and nuclear grade. Compared to SFI or PFI, PFI+SFI (HR 1.531, 95%CI 1.059‐2.212, p = 0.024), RVI (HR 1.809, 95%CI 1.243‐2.634, p = 0.002), RVI+FI (HR 2.400, 95%CI 1.801‐3.198, p < 0.001) were associated with poorer RFS. On subgroup analysis stratified according to the tumor size (4cm, > 4cm and 7cm, > 7cm), survivals were consistently poorer for the vein invasion groups compared to the fat invasion groups.
Conclusions: In T3a RCC, site of invasion was an independent progsnoticator of survival regardless of tumor size. Our findings may have implications for the selection of follow‐up strategies and identifying optimal candidates for adjuvant therapy.
Funding: None
Study of the Predictive Factors Affecting Outcomes of Patients Undergoing Transperitoneal Laparoscopic Donor Nephrectomy
Introduction: We aim to study the preoperative and intraoperative factors and compare against specific outcomes in patients undergoing transperitoneal laparoscopic donor nephrectomy and see if we could find what were the predictive factors for these outcomes
Methods: This is a prospective cohort study done in a single high volume transplant center. 153 kidney donors were evaluated over a period of 1 year. The preoperative factors such as age, gender, smoking status, obesity, visceral obesity, perinephric fat thickness, number of vessels, anatomic abnormalities, comorbidities, side of kidney and intraoperative factors such as lay of colon on the kidney, height of splenic or hepatic flexure of colon, loaded or unloaded colon, sticky mesenteric fat and compared against specific outcomes such as duration of surgery, duration of hospital stay, postoperative paralytic ileus, postoperative wound complications.
Results: Multivariate logistic regression models were used to study the variables of interest against the various outcomes. There were three positive risk factors for increased hospital stay, which were perinephric fat thickness and height of splenic or hepatic flexure of colon and smoking history. There was one positive risk factor for postoperative paralytic ileus which is lay of colon with relation to kidney and there was one positive risk factor for postoperative wound complication which was visceral fat area.
Conclusions: The predictive factors for adverse postoperative outcomes after transperitoneal laparoscopic donor nephrectomy were perinephric fat thickness, height of splenic or hepatic flexure, smoking status, lay or redundancy of colon with relation to kidney and visceral fat area
Funding: None
Retroperitoneal Laparoscopic Nephrectomy for Autosomal Dominant Polycystic Kidney Disease
Introduction: Autosomal dominant polycystic kidney disease (ADPKD) is an inherited disorder caused by mutations in the PKD1 and PKD2 genes that result in the kidneys becoming enlarged due to the formation of multiple cysts. Nephrectomy is commonly performed in patients with ADPKD because of abdominal distention due to increased renal volume, pressure symptoms on surrounding organs, and cyst infection. Open or laparoscopic surgery is the technique of choice, but laparoscopic surgery is more difficult than conventional laparoscopic nephrectomy due to renal size. We report on the results of our treatment of retroperitoneal laparoscopic nephrectomy.
Methods: Between 2019 and 2023, fifteen patients underwent retroperitoneal laparoscopic nephrectomy for ADPKD at Kagoshima University. All the surgery was done by the retroperitoneal approach using four ports. The specimen was removed from the additional incision, which connected port sites. In cases of concurrent kidney transplantation, the lower abdominal wound was extended for specimen extraction, and the operative time was defined as the time until nephrectomy. In addition, we retrospectively analyzed perioperative outcomes, including operative time, blood loss, and complications.
Results: The median age was 55 years (49 ‐ 62), and the sex was male in 9 cases and female in 6 patients. The median weight of the kidney was 1960 g (1160 ‐ 2805), the maximum diameter was 23cm (20 ‐ 25), the median operative time was 169 minutes (146 ‐ 219), and the blood loss was 150 mL (30 ‐ 210) including cyst fluid. Blood transfusions were performed in 6 patients, all of whom had undergone simultaneous renal transplantation and were transfused at the time of transplantation surgery. In pathology results, there were no cases of malignant disease. In addition, there were no significant complications in these cases.
Conclusions: Retroperitoneal laparoscopic nephrectomy for ADPKD was feasible and clinically safe. However, this study is limited by its single‐center, retrospective analysis, and a small number of cases.
Funding: None
Comparison of Perioperative Outcomes of Robot Assisted Partial Nephrectomy in T1a and T1b Renal Masses
Tunkut Doganca3, Mustafa Bilal Tuna1, Ilter Tufek2, Omer Burak Argun2, Can Obek2, Ali Rıza Kural2
1Acibadem Maslak Hospital, 2Acibadem University, School of Medicine, Urology, 3Acibadem Taksim Hospital, Urology
Presented By: Tunkut Doganca, MD
Introduction: The aim of this study is to compare perioperative outcomes of robot assisted partial nephrectomy (RAPN) in T1a and T1b renal masses.
Methods: This is a retrospective analysis of RAPN patients operated between 2008 and 2023 in a single institution. A total of 265 patients with T1a and 98 with T1b tumors underwent RAPN.
Results: Mean age and BMI in T1a patients were 53.89 ± 12.43 and 27.48 ± 4.33 kg/m2 and 52.23 ± 14.5 and 28.68 ± 5.17 kg/m2 in T1b patients, respectively. Mean tumor size was 26.78 ± 7.87 mm. in T1a and 49.46 ± 8.06 mm. in T1b patients. In T1a group, mean operative and warm ischemia times (WIT) were 97.14 ± 40.89 and 15.33 ± 8.7 minutes and in T1b group, 118.79 ± 36.9 and 18.78 ± 7.74 minutes, respectively. Mean estimated blood loss was 176.98 ± 201.03 and 263.57 ± 194.93 ml. in T1a and T1b patients, respectively. Surgical margins were positive in 6 (2%) T1a patients and in 3 (3%) T1b patients. Eleven patients (4% in T1a, 11% in T1b) had complications in each group; (1 Clavien I, 2 Clavien II, 8 Clavien IIIB in T1a) (2 Clavien I, 1 Clavien II, 7 Clavien IIIB and 1 Clavien IVA in T1b). Mean preoperative and postoperative creatinine were 0.88 ± 0.22 and 0.9 ± 0.25 mg/dl in T1a patients and 0.87 ± 0.21 and 0.93 ± 0.28 mg/dl in T1b patients, respectively. Mean preoperative and postoperative eGFR were 91.04 ± 18.74 and 89.62 ± 19.82 ml/min/1.73m2 in T1a patients and 93.22 ± 19.6 and 88.8 ± 21.13 ml/min/1.73m2 in T1b patients, respectively.
Conclusions: Compared to T1a renal masses, RAPN can be performed in T1b renal masses with slightly longer operative and warm ischemia times, higher complication rates and similar surgical margin positivity and renal function preservation rates.
Funding: None
Propensity Score Adjusted Comparison of Oncologic and Renal Function Outcomes with 14‐Year Follow‐up: Radiofrequency Ablation Versus Partial Nephrectomy
Genesis G. Dolgetta1, Tonya S. King1, Robert I. Carey2, Benjamin J. Behers3, Maximilian S. Carey1, Karim Ghazli2
1Sarasota Memorial Health Care System Research Institute, 2Sarasota Memorial Health Care System
3Florida State University College of Medicine
Presented By: Genesis G. Dolgetta, BS
Introduction: In this study, we describe the 14‐year follow‐up of oncologic and renal function outcomes for a cohort of patients who underwent laparoscopic radiofrequency ablation (LRFA) of SERMs with real‐time temperature monitoring of the ablation zone with non‐conducting fiberoptic thermistors versus a cohort of patients who underwent partial nephrectomy (PN).This study is unique due to the large size of the tumors, the length of the follow‐up, and the use of RENAL nephrometry scoring for all tumors.
Methods: All patients undergoing LRFA or PN for SERM were prospectively entered into an IRB‐approved database. Renal function was assessed at 3 months and annually thereafter. Changes in GFR were calculated using the Modification of Diet in Renal Disease formula. LRFA was performed with a Covidien Cooltip probe system using multiple probes and multi‐pass technique. Direct real‐time, fiberoptic temperature monitoring was performed for each case with temperature goals of greater than 60 degrees C achieved at the deep and peripheral margins. PN was performed with standard arterial and venous clamping and a sliding clip renorrhaphy closure technique.Oncologic and renal function outcomes for both cohorts were compared using a propensity‐score‐based analysis with adjustment for age, baseline renal function, tumor volume, RENAL score, histologic stage, and grade.
Results: Patients undergoing LRFA were older (median age 73 vs. 68 years, p < 0.001), with similar BMI (median 26.8 vs. 28.5), and gender (59% vs. 68% male, p = 0.17) compared to PN. Median tumor volume was 17.2 for LRFA and 33.5 for PN (p < 0.001), median pre‐surgery GFR was 59.7 for LRFA vs. 49.9 for PN (p = 0.002), and median RENAL score was 6.0 for LRFA vs. 9.0 for PN (p < 0.001). LRFA had a higher % of T1a patients (72% vs. 38.5%, p < 0.001).With propensity score adjustment, patients undergoing PN had 92% lower risk of DSM (p = 0.048), 98% lower odds of metastasis (p < 0.001), 95% lower odds of radical nephrectomy (p = 0.002), and 98% lower odds of overall salvage procedure (p < 0.001). Overall mortality was not significantly different between the groups (HR = 0.5, 95%CI 0.14‐1.59, p = 0.22).Four percent of patients undergoing LRFA required salvage PN (3/75). Propensity adjusted mean % change in GFR at one year was significantly greater for PN vs. LRFA (21.6% vs. ‐11.6%, p = 0.022).
Conclusions: Although LRFA is feasible with overall excellent preservation of kidney function and 94% disease‐specific survival, preservation of renal function and recurrence‐free survival decline inversely with tumor size and RENAL nephrometry score. Local tumor bed recurrence, metastasis, and DSM occur more frequently with LRFA than PN over 14‐year follow‐up with these large tumors despite the independent temperature monitoring with LRFA.
Funding: None.
Can Mayo Adhesive Probability Score Predict Perioperative Outcomes in Transperitoneal Laparoscopic Adrenal Surgeries?
1University of Health Sciences School of Medicine, Ankara State Hospital, Department of Urology, 2University of Health Sciences School of Medicine, Ankara State Hospital, Department of Radiology
3Balıkesir University School of Medicine, Department of Urology, 4Ministry of Health, Sirnak State Hospital, Department of Urology
Presented By: Altug Tuncel, Prof.
Introduction: Adherent perinephric fat (APF) may negatively influence on perioperative surgical outcomes of transperitoneal laparoscopic adrenal surgery. The Mayo Adhesive Probability (MAP) score is derived from preoperative cross‐sectional imaging measurements to detect APF. This study aimed to determine whether the MAP score can predict the perioperative outcomes in transperitoneal laparoscopic total and partial adrenalectomy.
Methods: Clinical data of 139 patients (82 female and 57 male) who underwent transperitoneal laparoscopic total (n = 116) or partial (n = 23) adrenalectomy between March 2013 and September 2022 were retrospectively analysed. According to the images obtained from preoperative contrast enhanced computed tomography or magnetic resonance imaging, patients were divided into two groups: Low MAP group (0‐1 points) and high MAP group (2‐5 points). General clinical features and perioperative outcomes were compared between the groups. In addition, regression analyses were performed to determine association between perioperative outcomes and clinical parameters.
Results: In patients with high MAP score;mean Body Mass Index (BMI), tumor size, operative time, estimated blood loss (EBL) and complication rate were found significantly higher compared to patients with low MAP score (Table 1). Comparison of the patients in two sub‐groups as total and partial adrenalectomy revealed that in both subgroups, operative time and EBL were significantly higher in high MAP score group. Moreover,complication rate in the total adrenalectomy sub‐group was significantly higher in thehigh MAP score group compared to the other (Table 2). Multivariable analyses revealed that high MAP score was an independent risk factor for complication rate. However, according to our results no significant effect of high MAP score on operative time, EBL and postoperative hospital stay duration was found (Table 3).
Conclusions: Our results suggest that high MAP score should be considered as an independent risk factor for complications of laparoscopictotal and partial adrenalectomy. In addition, we found no association between high MAP score withoperative time, EBL and postoperative hospital stay duration.
Funding: None
Robotic‐Assisted Adrenalectomy: Population‐Based Analysis of Contemporary Utilization Trends and Outcomes in the United States
Celeste Manfredi1, Antonio Franco1, Morgan R. Sturgis1, Francesco Ditonno1, Jamie Yoon1, Daniel Roadman1, Adan Z Becerra1, Srinivas Vourganti1, Riccardo Autorino1, Ephrem O Olweny1
1Rush university medical center
Presented By: Celeste Manfredi
Introduction: Despite widespread use of robotic assisted surgery over the past 2 decades, nationwide data on the contemporary utilization and outcomes of robotic‐assisted adrenal surgery are lacking. We investigated nationwide trends in the utilization of robotic‐assisted adrenalectomy for adrenal masses, and analyzed postoperative complications as well as impact of social determinants of health (SDOH) on postoperative complications.
Methods: Patients who underwent open vs. robotic/lap adrenalectomy between 2011 and 2021 were retrospectively analyzed using PearlDiver‐Mariner, a nationwide all‐payer insurance claims database. International Classification of Diseases diagnosis and procedure codes were used to identify the type of surgical operation, patient's characteristics, postoperative complications and presence of SDOH. Trends in utilization were analyzed using Mann‐Kendall test. Determinants of postoperative complications were analyzed using multivariable regression models.
Results: Overall, 11,477 patients underwent open (n = 3,751) and robotic/lap (n = 7,726) adrenalectomy. The overall numbers of open adrenalectomies significantly decreased from 2011 to 2021 (p = 0.05), while number of robotic adrenalectomies remained nearly stable over time (p > 0.05). Open adrenalectomies were primarily performed for adenoma (73%) vs carcinoma (26%) vs pheocromocytoma 1%), compared with 90% vs 9% vs 1% respectively for robotic adrenalectomy. The 60‐day postoperative complication rate was 16% for open vs. 10% for robotic adrenalectomy (p < 0.05). Presence of SDOH were identified in 949 patients (8 %); 172 (4%) for patients undergoing open vs 777 (10%) for those undergoing robotic surgery. SDOH were associated with significantly higher odds of postoperative complications (Open = OR:1.58, 95% CI:0.95‐2.54; Robot/Lap = OR:1.41, 95% CI:1.06‐1.84).
Conclusions: Minimally invasive adrenalectomy is utilized for 67% of adrenal masses in the contemporary era, but open surgery plays a bigger role for adrenocortical carcinoma. SDOH are associated with a higher risk of postoperative complications regardless of the surgical technique utilized.
Funding: None
Clinical and Biochemical Outcomes of Adrenalectomy in Primary‐Hyperaldosteronism, Comparison to Accepted Clinical and Biochemical Response
Fahed Atamna1, Orit Raz1, Dor Golomb1, Adi Leiba1, Alon Aisner1, Alla Simanovski1
1samson assuta ashdod university hospital
Presented By: fahed atamna, MD
Introduction: Adrenalectomy is a preferable treatment for adrenal adenoma producing hormone, also calls Conn syndrome. The effort of diagnosis Adrenal adenoma and Primary‐Hyperaldosteronism is insufficient and consequently, not enough adrenalectomies performed. In the era of Robotic assisted laparoscopic surgeries, we believe that this approach should be use more often, in‐order to avoid multiple medication use and better blood pressure control in those patients. This study aims to evaluate the effectiveness and outcomes of adrenalectomy as a treatment for Conn syndrome.
Methods: A cohort study, conducted on patients diagnosed with PA who underwent adrenalectomy . Clinical data, including preoperative laboratory results, imaging findings, surgical details, and postoperative outcomes, were collected and analyzed. Patients with suspected pheochromocytoma were excluded from this study. We defined Full success: as clinical and biochemical normalization (normal aldosterone and renin levels, and without medication). Partial success: defined as a decrease in aldosterone levels or the number of medications, and failure: defined as no change.
Results: From September 2019 to the present, eight patients underwent adrenalectomy for PA indications in our institution, three of whom were female. The median age was 47 years (range: 35‐80). Female patients were younger than male patients, 39 vs 61 years, respectively. All patients suffered from refractory hypertension, with elevated aldosterone levels, and suppressed renin levels.Before surgery, two patients were taking one medication for hypertension, while the remaining patients were taking 2‐4 medications. Adrenal venous sampling, required in one patient presented with bilateral adrenal adenoma.The median adrenal nodule size was 15 mm (range: 8‐77 mm).All patients underwent adrenalectomy using a minimally invasive Robotic and laparoscopic transperitoneal approach, with a standard surgical procedure and minimal blood loss. Transient hemodynamic instability was observed during surgery in one patient and in the postoperative recovery of an additional patient.Complete success was observed in six patients, two others achieved partial success as their aldosterone levels normalized, and hypertension medication were reduced. One failure was noted in this cohort study.No post‐operative complications, recorded.
Conclusions: The results of this study support the use of adrenalectomy as a viable therapeutic option, for Primary‐Hyperaldosteronism. This will require a team work of Nephrology, Anesthesiology, Radiology and Urology to be enable a proper patient selection.
Funding: none
Robot‐Assisted Posterior Retroperitoneal Adrenalectomy Without Assisted Suction Port
Kyung Kgi Park1
1Jeju National University
Presented By: kyung kgi park, MD, PhD
Introduction: Minimally invasive surgery is widely used for treating adrenal gland tumors. Robot‐assisted surgery with assisted suction port was considered more invasive than conventional three‐port laparoscopic surgery. This abstract describes our experience with three‐port retroperitoneoscopic robot‐assisted surgery for adrenal tumors.
Methods: Between March 2021 and December 2021, five patients underwent three‐port robot‐assisted PRA. Patients were placed in a prone jackknife position, and a 1 cm transverse skin incision was made below the lowest tip of the 12th rib. Retroperitoneal space was created, and two 8mm robot working ports were inserted. CO2 was insufflated, and an 8 mm robotic camera was placed at the center of the incision. The adrenal gland was dissected using a Maryland dissector and curved shears, and the adrenal vein was ligated with a hem‐o‐lok clip. Patient data were analyzed retrospectively.
Results: The mean patient age was 46.1 ± 7.9 years. Two patients underwent a right‐side approach, and three underwent a left‐side procedure. Three cases were pheochromocytoma, and two were benign adrenal cortical adenoma. The mean tumor size was 2.48 ± 1.58 cm. The mean surgery duration was 139 ± 57.6 minutes, and the mean estimated blood loss was 12.0 ± 6.8 ml. The average time to oral intake and postoperative hospital stay was 0.25 ± 0.01 days and 2.0 ± 1.23 days, respectively. No conversions to open surgery or postoperative complications occurred.
Conclusions: Our experience with three‐port retroperitoneoscopic robot‐assisted surgery for small adrenal tumors indicates its safety and feasibility. Further research is required to optimize patient selection criteria and verify its advantages over traditional PRA techniques.
Funding: none
Comparison of Perioperative Outcomes Between Robot‐Assisted Adrenalectomy and Laparoscopic Adrenalectomy: A Propensity Score Matching Analysis
Junseop Kim1, Chung Un Lee1, Jiwoong Yu1, Jae Hoon Chung1, Wan Song1, Minyoung Kang1, Hyun Hwan Sung1, Hwang Gyun Jeon1, Seong Il Seo1, Seong Soo Jeon1, Hyun Moo Lee1, Byong Chang Jeong1
1Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
Presented By: Junseop Kim, MD
Introduction: Adrenalectomy is primarily conducted through a minimally invasive approach. Following the introduction of the robotic system, robot‐assisted adrenalectomy (RAA) has been proposed as a novel surgical treatment for adrenal tumors. In this study, we compared the perioperative outcomes between RAA and laparoscopic adrenalectomy (LA).
Methods: We retrospectively collected data on patients who underwent either LA or RAA for adrenal tumors between February 2015 and March 2023. Of the 395 patients who underwent minimally invasive adrenalectomy, 354 underwent LA, and 41 underwent RAA. Patients in the LA and RAA groups were matched for age, sex, body mass index, tumor side and size using propensity score matching analysis. We compared perioperative outcomes, including operation time, estimated blood loss, use of a drainage tube, decrease in hemoglobin, and length of postoperative hospital stay. Complications for each surgical approach were compared, and factors for complications were analyzed.
Results: Propensity score matching analysis identified 123 patients, with 82 in the LA group and 41 in the RAA group. The mean tumor size was 40.9 ± 24.8 mm in the LA group and 42.2 ± 25.8 mm in the RAA group (p = 0.781), with the left side being more common in both groups (61.0% vs. 63.4%, p = 0.793). Perioperative data, including operation time (85.8 ± 32.5 vs. 83.5 ± 25.9, p = 0.695), estimated blood loss (80.9 ± 69.9 vs. 83.2 ± 73.9, p = 0.865), use of a drainage tube (59.8% vs. 63.4%, p = 0.695), length of postoperative hospital stay (3.8 ± 1.0 vs. 4.0 ± 0.9, p = 0.272), and decrease in hemoglobin (1.2 ± 0.9 vs. 1.2 ± 0.9, p = 0.747), showed no significant differences. The complication rate was lower in the RAA group, but the difference was not statistically significant (7.3% vs. 2.4%, p = 0.422). In a multivariate analysis, the only factor contributing to complications after adrenalectomy was tumor size (HR 1.031, 95% CI 1.005‐1.059, p = 0.021).
Conclusions: RAA provided comparable perioperative outcomes and demonstrated a better complication rate compared to LA, though the difference was not statistically significant. The only factor contributing to complications after adrenalectomy was tumor size.
Funding: None
Evaluation of the Utilization and Prognostic Value of Nonneoplastic Adjacent Kidney Pathology in Patients Undergoing Partial and Radical Nephrectomy
Jennifer L Nguyen1, Fahad Sheckley1, Teona Iarajuli1, Tanner Corse1, Ruth Sanchez De La Rosa1, Sharon Seidman1, Suzannah Sorin1, Katherine Kim2, Jacquelyn Roth1, Martin Malik2, Simon Gelman3, Wenlei He4, Gregory Lovallo1, Ravi Munver1, Mutahar Ahmed1, Michael Stifelman1
1Department of Urology, Hackensack University Medical Center, 2Hackensack Meridian School of Medicine, 3Office of Research Administration, Hackensack University Medical Center, 4Department of Pathology, Hackensack University Medical Center
Presented By: Jennifer L Nguyen, BS
Introduction: American Urological Association (AUA) guidelines for the management of renal masses include the pathologic evaluation of adjacent renal parenchyma following partial (PN) or radical nephrectomy (RN) for signs of intrinsic renal disease, particularly for patients with CKD or risk factors for developing CKD. We aim to evaluate the frequency and prognostic utility of this tool at a tertiary academic center.
Methods: We utilized a prospective, IRB‐approved single‐center database involving 862 patients who underwent PN or RN for a renal mass between 2017 and 2021 with GFR obtained at no fewer than 6‐month follow‐up. Adjacent pathological findings were classified according to the College of American Pathology Cancer Protocol guidelines. Continuous data were analyzed using a t‐test. Categorical data were analyzed using Chi‐Squared and Fisher's Exact Tests.
Results: Out of 394 patients who met inclusion criteria and underwent pathological evaluation of adjacent renal parenchyma, 287 (73%) patients underwent PN, and 107 (27%) underwent RN. There was a significant association between mean change in eGFR between radical and partial nephrectomies for vascular disease in adjacent kidney pathology (p = 0.042). Finding of vascular adjacent pathology and PN had a lower change in GFR compared to RN (‐5.69 vs. ‐20.85). Out of those that were omitted from evaluation for adjacent kidney pathology, 8.1% were from benign pathology.
Conclusions: Despite being an AUA guideline, pathological evaluation of non‐neoplastic adjacent renal parenchyma is perhaps underutilized, especially for those that had benign renal disease on histopathology. The pathology synoptic report should include a template for evaluating adjacent renal parenchyma in those that have either benign or malignant renal disease. This may be important for CKD management after nephrectomy. These findings need to be corroborated through larger, multi‐center analyses.
Funding: No funding was received for this work.
Robot‐Assisted versus Conventional Open Kidney Transplantation: A Comparative Study
Introduction: RAKT is a relatively newer approach for kidney transplantation. Open kidney transplant is the standardized approach for kidney transplantation. In this study we compared pre‐, intra‐ and postoperative parameters in medium term follow up of both approaches by propensity matching similar characteristics patients.
Methods: Data of 28 OKT and 28 RAKT propensity matched patients was collected during duration 2014 to 2022. OKT and RAKT patients were propensity matched for variables such as donor age, eGFR, side along with recipient age, BMI and comorbidities.
Results: Both the groups were comparable in terms of recipient age and BMI, donor age, creatinine, BMI, eGFR and comorbidities. Total ischemia time (p < 0.001) and postoperative day (POD) 1 creatinine (p < 0.001) was significantly higher in RAKT. However, postoperative 1 month (p = 0.12), 3 months (p = 0.60) and 1 year (p = 0.10) creatinine was comparable in both approaches. Postoperative complications (p = 0.90) including hemoglobin drop (p = 0.72) were comparable in both the groups. Graft survival was 78.5% in OKT group and 82.14% in RAKT group with median follow‐up of 60 months in both the groups.
Conclusions: In this comprehensive propensity matched analysis of RAKT with OKT, we conclude that RAKT has similar outcomes as OKT at medium term follow up upto 60 months in terms of graft survival. RAKT is a novel approach which is non‐inferior to established OKT approach.
Funding: none
The Use of 3d Printing in Robotic Surgery
Ryan Buettner2, Ron Hidalgo1, Brad Schwartz2
1Memorial Medical Center, 2Southern Illinois University School of Medicine
Presented By: Ryan Buettner, MD
Introduction: Preoperative planning for complex surgical procedures can be important for successful outcomes. Anatomical relationships on two‐dimensional radiographs such as computed tomography and magnetic resonance imaging do not always clarify or define these relationships. The use of 3‐dimensional printing has gained interest recently in preoperative planning and can afford a better look at anatomical relationships prior to entering the operative environment.
Methods: We employed 3‐D printing to help plan two robotic pelvic neurofibroma excisions and 5 robotic partial nephrectomies for complex renal tumors. Models printed on the Makerbot were brought into the Makerbot Print software as .stl files, arranged, sliced and exported to a usb drive. The print file was then transferred to the Makerbot printer via the usb. All prints have included a raft at the base and supports as needed. Supports are breakaway structures printed to provide a base while printing overhanging parts. The PLA supports are removed by hand, and with tools such as needle nose pliers. Given only the single nozzle, the supports are the same PLA used to create the model. After the model was printed in white PLA and, after supports were removed, they were then painted with acrylic paints.
Results: All operations were successful in renal preservation and excision of the neurofibromas. Pathology was showed negative margins in all patients and the neurofibroma patients have had resolution of their presenting lower extremity pain. We found the most important factor in utilizing 3D printing was the relationship between disease and vital structures.
Conclusions: Preoperative 3‐D printing of complex disease states may help in deciphering difficult or complex anatomy. As technology improves and costs of printing and printers decrease, utilization of this technology may become commonplace in operative planning.
Funding: None
WITHDRAWN
Title: Single Port Modified Partial Nephrectomy: Novel Technique for Simultaneous Access to Peritoneal and Retroperitoneal Partial Nephrectomy, Initial Clinical Experience
Fahad Sheckley1, Mutahar Ahmed1, Jennifer Nguyen1, Mubashir Billah1
1Hackensack University Medical Center
Presented By: Fahad Sheckley, MD
Introduction: Since its FDA approval in 2018, Intuitive Surgical DaVinci Single Port (SP) robotic platform has been a successfully used technology for multiple urological procedures. Single‐port robot‐assisted partial nephrectomy (SP‐RAPN) was performed with a transperitoneal peri‐umbilical incision or a subcostal incision for the retroperitoneal approach. An oblique lower quadrant incision perpendicular to the spoinoumbilical line, termed Single Port Ahmed Modification (SPAM), was used in this study. The purpose is to share our early intraoperative and perioperative outcomes and potential benefits for performing a successful incision for SPRAPN, especially in performing either a trans‐ or retroperitoneal approach through this incision, and to ease the transition to the retroperitoneum for a beginner.
Methods: This study is a prospective review of 78 SP Partial Nephrectomy cases between 03/2021 and 01/2023 by an experienced robotic surgeon. A single 2‐3 cm oblique incision parallel to the external oblique muscle, one‐third of the distance between the iliac crest and umbilicus, was used to insert the multichannel port to perform the RAPN. We extracted intra‐ and perioperative data of these patients to share the outcomes of this approach.
Results: SPRAPN was successfully completed in 78 patients (38 females and 40 males) without conversion to open or laparoscopic techniques. The mean age was 61.2 ± 12.1 years. The mean tumor size was 3.0 ± 1.2 cm, 43 were right‐sided masses, and 35 were left‐sided. The R.E.N.A.L Nephrometry score ranged from (4‐ 11) with an average of 7.0 ± 1.9. Average operating room time was 90.5 ± 24.6 min, estimated blood loss was 88.3 ± 134 ml and length of stay of 1.07 ± 0.7 days. 40/78 cases required clamping of the renal artery with average warm ischemia time 19.4 ± 6.7 min in patients who underwent clamping. No complications in all of 78 patients.
Conclusions: This study demonstrates the feasibility and reproducibility of SP‐RAPN using SPAM incision. This incision provides a standardized approach for surgeons to transition to the retroperitoneal approach using the SP platform.
Funding: N/A
MODERATED POSTER SESSION 20: DIVERSITY, EQUITY, INCLUSIVITY AND FEMALE UROLOGY
Partial vs. Radical Nephrectomy for T1 Renal Masses in the Elderly: Is there Age Discrimination?
Jennifer L Nguyen3, Kennedy Okhawere1, Teona Iarajuli2, Fahad Sheckley3, Catherine Implicito4, Hunter Hasley4, Laura Zuluaga1, Indu Saini1, Kevin Basralian3, Sharon Seidman3, Mutahar Ahmed3, Ahmed Mansour5, Ronney Abaza6, Daniel D Eun7, Akshay Bhandari8, Ashok Hemal9, James Porter10, Ravi Munver3, Simone Crivellaro11, Ketan Badani1, Michael Stifelman3
1Department of Urology, Mount Sinai Health System, 2Hackensack University Medical Center, 3Department of Urology, Hackensack University Medical Center, 4Hackensack Meridian School of Medicine, 5Department of Urology, UT Health San Antonio, 6Ohio Health, 7Department of Urology, Temple University Hospital, 8Division of Urology, Mount Sinai Medical Center, 9Department of Urology, Atrium Health Wake Forest Baptist & Wake Forest School of Medicine, 10Swedish Medical Center, 11Department of Urology, University of Illinois at Chicago
Presented By: Jennifer L Nguyen, B.S.
Introduction: We aim to evaluate the utilization of partial nephrectomy (PN) and radical nephrectomy (RN) among 3 different age groups and compare outcomes for patients ≥75 years.
Methods: We utilized a prospectively maintained multi‐institutional database of patients that underwent PN or RN between 2002 and 2023. Baseline characteristics, perioperative, and postoperative outcomes were compared between ≤59, 60‐74, and ≥75 years of age. Logistic regression was used to examine associations between baseline characteristics and receipt of PN.
Results: Of 4,035 patients, 3,464 (85.85%) underwent PN and 571 (14.15%) RN. Patients ≥75yr had higher comorbidity index, proportion of patients with hypertension and diabetes, and lower baseline eGFR. However, they have decreased utilization of PN (80.48%, p < 0.001). Compared to patients > 75yrs who had PN, those who received RN had larger tumor size (5.5 vs. 3.1cm, p < 0.001), R.E.N.A.L. score (10 vs. 7, p < 0.001), and tumor complexity (p < 0.001). Conversely, for those who received PN, there was no increase in surgical margins or complication rates, but a significant benefit in terms of ΔGFR (‐5.73 vs. ‐18.86, RN; p < 0.001).In adjusted analysis, high tumor complexity and increased tumor size were associated with decreased odds of receiving PN in all cohorts.
Conclusions: There is decreased utilization of PN among the elderly (≥75yr) despite the need for PN given their comorbid indications that affect kidney function. PN is safe and feasible for select elderly patients with a smaller decrease in eGFR. Therefore, elderly patients may potentially benefit from PN. In patients ≥75yr receiving a RN, 22% met elective criteria for PN suggesting potential for age bias. Advanced age alone should not deter the use of PN in appropriately selected patients.
Funding: No funding was received for this article.
Occupational Radiation Exposure During Pregnancy: A Retrospective Survey of Urologists on Perception, Experience, and Practice Patterns
Jessica Wenzel2, Michelle Jo Semins1, Casey Seideman2
1West Virginia University, 2Oregon Health & Science University
Presented By: Jessica Wenzel, MD
Introduction: Urology as a field has historically been male dominated, although now has an increasing number of women in the workforce. Peak reproductive years frequently overlap with residency training and early attending years. Exposure to ionizing radiation is a common occupational hazard in many procedural specialties. Other specialties that use radiation, such as interventional cardiology and interventional radiology, have shown little adjustments in practice patterns and no adverse outcomes amongst pregnant physicians in their fields in the setting of appropriate radiation safety measures. However, the impact of occupational radiation exposure during pregnancy for urologists is largely unknown. Our objective was to determine perception, characterize experience,and report on practices of urologists who have previously been pregnant during their urology career.
Methods: An anonymous online survey was distributed through relevant society membership bases and social media. Demographics, practice patterns, changes to practice patterns, and experience variables were recorded for respondents. Statistical analysis was performed in R studio.
Results: There were 384 respondents, 255 of whom identified as women. Of these, 164 had been previously pregnant. Female respondents were younger, completed training more recently, and were more likely to have adjusted their caseload due to radiation concerns compared to their male counterparts. Of women who had been pregnant, few had access to policies for who to notify (19%), policies for safety precautions (22%), custom‐fitted lead (35%), and maternity lead (20%). Most women (66%) relied on their own research for guidance on radiation safety during pregnancy, while some (41%) also used information from colleagues or mentors. Most did not know if their fetal dosimeter dose was within the safety limit. 46% of women would have taken greater precautions during pregnancy than they did.
Conclusions: Access to the proper tools to safely navigate pregnancy is inconsistent amongst practicing urologists. Evidence‐based guidelines are needed to better empower pregnant urologists.
Funding: None
Leveling the Playing Field: Evaluating Gender Disparities in Surgical Training Experience in Endourology Fellowships
Garrett Ungerer1, Kelly Lehner1, Maraika Robinson1, Aaron Potretzke1, Li‐Ming Su2, Kevin Koo1
1Mayo Clinic ‐ Rochester, 2University of Florida
Presented By: Kelly Lehner, MD
Introduction: Gender disparities exist in surgical training experience and case volumes among other surgical specialties. We aimed to characterize potential gender disparities in surgical training experience during endourology fellowships.
Methods: We analyzed surgical case logs submitted to the Endourological Society for all graduating fellows in 2020‐2022. Case logs were cross‐referenced with a list of verified fellowship graduates to ensure accuracy. Data from case logs for 2‐year fellows were halved to allow for analysis on a cases‐per‐year basis.
Results: Case logs for 131 endourology fellows were analyzed. 18 fellows were women (14%), corresponding to 3716 of 28961 (13%) total logged procedures. Average total surgical cases for women vs men were similar (228 vs 223, p = 0.5) (Figure). For stone cases, women averaged significantly higher volumes for PCNL cases (89 vs 51, p = 0.02). While there was a trend towards more women performing more lap/robotic (149 vs 136, p = 0.73) and ureteroscopy (134 vs 114, p = 0.87) cases, these differences were not statistically significant.
Conclusions: Women perform similar surgical case volumes overall during Endourological Society fellowships compared to men. These findings suggest that, in contrast to gender disparities in surgical training experience in other specialties, women and men achieve similar surgical opportunities in endourology fellowship, which strengthens the preparedness of the contemporary endourology workforce.
Funding: None
Progress or Persistent Disparity? Assessing the Persistent Gender Gap in the Endourology Training Pipeline
Garrett Ungerer1, Kelly Lehner1, Anessa Sax‐Bolder1, Aaron Potretzke1, Candace Granberg2, Kevin Koo1
Introduction: Despite increasing numbers of females matriculating into medical schools and urology residencies, women appear to be underrepresented in subspecialty fellowship training. We aimed to assess female match trends in the Endourological Society fellowship match over the past 10 years.
Methods: We analyzed endourology fellowship match data from the AUA for match years 2014‐2023 to characterize trends in application volumes and match success rates for female and male applicants. Mann‐ Kendall trend test was used to determine statistical significance.
Results: During the 2014‐2023 match cycles, 57 (9%) ofapplicants were women vs. 572 (91%) men. A significant increase in female applicants occurred over the study period (range 2‐13, p = 0.001)(Figure). A significant increase in women matching also occurred (p = 0.003). 45 (13%) females compared to 307 (87%) males suceessfullty matched into endourology.The match rate for female applicants averaged 80% (range 50%‐100%) compared to 54% for men (range 37%‐61%). The average proportion of vacancies filled by women was 12% (range 4%‐24%), but the increasing trend was not statistically significant (p = 0.23).
Conclusions: While the total number of women applying for and matching to endourology fellowship has significantly increased over the past 10 years, proportionally less women match in endourology overall. Closing the gender gap in the urology workforce will require thoughtful strategies to promote gender diversity in the endourology training pipeline and foster interest in endourology among female residents.
Funding: None
Women Report Decreased Stone Specific Quality of Life
Scott Quarrier2, David Song1, Karen Doersch2, Timothy Campbell2, Christopher Wanderling2, Nathan Schuler2, Rajat Jain2, Scott Quarrier2
1University of Rochester School of Medicine, 2University of Rochester Medical Center
Presented By: Scott Quarrier, MD
Introduction: Kidney stones are a prevalent condition that affects millions of individuals worldwide, leading to substantial morbidity and impaired quality of life. This study aims to compare the reported quality of life outcomes between men and women with kidney stones using the Wisconsin Stone Quality of Life Questionnaire (WISQOL), a validated disease‐specific questionnaire.
Methods: A retrospective review of medical records was conducted for new urolithiasis patients who completed the WISQOL questionnaire upon their initial visit to a kidney stone clinic between January 16, 2019, and April 13, 2023, with lower scores representing worse quality of life. Patients were categorized based on their reported presence of symptoms or pain related to kidney stones within the last 4 weeks of their visit and their legal sex. Two‐sample t‐tests were performed to determine statistical significance, with primary outcomes being the WISQOL total score and subscores.
Results: The study included a total of 1820 patients, with 923 males and 897 females. Females reported significantly lower WISQOL scores (M = 71.8) compared to males (M = 81.4) for the WISQOL total score and all WISQOL subdomains, including social impact, emotional impact, disease impact, and impact on vitality (p < 0.001 for all). Among asymptomatic patients, females (n = 418, M = 85.3) reported significantly lower WISQOL scores compared to males (n = 585, M = 89.0) (p < 0.001). Similarly, among symptomatic patients, females (n = 337, M = 56.8) reported significantly lower WISQOL scores compared to males (n = 219, M = 64.7) (p < 0.001).
Conclusions: The findings suggest that women with kidney stones experience lower quality of life compared to men across multiple domains. This discrepancy persists even when patients report being asymptomatic. By recognizing the unique challenges and concerns faced by men and women with kidney stones, healthcare professionals can optimize patient care and improve overall quality of life for men and women with kidney stones.
Funding: None
Female Surgeons Have Very Low Representation in Robotic‐Laparoscopic Urological Surgery: A Study of American Board of Urology Case Logs from 2011 to 2022
Natalie Passarelli1, Natalie Passarelli1, Alexa Steckler1, Borivoj Golijanin2, Samuel Eaton2, Vikas Bhatt2, Gyan Pareek2, Elias Hyams2
1The Warren Alpert Medical School at Brown University, 2Minimally Invasive Urology Institute, The Miriam Hospital; The Warren Alpert Medical School of Brown University
Presented By: Borivoj Golijanin
Introduction: Female surgeon representation in urology hasslowlyincreasedin recent years, from 8% in 2015 to 10% in2021.Womenremainparticularly underrepresented within robotic surgery,comprising a mere4.05% of thisfield.Ourobjectivewas toevaluate the gender distribution of surgeons performing robotic and laparoscopic surgery (RLS) in different urological subspecialties.
Methods: American Board of Urology surgicalcase logs from 2011‐2022were obtained. Cases withthe followingCPT codes for common RLS procedures were included:50543, 50544, 50545, 50546, 50548,55866, 57425, and S2900.Self‐reported physicianand patientgenders andphysicianspecialtywere captured.Rates ofsurgeries performed by female‐identifying physicianswere calculated for eachsub‐specialtyandCPT codedprocedure.
Results: The participation offemale surgeonsin RLS variedgreatly bysubspecialtyand CPT code. Overall,female surgeons performed 7.18% of RLS surgeries, with the largestrepresentation inFemale Urology (36.5%) and Pediatric Urology (24.2%), and hadlowerfemale representation in General Urology and Oncology (5.1% and 3.2%, respectively).Similarly, female surgeons performed fewer RLS procedures than males across CPT codes, with only laparoscopic sacrocolpopexy (57425)demonstrating greater relative representationof female surgeons(39.3%).
Conclusions: Althoughfemalesurgeonrepresentation inurology is increasing, involvement in RLSremains low across specialtiesand CPT codes, withthe greatest roleinlaparoscopicsacrocolpopexy (57425),parallelinga greater female surgeon involvement inFemale Urology. Additional studyofthe recruitment of women into RLS, as well assamesexpatient‐provider preference, iswarranted to ensure diversity and equity within thefield.
Funding: Brown Urology Department
Reporting of Race/Ethnicity in Clinical Trials of True Minimally Invasive Surgical Therapies for the Treatment of Benign Prostatic Hyperplasia: A Systematic Review
David Bouhadana9, David‐Dan Nguyen1, Anna‐Lisa Nguyen2, Rashid Sayyid3, Tuan Thanh Nguyen4, Kevin Zorn5, Bilal Chughtai6, Dean Elterman7, Quoc‐Dien Trinh8, Christopher Wallis3, Naeem Bhojani5
1Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada, 2Schulich School of Medicine and Dentistry, London, Ontario, Canada, 3Division of Urology, University of Toronto, Toronto, Ontario, Canada, 4University of California Irvine, 5Division of Urology, Centre hospitalier de l'Université de Montréal, Montreal, QC, Canada, 6Department of Urology, Weill Cornell Medical College/New York Presbyterian, New York, NY, USA, 7Division of Urology, Dept. of Surgery, University Health Network
University of Toronto, Toronto, Ontario, Canada, 8Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA, 9Division of Urology, McGill University, Montreal, Quebec, Canada
Presented By: David Bouhadana, MD
Introduction: Under‐representation of racial/ethnic minorities limits the external validity and generalizability ofrandomized controlledtrials(RCT). Thiscanworsenpre‐existinghealth disparities.We soughtto determinethe extent of racial reporting and enrolmentwithinRCTs oftrueminimally invasive surgical techniques(TMIST) for the office‐based treatment of benight prostatic hyperplasia (BPH).
Methods: We conducted a systematic reviewof RCTs of office‐based TMIST for the treatment of BPH. We searchedMEDLINE, Embase, and the Cochrane CENTRAL databases from inception through September 18th,2022.Studies were excluded if they 1) did not discuss a minimally invasive surgical treatment for BPH;
2) were not randomized controlled trials (i.e.reviews, case reports, commentaries, or conference proceedings); or3) were not published in the English language. Two reviewers independently screened the citations that were considered eligible for title, abstract and full‐text screening, with conflicts resolved by a third reviewer.In addition to studycharacteristics,participant ethnicity and raceenrolment and reportingwere collected.
Results: The included trials represented 2977 men. Sixteen studies reported onTransurethral microwave thermotherapy (TUMT), 6 onprostate arterial embolization (PAE), 2 onprostatic urethral lift (PUL), 1 onTemporarily Implanted Nitinol Device(iTIND), and 1 onwater vapour therapy (WVT). Study publication years ranged between 2004 and 2021. Eight studies were conducted in the US and/or had authors with US affiliations. Characteristics of the studies are further detailed inTable 1.None of the retained studies reported on the race/ethnicity of the study participants.
Conclusions: There is asignificantlack of racial/ethnic reporting in RCTs of TMIST for the treatment of BPH. Lack of racial reporting hinders the evaluation of racial enrolment. There is a need forthe development of structuredstandards withregardto racial reporting and enrolment for RCTs of TMIST.
Funding: None.
Racial Representation in Nephrolithiasis Guidelines: Are they Generalizable?
Dima Raskolnikov1, Benjamin Green1, Emily Hunt1, Julia Nadelmann1, Kara Watts1, Alex Small1
1Montefiore/Albert Einstein College of Medicine
Presented By: Dima Raskolnikov, MD
Introduction: Guidelines from the American Urological Association (AUA) and Endourological Society represent the highest level of evidence that inform clinical practice. However, the clinical trials on which they are based may not include sufficiently diverse patient populations to make their results generalizable. We hypothesized that the majority of clinical trials that guide kidney stone care fail to report the racial composition of their study populations.
Methods: We reviewed AUA/Endourological Society Guidelines for the Medical and Surgical Management of kidney stones for all referenced clinical trials. Studies reporting human subjects research were included. Study populations were reviewed for reported sex/gender, race, ethnicity, and study country of origin.
Results: Of the 380 studies referenced in these Guidelines, 293 reported the results of human subjects research and were included in our analysis. Only 20 of 293 studies (6.8%) reported the race/ethnicity of their subjects, while 254 (87%) reported sex/gender. Racial representation as a percentage of all patients on which the Guidelines are based is described in the Table. Studies from the United States (144 of 293, 49%) were more likely to report the race/ethnicity of their study populations than those performed in other countries (p = 0.017).
Conclusions: A small minority (6.8%) of clinical trials on which the AUA/Endourological Society Guidelines for kidney stone care are based report the racial/ethnic composition of their study populations. Among those studies that do report this data, minority patients are poorly represented. Future studies should report this data and include minority patients in order to ensure that Guidelines are broadly generalizable.
Funding: None
Female Surgeons Performing Robotic and Laparoscopic Surgery Treat a Disproportionate Percentage of Female Patients: A Study of American Board of Urology Case Logs
Natalie Passarelli1, Natalie Passarelli1, Alexa Steckler1, Borivoj Golijanin2, Elias Hyams2, Samuel Eaton3, Vikas Bhatt3, Gyan Pareek3
1The Warren Alpert Medical School at Brown University, 2Minimally Invasive Urology Institute, The Miriam Hospital; The Warren Alpert Medical School of Brown University., 3Minimally Invasive Urology Institute, The Miriam Hospital; The Warren Alpert Medical School of Brown University
Presented By: Borivoj Golijanin
Introduction: There has been a slow rise in female surgeon participation in Robotic and Laparoscopic Surgery (RLS), generally and within urology. Also, there is mixed evidence on whether male and female patients have gender preferences for their urological providers.We sought to evaluate, within RLS, if there are differences in gender distributions of patients for male vs. female surgeons.
Methods: RL‐related CPT codes were selected from the American Board of Urology case logs (2011‐2022). CPT codes were: 50543, 50544, 50545, 50546, 50548, 55866, 57425, and S2900. Self‐reported patient and physician genders were recorded. Gender rates of surgeons and their patients were calculated overall, and by subspecialty. The percentage of female physicians operating on female patients was recorded and analyzed overall, by subspecialty.
Results: Female providers performed 7.2% of RLS urological procedures (Table 1). Of these patients, 53.2% were female. Male providers had an average of 24.4% female patients, less than half of that of female physicians. Of note, female providers constituted 36.5% of Female Urology providers. Among subspecialties, female providers consistently had a higher percentage of female patients as compared to their male counterparts, with the exception of Pediatrics and Urolithiasis which showed equal representation (Table 2).
Conclusions: Female surgeons performing RLS treat a larger proportion of female patients relative to male surgeons, more than doubling the percentage of their male physician counterparts. Whether this tendency toward same gender physician‐patient pairing comes from the patient, provider, or both; and whether it is driven by preference, bias or structural reasons; remains unclear. Additional research to elucidatethis finding is warranted to understand referral and practice patterns to optimize quality, equity and inclusion.
Funding: Brown Urology Department Funding
Urinary Incontinence During Sexual Intercourse
Ben Sionov2, Masha Ben Zvi1, Alexander Tsivian2
1Obstetrics and Gynaecology, Wolfson medical centre, Holon, Israel, 2Urologic Surgery, Wolfson medical centre, Holon, Israel
Presented By: Ben Sionov, MD
Introduction: Urinary incontinence is a bothersome condition and has a detrimental effect on quality of life. The literature on the matter is unfortunately limited, few women actively initiate the discussion about this issue.In this study we aimed to report the incidence, diagnosis and management results of urinary incontinence during intercourse.
Methods: Retrospective analysis of patients with stress urinary incontinence (SUI) who underwent surgery for this problem between 2019 and 2022 was performed. Inclusion criteria were age under 60 years old (in this age range women are mostly sexually active), surgery for stress incontinence and follow up for at least three months. Clinical data including information on urinary incontinence during intercourse, diagnosis, management and treatment results were collected and analyzed.
Results: Of 103 women, 59 were included‐ of them, 27 patients (46%) with average age of 49.2 (range 40‐ 59) suffered from urinary incontinence during sexual intercourse prior to treatment. None of the patients complained until deliberately asked. Only one woman had urinary incontinence during orgasm, the other experienced incontinence during all stages of intercourse.The patients were ulteriorly divided based on the severity of the incontinence according to pads used daily; 5 pads or more 11 (40.7%) of the patients, 3‐4 pads 12 (44%), 1‐2 pads 3 women and one patient didn't use pads.All the patients underwent mid urethral sling surgery. In addition, pelvic organ prolapse repair was performed in two patients. In 23 patients (85.2%) urinary incontinence resolved following surgery including incontinence during intercourse. In the remaining 4 women the surgery was not successful both for stress and during intercourse.
Conclusions: Urinary incontinence during sexual intercourse is very frequent. Direct questioning is critical to diagnose and discover this condition.This subgroup of patients should be considered as a severe form of urinary incontinence.
Funding: none
Urethral Diverticula Without Surgical Removal ‐ Luck or Mistake?
Ben Sionov2, Masha Ben Zvi1, Alexander Tsivian2
1Obstetrics and Gynaecology, Wolfson Medical Centre, Holon, Israel, 2Urologic surgery, Wolfson Medical Centre, Holon, Israel
Presented By: Ben Sionov, MD
Introduction: The Incidence of urethral diverticula varies between 0.02‐6%. The natural history of the condition remains unclear. There is no consensus regarding who are the patients that should be offered surgical treatment and what is the right timing. Nowadays, most of the patients diagnosed with urethral diverticula will be offered surgical treatment, even if asymptomatic.This study aimed to evaluate the natural history of the condition in women diagnosed with urethral diverticula, not treated surgically due to various reasons.
Methods: Retrospective analysis of the database was performed. Patients with paraurethral masses were included. 126 patients answered the inclusion criteria. Demographic, clinical data, physical examination, imaging, type of treatment and the results were analyzed, in addition a telephonic survey was performed.
Results: 99 women were diagnosed with urethral diverticula, of them 21 women aged between 18 to 52 (average 35.8) years old were not treated surgically following the initial diagnosis.Of those, 11 patients had symptoms (group 1), while 10 were asymptomatic (group 2).Of the symptomatic patients (group 1) 4 underwent puncture and drainage of the content, 5 had spontaneous drainage. Five women (45%) underwent surgery later in life (from 1 to 20 years). In the asymptomatic patients (group 2) one patient had spontaneous drainage of the mass, with no recurrence. Only one patient (10%) underwent surgery to remove the diverticula. One patient was lost to follow up.Overall, in the study group, 28.5% of patients underwent surgery following conservative therapy, not as initial management option, of them 45% were symptomatic and 10% asymptomatic.
Conclusions: Most of the patients with asymptomatic urethral diverticula will benefit from conservative treatment/ observation alone.Following spontaneous drainage regression of the mass is possible, therefore, offering them conservative treatment is a reasonable option.In our opinion, the natural history of the condition suggests we are in presence of periurethral retention cyst, and not diverticula.
Funding: None
Risk of Anti‐Urinary Incontinence Surgery After Hysterectomy for Uterine Fibroids: A Nationwide Cohort Study
Jun Ho Lee3, Dong‐Gi Lee1, Gyeong Eun Min1, Hyung‐Lae Lee1, Kyung Jin Chung2
1Department of Urology, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, 2Department of Urology, Gachon University Gil Medical Center, Gachon University School of Medicine, 3Department of Urology, Nowon Eulji Medical Center, Eulji University, Seoul, Korea
Presented By: Gyeong Eun Min, MD, PhD
Introduction: We evaluated the relationship between previous hysterectomy for uterine fibroids and subsequent stress urinary incontinence (SUI).
Methods: We used national health insurance data. The hysterectomy group (aged 40 to 59) comprised patients who underwent hysterectomy for uterine fibroids between January 1, 2011, and December 31, 2014, and the control group (aged 40 to 59) comprised patients who visited a medical facility for a checkup during the same time span. Propensity score matching (PSM, 1:1) was performed to balance confounders. SUI was defined as the need for SUI surgery accompanied by a SUI diagnosis code.
Results: After matching, 81,373 cases (hysterectomy group) and 81,373 controls (nonhysterectomy group) were enrolled. The mean follow‐up period was 7.8 years in the controls and 7.9 years in the cases. The rate of anti‐incontinence surgery was modest but significantly higher in the cases than in the controls (1.7% vs.
2.0%; P < 0.001). Compared to the rate in the controls, abdominal hysterectomy significantly increased the rate of anti‐incontinence surgery before (HR (95% CI): 1.235 (1.116‐1.365)) and after adjusting for confounders (HR (95% CI): 1.215 (1.097‐1.347)). However, laparoscopic hysterectomy, laparoscopic hysterectomy with adnexal surgery, and abdominal hysterectomy with adnexal surgery did not increase anti‐ incontinence surgery rates compared to those in the controls. This significant relationship between abdominal hysterectomy and anti‐incontinence surgery was maintained after stratifying patients according to age group.
Conclusions: Patients who plan to undergo transabdominal hysterectomy for the treatment of uterine fibroids should be counseled about the risk of SUI, especially the risk of anti‐incontinence surgery.
Funding: None
The Power of Teamwork: Tackling the Urologic Challenges of Placenta Accreta
Ari Luder1
1Sheba Medical Center
Presented By: Ari Luder, MD
Introduction: Placenta accreta spectrum (PAS) is a complex obstetric condition with increasing global incidence and significant maternal morbidity and mortality rates. This study aims to evaluate the benefits of ureteral‐catheter stent (UCS) insertion in reducing urological injuries and overall postoperative complications in women with placenta accreta undergoing a cesarean section.
Methods: We retrospectively reviewed medical records of women diagnosed with placenta accreta, treated at our institution between 2011 and 2022. From2019 onwards all women with PAC were inserted a UCS. We reviewed demographics, medical history, hospital course including surgery reports, and peri‐operative outcomes. We then compared maternal and urological complications based on antenatal suspicion of accreta and the insertion of a UCS as a pre‐operative procedure.Main Outcome MeasuresBladder and ureteral injuries, prolonged maternal intensive care unit admission, a high volume of blood transfusion, length of stay after surgery, short and long‐term urologic complications ( bladder and ureter injury), and postoperative complications.
Results: A total of 417 women were included in the study We identified 108 cases of placenta accreta with a UCS insertion. When accreta was suspected a UCS was scheduled for insertion. There was a significantly reduced rate of urological injuries (5/108, 4.6%) compared to cases of placenta accreta without UCS insertion (43/309, 14%) (0.009,p < 0.05). Women with preoperative bilateral UC insertion had a lower incidence of overall pot‐operative complications (6/108, 5.6%) compared to women without UC (50/309, 15.6%) (0.005, p < 0.05).
Conclusions: Urologic injuries are common operative complications in placenta accreta cases undergoing cesarean section. Surgeons involved in these cases need to be aware of the risks associated with urological injuries and the potential benefits of interventions such as preoperative ureteric stent placement. These findings highlight the importance of a multidisciplinary approach of obstetricians, gynecologists, and urologists in the management of placenta accreta.
Funding: None
Safety and Efficacy of Transobturator Adjustment‐Controlled Tape in the Treatment of Stress Urinary Incontinence at 5‐Year Follow‐up
Sergey Sukhikh1, Roman Stroganov1, Yuri Kupriyanov1, Gevorg Kasyan1, Dmitry Pushkar1
1Moscow state university of medicine and dentistry named after A.I. Evdokimov
Presented By: Sergey Sukhikh, PhD
Introduction: Currently, suburethral slings are the standard of surgical treatment for stress urinary incontinence in women, which is very efficient, but also has several possible postoperative complications. Long‐term performance of mid‐urethral slings are scarcely studied.
Methods: The mid‐urethral synthetic tape with tension control mechanism (MUS ‐ TC) was developed as a polyvinyldinfluoride tape with absorbable collagen 5mm thick damping layer at mid‐urethral part. A prospective randomized trial initiated in 2018 showed a high efficacy and safety profile of this device. In the analysis of the results one year after surgery, the efficiency of surgical treatment was 96%, the rate of postoperative complications, infravesical obstruction, was 2%, and the de novo urgency was 6%. In the present study we evaluated long‐term outcomes (more than 5 years) by means of a telephone survey and validated questionnaires (UDI‐6, IIQ‐7) among patients who underwent MUS – TC. The study registered in ClinicalTrials.gov No. NCT04101279.
Results: The average score on the UDI‐6 survey was 1,22 ± 0,81 and 1,2 ± 0,77 on the IIQ‐7 survey. There was a non‐significant increase of scores after 60 months compared to 12 months after surgery. When analyzing individual clinical cases after 60 months, 10 patients noted worsening of symptoms. Of them, 6 patients noted recurrence of urinary incontinence when coughing or exercising. Accordingly, the subjective efficacy of surgical treatment during the 5‐year follow‐up period was 88%.
Conclusions: The efficacy and safety data in the mid‐term follow‐up of patients after MUS – TC are comparable with the worldwide data. However, further long‐term follow‐up of the patients is required.
Funding: no
Surgical Techniques and Operative Management for Salvage Robotic Sacrocolpopexy: Pelvic Floor Prolapse Repair After Previous Failed Attempts
Genesis G. Dolgetta1, Tonya S. King1, Robert I. Carey2, Benjamin J. Behers3, Maximilian S. Carey1, Karim Ghazli2, Victoria Y. Bird4
1Sarasota Memorial Health Care System Research Institute, 2Sarasota Memorial Health Care System
3Florida State University School of Medicine, 4Urologic Integrated Care
Presented By: Genesis G. Dolgetta, BS
Introduction: Robotic sacrocolpopexy (RASCP) is a transabdominal approach for repair of pelvic organ prolapse (POP) that reliably provides durable repair of high grade prolapse. Although reoperation for recurrent prolapse after RASCP should be a rare event, the techniques and problems associated with robotic salvage in these cases is under reported.
Methods: Data was collected from an IRB‐approved prospectively maintained database of robotic POP repair in a tertiary care hospital. The surgery was performed with a da Vinci Si or Xi system with 4 robotic ports and 1 assistant port by a single surgeon. Commercially available 4 x 24 cm Y‐shaped wide pore polypropylene mesh was modified to accommodate the anterior and posterior dissections of the vaginal walls, and these were attached with running barbed suture with 16‐20 sites of fixation. The long Y‐arm of the mesh was trimmed to size for attachment to the anterior longitudinal ligament with GoreTex sutures. Posterior peritoneal flaps were created, and the entirety of the mesh and repair was completely covered by the peritoneum. No mesh or suture was left exposed. Mid‐urethral slings were placed at the time of salvage RASCP (sRASCP) to prevent de novo stress incontinence. All repairs restored maximal vaginal length and desired vaginal axis. All patients for RASCP had stage 4 prolapse. There were no conversions from robotic to open.
Results: Between 2010 and 2022, a total of 450 patients underwent RASCP at the same institution. 8 (1.8%) were done in the salvage setting with a previous attempt at open or RASCP performed and pre‐existing mesh inside the abdomen. On reoperation for these RASCP patients for the purpose of salvage, 8/8 (100%) were found to have no connectivity of the mesh to the anterior longitudinal ligament (ALL). 4/8 (50%) had no connectivity to either the anterior or posterior vaginal vault. Mean age at salvage operation was 69.5 years and mean BMI was 28.5. Cases were completed with robotic console time between 105 and 123 minutes.
Conclusions: sRASCP is a safe and durable surgery for repair of prolapse in the setting of a failed first attempt of RASCP with pre‐existing mesh. Every case achieved excellent repair of prolapse.The most common finding in these cases was non‐attachment of the mesh to the ALL.All patients required dissection of the ALL for appropriate mesh attachment. Pre‐existing mesh can be used to help in repair as long as there is an appropriate attachment to the vaginal vault.Pre‐existing mesh should be excised if there is no useful vaginal or ALL attachment.
Funding: None.
Long‐Term Outcomes from the REMEEX System® in Female Patients with Intrinsic Sphincteric Deficiency and Recurrent Urinary Incontinence: Data from Minimum of 14 Years of Follow‐up
Phil Hyun Song1, Yeong Uk Kim1, Jae Young Kim1, Tae‐Hwan Kim2, Hee Chang Jung1, Kyung‐Jin Oh3
1Department of Urology, College of Medicine, Yeungnam University, 2Department of Urology, School of Medicine, Kyungpook National University, 3Chonnam National University Hospital
Presented By: Phil Hyun Song, MD.PhD.
Introduction: This study was conducted to evaluate the outcomes of the REMEEX systemⓇ (EXternal MEchanical REgulation, Neomedic International, Terrassa (Barcelona), Spain) for treatment of intrinsic sphincteric deficiency (ISD) and recurrent urinary incontinence (UI) in female patients.
Methods: From August 2006 to January 2008, a total of 43 patients underwent the REMEEX systemⓇ. Patients were categorized into failed UI (Group A, 16 patients) and ISD (Group B, 27 patients). Of the 43 patients, 16 had previous incontinence surgical interventions, 9 had other pelvic surgeries, 10 either had spine surgery, diabetes mellitus, cerebrovascular accident, Parkinson's disease, spine fracture, herniated lumbar disc, mood disorder or so on. The success rate of patients after surgery was assessed by cure and satisfaction rates postoperatively at follow‐up at 1, 3 and 14 years. Clinical, urodynamic, peri and post‐operative data with respect to success rates were analyzed.
Results: The mean age of patients was 73.1 years (range 58‐81) and mean follow‐up period 148.4 months (range, 168‐186). Total cure rates with the REMEEX systemⓇ(Group A/Group B) were 100.0/76.2% at 1 year, 90.9/79.0% at 3 years, and 81.4/69.4% at 14 years follow‐up. Satisfaction rates were 83.4/71.5% at 1 year, 81.8/68.4%, and 75.4%/62.5% at 14 years follow‐up in group A and B. Four patients (10.8%) experienced wound infections. Of these, one patient was treated using intravenous antibiotics and the other had their varitensor removed. Other minimal postoperative complications were immediately resolved.
Conclusions: The REMEEX systemⓇ may be an effective procedure regardless of previous incontinence surgical interventions and ISD. The correct sling tension is easily achieved during the early postoperative period, and when necessary, is able to convert late failures into cures. The problems of recurrent UI during the follow‐up period were also resolved successfully in every case.
Funding: None
Surgical Techniques for Management of Complete Vaginal Vault Eversion by Robotic Pelvic Floor Repair with Uterus Preservation
Tonya S. King2, Genesis G. Dolgetta1, Robert I. Carey2, Benjamin J. Behers3, Maximilian S. Carey1, Karim Ghazli2, Victoria Y. Bird4
1Sarasota Memorial Health Care System Research Institute, 2Sarasota Memorial Health Care System
3Florida State University College of Medicine, 4Urologic Integrated Care
Presented By: Tonya S. King, PhD
Introduction: Robotic sacrocolpopexy with uterus preservation (RASCP‐UP) is a transabdominal approach for repair of pelvic organ prolapse (POP) that avoids placement of transvaginal mesh and preserves female sexual organs. Although hysterectomy may be performed at the time of POP repair, many women choose to preserve their uterus for reasons of sexuality, female identity, religion, maintenance of maximal vaginal length and undisturbed vaginal blood supply, and resistance to removal of a normal organ.
Methods: Data was collected from an IRB‐approved prospectively maintained database of robotic POP repair in a tertiary care hospital. The surgery was performed with a da Vinci Si or Xi system with 4 robotic ports and 1 assistant port. Commercially available 4 x 24 cm Y‐shaped wide pore polypropylene mesh was modified to accommodate > 10 cm anterior and posterior dissections of the vaginal walls. The anterior vaginal wall component was brought through the broad ligament and joined with the posteriorly placed component for attachment to the anterior longitudinal ligament with GoreTex sutures. The mesh was then completely covered by peritoneum. Mid‐urethral slings were placed at the time of sacrocolpopexy to prevent de novo stress incontinence. All patients for RASCP‐UP had stage 4 prolapse with maximal anterior, posterior, and apical descent with the cervix at the apex of the descent. All patients had normal Pap smears and pelvic ultrasounds.
Results: Between 2010 and 2022, a total of 450 patients underwent RASCP at the same institution. Of these, 65 presented with complete vaginal vault eversion requesting RASCP‐UP. Mean age was 65.9 years and mean BMI was 28.0. Cases were completed with robotic console time between 59 and 123 minutes and all patients were discharged within 24‐48 hours. At mean 78‐month (12 – 140 month) follow‐up, there were no mesh erosions, hernias, or reoperations for prolapse. There was one reoperation for a hysterectomy at 6‐year follow‐up for suspected endometrial carcinoma and two reoperations for small bowel obstruction in patients with extensive lysis of adhesions.
Conclusions: RASCP‐UP is feasible for patients with severe POP who desire uterus preservation. The surgery restores normal vaginal axis and length without placement of mesh material through vaginal mucosa. Long‐term results show durable functional repair. Women presenting with vaginal vault eversion and maximal descent of cervix can undergo repair of pelvic floor prolapse with concomitant hysterectomy.
Funding: None.
'Here is My Take.' A Survey on Perceived Efficacy of Pharmacological Agents, and Prescribing Preferences Among Clinicians for Management of Female Lower Urinary Tract Symptoms
Ijeoma Nnorom1, Francesca Kum1, Gordon Muir1
1King's College Hospital London
Presented By: Ijeoma Nnorom, MBBS, MRCS
Introduction: This study aims to compare the prescribing choices of medications for female lower urinary tract symptoms (LUTS) to self‐administration preferences of Urologists and associated practitioners across the globe. The medications included in the survey are recommended by international guidelines, and data on their properties including efficacy andside effect profile are largely drawn from trials. According to the European Association of Urology (EAU), one systematic review showed no statistically significant difference in effectiveness between Mirabegron and Solifenacin at relieving symptoms, though at one year follow up, symptom reduction lay in favour of Mirabegron. Also, some studies among anticholinergics reveal no significant difference in in efficacy between them, but conflicting reports on this have been obtained from yet other studies with equally high levels of evidence.There is a paucity of data regarding the physician's take on these medications against the backdrop of existing data on efficacy and side effect profile, as well as (guideline) recommendations for their use. The personal (self prescription) preferences discovered may throw some light on clinicians' approval of these medicines. We also wanted to assess the tendencies of our colleagues in other parts of the globe who may use a different set of guidelines and/or have a varying array of medications accessible to themin comparison to those commonly used in United Kingdom (UK) practice.
Methods: An electronic survey of Urologists and allied practitioners, practicing within the United Kingdom (UK) and globally was conducted. On a 10‐point Likert scale, respondents were asked 3 questions about these medications: ‘Likelihood of prescribing’; the ‘perceived efficacy’, and ‘the likelihood of the respondent taking them’.6 agents were considered‐ Duloxetine, Solifenacin, Fesoterodine, Oxybutinin‐ Immediate Release (IR), Oxybutininin Extended Release (ER), and Mirabegron.
Results: Of the 119 respondents, most were from the UK (83%). 81% were Urologists and 14% Urology trainees.Mirabegron was the most preferred prescription for patients with 30% being ‘Extremely likely’ to prescribe it, whereas half were ‘Extremely unlikely’ to offer Duloxetine (least preferred choice). Up to 81% of practitioners > / = the weighted average of 8 were happy to prescribe this to female patients. Next most preferred (for patients) was Solifenacin with nearly 2/3rds of practitioners favorably disposed.The most available medication (17 respondents) was Mirabegron and none of them said it was unavailable in their countries of practice while the hardest to come by was Fesoterodine in at least 57% of respondents' countries.In terms of efficacy, again, Mirabegron was a winner with relief of symptoms, followed closely by Solifenacin among 78% and 71% (> / = respective weighted averages) of respondents. Duloxetine was deemed to have the least efficacy (42% > / = 3). Among antimuscarinics, oxybutinin (IR) ranked lowest, and there was no perceived variation in efficacy between Fesoterodine and Oxybutinin (ER).Self prescribing patterns were largely similar to patient prescribing patterns. A slight variation was noted with Solifenacin and Mirabegron. These 2 remained the most preferred choice. Howbeitamong physicians, solifenacin would be the better option.Overall, Duloxetinewas the least preferred choice for patients, for self and was deemed the least effective at relieving symptoms.
Conclusions: The prescribing choices of Urologists for female LUTS management largely mirror their personal preferences, a contrast to findings in the male LUTS study. The results obtained from this study can drive future studies on the actual factors which dictate prescribing choices in various climes‐ side effect profile, cost and payment methods, demographics, prevalent local prescriptions and more. Furthermore, more robust studies may provide much needed information which could drive development of future medication and prescribing climates that enhance desirable characteristics and minimize unfavorable ones.
Funding: None (Self funded)
Evaluation of Factors Associated with Small Bowel Obstruction After Robotic Sacrocolpopexy
Tonya S. King1, Genesis G. Dolgetta1, Robert I. Carey2, Benjamin J. Behers3, Maximilian S. Carey1, Karim Ghazli2, Victoria Y. Bird4
1Sarasota Memorial Health Care System Research Institute, 2Sarasota Memorial Health Care System
3Florida State University College of Medicine, 4Urologic Integrated Care
Presented By: Tonya S. King, PhD
Introduction: Robotic sacrocolpopexy (RASCP) is a transabdominal approach for repair of pelvic organ prolapse (POP) that avoids placement of transvaginal mesh and provides durable repair of high‐grade prolapse. Given that the procedure has a trans‐peritoneal component, there is a risk of reoperation due to small bowel obstruction (SBO).
Methods: Data was collected from an IRB‐approved prospectively maintained database of RASCP in a tertiary care hospital. The surgery was performed with a da Vinci Si or Xi system with 4 robotic ports and 1 assistant port by a single surgeon.Commercially available 4 x 24 cm Y‐shaped wide pore polypropylene mesh was modified to accommodate the anterior and posterior dissections of the vaginal walls and were attached with running barbed suture with 16‐20 sites of fixation. The long Y‐arm of the mesh was trimmed to size for attachment to the anterior longitudinal ligament with GoreTex sutures. Posterior peritoneal flaps were created, and the entirety of the mesh and repair was completely covered by peritoneum. No mesh or suture was left exposed. Mid‐urethral slings were placed at the time of sacrocolpopexy to prevent de novo stress incontinence. All patients for RASCP had stage 4 prolapse. There were no conversions from robotic to open.
Results: Between 2010 and 2022, 450 patients underwent RASCP at the same institution. 80 (17.8%) involved extensive lysis of adhesions (ELOS) and 370 did not. At mean 78‐month (12–140 month) follow‐ up, there were 8 (1.8%) reoperations for SBO. 6/80 (7.5%) patients with ELOS had reoperations for SBO.Median age of SBO patients was 71.5 years vs 70.0 for non‐SBO. Median BMI was 22.5 for the SBO patients compared to 26.3 for non‐SBO.Robotic console time was between 59 and 123 min.Median procedure time for RASCP with MUS was 122 min for SBO patients and 124 for non‐SBO. All 8 reoperations for SBO had previous abdominal procedures. In ELOS patients the risk of SBO was 7.5% and in patients without ELOS, the risk was 0.5%.
Conclusions: RASCP is a safe and durable surgery for repair of POP. Risk of reoperation for SBO is associated with concomitant ELOS. In ELOS patients the risk of SBO is 7.5% and in patients without ELOS, the risk is 0.5%. Although many patients presenting for RASCP have had previous abdominal operations, not all such patients require ELOS. For patients with histories of numerous prior bowel or abdominal surgeries who are at increased risk for ELOS at the time of RASCP, careful patient selection is recommended, and appropriate preoperative counseling suggested.
Funding: None.
Effectiveness Evaluation and Safety of BULKAMID Trans‐Urethral Injection for Female Stress Urinary Incontinence
Tzach Aviv1, Amir Buchler, MD2, Jack Baniel1, Shachar Aharony1
1Institute of Urology, Rabin Medical Center ‐ Beilinson Hospital, 2Meir Medical Center Tel‐Aviv University
Presented By: Amir Buchler, MD
Introduction: Stress urinary incontinence (SUI) is a common complaint among women. While the current treatment of choice is a mid‐ureteral sling surgery, it still carries a high complication risk of 30%. Bulkamid, Polyacrylamide hydrogel, is a homogeneous non‐particle gel designed to treat SUI by improving the urethral coaptation mechanism.We aim to describe the effectiveness and safety of BULKAMID trans‐urethral injection for female SUI.
Methods: We conducted a retrospective study on female patients aged 18 and older who underwent BULKAMID trans‐urethral injection at our institution between 2018 and 2022. Demographic data, urodynamic characteristics, intraoperative details, and complications were collected and analyzed using statistical methods.
Results: A total of 27 female patients underwent the procedure. Their median age was 65 (IQR 49‐74), with a mean BMI of 25.5 ± 4.0. Of these patients, 44% had previous MUS procedures. All the operations were performed under sedation, with a mean procedure time of 11 minutes (range 8‐15) and an injection volume of 1.7 ± 0.5cc in 4 sites. The main complications reported were bleeding (1), urgency (2), injection site pain (1), and dyspnea (1). At one‐month follow‐up,73% of the patients reported improvement in symptoms, 36.3% showed no leakage in physical examination, and 38.1% reported subjective and objective improvement. Younger age (56 Vs. 74, p = 0.01) correlated with subjective improvement. Weight, previous MUS procedure, and injection volume were not significantly correlated with clinical outcomes. Seven (25.9%) patients received additional BULKAMID injection (TOP‐UP) as an ancillary procedure, with three patients reporting improvement. Four (14.8%) patients from the entire cohort had undergone other treatments for SUI.
Conclusions: Urethral BULKAMID injection is a safe and effective treatment for SUI. A larger cohort is needed to characterize this treatment's target population better.
Funding: None
MODERATED POSTER SESSION 21: BPH 3
Endoscopic Enucleation of the Prostate: Outcomes in Patients with Small Prostates (≤ 40 cc).
Vladislav Petov4, Alexander Androsov1, Andrey Morozov2, Dmitry Enikeev3
1Institute for clinical medicine, Sechenov University, 2Institute for Urology and Reproductive Health, Sechenov University, 3Department of Urology, Medical University of Vienna, Vienna, Austria, 4Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia
Presented By: Vladislav Petov, MD
Introduction: Current EAU and AUA guidelines suggest endoscopic enucleation of the prostate (EEP) for all the patients with BPH regardless of the prostate volume. However, in patients with small prostates (≤ 40 cc) EEP may associated with prolonged surgery duration compared to transurethral resection of the prostate. So, the reasonability for EEP in patients with prostates ≤40 cc is still discussed. The aim of our study is to evaluate efficacy and safety of EEP in patients with BPH ≤40 cc.
Methods: A retrospective single‐center study was conducted in the Institute for Urology and Reproductive health of Sechenov University between 2020‐2023 years. Inclusion criteria were as follows: preoperative prostatic volume ≤40 cc; IPSS ≥20 or Qmax < 15 ml/sec; the management of BPH was performed using Thulium fiber laser enucleation of the prostate (ThuFLEP). Exclusion criteria: previous surgical interventions for BPH management, no postsurgical follow‐up data.
Results: A total of 104 participants were enrolled in the study. The baseline stats were as follows: mean age – 65.9 ± 7.2 years, median prostatic volume – 39 (35;40) cc, mean PSA – 2.6 ± 1.7 ng/ml, mean Qmax – 9.8 ± 2.4 ml/sec, median PVR – 70 (60;90) ml, median IPSS – 23 (22;25), median QoL 4 (4;5). Median operation duration was 40 (34.75;60) min, median enucleation weight – 29.5 (27;32) g, catheterization time – 2 (1;2) days, hospital stay – 3 (3;4) days. Transient stress urinary incontinence was observed in 10 patients; injury of the ureteral orifice – in 1 patient (Clavien‐Dindo I); hyperthermia – 5; clot retention – in 8 patients (Clavien‐ Dindo II); acute urinary retention – in 6 patients; clot retention with subsequent surgical revision – in 1 patient (Clavien‐Dindo III). At 6‐months follow‐up all functional parameters significantly improved except PSA: PSA was 1.0 ± 0.3 (p > 0.05) ng/ml; prostatic volume to 15 (10;15) ml (p < 0.01); Qmax – 22.5 ± 2.5 ml/sec (p < 0.01); PVR – 10 (0;15) ml (p < 0.01) ml; IPSS – 5 (4;7) (p < 0.01); QoL 2 (1;2) (p < 0.01). Among late complications there were stress urinary incontinence in 2 patients and urethral stricture in 1 patient. 1 and 3 years after surgery median PVR was 0 (0;34) and 0 (0;33) ml, respectively; mean Qmax – 26.4 ± 5.4 and 21.5 ± 5.2 ml/sec, respectively; median IPSS 5 (3;7) and 3 (2;5), respectively; median QoL – 1 (1;2) and 1 (0;2), respectively.
Conclusions: The results of our study affirm that EEP is a size independent BPH management procedure and it should be considered as a viable optional for surgical treatment in patients with prostates ≤40 cc too.
Funding: None.
Three‐Lobe vs. Two‐Lobe HoLEP ‐ is there a Difference?
Sagi A. Shpitzer1, Gherman Creiderman1, Ron Gilad1, Michael Frumer1, Tzach Aviv1, Muhammad Krenawi1, Tomer Weizman1, Shayel Bercovich1, Nadav Dekel1, Hadar Tamir1, Tal Wax1, Tomer Hasdai1, Yossi Ventura1, Niv Segal1, Hen Hendel1, Liran Zieber1, Dmitry Enikeev2, Yaron Ehrlich1, Abd E. Darawsha1
1Rabin Medical Center, 2Medical University of Vienna
Presented By: Sagi A. Shpitzer, MD
Introduction: Holmium laser enucleation of the prostate (HoLEP) originally employed the three‐lobe technique (3LT). In recent years, modified approaches have been introduced including the two‐ lobe technique (2LT). There are few studies comparing the results between these techniques. The objective of our study was to compare the two techniques in order to elucidate possible advantages of either technique.
Methods: We retrospectively analyzed all HoLEP surgeries in our institution performed between 2016 and 2022 in patients with a median lobe identified intraoperatively. Clinical, demographic and surgical parameters were compared between patients who underwent HoLEP using the three‐lobe and the two‐lobe techniques.
Results: The study included 457 patients, 405 of which underwent HoLEP with 3LT and 52 with 2LT. Preoperatively, there were no differences between the groups in regards to age, BMI, prostate size or PSA. Operative time did not differ between 3LT and 2LT (118 vs. 116 minutes, p = 0.58). Catheter indwelling time and hospital stay were similar between groups, as were readmission rates.
Conclusions: In our cohort, no differences were found in surgical outcomes between the 3LT and 2LT. Surgeon preference and experience in any particular technique should be the deciding factor when selecting the surgical technique for HoLEP.
Funding: None
Intra‐Operative Loop Diuretics to Improve Same‐Day Discharge Rates After HoLEP: Interim Analysis of a Prospective Randomized Controlled Trial
Nicholas Dean1, Jenny Guo1, Perry Xu1, Alyssa Mcdonald1, Allaa Fadl‐Alla1, Amy Krambeck1
1Northwestern University
Presented By: Perry Xu, MD
Introduction: Loop diuretics have been given historically during morcellation to promote urine production post‐operatively and to minimize the impact of fluid absorption during long procedures. Despite the wide‐ spread use of furosemide, no prior study has examined the effects of this medication on post‐operative outcomes including same day discharge (SDD), same‐day trial of void (SDTOV), re‐admission rates, and TUR syndrome. We sought to compare outcomes of HoLEP with and without the use of an intra‐operative loop diuretic.
Methods: From January 2023 to May 2023, we prospectively randomized 86 patients undergoing HoLEP 1:1 to receive or not receive 20mg of IV furosemide during morcellation. The primary outcome was differences in SDD and SDTOV. Secondary outcomes included intra‐operative efficiencies, post‐operative clinical outcomes, and rates of adverse events.
Results: There was no difference in demographics and prostate features between patients randomized to furosemide (n = 38) versus controls (n = 48) (p > 0.05). Intra‐operative variables including procedure, enucleation, and morcellation time were not different between groups (all p > 0.05). Patients receiving furosemide were less likely to undergo SDTOV (81.6% vs 97.8%, p = 0.01). Rate of SDD (Furosemide: 80.0% versus Control: 69.4%, p = 0.279), mean length of stay (LOS) (Furosemide: 11.3 vs Control: 13.0 hours, p = 0.638), and mean length of catheterization (Furosemide: 0.8 versus Control: 0.4 days, p = 0.093) did not differ between groups. There was no significant difference in rates of adverse events including 30‐day complications, re‐admissions, or ED presentations (all p > 0.05) (Table 1). No patients in either group experienced post‐operative fluid overload or electrolyte abnormalities.
Conclusions: In this interim analysis, IV furosemide during HoLEP does not improve rates of SDD, SDTOV, LOS, length of catheterization, or adverse events.
Funding: None
Durability Predictors from Over 330 Controlled Subjects Across 5 Studies of the Prostatic Urethral Lift (PUL)
Barber Neil3, Claus Roehrborn1, Peter Chin2
1UT Southwestern, 2South Coast Urology, 3Frimley Health NHS Foundation Trust
Presented By: Barber Neil, FRCS (Urol)
Introduction: Consistent patient experience and symptom outcomes have been demonstrated in 330+ patients treated with PUL in controlled trial settings. In this analysis, we examine baseline and procedural variables underlying treatment durability.
Methods: PUL patients from five controlled studies were aggregated to create a logistic regression model. Subjects that did not undergo surgical retreatment for BPH (+/‐ remaining BPH‐medication free) at five years post‐PUL were defined as demonstrating ‘successful durability.’ The model incorporated covariates including age, prostate volume, BMI, race, medical history (e.g., diabetes, UTI, retention), proxies of BPH disease severity (IPSS, Qmax, QoL, PSA, PVR), and procedural characteristics (implants per prostate volume, total number of implants). Odds ratio estimates were reported for variables found to be significant.
Results: PUL was durable in most subjects at five years. More implants were placed as prostate volumes increased; 4.8 implants were placed on average (SD 1.6). No BPH surgical retreatment events were observed in patients who received 7 or more implants.5‐year durability: The five‐year surgical retreatment rate was 13.7%. Baseline incomplete bladder emptying (IPSS Q1) increased the likelihood of surgical retreatment. Return to medication or surgical retreatment were associated with high baseline dissatisfaction (high QoL score), more severe symptoms (high total IPSS), and high obstructive IPSS domains (Q1 incomplete emptying, Q3 intermittency, Q5 weak stream). Durability was not found to be influenced by baseline PSA, PVR, BMI, race, medical history, age, or Qmax.
Conclusions: More advanced baseline obstructive symptoms negatively affect 5‐year durability following treatment with PUL, suggesting that earlier intervention may secure better outcomes in patients with BPH‐ associated LUTS.
Funding: Support from Teleflex
Median and Lateral Lobe Obstruction Patients Treated with the Prostatic Urethral Lift (PUL) Experience Consistent Outcomes
Barber Neil3, Gregg Eure1, Daniel Rukstalis2
1Urology of Virginia, 2Carilion Clinic, 3Frimley Health NHS Foundation Trust
Presented By: Barber Neil, FRCS(Urol)
Introduction: The novel BPH6 endpoint assessed significant LUTS relief, low morbidity, and speed of recovery, and revealed that PUL was superior to TURP in sexual function preservation and rapid recovery. The endpoint was applied initially to lateral lobe (LL) obstruction patients; more recently, the treatment of obstructive median lobe (OML) patients has been advanced by UroLift device enhancements. This analysis evaluates the BPH6 responder rate in the expanding population of OML patients treated with PUL.
Methods: The BPH6 composite endpoint was applied to 45 subjects with OML from the MedLift study (single arm; PUL for OML) (Table 1). ‘Responders' attained each element at 12 months post‐treatment; responder rates were compared to prior LL obstruction subjects treated with TURP and PUL (BPH6 RCT). A logistic regression model was built using pooled satisfaction data for LL and OML patients treated with PUL to examine baseline, procedural, and dynamic variables affecting 12‐month post‐treatment satisfaction.
Results: BHP6 responder rates were consistent between OML (53%) and LL patients treated with PUL (Table 1). ≥80% of OML patients achieved at least 30% baseline symptom improvement and indicated a ‘very good’ quality of recovery. Superior quality of recovery and ejaculatory function preservation were observed in OML compared to TURP LL patients; high‐severity adverse events were observed in 14.3% of TURP LL patients and 0.0% of OML patients (p < 0.01). On 12‐month pooled satisfaction outcomes, 89.5% of PUL subjects rated their urinary symptoms ‘very much better’, ‘much better’, or ‘a little better.’ Responders were observed to have significantly better baseline Qmax scores (responder mean 8.1 ml/s; failure mean 6.1 ml/s; p = 0.02); satisfaction corresponded with continuous improvement in post‐treatment QoL, IPSS, MSHQ‐EjD and BPHII.
Conclusions: In a controlled setting, most OML patients experienced significant LUTS relief, low morbidity and rapid recovery post‐PUL. Patients with LL and OML demonstrate similar BPH6 responder rates and high patient satisfaction following treatment with PUL
Funding: Teleflex
The Prostatic Urethral Lift (PUL) in Patients with Acute Urinary Retention (AUR): Earlier Intervention Predicts Treatment Success
Barber Neil3, Oliver Kayes1, Mark Rochester2
1St James University Hospital, 2Norfolk and Norwich University Hospital, 3Frimley Health NHS Foundation Trust
Presented By: Barber Neil, FRCS(Urol)
Introduction: Patients in AUR represent a challenging subset of BPH‐LUTS patients who benefit from the rapid restoration of voiding. Treatment pathways for AUR patients may be accelerated without jeopardizing patient outcomes by shifting to day‐case procedures such as PUL with demonstrated efficacy in retention patients. Urologists may better gauge treatment response to PUL in AUR patients with appropriate selection criteria. This analysis examines AUR patient baseline and procedural variables underlying treatment success following treatment with PUL.
Methods: With success defined as no catheter or surgical retreatment at 12 months post PUL, a logistic regression model was built to evaluate factors predicting successful outcomes for patients in the PULSAR study (single arm PUL in AUR; n = 51) and retention patients from the real‐world registry (RWRr; n = 388). Covariates included prostate volume, age, medical history (catheterization duration), BPH disease severity proxies (IPSS, QoL, Qmax, PVR, PSA), and procedural details (procedure time, number of implants, voiding efficiency). Results were reported as odds ratio point estimates with chi‐squared tests quantifying statistical significance.
Results: 73% of PULSAR subjects treated with PUL were catheter‐ and surgery‐free at 12 months, and higher post‐operative voiding efficiency was associated with success. RWRr patients experienced slightly higher catheter‐free rates (80%) with lower baseline PSA and PVR, procedural age < 70, and shorter pre‐ procedure catheter duration. When PULSAR and RWRr groups were combined in logistic regression analysis, higher post‐operative voiding efficiency and age < 70 were associated with successful outcomes. No significant associations emerged on stepwise multivariate analysis (Table 1).
Conclusions: Advancing age, higher PSA and PVR at baseline, and longer pre‐procedure catheter duration were associated with poor outcomes in AUR patients treated with PUL. Post‐PUL voiding efficiencies may correspond with long‐term treatment response.
Funding: Teleflex
Robot Assisted Simple Prostatectomy versus Holmium Laser Enucleation of the Prostate in Very Large Prostates: A Matched Pair Analysis with 74 Patients
Jonas Herrmann1, Friedrich O Hartung1, Maren J Wenk1, Karl‐Friedrich Kowalewski1, Maurice S Michel1
1University Medical Centre Mannheim
Presented By: Jonas Herrmann, MD
Introduction: According to current guidelines, benign prostatic hyperplasia in big glands can be treated with open, minimally invasive, or endoscopic enucleation. Robot assisted simple prostatectomy (RASP) and endoscopic procedures such as holmium laser enucleation of the prostate (HoLEP) are becoming more popular due to their favourable risk profile as compared to open simple prostatectomy. In terms of perioperative outcomes and complications, it is uncertain which approach is best.
Methods: We examined the perioperative data of 37 RASP surgeries conducted by experienced robotic surgeons in our department between 2015 and 2021. From a prospective database of 537 HoLEP surgeries done in our department between 2021 and 2023, we were able to match 37 patients. Prostate volume, age at surgery, and body mass index (BMI) were the matching criteria. Perioperative data such as OR time, catheter time, hospital stay, transfusion rate, and hemoglobin decline were analysed. Complication rates at 30 days were documented and graded using the Clavien‐Dindo‐Classification (CDC) and the Comprehensive Complication Index (CCI).
Results: Patients' characteristics were comparable between groups, with a similar mean prostate volume of 191 cm3 in RASP vs. 189 cm3 in HoLEP, a similar age at surgery (70.2 vs. 71.4 years), and a similar BMI (29.2 vs. 29.7). Operation time was significantly shorter in HoLEP (105vs. 156minutes, p < 0.001).
Hemoglobin decrease was significantly lower in HoLEP (1.36 vs. 1.90 g/dl p = 0.005), as was catheter time (2 vs. 5 days, p < 0.001) and hospital stay (4 vs. 7 days, p < 0.001). Transfusion rate was 8.1% in RASP and 0% in HoLEP. Overall complications occurred in 32% of RASP and in 10% of HoLEP procedures, the majority of which were minor. Major complications > CDC 3a occurred after two RASP cases and two HoLEP cases. CCI was significantly lower in HoLEP (p = 0.041)
Conclusions: In this population, HoLEP outperformed RASP, with significantly lower hemoglobin decline, shorter OR‐time, shorter catheter time, shorter hospital stay, and significantly less postoperative complications. Both treatments, however, are generally safe and effective in treating prostatic hyperplasia in extremely big glands.
Funding: No funding was received.
HoLEP Preoperative Continence Status Alters Short Term Postoperative Symptom Recovery But Not Long Term Recovery
Timothy Campbell1, David Song1, Karen Doersch1, Laena Hines1, Jodi Erler1, Hadley Lamascus1, Rajat Jain1, Scott Quarrier1
1University of Rochester School of Medicine and Dentistry
Presented By: Timothy Campbell, MD
Introduction: It is uncertain how preoperative continence status informs voiding symptoms post‐HoLEP. This study aims to describe the difference between these cohorts' voiding symptoms using the International Prostate Symptom Score (IPSS) and the Michigan Incontinence Symptom Index (M‐ISI) over the year following HoLEP.
Methods: In this single‐institution retrospective review of HoLEP patients between 11/6/2020 and 5/17/2023, participants were preoperatively classified as “continent” or “incontinent” based on participant report. Participants completed the IPSS and the M‐ISI prior to HoLEP and then at one week (1w), one month (1m), three months (3m), and one year (1y) post‐HoLEP. Two‐sample t‐Tests with a Benjamini‐Hochberg correction for false discovery were used to determine statistical significance.
Results: Pre‐HoLEP 146 participants were continent and 61 were incontinent. Among continent and incontinent patients, average age at HoLEP was 70.1 and 72.0 (p = 0.120), average preop prostate size was 109.4 g and 116.6 g (p = 0.295).Pre‐HoLEP, continent patients had total IPSS scores similar to incontinent patients 17.5 vs 19.6 (p = 0.212). At 1w, those continent pre‐HoLEP had significantly lower total IPSS scores compared with those incontinent pre‐HoLEP (11.0 vs 16.4 p = 0.039). Over 1 year of follow‐up IPSS total scores continued to improve in all participants. Over this year the cohorts demonstrated progressive clinical and statistical similarity.Pre‐HoLEP M‐ISI severity and bother scores were significantly different between cohorts. At 1‐week post‐HoLEP, both groups reported worsening of incontinence symptoms. At 3‐months through one year post‐HoLEP, M‐ISI Bother scores demonstrated improved voiding symptoms in both groups.
Conclusions: Patients who were continent pre‐HoLEP demonstrate significantly improved voiding symptoms at the 1wk time point compared with the more modest improvement seen by patients incontinent pre‐HoLEP.Both groups reported short term worsening incontinence. These findings can potentially improve preop counseling with patients considering HoLEP.
Funding: N/A
Microwave Transurethral Thermodilatation (TUTD) Prostatic Ablation: 42‐Month Asian Experience in 35 Consecutive Patients with Symptomatic Benign Prostatic Hyperplasia
Wai Man Patrick Chow1
1UMP Medical Services
Presented By: Wai Man Patrick CHOW, MB BCh FRCS(Glasg) FRCS(Urol) FCSHK FHKAM(Surgery
Introduction: Microwave Transurethral ThermoDilatation (TUTD) offers a unique 45‐minute, ambulatory outpatient procedure that is well tolerated under local anaesthesia for patients with symptomatic benign prostatic hyperplasia (BPH), by using simultaneous focused microwave heating and pressurized balloon dilatation therapy. About 95% of patient do not require a post‐treatment Foley catheter. They experience significant and immediate relief of their lower urinary tract symptoms (LUTS). We present our 42‐ monthfollow‐up clinical data on 35Asian patients clinical to demonstratethe clinical safety and efficacy of TUTD..
Methods: From August 2018 to December 2019, 35 patients (Age 54‐79, mean 62) with LUTS were treated under urethral Instilagel local anaesthesia with the TUTD device, PROLIEVE. ( Medifocus inc.). Their initial International Prostate Symptom Scores IPSS(17‐35, median 24), Quality of Life score QOL (4‐6, median 5), Protate Specific Antigen PSA (0.57‐7.7, mean 3.5), prostatic volumes (35‐84cc, mean 54cc), Qmax (1.7‐10.5 ml/s, mean 7.5ml/s) and Post Micturitional Residual Volume PMRV (50‐330ml, mean 190ml) were recorded pre‐treatment. The parameters were reassessed at 6 weeks, 3‐, and 6‐months post‐treatment. Further follow up with telephone review of IPSS and QOL scores were carried out at subsequent 6‐monthintervalswith the final follow up assessemnt for the last patient carried out in June 2023.
Results: IPSS: 2‐23 (median 12) at 6 weeks; 2‐22(median10) at 3 months; 2‐18 (median 9) at 6 months;2‐15 (median 7) at 42 months.QOL: 2‐3(median 2) at 6 weeks; 2‐3 (median 2) at 3 months;2‐3 (median 2) at 6 months; 2‐3 (median 2) at 42months.Qmax: 3.6‐14.9ml/s (mean 10ml/s) at 6 weeks; 6.8‐17.5ml/s (mean 13.2ml/s) at 3months, 12‐17.5 ml/s ( mean 15ml/s) at 6 months).PMRV: 0‐33ml (mean 8ml) at 6 weeks, and 0‐45ml (mean 20ml) at 3months; 5‐50 ml/s (mean 20ml/s) at 6 monthsUrological complications e.g., clot retention and sepsis were not observed. One patient required temporary post‐treatment Foley catheterization for 72 hours. Treatment related retrograde ejaculation or erectile dysfunction has not been reported. The procedure was well tolerated under local anaesthesia. Both voiding and storage symptoms improved.
Conclusions: Our 42 monthsexperience with TUTD in 35Asian patients compares favourably to the clinical outcomes and efficacy of the Caucasian cohort in the USFDA 5‐year follow‐up post‐approval study. We observed lasting post‐treatment improvements after 3.5 years in IPSS, QOL, Qmax and PMRV. We conclude that TUTD is safe and efficacious in the Asian population and should be offered as an option in the treatment of symptomatic Benign Prostatic Hyperplasia.. Long‐term prospective data collection in a larger patient population remains in progress.
Funding: None
Holmium Laser Enucleation of the Prostate After Previous Surgical Treatment for Benign Prostatic Hyperplasia
Tomer Weizman1, Shayel Bercovich1, Yossi Ventura1, Hen Hendel1, Liran Zieber1, Niv Segal1, Hadar Tamir1, Tzach Aviv1, Michael Frumer1, Sagi Arieh Shpitzer1, Nadav Dekel1, Tomer Hasdai1, David Lifshitz1, Muhammad Krenawi1, Ron Gilad1, Abd Elhalim Darawsha1, Yaron Ehrlich1, Gherman Creiderman1
1Rabin Medical Center
Presented By: Yossi Ventura, MD
Introduction: In the past, holmium laser enucleation of the prostate (HoLEP) in the retreatment setting was considered an anatomically challenging procedure with an increased chance of perioperative complications. With the population aging and the enucleation technique gaining more popularity, the number of patients undergoing HoLEP for benign prostatic hyperplasia (BPH) recurrence is increasing worldwide.In this study, we compared patients treated with primary HoLEP with those who had previous BPH surgery.
Methods: We retrospectively assessed data of patients who underwent HoLEP from July 2016 to September 2022 in our institution. Patients were divided into the retreatment group (group 1) and the primary group (group 2). All the procedures were performed by senior urologists at different stages of the learning curve.
Results: A total of 16 patients in Group 1 were compared to 688 patients in Group 2.In group 1, 13 patients had previous transurethral resection/incision of the prostate (TURP/TUIP), and 3 patients underwent open simple prostatectomy. Average time until retreatment was 16.7 years.Patients in group 1 were older (74.5 ± 7.18 years vs 71.52 ± 7.88 years) and had larger glands (122.9 ± 40.3 cc vs 111.±37.5 cc). Operative time in group 1 was 121 ± 27.6 min vs 115.2 ± 36.2 min in group 2. The mean weight of enucleated tissue was 97.18 ± 36.7 g vs 85.85 ± 41.9 g in groups 1 and 2 respectively. There was no significant difference in intra‐ and perioperative complications, postoperative catheterization time, and hospital stay.
Conclusions: HoLEP in the retreatment setting is a safe and feasible procedure. It is similar to primary HoLEP in terms of operative time, technique, perioperative complication rates, and outcomes.
Funding: none
Does Sheath Size Matter: Benchtop Comparison of Flow and Pressure Across Variety of Continuous Flow Endoscopes
Vishnuvardhan Ganesan1, Michael Borofsky1, Deepak Agarwal1
1University of Minnesota
Presented By: Vishnuvardhan Ganesan, MD
Introduction: Laser enucleation utilizes purpose‐built endoscopes for laser stabilization and continuous flow. No evaluation has been done with respect to flow or intravesical pressure with these scopes. We sought to evaluate the effect different endoscopes and sheath sizes on irrigation outflow and intravesical pressure.
Methods: Using a benchtop model using a silicone bladder model, five outer/inner sheath combinations were assessed: Storz 28/26Fr, Storz 26/26Fr, Wolf 26/24Fr, Wolf 26/22Fr, and Wolf 24/22Fr. A urodynamics pressure transducer was inserted alongside the scope for bladder pressure measurement and outflow from scope to drain was measured using uroflowmetry device. Four 1‐minute trials were recorded for each sheath and the steady state flow and pressure was recorded.
Results: The Storz 28F outer sheath and 26F inner sheath had the highest outflow (12.4 ± 0.5 mL/s, p < 0.01). The Wolf 24F outer and 22F inner had the lowest outflow (7.0 ± 0.0 mL/s, p < 0.01), Figure 1a. The steady state bladder pressure was the lowest in the Storz 28/26 (1.5 ± 1.7 cm H2O, p < 0.01)) and the greatest in the Storz 26/26 (24.2 ± 1.9 cm H2O, p < 0.01), Figure 1b
Conclusions: The Storz 28/26 combination had best outflow rate and lowest intravesical pressures in our benchtop study. Flow rates generally decreased with smaller sheath sizes and steady state bladder pressures increased as the difference between the outflow and inflow sheath size narrowed. These findings provide initial parameters that could guide sheath selection in future to optimize visualization and success of voiding trials.
Funding: None
Outcome of Holmium Laser Enucleation of the Prostate (HoLEP) in Very Large Prostates >150
Amir Zarror3, Ehud Gnessin1, Guy Verhovsky2, Mohammad Abed Elal2, Itay Sabler2, Amnon Zisman2
1Shamir Medical Center and Assuta Hospital, 2Shamir Medical Center, 3Department of Urology, Shamir Medical Center, Israel
Presented By: Amir Zarror, MD
Introduction: HoLEP is suitable for prostates of any size and is known to be safe and effective even in particularly large prostates. Other surgical approaches to large prostates are accompanied by significant bleeding, long catheter indwelling time and prolonged hospitalization. The aim of this study was to examine the results of HoLEP in very large prostates.
Methods: We retrospectively reviewed all HoLEP surgeries in two major medical centers by a single surgeon (EG). Our cohort consisted of all patients with prostates larger than or equal to 150ml. We reviewed the postoperative results within the follow‐up period.
Results: Out of 912 consecutive HoLEPs performed between January 2020 and March 2023, we identified 227 (24.8%) with prostate volume over 150ml (according to: US 57%, MRI 26%, CT 14%, TRUS 3%). Average prostate size prior to surgery was 192 ml (range 150‐395 cc). 72/227 patients (31.7%) had indwelling foley prior to surgery. Mean PSA before surgery was 9.4, IPSS was 22 and maximum flow rate 8.1 ml/s. Mean enucleation time was 62 minutes (range 29‐165), mean morcellation time 23 minutes (range 9‐100 minutes). There were no intraoperative complications. One patient was taken to revision from recovery due to hematuria, and one for forgotten prostate piece. All patients were successfully weaned from the catheter after surgery. No patient required a blood transfusion. With mean follow‐up of 7.5 months IPSS decreased to 7.95 (63% decrease), PSA to 1.12 (88% decrease). New urinary incontinence after surgery was reported by 4 (1.76%) patients. 208 patients (92%) were discharged after 24 hours of hospitalization without a catheter.
Conclusions: HoLEP surgery in skilled hands enables short hospitalization with few complications and with excellent results even in very large prostates.
Funding: none
Efficacy of Holmium Laser Enucleation of the Prostate (HoLEP) in the Management of Acute and Chronic Urinary Retention: A Retrospective Study
Husain Alaradi1, Parsa Nikoufar1, Amr Hodhod1, Moustafa Fathy1, Sai K Vangala1, Ahmed S. Zakaria1, Ruba Abdul Hadi1, Vahid Mehrnoush1, Loay Abbas1, Waleed Shabana1, Owen Prowse1, Ahmed Kotb1, Walid Shahrour1, Hazem Elmansy1
1Northern Ontario School of Medicine
Presented By: Sai Vangala, MD
Introduction: The objective of our study was to evaluate the efficacy and durability of holmium laser enucleation of the prostate (HoLEP) for the management of acute urinary retention (AUR), neurogenic chronic urinary retention (NCUR), and non‐neurogenic chronic urinary retention (NNCUR) and to determine outcomes compared to patients without preoperative urinary retention.
Methods: We conducted a retrospective study of prospectively collected data from individuals who underwent HoLEP at our institution from October 2017 to July 2022. Patient demographics and outcome measures were recorded, including indications for the procedure, median urinary volume drained or median post‐void residual urine volume (PVR) before catheterization or HoLEP. Chronic urinary retention (CUR) was defined as PVR > 300 mL in males able to void and initial catheter drainage > 1,000 mL in males unable to void, in the absence of pain. NCUR and NNCUR were differentiated based on the presence of any significant illness or injury with a neurological impact on the bladder. All patients had postoperative follow‐ up visits at 1, 3, 6, and 12 months. Our evaluation included the International Prostate Symptom Score (IPSS), quality‐of‐life (QoL) assessment, maximum urinary flow rate (Qmax), PVR, and catheter‐free status.
Results: Three hundred sixty‐eight males who underwent HoLEP were included in our study. The urinary retention (UR) group consisted of 189 patients (70 AUR, 42 NCUR, and 77 NNCUR), and the lower urinary tract symptoms (LUTS) group was comprised of 179 individuals. There were no statistically significant differences between the NCUR and NNCUR subgroups regarding demographics and outcomes. At 12 months follow‐up, the AUR group had a higher catheter‐free rate than the CUR group (p = 0.04) and other outcome variables were comparable between the two cohorts. The UR group had a significantly lower QoL score at 1 month (p = 0.01) and a significantly lower IPSS score at 1 and 12 months (p = 0.034 and 0.018, respectively) compared to the LUTS cohort. During all follow‐up visits, the UR group had a significantly higher PVR than the LUTS cohort. The successful first trial of void (TOV) rate for the UR and LUTS groups was 81% and 83.2%, respectively. At 12 months postoperative, the catheter‐free rate for the UR and LUTS cohorts was 96.3% and 99.4%, respectively.
Conclusions: HoLEP is an effective and durable treatment for urinary retention with a high catheter‐free rate and comparable outcomes when performed to manage LUTS.
Funding: None
Holmium Laser Enucleation of the Prostate for Prostate Larger than 100 Grams– A Single Tertiary Care Centre Experience
Introduction: Benign prostatic enlargement is a common clinical condition seen among aging men. It results in Lower Urinary Tract Symptoms (LUTS) and reduced quality of life. In recent years, Holmium Laser Enucleation of the Prostate (HoLEP) has come to the forefront as one of the most preferred surgical treatments, particularly for larger glands. Ourobjective was to analyse the patient profile and comorbidities, pre‐operative investigations, intra‐operative findings, post‐operative complications and outcomes of patients who had HoLEP for prostates weighing > 100 grams.
Methods: The data of all patients who underwent HoLEP from 2011‐2020 was retrospectively collected, after authorised audit registration and approval. Patients with prostates of, either ultrasound (USS) estimated volume of > 100 cc or enucleated tissue weight of > 100 g were included for final analysis. Various parameters including demographic profile, presenting symptoms, indication for surgery, intra‐operative findings, duration of hospital stay,complications and outcomes on follow upwere assessed.
Results: A total of 946 patients underwent HoLEP from January 2011 to December 2020. Among them, 202 patients had Ultrasound prostate volume of > 100 cc or enucleated tissue weight of > 100 g. The mean age of the included patient population was 73 years (52‐89). The most common indication for surgery was refractory retention, reported in 50% of the cases, followed by bothersome LUTS (29%) and high‐pressure chronic retention (21%). The serum creatinine ranged from 45‐1092 μmol/L and serum PSA ranged from 0.3 – 54 ng/ml. The mean prostate size was 150 g (100 – 584) with > 200 g in 15% of the cases.A majority (75%) of the patients had complete (trilobar) prostate enucleation with the rest having bilobar enucleation. The mean hospital stay was 1.3 days (1‐11 days) and only 6% of the patients had > 3 days ofhospital stay.Transient stress urinary incontinence was the most common complication notedin 19.8% of these patients. Other complications that were reported included retained prostate chips (2.4%), infection (1.2%), urethral stricture (2.4%), persistent LUTS (6.4 %) and haematuria (6.4%). One patient had complete incontinence on follow up requiring artificial urinary sphincter placement.
Conclusions: HoLEP is an efficient and safe procedure, resulting in improved functional outcomes, low morbidity, and few perioperative complications, even among a cohort of men with verylarge prostates.
Funding: None
Water Vapor Thermal Therapy: Technical Differences Among University Hospitals and Efficacy After 2 Years of Follow‐up
Alejandra Bravo Balado9, Silvia García Barreras1, Maurizio D'anna2, Victor Parejo3, Ignacio Torneo Ruiz4, Ana Cristina Tagalos Muñoz5, Alejandra Bravo‐Balado6, Lluís Peri7, Mario Domínguez Esteban8, Ester Fernández Guzmán8
1Hospital Ramon y Cajal, 2Hospital Clínic de Barcelona., 3Hospital de Girona Dr. Josep Trueta., 4Hospital Virgen de la Arrixaca, 5Hospital Ramon y Cajal., 6Fundació Puigvert, 7Hospital Clínic de Barcelona, 8Hospital Universitario Marqués de Valdecillas, 9Fudació Puigvert
Presented By: Alejandra Bravo Balado, MD
Introduction: This study was aimed to learning about the initial experience with water vapor thermal therapy (WVTT) for benign prostatic hyperplasia in Spanish university hospitals, and to describe the differences between technique and follow‐up observed among centres.
Methods: This multicentric retrospective observational study collected data on baseline characteristics, surgical and postoperative data, and follow‐up data at 1, 3, 6, 12, and 24 months, including validated questionnaires, uroflowmetric variations, complications, and the need for pharmacological or surgical retreatment after the procedure. The study also analyzed the possible triggers of acute urinary retention (AUR).
Results: A total of 105 patients from 6 university public hospitals were included. There were no differences found between the groups with and without AUR regarding time to bladder catheter (BC) removal (5 and 4.3 days respectively, p = 0.178), or prostatic volume (47.9 and 41.4 gr respectively, p = 0.266). The mean improvement at 3, 6, 12, and 24 months regarding maximum flow rate was 5.3, 5.2, 4.2 and 3.8 ml/s, respectively. When it comes to ejaculation, an improvement was observed at 3 months,and it was maintained at 24 months of follow‐up.Regarding variations among hospitals, the median time to BC removal, prostate volume, and number of injections for each hospital varied from 3.2 to 7 days, from 24.5 to 47 cc, and from 4 and 6 injections, respectively. Out of the 6 hospitals, 3 used an antibiotic prophylaxis scheme of 4 or 5 days, while the other 3 hospitals used no prophylaxis or only 1 day.
Conclusions: Minimally invasive treatment for BPH with WVTT has good functional outcomes at 24 months of follow‐up, doesn't significantly affecting sexual function and has a low incidence of complications. Small variations between the participating hospitals exist mainly concerning the immediate postoperative period.
Funding: None
Safety and Efficacy of Tamsulosin 0.4 mg as An Initial Dose in 1,219 Korean Patients with Moderate to Severe LUTS: A Phase IV Study
Jun Ho Lee3, Dong‐Gi Lee1, Gyeoing Eun Min1, Hyung‐Lae Lee1, Kyung Jin Chung2
1Department of Urology, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, 2Department of Urology, Gachon University Medical Center, Gachon University School of Medicine, 3Department of Urology, Nowon Eulji Medical Center, Eulji University
Presented By: Jun Ho Lee, MD,PhD
Introduction: An initial dose of 0.2 mg is recommended for Asian men. We investigated the safety and efficacy of tamsulosin 0.4 mg as the initial dose in Korean men with moderate to severe lower LUTS in everyday clinical practice.
Methods: A phase IV study was conducted in South Korea. Eligible patients were prescribed tamsulosin 0.4 mg for 6 months. We excluded patients with previous exposure to LUTS drugs and patients with an international prostate symptom score (IPSS) < 8.
Results: The mean total IPSS, storage subscore, voiding symptoms subscore, and QoL significantly decreased from 18.0, 10.8, 7.2 and 3.8 to 12.8, 7.5, 5.3, and 2.6, respectively, after 6 months of treatment. The number of nocturia episodes significantly decreased from 3.0 to 2.2 in patients who reported at least 2 nocturia events at baseline. A mean reduction in the IPSS was quantitatively equivalent in all age groups. The mean reduction in the IPSS was greater in the IPSS ≥20 group than in the IPSS < 20 group (mean reduction in the total IPSS: ‐2.6 in the IPSS < 20 group; ‐9.4 in the IPSS ≥20 group). All Treatment‐emergent adverse events (TEAEs) were mild. The most frequently recorded TEAE was dizziness, which was reported in 22 patients (1.8%).
Conclusions: Treatment of LUTS with tamsulosin 0.4 mg as the initial dose for 6 months in Korean men was effective in improving LUTS and showed a favorable safety profile in a real‐life setting.
Funding: None
Utilization of Holmium Laser Enucleation of the Prostate in United States Academic Centers
Eric Kurzrock1, Gabriela Gonzalez1
1UC Davis School of Medicine
Presented By: Eric Kurzrock, MD
Introduction: With improved outcomes in hemostasis, urinary symptoms, and complication rates, holmium laser enucleation of the prostate (HoLEP) utilization has been increasing. This study sought to evaluate the adoption of HoLEP and thulium laser enucleation of the prostate (ThuLEP) and associated patient characteristics.
Methods: The population data was obtained from the Association of American Medical Colleges (AAMC) ‐ Vizient Clinical Practice Solutions Center®(CPSC), used with permission of Vizient, Inc. All rights reserved. CPSC is a partnership between Vizient and the AAMC. The database was queried to identify patients with benign prostatic hyperplasia (BPH) treated surgically from October 2021 through September 2022. Men 40 years or older who had procedural intervention for BPH based upon ICD‐10 and CPT codesspecific to HoLEP, ThuLEP, transurethral resection of the prostate (TURP), laser vaporization, lasercoagulation, transurethral incision, microwave thermotherapy, radiofrequency thermotherapy, water vapor thermotherapy and prostatic urethral lift surgeries. HoLEP and ThuLEP interventions were combined and termed HoLEP. Men with a diagnosis of prostate cancer were excluded. Patient characteristics were analyzed with a mixed effects logistic regression model, including age by decade, race, insurance, and social deprivation index (SDI).
Results: The analysis included data from 64 academic centers and 12,670 patients who underwent surgery.TURP was performed most (40.0%) compared to HoLEP (24.4%), prostatic urethral lift (10.6%), vaporization (12.2%), Rezum (8.3%), and simple prostatectomy (3.2%). Every decade in age over 50 had significantly higher odds of HoLEP compared to 40‐49 year olds (OR ranging from 4 to 9).Hispanic subjects had significantly higher odds of HoLEP than White/Caucasian subjects, although raw usage rates were comparable (28.9% vs. 27%).There was no significant association between insurance and the utilization of HoLEP compared to other procedures. There was no significant association between SDI and HoLEP utilization except between patients with the highest deprivation index had 0.67 OR(0.486, 0.914; P = 0.01) of HoLEP compared to lowest SDI.
Conclusions: Older age and lower social deprivation were associated with a higher utilization of HoLEP. It is unknown whether these differences are due to patient preferences or counseling.
Funding: None
Perioperative Outcomes in Patients Undergoing Holmium Laser Enucleation of the Prostate (HoLEP) with and Without Diabetes Mellitus
Jenny Guo1, Nicholas Dean1, Jordan Rich1, Jessica Helon1, Amy Krambeck1
1Northwestern University
Presented By: Jenny Guo, MD
Introduction: Diabetes mellitus (DM) is a known risk factor in the perioperative setting for poor wound healing and postoperative complications. In this study, we compare surgical outcomes post‐HoLEP in patients with and without DM.
Methods: From January 2021 to April 2022, we collected a prospectively maintained database of 640 patients undergoing HoLEP. Patients with a history of neurologic diseases, radiation, radical prostatectomy after HoLEP, intra‐vesical BCG or chemotherapy were excluded from the control group. A total of 117 patients were identified as diabetics and 414 as non‐diabetics. DM patients were further categorized based on A1c levels and insulin dependence. Statistical analysis was performed using t‐tests, Chi‐squared, and binomial tests (p < 0.05).
Results: Diabetic patients were significantly more likely to have indwelling catheters prior to undergoing HoLEP (60% vs 38%, p = 0.002), history of UTIs pre‐op (28% vs 18%, p = 0.04), and ASA 3 or greater (72.8% vs 46.3%, p < 0.001). Post‐operatively, DM patients were more likely to be admitted rather than discharged same‐day (21% vs 8.5%, p < 0.001) and fail initial trial of void (15% vs 7.8%, p = 0.026). Within 3 months' follow‐up, DM patients had higher rates of complications of any kind (24% vs 12%, p = 0.003) and higher rates of UTIs (12% vs 2.8%, p < 0.001). HoLEP decreased the proportion of DM patients with at least 1 UTI pre vs post‐op (21% to 12%, p = 0.05). At time of last mean follow‐up (4.1 mos), 3/117 (3.2%) patients in the DM group required foley/CIC at 90 days compared to none in the non‐DM group (p = 0.01). Two of the 3 patients requiring catheterization had evidence of neurogenic bladder. Post‐op IPSS scores were similar between both groups (7.5 vs 7.8, p = 0.7). There were no differences in Michigan Incontinence Symptom Index (M‐ISI) severity/bother scores post‐op between DM and non‐DM groups (Severity: 7.48 vs 5.7, p = 0.13; Bother: 1.9 vs 1.5, p = 0.8). DM patients showed significant improvements in IPSS scores from 26 to 7.5 (p < 0.001). When stratified based on A1c levels and insulin dependence, no correlation was noted between increased A1c or insulin use and post‐op UTIs, IPSS or M‐ISI scores.
Conclusions: Diabetic patients appear to have similar IPSS and M‐ISI scores to non‐diabetics but have higher rates of post‐op complications, UTIs and need for catheterization. HoLEP is effective in reducing the need for catheterization and proportion of UTIs in diabetics. A1c levels and insulin dependence do not affect surgical outcomes.
Funding: none
Effect of Diuretic Use in Holmium Laser Enucleation of the Prostate (HoLEP) Outcomes
Jenny Guo1, Nicholas Dean1, Jordan Rich1, Noah Frydenlund1, Jessica Helon1, Amy Krambeck1
1Northwestern University
Presented By: Jenny Guo, MD
Introduction: Diuretic use has been shown in prior studies to be associated with worsened lower urinary tract symptoms (LUTS). The primary objective of this study was to compare International Prostate Symptom Scores (IPSS) in HoLEP patients on and off diuretics.
Methods: We identified patients currently prescribed diuretics amongst a single‐surgeon prospectively maintained database of 640 patients undergoing HoLEP from January 2021 to April 2022. Sub‐group analysis was performed for the following diuretic categories: loop (L), potassium‐sparing (PS), thiazide (T), and more than 1 diuretic (M). We excluded patients with history of neurologic diseases, radiation, radical prostatectomy after HoLEP, intra‐vesical BCG or chemotherapy from the control group. Statistical analysis was performed using t‐tests, Chi‐squared, and binomial tests (p < 0.05).
Results: A total of 182 patients were noted to be currently taking diuretics: L (43), PS (10), T (116), M (12), other (1). Diuretic patients were more likely to have indwelling catheters pre‐op (50% v vs 37%, p = 0.045). Patients on diuretics were more likely to require admission post‐HoLEP (20% vs 6.6%, p < 0.001) and experience an episode of post‐operative acute urinary retention (15% vs 7.3%, p = 0.01). Diuretic patients had significantly higher 90‐day complication rates of any kind (23% vs 12%, p = 0.002) but no differences in UTI rates (p = 0.3). In addition, patients on diuretics were more likely to be prescribed anticholinergics or mirabegron (32% vs 20%, p = 0.01) and pelvic floor physical therapy post‐op (37% vs 16%, p = 0.02). Diuretic patients showed decreases in IPSS scores pre vs post‐op (23.7 vs 8.6, p < 0.001) as well as in Michigan Incontinence Symptom Index (M‐ISI) bother scores (1.8 vs 1.2, p = 0.07) and M‐ISI severity scores (7.5 vs 6.7, p = 0.3). However, diuretic patients had significantly higher IPSS scores post‐op compared to non‐diuretic patients (8.6 vs 7.2, p = 0.02). Post‐op M‐ISI scores were similar in both groups. On sub‐group analysis, although not statistically significant, patients on more than 1 diuretic had higher IPSS scores post‐op compared to other diuretic types (9.2 (M) vs 8.3 (L) vs 8.3 (PS) vs 8.8 (T), p = 0.9).
Conclusions: HoLEP patients on diuretics show significant improvements in IPSS scores pre vs post‐ operatively. However, post‐op IPSS scores and complication rates remain higher than in non‐diuretic patients.
Funding: none
Are there Different Results in Different Sizes? HoLEP as a Size‐Independent Treatment for Enlarged Prostate
Joao Porto1, Ruben Blachman‐Braun1, Carlos Delgado2, Mohamad Zarli3, Ryan Chen1, Tarek Ajami1, Hemendra Shah1
1Desai Sethi Urology Institute, University of Miami, 2TecSalud del Tecnológico de Monterrey, 3Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University
Presented By: Joao Porto, MD
Introduction: Holmium Laser Enucleation of the Prostate (HoLEP) is a size‐independent treatment for enlarged prostates, but limited studies have assessed its results in very large prostates (> 200g) or small prostates (< 40g). Therefore, we analyzed the outcomes for prostates across the entire range ofsizes.
Methods: After review of patients who underwent HoLEP between 2017 and 2022, we excluded patients with a previous prostate cancer diagnosis, without baseline prostate size, and those who lost follow up. Patients were divided into 3 groups based on their baseline prostate size: Group 1 (Prostate < 40g), Group 2 (Prostate 40g – 199g), and Group 3 (Prostate > 200g). Differences among groups were assessed using the log‐rank test. A p‐value < 0.05 was considered statistically significant.
Results: 402 patients were analyzed and median baseline prostate size was 102 [74 ‐ 151.3] cc (range 10 ‐ 376 cc). Clinical and demographic variables were similar among groups (p > 0.05), except with baseline PSA (p < 0.001), frequency of preoperative prostate biopsy (p = 0.004), and median resected volume (p < 0.001) being higher in Group 3. The overall rate of complications was similar between groups (p > 0.05), although the rate of perioperative blood transfusion was higher in the Group 3 (p = 0.019). Roughly IPSS, Qmax, and PVR were similar among groups within the different time intervals (p > 0.05) (Table 2). Moreover, 17.4% of the patients reported incontinence at follow‐up and the incidence of different types of incontinence was found to be similar across the various groups (p > 0.05). The overall median time of the office appointment in which continence was recorded was 3.07 months (95% CI: 2.36 ‐ 3.78), and the median time in which continence was achieved was similar among groups (p = 0.575).
Conclusions: HoLEP has favorable and comparable outcomes across the entire spectrum of prostate sizes, but those with very large prostates may have higher rate of blood transfusion.
Funding: N/A
MODERATED POSTER SESSION 22: LAPAROSCOPIC AND ROBOTIC NEW TECHNOLOGY
A Novel Endoscopic Surgery Method: Transurethral Surgery ‐ NOTES (TUS‐NOTES) for Treatment of Vesicovaginal Fistula
1Kocaeli University Hospital ‐ Department of Urology, 2Medical University Charite ‐ Berlin ‐ Department of Urology
Presented By: Joerg Neymeyer, Dr.
Introduction: Vesicovaginal fistula (VVF) formation represents a condition with devastating consequences for the patient and continues to pose a significant challenge to the surgeon. To minimize the morbidity of classical fistula repair, we present a minimally invasive surgery technique in transurethral surgery‐ natural orifice translumenal endoscopic surgery (TUS‐NOTES) by using a new small fine needle holder and knot pusher.
Methods: A rigid cystoscope with 30 degree optics is inserted into the patients bladder with CO(2) insufflation. The fistulae orifices is excised with electrocautery. First the monocryl 3‐0 fibre is put into the needle holder. To fit into the needle is bended. The needle is put loose next to the cystoskope put into the bladder and after touching the wall the fibre is fixed at the end of the needle holder with a clamp. Now by a rotation the whole is at both sides stiched. With a grasp –put through the working channel‐ the needle is grasped and by loosing the clamp everything can be pulled out. By tying an extracorporal knot and putting an knot pusher over the fibre, the knot is fixed. This procedure is repeated till the whole is closed. The fibres are cutted.
Results: 29 cases were treated. The mean operative time was 45 min (25min‐110min), whereas the blood loss was less 10ml. Discharged at 3rd day.
Conclusions: To reduce morbidity and prolonged recovery of excision of the VVF ‐ TUS‐NOTES technique is efficacious and the preferred method of intervention.
Funding: none
Feasibility of Nonlinear Microscopy Technique for Evaluating Prostatectomy Margins in Real Time
Angela Estevez2, Timothy D. Weber1, Utsav Bansal2, Philip Kim2, Yue Sun2, Seymour Rosen2, Taylor St Jacques2, James G. Fujimoto1, Jeffrey Sun2, Gabriela Nieto‐Blanco2, Peter Chang2, Andrew A Wagner2
1Massachusetts Institute of Technology, 2Beth Israel Deaconess Medical Center
Presented By: Angela Estevez, MD
Introduction: Nonlinear microscopy (NLM) is an emerging imaging technology able to rapidly produce H&E histology‐like digital images in fresh surgical specimens. Our group has previously demonstrated the ability of NLM to accurately detect prostate cancer suggesting it might be a useful tool for intraoperative evaluation of margin status innerve‐sparingradical prostatectomy (Cahill et al. 2020). We present preliminary data on feasibility and accuracy of NLM to evaluate margin status compared to paraffin‐embedded H&E histology.
Methods: Nerve sparing status is determined based on standard of care. The specimen is marked with tissue marking dyes and fluorescent plastic beads, allowing visualization under NLM. The surgeon performs ex vivo resection of the neurovascular bundle, to simulate bilateral nerve‐sparing, and this margin is inked separately. The specimen is then grossed into slices, stained, and placed for evaluation. A genitourinary pathologist evaluates the posterior margins of the specimen using NLM, after which the specimen is submitted for standard histology.
Results: 20 participants were included in the analysis. The average time of specimen preparation (inking, ex‐ vivo resection, grossing) and NLM evaluation was 43 minutes. A total of 40 margins were evaluated by NLM, out of which 8 were reported as positive, 25 as negative, and 7 as indeterminate(Table 1).Among the positive margins 3 were later confirmed to be positive by H&E(Figure 1),while 5 were false positive. 1 case was false negative and 6 out of the 7 indeterminate margins were later confirmed to be negative by H&E.
Conclusions: NLM has the potential to evaluate margin status without compromising final H&E evaluation. It may be a higher throughput alternative to time and labor‐intensive techniques, such as frozen section analysis (Schlomm et al. 2012). However, it is necessary to improve timing and efficiency with further pilot cases.
Funding: NIH R01CA249151
First Look: Laser Speckle Imaging is a Novel Method to Identify and Preserve Neurovascular Bundle During Robotic Assisted Laparoscopic Radical Prostatectomy
Arun Rai1, Lee Richstone1, Louis Kavoussi1, Nicholas Kavoussi2, Manish Vira1, Jay Bishoff1, Vip Patel3
1Northwell Health, 2Vanderbilt University, 3Advent Health
Presented By: Arun Rai, MD, MBA, MSc
Introduction: Preserving neurovascular bundle (NVB) perfusion is been previously identified as an important factor in preserving erectile function and urinary continence after prostatectomy. Most current approaches for visualizing blood flow/perfusion in real‐time are: suboptimal (lack objectivity), cumbersome (need for reagent preparation and injection), and lack cost‐effective utility (need for large capital equipment). An optical imaging technique based on monochromatic coherent light known as Laser‐Speckle‐Contrast‐ Imaging (LSCI) represents a label‐free imaging method using coherent monochromatic light where blood flow and tissue perfusion can be detected. We present our initial multi‐center experience and feasibility with utilizing this novel technology to identify NVB during robotic assisted laparoscopic radical prostatectomy (RALP).
Methods: RALP was performed in surgeon's respective institutions (Global Robotics Institute, FL and Northwell Health, NY) with either multiport (Da Vinci Xi) or single port (Da Vinci SP) robotic equipment. ActivSurgical™'s ActivSight, is a laser speckle based endoscopic imaging module that is positioned between the endoscopic lens and the camera and has the ability to visualize real‐time perfusion. During RALP, an accessory port was utilized through which a 10mm laparoscopic lens with the ActivSight module attached was inserted at key points throughout the case via assistant.
Results: In both antegrade and retrograde nerve dissection, ActivSight was able to visualize NVB and demonstrate perfusion through dissection. Surgeons did not express any significant workflow alterations or difficulty with using ActivSight during dissection.
Conclusions: This is the first clinical experience to our knowledge describing laser speckle imaging during RALP. ActivSight's LSCI module was able to offer even highly‐experienced surgeons the ability to identify and aid in the preservation of NVB. While information presented here demonstrates some early potential promise, further research and development will be required to validate utility. Once validated, this technology holds the promise of potentially improving surgical “trifecta” outcomes in more patients through NVB preservation.
Funding: None
Laparoscopic Renal Denervation System for Treating Uncontrolled Hypertension: A Comparative Survival Swine Model
Chang Wook Jeong4, Jang Hee Han1, Si Hyun Kim1, Sang Youn Kim2, Bogyeong Han3, Minh‐Tung Do1
1Department of Urology, Seoul National University Hospital, 2Department of Radiology, Seoul National University Hospital, 3Department of Pathology, Seoul National University Hospital, 4Seoul National University Hospital
Presented By: Chang Wook Jeong, MD, PhD
Introduction: Hyperactivity of the sympathetic nervous system is recognized as a significant contributor to essential hypertension and resistant hypertension. Percutaneous catheter‐based renal denervation, which selectively eliminates hyperactive renal sympathetic nerves, has demonstrated mixed success in achieving consistent reductions in blood pressure. Hence, this study aims to elucidate the effects and safety of a novel Laparoscopic Renal Denervation System (LRDNS) for treating uncontrolled hypertension.
Methods: We devised an LRDNS optimized to completely ablate renal nerves while preventing thermal damage to renal arteries, irrespective of renal arterial innervation and size, in a swine model with mildly elevated hypertension. Hypertension was induced in all swine through a 3% high‐salt diet. The endpoints were evaluated over the survival period (4‐week[short‐term], 12‐week[long‐term], and 24‐week[extended long‐term]).
Results: LRDNS was performed on 18 swine (6 swine for each survival period), and a sham operation was performed on 9 swine (3 swine for each survival period). The mean time for the sham operation was 34.1 ± 8.5 minutes, while the LRDNS averaged at 55.2 ± 7.0 minutes. Compared to the sham control, the LRDNS group demonstrated a significant reduction in blood pressure over the 24‐week survival period (SBP changes from baseline, sham control: 15.8mmHg and LRDNS: ‐7.8mmHg, 23.6mmHg difference, p < 0.001)(Figure 1).
Tissue norepinephrine levels, were significantly reduced in the LRDNS group than sham control (5.84 ± 0.94 ng/g vs. 78.06 ± 13.84 ng/g, p < 0.0001). Minimal to mild medial injuries were observed, but no intimal injury was noted in the LRDNS group. Moreover, there were no significant adverse events, and all animals survived post‐procedure.
Conclusions: The study affirms the safety, and effectiveness of the novel LRDNS in a swine model, which compares favorably with, or is superior to, the sham procedure. No safety concerns related to the device were assumed at 4‐, 12‐, and 24‐weekpost‐treatment. This novel LRDNS is guaranteed for the first‐in‐human trial to treat uncontrolled hypertension.
Funding: This study was supported by DeepQure Inc. (Yeoksam, Seoul, South Korea)
Near Infrared Nerve‐Specific Fluorophores for Fluorescence Guided Prostatectomy
Connor Barth1, Nathan McMahon1, Lei Wang1, Summer Gibbs1
1Trace Biosciences
Presented By: Connor Barth, PhD
Introduction: Nerve damage impacts ∼8% of all surgical outcomes worldwide, incurring undue pain, loss of function, and high costs to healthcare systems. Conventional intraoperative nerve detection uses anatomical knowledge and white light (WL) visualization. However, nerves can be difficult to identify by conventional methods. Fluorescence‐guided surgery (FGS) offers a potential means for enhanced intraoperative nerve identification and preservation.
Methods: We have developed novel near‐infrared (NIR) nerve‐specific fluorophores that provide excellent nerve contrast with the ability to identify buried and invisible nerve structures. Additionally, we have characterized the nerve visualization performance in canine prostate models and resected human specimens to support clinical utility for prostatectomy.
Results: Several lead candidates of our novel fluorophores displayed bright NIR nerve‐specific fluorescence contrast. The lead NIR nerve‐specific fluorophore, BCP‐T108‐35, enabled buried nerve visualization in a swine iliac nerve where conventional WL visualization was insufficient for nerve identification during robotic surgery. Our lead agents also demonstrated compatibility with the da Vinci Firely system to produce high contrast nerve visualization in cavernous nerves following administration to canine prostate and resected human prostate tissue, validating utility for improved nerve identification during prostatectomy.
Conclusions: FGS has the potential to eliminate intraoperative nerve damage. Work is underway towards an investigational new drug application to the FDA for first‐in‐human clinical trials with our nerve specific fluorophores. Upon successful translation, this technology will provide enhanced visualization of nerves intraoperatively, to improve outcomes in nerve sparing prostatectomy surgery.
Funding: NIH Grant Funded:Clinical Translation of Near Infrared Nerve‐Specific Fluorophores for Nerve‐ sparing Prostatectomy (R44CA247639)
Minimally Invasive Removal of Leiomyomas of the Lower Urinary Tract via Transurethral Surgery with MSD
1Medical University Charite ‐ Berlin ‐ Department of Urology
Presented By: Joerg Neymeyer, Dr.
Introduction: Leiomyomas are benign tumors of smooth muscle origin and are rarely found in the lower urinary tract. Removal is often technically challenging due to a location deep in the pelvis with difficult exposition.
Methods: Data from five patients with leiomyoma of the lower urinary tract and treated via transurethral surgery in Notes‐technique by using the minimal suturing device instruments. Between May 2016 and October 2022, was analyzed retrospectively. Analysis included number, size and localization of the leiomyomas, symptoms, voiding function and complications. Preoperatively the diagnosis was confirmed by ultrasound guided biopsy.
Results: Patients presented with signs and symptoms including a palpable external genital mass, dysuria, urge urinary incontinence or dyspareunia. Usually physical examination revealed a non‐tender mass, 1.2‐ 2.8cm in diameter, with a smooth surface located above the urethra or bladderneck. The masses were sharply dissected and enucleated via transurethral bladderoscopy. No postoperative complications were found. Two weeks after the procedure, all patients had a normal voiding function. Terminal histopathological examination showed leiomyomas with fascicles with spindle‐shaped cells without mitosis.
Conclusions: In management of Leiomyomas of the lower urinary tract, a transvesical approach via bladderoscopy is a safe and feasible alternative to laparoscopic or transvaginal treatment. The prognosis is excellent since it has no risk of malignant transformation.
Funding: none
Robot‐Assisted Prostatectomies Using the Novel Avatera System: Our Initial Experience
Introduction: The clinical study presented, was designed for the presentation of our experience and outcomes of robotic‐assisted radical prostatectomy (RARP) with the use of the avaterarobotic system.
Methods: The data of the first patients who underwent extraperitoneal RARP with the avatera system were retrospectively collected and presented in the current study.Theprimary endpoints of this study were the operation time (including the draping, docking and console time),the successful completion of the operations and the major complications.
Results: Ten patients underwent RARP using the avatera system from June 2022 to July 2022 in our department. The surgeries were completed succesfully. The draping of the robotic unit was completed in 8,91(±2,01)minutes, while the mean docking time was 12,24(±8,67)minutes. The average console time was 103.2(±8.39) minutes. No conversion to laparoscopic or open prostatectomy was necessary, and no major complications were observed.
Conclusions: The early outcomes of the use of the avatera robotic system in RARP are presented. No major complications weres noticed. All the cases were safely and efficiently completed.
Funding: Not applicable
WITHDRAWN
Surgical Counseling in 3rd Millennium: The Hologram Project
Introduction: In the past few years many things are changing in urology. The advent of new technologies, such as 3D reconstruction, augmented reality and artificial intelligence, seems increasingly more crucial to offer the better standard of healthcare and to reach the best possible surgical outcome. In this study we wanted to show the 3D reconstruction to the patients undergoing partial nephrectomy using a hologram projector, in order to assess a better understanding of the procedure and its risks.
Methods: We selected patients from 18 to 80 years, capable of intentions and desire, with a new diagnosis of renal tumor. All the patients were diagnosed with a contrast enhanced CT scans. First of all, we standardized the counseling by showing to all the patients the CT scans and explaining for the first time the anatomy and the procedure. Then, with the help of the Biomedic Engineering of UNIMORE, which provided us the 3D reconstruction of patients with renal tumor, we developed a hologram of every reconstruction. We shown the reconstructions to the patients at first on the computer screen, then with the support of Hololens and, finally, with the support of a hologram projector. All the patients submitted a survey for the evaluation of their understanding of the anatomy, the surgery and the possible complications with a five grade Likert scale (from 1 to 5).
Results: The first 10 patients who submitted the surveys shown a better understanding with the holograms than with the CT scans only. The average result of understanding with the CT was 3,2 ± 0,8, with the 3D reconstruction it was 3,8 ± 0,8, with the Hololens it was 4 ± 0,5 and with the hologram projector it was 4,6 ± 0,2. All the patients felt more relieved and underwent the surgery with less anxiety.
Conclusions: In this study we demonstrated that the holograms are an excellent way to assess a better understanding in patient counseling. A cost‐benefit analysis could be useful to assess the cost‐effectiveness of the methodic compared to 3D printing.
Funding: None
Laparoscopic Versus Robotic Training Using the Avatera Robotic System in Basic Urological Skills
Introduction: To compare the laparoscopic and Avatera robotic system learning curves when medical students and urology residents perform basic urological laparoscopic.
Methods: Four groups were made from a pool of two final year medical students and six urology residents, in different years of residency depending on their experience in laparoscopy. Each group was trained for a two‐hour period of dry lab training on the Avatera® robotic system and a two‐hour period on the laparoscopic dry lab. Then the participants were tested in four basic laparoscopic skills as they are described by the European Association of Urology for the European training in basic urological laparoscopic skills (E‐ BLUS). The pre‐training and post‐training completion duration of each modality were evaluated.
Results: Every participant performed successfully the four‐hour multimodal training scheme using both the Avatera robotic system and the laparoscopic instruments. The post‐training completion duration was shorter in every modality and in both laparoscopic and robotic exercises. Furthermore, exercise duration reduction in every exercise using Avatera Robotic System was greater in comparison to the duration reduction using laparoscopic instruments.
Conclusions: The study showed that every participant achieved a greater reduction of the time needed to accomplish the basic urological laparoscopic skills using the Avatera Robotic System compared to the time reduction in the laparoscopic dry lab training set.
Funding: This study was conducted with no funding
Incisional Complications of Single Port Robot‐Assisted Procedures: Does Incision Location Matter?
Sarah Brink1, Nathan Cheng1, Jennifer Nguyen1, Teona Iarajuli2, Katherine Kim2, Meghana Singh2, Angelo Cadiente2, Andre Ho2, Ruchir Chaturvedi2, Catherine Implicito2, Gregory Lovallo1, Mutahar Ahmed1, Michael Stifelman1
1Hackensack University Medical Center, 2Hackensack Meridian School of Medicine
Presented By: Sarah Brink, MD
Introduction: The Single Port (SP) robot is a new technology utilized in urologic surgery. Extrapolating from single‐site laparoscopy data, there is concern regarding increased incisional complications given the size of the incision. This study seeks to evaluate SP incisional complications for renal, genitourinary reconstruction, bladder, and prostate surgeries.
Methods: IRB‐approved prospective databases were used to identify cases of SP robotic surgery from 2019 to 2022. All cases included had documentation of incision location and a minimum of 3‐month follow‐up. Postoperative outcomes included incisional hernia, wound infection, and/or wound dehiscence. Subgroup analysis was performed by incision location.
Results: 295 cases were analyzed. There were only 6 incisional complications (6/295, 2.0%), with 4 herniae, 2 wound infections, and 0 wound dehiscences. Among the 4 herniae, the highest incidence occurred via lower quadrant transperitoneal incision (4.2%, 1/24), followed by umbilical transperitoneal incision (3.4%, 2/58), and finally by infraumbilical extraperitoneal incision (0.6%, 1/180). There were no herniae via mid‐axillary or Pfannenstiel incisions. The transperitoneal (1/84, 1.2%) and extraperitoneal (1/211, 0.5%) groups had 1 wound infection each. Overall, the transperitoneal incisions accounted for a 4.8% (4/84) incidence of complications (3 herniae and 1 infection) versus the extraperitoneal incisions, which accounted for a 0.9% (2/211) incidence of complications (1 hernia and 1 infection).
Conclusions: To our knowledge, this represents the first descriptive study of SP incisional complications. Incisions that utilize an extraperitoneal approach have very low risk of hernia or infection. When using a transperitoneal approach, both the umbilical and lower quadrant incisions have low risk of hernia. Larger numbers and comparison data to multiport robotic surgery will help to elucidate the significance of our SP findings.
Funding: None.
An Artificial Intelligence‐Based Platform for Displaying Hidden Anatomical Structures in Robot‐Assisted Surgeries
Michael Frumer1, Daniel Kedar1, Jack Baniel1, Andrew Nado1, Shay Golan1
1Rabin Medical Center
Presented By: Michael Frumer, MD
Introduction: One of the main challenges in partial nephrectomy is spatial orientation and understanding the relationship between the mass and critical anatomical structures to achieve negative surgical margins and preserve the remaining structures. Today, the surgeon determines the planes of surgery through cognitive planning based on a preliminary review of pre‐operative imaging, whereas in real‐time, the anatomy is dynamic as the operation progresses. An augmented reality system includes virtual illustrations that merge with the environment in real‐time and are highlighted in the resulting image. This interactive system has the potential to help the surgeon navigate the surgical field by illustrating the location and boundaries of hidden structures.
Methods: The clinical characteristics and pre‐operative CT files of patients who underwent robotic‐assisted partial nephrectomy were collected, as well as the surgery film, which includes the information obtained from the robot's camera and an intraoperative drop‐in sonar probe. Using pre‐operative imaging, surgical film, advanced deep learning tools, and 3D reconstruction, we will create a computerized system to visually present hidden anatomical structures and tumor boundaries.
Results: Thus far, data from 5 patients have been processed. Their characteristics are detailed in Table 1.Illustrative images from the augmented reality system are currently in the advanced stages of development and will be presented.
Conclusions: In the future, it will be possible to use a computerized system for a real‐time virtual presentation of the hidden anatomical structures and tumor boundaries. The system may shorten surgery time, reduce complications, and help the beginner surgeon.
Funding: RSIP vision ltd
Pain Control Monitoring in Urologic Laparoscpic and Robotic Surgeries Using a Novel Nociception Level Device – a Randomized Prospective Trial
1Department of Urology, Carmel Medical Center, 2Department of Anaesthesiology, Carmel Medical Center
3Department of Urology, Carmel Medical center
Presented By: Ilona Pilosov Solomon, MD
Introduction: Nociception Level (NoL) is a novel device developed to objectively quantify patient's perceived pain in a non‐invasive manner during surgeries performed under general anesthesia, combining patient's autonomic signals to a single index. The higher the index the greater the pain perceived, and adequate pain control is defined between 10‐25.Our aim was to evaluate NoL‐guided opioid administration during laparoscopic and robotic urological surgeries.
Methods: This is a single center randomized‐prospective trial. All patients underwent robotic and laparoscopic radical prostatectomy, nephroureterectomy or partial nephrectomy, under propofol/remifentanil based anasthesia. The NoL index was recorded throughoutall surgeries, remifentanil administration was based on the NoL index in the study group and based on hemodynamic parameters in the controls. The primary endpoint was intraoperative remifentanil administration and morphine doses in the post‐anesthesia care unit (PACU), both adjusted to patient's weight. Secondary endpoints were postoperative visual analogue scale (VAS) scores recorded 30 and 60 minutes after surgery.
Results: Twenty‐three patients were included in final analysis. Median intraoperative NoL‐index was 18 and 20 in NoL‐guided and control groups, respectively (p = 0.33). Mean remifentanil‐adjusted‐to‐weight doses were 28.5 and 13.8 μg/kgin the study and control groups, respectively (p = 0.35).Mean 30 and 60‐minute postoperative VAS scores were, 3 and 2 in the NoL‐guided group vs. 4 and 3 in the control (p = 0.26 and p = 0.46, respectively). Morphine consumption during the PACU period was 0.01 mg/kgamong NoL‐patients and 0.02mg/kgin the controls (p = 0.17).
Conclusions: NoL index‐guided antinociception points to better pain control needed in urologic laparoscopic and robotic surgery even though this did not currently translate to reduced postoperative pain and opiate consumption respect to hemodynamic‐parameters based analgesia.
Funding: Non
Endoscopic Treatments for Ureteral Strictures After Kidney Transplantation: Experience of a Large‐Scale Prospective Study from a High‐Volume Center .
Cai Tang1, Jixiang Chen1, Xiaoshuai Gao1, Xin Wei1
1West China Hospital
Presented By: Cai Tang, PhD
Introduction: The aim of this prospective study was to assess the safety and effectiveness of endoscopic treatments for ureteral strictures after kidney transplantation (KT).
Methods: We prospectively collect clinical characteristics from 68 patients who received endoscopic treatments for ureteral strictures after KT from January 2019 to March 2022. The hydronephrosis volume, serum creatinine, urea nitrogen levels and eGFR before and after operation were collected. Paired T test was used to compare continuous data before and after operation, and p < 0.05 indicated statistically significant differences.
Results: Three different types of techniques were selected according to the different conditions of ureteral strictures after KT. Over a mean follow‐up time of 22.9 months (range 6–38 months), the overall success rate of the technique was 88.2% (60/68). The success rate of the type one (97.3%) was significantly higher than type two (77.8%) or type three (76.9%). The volume of hydronephrosis (64.4 ± 79.4 VS 43.9 ± 53.3 cm3, P = 0.023) , the blood creatinine level (105.5 ± 49.9 VS 90.4 ± 55.5 μmol/L, P = 0.021) and urea nitrogen level (6.6 ± 3.0 VS 5.4 ± 2.5 mmol/L, P = 0.0001) decreased significantly after surgery. The level of serum eGFR was elevated from 49.5 ± 16.6 ml/min/1.73 m2 preoperatively to 64.4 ± 17.5 ml/min/1.73 m2 postoperatively. Complications of surgery include hematuria (17.6%), pain (14.7%), urinary tract infections (14.7%) and lower urinary tract symptoms (7.4%). The incidences of stents migration, occlusion, and encrustation were 14.7%, 4.4%, and 2.9%, respectively.
Conclusions: Systemic endoscopic treatments were found to be safe and effective for ureteral strictures after KT with a long follow‐up time. This technique provides a new choice for the treatment of strictures after KT.
Funding: None
Benefits of Single‐Use Cystoscopy (SUC) with UroviuTM: An Innovative Approach for Cystoscopy.
Fernando J. Kim5, Marcelo Wroclawski1, Thiago Hota2, Daniel Moser3, Eduardo Terra Lucas4
1Centro Universitario FMABC, 2Universidade Federal do Parana, 3Willis‐Knighton Health Center, 4Hospital Divina Providencia, 5Denver Health Medical Center
Presented By: Fernando J. Kim, MD, MPH
Introduction: Recently, SUC financial advantages have been well reported. The objective of this study was to evaluate other benefits associated with the utilization of SUC with UroviuTM. By investigating factors such as ease of usage, patient comfort, procedural efficiency, and infection control, this study aimed to shed light on the overall impact and value of this technology in urological practice. UroviuTMrequires only an additional irrigation bag and tubing due to its compact and comprehensive design. (Figure 1)
Methods: A comprehensive evaluation was conducted, involving both quantitative and qualitative measures, to assess benefits of UroviuTM.A group of 32 urologists and urologists‐in‐training, both nationally and internationally (Brazilian urologists) were invited to participate in the study, with a focus on gathering their experiences and opinions regarding the use of UroviuTM. Surveys and interviews were conducted on factors such as ease of usage, patient comfort, procedural efficiency, and infection control.
Results: Ease to use UroviuTM: 29 respondents found extremely easy, while 3 found it easy. Furthermore, the learning curve for proficiency with UroviuTMwas found to be relatively short, requiring only 1‐5 cystoscopies. This demonstrates the efficiency and ease of adaptation UroviuTM, allowing urologists to quickly integrate UroviuTMinto their clinic procedures.Provider satisfaction with UroviuTMwas also remarkable, with 29 participants giving it a 5‐star rating and 3 participants rating it as 4 stars. Additionally, six Brazilian urologists highlighted the key attribute of UroviuTM, which is the ability to perform cystoscopies in the clinic rather than in the operating room (OR). This allows removal of ureteral stents, placement of difficult Foley catheters, and crucially, bladder tumor surveillance without the need for frequent OR visits every 3‐4 months. Currently, performing all cystoscopies in the OR not only increases the cost of care but also impacts patient recovery time and their ability to return to work faster, while also affecting the optimization of clinic flow.
Conclusions: These findings indicate that Single‐Use Cystoscopy with UroviuTM provides tangible benefits in terms of ease of usage, short learning curve, high provider satisfaction, and the ability to perform clinic‐ based procedures. By avoiding the need for frequent OR visits, this technology offers advantages in terms of cost‐effectiveness, patient recovery, and clinic efficiency.
Funding: none
Prevalence of Neuromuscular Disorders Among Urologists: Impact of Surgical Modality on Pain Type and Duration
Eric Regele1, Raymond Pak1, Hamid Norasi2, Ram A Pathak1, M Susan Hallbeck2, Eric A V Qualkenbush1
1Mayo Clinic Florida, 2Mayo Clinic Rochester
Presented By: Eric Regele, MD
Introduction: Physical and workplace demand on surgeons is an understudied field. The primary objective of this study was to investigate urology surgeons' intraoperative workload, well‐being, and neuromusculoskeletal disorders (NMSDs) and the potential associations with surgical modalities.
Methods: Electronic surveys were sent to urology surgeons across several sites of a large quaternary academic hospital system to record surgeons' intraoperative physical and mental workload (from 0‐10), NMSDs (yes/no questions), and the practice time they spent on different surgical modalities: open, laparoscopic, endoscopic, and robotic approaches.
Results: Nineteen surgeons (34%) completed the survey: 15 males (79%), age (mean (SD)) 46.4 (10) years, BMI = 24.6 (3.5), and the number of years being an attending surgeon = 12.7 (9.0) years. Nine (47%) reported at least one NMSD. The reported NMSDs included neck problems (3 participants), hip arthritis (2 participants), tennis elbow (lateral epicondylitis), wrist/forearm tendonitis, shoulder problems such as arthritis/inflammation, cervical disc issues, shoulder pain (tendonitis), lumbar disc issues, knee osteoarthritis, trigger finger, plantar fasciitis, thumb joint arthritis, and foot pain. 57.9% of the surgeons reported they had experienced or were experiencing work‐related neuromusculoskeletal pain and 38.9% of the surgeons believed physical discomfort/pain will influence their ability to perform surgical procedures in the future. The reported current body‐part discomfort was 21.1% in head and neck, 36.8% in upper extremity, 26.3% in torso/back, and 21.1% in lower extremity. Using a non‐parametric model, significant associations exist between surgical modality and intraoperative physical demand, NMSDs, and current/past work‐related neuromusculoskeletal pain.
Conclusions: Urologic surgeons are exposed to high prevalence of NMSDs, body part pain and discomfort, and work‐related neuromusculoskeletal pain, which may negatively affect their future career. It seems robotic surgery is associated with less physical demand and fewer work‐related neuromusculoskeletal symptoms. However, establishing any causal relationship between surgical modality and these symptoms needs more research.
Funding: None
Comparison of Perioperative Outcomes of Robot‐Assisted Radical Prostatectomy Using the Hinotori™ and the da Vinci Surgical System
1Division of Urology, Department of Surgery, Tottori University Faculty of Medicine
Presented By: Atsushi Yamamoto, MD
Introduction: To compare the perioperative outcomes of robot‐assisted radical prostatectomy (RARP) performed using the hinotoriTM and the da Vinci surgical system.RARP is being routinely performed at our center using the da Vinci surgical system since 2010. Recently, the first made in Japan surgical robotic system called the hinotoriTM has been introduced in our center. Over the last 14 months, we have been performing RARP at our center using both robotic systems.
Methods: This was a retrospective analysis of prospectively maintained data from the medical records. A total of ninety‐three patients who underwent RARP between April 2022 and May 2023 using the da Vinci and the hinotoriTM were included in this study. Port placements in both the groups were similar to the conventional port placement (4 robotic and 2 assistant trocars). Data of both the groups were analyzed for perioperative outcomes like operating time, console time, blood loss, post operative complications. Perioperative outcomes between the two groups were compared using t‐test and chi‐square test.
Results: For the hinotori™ group and the da Vinci group respectively, the median total operative time was 343 (range: 22‐448) minutes and 334 (range: 187‐432) minutes (p = 0.949), median console time was 271 (range: 147‐337) minutes and 254 (range: 126‐356) minutes (p = 0.982), median blood loss was 180 (range: 50‐600) ml, 172.5 (range: 0‐800) ml (p = 0.345). Forty patients (62.5%) underwent lymph node dissection in the hinotori™ group and 18 patients (62.0%) in the da Vinci group. The median number of lymph nodes removed were 22 (range: 3‐36) and 24 (range: 9‐47) (p = 0.288), respectively. Perioperative complications according to Clavien dindo gradeⅢ or higher complications were 1 (common bile duct stone) in the hinotori™ group and 2 (common bile duct stone, pulmonary thromboembolism) in the da Vinci group.
Conclusions: We did not find clinically significant differences in the operating time, the blood loss, the number of lymph nodes removed, and complications between 2 groups. RARP can be performed using the hinotoriTM with comparable perioperative outcomes to that of the da Vinci.
Funding: The hinotoriTM seems to be a safe system for RARP.
Outcomes of Robotic‐Assisted Radical Prostatectomy with Hugo RAS System: Initial Experience in Japan
Ken‐Ichi Tbata1, Marie Nkamura1, Daijiro Nishijima1, Masatsugu Iwamura2
1Kitasato University Kitasato Institute Hospital, 2Kitasato University
Presented By: Ken‐ichi Tbata, MD,PhD
Introduction: In recent years, various new surgical robot systems have been developed, and HugoTM RAS System (Hugo, Medtronic), the third robot following da Vinci and hinotori, was introduced in Japan for the first time in East Asia. The purpose of this study was to evaluate the perioperative outcomes of robotic‐ assisted radical prostatectomy (RARP) using Hugo in patients with localized prostate cancer.
Methods: We retrospectively analyzed ten consecutive patients who underwent RARP with Hugo from January to March 2023. The patients underwent transperitoneal or extraperitoneal RARP, using five or six trocars (4 robotic trocars and 1 or 2 for the assistant). We reported the clinical feasibility and safety of this new robotic platform, assessing perioperative data, including complications and early outcomes. Continuous variables were reported as median and ranges, categorical variables as proportions.
Results: All procedures were safe and feasible with no major complications or conversion. Median console time was 188 minutes (143‐222), and median estimated blood loss was 135ml (5‐330). Positive surgical margins were reported in 1 patient (11%) in pT2. All patients were hospitalized for 9 days on schedule, and the foley were removed 5 days after RARP. On the first appointment four weeks after surgery, PSA value of all patients were below 0.2 ng/ml.
Conclusions: We demonstrated preliminary perioperative outcome with safe and feasible procedures perfor‐ med with HugoTM RAS System. The surgeries were successfully executed with acceptable outcomes, without major complications. Further investigations with long‐term follow‐up are awaited to access postoperative functional and oncological outcomes.
Funding: none
Hugo® RAS Robotic Radical Prostatectomy – the Initial Experience and Learning Curve
Chi Fai Ng1, Chi Hang Yee1, Franco Lai1, Steven Leung1, Jeremy Teoh1, Peter Chiu1
1SH Ho Urology Centre, The Chinese University of Hong Kong
Presented By: Chi Fai Ng, MD
Introduction: Hugo® RAS is a new modular robotic system available for clinical usage. We would like to review our initial experience of using the system in robotic radical prostatectomy, with reference to our previous published data on da Vinci S and SP system. The result will provide insight in the adoption and learning curve of this new robotic system in centre with robotic experience.
Methods: In May 2023, 10 patients with clinical localized prostate cancer underwent robotic radical prostatectomy by the Hugo® RAS. Information related to patient and tumour characteristic, as well as perioperative parameters were prospectively collected, and compared with our reported experience on da Vinci S and SP system. (Int J Urol 2019; 26:878‐883)
Results: The median age of the 10 patients underwent Hugo® robotic prostatectomy was 68 years old, with median prostate size 43 cc and serum PSA level 9.4 ng/ml. The distribution of D'Amico low, intermediate and high‐risk groups were 20%, 70% and 10% respectively. There was not significant difference in these parameters with the da Vinci S and SP patients (20 cases in these 2 groups). Table 1 showed the intraoperative and perioperative parameters. There was again no significant difference observed in the three groups.
Conclusions: From our initial experience of radical prostatectomy with the Hugo ® RAS, the perioperative result was comparable with the use of other da Vinci system. The experience of da Vinci robotic system could be transferred to the new modular system with short learning curve, less than 10 cases.
Funding: Hong Kong UGC Research Matching Fund 8601526
Novel Hydrogel Haemostasis for Robot Assisted Radical Prostatectomy ‐ A Pilot Study
Kalpilan Ravichandran2, Adib Rahman1, Kale Munien1
1Toowoomba Hospital, 2Toowoomba hospital
Presented By: Adib Rahman
Introduction: Background and ObjectivePuraStat is a new synthetic haemostatic agent constituting peptides that self assemble into sheets when exposed to ionic charges.We aim to report our initial experience with PuraStat as an athermic topical haemostatic agent for use on the neurovascular bundle in robotic assisted radical prostatectomy
Methods: MethodDemographic and disease data for 31 consecutive patients undergoing robotic radical prostatectomy were recorded. PuraStat was used as the primary haemostatic agent of the neurovascular bundle, without thermal or suture haemostasis, unless necessary. Total blood loss was recorded. A qualitative assessment of PuraStat's transparency, efficacy, ease‐of‐use and overall satisfaction was made intraoperatively by the surgical assistant. Preoperative haemoglobin and Haematocrit were compared to 1‐ hour and next‐day postoperative results.Results were compared to perioperative outcomes of robotic radical prostatectomy in published literature.
Results: Results31 males aged between 49 and 77 underwent a robotic radical prostatectomy under a single surgeon for clinically significant prostate cancer, with Purastat used as the primary haemostatic agent at the neurovascular bundle. 3 patients required an additional haemostasis, but only one of these was at the NVB where Purastat was applied. The median prostate volume was 36ml. Mean blood loss was 350ml compared to 443ml in Yaxley et als study. The median change in haemoglobin the next day was 27mg/dl. No transfusions were required.
Conclusions: ConclusionOur Pilot study shows that PuraStat is a safe haemostatic agent in Robotic Radical prostatectomy with similar perioperative bleeding outcomes and a high level of intraoperative user satisfaction. Further investigation into postoperative and long‐term continence and erectile function will be interesting.
Funding: nil
MODERATED POSTER SESSION 23: EDUCATION AND SIMULATION
What is the Force Exerted by Urologists During Ureteral Access Sheath Placement?
Seyed Amiryaghoub M. Lavasani1, Kalon L. Morgan1, Allen Rojhani1, Andrei D. Cumpanas1, Rohit Bhatt1, Mariah Hernandez1, Kelvin Vo1, Amanda Mccormac1, Paul Piedras1, Nina Kar1, Minh‐Chau Vu1, Seyedamirvala Sadaat1, Ahmad Abdel‐Aziz1, Antonio R. H. Gorgen1, Seyed Hossein H. Sharifi1, Zachary E. Tano1, Sohrab N. Ali1, Pengbo Jiang1, Roshan M. Patel1, Jaime Landman1, Ralph V. Clayman1
1University of California, Irvine
Presented By: Seyed Amiryaghoub M. Lavasani
Introduction: Although ureteral access sheaths (UAS) can facilitate ureteroscopy (URS), they can also cause ureteral injury. Our earlier studies showed that limiting the force applied during UAS passage to 6 Newtons (N) can prevent injuries, while high‐grade injuries (splitting of the urothelium) occurred at forces above 8 N. Others have published that high grade ureteral injury occurred after the passage of a 14 Fr UAS in 13‐26% of patients. Accordingly, we developed a model to determine how much force urologists and residents‐in‐ training typically might use during UAS insertion.
Methods: Urologists with varying levels of experience were recruited from the 2022 American Urological Association and World Congress of Endourology meetings. Participants passed three UAS(s) (12, 14, and 16 Fr) into a male genitourinary model that contained a concealed force sensor. The participants were blinded to the fact that the exerted force was being recorded. An online survey was utilized to collect demographic data. Predictive factors of 16 Fr UAS placement forces outside of two predetermined ranges (4 N – 6 N or 4 N – 8 N) were ascertained through a polychotomous logistic regression (PLR).
Results: Among 121 participants inserting a 16 Fr UAS, 55 (45%) and 39 (32%) applied UAS forces exceeding 6 N and 8 N respectively, while 35 (29%) remained below 4 N. More years of practice was significantly associated with generating forces above 6N (Table 1A and 1B) (force > 6 N OR 1.049, 95% CI 1.004 ‐ 1.096,p = 0.032) and force > 8 N (OR 1.04, 95% CI 1.001 ‐ 1.081,p = 0.045). Performing less than 20 URS cases per month had a significantly lower likelihood of applying forces less than the 4 N – 8 N reference range (1 ‐ 10 URS:OR 0.231, 95% CI 0.069 ‐ 0.771,p = 0.017; 11 ‐ 20 URS: OR 0.3, 95% CI 0.095 ‐ 0.95,p = 0.041).
Conclusions: In conclusion, 32% of urologists exceeded the 8 N safety threshold; this group was positively associated with more years of practice.Conversely, 29% of urologists fell short of 4 N and thus exerted too little force when placing the UAS which might lead to using an undersized UAS; this group typically performed < 20 URS/month. These findings highlight the potential benefit of monitoring UAS insertion force in order to both avoid placing an undersized UAS (i.e., less procedural efficiency) or at the other extreme, avoiding ureteral injury.
Funding: None.
Friend or Foe: An Analysis of ChatGPT as An Aid in the Scientific Writing Process
Conner Brown1, Jacob Zac1, Ofer Gofrit1, Mordechai Duvdevani1
1Hadassah Medical Center
Presented By: Conner Brown, MD
Introduction: Artificial Intelligence (AI) has emerged as a transformative force, redefining the way we explore, analyze, and communicate knowledge. With its ability to process vast amounts of data, identify patterns, and generate insightful outputs, AI has become a cornerstone of various disciplines. One fascinating development within the realm of AI is ChatGPT, a state‐of‐the‐art language model designed by OpenAI. ChatGPT exhibits the ability to generate coherent and contextually relevant responses, making it a potentially invaluable tool for scientific writing. Researchers can harness the power of ChatGPT to streamline the writing process. Its capacity to offer real‐time suggestions, refine language usage, and assist in structuring scientific papers presents a paradigm shift in scholarly communication.This abstract presents a study comparing abstracts written by medical professionals with those generated by ChatGPT, thereby showcasing its potential for enhancing scholarly communication.
Methods: Ten abstracts were selected from those that were accepted and presented at the AUA annual meeting in recent years. These abstracts were written on the topics of PCNL and URS and reviewed by a committee of expert reviewers. We then instructed ChatGPT to generate a mirroring abstract, based on the exact title of the true abstract. These abstracts were then randomly labeled “Abstract 1A” or “Abstract 1B” – with one abstract being the original and the other being AI generated. This was repeated, at random, for the remaining nine abstracts. We then invited a panel of professor‐level urologists to review the papers and select which one of the two options for all ten groups they preferred based solely on readability and composition.
Results: A total of 20 votes were cast by the panel members regarding which abstract they preferred. The AI generated abstracts were selected 9/20 times while the abstracts written by human authors were preferred 11/20 times. There was no significant difference between the URS and PCNL groups, or reviewers.
Conclusions: The advent of AI utilities, such as ChatGPT, has the potential to make a profound yet startling impact on scientific writing. While the ethics of using ChatGPT as a writing aid are beyond the scope of this abstract, one must nevertheless understand that this proverbial genie cannot be put back in the bottle.
Furthermore, it is the strong recommendation of the authors that abstract committees, journals, and conference organizers swiftly develop and publicize a reasonable policy regarding the use of AI as a writing aid. Finally, for the sake of transparency, we proudly report that this abstract was not AI generated.
Funding: None
The Percutaneous Nephrostomy Puncture Training Model under Ultrasound‐Guidance in Porcine Model
Dae Young Jun7, Jae Yong Jeong1, Young Joon Moon2, Dong Hyuk Kang3, Hae Do Jung4, Seung Hyun Jeon5, Joo Yong Lee6
1Department of Urology, National Health Insurance Service Ilsan Hospital, 2Department of Urology, Kyungpook National University Hospital, 3epartment of Urology, Inha University College of Medicine, 4Department of Urology, Inje University Ilsan Paik Hospital, Inje University College of Medicine, 5Kyung Hee University Medical Center, Kyung Hee University School of Medicine, 6Department of Urology, Severance Hospital, Urological Science Institute, Yonsei University College of Medicine, 7Department of Urology, Severance Hospital, Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea
Presented By: Dae Young Jun, MD
Introduction: In recent years, there has been increasing interest in the use of ultrasound guidance for endoscopic and percutaneous procedures. Our aim was to develop a training model for ultrasound‐guided percutaneous renal access that can also be personalized to a specific patient in porcine model.
Methods: The Institutional Animal Care and Use Committee of our institute approved the study protocol. A female pig aged 6 months (weight, 48 kg) acclimated for 7–10 days in our animal facility was used for the training model. An anesthetized animal was placed in the dorsal lithotomy position. Before training, cystoscopic insertion of guidewire was performed under fluoroscopic guidance and retrograde irrigation to intrarenal space with 100 cmH2O was established. For nephrostomy puncture, a Chiba biopsy needle with an echo tip was used under ultrasound guidance. Eight urologic residents and three urologic consultants participated this study. Puncture time was defined as the nephrostomy time to confirm the flow of irrigation via a Chiba needle.
Results: All participants performed nephrostomy puncture under ultrasound‐guidance successfully. In satisfaction survey for clinical usability using 5‐point Likert scale, mean point was 4.64 and there was no difference between two groups (P = 0.903). Satisfaction survey for procedural difficulty showed that mean point was 4.09 and there was no difference between two groups (Table 1). In nephrostomy time, there was a significant difference between the first and second trials in all participants (278.8 ± 70.6 vs. 244.5 ± 47.0; P = 0.007). Especially, in residents, there was also a difference between two trials (P = 0.039), however, there was no difference in consultants (P = 0.250) (Table 2).
Conclusions: We developed a porcine model to train the nephrostomy puncture under ultrasound‐guidance. In nephrostomy time, this training model can be more effective for urologic residents than for consultants.
Funding: The research was supported (inpart)by the Korean Society for Urologic Ultrasonograph Grant 2020.
Standardization of a Progressive Resident Training Program in HOLEP Surgery
Dan Gralnek1
1Univ Wisconsin Madison
Presented By: Dan gralnek, MD
Introduction: Holmium Laser Enucleation of the Prostate (HOLEP) is a well‐established treatment of BPH in any size prostate. Despite well‐established HOLEP efficacy and AUA BPH Guideline endorsement, adoption rate remains low and an alleged steep learning curve is often cited as an obstacle to more widespread use in surgical management of BPH. Access to training for HOLEP is limited with few residents and fellows nationwide finishing their training ready to perform HOLEP independently. At our institution, HOLEP is performed at a high volume with > 400 HOLEP procedures year. We witnessed a pattern of trainee learning and competence such that several residents had taken HOLEP skills learned in residency and successfully transitioned to independent practice. We aim to assess trainee performance improvement objectively as they progress through our curriculum to better understand the resident and fellow learning curve for HOLEP. Our primary objective is to determine the number of training cases required to independently complete prostate enucleation of < 100g gland in 90 minutes or less.
Methods: After institutional review board approval, two HOLEP surgeons identified the technical steps required to reach HOLEP proficiency. A step‐wise approach to surgical teaching was defined as the University of Wisconsin HOLEP training curriculum (Table). A rubric was developed for the trainee and attending surgeonto be completed throughout the study duration. Study duration was set at one academic year (June 2021‐June 2022). De‐identified procedure information was prospectively collected including prostate size, imaging modality, total procedure duration, enucleation time, morcellation time, specimen weight, and intra‐op/immediate post‐op complications. Trainee performance evaluations documented Objective Structured Assessment of Technical Skills (OSATS) and Global Rating Scale (GRS) measurements as each resident progressed through the curriculum. A total of 201 evaluations were collected from trainees (57) and attendings (144).
Results: Evaluations were completed by two attendings (DG and CM) and a total of 14 trainees. Number of HOLEP cases recorded by each PGY‐level include PGY‐1 (1), PGY‐2 (20), PGY‐3 (11), PGY‐4 (173), PGY‐5 (48), and PGY‐6 (49). A total of 7 trainees reached the primary objective of independent enucleation of < 100g gland in < 90 minutes including 3/3 PGY‐4, 3/3 PGY‐5, and 1/1 PGY‐6. Number of cases to reach objective of full HOLEP was noted to average 31 (range 19‐44).
Conclusions: Using a progressive step wise standardized program, resident education in performing HOLEP surgery was successful in all residents during the study period. An average of 31 cases was required forindependence
Funding: an educational grant was extended through Lumenis for the study
Design and Validation of an Integrated Motion Tracking and Video Capture System for Flexible Ureteroscopy
1Temerity Faculty of Medicine, University of Toronto, 2Temerty Faculty of Medicine, University of Toronto; St. Michael's Hospital, Department of Surgery, Division of Urology, 3St. Michael's Hospital, Department of Surgery, Division of Urology; Institute of Medical Science, University of Toronto, 4WellSpring Research, 5Temerty Faculty of Medicine, University of Toronto; St. Michael's Hospital, Department of Surgery, Division of Urology; Li Ka Shing Knowledge Institute, St. Michael's Hospital; Department of Surgery, University of Toronto, 6Institute of Biomedical Engineering, University of Toronto; KITE ‐ Toronto Rehabilitation Institute, University Health Network
Presented By: Kashif Visram, MD, BMSc
Introduction: Hand/instrument motion‐tracking in surgical simulation provides valuable data to improve psychomotor skills and can serve as a formative evaluation tool. While motion analysis has been well‐studied in laparoscopic surgery, it has been poorly studied in endoscopic surgery. Very few studies look at motion‐ tracking for flexible ureteroscopy (fURS), a common surgical procedure which requires hand dexterity and 3D spatial awareness. To address this gap, we designed a synchronized motion‐tracking and video capture system for fURS capable of collecting objective metrics for use in surgical skills training.
Methods: A single‐use flexible ureteroscope was used to design and test our system. Motion tracking of the ureteroscope was performed using the Polhemus Patriot platform, inertial measurement units (IMUs) and an optical sensor. Specifically, the position (x, y, z) and orientation (roll, pitch, yaw) of the ureteroscope handle, deflection of the ureteroscope lever, and translation of the scope insertion point were collected. Video capture of the operator's hands was collected with a Raspberry Pi camera, and the recording of the endoscopic view was collected from the video tower. All peripherals were controlled by a Raspberry Pi 4 and synchronized to its system clock.
Results: Our system demonstrated good accuracy in detecting translation of the ureteroscope in the x‐ and y‐ axes, and yaw, pitch and roll of the ureteroscope at discrete orientations of 0, ±30, ±60 and ±90 degrees. Unique to fURS, the deflection of the lever was captured by the difference in IMU static accelerations with good accuracy. The optical sensor detected the translation of the ureteroscope at the insertion point with an average error of 5.51% when traversing distances of 25, 50 and 100 mm a total of ten times each.
Conclusions: We successfully developed a system capable of collecting motion‐analysis parameters and capturing videos unique to fURS. Future studies will focus on establishing the construct validity of this tool.
Funding: We would like to thank Unity Health Toronto for funding the study through the Keenan Research Summer Student (KRSS) Program.
Estimating Stone Fragment Size During Ureteroscopy: Does Training Experience Predict Safe Extraction?
Kelly Lehner1, Jayson Kemble1, Jamal Alamiri1, Boyd Viers1, Katherine Anderson1, Aaron Potretzke1, Kevin Koo1
1Mayo Clinic
Presented By: Kelly Lehner, MD
Introduction: Accurate estimation of stone fragment size during ureteroscopy facilitates safe extraction. We aimed to determine whether training experience improves the accuracy of estimating fragment size.
Methods: Six mock stones (range 1.2–7.4 mm) were placed in a renal model for simulated flexible ureteroscopy. Urology residents and high‐volume ureteroscopy surgeons estimated fragment size and extractability through a 12/14‐French sheath. Responses were compared among 3 training levels (PGY 1–2, PGY 3–5, and surgeons) and analyzed by objective measures of surgical experience and technical skill. Categorical and continuous variables were analyzed using ANOVA and Pearson correlation, respectively.
Results: 16 residents and 6 surgeons were included. Participants underestimated fragment size by 30% overall (Table 1). As fragment size increased, the discrepancy between estimates and true size also increased. There was no statistical difference in accuracy among training groups and no association with experience or skill. Participants nearly always (98%) correctly identified < 4 mm fragments as extractable; in contrast, participants identified > 4 mm fragments as not extractable only 59% of the time. There was similarly no difference in predicting extraction by training level, experience, or skill.
Conclusions: Both novice and experienced surgeons substantially underestimate fragment size during ureteroscopy, which may increase the risk of unsafe extraction. Technologies that enable real‐time measurement may improve accuracy, regardless of surgeon experience.
Funding: None
Informing Approach to the Subcapsular Renal Hematoma (SRH): A Ten‐Year Review of the Natural History and Progression of SRH
Arun Rai1, Elizabeth Lynch1, Jacob Gaines1, Justin James2, Zeph Okeke1, David Hoenig1, Jared Winoker1, Arthur Smith1
1Northwell Health, 2Sophie Davis School of Medicine
Presented By: Arun Rai, MD, MBA, MSc
Introduction: The subcapsular renal hematoma (SRH) is a rare radiologic finding, but one with significant potential risks in the acute and chronic settings. In order to better understand the clinical sequelae and ramifications, the urologic community needs to better understand the clinical course of SRH, and the severity of possible complications during management.
Methods: A natural language processing search algorithm in Nuance mPower Clinical Analytics screened CT and MRI studies for “renal hematomas” across nine Northwell Health hospitals, including a Level 1 Trauma Center from 2011 to 2021. Patients with at least 3 cross‐sectional exams to track progression and time to resolution were included. Retrospective chart review assessed etiology of hematoma, interventions and management of clinical sequelae.
Results: We included 97 patients with acute diagnosis of SRH in the native kidney. Etiologies included traumatic (21%), spontaneous (32%), and iatrogenic causes (47%), as seen in Table 1. Three patients developed Page kidney with hypertension secondary to renin‐angiotensin‐aldosterone system activation, two of which had solitary kidneys, each requiring new hemodialysis or operative hematoma evacuation. The Page kidney with a contralateral functional kidney was managed conservatively. Six patients developed infected perinephric hematomas, five requiring drainage by interventional radiology (IR) and one requiring nephrectomy, on day 85, on average. 21 patients had perinephric bleeding requiring IR angiography, 17 of which underwent renal artery embolization. One patient had intractable pain, requiring operative hematoma evacuation on day 34. Another patient developed abdominal compartment syndrome requiring decompressive laparotomy. [RA1]94 patients had repeat imaging within ten months, and 20 (21%) demonstrated hematoma resolution. 18 patients had imaging between 10 and 15 months, of which 8 (44%) had resolved. The average time to resolution was 368 days.
Conclusions: Subcapsular hematoma is a rare finding with only 97 identified in 10 years of a multi‐hospital database. 35% of patients required intervention including hemodialysis, embolization and nephrectomy. The most common iatrogenic cause was renal biopsy. One third of spontaneous SRH required embolization, most commonly those with underlying renal masses. Page kidney phenomenon is rare (3%), but possibly more likely in solitary kidney.
Funding: None
Trend in the Global Endourology Training Pipeline: Contemporary Analysis of Fellowship Match Outcomes
Garrett Ungerer1, Kelly Lehner1, Anessa Sax‐Bolder1, Reza Roshandel1, Aaron Potretzke1, Kevin Koo1
1Mayo Clinic ‐ Rochester
Presented By: Kelly Lehner, MD
Introduction: The proportion of urology residents pursuing fellowship training has increased. To better understand contemporary trends in the global endourology training pipeline, we analyzed results of the annual AUA endourology fellowship match.
Methods: We analyzed AUA endourology fellowship match statistics from 2014‐2023 to characterize trends in application volumes, vacancies, applicants, and successful matches.
Results: The number of training opportunities increased from 34 programs (36 positions) to 54 programs (59 positions). Despite an excess of applicants, an average of 13 positions (26%) are unfilled each year (range 8‐ 19). Applicant desirability did not appreciably change as an average of 75% of applicants (range 72%‐80%) were ranked by programs each year. Programs received an average of 15 applications (range 14‐18) and offered 7 interviews (range 6‐9). Applicants consistently completed an average of 4 interviews (range 3‐6). 75% of vacancies were filled by US graduating residents (range 55%‐89%), compared to 17% by non‐US‐ trained candidates and 8% by prior US graduates. The number of successful female candidates averaged 5 per year, increasing from 3 women in 2014 to 11 in 2023.
Conclusions: The volume of candidates and number of positions continues to increase, representing an overall increase in advanced endourology training. Only 3 out of 4 applicants are ranked by programs, and a relatively high proportion of vacancies go unfilled each year. Female and non‐US‐trained candidates remain underrepresented. Strategies to bolster the endourology training pipeline merit increased attention.
Funding: None
Eye Tracking Habits as An Objective Measure of the Progression of Surgical Skill
Courtney Yong3, Haozhi Chen1, Chinade Roper2, Chandru Sundaram3, Denny Yu1
1Purdue University, 2Indiana University School of Medicine, 3Indiana University
Presented By: Courtney Yong, MD
Introduction: While eye tracking habits have been shown to differ between complete novices with no surgical experience and experts, there has not been evidence to show a gradient of eye tracking behaviors during the development of surgical skills in training. We sought to determine whether there is measurable progress using eye tracking behavior during surgical training.
Methods: With IRB approval, urology residents, fellows, and attendings were recruited to participate in the study. The subjects were asked to watch a deidentified video of the bladder neck dissection during a prostatectomy that no participant had previously seen. The eye tracking habits of the subjects were measured using Tobii‐pro glasses (Tobii Pro Lab, Tobii AB, Danderyd Municipality, Sweden). An area‐of‐interest analysis was conducted with a target/non‐target approach, in which an expert clinician identified a region of interest throughout the video. Statistical analysis on the eye tracking measurements was carried out using an independent samples Kruskal‐Wallis test.
Results: 13 subjects were recruited: 4 experts (attendings), 5 novices (PGY 1‐3), and 4 intermediates (PGY 5 and fellows). Novices were found to have a significantly lower percentage of eye fixations (93.2% ± 1.98) that were on target compared to experts (98.0% ± 1.02), while the intermediates were between the two (95.8% ± 2.35). All three groups were significantly different from each other (p = 0.036, figure 1A). Average fixation duration was higher and more variable in intermediate‐level trainees (2.44 ± 1.18 seconds), with experts (1.37 ± 0.46 seconds) and novices (1.18 ± 0.32 seconds) having similar shorter fixation duration, although this was not statistically significant. Novices had significantly more total visits for both the target and non‐target area than experts, with intermediate level trainees having more variation (p = 0.02, figure 1B).
Conclusions: There is a measurable gradient in eye tracking habits from junior residents to senior residents and from senior residents to attendings. Further study into eye tracking habits during training may allow eye tracking as an objective measure for evaluation and assessment of surgical trainees.
Funding: Pilot Grant from the Purdue Institute for Cancer Research
Are 2 Years Better than 1? Differences in Stone Surgical Training Experience among Endourology Fellows
M. Reza Roshandel1, Garrett N. Ungerer1, Jamal M. Alamiri1, Aaron M. Potretzke1, Kevin Koo1
1Mayo Clinic, Department of Urology
Presented By: M. Reza Roshandel, MD
Introduction: Exposure to diverse stone procedures is a cornerstone of endourology fellowships. The Endourological Society offers two potential tracks and two fellowship durations for fellows interested in stone disease, but differences in case volumes are not well understood. We aimed to characterize potential differences in stone procedural experience among endourology fellows.
Methods: The Endourological Society case logs for fellows graduating between 2020 and 2022 were queried for percutaneous (PCNL) and ureteroscopic (URS) stone procedures. Fellows who completed either a stone‐ focused track or a combined stone/robotics track in both 2‐year and 1‐year programs were included. Case volumes for 2‐year fellowships were halved to facilitate comparisons of volumes per year of training.
Results: A total of 107 endourology fellows from 54 programs worldwide were analyzed. The number of stone procedures performed by fellows varied widely based on program duration and track (Figure). For stone track fellows, median overall stone case volume was 206 cases (63 PCNL and 134 URS). 2‐year stone track fellows performed significantly higher number of PCNL (86 vs 36, P < 0.01) and had a significantly larger proportion of PCNL among total fellowship cases (39% vs 29%, P < 0.01). URS volumes were similar regardless of fellowship duration (124 vs 153, P > 0.05). For combined stone/robotics track fellows, median overall stone case volume was 109 cases (39 PCNL and 64 URS). There were no significant differences between 2‐year vs 1‐year combined track fellows for overall stone case volume (137 vs 90), PCNL cases (40 vs 37), URS cases (94 vs 59), or the proportion of PCNL among total fellowship cases (70% vs 68%) (all P > 0.05).
Conclusions: Endourological Society fellows perform similar proportions of PCNL cases among the total volume of stone procedures, which is highest among2‐year stone track fellows. Training exposure to PCNL appears to be similar regardless of fellowship track or duration, which may help to strengthen theendourological workforce.
Funding: Endourological Society fellows perform similar proportions of PCNL cases among the total volume of stone procedures, which is highest among2‐year stone track fellows. Training exposure to PCNL appears to be similar regardless of fellowship track or duration, which may help to strengthen theendourological workforce.
Evaluating Robotic Assisted Partial Nephrectomy Surgeon Performance with Fully Convolutional Segmentation and Multitask Attention Networks
1Southern Methodist University (SMU), 2Duke University, 3UT Southwestern, 4SMU
Presented By: Jeffrey Gahan, MD
Introduction: We use machine learning to automate surgical skill evaluation from “real life” videos during the tumour resection and renography of a robotic assisted partial nephrectomy (RAPN). This expands previous work using synthetic tissue (much cleaner) to include actual surgeries. We investigate cascaded neural networks for predicting surgical proficiency scores (OSATS and GEARS) from RAPN videos. Novel to this work is the development of asemantic segmentation task which generates a mask (rather than bouding box) thattracks the various surgical instruments. The movements from the instruments found via semantic segmentation are processed by a scoring network (multi‐task CNN) that regresses (predicts) GEARS and OSATS scoring for each subcategory.
Methods: To train the semantic segmentation network, a human reviewer created masks for each portion of the robotic instrument in a subset of video frames.Seven different portions of the instruments (and background) are segmentedas: (1) Left‐arm (upper flexion), (2) Left‐arm (abduction), (3) Left grasping or cutting, (4) Right‐arm (upper flexion), (5) Right‐arm (abduction), (6) Right grasping or cutting, (7) Needle (see Figure). The input to the scoring network is from the output of the semantic segmentation networkaggregated over time. Each feature vector (time point) can contain up to seven masked objects with three components: the “x” and “y”coordinate of the mask's center and the mask's area. Thus each frame has 21 features (7 for “x”, 7 for “y”, and 7 for area).To inform the design of our scoring networks and evaluate their performance, we developed a dataset of RAPN segmented surgical videos and recruited reviewers to score each segmented video.Fellows and attending surgeons provided GEARS and OSATS scores based on video review. The videos were not divided based ontrainee vs.attending surgeon rather the reviewers were not aware of expertise level tin order to establish a more robust ground truth. The scoring network used feature input from the semantic segmentation network and regresses multiple frames into GEARS and OSATS scores (in other words predicts surgeon performance).
Results: For masking, we employed 872 labeled image frames for training, comprising more than 4,000 labeled pixel masks for the various instruments. We also used several negative examples (images without any surgical instruments) to help reduce false positives. Objective analysis of segmentation was not possible due to the massive amount of manual labor required, but subjective analysis shows good tracking of intruments consistent with human observation as seen in ther included example (see Figure).Six loss functions were evaluated to determinethe best inter‐rater matching accuracy (how well did it match human raters). The self‐ attention architecture with cross entropy loss (SA‐CE) performed best. The SA‐CE model was then trained repeatedly (over 1000 times) with randomly sampled training data from the dataset. Any data not chosen for training samples was used for evaluation. The maximum performance of any model from the bootstrap was 0.85 for both GEARS and OSATS.For GEARS, we found that the best performing subcategory is ``force sensitivity,'' while the lowest performing subcategory is ‘‘efficiency.''or OSATS, the best performers are ‘‘knowledge of instruments'' and ‘‘assistance,'' while the lowest performer is ‘‘time and motion.''
Conclusions: We developed a deep learning algorithm for scoring GEARS and OSATS from a dataset robotic partial nephrectomy procedure videos. We found that our network when trained with self‐attention and cross entropy loss (SA‐CE), performed substantially better than other architectures. We conclude that our methods for automated scoring are substantially better than chance, with predictions similar in agreement between the two surgeon raters. Future directions include the use of a larger and more diverse (as it relates to skill) training dataset.
Funding: none
Simulation in Urolithiasis: A Review of Literature Trends in the 26 Years
Carlotta Nedbal7, Victoria Jahrreiss1, Clara Cerrato2, Amelia Pietropaolo3, Andrea Benedetto Galosi4, Domenico Veneziano5, Panagiotis Kallidonis6, Bhaskar Kumar Somani2
1Department of Urology, University Hospitals Southampton, NHS Trust, Southampton, UK, AND Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria., 2Department of Urology, University Hospitals Southampton, NHS Trust, Southampton, UK., 3Department of Urology, University Hospitals Southampton, NHS Trust, Southampton, UK, 4Urology Unit, Azienda Ospedaliero‐ Universitaria delle Marche, Polytechnic University of Marche, Ancona, Italy., 5Smith Institute of Urology, Northwell Health, New York, NY, USA., 6Department of Urology, University Hospital of Patras, Patras, Greece, 7Urology Unit, Azienda Ospedaliero‐Universitaria delle Marche, Polytechnic University of Marche Ancona, Italy, AND Department of Urology, University Hospitals Southampton, NHS Trust, Southampton, UK.
Presented By: Carlotta Nedbal, MD
Introduction: To report the bibliometric publication trend on the application of “Simulation in Urolithiasis” over a period of 26 years from 1997 to 2023. We conducted this study analyzing the publication trends associated with simulation devices and stone disease, including both training simulation and surgical studies.
Methods: We conducted a comprehensive review of the literature searching through PubMed all published papers on “simulation” in “Urolithiasis” from 1997‐2023 with no language restrictions. Papers were then divided in three major categories: A ‐ Training, B ‐Clinical (surgical) and C –Diagnosis (radiology). Two time periods were identified, and papers were recorded according to year of publication: Period1 (1997‐2009) and Period2 (2010‐2022).
Results: 168 papers were identified over a 26‐year time, of which only 4 were not in English language. Groups A, B and C included 94, 66and 8papers respectively and there was an overall increase from Period1 to Period2 of +269%(p = 0.0002). This increase for groups A, B and C was +279% (p = 0.001), +264% (p = 0.0180), +200% (p = 0.2105) respectively.Group A papers included significant rise in papers on “URS training” (+225%, p = 0.0016) and in “PCNLtraining” (+850%, p = 0.0023) and a similar trend for both procedures where studies reported them together (+180%). In the last 5 years, from 2018 to 2022, URS appears to be the main focus of publications on training with simulation, with 17 papers in index journals. Group B papers included rise in papers in “URS”(+360%,p = 0.0039) and “PCNL” (+110%, p = 0.0181), while the analysis of papers on “SWL” (‐33%) and “ureteral stenting” (‐50%) showed a decreasing trend. Group C papers included rise in papers by +200%, with a low number of publications in both period demonstrating a lower interest compared to other simulations.
Conclusions: Simulation has been widely discussed among publications in the last two decades, and The trend of publication is still increasing, with a special interest reserved for application of simulators in residents training as well as in performance studies. PCNL and URS simulation has grown substantially, with numerous applications, from teaching to patient‐specific surgical planning and counseling, which should hopefully improve clinical outcomes and patient satisfaction.
Funding: None
Enhanced‐Pulse‐Setting (EPS) for HoLEP – Benefit for the Learning Curve? – A Prospective European Two‐Center Study
Sven Piesche3, Razvan Dican1, Horia Radu1, Michael Kortleve2
Introduction: Holmium Laser Enucleation of the Prostate with Enhanced Pulse Setting (HoLEP‐EPS) uses a high pulse energy to optimize the benefit of the mechanical dissecting effect of the Holmium laser pulse. As this crucially supports the surgeon to find and dissect the capsular layer, the EPS might be beneficial for beginners.We prospectively evaluated the learning curve of HoLEP‐EPS.
Methods: Using 6 standardized teaching steps and a mentored training, the learning curves of 5 HoLEP‐ beginners (Hof, Germany and Ede, The Netherlands) were created. Primary endpoint was the number of operations necessary to master the complete operation (enucleation as well as morcellation) without the teacher (Fig. 1)For all enucleationes the Enhanced Pulse Setting (EPS) (4J / 35 Hz or 3J / 37 Hz) was used. Laser machines, morcellators, resectoscopes as well as surgeons endourological experience varied.
Results: The median number of operations needed to master a HoLEP‐EPS was 9 (Range 5‐15) (Fig. 2)Average operation speed during the learning curve 0.69 g/minMediancatheter time 24 hRate of transient incontinence 18%.Complication rate (Clavien‐Dindo‐scale) II‐III 6%, IV‐V none.
Conclusions: HoLEP EPS with a standardized mentor based training provides a fast learning success as well as a low complication rate. Therefore, the EPS‐setting might be advantageous especially for beginners. However, comparative studies with other pulse settings are necessary to confirm the results.
Funding: None
Safety During the Endourology Procedures Among Urology Trainees
Kavita Gupta1, Kevin Labagnara1, Dima Raskolnikov2, Michelle Semins3, Alexander Small1
1Montefiore Medical Center and Albert Einstein School of Medicine, 2Montefiore Medical Center and Albert School of Medicine, 3West Virginia University School of Medicine
Presented By: Kavita Gupta, MD
Introduction: Urology trainees are at risk from numerous occupational hazards during endourology procedures including radiation, lasers, urine and blood pathogens, chemicals, and uncomfortable postures. With early awareness and education, personal danger can be reduced. We aimed to characterize and evaluate resident and fellow preparedness and safety for these occupational hazards.
Methods: Urology residents and fellows were surveyed through an online form distributed to residency program directors and endourology fellowship directors in the United States. Data were obtained on radiation/laser safety, protective equipment, ergonomics and personal injuries/exposures. Descriptive statistics were performed.
Results: 68 trainees responded including 52 residents (77%) and 16 fellows (24%). Respondents were 69% male, and all AUA sections participated (NY 38%, North Central 18%, Mid Atlantic 12%, Western 10% and other 22%). Respondents performed a median 5 (IQR 4‐10) endourology procedures per week. Regarding radiation safety, 65% received formal education (via online module 49%, lecture 32% and/or printed material 7%) and 35% received informal or no training. Nearly all use lead aprons (91% communal and/or 16% personal) and thyroid shields (81% communal and/or 24% personal), but only 50% use dosimeters and 16% use lead glasses. 69% have been accidentally exposed to radiation, as frequently as daily 3%, weekly 4% or monthly 15%. 3 trainees reported medical conditions potentially related to radiation including cataracts, thyroid cancer and infertility. Body fluid exposures were reported by 38% of trainees (23% eye splash and 6% sharp stick) with a median 5 (IQR 3‐10) exposures. 10% have taken prophylaxis for blood borne pathogens. Finally, 47% reported no ergonomic safety education. 87% suffered acute or chronic pain related to static posturing during endourology procedures, including neck pain 49%, back pain 49%, hand/wrist pain 40%, and shoulder pain 38%. 4 respondents have sought medical attention for these pains.
Conclusions: Trainee safety practices for endourology procedures are highly variable. Many lack formal education about radiation and ergonomic practices, and an alarming number have suffered exposures, medical conditions related to radiation, and acute and chronic pains from static posturing. There is a need to ensure trainees are learning methods to keep them healthy and safe during their career.
Funding: none
Compliance for Documentation of Urinary Catheterisation and Its Impact on TWOC Clinic Outcomes, Quality Improvement Project at Wythenshawe Hospital
Mahmoud Elmousili2, Thiru Gunendran1
1Manchester Foundation Trust, 2Wythenshawe Hospital, Manchester Foundation Trust
Presented By: Mahmoud Elmousili, MBBCH
Introduction: Documentation is essential to clinical practice, and proper catheterisation procedure documentation ensures continuity of care and effective handover among healthcare professionals. This project looked at the documentation at the A&E department and its impact on patients passing or failing TWOC.
Methods: Data were collected retrospectively from August to December 2021. 70 patients were included in the 1st cycle. Inclusion criteria included male patients who presented to A&E with acute/chronic retention, difficulty in changing catheter by district nurse (DN), haematuria and other catheter‐associated problems. Female patients and patients who were admitted to the hospital were excluded.
Results: The QIP found that 19% of patients had no documentation for PV bladder scan, and 69% had no DRE done. Nearly half of the patients hadn't had the type or size of catheter documented (59 & 52%, respectively). Only 31% of catheter introducers registered whether the catheter insertion was easy/difficult, while 11% provided their patients with Catheter Passports. Post catheterisation, 35% of the patient had no Tamsulosin/Finasteride prescribed; 17% failed TWOC, while the chances of successful TWOC increased to 35% with a prescription of Tamsulosin/Finasteride. Most patients who failed TWOC have no documented catheter type (14%). Moreover, the incidence of failing TWOC was higher in patients with latex catheters (4%) in comparison to silicone catheters (2%). Referral to TWOC clinic was missed in 10%, while DN referral was not done for 31% of patients.
Conclusions: There is clear evidence that the lack of proper documentation for the procedure has adverse outcomes for the TWOC clinic. Awareness among junior doctors, and nurses should be increased regarding standardised documentation. Moreover, a smart phrase integrated into HIVE can be a plausible solution.
Funding: Non applicable
Comparative Analysis of Current Versus Perceived Optimized Use of Point‐of‐Care Ultrasound in Urology
Ryan Steinberg1, Charles Schlaepfer1, Zubin Shetty1, Chad Tracy1, Vignesh Packiam1, Elizabeth Takacs1
1University of Iowa Health Care
Presented By: Ryan Steinberg, MD
Introduction: Point‐of‐care ultrasound (POCUS) is a valuable tool for clinicians with multiple benefits, including lack of ionizing radiation, portability, and real time results. Yet, implementation into urology practices has been slow, at best. While there is plentiful evidence supporting the merits of POCUS, there are no studies assessing contemporary practice patterns or perceived optimal POCUS utilization. We now aim to assess this amongst North American urologists.
Methods: An IRB‐approved survey was developed and disseminated to 6 of 8 AUA sub‐section by email. Data including demographics, prior training, current ultrasound utilization, and perceived optimal POCUS utilization was collected. Perceived optimal use was defined as a positive response to questions regarding when “POCUS is the most useful” (Figure 1). Data was collected via the University of Iowa RedCap system (NIH CTSA UL1TR002537). Descriptive statistics and Chi squared analyses were performed (p < 0.05).
Results: There were 199 respondents, of which 51% worked in an academic practice and 68% had > 10 years practice experience. Most respondents (77%) used some form of POCUS in practice but only 37% had prior formal training. When considering organ‐specific POCUS, significant disparities between perceived optimal use and current use were noted for renal (optimal 88% vs current 58%), testes (74% vs 37%), and penile (37% vs 19%) studies (Table 1). These changes did not appear to be driven by those who are not current POCUS users. Similar differences were also seen in both diagnostic (81 vs 52%, p < 0.01) and therapeutic (24 vs 9%, p < 0.01) based utilization. Finally, the emergency room was the only setting in which perceived optimal use differed from current use (39% vs 16%, p < 0.01).
Conclusions: POCUS appears to be underutilized in various aspects of urologic practice. Exploring means for increased POCUS training, particularly in diagnostic ultrasound focused on the kidneys, testes and penis, is warranted.
Funding: University of Iowa Health Care 2021 Graduate Medical Education Innovation Grant
Incidence and Predictors of Endourologic Fellowship Delays
Nicholas Dean1, Mitchell Huang1, Matthew Lee2, Mark Assmus3, Perry Xu1, Jenny Guo1, Amy Krambeck1
1Northwestern University, 2Ohio State University, 3University of Calgary
Presented By: Perry Xu, MD
Introduction: Most graduating urology residents are under contract until June 30th and many fellowships begin on July 1st. Fellowship training may require relocation, hospital credentialling, new medical licenses, and governmental clearances leading to possible delays in clinical starts. Our objective is to identify the incidence and predictors of endourologic fellowship delays.
Methods: We surveyed 250 Endourologic Society fellows (2017‐2022). All statistical analysis was performed using Excel.
Results: A total of 77 endourologists and current fellows responded. Most respondents (n = 66/77, 85.7%) relocated for their fellowship training. Of those that re‐located, 54.3% (n = 25/46) left their residency training prior to the official end date. Delays in the commencement of fellowship clinical activity were commonly reported (28.6% n = 22/77). Fellowship training in the COVID‐era (2020‐2022) and fellowships requiring international re‐location were associated with more frequent (OR 4.9, p < 0.01) and longer delay durations (> 2weeks) (OR 17.4, p < 0.01). Almost half of international fellows who experienced delays were prohibited from practicing medicine for greater than 4 weeks (41.7%, n = 5/12). Fellows experiencing clinical delays considered these delays “stressful” (68.2%, n = 15/22) and 40.9% (n = 9/22) reported these delays as “very stressful”. Most respondents (80.9%, n = 55/68) supported delaying the official endourologic fellowship start date.
Conclusions: Almost one third of responding endourologic fellows experienced stressful delays in their fellowship training. Fellows requiring international relocation experienced more frequent and longer fellowship delays. It is unknown how these unproportionate fellowship delays affect the diversity of fellowship candidate selection and training experience. Adjustments in the time from resident completion to fellowship initiation could help to alleviate delays in training and the associated stress on the trainees.
Funding: None
3D Rendering of Cystoscopy Video Footage: A Novel Method Utilizing Neural Radiance Field Processing
Jonathan Katz1, Jamie Finegan1, Jingpei Lu2, Shan Lin2, Michael Yip2, Roger Sur1
1UCSD/Department of Urology, 2UCSD/Department of Computer Science
Presented By: Jonathan Katz
Introduction: Recent developments in Neural Radiance Field Processing (NERF) have leveraged the power of neural networks to quickly reconstruct 3D spaces from 2D images. Our objective was to utilize this technology to 3D render video recordings of diagnostic cystoscopies and test their fidelity.
Methods: With IRB approval we recorded two diagnostic cystoscopies (one with an Ambu disposable flexible cystoscope and the other with a Wolf digital cystoscope). We converted the videos to images and then curated the images to choose approximately 100 images, which minimized blur and spanned a large segment of the bladder. We then utilized the NVIDIA Instant Neural Graphics Primitives (iNGP), a NeRF algorithm that uses multiresolution hash encoding with a compact neural network for significantly faster convergence, to reconstruct the bladder and render novel, unseen views. We computed the structural index similarity (SSIM) and Peak signal to noise ratio (PSNR) to assess the quality and fidelity of the 3D rendering.
Results: Both videos were able to be utilized for 3D rendering using iNGP. The rendering derived from the Wolf cystoscopy had a PSNR = 29.8 [min = 27.2, max = 32.6] and SSIM = 0.89. Similarly, the rendering derived from the Ambu cystoscopy had a PSNR = 31.3 [min = 27.1, max = 35.1] and SSIM = 0.90, static sample images below (Image 1).
Conclusions: Independent of cystoscopy equipment, both 3D renderings achieved reasonable fidelity. Major limitations to widespread adoption of this technology include the need for a curator to select representative and high‐quality images from the initial cystoscopy video recording and the relatively small segments of bladder successfully rendered. Nonetheless, we feel that with further refinement this technology can be scaled to create 3D renderings of cystoscopies that will enable evaluation of both completeness and quality of the cystoscopy. Furthermore, this technology would be able to facilitate the comparison of cystoscopies performed in the same patient over time.
Funding: None
American College of Surgeons Simulation Fellowships at Two Institutions and Their Global Impact on Endourology
Robert Sweet7, Burak Argun1, Sanket Chauhan2, Domenico Veneziano3, Zichen Zhao4, Yasser Noureldin5, Tony Chen6, Lauren Poniatowski7, Jonathan Wingate8, Andrew Rabley7
1Acibadem Hospital, 2Baylor Scott and White Health, 3Northwell Health, 4Peking University Shougang Hospital, 5Northern Ontario University, 6Stanford University, 7University of Washington, 8Uniformed Services University
Presented By: Robert Sweet, MD, FACS, MAMSE
Introduction: The role of simulation‐based education for training has expanded over the last two decades. “Healthcare SimulationScience” has begun to emerge as a multidisciplinary discipline including an understanding of our clinical discipline and its greater role in the healthcare system, education, engineering and the arts. The inherently diversenatureof this new discipline has stymied the growth of the field through a lack of a unified and shared understanding of related fields'knowledge, skills, nomenclature, and culture. To facilitate the growth of this new discipline, there was a need to develop a formal training program to prepare individuals to lead and develop programs to more effectively disseminate the benefits of simulation worldwide.
Methods: The first formal surgical simulation training fellowship was created in 2009 at the University of Minnesota. A formal structured curriculum with leadership, administrative, research and education learning objectives were presented to the American College of Surgeons to establish an accreditation process and it was approved in 2012. As of 2023, 20 programs are now accredited by the ACSto provide this type of education around the world. Two programs (UMN and UW) had experience with training several endourologists. Impact metrics were measured through follow‐up structured interviews with the former fellows.
Results: At the two institutions, between 2009‐2023,including a pandemic that significantly impacted training opportunities, twelve fellows have graduated from the program. 6 (50%) are endourologists, 3(25%) are (other) urologists and 3(25%) are from other interventional disciplineswho havegone on to leadership positions in various aspects of healthcare simulation science. To date, amongst many other impactful, broader healthcare initiatives, the trained endourologists/urologists collectively provided 19,762 urology learner‐ hours(l‐h) with an additional ∼54,000 l‐h in other disciplines, developed 28 simulators, contributed to the creation of 43 urology and 105 other curricula, published 49 simulation articles, wereresponsible for starting 3 international simulation centers, lead/found 5international training programs and started 3 simulation companies.
Conclusions: Formalsimulation science training of endourologists has the potential to make anenormousimpact on the development, deployment, and global dissemination of skills through simulation‐ based education around the world.
Funding: The University of Minnesota Board of Regents funded the program from 2009‐2016.The Pellegrini‐Oelschlager endowed fellowship funded the University of Washingtonprogram from 2016‐present.
Use of the OR Black Box to Evaluate Operating Room Economic Efficiency – the Northwell Experience
Arun Rai1, Louis Kavoussi1, Leah Beland1
1Northwell Health
Presented By: Arun Rai, MD, MBA, MSc
Introduction: Operating room (OR) utilization is a key component of economic considerations utilized by OR directors and hospital administrators. Case start times and turn over time can significantly impact OR utilization and overall economic efficiency. The OR Black Box® (ORBB) is a recording platform that integrates both audio and visual recordings of the operating room and procedure. We utilized information from the ORBB to identify factors that impact OR utilization as well as compliance with safety protocols.
Methods: This is a prospective analysis of operating room utilization at a tertiary academic health center using a novel data capture device designed for use in the operating room. Information from the ORBB of three busy operating rooms were reviewed from February 7 to September 4 of 2022 to evaluate case on‐time starts, block utilization, turnover time, and compliance with pre‐procedural ‘time out’ safety checklist. Block utilization is defined as the time in which a patient is in the OR for the 9‐hour block periods or is it “the sum of the time it takes to perform each surgical procedure plus the total turnover time, divided by the time available”. The turn‐over times were compared to national averages provided by the ORBB platform.
Results: Data from 1342 cases were included for analysis. Average turnover time across the three ORs was 46 minutes, which is above the 38‐minute national average for all ORs equipped with the ORBB. This increased turnover time equated to 30‐31 hours of overtime, which at our institution amounts to approximately $1,460 of additional costs. On average, there was 67% block utilization time across the 3 ORs, which represents the amount of time that a patient is present in the OR. Cases started on time 68% of the time for all ORs, however when looking at urology cases only, cases started 100% on‐time. From a safety checklist standpoint, 97% of cases had a time‐out completed correctly per hospital policy.
Conclusions: Data derived from the ORBB allows for assessment of OR utilization and adherence to safety protocols. This data is critical from a health management standpoint to ensure judicious use of hospital resources. Further data is needed to understand factors prolonging turn‐over time at our institution as well as those preventing on‐time start among services other than urology. Further data will need to evaluate factors enabling urology cases to achieve a 100% on‐time start, such that other services can achieve similar rates. Ultimately improve OR block utilization.
Funding: None
MODERATED POSTER SESSION 24: PROSTATE AND BLADDER IMAGING
Do 5‐Alpha Reductase Inhibitors Influence the Features of Suspicious Lesions on Magnetic Resonance Imaging and Targeted Biopsy Results for Prostate Cancer Diagnosis?
Introduction: 5‐alpha reductase inhibitors (5‐ARI) change hormonal pathways and reduce prostate size. We evaluated the effects of 5‐ARI on prostatic multiparametric magnetic resonance imaging (mpMRI) suspicious findings and identification of prostate cancer using mpMRI‐targeted biopsies.
Methods: We conducted a retrospective study including 482 consecutive patients who underwent mpMRI‐ targeted biopsies between 2017‐2021. Number of suspicious lesions, their Prostate Imaging Reporting & Data System version 2 (PIRADS v2) scores, and identification of clinically significant prostate cancer (CSPC), both overall and from regions of interest (targeted‐CSPC), were compared between patients treated with 5‐ARI for a minimum of 6 months on the time the MRI was performed and the others.
Results: Patients treated with 5‐ARI were older (p < 0.001) with higher rates of previous prostate biopsies (p = 0.03). Maximal PIRADS scores were 3, 4 and 5 in 9 (22%), 24 (58%) and 8 (20%) patients among 5‐ARI patients, and 97 (22%), 251 (57%) and 93 (21%) patients among the others, and were not different between the groups (p = 0.97, Table 1). The number of suspicious lesions per patient was also not different between the groups (p = 0.8). Overall CSPC and targeted‐CSPC identification rates among 5‐ARI patients were 41% and 31%, respectively, and were not different compared to the others (p = 0.39 and p = 0.86, respectively). Rates of targeted‐CSPC for each PIRADS score were not affected by 5‐ARI treatment (Table 1). 5‐ARI treatment was not associated with neither PIRADS5 score nor targeted‐CSPC on logistic regression analyses (OR = 0.9, 95%CI 0.4‐2 and OR = 1, 95%CI 0.5‐2.1, respectively). Insignificant prostate cancer identification was higher among patients not treated with 5‐ARI (p = 0.01).
Conclusions: 5‐ARI treatment is not associated with number of lesions, PIRADS score alterations or targeted biopsy results. Patients treated with 5‐ARI with suspicious lesions should not be addressed differently during the mpMRI‐related diagnostic process.
Funding: None
Utility of Noninvasive Biomarker Testing and MRI in Predicting Prostate Cancer Diagnosis
Mark I Sultan1, Mark I Sultan1, Linda M Huynh1, Sarah Kamil1, Ahmad Abdelaziz1, Muhammed a Hammad1, Greg E Gin1, David I Lee1, Ramy Youssef1
1University of California, Irvine
Presented By: Mark I Sultan, MD
Introduction: The use of Magnetic Resonance Imaging (MRI) and noninvasive biomarker for biopsy decision making has been rising among urologists. We aim to assess the diagnostic performance and utility of the ExoDx IntelliScore and an OPKO4K score to predict prostate cancer in men presenting with elevated Prostate Specific Antigen (PSA)‐ both as independent predictors and in combination with clinical/MRI imaging characteristics.
Methods: Patients with elevated PSA from 2017‐2020 were retrospectively reviewed. Abnormal tests were defined as an OPKO4K score ≥7.5% and an ExoDx IntelliScore ≥15.6. Four regression models and receiver‐ operator characteristic (ROC) curves were generated based on: (1) age, baseline PSA, and digital rectal exam, (2) model 1 + OPKO4K 4Kscore ≥7.5%, (3) model 2 + ExoDx IntelliScore ≥15.6, and (4) model 3 + MRI PIRADS 4‐5.
Results: 359 men received an OPKO4K test, 307 had MRI and 113 had ExoDx tests. Ultimately, 163 men proceeded to prostate biopsy and 196 (55%) were saved from invasive biopsies after discussion of additional testing. Mean age was 65.0 ± 8.7 years and mean baseline PSA was 7.1 ± 6.1ng/ml. Positive biopsies were found in 84 (51.5%) men. The sensitivity and negative predictive value of an OPKO4K score were 86.7% and 72.3%; values for an ExoDx test were 76.5% and 77.1%, respectively.Opko4K score, ExoDx IntelliScore, and MRI characteristics significantly improved predictive capability. On logistic regression modeling, classical clinical markers (Age, PSA, DRE) generated an AUC of 0.559. The addition of an OPKO4K score raised the AUC to 0.653. The stepwise addition of an ExoDx score raised the AUC to 0.766. The combined use of both biomarkers, patient characteristics, and MRI results yielded an AUC of 0.825.
Conclusions: This analysis demonstrates the high negative predictive value of both the OPKO4K score and ExoDX IntelliScore independently – while demonstrating that the combination of an OPKO4K score with an ExoDX IntelliScore also increases diagnostic accuracy. A model combining an ExoDx Prostate test with an OPKO4K score, MP‐MRI, DRE, and patient serum PSA displayed high predictive capability for biopsy confirmed prostate cancer. Our data supports prospective evaluation of diagnostic algorithm combining non‐ invasive biomarkers with MRI for prostate biopsy decision making.
Funding: None
WITHDRAWN
Can We Better Evaluate Extraprostatic Extension (EPE) Before Surgery? Use of Prostate MRI EPE Scoring System to Predict Post Prostatectomy Locally Advanced Prostate Cancer
Angela Estevez1, Utsav Bansal1, Joseph Black1, Tatum Williamson1, Sumedh Kaul1, Catrina Crociani1, Jeffrey Sun1, Leo Tsai1, Sara Babapour1, Jodi Mechaber Di Fiori1, Boris Gershman1, Peter Chang1, Andrew A. Wagner1
1Beth Israel Deaconess Medical Center
Presented By: Angela Estevez, MD
Introduction: Delineatingextraprostatic extension (EPE) is crucial for the treatment of patients with prostate cancer. EPE is associated with increased risk of recurrence, positive surgical margins, and metastatic disease.A preoperative assessment of presence and location of EPE can help guide surgical decision making as to the nerve‐sparing approach.TheMRI‐based EPE grading system developed by Mehralivand et al (Table 1) has not been widely adopted. The purpose of thestudy is to examine theabilityof MRI‐based EPE scoring to accurately detect EPEon pathology.
Methods: We conducted a retrospective review of adult male patients who underwent a prostate MRI with EPE scoring by a trained radiologist and subsequent robotic radical prostatectomy at our tertiary level center from September 2020 to December 2022. The associations between MRI EPE score (mEPE) and the presence of EPE on surgical pathology (pEPE) were examined using logistic regression.
Results: A total of 194 patients were identified with a median age of 63 years and median PSA of 7 ng/mL. The rates of pEPE across mEPE scores are presented in Table 2. Among those with mEPE score 3, 96% had pEPE (Table 2). On univariable regression, those patients who had an mEPE score > = 2 had an increased risk of pEPE compared to those with mEPE score of 0 (OR 10.2; 95% CI 4.7‐22.1, p < 0.05) Furthermore, those with an mEPE score 3 were significantly more likely to have pEPE compared to those with mEPE score 0,1 and 2 independently (Table 3).
Conclusions: MRI EPE is an easily definable tool that strongly correlates with the presence of pEPE. Moving forward, mEPE status may assist in augmented patient and surgical counseling.
Funding: None
The Use of Neuronal Network Machine Learning to Predict Pathologically Significant Prostate Cancer Upgrading in Patients Diagnosed with GG1 Disease on Prostate Biopsy
Omri Nativ1, Ehud Berger1, Kamil Malshy1, Omer Sadeh1, Etan Eigner1, Alexander Kastin1, Alexander Kravtzov1, Edmond Sabo2, Azik Hoffman1, Gilad Amiel1
1Rambam Medical Center, 2Carmel Medical Center
Presented By: Omri Nativ, M.D
Introduction: The management of PCa is based on a risk stratification where in the case of localized disease the patients are elected for either active surveillance or an invasive treatment. This risk stratification system is based on three main parameters: PSA level, Gleason grade and the clinical stage of the disease. Despite the clinical definition of a low‐risk disease, in certain cases the disease biology is actually aggressive with a potential to become a significant disease or in other cases a sampling error has undegraded the true disease pathology. The aim of our study was to determine the probability of Gleason score upgrading to a clinically significant disease using neuronal network machine learning.
Methods: Using our local radical prostatectomy registry, we have retrospectively reviewed patients' medical records for Age, BMI, PSA level at diagnosis, prostate biopsy findings, prostate volume, PSA‐D, D'Amico risk classification and pathological staging following prostate biopsy and surgery. Clinically significant (CS) PCa was defined as Gleason 7(3 + 4) and higher (≥ GG 2). Univariant and multivariant analyses were used to predict significant PCa at radical prostatectomy specimens. Fisher exact and Mann‐Whitney U tests were used for categorical and continuous variables, respectively. Next, a neural network (NN) machine learning model was trained using the above variables in order to predict the probability of pathologically upgrading to a CS disease. A back propagation algorithm was used for validation of the NN.
Results: 428 patients underwent robotic‐assisted radical prostatectomy between 2012 and 2021 in our institution. 72 patients (17%) had a clinically insignificant disease determined by prostate biopsy. of which 34 patients (72%) were upgraded to a CS disease on the final pathology. On univariate and multivariate analysis, the only preoperative variable that predicted a CS final pathology was the PSA‐density (PSAD) with a sensitivity and specificity of 36% and 74% respectively. When using the NN machine learning the probability to predict disease upgrading was more accurate with a sensitivity and specificity of 94.1% and 97.1% respectively
Conclusions: NN machine learning can be trained and used for predicting the probability of PCa upgrading in patients with a biopsy proven Gleason 6 disease. In our cohort the NN sensitivity and specificity were superior compared to the traditional descriptive statistics
Funding: None
The Utility of a Radiomic Model in Predicting Prostate Cancer Recurrence Following Surgical Treatment
Linda Huynh`3, Jacob Marasco1, Thomas Ahlering2, Shuo Wang3, Michael Baine3
1Creighton University, 2University of California, Irvine, 3University of Nebraska Medical Center
Presented By: Linda Huynh`, MSc
Introduction: Multi‐parametric magnetic resonance imaging (mpMRI)‐derived radiomics have been shown to capture sub‐visual patterns for quantitative characterization of prostate cancer (PC) phenotypes. The present study seeks to develop, test, and compare the performance of an MRI‐derived radiomic model for the prediction of PC recurrence following definitive treatment with radical prostatectomy (RP).
Methods: mpMRI was obtained from 76 patients who had a minimum of 2 years follow‐up following RP. The prostate was manually delineated as the region of interest and 924 radiomic features were extracted. All features were tested for stability via intraclass correlation coefficient (ICC) and image normalization via histogram matching.
Results: Six important and non‐redundant features were found to be predictors of PC recurrence at a median of 4.1 (2.2) years and were aggregated into a radiomic model. Five‐fold, ten‐run cross‐validation yielded a receiver‐operator characteristic area under the curve (ROC‐AUC) of 0.95 ± 0.06 in the training set (n = 56). In comparison, the UCSF Cancer of the Prostate Risk Assessment score and MSKCC Pre‐Radical Prostatectomy nomograms yielded AUC of 0.72 ± 0.07 and 0.82 ± 0.07, respectively. Finally, when the radiomic model was applied to the test set (n = 20), ROC‐AUC was 0.67 and sensitivity, specificity, positive predictive value, and negative predictive value were 33%, 100%, 40% and 100%, respectively.
Conclusions: The present study is a proof of concept for the use of an mpMRI‐derived radiomic model in predicting PC recurrence in 76 prostate cancer patients, yielding six radiomic features significantly associated with recurrence following RP. When these features were aggregated into a radiomic signature, this signature predicted recurrence well in cross‐validation and predicted patients at low‐risk for recurrence with 100% specificity. Furthermore, when predictive capability was compared with the UCSF‐CAPRA score, the radiomic model illustrated significantly higher ROC‐AUC.
Funding: N/A
Increasing Trend of PIRADS 5 on mpMRI with Lower Rates of Clinically Significant Prostate Cancer
Alexander Homer2, Rebecca M. Ortiz1, Borivoj Golijanin2, Sai Allu1, Natalie Passarelli1, Vikas Bhatt2, Gyan Pareek1, Elias S. Hyams2
1The Minimally Invasive Urology Institute, The Miriam Hospital, Urology Division, Warren Alpert Medical School of Brown University, 2The Minimally Invasive Urology Institute, The Miriam Hospital, Urology Division, Warren Alpert Medical School of Brown University, Providence, RI, USA
Presented By: Alexander Homer, AB
Introduction: Multiparametric MRI (mpMRI) has become a standard of care in the evaluation of clinically significant prostate cancer (csPCa). Concerns have been raised regarding the learning curve of radiologists and the subjective nature of interpretation. This study aimed to assess the trends in MRI interpretation and the diagnostic accuracy of MRI fusion biopsy.
Methods: A retrospective analysis was conducted on patients without a history of prostate cancer who underwent a 3T mpMRI and TRUS fusion biopsy at a single center between 2017 and 2020. The presence of csPCa was determined based on Grade Group 2 (GG2) or higher, cancer volume > 0.5 mL, or evidence of extra‐prostatic extension. Logistic regression examined temporal trends in csPCa probability, GG2+ disease, positive biopsy in more than 50% of cores, perineural invasion, PIRADS 3, 4, or 5, csPCa among PIRADS 3 and PIRADS 4/5 patients, and the association between PSA density and high‐grade (HG) disease in PIRADS 4/5 patients. OLS regression analyzed trends in cancer volume.
Results: 311 subjects met the inclusion criteria. The percentages of PIRADS 3, 4, and 5 findings were 18.3%, 29.9%, and 14.5%, respectively. There were increased odds of detecting PIRADS 4/5 (OR: 1.53, 95% CI: 1.27‐1.84), csPCa (OR: 1.40, 95% CI: 1.17‐1.68), > 50% positive cores (OR: 1.80, 95% CI: 1.44‐2.27), and perineural invasion (OR 1.81, 95% CI: 1.30‐2.64) year‐over‐year. Cancer volume increased 0.028 mL per year (SE: 0.0077). csPCa was detected in 17.5%, 46.2%, and 60% of PIRADS 3, 4, and 5 exams, respectively. Odds of finding csPCa in PIRADS 4/5 (OR 1.27, 95% CI: 1.006‐1.611) and PIRADS 3 lesions (OR 1.52, 95% CI: 1.26‐1.86) significantly increased per year. While odds of finding HG cancer in PIRADS 4/5 lesions did not significantly change, there was an increase in PIRADS 3 lesions (OR 1.42, 95% CI: 1.17‐ 1.74). PSA density > 0.15 (OR: 2.31 CI: 1.12‐4.84) and log PSA density (OR 1.76, CI: 1.085‐3.03) were associated with higher PIRADS 4/5 specificity.
Conclusions: Over time, PIRADS 4/5 findings and csPCa have increased in men undergoing mpMRI, indicating improved radiologist skills and a potential trend towards more aggressive cancer. However, PIRADS 5 had lower than expected rates of significant disease. Assessing the negative predictive value in mpMRI remains challenging as those with normal imaging are often monitored instead of biopsied. Continuous evaluation of MRI accuracy and trends is vital for high‐quality risk assessment.
Funding: None
Impact of Clinical and Radiographic Factors on Cancer Detection Rate of MRI Targeted PIRADS Lesions
Ahmad Alzubaidi1, Xuanjia Fan1, Mo Said2, R. Grant Owens1, Michael Maidaa3, Suraj Pursnani1, Scott Owens4, Thomas Stringer3, Chad Tracy2, Jay Raman1
1Penn State Health, 2University of Iowa, 3University of Florida, 4UPMC
Presented By: Ahmad Alzubaidi, M.D.
Introduction: mpMRI targeted prostate biopsy improves detection of clinically significant cancer (CSC; Grade Group ≥2). Continued refinements in predicting pre‐biopsy probability of CSC are essential for optimal patient counseling. We investigated potential factors related to improved cancer detection rates (CDR) of CSC in patients with PIRADS ≥3 lesions.
Methods: The pathology of 980 index lesions of patients who underwent transrectal mpMRI targeted prostate biopsy across 4 academic centers between 2017‐ 2020 was reviewed. PIRADS lesion distribution included 291 PIRADS‐5, 374 PIRADS‐4, and 315 PIRADS‐3. Patients with index lesions within the anterior fibromuscular stroma (n = 74) were excluded due to low numbers. We compared CDR of PIRADS ≥3 lesions based on location (transitional zone (TZ) vs peripheral zone (PZ)), PSA density (cutoff of 0.15 ng/mL/cm3 ) and history of prior negative conventional TRUS biopsy
Results: Median patient age, PSA, and prostate volume was 66 years (43‐90), 7.82 mg/dl (0.2‐277), and 54 cm3 (12‐173), respectively. For PIRADS‐5, PIRADS‐4, and PIRADS‐3 lesions, CSC was detected in 164 patients (56%), 133 patients (36%), and 49 patients (16%), respectively. Notably, higher PSA density, no prior history of TRUS biopsy and PZ lesions were associated with higher CDR (Figure). CDR stratified across the factors of interest highlights significant variance across subgroups. For example, CDR for PIRADS‐5, PZ lesions in patients with PSAD ≥0.15 and prior negative biopsy
Conclusions: For patients undergoing MRI targeted biopsy of PIRADS ≥3 lesions, CDR varied significantly based on location, prior history of negative TRUS biopsy and PSA density. Such considerations are critical for patient counseling when evaluating the merits and potential yield of mpMRI targeted biopsy
Funding: None
Artificial Intelligence: A Tool for Aiding in Timely and High‐Quality Prostate Cancer Diagnostics and Care
Puranjay Shori5, Puranjay Shori1, Jong Kim2, Robert Carey3, Victoria Bird4
1University of Florida, 2Doctors Imaging Group, 3Florida State University College of Medicine, 4Urologic Integrated Care, 5UTHealth Houston School of Public Health
Presented By: Victoria Bird, MD
Introduction: This study compares artificial intelligence (AI) derived and human derived whole gland segmentation of the prostate, seminal vesicle, and urethra through magnetic resonance imaging (MRI) and evaluates the practical use of this technology to streamline workflow and care through procedures such as MRI‐ultrasound fusion prostate biopsies.
Methods: The AI generated “auto contours” for prostate MRIs of 31 patients were generated through a medical image softwareto produce contours of the prostate, seminal vesicle, and urethra. These MRIs were also contoured manually by both a board‐certified urologist and a radiologist, and the volumetric conformity of the 3 groups of contours was evaluated through the the Dice and Jaccard coefficients, as well as other metrics such as the Hausdorff distance (HD), and Mean Distance to Agreement (MDA). The elapsed time to produce contours was also recorded.
Results: The average volumetric Dice and Jaccard coefficients, HD, and MDA for the AI and urologist contoured images (AI‐U) were 0.875, 0.779, 9.186 mm, and 1.410 mm for the whole gland segmentation of the prostate, 0.377, 0.260, 14.708 mm, and 4.260 mm for the seminal vesicle, and 0.283, 0.178, 18.117 mm, and 4.907 mm for the urethra; for the AI and radiologist contours (AI‐R), the values were 0.757, 0.614, 17.562 mm, and 3.050 mm for the prostate, 0.451, 0.315 16.069 mm, and 4.075 mm for the seminal vesicle, and 0.162, 0.092, 19.956 mm, and 4.798 mm for the urethra. In comparing the contours of the urologist to the radiologist (U‐R), the values of the prostate were 0.769, 0.630, 15.109 mm, and 2.733 mm, for the seminal vesicle, 0.471, 0.333, 12.981 mm, 3.264 mm, and for the urethra, 0.144, 0.080, 13.560 mm, and 3.406 mm. For the prostate and urethra, the AI‐U comparison was different than the other comparisons (p < 0.05). For the seminal vesicle, no statistical difference in the 3 Dice coefficients was observed (p > 0.05). The average times to produce contours for AI, a urologist, and a radiologist were 96.5 seconds, 285.8 seconds, and 217.9 seconds, respectively (p < 0.05 for each time).
Conclusions: The results suggest that, for the seminal vesicle, no statistical difference between the Dice similarities of AI‐U, AI‐R, and U‐R was observed. Though the contours of the prostate and urethra did show a higher conformity for AI‐U than AI‐R and U‐R, because AI‐R and U‐R presented similar conformities, it is unlikely this variability is linked to the AI's accuracy. Hence, AI varies in conformity as much as other physicians and generates contours in less time, and current AI software holds potential as an effort‐reducing tool for streamlining prostate cancer diagnostics in the clinical setting.
Funding: None
Reconciling Discordance Between PIRADS‐4 Lesions and Targeted Biopsy Histology – Early Experience with a Structured Multidisciplinary Quality Improvement Protocol and PI‐RADS 4 Subcategorization
Sriram Deivasigamani1, Srinath Kotamarti1, Eric S Adams2, Dylan Zhang2, Zoe Michael1, Thomas J. Polascik2, Rajan T Gupta2
1Duke University Medical Center, 2Duke University Medical Center
Presented By: Sriram Deivasigamani, MD
Introduction: PI‐RADS 4 lesions are considered to have a “high” likelihood of clinically‐significant prostate cancer (csPCa). However, patients undergoing targeted biopsy have a range of histologic findings. Understanding discordant cases is critical to improve diagnostic accuracy and inform subsequent management. We studied early findings from implementation of a multidisciplinary Quality Improvement (QI) protocol for reconciling discordance and evaluate the potential heterogeneity of PI‐RADS 4.
Methods: Patients with mpMRI PI‐RADS 4 lesions undergoing fusion‐targeted biopsy from Jan 2017 to May 2021 were retrospectively reviewed. The discordant targeted biopsy pathology (benign/GG1) was evaluated utilizing a QI protocol and all lesions were subcategorized based on ADC values. Positive Predictive Value (PPV) for PI‐RADS 4 lesions overall and the Cancer Detection Rate (CDR) for subcategorized lesions were calculated.
Results: 248 patients with 286 lesions were reviewed. Prior to re‐review, PI‐RADS 4 PPV for > GG1 and > GG2 lesions were 0.55 and 0.34, increasing to 0.67 and 0.43 following reconciliation. Lesion subcategorization based on ADC value as higher suspicion (4+) and lower suspicion (4‐) resulted in 158 and 117 lesions, with reverse‐fusion analysis revealing that 61% and 17% of lesions contained csPCa, respectively. Subgroup analysis among PI‐RADS 4+ lesions led to an increase in the CDR to 75% and 61% for > GG1 and > GG2.
Conclusions: Use of multidisciplinary QI protocol to review discordance cases of PI‐RADS 4 improves diagnostic accuracy and guides subsequent management. Our findings highlight the known heterogeneity of this category with reference to csPCa CDR, suggesting the potential value of PI‐RADS 4 subcategorization.
Funding: None
How Many Transperineal Fusion Prostate Biopsies Needed from a Lesion on MRI for Accurate Diagnosis of Significant Prostate Cancer?
David Dothan4, Ariel Mamber1, Abd Shabaneh1, Ofer Beniaminov2, Sofia Zilber3, Boris Chertin1, Dmitry Koulikov1
1Shaare Zedek Medical Center, Urology department., 2Shaare Zedem Medical Center, Radiology department., 3Shaare Zedek Medical Center, Pathology department., 4Shaare Zedek Medical Center , Urology department.
Presented By: David Dothan, MD
Introduction: There is no consensus for the number of targeted biopsies taken from a single lesion on prostate MRI. There are studies which addressed this topic, but all are retrospective. Each single biopsy increases the risk for complication mainly infections and urinary retention. We examined the incremental detection rate of prostate cancer in each subsequent biopsy from a single lesion, to find what is the ideal number of biopsies from a single lesion.
Methods: The demographic, clinical and pathologic data from men who underwent transperineal fusion biopsy of the prostate was collected prospectively. Navigo fusion system was utilized. PI‐RADS version 2.1 was utilized, a lesion PI‐RADS 3 and more was targeted. From one Index lesion 5 sequential targeted biopsies were taken. Systematic biopsies were performed. Clinically significant prostate cancer was defined as Gleason grade ≥3 + 4. Patients with PSA above 20 ng/ml, status post local/systemic/hormonal therapy were excluded.
Results: From March 2022 until March 2023, 96 men met the inclusion criteria. Mean age was 67.3 ± 6.2, mean PSA 7 ± 3.7. Fifty‐seven (59.4%) patients were diagnosed with prostate cancer. In 44(45.8%) patients cancer was detected in the targeted biopsies form the Index lesion: 32(33.3%) in the first biopsy, 39(40.62%) in the first two biopsies,43(44.8%) in the first three biopsies and 44(45.8%) in all five biopsies. Clinically significant cancer was detected in 16(36.4%) of the first two biopsies, the 3rd, 4th and 5th biopsies together added only 1(2.3%) cases of clinically significant cancer.
Conclusions: The majority of clinically significant prostate cancer will be detected during the initial two transperineal fusion biopsies targeting the index lesion. Subsequent biopsies (3rd, 4th, and 5th) yield minimal additional cancer findings, primarily consisting of non‐clinically significant cases.
Funding: None
The Risk of Prostate Cancer Progression During Active Surveillance is Greater Among Patients with An MRI Demonstrating a PIRADS 4 or Higher Lesion
David Margel1, Yaara Ber1
1Raphael Hospital
Presented By: David Margel, MD, PhD, MBA
Introduction: Active surveillance is an accepted treatment for low‐risk prostate cancer, but still between 30‐ 50% of patients need treatment. Prostate MRI is an integral part of a patient's evaluation before a prostate biopsy. The purpose of this study was to check whether there is a difference in the risk of progression depending on initial MRI findings.
Methods: In this study, we included men who were diagnosed with low‐risk prostate cancer in an initial fusion biopsy. All men includedchose activesurveillance and performed atleast one more fusion biopsy during follow‐up. We only included patients whoseprostate cancer was sampled in the indexlesion of the initial MRI. We divided the patients according to the severity of the PIRADS score in the INDEX LESION performed prior to the first biopsy.The primary study outcome was disease progression ( to GG2 or higher) during active suivailance in the index lesion.We performed univariate and multivariate analyses to predict progression and in addition we performed several sensitivity analyzes to confirm the findings.
Results: 203 patients were included in the study (PIRADS 3 = 69; PIRADS 4 = 94; PIRADS 5 = 40) At a median follow‐up of 30 months, disease progression was observed in 52% of patients. Of these, 22% of patients with PIRADS 3 (n = 15); 65% of patients with PIRADS 4 (n = 61); and for 75% of the patients with PIRADS 5 (n = 29).On multivariable analysis, PIRADS score was an independent predictor for disease progression (PIRADS4 and above HR 3.3 95%CI 2.1‐3.9).On multiplesensitivity analyses, the association of progression to initial PIRADS score remained strong even after controlling forinitial PSA level, the size of the prostate, the location of the lesion, the identity of the biopsy operator/pathologist or radiologist and the time between biopsies.
Conclusions: Among men with low‐risk prostate cancer a PIRADS grade of 4 or higher on MRI is associated with a high risk of progression. It is unclear whether this is reclassification or true biological progression.
Funding: none
Validation of MR/US Fusion Biopsy for Prostate for the Detection of Prostate Cancer in Japanese Men
1Department of Urology, Kawasaki Medical School, 2Department of Urology, Kawasaki Medical School General Clinical Center, 3Department of Urology, Kawasaki Medical School Clinical Medical Center, 4Department of Radiology, Kawasaki Medical School
Presented By: Shintaro Takahashi
Introduction: Japanese men differ from Western men in age of onset, biological aggressiveness, and tumor size in prostate cancer (PCa). Clinical efforts to verify its accuracy for risk stratification of PCa in Japanese men have recently started. The aim of the study was to evaluate the cancer detection rate of the Prostate Imaging and Reporting Data System (PI‐RADS) version 2 (v2) in Japanese men using MR/US fusion‐guided biopsy.
Methods: We collected data from a cohort of 205 men who underwent MRI‐ultrasound fusion targeted biopsy for suspected PCa in our institution from August 31, 2018 to March 31, 2020. The cases with above 20.0 ng/ml on PSA value were excluded from this study. Single radiologist (TT) evaluated multiparametric MRI (mpMRI) using thePI‐RADS v2 by consensus. Targeted biopsy was performed for lesions with PI‐ RADS categories of 1 to 5. After targeted biopsy, concurrent standard systematic 10 or 12‐core systematic prostate biopsy was performed in all patients. Gleason 3 + 4 or greater was defined as clinically significant PCa (csPCa).
Results: The median age was 70 (45‐89) years, the median PSA level was 6.71 (1.31‐19.9) ng/ml. A total of 347 lesions with a mean of 1.7 suspicious lesions per patient were detected by mpMRI were classified as PI‐ RADS category 1 in 8 lesions, 2 in 47 lesions, category 3 in 119 lesions, category 4 in 150 lesions and category 5 in 23 lesions. A median of 2.5 target biopsy cores per suspicious lesion were taken. Overall PCa detection rates were 0%, 8.5%, 23.5%, 64.0%, and 87.0% for PI‐RADS categories 1, 2, 3, 4, and 5, respectively (p < 0.001). A higher detection rate for csPCa was 0%, 2.1%, 12.6%, 40.0%, 73.9% for PI‐ RADS categories 1, 2, 3, 4 and 5, respectively (p < 0.001). PCa and csPCa detection rate per patient basis were 63.9% and 42.9%, respectively. Among patients diagnosed csPCa by biopsy, negative or clinically insignificant PCa (cisPCa) in the systemic biopsy but csPCa in the target biopsy was observed in 21 cases (10.2%). On the other hand, negative or cisPCa in the target biopsy but csPCa in the systemic biopsy was observed in 16 cases (7.8%). CisPCa diagnosis per patient basis was observed in 43 cases (21%). Among patients diagnosed cisPCa by biopsy, negative in the systemic biopsy but cisPCa in the target biopsy was observed in 8 cases (3.9%).
Conclusions: PI‐RADS v2 using MR/US fusion‐guided biopsy is significantly associated with the presence of csPCa in Japanese men. When performing systemic biopsy, the combination with target biopsy still improves the detection of clinically significant PCa above 10%, but also increased the detection of clinically insignificant PCa by about 4%.
Funding: None
A Prospective Study of MRI‐Ultrasound Fusion‐Guided Focal High‐Dose‐Rate Brachytherapy for Primary Localized Prostate Cancer
1Department of Radiology, Kawasaki Medical School General Medical Center, 2Department of Radiology, Kawasaki Medical School, 3Department of Urology, Kawasaki Medical School, 4Department of Urology, Kawasaki Medical School General Medical Center
Presented By: Yoshiyuki Miyaji, MD, PhD
Introduction: Focal therapy for prostate cancer in cases with low to intermediate risks is increasingly important. In this study, we examined the initial therapeutic outcomes of focal high‐dose‐rate brachytherapy (HDR‐BT) for target lesions in patients with primary localized prostate cancer.
Methods: A prospective study was performed in 16 patients who underwent HDR‐BT from April 1, 2020 to December 31, 2021. The suspect lesion on MRI was identified on transrectal 3D‐US imaging to place an applicator needle through the perineal area. The planning target volume (PTV) was determined as the gross tumor volume (GTV) plus a margin of 5 mm, and a dose of 19 Gy/fraction was administered to the PTV. Follow‐up schedule included prostate‐specific antigen (PSA) measurement at 1 and every 3 months and MRI at 3 and every 6 months after treatment. Second look biopsy at treatment area and systematic biopsy were performed at one year after HDR‐BT.
Results: The 16 patients treated with HDR‐BT had a median follow‐up period of 22.5 (range 12‐33) months. The median age was 73.5 (65‐85) years, the median pre‐treatment PSA level was 7.79 (2.37‐14.17) ng/ml, the median prostate volume (PV) was 39.5 cm3, and the Gleason score was 3 + 3 in 4 cases and 3 + 4 in 12 cases. The median PTV was 4.52 cm3 and the median PTV to prostate volume (PTV/PV) ratio was 10.6% (4.7‐ 25.6%). Scheduled treatment was provided for all patients without any problems and there were no unexpected adverse events. During follow‐up, there were no genitourinary (GU) or gastrointestinal (GI) adverse events. The median PSA reduction rate at 6 months after treatment was 67.8% (4.6‐92.5%) and reduction of ≥50% occurred in 10 patients (62.5%). Biochemical failure based on the Phoenix ASTRO consensus (nadir +2) was 100% at 1 year and 78% at 2 years. MRI showed therapeutic effects on the target lesion in 12 cases (75%). The PSA reduction rate at 6 months of cases with therapeutic effects on MRI was significantly higher compared with those of cases with no therapeutic effects on MRI (p = 0.0053). The 2nd look biopsy at one year after treatment were performed in 15 cases. Five cases detected viable cell in treatment area, and 4 cases detected ≥ Gleason score 3 + 4 cancer in non‐treatment area. The PSA reduction rate at 6 months of cases with positive on 2nd look biopsy was significantly lower compared with those of cases with benign on 2nd look biopsy (p = 0.0491).
Conclusions: MRI‐US fusion‐guided focal HDR‐BT is a safe treatment that causes no GU and GI adverse events. These results may be due to the small PTV/PV ratio. However, the therapeutic range of HDR‐BT is limited and the Phoenix ASTRO consensus for normal radiotherapy is not applicable. The PSA reduction rate at 6 months may be a useful alternative biochemical marker for prediction of the therapeutic effects of focal HDR‐BT.
Funding: None
Comparison of Procedural Anxiety and Pain Associated with Conventional Transrectal Prostate Biopsy versus MRI/US Fusion‐guided Biopsy: A Prospective Cohort Trial.
Sriram Deivasigamani1, Eric S. Adams1, Srinath Kotamarti1, Mahdi Mottaghi2, Thomas J. Polascik1
1Duke University Medical Center, 2Duke University MEDICAL Center
Presented By: Sriram Deivasigamani, MBBS
Introduction: Prostate cancer diagnosis relies on biopsy procedures, with transrectal ultrasound (TRUS) biopsy remains widely used. However, MRI/US fusion biopsy (FB) shows promise in improving accuracy but the pain and anxiety experienced by patients during biopsies is often overlooked. This study aims to compare pain and anxiety levels between FBand standard TRUS‐guided biopsy, addressing a gap in knowledge and improving patient experiences.
Methods: This prospective trial, approved by an institutional review board, included adult men undergoing prostate biopsy. Patients received identical peri‐procedural care, and the biopsy technique was chosen based on clinical indication and imaging findings. Standard analgesia was administered to both groups. The primary outcome compared patient anxiety levels using the STAI questionnaire, while the secondary outcome assessed post‐procedure pain using a numerical rating scale.
Results: A total of 165 patients were included in the study, with 99 undergoing TRUS biopsy and 66 undergoing FB. There were no significant differences between the groups in terms of age, race, PSA level, prostate volume, number of prior biopsies, and previous anxiety and pain medications. The FB group had a significantly higher number of biopsy cores and longer procedure time compared to TRUS biopsy (16.2 vs. 12 cores, p = 0.001) and (23 vs. 10 minutes, p = 0.001). The TRUS biopsy patients were found to experience lower post‐procedural anxiety compared to FB, a mean difference of ‐7 (95% CI, ‐9, ‐4.5, p = 0.001) and 89% of FB group patients experienced severe anxiety compared to 59% STB, p = 0.002. No difference in pain (p = 0.7) was found between the cohorts and most of them (STB vs FB) reported experiencing mild pain (53% vs 73%, p = 0.1). The number of prior biopsies was associated with the severity of post‐procedural anxiety in the FB group (p = 0.04). There was a positive correlation between pre‐procedural and post‐procedural anxiety levels, but no significant correlation between post‐procedural anxiety and pain levels.
Conclusions: Fusion biopsy is associated with higher post‐procedural anxiety compared to standard TRUS biopsy. Patients with a history of repeat biopsies are more prone to experiencing severe anxiety. Counselling can play a crucial role in reducing patient discomfort, alleviating anxiety, and enhancing compliance with recommended procedures, especially with the growing acceptance of active surveillance in prostate cancer management.
Funding: None
Prostate Size on MRI: A Gross Overestimation
Charan Mohan1, Gregory Mullen1, Jared Winoeker1, Arun Rai1, Zeph Okeke1, David Hoenig1, Tareq Aro1
1The Smith Institute for Urology, Northwell Health
Presented By: Charan Mohan, MD
Introduction: Prostate MRI has been used as a gold standard to determine prostate size allowing for more accurate preoperative surgical planning. The objective of this study was to assess the performance of MRI in predicting prostate size by comparing the reduction in prostate by surgical weight to postoperative reduction of PSA following laser enucleation of the prostate (LEP).
Results: 30 patients were included in the analysis. Median age was 70 years (IQR 63‐73). Median prostate volume on MRI was 115 mL (IQR 90.3‐154.8) and median preoperative PSA was 6.5 ng/mL (IQR 4.8‐9.9). The median percent change based on prostate weight was 59.1% (IQR 45.9‐69.6) compared to median change in PSA which was 90.4% (IQR 79.8‐95.1). This difference was statistically significant (p = 0.005).
Conclusions: The percent change in PSA following LEP is significantly higher than the presumed reduction in prostate weight. This suggests MRI oversizes prostates in planning for BPH surgery, particularly with larger glands. Possible explanation may be inclusion of all prostatic components in measurement on MRI while only prostatic adenoma is included in postoperative specimens. Alternatively, the conventional density assumption of 1 mL of prostate volume to 1 g of prostatic tissue may not be accurate in larger glands and modifications to this conversion need to be adapted for prostatic composition. Care should be taken when counseling patients on BPH therapy when using imaging measurements, even when MRI is utilized.
Funding: none
Trans‐Perineal Ultrasound Imaging of the Prostate – a Pilot Study
Omer Sadeh2, Shir Tiger1, Dan Leibowitz1, Gilad Amiel2
1Department of Urology, Kaplan Medical Center, Rehovot, Israel, 2Department of Urology, Rambam Health Care Campus, Haifa, Israel
Presented By: Omer Sadeh, MD
Introduction: Trans‐perineal (TP) ultrasound (US) of the prostate and pelvis may provide a non‐invasive, non‐painful, office‐based method to visualize, evaluate and measure the prostate, and diagnose various conditions. It may also allow live imaging guidance for procedures and treatments presently performed using trans‐rectal (TR) or trans‐urethral approaches.This pilot study was designed to assess the feasibility of visualization and evaluation of the prostate via TPUS.
Methods: Twenty subjects scheduled for TRUS‐guided prostate biopsy in two medical centers in Israel during 2022 underwent TPUS evaluation of the prostate and pelvic organs using an abdominal curvilinear probe with the BK FlexFocus 500/800 machines. Patients were positioned in the lithotomy position. Examinations were performed by two urologists with extensive experience in conventional prostate US. Investigators noted adequate visualization of various pelvic organs and anatomical landmarks in the sagittal and coronal views (n = 20). Prostate diameters were measured in the base‐apex (length) and anterior‐posterior (height) aspects. In six patients right‐left (width) measurement was also available, thus allowing calculation of prostate volume. Measurements were later compared to those taken by TRUS (n = 11).
Results: Using the TPUS approach, the prostate and bladder were clearly identified in all subjects. Bladder neck and seminal vesicles were viewed in 95% of examinees, pubic bone & rectum in 85%, and the urethra in 80%.Prostate landmark identification rates are depicted in table 1.Prostate diameters measured by TPUS and TRUS were compared using Wilcoxon Signed Ranks Test. No statistically significant differences were found between the two methods for length (p = 0.248), width (p = 0.917) or volume (p = 0.075).
Conclusions: TPUS of the prostate requires operator experience in performing and interpreting. An operator learning curve is expected. According to this preliminary study, prostate TPUS may offer a feasible, accurate and simple alternative to some examinations and procedures currently performed using TRUS. Future applications under development include TP high‐intensity focused US treatment of benign prostatic hyperplasia & localized prostate cancer and TPUS‐enhanced “video” urodynamics.
Funding: NINA Medical
Prostate Artery Embolization: A Promising Approach for Catheter Weaning
Gabriel Alejandro Molineros Mayorga2, Allan Bloom1
1Hadassah Ein Kerem, 2Hadassah Ein KErem
Presented By: Gabriel Alejandro Molineros Mayorga, MD
Introduction: Patients with a permanent urinary catheter due to urinary retention caused by an enlarged prostate were previously treated with open or endoscopic prostatectomy if conservative treatment failed or if there was kidney damage during the retention episode.Prostate artery embolization (PAE) has emerged as a less invasive alternative for weaning urinary catheters in patients with underlying prostate conditions. This study aims to evaluate the effectiveness and safety of PAE in catheter weaning, as well as the incidence of post‐procedure complications.
Methods: A retrospective analysis was conducted on 70 patients who underwent PAE at our institution. Among them, 18 patients had indwelling urinary catheters. Patient demographics, including age and comorbidities, were recorded. The prostate size was measured before and after the procedure. Follow‐up duration after PAE was documented. The primary outcome was the successful weaning of catheters. Complications were assessed using the Clavien Dindo classification system.
Results: Out of the 70 patients who underwent PAE, 18 had indwelling urinary catheters. The mean age of the patients was 75.22 years (SD: 10.14). The mean prostate size was 155 grams (SD: 74.23). The average follow‐up duration after the procedure was 3 months (SD: 5.8). A total of 17 patients successfully weaned from their catheters.Complications: The reported complications after PAE were as follows:Fever: Two patients experienced post‐procedure fever (Clavien Dindo classification I).Pain requiring admission to the ward: One patient reported post‐procedure pain that necessitated hospitalization (Clavien Dindo classification I).Temporary acute renal failure: One patient experienced temporary acute renal failure, which resolved within one week (Clavien Dindo classification IVa).Uroflowmetric values measured after the procedure were:QMAX (Maximum Flow Rate): The mean QMAX observed was 12.86 ml/sec.PVR (Post‐void Residual): The mean PVR was 145 cc.Voided Volume: The mean voided volume was 157.29 cc.Complications: The reported complications after PAE were as follows:Fever: Two patients experienced post‐procedure fever (Clavien Dindo classification I).Pain requiring admission to the ward: One patient reported post‐procedure pain that necessitated hospitalization (Clavien Dindo classification I).Temporary acute renal failure: One patient experienced temporary acute renal failure, which resolved within one week (Clavien Dindo classification IVa).
Conclusions: The findings demonstrate that PAE can effectively facilitate catheter weaning in patients with indwelling urinary catheters. The success rate of catheter weaning was significant, with 17 out of 18 patients achieving this outcome. Although complications were observed, they were generally low in severity and manageable.Prostate artery embolization shows promise as a valuable approach for catheter weaning in patients with indwelling urinary catheters. The high success rate in discontinuing catheterization and the low reported complications observed in this study present this procedure as a potential option for catheter weaning in patients with indwelling urinary catheters. Further research with larger sample sizes and longer follow‐up periods is recommended to confirm these findings and assess the long‐term efficacy and safety of PAE.
Funding: N/A
WITHDRAWN
PSMA‐PET and Decipher Score as Predictors of Extraprostatic Extension in Unfavorable Intermediate‐ or High‐Risk Prostate Cancer
Courtney Yong1, Isamu Tachibana1, Mark Green1, Mark Tann1, Michael Koch1, Clinton Bahler1
1Indiana University
Presented By: Courtney Yong, MD
Introduction: Preoperatively predicting extraprostatic extension (EPE) in prostate cancer is important to determine which patients can safely undergo a nerve‐sparing prostatectomy while preserving oncologic control. We examined whether 68Ga‐PSMA‐11 PET CT (PSMA PET), multiparametric MRI (mpMRI), or Decipher analysis would independently predict EPE in prostate cancer patients undergoing radical prostatectomy.
Methods: We prospectively enrolled 50 patients with clinically significant, localized prostate cancer, defined as ≥3 cores of Gleason 3 + 4 or worse. The patients underwent both mpMRI and PSMA PET prior to radical prostatectomy. Images were read by dedicated radiologists to identifyEPEat the nerve bundles, apex, and bladder neck and seminal vesicle invasion. Tissue from the final pathology specimen was also sent for Decipher analysis and given a score from 0 to 1, with 1 being highest risk and > 0.6 being considered high risk. Multivariate logistic regression was used to determine the odds ratio (OR) for EPE based on positivity on imaging or Decipher score.
Results: The average age and PSA of patients was 61.5 and 6.97 respectively. 72% of patients had Gleason 4 + 3 or higher on biopsy. The average Decipher score was 0.58. Both PSMA PET positive for EPE (OR 9.8, 95% CI 1.5‐62, p = 0.02) and Decipher score higher than 0.6 (OR 2.4, 95% CI 1.0‐5.7, p = 0.05) were predictive of EPE on final pathology. However, positive mpMRI (OR 0.74, 95% CI 0.16‐3.5, p = 0.71) and PSA density > 0.15 (OR0.17, 95% CI 0.0038‐7.7, p = 0.36) were not predictive of EPE.
Conclusions: Both PSMA PET and Decipher score on final prostatectomy pathology are independent predictors of EPE on final pathology. Future research on Decipher score on preoperative biopsy tissue is necessary to assist in further stratifying these patients and identifying those who can safely undergo nerve‐ sparing.
Funding: American Cancer Society Institutional research grant #19‐144‐24‐IRG
MODERATED POSTER SESSION 25: BPH 4
Impact of Anticoagulation on Operative Efficiency in HoLEP Patients
T. Max Shelton1, Cameron McClaine1, Abigail Beard1, Thomas Murphy1, Rj Caras1, Austen Slade1, Marcelino Rivera1
1Indiana University School of Medicine
Presented By: T. Max Shelton, MD
Introduction: Anticoagulant usage raises questions about these medications' impact on hemostasis during Holmium Laser Enucleation of the Prostate (HoLEP). We performed a retrospective review of HoLEP patients on anticoagulant (AC) or antiplatelet (AP) medications to examine their impact on operating efficiency during HoLEP.
Methods: We performed a retrospective review of our institutional HoLEP database including patients with no AC/AP usage, holding AC/AP, or continuing AC/AP through surgery. Hemostasis time was calculated as analogous to OR time not dedicated to enucleation or morcellation. Grams enucleated per minute, total laser‐ energy usage (kJ), and laser‐energy per gram of tissue enucleated were also analyzed to evaluate operative efficiency.
Results: We included 621 patients who underwent HoLEP from July 2018 to August 2022; 49 continued AC/AP through surgery, 101 held preoperatively, and 471 had no AC/AP usage. There was no difference in hemostasis time between those continuing AC/AP, patients holding these medications, and non‐ anticoagulated patients (19.12 vs. 18.16 vs. 18.93; p = 0.825). There was no difference in mean total energy used (120.25 vs. 120.25 vs. 121.09; p = 0.992) or kJ/gram enucleated among the groups (3.58 vs. 2.47 vs. 2.71; p = 0.092). However, mean enucleated grams/minute was different among the groups (1.25 vs. 1.44 vs. 1.64; p = 0.016). OR specimen weight was different in those who continued AC/AP and those with no AC/AP usage (54.29 vs. 77.46; p = 0.017).
Conclusions: HoLEP is safe and equally efficient for patients who require AC or AP therapy. While enucleation efficiency was different between the groups, there was no statistically significant difference in operative efficiency in those who continued or discontinued AC/AP.
Funding: None
Effect of Patient Age on Improvement After Aquablation
David Nusbaum2, James Kearns1, Alexander Glaser1, Brian Helfand1
1NorthShore University HealthSystem, 2University of Chicago Medical Center
Presented By: David Nusbaum
Introduction: A previous randomized trial showed worse measures of bladder function in men who delayed surgical intervention for benign prostatic hyperplasia (BPH). Aquablation is a technique that utilizes water jet ablation for treatment of lower urinary tract symptoms (LUTS) secondary to BPH. The objective of this study was to evaluate the effect of patient age on measures of improvement after Aquablation.
Methods: A prospective dataset of men who underwent Aquablation at a single institution between March 2019 and May 2023 was analyzed. Baseline characteristics including prostate size, International Prostate Symptom Score (IPSS), and post‐void residual (PVR) were compared between men age ≤65, 66‐79, and ≥80. Correlation coefficients were calculated to measure the relationship between age and change in IPSS and PVR after surgery.
Results: Data were available for267patients, of whom24 (9.0%) were age 80 or older. There were no significant differences in median prostate size or PVR between different age groups at baseline. Older patients had a lower median pre‐operative IPSS compared to younger patients; however median IPSS was > 18 for all age categories, indicating significant LUTS in this cohort. There was a positive correlation between patient age and change in IPSS after surgery (Pearson's correlation coefficient = 0.22, p = 0.002; Figure 1). There was not a significant correlation between age and change in PVR.
Conclusions: After Aquablation, younger patients tended to have greater improvement in IPSS scores compared to older patients, indicating that intervention at a younger age may be beneficial for patients. Across age categories, most men experienced improvement in urinary symptoms after surgery. Future validation in larger cohorts is required.
Funding: None
Pulsemodulation in Enblock Holmium Laser Enucleation of the Prostate: Does it Really Make a Difference? a Propensity Score Matched Analysis of 234 Patients.
Jonas Herrmann1, Friedrich O Hartung1, Maren J Wenk1, Britta Grüne1, Luisa Egen1, Maurice S Michel1
1University Medical Centre Mannheim
Presented By: Jonas Herrmann, MD
Introduction: Holmium laser enucleation of the prostate (HoLEP) is an established surgical option in the treatment of benign prostatic hyperplasia regardless of the prostate volume. Pulse modulation, such as Moses Technology, has recently been introduced and may offer potential advantages in HoLEP. The purpose of this study was to compare the clinical safety and efficacy of MOSES laser enucleation of the prostate (MoLEP) to HoLEP with a conventional pulse setting in a tertiary center.
Methods: Perioperative data from 117 patients who underwent MoLEP performed by an experienced endoscopic surgeon at our institution from 2021 to 2023 was prospectively collected in our database. Propensity score matching using prostate volume, patient age, body mass index (BMI), and anticoagulant intake was performed using a database of 237 patients treated by HoLEP by the same surgeon during the same period. In total, 234 patients were included in this study. 30‐day complications were recorded and graded according to the Clavien‐Dindo Classification (CDC), and the Comprehensive Complication Index (CCI).
Results: Preoperative parameters were similar between groups, with a mean prostate volume of 104 ml (MoLEP) vs. 102 ml (HoLEP), age (70 vs. 71 years), BMI (27 vs. 27), and intake of anticoagulants (34% vs. 35%). All cases were performed using the EnBlock technique with early apical release. Overall, there was no significant difference in mean operation time (61.5 vs. 58.1 min, p = 0.42), enucleation efficiency (2.5 vs. 2.6 g/min, p = 0.74), hemoglobin drop (0.9 vs. 0.7 mg/dl, p = 0.48), and hemostasis time (7.8 vs. 8 min, p = 0.75). Complication rates were very low in both groups (16.2% in HoLEP and 17.1% in MoLEP). No differences were noted in both CDC (p = 0.63) and CCI (p = 0.24). The rate of relevant complications > CDC IIIa was 0.9% in HoLEP (1 case of endoscopic clot evacuation and bipolar coagulation) and 1.7% in MoLEP (2 cases of endoscopic coagulation due to bleeding). No transfusions were administered in either group.
Conclusions: In this series, there were no significant differences in perioperative parameters such as procedure time, enucleation time, hemostasis time or blood loss. Further, there were no differences in complication rates graded by the CDC or CCI. Overall, enucleation efficiency was high in both groups and the procedure time was short. HoLEP is an extremely efficient and safe treatment option in experienced hands, regardless of the use of pulse modulation technology.
Funding: No funding was received.
Incidental Prostate Cancer After HoLEP: Factors Associated with Clinically Significant Residual Disease and Further Treatment
Hansen Lui1, Steven Monda1, Onika Noel2, Abdisalam Hassan1, Noah Canvasser1
1UC Davis Health, 2University of Texas, San Antonio
Presented By: Hansen Lui, MD, MS
Introduction: Higher rates of incidental prostate cancer (iPCa) are expected after holmium laser enucleation of the prostate (HoLEP) compared to transurethral resection owing to larger volumes of tissue resected. While patients with insignificant disease are often placed on active surveillance (AS), a small portion will have clinically significant residual disease and warrant further staging and treatment. Our objective was to assess predictors of clinically significant residual disease and treatment after HOLEP.
Methods: We retrospectively reviewed patients who underwent HoLEP from February 2020 to November 2021 at a single institution, with follow up through September 2022. Patients with iPCa on AS were compared to those who underwent treatment. HoLEP pathology, post‐operative PSA, and post‐operative PSA density (pPSAD = post‐op PSA/residual prostate volume) were assessed. Post‐HoLEP staging MRI was obtained in patients based on age and pathology.
Results: A total of 193 patients underwent HOLEP. The rates of iPCa and Grade Group 2+ (GG2) was 16% (n = 31) and 7% (n = 14), respectively. Three patients were excluded due to lost to follow‐up. Six patients were treated with localized (n = 4) or systemic therapy (n = 2). Compared to AS, patients who received treatment had more GG2+ disease (83.3 vs 31.8%, p = 0.02), a higher percentage of cancer in their pathology (24.3 ± 16.9 vs 2.0 ± 2.3%, p < 0.001) and higher post‐operative PSA (16.2 ± 23.6 vs 1.4 ± 1.9 ng/mL, p < 0.001) and pPSAD (1.5 ± 2.1 vs 0.1 ± 0.1 ng/mL2, p < 0.001). On post‐HoLEP staging MRI, 66.7% of those who received treatment had PIRADS 3‐5 lesions, compared to 18.2% in those on AS (p = 0.04).
Conclusions: Pathologic grade, percentage of prostate cancer in the tissue, and post‐operative PSA and pPSAD can help inform those who warrant staging MRI, and may need treatment after HoLEP. Additional longitudinal studies are required to further stratify prostate cancer progression risk within the iPCa population.
Funding: None
is Your Continuous Bladder Irrigation Control Effective: Assessing Flow Rate Discrepancies and Discussing Their Clinical Implications
1Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; St. Michael's Hospital, Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada, 2Institute of Biomedical Engineering, University of Toronto, Toronto, ON, Canada; KITE – Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada, 3The University of Limerick, School of Medicine, Limerick, Ireland; St. Michael's Hospital, Division of Urology, Department of Surgery, University of Toronto
Toronto, ON, Canada, 4WellSpring Research, Toronto, ON, Canada, 5Institute of Medical Science, University of Toronto, ON, Canada; Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; St.
Michael's Hospital, Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada, 6Institute of Medical Science, University of Toronto, ON, Canada; St. Michael's Hospital, Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada
Presented By: Egor Parkhomenko, B.Sc, MD
Introduction: Maintaining an appropriate flow rate (FR) during continuous bladder irrigation (CBI) is important to mitigate blood stasis and urinary clot retention. However, guidelines for controlling FR are absent and consensus amongst healthcare providers is lacking. Furthermore, intrinsic differences in equipment confound FR control. For these reasons, we compared FR through 3 commonly used brands of CBI tubing and discussed their implications.
Methods: 3L saline bags were hung from weight sensors that were retrofitted to an IV pole. Weight change over time was used to determine FR. The roller clamp affixed to the CBI tubing was divided into 5 equal setpoints (SP), and the roller wheel (RW) was cycled between SPs and the closed position in 30‐second intervals. We conducted 3 trials with 2 sets of tubing from each brand, both with and without a 22 Fr catheter attached.
Results: Figure 1 shows the average FR at the 5 SPs with and without a catheter attached. The gray bars represent experiments without a catheter and report the potential FR achievable without any restrictions. Significant inter‐brand differences exist at each SP; for example, Brand A had no flow until SP3, whereas Brand B reaches 50% of max FR at SP1. The colored bars represent experiments with a catheter and report the FR achieved in clinical practice. With a catheter attached, all 3 brands have limited adjustability and the same maximum FR.
Conclusions: Our data show that the RW is an unreliable predictor of FR and does not scale linearly, which can be problematic as clinicians intended changes may not be occurring as expected. Furthermore, with a catheter attached, the RW seems to act like an “on‐off” switch and provides extremely limited FR control, suggesting that the catheter is the FR‐determining step. This may be concerning since, presently, the RW is the only way to regulate CBI and may inferthat standardized guidelines cannot be generalized for different brands if titrating based on the RW.
Funding: None.
Increased Oscillation Rate Improves Morcellation Efficiency in Holmium Laser Enucleation of the Prostate
T. Max Shelton1, Cameron Mcclaine1, Andrew Adeola1, Rj Caras1, Austen Slade1, Deepak Agarwal2, Tim Large1, Marcelino Rivera1
1Indiana University School of Medicine, 2University of Minnesota School of Medicine
Presented By: T. Max Shelton, MD
Introduction: Tissue morcellation has become increasingly efficient, yet remains a rate limiting step in holmium enucleation of the prostate (HoLEP). Limited data exists on how the rate of oscillation by the morcellator blades affects morcellation efficiency (ME).
Methods: A retrospective review was performed of our HoLEP proceduresperformed by two surgeons from 7/1/2019 to 8/25/2022. All morcellation was performed with the Wolf Piranhadevice and enucleation was performed with Moses 2.0 technology. Surgeon 1 routinely uses 1500 oscillations/min (low rate) and Surgeon 2 uses a rate of 6000 oscillations/min (high rate). The primary endpoint was morcellation efficiency (grams/minute). Secondary endpoints include enucleation efficiency, mean tissue specimen weight, and preoperative prostate volume. The data was also subgrouped into small and large specimen weights (< 150 gms and > 150 gms) to delineate any differences based on amount of tissue.
Results: 94 HoLEPs were analyzed, 302 by Surgeon 1 and 592 by Surgeon 2. Surgeon 2 had larger preoperative prostate volumes (126 vs 101; p < 0.001) and specimen tissue weights (86.0 vs 61.1; p < 0.001). Morcellation time was longer in the low rate group (11.3 vs 6.1 min, p < 0.001) and ME was lower in the low rate group (9.3 vs 12.1 g/min, p < 0.001). The difference in ME was inversely proportional to specimen weight. When the data was subgrouped by specimen weight (< 150 gms and > 150 gms), there was a significant difference below 150 gms (9.3 vs 12.3; p < 0.001) in ME, yet no significant difference in the large tissue group (8.8 vs 9.4; p = 0.42).
Conclusions: Increased oscillation rate during morcellation leads to a decrease in morcellation time and increased morcellation efficiency during prostate enucleation. Future prospective studies will serve to evaluate this finding across a larger numbers of institutions, and evaluate ways to increase ME in large prostate cohorts (i.e. > 150 gms).
Funding: None
Patient Awareness of Holmium Laser Enucleation of the Prostate and Alternative Treatments of Benign Prostatic Hyperplasia
T. Max Shelton1, Rachel Gross1, Saveda Majety1, Mariah Thomas1, Rj Caras1, Austen Slade1, Marcelino Rivera1
1Indiana University School of Medicine
Presented By: T. Max Shelton, MD
Introduction: Patient literacy in medical treatment is essential to providing quality patient‐centered care. Holmium laser enucleation of the prostate (HoLEP) was first described in the 1990s and has established itself as a durable and cost‐effective surgical treatment for benign prostatic hyperplasia (BPH). This study aims to evaluate patient knowledge of HoLEP among patients who underwent this procedure at Indiana University Health between 2019 and 2022.
Methods: This retrospective cohort study included a survey of eight multiple choice questions which was sent via SMS text message to 2322 patients who previously underwent HoLEP at Methodist Hospital. Data was collected using research electronic data capture (REDCap). A total of 59 patients responded to the survey.
Results: Of those contacted, 59 patients responded to the survey (2.5% of total). The average age was 69.5 years at the time of surgery. 93% of patients did not have any BPH surgical treatments prior to HoLEP. The average time between surgery date and survey response was 31 months. A total of 69.5% of patients were referred by local urologists and 15% by their primary care physician (PCP). Less than a third of patients sought out multiple opinions on treatment options and even less (13.6%) traveled from out of state for treatment. Of those who did travel, 75% were from neighboring states. Outside of HoLEP, TURP and Urolift were the most well‐known procedures with 58% and 36% of respondents respectively hearing of the procedures preoperatively. 88% of patients who underwent HoLEP reported satisfaction and would recommend the procedure to a friend or family member. The most common reasons listed for the 7 patients who would not recommend the procedure were prolonged leakage and affected sexual performance.
Conclusions: Patients were more likely to be referred by their urologist than hear of HoLEP from their PCP, online source, or friend. Over half of patients had knowledge of other BPH surgical procedures preoperatively, but most patients did not seek out multiple opinions or undergo any surgical treatments prior to HoLEP. Overall patient satisfaction remained high after an average of 2.5 years post‐operatively. Further studies are warranted to analyze PCP HoLEP awareness and referral practices.
Funding: None
Fate of Incidentally Found Urethral Strictures During Holmium Laser Enucleation of the Prostate (HoLEP)
Mohammad Abed Elal3, Guy Verhovsky1, Ehud Gnessin2, Amir Zarror1, Itay Sabler1, Amnon Zisman1
1Shamir Medical Center, 2Shamir Medical Center and Assuta Hospital, 3Department of Urology, Shamir Medical Center, Israel
Presented By: Mohammad Abed Elal, MD
Introduction: The prevalence of urethral stricture is about 0.9% in the general population. There is little data regarding its incidence when encountered during BPH surgery, and there is a debate on the right way to manage such strictures when encountered. We dilated the stricture with gradual dilators and proceeded with HoLEP surgery. The aim of this study was to examine the short‐term outcome of this approach.
Methods: We retrospectively reviewed all HoLEP surgeries performed by a single surgeon (EG) in two major hospitals. HoLEP was done using a 26F scope. Patients in whom a urethral stricture was encountered and dilated during surgery composed our cohort. We reviewed the postoperative outcomes within the follow‐ up period. The primary endpoint was stricture recurrence requiring additional treatment.
Results: Out of 644 consecutive HoLEP surgeries performed between January 2020 and July 2022, we identified 38 (5.9%) with a urethral stricture that was found during surgery. Most of the strictures were bulbar 32/38 (84%) or assessed as clinically insignificant 24/38 (63%) (at least 14F). During a median follow‐up of 89 days, 24/38 (63%) did well and did not need further assessment or treatment. Factors predicting stricture recurrence were; non‐bulbar urethral stricture (penile or membranous) of whom about two thirds failed, and clinically significant strictures of whom 64% failed.
Conclusions: In our cohort, the incidence of a urethral stricture encountered during HoLEP is approximately 6%. Following initial dilation of the stricture during surgery ‐ about a quarter of the insignificant urethral strictures, and two‐thirds of the significant strictures will recur and require additional intervention.
Funding: none
Outcome of Patients with Parkinson's Disease Undergoing Holmium Laser Enucleation of the Prostate (HoLEP)
Amir Zarror3, Ehud Gnessin1, Itay Sabler2, Amnon Zisman2
1Shamir Medical Center and Assuta Hospital, 2Shamir Medical Center, 3Department of Urology, Shamir Medical Center, Israel
Presented By: Amir Zarror, MD
Introduction: History of Parkinson's Disease (PD) is considered a significant risk factor in patients undergoing BPH surgery, mainly due to increased risks of worse peri‐operative outcome and post‐operative incontinence. We sought to assess the short‐term outcomes of these patients and compared it to patients without history of neurological disease.
Methods: We retrospectively reviewed all HoLEP surgeries performed by a single surgeon (EG) in two major hospitals from January 2020 to December 2022. We identified 7 patients with PD and compared it to 688 without known neurological disease, history of CVA or significant diabetic neuropathy.
Results: Patients' age was similar between the groups (68.8 in PD vs. 70.71 in control group, p = 0.9). Compared to our control, patients with PD had smaller prostates (average prostate volume 82 vs. 122ml, p < 0.028), and were more likely to have indwelling catheter prior to surgery (57% vs. 28%, p < 0.01). One PD patient had mild urinary incontinence prior to surgery. There were no intraoperative complications in PD group. Postoperatively, one PD patient (14%) failed his initial voiding trial (compared to 8.3% in the control group) but five days later was able to void successfully. At time of last follow‐up (2.7 months (PD group) vs
5.8 months) all PD patients were able to void spontaneously. One PD patient had new onset minimal urinary incontinence (protective pad) and one that was leaking prior to surgery has worsening of his symptoms. Although numbers are small, PD patients had significant improvement of IPSS and bother index (BI) in pre‐ vs. post‐op period (IPSS ‐ 25 pre vs. 11.75 post‐op, BI – 5.2 vs.1.5).
Conclusions: When indicated, patients with PD should not be excluded from having BPH surgery. In our study, although small, all patients with PD who had HoLEP surgery were able to void spontaneously with minimal peri‐operative complications and good functional outcome.
Funding: none
1470nm Diode Laser Enucleation of the Prostate in Glands Greater than 150 gm
P. Walker Prillaman1, Douglas Kelly1
1Urology of Virginia
Presented By: P. Walker Prillaman, MD
Introduction: Laser enucleation of the prostate is an effective and durable endoscopic procedure for BPH. While Holmium and Thulium enucleation are considered standards of care for large glands, this study sought to investigate the 1470nm Diode laser with adenomas > 150 gm. We hypothesize that DiLEP will yield similar outcomes with a similar side effect profile.
Methods: A retrospective review of one surgeon's experience with DiLEP was conducted in men undergoing surgery from Oct 2016 to Apr 2022. Pre‐op variables included prostate size and prior BPH procedure. Peri‐op variables included operative time, enucleation weight, presence of cancer, length of stay, and transfusion rate. We assessed post‐op complications and need for further procedures. We compared pre to post‐op PVR, retention rates, and IPSS and QOL scores at pre‐op, 1 month, 3 months, and 12 months post‐op.
Results: 71 men were identified for inclusion. Mean follow‐up was 17.7 (SD 13.5) months. Mean operative time was 143.2 (SD 48.2) minutes. The average enucleation weight (pathologist reported) was 93.6 (SD 45.0) grams, with a mean prostate size of 216.0 (SD 52.1) grams. Mean hospital stay was 1.28 (SD 2.0) days. 2 patients (2.8%) required a transfusion. 3 patients (4.2%) were found to have prostate cancer. 6 patients (8.5%) had undergone a prior BPH procedure, while 3 (4.2%) required a subsequent surgery. 8 patients experienced a significant post‐op complication, notable for 3 requiring clot evacuation, 1 with urosepsis, 2 DVTs, and 1 CVA. Mean IPSS score at the pre‐op, 1 month, 3 month, and 12 month post‐op mark were 15.5 (SD 8.64), 8.2 (SD 5.8), 5.7 (SD 4.7), and 3.9 (SD 3.4), respectively. Similarly, QOL scores were 3.9 (SD 1.4), 2.6 (SD 1.5), 2.0 (SD 1.7), and 1.9 (SD 1.4) respectively. The mean pre‐op PVR was 396.7 cc (SD 369.9) compared to post‐op of 64.5 cc (SD 66.7). While 64.8% of patients experienced retention pre‐op, only 3.2% experienced it post‐op.
Conclusions: To our knowledge this is the largest reported 1470nm DiLEP series with the largest mean prostate size. With favorable hemostatic and depth of penetration qualities (∼ 1mm), the 1470nm Diode laser appears to be a safe and effective energy modality for enucleation. DiLEP is reported here to have similar complication rates and improvements in IPSS and QOL scores compared to those previously reported for HoLEP and ThuLEP. Longer follow‐up will be useful in demonstrating its durability. Randomized trials will be the next step to assess if DiLEP should be considered a standard of care for large glands.
Funding: None
Retrospective Study Comparing the Impact of Antibiotic Prophylaxis on Infectious Complications After Holmium Laser Enucleation of the Prostate in High‐Risk vs Low‐Risk Patients
Fabrice Henry1, Nikhil Prahmod1, Suruchi Ramanujan2, James Bena1, Smita De1
1Cleveland Clinic Glickman Urological and Kidney Institute, 2Case Western Reserve University College of Medicine
Presented By: Fabrice Henry, MD
Introduction: Overall infectious complications after holmium laser enucleation of the prostate (HoLEP) are low but the rates of infections between high‐ vs. low‐risk patients is unknown. We aimed to assess rates of infectious complications between high‐risk vs. low‐risk patients undergoing HoLEP. We secondarily aimed to evaluate the effect of preoperative antibiotic duration on infection rates in high‐risk patients.
Methods: Patients who underwent HoLEP at our institution were retrospectively reviewed. Patients were classified as “high risk” if they were catheter dependent at the time of surgery (indwelling or intermittent catheterization) or had a positive pre‐operative culture within 2 weeks of surgery. The primary endpoint was any post‐operative genitourinary infection within 30 days of HoLEP. Within the high‐risk group, long and short duration of antibiotics was defined as > 3 days and ≤3 days. Secondary endpoints included functional outcomes and prostate specific antigen.
Results: 190 patients met inclusion criteria. 61% of patients were classified as high risk. Of the high‐risk patients, 59% received a long course of antibiotics, while 41% received a short course. Overall infection rates were 4.7%, with no significant difference between high‐ and low‐risk patients or between long and short courses of antibiotics for high‐risk patients. High‐risk patients received a broader spectrum of preoperative antibiotics.
Conclusions: A higher risk of postoperative infections after HoLEP may be mitigated by extended antibiotics. Larger, prospective randomized trials are needed to identify ideal antibiotic protocols for high‐ risk patients undergoing HoLEP.
Funding: None
Distribution of Chief Complaints Among Patients Undergoing Aquablation
David Nusbaum1, Clark Judge1, Hernan Lescay1, Alexander Glaser2, Brian Helfand2, James Kearns2
1University of Chicago Medical Center, 2NorthShore University HealthSystem
Presented By: David Nusbaum
Introduction: Previous studies have demonstrated that men can identify a motivating or “chief” urinary complaint that drives them to seek treatment.Nocturia has been shown to be the most frequent chief complaint in men with lower urinary tract symptoms (LUTS) presenting to an outpatient urology clinic. However, the distribution of chief complaints and associated characteristics of men undergoing surgery for LUTS secondary to benign prostatic hyperplasia (BPH) areunknown. The objective of this study was to evaluate the distribution of chief complaints and clinical factors in patients electing to undergo a bladder outlet procedure.
Methods: Data were prospectively gathered for consecutive patients who underwent Aquablation between March 2019 and May 2023 at a single institution. All men were asked to identify a chief complaint. Baseline characteristics including prostate size, post‐void residual (PVR), and International Prostate Symptom Score (IPSS) were compared, stratified by chief complaint. Change in PVR and IPSS after surgery were assessed. The Kruskal‐Wallis test and Fisher's exact test were used for testing between groups.
Results: Two‐hundred‐sixty (260) men who underwent Aquablation for BPH and LUTS were included. Weak stream was the most common chief complaint, reported by 117 (45%) men. Baseline PVR was higher in patients with a chief complaint of weak stream or incomplete emptying, and these men experienced a larger median improvement in PVR after surgery compared to those with other chief complaints. There were no differences in baseline IPSS or change in IPSS after surgery when stratified by chief complaint.
Conclusions: Weak stream was the most common chief complaint in this cohort of men who underwent Aquablation for LUTS and BPH. This differs from the population of men presenting to a urology clinic for LUTS, where nocturia is the most common chief complaint. Men with a chief complaint of weak stream or incomplete emptying had a higher median PVR at baseline, and a larger median improvement in PVR after surgery. Regardless of chief complaint, patients experienced similar improvements in IPSS after surgery.
Funding: None
Aquablation and Antithrombotics: Evaluation of Safety, Post‐Operative Bleeding Rates and Clinical Outcomes
Anindyo Chakraborty12, Iman Sadri1, David‐Dan Nguyen2, Adel Arezki3, Kussil Oumedjbeur4, Naeem Bhojani5, Dean Elterman2, Bilal Chugtai6, Peter Gilling7, Mihir Desai8, Leo Doumanian9, Alexis Te6, Gopal Baldini10, Claus Roehrborn11, Kevin Zorn5
1Department of Urology, McGill University, 2Division of Urology, University Health Network, University of Toronto, 3Department of Urology, McGill University,, 4Division of Experimental Surgery, McGill University, 5Division of Urology, Centre Hospitalier de L'Université de Montréal, 6Department of Urology, Weill Cornell Medical College–New York Presbyterian Hospital, 7Department of Urology, Tauranga Hospital, 8Catherine and Joseph Aresty Department of Urology, Keck School of Medicine, 9Institute of Urology, University of Southern California, 10Department of Urology, Wake Forest University, 11Urology, The University of Texas Southwestern Medical Center, 12Faculty of Medicine and Health Sciences, McGill University
Presented By: Anindyo Chakraborty, BSc.
Introduction: In this study, men undergoing Aquablation robotic prostate surgery with and without perioperative antithrombotic medications were examined for bleeding and other adverse events.
Methods: The study included 116 men with moderate‐to‐severe lower urinary tract symptoms who were part of the WATER prospective trial (NCT02505919) undergoing Aquablation therapy. Patients were assigned to one of two groups based on their antithrombotic use. Antithrombotic medications included antiplatelets (low dose aspirin and high dose aspirin/antiplatelets) and anticoagulation (warfarin). Intraoperative hemostasis was achieved via no‐cautery balloon tamponde or cautery. Primary endpoints were immediate post‐operative heamturia rates and changes in hemoglobin. Secondary endpoints were 90‐day bleeding complications and rates ofnon‐bleeding post‐operative adverse events.
Results: Forty‐one men taking regular antithombotic medications in both the perioperative and post operative period were compared to 75 men with no use of antithrombotic medications. The rates of alpha‐blocker or 5‐ alpha reductase inhibitor medications were comparable between both groups. There were no significant differences in perioperative hemoglobin levels. Post‐operative hemoglobin dropped by among the antithrombotic gorup and in the antithrombotic‐naïve group (p = 0.896). Four (9.8%) men in the antithrombotic group and 4 (5.3%) men in the antithrombotic‐naïve group encountered a Clavien‐Dindo Grade 1 complication in the 3‐month postoperative period (p = 0.451). Eight (19.5%) men in the antithrombotic group experienced a Clavien‐Dindo Grade 2 complication, none of which was associated with bleeding,whereas that number was 11 (14.7%) for theantithrombotic‐naïve group (p = 0.601). Four (9.8%) men in the antithrombotic group and 4 (5.3%) men in the antithrombotic‐naïve group had de‐novo ejaculatory dysfunction (p = 0.451). No de novo erectile dysfunction was seen in either group. A single patient (2.4%) in the antithrombotic group required a blood transfusion whereas none did in the antithrombotic‐naïve group(p = 0.353).
Conclusions: Aquablation shares similar post‐operative bleeding outcomes and other adverse rates for men with BPH who are on antithrombotic therapy to those without any antithrombotic medications.
Funding: The original trial from which the data is derived was funded by PROCEPT BioRobotics. However, no funding was attributed for the purposes of this study.
is the Urolift a Fertility Sparing Technique in Patients Suffered from Benign Prostate Hypertrophy?
Edoardo Tocci1, Nicola D'altilia1, Gian Maria Busetto1, Vito Mancini1, Edoardo Tocci1, Ugo Giovanni Falagario1, Carlo Bettocchi1, Giuseppe Carrieri1, Pasquale Annese2
1University of Foggia, 2Policlinico Riuniti di Foggia
Presented By: Edoardo Tocci, MD
Introduction: Benign prostatic hypertrophy (BPH) is a common disease in aging males. Some patients under 50 years of age reported lower urinary tract disorders (LUTS) due to BPH. If desirous of paternity, drugs treatment remains the only one due to the risk of anejaculation after surgery. The first aim of the study was to report functional outcomes related to fertility preservation evaluated by sperm test in a population under 50 years of age who underwent UroLift.
Methods: Included 20 young men with LUTS from BPH assessed by the International Prostate Symptom Score (IPSS), with normal erectile (EF) and ejaculatory function (EjF) assessed by the International Index of Erectile Dysfunction (IIEF‐5) and Male Sexual Health Questionnaire for Ejaculatory Dysfunction (MSHQ‐ EjD‐SF). Semen analysis was performed before and 6 months after surgery with evaluation of pH, volume, sperm concentration, motility, vitality and morphology of sperms. All preoperatively underwent, uroflowmetry (UFM), digital rectal examination, transrectal prostate ultrasound to measure prostate volume, PSA, cystoscopy and urodynamics test if necessary. Urinary function was scheduled at 1,3, 6, 12 months with UFM, IPSS, IIEF‐5, and MSHQ‐EjD‐SF. First PSA and cistoscopy were repeated at 6 month.
Results: The mean age of the patients was 44.5 (36.5, 48) years. Mean operative time was 15 (10, 20) min and 2.5 (2, 4) implats per patients were used. At 3 months there were no difference in terms of total sperm count, volume, pH, motility, vitality, morphology, liquefaction, leucocytes (p = 0.9; p = 0.8; p = 0.7; p = 1; p = 1; p = 1; p = 0,2; p = 0.5). No patient presented retrograde ejaculation. Q‐max increased by 64.4% (p = 0.001), PVR decreased by 66.6% (p = 0.016), and IPSS decreased by 60% (p < 0.001). IIEF and MSHQ‐EjD‐SF were similarly preserved (p = 0.14, p = 0.4).
Conclusions: We can conclude new findings regarding sparing of sperm parameters following UroLift, furthermore, no one reported retroejaculation or volume alteration. UroLift was confirmed to be effective as a technique in improving urinary functional disorders secondary to BPH.
Funding: none
Modified Mini Bladder Neck Incision Combined with Urolift for Subset of Men with BPE and High/Tight Bladder Neck
Keng Lim Ng1, Rami Abuseedou1, Neil Barber1
1Frimley Health NHS Foundation Trust
Presented By: Keng Lim Ng, BSc(MED), MBBS, MS, FRCS(Urol), PhD
Introduction: Urolift is widely accepted as treatment for men with moderate/severe LUTS secondary to BPE with excellent post op urinary flow outcomes while preserving sexual function. However in a subset of men who present with prostatic enlargement andconcomitant high and tight bladderneck, urolift alone with not achieve satisfactory outcomes. Therefore, in our institution , we have modified the surgical technique to combine a mini bladder neck incision (mini BNI) with urolift and have achieved good outcomes while preserving erections and antegrade ejaculation.
Methods: Retrospective data of mini BNI and urolift were collected from September 2019 to September 2022 in our single institution. Following pre operative flexible cystoscopy assessment, these patients were counselled for the procedure. All cases were done under sedation in a daycase procedure room. A 6 oclock vertical mini incision at the bladder neck was done with electocautery Collins knife, followed by 4 urolift implants to achieve a wide open bladder neck and prostatic fossa. Data including IPSS, flowmetry, sexual function and patient satisfaction were recorded accordingly.
Results: 40 procedures were performed with median age of 70 years and mean prostate volume of 40mls. All patients underwent procedure under sedation and were dischargedon same day. 90% o fpateitns were discharged without catheter while other 4 returned for successful TWOC 3 days later. Preop mean IPSS score reduced from 17 to 8 post operatively. Mean quality of life scores reduced from 4.7 (preop) to 2.3 (post op). Maximum flow rate improved by 60% post surgery. Post operatively, all sexually activepatients described no worsening of erectile function and maintainedantegrade ejaculation. No significant post op complications were recorded except for one case who had UTI treated in the community.
Conclusions: From our early experience, this modified technique of mini BNI combined with urolift is safe, effective minimally invasive treatment for subset of men with BPE with concomitant high/tight bladder neck while preserving sexual function. Further collection ofdata will be needed to assess the efficacy of this procedure in the long term.
Funding: No funding received for this.
Early Experience and Feasibility of Daycase Aquablation for BPH in a Single UK Institution
Keng Ng2, Neil Barber1
1Frimley Health NHS Foundation trust, 2Frimley Health NHS Foundation Trust
Presented By: Keng Ng, BSc(Med), MBBS, MS, FRCS(Urol), PhD
Introduction: Aquablation involving ultrasound guided robotic water jet ablation of the prostate has resulted in significant improvements in management of LUTS in men with enlarged prostates with faster recovery. We have recently successfully performed aquablation as a daycase procedure with same day discharge on selected patients with a return for TWOC a few days later.
Methods: Retrospective data were collected during a period of 5months (Dec 22‐ May23) on 30patients who had aquablation with same day discharge in the evening of the operation with catheters and retruned for TWOC 3 days later. Patients who were living within local suburbs were consented and counselled for the daycase procedure. Data including preop and post op IPSS, flowmetry, TWOC outcomes were collected.
Results: 30 patients had aquablation as daycase procedure, with median age of 69 years, mean prostate volume 63.3cc (40% trilobar). All patients were discharged on same day with catheters and had successful TWOC 3 days later. Threepatients presented with urinary retention about a week later (one clot retention, 2 had acute on chronic retention) while another had urgency and frequency which was managed conservatively. Post op Qmax improved to 22.2mls/s from preop Qmax of 8.65mls/s. Mean preop IPSS score of 22 reduced to only 5 post procedure, with QoL improving from 4.6 preop to 1 (pleased) post op.
Conclusions: This early experience on a small cohort of patients has proven that aquablation can be safely performed as day case procedure. This successful proof of concept for daycase aquablation will enable us to confidently perform aquablation aiming for same day discharge thus reducing the pressures on bed shortages in the NHS hospitals. Ongoing further data collection will enhance our confidence inperforming such cases as daycases.
Funding: None
Prostatic Dimensions, Not Volume, Predicts HoLEP Operative Time
Jonathan Modai1, Parth Patel1, Roi Babaoff2, James Lee1, Dong Shin1, Kymora Scotland1, Matthew Dunn1
1UCLA, 2Rabin Medical Center
Presented By: Jonathan Modai, MD
Introduction: Over the past three decades, Holmium laser enucleation of prostate (HoLEP) has emerged as the gold‐standard treatment for benign prostate hypertrophy (BPH), thanks to its ability to achieve profound and durable functional results in a minimally invasive way for prostates of all sizes. Still, widespread adoption has been slow, hindered by a steep learning curve and difficulties in performing the procedure in an efficient way. Understanding factors affecting operative time can allow surgeons to schedule their cases more precisely and may help with resource allocation for challenging cases.
Methods: We performed a prospective observational cohort study of patients undergoing HoLEP by a single surgeon from 2020 to 2022. Demographic, clinical, and radiographic variables were collected for analysis. Univariate and multivariable logistic regression analyses were performed to identify factors affecting surgery time.
Results: A total of 303 patients were included in the analysis. The average age was 70 years (44‐86 years), average prostate size was 121cc (20‐315cc) and average operative time was 159 minutes (15‐414 minutes). Univariate analysis found body mass index, pre‐operative catheter dependence, prostate volume, prostate height (anterior‐posterior), prostate width (transverse), and prostatic urethral length all affected operative time. Multivariate analysis demonstrated that prostatic urethral length, prostate height, and length‐to‐width ratio had a clinically significant impact on operative time, with each 1cm increase in prostate height and prostatic urethral length predicting a 38 and 44 min increase in operational time, respectively. Prostates with lower length‐to‐width ratios were found to be more challenging, requiring 5 minutes more for every 0.1 decrease in this ratio.
Conclusions: Rather than gland volume, the operative times of our HoLEP procedures were associated with prostatic urethral length,height, and length‐to‐width ratios. These findings can help surgeons with allocating time and resources properly for cases that may be expected to last longer than others.
Funding: None
Trends in Surgical Treatment for Benign Hyperplasia of Prostate: A Multi‐Center 12‐Year Retrospective Study from Israel
Karin Lifshitz8, Hen Hendel1, Yaron Ehrlich1, Omer Anis2, Zohar Dotan2, Guy Verhovsky3, Ehud Gnessin3, Rabeea Moed4, Nicola Mabjeesh4, Mahmood Abbas5, Ilan Kafka5, Ali Safadi6, Ran Katz6, Mario Sofer7
1Division of Urology ,Rabin Medical Center, 2Sheba medical center, Urology, 3Shamir Medical Center, Urology, 4Soroka Medical Center, Urology, 5Shaare Zedek Medical Center, Urology, 6Ziv medical center, 7Tel Aviv medical center, 8Tel Aviv Medical center, Department of Urology
Presented By: Karin Lifshitz, MD
Introduction: Surgical management options for BPH have changed considerably over the past 20 years. Therefore, we aimed to investigate national BPH surgical trends in the Israeli population.
Methods: The study cohort comprised 13,521 consecutive BPH surgeries performed between 2010‐2022 in 7 academic centers. Analysis was performed by number and types of surgery, demographic data, hospital stay, and the influence of introducing holmium laser enucleation of the prostate (HoLEP).
Results: There were 9916 (73%) transurethral resections of the prostate (TURP), 1644 (12%) open surgeries, 1542 (12%) HoLEP, and 419 (3%) other surgeries. An annual increment of 5% for an overall cumulative increase of 68% over 12 years was noted (Figure). The introduction of HoLEP determined the disappearance of open surgeries and a decreasing tendency to perform TURPs. The overall patients' average age was 72.4 (9.5 ± SD) years, slightly increasing to 73.1 (8.6 ± SD) in the last year of the study. The overall hospital stay was 3.4 days (4.3 ± SD) for the entire cohort, with a statistically significant decrease over time (1.3 ± SD; p < 0.05). HoLEP had an average stay of 1.6 (1.4 ± SD), statistically significantly shorter in comparison to open and other endoscopic surgeries (p < 0.05). Overall, there was a temporal statistically significant decrease in hospital stay (3.9 vs. 2.6 days; p < 0.05).
Conclusions: The number of BPH surgical treatments in Israel is constantly increasing with a shift to minimally invasive procedures and, subsequently, the abandonment of open surgery. Despite a constant increase in the age of the population, the average age for surgery did not significantly increase. The 68% cumulative increment in BPH surgeries over the years suggests that more comprehensive and faster implementation of size‐independent, short‐hospitalization approaches (e.g., HoLEP) can benefit both patients and the medical system.
Funding: This studywas not funded by any external sources
Correlation Between Serum Testosterone and Prostate‐Specific Antigen (PSA) in Ordinary Males
Jun Ho Lee3, Dong‐Gi Lee1, Hyung‐Lae Lee1, Gyeong Eun Min1, Kyung‐Jin Chung2
1Department of Urology, School of Medicine, Kyung Hee University, 2Gachon University Gil Hospital
3Department of Urology, Nowon Eulji Medical Center, Eulji University, Seoul, Korea
Presented By: Dong-Gi Lee, MD, PhD
Introduction: Prostate specific antigen (PSA) dose a major role in diagnosis of prostate cancer. In many cases additional considerations such as PSA density, PSA velocity or free PSA are necessary because PSA is not specific for prostate cancer. There are few studies about relations between serum testosterone and PSA. We investigated the association of serum testosterone and PSA.
Methods: We retrospectively reviewed 9318 male patients who visited our urology clinic for benign prostatic hyperplasia or regular health check‐up. 582 patients were excluded because of PSA level > 4.0ng/ml, current usage of 5a‐reductase inhibitors, pyuria and lack of data. Total 8736 patients were enrolled for analysis. We evaluated the relation between serum testosterone and PSA with adjustments of age, prostate size, plasma volume and metabolic syndrome.
Results: Mean age of enrolled patients were 50.2 ± 5.6 years. PSA showed positive relationship with serum testosterone. After fully adjusting for age, total prostate volume, plasma volume and metabolic syndrome, the geometric mean PSA linearly and significantly increased as a quartile testosterone increased (P = 0.047). Additionally, there was significant difference in adjusted mean of PSA between 1st quartile and 4th quartile group of testosterone (P = 0.006) and between 2nd quartile and 4th quartile group of testosterone (P = 0.006). There was significant difference in adjusted mean of PSA between a group with hypogonadism (serum testosterone < 3.5 ng/mL) and between a group without hypogonadism (P = 0.002).
Conclusions: The present study suggests that PSA may have positive correlation with serum testosterone. Careful considerations about serum testosterone are recommended for the interpretation of PSA results.
Funding: None
Transurethral Enucleation with Bipolar Using TUEB Loop for Benign Prostatic Hyperplasia: is it Effective Treatment Regardless of Prostate Size?
Jun Hagiuda1, Tsukasa Masuda1, Ryohei Takahashi1, Satoshi Tamaki1, Ken Nakagawa1
1Tokyo Dental College, Ichikawa General Hospital
Presented By: Jun Hagiuda, MD, PhD
Introduction: Bipolar transurethral enucleation of prostate is one of the useful treatments for large benign prostate hyperplasia (BPH). However, how the outcome changes according to prostate size were rarely elucidated. The aim of this study is to confirm the efficacy and safety regardless of prostate size treated by transurethral enucleation with bipolar (TUEB) in which specially developed TUEB loop was used.
Methods: A total of 211 patients who received TUEB were categorized into two groups depend on prostate size; the small (≤ 80mL) and large prostate volume group (> 80mL). Background and outcome of treatment were compared.
Results: Operation time (111.5 vs 163.6 minutes), enucleation time (48.3 vs 65.6 min) and morcellation time (11.2 vs 24.4 min) were longer and hemoglobin decreased significantly (0.81 vs 1.33 g/dL) in large BPH group. However, the enucleation efficiency (0.71 vs 1.00 g/min), Prostate Specific Antigen reduction rate (26.0 vs 16.0 %) and catheterization time (2.89 vs 2.68 days) were significantly better in large BPH group with similar enucleation rate (81 vs 78 %). International Prostate Symptom Score, maximum flow rate of uroflowmetry and post void residual urine were improved at 3‐, 6‐, and 12 months compared with baseline in both groups. No one has received blood transfusion. There was no difference in frequency of postoperative clot retention, urethral stricture, stress incontinence at 3‐ 6‐ and 12 months.
Conclusions: Transurethral enucleation with bipolar using TUEB loopshowed higher enucleation efficiency, efficacy and safety for BPH surgery regardless of prostate size. TUEB would be considered as one of the best options for large BPH treatment which is uncontrollable under medication.
Readability and Accuracy of Artificial Intelligence Generated Outputs Compared to CUA Patient Information Materials
Connor Forbes1, Alec Mitchell1, Abdul Halawani1
1UBC Urology
Presented By: Connor Forbes, MD, FRCSC
Introduction: Patient Information Materials (PIMs) published by major urologic organizations are a reliable adjunct to improve patient understanding of kidney stone disease, and to help them navigate complex choices. Significant recent advances in machine learning language models have disrupted patient engagement in online information, namely through generative pre‐trained transfomers. These “chatbots” supply easily accessible, apparently authoritative but unsourced responses to queries. As consumption of this type of information is increasing exponentially among patients, we compared readability and accuracy of artificial intelligence‐generated PIMs to those supplied by the CUA, AUA, and EAU for kidney stones.
Methods: PIMs from CUA, AUA, and EAU on 4 topics related to nephrolithiasis were assessed; general information, dietary, surgical and medical management. We then assessed therer readability with three standard readability scoring systems.Next, we completed a basic web search to identify the top patient questions related to kidney stones. The first five hits for ‘Patient questions Kidney Stones' were surveyed and the ten most frequently occurring questions were chosen. These were assigned to one of four categories based on our previous work; general information, dietary management, surgical management and medical management. These were then input into ChatGPT and the outputs then analyzed for accuracy and readability. Accuracy was assessed by two independent reviewers and graded from 1‐5 (1 = accurate, 5 = inaccurate), while readability was scored based on validated readability indexes, SMOG, Gunning Fog and FKGL (as in our previous work)
Results: Readabiity for ChatGPT outputs ranged from 13.1‐14.1. This represents a uniformly more complex score across all topics in comparison to PIMs published by the CUA which ranged from 9.5‐11.6. Furthermore, CUA PIM's on both medical and surgical management of stones were almost two grade levels simpler than dietary and general information (9.5, 9.5‐ 11.6, 11.3). this trend was not seen for the ChatGPT outputs which had minimal variability and all scored above 13 (13.1‐14.1). Accuracy was also investigated, and the ChatGPT outputs scored 2, 2, 2 and 3. Indicating ‘accurate with minor details omitted’.
Conclusions: ChatGPT's outputs on patient questions related to nephrolithiasis do not compare favourably to the CUA PIM's in terms of patient readability. They were almost two grade levels more complex than their CUA counterparts, and in the case of both surgical, and medical management, almost four grade levels. However, accuracy of the output was reasonable, but not perfect with most topics having minor detail omissions. As these AI resources become more integrated into our patients lives, its important we as clinicicians are aware of the limitations to provide appropriate counselling.
Funding: None
Evaluating the Feasibility of ChatGPT in Responding to Electronic Patient‐Provider Communication
Vishnuvardhan Ganesan1, Hailey Fyre1, Deepak Agarwal1, Michael Borofsky1
1University of Minnesota
Presented By: Vishnuvardhan Ganesan, MD
Introduction: The number of patient portal messages sent to providers continues to rise with increased uptake of electronic medical records. Using large language models such as GPT‐4 to triage or answer messages could help improve timely responses and patient satisfaction. In this study we evaluated the use of ChatGPT on its ability to answer patient questions sent to an outpatient endourology clinic.
Methods: We collected all messages sent by patients through the EPIC MyChart portal to two endourologists at our institution between March 2023 to April 2023. After removing identifying information and rewording the question, ChatGPT was queried for responses. The quality of responses was then independently assessed by three urologists. Each response was carefully evaluated and graded on a scale ranging from “Very Poor” to “Very Good” to determine the quality of information provided. Additionally, the urologists determined whether the AI‐generated response was helpful or not, categorizing it as either “yes” or “no.”
Results: 97 questions from patients were analyzed.When the quality of the information in the responses was assessed, they were good or very good in only 20% of responses. This was better for responses to patient updates (53%) and post‐op questions (46%), Figure 1. Responses were rated as “not helpful” for majority of questions (76%). Chat GPT included disclaimers in 25% (25/97) of the responses. It responded that it is not able to answer the question because it is “not authorized”, or it “cannot provide medical advice”, or it “doesn't have access” to medical records or medical history. In 68% (66/97) of responses ChatGPT asks for the user to consult with a healthcare provider. In 4% (4/97) of responses ChatGPT suggested going to emergency room.
Conclusions: AI generated responses for patient questions were rated as “not helpful” by the assessors 76% of the time but appear to be better for subset of patient update and post‐op questions. While not ready for clinical use in its current form, we feel with integration with clinical context or medical and surgical history there is significant potential for AI as a triage system.
Funding: None
Adopting Machine Vision Augmentation to Detect Detrusor Instability in Overactive Bladder: A Frontier of Artificial Intelligence Application in Functional Urology
Jin Yong1, Yuguang Tan1, Shauna Jia Qian Woo1, Lay Guat Ng1, Mark Kei Fong Wong2
1Singapore General Hospital, Singhealth, Singapore, 2Endosiq Technology Singapore
Presented By: Jin Yong, MMed (Surg)
Introduction: Overactive bladder (OAB) is an increasingly prevalent urological condition. Routine urodynamics study (UDS) is invasive, inconsistent and simply impractical in every outpatient setting. We aim to prove that detrusor instability in OAB can be identified based on keypoint movements of the vascular network of the detrusor using our novel cystoscopy based machine vision software.
Methods: We prospectively collected 158 cystoscopy videos and extracted 30‐60 second clips from each video. The recordings were first filtered to remove videos with significant artefacts, leaving 109 cystoscopy videos (31 previously UDS confirmed DO, 78 non‐OAB). Thereafter, the videos were enhanced to improve resolution and enlarge the vascular network on the detrusor. Mosaic stitching and 3D Mapping was performed to stitch single frames into a large panorama that was reconstituted into a 3D sphere to emulate the shape of the bladder. Thereafter, the vascular network underwent UNet Segmentation to create keypoints for analysis, generating an average of 300 keypoints per frame. Finally, the movement of these keypoints over time was generated into a heat map using Keypoint Motion Spectra, as a surrogate for areas of detrusor microcontraction.
Results: Results demonstrated a greater amount of overall movement of keypoints in the OAB group as compared to the non‐OAB group. Combined heatmap also evidenced a greater amount of movement per frame in each cystoscopy video (Fig 1). This is reiterated numerically by the greater mean pixel deviations per frame in the OAB group of 84.71 compared to 26.23 in the non‐OAB group (Fig 2).
Conclusions: Our novel machine vision augmentation model yields promising results in identifying DI in OAB patients, using movements of keypoints on the blood vessel network in our cystoscopy based software. Differentiating this degree of movement can potentially allow for diagnosis of OAB using a cystoscopy based tool in the future, as well as allow for targeted areas of intra‐detrusor treatment to minimize side effects and maximize efficacy of drugs.
Funding: None
Leveraging an Artificial Intelligence Language Model, for Scientific Abstract Optimization: Enhancing Conciseness, Word Count Adherence, and Beyond
Laurence Hou1, Ernest Tong1, Ravi Munver2
1Hackensack University Medical Center, 2Hackensack Unviersity Medical Center
Presented By: Laurence Hou, MD
Introduction: The creation and editing of scientific abstracts are critical for succinctly summarizing research studies. This study explores the use of ChatGPT, an artificial intelligence (AI) language model, to enhance abstract optimization by improving conciseness, adhering to word count limitations, and providing additional value‐add features. The objective is to evaluate the effectiveness of ChatGPT in abstract optimization for abstracts to be submitted to the World Congress of Endourology.
Methods: We conducted a study of six diverse minimally invasive urologic surgery scientific abstracts. ChatGPT was employed as an intelligent assistant in two main stages: initial generation and iterative refinement. The model was used to draft preliminary abstracts based on research materials and key findings. The iterative refinement process involved interactive fine‐tuning of abstracts using ChatGPT's real‐time feedback and suggestions.
Results: ChatGPT facilitated concise expression and adherence to word count restrictions by providing estimated word counts for each section. The iterative refinement process helped remove redundancies and extraneous details, optimizing abstracts for brevity. ChatGPT's language proficiency also enhanced the overall quality of the abstracts by suggesting improved vocabulary choices, refining sentence construction, and ensuring consistency of terminology.
Conclusions: ChatGPT proved highly useful in abstract optimization for the World Congress of Endourology, enhancing readability, quality, and time efficiency. Researchers can leverage ChatGPT to achieve concise, impactful abstracts. It is important to note that human oversight is necessary to evaluate and validate the generated suggestions for scientific accuracy and context appropriateness. The integration of AI language models holds significant promise for efficient communication of research findings.
Funding: N/A
Antibiotic Resistance Gene Presence Leads to Increased Infection in Individuals with Urological Devices
Sromona Mukherjee3, Glenn T. Werneburg1, Daniel Hettel1, Scott Lundy1, Ava Adler1, Smita De1, Raymond Rackley1, Daniel A. Shoskes2, Aaron W Miller1
1Cleveland Clinic, 2Exact Sciences, 3Cleveland Clinic Foundation
Presented By: Sromona Mukherjee, Phd
Introduction: The artificial urinary sphincter (AUS) is an effective treatment option for stress urinary incontinence due to intrinsic sphincteric deficiency in the context of neurogenic lower urinary tract dysfunction, or following prostatectomy. A subset of AUS devices is subject to infection.The penile prosthesis is an effective treatment option for erectile dysfunction with a long‐term satisfaction of > 90% for both patient and partner. The most common type of penile prosthesis is the inflatable penile prosthesis (IPP). Infection is among the most feared complications associated with IPP placement and is associated with significant morbidity and cost burden exceeding six times the cost of initial uncomplicated IPP placement. We sought to determine the presence of antibiotic resistance genes in these samples obtained from patients.
Methods: RT‐PCR was performed on samples from 15 of the 18 AUS and 25 of 27 device biofilms IPP device following DNA extractions was performed to detect commonly found antibiotic resistance genes.
Results: In AUS samples, sul2 (encoding for sulfonadmide resistance) was detected in 8 of 15 (53%) biofilms. ampC (encoding for penicillin resistance) was detected in 11 of 15 (73%) biofilms. An rpoB mutation associated with rifampin resistance was detected in 8 of 15 (53%) biofilms. tetA (encoding for tetracycline resistance) was not detected in the biofilms. The fimH adhesin gene, associated with biofilm formation, was detected in 10 of 15 (67%) biofilms.In IPP samples , Sul2 was present in 48% of samples, ampC in 92% of samples, tetA (in 12% ), rifampin resistance in 36% of samples. The fimH adhesin gene, was detected in 48% of samples. The detection of antibiotic resistance genes or fimH gene did not differ by infection status, antibiotic use in the past 30 days, pain status, or device type. The rpoB mutation was detected in biofilms from 35% of IPPs with minocycline/rifampin coating, 25% of IPPs with user‐defined antibiotic irrigation, and 50% of malleable devices (p = 0.76). tetA was detected in biofilms from 5.9% of IPPs with rifampin/minocycline coating, 25% of IPPs with user‐defined antibiotic irrigation, and 12% of malleable devices (p = 0.39).
Conclusions: We hypothesize that individuals commonly exposed to antibiotics select for antibiotic resistant genes thereby reducing the effectiveness of the administered antibiotic following an infection. Knowledge of previous antibiotic history may be beneficial while administering them in case of infection with a urological device.
Funding: NA
Combined Urethral and Endovascular Treatment of Arterioureteral Fistulas with Fully Covered Stents Risk‐Adapted in Radiated and Preoperated Patients
1Kocaeli University Hospital, 2Medical University Charite ‐ Berlin ‐ Department of Urology, 3Medical University Charite ‐ Berlin ‐ Department of Vascular Surgery
Presented By: Joerg Neymeyer, Dr.
Introduction: Arterio‐ureteral fistulae are abnormal connections between blood vessels and the ureter and most commonly involve the iliac arteries and the ureter. They are rare entities, and only around 200 cases have been reported in the literature. However, the majority of fistulae are secondary, occurring due to radiation or surgery for urological and gynecological cancers, vascular or pelvic surgeries. Our procedure consents include a statement regarding the use of images such as radiographs without patient identifiers for teaching and illustrative purposes. Our institutional policy does not require patient consents for case reports. Case reports are also exempt from institutional board review.
Methods: We present 21 cases of arterio‐ureteral fistulae that presented with lifethreatening hematuria. 11 patients were treated successfully with ureteral covered stent placement (Allium ureteral stent 200x9mm) and 10 patients are combined treated with uretral (Allium ureteral stent 200x9mm) and endovascular (Endovascular Stent Graft) covered stents placement. Mean surgery time was 55min (16‐ 95min). The position, continuity and sealing of the stent in the ureter and vessel were documented by radiological contrast imaging.
Results: All patients were treated successfully with ureteral or with combined uretral and endovascular covered stent placement.
Conclusions: Conclusions: In conclusion, ureteral or with combined uretral and endovascular covered stent placement of covered stents is a feasible minimal invasive therapeutic option for the treatment of acute life‐ threatening hemorrhage due to arterio‐uretral fistulae.
Funding: None
Management of Calcified Ureteral Catheters and Functional Results. Experience After One Year of Pandemic on a Mexican Single Center.
Ricardo Emanuel Domínguez Castillo2, Carlos Martínez Arroyo1, Daniel Alejandro Arreola Ramírez2, Alejandro Haddad Servín1, Antonio Yaromin Muñoz López1
1Hospital General Dr. Manuel Gea González, 2Hospital General Dr. Manuel Gea González.
Introduction: It is known as “calcified ureteral catheter”, one that cannot be removed by cystoscopy during the first attempt without the help of other auxiliary measures, due to encrustation or stone formation in it. They can occur in up to 13% of cases. The situation due to the COVID‐19 pandemic favored the loss of follow‐up of patients, which conditioned the presentation of calcified catheters in any degree, requiring an approach in multiple modalities.
Methods: Retrospective cohort study. We identified 15 patients who had one or two ureteral catheters placed between October 2019 and March 2021. All had some degree of catheter calcification according to the FECal classification. Surgical treatment performed, number of procedures, stone‐free status, pre‐ and post‐treatment glomerular filtration rate were reviewed. 15 patients with calcified JJ catheter, with a mean age of 46.6 years. The average time being JJ catheter carriers was 9.06 months.
Results: Endoscopic procedures were performed in 88.6%, 6.6% with laparoscopic procedure (due to renal atrophy) and 6.6% endoscopic + open procedure. Two patients required more than one procedure for its resolution. 100% of patients remain stone‐free. The average glomerular filtration rate prior to JJ catheter placement was 75.9 mL/min/m2. The average post‐treatment glomerular filtration rate was 80.56 ml/min/m2.
Conclusions: Despite the complications generated by the loss of follow‐up due to the pandemic, it was possible to offer, to the majority, of patients with this condition a resolution of the underlying pathology and complication in a single surgical time, thus favoring a better short‐term and even long‐term results, functionally speaking.
Funding: None
is Your Career Hurting you? a Geographically Controlled Assessment of Medical and Surgical Ergonomics
1University of Colorado Anschutz School of Medicine, 2University of Colorado Department of Surgery/ Urology, 3University of Colorado Department of Pediatrics, 4University of Colorado/ Rocky Mountain Regional VA Hospital
Presented By: Granville Lloyd, MD
Introduction: Ergonomic research has primarily focused on surgeons due to perceived risk of work induced musculoskeletal disorders (WIMD). There remains little data analyzing WIMD including non‐surgical specialties, especially in a setting controlled for environmental factors. We set out to assess the relationship of pain, need for surgical intervention, practice type, screen time and other factors in a controlled cross‐specialty cohort of practicing physicians.
Methods: An anonymous web survey was distributed to participating departments of our institution, including Surgery including Urology, Anesthesiology, Emergency Medicine (EM), Otolaryngology (ENT), Family Medicine, Internal Medicine, Neurology, Neurosurgery, Pediatrics. The primary outcome measures were subjective reports of significant neck and back pain and need for surgical intervention. Qualtrics Software backed on a secure CU server was utilized to manage data. Chi‐square analysis was performed to analyze variance in means and percentages across the specialties.
Results: Data was extracted from 746 surveys collected across 10 departments. Analysis was restricted to MD/DO attending physicians (n = 476). The department of ENT, Pediatrics, and Surgery had the highest rates of significant pain (81.82%, 61.11%, and 58.11% respectively; p = 0.027). The greatest time spent on computer tasks were Internal Medicine and Family Medicine at 5.54 and 5.36 hrs/day (p < 0.001). ENT and Surgery had the highest percentage of respondents who attribute their WIMD to their career at 66.67% and 52.38% respectively (p < 0.001).
Conclusions: We found greater subjective pain among procedural specialties; this suggests but does not prove a causative role intrinsic to specialty. The higher proportion of proceduralists who attribute their pain to their career may represent departments in need of ergonomic intervention. The increased time spent on computer related tasks in non‐procedural departments represents a workforce that may benefit from further investigation but does not appear related to WIMD.The inpatient pediatrics department had the highest percentage of significant pain of the non‐procedural specialties. This may be attributable to multiple factors unique to pediatrics however no definitive causation can be determined. Further research is crucial to protect and retain a healthy physician workforce.
Funding: none
Beyond the Science: The Hidden Costs of Printed Poster Presentations at Urology Conferences
Robert Medairos1, Austin Livingston1, Rand Wilcox Vanden Berg1, Jordan Foreman1, Andrew Peterston1, Chuck Scales1, Jodi Antonelli1, Michael Lipkin1, Glenn Preminger1, Robert Medairos1
1Duke University Medical Center
Presented By: Robert Medairos, MD
Introduction: Poster presentations serve a vital function in the dissemination of research at urologic conferences, yet the financial and environmental implications remain unexplored. While accessible alternatives to traditional printed posters exist, a comparative analysis has not been performed. This study aims to compare the economic and environmental impacts of traditional printed poster presentations with various alternative formats at major urological conferences in recent years.
Methods: Conference agendas and number of poster presentations from selected urology conferences in 2021 and 2022 were reviewed. The costs, (US Dollars, $), were based on the average price of standard printing services ($90 for a 36” x 72” poster). The environmental impact from printing the poster was evaluated using the Hewlett‐Packard carbon footprint calculator. Comparative estimates for several alternative presentation formats included compact posters ($60 for a 36” x 48”), digital viewing via 43” television (TV) screens, projected posters, and a printed QR code page (8.5” x 11”) linked to an online poster. Energy consumption for two‐hour usage of TVs or portable projectors was derived from Energy.gov data. The assumption was held that posters were printed once for a specific conference. Transportation and shipping costs, as well as the production and recycling of gloss paper and electronics were excluded from the analysis.
Results: Table 1 presents the number of posters at selected conferences by year, along with the alternatives. The total cost to presenters in 2021 was $236,340 and $262,710 in 2022. This resulted in 3789 kWh (2021) and 4212 kWh (2022) of energy usage. In contrast, conferences with digital presentations incurred no direct economic cost for poster presentation. The energy required to display posters on a TV screen was estimated to be 263 kWh in 2021 and 292 kWh in 2022, indicating a 93% reduction in energy consumption. A 33% reduction in both costs and carbon emissions was estimated for compact posters.
Conclusions: Traditional posters pose a significant financial and environmental cost. The potential for developing an innovative, sustainable platform for research dissemination warrants further exploration. Potential strategies include conversion to completely digital formats, a hybrid format with online hosting of posters linked to printed QR codes, or standardizing more compact posters.
Funding: N/A
“Does Music Really Have a Calming Effect on Pain and Anxiety in Patients Undergoing Outpatient Cystoscopy?”
1Department of Urology, Konyang University College of Medicine
Presented By: Dong-Hoon Koh, MD
Introduction: Cystoscopy is a commonly performed procedure in urological outpatient departments. However, the pain, discomfort, oranxiety experienced during the procedure can significantly impact patient compliance and adherence to necessary surveillance and management. Therefore, we conducted a study to investigate the potential effect of music in reducing pain and anxiety during outpatient cystoscopy.
Methods: A prospective, single‐institute, randomized study was conducted to classify patients into two groups: a music group and a no music group. Both groups completed surveys before and after the cystoscopy procedure, and separate questionnaires related to the study were administered to both patients and physicians. The group that did not listen to music underwent outpatient cystoscopy under local anesthesia as usual, including the use of 2% lidocaine gel and analgesics. In contrast, the music group had the same procedure but with the addition of classical music, specifically “Air on the G String” from Suite No. 3 in D major, BWV 1068.
Results: Between February and April 2023, 98 patients underwent elective outpatient cystoscopy. Patient‐ reported outcomes showed no significant difference in discomfort, embarrassment, satisfaction, and pain between the music and no music groups, except for STAI‐X‐1. However, physicians noted significant differences across all measured aspects between the two groups.
Conclusions: While specific reports of pain improvement in patients undergoing cystoscopy under the influence of music were not found, a potential trend indicating such benefits was observed, aligning with previous research findings.
Funding: The authors have not received any funding.
Comparing 4.8 Fr and 6 Fr Ureteral Stents in Terms of Urological Complications Linked to Kidney Transplantation Using a Prospective Randomized Controlled Trial
Introduction: Kidney transplantation (KT) is considered the gold standard treatment for end‐stage kidney disease. Prophylactic ureteric stenting in KT reduces major urological complications. However, at present, there is no consensus on the ideal size of ureteral stents. Our objective is todetermine the optimal size for stents in this clinical setting.
Methods: We prospectively recruited 70 patients who were undergoing KT between February and December 2021 and randomly assigned them to either the 4.8 Fr or the 6 Fr ureteral stent groups with a 1:1 ratio. Basic characteristics, postoperative adverse events within three months of transplantation, and answers to the ureteral stent symptom questionnaire (USSQ) were collected and analyzed.
Results: The findings demonstrated that the use of a 4.8 Fr during the ureteroneocystostomy step was not inferior to that of a 6 Fr in terms of urinary leakage (11.4% vs. 2.9%, p = 0.164) anastomotic stricture (2.9% vs. 0%, p = 0.314), and postoperative urinary tract infection (28.6% vs. 20.0%, p = 0.403). Furthermore, the USSQ scores for urinary symptoms werehigher for the 6 Fr stent than for the 4.8 Fr stent.
Conclusions: Based on the evidence from the present study, implanting a 4.8 Fr ureteral stent was not inferior to using a 6 Fr stent in patients who had undergone KT in terms of anastomotic adverse events, though it improved stent‐related symptoms.
Funding: None
Exploring the Potential of Single‐Use Cystoscopes in Modern Urological Practice: A Comparative Study
Adam Ostrowski1, Filip Kowalski1, Pawel Lipowski1, Magdalena Ostrowska2, Jan Adamowicz1, Tomasz Drewa1
1Department of Urology, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland, 2Department of Otolaryngology, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland
Presented By: Adam Ostrowski, MD, PhD, FEBU
Introduction: Single‐use endoscopic devices have gained popularity in recent years, and while there is limited information available, a newly designed single‐use cystoscope shows promise. This portable, self‐ contained device features its own light source, touch‐screen, and recording capabilities. However, there is a lack of published studies on this particular scope. Therefore, the aim of this study was to compare the single‐ use cystoscope with reusable devices in terms of performing cystoscopy, video quality, patients' tolerability, and the presence of side effects.
Methods: We enrolled 67 patients (37 female and 30 male) for single‐use cystoscopy and 40 (19 female and 21 male) as controls with regular cystoscopy. Before and after each cystoscopic examination, a urine dipstick test was conducted. Urologists provided rankings of the single‐use device based on various aspects. Patients were asked to rate their pain on the Visual Analogue Scale (VAS), and a follow‐up assessment was performed five days after the procedure. Female patients had a single‐use cystoscopy done with a semirigid 12 Fr cannula for diagnostic purposes, 12 female patients had botulinum toxin injected with a 14 Fr semirigid cannula with an inbuilt needle, and all men had a fully flexible cannula used.
Results: Results showed high ratings for the ease of assembly (4.84 out of 5), illumination (4.76), fluid flow (4.95), scope flexibility (4.91), access to the bladder (4.94), and bladder visualization (4.59). In 94,0% of cases, urologists reported that the procedure was easier than usual, while 6.0% said it was similar. The average patient pain during the examination was rated at 1,26 out of 10, significantly decreasing to 0.22 after the procedure. Respective values for regular cystoscopy were 1,05 and 0.575. Patients with previous cystoscopy experiences reported less or substantially less pain in 97.2% of cases. Mild dysuric symptoms within five days were reported in 3 out of 67 patients in single‐use cystoscopy and 10 out of 40 patients in reusable.
Conclusions: In conclusion, the tested single‐use cystoscope proves to be a viable alternative to standard reusable instruments for cystoscopy. It offers ease of use and provides good visualization of the bladder when compared to traditional cystoscopy methods. Moreover, patient tolerability was excellent. Further research and clinical trials are warranted to validate these findings and explore the full potential of single‐use endoscopic devices in urological procedures.
Funding: None
Mucormycosis of Urinary Bladder,,Unusual Presentation. A Case Report
Introduction: NovelCorona Virus Disease 2019 (COVID‐19) infection has been associated with various bacterial and fungal co‐infections.Themajor and fatal among these infections involves Mucormycosis. In 2021, there has been a huge surge of COVID‐19 cases in India, especially the Western India. Post COVID‐19 Mucormycosis has been rampant with serious morbidity and mortality rates, involving mainlythe rhino‐ orbital, oro‐facial and maxillary areas of the human body.However, urological complications post COVID‐19 are not much reported till date. Mucormycosishas been reported toaffect the kidneys.Urinary bladder involvement of Mucormycosis has been reported till now as a single case, in the pre COVID era in an immuno‐compromised patient. Isolatedurinary bladder involvementas a complicationpost COVIDhas not been reported till date.We report the first single case of Urinary bladder Mucormycosis post COVIDwith resultant Obstructive uropathyand review the literature.The objective is to increase the awareness regardingsucha rare diagnosis and its appropriate management in the current pandemic era.
Methods: A 62 year old gentleman was admitted with the symptoms of breathlessness requiring oxygen support.He wasdiagnosed with COVID by RT PCR and HRCT Thoraxandrecentonset of Diabetes Mellitus. He required Injection Remdesevir, steroids, Low Molecular Weight Heparin and Insulin. The patient's general condition gradually improved. However, on the 20thpost COVID day, he developed oliguria, fever and storage Lower Urinary Tract symptoms (LUTS). His blood investigations showed raised Total leucocyte counts, serum Creatinine and C Reactive Protein (CRP). Urine analysis showed plenty of WhiteBlood Cells (WBCs)and fungal KOH stain was positive. Non Contrast CT Scan KUB (NCCT KUB) revealed bilateral Hydroureteronephrosiswith cystitis.Suspecting sloughed papillary necrosis to be the cause of Obstructive uropathy, the patient was planned for bilateralRetrograde Pyelography (RGP) and Double J stenting.Under Anaesthesia, Cystoscopy revealed red cherry like ulcerated areas with mass like lesion involving the whole of bladder wall. Bladder biopsies were taken from suspicious areas. Bilateral ureteric orifices could not be identified. Hence, Ultrasound guided bilateral Percutaneous Nephrostomies (PCN) were placed. Post‐operative broad spectrum antibiotics and anti‐fungal treatment were administered. The histopathology of bladder biopsy showedmononuclear inflammatory infiltrate with broad non‐septate fungal hyphae with irregular branching, consistent with Mucormycosis.This wasconfirmed by the use of special stains such as Hematoxylin and Eosin (H&E) andPeriodic acid–Schiff stain (PAS).Infectious disease specialistand Nephrologistopinion weretaken and InjectableLiposomalAmphotericin B was administered.
Results: The patient improved clinically after bilateral PCNand hisserum creatininerecovered to normal.Heresponded well toLiposomalAmphotericin Bwithout anyside effectsor rise in serum creatinine. The patient iscurrently under closefollow‐upfor further management.
Conclusions: COVID‐19 has unfolded several unknown and rare complications therebypresenting a great challenge forthe treating physicians. Mucormycosis has been always very difficult to treat due to the high morbidity and mortality of the fungal disease and the side effects of the treatment itself.Urological Mucormycosis has not been reported post COVID‐19.Also, bladder involvement of Mucormycosis has been only a single case till now. Hence, Bladder Mucormycosis as the cause of obstructive uropathy is a diagnosis of exclusion. However, considering the severe spread of Mucormycosis in non‐urological cases in the western India,we had a high index of suspicion in this case. The histological diagnosis helped usguidestarting the appropriate anti‐fungal treatment in the form of Amphotericin B for the treatment of Mucormycosis. Thus, timely diagnosis and specific treatment canhelpprevent morbidity and mortality due to Mucormycosis in the patients.
Funding: None
Facilitating Expedited Discharge through IDC Removal During Ward Rounds
Kale Munien1, Adib Rahman1, William Harrison1, Devang Desai1
1QLD Health
Presented By: Adib Rahman
Introduction: Following urological procedures, it is common practice to utilise postoperative indwelling catheters (IDCs) that require a subsequent trial of void (TOV) before patients can be discharged. The necessity for extensive nursing care during this process can result in delays in initiating the TOV and overall discharge, particularly in hospitals with heavy workloads and limited staff. To address this issue, our hospital's urological team introduced a protocol, which involved the removal of IDCs during ward rounds when deemed appropriate based on clinical assessment. The primary objective of this study was to evaluate the effectiveness of this protocol in reducing the length of hospital stay (LOS) and expediting the discharge process. Additionally, the study aimed to examine any potential differences in complications or readmission rates as secondary outcomes.
Methods: In 2022, a prospective study was conducted at a regional hospital that specialises in urology care. The study enrolled patients who underwent transurethral resection of the prostate (TURP), transurethral resection of bladder tumour (TURBT), or bladder neck incision (BNI) procedures, wherein the standard practice involved placing indwelling catheters (IDCs). The data obtained from the intervention group was then compared to retrospective data from the same period in 2021. Various factors including age, BMI, ASA score, operation duration, length of hospital stay (LOS), complications, and readmissions were recorded and subjected to statistical analysis.
Results: The two groups exhibited similarity, with the exception of BMI. The intervention group displayed an average length of hospital stay (LOS) of 55.98 hours (range: 24.5‐126.75), whereas the non‐intervention group had an average LOS of 61.11 hours (range: 24.25‐125). However, this disparity did not yield statistical significance (p = 0.238). In terms of postoperative outcomes, the intervention group experienced three complications and two readmissions, while the non‐intervention group encountered five complications and five readmissions.
Conclusions: The findings of this study revealed a noteworthy and clinically meaningful decrease in the length of hospital stay (LOS) by 5.14 hours among patients who underwent the implemented protocol. This reduction has the potential to enable earlier discharge and enhance the overall flow of the hospital. Notably, the new protocol did not exhibit any substantial influence on complications or readmission rates. These findings emphasise the impact of a straightforward intervention on the discharge process following urological procedures.
Funding: Nil
The Management Dilemma Posed by Urachal Remnant Pathology: A Local Experience
Kapilan Ravichandran2, Adib Rahman1, Kale Munien1
1Toowoomba Hospital, 2Toowoomba hospital
Presented By: Adib Rahman
Introduction: The diagnosis and management of urachal pathology remains an area of uncertainty. The decision to excise instead of regular surveillance is made challenging due to a varied clinical presentation, non‐standardised investigative approach, and potential malignant transformation of this pathology. The objective of this study is to assess the clinical presentation, diagnosis, therapeutic management, and outcomes of urachal anomalies in our health area.
Methods: We retrospectively compiled data of adult patients reviewed in the Royal Hobart Hospital over a 5‐ year period between 2017 and 2021. We then conducted a literature review to assess the current recommendations and opinions in urachal pathology to compare to our current practice.
Results: Between 2017 and 2021 there were seven patients seen with urachal pathologies, five male and two female, aged between 32 and 73. Four were incidentally detected on imaging studies (three CT and one USS) and three presented withvarious symptoms. Of the symptomatic patients, all presented with recurrent urinary tract infections alongside a combination of lower abdominal pain, haematuria, and subjective fevers. Six patients had a urine MCS completed, with three showing no growth, two samples that were contaminated and one with a mixed growth. All patients had a CT scan, three had an ultrasound and two had an MRI. Furthermore, following imaging, two patients had a biopsy of the lesion. Four patients proceeded to surgical excision of the lesion (one laparoscopic vs three open), and of these there were no immediate surgical complications. One patient chose not to follow up and two remain waiting for an initial cystoscopy. Histologically, one urachal remnant was lined by intestinal epithelium, and one showed a mucinous cystic tumour. This is of interest as both these have malignant potential, albeit low. The remaining were benign urachal remnants.
Conclusions: In keeping with current literature, our series demonstrates the clinical conundrum of the uncommon urachal remnant. Excision of lesions with malignant potential confirms the need for adequate and thorough counselling of patients, and joint decision making around operative versus surveillance approaches. Our data suggests that surgical excision of urachal remnants is a safe option and may lead to the removal of incidentally detected lesions with malignant potential.
Funding: nil
Is the Diameter of the Iliac Artery Indicative of Ureteral Diameter?
Andrei Cumpanas4, Nina H. Kar1, Zachary E. Tano2, Sohrab N. Ali3, Roshan M. Patel3, Jaime Landman3, Ralph V. Clayman3
1Burrell College of Osteopathic Medicine, New Mexico State University, 2Department of Urology, University of California, Irvine,, 3Department of Urology, University of California, Irvine, USA, 4Department of Urology, University of California, Irvine; Orange, CA, USA
Presented By: Andrei Cumpanas, MD
Introduction: In a recently published study from China, the diameter of the common iliac artery (dCIA) ipsilateral to the ureter was directly correlated with the successful passage of a 14Fr ureteral access sheath (UAS). This finding could guide decision‐making with regard to limiting pre‐operative stenting to only those patients who, based on their dCIA, would likely fail to accept a 14Fr or larger UAS. Accordingly, we sought to corroborate these findings by retrospectively measuring the dCIA on a cohort of flexible ureteroscopy (FUS) patients undergoing ureteroscopic stone treatment at our institution.
Methods: We reviewed the CT scan of 160 unstented patients in California, undergoing FUS with UAS deployment between March 2017 and September 2022. In each patient, UAS deployment was monitored with a UCI force sensor and an appropriately sized UAS was placed. We compared the dCIA with the successful deployment of a 12 Fr, 14 Fr or 16 Fr UAS using two statistical methodologies: a linear regression model and a logistic regression model.
Results: When considering both the dCIA as well as the maximum size of the UAS deployed at < 6N as continuous numerical variables, using a linear regression model, dCIA did not predict the size of the deployed UAS (R2 = 0.0002, p‐value = 0.87). In the logistic regression model, the dCIA was considered as a continuous variable, while the UAS group was defined as a binary variable: successful versus failed deployment of a 12 Fr, 14 Fr or 16 Fr UAS at < 6N[CA1][CA2] did not correlate with the successful deployment of the various UASs (Figure 1).
Conclusions: Among patients in California, we were unable to support the contention that the dCIA is associated with the deployment of a 12Fr, 14Fr or 16 Fr UAS at < 6N.
Funding: None.
Renal and Perinephric Abscesses in the Tropics: Insights from a Retrospective Study
Kapilan Ravichandran1, Adib Rahman1, William Harrison1
1Toowoomba Hospital
Presented By: Adib Rahman
Introduction: To establish the demographic, clinical, radiological and laboratory profiles of renal abscess and perinephric abscess with related treatment and outcomes at a tertiary tropical Australian Hospital. Risk factors for development of large abscesses (greater than 3cm) were identified as well as an analysis of the experience of Indigenous patients.
Methods: A thorough retrospective analysis was carried out on the medical records of all patients diagnosed with renal and perinephric abscesses between January 2013 and January 2023. The collected data were subjected to comprehensive statistical analysis, primarily utilizing descriptive statistics. To determine the risk factors associated with the development of large abscesses, univariate logistic regression analysis was employed. Variables showing significant associations in the univariate analysis were then included in a multivariate logistic regression model to identify independent risk factors. Furthermore, a sub‐group analysis was conducted to investigate the unique characteristics and outcomes among the Indigenous Population.
Results: The identified patient cohort consisted of 63 individuals, with renal abscesses observed in 31 cases, perinephric abscesses in 20 cases, and combined abscesses in 11 cases. Flank pain and fevers were the most common presenting symptoms, reported in 80% and 70% of the patients, respectively. Diabetes mellitus emerged as the primary predisposing condition, noted in 60% of the cases. Escherichia coli was the predominant microorganism isolated from pus cultures, accounting for 68% of the cases, with 30% of these strains being extended‐spectrum beta‐lactamase (ESBL) producing. The main treatment approach involved intravenous (IV) antibiotics alone in 51% of the patients, while IV antibiotics with aspiration and IV antibiotics with drainage were employed in 6% and 43% of the cases, respectively. Regrettably, one death occurred during the study period. Our analysis also revealed that advanced age (> 60 years) and a symptom duration exceeding 7 days prior to presentation were identified as significant risk factors for the development of large abscesses. Furthermore, subgroup analysis focusing on the indigenous population revealed that they presented at a younger age (mean age 39.5 years) compared to non‐indigenous individuals (mean age 47.5 years) and experienced a longer duration of symptoms prior to seeking medical attention (mean of 8 days). Indigenous patients also had a lengthier hospital stay (mean of 7.1 days) compared to non‐indigenous patients (mean of 5.1 days).
Conclusions: Study highlights the common clinical features, prevalent organism and associated co‐ morbidities with renal and perinephric abscesses in a Tertiary centre in Australia. Furthermore the study suggest that there is a need for increased awareness and education of the signs and symptoms especially in the indigenous population. These findings highlight the importance of tailored management strategies and further research to address the unique characteristics and needs of different patient populations in the context of renal and perinephric abscesses in Tropical Queensland.
Funding: Ni
Selective Renal Embolization as a Rescue Therapy for Massive Renal Bleeding
Horacio V. Sanguinetti4, Mayra Ivette Caipe Bedoya1, Eduardo Edilio Ventura Semidey2, Marcos Luis Nuñez3, Juan Guillermo Ruiz3, Norberto Bernardo1
1Hospital de Clinicas Jose de San Martin., 2Hsopital de Clinicas Jose de San Martin, 3Hospital de Clinicas Jose de San Martin, 4Hospital de clinicas Jose de San Martin.
Presented By: Horacio V. Sanguinetti, MD, PHD.
Introduction: Selective renal embolization is a minimally invasive procedure historically used to treat various renal conditions, such as tumors and vascular lesions. At our hospital, a series of cases of selective renal embolization have been performed, with diverse etiologies. The aim of this study is to analyze the efficacy and safety of this treatment at our center.
Methods: Retrospective descriptive study analyzing the medical records of patients who underwent endovascular treatment for anemic hematuria, regardless of the cause, at José de San Martin Clinical Hospital from 2013 to 2023. Selective renal embolization was performed by inserting a catheter into the femoral artery, followed by a hydrophilic cobra catheter towards the affected renal artery. Once in the renal artery, an embolic solution was administered to block blood flow. We evaluated the cause of the renal injury, number of embolizations, computed tomography and angiographic findings, embolization materials used, number of transfused blood units, and postoperative complications of embolization.
Results: A total of 7 patients were included, 5 females and 2 males, with a mean age of 58.7 years (42‐72 years). The mechanism of injury was 14.2% renal artery aneurysms, 14.2% renal trauma, 28.5% percutaneous renal biopsy, and 42% were post‐endourological procedures (URS and NLP). Renal mass preservation was achieved in 57.6% of patients, while 42.8% required emergency nephrectomy due to persistent hematuria with hemodynamic decompensation. Regarding the safety of the procedure, no major complications were observed post‐embolization. The most common complications were fever (57.1%), lumbar region pain (42.8%), and renal collection (14.2%), all of which were satisfactorily resolved with conservative treatment. Computed tomography and angiography findings included contrast extravasation in one patient, pseudoaneurysms in three patients, perirenal hematoma in two patients, and renal aneurysm in one patient. The mean number of blood units transfused was 4.5 (range: 1‐8 UPR).
Conclusions: Selective renal embolization is an effective and safe option as a rescue measure in patients with massive renal bleeding. The results of this retrospective study in our hospital suggest that this procedure can be successfully performed and provide a valuable alternative to open surgery or radical nephrectomy.
Funding: We do not have funds in the work.
Stent Fracture
Deepak Janardhanan1
1Fakeeh University Hospital
Presented By: Deepak Janardhanan, MCh, FACS, FEBU
Introduction: Polyurethane, due to its low cost, high versatility and availability, it commonly used for ureteral stents. Spontaneous fracture of these stents is rare.Since 1967,the indwelling ureteral stent has become a fundamental part of urology practice in an era of expanding endourological procedures. Ureteral stents are used in a variety of indications for renal transplantation, genitourinary oncology, trauma and reconstructive surgeries.Polyurethane, due to its low cost, high versatility and availability, is commonly used for ureteral stents. Since its introduction, complications had been encountered and resulted in significant morbidity. Pain, bladder irritative symptoms and fever are signs of early complications related to polyurethane ureteral stents; moreover, late complications, such as encrustation, infections and fragmentation, are more troublesome.Cases of fragmented ureteral stents are rareand are classified as grade 3 on the Clavien Classification of Surgical Complications
Methods: 35‐year‐old male with no known medical comorbidities consulted at the outpatient clinic due to right flank pain and gross hematuria. Eight months earlier, he had 6 × 24‐cm Tecoflex polyurethane double pigtail ureteral stent inserted on the right side for temporary relief of post‐intracorporeal lithotripsy ureteral edema at another facility.Physical examination was unremarkable. Routine biochemical parameters were normal: urinalysis revealed proteinuria (250 mg/dL) hematuria red blood cells (RBC) (3+ blood) .Urine culture showed no growth.A X ray KUB and computed tomography (CT) showed an fractured indwelling right ureteral stent with missing distal part of the stent below L5 vertibral body. dilated pelvicalyceal system of the right kidney was also noted. Retrieval of stent fragment was done video‐assisted using Fr 6.5 semi‐ rigid ureteroscope with the patient placed on lithotomy Fowler's position. On ureteroscopy, the ureteral mucosa on the right proximal segment of the ureter appeared edematous and erythematous. Using a ureteral foreign body grasper, we removed the stent fragments as piece meal under directvisualization on the camera monitor.Open ureteral catheter was removed after 48 hours. The patient recovered well and discharged on postoperative day 3.
Results: When the stent is exposed to different factors in the urine and the urothelium for a long time, it may lead to loss of strength, elasticity and flexibility of the stent;the degradation of stent polymers leads to loss of tensile strength and hardening of the stent.When the stent is exposed to different factors in the urine and the urothelium for a long time, it may lead to loss of strength, elasticity and flexibility of the stent;the degradation of stent polymers leads to loss of tensile strength and hardening of the stent.When the stent is exposed to different factors in the urine and the urothelium for a long time, it may lead to loss of strength, elasticity and flexibility of the stent; the degradation of stent polymers leads to loss of tensile strength and hardening of the stent.
Conclusions: Retrieving a proximally fragmented double‐J ureteral stent can be frustrating and technically challenging.Strategy to prevent stent fracture is to decrease the time of the indwelling stent and strict follow‐ up using a computerized patient registry to track patients.
Funding: nil
MODERATED POSTER SESSION 27: STONES: INSTRUMENTATION AND NEW TECHNOLOGY 1
Efficient and Accurate CT‐Based Stone Volume Determination: Development of An Automated Artificial Intelligence Algorithm
Andrei D. Cumpanas3, Chanon Chantaduly1, Kalon L Morgan2, Antonio R.H. Gorgen2, Candices M. Tran3, Yi Xi Wu3, Amanda Mccormac2, Sohrab N. Ali2, Pengbo Jiang2, Zachary E. Tano2, Roshan M. Patel2, Peter Chang4, Jaime Landman2, Ralph V. Clayman2
1Center for Artificial Intelligence in Diagnostic Medicine, University of California, Irvine, 2Department of Urology, University of California, Irvine;, 3Department of Urology, University of California, Irvine, 4Department of Radiological Sciences, University of California, Irvine;
Presented By: Andrei D. Cumpanas, MD
Introduction: Given the irregular shape of most renal stones, linear measurements, alone or as part of an ellipsoid formula , fail to accurately depict the true stone burden. We sought to train an AI algorithm to assess CT‐based stone volume determinations.
Methods: A research physician fellow who was previously validated against a board‐certified radiologist (interclass correlation coefficient of 0.99) established the “ground truth” for stone volume using 3D Slicer™ in 322 CT scans. To assess the convolutional neural networks' (CNN) performance in determining stone volume both a Pearson correlation coefficient (R) and a Dice Overlap Score were calculated. Statistical analysis included a 5‐fold cross validation. The volume of the stone with the largest linear measurement on a CT scan was determined by the UCI AI algorithm as well as by using the three best‐fit ellipsoid formulas (Figure 1); these values were compared to the “ground truth”.
Results: The UCI AI algorithm was accurate(R = 0.99) and precise (Dice score = 0.96) for determining stone volume (Figure 2). The CNN outperformed the 3‐ellipsoid formula‐based volume predictions (Table 1). The algorithm's accuracy and precision improved when measuring larger stones (i.e. > 2cm), as larger stones tended to have more irregular shapes; in contrast, the ellipsoid‐determined volumes displayed an opposite trend (Table 1).Indeed, even with the best of the ellipsoid formulas, the larger stone burden was overestimated by 27% to 88%.
Conclusions: The UCI Urology AI algorithm determined renal stone volumes in an accurate and precise way; it outperformed all three ellipsoid formulas.
Funding: None
Assessing the Impact of Intrarenal Pressure on Renal Artery Flow During Ureteroscopy: An In‐Vivo Porcine Study
Ron Marom1, William W. Roberts1, Julie J. Dau1, Timothy L. Hall1, Khurshid R. Ghani1
1University of Michigan
Presented By: Ron Marom, MD
Introduction: High irrigation rates are commonly used during high‐power laser lithotripsy and can in some cases increase intrarenal pressure (IRP) substantially. In addition to pyelovenous backflow and associated risks of infection and sepsis, concerns have been raised that elevated IRP may also diminish renal artery flow and perfusion of the kidney. In this study we soughtto investigate changes in renal artery blood flow in response to elevation of IRP during ureteroscopy in an in‐vivo porcine model.
Methods: After laparotomy, the renal hilum was exposed and an ultrasonic flow cuff was placed on the renal artery. Ureteroscopy was performed on three kidney units of two porcine subjects using a prototype ureteroscope with a pressure sensor at its tip. A modified ureteral access sheath was used to adjust the outlet resistance and allowed control of IRP. Saline irrigation was delivered at two rates to induce IRPs of approximately 30 mmHg and 100 mmHg alternately for periods of two minutes for up to 15 cycles for each kidney unit. Irrigation rate, IRP, and arterial blood flow were recorded in real‐time. Using MATLAB, the data streams were aligned, and the arterial flow was measured in response to the IRP. To account for systemic variation in blood flow, the percentage reduction in renal artery flow at high IRP was calculated with respect to the arterial flow value at low IRP, derived from the average of the two adjacent cycles.A control data set was obtained by placing the ultrasonic flow cuff on one kidney while performing ureteroscopy with the same experimental conditions on the contralateral side.
Results: At elevated IRP (100 mmHg) renal artery blood flow was reduced in all three renal units (Fig A) by 10‐20% but not in the control (Fig B).
Conclusions: ‐ Renal artery blood flow decreased 10‐20% when IRP was increased from 30 to 100 mmHg in the porcine model. This decreased renal blood flow is unlikely to have an appreciable effect on tissue oxygenation or heat sink capacity during ureteroscopy.
Funding: Research grant from Boston ScientificDisclaimer: The prototype ureteroscope used in this study was a concept device/technology which was not available for sale at the time the study was conducted. Pre‐ clinical study results may not necessarily be indicative of clinical performance.
Novel Nanoparticle Coatings with Antibacterial and Antibiofilm Properties.
Aaron W. Miller3, Juan Sebastian Rodriguez‐Alvarez1, Yue Xu2, Smita De1, Jorge Gutierrez‐Aceves1, Vijay Krishna2
1Cleveland Clinic Glickman Urological and Kidney Institute, 2Cleveland Clinic Lerner Research Institute
3Cleveland Clinic Glickman Urological and Kidney Institute/Assistant Staff
Presented By: Aaron W. Miller, PhD
Introduction: Device‐associated infections, particularly arising from urinary catheters and stents are frequent causes of healthcare related infections. These infections are often associated with biofilm formation and ultimately require device removal. Escherichia Coli is one of the most commonly isolated bacteria in such biofilms. Silver coatings have been used to minimize infections due to its intrinsic antibacterial properties, and gold‐silver mixtures have superior antimicrobial activity. We designed novel antimicrobial nanoparticles (NP) composed of silver and gold with polyhydroxy‐fullerenes (PHF); proposed to enhance reactive oxygen species formation. Coatings of these novel NPs were evaluated for antimicrobial and anti‐biofilm formation properties against E. coli.
Methods: PHF was used for synthesizing gold (AuNP), silver (AgNP), gold‐silver bimetallic (AuAgNP) and silver‐platinum bimetallic (AgPtNP) NPs. Resulting mixtures were coated on polyurethane discs. To induce biofilm formation on surfaces, coated and uncoated discs were incubated overnight in broth containing E. coli. The resulting broth was sampled and serially diluted to evaluate bactericidal properties of the NP coatings on E. coli. Biofilms were detached from the discs into phosphate‐buffered saline, then serially diluted. All dilutions were incubated for quantification of colony forming units (CFU) and CFU/mL. All experiments were done in triplicate.
Results: AuNP did not show any significant antibacterial or anti‐biofilm activity whereas AgNP showed a bactericidal effect with a mean 3.2‐log reduction of E. coli CFUs compared to uncoated controls (p < 0.001). Antibacterial activity of AgPtNP was similar to AgNP. In contrast, a significant bactericidal effect was observed with AuAgNP with a mean 5‐log reduction. This was further investigated by testing a 1:1 mixture of AuNP and AgNP, which showed a mean 8.5‐log reduction, suggesting a strong synergetic effect between gold and silver NPs. Most of these reductions were also observed for anti‐biofilm activity (Figure 1).
Conclusions: A combined gold and silver nanoparticle coating with large antibacterial and antibiofilm activity could potentially reduce implant colonization and associated infections.
Funding: Cleveland Clinic Caregiver Catalyst Award, Lerner Research Institute Seed Funds
Thermal Tissue Mapping During Laser Lithotripsy in an In‐Vivo Porcine Model
Ron Marom1, William W. Roberts1, Julie J. Dau1, Timothy L. Hall1, Khurshid R. Ghani1
1University of Michigan
Presented By: Ron Marom, MD
Introduction: Higher power laser settings can yield smaller stone fragments and faster endoscopic treatments but also impose a thermal risk to the surrounding healthy renal tissues. While high fluid temperatures have been seen in both in‐vitro and in‐vivo studies with laser lithotripsy, the thermal distribution within the renal parenchyma has not been characterized. Additionally, the heat‐sink effect of vascular perfusion remains uncertain. In this in‐vivo study we sought to map the renal temperature distribution in response to laser activation in a calyx in both perfused and non‐perfused states.
Methods: Ureteroscopy was performed in three porcine subjects with a prototype ureteroscope containing a temperature and a pressure sensor at its tip. The distal end of the ureteroscope was positioned in the middle of a calyx and maintained there for the entire experiment. A multi‐point needle with four thermocouple sensors located 5, 15, 25, and 35 mm from the tip was introduced percutaneously into the same calyx using US guidance. The first sensor was positioned inside the calyx. Three trials of 60 second laser activation (40 W) were conducted with irrigation of 8 ml/min. After euthanasia, three trials with the same settings were repeated. Thermal dose was calculated from the time‐temperature curves for each thermocouple using the Sapareto and Dewey methodology. The threshold of thermal tissue injury was considered to be t43 = 120 equivalent minutes.
Results: The collecting system fluid temperature increased by over 30 °C and surpassed the thermal threshold in all trials. The temperature at the second thermocouple in the medulla increased to a lesser degree, but still surpassed thermal threshold in some trials. Comparing perfused and non‐perfused trials, temperature curves were similar except at the 3rd thermocouple in the renal cortex where temperatures increased much more without perfusion.
Conclusions: High‐power laser settings (40 W) with lower irrigation rates can induce potentially injurious temperatures in the in‐vivo porcine model, particularly in the region adjacent to the collecting system. Furthermore, vascular perfusion appears to have limited effect on mitigating thermal spread in the medulla.
Funding: Research grant from Boston ScientificDisclaimer: Prototype ureteroscope used in this study was a concept device/technology, which was not available for sale at the time the study was conducted. Pre‐clinical study results may not necessarily be indicative of clinical performance.
Utilizing a Novel Force Sensor for Clinical Assessment of Maximum Ureteral Circumference
Amanda Mccormac4, Sohrab N. Ali1, Paul Piedras1, Minh‐Chau Vu1, Andrew S. Afyouni1, Zachary E. Tano1, Kathryn Osann2, Pengbo Jiang1, Roshan M. Patel1, Michael Klopfer3, Jaime Landman1, Ralph V. Clayman1
1Department of Urology, University of California, Irvine, 2Department of Medicine and Program in Public Health, University of California, Irvine, 3Henry Samueli School of Engineering, University of California, Irvine, 4University of California‐Irvine, Department of Urology
Presented By: Amanda McCormac, BS
Introduction: Using the novel UCI force sensor as an indicator of force for ureteral access sheath (UAS) insertion, we determined that splitting of the urothelium could be avoided if the insertion force was limited to ≤ 6 Newtons (N). Herein, we define the inherent, safe expandability of the human ureter using sequential passage of urethral dilators at ≤6 N.
Methods: Ureteral sizing was performed on 75 patients undergoing ureteroscopy by passing a series of 35 cm long urethral dilators in 2 Fr increments until 6 N was reached. Next, ureteroscopy was performed and a post‐ureteroscopic lesion scale (PULS) grade was recorded. An appropriate size UAS was inserted and the URS procedure was completed. Multivariate logistic regression analysis was conducted to evaluate the impact of age, gender, tamsulosin and stents on the ability to pass ≥16 Fr dilators.
Results: Among 75 patients, 37 cm long, urethral dilators were successfully passed into the ureter up to the 6 N threshold in 37.3% at ≤12 Fr, 24% at 14 Fr, 24% at 16 Fr, and 14.6% at ≥18 Fr (18‐24 Fr). The mean maximum dilator diameter was 14 Fr. Logistic regression revealed that preprocedural ureteral stenting favored passage of ≥16 Fr dilators (OR 15.47, 95% CI 1.44 – 166.86; p = 0.024). Neither gender nor age were significant differentiators. The effect of tamsulosin alone was not statistically significant (OR 0.60, 95% CI 0.15 – 2.32; p = 0.454). In addition, the interaction effect was not found significant; as such, stent plus tamsulosin did not differ from stent alone (OR for interaction = 1.85, range 0.089 – 38.63; p = 0.690).
Conclusions: The unstented human ureter can be sized, without risk, to an average circumference of 14 Fr; this increased to 16 Fr in the pre‐stented ureter. Preoperative administration of tamsulosin was of no benefit.
Funding: None.
Will Chat GPT Replace Office Endourologists?
Subiksha Subramonian4, Kesavapillai Subramonian1, Yuko Smith1, Ivo Dukic1, Joe Philip2, Sri Sriprasad3
1Queen Elizabeth Hospital, 2Bristol Urological Institute, 3Darent Valley Hospital, 4Royal London Hospital
Presented By: Subiksha Subramonian, MBBChir, MA (Cantab), MRCS
Introduction: In this paper, we aim to study the use of Chat GPT4(Openai.com) as a source of information for patients with urinary stone disease. Chat GPT uses machine learning from a vast dataset on the Internet, to generate responses to questions, by predicting what comes next given a certain prompt. Patients with stone disease frequently use the Internet/AI resources for their diagnosis and treatment. We aim to study the accuracy and detailedness of Chat GPT by asking common questions posed by stone patients to their treating Urologists and assessing the reliability of answers by cross checking with a panel of Endourologists.
Methods: The following questions were asked using Chat GPT, and the answers rated from 1‐5 (Least to Most Accurate) and 1‐5 (Least to Most Detailed) by a panel of Endourologists. The same questions were repeatedly posed to Chat GPT to check the variability of answers.Three simple questions: 1. I have pain in my back and I am passing blood in my urine. What is the likely diagnosis? 2. I think I may have kidney stones. What test should I do to diagnose them? 3. The CT scan showed a 5mm stone in my ureter. What is the best treatment?Five more nuanced questions: 4. What are my chances of passing a 5mm ureteric stone? 5. How long can I wait for the stone to pass safely? 6. I have a 5mm stone in my ureter and fever and shivers. What is the best treatment ? 7. Should I avoid calcium supplements to prevent kidney stones? 8. Should I have lithotripsy or ureteroscopy for my 5mm lower pole stone ?
Results: Average panel ratings for the answers from Chat GPT for the above 8 questions is displayed in Chart 1, for their accuracy and detailedness.The generic 3 questions were generally answered well by Chat GPT scoring on average 3.4 out of 5 for accuracy and 3.87 out of 5 for detailedness. The more nuanced 5 questions were answered less well by Chat GPT, scoring an average of 2.6 out of 5 for accuracy and 3.11 out of 5 for detailedness. Chat GPT scored better overall on the ‘detailedness' parameter than the ‘accuracy’ parameter across all of the questions.Repeated questioning to Chat GPT yielded more succinct answers with no change in the accuracy or content of the answers.
Conclusions: For general queries from patients, Chat GPT is a reliable source of information. However, for more specific questions about stone management, Chat GPT was not a reliable source.
Funding: Nil
Initial Experience with Robotic Mini‐Percutaneous Nephrolithotomy (PCNL) and Ureteroscopic (URS) Lithotripsy
Andrei Cumpanas4, Mihir M. Desai1, Nancy L. Sehgel2, Jacob W. Caldwell2, Chiara Gatti2, Andrei D. Cumpanas3, Pengbo Jiang3, Roshan M. Patel3, Ralph V. Clayman3, Jaime Landman3
1Department of Urology, University of Southern California, 2Ethicon Research & Development, 3Department of Urology, University of California Irvine, 4Department of Urology, University of California, Irvine; Orange, CA, USA
Presented By: Andrei Cumpanas, MD
Introduction: We describe the initial clinical experience with a novel PCNL approach that combines electromagnetic (EM) targeting, robotic URS lithotripsy, a robotic percutaneous catheter for stone immobilization and fragment removal and an integrated irrigation and suction fluid management system.
Methods: Four patients underwent robotic PCNL and URS lithotripsy of their kidney calculi at University of California Irvine's Department of Urology, using the novel MONARCH™ Platform (Ethicon, Redwood City, CA) (Figure 1‐A). Procedures were performed in a modified supine position. Percutaneous access was gained using a novel EM targeting system (Figure 1‐B). An 18 Fr percutaneous sheath was placed for deployment of a flexible 15 Fr steerable suction catheter. Stone visualization and ablation was performed ureteroscopically. Both the suction catheter and ureteroscope were robotically driven via a hand‐held robotic controller that also controlled a third‐party laser fiber, robotic basket, as well as the irrigation and aspiration system (Figure 1‐C).
Results: To date, all robotic procedures have been technically successful, without any device‐ or surgically related complications. With a preoperative stone burden ranging from 10.5 mm to 24.6 mm (CT‐ segmentation‐derived volumes: 1411.44 mm3 ‐ 2067.21 mm3), the combined robotic PCNL and URS lithotripsy were associated with a reduction in stone burden volume ranging from 81% to 100% as assessed by thin slice CT imaging performed within 30 days of the surgery (Figure 2). Blood loss ranged from 25 mL to 150 mL. The operative time ranged from 129‐388 min.
Conclusions: Early robotic mini‐PCNL clinical experience shows technical feasibility, early promise of the integrated fluid management system and novel EM targeting system. This robotic PCNL platform allows for the completion of the entire procedure and control of all retrograde and antegrade instruments by a single urologist.
Funding: Sponsor: Auris Health, Inc.
Who is the Winner? Superpulsed Thulium Fiber Laser vs. Pulse Modulated High Power Holmium:YAG Laser for Retrograde Intrarenal Surgery
Raymond Khargi1, Alan J. Yaghoubian1, Anna Ricapito2, Christopher Connors1, Samuel Yim3, Blair Gallante1, Johnathan A. Khusid1, William M. Atallah1, Mantu Gupta1
1Icahn School of Medicine at Mount Sinai, 2University of Foggia, Department of Urology, 3SUNY Downstate Health Sciences University
Presented By: Anna Ricapito, MD
Introduction: Currently, pulse modulated high power holmium:yttrium‐aluminum‐garnet (Ho:YAG) and superpulsed thulium fiber laser (TFL) are the two laser systems routinely used in kidney stone surgery. However, to date, there have been no head‐to‐head randomized controlled trials comparing efficacy for solely renal stone lithotripsy. To this end, we aimed to compare the stone free rates, intraoperative efficiency, and complication rates of the two leading contemporary laser systems used in retrograde intrarenal surgery (RIRS).
Methods: This is an on‐going prospective randomized trial of patients undergoing single stage unilateral RIRS with preoperative computed tomography (CT) proven renal stones between 5 and 20 mm. Patients with ureteral stones were excluded. Patients were then randomized to either Ho:YAG or TFL group after undergoing anesthesia. Laser settings, energy output, and lasing time, were recorded intraoperatively. Patients were followed post‐operatively to determine complication rates and ED visits. Primary outcome was stone‐ free rate which was evaluated by CT scan at 6 weeks postoperatively. Two different definitions of stone‐free rate were used: category A was defined as zero residual fragments and category B defined as no fragments greater than ≥3 mm. Secondary outcomes included laser efficiency (laser energy used per unit volume of stone) laser activity (laser‐on time per total lithotripsy time) and fragmentation speed (volume of stone fragmented per second) and postoperative complications. Categorical variables were compared between groups using Chi‐square of Fisher's exact tests while continuous variables were analyzed using Mann‐ Whitney U‐tests.
Results: 27 patients were randomized to Ho:YAG (n = 14) or TFL (n = 13) groups. Category A stone‐free rates were 71.4% and 61.5% for Ho:YAG and TFL respectively (p = .695). Category B stone‐free rates were 92.9% and 61.5% for Ho:YAG and TFL respectively (p = .077). Total energy used (2.54 vs. 1.98 kJ, p = 0.734), lasering time (9.90 vs. 7.25 min, p = 0.489), lithotripsy time (19.5 vs. 16 min, p = 0.587), operative time (52.5 vs. 66 min, p = .645) were similar. Laser efficiency (23.18 vs. 12.96 kJ/mm3, p = 0.228), laser activity (53% vs. 40%, p = .448), and fragmentation speed (.19 vs. .25 mm3/s, p = 0.293) did not differ in Ho:YAG vs. TFL respectively. ED visits (7.1% vs. 7.7%, p = 1.0) and Clavien complications (0% vs. 7.7%, p = .481) were similar between groups. There were no readmissions for either group.
Conclusions: Our preliminary data did not show significant differences in any clinically relevant domain, including stone‐free rates, intraoperative efficiency measures, or postoperative complications when comparing Ho:YAG and TFL during RIRS for renal stones. In light of the data, laser choice should be left to surgeon's preference.
Funding: None
Novel Anti‐Reflux Stent: Discovering the Optimal Length and Angle in An Ex‐Vivo Study
Yong Jie Jeremy Tay1, Ya Dong Lu1, Kheng Sit Jay Lim1, Lay Guat Ng1
1Singapore General Hospital
Presented By: Yong Jie Jeremy Tay, MBBS, MRCS
Introduction: Ureteral stents are widely used in our clinical practice to maintain a patent conduit between the kidney and bladder, which can be occluded due to urinary stones, urinary tract malignancies, extrinsic compression or strictures of the ureters. Physiologically, urine flow in an unidirectional way from the kidneys to the bladder via naturally occurring ureteral peristalsis and the occlusion of one way valve at the vesicoureteral junction. However, the presence of a ureteral stent inadvertently allows for urinary reflux by allowing a bidirectional flow and inactivating the physiological valve, especially in a high pressured bladder. This presents an inconvenient problem of reflux pyelonephritis which can be further compounded by a loss of renal function.The use of stents with anti‐reflux properties have been postulated to reduce the incidence of pyelonephritis by reducing urinary reflux. Existing anti‐reflux stents with its inherent design flaws have precluded its adoption in our clinical practice. Current solutions mainly address the intraluminal urinary reflux and neglects the prevention of extraluminal reflux.We aim to design an anti‐reflux device which can be deployed onto ureteral stents, allowing unidirectional urinary drainage by reducing retrograde urinary flow in both aintraluminal and extraluminal manner. The optimal skirting material type, length and angle is to achieve this objective is not known. Therefore, our bench study seeks to explore the optimal conditions for the purpose of designing this novel anti‐reflux device.
Methods: We 3D printed a 1:1 human urinary tract model with two pressure sensors placed in the ureter and bladder. A hand‐applied bladder pressure was generated manually to stimulate bladder contractions and thus reflux pressure. The differential pressures between the bladder and ureter was measured. A combination of differentangles(60°, 80°, 100°, 110°, 120° and 130°) and lengths of skirting (0.5, 1, 1.5 and 2cm) was evaluated.
Results: Our study showed that the optimal skirting angle and length are 80° and 2cm respectively. Our anti‐ reflux device skirting design can effectively reduce pressure transmission from bladder to ureter in an ex vivo model.
Conclusions: The study has provided evidence that the optimal skirting angle and lengthare 80° and 2cm respectively and that it can reduce pressure transmission from bladder to ureter in an ex vivo model. We aim to next experiment our prototype device in an in‐vivo environment on a porcine model to further validate our results.
Funding: NA
Retrograde Intrarenal Surgery Using the Ily Robotic Flexible Ureteroscope: A Single Centre Experience
Wojciech Krajewski1, Łukasz Nowak1, Joanna Chorbińska1, Szymon Pisarski1, Jan Łaszkiewicz1, Wojciech Tomczak1, Bartosz Małkiewicz1, Tomasz Szydełko1
1Department of Minimally Invasive and Robotic Urology, University Center of Excellence in Urology, Wrocław Medical University, Wrocław, Poland
Presented By: Wojciech Krajewski, Prof., MD, PHD
Introduction: The ILY robotic flexible ureteroscope has been introduced in retrograde intrarenal surgery (RIRS) in order to improve intraoperative ergonomics, distance operator from ionizing radiation and shorten the learning curve. The robot is a remotely controlled ureteroscope holder that allows transmission of all basic flexible ureteroscopy (fURS) movements.We aimed to assess the clinical performance and feasibility of the ILY robot during RIRS and combined endoscopic procedures.
Methods: The RIRS procedures were performed using the ILY robotic arm in 57 adult patients (46 RIRS, 11 endoscopic combined intrarenal surgeries (ECIRS)) from 2022 to 2023 by an experienced endourological team. The staff have been adept in manipulating the device's controller (commercially available gaming console device) before the onset of the study. First 5 cases performed by our team were excluded from the analysis, as some training was necessary to get familiar with the device. Hawk flexible ureteroscopes and Quanta CyberHo 60w holmium laser with 272 micrones fiber were used during every RIRS.
Results: In order to assist calibration, draping and docking of the device one additional briefly trained person (nurse/technician) was needed. Turning on and calibration of the device took approximately 100 s. Average draping time was 93 s using original ILY drapes (range 69‐229) and 47 s (range 23‐71) using classic drapes designed for C‐arm covering. Mean docking time was 73 s (range 32‐124) in procedures with ureteral access sheath (UAS) and 61 s (range 30‐99) in procedures without it. The undocking took less than 20 s in every case. Mean age of patients included in the study was 46 years (range 18‐82 years). For RIRS cases average stone size was 1.3 cm (range 0.8‐2.3 cm), while for ECIRS procedures the mean biggest stone size was 1.9 cm (range 1.1‐5.6). 37 (65%) patients were pre‐stented (32 RIRS and 5 ECIRS cases). Moreover, 34 (73.9%) RIRS and 4 (36.4%) ECIRS procedures were performed with UAS, the majority in males. 10.7Fr UAS was used in all patients. Average procedure time was 63 min (range 15‐91 min) for RIRS (counting from the first insertion of the scope into the bladder to the bladder catheterisation) and 55 min (range 32‐83 min) for ECIRS (counting from the first insertion of the nephroscope into the kidney to the bladder catheterisation). Endoscopically proven stone free rate (defined as no visible residual fragments bigger than 2 times laser fiber diameter) was achieved in 37 (80.4%) RIRS and 10 (90.9%) ECIRS patients. 17 (36.9%) RIRS and 8 (72.7%) ECIRS procedures required robot undocking and conversion in order to perform basketing and stone fragments retrieval/transposition.
Conclusions: The use of ILY robot during endourological procedures is feasible and urologists that are familiar with the device controller do not require extensive training. The time needed for device draping, docking and undocking is approximately 3 min.
Funding: None.
Intraoperative Acute Ureteral Dilation Using Electromotive Drug Administration (EMDA) in An in‐Vivo Animal Study
Seyed Hossein Hosseini Sharifi1, Ralph V. Clayman1, Zachary E. Tano1, Bruce Gao1, Seyed Amiryaghoub M. Lavasani1, Yi Xi Wu1, Babak Naimi2, Seyedamirvala Saadat1, Ahmad Abdel‐Aziz1, Sohrab Naushad Ali1, Pengbo Jiang1, Roshan M. Patel1, Jaime Landman1, Ralph V. Clayman1
1Department of Urology, University of California, Irvine, CA, USA, 2Quantitative Biodiversity Dynamics – Utrecht University
Presented By: Bruce Gao, MD
Introduction: A limiting factor in the passage of a ureteral access sheath (UAS) is the small diameter of the ureter.Electromotive Drug Administration (EMDA) has the ability to drive a drug deep into the wall of the bladder urothelium. Accordingly, we used EMDA to test ureteral distensibility with three smooth muscle relaxants.
Methods: In 18 female Yorkshire pigs, baseline distensibility of both ureters was determined by passing 35 cm long, Cook Medical® urethral dilators (10 Fr to 24 Fr) in 2 Fr increments at a maximal force of 3.5 Newtons as determined by the UCI UAS force sensor.The size of the UAS passed and the highest ureteral location reached (i.e. proximal, middle, or distal ureter) was recorded.Flexible ureteroscopy was performed and a post‐ureteroscopic lesion scale (PULS) grade was recorded.Next, a proprietary EMDA catheter was passed into both ureters.On the experimental side, the EMDA catheter was activated while three different medications diluted in 100 ml sterile water were infused at 5 ml/min for 20 minutes: alfuzosin 10 mg, isoproterenol 1 mg, and aminophylline 500 mg (six pigs per drug). In the contralateral control ureter, the EMDA catheter was not activated while saline was infused at 5 ml/min for 20 minutes. Ureteral distensibility was determined at 3.5N; flexible ureteroscopy was performed and a PULS grade was recorded. Pigs were euthanized, and ureters were excised and snap‐frozen for histopathological analysis.
Results: Intraureteral EMDA administration of alfuzosin and isoproterenol resulted in insertion of a larger dilator in 2/6 and 1/6 experimental ureters, respectively.When compared to their respective contralateral control ureter (i.e., R program, and Wilcoxon signed rank test) neither reached statistical significance (p = 0.17, p = 0.68, respectively).No ureter in the aminophylline group accommodated a larger dilator. Among the ureters without augmentation in UAS size, there was increased progress of the same size UAS in 100%, 60% and 66% of the alfuzosin, isoproterenol and aminophylline infused ureters, respectively.PULS grades were all low grade (i.e., < 2).
Conclusions: Among three EMDA tested drugs, only alfuzosin trended to improve ureteral distensibility, albeit without attaining statistical significance.
Funding: None
Thulium Fibre Laser Lithotripsy and Stone Composition: Dust or Bust?
Jason Y. Lee2, Simon Czajkowski1, Bruce Gao2
1Division of Urology, Department of Surgery, University Health Network, 2Division of Urology, Department of Surgery, University of Toronto, University Health Network
Presented By: Bruce Gao, MD
Introduction: After demonstrating efficacious in vitro efficacy, the thulium fibre laser (TFL) has been released to market with promising initial clinical results. At our institution, reduced TFL lithotripsy was observed during certain stone cases. The purpose of this study was to identify whether stone composition affects TFL lithotripsy.
Methods: We conducted a retrospective review of all patients that had undergone TFL laser lithotripsy (SOLTIVETM SuperPulsed Laser System, Olympus America) at our institution between July 2020 and January 2022. Only patients with stone analysis data were included. Demographic and stone‐specific data were collected and correlated with subjective (surgeon rating) and objective measures of lithotripsy efficacy.
Results: A total of 91 patients were included in the study. Mean age was 59.8 years, mean BMI was 27.5, and mean stone volume was 438 mm3 (Table 1). Stone composition correlated withpatient age (p = 0.008), mean stone density (p < 0.001), mean stone volume treated per laser time (p = 0.033), and surgeon rating of TFL efficacy (p < 0.001). Lower surgeon rating of TFL efficacy correlated withhigherstone density (p = 0.011), greater numberof laser pulses used (p = 0.035), and stone composition (p = 0.035). Stones composed of CaPO4 + struvite had lower surgeon rating of TFL efficacy, while pure uric acid and mixed CaOx + uric acid stones had the best rating. Stone location correlated with total energy (J) used (p = 0.036) but not with any other TFL efficacy measures or stone composition (α = 0.05).
Conclusions: Stone composition, particularly CaPO4 + struvite, seems to be associated with reduced TFL lithotripsy. A limitation of our retrospective study is that we were unable to differentiate between brushite and apatite stones. The relationship between stone composition and TFL lithotripsy requires further evaluation prospectively, while basic science research is required to understand the biophysical mechanisms of reduced lithotripsy.
Funding: None.
Is Upfront Endoscopic Combined Intrarenal Surgery More Cost‐Effective than Percutaenous Nephrolithotripsy?
Sundaram Palaniappan1, Joshua Yi Min Tung1, Xinyan Yang1, Alvin Wei Xiang Low1, Yongwei Lim1
1Sengkang General Hospital
Presented By: Sundaram Palaniappan
Introduction: The utility of Endoscopic Combined Intrarenal Surgery (ECIRS) as a superior alternative to Percutaneous Nephrolithotripsy (PCNL) in terms of safety, efficacy, and lower rates of complications has been established, despite the higher costs involved due to the requirement of dual surgical modalities and surgeons. The primary objective of this study was conducting a cost‐effectiveness analysis between these two therapeutic strategies for renal stones which, surprisingly, remains unexplored. We aimed to investigate the cost‐utility of adopting ECIRS as the preliminary treatment strategy in comparison to PCNL, considering real‐world outcomes and follow‐up data to identify the optimal approach for large renal stones.
Methods: A microsimulation model was designed using TreeAge Pro to ascertain the impact of two treatment strategies, namely PCNL and initial ECIRS, on the stone‐free rates, costs, secondary procedure requirements, and Quality‐Adjusted Life‐Years (QALYs). The model employed a 3‐year time horizon and a 3‐month cycle length. A Markov model alongside a probabilistic sensitivity analysis was incorporated to calculate the costs and outcomes associated with the two strategies. Further, the cost‐effectiveness of the treatments was evaluated across various willingness‐to‐pay (WTP) thresholds.
Results: At the 3‐year horizon, the incremental costs with respect to PCNL were approximately S$3700, and the QALY increment was 0.08. ECIRS as the preliminary treatment, although more expensive, was found to be superior in effectiveness compared to PCNL, exhibiting a decreased complication rate (20% vs 35%) and an enhanced stone‐free rate (73.33% vs 58.75%). The approximate incremental cost per QALY gained was S$47,950, establishing ECIRS as a cost‐effective option at a WTP threshold of S$50,000. However, a probabilistic sensitivity analysis revealed that merely 46.6% of the simulation fell beneath the WTP threshold of S$50,000.
Conclusions: This study underpins the potential of ECIRS to be a cost‐effective initial treatment strategy for patients diagnosed with renal stones, who may otherwise undergo PCNL. The cost‐efficiency was primarily driven by reduced complication rates and improved stone‐free rates.
Funding: None
A Pilot Study of a Novel Syphon Ureteral Access Sheath Shows Potential to Reduce Renal Pressures and Improve Irrigant Flow.
John Lazarus1, Siyasanga Yekani1, Melanie De Bruyn1, Lisa Kaestner1
1University of Cape Town
Presented By: John Lazarus, MBChB, FC UROL (SA)
Introduction: To describe a novel syphon ureteral access sheath (UAS) intended for use during flexible uretero‐renoscopy (fURS). We aimed to report on a pilot study as well as intrarenal pressures (IRP) and irrigant flow volumes compared to traditional UAS.
Methods: Patients undergoing routine fURS for single, < 2cm intrarenal nephrolithiasis were identified, and written informed consent was obtained. Irrigation via the fURS was instilled through the novel 11/13 Fr UAS without (a proxy for a traditional UAS) and with the novel syphon box attached. Measured minute irrigant flow volume, steady state and bolus IRP were compared.
Results: Ten participants (6 males and 4 females) were treated with the syphon UAS. All procedures were completed safely without intra‐operative complications.The mean baseline IRP with and without the syphon was 18 vs 29 mmHG (p < 0.001, SD 4.0 vs 4.8).The mean minute irrigant flow volume with and without the syphon was 31 vs 21 ml (p < 0.001, SD 6.4 vs 3.3).The mean peak IRP following a 10 ml bolus with and without the syphon was 71 vs 104 mmHg (p = 0.03, SD 74 vs 59).
Conclusions: The described novel UAS is different from traditional devices by incorporating a syphon mechanism. This pilot trial demonstrates that the novel syphon UAS may hold clinical potential to reduce IRP and increase irrigant flow compared to traditional UAS. Firm conclusions about efficacy and safety require assessment of the device in a larger clinical trial.
Funding: Wismed, Durban, South Africa provided funding for the trial.
Safety and Efficacy of Electromotive Drug Administration in the Renal Pelvis: First In‐ Vivo Porcine Feasibility Study
Ralph V. Clayman1, Seyed Hossein Hosseini Sharifi1, Zachary E. Tano1, Bruce Gao1, Seyed Amiryaghoub M. Lavasani1, Yi Xi Wu1, Sohrab Naushad Ali1, Erika Martinez‐Carcamo1, Mahra Nourbakhsh2, Pengbo Jiang1, Roshan M. Patel1, Michael Daneshvar1, Jaime Landman1, Ralph V. Clayman1
1University of California, Irvine. Department of Urology, 2University of California, Irvine. Department of Pathology
Presented By: Bruce Gao, MD
Introduction: Electromotive drug administration (EMDA) is a technique used to amplify drug delivery to targeted tissues. Previously, we presented the safety and feasibility of using EMDA to drive a positively charged, small molecule into the ureteral wall. Herein we investigated the safety and efficacy of EMDA in the renal pelvis during an upper tract infusion of methylene blue. To the best of our knowledge, this is the first application of EMDA in the renal pelvis.
Methods: In a female Yorkshire pig under general anesthesia, a midline incision was made, and the retroperitoneal space was accessed. The proximal ureters were sharply transected two inches distal to the ureteropelvic junction. An 8 Fr dual lumen catheter and a 24 AWG silver wire insulated by passage through a 5 Fr catheter fenestrated in three rows (0.3 mm each)in its 5 cm distal end were inserted into both renal pelvises. The ureteral tissue around the catheter was secured with a 2‐0 silk suture, creating a water‐tight seal around the catheter. A dispersive pad was affixed to the flank on the experimental side and connected to the negative electrode of the EMDA generator (Physion® Mini 30N2). Methylene blue (0.1%), a positively charged, water‐soluble stain with a molecular weight of 334 Daltons, was infused via the dual lumen catheter using a drug infusion pump at a rate of 5 ml/min; one lumen of the 8Fr catheter was left open to gravity drainage.A positive pulsed electrical current of 4 mA was applied for 20 minutes in the experimental ureter. The same infusion was performed on the contralateral side; however, the silver wire was not activated.The pig was euthanized, and both kidneys were excised and frozen for subsequent histopathological analysis.
Results: The experimental renal pelvis exhibited dense staining on a macroscopic level. Under H&E staining, both pelvises displayed slight denudation of the urothelial cells due to the freezing of the specimens; no injury was found in the deeper tissues. Frozen sections of the experimental renal pelvis revealed a dense and diffuse penetration of methylene blue into the urothelium and lamina propria. Conversely, the control kidney showed faint methylene blue staining of the urothelium without deeper penetration.
Conclusions: In the porcine renal pelvis, EMDA increased the penetration of a small water‐soluble charged molecule into the urothelium and lamina propria.
Funding: None
Pulsed Thulium:YAG Laser: Ready to Dust All Urinary Stone Composition Types? Results from a PEARLS Analysis
Jia‐Lun Kwok9, Eugenio Ventimiglia1, Vincent De Coninck2, Mariela Corrales3, Alba Sierra4, Frédéric Panthier3, Felipe Pauchard5, Florian Schmid6, Manuela Hunziker6, Cédric Poyet6, Michel Daudon7, Olivier Traxer3, Daniel Eberli6, Etienne Xavier Keller8
1Division of Experimental Oncology/Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy ; Young Academic Urologists (YAU), Endourology & Urolithiasis Working Group, Arnhem, The Netherlands; Progressive Endourological Association for Research and Leading Solutions (PEARLS), 2Department of Urology, AZ Klina, Brasschaat, Belgium ; Young Academic Urologists (YAU), Endourology & Urolithiasis Working Group, Arnhem, The Netherlands ; Progressive Endourological Association for Research and Leading Solutions (PEARLS), 3Sorbonne Université, GRC n°20, Groupe de Recherche Clinique sur la Lithiase Urinaire, Hôpital Tenon, F‐75020 Paris, France ; Progressive Endourological Association for Research and Leading Solutions (PEARLS), 4Urology Department, Hospital Clinic de Barcelona, Villarroel 170, 08036 Barcelona, Spain ; Young Academic Urologists (YAU), Endourology & Urolithiasis Working Group, Arnhem, The Netherlands ; Progressive Endourological Association for Research and Leading Solutions (PEARLS), 5Urology Department, Hospital Naval Almirante Nef, Viña del Mar 2520000, Chile ; Progressive Endourological Association for Research and Leading Solutions (PEARLS), 6Department of Urology, University Hospital Zurich, University of Zurich, Zurich, Switzerland, 7Sorbonne Université, Hôpital Tenon, CRISTAL Laboratory, Paris, France, 8Department of Urology, University Hospital Zurich, University of Zurich, Zurich, Switzerland ; Young Academic Urologists (YAU), Endourology & Urolithiasis Working Group, Arnhem, The Netherlands; Progressive Endourological Association for Research and Leading Solutions (PEARLS), 9Department of Urology, University Hospital Zurich, University of Zurich, Zurich, Switzerland ; Department of Urology, Tan Tock Seng Hospital Singapore, Singapore
Introduction: A novel pulsed thulium:yttrium‐aluminum‐garnet (p‐Tm:YAG) laser has recently been introduced for clinical use. Few in vitro evaluations are available in literature, andall based on artificial stone models – not on human urinary stones. The aim of the present study was to evaluate whether stone dust can be obtained from all prevailing stone composition types using the p‐Tm:YAG, including analysis of stone particle size after lithotripsy.
Methods: Human urinary stones of 7 different compositions were subjected to in vitro lithotripsy using a p‐ Tm:YAG laser with 270 μm silica core fibers (Thulio®, Dornier MedTech GmbH®, Wessling, Germany). A cumulative energy of 1000 J was applied to each stone using one of three laser settings: 0.1J x 100Hz, 0.4J x 25Hz, and 2.0J x 5Hz (average power 10W). After lithotripsy, larger remnant fragments were separated from stone dust using a previously described method depending on the floating ability of dust particles. Fragments and dust samples were then passed through laboratory sieves to evaluate stone particle count according to a semi‐quantitative analysis relying on a previous definition of stone dust (i.e. stone particles ≤250 μm).
Results: The p‐Tm:YAG laser was able to produce stone dust from lithotripsy up to measured smallest mesh size of 63 μm in all seven urinary stone composition types. Notably, all dust samples from all seven stone types and with all three laser settings had high counts of particles in the size range agreeing with the stone dust definition, i.e. ≤250 μm.
Conclusions: To the best of our knowledge, this is the first study in literature proving the p‐Tm:YAG laser to be capable of dusting all prevailing human urinary stone compositions, with production of dust particles ≤250μm. These findings are pivotal for the broader future implementation of the p‐Tm:YAG in clinical routine.
Funding: None
Illumination Properties of Flexible Ureteroscopes: An Advanced Comparative Analysis in a Kidney Model from PEARLS Members
Jia‐Lun Kwok10, Vincent De Coninck1, Eugenio Ventimiglia2, Yazeed Barghouthy3, Alexandre Danilovic4, Niamh Smyth5, Jan Brachlow6, Florian Schmid7, Manuela Hunziker7, Cédric Poyet7, Olivier Traxer8, Daniel Eberli7, Etienne Xavier Keller9
1Department of Urology, AZ Klina, Brasschaat, Belgium ; Young Academic Urologists (YAU), Endourology & Urolithiasis Working Group, Arnhem, The Netherlands ; Progressive Endourological Association for Research and Leading Solutions (PEARLS), 2Division of Experimental Oncology/Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy ; Young Academic Urologists (YAU), Endourology & Urolithiasis Working Group, Arnhem, The Netherlands; Progressive Endourological Association for Research and Leading Solutions (PEARLS), 3Department of Urology, Centre Hospitalier de Valenciennes, Valenciennes, France ; Progressive Endourological Association for Research and Leading Solutions (PEARLS), 4Department of Urology, Universidade de São Paulo Hospital das Clínicas ‐ HCUSP Department of Urology, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil ; Progressive Endourological Association for Research and Leading Solutions (PEARLS), 5University Hospital Monklands, Monkscourt Avenue, Airdrie, ML60JS, United Kingdom ; Progressive Endourological Association for Research and Leading Solutions (PEARLS), 6Zentrum für Urologie Winterthur, Winterthur, Switzerland ; Progressive Endourological Association for Research and Leading Solutions (PEARLS), 7Department of Urology, University Hospital Zurich, University of Zurich, Zurich, Switzerland, 8Sorbonne Université, GRC n°20, Groupe de Recherche Clinique sur la Lithiase Urinaire, Hôpital Tenon, F‐75020 Paris, France ; Progressive Endourological Association for Research and Leading Solutions (PEARLS), 9Department of Urology, University Hospital Zurich, University of Zurich, Zurich, Switzerland ; Young Academic Urologists (YAU), Endourology & Urolithiasis Working Group, Arnhem, The Netherlands ; Progressive Endourological Association for Research and Leading Solutions (PEARLS), 10Department of Urology, University Hospital Zurich, University of Zurich, Zurich, Switzerland ; Department of Urology, Tan Tock Seng Hospital Singapore, Singapore
Introduction: Optical characteristics of flexible ureteroscopes have been extensively evaluated in air. To the best of our knowledge, the effects of an enclosed cavity in the kidney collecting system in saline on light properties of ureteroscopes is unknown. The aim of the study was to evaluate light properties in an in‐vitro kidney model setting in saline, simulating the human kidney collecting system.
Methods: We evaluated a series of contemporary flexible ureteroscopes including the Storz Flex‐Xc and Flex‐X2s, Olympus V3 and P7, Pusen 7.5F and 9.2F, as well as OTU Wiscope using a 3D printed pink in‐ vitro kidney model consisting of a closed spherical cavity with 20mm diameter submerged in saline. A colour spectrometer incorporating the Vishay VEML 6040 color sensor was used for lux measurements at different openings located at the centre (direct light), 45°(direct and indirect light) and 90°(indirect light only) to the axis of the scope.
Results: The maximum illuminance was at the centre opening for all scopes (range: 516 to 12058 lux at 50% brightness and 454 to 11871 lux at 100% brightness settings). For each scope, when comparing illuminance at centre vs 45° or 90°openings, the difference ranged from ‐43% to ‐92% at 50% brightness and ‐43% to ‐88% at 100% brightness settings (all p < 0.01). The two scopes with the highest peripheral drop were the P7 (centre vs 45°: ‐88%, ‐83%; centre vs 90°: ‐92%, ‐87% at 50% and 100% brightness respectively) and the Pusen 9.2F (centre vs 45°: ‐86%, ‐85%; centre vs 90°: ‐89%, ‐88% at 50% and 100% brightness respectively). The scope with the least peripheral drop was the Pusen 7.5F (centre vs 45°: ‐49%, ‐48%; centre vs 90°: ‐43%, ‐43% at 50% and 100% brightness respectively).
Conclusions: Illumination varies widely between ureteroscopes in an enclosed cavity in saline, with brightness differing as well within scopes at centre vs 45° and 90° positions. Scopes can have a peripheral illuminance drop as high as ‐92% compared to the centre, which is an undesirable property possibly impacting diagnostic purposes in ureteroscopy. Urologists should be aware of this as it may affect the choice of ureteroscopes and light brightness setting used in surgery.
Funding: None
Ureteroscopes Can Suck. a Novel Suction Technique with Readily Available or Supplies
Jacob Thatcher2, Robert Barsky1
1New Jersey Urology, 2Jefferson, New Jersey
Presented By: Jacob Thatcher, DO
Introduction: Documentation of stone disease extends back thousands of years. It wasn't until Hugh Young reported ureteroscopy in 1929 that we were able to interrogate the upper genitourinary system. Over time the maneuverability, and visibility of the ureteroscope has improved, but still the mechanics of lithotripsy and stone basket extraction in large part has remained the same.Presently there are at least two underappreciated limitations in ureteroscopy: 1. High pressures are required for visibility, lithotripsy, and basket extraction. These high pressures lead to pyelovenous back flow and have been associated with post operative sepsis and pain,2. Visibility is often poor, which can necessitate second look ureteroscopy. The significance of renal pressures remains unclear. Physiologic pressure is 5‐10 mmHg. Yet with irrigation devices renal pressures have been measured as high as 300mmHg. We present a method to manage the intrarenal pressure and improve visibility by suctioning irrigant with readily available and cheap supplies available in any standard operating room.
Methods: This study was conducted in a cohort of 25 patients with large renal calculi (0.9‐1.5cm) and was approved by the Institutional Review Board at Rowan School of Medicine. The patients were randomized to either the standard of care, which allowed for passive drainage through a ureteric access sheath only, or the standard of care with the addition of our suctioning device. Figure one shows the supplies used for our device, which includes a three‐way UroLok™adaptor (a), flexible ureteroscope (Olympus) and single action pump (b). Suction (Stryker Neptune™) was regulated by an Argyle™suction catheter (c) and suction tubing (d). Figure two represents the assembled suction device during a flexible ureteroscopy. In both groups, we measured the fluid irrigated with the single action pump and compared it with the fluid thatdrained passively through the ureteric access sheath.
Results: Surprisingly, volume of irrigation with the single action pump remained constant in both groups (∼900mL). Passive drainage was also constant (∼500mL). However, in our study cohort, we found that we were able to suction an additional ∼300 mL of irrigant, blood clot and fine stone fragments that would have otherwise not been accounted for.
Conclusions: We show a model for a novel and inexpensive suctioning device from available supplies within any operating room that effectively suctions irrigant that would have otherwise been left in the kidney post operatively. Further work will be pursued with this model to quantifiably access visibility, case time, post operative pain and sepsis.
Funding: None
Four Dimension Analysis of Heat Generation During Ho:YAG and Thulium Fiber Laser Activation: An in Vitro Thermographic Study
Luigi Candela1, Daniele Robesti1, Margherita Fantin1, Christian Corsini1, Luca Villa1, Ioannis Kartalas Goumas2, Silvia Proietti3, Guido Giusti3, Cesare Scoffone4, Cecilia Cracco4, Olivier Traxer5, Francesco Montorsi1, Esteban Emiliani6, Etienne Keller7, Andrea Salonia1, Paola Saccomandi8, Eugenio Ventimiglia1
1Division of Experimental Oncology, Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy.
Università Vita‐Salute San Raffaele., 2Department of Urology, Istituto Clinico Beato Matteo, 27029 Vigevano, Italy., 3Department of Urology, IRCCS San Raffaele Hospital, Milan, Italy. European Training Center in Endourology, Milan, Italy, 4Department of Urology, Cottolengo Hospital, Torino, Italy., 5Urology Unit, Tenon Hospital, Paris, France, 6Department of Urology, Fundación puigvert. Universidad Autónoma de Barcelona, 7Department of Urology, University Hospital Zurich, University of Zurich, Zurich, Switzerland., 8Department of Mechanical Engineering, Politecnico di Milano, Milan, Italy
Presented By: Luigi Candela, MD
Introduction: Endourological laser applications in the upper urinary tract result in heat generation. Several laboratory experiments have been carried out to characterize fluid temperature during laser activation. However, an analysis of spatial distribution of generated heat has never been performed before. We aimed at assessing heat generation and distribution in an in‐vitro caliceal model during both Ho:YAG and thulium fiber laser (TFL) activation.
Methods: The experimental setup consisted of a glass pipette with an open roof bulb n a 37°C water bath simulating a renal calyx (Figure 1a). Two different scenarios were analyzed:1) laser activation without irrigation.2) laser activation with irrigation (saline), with an irrigating pressure set at 40 mmHg and the laser fiber conducted through a flexible ureteroscope working channel (Lithovue, Boston Scientific) inserted through a 12‐14 ureteral access sheath. In both cases, the laser fiber was activated at the center of the calyx. For live temperature monitoring during laser activation, a thermal camera was placed perpendicular to the open roof of the pipette bulb. All test were performed using an high power Ho:YAG laser generator set with the lowest available peak power (Cyber Ho 150 W, Quanta System) and a Thulium Fiber Laser set with the highest available peak power (TFL, FiberDust 60W, Quanta System). The spatial and temporal temperature fluctuations were documented with a thermal camera (T865, resolution 640x480 px, FLIR) and recorded during 60 seconds of uninterrupted laser activation, at different power and frequency settings with or without irrigation. Tested powers were 5 W, 10 W, 20 W, and 40 W. Each experimental configuration was repeated at least three times to ensure reliable results. Descriptive statistics was used to compare Ho:YAG and TFL peak temperature, as well as time required to reach 43°C temperature at 2 mm distance from the laser fiber tip.
Results: Figure 1b and 1c graphically report the relationship between laser activation time and special distribution of generated heat for Ho:YAG and TFL respectively, showing a similar profile. No difference was found between the two lasers regarding both peak temperatures and time to reach 43°C at 2 mm distance from the laser fiber tip (all p > 0.05), irrespectively of irrigation.
Conclusions: TFL and Ho:YAG laser show similar profile both in temperature rise and spatial distribution of generated heat.
Funding: none
a Machine Learning Model to Determine Calcium vs Non‐Calcium Stone Composition: Implications for Treatment Strategies and Pathophysiological Insights
Jennifer Bjazevic2, John Chmiel1, Gerrit Stuivenberg1, Jennifer Wong2, Linda Nott2, Jeremy Burton3, Hassan Razvi2
1Department of Microbiology & Immunology, Western University, London, Canada, 2Division of Urology, Department of Surgery, Western University, London, Canada, 3Division of Urology, Department of Surgery, Western University, London, Canada; Department of Microbiology & Immunology, Western University, London, Canada
Presented By: Jennifer Bjazevic, MSc, MD, FRCSC
Introduction: Preventative strategies and surgical treatment for urolithiasis depend on stone composition. However, stone composition is often unknown until the stone is passed or surgically managed. Given that stone composition likely reflects the physiological parameters during its formation, we used clinical data from stone formers to predict calcium vs non‐calcium stone composition.
Methods: Stone composition, 24‐hour urine results, serum biochemistry, and demographics were prospectively collected from calcium (n = 625) and non‐calcium (n = 152) stone patients at a tertiary care centre metabolic stone clinic. Binary classification of calcium vs non‐calcium composition was performed using a gradient boosted tree algorithm (Figure 1A). This algorithm converts multiple weak learners to strong learners to better classify stone types. Class imbalance was addressed by upsampling the minority class and hyperparameters were tuned using Bayesian optimization.
Results: Our model showed acceptable performance with an area under the receiver operator characteristics (AUC‐ROC) curve of 0.79 (Figure 1B). The model had a good degree of sensitivity of 0.86 and a moderate degree of sensitivity of 0.56 (Figure 1C). The model demonstrated that 24‐hour urine calcium and creatinine, blood phosphate and urate, and BMI were the most significant predictors of classification (Figure 1D). Sex, urine dipstick results, and blood parathyroid levels were the least important predictors in the model (Figure 1D).
Conclusions: We have demonstrated that clinical data can be used to predict stone composition, which may help urologists determine stone type and guide their management plan before stone treatment. Moreover, the model provides a better understanding of key clinical features of stone disease, which sheds light on the underlying pathophysiology. By extending machine learning algorithms, it will be possible to determine specific compositions of stones and ultimately improve medical therapy for stone formers.
Funding: None
MODERATED POSTER SESSION 28: STONES: INSTRUMENTATION AND NEW TECHNOLOGY 2
Adoption of the MOSES 120W Holmium Laser is Associated with Significant Decreased Operative Time During Ureteroscopic Stone Extraction at a Large Tertiary Referral Center
Samit Sunny Roy1, David Thompson1, Jessica Lange1
1Erlanger Health System
Presented By: Alex Hwang, MD
Introduction: As technologic advancement continues to improve in urology it is critical to evaluate objective outcomes after adoption to ensure appropriate value added to patients and clinicians. There are few studies examining the real‐world results of adoption of the MOSES 120‐watt holmium laser compared to prior laser models for ureteroscopic stone extraction (USE) with regards to operative time. We hypothesized that there would be a significant decrease in operative time for USE regardless of demographics or perioperative variables when using MOSES laser compared to prior models.
Methods: Medical records for all USE procedures (CPT 52356) in patients > 18 years of age at a single academic tertiary referral center performed by a single endourologist between 2019‐2022 were collected. Cases during which other procedures were performed concurrently were excluded. Demographic and perioperative data were abstracted from the medical record. Data was analyzed using Stata statistical software v16 using chi‐square, t‐tests, Wilcoxon rank‐sum tests, and multivariable linear regression where appropriate.
Results: A total of 238 USE cases were performed between 2019‐2022. Of these, 53 (22.3%) were performed prior to adoption of the MOSES laser at our institution using 120W laser. There were no differences in patient sex (54 vs 64% female; p = 0.14), BMI (31.0 vs 31.7; p = 0.61), pre‐stented patients (51% vs 57%; p = 0.45), intraoperative stent placement (96 vs 95%; p = 0.63), average Hounsfield units (911 vs 873; = 0.47), maximum stone length (12 vs 13 mm; p = 0.33), use of semirigid ureteroscope (89% vs 79%; p = 0.13), or stone location (58% vs 46% renal; p = 0.29). After adoption of MOSES laser there was a increase in average patient age (49 vs 54 years; p = 0.030) as well as a decrease in average procedure time (60.3 vs 49.6 min; p = 0.003). Multivariable linear regression modeling was performed to determine significant predictors of procedure time after controlling for relevant factors. Use of the MOSES laser (p = 0.004), stone volume (p < 0.001), and ureteral stone location (p = 0.011) were the only significant predictors of procedure time after controlling for above listed variables.
Conclusions: There was a significant decrease in procedure time after adoption of the MOSES laser system even after controlling for demographic and perioperative factors.
Funding: N/A
Artificial Intelligence in Urology: Application of a Machine Learning Model to Predict the Risk of Urolithiasis in a General Population
1Universidad de Chile, 2Universidad del Desarrollo, 3Clinica las Condes, 4Urology Department, Universidad de Chile, Hospital Clínico San Borja Arriarán
Presented By: Belén Giménez, MD
Introduction: Artificial Intelligence (AI) can be used to recognize patterns and make predictions of future events from large amount of data. Due to the increasing incidence of urolithiasis, and its known association with genetic, nutritional, and environmental factors, it is relevant to implement interventions that help prevent the development of urolithiasis in the general population. Our aim was to create an AI model to predict the probability of a patient to develop kidney stones.
Methods: An extensive questionnaire was created to collect information about different risk factors for urolithiasis in individuals with and without history of kidney stones. Demographic, nutritional and exercise habits information, medical and family history, along with data from blood and urine analysis were collected. A supervised Machine Learning (ML) model was developed (Python Software Foundation). The performance of four models (Logistic regression, decision tree classifier, random forest classifier, extra trees classifier) to predict the occurrence of kidney stones was evaluated by determining the weight of each variable.
Results: A total of 730 questionnaires answered by Chilean individuals were included. All four models showed a high range of performance (70‐83%) and identified as the strongest predictors for kidney stones development, the history of surgery for kidney stones, BMI of 30, beer consumption (3 times per week), burnt orange color of voided urine, history of calcium phosphate stones, weight gain in the past year (> 5% of basal weight) and low water intake (< 1 liter). Clear or pale straw yellow urine, not feeling thirsty during the day, use of potassium citrate, and regular consumption of calcium, fruits, and vegetables were identified as protective factors.
Conclusions: The use of ML algorithms to predict the risk of urolithiasis is reliable and effective. The models analyzed could be used to identify patients at higher risk of developing urolithiasis and address modifiable factors to reduce the incidence of this disease. The collection of quality clinical information and the application of predictive risk algorithms is an emergent tool that will allow the development of preventive public policies for this chronic disease of growing importance.
Funding: None
A Comparison of the Thulium Fiber Laser versus Holmium:YAG Laser Lithotripsy of Upper Urinary Tract Calculi: Preliminary Results of a Randomized Prospective Clinical Trial
Eduardo Gonzalez‐Cuenca1, Mario Basulto‐Martinez1, Linda Nott1, Stephen E. Pautler1, John Denstedt1, Jennifer Bjazevic1, Hassan Razvi1
1Division of Urology, Department of Surgery, Schulich School of Medicine and Dentistry. Western University, London, ON, Canada.
Presented By: Eduardo Gonzalez‐Cuenca
Introduction: The Holmium:yttrium‐aluminium‐garnet (Ho:YAG) laser has become indispensable in endourology since its introduction in 1995, due to its wide safety margin and efficient stone fragmentation capabilities. Various technological advancements in laser lithotripsy have been developed since then, in an attempt to overcome some of the limitations of the original devices. The Thulium Fiber Laser (TFL), is the latest innovation and early clinical experience has suggested improvements in stone fragmentation and dusting capabilities compared to the Ho:YAG laser. The aim of our research was to compare the 2 laser technologies in a prospective, randomized protocol to investigate whether there were any differences in the efficiency of stone disruption including laser on time and total energy.
Methods: Patients undergoing ureteroscopy for renal stones from a single institution were recruited and prospectively assigned to receive either the Ho:YAG or TFL laser for their procedure. Patients ≥18‐years‐ oldwith a renal calculi 8‐20mm in size anda mean stone density of > 600 Hounsfield units were included.Pre‐operative patient and stone characteristics, intra‐operative variables including laser time, energy and operative time were assessed. Post‐operative outcomes including 3‐month post‐operative stone free rate on CT scan and complication rates were compared.
Results: To date, 30 patients have been recruited (15 in each arm).The laser‐on time (p = .683), total operative time (p = .578), total laser energy (p = .935), ablation speed (p = .345) and ablation efficiency (p = .713) were not statistical different between groups. Trends in favor of TFL were seen in shorter laser‐on time (384 VS 521 s), total operative (35.6 VS 38.2 min), decreased Total Laser Energy (6273 VS 6919 J), improved ablation efficiency (11.3 VS 11.9 J/mm3) and increased ablation speed (1.09 VS 1.19 mm3/second).To date, we have available 3‐month follow‐up information from 10 patients with post‐operative non‐constrast CT scan.
Conclusions: Preliminary results suggest similar outcomes between the two laser technologies for routine ureteroscopy in renal stone disease. However, several parameters are trending in favor of the TFL laser technology and recruitment fulfillment will be necessary to determine if there is significant difference between TFL and Ho:YAG laser technologies that are clinically meaningful.
Funding: No conflicts of interest from the authors
Power Loss at Fiber Output Among Lasers: Are they All Similar? An in Vitro Study
Marie Chicaud5, Stessy Kutchukian1, Laurent Berthe2, Catalina Solano3, Luigi Candela4, Steeve Doizi3, Olivier Traxer3, Frederic Panthier3
1Service d'urologie, CHU de Poitiers, 2PIMM, UMR 8006 CNRS‐Arts et Métiers ParisTech, 3Service d'urologie, APHP, Hôpital Tenon, 4Division of experimental oncology/unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy; Vital‐Salute San Raffaele University,, 5Service d'urologie, CHU de Limoges
Presented By: Marie Chicaud, MD
Introduction: Holmium:YAG (Ho:YAG) and Thulium Fiber Laser (TFL) are commonly used for laser lithotripsy. Recently, a new pulsed‐Thulium:YAG (p‐Tm:YAG) has been proposed as an alternative. The Fiber Output Power (FOP) is a main determinant of laser lithotripsy, and differs from power set on generator (PSG). We aimed to determinate the power loss (PL) between FOP and PSG among laser sources and settings.
Results: In saline at 10W, the PP was 27.35% for Ho:YAG, 9.2% for EMS‐TFL, 15.19% for COLOPLAST‐ TFL and 16.53% for p‐Tm:YAG. At 15W, the PP was 28% for Ho:YAG, 13.27% for EMS‐TFL, 15.47% for COLOPLAST‐TFL and 13.67% for p‐Tm:YAG. After 30s of laser activation, the FOP was better than at the beginning by about 1% and without variation at 60s. For all lasers and settings, FOP and PSG were significantly different (p < 0.05), however no difference in PP between PSF‐T0 and T30 and T60. We obtained similar results against synthetic calculations. Comparing laser sources at the same setting(1J,10Hz), the PL of Ho:YAG was significantly different from other laser sources(p < 0.05).
Conclusions: Urologists should consider FOP during laser lithotripsy, which differs consistently from the PSG. After an initial loss the output power seems to stay sand. The PL of the Ho:YAG seems almost twice more than the TFL and the pTm:YAG, which are not different. This should be considered in clinical practice and in fiber preservation.
Funding: None
Peak Power : Is Pulsed‐Thulium:YAG the Real Answer for Effective Lithotripsy?
Marie Chicaud5, Stessy Kutchukian1, Laurent Berthe2, Luigi Candela3, Catalina Solano4, Steeve Doizi4, Olivier Traxer4, Frederic Panthier4
1Service d'urologie, CHU de Poitiers, 2PIMM, UMR 8006 CNRS‐Arts et Métiers ParisTech, 3Division of experimental oncology/unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy; Vital‐Salute San Raffaele University, 4Service d'urologie, APHP, Hôpital Tenon, 5Service d'urologie, CHU de Limoges
Presented By: Marie Chicaud, MD
Introduction: Among laser sources, the pulse profiles differ. Two lasers stand out: Holmium:YAG (Ho:YAG) with a non‐uniform profile and Thulium Fiber Laser (TFL) with a regular and uniform profile, with an immediately maximum amplitude stable over time. Recently, pulsed‐Thulium:YAG (p‐Tm:YAG) has been proposed as an alternative. The objective of our study was to compare p‐Tm:YAG and TFL pulse profiles.
Methods: Two laser generators were used (100Wp‐Tm:YAG (Thulio®, Dornier, Germany) and 60W‐TFL (EMS, Switzerland)) with 270μm laser fibers. Average power and pulse profiles were acquired using a wattmeter and an oscilloscope (InfiniiVision DSO5014A (Agilent Technologies®)), the fiber is put in an integrating sphere with a photodiode sensor. We used different settings between 3 and 10W.Settings are displayed in Table 1 and the set‐up is presented in Figure 1. Fibers were cut with ceramic scissors and stripped between each test, repeated three times. The peak power (PP) was calculated for each parameter (average power(W)/(frequency(Hz)xPulse duration(s)).
Results: Tm:YAG presented a uniform and stable over the time profile, regardless to pulse modulation : dusting, fragmenting, captive fragmenting, soft tissue, flex short pulse and flex long pulse. The PP ranged from 561W to 2228Wwith a difference of PP and pulse duration following pulse mode set on generator. For the TFL, we set the laser on 500W corresponding to PP3. For all settings, we obtained a PP which still constant around 430 and 503W (mean value : 449W) with always a uniform profile. The p‐Tm:YAG PP was always higher than the TFL one which remained fixed. Only the pulse duration increased with energy.
Conclusions: The p‐Tm:YAG presents a stable uniform profile superimposable to that of the TFL contrary to the Ho:YAG laser. The peak power, varying from 500 to 2200W, is intermediate between Ho:YAG and TFL lasers. Several pulse modulations are available but preclinical and clinical data are lacking to define the place of each during lithotripsy.
Funding: none
A Pressure Comparison Between Two Different Mini‐PCNL Nephroscopes
Akin S. Amasyali1, Ala'a Farkouh1, Matthew Wilson1, Kanha Shete1, Matthew Buell1, Akin S. Amasyali1, Rose Leu1, Sikai Song1, Zhamshid Okhunov1, D. Duane Baldwin1
1Loma Linda University Health
Presented By: Akin S. Amasyali, MD
Introduction: Mini‐PCNL is gaining popularity among endourologists as it is associated with less bleeding and shorter hospital stays. One of the few drawbacks of mini‐PCNL has been increased renal pelvic pressure (RPP) and subsequent increased risk for infection/sepsis. The purpose of this study was to compare the RPP between two commercially available mini‐PCNL scopes and a standard 30 Fr PCNL.
Methods: A previously created prone PCNL model constructed from an actual patient was utilized to compare RPPs in a benchtop experiment. Two mini‐PCNLs (Storz and Olympus) and a standard PCNL (Storz) were compared (Table 1). RPPs were measured by connecting an a‐line monitor to a flexible ureteroscope retrogradely positioned in the renal pelvis. In all trials, inflow irrigation was set at 60 cmH2O. Five trials were performed in each of the following scenarios for each scope: outflow open, outflow closed (not available in the Storz mini‐PCNL), 272 μm laser fiber, 3‐prong grasper, and ultrasonic lithotripter with and without suction. If RPP exceeded 65 cmH2O, the trial was terminated. RPP was compared between scopes and conditions using a Kruskal‐Wallis test with post‐hoc analysis, or Mann‐Whitney U test. A p‐value < 0.05 was considered significant.
Results: There was no significant difference between the two mini‐PCNL nephroscopes used in any scenario (Table 1). With the outflow open, both mini‐PCNLs resulted in significantly higher RPP compared to the standard PCNL (Table 1). Closure of the outflow with the Olympus mini‐PCNL resulted in pressures > 65 cmH2O. When working with both mini‐PCNL scopes, addition of the 3‐prong grasper and the ultrasonic lithotripter significantly reduced RPP. Adding suction to the lithotripter further reduced pressure. During mini‐PCNL with both nephroscopes, pressures exceeded 30 cmH2O during irrigation and when using the laser. In contrast, using the standard PCNL, RPP never exceeded 30 cmH2O.
Conclusions: There was no difference in the RPPs between the Storz and the Olympus mini‐PCNL scopes, except that closure of the outflow with the Olympus resulted in very high RPPs. Addition of the 3‐prong grasper and lithotripter significantly reduced the pressure. The standard PCNL had significantly lower pressures while irrigating and when using the laser.
Funding: None
Can Ultra‐Low Dose Fluoroscopy Be Used for Renal Access? a Benchtop Comparison of Two Techniques
Zhamshid Okhunov1, Tyler Humphries1, Ala'a Farkouh1, Matthew I. Buell1, Akin S. Amasyali1, Rose Leu1, Kanha Shete1, Katya Hanessian1, Zhamshid Okhunov1, D. Duane Baldwin1
1Loma Linda University Health
Presented By: Zhamshid Okhunov, MD
Introduction: During percutaneous nephrolithotomy (PCNL), access is most frequently achieved using continuous fluoroscopy, subjecting both patients and surgeons to radiation. Recently, pulsed fluoroscopy and low dose settings have been applied to endourologic procedures but may make establishing renal access challenging. The purpose of this study was to compare two different techniques for establishing renal access using ultra‐low dose pulsed fluoroscopy settings in a benchtop model.
Methods: A renal access model was created with a 12th rib and a target positioned in the upper calyx (Figure 1A). Ten urology attendings/trainees and ten medical students participated in a prospective, randomized, cross‐over, benchtop study using two ultra‐low dose fluoroscopy techniques. In all trials, the low dose button was selected and combined with pulsed fluoroscopy at 1 pulse per second. In the first technique (Figure 1B), an 18‐gauge needle was held using a metal clamp and inserted using a conventional bull's‐eye method. In the second technique (Figure 1C & 1D), a laser beam from the image intensifier was used to guide insertion of a specialized needle, using a low‐density handle. Fluoroscopy time, radiation dose, renal access time, and total number of attempts were recorded. Participants then rated the difficulty (1‐10) and satisfaction with each technique. Paired comparisons were conducted using Wilcoxon signed‐rank test, with p‐value < 0.05 considered significant.
Results: Both ultra‐low dose techniques had a high success rate with 95% for laser‐guided and 85% for conventional after 3 trials (p = 0.29). The mean fluoroscopy time for the laser technique (4.1 sec) was 44% lower than the conventional needle (7.3 sec; p = 0.043). Even at the lowest fluoroscopy settings, the average radiation used was significantly higher when using the conventional needle (1.5 mGy) compared to the laser‐ guided needle (0.81 mGy; p = 0.04). Access was significantly easier using the laser‐guided technique (4.6/10) vs the conventional needle (6.6/10; p = 0.021). 80% preferred using the laser‐guided technique to establish renal access.
Conclusions: Although challenging, pulsed and low dose fluoroscopy can be used for establishing renal access during PCNL. Addition of a specialized laser‐guided needle further reduces fluoroscopy time and simplifies the procedure.
Funding: None
Utilization of Bing AI Chatbot for Stone Management Questions: A Comparison of Chat Response Modes and the AUA Guidelines
Daniel R. Hanna1, Willian Ito1, Russell S. Terry2, Wilson R. Molina1, Bristol B. Whiles1
1University of Kansas Medical Center, 2University of Florida
Presented By: Daniel R. Hanna, MD
Introduction: As multiple artificial intelligence (AI) chat models become available for public use, this technology will inevitably enter the healthcare space. Patients are likely to use AI chatbots to help answer medical questions. Bing AI (Microsoft) is a new chatbot with 3 different question response modes: More Creative, Balanced, and Precise. It is unclear if Bing AI can accurately answer medical questions and if the different modes alter its responses. In this study, we aim to evaluate each Bing AI response mode for surgical management of nephrolithiasis questions.
Methods: We created 20 questions based on the AUA Surgical Management of Stones guideline. Bing AI's response was evaluated in each of its beta chat modes by two physicians using the validated Brief DISCERN score, originally developed to evaluate the quality of healthcare information online. The score is on a scale of 6‐30 and addressed the aims, relevance, sources, and bias. Guideline adherence, expressing empathy, recommending physician consultation, or stating it could not answer the inquiry were also evaluated. We used descriptive statistics to evaluate responses and an ANOVA to compare the results of the three chat modes.
Results: Brief DISCERN Score in More Creative, Balanced, and Precise response modes were: 22.6 (IQR 21.5‐23.75), 22.95 (IQR 22.375‐24.125), and 22.25 (IQR 20.375‐24.5), respectively. There was no difference in Brief DISCERN scores between the three chat modes (p = 0.52). However, when evaluating response appropriateness, More Creative mode was superior (85% vs. Balanced 75% vs. Precise 45% p = 0.017). No statistically significant difference between modes was found in guideline adherence, empathy, recommending consulting a doctor, or inability to answer the prompt. However, More Creative mode scored highest in each of these categories (Figure 1).
Conclusions: All three Bing AI modes scored well on surgical stone management suggestions. Our data shows that in this small cohort, More Creative mode gave the most appropriate responses to stone management questions. Importantly, it also had the highest incidence of recommending consultation or stating it could not answer the question. For the best results, patients should use Bing's More Creative mode for stone questions. However, additional studies are needed to better understand this AI chatbot. Patients should use caution when utilizing this technology, considering there is a 15% inappropriate response rate, even on the best chat mode.
Funding: N/A
Flexible and Navigable Suction Ureteric Access Sheath (FANS) for Retrograde Intra Renal Surgery (RIRS), Whats the Verdict from An Audit Study?
Vineet Gauhar8, Daniele Castellani1, Olivier Traxer2, Ben Chew3, Deepak Ragoori4, Jeremyyuen‐Chun Teoh5, Saeed Bin Hamri6, Bhaskar Somani7
1Azienda Ospedaliero‐Universitaria Ospedali Riuniti di Ancona, 2Sorbonne University, Department of Urology Hôpital Tenon,, 3University of British Columbia, 4Asian Institute of NephroUrology(AINU), 5S.H. Ho Urology Centre, Department of Surgery, Faculty of Medicine, The Chinese University of Hong Kong, 6Advanced Laser Endourology at king Abdulaziz National Guard Medical City, 7university hospital NHS trust,, 8Ng Teng Fong General Hospital
Presented By: Vineet Gauhar, MCh
Introduction: Suction, asers and technology are changing the landscape in modern endourology. Efforts are focussed in improving single stage stone free rate (SFR), minimising re‐intervention and reducing septic complications and improving PROMs in Retrograde intrarenal surgery (RIRS). Primary aim was to evaluate the ease, manoeuvrability and intraoperative visibility using a new Flexible and navigable suction acess sheath (FANS)during lithotripsy and its ability to extract fragments. Secondary outcomes were to assess SFR, short term complications (i.e. up to 3 months), to report mechanical failures, scope and sheath damage.
Methods: Anonymized retrospective clnical audit of data on (AINU12/2022)RIRS performed in adults using 2 sizes of (12fr and 10fr)FANS called the ELEPHANT sheath from Yingbao company made in China, in two centres between Nov 2021 and Oct 2022was perfomed. Inclusion criteria were adult with renal stones Complications evaluated within 30 days from RIRS up to 3 months. SFR was absence of single RF > 2 mm on CT. Steps involved i) lithotomy ii) cystoscopy iii) semirigid ureteroscopy iv) insertion of FANS under fluoroscopy; v) deploying a dsisposable scope 8 Fr in a 12 Fr sheath (Group1) and 7.5 Fr for 10 Fr (Group2).Irrigation using the attached TRAXERFLOW was used to improve the flow in view of simultyaneous suction and aspiration intraoperatively.
Results: Table 1 and 2 show outcomes.16 patients in Group 1 and 15 in Group 2Overall,the 10 Fr FANS fared superiorly to 12 Fr sheaths. Both shaths were deflecatble even when the infundibulum‐pelvic angle was acute with sligt advantage for the 10fr in the Lower pole.18 of 31 patients observed overnight with a ureteric catheter instead of a double j. All patients discharged within 24 hours with no readmission, Apart from a transcinet fever in some patients traetaed with overnight antibiotics there were no cases of sepsis. At 3‐month, SFR was significantly higher in Group 2 (94.7% vs 68.8%, p = 0.01). No patient had RF larger than 4 mm. No infectious complications seen.
Conclusions: After a learning curve of 3‐4 cases that require urologists to skillfully handle the scope and sheath simultaneously under fluroscopy guidance whilst navigating the anatomy and aspirating dust and fragments, it appears that RIRS with FANS is replicable, safe, achieves a high single stage SFR. Using a disposable scope allows for maximising the torque needed to actively and passively deflect the scope and sheath in the PCS. The 7.5Fr scope and 10fr sheath combination is marginally better in this. Suction has a dual advantage of aspirating and mainataing a low intrarenal pressure and avoids overdistention of the system. If on table inspection confirms no RF, using this sheath can potentially minimise need for stents, accessories and re‐interventions which can be a cost saving option.
Funding: NIL
Pulsed Thulium:YAG Laser: What is the Ablation Efficiency During Lithotripsy of Human Urinary Stones? Results from An in‐vitro PEARLS Study
Jia‐Lun Kwok11, Eugenio Ventimiglia1, Vincent De Coninck2, Yazeed Barghouthy3, Alexandre Danilovic4, Anil Shrestha5, Niamh Smyth6, Florian Schmid7, Manuela Hunziker7, CÉDric Poyet7, Michel Daudon8, Olivier Traxer9, Daniel Eberli7, Etienne Xavier Keller10
1Division of Experimental Oncology/Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy ; Young Academic Urologists (YAU), Endourology & Urolithiasis Working Group, Arnhem, The Netherlands; Progressive Endourological Association for Research and Leading Solutions (PEARLS), 2Department of Urology, AZ Klina, Brasschaat, Belgium ; Young Academic Urologists (YAU) Endourology & Urolithiasis Working Group, Arnhem, The Netherlands ; Progressive Endourological Association for Research and Leading Solutions (PEARLS), 3Department of Urology, Centre Hospitalier de Valenciennes, Valenciennes, France ; Progressive Endourological Association for Research and Leading Solutions (PEARLS), 4Department of Urology, Universidade de São Paulo Hospital das Clínicas ‐ HCUSP, Department of Urology, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil ; Progressive Endourological Association for Research and Leading Solutions (PEARLS), 5Department of Urology, National Academy of Medical Sciences, Bir Hospital and B&B Hospital, Gwarko Lalitpur, Nepal ; Progressive Endourological Association for Research and Leading Solutions (PEARLS), 6University Hospital Monklands, Monkscourt Avenue, Airdrie, ML60JS, United Kingdom ; Progressive Endourological Association for Research and Leading Solutions (PEARLS), 7Department of Urology, University Hospital Zurich, University of Zurich, Zurich, Switzerland, 8Sorbonne Université, Hôpital Tenon, CRISTAL Laboratory, Paris, France, 9Sorbonne Université, GRC n°20, Groupe de Recherche Clinique sur la Lithiase Urinaire, Hôpital Tenon, F‐75020 Paris, France ; Progressive Endourological Association for Research and Leading Solutions (PEARLS), 10Department of Urology, University Hospital Zurich, University of Zurich, Zurich, Switzerland ; Young Academic Urologists (YAU), Endourology & Urolithiasis Working Group, Arnhem, The Netherlands ; Progressive Endourological Association for Research and Leading Solutions (PEARLS), 11Department of Urology, University Hospital Zurich, University of Zurich, Zurich, Switzerland ; Department of Urology, Tan Tock Seng Hospital Singapore, Singapore
Introduction: Recently, the novel pulsed thulium:yttrium‐aluminum‐garnet (p‐Tm:YAG) laser has been introduced for clinical use. Studies found in literature so far present promising results on p‐Tm:YAG ablation efficiency, although all were based on artificial stone models (eg. BegoStone) – not on human urinary stones. The aim of the present study was to evaluate the p‐Tm:YAG ablation efficiency with human urinary stones.
Methods: Two human urinary stone compositions were subjected to laser lithotripsy using a p‐Tm:YAG laser generator (Thulio® ,Dornier MedTech GmbH®, Wessling, Germany): calcium oxalate monohydrate (COM) and uric acid (UA). A cumulative energy of 200 J was applied to each stone using one of three laser settings: 0.1J x 100Hz, 0.4J x 25Hz, and 2.0J x 5Hz (average power 10W). After lithotripsy, stone samples were passed through a laboratory sieve with a 250 μm mesh size opening. Ablated stone mass was calculated from the difference in weight between the pre‐lithotripsy stone and post‐lithotripsy remnant fragments > 250 μm. Ablation efficiency was defined as ablated stone mass per unit of energy applied (mg/J).
Results: Mean ablation efficiency was 0.04, 0.06, 0.07 mg/J (COM) and 0.04, 0.05, 0.06 mg/J (UA) for each of the above laser settings, respectively. When considering laser settings, there was no significant difference in ablation efficiency between any of the settings for both COM and UA (ANOVA p = 0.08 and p = 0.11, respectively). Likewise, when considering stone composition within each laser setting, there was no significant difference in ablation efficiency between both composition types COM and UA (0.1J x 100Hz: p = 0.89, 0.4J x 25Hz: p = 0.22, 2.0J x 5Hz: p = 0.45). There was however a non‐significant pattern of better ablation efficiency for COM as compared to UA.
Conclusions: To the best of our knowledge, this is the first study showing ablation efficiency of the p‐ Tm:YAG laser on human urinary stones. The p‐Tm:YAG appears to ablate COM and UA stones equally well, with no significant differences between differing laser settings.
Funding: None
Blackout and Whiteout in Flexible Ureteroscopy: First Report on a Phenomenon Observed by PEARLS Members
Jia‐Lun Kwok10, Vincent De Coninck1, Hatem Kamkoum2, Felipe Pauchard3, Anil Shrestha4, Vineet Gauhar5, Jan Brachlow6, Florian Schmid7, Manuela Hunziker7, Cédric Poyet7, Olivier Traxer8, Daniel Eberli7, Etienne Xavier Keller9
1Department of Urology, AZ Klina, Brasschaat, Belgium ; Young Academic Urologists (YAU), Endourology & Urolithiasis Working Group, Arnhem, The Netherlands ; Progressive Endourological Association for Research and Leading Solutions (PEARLS), 2Hamad Medical Corporation, Doha, Qatar ; Progressive Endourological Association for Research and Leading Solutions (PEARLS), 3Urology Department, Hospital Naval Almirante Nef, Viña del Mar 2520000, Chile ; Progressive Endourological Association for Research and Leading Solutions (PEARLS), 4Department of Urology, National Academy of Medical Sciences, Bir Hospital and B&B Hospital, Gwarko Lalitpur, Nepal ; Progressive Endourological Association for Research and Leading Solutions (PEARLS), 5Department of Urology, Ng Teng Fong General Hospital, Singapore, Singapore; Progressive Endourological Association for Research and Leading Solutions (PEARLS)
6Zentrum für Urologie Winterthur, Winterthur, Switzerland ; Progressive Endourological Association for Research and Leading Solutions (PEARLS), 7Department of Urology, University Hospital Zurich, University of Zurich, Zurich, Switzerland, 8Sorbonne Université, GRC n°20, Groupe de Recherche Clinique sur la Lithiase Urinaire, Hôpital Tenon, F‐75020 Paris, France ; Progressive Endourological Association for Research and Leading Solutions (PEARLS), 9Department of Urology, University Hospital Zurich, University of Zurich, Zurich, Switzerland ; Young Academic Urologists (YAU), Endourology & Urolithiasis Working Group, Arnhem, The Netherlands ; Progressive Endourological Association for Research and Leading Solutions (PEARLS), 10Department of Urology, University Hospital Zurich, University of Zurich, Zurich, Switzerland ; Department of Urology, Tan Tock Seng Hospital Singapore, Singapore
Introduction: Imaging properties of flexible ureteroscopes have been extensively evaluated – mostly in air. No study to date evaluated the effects of varying brightness settings on image quality from ureteroscopes submerged in saline. The aim of the study was to evaluate blackout and whiteout occurrences in an in‐vitro kidney model.
Methods: We evaluated a series of contemporary flexible ureteroscopes including the Storz Flex‐Xc and Flex‐X2s, Olympus V3 and P7, Pusen 7.5F and 9.2F, as well as OTU Wiscope using a 3D printed pink in‐ vitro kidney model consisting of a closed spherical cavity with 20mm diameter submerged in saline. Endoscopic images were captured with the tip of the ureteroscope at 5mm,10mm and 20mm distance from the inner surface of the sphere – mimicking situations frequently found in clinical routine. The complete range of brightness settings and video capture modes were evaluated for each scope – where available. Images were analysed for their histogram on the distribution of brightness values (scale range 0 to 255). Blackout and whiteout were defined as median histogram ranges from 0 to 30 and 225 to 255, respectively (image on monitor too dark or too bright for the human eye, respectively).
Results: Blackout occurred with the P7, Pusen 7.5F and WiScope at all evaluated distance settings – mostly with lowest brightness settings. Whiteout occurred with the Flex‐X2s, V3 and P7 at 5mm and 10mm distance, as well as with the V3 and P7 for the 20mm distance setting – mostly with highest brightness settings. Scopes that had neither blackout nor whiteout over all brightness settings and video capture modes were the Flex‐Xc and Pusen 9.2F at 5mm and at 10mm, as well as the Flex‐Xc, Flex‐X2s and Pusen 9.2F at 20mm distance.
Conclusions: Blackout or whiteout of images is an undesirable property that was found for several scopes, possibly impacting diagnostic and therapeutic purposes during ureteroscopy. These observations form a guide for urologists which may impact their choice of instruments and corresponding settings.
Funding: None
A Prospective Randomized Single‐Center Comparison of Sp TFL Using 150‐μm and 200‐μm Laser Fibers and Ho:YAG for RIRS
Mark Taratkin9, Dmitry Enikeev1, Camilla Azilgareeva2, Vladislav Petov3, Andrey Morozov3, Diana Babaevskaya2, Dmitry Korolev Korolev3, Stanislav Ali3, Vincent De Coninck4, Gagik Akopyan13, Cesare Marco Scoffone5, Denis Chinenov3, Alexander Androsov2, Harun Fajkovic6, David Lifshitz7, Olivier Traxer8
1Institute for Urology and Reproductive Health, Sechenov First Moscow State Medical University (Sechenov University);., Department of Urology and Comprehensive Cancer Center, Medical University of Vienna, 2Sklifosovsky Institute for Clinical Medicine, Sechenov First Moscow State Medical University (Sechenov University), 3Institute for Urology and Reproductive Health, Sechenov First Moscow State Medical University (Sechenov University), 4Department of Urology, AZ Klina, 5Department of Urology, Cottolengo Hospital, 65Department of Urology, Medical University of Vienna, 78Sackler School of Medicine, Tel‐Aviv University, 8GRC #20 Lithiase Urinaire, Sorbonne University, Hôpital Tenon, 9Institute for Urology and
Reproductive Health, Sechenov First Moscow State Medical University (Sechenov University) Moscow, Russian Federation
Presented By: Mark Taratkin, M.D., urologist, researcher
Introduction: The aims of the study were: 1) to compare the SuperPulsed Thulium fiber laser (SP TFL) and the Holmium YAG (Ho:YAG) laser for retrograde intra renal surgery (RIRS) and 2) to compare the efficacy of using SP TFL laser fibers (LF) of different diameters (150 μm and 200 μm) for RIRS.
Methods: A prospective randomized single‐blinded trial was conducted. Patients with stones from 10 to 20 mm were randomly assigned RIRS in three groups: (1) SP TFL (NTO IRE‐Polus, Russia) with LF diameter of 150 μm; (2) SP TFL with 200 μm LF; and (3) Ho:YAG (Lumenis, USA) with 200‐μm LF. The procedures were performed by 5 surgeons experienced in laser lithotripsy (> 50 RIRS). Stone size, density, surgery length and laser on time (LOT) were measured. The stone‐free rates (SFR) were assessed with a low‐dose CT scan 90 days postoperatively.
Results: Between January 2020 and October 2021, 96 patients with kidney stones were randomized to undergo RIRS with SP TFL using a 150‐μm fiber (34 patients) and a 200‐μm fiber (32 patients) and RIRS with Ho:YAG (30 patients). The median LOT was minimal in the group of SP TFL with 200‐μm (9.2 (6.2 ‐ 14.6) min. Similar results were found in SP TFL with 150‐μm (11.4 (7.7 ‐ 14.9) min, p = 0.390) whilst a longer LOT was found in Ho:YAG (14.1 (10.8 ‐ 18.1)) min, p = 0.021). Similar findings were observed in total energy: SP TFL with 200‐μm (8.4 (5.8‐15.2) kJ; SP TFL using 150‐μm (10.8 (7.3‐13.5) kJ, p = 0.626) and in Ho:YAG (15.2 (11.1‐25.3) kJ, p = 0.005). The duration of the surgery was shortest in SP TFL with 150‐μm (60.2 ± 20.1 min) which was shorter than that of SP TFL with 200‐μm (74.4 ± 26.3 min, p = 0.044). Both durations were shorter than that of Ho:YAG (90.0 ± 31.8 min, p = 0.006).The SFR at 3 months was 100% (no fragments larger than 2 mm were observed). The postoperative complication rate was low, with grade I‐II Clavien‐Dindo complications present in 2 (2.1%) patients. No differences were found between the groups.
Conclusions: Irrespective of the stone type and density, RIRS with SP TFL laser is a safe and efficient procedure. Whilst the introduction of smaller fibers may have the potential to reduce the duration of surgery, SP TFL results in a reduction in the LOT and total energy for stone ablation in RIRS compared with Ho:YAG. The stone free rate and complication rates were comparable between the lasers.
Funding: the study is deprived of funding
Clinical Efficiency of Thulium Fiber Laser for RIRS in Large Volume Stones (15‐25mm) – A Multicentric Experience
Introduction: The Thulium fiber laser (TFL) is a promising new tool in the field of endoscopic laser lithotripsy, but is it efficacious in managing large stones using flexible ureteroscopy remains to be seen. Our objective was to analyse the clinical efficiency of TFL in large volume stones during retrograde intrarenal surgery.
Methods: Patients with large volume renal stones (> 1000mm3) and size of 15‐25mm, operated at two different centres, from May 2020 to April 2021, were enrolled.RIRS was performed using 60W Superpulse thulium fiber laserTM (IPG Photonics, Russia).Demographic data, stone parameters, lasing time, total operating time were recorded, laser efficacy (J/mm3) and ablation speed(mm3/sec) were calculated. Complications were assessed using Clavien Dindo grading. NCCT KUB was done at 1 month post operatively to calculate stone free rate.
Results: A total of 76 patients were included and analysed in the study. Mean stone volume was 1860.79 ± 1172.61 (1169.27‐2193.25) mm3 Mean stone density was 1099.80 ± 313.65 (875.00‐1317.00) HU . Mean laser time was 537.79 ± 689.89 (21.00‐1080.00) sec, mean total operating time was 43.38 ± 12.96 (35.00‐51.25) min, Mean laser efficacy was 20.30 ± 15.5 (8.88‐25.57) J/mm3 Mean ablation speed was 1.32 ± 0.7 (0.82‐1.64) mm3/sec A strong positive correlation between stone volume and ablation speed (r = 0.659, p = 0.000), A moderate negative correlation between volume and laser efficacy (J/mm3) (r = ‐0.392, p = 0.000). With increasing volume of the stone, J/mm3 decreased significantly and ablation speed increased significantly (p < 0.001). Complications occurred in 21.05% (16/76) patients, most of which were Clavien grades 1‐2. Overall Stone free rate is 96.05%.
Conclusions: With an increase is stone volume, laser efficiency increases as less energy is required to ablate every mm3 of stone.
Funding: None
Ureteral Stents: What Your Eyes Can't See !
Stessy Kutchukian6, Marie Chicaud1, Catalina Solano2, Luigi Candela3, Mariela Corrales2, Steeve Doizi4, Dominique Bazin5, Olivier Traxer2, Frederic Panthier2
1CHU de Limoges, 2Hôpital de Tenon, 3Institut de San Raffaele, 4Hopital de Tenon, 5Université de Paris Saclay, 6CHU de Poitiers
Presented By: Stessy Kutchukian, résidant
Introduction: Tolerance and encrustation represent two main complications that occur with ureteral stents (US) in endourology. Various compositions (silicone, polyurethane or metallic alloy) can be used for ureteral stent fabrication. Smoother materials are supposed to limit US encrustation. This in vitro study aimed to characterize US surfaces before utilization.
Methods: Five ureteral stent models were included. All stents were unused and with various composition or manufacture : two double loop ureteral stent (Coloplast ImaJin, Boston Scientific TriaSoft), two tumor stent (Coloplast Vortek Tumor Stent, Bard Urosoft Tumor Stent) and one ureteral stent pigtail US (Rocamed JFil). All EUs were made of polyurethane except Coloplast ImaJin in silicone. Four parts of the stent were specifically analyzed underhigh‐resolution scanning electron microscopy (HR‐SEM): core surface, lateral orifice, loop and marking surface. Imperfection was defined as an irregularity of 10μm or more. US were compared on these criteria for all parts.
Results: Figure 1 and 2 presents the HR‐SEM constatations. All tested US presented imperfections regardless of stent type and composition. There was imperfection of more than 10mm and was mainly positioned on stent's loop and stent's lateral orifice. On the core or marking surface we noticed mainly rough surface but no imperfections more than 10mm except for Coloplast ImaJin. Sometimes there was additional material like on stent's loop for Rocamed JFil and Coloplast ImaJin.
Conclusions: This study confirmed that US was not perfectly smooth even before utilization. We notice the rough surface regardless of the type of stent. These imperfections could have an impact on encrustation. It would be interesting to know the manufacturing process to deepen this observation.
Funding: None
Steerable Ureteroscopic Renal Evacuation Device for Treatment of Large Volume Kidney Stones
Gregory Mullen1, Arun Rai1, Charan Mohan1, Luke Griffiths1, Jared Winoker1, Tareq Aro1, David Hoenig1, Zeph Okeke1
1Smith Institute for Urology Northwell Health
Presented By: Gregory Mullen, MD
Introduction: The goal of surgical treatment of kidney stones is to maximize stone free rate (SFR) while minimizing morbidity. Patients with large volume kidney stone disease and absolute or relative contraindications to percutaneous nephrolithotomy (PCNL) have limited treatment options. We report our experience using a novel steerable ureteroscopic renal evacuation (SURE) device that suctions stone fragments during ureterorenoscopy (URS) with laser lithotripsy.
Methods: A retrospective review of all cases using SURE in our health system was performed. Patient demographics, stone characteristics, operative demographics, and outcomes were recorded.
Results: Forty‐three cases of SURE were performed on thirty‐nine patients. Average preoperative stone volume was 1158 mm3. Twenty‐six patients had postoperative imaging performed. Ultrasound (US) was performed on thirteen patients and CT scan was performed on thirteen patients. Of patients who received a CT scan postoperatively, absolute SFR (no stone fragments) was 53.8% and overall SFR (stone fragments up to 4 mm) was 84.6%. There were no intraoperative complications observed. Postoperative sepsis occurred in 5.1% of patients.
Conclusions: SURE is effective for removal of large volume kidney stones with high SFR and low morbidity.
Funding: None
WITHDRAWN
Suction through Ureteroscope Channel of Kidney‐Stone Dust for Ultimate Stone Treatment (SUCKDUST)
Justin Achua2, Eric Ballon‐Landa1, Brett Weisen2, Granville Lloyd1, Mark Sawyer1
1Rocky Mountain Regional Veterans Administration Medical Center, 2University of Colorado Anschutz Medical Campus
Presented By: Justin Achua, MD
Introduction: Since our initial reported series describing ultra‐low‐dose (ULD) intraoperative CT (ICT) during treatment of large stones(n = 23), including ureteroscopy (URS) cases, we developed a novel and simple retrograde suction technique to manage poor visualization during dusting. This technique also has improved ICT imaging and allowed rapid decrease in intra‐renal pressure (IRP)using the LithoVue Elite (LVE) pressure monitoring scope(Boston Scientific).
Methods: “Suction through Ureteroscope Channel of Kidney‐stone Dust for Ultimate Stone Treatment” (SUCKDUST) technique uses suction tubing advanced through a 10 mL Luer‐lock syringe. The syringe is attached to the side port of a Urolokirrigation device with external suction set to 200‐250mmHg.The scope is withdrawn to the renal pelvis; and the valve is opened (0.5‐2s) to suction debris. The valve is closed before the collecting system collapses to avoid potential trauma. The technique was recently modified(m‐SUCKDUST) for finely controlled suction appropriate for acalyx or near the urothelium, allowing variable strength and immediate cessation of suction.
Results: SUCKDUST technique has been used in 11 URS cases, including 9/11 (82%) of cases using the LVE(m‐SUCKDUST, n = 4). With IRP ≥40 mmHg, SUCKDUST allowed pressures to immediately drop (< 10 mmHg)in absence of channel instruments. All three cases with repeated ULD ICT had substantial improvement in residual dust following SUCKDUST, including complete resolution of a 2.4 cm diameter dust collection in one case.
Conclusions: Our simple retrograde suction technique allows for clearance of dust and rapid IRP reduction. Besides improving ICT interpretations, SUCKDUST may be particularly beneficial for patients with infected stones or who are anticoagulated when measured IRP exceeds acceptable thresholds. SUCKDUST could also have potential to improve stone‐free rates.
Funding: None
in‐Vitro Comparison of a Novel Recessed‐Tip vs Standard Laser Fiber for Stone Disintegration Using the Thulium Fiber Laser (TFL)
Fabrice Henry1, Juan Sebastian Rodriguez Alvarez1, Sri Sivalingam1
1Cleveland Clinic Glickman Urological Institute
Presented By: Fabrice Henry, MD
Introduction: A novel recessed tip (RT) laser fiber (Excalibur™) has been developed for use with ureteroscopy and laser lithotripsy, theorized to increase fragmentation efficacy and reduce fiber burn‐back. Using a bench‐top model with TFL, we compared the dusting efficiency and fiber durability of the novel RT vs standard bare tip (BT) fibers, using two combinations of energy and frequency settings.
Methods: Canine stones of similar weight and composition (100% CaOx monohydrate) were placed in a ureteroscopy model, using a saline‐filled clear tube set at a 40 degree angle, with a mesh plug (1 mm aperture) at the end of the tube (Fig 1 c&d). The Quanta FiberDust SuperPulsed TFL was used with BT fibers (n = 6) and RT fibers (n = 6), inserted through an Olympus P6 ureteroscope. A single urologist dusted each stone until it was completely disintegrated, or up to a 5 minute cut‐off time. Dusting was performed at 0.3 J and 100 Hz (3 trials each, with BT and RT fibers), and pop‐dusting at 0.6 J and 30 Hz, again for 3 trials with each fiber type. Any remaining fragments after five minutes were removed and weighed. Dusting time and efficacy, visible “sparking”, and fiber burn‐back were assessed after stone treatment.
Results: Complete stone treatment within 5 minutes was accomplished with all six BT fibers with an average time of 3.77 min. One of the RT fibers was excluded from analysis due to a manufacturing defect. Only 2 of 5 trials with RT fibers succeeded in completely dusting the stone in a 5 minute period, with an average residual stone volume of 30.8% (15.5% dusting, 52.1% pop dusting). The BT fibers had significantly increased burn‐ back (average 0.56 mm) compared to the RT fibers (0.08 mm) (p = 0.05).
Conclusions: RT fibers result in less burn‐back compared to BT fibers but trended towards less efficient dusting and pop‐dusting. The theoretical benefit of a recessed tip fiber was not evidenced in this study, indicating further research is required to elucidate the potential utility of RT fibers.
Funding: None
Current Practice Patterns of Laser Utilization in Treatment of Urolithiasis
Fabrice Henry1, Jianbo Li1, Jorge Gutierrez1, Sri Sivalingam1
1Cleveland Clinic Glickman Urological Institute
Presented By: Fabrice Henry, MD
Introduction: There has been an influx of novel laser technologies for the treatment of urolithiasis. We sought to evaluate the current utilization patterns of the various laser modalities in the surgical management of stones among Endourologists.
Methods: An online survey was distributed to Endourological Society members using RedCAP. Questions included demographics, laser modality, indication‐specific laser settings, laser acquisition models, and surgeon knowledge. Statistical analysis was done using R statistical software.
Results: 183 responses were received after two email blasts to members of the Endourological Society. Most respondents were in the United States (33.3%), followed by Canada (10.9%). Most respondents had been in practice at least > 10 years (63.9%), were academic urologists (62.8%) and had fellowship training in Endourology (65.6%). The most frequently used laser was high‐power holmium (HPH, 71.6%), followed by low‐power holmium (LPH, 44.4%) and thulium fiber laser (TFL, 43.8%). Most laser units were purchased on capital, with smaller percentages acquired through placement or rental agreements. There was no significant difference in acquisition models between laser types. TFL was used significantly more often by urologists in practice less than 10 years compared to those in practice 20 years or more (53% vs 28.1%, p = 0.009), by those in an academic hospitals compared to private practices (52.2% vs 13.2%, p < 0.001), and by those with Endourology fellowship training (47.5% vs 27.0%, p = 0.011).Although most surgeons are confident in their ability to select the best laser setting (44.2% often, 40.7% always), the majority change laser settings during a case (52.2% often, 16.8% always). Most surgeons are interested in further education on laser usage (68.5%).
Conclusions: Despite being relatively new, TFL is being used as commonly as LPH lasers indicating rapid adoption. Notably, there is a desire for further learning opportunities regarding laser use.
Funding: None
Preset Parameters in Thulium Fiber Laser: is it Useful?
Alba Sierra1
1Hospital Clinic
Presented By: Alba Sierra, MD, FEBU
Introduction: Thulium Fiber Laser technology has made are markable entry among the treatment of urological diseases, with much expectation from outstanding premarket data. However, as shown through variable proposals from users, reaching most efficient settings may remain challenging, specifically for beginners. To manage a good compromise between efficacy and safety, engineers and experts have developed specific graphical user interface (GUI) with embedded pre‐settings. The aim of the study was to test the easiness of use of the Coloplast TFL DriveGUI in different urological area. For stone treatment, this interface allowstargeting the type of stone, its location, the expected laser effect and proposes a range of settings to manage both efficacy and safety.
Methods: 5 seniors and 4 junior (< 80 URS/year) urologist surgeons were asked to perform a multiple‐ steps cenario on lithiasis treatment by using the pre‐settings of the Coloplast TFL Drive and then repeat the scenariounder the free mode. The same protocol was then followed with another multiple‐steps cenario on BPH treatment. The number of clicks and time needed to reach the targeted steps were recorded for each scenario, mode, and participant. At the end, aquestionnaire on the perception of the interface and scrolling pedal management was completed by each participant.
Results: In total, the number of clicks in pre‐settings modeis decreased by 61% (lithiasis scenario;p = 0.002)or 71% (BPH; p = 0.001)compared to free mode.As expected, the time necessary to perform the scenario in pre‐settingsmode is decreased by 75% (lithiasis scenario;p = 0.004)or 71% (BPH; p = 0.001)compared to the free mode.100% ofparticipants evaluate the GUI as intuitive and easy to use.In terms of learning curve, 55% of surgeons were able to manage the interface as quickly as a trained user on the first attempt.The right pedalaimed to scroll from a laser effect to another one was as well considered as easy or very easy to use. 66% of participants think that pre‐settings will increase their efficacy and 89% would use the pre‐settings regularly(for 50 to 100% of their patients).88% of the users feel more confident with the pre‐settings.No differences between senior and junior were shown.
Conclusions: A Graphical user interface with pre‐settings reduces the time to set‐up the parameters of the laser. Coloplast TFL DriveGUI is intuitive in its use, easy to navigate, allowing quick selection of right parameters. It inspires confidence regarding safety and expectation of increased efficacy compared to laser with no pre‐settings mode.
Outcomes of Same Sitting Bilateral Flexible Ureteroscopy for Renal Stones in a Real‐World Experience in 1250 Patients
Vineet Gauhar22, Daniele Castellani1, Olivier Traxer2, Deepak Ragoori3, Nariman Gadzhiev4, Yiloren Tanidir5, Takaaki Inoue6, Esteban Emiliani7, Saeed Bin Hamri8, Mohamed Amine Lakmichi9, Chandra Mohan Vaddi10, Chin Tiong Heng11, Boyke Soebhali12, Sumit More13, Vikram Sridharan14, Mehmet Ilker Gökce15, Azimdjon N. Tursunkulov16, Arvind Ganpule17, Giacomo Maria Pirola18, Cemil Aydin19, Ben Hall Chew20, Bhaskar K Somani21
1Urology Unit, Azienda Ospedaliero‐Universitaria delle Marche, Università Politecnica delle Marche,, 2Department of Urology AP‐HP, Sorbonne University, Tenon Hospital,, 3Department of Urology, Asian Institute of Nephrology & Urology, 4Department of Urology, Saint‐Petersburg State University Hospital,, 5Department of Urology, School of Medicine, Marmara University, 6Department of Urology, Hara Genitourinary Private Hospital, Kobe University,, 7Department of Urology, Fundacion Puigvert, Autónomos University of Barcelona,, 8Division of Urology, Department of Surgery, Ministry of the National Guard Health Affairs, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center,, 9Department of Urology, University Hospital Mohammed the VIth of Marrakesh,, 10Department of Urology, Preeti Urology and Kidney Hospital, 11Department of Urology, Ng Teng Fong General Hospital,, 12Department of Urology, Abdul Wahab Sjahranie Hospital, Medical Faculty Mulawarman University,, 13Department of Urology, Sarvodaya Hospital and Research Centre,, 14Department of Urology, Sree Paduka Speciality Hospital, 15Department of Urology, Ankara University, School of Medicine,, 16Urology Division, AkfaMedline Hospital,, 17Department of Urology, Muļjibhai Patel Urological Hospital,, 18Urology Department, San Giuseppe Hospital, IRCCS Multimedica, Multimedica Group, 19Department of Urology, Hitit University, School of Medicine,, 20Department of Urology, University of British Columbia,, 21Department of Urology, University Hospitals Southampton, NHS Trust,, 22Ng Teng Fong General Hospital, NUHS
Presented By: Vineet Gauhar, MCh, Dip URO
Introduction: Bilateral kidney stones are commonly treated as staged procedures due to concerns of sepsis and possible inadvertent bilateral kidney and ureter damage as well as inability to completely clear all stones by retrograde intra renal surgery(RIRS). However having acquired sufficient experience endourologists perform single stage same sitting bilateral RIRS(SSB‐RIRS) with potential advantages of saving another operative and anesthesia intervention for patients. We analysed the outcomes, practice preferences and limitations of this surgery in a global real world setting.
Methods: Data from adults who underwent bilateral RIRS in 21centers were retrospectively reviewed (January 2015‐June 2022).Inclusion criteria:unilateral/bilateral symptomatic bilateral stone(s) of any size/location in both kidneys, bilateral stones on follow‐up with symptom/stone progression. Stone‐free rate (SFR) was defines as absence of fragments > 3 mm at 3 months. Outcome Measurements and Statistical Analysis Continuous variables are presented as median and (25th‐75th percentiles). Multivariable logistic regression analysis was performed to evaluate independent predictors of sepsis and bilateral SFR.
Results: Please see tables:1250 patients were included. Median age was 48.0 (36‐61)years. 58.2% of patients were pre‐stented. Median stone diameter was 10 mm on bothsides. Multiple stones were present in 45.3% and 47.9% of left and right kidneys.Surgery was stopped in 6.8% of cases. Median surgical time was 75.0 (55‐90) minutes.Complications were transient fever (10.7%), fever/infection needing prolonged stay (5.5%), sepsis (2%), blood transfusion (1.3%). Bilateral and unilateral SFR was 73.0%and 17.4%, respectively. Female (OR 2.97 95% CI 1.18‐7.49,p = 0.02), no antibiotic prophylaxis (OR 5.99 95% CI 2.28‐ 15.73,p < 0.001), kidney anomalies (OR 5.91 95% CI1.96‐17.94,p < 0.001), surgical time ≥100 minutes (OR 2.86 95% CI 1.12‐7.31,p = 0.03) were factors associated with sepsis. Female (OR 1.88 95% CI 1.35‐2.62, p < 0.001), bilateral pre‐stenting (OR 2.16 95% CI 1.16‐7.66, p = 0.04), use of high‐power HL (OR1.63 95% CI 1.14‐2.34, p < 0.01), TFL (OR 2.50 95% CI 1.32‐4.74, p < 0.01) were predictors of bilateral SFR.
Conclusions: SSB‐RIRS is an effective treatment for patients with bilateralstones with a short postoperative stay and an acceptable rate of complications. Pre‐stenting, the use of high‐power HL and TFL, and avoiding a large stone burden are key factors to achieve a high bilateralSFR. We recommend that using prophylactic antibiotics, limiting operative time to100 minutes, and using a UAS will help to mitigate the risk of sepsis in SSB‐RIRS.Maximizing hospital and surgeon resources, avoiding duplicate use of accessories, single operating costandimportantly one anesthesia are definite winners for advocating this procedure.
Funding: NIL
Colonization of Carbapenemase‐Producing Enterobacteriales (CPE) in the Context of An Outbreak – Impact on Morbidity after Ureteroscopy (URS) for Urinary Stones
Ana Sofia Araújo1, Ricardo Rodrigues1, Catarina Tinoco1, Andreia Cardoso1, Mariana Capinha1, Luís Pinto1, Vera Marques1, Carlos Oliveira1, Pedro Coelho2, Paulo Mota1
1Hospital de Braga, 2Escola de Medicina da Universidade do Minho
Presented By: Ana Sofia Araújo, MD
Introduction: URS is one of the most used treatments for urinary stones with 9‐25% post‐procedure overall complications, including 15% urinary tract infections (UTI) and 5% urosepsis. In 2022, an outbreak of CPE was detected with 40‐50% morbidity due to limited treatment options in this multidrug‐resistant set.So, we aim to evaluate the CPE colonization in urine culture (UC) and rectal swabs (RS) before URS for urinary stones and its impact on patient morbidity.
Methods: We conducted a retrospective observational single‐center study including all patients who underwent URS for urinary stones in 2022. Statistical analysis was done using IBM®SPSS®, version 27.0.
Results: A total of 381 patients were enrolled in this study, with the most prevalent comorbidity being diabetes mellitus (20.2%). Most patients didn't have a previous indwelling urinary catheter (59.9%) and the prevalence of antibiotic treatment in the last 6 months was 50.7%, being cephalosporines the most used (44.4%). The prevalence of colonization by any bacteria in UC was 39.1% and the prevalence of RS and UC colonization by CPE was 10.5% and 16.0%, respectively. Despite that, antibiotic prophylaxis beyond perioperative was low (15.2%), and most commonly two days (6.6%). Flexible URS was the most common (60.6%) with a single stone (65.4%) and a median operative time of 24.0 minutes. 99.2% of patients had a postoperative catheter (55.1% double‐J; 42.8% mono‐J). Patients with CPE colonization on RS and UC were associated with 37.9%UTI with hospitalization (p < 0.001,ri = 3.4), 6.9 % of bacteremia (p = 0.011,ri = 4.7), and 41.4% of at least one early complication (p < 0.001,ri = 3.4). Even among patients with CPE colonization on RS (but not in UC), 45.5% (ri = 2.8) had UTI with hospitalization, and 45.5% (ri = 2.4)presented with at least one complication. These results remained statistically significant even when adjusted for the previously cited confounders. Otherwise, the prevalence of UTI with hospitalization and having atleast one early complication were significantly lower in patients with negative RS and UC (6.6%, ri = ‐3.0; 9.6% ri = ‐2.5, respectively).
Conclusions: In patients who aren't colonized by CPE in either RS or UC, the risk of infectious complications after surgery or having at least one complication is similar to previous literature.However, RS colonization by CPE significantly increases these rates, highlighting the urgency of stopping this outbreak and preventing antibiotic resistance.
Funding: None
Particle Size Distribution of Urinary Stones after Ho:YAG Laser Ablation
Bingyuan Yang2, Aditi Ray1, James Zhang1, Ben Turney2
1Boston Scientific Corporation, 2University of Oxford
Presented By: Bingyuan Yang, MB BChir
Introduction: Laser lithotripsy destroys urinary stones by ablating them into dust and fine particles. Extremely small particles may remain in suspension and are presumed to wash out in the urine, while larger particles may need to be extracted intraoperatively. The distribution of the resulting stone fragments therefore has important clinical implications. We report the size distribution of calcium oxalate and struvite stones after ablation with a Ho:YAG laser.
Methods: Canine calcium oxalate (CO) and struvite stones were soaked in water for 1 hour then ablated using a Ho:YAG laser (Lumenis Pulse™ 120h, Boston Scientific, USA) using 1J 10Hz short pulse settings and a 230um fibre. Ablation was done by hand in a dish by a “painting” motion across the surface of the stone. The stone fragments were collected and separated by size by wet sieving using 2000um, 1000um, 500um, 250um, 125um and 63um sieve sizes. The solid component of each fraction was captured using 11um filter paper, dried for 24 hours and the dry weight recorded. 3 samples were used for each stone type.
Results: Particle size has a bimodal distribution, with peaks at the smallest and largest particle sizes. The distribution is similar for both stone types, with CO having slightly larger particles on average. The proportion of particles > 500um was 18.5% for struvite and 21.0% for CO.56% of starting stone mass was recovered for struvite, compared to 90% for CO. This suggests that struvite produces more ultra‐fine particles that are too small to be collected by 11um filter paper.
Conclusions: The size of stone particles after laser ablation follows a bimodal distribution with peaks at < 63um and 500‐2000um. This suggests that there is more than one mechanism involved in stone ablation, with one generating fine dust < 250um and one generating larger particles > 250um.About 20% of stone particles are > 500um, which may not wash out of the kidney spontaneously and may contribute to lower stone‐free rates and higher rates of recurrence. These particles are too small to ablate further by laser, and their large number and relatively small size makes basket extraction impractical or impossible. Thus, techniques or technologies are required to remove these particles completely to achieve stone‐free status.Disclaimer: Bench test results may not necessarily be indicative of clinical performance.
Funding: Boston Scientific Corporation: research grant
Understanding the Role of Ureteral Access Sheath in Preventing Acute Kidney Injury in Patients Treated with Ureteroscopy and Ho:YAG Laser for Urinary Stone
Luigi Candela4, Luca Villa1, Margherita Fantin2, Catalina Solano3, Mariela Corrales3, Marie Chicaud3, Stessy Kutchukian3, Frederic Panthier3, Steeve Doizi3, Alessia D'Arma2, Olivier Traxer3, Eugenio Ventimiglia2, Francesco Montorsi2, Andrea Salonia2
1Università Vita‐ Salute San Raffaele, Milan, Italy, 2Università Vita‐Salute San Raffaele, Milan, Italy, 3Urology Unit, Tenon Hospital, Paris, France, 4Division of Experimental Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy. Università Vita‐Salute San Raffaele, Milan, Italy
Presented By: Luigi Candela, MD
Introduction: The use of ureteral access sheath (UAS) improves the irrigation flow during ureteroscopy (URS), thus limiting the increase of intrarenal pressure and temperature. Elevated intrarenal pressure and temperature may cause renal parenchymal impairment. We aimed at evaluating the relationship between the UAS use and the occurrence of post‐operative acute kidney injury (AKI) in stone patients treated with URS.
Methods: Data from 584 patients treated with URS and Ho:YAG laser lithotripsy for ureteral/renal stone from February 2015 to October 2022 at a single academic referral centre were analysed. UAS (10/12 Fr) placement was attempted during intrarenal surgery. Post‐operative AKI was defined as an increasing of serum creatinine level > 0.3mg/dL within post‐operative day two according to the Kidney Disease Improving Global Outcomes (KDIGO) criteria.Univariable (UVA) and multivariable (MVA) logistic regression analyses tested the association of patients' characteristics (age at surgery, CCI score, renal function, stone diameter, hydronephrosis, stone location, pre‐stenting) and operative data (use of UAS, operative time) with the rate of post‐operative AKI.
Results: Complete data including pre‐ and post‐operative serum creatinine levels of 150 URS procedures were available. Median (IQR) age was 58 (48‐68) years, and median (IQR) operative time was 60 (45‐90) minutes. Eighty‐four (58%) patients were male and 20 (13%) patients had a CCI ≥1. Median (IQR) preoperative serum creatinine level and estimated Glomerular Filtration Rate (eGFR) were 1 (0.85‐1.25) mg/dL and 74 (54‐88) mL/min, respectively. Overall, 44 (29%) patients had preoperative chronic kidney disease stage ≥3 (i.e. eGFR < 60 mL/min). Stone was located in kidney, ureter or both in 46 (31%), 74 (49%) and 30 (20%) patients, respectively. UAS was used in 77 (51%) procedures. Overall, post URS AKI occurred in 12 (8%) patients; of those, 6 procedures were carried out with and 6 without UAS. At UVA and MVA performing URS without UAS was not associated with an increased risk of AKI (OR = 1.97;95%CI = 0.43‐8.97;p = 0.38). Interestingly, age at surgery and operative time resulted independent predictors of post‐operative AKI (OR = 1.07;95%CI = 1.00‐1.13;p = 0.03 and OR = 1.02;95%CI = 1.00‐ 1.03;p = 0.02, respectively).
Conclusions: AKI is a not neglectable postoperative complication in patients treated with URS.The use of UAS does not influence the onset of post URS AKI. However, older age and longer URS procedure are associated with a higher risk of developing post‐operative AKI. Current findings should be considered for the peri‐operative management of stone patients treated with URS.
Funding: none
Stone Factors Influencing Laser Energy and Time of Thulium Fiber Laser: A Comprehensive Analysis
Bristol Whiles4, Wilson Molina1, Willian Ito1, Nicholas Choi2, Daniel Reich3, Kunal Hanchate3, Mihaela Sardiu1, Holly Smith1, David Duchene1, Vincent Bird4
1The University of Kansas Health System, 2University of Kansas School of Medicine, 3University of Florida College of Medicine, 4University of Florida
Presented By: Crystal Valadon, MD, MBA
Introduction: Thulium fiber laser (TFL) is widely used in ureteroscopic laser lithotripsy. Computerized tomography (CT) scan is the preferred pre‐operative imaging for nephrolithiasis due to its precise stone characteristics. This study examines the relationship between preoperative stone features and cumulative laser energy and time.
Methods: A retrospective multicenter study (01‐2020 to 04‐2023) included stone‐free patients after ureteroscopy using TFL (Soltive™ 60W). Exclusion criteria: pregnancy, age < 18, anatomical abnormalities, additional procedures, and missing stone or laser data. Stone measurements were conducted by an experienced urologist at each institution.
Results: The study included 200 patients. Table 1 displays patient, stone, and peri‐operative characteristics. Laser energy showed significant positive correlations with stone size (r = 0.59, p < .001), volume (r = 0.73, p < .001), density (r = 0.44, p < .001), location (r = 0.40, p < .001), and ureteroscopic technique (r = 0.14, p = 0.04). Similarly, these factors significantly impacted laser time, except for ureteroscopic technique (r = 0.57, p < .001; r = 0.70, p < .001; r = 0.38, p < .001; r = 0.29, p < .001, respectively). Stone composition or fiber size had no significant correlation with energy (r = ‐0.05, p = 0.45; r = ‐0.04, p = 0.55) or time (r = ‐0.07, p = 0.31; r = 0.04, p = 0.49). In univariate and multivariate analyses, stone volume, density, and location were significant determinants of laser energy. Stone volume remained significant for laser time in the multivariate analysis (Table 2). Median ablation efficiency and speed were 14,553 J/cm3and 0.98 mm3/s, respectively, with no signification variation based on stone composition (p = 0.52 and p = 0.68).
Conclusions: During TFL‐assisted ureteroscopy for stone disease, increased laser energy and time are associated with larger stone dimensions, increased density, and renal location. Stone composition and fiber size do not significantly affect cumulative laser energy or time requirements.
Funding: N/A
Comparing Outcomes of Thulium Fiber Laser Versus High‐Power Holmium:YAG Laser Lithotripsy in Pediatric Patients Managed with RIRS for Kidney Stones: A Multicenter Retrospective Study
Luigi Candela11, Daniele Castellani1, Catalina Solano2, Mariela Corrales2, Marie Chicaud2, Stessy Kutchukian2, Frederic Panthier2, Steeve Doizi2, Jeremy Yuen‐Chun Teoh3, Yiloren Tanidir4, Khi Yung Fong5, Chandramohan Vaddi6, Mriganka Mani Sinha7, Deepak Ragoori8, Bhaskar Kumar Soman7, Francesco Montorsi9, Andrea Salonia9, Olivier Traxer2, Vineet Gauhar10
1Urology Unit, Azienda ospedaliero‐Universitaria delle Marche, Università Politecnica delle Marche, Ancona, Italy, 2Urology Unit, Tenon Hospital, Paris, France, 3S.H. Ho Urology Centre, The Chinese University of Hong Kong, Hong Kong, China, 4Marmara University Istanbul Pendik Education and Research Hospital, Urology, Istanbul, Turkey, 5National University Hospital, Singapore, 6Preeti Urology and Kidney Hospital, Telangana, India, 7University Hospital Southampton NHS Foundation Trust, Southampton, UK, 8Asian Institute of NephroUrology; Hyderabad, 9Università Vita‐Salute San Raffaele, Milan, Italy, 10Division of Urology, Ng Teng Fong General Hospital, National University Health System, Singapore, 11Division of Experimental Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy. Università Vita‐ Salute San Raffaele, Milan, Italy
Presented By: Luigi Candela, MD
Introduction: Retrograde intrarenal surgery (RIRS) with laser lithotripsy is increasingly used as an alternative to shock wave lithotripsy for pediatric patients with upper urinary tract stones. Holmium:YAG (Ho:YAG) laser represents the gold standard for RIRS lithotripsy due to its proven efficacy and safety in pediatric patients. Recently, Thulium Fiber Laser (TFL) has been introduced in clinical practice for stone lithotripsy as a promising alternative to Ho:YAG laser.We sought to evaluate TFL safety and efficacy compared to High‐power (HP) Ho:YAG laser in pediatric patients who have undergone RIRS for kidney stones.
Methods: We retrospectively reviewed data from pediatric patients who underwent RIRS for kidney stones < 2cm in greatest diameter between 2018 and 2020 in 4 Urology Departments. Outcomes of interest were: i) safety of the procedures, assessed through intra‐ and postoperative complications, and ii) efficacy of the technique assessed through surgical operative time (OT), stone‐free rate and reintervention rate. Complete perioperative data were collected.Complications were assessed 4 to 6 weeks post‐operatively. Stone‐free (SF) was defined as the absence of visible fragments or as the presence of a single residual fragment ≤2 mm at 3 months post‐operative imaging. Student's T‐test for continuous variables, and Chi‐square and Fisher's exact test for categorical variables were used to compare outcomes between patients treated with HP Ho:YAG (Group 1) and TFL (Group 2). Univariate (UVA) and multivariate (MVA) logistic regression analyses were performed to predict SF‐associated factors.
Results: Data from 126 pediatric patients were analyzed, 97 in group 1 and 29 in group 2.Mean (SD) age was 10 (4.7) and 7 (4.73) years in group 1 and 2 (p = 0.004), respectively. Mean (SD) largest stone diameter was 9.7 (4.23) vs 10.97 (3.69) mm in group 1 and 2, respectively (p = 0.325).Rate of elevated serum creatinine, positive urine culture, ureteral pre‐stenting, preoperative administration of tamsulosin and antibiotics, normal kidney anatomy, and number and location of stones were comparable between group 1 and 2 (all p > 0.05).All the procedures were successfully performed and no intraoperative complications were reported in both groups.No major postoperative complication occurred. SF rate was 81.4% and 89.7% (p = 0.45) and reintervention rate was 14.4% and 6.89% (p = 0.046) in group 1 and 2, respectively. At UVA and MVA, the type of laser did not influence SF rate. However, pre‐stenting and single stones were positively associated with SR rate.
Conclusions: Both laser technologies are safe and effective and showed similar SF rates. TFL showed less OT and lower re‐intervention rate.These results provide the opportunity to urologists to use either TFL or Ho:YAG laser during RIRS in pediatric patients since both technologies demonstrated satisfactory outcomes.Further prospective comparative studies are needed to corroborate our findings.
Funding: none
Optimizing Long‐Term Renal Function Preservation in Cystinuric Patients through Ureteroscopy: Results from a Tertiary Care Referral Center.
Luigi Candela4, Eugenio Ventimiglia1, Marie Chicaud2, Catalina Solano2, Stessy Kutchukian2, Mariela Corrales2, Luca Villa1, Frederic Panthier2, Steeve Doizi2, Emmanuel Letavernier3, Jean Philippe Haymann3, Michel Daudon3, Francesco Montorsi1, Salonia Andrea1, Olivier Traxer2
1Università Vita‐Salute San Raffaele, Milan, Italy, 2Urology Unit, Tenon Hospital, Paris, France, 3Nephrology Unit, Tenon Hospital, Paris, France, 4Division of Experimental Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy. Università Vita‐Salute San Raffaele, Milan, Italy
Presented By: Luigi Candela, MD
Introduction: Patients suffering from cystinuria experience high stone recurrence rate which results in a considerable number of surgical interventions during lifetime. These patients are at higher risk of developing early chronic kidney disease compared to other urinary stone formers and general population. To improve renal prognosis, non‐invasive urological interventions should be preferred to manage stone recurrences.We sought to evaluate long‐term renal function modification of cystinuric patients exclusively treated with retrograde ureteroscopy (URS) and Holmium:YAG or Thulium fiber laser lithotripsy.
Methods: Data from 112 cystinuric patients treated for ureteral/renal stones from 2001 to 2021 at a single academic referral centre were retrospectively analysed. Stone analysis confirmed the diagnosis of cystinuria. Estimated Glomerular Filtration Rate (eGFR) was calculated using the first and the last available serum creatinine level according to the Modification of Diet in Renal Disease (MDRD) formula. Chronic Kidney Disease (CKD) stage was assessed according to the National Kidney Foundation (NKF) classification. Severe CKD was defined as CKD stage ≥3 (i.e. eGFR < 60 ml/min). Regular nephrological management (NM) was defined as 1 nephrological consultation every 12‐18 months, according to our internal protocol. Descriptive statistics were used to analyse the cohort data.
Results: Complete data including serum creatinine levels of 46 cystinuric patients exclusively treated with URS were available. Median (IQR) age at diagnosis and at first URS in our centre were 18 (10‐26) and 32 (22‐46) years, respectively. Twenty‐eight (60.8%) patients were male, and 13 (28%) patients had a CCI ≥1. Median (IQR) follow‐up was 101 (70—146) months. Median (IQR) interval between the first and the last available creatinine level was 64 (45‐78) months. Median (IQR) number of fURS and recurrences during FU were 6 (3.75‐10.25) and 2.5 (1‐4), respectively. At the end of follow‐up, 18 (39%) patients were stone‐free. Thirty‐nine (85%) patients had at least 1 nephrological consultation in our center and 19 (43%) had regular NM during follow‐up. Median (IQR) first and last eGFR were 72 (57‐97.5) and 74 (66‐88) mL/min, respectively. Eight (17%) and 5 (10.8%) patients had severe CKD at the beginning and the end of the follow‐ up, respectively. Overall, 40 (87%) patients had stable or improved renal function within the follow‐up.
Conclusions: Severe CKD is a not neglectable complication that occurs in more than 1 out 6 cystinuric patients at an early stage of life. However, most of patients treated conservatively with URS in a referral center have stable or improved renal function within a long‐term follow‐up.Current findings should be considered for the surgical management of cystinuric patients.
Funding: none
A Prospective Randomised Controlled Trial Comparing Dusting and Fragmentation Modes of Thulium Fiber Laser in Retrograde Intrarenal Surgery
1MPUH: Muljibhai Patel Urological Hospital, Nadiad, India
Presented By: Niramya Pathak, MD
Introduction: To compare the dusting versus fragmentation modes with Thulium fibre laser (TFL) in Retrograde Intrarenal Surgery (RIRS) for upper tract stones using the same fixed low power laser settings in both the arms. Primary objective was to compare stone free rate and secondary objectives were to compare mean operating times, hospital stay duration, complication rates, need for secondary procedures, and laser efficacy.
Methods: A prospective randomised trial, with patients having proximal ureteral or renal stones of 10‐20 mm size and planned for RIRS was done at a single institute. Total of 60 consecutively admitted patients with signed consent were included for randomization with 30 patients in each arm of dusting and fragmentation modes.
Results: Median age in dusting and fragmentation arms were 41.5 and 45.5 years, median stone sizes were 10.45 and 12.25 mm, median stone volume was351.6 and 490.7 mm3 and median stone density of 1263.5 HU in both arms. Median hospital stay duration wasof 2 days in both arms. Lasing time was significantly lesser in the Fragmentation group (20.5 min,IQR 15.12‐31.62) than in dusting group (34.25 min, IQR 26.62‐38.62), p < 0.001. Higher ablation speed for fragmentation mode (0.405 mm3/sec, IQR 0.337‐ 0.635) than dusting mode (0.17 mm3/sec, IQR 0.135‐0.325), p < 0.001. Stone free rates and complication rates were comparable in both the arms.
Conclusions: TFL in fragmentation mode has shorter lasing times and better laser efficacy than dusting mode with comparable minimal complications, stone free rates and hospital stay duration.
Funding: None
Optimal Stone Density for Dusting Lithotripsy with Vapor Tunnel Ho:YAG Pulse Modality
Luis Rico1, Pablo Contreras1, Sofia Butori1, Leandro Blas1, Emanuel Martinez Pagano1, Carlos Ameri1
1Hospital Alemán de Buenos Aires, Argentina
Presented By: Luis Rico, MD
Introduction: The new pulse modality Vapor‐Tunnel™ (VT) consists of a very long pulse that uses the minimum peak power, causing the energy to pass through a previously created vapor channel or tunnel. There are multiple studies that have shown excellent dusting lithotripsy efficacy. However, there are no in‐vivo studies that have compared the VT lithotripsy efficacy according the to the stone density.
Methods: A retrospective comparative study of 152 patients who underwent retrograde intrarenal surgery using VT Ho:YAG laser was performed. We included non‐complex kidney stones (Guy Stone I) and excluded multiple kidney stones. We divided the patients according the stone density (Group 1: < 1000UH vs Group 2: > 1000UH). In all procedures, 1J/10Hz (10W) with VT pulse modality was utilized. Stone size, body mass index (BMI), laser emission time, and total operative time were recorded. We also assessed the lithotripsy efficacy (Joules/mm3). The stone‐free rate was defined as the absence of stone fragments in a non‐ contrast abdominal computed tomography four weeks after the procedure
Results: 93 patients were included in Group 1 and 59 in Group 2. There was no significant difference in age, gender and stone location. BMI was significant higher in Group 1 (27.3 vs 25.2) and the median stone volume was higher in Group 2 (846 vs 672mm3). Total energy used (11.9kJ vs. 24kJ), the laser emission time (19min vs. 30min), and the total operative time (60min vs. 85min), were significantly lower in the Group 1. Stone‐free rate (SFR) was significantly higher in Group 1 (96.7% vs 57.6%, p < 0.001) with a total SFR of 81.6%. In Group 1 all the patients were discharged on the same‐day (p < 0.001) and when we evaluated the efficacy of laser lithotripsy, a significantly lower difference was obtained (median 18.6 Joules/mm3 vs. median 18.6 Joules/mm3).
Conclusions: In soft stones (< 1000UH) the VT pulse modality was associated with decreased laser time and operative time. Additionally, it increased lithotripsy efficacy and the SFR compared to hard stones (> 1000UH) with the same laser settings and pulse modality.
Funding: No funding
A New Scoring System for Predicting Febrile Urinary Tract Infection After Retrograde Intrarenal Surgery
Altug Tuncel3, Cagdas Senel1, Cagdas Senel1, Anil Erkan2, Tanju Keten3, Ibrahim Can Aykanat4, Ali Yasin Ozercan5, Koray Tatlici3, Serdar Basboga3, Sinan Saracli6, Ozer Guzel3, Altug Tuncel3
1Balıkesir University School of Medicine, Department of Urology, 2University of Health Sciences, Bursa Yuksek Ihtisas Training and Research Hospital, Department of Urology, 3University of Health Sciences School of Medicine, Ankara State Hospital, Department of Urology, 4Koc University School of Medicine, Department of Urology, 5Ministry of Health, Sirnak State Hospital, Department of Urology, 6Balıkesir University School of Medicine, Department of Biostatistics
Presented By: Altug Tuncel, Prof.
Introduction: The widespread use of retrograde intrarenal surgery (RIRS) in upper urinary tract stone disease brings along infectious complications. In the current study we aimed to define a new scoring system for predicting febrile urinary tract infection (F‐UTI) following RIRS.
Methods: We retrospectively analysed the medical records of the patients who underwent RIRS due to upper urinary tract stone disease in three different tertiary centers between January 2021 and January 2023. A total of 511 patients were included in the study and demographic, radiological and laboratory data were recorded.The patients were divided into two groups. Group 1consisted of 34 patients who suffered postoperative F‐UTI and Group 2 consisted of 477 patients who did not.A comparison between the groups was performed by using T‐test and Chi‐square test.We used feature selection to determine the relevant variables via Weka®software. Consistency subset evaluator and greedy stepwise techniques were used for attribute selection. Logistic regression analysis was performed with the variables that obtained from feature selection to develop our scoring system. The accuracy of discrimination was assessed by the receiver operating characteristic (ROC) curve.
Results: The mean age of the patients was 50.3 ± 14.4 years and the mean stone size was 15 ± 5.3 mm (Table 1). Five of 19 variables namely diabetes, hydronephrosis, administration type, previous post‐ ureterorenoscopy (URS) UTI history and urine leucocyte were obtained from feature selection. Binary logistic regression analysis showed that hydronephrosis (p = 0.011), previous post‐URS UTI history (p = 0.007) and urine leucocyte (p = 0.001) were significant independent predictors of F‐UTI following RIRS (Table 2). These three factors showed good discrimination with the area under curve (AUC) value 0.837 (95% CI: 0.765–0.910). In the presence of at least one of these factors, 32 of 34 patients who complicated withpostoperativeF‐UTI were successfully predicted (Table 3).
Conclusions: Our study demonstrated that hydronephrosis, previous post‐URS UTI history and urine leucocyte are significant predictors of infectious complications following RIRS. In addition, this scoring system that we develop based on these factors can successfully discriminate the patients that complicated with F‐UTI after RIRS. Our results need to be confirmed with further studies.
Funding: None
Outcomes of Ureteroscopy and Laser Fragmentation Using a 60W MOSES Laser: A 3‐Year Prospective Study from a University Teaching Hospital
Victoria Jahrreiss4, Francesco Ripa1, Carlotta Nedbal2, Clara Cerrato3, Amelia Pietropaolo3, Bhaskar Somani3
1Department of Stones and Endourology, University College London Hospitals, 2University Hospital Southampton NHS Trust, Università Politecnica delle Marche, Ancona, Italy, 3University Hospital Southampton NHS Trust, 4University Hospital Southampton NHS Trust, Southampton, UK; Department of Urology Medical University Vienna, Austria
Presented By: Victoria Jahrreiss, MD
Introduction: MOSES holmium laser lithotripsy uses “pulse modulation”. As the clinical evidence on the efficacy of 60W Holmium laser with MOSES technology is scarce, we analysed the outcomes of patients treated with this laser at our institution.
Methods: 103 consecutive patients with urinary stones (80 kidney stones and 23 ureteral stones) were treated with the 60W MOSES laser from 2020 until 2022, and were included in our analysis.Patient data and outcomes were prospectively collected, and analysis was performed regarding patient demographics, stone parameters, as well as stone free rate, operating time, length of stay, peri and postoperative complications.
Results: With a median age of 55 (39‐68) years, the male: female ratio was 56:47.The median stone size was 12mm (IQR:7‐19), with a mean number of urinary stones of 1.82 (SD ±1.4). While 36 (35%) patients were pre‐stented, a ureteral access sheath was inserted in 36 (35%) patients. The median operative time was 44 min (IQR:22.5‐59.5), and 64 (62.1%) patients received post‐operative stenting. Minor perioperative complications were observed in 4 patients (3.9%) and after the first procedure 93 (90.3%) patients were stone‐free. The median length of hospital stay was 1 day (IQR 0‐1).
Conclusions: This study demonstrated that 60W MOSES laser was safe and efficient for the treatment of urinary stones with high stone‐free rates and mild perioperative complications. More studies with larger cohorts are necessary in the future to confirm our results.
Funding: None.
Evaluation of Stone Volume and Complications of Patients Undergoing Flexible Ureteroscopy (f‐URS) for Renal and Proximal Ureteral Stone Disease; Single Center Results
Arda Tunc Aydinoglu1, Resat Aydin1, Yasin Ates1, Ahmet Baris Aydin1, Tzevat Tefik2, Faruk Ozcan1
1Istanbul University Faculty of Medicine, 2Istanbul
Presented By: Arda Tunc Aydinoglu, MD
Introduction: Recent technological advances in endourology have made retrograde intrarenal surgery (RIRS) a more popular method for the treatment of urolithiasis. Although RIRSis widely used in kidney stones smaller than 2 cm, it has been used with increasing frequency in stones larger than 2 cm. In addition, new instruments such as high‐power holmium lasers, thulium fiber lasers and disposable ureteroscopes have been introduced for greater safety, efficiency and comfort for both patients and surgeons. Radiolucent stones, stones in the kidney anatomy that are not suitable for SWL, treatment with anticoagulants, coexistence of kidney and ureteral stones and bleeding disorders are the advantages for this surgery. The aim of RIRSis to achieve stone‐freeas in other stone surgeries. It is a known fact that the stone‐free rate (SFR) is lower in patients undergoing f‐URS for upper urinary tract stones compared to percutaneous nephrolithotomy. Some nomograms have been developed to estimate SFR after f‐URS to guide the selection of optimal therapy. Various preoperative features have been described, including stone volume and number, presence of lower pole stones or hydronephrosis, and operators experience with f‐URS.
Methods: The data of patients who underwent F‐URS for proximal ureter and/or renal pelvis stones between January 2018 and February 2023 at the Department of Urology, Istanbul Faculty of Medicine were evaluated retrospectively. Demographic characteristics of the patients, operation time, stone localization, preoperative stone volume, postoperative stone volume and postoperative complications were determined. Stone volumes were calculated using the “3D Slicer image computing” program by using the preoperative and postoperative Computed Tomography (CT) images of the patient, residual fragments of 2 mm and below were considered stone free. When calculating the stone volume in patients with more than one stone, the volume of each stone was calculated and added together. Postoperative KUB of the patients who did not have CT imaging in the postoperative evaluation were was used. Perioperative complications were classified using the modified Clavien system.
Results: Between January 2018 and February 2023, F‐URS procedure was performed on 130 patients due to proximal ureter or kidney stones in the Urology Department of Istanbul Faculty of Medicine. All patients were operated in the standard lithotomy position. The mean age of the patients was 49.2 (12‐85). The age of 3 patients was under 18. 38 of the patients were female and 92 were male. 12 patients had multiple stones in the proximal ureter, 5 at the ureteropelvic (UP) junction, 13 at the upper pole, 22 at the middle pole, 19 at the renal pelvis, 34 at the lower pole, and 21 at different calyces. At the end of the operation, JJ stent was placed in all patients. Preoperative and postoperative CT images of 66 (50.7%) people were obtained and stone volumes were calculated. The mean preoperative stone volume was 90 mm3 (11.82 mm3‐10534.4 mm3). The mean stone volume of the patients in the first 3 months postoperatively was calculated as 64 mm3 in the CT images. 49 (37.6%) patients were found to be free of calculus postoperatively. The mean operation duration was 97 minutes (20 minutes ‐269 minutes). Perioperative or postoperative complications were detected in 18 (13.8%) patients. Grade‐1 complications were detected in 9 patients, grade‐2 complications in 5 patients, and grade‐3 complications in 4 patients; Mortality did not occur in any of the patients. The postoperative hospital stay was found to be 1.6 days.
Conclusions: Postoperative stone volume of patients undergoing F‐URS for kidney stone disease may be higher than expected when evaluated with unenhanced CT images.
Funding: None
Deferred Emergency Flexible Ureteroscopy of Kidney Stones : A Mono‐Centric Experience (Flexi‐URG Study)
Louise Duffaut1, Frederic Panthier1, Marie Chicaud1, Stessy Kutchukian1, Catalina Solano1, Luigi Candela1, Mariela Corrales1, Steeve Doizi1, Olivier Traxer1
1Clinical Research group on urinary lithiasis, Tenon hospital, Sorbonne Université
Presented By: Louise DUFFAUT, MD
Introduction: Flexible Ureteroscopy (fURS) with laser lithotripsy is one of the surgical options following French CLAFU recommendations. After a renal colic, a satisfying pain management isn't always present and can require a surgical drainage. The aim of this study is to estimate the practicability of a differed fURS in chosen patients with an ureteral lithiasis.
Methods: Patients who have been seen by a doctor for a renal colic (RC) due to a unique ureteral lithiasis and again for persistant pain where included in a prospective way between November 2019 and May 2023, after realisation of a sterile CBEU. Where excluded patients needing an urgent drainage (acute obstructive pyelonephritis, hyperalgesic RC, acute renal insufficiency). The maximal delay between RC and fURS was inferior to 2 weeks. Where collected demographic, lithiasis (maximal diameter, density, localisation) and surgical (equipment, length, lithotripsy parameters) characteristics. Complications where classified according to Clavien‐Dindo. The without residual fragments (WRF) rate was evaluated by endoscopy and on the post‐ surgical imaging.
Results: 23 patients where included, with a median age of 55 years, the sex ratio was 2,1 (M) with a median BMI of 21 Kg/cm2 (Table1). 57% had preceding surgical treatment of lithiasis. The lithiasis where located for respectively 31%, 18% and 36% in the pelvic ureter, the lumbar, or pyelo‐ureteric junction. They presented a median diameter and volume of 9,5(7‐12)mm and 540(303‐660)mm3. fURS was possible for all the patients, without a ureteral sheath, with an optic, numeric and single use ureteroscope in respectively 55,3, 13 et 21,7% (Table 2). TFL laser was employed in 91,4 % of patients, using low energy, low frequency and power. The WRF was assessed at 100%, without urétéral stenosis at 3 month post surgery. Despite a negative pre‐surgery CBEU, one patient presented a febrile urinary infection after surgery.
Conclusions: Our study shows that deferred emergency fURS in chosen patients with a ureteral lithiasis is feasible with a low complication rate, including absence of post‐operative ureteral stenosis. A multi‐centric study could confirm the results of this pilot study as well as eligible patients.
Funding: No funding
Preliminary Data from a Prospective Cohort Study on Patient‐Reported and Surgical Outcomes of Ureteroscopy under Sedation Versus Spinal/General Anesthesia
Kunal Jain1, Brian Peters1, Premal Patel1, Gregory Hosier1
1University of Manitoba, Section of Urology
Presented By: Kunal Jain, MD
Introduction: The standard of care is to perform ureteroscopy under spinal or general anesthesia; however, it has been demonstrated that ureteroscopy can be safely performed under conscious sedation. Literature has lacked is in comparing patient‐reported and surgical outcomes for ureteroscopy under sedation versus spinal/general anesthesia. We aimed to address this knowledge gap.
Methods: All ureteroscopies from June to December 2023 performed at the provincial stone‐centre, tertiary‐ care hospital will be approached for enrollment. Patient‐specific, procedure‐specific, and peri‐operative variables will be collected. A validated questionnaire to assess patients' pain and tolerability will be distributed to nurses and surgeons on the day of the procedure and to patients one‐week post‐procedure. The primary outcome is patient tolerability of ureteroscopy with sedation versus spinal/general anesthesia. Secondary outcomes include stone‐free rate, peri‐operative complications, and predictors of opting for anesthetic type. Statistical analysis including univariable‐ and multivariable‐adjusted logistic regression analyses will be performed.
Results: 5 ureteroscopies have occurred, all under sedation. 4/5 (80%) were in males. Ages ranged from 18‐72. All had Charlson comorbidity index values 3 or less. Stones ranged from 2 to 8mm in size. 2/5 (60%) were intrapolar and 1/5 (20%) each were in the upper, mid, and distal ureter. All ureteroscopies were successfully completed under sedation with surgeon perceived stone burden as either no remaining stones or stone fragments small enough to pass. Mean operative, anesthetic, and recovery times were 20 (6‐45), 5 (3‐ 10), and 36 (30‐45) minutes, respectively. No patients required additional analgesics, anti‐emetics, or admission. Surgeon perceived patient tolerability ranged from 1‐4/10 whereas nurse perceived patient tolerability ranged from 1‐7/10 on the visual analogue scale. Of the 3/5 (60%) patients who responded, 2/3 (66%) reported an uncomplicated experience. 1/3 (33%) felt pain with a mild headache that resolved within 4 hours after the surgery. Pain 2 hours after surgery was reported as a maximum of 2/10. All would choose sedation in the future.
Conclusions: Preliminary data shows that ureteroscopy under sedation is well tolerated. We hope to show that patient‐reported and surgical outcomes of ureteroscopy under sedation are comparable, if not better, than those under spinal/general anesthesia, without placing those choosing sedation at additional risk.
Funding: None.
Health Utility Assessment in Patients with Ureteral Stents, and Association with Ureteral Stent Symptom Questionnaire (USSQ) Scores
Ephrem Olweny1, Jamie Yoon1, David Katz1, Christopher Ly1, Avinash Mamgain1, Morgan Sturgis1
1Rush University Medical Center
Presented By: Ephrem Olweny, MD
Introduction: Health utilities define the strength of individuals' preferences for specific health states, recorded on a scale ranging from 0 (representing death) and 1 (representing perfect health.). Data on health utilities in patients with ureteral stents are sparse. We assessed health utilities in stented patients and evaluated their statistical association with USSQ scores.
Methods: Adult (≥ 18 years) kidney stone patients undergoing ureteroscopic lithotripsywith planned stent insertion at a single academic institution were recruited. Each participant completed 4 surveys during the study period: demographics and SF‐36 v2 surveys preoperatively, and SF‐36 v2 and USSQ surveys postoperatively (at time of stent removal). Health utilities were assessed using the SF‐6D, which is derived from the SF‐36. Relationship between health utility and USSQ scores was evaluated using univariable and multivariable regression analyses.
Results: 37 patients have been enrolled to date to date; mean (SD) age was 52.7 (15.8), 64.9% were female. Mean preoperative utility score was 0.68 (0.13), decreasing to 0.64 (0.12) after stent insertion (p = 0.06). Mean USSQ pain, urinary and general health (GH) scores were 21.2 (9.5), 31.1 (8.0) and 16.1 (4.4) respectively. Statistically significant association between SF‐6D utility and USSQ scores was observed only for the USSQ GH score, which explained 24.6% of the variance in Sf‐6D utility score on multivariable analysis (p = 0.016).
Conclusions: Preference‐based assessment of quality of life in patients with ureteral stents can adequately be assessed using SF‐6D utilities, which bear statistical association with the USSQ sub‐domain score for general health perception. Quantifying utilities in stented patients provides value in estimating the disease burden associated with stent discomfort, and in providing metrics than can be incorporated in future healthcare econometric analyses.
Funding: none
Tranexamic Acid in Challenging Stone Cases of Retrograde Intrarenal Surgery. a Preliminary Study
1Istinye Universtiy Faculty of Medicine, Depatment of Urology, Istanbul, Turkey, 2Department of Urology, Istanbul University Istanbul Faculty of Medicine
Presented By: Rifat Burak Ergül
Introduction: With the recent technological advances in endourology, retrograde intrarenal surgery (RIRS) has become a more popular procedure for the treatment of kidney stone. In addition, since the introduction of new laser systems and advanced flexible ureteroscopy with miniature ureteroscopes, retrograde intrarenal surgery has become feasible for more complex kidney stones.Image quality in RIRS is an important parameter that affects the success of the operation and postoperative complications. Perioperative bleeding is an important complication that degrades the image during the operation. It is thought that the underlying reason for the increase in the amount of bleeding, especially in urological surgeries, is the fibrinolytic effect of high plasminogen concentration in the urine. It is predicted that even minimal bleeding during RIRS will affect the image quality of the operation, thus prolonging the operation time, reducing the success of the operation, and even increasing the complication. In our study, we aimed to investigate the safety and effectiveness of tranexamic acid used in RIRS in patients with challenging stone cases.
Methods: Data of 42 patients who underwent RIRS for complex kidney stones between November 2020 and April 2023 were analyzed. In the study, we used the ITO score from RIRS nomograms to identify complex cases. We defined complex cases as ITO scores of 15 and below. Group 1 included 21 patients who were administered tranexamic acid and group 2 included 21 patients who were not administered tranexamic acid. At the beginning of anesthesia induction, 500 mg of tranexamic acid diluted in 100 ml of saline was infused intravenously over 10 minutes. Preoperative demographic data of the patients, stone features, and postoperative outcomes were noted. In addition, the modified Clavien–Dindo classification system (MCDCS) was used to evaluate the postoperative complications of RIRS. Continuous data were compared with the Mann‐Whitney U test, and categorical data were compared with the chi‐square test.
Results: The mean age of group 1 was 40 ± 14 (23‐74), while group 2 was 46.6 ± 15 (20‐73). the male/female ratio was 11/10 and 15/6 in Group 1 and Group 2, respectively. There was no significant difference between the groups in terms of demographic data and stone characteristics. Fluoroscopy, f‐URS, and stone disintegration times were statistically significantly lower in group 1. (p < 0.05) We noticed that the operation was lower in Group 1, although it was not statistically significant. While the number of complications was lower in group 2, it was not statistically significant. The stone‐free rate rates were the same for both groups. Tranexamic acid‐induced thromboembolic events were not observed in any of the patients.
Conclusions: With tranexamic acid, it is possible to perform an effective and safeRIRS procedure in challenging stone cases. Future studies would support the outcomes of this study.
Funding: None
Complications Associated with Raised Intrarenal Pressures During Ureteroscopy
Anne Hong1, Cliodhna Browne1, Greg Jack1, Damien Bolton1
1Austin Health
Presented By: Anne Hong, MD
Introduction: Raised intrarenal pressure (IRP) during ureteroscopy has been attributed to infectious complications. To study this, we assess intrarenal pressures in human subjects using pressure guidewire technology.
Methods: Patients undergoing ureteroscopy for urolithiasis were recruited to the present study. During the procedure, the pressure guidewire was used for all pressure measurement. The pressure guidewire was inserted with the pressure sensor positioned in the renal pelvis at the beginning of the procedure. The remainder of the procedures were performed without deviation from usual. The operating surgeon was blinded to the live intrarenal measurements. The primary outcome was infective complications. Secondary outcomes include ipsilateral flank pain. Maximal IRPs were also recorded.
Results: Results:44 patients who underwent 47 procedures were included. The mean age was 52 years and 32 (73%) were male patients. 3 (7%) had long term urinary catheters.There were 7 proximal ureteric stones, 3 pelviureteral junction stones and 37 intrarenal stones. Of the procedures, 17 (36%) had pre‐operative positive urine culture and was managed with antibiotics. 26 (55%) of procedures had pre‐existing ureteric stents. Intra‐operatively, 36 (77%) of procedures used an access sheath. The mean IRP at rest (with wires only) was 18mmHg. The mean of the maximal IRPs achieved during manipulation was 128mmHg.A total of 8 procedures (19%) deviated from routine post operative care. 2 cases (4.2%) experienced hypotension immediately post operatively without other features. 3 cases (6%) resulted in infective symptoms. 3 cases (6%) presenting to the emergency department with severe flank pains. Pooling the IRP data of all 8 cases, the average and maximum IRPs were higher than those who did not experience any complications – at 37 vs. 32mmHg and 135 vs. 128 mmHg, although these were not statistically significant.
Conclusions: IRPs are highly susceptible to manipulation during ureteroscopy, increasing from 18mmHg to 128mmHg in our study. These elevated pressures may put patients at risk of complications, as demonstrated by our patient cohort.
Funding: This study was funded by Boston Scientific with a grant via the Investigator Sponsored Research Program.
Ureteroscopy in the Octogenarian and Nonagenarian Population
Micah Levy1, Daniel Wang1, Christopher Connors1, Aaron Walt1, Jacob Stifelman1, Olamide Omidele1, Francisca Larenas1, Michael Palese1
1Icahn School of Medicine at Mount Sinai
Presented By: Micah Levy
Introduction: Ureteroscopy (URS) is a safe and effective method for stone removal. However, few studies have identified the safety and efficacy of URS in the elderly population, specifically those 80 years and older. We analyzed URS outcomes in the octogenarian and nonagenarian populations as compared to those of the younger population across a large New York City hospital system.
Methods: Patients receiving URS for stone management at our institution between 2017 ‐2019 were retrospectively reviewed. Demographics, stone characteristics, and surgical outcomes including stone free rate (SFR), complications, and imaging follow up were recorded. Analysis compared patients ≥80 years old (elderly) to those < 80 years old (control) using a 1:3 ratio while matching patients based on American Society of Anesthesiology (ASA) scores.
Results: 80 elderly patients (ASA 2: 28, ASA > 3: 52) matched to 240 control patients (ASA 2: 84, ASA > 3: 156) were analyzed. The median age was 83 for elderly patients and 61 for controls. Elderly patients had significantly lower BMI (25.24 vs. 28.81, p < 0.001), statistically significant, but clinically insignificant smaller primary stone size (0.7 cm vs. 0.8 cm, p = 0.028), and higher rates of prior stenting (40.58% vs. 23.49%, p = 0.015). There were no significant differences in other demographic or stone characteristics. There were no significant differences in SFR for primary stones (77.19% vs. 84.21%, p = 0.315) or secondary/non‐obstructive stones (91.07% vs. 88.89%, p = 0.804), nor were there differences in operative times, rate of same‐day‐discharge, or rates of complications and reoperations. Lastly, while there were no differences in the rate of 365‐day imaging follow up (65.00% vs. 65.69%, p > 0.999), elderly patients did have a higher rate of imaging follow up within the recommended 90‐day post‐operative period (78.85% vs. 54.72%, p = 0.003). These results remained consistent with multivariate analysis controlling for demographic and preoperative stone characteristics.
Conclusions: URS is a safe and effective method for stone management in the octogenarian and nonagenarian population with equivalent SFR and complication rates, and potentially more consistent follow‐ up when compared to the younger population.
Funding: Partial funding from the Endourology Society Summer Scholarship awarded to Micah Levy.
Rates of Endoscopic Intervention in Planned Extracorporeal Shockwave Lithotripsy of Stones >20mm with Index Stent Insertion
Emma Stehr1, Akshay Kothari1
1The Prince Charles Hospital, Queensland Health
Presented By: Emma Stehr, BMBS
Introduction: Management of stones > 20mm can often be a complex conversation with patients. Both the American Urology Association (AUA) and the European Association of Urology recommend consideration of a percutaneous approach in larger stones ≥20mm. Despite this, patient preferences and comorbidities are often at odds with this ideal. In a Queensland public‐sector high‐volume stone unit, after discussion with patients, often a tailored approach is formulated. The object of this study was to review the rates of endoscopic requirement for completionin management of stones > 20mm initially managed with extracorporeal shock wave lithotripsy (ESWL) and an index stent insertion. In a tertiary stone centre, with Queensland's only public full‐time lithotripter, multimodal therapy can be offered.
Methods: This study retrospectively analysed data from all planned elective procedures for renal stones ≥20mm who underwent index stent insertion with ESWL for management at a single site high‐volume public stone unit from 1st January 2017‐31st December 2022. All ESWL treatments wereadministered under the guidance of a consultant urologist with delivered shocks dependent on intra‐operative fragmentation assessment. All stones included in this study were radio‐opaque in nature. Incomplete clearance was considered if fragments remaining were ≥3mm.
Results: 43 patients met inclusion criteria. ESWL management was utilised by 25 patients without endoscopic management (including basketing or laser lithotripsy). 16.67% of patients required endoscopic management with 3 or more procedures after ESWL.
Conclusions: ESWL treatment can be considered in close discussion with the patient however this small cohort highlights that patients should be counselled on the risk of multimodal and repeated treatments for stone clearance.
Funding: None
Single‐J Stents After Renal Lithiasis Surgery: Can We Rely on Their Safety? a Prospective Comparative Study
Catarina Laranjo Tinoco1, Andreia Cardoso1, Ricardo Rodrigues1, Ana Sofia Araújo1, Mariana Capinha1, Luís Pinto1, Sara Anacleto1, Jorge Ribeiro1, Carlos Oliveira1, Emanuel Carvalho‐Dias1, Miguel Mendes1, Vera Marques1, João Pimentel Torres1, MáRio Alves1, Paulo Mota1
1Hospital de Braga
Presented By: Catarina Laranjo Tinoco
Introduction: Ureteral catheterization is commonly employed after ureterorenoscopy (URS) procedures, even in uncomplicated procedures. Our aim was to compare the two most frequent ureteral catheters used in our centre in terms of safety.
Methods: We conducted a prospective randomized unblinded study involving patients who underwent flexible URS for renal stones between July 2022 and May 2023. Exclusion criteria included ureteral stones, urinary malformations, active urothelial neoplasia, and prior reconstructive surgery. The catheters used were single‐J stents (removed the morning after the surgery, < 24h) and double‐J stents (extracted in a subsequent appointment). The main outcomes were emergency department admission, postoperative complications (assessed within 30 days) and reintervention rate.
Results: Ninety‐seven patients were included, with 50 in the single‐J group (Group J) and 47 in the double‐J group (Group JJ). Baseline characteristics did not differ between groups (Table 1). Double‐J stents were removed after a median of 28 days (IQR 21‐36). No intraoperative complications were reported. There were no statistically significant differences in emergency department admission between the groups (22% in Group J vs 12.8% in Group JJ, p = 0.232) nor in total complications (12% vs 10.6%, p = 0.833). Only one patient in each group experienced a complication above Grade III according to the Clavien‐Dindo Classification and required reintervention, without statistically significant differences between stent type (2% vs 2.1%, p = 0.737) – an obstructive pyelonephritis requiring stenting in Group J and an incrusted stent requiring endourological treatment in Group JJ.
Conclusions: Single‐J stents did not associate with statistical differences in post‐operative complications, rehospitalization or reintervention. Therefore, they seem a viable alternative for complete flexible URS, reducing hospital visits for stent removal and the associated complications like stent‐related symptoms related and forgotten stents.
Funding: None
Facilitated Ureteroscopy Using DJ Stent Implantation in Ureterolithiasis: A Retrospective Study
Ghalib Lidawi3, Rami Abu Fanne1, Muhammad Majdoub2, Mohsin Asali1, Ronen Rub1
1Hillel Yaffe Medical Center, 2Hillel Yaffe Medical Center/ Technion Israel Institute of Technology, 3Hillel Yaffe Medical Centerq Technion Israel Institute of Technology
Presented By: Ghalib Lidawi, MD
Introduction: Objective: To investigate the impact of preoperative double J (DJ) stent insertion on outcomes of retrograde semi‐rigid ureteroscopy (URS) in patients with upper small and medium sized ureteral stones.
Methods: Between April 2018 and September 2019, we retrospectively reviewed the medical register of Hillel Yaffe tertiary reference Centre (HYMC) for patients who had undergone retrograde semi‐rigid URS for urolithiasis. Patients were separated into two groups depending on whether they underwent DJ stent placement before URS (Group A) or not (Group B). Operating time, stone clearance rate, number of insertions of post‐operative DJ stents, duration of post‐operative stents, complication rate and requirement for repeat URS were compared between groups.
Results: 318 procedures undertaken in 290 patients were included (Group A, 83 procedures in 80 patients; Group B, 235 procedures in 210 patients). By comparison with the non‐stented group, patients in the preoperative DJ stented group had a lower complications, required less postoperative DJ stent insertion, had shorter duration of postoperative DJ stent and needed less complementary procedures. Nonetheless, there was no difference in operating time and the clearance rate between the groups.
Conclusions: Facilitated semi‐rigid ureteroscopy with upstream preoperative DJ stenting for small and medium size ureteral stones had favorable outcomes compared with primary ureteroscopy
Funding: none
MODERATED POSTER SESSION 30: BPH 5
Trends and Complication Rates for TURP, Laser Procedures, and MIST for BPH in the State of New York (2004‐2021)
Juan Sebastian Arroyave Villada1, Daniel Wang1, Christopher Connors1, Micah Levy1, Khawaja Ali Bilal1, Khawaja Hasan Bilal1, Osama Zaytoun1, Francisca Larenas1, Michael Palese1
1Icahn School of Medicine at Mount Sinai
Presented By: Juan Sebastian Arroyave Villada, B.S.
Introduction: Transurethral resection of the prostate (TURP), laser procedures, and minimally invasive surgical techniques (MIST) are used for BPH management. Understanding utilization trends and outcomes for these procedures is crucial for tracking management preferences and improving patient outcomes.
Methods: We queried the New York Statewide Planning and Research Cooperative System (SPARCS) database from 2004 to 2021. We used a combination of CPT, ICD9 and ICD10 codes to define categories of TURP, laser (coagulation, vaporization, enucleation), and MIST (microwave therapy, needle ablation, UroLift, nitinol implant, transurethral incision, stenting, Aquablation, Rezum, prostatic injections). We retrieved utilization frequencies and rates of complications (urethral stricture, urinary tract infection (UTI), hematuria, incontinence, and bladder neck contracture) for each procedure. Complication rates were compared between procedures using TURP as reference and odds‐ratios were obtained.
Results: 177,040 cases of BPH managed with the target procedures were identified: 93,157 (52.6%) TURP, 55,899 (31.6%) laser, and 27,984 (15.8%) MIST. Incidence of BPH increased from 2004 to 2021 (Figure 1). Utilization rates for TURP and laser procedures decreased and stayed the same, respectively, over this time period. MIST utilization increased, thereby capturing a greater proportion of total BPH cases (Figure 1). Compared to laser, TURP was associated with higher odds of UTI (1.312, p < 0.01), bladder neck contracture (1.038, p = 0.017), urethral stricture (1.226, p < 0.01), and hematuria (1.182, p < 0.01). Relative to MIST, TURP had higher odds of UTI (2.449, p < 0.01), bladder neck contracture (2.042, p < 0.01), and hematuria (1.882, p < 0.01). Finally, TURP resulted in lower odds of incontinence and urethral stricture relative to MIST (0.782, p < 0.01; 0.878, p < 0.01).
Conclusions: TURP and Laser utilization have declined steadily from 2004‐2021, but TURP continues to make up almost 50% of all BPH procedures in the modern treatment era. MIST procedures are gaining popularity and being utilized in a greater proportion of total BPH cases. Compared to TURP and Laser procedures, MIST is associated with lower rates of UTI, hematuria, and bladder neck contracture, but higher risk of urethral stricture and incontinence.
Funding: None
Mini‐HoLEP (MILEP) vs HoLEP: A Propensity Score‐Matched Analysis
Tarek Taha1, Savin Ziv1, Karin Lifshitz1, Yotam Verdgoron1, Tomer Mendelson1, Yuval Bar‐Yosef1, Ofer Yossepowitch1, Mario Sofer1
1Sourasky Medical Center (Ichilov), Tel‐Aviv, Israel
Presented By: Tarek Taha, MD
Introduction: Minimal invasiveness improves outcome in many surgical fields including urology. We aimed to assess intraoperative performance and clinical outcome of miniaturized holmium laser enucleation of prostate (MiLEP) by means of a novel 22FR laser endoscope with a same‐size adapted morcescope.
Methods: We ran a propensity score‐matched analysis on all consecutive laser enucleations of prostate performed in our institution between 9/2022 and 2/2023. It resulted in two matched groups of men who underwent MiLEP 22 FR and those who underwent holmium laser enucleation of prostate (HoLEP 26 Fr). Their demographics, presentations, indications for surgery, intraoperative course, and outcomes underwent statistical analysis.
Results: Eighty men were suitable for study entry (MiLEP 22 FR [n = 40] and HoLEP 26 Fr [n = 40]). MiLEP was associated with significantly less intraoperative irrigation (20.5 L vs 15 L, p = 0.002E‐3), less decrease in body core temperature (0.6oC vs 0.1oC, p = 0.003E‐5), and less need for meatal dilation (25% vs 78%, p = 0.01E‐3). These parameters were identified as being independent in the multivariate analysis. There was a trend towards less and a shorter period of postoperative stress incontinence (SI) for the MiLEP group compared to the HoLEP group: 15% and 42% (p = 0.01) at 1 month, 8% and 14% (p = 0.07) at 2 months, and 0 and 0.3% (p = 1) at 3 months, respectively. There were no differences in prostatic enucleation effectiveness, operative time, hospital stay, complications, and improvement in the international prostate symptom score and quality of life score.
Conclusions: MiLEP is feasible and provides better maintenance of body core temperature, reduction in amount of fluid irrigation, and decrease in need for meatal dilation without affecting effectiveness in comparison to HoLEP. MiLEP may reduce early postoperative stress incontinence, thereby shortening the recovery period.
Funding: None
WITHDRAWN
Re‐Thinking the “Catheter‐for‐Life” Mentality: Holmium Laser Enucleation of the Prostate (HoLEP) in Men ≥90‐Years‐Old
Nicholas Dean1, Jenny Guo1, Clarissa Wong1, Perry Xu1, Amy Krambeck1
1Northwestern University
Presented By: Perry Xu, MD
Introduction: Patients ≥90‐years‐old with symptomatic BPH are often not offered surgical intervention based on safety concerns regarding their advanced age. For many of these men, indwelling or intermittent catheterization are the only recommended treatment options. The objective of our study was to examine the safety and efficacy of HoLEP in ≥90‐year‐old patients.
Methods: We retrospectively identified men aged ≥90who underwent HoLEP from our BPH database and compared them to HoLEP controls. All HoLEP procedures were performed with MOSES 2.0 laser technology. Descriptive statistics and two‐tailed T‐Tests were performed with SPSS (p < 0.05).
Results: Overall, we identified 16 men aged ≥90who underwent HoLEP between March 2021 to February 2023 at our institution. The mean patient age was 92.4 years (range: 90‐97) and the mean pre‐operative prostate volume was 127.9mL. Most patients required pre‐operative catheterization for urinary retention (13/16, 81.3%) and half had a history of recurrent urinary tract infections (8/16, 50.0%). Almost half of these patients were therapeutically anti‐coagulated (AC) (7/16, 43.8%). Only a minority of the patients were candidates for same‐day trial of void and were discharged on the same‐day of their operation (2/16, 12.5%). Mean length of stay (LOS) was 27.7 hours and mean catheter duration was 1.25 days. When comparing the ≥90 baseline characteristics to HoLEP controls (n = 781), the ≥90cohort had a higher rate of cognitive‐ impairment, history of pre‐op UTI's, pre‐op AC, ASA score, and lower BMI (all p < 0.05). There was no difference between the groups in regards to procedural time, pathologic specimen weight, post‐operative AUASS, MISI score, rate of ER presentations, re‐admissions, or 90‐day complications (all p > 0.05). There were no 90‐day mortalities in the aged ≥90 cohort, but at a mean follow‐up of 9.6 months, 3/16 (18.8%) patients have died from unrelated causes. All living patients aged ≥90 years‐old are currently free from catheterization.
Conclusions: HoLEP can be a safe and effective surgical treatment option for motivated patients ≥90‐years‐ old that are deemed fit to undergo a general or spinal anesthetic. Patient functional and safety outcomes after HoLEP were maintained regardless of patient age.
Funding: None
Long‐Term Efficacy of Transurethral Enucleation with Bipolar for Benign Prostatic Hyperplasia: A 24‐Month Follow‐up Study”
Introduction: Transurethral resection of the prostate has been the standard surgical treatment for benign prostatic hyperplasia (BPH). We previously reported that Transurethral Enucleation by Bipolar (TUEB) is a comparable and safe alternative to TURP for managing BPH, including patients with large prostate volumes (PV) exceeding 80ml. However, limited data exists regarding the long‐term efficacy of TUEB. In this study, we aimed to analyze the efficacy of TUEB over a 24‐month follow‐up period.
Methods: We retrospectively examined 60 patients with medication‐resistant BPH who underwent TUEB at our institution between 2017 and 2022. Preoperative and postoperative assessments included the international prostate symptom score (IPSS), quality of life score (QoLs), uroflowmetry (Qmax), Overactive Bladder Symptom Score (OABSS), Nocturia Score (Nocs), and serum prostate‐specific antigen (PSA) levels. Data were collected at various time points up to 24 months postoperatively. Statistical analysis was performed using the chi‐square test and Student's t‐test.
Results: All patients had sufficient data available for analysis. Baseline measurements showed a mean IPSS of 17.5, QoLs of 5.0, Qmax of 8.5 mL/s, OABSS of 5.0, and Nocs of 2.0. At 24 months postoperatively, significant improvements were observed in several parameters: mean IPSS decreased to 3.0, QoLs improved to 0.5, Qmax increased to 23.7 mL/s, and OABSS decreased to 2.0. However, there was no significant improvement in Nocs, which remained at 2.0. Median PSA levels decreased by 92.2% at 12 months postoperatively. Prostate cancer was detected in 5 (7%) patients, and 3 (4%) patients experienced postoperative urethral strictures requiring bougie dilation.
Conclusions: The efficacy of TUEB remained consistent over the 24‐month follow‐up period. TUEB proved to be an effective. The improvements in symptoms, quality of life, and uroflowmetry parameters were sustained throughout the follow‐up period. Furthermore, TUEB demonstrated effectiveness in managing overactive bladder symptoms, which persisted for 24 months. However, the occurrence of prostate cancer and postoperative urethral strictures highlights the need for appropriate monitoring and management during the postoperative period.
Funding: no funding
Efficiency and Safety of the Thulium Laser in Surgical Treatment of BPH: Experience in the One Center.
Roman Andreev2, Konstantin Kolontarev1, Dmitriy Pushkar1, Elena Lazareva1
1Moscow State University of Medicine and Dentistry named after A.I. Evdokimov, 2The S.I. Spasokukotsky City Clinical Hospital, Moscow, Russia
Presented By: Roman Andreev, FACS
Introduction: Transurethral access is common in operations for prostatic adenoma. Transurethral monopolar and bipolar resection of the prostate have been the gold standard in the surgical treatment of prostatic adenoma for the past decades and are widely used by urologists around the world. However, patients undergoing transurethral electroresection of the prostate in the first weeks have hematuria, a pronounced pain syndrome and discomfort. In order to improve the results of surgical treatment of prostatic hyperplasia and improve the quality of life of patients, laser systems allowing to perform enucleation, vaporization and vapor resection of the prostate have been developed and introduced.The aim of the study: to evaluate the results of transurethral vaporesection of the prostate using the Thulium laser.
Methods: Patients had a transurethral vaporesection of the prostate using a Thulium laser. A 1000‐micron fiber and the set power 200 W were used. The combination of laser type, fiber size and power allow high‐ speed resection of adenomatous tissue with minimal blood loss and excludes the possibility of TUR syndrome. In order to preserve the histological material during the surgical treatment of the patients by vaporization method we resected the prostatic adenoma sections of about 0,5‐1 cm in size. The resected tissue was removed through the resectoscope tube using the evacuator.370 patients were operated on using this method. Such parameters as resection time, improvement of urine rate (Q max), post‐void residual (PVR), International Prostate Symptom Scoring System (IPSS) and quality of life index (QoL) were assessed.
Results: The mean age of pateints was 67 years (46 to 98). The average prostate volume was 118.4 cm3.The average time of vaporesection was 102 minutes. The duration of urethral catheter placement was 1.8 days. Qmax significantly improved from an average of 4.8 to 20.4 ml. PVR decreased from 94 to 17 ml. There were also improvements in IPSS from 20.1 to 6.2 and QoL from 4 to 1. No patient required hemotransfusions or repeated bladder drainage. 2 patients required the use of hemostatic drugs. Two patients required repeated hospitalization for surgical treatment of bladder neck sclerosis.
Conclusions: Evaluation of the results of laser vaporesection of the prostate using Thulium laser has shown high safety and efficiency of surgical treatment. This method allows to operate on patients with prostatic adenoma volumes over 150 cm3, also on patients taking anticoagulants for a long time, preserve histological material to exclude oncological process. The data of the 3‐year follow‐up showed significant improvements in the patients' quality of life and urinary symptoms. Longer follow‐up and inclusion of more patients in the study are required to assess the persistence of the results.
Funding: no funding
Surgical Reintervention Requirements Following GreenLight PVP: A Single‐Center Experience Using Three Different Laser Device Models
Bora Özveren1, Nejdet KarşıYakalı1, Levent Türkeri1
1Acıbadem University, School of Medicine
Presented By: Bora Özveren, MD, FEBU
Introduction: The purpose of this study was to assess the incidence, risk factors, and timing of specific causes of surgical reinterventions required after PVP due to bladder neck contracture (BNC), urethral stricture (US), or persistent/recurrent prostate adenomain patients who were treated and followed up in the same department. We also investigated the impact of different PVP laser device models and specific perioperative clinical parameters on each cause of reoperations.
Methods: This is a retrospective observational analysis of prospectively collected data on consecutive men undergoing PVP with the Greenlight KTP, HPS, and XPS laser devices between 2004 and 2019 in a single center.
Results: The overall rate of reoperations was 13.8% during a 61‐month median follow‐up of 377 patients. Reoperations were due to BNC, US, and adenoma in 7.7%, 5.6%, and 4.8% of cases, respectively. The median interval until reoperation for US (11 months) was significantly shorter.None of the risk factors had any relevance to US.In patients who underwent reoperation for BNC, lasing time and energy were significantly lower, and the prostate volume was smaller; however, the multivariate analysis only identified shorter lasing time as a predictor.In patients who had reoperation for persistent/recurrent adenoma, the PSA was increased, while the prostate volume was non‐significantly high, and performance by less‐experienced surgeons was associated with a higher rate of reoperations (p < 0.05). A longer lasing time predicted an increased risk of reoperation for adenoma in multivariate analysis.
Conclusions: An unselective utilization of Greenlight PVP in the treatment of BPH patients may result in a relatively high rate of reoperations. The correlation of BNC with shorter lasing time may imply a higher risk after PVP of smaller prostates. A longer lasing time predicts an increased risk of reoperation due to persistent/recurrent adenoma, which may be related to higher prostate volumes and inefficient PVP by less‐ experienced surgeons.
Funding: None
The Butterfly Transurethral Device for the Management of BPH – Over 4‐Year Experience and Effectiveness Analysis
Ran Katz7, Ali Safadi1, Muhammd Abu Ahmed1, Shmuel Roizman2, Amnon Zisman3, Mahran Kabha4, Yoram Dekel4, Jack Baniel5, Shachar Aharoni6
1Ziv Medical Center, 2Shamir Medical Center, 3Shamir medical center, 4Carmel Medical Center, 5Rabin Medical Center, 6Rabin, 7Ziv Medical Center, Safed, Israel
Presented By: Ran Katz, MD
Introduction: To assess the effectiveness of the Butterfly device and its effect on LUTS.
Methods: The Butterfly device was implanted as part of a multi‐center clinical trial performed in Israel. It included so far 92 men who were treated for at least one year for BPH and were candidates for TURP with a Qmax ˂ 13 ml/sec and an IPSS score > 12. The device was inserted through cystoscopy under local anesthesia and sedation. No catheter was left. Follow up assessment included uroflowmetry, IPSS, QoL and sexual questionnaires. Patients whose score on questions 1,3,5,6 of the IPSS was higher than the score of questions 2,4,7 were defined as predominantly obstructed. Response to intervention was defined as at least 4 points improvement in the IPSS.This paper focus on the last 20 patients who were predominantly obstructed
Results: Patients' mean age was 68 (50‐82). Maximal follow‐up period was 4.5 years. Looking specifically the last 20 predominantly obstructed patients, Qmax improvement was 42% and IPSS improvement 40%. The intervention response rate was 86% at 3 and 12 months.No patient reported deterioration of sexual function and sexually active patients reported antegrade ejaculation. Adverse events were mainly Clavien‐ Dindo 1‐2. only 3 devices were removed
Conclusions: The butterfly device is effective in the management of BPH with good tolerability and a low rate of complications with an excellent response rate in predominantly obstructed patients.
Funding: Butterfly Medical ‐ Yoqneam, Israel
Accuracy of Surgeon Detected Incidental Prostate Cancer (PCa) During Holmium Laser Enucleation of the Prostate (HoLEP)
Nicholas Dean1, Jenny Guo1, Eric Li1, Perry Xu1, Amy Krambeck1
1Northwestern University
Presented By: Perry Xu, MD
Introduction: HoLEP is associated with advantages over minimally invasive prostate therapies (MIST) for BPH. One advantage of HoLEP is the ability to remove prostate tissue for accurate pathologic assessment. Intra‐operative assessment of tissue dissection during enucleation may also allow the experienced surgeon to predict the presence or absence of incidental PCa at time of HoLEP. We aimed to assess the accuracy of intra‐ operative surgeon detected incidental PCa at time of HoLEP.
Methods: A single surgeon (AEK) maintained a prospective BPH database at Northwestern Hospital from Jan 2021 to present. From April 2022 to present the surgeon has been recording if they believe cancer is visually detected during enucleation immediately after the procedure. Variables collected included patient demographics, surgeon visualization of cancer at time of the procedure, and final HoLEP pathology. Patients with a prior diagnosis of PCa on active surveillance were excluded from our analysis. Statistical analysis was performed with SPSS.
Results: We identified 217 patients without a history of PCa who underwent HoLEP between April to Oct 2022. Incidental PCa was identified in 13.4% of men on final pathology (29/217) and 55.2% were diagnosed with grade group(GG)1 (n = 16), 34.4% GG2 (n = 10), and 10.3% GG3‐5 (n = 3) disease. The surgeon intra‐ operatively determined the correct status of PCa on final pathology in 81.2% (176) of patients. Overall surgeon detection of PCa had a sensitivity of 37.5%, specificity of 92%, PPV of 51.7%, and a NPV of 86.7%. The surgeon correctly identified all patients with incidental GG3‐5 PCa (n = 3) and incidental urothelial cancers involving the prostate (n = 2). Patients thought to have cancer at time of HoLEP with benign final pathology had higher rates of pre‐operative indwelling catheters (56.3% versus 25.5%, p < 0.01), but no differences in prior biopsies, prostatitis, or 5ARI use (all p > 0.05).
Conclusions: High grade PCa, as well as urothelial cancer can accurately be identified at time of HoLEP; however, low grade cancers cannot reliably be detected. If the surgeon believes they visualize cancer at time of HoLEP, thorough pathologic evaluation is needed to differentiate from catheter related inflammation; however, lack of visualization does not rule out low grade cancer.
Funding: None
Thulium Fiber Laser Enucleation vs Minimally Invasive Simple Prostatectomy in Large BPH (>120 cc)
Vladislav Petov1, Leonid Rapoport1, Ekaterina Timofeeva2, Andrey Bazarkin2, Mark Taratkin1, Michael Enikeev1, Evgeny Bezrukov1, Roman Sukhanov1, Evgeny Shpot1, Alim Dymov1
1Institute for Urology and Reproductive Health, Sechenov First Moscow State Medical University (Sechenov University), 2Sklifosovsky Institute for Clinical Medicine, Sechenov First Moscow State Medical University (Sechenov University)
Introduction: According to the current EAU guidelines, the main methods of surgical treatment for patients with large benign prostate hyperplasia (BPH) (> 80 cc) are endoscopic enucleation (EEP) and open simple prostatectomy. An alternative method of treatment is minimally simple prostatectomy (MISP; laparoscopic/robotic). To date, there are few studies demonstrating its effectiveness.The aim of the study is to compare the perioperative results of EEP and MISP in patients with large BPH
Methods: A retrospective study was conducted from 2020 to 2023. We enrolled patients, who underwent one of the following interventions: thulium fiber laser EEP (ThuFLEP), laparoscopic or robotic MISP (l‐MISP, r‐ MISP). Inclusion criteria: severe lower urinary tract symptoms (IPSS > 20) and/or Qmax < 15 ml/sec and prostate volume > 120 cc. The operations were compared in terms of efficiency and safety. The effectiveness was assessed by the duration of the operation, the mass of the removed tissue, resection rate; safety ‐ by the level of hemoglobin drop, complications rate (according to Clavien‐Dindo). The duration of catheterization and hospitalization was also evaluated.
Results: The analysis included data of 268 patients (ThuFLEP – 225, l‐MISP – 33, r‐MISP – 10 patients, respectively). The groups did not differ in age (p = 0.6), residual urine volume (p = 0.5), Qmax (p = 0.93), and IPSS score (p = 0.05). A statistically significant difference was found in relation to prostate volume (ThuFLEP – 161 ± 89 cc, l‐MISP – 205 ± 48 cc, r‐MISP – 183 ± 60 cc; p < 0.01). The duration of the operation was significantly longer in the MISP groups (ThuFLEP ‐102 ± 35 min, l‐MISP – 146 ± 52 min, r‐MISP – 165 ± 73 min; p < 0.01). At the same time, the mass of the removed tissue did not differ (ThuFLEP – 121 ± 31 g, l‐ MISP – 139 ± 34 g, r‐MISP – 130 ± 46 g; p = 0.10). The resection rate is higher during enucleation (ThuFLEP ‐1.2 ± 0.4 g/min, l‐MISP‐ 0.98 ± 0.34 g/min, r‐MISP‐ 0.77 ± 0.44 g/min; p = 0.04). The hemoglobin drop did not differ (p = 0.29), however, the frequency of hemotransfusions was higher with LPR‐A (ThuFLEP and r‐ MISP– 0%, l‐MISP‐ 15.5%; p < 0.01). The frequency of other complications of Clavien‐Dindo ≤ II is also significantly lower in the ThuFLEP group (p = 0.01), while the frequency of Clavien‐Dindo ≥ III is comparable (p = 0.99). Additional interventions (cystolithotomy, hernioplasty, vasectomy, diverticulectomy) were more often performed with MISP (ThuFLEP – 4%, l‐MISP– 51%, r‐MISP– 30%; p < 0.01). The duration of catheterization, as well as hospitalization, is significantly lower with ThuFLEP (p < 0.01).
Conclusions: In general, ThuFLEP demonstrates efficiency comparable with MISP in treatment of patients with large BPH. Despite the fact that ThuFLEP is considered more safety, probably MISP might be preferable in the presence of severe concomitant pathology (multiple stones, inguinal hernia, diverticula etc.), because it allows to treat both conditions via single surgical access.
Funding: The study is deprived of funding
Assessment of Bladder Botulinum Toxin Injection Risk Factors Following Holmium Laser Enucleation of the Prostate
T. Max Shelton1, Precious Okoruwa1, Tyler Hesselbrock1, Mariah Thomas1, Minka Gill1, RJ Caras1, Austen Slade1, Marcelino Rivera1
1Indiana University School of Medicine
Presented By: T. Max Shelton, MD
Introduction: Holmium laser enucleation of the prostate (HoLEP) is a size independent surgical option for patients with symptomatic prostatic enlargement. A significant proportion of patients experience lower urinary tract symptoms (LUTS) following outlet procedures. This study analyzed a retrospective cohort of HoLEP patients to determine risk factors for bladder botulinum toxin therapy (BTT) following HoLEP.
Methods: 2482 patients underwent HoLEP at a single institution between 7/1/2019 and 10/1/2022. 13 patients underwent BTT following HoLEP. We randomly assigned 13 age‐matched non‐catheter‐dependent post‐HoLEP patients and compared outcomes.
Results: Average prostate volume of the non‐BTT group was 114.3 vs. 58.8 g in the BTT group (p = 0.02). Average enucleation times were 49.2 vs. 37.2 minutes for non‐BTT and BTT patients (p = 0.15). Energy per gram enucleated was 2.2 kJ/gram vs. 4.1 kJ/gram in non‐BTT and BTT patients (p = 0.04). Significance was reached for higher preoperative tamsulosin (p = 0.03) and lower anticholinergic usage (p = 0.03) in non‐BT patients. Mean time to BTT was 13.6 months following HoLEP. No differences were found in pre‐operative PSA, presence of median lobe, diabetes mellitus, or neurological disorders. The average number of BTT treatments was 1.1 with mean time to treatment of 13.6 months. All BTT patients failed at least 1 non‐ invasive medical treatment prior to BTT.
Conclusions: Prostate size, enucleated volumes, and energy used per gram of tissue resected were notably different in BTT and non‐BTT patients. Preoperative tamsulosin usage was significantly lower and anticholinergic usage was higher in BTT patients. Future studies are warranted to analyze risk factors for post‐HoLEP LUTS.
Funding: None
Holmium Laser Enucleation of the Prostate Development in a Latin American Reference Center: A Retrospective Study
Francisco Javier Sánchez Gutierréz3, Cristian Ivan Pelayo Avendaño1, José Ernesto Aguayo Becerra2, Ramses Arturo Rosas Calaña2, Isaac Daniel Arreola Jiménez2, Ricardo Agustin Leal Marroquin2
1Hospital Regional de Alta Especialidad ISSSTE Morelia, 2Hospital Regional de León ISSSTE, 3Hospital Regional de León ISSSTE
Presented By: Francisco Javier Sánchez Gutierréz, MD
Introduction: Lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) is one of the most common diseases in men over 60 years of age, reaching an incidence close to 80% in those over 70 years of age. Historically, the surgical treatment of BPH was transurethral resection of the prostate (TURP), currently scientific evidence has positioned holmium laser enucleation of the prostate (HOLEP) as the treatment of choice for BPH. The HOLEP in Latin America continues to grow in popularity and application; implying a great challenge its implementation in the public health system, development of surgical technique, and training of health personnel. Objectives: Analyze the technical‐surgical advances, time surgery, blood loss and complications since the implementation of the HOLEP as a treatment standard for patients with BHP in a reference center of the public health system in Mexico.
Methods: We conducted a retrospective study in patients who underwent HOLEP over a period of 8 years, using multivariable and medical records analysis.
Results: Information was collected from 253 HOLEP in patients with LUTS, performed between August 28, 2016, to May 29, 2023. The surgical technique in bloc with early release of the sphincter was the most performed with a total of 174 surgeries; the “bilobar” technique in 71 cases; than the “trilobar” technique in 8 cases. Intraoperative bleeding was analyzed, finding an average bleeding of 387ml in 2016, compared to a reported bleeding of 141ml in 2023. The hospital stays in 2016 was 1.42 days on average; compared to 0.35 days in 2023. The amount of tissue obtained through HOLEP in 2016 averaged 35.3 grams, compared to 63.4 grams in 2023; while the surgical time went from 151 minutes to 124 minutes respectively. 22 complications were reported (13 urethral strictures, 5 bladder neck contractures, 1 hypovolemic shock, 1 ureteral injury, and hospital readmission due to postoperative bleeding secondary to HOLEP, representing 8.6% of adverse events.
Conclusions: HOLEP is the new gold standard for BHP treatment, the acquisition of surgical skill leads to a decrease in postoperative bleeding, hospital stay, being a procedure that can be performed safely on an outpatient basis without increasing the incidence of complications.
Funding: None
Long‐Term Outcomes of ThuFLEP and HoLEP – a 10‐Year Single Center Experience
Vladislav Petov2, Dmitry Enikeev1, Diana Babaevskaya2, Mark Taratkin2, Aleksandr Androsov3, Andrey Morozov2
1Department of Urology, Medical University of Vienna, 2Institute for Urology and Reproductive Health, Sechenov University, 3Institute for clinical medicine, Sechenov University
Presented By: Vladislav Petov, MD
Introduction: To date, long‐term outcomes of endoscopic enucleation of the prostate (EEP) remain understudied. The objective of our study was to analyze the long‐term efficacy and safety of holmium and thulium fiber laser enucleation of the prostate (HoLEP and ThuFLEP).
Methods: We performed a retrospective analysis of data collected during the period from 2013 to 2021. Inclusion criteria: patients after HoLEP or ThuFLEP performed for severe LUTS (IPSS > 20 and/or Qmax < 15 ml/s). Efficiency was evaluated according to functional outcomes, post‐void residual urine (PVR), Qmax, IPSS and QoL; safety ‐ by the frequency of early and late postoperative complications.
Results: The data on 2390 patients was collected; 127 from the HoLEP group and 1328 from the ThuFLEP group were included to the final analyses. The functional outcomes of HoLEP after 3 years are as follows: PVR ‐ 31.4 ± 11.7 ml, Qmax 21.8 ± 5.4 ml/s, IPSS 5.9 ± 2.4, QoL 1.6 ± 1.2; after ThuFLEP: PVR ‐ 18.2 ± 20.1 ml, Qmax 21.6 ± 5.7 ml/s, IPSS 4.1 ± 2.0, QoL 1.3 ± 1.1. In the early postoperative period (< 3 months), the following I‐II Clavien‐Dindo complications were detected: transient urinary incontinence (5.5% after HoLEP and 9.7% after ThuFLEP), clot retention (7.8% each in both groups), urinary tract infections (3.9% and 2.5%), injury of the bladder wall (1.6% and 0.3%) and injury of the ureteral orifice (0.8% and 0.3%). The frequency of grade III or higher complications according to Clavien‐Dindo: acute urinary retention (HoLEP ‐ 6.3%, ThuFLEP ‐ 3.7%), clot retention with surgical revision (4.7% and 0.8%), incomplete morcellation (3.9% and 1.1%). Late complications were detected in 3.6% of patients: urethral stricture ‐ in 2.4% (HoLEP) and 1.1% (ThuFLEP), bladder neck contracture ‐ 1.6% and 0.9%, stress urinary incontinence for more than 6 months ‐ in 1.6% and 1.2%.
Conclusions: EEP is an effective method in the long term elimination of LUTS related to BPO, regardless of the source of energy. Both early and late postoperative results, as well as the number of complications are satisfactory irrespective of the type of enucleation (HoLEP, ThuFLEP).
Funding: None.
Reversible and Minimally Invasive Technique to Treat Obstructive Lower Urinary Tract Symptoms after Pelvic Radiation
Jonathan N. Warner1, Sarah McGriff1
1Mayo Clinic
Presented By: Jonathan N. Warner, MD
Introduction: Management of patients with obstructive lower urinary tracts symptoms (LUTS) after pelvic radiation can be challenging due to risk of post‐operative stress urinary incontinence (SUI). The objective of this study was to assess efficacy and outcomes of a minimally invasive, reversible procedure (i.e., UroLift®) after pelvic radiation.
Methods: A retrospective review of patients who underwent UroLift® procedure at a Mayo Clinic facility from November 2019 to May 2023 after pelvic radiation was completed.
Results: Sixteen patients were included in the analysis. Comparison of pre‐operative and post‐operative International Prostate Symptom Scores (IPSS) demonstrated a significant improvement in quality of life after UroLift® by average of 1.89on a 6‐point scale (p = .0013, n = 9). Only one patient developed de novo urinary retention. Four patients that were intermittently catheterizing pre‐operatively were able to decrease daily catheterization rate. Importantly, none of the patients developed post‐operative SUI requiring immediate removal of UroLift® implants.
Conclusions: UroLift® is a safe and efficacious procedure to treat obstructive LUTS after pelvic radiation.
Funding: None
To Evaluate the Influence of Operator Dependent Factors and Patient Factors on the Effectiveness of Performing HoLEP Within Our Centre Over Two Years
Archana Raysee2, Branemir Penev1
1Maidstone and Tunbridgewells Hospital, 2Maidstone and Tunbridgewells foundation trust
Presented By: Archana Raysee, Ms/ MBBS, MRCS
Introduction: HoLEP is considered as a popular procedure for treatment of bladder outlet obstruction secondary to prostatic enlargement. Various techniques have been introduced to perform the procedure, sometime depending on surgeon's experience and choice. We have studied the data in our hospital to assess the efficiency of the procedure by different surgeons.
Methods: Data was collected prospectively for 305 consecutive patients who underwent HoLEP from 1/12/2020 to 1/12/2022 Efficiency was calculated by assessing the weight of tissue removed over the total operative time (gm/min). Data was referenced for 5 surgeons at the site . Comparison of the impact of surgeon experience and technique on HoLEP efficiency. Parameters included: ‐ estimated prostate size (cc) on either DRE, USS, CT, or MRI; ‐ surgical technique (en‐bloc, 2‐lobe, or 3 lobe) ‐ specimen weight (gm); ‐ operating surgeon and ‐ duration of operation
Results: Across all cases, the mean prostate size was 105cc with mean operative time of 90 minutes, thus giving the departmental average efficiency of 0.66gm/min. Surgeon MSC utilised an en‐bloc technique with an average efficiency of 0.77gm/min (for mean prostates size 133cc and mean enucleated weight 68.4gm, n = 68) .Surgeon BP performed en‐bloc and 2 lobe enucleation in 70:90 of cases (n = 160) with an efficiency of 0.69gm/min. The remainder of surgeons performed 2 or 3 lobe techniques, resulting in average efficiency of 0.54gm/min (n = 38), 0.5gm/min (n = 25) and 0.43gm/min (n = 14) for surgeons AH, TS and HY, respectively
Conclusions: The data demonstrates positive correlation between surgeon experience/case load and efficiency of the operation. • En‐bloc surgical technique and larger prostate size are also associated with increased efficiency. • These findings could have implications for theatre planning, optimising surgical technique and approaches to training future HoLEP fellows
Funding: Nothing to declare
The Effects of Tanexamic Acid on Bleeding with Aquablation
Vibha Sabharwal2, Kevin Hilton1
1Quincy Medical Group, 2U Chicago Medicine Advent Health
Presented By: Vibha Sabharwal, MD
Introduction: Although a very effective procedure for BPH, Aquablation of the prostate can be associated with significant blood loss.This study was designed to determine if the use of tranexamic acid at induction had any benefit during Aquablation of the prostate.
Methods: A total of 23 patients were included in the study. The same surgeon performed all of the operations. Twelve patients were randomized to receive no tranexamic acid, and 11 patients were given 1 gram of tranexamic acid at induction of anesthesia
Results: There was no difference in intraoperative blood loss in either group (75cc in no TXA group vs 72cc in the TXA group). Length of stay in the hospital was also similar in both groups (1.9 days in no TXA group vs 1.6 days in TXA group). However, the average operative time was reduced by 13 minutes in the tranexamic acid group (54minvs 68min).Furthermore, the average drop in hemoglobin on postoperative day one wasdouble in the non‐TXA group (0.8units) versus the TXA group (0.4 units). Nothromboembolic events occured in the immediate postoperative period in either group.
Conclusions: Although this small study did not show a significant difference in intraoperative blood loss with the use of TXA during Aquablation of the prostate, there does appear to be some benefit. Shorter operative time suggests earlier control of bleeding. Furthermore, the drop in hemoglobin was much less in the TXA group compared to the non TXA group. This may suggest some benefit in controlling ongoing bleeding after surgery.
Narmina Khanmammadova1, Narmina Khanmammadova1, Tuan Thanh Nguyen2, Rafael Gevorkyan1, Maria Epino1, Jacob Basilius1, Catherine Fung1, Caroline Nguyen1, Sohrab Naushad Ali1, Mohammed Shahait3, David I Lee1
1University of California, Irvine, Department of Urology, 2University of Medicine and Pharmacy at Ho Chi Minh City, 3Clemenceau Medical Center, Department of Surgery
Presented By: Narmina Khanmammadova, MD
Introduction: Robot‐assisted simple prostatectomy (RASP) has been shown to have favorable perioperative outcomes for large prostate sizes (> 100 mm3). It has lower perioperative morbidity rates and shorter recovery time compared to open surgery and the learning curve is shorter compared to laser enucleation of the prostate. Same‐day discharge (SDD) pathway for RASP might reduce the cost of care.In this study, we report outcomes of our RASP with the SDD pathway.
Methods: Following the IRB approval, data from 34 patients who underwent RASP between July 2021 to March 2023 were collected prospectively.Patients follow ERAS protocol and are given preoperative and postoperative educational materials. SDD pathway is explained by healthcare providers. Data of unintended calls or text messages to healthcare providers through the Epic My Chart as well as unintended visits to urology clinic or Emergency Department (ED) was collected.
Results: Patient characteristics are demonstrated in Table 1. 19 (57.6%) patients were in retention before surgery, 27 (81.8%) patients reported using alpha‐blockers while 13 (39.4%) patients were using 5‐α reductase inhibitors preoperatively. Mean operative time was 134.97 ± 34.8 mins, median estimated blood loss was 100 (50 – 100) mL, median weight of the resected adenoma was 72.13 (43.73 ‐ 96.38) mL. Median length of hospital stay was 152 (116.5 ‐ 191) mins and median pain score at discharge time was 3 (0 – 4.25). None of the patients required continuous bladder irrigation or had surgicaldrain. Median length of the catheterization was 7 (7 – 8) days. There were no perioperative complications, blood transfusion, or conversion to open. 31 (91.2%) were discharged home on the day of surgery and all patients were able to urinate after the catheter removal. Two patients were readmitted in 30 days due to the causes unrelated to the same day discharge. Only 4 (12.1%) patients needed to visit the clinic or ED and 3 (9.1%) patients needed to contact healthcare providers during the 1st week after surgery.
Conclusions: Outpatient RASP is an excellent option to eliminate routine hospital stays with favorable postoperative outcomes. This might encourage surgeons to adapt RASP into their BPH practice, without the pressure for capital investment and steep learning curve required to offer laser enucleation.
Funding: This study received no fundings.
Outcomes of Robotic Assisted Simple Prostatectomy for the Management of Large Prostatic Adenomas
Ronald Cadillo‐Chavez1, Hector Lopez‐Huertas1
1University of Puerto Rico
Presented By: Ronald Cadillo‐chavez, MD
Introduction: Robotic assisted simple prostatectomy (RASP) has been described as a good alternative in the management of large prostates. We described our experience with retzius‐sparing robotic assisted simple prostatectomy.
Methods: A retrospective reviewed of 82 patients who underwent RASP in our institution from August 2014 to October 2021. All procedures were performed by the single surgeon (RCC). We evaluate pre‐operative and post‐operative outcomes for a minimum follow up of year and half.
Results: Mean age was 66.8 years (Range from 52 to 83), body mass index (BMI) was 29.1 kg/m2 (Range from 23 to 42.7) and ASA Score was 2 (Range from 2 to 3). Mean prostate volume was 168.5gr (Range from 93 to 520 gr). Of 82 patients 10 (12.1%) had a previous endoscopic procedure. Mean operative time was 108 min (Range from 75 to 165), estimated blood loss was 150 ml (Range from 100 to 200) and length of stay was 1 day (Range from 1 to 2). Foley catheter was removed after 5 days in all cases. Mean variation between pre and post operative hemoglobin was around 1.2 gr/dl. Bladder irrigation was not needed. The Da Vinci XI were used for the cases. Mean specimen size weight was 120.8 gr (72‐.375). Pathology revealed benign prostatic hyperplasia: 79 (96.3 %), adenocarcinoma prostate 3 (3.7%)There were no conversions to open surgery. There was no need for intra or post‐operative blood transfusion. There were two post‐operative complications (Clavien‐Dindo grade I).There was a significant improvement in post‐operative IPSS score, Qmax and PVR. All patient with durable and good urinary and functional outcomes.Of 82 patients, 87.8% had at least a follow‐up of ≥2year and 12.2% had a minimum follow‐up of 1.5 year.
Conclusions: RASP is a good option to manage large prostatic adenomas with good functional outcomes and low complications rate at medium follow up
Funding: None
Efficacy of RezŪm Water Vapor Thermal Therapy for Surgical Management of Benign Prostatic Hyperplasia in Prostates Over 80 Grams
Ryan Buettner1, Brad Schwartz1, Adam Jenks1, Tiffany Damm1, Krisitin Delfino1, Danuta Dynda1, Nick Tadros1
1Southern Illinois University
Presented By: Ryan Buettner, MD
Introduction: Rezūm™ transurethral water vapor thermal therapy is an effective minimally invasive surgical therapy to relieve lower urinary tract symptoms (LUTS) in men associated with benign prostatic hyperplasia (BPH). It is currently indicated for men 50 years of age or older with a prostate volume between 30 and 80 grams(g). The purpose of this study is to explore the efficacy and complications of Rezūm™ procedure for prostates greater than 80g.
Methods: We performed a retrospective chart review analyzing men with prostates greater than 80g as measured by Magnetic Resonance Imaging, Computed Tomography or Transrectal Ultrasound who underwent a Rezūm™ procedure performed at a single institution from December 2015‐June 2020. Patients were excluded from review if their prostate was ≤80g, or if they had prior surgical management of BPH. Analysis included International Prostate Symptom Score (IPSS), and use of alpha‐1 blockers or 5‐alpha reductase inhibitors (5‐ARI). Data was collated in REDCap and analyzed using the McNemar test for paired nominal data.
Results: A total of 348 charts were reviewed with 57 men meeting criteria for this study. They had a mean age (SD) of 70.8 years old (8.86) and 92.98% were Caucasian. Mean prostate size was 107.5g (23.9), ranging from 80.1g to 175.4g. Mean preoperative IPSS was 18.97 (8.42) with a mean postoperative score of 8.62 (7.54) resulting in a significant reduction of 10.79 points (p < 0.0001). Pre‐operatively, 44 men were noted to be on alpha‐1 blocker therapy, most commonly tamsulosin (n = 39). Of those, 22.7% (n = 10) of men took a 5‐ARI in combination, most commonly finasteride (n = 8). Medical therapy was eliminated in 52% of men post‐operatively (p < 0.0001). The intraoperative complication rate was low with only one patient developing hematuria managed with continuous bladder irrigation and another requiring cauterization of prostatic bleeding. There were no reported injuries to the urethra, rectum, or bladder.
Conclusions: Rezūm™ use in large prostates appears to be safe without significant complications. We saw a significant decrease in IPSS score and utilization of medical therapy post‐operatively. Further investigation could help determine how long patients receive relief of symptoms with Rezūm™, and which patients are more likely to fail Rezūm™ as a primary surgical therapy based on a prostate size greater than 80g.
Funding: None
Pre‐Operative Prostate Artery Embolization Before Transurethral Resection of Prostate for Prostate Glands Larger than 80cc – a Randomised Controlled Trial
Alvin Lee2, Shu Hui Neo1, Tze Kiat Ng2, Edwin Jonathan Aslim2, Yufei Qiao2, Allen Sim3, Pradesh Kumar4, Sivanathan Chandramohan2, John Yuen2, Kenneth Chen2
1Sengkang General Hospital, 2Singapore General Hospital, 3Gleneagles Medini Johor, 4Sunway Medical Centre
Presented By: Alvin Lee, MBBS, MRCS
Introduction: The objective of our study was to evaluate the impact of preoperative prostate artery embolisation (PAE) on intraoperative blood loss during transurethral resection of the prostate (TURP) in glands larger than 80cc.
Methods: A prospective, surgeon‐blinded randomised controlled clinical trial was conducted at a single tertiary centre. Patients with prostate volume more than 80cc with indications for TURP were randomised (1:1) to pre‐operative prostatic artery embolization followed by TURP (Group A ‐ intervention arm) versus TURP alone (Group B ‐ control arm). The primary outcome studied was blood loss measured as absolute
reduction in haemoglobin post‐operatively and secondary outcomes measured were resection efficiency (resected weight per min) and post‐operative complication rate.
Results: Our study included 10 patients each in Group A and B. Median prostate volume was 119 mL versus 140 mL and median pre‐operative haemoglobin was 13.3 g/dL (IQR 12.5 – 14.3 g/dL) versus 14.4 g/dL (IQR 10.1 – 15.2 g/dL) in Group A and B respectively. Change in post‐operative haemoglobin was significantly greater in Group B compared to Group A (‐1.4 g/dL vs +0.5g/dL, p = 0.015). There were no significant differences between the percentage of prostate weight resected (56% vs 48%, p = 0.151) and resection efficiency (0.7 g/min versus 0.6 g/min, p = 0.853) between group A and B. Two patients in Group B received one unit of red blood cell transfusion compared to only 1 patient in Group A (p = 1.00). One patient from each group had to be brought back to the operation room for haemostasis.
Conclusions: Pre‐operative PAE reduced intra‐operative blood loss in men with large prostate glands undergoing transurethral resection of prostate but did not impact resection efficiency nor complication rate.
Funding: Nil
MODERATED POSTER SESSION 31: ENDOUROLOGY ONCOLOGY
First Experience with Laser En‐Bloc Resection of Bladder Tumor in a High‐Volume Endourological Center
Yossi Ventura2, Yaron Ehrlich1, Dmitry Enikeev2, Abd Elhalim Darawsha1, Ron Gilad1, Tomer Weizman1, David a. Lifshitz1, Gherman Creiderman1
1Rabin medical center, 2Rabin Medical Center
Presented By: Yossi Ventura, MD
Introduction: Laser en bloc resection of bladder tumor (L‐ERBT) is associated with lower intra‐ and perioperative morbidity and provides better pathological samples contributing to improved staging of non‐ muscle invasive bladder cancer (NMIBC). Current EAU guidelines recommend it as an alternative to conventional piecemeal resection. Its potential to avoid repeat surgery and improve recurrence rates is under investigation. In the current study, we present our first experience with the L‐ERBT technique.
Methods: A retrospective analysis of 16 L‐ERBTs performed in our institution from December 2022 to May 2023 was conducted. All the patients were operated on by senior endourologists unexperienced in this technique under intraoperative guidance of a surgeon highly experienced in L‐ERBT (D.E.) using high‐ pulsed Ho: YAG lasers (Lumenis/Quanta) and a thulium fiber laser (Quanta).
Results: Three of 16 cases were excluded because of conversion to conventional piecemeal resection. Nine of 13 patients had primary bladder tumor, 2 patients had recurrent NMIBC, 1 patient was treated with ERBT as part of bladder preservation treatment for muscle invasive bladder cancer (MIBC). One patient had recurrent bladder and upper urinary tract tumor. The surgery was performed under general or spinal anesthesia. Average number and size of tumors was 1.4 and 2.4 cm respectively. In 3 cases, tumor size was above 3 cm. Most of the tumors were located on the lateral walls, but anterior wall and dome tumors were also present. Average operative time was 80 minutes. Two patients underwent ureteral orifice resection and stent insertion, and two patients underwent unilateral diagnostic ureteroscopy. No intraoperative complications were reported. Average catheter indwelling time and hospital stay was 1.8 days. Two patients developed non‐urological complications after surgery. The detrusor was present in 11 of 13 cases.
Conclusions: L‐ERBT offers low intraoperative complication rates and short hospital stay while also providing high‐quality tissue samples for pathology. The technique can be implemented for tumors measuring over 3 cm at any location using different types of lasers. The technique is also feasible within the multimodal bladder‐preserving approach in muscle‐invasive cancer.
Funding: None
Assessing the Impact of Percutaneous Nephrostomy Presence on Neoadjuvant Treatment Quality in Patients with Muscle Invasive Bladder Cancer
1Tel Aviv Sourasky Medical Center, 2Chaim Sheba Medical Center, 33Chaim Sheba Medical Center, 4Rambam Health Campus, 5Carmel Medical Center, 6Rabin Medical Center
Presented By: Ziv Savin, MD
Introduction: Symptomatic hydronephrosis associated with muscle invasive bladder cancer (MIBC) necessitates percutaneous nephrostomy (PCN) insertion before neoadjuvant chemotherapy (NAC). This study assesses the impact of PCN presence on standard intended NAC quality, its related complications and outcome after radical cystectomy (RC).
Methods: The study comprises a retrospective, multicenter cohort of 193 consecutive RCs performed between 2016‐2019. Eighty (42%) of these patients received NAC and were divided in two comparison groups by presence (n = 26; 33%) or absence (n = 54; 67%) of PCN. Endpoints included completion of adequate NAC treatment (cisplatin‐based chemotherapy for at least 4 courses), complications during NAC, post‐RC complications and hospital stay.
Results: Overall, patients with PCN (45/193; 23%) featured a higher referral rate to NAC (58% vs. 36%, p = 0.01), worse glomerular filtration rates (p < 0.001) and more adverse events (p = 0.04), in comparison to non‐PCN patients. In the NAC cohort, PCN patients had less adequate treatment rates (54% vs. 85%, p = 0.005), and more infections (35% vs, 7%; p = 0.008) and hospitalizations (58% vs. 13%; p < 0.001) during chemotherapy, as presented in the table. Post‐RC outcome was similar for both comparison groups. PCN was an independent risk factor for inadequate NAC (OR = 3.9, p = 0.04), and infections (OR = 11.3, p = 0.01) and hospitalizations (OR = 7.5, p = 0.004) during NAC.
Conclusions: PCN in MIBC patients is a significant risk factor for inadequate NAC and adverse events during treatment. This finding may quire the rationale of NAC, potentially leading to consideration of NAC avoidance and upfront RC in PCN patients. Further survival studies with long follow‐up are needed for elucidating this issue.
Funding: None
Histologic Examination after Laser En Bloc Resection of Bladder Tumor
Tomer Weizman1, Yossi Ventura1, Dmitry Enikeev1, Yaron Ehrlich1, Abd Elhalim Darawsha1, Gherman Creiderman1, David Lifshitz1, Ron Gilad1
1Rabin Medical Center
Presented By: Gherman Creiderman, MD
Introduction: Laser en bloc resection of non‐muscle‐invasive bladder cancer (NMIBC) is a promising surgical option which may prove to be superior to transurethral resection of bladder tumor (TURBT) in terms of complication rates. Studies have shown that laser en bloc resection of bladder tumors (L‐ERBT) provides a specimen of better quality and offers higher rates of detrusor muscle detection compared to TURBT, 96‐ 100% vs 50‐86%. While recent studies emphasize the crucial role of vertical surgical margins, horizontal margins should be considered as well. This study aims to analyze the tissue resected during L‐ERBT.
Methods: We retrospectively assessed data of patients who underwent L‐ERBT using Ho: YAG laser (Lumenis, Quanta) and thulium fiber laser (Quanta) from December 2022 to May 2023 in our institution. All the specimens were analyzed by experienced genitourinary pathologists.
Results: A total of 13 patients (11 males and 2 females) with mean age of 69 ± 15.12 years underwent L‐ ERBT. Average tumor size was 2.4 cm. In 10 cases, the specimen was evacuated through the endoscope, in 2 it was morcellated, and in 1 case it was extracted with a nephroscope grasper.The detrusor muscle was present in 84.6% (11/13) of specimens. In 10 out of 13, the horizontal surgical margins were unavailable for assessment, in the other 3 the horizontal margins were positive. Histologic examination revealed 3 cases of low‐grade NMIBC, 3 cases of high‐grade NMIBC, 4 cases of MIBC, no malignancy in 3 cases. In all 3 morcellated specimens, the detrusor muscle was detected; 1 was low‐grade NMIBC, 1 was high‐grade NMIBC and 1 was MIBC.
Conclusions: L‐ERBT is feasible in large tumors. Histologic examination of the specimen makes it possible to detect the detrusor and invasion, as well as to establish tumor grade irrespective of the extraction method, including morcellation. En bloc removal enables assessment of lateral surgical margins as well, which may play a significant role in subsequent treatment.
Funding: none
Laser En Bloc Resection in Large Bladder Tumors
Ron Gilad2, Yaron Ehrlich1, Abd Elhalim Darawsha1, Gherman Creiderman1, Tomer Weizman1, Yossi Ventura1, Dmitry Enikeev1, David Lifshitz1
1Rabin Medical Center, 2Rabin medical center, Petach Tikva, Israel
Presented By: Ron Gilad, MD
Introduction: Laser en bloc resection of bladder tumor (L‐ERBT) is a promising procedure with an excellent safety profile. L‐ERBT in large tumors is challenging due to technical difficulties in tumor evacuation and possible need for piecemeal extraction which renders pathological assessment challenging and makes some surgeons shy away from performing L‐ERBT for tumors larger than 3 cm. For the same reason it is acceptable to perform resection of such a tumor in two steps, resecting the tumour base after resection of the protruding part of the tumor.This study describes our initial experience with ERBT in tumors over 3 cm.
Methods: We retrospectively assessed data of patients who underwent L‐ERBT with high‐pulsed holmium:YAG laser with pulse modulation or thulium fiber laser from December 2022 to May 2023 in our facility. Out of 13 cases, 3 featured tumours over 3 cm. All the surgeries were performed under the supervision of a surgeon highly experienced in L‐ERBT (D.E.).
Results: Two patients had tumor of 4 cm. One was successfully extracted with a loop, whereas the other was morcellated. The average operative time was 129 minutes. One patient had a 7 cm tumour in the anterior wall and dome which was difficult to access. His surgery took 210 minutes, and the tumor was morcellated. While no intraoperative complications were observed in all 3 cases, the patient with the 7 cm tumor developed NSTEMI postoperatively prompting referral to the cardiac intensive care unit where he fully recovered. Histologic examination of the tumor extracted en bloc revealed LG NMIBC with a positive horizontal margin and presence of the detrusor. Two other pathology samples were morcellated, and no additional biopsy from the tumor base was taken. However, the detrusor muscle was detected on pathology in both samples. One was HG NMIBC and the other MIBC.
Conclusions: L‐ERBT in large tumors is technically challenging at the beginning of learning. Detrusor presence may be identified in morcellated tissue, although it is more difficult to assess muscle invasion in such specimen. Thus, we may potentially omit a 2‐step procedure in patients with difficult tumor location or deep tumour invasion, although it might be best to assess muscle invasion. Further investigation is needed.
Funding: none
Laser En Bloc Resection of Large (>3 cm) Bladder Tumors: Feasibility and Mid‐Term Outcomes
Vladislav Petov3, Dmitry Enikeev1, Mansur Mustafin2, Mark Taratkin3, Andrey Morozov3
1Department of Urology, Medical University of Vienna, 2Institute for clinical medicine, Sechenov University
3Institute for Urology and Reproductive Health, Sechenov University
Presented By: Vladislav Petov, MD
Introduction: En bloc resection is a novel modality which is potentially more reliable staging‐wise than transurethral resection of bladder tumor. However, there is not enough data on en bloc resection of large bladder tumors owing to technical challenges surgeons face. The aim of the study was to assess the safety and efficacy, intra‐ and postoperative complications and oncological outcomes of en bloc resection of bladder tumors larger than 3 cm.
Methods: We conducted a single‐center retrospective study. Inclusion criteria were as follows: age 18 years or older, primary bladder tumor with a diameter of ≥3 cm and no history of upper tract urothelial carcinoma (UTUC). En bloc was performed with a thulium fiber laser. Laser settings were 1J and 10W.Primary outcome was relapse‐free survival at 3 months, 6 months and 1 year. Secondary outcomes were the efficacy of the surgery determined by operative time, detrusor presence in the specimen, catheter in‐dwelling time; and safety determined by hemoglobin drop and postoperative complication rates (according to the Clavien‐Dindo scale).
Results: A total of 36 patients (31 males (86%) and 5 females (14%)) matching eligibility criteria were treated between 2020 and 2022. Median patient age was 62 years (IQR 57; 70). Median tumor size was 42 mm (IQR 35; 51). Thirty‐two (89%) patients had only 1 tumor, 3 patients (8%) had 2 tumors, and 1 patient (3%) had 3 tumors.En bloc resection was feasible in all the patients; no conversions to piecemeal resection occurred. Median operative time was 62 min (IQR 53; 90). Tumor removal method was extraction in 29 patients (80%) and morcellation in 7 patients (20%). Median hemoglobin drop was 6 g/l (IQR 1; 12). Median catheter in‐dwelling time was 2 days (IQR 1; 3). The muscular layer was identified in 91.5% cases. No patients required blood transfusion after the procedure. Postoperative complications were observed in 4 patients. Two patients required repeat surgery due to postoperative bleeding (Clavien‐Dindo Grade 3) and 1 patient developed acute prostatitis which warranted use of antibiotics (Clavien‐Dindo Grade 2). Thirteen patients (36%) were graded G3, 20 patients (56%) G2 and 3 patients (8%) G1 (according to WHO 1973). Thirty patients (83%) were staged T1, 5 patients (14%) T2 and 1 patient (3%) Ta. Follow‐up data was available for 19 patients. Postoperatively, 12 patients (63%) underwent 6 courses of adjuvant intravesical chemotherapy, 2 patients (11%) underwent 4 courses of systemic chemotherapy with cisplatin and gemcitabine. One patient (5%) received the Bacillus Calmette–Guérin(BCG)vaccine. Four patients (21%) required no subsequent therapy.Overall survival rate at 3 months was 100 %, and relapse‐free survival was 84 %. Only 14 patients reached 6 months follow‐up. Overall survival rate at 6 months was 100 %, and relapse‐ free survival was 79 %. Ten patients reached 1 year follow‐up. Overall survival rate at 1 year was 100 %, and relapse‐free survival was 70 %.
Conclusions: En bloc resection of bladder tumors is a feasible approach to management of large bladder tumors with promising relapse‐free survival and high rate of detrusor detection in the specimen.
Funding: None.
“Hidden in Urine: Assessing the Diagnostic Accuracy of Urine Cytology in Low‐Grade Urothelial Carcinoma Patients”
George Shaker1, James Henderson1
1Aneurin Bevan NHS health board
Presented By: George Shaker, MRCS
Introduction: Urothelial carcinoma (UC) is the predominant form of bladder cancer, accounting for approximately 90% of cases. It can be categorized into low‐grade and high‐grade UC. Low‐grade UC is associated with a better prognosis and generally has a milder malignancy than high‐grade UC. The utility of urine cytology in detecting UC, particularly low‐grade UC, is a subject of continuous debate. Reliable diagnosis of low‐grade UC through urine cytology is important for early diagnosis and treatment, as well as for long‐term survival.
Methods: This retrospective study aimed to evaluate the diagnostic accuracy of urine cytology in low‐grade UC patients. The study analyzed 400 patients with a confirmed diagnosis of low‐grade UC at a tertiary referral center, who underwent urine cytology and cystoscopy between January 2010 and December 2018. The results of urine cytology were correlated with cystoscopy findings and biopsy results. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were calculated. The McNemar test was used to compare the sensitivity and specificity of urine cytology between different low‐grade UC patients.
Results: Of the 400 participants, 298 (74.5%) were men and 102 (25.5%) were women, with a mean age of
58.4 years. The sensitivity, specificity, PPV, NPV, and accuracy of urine cytology were 63.6%, 97.5%, 91.2%, 88.8%, and 89.5%, respectively. The sensitivity of urine cytology in male patients was higher than that in female patients (67.3% vs. 48.5%, p = 0.017). There was no significant difference in the specificity of urine cytology between male and female patients (97.5% vs. 97.1%, p = 0.768).
Conclusions: Urine cytology is a useful diagnostic tool in low‐grade UC patients, with higher specificity and PPV. The diagnostic accuracy of urine cytology for low‐grade UC was found to be adequate but not exceptional. The sensitivity of urine cytology was higher in male patients than in female patients. Therefore, the results suggest that urine cytology, although not exceptional, can provide vital information for the diagnosis of low‐grade UC, particularly in male patients.
Funding: none
Failure of Tandem Ureteral Stents for Malignant Ureteral Obstruction‐ What's Next?
Introduction: The success rate of drainage with tandem ureteral stents (TUS) for malignant ureteral obstruction (MUO) is 72‐87%. Failure of TUS is usually followed by the insertion of a percutaneous nephrostomy tube (PCN). The objective of this study was to examine the possibility of replacing the first‐ time failed TUS with a new pair of TUS‐ the success rate of the procedure, and the risk factors for a second failure.
Methods: The medical records of all patients with MUO who underwent balloon dilation and TUS insertion in our institution between 2014‐2022 were retrospectively analyzed. Failure of TUS was defined as an episode of urosepsis, recurrent urinary tract infections, acute kidney failure, or detection of new hydronephrosis on imaging scans. Independent risk predictors of failure of secondary TUS were determined by a multivariate cox regression analysis.
Results: 240 procedures were performed on 186 patients during the study period. 67 (36%) patients failed for the first time after a median follow‐up time of 7 months (IQR 4‐17). Of which, 25 (37.4%) patients were drained by a PCN, and 42 (62.6%) were treated by exchanging the TUS with a new pair. Among the patients who underwent a second TUS insertion, 18 (42.8%) did not fail again, and continued to enjoy timely replacements of the TUS. However, 24 (57.2%) patients did fail for the second time and were drained via PCN.In a multivariant analysis, we found that inserting the same diameter TUS as the pair that failed (p = 0.002) and time to first failure ≤6 months (p = 0.006) were significant risk factors for a second failure of TUS.Cox regression analysis found that distal ureteral stricture predicts shorter time to second failure.During the study period, the group that didn't fail for a second time underwent 73 replacements of TUS overall (4 ± 2.3 procedures per patient) in a median follow‐up time of 19.5 months.
Conclusions: The success rate of replacing TUS after its failure is 42.8%. When replacing failed TUS, one should consider larger‐diameter stents.
Funding: None.
Risk Factors for Failure of Tandem Ureteral Stents Drainage for Malignant Ureteral Obstruction
Introduction: Malignant ureteral obstruction (MUO) may cause renal function impairment, renal colic, and infection. The most common management options for MUO are drainage by a percutaneous nephrostomy (PCN) or ureteral stents, each has its merits. Single ureteral stent has a failure rate of 40%, while tandem ureteral stents (TUS) provide better drainage, with a failure rate of 27.1%. The objective of this study was to examine the risk factors for failure of TUS drainage.
Methods: The medical records of all patients with MUO who underwent balloon dilation and TUS insertion in our institution between 2014‐2022 were retrospectively reviewed. Failure was measured by episodes of urosepsis, recurrent urinary tract infections, acute kidney failure, or a new hydronephrosis. We looked for independent risk predictors of TUS failure using multivariate analysis.
Results: A total of 240 TUS insertions were performed on 186 patients during the study period. During a median follow‐up time of 14 months (IQR 6‐25), In 119 (64%) the drainage by TUS succeeded, and timely replacements of the TUS was carried. Out of the 67 (36%) patients who failed, 25 (13.4%) patients were drained by PCN after a median follow‐up time of 7 months (IQR 2‐16), and 42 (22.6%) patients underwent replacement of the TUS after a follow‐up time of 7 months (IQR 4‐17).TUS failure risk was 41.4% in patients with gynecological malignancies, 38.6% in patients with gastrointestinal malignancies, 19% in urinary malignancies, and 11% in hematological malignancies (p = 0.136).When comparing the cases that failed drainage with TUS to those who succeeded, the following were found as independent risk factors for TUS failure: female gender (88% vs. 68%, respectively, p = 0.002, OR = 3.46), primary pelvic tumor (77.6% vs. 51.2%. p = 0.001, OR = 1.75), distal ureteral obstruction (86.5% vs. 73.9%, p = 0.04. OR = 2.27).Cox regression analysis found a shorter time to failure in females (13 months vs. 16 months in males, p = 0.028).
Conclusions: The long‐term success rate of TUS drainage for MUO is 64%. Risk factors related to the failure of drainage by TUS are female gender, distal ureteral stricture, and primary pelvic tumor. The failure rate is higher in the gynecological and gastrointestinal malignancies. These factors should be considered when tailoring the treatment of patients with MUO.
Funding: None.
Comparison of Self‐Locking Versus Non‐Self‐Locking Percutaneous Nephrostomy for Long‐ Term Urinary Diversion in Malignant Ureteric Obstruction
1Division of Urology, Department of Surgery, Queen Elizabeth Hospital, Hong Kong SAR, 2Department of Radiology and Imaging, Queen Elizabeth Hospital, Hong Kong SAR
Presented By: CH Tsz
Introduction: A retrospective cohort study was conducted to evaluate the efficacy and complications of self‐ locking percutaneous nephrostomy (PCN) catheters compared to non‐self‐locking catheters for long‐term urinary diversion in patients with malignant ureteric obstruction.
Methods: All patients with malignant ureteric obstruction arranged to have long‐term urinary diversion by unilateral or bilateral PCN for palliative intent between January 2019 and March 2023 in a single institution were included. Data were retrieved retrospectively to compare the outcomes including complication rate, specifically dislodgement rate, grade of complications, re‐intervention rate, number of emergency readmissions and duration of hospitalisation.
Results: A total of 449 procedures were included in this study including 212 non‐self‐locking and 237 self‐ locking catheters. There was no difference between two groups in terms of patients' characteristics. Comparative analyses showed that self‐locking catheters were associated with a significantly reduced complication rate (16.5% vs 30.2%, p = 0.001) and dislodgement rate (1.3% vs 13.2%, p = 0.000), and a decrease in need for early catheter revision (8.4% vs 21.7%,p = 0.000). Self‐locking group also showed a lower rate of emergency readmissions (16.0% vs 25.5%, p = 0.001) and shorter average length of stay during readmissions (6.28 vs 11.59 days, p = 0.006).
Conclusions: Self‐locking PCN is safe and effective in the population of malignant ureteric obstruction requiring long‐term urinary diversion. It may also have superiority over non‐self‐locking catheters with its lower complication and reintervention rates and potentially improving patients' quality of life.
Funding: The authors received no financial support for this study.
Malignant Ureteral Obstructions. Success and Failure Factors Using Metallic Ureteral Stents
Pablo Contreras1, Emanuel Martinez Pagano1, Sofia Butori1, Luis Rico1, Pablo Sabeh Hamdan1, Leandro Blas1
1Hospital Alemán de Buenos Aires
Presented By: Pablo Contreras, MD
Introduction: Extrinsic malignant ureteral obstruction (MUO) usually appears at advanced stages of an abdomino‐pelvic oncological disease. Polymeric ureteral catheters (PC) are widely used but their composition makes them not very resistant to progressive tumor compression and they present high rates of failure. Our objectives were to analyze the results of the use of the metallic ureteral stents for the treatment of extrinsic MOU in our institution, and to evaluate the prognostic risk factors of death in these patients in order to help in decision making.
Methods: A retrospective study was conducted, selecting patients with extrinsic MUO treated with metallic ureteral stent (Resonance®) between 2008 and 2022. The success of the catheter placement was evaluated after 12 weeks and was defined as a decrease in the creatinine level or less hydronephrosis compared to the preoperative results.
Results: Eighty‐nine patients underwent a urinary diversion with metallic ureteral stents for MUO. 77.5% of the patients had a follow‐up longer than three months. 79.7% patients showed a decrease in creatinine levesl and non or mild hydronephrosis on imaging. On univariate analysis, the presence of ascites HR 2.60 (p = 0.002), pleural effusion HR 3.87 (p < 0.001), visceral metastasis HR 2.2 (p = 0.008), albumin < 3.5 g/dl HR 2.36 (p = 0.009) and preoperative creatinine > 2 mg/dl HR 3.53 (p = 0.000) were significantly associated with risk of death within 12 months. In the multivariate analysis, pleural effusion HR 3.12 (p < 0.015), presence of visceral metastasis HR 2.11 (p = 0.015), albumin < 3.5 g/dl HR 2.20 (p = 0.044) and preoperative creatinine > 2 mg/dl HR 4.62 (p = 0.000) were significant for the risk of death.
Conclusions: The use of metal ureteral stent was effective in most of the patients with MUO. Prognostic death risk factors, such as pleural effusion, metastasis, hypoalbuminemia, and creatinine > 2 mg/dl were useful for patient selection. The decision to place a long‐term metal ureteral stent should be personalized for each patient.
Funding: —
MODERATED POSTER SESSION 32: STONES: INSTRUMENTATION AND NEW TECHNOLOGY 3
Complication Risk of Endourological Procedures: A Systematic Review to Examine the Role of Intrarenal Pressure
Naeem Bhojani5, Helene U. Jung1, Esteban Emiliani2, Larry E. Miller3, Anna L. Miller3, Ben H Chew4
1University of Souther Denmark, 2Autonomous University of Barcelona, 3Miller Scientific, 4University of British Columbia, 5University of Montreal
Presented By: Naeem Bhojani, MD, FRCSC
Introduction: Percutaneous nephrolithotomy and ureteroscopy are common endourological procedures to treat renal stone disease. While highly effective, these procedures carry the risk of complications such as infection, systemic inflammatory response syndrome, and sepsis. Intrarenal pressure (IRP) during these procedures has been thought to play a role in these complications. We performed a contemporary systematic review of experimental studies that reported the associations among IRP, duration of exposure, and complication rates during endourological procedures.
Methods: A systematic review was performed. We identified 12 studies (7 preclinical, 5 clinical) published between January 2000 and December 2022 that reported outcomes of 509 endourological procedures where the relationships of IRP and complication risk were reported or calculable (Table 1).
Results: Physiological IRP ranged from 6 to 11 mmHg under normal conditions. During endourological surgery, mean IRP was commonly between 20‐40 mmHg although pressure spikes > 300 mmHg were also reported. No study reported increased complication risk when peak IRP remained below 30 mmHg, or when mean IRP remained below 20 mmHg for procedures lasting over 10 minutes. However, above these limits, the association of IRP with complication risk was variable.
Conclusions: IRP is not routinely measured during endourological procedures since specialized equipment is needed. Our findings suggest that IRP monitoring during endourological procedures may be useful in mitigating complication risk. Recent advancements in endourology instruments have led to the development of integrated pressure sensors that enable continuous monitoring of IRP. Further studies will help determine if the risk of complications is greater in cases where IRP is above 20‐30mmHg. Further questions about whether spikes of peak pressure or sustained pressure elevation are more responsible for these complications.
Funding: Boston Scientific
Break Wave Lithotripsy and Ultrasonic Propulsion Technology for the Treatment of Renal Calculi in a Harbor Seal and Ureteral Calculi in a Bottlenose Dolphin
Michael R. Bailey1, Arturo Holmes1, Ben Chew2, Robert Laughlin3, Jean Buckley2, Erica Kiewice3, Michael Dancel3, David Blasko3, Victor Wong2, Abdulghafour Halawani4, Kyochul Koo5, Doug Corl6, Paul Fasolo6, Oren Levy6, Jeff Thiel1, Jammy Eichman7, Jennifer Meegan7, Martin Haulena8
1University of Washington, 2University of British Columbia, 3The Mirage Hotel, 4King Abdulaziz University, 5Yonsei University College of Medicine, 6SonoMotion, 7National Marine Mammal Foundation, 8Vancouver Aquarium in British Columbia
Presented By: Michael R. Bailey, PhD
Introduction: Marine mammals may be susceptible to developing kidney stones, which can be challenging to treat surgically. Here, we describe the use of a new minimally invasive technology, burst wave lithotripsy (BWL) and ultrasonic propulsion to treat ureteral calculi in a 48‐year‐old female bottlenose dolphin (Tursiops truncatus) and to reduce renal stone burden in a 23‐year‐old male harbor seal (Phoca vitulina).
Methods: BWL and ultrasonic propulsion were delivered transcutaneously in sinusoidal ultrasound bursts to fragment and reposition stones, respectively for both cases. Targeting and monitoring were performed with real‐time imaging integrated within the BWL system. The dolphin case received a 10‐minute and a 20‐minute BWL treatment conducted approximately 24 hours apart to treat two 8‐10 mm partially obstructing right mid‐ ureteral stones, using oral sedation alone. For the harbor seal, while under general anesthesia, retrograde ureteroscopy attempts were unsuccessful because of ureteral tortuosity, and a 30‐minute BWL treatment was targeted on one 10‐mm right kidney stone cluster in attempt to reduce the renal stone burden.
Results: In the dolphin case, the ureteral stones appeared to fragment, spread apart, and move with ultrasound propulsion. On post‐treatment days 1 and 9, the right ureteral calculi fragments shifted caudally to the ureteral orifice (UO), respectively. On day 10, the calculi fragments passed, and the hydroureter resolved. In the harbor seal, the stone cluster was observed to fragment and was not visible on the postoperative CT scan. The seal had gross hematuria and a day of behavior indicating stone passage but overall, an uneventful recovery.
Conclusions: New BWL and ultrasonic propulsion technologies successfully relieved ureteral stone obstruction in a geriatric dolphin and reduced renal stone burden in a geriatric harbor seal.
Funding: Work supported by The Mirage Hotel, SonoMotion, and NIH P01 DK043881.
Outcome and Efficiency of Thulium Fiber Laser (TFL) for Laser Lithotripsy of Renal Calculi at a Fixed Setting of 0.5J and 70Hz
Nitin Sharma3, Puja Sengupta1, Leann Shelmire2
1Lake Erie College of Osteopathic Medicine, 2St James Mercy Hospital, 3University of Rochester Medical Center
Presented By: Nitin Sharma, MD
Introduction: Recently TFL has been introduced in the urologist's armamentarium and many ex‐vivo studies have shown good dusting capabilities of TFL. None of the studies have actually evaluated ideal dusting settings for TFL. The objective of our study was to evaluate the results of intracorporeal lithotripsy of renal stone using TFL at a fixed setting of 0.5J and 70Hz.
Methods: 145 Patients diagnosed with renal stones were prospectively enrolled for either ureteroscopy or Mini‐Percutaneous nephrolitholtripsy (PCNL), based on stone size. All patients underwent laser lithotripsy using TFL (Fiber Dust®, Quanta) at a fixed setting of 0.5J and 70 Hz irrespective of stone size or composition from May 2022 till January. Basic demographic information, stone characteristics, Total laser time (TLT) (Laser on till off time) and laser lithotripsy time (LLT) (Time laser pedal is actually pressed), and postoperative outcomes were evaluated. Ablation speed (Ratio of stone volume and laser lithotripsy time) and ablation efficiency (Ratio of Total energy used and stone volume) were also calculated.
Results: 145 patients with renal calculi > 10 mm in size were included in the study with a median age of 55 years. 140 patients underwent ureteroscopy and 5 underwent Mini‐PCNL. All stones were dusted at the fixed settings of 500mJ and 70 Hz. Mean laser ablation speed and ablation efficiency were 4.23 mm3/sec and 0.024 J/mm3 respectively. During ureteroscopy, these settings were able to achieve very fine stone dust (fragment size less than 200 microns laser fiber) by using the painting technique by continuously moving the laser fiber over the stone surface and firing from a distance. During Mini‐PCNL using these settings, we were able to achieve fragments of size 3‐4 mm by avoiding movement of laser fiber using the contact technique and stopping lithotripsy once stone fragments reach 4 mm size, which werethen evacuated using the whirlpool effect. Baskets were not used in any case. All 5 mini‐PCNLs had stone sizes 30‐45 mm, with a mean of 37.5 mm. Intraoperative complications were Gr1 mucosal ureteral injury in 2 patients and Gr 3 ureteral injury from access sheath in 1 patient which healed completely after stenting for 3 weeks. 138 patients have completed post‐operative imaging (Low dose CT at 3 months). 114(82.6%) had achieved complete clearance (insignificant residual fragment i.e., < 4mm) at 3 months.
Conclusions: Despite various ex‐vivo and few in‐vivo studies using TFL, there is no clear consensus on ideal settings for dusting or fragmentation using TFL. This initial series using SP‐TFL at a fixed setting has shown both efficient dusting as well as fragmentation at 0.5J and 70 Hz. Further studies comparing different laser settings and different stone composition needs to be done to find ideal settings for TFL.
Funding: None
Trends of ‘Artificial Intelligence, Machine Learning, Virtual Reality and Radiomics in Urolithiasis' Over the Last 30 Years as Published in the Literature
Carlotta Nedbal5, Clara Cerrato1, Victoria Jahrreiss2, Amelia Pietropaolo3, Andrea Benedetto Galosi4, Daniele Castellani4, Bhaskar Kumar Somani3
1Department of Urology, University Hospitals Southampton, NHS Trust, Southampton, UK, 2Department of Urology, University Hospitals Southampton, NHS Trust, Southampton, UK, AND Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria, 3Department of Urology, University Hospitals Southampton, NHS Trust, Southampton, UK., 4Urology Unit, Azienda Ospedaliero‐ Universitaria delle Marche, Polytechnic University of Le Marche, Ancona, Italy., 5Urology Unit, Azienda Ospedaliero‐Universitaria delle Marche, Università Politecnica delle Marche, Ancona, Italy, AND Department of Urology, University Hospitals Southampton, NHS Trust, Southampton, UK
Presented By: Carlotta Nedbal, MD
Introduction: To analyze the bibliometric publication trend on the application of “Artificial Intelligence (AI) and its subsets (Machine Learning – ML, Virtual reality – VR, radiomics etc.) in Urolithiasis” in a period of 30 years from 1994 to 2023. We conducted this study looking at the publication trend associated with AI and stone disease, including both clinical and surgical applications and training in endourology.
Methods: Though a MeshTerms research on PubMed database, we performed a comprehensive review of the literature from 1994 to 2023 for all published papers on “AI, ML, VR and Radiomics” in “Urolithiasis” with papers in all languages included in the final review. Papers were then divided in three major categories: A ‐ Clinical (Non‐surgical), B ‐Clinical (surgical) and C ‐ Training papers. According to year of publication, each article was then assigned to one of three time periods (decades): Period1 (1994‐2003), Period2 (2004‐2013), Period3 (2014‐2023).
Results: Over a 30‐year time, 343 papers have been published on the subject, including 319 in English language and 24 in non‐English language. Groups A, B and C included 129, 163 and 51 papers respectively and there was an overall increase from Period1 to Period2 of 123%(p = 0.009) and to period 3 of 453% (p = 0.003). This increase from Period2 to Period3 for groups A, B and C was 476%(p = 0.019), 616%(0.001) and 185% (p < 0.001) respectively.Group A papers included rise from Period2 to Period3 in papers on “stone characteristics” (+2100%;p = 0.011) and in “renal function” (+6000%, p = 0.002), “stone diagnosis” (+192%, p = 0.123), “prediction of stone passage” (+400%, p = 0.232) and “quality of life” (+1000%, p = 0.331).Group B papers included rise in papers in “URS”(+2650%, p = 0.008), “PCNL” (+600%, p = 0.001) and “SWL” (+650%,p = 0.018). A second analysis on surgical papers pointed out that papers on “Stone targeting” (+453%, p < 0.001), “Outcomes” (+850%,p = 0.013) and “Technological Innovation” (p = 0.0311) had rising trends. Group C papers included rise in papers in “PCNL” (+300%, p = 0.039), followed by a positive trend of “URS” (+188%,p = 0.003).
Conclusions: Publications on AI and its subset areas for urolithiasis have seen an exponential increase over the last 3 decades and in particular over the last decade, with an increase in surgical and non‐surgical clinical areas as well as in training. While applications related to new technology has fuelled this, PCNL particularly seems to garner most interest. Future AI related growth in the field of endourology and urolithiasis is likely to improve training and patient centered decision making and clinical outcomes.
Funding: None
Instrumental Dead Space and Proximal Working Channel Connector Design in Flexible Ureteroscopy: A New Concept
Jia‐Lun Kwok9, Vincent De Coninck1, Amelia Pietropaolo2, Patrick Juliebø‐Jones3, Eugenio Ventimiglia4, Thomas Tailly5, Florian Schmid6, Manuela Hunziker6, Cédric Poyet6, Olivier Traxer7, Daniel Eberli6, Etienne Xavier Keller8
1Department of Urology, AZ Klina, Brasschaat, Belgium ; Young Academic Urologists (YAU), Endourology & Urolithiasis Working Group, Arnhem, The Netherlands ; Progressive Endourological Association for Research and Leading Solutions (PEARLS), 2Department of Urology, University Hospital Southampton, Southampton, UK ; Young Academic Urologists (YAU), Endourology & Urolithiasis Working Group, Arnhem, The Netherlands, 3Department of Urology, Haukeland University Hospital, Bergen, Norway ; Young Academic Urologists (YAU), Endourology & Urolithiasis Working Group, Arnhem, The Netherlands, 4Division of Experimental Oncology/Unit of Urology, Urological Research Institute, IRCCS Ospedale San
Raffaele, Milan, Italy ; Young Academic Urologists (YAU), Endourology & Urolithiasis Working Group, Arnhem, The Netherlands; Progressive Endourological Association for Research and Leading Solutions (PEARLS), 5Department of Urology, University Hospital Ghent, Belgium ; Young Academic Urologists (YAU), Endourology & Urolithiasis Working Group, Arnhem, The Netherlands, 6Department of Urology, University Hospital Zurich, University of Zurich, Zurich, Switzerland, 7Sorbonne Université, GRC n°20, Groupe de Recherche Clinique sur la Lithiase Urinaire, Hôpital Tenon, F‐75020 Paris, France ; Progressive Endourological Association for Research and Leading Solutions (PEARLS), 8Department of Urology, University Hospital Zurich, University of Zurich, Zurich, Switzerland ; Young Academic Urologists (YAU), Endourology & Urolithiasis Working Group, Arnhem, The Netherlands ; Progressive Endourological Association for Research and Leading Solutions (PEARLS), 9Department of Urology, University Hospital Zurich, University of Zurich, Zurich, Switzerland ; Department of Urology, Tan Tock Seng Hospital Singapore, Singapore
Introduction: The objective of this study was to evaluate a new concept in flexible ureteroscopy: instrumental dead space (IDS). Various proximal working channel connector designs, as well as the impact of ancillary devices occupying the working channel were evaluated in currently available flexible ureteroscopes.
Methods: IDS was defined as the volume of saline irrigation needed to inject at the proximal connector for delivery at the distal working channel tip. Because IDS is related to working channel diameter and length, we also reviewed proximal connector design as well as occupation of working channel by ancillary devices.
Results: IDS significantly varied between flexible ureteroscope models, ranging from 1.1 ml for the Pusen bare scopes, up to 2.3 ml for Olympus scopes with their 4‐way connector (p < 0.001). Proximal connector designs showed a high degree of variability in the number of available Luer locks, valves, seals, angles and rotative characteristics. The measured length of the working channel of bare scopes ranged between 739 to 854 mm and significantly correlated with measured IDS (R2 = 0.82, p < 0.001). The coupling of scopes with an alternative ancillary proximal connector and the insertion of ancillary devices into the working channel significantly reduced IDS (mean IDS reduction of 0.1 to 0.5 ml; p < 0.001).
Conclusions: IDS appears as a new parameter that should be considered for future applications of flexible ureteroscopes. A low IDS seems desirable for clinical applications. Main factors impacting IDS are working channel and proximal connector design, as well as ancillary devices inserted into the working channel. Future studies should clarify how reducing IDS may affect irrigation flow, intrarenal pressure and direct in‐scope suction, as well as evaluate the most desirable proximal connector design properties.
Funding: None
Retrograde Percutaneous Nephrolithotomy Using RetroPerc: An Early Adopter's Experience
Natalia L. Arias Villela1, Andy J. Martinez Morales1, Max R. Drescher1, Julio G. Davalos1
1Chesapeake Urology
Presented By: Natalia L. Arias Villela, MD
Introduction: Retrograde renal access percutaneous nephrolithotomy technique was first described by Lawson in 1983. However, the technique was not widely adopted in the urology community. RetroPerc® is a new retrograde access device that uses direct endoscopic visualization with a flexible ureteroscope.
RetroPerc® may be an alternative for the urologist who is not comfortable obtaining antegrade access to perform a percutaneous nephrolithotomy.
Methods: Procedures were performed by a single surgeon in a freestanding ambulatory surgical center. RetroPerc® was used in a total of 8 cases. Patient ages ranged from 53 to 74 years old, BMIs ranged from 22.1 to 33.7, and stone burden ranged from 14 to 40mm with primary localization in the renal pelvis or the lower pole. C‐arm fluoroscopy was used to track the puncture wire from the selected calix to its exit site in the skin.
Results: Retrograde access was successful in 6 of the 8 patients. Retrograde punctures were performed in inter‐pole or lower pole calyces. Puncture‐to‐skin exit times ranged from 35 to 183 seconds. Factors that led to unsuccessful punctures included: puncture wire hitting a rib, puncture wire that tracked caudally and became unsuitable for tract dilation, and unidentifiable puncture wire skin exit site. No complications related to the renal access were noted.
Conclusions: RetroPerc® is a viable and safe alternative for retrograde renal access. Both inter‐pole and lower pole calyces are suitable for retrograde punctures sites. Unsuccessful retrograde puncture attempts were likely related to the learning curve associated with a new technique and not with inherent limitations of the device or method. Appropriate patient selection and surgical planning are key for successful implementation of RetroPerc® when obtaining retrograde access. Further research is needed to identify cases where retrograde access may be more advantageous than the traditional antegrade approach.
Funding: None
Simultaneous Retrograde Ureteroscopy Via Ileal Conduit and Contralateral PCNL
Kelly Lehner1, Bridget Findlay1, Jamal Alamiri1, Tal Cohen1, Carly Thompson1, Kevin Wymer1, Kevin Koo1, Aaron Potretzke1
1Mayo Clinic
Presented By: Kelly Lehner, MD
Introduction: Urolithiasis is one of the most frequent complications of urinary diversion. Treatment can be challenging given altered anatomy and difficulty with retrograde access. Herein, we present a case of a 32 yo male with spina bifida and ileal conduit urinary diversion who presented with left > right renal stone burden and recurrent urinary tract infections.
Methods: Patient underwent left percutaneous nephrostomy tube placement and right ureteral stent placement via ileal conduit by interventional radiology. He then proceeded to the operating room for simultaneous right retrograde ureteroscopy via the conduit and left percutaneous nephrolithotomy (PCNL).
Results: The left nephrostomy tube tract was balloon dilated to allow access with a 30Fr sheath, while a 12‐ 14Fr ureteral access sheath was placed on the right side (Figure 1). In a simultaneous fashion, the 2.5cm left total renal stone burden was treated using the Swiss LithoClast ® Trilogy Lithotripter and the 1cm right total renal stone burden was treated via basket extraction using the flexible ureteroscope. Total operative time was 97 min. He discharged on postoperative day 1 without complication and stone free.
Conclusions: Simultaneous retrograde ureteroscopy and contralateral PCNL is a safe and effective means of treating bilateral renal stone burden in patients with ileal conduit urinary diversion.
Funding: None
A Novel Less Traumatic Improved Model Needle for Kidney Puncture. Experimental and Clinical Studies
Andrey Morozov4, Stanislav Ali1, Nikita Kalinin1, Alexander Androsov2, Ilya Bogatirev1, Ksenia Shelkunova3, Magomed Gazimiev1
1Institute for Urology and Reproductive Health, Sechenov University, 2Institute for Clinical medicine, Sechenov University, Moscow, Russia, 3Medical Research and Educational Center, Moscow State University, 4Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia
Presented By: Andrey Morozov, MD, PhD
Introduction: An essential proportion of percutaneous nephrolithotomy (PCNL) complications occur during kidney puncture. One of the most common complications is bleeding. To decrease complication rate, we developed a novel MG needle consisting of the following 3 parts: a pointed cannula, an atraumatic mandrin‐ bulb and a spring mechanism pushing the mandrin‐bulb forward. The aim of the study is to assess efficacy and safety of kidney puncture during PCNL using a novel less‐traumatic MG needle within a clinical trial.
Methods: We conducted a prospective randomized (1:1) single‐center study on the patients who underwent PCNL via single access and 1 lithotripsy session. Exclusion criteria were as follows: staghorn nephrolithiasis, pre‐existing nephrostomy drainage, prior history of kidney surgery (including PCNL), anomalous kidney, acute pyelonephritis, and blood clotting disorders. In the experimental group, kidney puncture was performed with a novel MG needle whilst in the control group, standard Trocar or Chiba puncture needles (Coloplast A/S, Denmark) were used (all of them were 18G). Primary endpoint: hemoglobin drop. Secondary endpoints: complication rate and grade according to the Clavien‐Dindo scale, stone‐free rate (SFR) at 3 months after surgery on follow‐up CT.
Results: A total of 126 patients were enrolled. Baseline data (age, BMI, stone size and density) was comparable between the groups. Patients who underwent standard puncture had higher hemoglobin drop in the early postoperative period (8.5% vs 5.8%, p = 0.024). Although there was no statistical difference in overall complication rate between the two groups (p = 0.302); 5 severe Clavien‐Dindo IIIa complications occurred in the control group and 2 in the experimental. Stone‐free rate did not differ significantly, 84.1% vs 82.5%, p = 0.58. Median procedure duration also was comparable, 77.5 (70‐90) min vs 70 (60‐90) min, p = 0.133.
Conclusions: Less‐traumatic needle for kidney puncture may reduce hemoglobin drop and even prevent the development of severe complications. At the same time, in terms of SFR the efficacy of PCNL remains the same.
Funding: None.
UroViu: Disrupting the Status Quo of Emergent Cystocopy in a Safety Net Hospital
Fernando J. Kim2, Kyle Szymanski1, Sharon White2, Connie Wolf1, Ian McComb1
1Denver Health, 2Denver Health Medical Center
Presented By: Fernando J. Kim, MD, MPH
Introduction: Previous studies have shown that Single‐use flexible cystoscopy (SUFC) is both efficient and cost‐effective compared to reusable cystoscopes. This study aimed to evaluate the effectiveness of a novel single‐use cystoscope, UroViu, (Figure 1) in emergent cases at a safety net hospital and providers (urologists‐ in‐training) satisfaction.
Methods: This study was conducted at a single center and involved the evaluation of UroViu SUFC between November 2022 and May 2023. The study assessed the time required to assemble the device, provider satisfaction, and successful completion of tasks. UroViu only requires a handheld processor/display, sterile saline, and tubing for its operation.
Results: A total of 60 SUFC procedures were performed, with 28 cystoscopies in the emergency department (ED) and 32 in the inpatient ward for acute urinary retention (AUR) in male patients. The current workflow for these interventions necessitates the availability of flexible sterile reusable scopes and corresponding video towers. The average setup time for the current system (difficult Foley cart) has been reported as 66 + 7 minutes. In contrast, UroViu demonstrated portability, easy assembly, and high‐quality visualization of the surgical field. All devices were assembled in less than one minute. Provider satisfaction surveys conducted after the procedures revealed an average rating of 3 stars (1 = poor, 2 = moderate, 3 = excellent), with successful placement of Foley catheters in all patients with the exception of 3 patients that required intervention in the OR.
Conclusions: UroViu proved to be easy to assemble, fast, and successful in managing AUR in male patients. By disrupting the norm and offering a cost‐effective solution with quicker assembly times for emergent and elective procedures, UroViu eliminates the need for a video tower or sterilization process. One key advantage of the UroViu cystoscope is its user‐friendliness, which improves efficiency and patient satisfaction. Additionally, its disposable nature enhances patient safety compared to reusable devices.
Funding: none
Dual‐Energy Lithotripter for Treatment of Large Bladder Calculi
Samuel Eaton3, Rebecca Wales1, Alexander Homer1, Benjamin Ahn1, Borivoj Golijanin2, Rebecca Ortiz2, Taylor Braunagel2, Christopher Tucci2
1Warren Alpert Medical School of Brown University, 2Minimally Invasive Urology Institute of the Miriam Hospital, 3Minimally Invasive Urology Institute of the Miriam Hospital, Warren Alpert Medical School of Brown University
Presented By: Samuel Eaton, MD
Introduction: The most common treatment for bladder stones includes transurethral cystolitholapaxy which is most frequently done using a holmium laser. Use of ultrasonic and combined lithotripters is routinely used for treatment of renal calculi. Data is limited in use of this technology for the treatment of bladder stones. We present our experience using a combined ultrasonic and an electromagnetic impactor with simultaneous suction to remove stone fragments, in the management of larger bladder calculi.
Methods: All records of consecutive bladder calculi treated by dual energy lithotripter (LithoClast Trilogy, EMS/Boston Scientific) between 2022 and 2023 were retrospectively reviewed. Procedures were conducted either transurethrally or percutaneously through sheath based on surgeon preference. Data was collected on stone size, number, composition, duration of procedure, additional procedures performed, and surgical complications.
Results: Seven consecutive patients – with an average age of 68, of whom one was female ‐ were treated by the Trilogy device between November 2020 and March 2023. The surgical approach used was transurethral for 5 patients and percutaneous for 2 patients. The number of calculi in the bladder ranged from 1‐4, and the average size of the largest stone was 35.9 mm, with a range of stone size from 20‐60 mm at time of treatment with Trilogy. Procedural times varied from 30 to 159 minutes.
Conclusions: This series demonstrates safety and effectivity of a dual energy lithotripter designed for nephrolithotomy for the management of large bladder calculi. While laser is used effectively for most stones, for large stones, the combination of features available with the Trilogy device make it a useful tool in cystolitholapaxy and may be able to decrease need for open procedures.
Funding: None.
Whole Renal Stone vs. Fragment Analysis Effects Final Composition Report
Omri Zonenfeld1, Ilan B. Klein1, Yuval Freifeld1, Rani Zreik Zreik1, Mahran Kabaha1, Israel Ben Zichry1, Gazi Fares1, Yoram Dekel1, Ilan B, Klein1
1Carmel Medical Center
Presented By: Omri Zonenfeld, MD
Introduction: Urinary stone composition has a critical role in determining stone formers follow‐up and treatment plans. In this study, our aim was to evaluate changes in stone composition for fragment Vs. whole stone sent for analysis.
Methods: A prospective single‐center study. All stones obtained during ureteroscopy or PCNL were sent for standard Fourier‐transform infrared spectroscopy (FTIR) analysis at a single central lab. The study group wascomprised of patients who had whole stones and fragments extracted. Fragments and whole stones were sent for analysis separately. The Control group was comprised of patients who had only fragments extracted that were then divided into 2 batches and sent separately for analysis. Clinical and operative data were collected to determine factors affecting the disparity in analysis results.
Results: There were 28 patients enrolled, 9 in the study group and 19 in the control group. The disparity in stone analysis was observed in 56% vs 5% (p = 0.003) in the study and control groups respectively. Calcium oxalate monohydrate was the most common stone type and disparities were noted in uric acid, struvite, and calcium phosphate components. Only the number of stones treated and procedure performed (PCNL) had a significant impact on analysis disparity (p = 0.002 & p = 0.03 respectively). No effects were found for Age, gender BMI or HU.
Conclusions: All stones obtained per procedure should be sent for analysis, as whole stones Vs. fragments may impact the final stone analysis report.
Funding: None.
Stent Syndrome. Does the Diameter Matter? Results of a Randomized Trial
Pablo Contreras3, Sofia Butori1, Emanuel Martinez Pagano2, Nicolas Bonanno1, Luis Rico1, Leandro Blas1
1Hospital Aleman, 2Hospital Aleman de Buenos Aires, 3Hospital Alemán
Presented By: Pablo Contreras, MD
Introduction: Double‐pigtail ureteral stents are used for multiple purposes in Urology. Despite they temporize the subsequent treatment of lithiasis, they may cause different symptoms such as suprapubic or flank pain, vesicoureteral reflux, hematuria, bladder irritation, urgency, or incontinence, that impact on quality of life (QoL).Purpose: assessed whether the diameter of ureteral stents (4.7 Fr, 6 Fr, 7 Fr) has an impact on catheter‐associated symptoms and their impact on quality of life.
Methods: 194 patients undergoing ureteral stent insertion after ureterorenoscopy between December 2018 and December 2022 were prospectively enrolled and randomized into three categories: 4.7 Fr (Group 1, n = 71), 6 Fr (Group 2, n = 65) and 7 Fr (Group 3, n = 58). Whitin one week after the double j (DJ) placement, patients completed the “Ureteric Stent Symptoms Questionnaire”.
Results: The domains in which found a significant difference was in “work” and “additional problems (AP)”. “Work” had a result of 13.75 SD 5.01 in favor of the group with 4.7 Fr (p = 0.014). In the domain AP patients in G3 demonstrated that they had fewer visits to emergency. In questions U4 and U5 about urinary incontinence warned or unaware, patients in G2 and G3 developed these symptoms more than patients in G1, p < 0.001 and 0.041 respectively for U4 and U5. In “sexual activity” domain, specifically in question S3, which emphasizes whether the patient have ever suffered any type of pain during sexual activity, resulting that patients with 4.7 have not had or have had milder symptoms in relation to catheters with a larger diameter.
Conclusions: Ureteral catheter related symptoms may affect quality of life in most cases. The 4.7 Fr catheter produced significantly less urinary incontinence, faster work reincorporation, less symptoms related to sexual activity and less catheter related symptoms than 6 and 7 Fr Catheters.
Funding: —
Effect of Antihistamine on Ureteral Stent‐Related Symptoms: Interim Analysis of a Double‐ Blinded Randomized Controlled Trial
David Han1, Ojas Shah1, Ezra Margolin1, Miyad Movassaghi1, Jeffrey Johnson2, Mahveesh Chowdhury1, Srinath‐Reddi Pingle1, Ron Golan3, Michael Schulster1, David Weiner1
1Columbia University Irving Medical Center, 2Weill Cornell Medical Center, 3Sansum Clinic Urology
Presented By: David Han, MD,MS
Introduction: Histamine is a mast cell‐derived mediator shown to be involved in ureteral peristalsis as well as bladder contraction, inflammation, and hypersensitivity. Given antihistamine's use for symptom relief in bladder pain syndrome by potentially blocking mast cell activation, we evaluated the effect of antihistamine medication on ureteral stent‐related symptoms.
Methods: We performed a double‐blinded randomized controlled trial of adults undergoing unilateral ureteroscopy with stent placement for kidney/ureteral stone treatment. Patients with neurogenic bladder, chronic kidney disease, or urologic malignancy were excluded. Coloplast Imajin® silicone stents were used for all procedures. In addition to non‐steroidal anti‐inflammatory medications for post‐operative pain control, patients were prescribed a 10‐day course of either Fexofenadine 180mg oral daily (study arm) or placebo (control). Patients were prescribed breakthrough narcotic analgesia only as needed. Patients completed the Ureteric Stent Symptoms Questionnaire (USSQ) three times: pre‐operatively without stent, with stent in situ immediately prior to stent removal, and post‐stent at 4‐ to 6‐week follow‐up. Higher scores represented increasing symptom severity. The primary outcomes were differences in USSQ urinary symptom and pain scores immediately prior to stent removal, compared using Student's t‐test.
Results: Of 64 patients (33 control and 31 study arm), mean age was 53 years and majority were men (58%). Mean stone burden (10mm) and mean time to stent removal (11 days) were similar between groups. With stent in situ, there were no differences in urinary symptom or pain scores between study arm and control groups (29 vs. 29, p = 0.97 and 16vs. 17, p = 0.63; Figure); additionally, there were no differences between cohorts in any USSQ domain (p > 0.05). There were no differences between study and control groups in mean duration of narcotic analgesia use (1 vs. 2 days, p = 0.45), mean number of office phone calls for urinary symptoms (0.1 vs. 0.4, p = 0.14), or number of Emergency Department visits (3 vs. 3, p = 1.00). No patient experienced adverse drug events.
Conclusions: In an interim analysis at over 75% of target accrual, post‐operative antihistamines were well‐ tolerated but did not reduce ureteral stent‐related symptoms.
Environmental Impact of Flexible Cystoscopy: A Comparative Analysis Between Carbon Footprint of Isiris® Single‐Use Cystoscope and Reusable Flexible Cystoscope and a Systematic Review of Literature
Victoria Jahrreiss4, Pierre Sarrot1, Niall Davis2, Bhaskar Somani3
1Medical affairs department, Coloplast, Le Plessis‐Robinson, France, 2Department of Urology, Beaumont Hospital and Royal College of Surgeons in Ireland, 3University Hospital Southampton NHS Trust, 4University Hospital Southampton NHS Trust, Southampton, UK; Department of Urology Medical University Vienna, Austria
Presented By: Victoria Jahrreiss, MD
Introduction: Considering ongoing concerns about sustainability and environmental impact, the discussion about the carbon footprint of single‐use endoscopes compared to reusable scopes is highly relevant. There still is a lack of data on the environmental impact of single‐use flexible cystoscopes. Therefore, the objective was to review the existing literature about carbon footprint of flexible cystoscopy and to analyse the
environmental impact of the Isiris® (Coloplast) single‐use flexible cystoscope compared to a reusable flexible cystoscope.
Methods: First, a systematic review on single‐use and reusable cystoscope carbon footprint was performed according to the PRISMA statement. Secondly, carbon footprints of Isiris® single‐use flexible cystoscope and reusable cystoscope were analysed and compared.Life cycle of the single‐use flexible cystoscope was divided in 3 steps: Manufacturing, sterilization, and disposal, with several steps considered to estimate the carbon footprint over the life cycle: For each step, the carbon footprint values were collected and adapted from previous comparable published data on flexible ureteroscope.
Results: The systematic literature review evidenced total carbon emissions within range of 2.06‐2.41 kg CO2 per each use of single‐use flexible cystoscope compared to a wide range of 0.53‐4.23 kg CO2 per each case of reusable flexible cystoscope. The carbon footprint comparative analysis between Isiris® single‐use flexible cystoscope and reusable cystoscope concluded in favour of the single‐use cystoscope. Based on our calculation, the total carbon emissions for a reusable flexible cystoscope could be refined to an estimated range of 2.40 – 3.99 kg CO2 per case, depending on the endoscopic activity of the unit, and to 1.76 kg CO2 per case for Isiris® single‐use cystoscope.
Conclusions: The systematic literature review demonstrated disparate results depending on the calculation method used for carbon footprint analysis. However, the results tend rather towards a lower environmental impact of single‐use devices. In comparison to a reusable flexible cystoscope, Isiris® compared favourably in terms of carbon footprint
The Impact of Single‐Use Cystoscopes on Clinical Time Workflow in An Outpatient Setting
Robert Medairos1, Robert Medairos1, Francois Soto‐Palou1, Zachary Dionise1, Rachel Locascio1, Jodi Antonelli1, Glenn Preminger1, Michael Lipkin1
1Duke University Medical Center
Presented By: Robert Medairos, MD
Introduction: Outpatient cystoscopy is one of the most commonly performed procedures, which is traditionally performed with reusable equipment. Cleaning, maintaining, and preparing reusable cystoscopes can use a lot of clinical staff time. The single‐use cystoscope recently developed by Ambu (Ballerup, Denmark) has come to market, and the impact on clinical workflow has yet to be explored. Our aim was to evaluate the change in overall clinical encounter time and clinical capacity after transitioning to single‐use cystoscopes in an outpatient urology setting.
Methods: A single‐institution prospective study comparing two full outpatient urology procedure clinic days was performed. Discrete categories for each portion of nursing care responsibilities were defined, and time spent during each category was recorded. Two separate clinic days, one where reusable cystoscopes were exclusively used and one after the transition to single use cystoscopes had occurred were analyzed. Overall clinical encounter time and the number of procedures per clinic day before and after the transition to single‐ use cystoscopy clinics were compared.
Results: A total number of 24 outpatient Urology procedures were performed, producing the same number of cystoscopy procedures on both the reusable and single‐use cystoscopy clinic days. Preliminary cystoscope cleaning and transportation tasks by nursing staff were eliminated when utilizing single‐use cystoscopes (Table 1). Average total encounter time decreased from 66 to 44 minutes, resulting in a 34% reduction in clinical encounter time. The average number of flexible cystoscopy procedures increased after the transition (single‐use cystoscope clinic average 13.6 ± 3.7 vs re‐usable cystoscope clinic average 8.8 ± 4.0 p = < 0.03).
Conclusions: Transition to a completely single‐use cystoscopy outpatient procedure clinic improved clinical efficiency, which allowed for increased the clinical patient volume from 12 to 21 patients per clinic day.
Funding: N/A
Evaluating Patient Tolerability for Endourological Procedures under Conscious Sedation: A Prospective Study
Kunal Jain3, Kapilan Panchendrabose1, Andrew Pierce1, Dhiraj S Bal1, Naomi T Gebru2, Raman Grewal2, Kunal Jain3, Micah Grubert Van Iderstine1, Ruben Blachman‐Braun4, Gregory W Hosier3, M Eric J Saltel3, Brian Gt Peters3, Robert J Bard3, Jeffrey Saranchuk3, Premal Patel3
1Max Rady College of Medicine, University of Manitoba, 2Department of Microbiology, University of Manitoba, 3Section of Urology, Department of Surgery, University of Manitoba, 4Department of Urology, University of Miami
Introduction: Administration of general or spinal anesthesia is associated with anesthetic‐related complications, long operating room wait times, and high costs. The use of intravenous (IV) conscious sedation and/or local anesthesia is an emerging alternative for a myriad of urologic procedures. Our objective was to prospectively evaluate patient‐reported and surgical outcomes of patients undergoing urologic procedures with conscious sedation and/or local anesthesia.
Methods: Patients were enrolled from June 2021 to August 2021. All procedures were completed using fentanyl, midazolam or both and patient and procedural data were recorded upon completion. Patients were telephoned 4‐6 weeks after their procedure to complete a standardized patient tolerability questionnaire. A multivariable adjusted logistic regression analysis was performed to evaluate whether a patient would opt for conscious sedation again as opposed to general/spinal anesthesia.
Results: A total of 196 procedures were performed: 27 (13.8%)for rigid URS, 34 (17.3%) for flexible URS, 57 (29.1%) for stent insertion or exchange, 14 (7.1%) for scrotal or penile surgery, 36 (18.4%) for urethral dilation, and 28 (14.3%) for advanced cystoscopic procedures. There was an overall success rate of 98.5% and 0% intraoperative complication rate. The stent insertion/exchange cohort was the only group without a 100% success rate due to one patient's inability to tolerate pain. For those who underwent management of urolithiasis (n = 34), 2 were in the bladder, 15 in the lower ureter, 2 in the mid ureter, 7 in the upper ureter, 6 in the renal pelvis and 2 with multiple calculi. Mean stone size was 5.9 mm (range: 3‐15 mm). In our subgroup stone analysis, there was no difference in tolerability for rigid or flexible URS, stone location, stone size, or procedure side. At 4‐6 weeks follow‐up, 85.6% of patients reported they would opt for conscious sedation as opposed to general/spinal anesthesia. Predictors of opting for conscious sedation wereolder age (OR: 1.049; p = 0.017) and surgeon perceived level of patient tolerability (OR: 2.124; p < 0.001, scored 1‐ 10). No statistically significant differences were found with respect to BMI, gender, prior conscious sedation experience, procedure, IV drug administration, or length of procedure.
Conclusions: Physician‐directed, nursing‐administered IV conscious sedation is a viable alternative for many urologic procedures, especially endourologic procedures, and has minimal risk of perioperative complications.
Funding: None.
Contemporary Use of Endoluminal Ultrasound in the Ureter
Jake Tempo2, Jeremy Bolton1, Joseph Ischia2, Damien Bolton2
1Monash University, 2Austin Health
Presented By: Jake Tempo, BMBS
Introduction: Endoluminal ultrasound is widely deployed in respiratory and gastrointestinal diseases and during intravascular cases. Transducers, on 6‐9Fr catheters, are available however, the use of ELUS in upper tract diseases is currently low. Locating sub‐mucosal stones intra‐operatively, staging upper tract urothelial carcinoma and avoiding crossing vessels at endopyelotomy are important and ongoing issues that urologists face that may benefit from endoluminal imaging.
Methods: A literature review was performed to assess the efficacy of ELUS in the following ureteric diseases; urolithiasis, upper tract urothelial carcinoma, stricture disease and pelvico‐ureteric junction obstruction (PUJO).
Results: Endoluminal ultrasound has proven to be useful at the time of endopyelotomy for PUJO as it can identify crossing vessels, some not detectable on CT angiography, and allow the urologist to avoid these when making their incision. In one study 16 out of 37 patients had the endopyelotomy location changed due to ELUS findings and no bleeding events occurred. The endopyelotomy success rate was 87.5%.Ureteric ELUS may be utilised for submucosal ureteric stones as they are highly visible. Endoluminal ultrasound may be deployed in the case of known sub‐mucosal urolithiasis when the ureter appears stone‐free. It may help identify sub‐mucosal stones, or stones within diverticulum.Ureteric ELUS provides 360° imaging which has been demonstrated to assess ureteric stricture length, degree of fibrosis and aetiology. Endoluminal ultrasound has been reported to identify retroperitoneal fibrosis, endometrioma, submucosal stones, urinomas and cancers.Endoluminal ultrasound has been analysed for its use in determining muscle invasive urothelial carcinoma of the ureter. The PPV for > / = pT2 was only 16.7% in one study of six patients with MIBC and 76.2% in 21 patients with < pT2 disease.
Conclusions: Ureteric ELUS has been reported to be a useful tool in endopyelotomy, urolithiasis and stricture disease. The staging of ureteric urothelial carcinoma remains unsatisfactory with current imaging techniques and biopsy methods and, based on the current literature, ELUS does not appear to have a strong enough PPV to determine muscle invasion however larger studies are required.
Funding: None
Efficiency of Self‐Expanding Nitinol‐Polymer Stents in Endoscopic Treatment of Ureteral Strictures
Filip Kowalski2, Tomasz Drewa1
1A.Jurasz Memorial University Hospital No 1, 2A.Jurasz Memorial University Hospital No 1 in Bydgoszcz, Poland
Presented By: Filip Kowalski, PhD
Introduction: Treatment of ureteral strictures is challenging for urologists due to its high recurrence rate. The effectiveness of endoscopic treatment of ureteral strictures varies from 60 to 85%. In complex (e.g. ureterointestinal anastomotic strictures) or complicated cases the effectiveness drops to 10‐30%. The promising tools regarding the effectiveness of endoscopic treatment seems to be self‐expanding ureteral stents,its unique construction (elastic nitinol alloy covered by a polymer) allows to keep it in the urinary system up to three years.The objective of our study was to investigate if novel stents improve results of endoscopic treatment of ureteral strictures.
Methods: In the years 2020‐2023, 56 patients with ureteral strictures underwent implantation of self‐ expanding ureteral stents in our department. 58stents were implemented. 47 out of 56 patients (84%) had iatrogenic ureteral strictures (secondary to surgery or radiotherapy). Strictures were divided into complicated and uncomplicated. Uncomplicated stricture was defined as a single stricture, up to 2cm long. Mean impantation time was 38 minutes. Mean explantation time was 24 minutes. Before implantation of the stent, the stricture was dilatated (min.9F, max.14F).Implantation of stent was performed under endoscopic vision and fluoroscopy. 20cm / 9F and 12cm / 10F stents were used. 32 of 58 stents were explanted (55%). 17 of 32 stents (53%) were explanted before scheduled time. Average indwelling time was 10 months. In the follow up, 69% of patients had renoscyntygraphy before and after the procedures (implantation and explantation). 95% of patients had ultrasound before and after the procedures (implantation and explantation).
Results: Average renal function before implantation of the stent was 43% (GFR 33,8 ml/min). Average renal function with ureteralstent was 35% (GFR 33,3 ml/min). Average renal function after explantation of the stent was 42,3% (32 ml/min).Average creatinine level before implantation of the stent was 1,13 ml/min/1,73m2. Average creatinine level with ureteralstent was 1,24 ml/min/1,73m2. Average creatinine after explantation was 1,65 ml/min/1,73m2.Major complications (Clavien‐Dindo > 2) occurred in 23% of patients (3A:11 patients, 3B: 1 patient, 5: 1 patient). Stent migration was observed in 34% cases.Improvement in the quality of life was reported by 74% of patients, while 24% of patients estimated their quality of life as the same as before the procedure. Ultrasound urine retention in renal collecting system was observed in 70% of patients with implemented stent. 76% of patients had ultrasound urine retention after stent explantation.Full therapeutic success (no need of renal stenting and good renal outflow proved in renoscyntygraphy) was achieved in 23 of 38 patients (60%), however in uncomplicated strictures group full therapeutic success was achieved in 19 of 21 cases (90%). 4 patients in uncomplicated strictures group were patients with ureterointestinal anastomotic strictures, and they achieved 100% full therapeutic success rate. In complicated strictures group, full therapeutic success was achieved in 5 of 18 patients (27%) but feasible renal outflow during stenting in that group was achieved in 21 of 25 patients (84%).
Conclusions: High efficiency of self-expanding stents is limited to uncomplicated strictures (single, < 2cm). With regard to complicated strictures, they can be used as kidney drainage system but won't be effective in full recovery of a stricture. In most of the casesstents improved the quality of life of patients with ureteral strictures. Decrease in renal function should be discussed with the patient due to hydronephrosis during and after the stenting.
Funding: None
Memokath 051 for Refractory Ureteric Obstruction: Our 3 Year Experience
John Hayes2, Parag Sonawane1, Kalpesh Parmar1, Chandrasekharan Badrakumar1
1The James Cook University Hospital, 2Department of Urology. The James Cook University Hospital.
Presented By: John Hayes
Introduction: Memokath051 (MMK) is a thermo‐expandable nickel‐titanium alloy stent used in themanagement of ureteric obstruction. The proposed advantages of MMK over the traditional double‐J stent include the avoidance of repeated stent changes, reduced irritative bladder symptoms and potential longterm cost savings. The National Institute for Health and Care Excellence (NICE) has recently recommended its use in selected cases. In this series we evaluate the outcomes of MMK in double‐J stentdependent patients.
Methods: A retrospective analysis of a prospectively maintained database of MMK insertions at a single unitbetween February 2020 and May 2023 was conducted. Inclusion criteria comprised patients that were (1)stent dependant (2) hadananticipated life expectancy of > 1 year and (3) were unsuitable for reconstructive procedures. Patients were followed up for stent position and patency with biochemical and radiological investigations. Outcome measures includedstent function,migration rates andadverse events.
Results: Forty‐nine consecutive MMKs were inserted in 34patients (20 female and 14male). This included 33unilateral and 8 bilateral stent insertions. 20 patients had a benign and 14 an underlyingmalignant aetiology. Prior to MMK insertion, patients were dependent on their double‐J stent(s)for a median of 33months (4‐180). The median followup following MMKinsertionwas 32months (6‐44).12‐, 24‐ and 36‐ month stent function rates were 60%, 56% and 56% respectively.There were 11 stent migrations, 7blockages, 2encrustations, 3episodes of urosepsis and 1 ureteric perforation.
Conclusions: Our case series would suggest that MMK051 has a role in select patients with refractory ureteric obstruction. The rateof stent migration is particularly high within the first year of insertion. Longer‐term followup data are requiredincluding more evidence in relation to patient‐reported outcomes. We await the results of the MinUS study;specifically designed to investigate quality‐of‐life outcomes of MMK versus double‐J stent.
Funding: None
4 Years of the Optilume® Drug Coated Balloon for Recurrent Anterior Urethral Strictures: A Summary of ROBUST I, II and III
Dean Elterman3, Sean Elliott1, Jessica Delong2, Ramon Virasoro2
1University of Minnesota, 2Eastern Virginia Medical School, 3University of Toronto
Presented By: Dean Elterman, MD, MSc, FRCSC
Introduction: The Optilume Drug Coated Balloon has been studied in three clinical investigations (ROBUST I, II and III). ROBUST I, the first in‐man trial conducted as a single arm, prospective multicenter study (4 sites, 53 subjects) followed by ROBUST II, early feasibility (5 sites, 15 subjects), and ROBUST III, the randomized pivotal trial (79 Optilume subjects). Optilume data combined from all three studies is presented here.
Methods: A total of 148 subjects were treated with Optilume in ROBUST I, II and III in Latin America, Canada, and the United States. Men with anterior urethral strictures ≤3cm and 1‐4 prior endoscopic interventions were treated with Optilume. Follow‐up was completed at 3 months, 6 months and annually thereafter. All studies were designed to follow subjects through 5 years with ROBUST I currently at 4‐year follow‐up, ROBUST II at 3‐year follow‐up and ROBUST III at 2‐year follow‐up, respectively.Outcomes included anatomic success at 6 months, International Prostate Symptom Score (IPSS), quality of life, freedom from repeat intervention, erectile function, flow rate (Qmax), and post‐void residual volume. Subjects receiving secondary treatment were considered failures. The safety endpoint assessed serious urinary events. Patients who failed standard of care therapy in the control arm of ROBUST III were allowed to cross over at 6 months and were followed.
Results: At the time of this abstract submission, IPSS improved in all patients treated with Optilume from 22.5 at baseline to 7.8 at 4 years. Peak urinary flow rate had a sharp, sustained improvement for patients treated with Optilume through follow‐up (7.1 to 14). Freedom from repeat intervention is approximately 73% at 4‐year follow‐up. Patients who crossed over in the ROBUST III study experienced significant improvements in IPSS and Qmax. Results will be updated at the time of the presentation.
Conclusions: Subjects with recurrent bulbar strictures treated with Optilume® paclitaxel‐coated balloon exhibited significant improvement in symptomatic and functional outcomes through 4 years post treatment with demonstrably improved recurrence rates. There was no impact on erectile function and there were no serious adverse events.
Funding: Urotronic
MODERATED POSTER SESSION 33: PCNL 3
The Path to An Opioid‐Free Percutaneous Nephrolithotomy: A Feasibility Study
Charan Mohan1, Gregory Mullen1, Jared Winoker1, David Hoenig1, Arun Rai1, Zeph Okeke1, Tareq Aro1
1The Smith Institute for Urology, Northwell Health
Presented By: Charan Mohan, MD
Introduction: Pain management following Percutaneous Nephrolithotomy (PCNL) is prudent given the ongoing opioid epidemic. While adjuncts such as quadratus lumborum and erector spinae blocks have been investigated as non‐opioid analgesics for PCNL, these require trained physicians and coordination with the operating room staff. We evaluate the feasibility of a no‐opioid, same‐day discharge protocol for PCNL using local bupivacaine liposome injectable suspension (EXPAREL®)
Methods: A retrospective analysis of miniature PCNLs (mini‐PCNL) performed by a single fellowship trained surgeon at a single institution was performed. Inclusion criteria was same day, tubeless procedures. Access was performed by the urologist, tract dilated using single step metallic dilator to 16Fr, and all patients discharged with a ureteral stent. At the conclusion of the procedure all patients received local injection of a mixture of 20cc EXPAREL® with 20cc 25% bupivacaine. This combination provides immediate short‐term and longer acting anesthesia. Demographic and surgical data was collected for all patients. Primary endpoint was the need for opioids after surgery and after discharge.
Results: A total of 16 patients were included in the analysis with a median age 60 (IQR 51‐71). 12 patients (75%) had stone burden greater than 2 cm, concomitant ureteroscopy was performed in 7 patients (44%), 1 patient required dilation of a ureteral stricture, and 1 patient had a horseshoe kidney. Of the 16 patients, only 3 were prescribed opioids at discharge, with an 83% completely opioid free rate. There were no re‐ admissions in this series, and none of the 16 patients requested additional opioids following surgery for one month.
Conclusions: This protocol of local anesthesia with bupivacaine liposome injectable suspension can help facilitate a same‐day, no‐opioid discharge protocol for mini‐PCNL, especially when access to more complicated protocols may not be readily available. This protocol also shows similar results in patients with complex and large stone burden. Further evaluation is needed in controlled prospective trials to validate these findings.
Funding: none
A Novel Prone Positioning Technique During Percutaneous Nephrolithotomy (PCNL) Using Single Transverse Chest Roll
Jenny Guo1, Nicholas Dean1, Mark Assmus2, Sai Kumar1, Xinlei Mi1, Amanda Knutson1, Amy Krambeck1, Matthew Lee3
1Northwestern University, 2University of Calgary, 3The Ohio State University
Presented By: Jenny Guo, MD
Introduction: Traditionally, prone positioning during PCNL has involved usage of two supports located at the chest and the pelvis. Currently, there are no studies in the literature describing the benefits of utilizing two supports, which can be time‐intensive and physically demanding to position. In this study, we compared anesthetic parameters using a novel single transverse chest roll (STR) technique to the double transverse roll technique (DTR).
Methods: A retrospective review of 441 patients who underwent PCNL at our institution between 2018 to 2022 was performed. A total of 4 surgeons were included—surgeon 1 utilized the STR technique while surgeons 2, 3, and 4 used the DTR technique. Anesthetic parameters including end tidal CO2 (ETCO2), mean arterial pressure (MAP), peak airway pressure (Ppeak), plateau airway pressure (Pplat), positive end expiratory pressure (PEEP), oxygen saturation (SpO2), and tidal volume (TV) were compared between both groups at 0 (supine), 15, 30, and 60 minute (min) post‐intubation intervals. Mixed effects regression models with interaction were created and pairwise comparisons were made between both groups. P‐values were adjusted using Tukey's method for multiple comparison (p < 0.05).
Results: A total of 581 PCNLs were performed with 199 using STR and 382 using DTR. Surgery duration (122 vs 127, p = 0.3), ASA class (p = 0.5), and age (57.7 vs 55.8, p = 0.13) were similar amongst the STR and DTR groups, respectively. Estimated blood loss (59cc vs 83cc, p = 0.007) and length of stay (77 hrs vs 163 hrs, p = < 0.001) was significantly lower in the STR group. There was no statistical differences in ETCO2 and PEEP at all time intervals. There was a significantly lower Ppeak and Pplat in the STR compared to DTR group at 0, 15, 30, and 60min (p < 0.001), which has been shown to be predictive of lower blood loss. Figure 1 displays the boxplot comparison of all anesthetic parameters.
Conclusions: Usage of a single transverse chest roll during prone PCNL appears to be a safe and effective positioning method.
Funding: none
WITHDRAWN
Discharge Without Opioids Following Percutaneous Nephrolithotomy is Safe and Feasible Using a Nonopioid Pathway
David Sobel2, Philip Caffery1, Evelyn James2, Rebecca Ortiz3, Aidan Peat4, Maximilian Jentzsch5, Erin Santos2, Chris Tucci3, Gyan Pareek1
1Brown University, 2Maine Medical Center, 3The Miriam Hospital Minimally Invasive Urology Institute 4Tufts University School of Medicine, 5University of Washington
Presented By: David Sobel, MD
Introduction: Recent studies have demonstrated the success of opioid‐sparing pathways for ureteroscopy, however, the feasibility of opioid‐free discharge after percutaneous nephrolithotomy (PCNL) has not been evaluated. This study aims to determine the feasibility of a novel nonopioid protocol consisting of enhanced preoperative counseling, multimodal nonopioid analgesics and detailed postoperative instructions.
Methods: A prospective feasibility study supported by NIGMS/NIH (P20GM125507) was conducted at a single institution. All subjects underwent single tract 30fr PCNL with urologist access and ureteral stent placement. Control arm subjects received postoperative opioid prescriptions at the discretion of the provider. Patients in the intervention arm underwent preoperative counseling, standardized orders (Figure 1) and specialized discharge instructions. Primary outcomes assessed were discharge without opioid prescription, emergency department (ED) visits for pain, worrisome telephone calls or requests for prescription refills.
Results: Fourteen subjects were enrolled in the control arm. Of these, 10 (71%) were discharged with opioid prescriptions and 4 (29%) were discharged without opioids. Of the 10 discharged with opioids, 2 (14%) presented to the ED for pain concerns and received a new prescription for opioids. One subject (7%) called the office and was provided reassurance over the phone. No outpatient prescription refills were ordered. Six subjects underwent intervention and received the novel nonopioid protocol. All subjects (100%) in the intervention arm were discharged without opioids. No subjects (0%) presented to the ED for pain concerns. One subject (17%) called the office and was provided reassurance. No new prescriptions for opioids were written.
Conclusions: This small feasibility study demonstrates that patients undergoing PCNL via this novel nonopioid pathway can be safely discharged without opioid prescriptions without impact on outpatient resources. Four subjects in the control arm were discharged without opioids based on provider discretion, suggesting that the standard of care to include an opioid prescription may be changing. Larger studies are ongoing to fully evaluate this protocol.
Funding: Research reported is supported by the National Institute of General Medical Sciences of the NIH under grant number P20GM125507. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Urologists Should Consider Routine Antifungal Prophylaxis in High Sepsis Risk Patients Undergoing Percutaneous Nephrolithotomy
Architha Sudhakar1, Erin Santos1, Evelyn James1, David Sobel1
1Maine Medical Center, Division of Urologic Surgery
Presented By: Architha Sudhakar, MD
Introduction: Current AUA guidelines do not recommend routine antifungal prophylaxis for patients undergoing percutaneous nephrolithotomy (PCNL), and only recommend single dose prophylaxis for patients with asymptomatic funguria detected on preoperative urine culture (PUC) prior to surgery. Previous research demonstrates that PUCs and renal stone cultures (RSCs) obtained during PCNL are often discordant, with
RSCs sometimes isolating atypical pathogens. We examined the role for routine antifungal prophylaxis in “high sepsis risk patients,” defined at our institution as patients with chronic indwelling catheters (foley, SPT, nephrostomy tube), staghorn stones, limited body mobility due to neurologic conditions, or history of sepsis of urinary origin within three months.
Methods: A systematic retrospective review of all PCNL procedures performed at a single academic institution from October 2016 through February 2023 was conducted. Procedures were included if RSC was obtained and sent during PCNL. Other variables such as PUC and incidence of postoperative sepsis (measured by qSOFA score) were recorded. The association between positive PUC and RSC speciation and postoperative sepsis was analyzed.
Results: Of 263 procedures included, 86 (33%) had positive RSC (Table 1). Within the positive RSC group, 21 (24%) stone cultures grew yeast. Yeast was the second most common pathogen speciated. Other dominant species in positive RSC included Enterococcus (29%), Proteus (23%), Pseudomonas (13%), and E. coli (13%).Of the patients with yeast‐growing RSC, 16 (76%) patients in the yeast‐growing RSC group were considered “high sepsis risk” according to our institutional criteria. 5 (24%) developed postoperative sepsis and only one of these received antifungals preoperatively. All 5 patients were classified as high sepsis risk.The overall incidence of patients with positive RSC and concordant positive PUC was 70% (Table 2). Only 5/21 (24%) patients with RSC demonstrating yeast had a concordant PUC with yeast growth. Yeast was the fifth most common pathogen speciated in PUCs. The overall incidence of postoperative sepsis was 7%.
Conclusions: Routine antifungal prophylaxis should be considered for any patient with high risk for sepsis undergoing PCNL regardless of preoperative urine culture. Yeast was found to be present in a high proportion of renal stone cultures which was not apparent on corresponding preoperative urine cultures. Our institution has implemented a high sepsis risk protocol utilizing a routine preoperative course of three days of fluconazole in addition to targeted antibiotics and antifungals with broad spectrum antibiotics perioperatively. Studies are ongoing to evaluate infectious outcomes following initiation of this protocol. We encourage other urologists to study their institutional stone culture antibiogram as this may inform augmented antimicrobial prophylaxis to reduce sepsis in these high risk patients.
Funding: No funding to disclose
PCNL for De‐Novo Urolithiasis After Kidney Transplantation: A Systematic Review of the Literature
Clara Cerrato1, Victoria Jahrreis1, Carlotta Nedbal1, Francesco Ripa2, Vincenzo De Marco3, Manoj Monga4, B. M. Zeeshan Hameed5, Peter Kronenberg6, Amelia Pietropaolo1, Bhaskar Somani1
1University Hospital Southampton NHS Trust, Southampton, UK, 2Department of Urology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milano, 3Urology Department, Azienda Ospedaliera Universitaria Integrata di Verona, 4Department of Urology, University of California San Diego, 5Father Muller Medical College Hospital, 6Hospital CUF Descobertas
Presented By: Clara Cerrato, MD
Introduction: Renal transplantation is the treatment for end stage renal disease that offers better quality of life and survival. Among the possible complications that might affect allografts, urolithiasis might have severe consequences, causing acute renal dysfunction (AKI) or septic events in immunocompromised patients. Allograft stones might be treated with external shockwave lithotripsy (ESWL), flexible ureteroscopy and lasertripsy (fURSL) or percutaneous nephrolithotomy (PCNL). A gap in the literature and guidelines exists regarding the best treatment option in this setting of patients. The aim of this Cochrane style review was to assess the safety and efficacy of PCNL in transplanted patients.
Methods: A comprehensive search in the literature was performed including articles between January 1987 and March 2023. Only English original articles were selected.
Results: Nine articles (108 patients) were included in the review. The mean age was 46.44 (±8.7) years with a male:female ratio of 54:44. The mean onset time between the transplantation and urolithiasis was 47.54 (±23.9) months. Patients more frequently presented with AKI (32.3%), followed by UTI and fever (24.2%), and oliguria (12.9%). The mean stone size was 20.1 mm (±7.3mm), and stones were more frequently located in the calyces or pelvis (41%), at the uretero‐pelvic junction (23.1%) or proximal ureter (28.2%). Overall, PCNL (22‐30F) were more frequently performed than mini‐PCNLs (16‐20F) (52.4% vs. 47.6%, respectively). Puncture was performed either ultrasound (USS) guided (42.9%), or fluoroscopy guided (14.3%) or via combined approach (USS+fluoroscopy) (42.9%). The overall stone free rate (SFR) and complication rates were 92.95% (range:77‐100%) and 5.5% (6/108), respectively, with only one major complication reported. Stones were mainly composed of calcium oxalate (42.6%), followed by uric acid (14.8%) and composite (uric acid/calcium oxalate) (13%). Post‐operatively, commonly a ureteral stent and a nephrostomy were placed (47%). Overall, during follow‐up (mean: 32.5 months), recurrence rate was 3.7% (4/108) and the mean creatinine was 1.37 mg/dL (±0.28).
Conclusions: PCNL remains a safe and effective option in de‐novo allograft urolithiasis, allowing to treat large stones in one step‐surgery. A good SFR is achieved with a low risk of minor complication. These patients should be treated in an endourology centre in conjunction with the renal or transplant team.
Funding: None.
How Possible is Staghorn Kidney Stones Stone‐Free?
Nebil Akdogan1, Nebil Akdogan1, Mutlu Deger1, Tunahan Ates1, Mert Evirgen1, Ismail Onder Yilmaz2, Ali Borekoglu3, Volkan Izol1, Ibrahim Atilla Aridogan1
1Cukurova University, Faculty of Medicine, Department of Urology, Adana, Turkey 2Ceyhan Public Hospital, Adana, Turkey, 3Mersin City Hospital, Mersin, Turkey
Presented By: Nebil Akdogan, MD
Introduction: Stone‐free in staghorn kidney stones is not always possible, but depends on many factors. In this study, we aimed to investigate the stone‐free rates of patients with staghorn type kidney stones after percutaneous nephrolithotomy (PNL).
Methods: 213 patients who were operated for staghorn kidney stones between September 2007 and July 2021 were retrospectively analyzed. Patients' age, body mass index, operation side, whether there is residual stone (SF/CIRF: stone‐free, CSRF: clinically significant stone), whether there is a history of previous urological intervention on the operation side (Extracorporeal Shock Wave Lithotripsy, Percutaneous Nephrolithotomy, Open Nephrolithotomy), the presence or absence of additional features, stone sizes, operation and scopy times, and whether a second and third entry was made were included in the study. Patients whose operation was terminated due to bleeding and anesthesia‐related reasons were excluded from the study. All operations were carried out by a single team. The statistics of the study were made using the SPSS program, Chi‐Square and Paired Samples T tests.
Results: Of the patients with clinically significant stone burden, 50 (60%) had a history of urological intervention on the same side. Statistically, this difference was significant (p:0.001, chi‐square test). The meanBMI was found to be 26.5 ± 7.32 on the SF/CIRF side and 28.99 ± 7.55on the CSRF side , and it was statistically different (p:0.018, independent samples t test). The mean stone burden was found to be1120.51 ± 524.73mm3 on the SF/CIRF side and 1535.37 ± 926.47mm3on the CSRF side, and this difference was statistically significant (p:0.001, independent samples t test).98 (46%) patients received the second entry, and 20 (8%) patients received the third entry. Stone free was observed in 73 (74%) patients (p:0.001, chi‐ square test) who entered the 2nd entry, and 17 (85%) of the patients who entered the 3rd entry (p:0.023, chi‐ square test) and it was statistically significant.
Conclusions: As the body mass indexes of the patients increase, the probability of stone free decreases. Prior intervention in the kidney where the operation will be performed and the increase in the stone volume of the patients reduce the possibility of stone‐free. If appropriate conditions are provided when necessary; Making the second and third entries should not be avoided.
Funding: NONE
The First 300 Cases of Endoscopic‐Combined Intrarenal Surgery in Korea: Factors for Postoperative Successful Outcomes
Dae Young Jun7, Jun Seok Sohn1, Jae Yong Jeong2, Young Joon Moon3, Dong Hyuk Kang4, Hae Do Jung5, Seung Hyun Jeon6, Joo Yong Lee7
1Department of Medicine, Yonsei University College of Medicine, Seoul, Korea, 2Department of Urology, National Health Insurance Service Ilsan Hospital, Goyang, Korea, 3Department of Urology, Kyungpook National University Hospital, Daegu, Korea, 4Department of Urology, Inha University College of Medicine, Incheon, Korea, 5Department of Urology, Inje University Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea, 6Department of Urology, Kyung Hee University College of Medicine, Seoul, Korea, 7Department of Urology, Severance Hospital, Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea
Presented By: Dae Young Jun, MD.
Introduction: We shared the experience of endoscopic combined intrarenal surgery (ECIRS) and analyze surgical outcomes and successful factors in the consecutive 300 ECIRS cases.
Methods: We performed ECIRS for 300 adult patients in August 2017 to May 2021. Fifty‐six patients underwent standard‐ECIRS using 24 Fr nephroscope and 237 underwent mini‐ECIRS with 12 Fr mini‐ nephroscope. Seven patients underwent ultramini‐ECIRS with 8.5 Fr MIP‐S nephroscope. All cases were performed simultaneously using flexible ureteroscope. An ECIRS was performed with the patient under general anesthesia in the intermediate‐supine (GMSV) position.
Results: One hundred eighty‐two patients were male and 118 were female and mean age was 58.78 ± 13.48 years. Mean maximal stone length (MSL) was 28.28 ± 14.24 mm. The average mean stone density (MSD) was 1037.61 ± 367.15 HU and mean stone heterogeneity index (SHI) was 179.50 ± 99.31 HU. Variation coefficient of stone density (VCSD) was 18.51 ± 18.13 and linear calculus density (LCD) was 0.84 ± 1.13. The Seoul National University Renal Stone Complexity (S‐ReSC) score was 4.42 ± 2.60 and the average modified S‐ ReSC score was 6.56 ± 3.35. Mean operative time was 78.28 ± 32.56 minutes, and the patient was discharged on postoperative day 2 (IQR 2‐3). Thirty‐four patients underwent simultaneous ipsilateral ECIRS and contralateral RIRS, and 14 patients underwent ipsilateral ureteroscopic ureterolithotomy. There were significant differences in MSL, LCD, S‐ReSC, and modified S‐ReSC scores in stone characteristics and operation time in peri‐operative outcomes between failure and success groups after ECIRS (Table 1). In logistic regression models, MSL (OR 0.963; 95% CI 0.944‐0,982; P < 0.001), LCD (OR 4.894; 95% CI 2.112‐13.306; P < 0.001), S‐ReSC (OR 0.823; 95% CI 0.733‐0.923; P < 0.001) and modified S‐ReSC scores (OR 0.859; 95% CI 0.780‐0.942; P = 0.001) were significant factors for success rate after ECIRS.
Conclusions: In patients underwent ECIRS, the size factors of stones including MSL, LCD, S‐ReSC and modified S‐ReSC were significant predictable factors for postoperative successful outcomes.
Funding: None.
is Percutaneous Nephrolithotomy Effective and Safe in Infants Younger than 2 Years Old? Comparison of Mini and Standard Percutaneous Nephrolithotomy
Nebil Akdogan1, Nebil Akdogan1, Mutlu Deger1, Ismail Onder Yilmaz2, Ali Borekoglu3, Volkan Izol1, Ibrahim Atilla Aridogan1, Nihat Satar1
1Cukurova University, Faculty of Medicine, Department of Urology, Adana, Turkey 2Ceyhan Public Hospital, Adana, Turkey, 3Mersin City Hospital, Mersin, Turkey
Presented By: Nebil Akdogan, MD
Introduction: Many studies have been conducted on mini percutaneous nephrolithotomy (MPCNL) and standard percutaneous nephrolithotomy (SPCNL) in adults and children. Due to the small urinary system in infants, various difficulties are experienced in percutaneous nephrolithotomy.Our aim is to compare the differences, efficacy, and safety of MPCNL and SPCNL results in infants less than two years old.
Methods: We retrospectively analyzed 163 patients younger than two years of age who underwent percutaneous nephrolithotomy (PCNL) in our institution between September 1999 and March 2022. The patients were divided into two groups depending on the tract size. The MPCNL group consisted of 73 patients with a tract of 22 Fr or less, and the SPCNL consisted of 90 patients with a tract greater than 22 Fr.
Results: The median age of 163 patients included in the study was 17.3 (range 7‐24) months. Although the median stone size was lower in the SPCNL group, no statistically significant difference was found between the two groups in terms of stone size (p = 0.073). The median operative time was 74.8 minutes in the MPCNL group and 62.8 minutes in the SPCNL group, with a statistically significant difference (p = 0.002). Stone free rates (SFR) were 89% and 90.8% in the MPCNL and SPCNL groups, and the clinically insignificant residual fragments(CIRF) rates were 11% and 4.6%, respectively (p = 0.064). The fluoroscopy time, nephrostomy withdrawal time, and hospitalization stay were similar in the two PCNL groups (p = 0.535, p = 0.253, and p = 0.143, respectively).Postoperative fever was similar in MPCNL and SPCNL groups (p = 0.504). Although bleeding and blood transfusion rates were higher in the SPCNL group, there was no statistically significant difference (p = 0.248 and p = 0.420, respectively). Prolonged urinary leakage occurred in 6 (8.2%) patients in the MPCNL group and 1 (1.1%) patient in the SPCNL group, with a statistically significant difference (p = 0.026). In the SPCNL group, ureteral avulsion occurred in one patient, ureteropelvic junction perforation in one patient, conversion to open surgery in one patient, and colon injury in one patient.
Conclusions: With the development of MPCNL, the use of SPCNL in infants has decreased considerably. However, SPCNL continues to take its place as an effective and reliable method when needed in suitable patients. Although PCNL in infants shows some differences from adults, it is an effective and safe method for suitable patients.
Funding: NONE
Facilitating Percutaneous Nephrostolithotomy by Using Multimodal Radiographic Techniques in a Team‐Oriented Approach
Gilad Hampel3, Ori Hampel1, Nehemia Hampel2
1Managing Partner, Adult and Pediatric Urology of Houston LLP, 2Professor Emeritus, Case Western Reserve University School of Medicine, 3Tulane University School of Medicine
Presented By: Ori Hampel, MD
Introduction: Successful percutaneous nephrostolithotomy (PCNL) hinges on obtaining ideal percutaneous access. Challenges in obtaining ideal access discourage many urologists from personally pursuing PCNL for their patients. Interventional radiologists are more facile than most urologists at percutaneous access, while most urologists can perform PCNL given adequate access. We present techniques for optimizing access for PCNL applicable in various hospital settings while decreasing radiation exposure.
Methods: An open‐ended ureteral catheter is placed in retrograde fashion. A solution of iodinated contrast and methylene blue or indigo carmine is used to distend the collecting system to enhance access. We utilize ultrasonography in addition to fluoroscopy. We use an intraoperative team approach which includes the interventional radiologist working with the urologist in the operating room.
Results: Our techniques have been optimizedover 25 years. Distending the collecting system in retrograde fashion improves percutaneous renal access by: (1) opacifying the collecting system with concentrated contrast, (2) facilitating wire negotiation around stones by stretching the collecting system away from the stone, and (3) introducing intrarenal fluid which facilitates using ultrasound for initial access and decreases radiation exposure. Adding the blue dye improves verification of renal collecting system access by ensuring the fluid aspirated via the access needle is indeed from the collecting system. This verification additionally decreases radiation exposure. Incorporating interventional radiology into the intraoperative surgical team facilitates percutaneous access and improves efficiency of percutaneous stone management.
Conclusions: Distending the collecting system with concentrated iodinated contrast along with a blue dye improves percutaneous access for PCNL. Having the urologist guide the interventional radiologist in the operating room improves negotiating the access needle into the correct calyx with the ideal trajectory, which allows excellent stone clearance and improves care. Our approach also decreases radiation exposure to the patient and the surgical team. A multidisciplinary approach including urologist and interventional radiologist working together in the operating theatre provides better care while allowing urologists less facile in percutaneous renal access to successfully perform PCNL in various hospital settings.
Funding: Not Applicable
Bayesian Network Meta‐Analysis of Stone‐Free Rates After Retrograde Ureteroscopy, Percutaneous Nephrolithotomy and Mini–Percutaneous Nephrolithotomy
Wesley a. Mayer1, David E. Hinojosa‐Gonzalez1, Gal Saffati1, Shane Kronstedt1, Connor Rodriguez1, Richard Link1
1Baylor College of Medicine
Presented By: Wesley A. Mayer, MD
Introduction: Current guidelines endorse a variety of endourologic techniques for the management of renal stones. Percutaneous Nephrolithotomy (PCNL), while more invasive than retrograde intrarenal surgery (RIRS), has evolved toward smaller tract sizes and instrumentation. The relative effectiveness of these various endoscopic techniques has been studied in randomized clinical trials (RCTs), yielding mixed results. We executed a network meta‐analysis to analyze the available evidence comparing stone‐free rates of various endoscopic.
Methods: A systematic review was performed, identifying RCTs comparing RIRS, standard‐PCNL (tract size of 22‐30F), mini‐PCNL (15‐21F), ultramini‐PCNL (10‐14F), and Micro‐PCNL (10‐14F) in patients with renal stones. Studies were grouped by location and size of stones (lower pole, renal stone 1‐2 cm versus > 2 cm). Extracted data were used to build a Bayesian network to model comparisons. Meta‐regression adjusted for variations in stone‐free definition criteria. Results are presented in odds ratios with (95% credible interval).
Results: A total of 43 trials were analyzed, including 7,308 patients. For lower pole stones, 1,792 patients from 14 RCTs were analyzed, providing comparisons of RIRS vs. standard‐PCNL vs. mini‐PCNL vs. ultramini‐PCNL vs micro‐PCNL. Compared to PCNL, RIRS had the lowest SFR compared to all varieties of percutaneous surgery (Figure 1A). For renal stones of 1‐2 cm, 2,079 patients from 16 RCTs provided data for comparisons of RIRS vs. standard‐PCNL vs. mini‐PCNL vs. ultramini‐PCNL (Figure 1B); SFR were similar between all procedures. For stones > 2 cm, 4,012 patients from 19 RCTs compared RIRS vs. standard‐ PCNL vs. mini‐PCNL vs. ultramini‐PCNL; RIRS showed significantly decreased SFR vs. standard PCNL, mini‐PCNL, and ultramini‐PCNL (Figure 1C).
Conclusions: Standard‐PCNL and mini‐PCNL have similar SFR. In lower pole and larger stones, RIRS has decreased SFR vs. percutaneous interventions. Data on ultramini‐PCNL and micro‐PCNL is limited but appears to perform similarly to mini‐PCNL. Further studies are needed to increase the certainty of findings.
Funding: None
Indirect Comparison of Peripheral Nerve Blocks' Impact on Post‐Percutaneous Nephrolithotomy Pain Management: A Systematic Review and Bayesian Network Meta‐Analysis
Brian H Eisner2, Juliana Villanueva1, Michal Segall2
1Columbia, 2Massachusetts General Hospital
Presented By: Brian H Eisner, MD
Introduction: Urolithiasis has notably increased incidence rates within the United States. Consequently, a range of therapeutic strategies has been developed to address this condition, among which Percutaneous Nephrolithotomy (PCNL) is a frequently employed intervention for > 2cm stones. However, PCNL's increased efficiency comes at the cost of higher complications and transfusion rates with increased postoperative pain. Peripheral nerve blocks are being studied to reduce pain and narcotics requirements in these patients. Although there are no direct comparisons of different block types, network meta‐analysis can provide preliminary comparisons and estimate treatment differences even without direct evidence.
Methods: We systematically searched multiple databases to identify relevant articles on peripheral nerve blocks in patients undergoing PCNL in October 2021. We included randomized controlled clinical trials (RCTs) comparing these blocks to general anesthesia. Studies using spinal anesthesia as a control group were excluded. We performed data extraction and analysis with a Bayesian network meta‐analysis framework. We assessed Heterogeneity using Higgins. Model fits and consistency were also evaluated, and treatment ranking was analyzed using the SUCRA curve. Drugs with similar effects but varying dosages were grouped for analysis
Results: A total of 15 RCTs were analyzed, with five studies on para‐vertebral blocks (PVB), three on erector spinal blocks (ESB), five on quadratus lumborum block (QLB), and two on intercostal nerve blocks (ICNB). The analysis included 702 patients, with 353 undergoing general anesthesia, 115 receiving PVB, 86 receiving ESB, 98 receiving QLB, and 50 receiving ICNB. Among the 13 studies that reported Visual Analogue Scale (VAS) scores, all interventions showed significantly decreased mean differences compared to general anesthesia. The highest SUCRA score for VAS scores was observed for ICNB at 0.865, followed by ESB at 0.629.
Conclusions: PNBs are similarly efficient at reducing postoperative VAS scores. PVB seems to lower rates of rescue analgesics and nausea and vomiting. Urologists should consider integrating this multidisciplinary approach to reduce patient pain and opioid use. Further high‐quality studies are needed to confirm these findings.
Funding: No funding was received
A Population‐Based Analysis of the COVID‐19 Generated Surgical Backlog for Ureteroscopy, Percutaneous Nephrolithotomy, and Extracorporeal Shockwave Lithotripsy
Paul Cheon2, David Gomez1, Kenneth T. Pace2
1Division of General Surgery, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
2Division of Urology, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
Presented By: Egor Parkhomenko, MD
Introduction: The COVID‐19 pandemic had a global impact on elective surgery with delays and slowdowns, resulting in large surgical backlogs. Delay in elective surgery, such as kidney stone treatment, may lead to increased emergency department presentations and need for urgent interventions. We aimed to identify periods of surgical backlog and recovery in elective ureteroscopy/laser lithotripsy (URS), percutaneous nephrolithotomy (PCNL), and extracorporeal shockwave lithotripsy (ESWL) during and following the COVID‐19 pandemic.
Methods: Population‐based rates of elective URS, PCNL and ESWL during the first (March‐June 2020) and second (November 2020‐February 2021) waves of COVID‐19 and the following 19 months in Ontario, Canada, were quantified. Poisson generated estimating equation models were used to predict expected rates during COVID‐19 based on the pre‐COVID‐19 period. The standardized rate ratios (SRRs) of observed (actual stone treatment events) to expected rates was generated for surgical procedures.
Results: Overall, 25927 elective URS, 1507 PCNL, and 1730 ESWL cases were identified. During the first COVID‐19 period, overall elective stone procedures decreased by as much as 67% (SRR 0.327; 0.313‐ 0.341), and continued to be performed at below expected rate post‐COVID‐19 waves. In absolute terms, the backlog was greatest for URS performed below the expected rate (1071 cases), while in relative terms, the under‐performance of PCNL was the greatest during and after COVID‐19 waves (SRR 0.571; 0.355‐0.634). ESWL was the only procedure with sustained periods of recovery, as high as 49% above expected (SRR 1.494; 1.300‐1.717).
Conclusions: An overall decrease in elective stone procedures were observed during the COVID‐19 pandemic. URS and PCNL were being performed at below or expected rates post‐COVID‐19 pandemic without significant periods of recovery, suggesting a backlog of these procedures. We are currently examining emergency department presentations and urgent interventions related to kidney stones to assess any correlation between surgical backlog and patient outcomes.
Funding: The Research Innovation Council of the St. Michaels Hospital Foundation and the Ontario Health Data Platform(David Gomez)
Endourology Treatments for De‐Novo Allograft Urolithiasis: A Systematic Review of the Literature
Clara Cerrato1, Victoria Jahrreis1, Carlotta Nedbal1, Francesco Ripa2, Vincenzo De Marco3, Manoj Monga4, B. M. Zeeshan Hameed5, Peter Kronenberg6, Amelia Pietropaolo1, Bhaskar Somani1
1University Hospital Southampton NHS Trust, 2Department of Urology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milano, 3Department of Urology, Azienda Ospedaliera Universitaria Integrata di Verona, 47Department of Urology, University of California San Diego, 5Father Muller Medical College Hospital, 6Hospital CUF Descobertas
Presented By: Clara Cerrato, MD
Introduction: Urolithiasis is a rare complication of renal transplantation.As per Guidelines, allograft stones might be treated with external shockwave lithotripsy (ESWL), flexible ureteroscopy and lasertripsy (fURSL) or percutaneous nephrolithotomy (PCNL). However, no technique resulted to be superior to the other. In this Cochrane‐style review we wanted to assess the safety and efficacy of each endourologic minimally invasive treatment for de novo urolithiasis in transplanted patients.
Methods: A comprehensive search in the literature was performed including articles between November 2003 and March 2023. Only English original articles were selected. This survey was registered in PROSPERO with the numberCRD42023412910.
Results: Twenty‐two papers (318 patients) were included in the review. Patients were mainly males (56.8%), mean age was 45.4 (±10.1) years. The mean onset between transplantation and urolithiasis was 41.9 (±25.2) months. At diagnosis patients were usually asymptomatic; when symptomatic, they more frequently presented with acute kidney failure (AKI, 14.6%), followed by hematuria (14.3%), and urinary tract infection (UTI) or fever (13.3%). Overall, stones were predominantly located in the kidney (52.8%). Patients were treated with URS (40.6%), followed by PCNL (34.0%) and SWL (25.4%). The choice of treatment was driven by stone size, location, and surgeon's preference. The overall stone size was 13.1 (±7.4) mm and stone free rates (SFR,%) were 94.08%, 81%, 80.6%, for PCNL, ESWL and URS, respectively. For PCNL, ESWL and URS, 6, 5, and 11 patients needed a second intervention for complete stone clearance, respectively. Overall, stones analysis revealed a predominance of calcium oxalate stones (17.3%), followed by uric acid (5.1%), struvite or calcium phosphate stones (3.7% each, respectively). Overall complication rate was 10.38% (33/318). Major complications according to the Clavien Dindo classification (III/IV) were 1 (1/6), 1 (1/10), and 7 (7/17), for PCNL, ESWL and URS, respectively. Overall, during follow‐up (44.01 months), recurrence rate was4.4% (14/318) and the mean creatinine was 1.36 mg/dL (±0.3), with generally no reports of allografts loss of function.
Conclusions: Urolithiasis in allograft population remains a rare event. All endourological procedures are safe and effective options to treat de‐novo allograft urolithiasis. The procedure should be decided according to stone size, location and surgeon expertise. Given the technical difficulties and the challenging allograft anatomy, patients should be treated in an endourology referral centre in conjunction with the renal or transplant team.
Funding: None.
One‐Year Follow‐up of a Multidisciplinary Approach to Percutaneous Cholelithotomy for Inoperable Calculous Cholecystitis: A Multi‐Institutional Prospective Review
Daniel Marchalik1, Neil Jain1, William Browne2, Venkatesh Balaji2, Timoth Mcclure2, Kenneth Lim1, John Smirniotopolous1
1Georgetown University, 2Weill Cornell
Presented By: Daniel Marchalik, MD, MBA
Introduction: The aim of this study is to assess for long‐term efficacy of percutaneous large bore (24–30 French) gallstone extraction for a subset of patients who are poor surgical candidates employing a multi‐ discplinary team of urology and interventional radiology.
Methods: This is a multi‐institutional Institutional Review Board‐approved prospective observational review of patients at two large academic centers who presented with acute calculous cholecystitis and were determined to be high‐risk surgical candidates. Review parameters included procedural technical and clinical data, clinical presentation, average hospital length of stay, and post‐intervention symptom reduction. Technical success was defined as the removal of all stones during the procedure. Clinical success was defined as stone‐free on 12‐month follow‐up imaging.
Results: Fifteen patients (mean age 77.9yr, range 52–94yr; 8 male and 7 female) underwent large bore sheath (24–30Fr) cholangioscopy assisted gallstone extraction using principles and equipment similar to percutaneous nephrolithotomy. Lithotripsy was performed primarily using the ShockPulse‐SE lithotripter.
The size of the gallstones ranged from 0.5–4.0cm. All patients had prior transhepatic or transperitoneal cholecystostomy access for 3‐6 weeks prior to gallstone extraction.All patients' indwelling accesses were upsized to 24Fr or 30Fr sheaths using either the NephroMax balloon sheath system or the X‐Force balloon dilation catheter. There was 93.3% technical success rate with no major procedure‐related complications. 93.3% were symptom and pain‐free immediately post‐procedure. There were no major complications. Median hospital stay was 1‐day post‐procedure. Of the fifteen patients, nine patients had 12‐month follow‐up US or CT. 33% had recurrent cholelithiasis and 0% had recurrent cholecystitis on imaging.
Conclusions: Majority of patients were stone‐free on one‐year follow‐up imaging after percutaneous fluoroscopic‐guided large bore (24 − 30 French) gallstone extraction. Urologic expertise plays a key role in providing multi‐discplinary support in this novel approach to gallstone lithotripsy.
Funding: none
Fractured and Fully Encrusted Retained Ureteral Stent
Nir Tomer1, Nir Tomer1, Johnathan Khusid1
1Mount Sinai Hospital
Presented By: Nir Tomer, MD
Introduction: Ureteral stent encrustation is a devastating complication that can occur if a ureteral stent is retained for a prolonged period. Here we discuss a case report of severely encrusted, fractured bilateral ureteral stents.
Methods: We reviewed a case of a 54‐year‐old man who presented to our hospital with malaise and flank pain. Imaging revealed multiple retained foreign bodies and near‐total urinary tract stone disease including a fractured, fully encrusted, right ureteral stent, massive bladder stone, urethral stone, bilateral renal stones, right nephrostomy catheter, and left percutaneous nephroureteral catheter. Per external records, bilateral ureteral stents were placed in 2015 for nephrolithiasis. However, he was lost to follow up and his subsequent procedural history is unclear.
Results: Definitive nephron‐sparing, endoscopic management was pursued via cystolitholapaxy, ureteroscopic laser lithotripsy, and percutaneous nephrolithotomy (PCNL). The severe encrustation and fractured state of the right stent necessitated staged extraction over three procedures for the distal, proximal, and middle segments. In total, the patient underwent five staged endoscopic procedures to successfully render his urinary tract stone and foreign body free. First, he underwent cystolitholapaxy, right distal ureteroscopy and laser lithotripsy with extraction of distal curl. Second, he underwent a right PCNL, extraction of proximal curl and right tandem stent placement. Third he underwent a left PCNL, extraction of the left nephroureteral catheter and left ureteral stent placement. Fourth he underwent a right PCNL with extraction of the middle portion of the retained stent, new right ureteral stent placement, and left stent removal. Fifth he underwent a right ureteroscopy, laser lithotripsy to remove residual stone fragments and removal of the right stent. His creatinine pre‐procedure was 2.2 and his creatinine at the conclusion of his staged procedures was 1.3 (his baseline).
Conclusions: In severe pan‐urinary tract stone disease, all modalities in the endourologist's armamentarium should be utilized. Importantly, use of a tandem stent allowed for repeated safe access to the ureter during the staged extraction procedures. In our case, our patient ultimately required five staged procedures to treat the patients stone disease and render the patient stone and foreign body free.
Funding: None
Comparing Laparoscopic Ureterolithotomy and Ureterorenoscopy for Upper Ureteral Stones: Efficacy and Complication Rates
Goktug Kalender2, Ugur Aferin1, Berin Selcuk1, Muhammet Demirbilek1, Mehmet Hamza Gultekin1, Bulent Onal1
1Istanbul University‐Cerrahpasa, Cerrahpasa Faculty of Medicine, 2Istanbul University‐Cerrahpasa, Cerrahpasa School of Medicine
Presented By: Goktug Kalender, MD
Introduction: We aimed to compare the efficacy, need for auxiliary procedures, and complications of ureterorenoscopy (URS) and laparoscopic ureterolithotomy (LU) for proximal and mid‐ureteral stones ≥1.5 cm.
Methods: Medical dates of patients who underwent LU and URS between July 2004 and November 2021 were retrospectively reviewed. Patients with proximal and mid‐ureteral stones ≥15 mm in size were selected from this database. We excluded patients with stone size < 15 mm, distal ureteral stone, previous ipsilateral ureteral operation history, and any underlying ureteric pathology such as tumor or stricture. Patient demographics, stone characteristics, perioperative data, and follow‐up charts were collected for each patient. For stone size, the longest axis of the stone was considered in non‐contrast computerized tomography. Statistical analysis of all data was evaluated using Independent Samples T‐test, The Mann–Whitney U test, χ 2 and Fisher's Exact Tests. The statistical significance limit of all evaluations was accepted as p < 0.05.
Results: All results related to the study were presented in Tables 1, 2, and 3.
Conclusions: LU should be the first choice for the treatment of upper ureteral stones ≥15 mm due to its high stone clearance rates and efficiency quotient, less need for auxiliary treatment, and major complication rates.
Funding: None.
A Population‐Based Retrospective Cohort Study Comparing Trends in the Surgical Management of Urinary Stone Disease in Canada and Israel
Dor Golomb1, Orit Raz1, Amir Cooper1, Andrew Mcclure4 McClure2, Sumit Dave3, Fernanda Gabrigna Berto3, Jennifer Bjazevic3, Hassan Razvi3
1Assuta Ashdod University Hospital, 2Department of Surgery, Schulich School of Medicine and Dentistry London Health Sciences Centre, London, Ontario, Canada, 3Division of Urology, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
Presented By: Dor Golomb, MD
Introduction: Stone related surgical intervention has increased around the world. Our objective was to compare trends and incidence of surgical intervention for adults with upper urinary tract stones in the different geographical areas of Ontario, Canada and Israel.
Methods: A retrospective, population‐based cohort study was conducted utilizing administrative databases held at the Clalit Health Service in Israel and the Canadian Institute for Health Information, Discharge Abstract Database or via physician billing information using the Ontario Health Insurance Plan database in Canada. We identified all adults (≥18 years) who underwent their first surgical treatment for urolithiasis.
Descriptive statistics were used to summarize baseline patient demographics and surgical trends were analyzed using the Cochrane‐Armitage test for trend.
Results: Between 2003‐2018 36,624 and 134,585 patients underwent their first stone related surgical procedure in Israel and Ontario, respectively. In the years investigated, the number of insured adults at Clalit Health Services grew by 21%, compared to 24.4% growth of the population in Ontario. The total number of surgically treated stone procedures increased by 82.1% and 80.5% in Israel and Ontario, respectively. The number of surgical procedures per 100,000 people grew by 51% in Israel, compared to 45.3% in Ontario. By type of procedure, ureteroscopy (URS) increased by 351% and 158%, percutaneous nephrolithotomy (PCNL) increased by 63% and 187%, while the number of shock wave lithotripsy (SWL) declined by 79% and 31.4% in Israel and Ontario, respectively.
Conclusions: The number of stone related surgical procedures performed rose significantly in both countries. The increased incidence in Israel was higher compared to Ontario. The rising incidence of stone related surgery may imply an increasing incidence of urolithiasis or a reflect a changing trend in the indications for intervention.
Funding: None.
Safety and Efficacy of Ambulatory Tubeless Mini‐Percutaneous Nephrolithotomy (Mini‐ PCNL) in the Management of 10–25‐Millimeter Renal Calculi: A Retrospective Study
Husain Alaradi1, Parsa Nikoufar1, Amr Hodhod1, Moustafa Fathy1, Sai K Vangala1, Ahmed S Zakaria1, Ruba Abdul Hadi1, Loay Abbas1, Waleed Shabana1, Ahmed Kotb1, Walid Shahrour1, Hazem Elmansy1
1Northern Ontario School of Medicine
Presented By: Sai Vangala, MD
Introduction: To study the safety and efficacy of ambulatory tubeless mini‐percutaneous nephrolithotomy (mini‐PCNL) in the management of 10‐25 mm renal stones.
Methods: We conducted a retrospective study of patients who underwent mini‐PCNL at our institution from September 2018 to September 2022. Ninety‐five patients with 10‐25 mm renal calculi were included in the study. All participants underwent a CT renal colic scan preoperatively, on postoperative day one (POD 1), and at 3 months follow‐up. Patient demographics and outcome measures were recorded, including stone characteristics, operative time, hospital stay, stone‐free rate (SFR), complication rates, and subsequent Emergency Room (ER) visits. Patients were deemed stone‐free if they had no fragments or residual fragments < 4 mm.
Results: The median maximum stone diameter was 16 (10‐25) mm. Twenty‐nine patients (30.5 %) had multiple renal calculi. The median operative time was 64 (38‐135) minutes. Ninety percent of patients had a totally tubeless procedure. All patients were discharged home on the same operative day with a median hospitalization time of 6 hours. Seven (7.4%) postoperative ER visits were recorded, and one (1.1%) led to hospital readmission. The frequency of Grade I, II, and III Clavien‐Dindo complications were 14 (14.7%), 2 (2.1%), and 1 (1.1%), respectively. The SFR on POD 1 and 3‐months follow‐up was 73.6 % and 92.6%, respectively. None of the patients in the study required retreatment.
Conclusions: Ambulatory tubeless mini‐PCNL is a safe and effective treatment option for 10‐25 mm renal calculi with a reasonable SFR, low morbidity and short hospital stay. Patients may benefit from decreased postoperative analgesic use.
Funding: None
MODERATED POSTER SESSION 34: STONES URETEROSCOPY 4 AND SWL
Break WaveTM Lithotripsy for Urolithiasis: Results of the First‐in‐Human International Multicenter Clinical Trial
Ben H Chew5, Jonathan D. Harper1, Roger L Sur2, Thomas Chi3, Shubha De4, Anne R. Buckley5, Ryan F Paterson5, Connor M Forbes5, M. Kennedy Hall1, Ross Kessler1, Jason R Woo6, Ralph C Wang3, David B Bayne7, Derek Bochinski4, Trevor Schuler4, Tim A Wollin4, Rahim Samji4, Mathew Sorensen1
1University of Washington, 2University of California San Diego, 3University California San Francisco, 4University of Alberta, 5University of British Columbia, 6University California San Diego, 7University of California San Francisco
Presented By: Ben H Chew, MSc, MD, FRCSC
Introduction: Break Wave lithotripsy is a new non‐invasive technology for the treatment of urolithiasis that can be performed with little to no anesthesia, potentially allowing stone treatment in non‐operative settings. This study reports safety, efficacy, and anesthesia requirements from a first‐in‐human, prospective, multicenter, open‐label single‐arm clinical trial (NCT03811171) utilizing the SonoMotion (San Mateo, CA) Break Wave device.
Methods: Forty‐four (44) patients with ureteral or renal stones were treated across five North American centers (US/Canada) between 08/2019 – 02/2022. Patients were recruited and treated in the operating room, office/clinic, or emergency department (ED). Thirty minutes of Break Wave therapy was delivered under continuous ultrasonography targeting. Varying therapy dose levels up to 8MPa of acoustic pressure were administered and safety, effectiveness and anesthesia requirements were assessed to establish optimal dose settings. The efficacy objective was stone free rate or fragments ≤4 mm assessed via non‐contrast CT at 8‐12 weeks by an independent radiologist. Patients were followed for 90 days with all adverse events (AEs) recorded.
Results: Target stones were in typical locations and sizes (Table 1) with 59% renal (n = 26) and 41% in the distal ureter (DU) (n = 18). No serious AEs, hematomas, cardiac arrythmia or sepsis occurred at any dose level. Overall, 86% of subjects received either no medication (50%) or minor analgesia (36%) (e.g., ketorolac 15‐30mg). All patients completed the procedure. Stone fragmentation occurred in 88% of cases, with 70% of subjects being either completely stone free or with fragments ≤4 mm on CT. The retreatment rate was 7% within 90 days with either SWL or URS. The optimal dose setting was identified and delivered to 36 of 44 patients. Of these 36 patients, 75% had fragments ≤4mm and 58% were completely stone free, 71% of lower pole patients (n = 14) had fragments ≤4mm with 29% stone free, and 89% of DU patients (n = 18) were completely stone free.
Conclusions: Break Wave Lithotripsy appears to be a safe and effective non‐invasive stone therapy requiring little to no anesthesia. It is potentially suitable for non‐operative environments such as the office or ED and is being evaluated in ongoing trials.
Funding: Work supported by NIH – NIDDK (R44DK1097790) and Sonomotion Inc.
SWL for De‐Novo Urolithiasis After Kidney Transplantation: A Systematic Review of the Literature
Clara Cerrato1, Victoria Jahrreis1, Carlotta Nedbal1, Francesco Ripa2, Vincenzo De Marco3, Manoj Monga4, Amelia Pietropaolo1, Bhaskar Somani1
1University Hospital Southampton NHS Trust, 2Department of Urology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milano, 3Azienda Ospedaliera Universitaria Integrata di Verona, 4Department of Urology, University of California San Diego, San Diego
Presented By: Clara Cerrato, MD
Introduction: Renal transplantation remains the best therapeutic approach to treat end‐stage renal disease (ESRD). Allograft urolithiasis is an uncommon, challenging, and a potentially dangerous clinical problem. Treatment of allograft stones include external shockwave lithotripsy (ESWL), flexible ureteroscopy and lasertripsy (fURSL) or percutaneous nephrolithotomy (PCNL). A gap in the literature and guidelines exists regarding the treatment in this setting of patients. The aim of this Cochrane style review was to collect preoperative and treatment characteristics, and to evaluate the outcomes of post‐transplant ESWL for stone disease.
Methods: A comprehensive search in the literature was performed including articles between January 1987 and March 2023. Only English original articles with a minimum of five patients were selected.
Results: Eight articles (81 patients) were included in the review (Table 1). Patients were mainly males and mean age was 41.9 years (±7.07). The diagnosis was mainly incidental, and the most cited symptoms at presentation were macrohematuria, urinary tract infection (UTI), and deterioration of renal function. Stones were predominantly located in the kidney (65.5 %), with a mean stone size of 13.1 mm (±2.28mm). Pre‐ operative drainage, either ureteral stent or nephrostomy tube, was placed in 11 patients (13.5%). Post‐ operatively one study reported about the routine use of ureteral stent and another about the use ofalpha‐ blocker therapy. The overall stone free rate was 81% (range: 50‐100%). Five patients (6.1%) required a second treatment for residual fragments, either fURS (n = 1) or PCNL (n = 4). Two studies reported stone recurrences in 3 patients. The overall complication rate was 17.2% (14/81), and complications reported were graded as follows: seven Clavien I (transient hematuria, conservativemanagement), six Clavien II (UTI requiring antibiotic therapy), and one Clavien IIIa (steinstrasse requiring a nephrostomy placement and a subsequent reintervention).
Conclusions: ESWL remains a safe and effective option to treat de‐novo stones after transplantation. Higher level studies are needed to better address allograft urolithiasis management.
Funding: None.
Machine Learning Clinical Nomogram to Predict Success Rate of Shock Wave Lithotripsy
Jan Svihra Jr.3, Peter Svihra1, Lukas Bris2, Igor Sopilko2, Jan Luptak3
1CERN, 2University hospital Martin, 3Jessenius faculty of medicine of Comenius University
Presented By: Jan Svihra Jr., MD,PhD
Introduction: Although several reliable algorithms predicting a shock wave lithotripsy (SWL) success rate exist, anovel aproach of machine learning was seldom used. In this study we developed aclinical nomogram to predict success rate of an SWL of kidney stones using machine learning models.
Methods: Aretrospective analysis of SWL in kidney stone patients was performed. Demographic data, stone size, stone area, stone location inside the kidney, stone density, skin to stone distance (SSD), stent presence, hydronephrosis presence and complication rate were analysed. Success of a SWL was defined as a stone‐free rate (SFR) with stone fragments smaller than 4 mm. Programming language Python, namely the scikit‐learn library, was used for machine learning purposes. The study was approved by the local ethics committee.
Results: 102 patients (68.6 % males) with a mean stone size of 9.1 ± 3.1 mm and SSD 8.4 ± 1.8 cm were analyzed. Using different machine learning models we have defined a probability of an SWL success. The best probability was found with SSD ≤8 cm and stone area ≤60 mm2in all locations with exception of a lower kidney pole (Fig. 1).
Conclusions: We have identified parameters to create a machine learning nomogram that predicts success rate of an SWL in patients with kidney stones.
Funding: None
Can Pain Catastrophizing Scale Help Predict the Outcomes of Schock Wave Lithotripsy?
Introduction: Shock wave lithotripsy (SWL) is a primary procedure utilized for the treatment of renal lithiasis measuring less than 2 cm. Unlike alternative lithiasis treatment methods, SWL is typically performed on an outpatient basis, without the need for anesthesia. The Pain Catastrophizing Scale (PCS) is a validated questionnaire that assesses the extent to which patients catastrophize pain based on their prior experiences. The objective of this study is to evaluate the predictive capacity of the pain catastrophizing scale in determining the outcomes of shock wave lithotripsy.
Methods: Prospective enrollment of patients scheduled for SWL occurred between October 1, 2022, and January 31, 2023. The patients' gender and the size of the largest lithiasis in millimeters were documented. On the day of the procedure, patients completed the PCS, consisting of 13 questions with 5 response options, each assigned a value ranging from 0 to 4 points. A single dose of Ketorolac 10 mg was administered to patients, after which the procedure was performed without anesthesia. Following the procedure, patients provided a pain score using a Visual Analog Scale (VAS) ranging from 1 to 10 points. At the 4‐week mark, all patients underwent a Computed Tomography evaluation to assess the presence of residual lithiasis, considering fragments larger than 3 mm. The patients were divided into two groups based on their PCS scores: Non‐catastrophizers with PCS scores ≤14 points and catastrophizers with PCS scores > 14 points. The results were subsequently evaluated using chi‐square analysis.
Results: A total of 46 patients (15 women and 31 men) were evaluated, all presenting kidney stones with an average lithiasis size of 7.15 mm (ranging from 5 to 11 mm). The average PCS score was 13.95 points. Residual lithiasis was detected in 11 patients (23.9%). The non‐catastrophizer group (PCS ≤14) comprised 35 patients, with an average initial lithiasis size of 7.11 mm and an average VAS score of 4.7 points. Among these patients, 5 were found to have residual lithiasis (17.1%). The catastrophizer group (PCS > 14) consisted of 11 patients, with an average initial lithiasis size of 7.27 mm and an average VAS score of 6.3 points. Within this group, 6 patients exhibited residual lithiasis (45.5%) (p < 0.001).
Conclusions: Our study indicates that patients who exhibit a higher degree of pain catastrophization (PCS > 14) are more likely to experience residual lithiasis following shock wave lithotripsy.
Funding: None
Peri‐Splenic Hemorrhage After Extracorporeal Shockwave Lithotripsy
Mark Noble1, Paul Oh1, Madison Lyon1, Scott Lundy1
1Cleveland Clinic
Presented By: Mark Noble, MD
Introduction: Major hemorrhagic complications after left extracorporeal shockwave lithotripsy (ESWL) are quite rare. We present a 33‐year old patient who developed the very unusual outcome of a large splenic hemorrhage and hemoperitoneum after left ESWL for a non‐obstructing 0.9 cm mid‐renal stone. We discuss our management experience with this very rare event and contrast our experience withthe few, other such reports in the medical literature.
Methods: A 33‐year old male with history of Gilbert syndrome was evaluated for 3 weeks of intermittent left flank pain. An abdominal CT showed a 0.9 cm non‐obstructing left mid‐renal stone (HU 1400) with a skin‐ to‐stone distance of 6.4 cm. Pre‐operative lab work was otherwise normal. The patient was offered left ureteroscopy with laser lithotripsy and extracorporeal shockwave lithotripsy (ESWL) and elected to proceed with ESWL. A Dornier Delta III lithotripter was used (2500 shocks, 60 shocks per minute, 1 to 7 mAmp), and good dispersion of the stone was noted on fluoroscopy during the procedure.
Results: Twelve hours post‐operatively, the patient developed abdominal pain followed by a syncopal episode necessitating travel to the nearest emergency room. The patient was tachycardic to 112 but hemodynamically stable on admission, with mean arterial pressures in the high 80s. Exam was significant for guarding and left flank tenderness. Hemoglobin was 8.6 from pre‐operative 15.1 g/dL, and FAST revealed hemoperitoneum. A CT scan was performed (Figure1).Although perinephric hematoma from ESWL is not uncommon (1‐25%), extra‐renal injuries are exceedingly rare, with only ten other case reports of splenic rupture identified in the medical literature. All reported splenic injuries were from left‐sided ESWL with the most common clinical presentation beingprogressive abdominal pain and hypotension. All patients in these reports underwent splenectomy. Ourscenario was uniquelyamenable to angiography given the isolated nature of the splenic injury and the patient's hemodynamic stability.
Conclusions: Acute care surgical guidelines for blunt splenic injuries recommend non‐operative management if hemodynamically stable and without peritonitis, laparotomy if both hemodynamically unstable and with peritonitis, and angiography with embolization if hemodynamically stable but with grade III+ injury, contrast blush, moderate hemoperitoneum, or ongoing bleeding. Because many urologists who routinely perform ESWL for treatment of nephrolithiasis are not aware of splenic rupture as a possible complication, we wish to relate that in patients presenting with syncope or abdominal pain after left‐sided ESWL, splenic parenchymal or vascular rupture should be considered and treated according to acute care trauma guidelines.
Funding: None
Effect of Focal Zone Size on Treatment Outcomes and Renal Injury Following Extracorporeal Shockwave Lithotripsy of Renal Calculi: A Prospective Randomized Study
Chi Fai Ng1, Chi Hang Yee1, Jeremy Teoh1, Peter Chiu1, Angel Kong1, Becky Lau1, Vincy Ho1, Ka Tak Wong2, Winnie Chu2
1SH Ho Urology Centre, Department of Surgery, The Chinese University of Hong Kong, 2Department of Imaging and Interventional Radiology, Prince of Wales Hospital, The Chinese University of Hong Kong
Presented By: Chi Fai Ng, MD
Introduction: To compare the efficacy and safety of standard or extended focal zone (FZ) size in shockwave lithotripsy (SWL) for patients with renal stones.
Methods: In this prospective study conducted between April 2018 to October 2022, patients with renal stones were randomized to receive SWL with either standard or extended FZ. Treatment was delivered using a Modulith SLX‐F2 lithotripter with a maximum of 3000 shocks at 1.5 Hz. The primary outcome was treatment success at 12 weeks after a single SWL session, defined as the lack of a stone or stone fragment < 4 mm on computed tomography. Secondary outcome included the incidence of perinephric hematoma, stone‐free rate and changes in the urinary levels of acute renal injury markers.
Results: 320 patients were recruited, and 276 patients were randomized into the 2 groups. The two groups had similar baseline parameters. was significantly better for standard FZ (74.3%) than extended FZ group (59.3%) (p = 0.009). Standard FZ also had significant better stone free rate (36.8% vs 23.0%, p = 0.013) and less pain after treatment. Both groups had similar perinephric haematoma formation rate, unplanned hospital admission rate and changes in urinary acute renal injury markers.
Conclusions: The standard focal zone has better treatment efficacy and similar safety when compared with extended focal zone during SWL for renal stone.
Funding: Hong Kong UGC Research Matching Grant 8601454
Prediction of Stone Free Rate after Extracorporeal Shock Wave Lithotripsy Using Modified Seoul National University Renal Stone Complexity Scoring System
1Faculty of Medicine Ramathibodi Hospital, Mahidol University, 2Division of Urology, Department of Surgery, Faculty of Medicine Ramathibodi Hospital, 3Ranong Hospital
Presented By: Chinnakhet Ketsuwan
Introduction: The modified Seoul National University Renal Stone Complexity scoring system (S‐ReSC‐R) has been proposed as a novel prediction tool for urolithiasis management, including retrograde intrarenal surgery and percutaneous nephrolithotomy. We aim to determine the S‐ReSC‐R score system for application in extracorporeal shock wave lithotripsy (ESWL) in predicting stone‐free rates.
Methods: The data of patients who received ESWL between 2018 and 2020 at a tertiary referral center were audited retrospectively. A total of 200 patients were included, and an S‐ReSC‐R score was assigned according to the number of sites involved in the collecting system. The stone‐free rate (SFR) was examined. We applied receiver operating characteristic curve analysis to the data to evaluate the predictive accuracy.
Results: The overall SFR after single‐session treatment was 61.5%. The S‐ReSC‐R scores were significantly higher in patients successfully treated with ESWL compared with patients in whom ESWL failed (p < 0.001). SFR was significantly decreased in the order of low (1–2: 70.1%), intermediate (3–4: 38.2%), and high (5–12: 20.0%) score groups, respectively (p < 0.001). The multivariate analyses demonstrated that a S‐ReSC‐R score was identified as independent factors affecting SWL success (p = 0.021). The area under the receiver operating characteristic curve of the S‐ReSC‐R score was 0.742.
Conclusions: The S‐ReSC‐R was proven to be an effective tool for predicting SFR following ESWL. Therefore, patients who plan to undergo ESWL should be evaluated with S‐ReSC‐R before surgery.
Funding: No funding.
Impact of Adjunctive Alpha‐Blocker Therapy on Outcomes of Ureterorenoscopy for Large Kidney Stones
George Tawfellos3, Priscilla Rogriguez1, Maithili Gopalakrishnan2, Alice Cheung2, Mark White2, Luay Alshara2
1Albany Medical College, 2Albany Medical Center, 3Albany Medical College
Presented By: George Tawfellos, BA
Introduction: α‐1A‐specific antagonists may facilitate the use of larger ureteral access sheaths by inducing selective ureteral smooth muscle relaxation. This can contribute to improved stone clearance and drainage in flexible ureteroscopy. We sought the effect of pre‐operative α‐1A‐ antagonists on stone free rates, intra and post‐operative outcomes for elective ureteroscopy in the treatment of kidney stones larger than 10mm.
Methods: A single center retrospective analysis was conducted for 147 patients who underwent elective ureteroscopy with holmium laser lithotripsy between September 2019 and January 2023 for kidney stones larger than 10mm. The patients were divided into two groups, a study group who were on alpha‐1 blockers (tamsulosin 0.4mg) for at least one week prior to surgery and control group who received no preoperative alpha‐1 blockers. All patients had preoperative CT images. The mean stone burden was 17.4mm. We excluded patients that were pre‐stented, with ureteral stones and with kidney stones smaller than 10mm. We recorded intraoperative sheath size, operative time, residual stones greater than 3 mm on imaging within 90 days post‐surgery, re‐operation rates, unplanned ED or clinic visits and hospital re‐admissions within 30 days.
Results: Among the 147 patients included, around half of the patients were within the study group (N = 70, 47.6%). Our study and control groups had similar stone burden (16.8 mm vs. 19 mm p = 0.07) and similar median stone hardness (738 vs 834 Hounsfield units, p = 0.08). A larger sheath was used significantly more often in the study group (54.3%) compared to the control group (p = 0.022). The rate of stone visualization on post‐operative imaging within 90 days was less in the study group (39% vs. 60%; p = 0.034). There was a smaller median residual stone size in the study group (p = 0.002), and a less re‐operative rate (2% vs. 22.3%; p = 0.0004). There was no significant difference in mean OR time (78.3 vs. 73.7 minutes, p = 0.44), length of hospital stay (0.995 vs. 0.422, p = 0.626), or rate of hospital readmission (2.9% vs. 7.9%, p = 0.28).
Conclusions: Using pre‐operative alpha‐1 selective antagonists showed significant promise in intraoperative and postoperative success. Its pre‐operative use is encouraged for elective ureteroscopic management of large kidney stones.
Funding: N/A
Endoscopic Evaluation of Ureteral Stone Impaction Highlights Significant Variability in Definitions Between Surgeons
Brendan Yi4, Gregory Mullen1, Ray Khargi2, Tareq Aro1, Alan Yaghoubian2, Mantu Gupta2, William Atallah2, Dima Raskolnikov3, Alexander Small3, Christopher Hartman1, Christian Tabib1, David Hoenig1, Zeph Okeke1, Arthur Smith1, Arun Rai1, Jared Winoker4
1Northwell Health, 2Mount Sinai School of Medicine, 3Montefiore Health, 4Lenox Hill Hospital, Northwell Health
Presented By: Brendan Yi
Introduction: The ability to detect ureteral stone impaction preoperatively might carry an array of clinical implications. Previous attempts to predict impaction based on CT findings are inherently limited by the lack of a gold standard comparator and rely on unvalidated, single‐surgeon estimation of intraoperative impaction. At present, there is no validated definition of impaction and it is unknown to what degree various surgeons would agree on impaction severity given the same case. We sought to investigate surgeon perspectives and variability in estimating ureteral stone impaction based on a curated ureteroscopy video catalog. This was performed with the overarching goal of developing a consensus grading system and gold standard dataset for future investigation of CT‐based stone impaction prediction.
Methods: A catalog of 35 primary ureteroscopy cases was created and distributed to a group of fellowship‐ trained endourologists. All videos featured visual inspection of the surrounding tissue, guidewire passage next to the stone, as possible, and gentle nudging of the stone with the scope to assess its mobility. Without any predefined criteria or pre‐rating discussion, participants were asked to independently rate the degree of impaction on 2 different scales: continuous (0‐9) and categorical (none/mild/moderate/severe). After a first pass, participants rated the videos in a new, random order. Inter‐ and intra‐rater agreement across both rating systems was evaluated. For categorical ratings, strong agreement between raters was defined as at least 70% majority.
Results: 35 videos were initially rated by13 surgeons and 11/13 performed second pass ratings. There was a significant amount of inter‐ and intra‐rater variability in assessing stone impaction. Second pass video reviewstended to receive higher severity ratings. Only 13/35 videos had strong agreement (> 70%) on degree of impaction (6 none, 7 severe) and only 2 of these 13 had 100% agreement (1 none, 1 severe). Continuous scale ratings mirrored the categorical ratings for the none and severe impaction cases. There were no cases with consensus agreement of mild or moderate impaction. More than one‐third (12/35) of videos had at least 1 vote for each of the 4 severity categories, indicating stark disagreement between surgeons on what constitutes impaction.
Conclusions: There is significant variability amongst endourologists regarding the definition and the severity of stone impaction. When strong agreement occurs, it is in determining whether a stone is severely impacted or not at all. While the clinical significance of impaction on patient outcomes is yet to be determined, these initial findings suggest further work is needed to expound on the definition of impaction, including standardized endoscopic criteria. Moreover, a tripartite classification system may be the most appropriate manner of grouping ureteral stones on the basis of impaction.
Funding: None.
Current Practice Patterns of Thulium Fiber Lasers in Treatment of Urolithiasis
Fabrice Henry1, Jianbo Li1, Jorge Gutierrez1, Sri Sivalingam1
1Glickman Urological & Kidney Institute, Cleveland Clinic
Presented By: Fabrice Henry, MD
Introduction: The introduction of Thulium Fiber Laser (TFL) has changed the landscape of laser use in the surgical management of urolithiasis. Given the paucity of literature on how surgeons are utilizing TFL in practice, we sought to evaluate current utilization patterns of this technology among Endourologists.
Methods: An online survey was distributed to Endourological Society members using RedCAP. Questions included demographics, laser modality (low‐power holmium (LPH), high‐power holmium (HPH), and TFL), indication‐specific laser settings (i.e., ureteral dusting and fragmentation; renal dusting, fragmentation and pop dusting; percutaneous nephrolithotomy (PCNL), and cystolitholapaxy). Data was analyzed using R statistical software.
Results: 183 responses were received after two email blasts to Endourological Society members. TFL was used significantly more often by urologists in practice less than 10 years compared to those in practice 20 years or more (53% vs 28.1%, p = 0.009), by those in academic hospitals compared to private practices (52.2% vs 13.2%, p < 0.001), and by those with Endourology fellowship training (47.5% vs 27.0%, p = 0.011)TFL was used most for renal stone dusting (37.1%), followed by ureteral stone dusting (31.6%). Use was similar between ureteral stone fragmentation (27.3%), renal stone pop dusting (25.7%) and renal stone fragmentation (27.5%). It was least commonly utilized in cystolitholapaxy (15.8%) and PCNL (13.5%).Energy settings (J) were significantly lower for TFL in most scenarios, except for ureteral stone fragmentation. Frequency settings were significantly higher for TFL versus LPH in all settings except ureteral fragmentation, and significantly higher versus HPH in renal stone fragmentation. (See Table 1). Most surgeons indicated an interest in further education on laser usage in stones surgery (68.5%).
Conclusions: Despite being a relatively new technology, TFL is being more commonly used. When using TFL, surgeons tend to use lower energy and higher frequency compared to holmium lasers. Our study indicates there is variation in the uptake of TFL technology by urologists within the endourological society and indicates a need for further education in available technology in the management of urolithiasis.
Funding: None
SuperPulsed Thulium Laser Fiber versus High‐Power Holmium:YAG Laser in Ureteroscopic Laser Lithotripsy: A Case‐Control Study
Bristol Whiles1, Wilson Molina1, Willian Ito1, Nicholas Choi2, George Letner2, Dillon Prokop2, Crystal Valadon2, Donald Neff1, David Duchene1
1The University of Kansas Health System, 2University of Kansas School of Medicine
Presented By: Crystal Valadon, MD, MBA
Introduction: Currently, evidence is limited when comparing high‐power laser platforms in ureteroscopic lithotripsy. We aimed to examine the outcomes of the SuperPulsed Thulium Fiber™ (SPTF) versus the high‐ power holmium:yttrium‐aluminum‐garnet (HoYAG) laser for lithotripsy.
Methods: We conducted a retrospective chart review from 01/2019‐12/2021 on patients undergoing elective ureteroscopy to address stone disease regardless of stone size, location, or scope type. Exclusion criteria included patients with an untreated positive urine culture prior to 3 months of the procedure and patients who did not have a follow‐up imaging exam or did not complete the 12‐week post‐procedural visit. The utilized HoYAG platform was the Lumenis Pulse P120H™ (120W, Boston Sci®, US), while the TFL comprised the Soltive™ SPTF (60W, Olympus®, Japan) laser. Stone‐free status (SFS) was defined as the absence of stone fragments ≥2mm on imaging (ultrasound or CT scan) at the 12‐week postoperative visit.
Results: Of the initial 508 patients, 336 met the study criteria. Patients and stone characteristics were comparable, with no significant difference between groups. Dusting technique was utilized more often in the SPTF group (18.5% vs. 6.2%, p = 0.03). The median total laser time and ablation efficiency (kJ/cm3) were similar between groups. Despite we found higher median total laser energy and higher ablation speeds (mm3/s) when utilizing the SPTF, total operative time was not significantly different. Overall, SFSs for HoYAG and TFL were 85.9% vs. 85.3% (OR 1.07, CI95% 0.56–2.06, p = 0.82), respectively. In the stone location subgroup analysis, SFSs were comparable between groups – Table 1.
Conclusions: Overall, there is no significant difference in SFS between HoYAG and SPTF groups, along with similar ablation efficiency and complication rates. Although ablation speed was significantly higher in the SPTF, total operative time was comparable.
Funding: No funding.
Endourology Surgeries. Single vs. Multi Use Flexible Scopes: is One of Them a Better Choice ?
Eyal Riemer2, Amitay Lorber1, Leonid Boyarsky2, Ofer Gofrit2, Mordechai Duvdevani1
Introduction: Ureteroscopy for the treatment of urolithiasis is one of the most common procedures in the world of endourology. This study seeks to compare single use with multi use flexible scopes in holmium laser lithotripsy ureteroscopy procedures.
Methods: A retrospective observational study was performed over a database of 2380 ureteroscopy procedures collected since October 2013 by the endourology unit of a single tertiary center. From the database, only cases that were performed using a flexible scope were included. The data was divided into two categories according to the type of flexible scope used: procedures performed with a multi use flexible scope (MU) and procedures performed with a single use flexible scope (SU). The outcomes analyzed were Surgical Time (ST), which was measured from the beginning of the surgeon's performance to it's end, and Energy Density (ED), which is the total laser energy divided by the stone's volume. Statistical analysis was performed using SPSS version 29.
Results: 1200 cases were included. 974 cases in the MU group and 226 cases in the SU group. Significant difference was found in ST: 33.37 ± 18.04 minutes in the MU group vs. 38.16 ± 18.50 in the SU group, with a p value smaller than 0.001.In ED no significant difference was found: 19.09 ± 62.36 Joules per cubic millimeter in the MU group vs. 19.81 ± 16.84 Joules per cubic millimeter in the SU group, with a p value of 0.375.
Conclusions: Our data displays a slight elongation in ST when using single use flexible scopes, and no significant difference in ED. An interesting finding is the difference in standard deviation in ED between the groups, of more the 300%. This finding may imply that the single use flexible scopes were more predictable and allowed for more precision when using the laser. This finding should be further investigated, as it may have an implication on clinical practice.
Funding: None
Comparative Analysis of Unilateral and Bilateral Flexible Ureteroscopy. a Cohort Multicentre Study
Aleksander Petrov1, Nariman Gadzhiev,1, Ivan Gorgotsky2, Dmitrii Shkarupa2, Vigen Malkhasyan3, Vladimir Vorobev4, Andrei Shkarupa2
1St. Petersburg State University – Pirogov Clinic of Advanced Medical Technologies St. Petersburg, Russian Federation, 2Pirogov Clinic of Advanced Medical Technologies; St. Petersburg State University St. Petersburg, Russian Federation, 3Department of Urology A.I. Yevdokimov Moscow State University of Medicine and Dentistry of the Ministry of Healthcare of the Russion Federation, 4Department of General Surgery and Anesthesiology, Irkutsk State Medical University, Irkutsk, Russian Federation
Presented By: Aleksander Petrov
Introduction: Flexible ureteropyeloscopy (URS) with laser lithotripsy is the gold standard for minimally invasive treatment in patients with kidney stones up to 20 mm. Currently, there is no objective data on the safety of bilateral interventions. The aim of our work was to analyze the results of bilateral flexible URS (D‐ URS) versus unilateral flexible URS (O‐URS).
Methods: The research was made between July 2022 and December 2022 and involved 80 patients divided into 2 groups. Group 1 patients (n = 40) underwent O‐URS and Group 2 patients (n = 40) were subjected to D‐ URS. The baseline figures were comparable between the groups, but in the D‐URS group there was a 39% higher incidence of multiple stones (p > 0.002) and a 28% higher incidence of stones in the lower bowl groups (p > 0.001). Previous interventions were also more frequent in group 1 (D‐URS) patients. A surgical indication was the presence of a stone up to 20mm in size.
Results: The rates of complete stone clearance did not differ considerably between the groups and were amounted to 95% and 97.5% respectively (p > 0.9). No serious complications of Clavien III‐V were observed in either group (p > 0.9).
Conclusions: D‐URS is a safe and effective technique to treat patients with bilateral kidney stones by removing stones from both sides in a single anaesthetic. These interventions reduce the overall duration and cost of treatment and allow rapid recovery. Further research is required to determine the role of bilateral flexible URS in the surgical treatment of patients with bilateral nephrolithiasis.
Funding: The study was not sponsored (own resources).
Management of Ureteral and Kidney Stone Disease with Fluoroless Ureteroscopy, Experience on a Mexican Single Center
Ricardo Emanuel Domínguez Castillo2, Carlos Martínez Arroyo1, Daniel Alejandro Arreola Ramírez1, Alejandro Haddad Servín1, Antonio Yaromin Muñoz López2
1Hospital General Dr. Manuel Gea González, 2Hospital General Dr Manuel Gea González
Introduction: Actually, the gold standard for the management of ureteral and kidney stones is semirigid and flexible ureteroscopy.92.64% of the practitioners in Latin America consider URS as the first choice treatment for ureteral and kidney stones. About the different techniques of treatment of lithiasis, 98.5% of the physicians routinely practice semi‐rigid URS and 78.2% flexible URS.Data have shown that the rate of radiation exposure during a URS can range from 1.2 to 29.7 mGy. These type of patients with an acute stone episode undergo an average of four diagnostic imaging studies in a year, which have been calculated to yield a total cumulative dose of 29.7 mGy.Although the radiation dose in ureteroscopy is low, we must consider that during this procedure different people are exposed to this risk (patients, doctors, nurses, etc.). Currently, guidelines do not recommend or are against the use of fURS in practice. However, this practice aims to reduce radiation exposure in the operating room without having a lower efficiency in terms of results. We present the experience in fluoroless ureteroscopy at our center.
Methods: We performed 164 procedures between rigid and flexible ureteroscopy, all of them fluoroless, for resolution of renal and ureteral lithiasis in a period of 9 months between April 2022 and January 2023. All steps of each procedure (safety guidewire placement, rigid ureteroscopy, second guidewire ascent, ureteral access sheath placement, pyeloscopy, lithotripsy, and JJ stent placement) were performed fluoroless.Patient demographics and stone features (number, size and location) were evaluated preoperatively. The results of the procedures were evaluated with the stone‐free rate, surgical time, complications, and hospital readmissions.
Results: A total of 164 procedures was performed, of them 82 (50%) were woman and 82 men (50%) with an average age of 45.3 years. The stones features were: average stone number 1.39, a median stone diameter of 9.39 mm, the localization of the stones was distal ureter 14 (8.5%), medium ureter 45 (27.4%), proximal ureter 22 (14.1%) and renal 83 (50%). The surgery performed was 59 rigid ureteroscopy (36%), 105 flexible ureteroscopy (64%). The mean operative time was 65.59 min. The stone free rate was 81%. The rate of complications was 2.5% including one patient with a Clavien Dindo > III (ureteral stenosis).
Conclusions: Fluoroless ureteroscopy is demonstrated as a safe technique for the patient with results comparable to the conventional technique and a low range of complications, therefore this technique can be taken into account in patients whose context exposes them to more radiation as patients with recurrent lithiasis, underlying metabolic problems in whom a greater number of control studies are necessary.
Funding: None
Don't Skirt the Question: Lead Bed Skirts in the OR, An Intervention
Jacob Thatcher2, Thomas Mueller1
1New Jersey Urology, 2Jefferson New Jersey
Presented By: Jacob Thatcher, DO
Introduction: Fluoroscopy is an important tool in endourology. Residents spend a significant amount of time using fluoroscopy. Using extrapolated data collected from our OR using real time Geiger counters we showed that despite using low dose technology, leaded aprons and thyroid shields, the standard dose a resident receives over one year is 11% over the annual total radiation dose limit to the eyes and near the annual total dose radiation for the entire body. This doesn't include the omnipresent ambient radiation exposure. The aim of our current study is to investigate the reduction in radiation exposure to the primary surgeon and anesthesia when a lead skirt is installed around the table.
Methods: We placed lead skirts circumferentially around the operating room table and using the Radex One Quarta Geiger Dosimeters at the level of the eyes, buttocks, anesthesia outer chest pocket and adjacent to the x‐ray tube we collected real time radiation exposure for each procedure. We compared these data with data collected using the same configuration without the lead operating room table skirt.
Results: Radiation exposure to various body parts during eighty‐one endourologic procedures over a six‐ month period was tabulated. The normalized average was then compared. The highest amount of radiation received was to the eyes ‐ 8.42μGy, followed by groin ‐ 1.76μGy, backside ‐ 1.53μGy, and inner chest ‐ 1.07μGy per procedure.By simply installing a leaded skirt around the four sides of the table, we show that this attenuates the scattered dose radiation to all areas. Most notably, the reduction in radiation to the eyes is reduced from 8.42 to 1.46, a nearly 500% reduction in radiation (table 1). Similarly, radiation to the buttocks is reduced by almost 200%. This datareflects a potential intervention that is simple, cost effective and revolutionary in fluoroscopy.
Conclusions: Residents are exposed to high amounts of radiation during fluoroscopic procedures, which could be harmful. Dose exposure varies by body region.We show that the radiation to anesthesia is nearly equivalent to that of the primary surgeon. Installing a lead skirt around the table significantly reduces radiation scatter in the operating room. This represents a cheap and practical intervention to improve operating room safety. This intervention can be implemented across multiple specialties.
Funding: Osteopathic Heritage Grant, Rowan University School of Medicine
Management of Large‐Caliber Ureteral Stent with Encrustrations. 10 Years Experiences and over 1000 Cases
1Kocaeli University Hospital ‐ Department of Urology, 2Medical University Charite ‐ Berlin ‐ Department of Urology
Presented By: Joerg Neymeyer, Dr.
Introduction: Allium Ureteral Stents (AUS) are self‐expandable, metallic stents (Nitinol) which is fully coated with Co‐Polymer. It is used for ureteral strictures, ureterovaginal fistula, and ureteral avulsion treatments. Encrustation of the stent is one of feared complications of urinary tract stents. For AUS despite the protective effect of Co‐Polymer against encrustation, this condition is always argued.
Methods: Charts of the patients who inserted AUS since 2011 were evaluated. Data regarding AUS encrustation including indication of stents, duration till the encrustation, degree of encrustation and management type were noted.
Results: 1109 AUS cases. The indications were: ureteral stricture in 823 patients, ureterovaginal fistula in 214 patiens and partial/total ureteral avulsion in 72 patients. Of them 27 patients diagnosed with stent encrustation wit CT scan, 19 were partially obstructing the stent lumen and 8 were totally obstructing urine passage through the stent. The duration till the encrustation were 30‐36 months. Cases with partial obstruction were treated with just ureteroscopic stent removal. A strong grasper was enough for this aim, no intraluminal stone fragmentation was needed. Cases with total obstruction due to encrustation a pneumatic lithotripter was used for stone fragmentation inside of the AUS, and then stent removal was performed. One case has a stone formation in the renal pelvis, thus a percutenous access was needed for stone and stent removal. We did not observe a tissue ingrowth and ureteral damage during stent removal.
Conclusions: Despite the co—polymer coating an encrustation may occur. The rate is acceptable and endoscopic management with pneumatic lithotripter and a strong grasper is an effective option. To reduce the chance of encrustation, decreasing AUS indwelling time (2 years) may be helpful. Periodic evaluation of the patient with US and CT scan is necessary to diagnose hydronephrosis and encrustation for early diagnosis.
Funding: none
Gender Differences in Ergonomics During URS
Smita De2, Erin Kim1, Alec Sun1, Juan Sebastian Rodriguez‐Alvarez2, Louisa Ho2, Kyle O'laughlin3
1Case Western Reserve University School of Medicine, 2Cleveland Clinic Glickman and Urological Kidney Institute, 3Cleveland Clinic Lerner Research Institute Department of Biomedical Engineering
Presented By: Smita De, MD, PhD
Introduction: Musculoskeletal complaints and orthopedic problems are common among urologists, with higher rates reported by female urologists and those with greater ureteroscopy (URS) case loads. Ergonomics during URS has not been well studied, particularly as related to gender. We aimed to assess differences in muscle activation and mental workload during simulated URS based on gender as well as surgeon position and ureteroscope type.
Methods: Urology trainees and staff at our institution were recruited. Subject variables (including gender and glove size) were collected. Surface electromyography (EMG) was measured in muscle groups of the ureteroscope driving upper extremity and back. The maximum voluntary contraction (MVC) was measured for each muscle 3 times, followed by EMG measurements during 3 simulated flexible URS tasks in randomized order: navigation, basketing, and dusting. Subjects were evaluated while sitting vs. standing and with single‐use vs. reusable ureteroscopes. The root‐mean‐square of the EMG signal was calculated for each muscle in each condition and then normalized to the mean MVC for each subject to produce %MVC. Mean %MVC in each muscle was compared between men and women for different conditions. Mental workload was assessed using the National Aeronautics and Space Administration Task Load Index (NASA‐TLX). Paired Wilcoxon rank‐sum tests and multivariate linear regressions were conducted to associate %MVC of muscle groups with trial conditions and gender.
Results: Greater %MVC was recorded in women vs. men in the forearm flexor, forearm extensor, biceps, and triceps in all conditions, with the greatest difference displayed in the forearm flexor across all positions and ureteroscope types (Figure). Even when evaluating by task, deltoid and trapezius did not differ between men and women. With the reusable ureteroscope, an increase of 1 in glove size decreased forearm flexor MVC by 6.69%. Women reported higher mental workload per NASA‐TLX scores for all comparisons (p < 0.01).
Conclusions: Surgeon ergonomics, based on muscle activation and mental workload, during URS may vary between men and women regardless of position or ureteroscope type and should be further investigated. Ureteroscope design could be optimized for smaller hand sizes to reduce muscle strain and risk of injury.
Funding: Cleveland Clinic Research Program Committee and Glickman Urological Kidney Institute
Safety and Efficacy of Ureteral Stents under Local Anesthesia: A St. Michael's Hospital Experience
Paul Cheon1, Kashif Visram1, Shamir Malik2, Jason Y. Lee3, Michael Ordon1, Kenneth T. Pace1, Robert J. Stewart1, Monica Farcas1
1Division of Urology, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada, 2Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada., 3Division of Urology, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
Presented By: Kashif Visram, MD
Introduction: Ureteral stents are utilized for various indications, such as obstructing stones, ureteral strictures, and ureteropelvic junction obstructions. Insertion of ureteral stents are typically done with the patient under general anesthesia (GA) which requires substantial OR resources. Stent insertion under local anesthesia (LA) has been described in the literature, but uncommonly used. At our hospital this has been a standard practice for many years (St. Michael's Hospital, Toronto). Our aim is to describe our experience of ureteral stent placement under LA and demonstrate its safety and efficacy.
Methods: In this retrospective observational study, patients who underwent ureteral stent insertion under LA for any indication at our centre between 2017 and 2022 under a single surgeon were identified. All patients were provided transurethral xylocaine jelly only (with no conscious sedation or general anaesthesia), and flexible cystoscopes were used along with c‐arm fluoroscopy for insertion or exchange of ureteral stent(s) in the cystoscopy unit. Patient demographics, indication for stent, size and location of stone (if applicable), success, reason for failure, requirement for admission, patient tolerance and complications, were analyzed.
Results: A total of 53 patients were identified to have undergone ureteral stent insertion or exchange under LA. With regards to indication, 36 (68%) patients had obstructing ureteral stones, 7 (13%) patients had ureteropelvic junction obstruction, and 6 (11%) patients had ureteric strictures. Forty‐eight (90.5%) patients had successful outcomes; of which 44 (83%) patients had successful unilateral stent insertions, 4 (7.5%) patients had successful bilateral stent insertions, and 4 (7.5%) had successful unilateral stent exchanges. There were 4 (7.5%) failed stent attempts identified. Two of these failed attempts were due to patient intolerance. Two patients reported discomfort under LA despite successful outcomes. No patient was admitted for post‐procedural or stent related pain.
Conclusions: Insertion of ureteric stents under LA is effective and efficient, especially for obstructing ureteral stones, and is well tolerated by patients. With correct patient selection, this may be a useful approach and may decrease OR time and use of OR/anesthesia resources. Limitations of our study include the retrospective nature of our data, the lack of a GA arm for comparison, and single surgeon sample. Next steps include further analysis of the other urologists' patients at our centre meeting the inclusion criteria.
Funding: The authors have no funding to declare.
Perioperative Erection in Endourological Surgery: How to Deal with it?
Mounir Jamali1, Hakim Oukouhou1, Nabil Louardi1, Abdessamad Bahri1, Mohammed Alami1, Ahmed Ameur1
1Urology Department, Mohammed V Military Hospital, Rabat, Morocco
Presented By: Mounir Jamali, MD
Introduction: During endo‐urological surgery, surgeons may face a notable difficulty caused by perioperative erection, which shares similarities with priapism. The occurrence of perioperative erection, with incidence rates varying between 0.1% and 2.4% depending on the medical team, can be triggered by spinal cord or general anesthesia. This complication can potentially complicate or even postpone the surgical procedure. The mechanisms involved are not yet fully understood, but the management of this condition has made significant advancements in recent years, despite the lack of a consensus.
Methods: Mechanisms: Physiological erection: Induction of erection can be either reflex, linked to tactile stimulation of the genitalia which activates the autonomic pathway, or psychogenic, initiated by cortical centers via the spinal cord.2 pathways are responsible for erection and detumescence:· Sympathetic pathway (T10‐L2): anti‐erectile through its adrenergic system acts on alpha‐adrenergic receptors to induce smooth muscle contraction and thus maintain detumescence.· Parasympathetic pathway (S2‐S4): pro‐erectile, leading to smooth muscle relaxation, partial closure of venules and arteriovenous shunts, and rigidity.Intraoperative erection: More frequently induced by epidural and general anesthesia than by spinal anesthesia, according to the various authors, its appearance during spinal cord anesthesia is due to manipulations carried out before the sensory block has fully set in, or to partial blockade of the sacral segments (S2 to S4). As for general anesthesia, the agents used induce depression of the cortical centers inhibiting psychogenic erection, which can be potentiated by instrumentation of the genital region.
Results: Management:Treatment is inspired by that of priapism, with the administration of vasoactive alpha stimulants in the form of intra‐cavernosal injections capable of inducing detumescence.A number of molecules have been reported in the literature, but there is no definite consensus. These include phenylephrine, noradrenaline, and adrenaline, which have been used since the 1990s. Intravenous administration of ketamine has also been reported. However, the use of these products is not without risk, with systemic adverse effects that can lead to pulmonary edema, hypertensive crisis, rhythm disturbance, or even death. Phenylephrine stands out for its superior safety compared with other alpha stimulants (Table 1).Other methods have been reported: dorsal nerve block using 0.25% bupivacaine seems a safe method if intra‐cavernosal injections are contraindicated. Deepening general anesthesia does not appear to be effective.
Conclusions: Despite its rare occurrence, an intraoperative erection compromises the procedure, and its rapid management requires cooperation between the urologist and the anesthetist in order to manage the method and molecule chosen. Intracavernosal injection of phenylephrine appears to be the most effective and safest method in the absence of contraindications.
Funding: No funding needed
Maximizing Efficiency in Endourology: The Time‐Saving Impact of Skilled Anesthesiologists
Gabriel Molineros1, Conner Brown1
1Hadassah Ein Kerem
Presented By: Gabriel Molineros, MD
Introduction: Over the years, the field of endourology has experienced significant advances in surgical techniques, instrumentation, and patient care. The role of the anesthesiologist is a key factor which contributes to the overall effectiveness of endourological procedures. By providing proper anesthetic and perioperative care, skilled anesthesiologists play an essential duty in ensuring patient safety and optimizing surgical results. However, the real influence of experienced anesthesiologists on endourology time efficiency is unidentified. The aim of this study is to assess the extent to which a skilled anesthesiologist can save time during endourological procedures.
Methods: This paper presents a retrospective study of 2,195 patients who underwent retrograde intrarenal surgery (RIRS) or ureteroscopy at Hadassah Medical Center between 2013 and 2022. Among the patients studied, the endourology anesthesiologist was present in 1,893 cases, while other anesthesiologists were involved in the remaining 302 cases. By comparing these two groups, we examine the association between the presence of a skilled anesthesiologist and various time‐related parameters, specifically focusing on anesthesia duration and extrapolating the results to the amount of cases that can be done yearly in our institution.
Results: Significant differences in anesthesia duration between the two groups was identified. The endourology anesthesiologist (EA) demonstrates a mean anesthesia time of 19.78 minutes (SD = 15.23), with a minimum time of 1 minute and a maximum of 164 minutes. In contrast, the other anesthesiologists (OA) have a mean anesthesia time of 32.57 minutes (SD = 25.01), with a minimum time of 3 minutes and a maximum of 217 minutes. The T‐score, comparing the EA to OA, is calculated to be ‐12.08, indicating a substantial difference. It is important to note that the anesthesia time considered in this study encompasses the duration from induction of anesthesia until extubation of the patient, excluding the duration of the surgical procedure itself. In the context of our institution, where an average of 64 hours of endourology block‐time are allotted each month, we can extrapolate these results as it follows: The average duration of a case with EA is 30 minutes, while the average duration of a case with OA is 45 minutes. Number of cases with EA = 3,840 minutes / 30 minutes per case = 128 cases Number of cases with OA = 3,840 minutes / 45 minutes per case = 85.33 cases (approximately) Based on these calculations, with 64 hours of block‐time per month, one can perform approximately 128 cases with EA and approximately 85 cases with OA.
Conclusions: The significantly shorter anesthesia time associated with EA suggests a more efficient administration and management of anesthesia, anticipation of the surgeon's needs and intimate knowledge of the endourological workflow. This contributes to overall time savings in endourological procedures. With shorter OR times leading to an increase in the absolute number of cases per month, OR lead time and waiting lists can be significantly shortened. The significantly shorter anesthesia duration associated with the endourology anesthesiologist underscores the importance of expertise and experience in optimizing patient care and enhancing surgical efficiency. In our institution, as in others, the cumulative time savings can result in the dual effect of increasing profitability while expanding patient access to a vital clinical resource. The results of this study provide evidence of the time‐saving benefits associated with a skilled anesthesiologist in endourology. The significantly shorter anesthesia duration observed with the EA emphasizes the importance of their role in optimizing patient care and enhancing overall surgical efficiency. These findings give an incredible output for healthcare providers, administrators, and policymakers, showing the need for skilled, or even designated, anesthesiologists in endourological teams to maximize time savings, improve patient outcomes, and enhance overall efficiency in the field.
Funding: there is not
MODERATED POSTER SESSION 35: RECONSTRUCTIVE SURGERY
Time for DJ Indwelling Ureteral Stent Removal Following Primary or Salvage Pyeloplasty in US Adult Patients: Results from Insurance‐Claim Population‐Based Cohort Analysis
Francesco Del Giudice3, Deok Hyun Han1, Satvir Basran2, Shufeng Li2, Simon Conti2, Federico Belladelli2, Benjamin I. Chung2
1Stanford University School of Medicine, 2Department of Urology, Stanford University School of Medicine
3“Sapienza” University of Rome
Presented By: Francesco Del Giudice, MD
Introduction: Ureteropelvic junction obstruction (UPJO) is the most common congenital anomaly of the ureter in the US. UPJO presenting in adults could be congenital or acquired and an increasing number of subclinical and asymptomatic UPJO are diagnosed incidentally on cross‐sectional imaging studies. While double‐J (DJ) indwelling stent placement during the end phase of pyeloplasty uretero‐pelvic junction anastomosis is a well‐established standard of care, there is no consensus regarding time to DJ stent removal among endourological international guidelines. Accordingly, we sought to investigate trends and patterns influencing the choice for early rather than later DJ stent removal across a large insurance claim dataset from US.
Methods: Men ≥18 y/o undergone primary or salvage, open or minimally invasive (MIS) pyeloplasty followed by DJ stent placement for UPJO were identified in the IBM Marketscan® Research De‐identified Database between 2007 and 2015. Time from pyeloplasty and subsequent DJ stent removal was assessed. Descriptive statistics as well as multivariable regression modeling were implemented to examine trends and patters of DJ indwelling duration with demographics and perioperative factors affecting time to stent removal.
Results: In total, n = 4,925 subjects (49.6% male, 50.4% female) with mean age of 31.5 (SD: 21.6) years were reviewed. Median time for DJ stent was steady across the range of study time from 5.9 (0.9 – 51.0) days in 2007 up to 5.7 (0.4 – 29.9) days in 2015. This was also mainly unchanged when examining on sub‐group by age, gender, Charlson comorbidity index (CCI), US region and surgical pyeloplasty indication (primary vs. salvage) or approach (open vs. MIS). Of note, at Cox regression modeling, older median age, female gender, as well as primary indication with MIS approach were all independently associated with lower DJ stenting interval (adjusted Hazard Ratio [HR], 1.13 95% confidence interval [CI], 1.05 ‐ 1.2, aHR, 1.08, 95%CI, 1.02 ‐ 1.15, aHR, 1.24, 95%CI,1.12 ‐ 1.37, aHR, 1.24 95%CI,1.16 ‐ 1.31, respectively). On the opposite, ≥ CCI 2 and longer length for hospital stay at the time of the procedure were found to increase the risk for longer time to DJ stent removal (aHR, 0.89, 95%CI, 0.82 ‐ 0.96, and aHR, 0.74, 95%CI, 0.65 ‐ 0.84).
Conclusions: The decision whether how long DJ ureteral stents after pyeloplasty should be maintained in place is an open topic with absence of standardized protocols in the US. To the best of our knowledge this is the first study on a large US population‐based cohort addressing trends and predictors for decision‐making in timing for DJ stent removal. Our findings could help for tailoring the shape of more patient‐oriented risk stratification for adverse events including UPJO relapse or perioperative complications in future research.
Funding: None
A Comparison of Outcomes: Open Versus Robotic Transplant Ureteral Reimplant
Mouneeb Choudry1, Daniel Heidenberg1, Kian Ahmadieh1, Scott Cheney1
1Mayo Clinic Arizona
Presented By: Mouneeb Choudry, MD
Introduction: To compare patient outcomes and complications after open vs. robotic ureteral reimplantation of transplanted kidneys. Ureteral strictures of the transplant kidney may require complex reconstruction. This was classically performed with an open approach, but robotic techniques have emerged. Data comparing these approaches is scare, therefore we investigate the clinical outcomes of the robotic compared to open transplant ureteral reimplant.
Methods: All patients who underwent ureteral reimplant of a transplant kidney at three tertiary care centers were retrospectively reviewed over a 10 year period. We compared patient demographics, perioperative and postoperative data with at least one year follow up. T‐test and chi squared analysis were used to evaluate continuous and categorical data respectively.
Results: Ninety six patients underwent transplant ureteral reimplant. Fifty one patients underwent open repair and 45 underwent robotic transplant reimplant. There were no differences in patient demographics. The open approach had shorter operative times than the robotic (161 min vs 271 min, p < .001) with similar post surgical hospitalization length of stay (2 days vs 2 days, p = .137). The open and robotic approaches had similar post‐operative creatinine nadir (1.4 mg/dL vs 1.39 mg/dL, p = .997), and stricture recurrence (p = 1.0).
Conclusions: Robotic and open transplant reimplant techniques demonstrate similar postoperative clinical outcomes and complication rates. Shared decision making and surgeon technical experience should be the guiding factor in surgical planning.
Funding: We have no funding to disclose for this project.
Open, Laparoscopic, and Robotic Ureteral Reimplantation: A Single Center Comparative Study
Stephanie Banks1, Sarah Razavi1, Alexa R. Meyer1, Aaron Zhang1, Aleem Khan1, Louis R. Kavoussi1, Lee Richstone1
1Northwell Health Institute
Presented By: Stephanie Banks, Medical Student
Introduction: Minimally invasive (MIS) techniques have become the mainstay of numerous urologic proceduresgiven the potential for decreased morbidity compared to open. In this series, we compared outcomes of laparoscopic (LAP), robotic (RA), and open ureteral reimplantation (UR) techniques in a large cohort.
Methods: All MIS (LAP or RA) and open UR cases at our institution between 2014 and 2021 were identified. Data collected included baseline, pathologic, perioperative, and postoperative features. Chi‐ squared and ANOVA with post hoc Tukey analysis were performed for all categorical and continuous variables, respectively.
Results: A total of 322 patients underwent UR, including 95 (29.5%) open, 124 (38.5%) LAP, and 103 (32.0%) RA. Groups were similar in terms of race, number of previous abdominal surgeries, and laterality of the operation (Table 1). Patients in the LAP group were found to be significantly younger (p < 0.001), had higher BMIs (p = 0.02), were more likely to be female (p = 0.035), and had higher American Society of Anesthesiologists (ASA) scores (p = 0.0003) than both the open and RA groups. Malignancy as the indication for surgery was more common in the LAP group than in the open group (p = 0.014). Operative time was significantly shorter for the LAP group (240.0 min) compared to the open group (263.5 min) (p = 0.031). Estimated blood loss (EBL) was significantly higher in the open group (200 ml) compared to both the LAP (150 ml) and RA groups (100 ml) (p = 0.0003). Rates of conversion to open technique were comparable in both LAP (4, 4.9%) and RA (1, 1.0%) groups. Length of stay (LOS) was significantly longer in the open group (6 days) compared to both the LAP (3 days) and RA group (2 days) (p < 0.0001). On post hoc analysis, the open group had significantly more complications (14, 14.4%) than both RA (7, 6.8%) and LAP (4, 3.2%) (p = 0.005) groups. There were no significant differences between groups regarding postop treatment failures or 90‐day readmission rates.
Conclusions: While both MIS and open UR approaches are feasible and effective, MIS offers lower EBL, shorter LOS, and decreased complications.
Funding: None.
Robotic Intracorporeal Urinary Diversion with Utilizing ICG is a Promising Approach in Terms of Preventing Benign Ureteroenteric Strictures
Tunkut Doganca3, Mustafa Bilal Tuna1, Omer Burak Argun2, Ilter Tufek2, Can Obek2, Ali Riza Kural2
1Acibadem Maslak Hospital, Urology, 2Acibadem University, School of Medicine, Urology, 3Acibadem Taksim Hospital, Urology
Presented By: Tunkut Doganca, MD
Introduction: 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 due to muscle invasive bladder cancer 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 ureteral 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.
Funding: None
Reduction and Nonreduction Dismembered Pyeloplasty: Analysis of Perioperative and Follow‐up Outcomes
Jennifer L Nguyen2, Teona Iarajuli1, Allison Brown1, Nicholas Campo1, Sreya Das1, Ruchir Chaturvedi1, Simon Gelman2, Ruth Sanchez De La Rosa2, Ravi Munver2, Mutahar Ahmed2, Michael Stifelman2
1Hackensack Meridian School of Medicine, 2Department of Urology, Hackensack University Medical Center
Presented By: Jennifer L Nguyen, BS
Introduction: To compare the perioperative and postoperative outcomes of reduction and non reduction dismembered robotic pyeloplasty.
Methods: We performed a retrospective and prospective review of our genitourinary reconstructive database for all patients who underwent robotic pyeloplasty from 2019 to 2022 at a single institution. Patient demographics, intraoperative data, and postoperative outcomes were collected and analyzed. 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: In total, 21 (38.5%) and 24 (61.5%) patients underwent Non‐reduction and reduction robotic pyeloplasty, respectively. There were no statistical difference in age, sex, BMI and other demographic values.In terms of the perioperative outcomes, there were no significant differences in operating time (p = 0.172), estimated blood loss (p = 0.491), and 30 day post op major complications (p = 0.467). At a median follow‐up of 18.5 and 24.5 weeks, there was no difference in documented failure rates between non‐reduction and reduction pyeloplasty groups (p = 1.00).
Conclusions: We demonstrated similar perioperative and postoperative outcomes between reduction and non‐reduction dismembered robotic pyeloplasty groups.
Funding: No funding was received for this article
Robotic Buccal Mucosal Graft Ureteroplasty: Early Single Institutional Outcomes
Alexander Hwang1, Benjamin Waldorf1, Jessica Lange1, Ziho Lee2
1University of Tennessee College of Medicine, Chattanooga ‐ Erlanger Department of Urology
2Northwestern Feinberg School of Medicine
Presented By: Alexander Hwang, MD
Introduction: Here we report our early outcomes from ten consecutive patients who underwent robotic buccal mucosal graft (BMG) ureteroplasty for ureteral stricture disease at our regional tertiary care center.
Methods: We retrospectively reviewed our database to identify all patients who underwent robotic BMG ureteroplasty at our institution. Ten patients underwent robotic BMG ureteroplasty for benign ureteral stricture disease between January 2019 and March 2023. The decision to proceed with robotic BMG ureteroplasty was made by the primary surgeon at the time of the operation based on imaging analysis, patient history, and intraoperative findings. Patient demographics, perioperative data, and short‐term results were analyzed. All patients underwent anterior BMG onlay. Nine/10 (90%) grafts were backed with an omental flap and 1/10 (10%) with backed with colonic mesentery. Our primary outcome was successful repair of the ureteral stricture, defined as resolution of flank pain in the affected kidney and lack of obstruction on postoperative functional imaging.
Results: All 10 patients underwent technically successful robotic BMG ureteroplasty by a single surgeon. There were no intraoperative complications. Median OR time was 301 min (range 210 ‐ 378 min), median EBL was 25 mL (range 20‐ 50) ml. Median length of stay was 1 day (range 0‐2 days). Median stricture length was 3 cm (range 2.5‐4). Seven/10 (70%) strictures were in the proximal ureter, 2/10 (20%) strictures were located in the middle ureter, and 1/10(10%) strictures was located in the distal ureter. One/10 (10%) stricture was secondary to iatrogenic injury. One patient had a history of retroperitoneal radiation for previously managed testicular seminoma. One patient underwent BMG ureteroplasty following a failed robotic pyeloplasty. Nine/10 patients underwent successful repair. One patient underwent BMG ureteroplasty for attempted salvage of a marginally functional kidney. Follow up retrograde pyelography showed a patent repair, but obstruction could not be adequately assessed with functional imaging.
Conclusions: Robotic BMG ureteroplasty is a useful and feasible option for management of ureteral stricture disease. With adequate surgeon experience, robotic BMG ureteroplasty can be performed successfully with minimal patient morbidity.
Funding: None
Repositioning of Ureteropelvic Junction (UPJ) in Robotic Assisted Laparoscopic Pyeloplasty (RALP)
Introduction: To evaluate surgical outcomes of Robotic Assisted Laparoscopic dismembered pyeloplasty (RALP) with UPJ repositioning as a modified technique during which the UPJ is brought to a new location to ease with the anastomosis.
Methods: We have performed a retrospective review of all RALP cases performed between the years 2016‐ 2022 at our department. In a selected group of patients repositioning of the UPJ was performed. In brief, the original junction was suture ligated, the spatulated ureter was anatomized end to side to the most dependent and accessible part of the renal pelvis. Performing repositioning was determined by the surgeon during the procedure. We have compared the demographic data, surgical and post‐surgical outcomes to a group that underwent classical A.H dismembered pyeloplasty.
Results: Overall, 70 patients underwent robotic assisted laparoscopic dismembered pyeloplasty and were included in the study, 15 in the repositioning group and 55 in the A.H group. Median age was 26 month (IQR 7‐150) and median operative time was 140 minutes (IQR 129‐192) and 170 (IQR 135‐207) in the repositioning and A.H group respectively. The cause for UPJ repositioning was: crossing vessel (n = 5), high UPJ insertion (n = 8), renal malformation (horse shoe, double collecting system, n = 2). There was no difference between the groups regarding follow up, AP diameter, UTD classification SFU classification, split renal function and diuretic T1/2 pre and postoperatively. Post operatively both groups showed improvement in AP diameter and diuretic T1/2 (P = 0.48). There was 1 case of failure requiring redo‐surgery in the repositioning group (6.6%) and 3 in the AH groups (5.5%), (P > 0.05). Overall, there were 3 cases of Clavien‐Dindo grade 3 complications, all in the AH group (2 cases of urine leak from anastomosis, one case of port side hernia).
Conclusions: Repositioning of the UPJ is optional in cases when the obstructed UPJ is in a non‐optimal anatomical position. This simple modification does not negatively effect complications or surgical outcomes and may be added to the armamentarium of RALP.
Funding: None
Comparison of Robotic Salvage Ureteroplasty Between Excision and Primary Anastomosis and Buccal Mucosa Graft Technique: A Preliminary Report
1Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
Presented By: Chung Un Lee, MD
Introduction: Wepresent our experience of robotic salvage treatment with/without using buccal mucosa graft for the management of strictures of ureteropelvic junction and upper ureter.
Methods: Between April 2018, and January 2023, 19 patients who underwent robotic salvage ureteroplasty with excision and primary anastomosis (RSU‐EPA) and 15 patients who underwent robotic salvage ureteroplasty with buccal mucosa graft (RSU‐BMG) for ureteropelvic junction and upper ureter were enrolled in this study. Patient demographics, peri‐operative, and follow‐up data including change in renal function and success rate were collected and compared.Clinical success was defined as the disappearance of preoperative symptoms including pain and preservation of renal function. Radiological success was defined as non‐obstructive excretion in diuretic renal scan.
Results: Primary outcome of this study is success rate including clinical and radiological success. Prior failed reconstruction is more frequent in RSU‐BMG compare with RSU‐EPA (2(1‐3) vs, 1(1‐2), p = 0.021). Prior second treatment is more frequent in RSU‐BMG compare with RSU‐EPA (3(15.8%) vs, 9(60%), p = 0.007), and there were two patients (13.3%) in RSU‐BMG and no patients in RSU‐EPA with prior 3rd treatment. Console time is longer in RSU‐BMG (208.6 ± 72.7 vs, 262.5 ± 64.2, p = 0.031). However other perioperative data including estimated blood loss, postoperative hospital stay and double J stent remove day were not significantly different between two groups. Complications occurred in two patient (10.5%) in RSU‐EPA and three patients (20%) in RSU‐BMG, but there was no statistical difference. Clinical success and radiological success rate is 89.5% and 94.7% in RSU‐EPA, and 100% in RSU‐BMG. There was no significant difference in estimated glomerular filtration rate and relative renal uptake between preoperative and postoperative 1‐, 6‐, and 12‐month value in two groups.
Conclusions: Both RSU‐EPA and RSU‐BMG are good treatment option for the management of strictures of ureteropelvic junction and upper ureter. Though there were not statistical difference in success rate, RSU‐ BMG showed promising results.
Funding: None
Open Versus Robotic‐Assisted Laparoscopic Boari Bladder Flap Plasty: Comparable Perioperative Outcomes
Sophia Hook2, Holger BöHme1, Christopher Netsch1, Benedikt Becker1, Andreas J. Gross1, Clemens Mathias Rosenbaum1
1Asklepios Klinik Barmbek, 2Sophia Hook
Presented By: Sophia Hook
Introduction: Boari bladder flap plasty is the method of choice for reconstructing distal and mid ureteral strictures. In this study we compare the perioperative outcomes of open and robotic‐assisted laparoscopic Boari bladder flap plasty.
Methods: This study aimed to retrospectively analyse intra‐ and postoperative course after open (2018 ‐ 2020) and robotic‐assisted (2021 ‐ 2022) Boari bladder flap plasty. The open Boari bladder flap plasty was always performed extraperitoneally. The robotic‐assisted Boari bladder flap plasty was performed through a transperitoneal approach using the 4‐arm DaVinci X system in a side docking technique. Nopsoasbladder hitch was performed. In both the open and robotic‐assisted surgeriesa DJ stent and a urethralcatheter were inserted intraoperatively.
Results: Total of 9 patients underwent open Boari bladder flap plasty and 6 patients underwent robotic‐ assisted Boari bladder flap plasty. The preoperative characteristics of the patients did not differ significantly.Preoperative renal function did not differ between the two groups (Mean GFR: 71.3 (±19.2) vs. 77.8 (15.3) ml/min; n.s.). The operating time did not differ significantly (Mean 122 ± 12 vs. 129 ± 39 min; n.s.). There was no significant blood loss in either group and no significant intra‐ or postoperative complications occurred. The mean length of hospital stay was 9.9 days for open(±3.8) vs. 6.0 days (± 2.0) for robotic‐assistend surgery(p = 0.045). Postoperative renal function did not differ between the two groups (Mean GFR: 78.3 (±17.4) vs. 87.2 (5.1) ml/min; n.s.).
Conclusions: Robotic‐assistedBoari bladder flap plasty is a safe alternative to open surgery. The hospital stay is shorter for robotic‐assisted surgery.
Funding: None
Efficacy of a Ureteral Illuminating Catheter in Robot‐Assisted Ureteral Reconstruction
Introduction: Ureteral stricture is a challenging condition commonly observed after ureteral stone impaction and endoscopic procedures. Although endoscopic ureterotomy is performed, there are still some cases that are difficult to treat. At our institution, we initiated robot‐assisted ureteral reconstruction as an advanced medical procedure starting in the fiscal year 2022. However, the accurate identification of the stricture site has been challenging. Therefore, this study aimed to investigate the utility of a ureteral illuminating catheter (IRIS U‐ kit@) for robot‐assisted ureteral reconstruction.
Methods: This single‐center prospective study was conducted between April 2022 and May 2023 at Nagoya City University Hospital in Japan. After obtaining informed consent from the patients with ureteral strictures following ureteral stone treatment, robot‐assisted ureteral reconstruction was performed. Following general anesthesia, an IRIS catheter was inserted transurethrally and placed just below the site of the stricture under fluoroscopic guidance in the lithotomy position. The catheter was illuminated with near‐infrared light during robot‐assisted identification and securing of the stricture (Figure 1). The procedure was completed by replacing the catheter with a double‐J stent during the ureteral anastomosis.
Results: The average age of the patients was 56 years, with a mean BMI of 24.8 kg/m2. The median length of the ureteral stricture was 25 mm. When compared to a control group of 8 cases using conventional ureteral catheters, the robot‐assisted group demonstrated significant reductions in console time (114 min vs. 176 min, p = 0.045) and time to securing the ureter (48 min vs. 83 min, p = 0.22), as well as a shorter anastomosis time (20 min vs. 31 min, p = 0.221). The ureters were anastomosed end‐to‐end, and closure was achieved with six sutures using 4‐0 and 5‐0 PDS. In all cases, the ureteral catheter was removed one month postoperatively, and no urinary obstruction was observed.
Conclusions: Use of a ureteral illuminating catheter is beneficial for robot‐assisted ureteral reconstruction
Funding: none
Single‐Port Robotic‐Assisted Pyeloplasty: Multi‐Institutional Experience from Single Port Advanced Research Consortium
Jennifer L Nguyen4, Teona Iarajuli1, Ethan Ferguson2, Roxana Ramos2, Jaya Chavali2, Graham Hale3, Cairo Stanislaus1, Sreya Das1, Catherine Implicito1, Katherine Kim1, Kyle Featherston1, Mutahar Ahmed4, Simone Crivellaro5, Jihad Kaouk2, Michael Stifelman4
1Hackensack Meridian School of Medicine, 2Urology Department, Cleveland Clinic, 3Department of Urology, University of Illinois at Chicago, 4Department of Urology, Hackensack University Medical Center, 5Department of Urology, University of Illinois at Chicago.
Presented By: Jennifer L Nguyen, BS
Introduction: We present the largest multi‐institutional Single‐Port (SP) robot‐assisted pyeloplasty series using the Single Port Advanced Research Consortium (SPARC) database to evaluate the efficacy and reproducibility of this procedure amongst different institutions.
Methods: We utilized a multi‐center retrospective and prospective genitourinary reconstructive database, to select patients who underwent single‐port pyeloplasty between 2020 and 2022. Data was obtained from three institutions. Continuous data were analyzed using the Kruskal‐Wallis. Categorical data were analyzed using Chi‐Squared.
Results: 81 patients were evaluated. Demographic variables such as age, sex, BMI, location, and laterality did not differ significantly between the three institutions (Table 1 ).Perioperative and follow‐up outcomes are summarized in Table 2. There was no statistically significant difference between the institutions in terms of estimated blood loss (EBL), intraoperative and postoperative complication rates, length of hospital stay, follow‐up, and documented success rates. Of note, institution 1 performed more pyeloplasty procedures on congenital obstructions than the other two institutions (p < 0.001). Additionally, institution 1 had significantly lower operative time than the others (p < 0.001).
Conclusions: SP pyeloplasty may be performed safely and is reproducible at multiple institutions with no differences in outcomes except for slightly decreased operative times at one institution. The short operating times at institution 1 may be related to the fact that more procedures were performed for congenital abnormalities vs. impacted stones and inflammation.
Funding: No funding was received for this article
Robot‐Assisted Reconstruction of a Retrocaval Ureter: A Clinical Case
Sergey Sukhikh1, Vigen Malkhasyan1, Konstantin Kolontarev1, Dmitry Pushkar1
1Moscow state university of medicine and dentistry named after A.I. Evdokimov
Presented By: Sergey Sukhikh, PhD
Introduction: Retrocaval ureter is a rare condition caused by an anomaly of the inferior vena cava (IVC). However, when symptoms appear, most often by the age of 30‐40 years, this diagnosis remains little known to specialists. This paper presents a clinical case of a patient with retrocaval ureter and a surgical method of treatment for this disease.
Methods: A 30‐year‐old woman complains of right lumbar pain radiating to the right side of the abdomen. The pain was intense and recurrent for 2 years (3‐4 times a month), more often at night, relieved after urination. The patient was observed by a gynecologist, surgeon, neurologist. Retrocaval ureter (type II ‐ the intersection with the IVC is at the level of the renal pelvis) was diagnosed on a CT scan with contrast. The ultrasound examination with intravenous furosemide 20 mg revealed ureteropyelocalicoectasia on the right side at 5 and 15 min of the examination. The patient underwent robot‐assisted reconstruction of a retrocaval ureter (antecaval ureteroureterostomy).
Results: The da Vinci Xi robotic system was used, 3 robotic ports, 2 assistant ports and an optical port were set. The operation time was 60 min. Blood loss was 30 ml. There were no perioperative complications. The ureteric stent was removed 1 month after the operation. The regression of pain syndrome was noted. After 3, 6 months there were performed renal ultrasound tests, CT with contrast, which excluded dilation of the right renal pelvis and calyxes and confirmed the positive results of surgical treatment.
Conclusions: Robot‐assisted ureteroureterostomy is a safe and effective procedure and an excellent minimally invasive treatment for retrocaval ureter. Given the positive short‐term result (9 months of follow‐ up), we plan to continue dynamic follow‐up of this patient.
Funding: No
Multi‐Institutional Experience Utilizing Omental Wrap in Robotic Urinary Reconstruction
Jennifer L Nguyen1, Teona Iarajuli1, Tanner Corse1, Aamirah McCutchen2, Allison Brown2, Melody Ong1, Fahad Sheckley1, David Strauss3, Naveen Krishnan3, Kirthishri Mishra4, Ruth Sanchez De La Rosa1, Mutahar Ahmed1, Ravi Munver1, Daniel Eun5, Lee Zhao6, Michael Stifelman1
1Department of Urology, Hackensack University Medical Center, 2Hackensack Meridian School of Medicine, 3Temple University Hospital Department of Urology, 4Department of Urology, New York University, Langone Medical Center, New York, NY, USA, 5Department of Urology, Temple University School of Medicine, 6Department of Urology, New York University, Langone Medical Center
Presented By: Jennifer L Nguyen, BS
Introduction: To describe our experience using adjunctive omental wrap in robotic ureteral reconstruction (RUR) in the management of ureteral strictures.
Methods: Using the multi‐center Collaborative of Reconstructive Robotic Ureteral Surgery (CORRUS) database, we identified patients who underwent RUR with adjunctive omental wrap from September 2013 to March 2021. We completed comparative analysis in patients undergoing buccal mucosal graft (BMG) ureteroplasty, ureteroureterostomy (UU), and refluxing reimplant with and without omental wrap.
Results: 143 patients underwent RUR with adjunctive omental wrap for neovascularization. Prior ureteral interventions were performed in 62 patients (43.4%). The median intraoperative stricture length was 3.0 cm (IQR: 2.0‐4.0), median operative time (OT) was 214.5 minutes (IQR: 174.8‐277.5), and the median postoperative length of stay was one night. We observed 5 (3.6%) intraoperative complications and 4 (2.8%) major postoperative complications (≥Clavien Grade 3). We report a success rate of 86.0% (123/143) with a median follow‐up of 15.5 months (4.8‐34.5) with documented instances of failure occurring at a median of 5.3 months following surgery . In comparative analysis, out of 7 buccal ureteroplasty cases where no omental wrap was utilized, 4 (57.1%) had perinephric flap, 2 (28.6%) had gerota, and 1 (14.3%) had a mesenteric wrap. In the UU cases where no omental wrap was utilized, no other adjacent vascular procedure was documented, and this cohort did not demonstrate significant differences in OT, intraoperative complication rates, 30‐day postoperative complication rates, or failure rates when compared to the omental wrap cohort.
Conclusions: The omental wrap is a versatile, safe, and effective technique for adjunctive use in RUR. It has gathered popularity for graft inosculation in the BMG procedure for its excellent outcomes. Though it has no statistical benefit in the UU group, it doesn't adversely affect perioperative outcomes whenever used.
Funding: No funding was received for the writing of this article.
Which Factors Affect the Docking Time in Pediatric Robotic Urological Surgery: A Preliminary Report
Goktug Kalender2, Bülent Önal1, Elif Altınay Kırlı1, Uğur Aferin1, Muhammet Demirbilek1
1Istanbul University‐Cerrahpasa, Cerrahpasa Faculty of Medicine, 2Istanbul University‐Cerrahpasa, Cerrahpasa School of Medicine
Presented By: Goktug Kalender, MD
Introduction: Despite all the advantages of robot‐assisted laparoscopic surgery (RALS), there may be difficulties in its application in children depending on physical characteristics especially in docking protocol, which may lead to longer operational time. We aimed to identify novel criterias; which affect the docking time in pediatric robotic urological surgery.
Methods: Pediatric patients (0‐17yrs) with anterior superior iliac spinal distance > 13 and puboxiphoid distance > 15 cm whom underwent RALS between the years 2018‐2021 were included into the study. Procedures were performed under the command of a single experienced surgeon using transperitoneal approach.Docking time was identified as the timespan; enclosing the planning of the trocar entry sites, their placement and the attachement of the respective robotic arms. Console time presented the timespan of the surgical protocol before undocking. The patient groups were determined according to the docking time (Group 1 ≤ 25 minutes, Group 2> 25 minutes).
Results: RALS was performed on 20 patients(M:F = 2.3) with a median age of 72,6 months(10‐204). The urologic surgeries performed on patients were specified as pyeloplasty(n = 11), ureteroneocystostomy(n = 4), heminephrectomy(n = 3),nephrectomy(n = 1) and diverticulectomy (n = 1). Children with longer docking time(Group 2;n = 10)were found to have younger ages(mean 104 vs 40 months;p = 0.006), less body weight(mean 35 vs 17 kg; p = 0.003) and smaller stature(mean 135 vs 99 cm;p = 0.001). Variations in trocar placement based on procedure protocols (transvers vs linear:11/9) had no statistically significant effect on docking time(p = 0.780). The console time were similar in groups (p = 0.67).
Conclusions: RALS is a feasible surgical option for pediatric patients. Longer operation times; which had been atributed as a disadvantage of this technique, can be avoided by proper patient selection prior to surgery. Patients age, height and weight should be considered when evaluating a patients eligibility for RALS.
Funding: None.
Robotic Assisted Laparoscopic Pyeloplasty (RALP) in Challenging Cases of Ureteropelvic Junction Obstruction (UPJO) in the Pediatric Population ‐ A Multi‐Center Review
Leon Chertin1, Guy Verhovsky1, Jaudat Jaber2, Boris Chertin2, Amnon Zisman1, Stanislav Kocherov1, Amos Neheman3
1Shamir Medical Center, 2Shaare Zedek Medical Center, 3Meir Medical Center
Presented By: Leon Chertin, MD
Introduction: To report a multi‐institutional international experience in performing robotic pyeloplasty for complicated cases of ureteropelvic junction obstruction (UPJO) in the pediatric population and assess feasibility and outcomes.
Methods: Retrospective chart review of all pediatric patients who underwent RALP for UPJO in challenging cases between 2013‐2021 were included. Demographics, perioperative surgical data, complications, and results are described. Challenging case were defined as: bilateral UPJO, failure of previous open pyeloplasty (thus re‐do cases), correction of UPJO in kidneys with anatomical variations, huge hydronephrosis and low weight infants (< 6 kg).
Results: Over an 8‐year period, 36 children (62% males and 38% females) met the inclusion criteria for our study. 15 patients underwent RALP for recurrent UPJO amongst them 2 children required simultaneous surgery for renal stones, 3 cases of lower pole UPJO in double collecting system, 3 cases of pelvic and horseshoe kidneys, 10 cases of infants weighing < 6 kg, 3 cases of huge hydronephrosis and 2 case of bilateral UPJO. The median age and weight were 36 month (IQR 14‐84) and 12 kg (IQR 10–20.5) respectively. All robotic cases were completed successfully with no conversion to an open procedure. The median operative time was 120 minutes (IQR 90‐135). The mean length of hospital stay (LOS) was 2.6 days. 4 patients (17%) had postoperative complications—1 ileus (Clavien‐Dindo grade [CDG] I), 3 urinary tract infections (CDG II). No CDG III or higher complications were encountered. At a median follow‐up of 36 month, the success rate was 95% with 1 patient requiring another re‐do procedure due to recurrent obstruction.
Conclusions: Our data suggests that RALP is safe and effective even for challenging cases of UPJO in children.
Funding: None
Urinary Diversion, with or Without Cystectomy, for Non‐Malignant Conditions: Perioperative Complications and Postoperative Quality of Life
Amir Buchler2, Roi Babaoff1, Hadar Tamir1, Daniel Kedar1, Jack Baniel1, Shachar Aharony1
1Department of Urology, Rabin Medical Center, 2Department of Urology, Rabin Medical Center, Petach Tikva, Israel
Presented By: Amir Buchler, MD
Introduction: Urinary diversion, with or without cystectomy, is a final option for individuals experiencing end‐stage lower urinary tract dysfunction caused by non‐malignant bladder conditions. Our objective was to delineate the perioperative complications and assess the postoperative quality of life (QOL) in patients undergoing this procedure.
Methods: A retrospective analysis was conducted by scrutinizing the medical records of patients who underwent surgical intervention for benign conditions from 2016 to Jan. 2023. We used the Clavien‐Dindo scale to evaluate postoperative complications which were categorized into early (< 30 days) and late (> 30 days) complications. To estimate the impact on QOL, we used the validated EORTC QLQ‐C30 questionnaire (questions 1‐5) and the QLQ‐BLM30 questionnaire (questions 38‐43). Higher scores were indicative of bothersome QOL symptoms. Furthermore, the overall QOL was assessed by the QLQ‐C30 global health status questionnaire (questions 29‐30), with higher scores indicating improved QOL.
Results: During the study period, 23 patients underwent surgical interventions. Demographic and clinical profiles are presented in table 1.The median operative time was 310 (IQR 239‐353) minutes. Intraoperative complications consisted of bleeding requiring blood transfusion in 5 (22%) patients, each receiving 2 units of PBC. The mean hemoglobin decrease was 1.6 ± 1.3 mg/dL. The median inpatient stay was 14 (IQR: 12‐18) days.In a median follow‐up of 19.4(IQR 14‐46) months, postoperative complications were observed in 14 patients with a median onset of 10 (IQR 6‐17) days from surgery.Clavien‐Dindo's postoperative complication rate was ≤2 in 86.9% of the patients. Two patients suffered late complications on postoperative days 32 and 52. One of these patients mourned from recurrent septic events and died three months postoperatively.The mean scores on the QLQ ‐BLM30 (range 6‐24) and QLQ‐C30 (range 5‐20) were 10.2 ± 3 and 10.5 ± 4.3, respectively. The mean scores (range 2‐14) on the QLQ‐C30 global health status were 9.9 ± 3.
Conclusions: Urinary diversion with or without cystectomy for benign conditions is a viable and safe procedure that preserves a high postoperative QOL. Therefore, we advocate for considering and including this intervention as a last‐resort treatment option for patients with refractory non‐malignant lower urinary tract dysfunction.
Funding: None
“Transforming Urethroplasty Practices: Centralising Care in an Australian Regional Specialty Centre”
Kale Munien2, Adib Rahman1, William Harrison1, Devang Desai1
1QLD Health, 2QLD Health Toowoomba Hospital
Presented By: Adib Rahman
Introduction: The Toowoomba Base Hospital, situated in a regional area west of Brisbane, Queensland, serves a wide geographical catchment area that extends beyond state borders. Many patients residing in these areas prefer receiving treatment within their local vicinity. Our specialised service, which focuses on the management of urethral stricture disease (USD), offers a distinctive and expanding centralised approach, deviating from the traditional practice found in tertiary hospitals. Our comprehensive five‐year prospective study examines the variations in complexity, patient demographics, and outcomes within this service, drawing comparisons to international data.
Methods: Urinary function, quality of life, sexual function, and patient satisfaction were evaluated both before and after the surgery at multiple time points (one, three, six, and 12 months). A standardised technique for BMG urethroplasty, performed by a reconstructive urologist with fellowship training, was employed.
Patient characteristics, geographical location, previous methods of managing strictures, and the complexity of the strictures were documented.
Results: This study enrolled a total of 54 patients, with an average age of 57, BMI of 31, and ASA score of 2. The etiology of strictures in these patients was classified as inflammatory (1), idiopathic (25), iatrogenic (22), or traumatic (6). Prior management included multiple dilatations (maximum 40) and urethrotomies (maximum 4), with 33% of patients requiring clean intermittent self‐catheterization (CISC). Eight patients underwent double‐face urethroplasty. Among the patients, 19 had near‐obliterative strictures and 7 had obliterative strictures. The patient located furthest geographically was 1353 km away, and eight patients were referred from metropolitan centers. The outcomes of the study were consistent with international data. The success rate of the initial procedure was 97%, which increased to 100% after redo urethroplasty.
Conclusions: This study provides evidence that centralising the management of urethral stricture disease (USD) in regional centres is a successful approach to overcome the challenges posed by Australia's extensive geographic area. Despite dealing with more complex strictures and various patient factors, the functional and operative outcomes achieved in this regional centre were comparable to international data. It should be noted that centralisation does not necessarily require a major city center, but rather a center that delivers suitable care. This model could be applied to other subspecialty procedures, offering improved healthcare accessibility while maintaining favorable patient outcomes.
Funding: No funding
Peyronie's Disease: Preputial Graft in Penile Curvature Surgery Correction, a Single Center Experience with 68 Patients
1Hospital of Vaio, 2Università di Modena e Reggio Emilia, 3Ospedale di Vaio, 4Ospedale di Baggiovara
Presented By: Stefano Di Bari
Introduction: Surgical therapy for Peyronie's disease (PD) is reserved for patients with severe penile deformity that fails to improve with medical treatment and impedes sexual intercourse. Surgical treatment should be delayed until the acute inflammatory phase has resolved and should be considered in patients with deformity that impairs sexual function. Plaque incision or excision with grafting has been suggested as an option in patients with a penile curvature greater than 60°, a shortened penis, and/or an hourglass or complex deformity. Our purpose is to assess efficacy, complications and degree of patient satisfaction of preputial skin graft for treatment of penile curvatures by grafting corporoplasty. 68 patients (15‐76 y) were treated between 2012 and 2021, with a degree of curvature between 30° and 80°at Fidenza Hospital. The patients analyzed had more than 17 valutaden with IEFF‐5 score before the surgical procedure.
Methods: The surgery was performed by subcoronal incision, next degloving and preputial patch preparation. Next detachment of the nervous vascular bundle and incision of the double inverted T plate and application of the preputial patch. Compressive medication and catheterization.All patients were hospitalized for 4 days with removal of compressive medication on the third day and removal of the bladder catheter. Post‐operative medication about 7 days after discharge with no evidence of major complications (about 10 patients had penile hematoma resolved with conservative therapy). About 6 months after surgery, patients were asked about the degree of satisfaction valueted IEFF‐5 and the possible appearance of postoperative penile curvatures.
Results: Of the 68 patients operated 44 (64.7% of patients) had an IEFF‐5 greater than 17 without a recurrence of curvature, 19 patients had an IEFF‐5 less than 17 (27.9%) without a recurrence of curvature, 5 patients (7.4%) had an IEFF‐5 greater than 17 but had a penile curvature recurrence of less than 30%. Only 10 patients post‐operative complication.
Conclusions: The aim of the surgical treatment in Peyronie's disease is to correct the deformity while preserving or improving erectile capacity of the penis. Appropriate treatment options should be individualized according to the patients' expectations and erectile capacity. Preputial graft has similar outcome compared to other Autologous grafts like Vein, Tunica vaginalis, Tunica albuginea, Buccal mucosa, Lingual mucosa, Fascia lata.
Funding: None
Examining the Results of Urethroplasty for Challenging Urethral Strictures: Insights from a Retrospective Study at a Regional Australian Center
Kapilan Ravichandran1, Adib Rahman1, William Harrison1
1Toowoomba Hospital
Presented By: Adib Rahman
Introduction: Complex urethral strictures, such as panurethral strictures, hypospadias, and double face urethroplasty, present unique challenges in terms of management and successful treatment outcomes. Despite their clinical significance, there is a lack of comprehensive data and studies specifically focusing on the outcomes of urethroplasty for these complex cases. This study aims to address this knowledge gap by evaluating the outcomes of urethroplasty for complex urethral strictures at a regional Australian center.
Methods: A retrospective chart review was conducted on all patients who underwent complex urethroplasty for panurethral strictures, hypospadias, and double face urethroplasty between August 2017 to January 2023. Patient demographics, technique and outcomes were analysed utilising descriptive statistics.
Results: A total of 33 patients underwent complex urethroplasty, accounting for 16% of the unit's overall workload (n = 206). Among these patients, 7 had panurethral strictures, all of which were treated using the buccal mucosal graft dorsal onlay technique. Additionally, 12 patients underwent double face urethroplasty (including 1 female patient), while 14 patients had hypospadias (8 dorsal inlay, 4 Johansson procedures, 1 ventral inlay, and 1 preputial skin graft). The average age of the patients was 56.14 years, and the mean follow‐up period was 13 months.Prior to undergoing urethroplasty, 21 out of the 33 patients (63%) had experienced failed dilatation treatment, and 8 patients (24%) had undergone previous urethroplasty. The outcomes observed in this study were consistent with the existing literature. Recurrence of strictures was noted in 1 patient with a panurethral stricture, 1 patient who had undergone double face urethroplasty, and 1 patient who had undergone hypospadias repair. Notably, a history of previous urethroplasty (100% of cases) was identified as a significant risk factor for stricture recurrence with the double face technique. The maximum flow rate (Qmax) showed an improvement of 96% at 3 months following the procedure.In terms of subjective patient satisfaction with urinary tract symptoms, it was reported to be 90% at 3 months, 82% at 6 months, and 75% at 12 months post‐urethroplasty. These findings indicate favorable outcomes and highlight the positive impact of complex urethroplasty in improving patients' quality of life and managing their urinary tract symptoms.
Conclusions: The study results suggest that complex urethroplasty can be successfully performed at a regional center by a fellowship‐trained surgeon, with outcomes comparable to those seen in high‐volume centers.
Funding: nil
Exploring the Etiology and Extent of Anterior Urethral Strictures
Kale Munien2, Adib Rahman1, William Harrison1, Devang Desai1
1Queensland Health, 2Queensland Health Toowoomba Hospital
Presented By: Adib Rahman
Introduction: Lichen sclerosis (LS) is recognized as a contributing factor in 10% of instances of idiopathic urethral stricture disease (IUSD), and this has significant implications for treatment approaches due to the underlying pathophysiology. Conventional excision urethroplasty may not yield optimal outcomes as inflammation frequently extends beyond the visible stricture. The primary objectives of this study are to address two research inquiries: the role of LS as an idiopathic cause of strictures and the presence of histological indications pointing to a predisposition of the surrounding tissue to develop strictures.
Methods: Patients diagnosed with IUSD underwent biopsies at the location of the stricture, as well as at one and two centimeters proximal and distal to it. Histological analysis encompassed macroscopic and microscopic observations, such as the identification of LS, hyperkeratosis, alterations in the epidermis, lichenoid infiltrates, ulceration, scarring, and inflammation. Methylene blue was employed to facilitate the identification of compromised urothelium. Subsequently, patients were prospectively monitored following the urethroplasty procedure.
Results: A total of fifteen male patients were recruited between 2019 and 2022. No patient showed visible signs of LS, whereas microscopic evidence of LS was found in two patients solely at the two‐centimeter proximal biopsy site. Scarring was observed in 93% of patients both proximal and distal to the stricture, while 20‐40% exhibited signs of inflammation. Among the patients with microscopic LS and inflammatory changes, one experienced stricture recurrence following urethroplasty. Additionally, one patient diagnosed with inflammatory changes was found to have urethral carcinoma in situ and subsequently underwent penectomy.
Conclusions: The results indicate that LS could potentially be an underlying cause of IUSD. Furthermore, the pathophysiology of the condition may involve scarring and inflammation that extend beyond the strictured area, even distally from the stricture site. When encountering cases of inflammatory changes, it is crucial to conduct a thorough assessment for concurrent urethral pathologies. These findings have implications for the surgical management of IUSD and emphasize the need for additional research on the utility of routine biopsy and potential drug targets in USD.
Funding: No funding
VIDEO SESSION
Video Session 1: Endourology and Stones
Surgical Technique and Early Clinical Experience with the MONARCH™ Robotic Mini‐ Percutaneous Nephrolithotomy and Ureteroscopy System
Andrei Cumpanas4, Mihir Desai1, Roshan M. Patel2, Pengbo Jiang2, Jaime Altamirano2, Antonio R.H. Gorgen2, Nancy Sehgel3, Jacob W. Caldwell3, Chiara Gatti3, Ralph V. Clayman2, Jaime Landman2
1Department of Urology, University of Southern California, 2Department of Urology, University of California Irvine, 3Ethicon Research & Development, 4Department of Urology, University of California, Irvine; Orange, CA, USA
Presented By: Andrei Cumpanas, MD
Introduction and Objective: We describe the initial global clinical experience with the novel MONARCHTM robotic mini‐percutaneous nephrolithotomy (PCNL) system. The MONARCHTM platform (Ethicon, Redwood City, CA) allows a urologist to complete the PCNL procedure with a hand‐held device that allows for simultaneous control of a robotic ureteroscope, a robotic flexible percutaneous suction catheter, irrigation, laser lithotripsy, and a robot‐ operated basket. The novel technique combines robotic ureteroscopic lithotripsy with stone immobilization and extraction via the robotic flexible steerable percutaneous suction catheter.
Methods: All procedures were performed with the MONARCH™ robot; the patient was placed in a modified supine position. The platform includes a novel electromagnetic (EM) targeting system for gaining percutaneous access to the kidney with an 18 Fr percutaneous sheath through which a flexible 15 Fr steerable robotic suction catheter could be deployed. The robotic ureteroscope was used for stone visualization and Holmium laser ablation. The 15 Fr steerable robotic suction catheter was used to relocate stones into a more favorable location for ureteroscopic lithotripsy and to immobilize and then aspirate stone fragments. The suction catheter, robotic ureteroscope, irrigation system, laser and robotic basket were each robotically controlled via a hand‐held controller.
Results: Between January and April 2023, four patients underwent robotic PCNL procedures at the University of California Irvine. In all cases, the EM targeting system resulted in a single pass of the nephrostomy needle with millimeter precision into the selected calyx. Table 1 summarizes the demographic information, pre‐ operative stone burden and post‐operative CT based outcome. To date all robotic procedures have been technically successful, without complications. The reduction in stone burden volume ranged from 81% to 100%. Blood loss ranged from 25 mL to 150 mL.
Conclusions: Initial experience with the MONARCH™ platform for simultaneous robotic PCNL and ureteroscopy provided for uncomplicated percutaneous access and significant stone volume reduction with all functions being performed by one urologist.
Funding: Auris Health, Inc.
Flexible and Navigable Suction Ureteric Access Sheath ‐ A Step by Step Demonstration and Our Experience in Improving the Outcomes of Retrograde Intrarenal Surgery
Deepak Ragoori10, Vineet Gauhar1, Olivier Traxer2, Daniele Castellani3, Chin Tiong Heng4, Saeed Bin Hamri5, Nariman Gadzhiev6, Jeremy Yuen‐Chun Teoh7, Ben Chew8, Bhaskar Kumar Somani9
1Ng Teng Fong general Hospital, NUHS, 2Sorbonne University, Department of Urology Hôpital Tenon, Paris, France, 3Azienda Ospedaliero‐Universitaria Ospedali Riuniti di Ancona, 4Ng Teng Fong General Hospital, NUHS, 5king Abdulaziz National Guard Medical City, 6Saint Petersburg State University Hospital, 7S.H. Ho Urology Centre, Department of Surgery, Faculty of Medicine, The Chinese University of Hong Kong, 8University of British Columbia, 9university hospital NHS trust,, 10Asian Institute of Nephrology and Urology
Introduction and Objective: 328Retrograde intrarenal surgery (RIRS) is a well‐established and proven modality of treatment for renal calculi and with the advent of newer high‐power LASERs, the ability to dust the stones has improved drastically.
However, the challenge remains in clearing this fine dust and tiny fragments which become a nidus for future stone recurrence if not completely cleared. To improve the aspiration of stone dust and fragments a new invention in the form of a Flexible and Navigable Ureteric Access Sheath (FANS) has been made. We present our experience with FANS and the objective is to demonstrate technique and share our initial experience in 45 cases.
Methods: Forty‐five patients underwent RIRS where FANS were used between September 2022 and March 2023 in 3 centers. A retrospective analysis was performed to assess intraoperative, postoperative ( within 24 hours ), and follow‐up within 3 months outcomes. Ease of performing the surgery, mechanical failures, and technical difficulties were noted. For the video, Clearpetra 12/14 Fr FANS sheath was used with a TFL LASER for renal pelvic calculus. The stones were categorized based on GUY's score. The outcomes were reported for immediate and 3‐month stone‐free rate (SFR) and complications.
Results: RIRS was successfully performed in all 45 patients. Only patients with single stones were included. Nine patients were under GUY's score (GS) I category, 19 under GS II, 12 under GS III, and 5 under GS IV categories respectively. CT scan done in the immediate postoperative period ( 24 hrs ) had no evidence of pelvicalyceal injury or perinephric fluid collection, a 100 % stone‐free rate was seen in 71.1% of patients, and 93.3 % SFR at 3 months. The access sheath tip was damaged in 3 cases due to LASER. There was no sheath or scope malfunction. There was transient fever which was resolved by giving antibiotics in 35.6% of the patients and none had sepsis. A double ‘J’ stent was placed in 28 patients and the ureteric catheter was placed overnight in 12 patients.
Conclusion: Flexible and navigable suction (FANS) ureteric access sheath improves single‐session SFR and reduces the need for intraoperative accessories and the necessity to place a DJ stent. FANS can be used safely with experience and minimal complications. Helps reduce hospital costs by reducing ancillary treatment, post‐op follow‐up visits, and imaging, there by reducing the overall cost to the patient.
Single Port Robotic Techniques for Management of Complex Stone Cases
Akhil Saji1, Rogerio Huang1, Nathan Cheng2, Ben Rudnick2, David Ambinder1, Mubashir Billah2, Mutahar Ahmed2
1New York Medical College‐Westchester Medical Center, 2Hackensack University Medical Center
Presented By: Akhil Saji, MD
Introduction and Objective: Percutaneous nephrolithotomy (PCNL) remains the mainstay treatment modality for total renal stone burden greater than 2cm or for isolated lower pole renal stone burden greater than 1cm. In patients with contraindications to PCNL or PCNL failure, there remain few viable treatment modalities to render such patients stone free. In this video, we demonstrate a variety of techniques on how the da Vinci Single‐Port (SP) robotic platform can be utilized to perform minimally invasive pyelolithotomy, nephrolithotomy, and removal of encrusted ureteral stents.
Methods: Patient one is a 70‐year‐old male with a 2.5x2.3cm staghorn calculus in a chronically obstructed left kidney with cortical thinning presenting a relative contraindication to PCNL. Patient two is a 54‐year‐old male with a history of nephrolithiasis found to have an encrusted right ureteral stent with bladder and renal calculi. Both patients were counseled and consented to treatment with SP nephrolithotomy and pyelolithotomy with encrusted stent removal respectively.
Results: Mean operative time and blood loss were 101 minutes and 42 mL respectively. No drains were required post‐ operatively. Both patients were amenable to same‐day discharge. Zero 30‐day or 90‐day complications were noted at the follow‐up visit. Both patients demonstrated evidence of complete stone clearance on surveillance cross‐sectional imaging.
Conclusions: The combination of the SP robotic platform and the SPAM incision technique, based on McBurney's point, enables a novel, reproducible, and effective approach to treating complex stone patients who are refractory to traditional management.
A Sample of the Field: A Comparison of Usability and Image Quality of Widely Available Single‐Use Ureteroscopes
Stephen Hassig1, Kaela Mali1, Shreya Patel2, Scott Quarrier1, Rajat Jain1
1University of Rochester Medical Center, 2Georgetown University Medical Center
Presented By: Stephen Hassig, MD, MBA
Introduction and Objective: Mechanical and visual properties were compared between six single‐use (SU) ureteroscopes: Boston Scientific LithoVue, Dornier Axis, OTU WiScope, Pusen Uscope, BD Aptra, Storz Flex XC1; and a digital reusable ureteroscope: Olympus URF‐V2.
Methods: LithoVue, Axis, WiScope, Uscope, Flex XC1, Aptra scopes were used by faculty and residents in consecutive ureteroscopy cases. The University of Wisconsin Flexible Ureteroscopy Evaluation Instrument was used to rate historic experience, image quality, deflection strength, control intuitiveness, ease of irrigation, ease of ureteroscope access, functionality of working channel, and overall satisfaction on a 1‐5 scale. Blinded participants also viewed one‐minute ureteroscopy videos from cases using LithoVue, Axis, Uscope, Flex XC1 and Aptra SU scopes and the reusable scope, URF‐V2. Resolution, contrast, color, sharpness, glare, depth perception, distortion/artifact, and overall image quality were rated on a 1‐5 scale. MANOVA statistics for the two assessments above were completed with SPSS.
Results: 110 hands‐on scope evaluations were completed (LithoVue n = 20, Axis n = 16, WiScope n = 18, Uscope n = 7, Flex XC1 n = 17, Aptra n = 32) and 90 video comparisons were completed (n = 15 for LithoVue, Axis, Uscope, Flex XC1, Aptra, URF‐V2). Internal consistency was demonstrated (Cronbach α > 0.90 in all instances). In hands‐on testing, overall satisfaction, quality of image, and functionality of working channel were rated lower for Uscope than other scopes (p < 0.05). Flex XC1 had higher quality of image and ease of irrigation (p < 0.05). LithoVue and Flex XC1 had the highest mean overall satisfaction scores, 4.32 and 4.15 respectively, however these results were not statistically significant compared to Axis and WiScope. Overall image quality, glare, sharpness, and image resolution were rated higher in the Flex XC1 than the first‐ generation single‐use scopes (Lithovue, Axis, and Uscope) (all p < 0.05). Flex XC1 was visually preferred over other scopes on all aspects except distortion/artifacts, glare, depth perception (p < 0.05) where it was similar to Aptra and URF‐V2.
Conclusions: The Flex XC1 outperformed every other scope in multiples measures in the purely visual comparison, with the reusable URF‐V2 and single‐use Aptra following, suggesting the CMOS sensor used in the second‐generation SU scopes is superior to earlier sensors. Mechanically, reviewers preferred LithoVue and Flex XC1 though not overwhelmingly so.
From CT to 3D: Kidney Model Creation 101
Zhamshid Okhunov2, Carter Ware1, Vance Gentry1, Akin S. Amasyali2, Ala'a Farkouh2, Matthew I. Buell2, Zhamshid Okhunov2, D. Duane Baldwin2
1Loma Linda University School of Medicine, 2Loma Linda University Medical Center
Presented By: Zhamshid Okhunov, MD
Introduction and Objective: 3‐Dimensional printing is a useful tool that can be employed in operative planning, education, and research. Benchtop research is a critical starting point for the development of new technologies and techniques. This video demonstrates how to create a 3‐dimensional kidney model from a CT image that can be used for training and research.
Materials and Methods: In this video, we show step‐by‐step how to take a CT image in the DICOM format and turn it into a 3‐ dimensional silicone kidney. Steps include choosing a CT for printing, anonymizing and downloading the CT, selecting the desired organ in the CT image, optimizing that selection for printing, designing the mold, slicing the mold for transfer to the 3D printer, printing materials choice, printing, and molding. Software and equipment used included Aquarius iNtuition Viewer™, 3D Slicer, Meshmixer ™, Fusion 360™, Prusa Slicer, Bambu Studio, Prusa Mini printer, Bambu Labs X1C printer, polyvinyl acetate (PVA) filament, and polylactic acid (PLA) filament.
Results: This video demonstrates the creation of a silicone kidney, complete with renal pelvis and collecting system from the starting point of a CT image. The video is intended to be a guide, covering the steps required to complete this process. Additionally, the steps laid out in this video can be easily transferred to the creation of other solid organ models and thus have a wide variety of applications for many urologic procedures.
Conclusions: Printing a 3D model or mold from a CT image provides a useful tool for easy creation of anatomically correct models that can be used for research and training. Use of models like these can decrease the requirement for live animal models and allow for more accurate and cost‐effective anatomic representations.
First‐in‐Human Experience with the LithoVue(TM) Elite Single Use Ureteroscope: Impact of UAS on Intrarenal Pressure
Ben H Chew3, Abdulghafour Halawani1, Kyochul Koo2, Victor K.F. Wong3, Naeem Bhojani4
1King Abdulaziz University, 2Yonsei University College of Medicine, 3University of British Columbia,4 University of Montreal
Presented By: Ben H Chew, MD, MSc, FRCSC
Introduction and Objective: We described the 1st in human use of the novel pressure sensing digital flexible ureteral scope, LithoVue Elite (Boston Scientific). By measuring intrarenal pressure in renal time, we were able to determine if the pressure may become elevated and contribute to potential postoperative complications.
Methods: The LithoVue Elite Ureteroscope was used clinically and the first in human cases have occurred in Canada. A pressure bag set at 150 mmHg was used for pressurized irrigation. A ureteral access sheath was used at the discretion of the surgeon. Pressure readings were delivered 4 times a second. Readings of the intrarenal pressure are displayed on the video interface where the endoscopic image is viewed in real time (Figure 1).
Results: Two cases are discussed here. One case shows that the intrarenal pressure with a ureteral access sheath ranges between 25‐30 mmHg. In the exact same patient on the other kidney, no ureteral access sheath was used and the pressure is seen to be approximately 100 mmHg. Another case shows a patient under spinal anesthesia. When the pressure goes
>115 mmHg, the patient describes pain and insertion of a UAS lowers the pressure to 15 mmHg and her pain subsides.
Conclusion: The LithoVue Elite ureteroscope was able to monitor intrarenal pressure in real time. Ureteral access sheath use in these 2 cases showed a decrease in intrarenal pressure and where the patient was awake under spinal anesthetic, a UAS decreased her pain from high intrarenal pressure. The use of a new ureteroscope that can monitor intrarenal pressure in real time will help further investigation of the effects of intrarenal pressure during and after ureteroscopy.
Training Future Endourologists: Validation of a Simple Percutaneous Renal Access Model
Sikai Song1, Ala'a Farkouh1, Tyler Humphries1, Matthew I. Buell1, Akin S. Amasyali1, Rose Leu1, Kanha Shete1, Sikai Song1, Kai Wen Cheng1, Alphie Rotinsulu1, D. Duane Baldwin1
1Loma Linda University Health
Presented By: Sikai Song, MD
Introduction and Objective: Establishing renal access is the most challenging step of percutaneous nephrolithotomy. Adequate training of urology residents is essential, as improper access can lead to increased morbidity and potential mortality. The purpose of this video presentation is to demonstrate the design, creation, and validation of a simple training model for renal access.
Methods: Using commercially available software, a mold of the renal parenchyma and collecting system was created from a patient's CT Urogram and then 3D‐printed. A silicone kidney model was created from this mold, giving a coronally bisected right kidney with calyceal system. This model was embedded in ballistic gelatin, which simulated the surrounding muscles and subcutaneous tissue. The final position of the kidney and surrounding gelatin simulated prone PCNL of the right kidney. A small metal ring was used as the target for renal access and was placed in the upper calyx upon a grid to allow measurement of distance from target. A piece of calcium carbonate was embedded into the gelatin over the upper pole of the kidney and simulated a palpable 12th rib. The entire model was covered with an opaque sheet to simulate skin and fluoroscopy was used to guide renal access. Five urologists and 15 novices took part in establishing renal access following training. The primary endpoint was validation of this training model. Construct validity was evaluated by comparing the distance from the target between urologists and novices using the Mann‐Whitney U test.
Participants were then asked to fill out a survey about the training model to evaluate its face validity.
Results: All 5 urologists successfully entered the ring. Of the 15 novices, 67% missed the ring, with an average distance of 3.07 mm from the target (p = 0.025). 90% of subjects felt the model was an accurate representation of renal access anatomy. All felt that this model would increase their understanding of renal access and 75% were extremely likely to recommend it for training.
Conclusion: This video demonstrated the design, creation, and validation of a simple training model for renal access. The model is simple, inexpensive, does not contaminate, and does not raise ethical concerns. Use of models like this could increase the skill of trainees and subsequently reduce patient morbidity.
The Vortex Effect in Mini‐PCNL: Improved Understanding with a Phantom Model and Computational Fluid Dynamics
Crystal Valadon1, Wilson Molina1, Willian Ito1, Dillon Prokop2, Bristol Whiles1, Donald Neff1, David Duchene1
1The University of Kansas Health System, 2University of Kansas School of Medicine
Presented By: Crystal Valadon, MD
Introduction and Objective: Minimally invasive percutaneous nephrolithotomy (MIP) was initially discredited with assumptions of difficult stone fragment retrieval because of the equipment's smaller size. However, in 2008 Nagele et al. described a hydrodynamic phenomenon that allowed stone retrieval without the aid of endoscopic tools. This study aims to describe the physical principles of the “vortex effect” to better understand its applicability in MIP procedures.
Methods: Two acrylic phantom models were built based on the cross‐sectional area (CSA) ratio of a MIP nephroscope and access sheaths (15/16F and 21/22F MIP‐M™, Karl Storz®). The nephroscope‐phantom was 10mm in diameter. The access sheaths had diameters of 14mm (CSA ratio: 0.69) and 20mm (CSA ratio: 0.30). The models were adapted to generate hydrolysis, and hydrogen bubbles enhanced flow visualization on a green laser background. After calibration, the experimental flow rate was set to 12.0mL/sec. Three 30‐second trials assessing the flow were performed with each model. Computational fluid dynamic simulations (CFD) were completed to determine the speed and pressure profiles.
Results: In both models, as the incoming fluid from the nephroscope‐phantom attempted to move toward the collecting system, a stagnation point (SP) was demonstrated. No fluid entered the collecting system phantom. Utilizing the 14mm‐sheath, we observed a random generation of several vortices and a pressure gradient (PG) of 114.4Pa between the nephroscope's tip and SP. When the 20mm‐sheath was examined, a significantly smaller PG (19.4Pa) and no noticeable vortices were noted.
Conclusions: The speed of the fluid and equipment geometry regulate the pressure gradient and the vortices field, which are responsible for the production of the vortex effect. Considering the same flow rate, a higher ratio between the cross‐sectional area of the nephroscope and access sheath results in improved efficacy of the vortex.
Impact of Renal Access Angle and Speed of Nephroscope Retrieval Movements on the Vortex Effect
Crystal Valadon1, Wilson Molina1, Willian Ito1, Dillon Prokop2, Bristol Whiles1, Donald Neff1, David Duchene1
1The University of Kansas Health System, 2University of Kansas School of Medicine
Presented By: Crystal Valadon, MD
Introduction: The vortex effect (VE) is widely utilized in mini‐percutaneous nephrolithotomy (mini‐PCNL), although its physical components are still poorly understood. This study aimed to analyze the influence of different renal access angles and nephroscope retrieval speeds on the VE's efficacy during mini‐PCNL.
Methods: A Pexiglas™ (KUS®) model was built based on the dimensions of a 15/16Fr mini‐PCNL set (Karl Storz®). The flow rate was continuous via an automatic pump and calibrated to achieve hydrodynamic equivalence to the real equipment. One experiment consisted of retrieving all 30 stone phantoms (3mm diameter) utilizing only the VE. Cumulative time to retrieve all stones was measured. An accelerometer recorded instant speeds every 0.08s, and 3 experiments were performed at each angle (0°, 45°, and 90°). We classified the effectiveness of the VE in each experiment (Figure 1). A logistic regression model was built utilizing maximum speeds and access angles (AA) to predict the effectiveness of the VE.
Results: Mean cumulative time was 28.1s at 0° vs. 116.5s at 45° vs. 101.4s at 90°(p < 0.01). We noted significantly higher speeds at 0° in comparison to 45° and 90° (p < 0.01); however, differences between 45° and 90° were not statistically significant. The regression model demonstrated a negative association between increased speeds and VE's effectiveness (OR 0.547, CI 95% 0.350‐0.855, p < 0.01). When controlling for maximum speed, the 0° angle had nearly a 100‐fold increased chance of obtaining at least a partially effective VE (OR 0.017, CI 95% 0.002‐0.141, p < 0.01).
Conclusions: Increasing the renal access angle negatively impacts the nephroscope retrieval speeds. This significantly increased procedure time in the laboratory model, suggesting that the VE is less effective at higher sheath angles.
Renal Endometriosis: A Rare Treatable Disease with High‐Powered Holmium Laser Ablation
Jingqiu Li1, Jin Yong1, Vipatsorn Shutchaidat1, Kae Jack Tay1, Henry Ho1
1Singapore General Hospital,
Presented By: Jingqiu Li, MD
Introduction and Objective: Endometriosis is a common disorder affecting 5‐10% of all reproductive‐age females. It predominantly affects the pelvic reproductive organs but can also be found in non‐reproductive organs, including the urinary system. The most common sites of urinary tract endometrioses are the bladder, ureter, and kidney, with a ratio of 40:5:1, respectively. Renal endometriosis is extremely rare. There only have been 16 histology‐proven renal endometrioses reported in the literature over the past 30 years. We present the use of high‐powered holmium laser ablation for a patient with renal endometriosis.
Methods: A 38‐year‐old female with a history of chronic kidney disease secondary to glomerulonephritis was referred to our center for microscopic hematuria. She denies any urinary symptoms or cyclical hematuria. Contrast‐ enhanced ultrasound of the kidneys and computer tomography (CT) urography showed a solid mass arising from the right upper calyx and extending to the renal pelvis. Management options, including ureterorenoscopy with biopsy and radical nephroureterectomy, were discussed with the patient in detail. Given her age and the size of the mass, the patient was recommended to consider ureterorenoscopy with biopsy. She decided to proceed with ureterorenoscopy as per our recommendation, which showed a sizeable polypoidal lesion protruding into the renal pelvis intra‐operatively. Biopsy was taken from the lesion, and histology revealed stromal and glandular proliferation in keeping with endometriosis. The patient subsequently had high‐powered Holmium laser ablation of the lesion with a flexible ureteroscope, using a laser setting of 1J 15Hz.
Results: The total laser time was eleven minutes. She was discharged well on the same day with no intra‐operative or post‐operative complications. Follow‐up imaging at six months post‐operatively showed complete ablation of the lesion with no recurrence.
Conclusion: Renal endometriosis is a rare disease with limited evidence available suggesting the optimal management. We report a case of biopsy‐proven renal endometriosis, which was successfully treated with endoscopic high‐ powered holmium laser ablation treatment.
Endoscopic Resection of a Ureteroenteric Anastomotic Tumor Recurrence After Radical Cystectomy: A Novel Approach Using Bipolar Resection Through an Ileal Conduit
Kelly Lehner1, Kevin Koo1, Aaron Potretzke1
1Mayo Clinic
Presented By: Kelly Lehner, MD
Introduction and Objective: Upper tract urothelial carcinoma (UTUC) after radical cystectomy is a relatively uncommon occurrence, with reported rates in the literature ranging from 0.8% to 6.4%.1 For low‐grade, noninvasive disease, endoscopic tumor resection provides an effective nephron‐sparing mangement approach, although the ability to effectively carry out laser ablation may be limited by tumor size. In this video, we present a novel management technique for relatively large volume UTUC recurrence in a 53‐year‐old male who previously underwent radical cystectomy and creation of an ileal conduit.
Methods: Our patient had a history of low grade and high grade Ta and failed multiple courses of intravesical management prior to cystectomy. At the time of cystectomy, papillary tumor was noted in the distal left ureter, and was able to be resected with negative margin prior to ureteral implantation into the conduit. Three years later, during routine surveillance, he was found to have papillary tumor recurrence in the ureters, renal pelvices, and at the site of the ureteroenteric anastamosis. Biopsy revealed low grade, noninvasive tumor. Due to bulky tumor size at the ureteroenteric anastamosis, this area proved difficult to manage with endoscopic laser ablation alone. The patient strongly desired a kidney sparing approach.
Results: Due to tumor size, an alternative approach was sought to achieve complete tumor resection. In this video, we demonstrate a novel technique of using a bipolar resectoscope to perform endoscopic tumor resection through an ileal conduit. Cutting loop electrocautery was used to resect a 4‐cm tumor emanating from the left ureteral orifice into the ileal conduit. Total resection time was 29 minutes. There was no concern for injury to the stoma, ileal conduit, or ureteral anastamosis, confirmed with intraoperative loopogram and retrograde pyelograms.
Conclusions: For bulky urothelial tumors accessible within an ileal conduit, tumor resection with a bipolar resectoscope offers a safe, feasible, and efficient method of kidney sparing UTUC management.
1. Gakis G, Black PC, Bochner BH, et al. Systematic Review on the Fate of the Remnant Urothelium after Radical Cystectomy. Eur Urol. Apr 2017;71(4):545‐557. doi:10.1016/j.eururo.2016.09.035
A Novel Approach to Complex Bladder Stone Removal Using Combination of Trilogy Lithotripter and Piranha Morcellator
Samuel Eaton4, Emma Waddell1, Borivoj Golijanin2, Taylor Braunagel3, Christopher Tucci2, Vikas Bhatt2
1The Warren Alpert Medical School of Brown University, 2Minimally Invasive Urology Institute, The Miriam Hospital, 3TBraunagel@lifespan.org, 4Minimally Invasive Urology Institute, The Miriam Hospital and The Warren Alpert Medical School of Brown University
Presented By: Samuel Eaton, MD
Introduction and Objective: Management of large stones in the bladder can be challenging. The Richard Wolf Piranha morcellator is traditionally used to remove prostatic tissue from the bladder after endoscopic enucleation of the prostate. In this video, we demonstrate its application to the treatment of a large matrix bladder stone.
Methods: An 84‐year‐old man with a history of nephrolithiasis and recurrent proteus UTI presented with gross hematuria and was found to have complex matrix stones in the right kidney and bladder. He was taken to the operating room for management with holmium laser, but after two hours, only the renal stones were successfully treated by ureteroscopy and laser lithotripsy. The bladder stone was noted to have a mixed composition with some solid component but a large gelatinous matrix. Attempts to manage the bladder stone with laser and bipolar resectoscope had very limited success. Total procedure time was 277 minutes. One month later, the bladder stone was removed with a combination of Trilogy Lithotripter and Piranha morcellator. In this video, we demonstrate use of these devices for management of a complex, hard‐to‐treat stone. Trilogy Lithotripter was used to remove the solid shell component of the stone but was ineffective against the gelatinous matrix. We switched to the Piranha Morcellator, which rapidly removed the remainder of the stone.
Results: The procedure to address the bladder stone lasted 30 minutes. The stone was removed in its entirety, and there was no injury to the bladder. The patient recovered well postoperatively and was discharged to home on the same day. The patient now has no evidence of residual stone on imaging and no further UTI at one year follow‐up.
Conclusions: Use of the rotational morcellator is a feasible and efficient option to remove complex matrix stones in the bladder for which treatment with standard methods including cystolitholapaxy prove difficult.
Distal Right Ureterolithotomy
Vinayak Banerjee1, Michael Phelan1, Shu Wang1
1University of Maryland School of Medicine
Presented By: Vinayak Banerjee, MS, BS
Introduction and Objective: The most common surgical interventions for ureteral stone include ureteroscopy (URS) and extracorporeal shock wave lithotripsy (ESWL). However, in patients with large ureteral stones, endoscopic stone retrieval has a low success rate for stone clearance and potentially high complication rate for ureteral injuries and subsequent strictures. In this video, we performed a robotic‐assisted ureteral lithotomy to completely extract a large ureteral stone and reduce intra‐ and post‐operative complications.
Methods: An 81‐year old male with a history of prostate cancer presented with gross hematuria and work‐up showed a 5cm right distal ureteral stone and mild hydronephrosis on an abdominal CT scan. MAG3 study revealed no obstructive uropathy. A robotic approach to retrieve the stone was planned. The ureter was carefully dissected in a circumferential manner from the iliacs. Intraoperative ultrasound was used to locate the stone. The anterior ureter was sharply unroofed over the stone and the stone was removed. Reconstruction of the ureter was accomplished via a running suture. A flexible cystocope was then used to place a double‐J stent within the newly reconstructed ureter. There were no complications during the procedure.
Results: The postoperative timeline was uneventful and the patient was discharged in two days. The stone measured 5cm in length and 1cm in diameter. Stone analysis showed 80% magnesium ammonium phosphate (struvite) and 20% calcium phosphate. Ureteral stents were removed one month after the surgery. No ureteral strictures were found during the 5‐month follow‐up.
Conclusions: We experienced no intra‐ or postoperative complications from the robotic‐assisted ureterolithotomy. It is safe and efficient for the retrieval of large ureteral stone.
Source of Funding: None.
Percutaneous Stone Removal in Patients with Urinary Diversions
Patients with urinary diversions and stones represent a unique challenge for stone removal. This video will review a variety of techniques to remove stones via a percutaneous approach in patients with urinary diversions.
The Simultaneous Laparoscopic Management of Uretero‐Pelvic Junction Obstruction and Renal Lithiasis‐A Video Demonstration
Presented By: Akshay Nathani, DNB urology Fellow in world endourology society
Introduction: Approximately one out of five patients with ureteropelvic junction obstruction (UPJO) present lithiasis in the same setting. There is a 70‐fold increase chance of developing renal lithiasis in UPJO. Therapeutic controversy exists regarding the ideal management of the same. We present our review of cases and outcomes of simultaneous management of UPJO and pelvic or calyceal lithiasis with the use of rigid ureteroscopy, flexible ureteroscopy and use of lithoclast for the management of such cases.
Methods: We performed a retrospective review of our series over a 5 year period. We operated on 12 such patients. The inclusion criteria was presence of symptomatically significant pain and radiologically proven UPJO along with the presence of ipsilateral calculi. All the operations were performed by a single surgeon with over 100 cases of laparoscopic pyeloplasties as experience. Intra‐operatively, the repair of the UPJO was performed as per standard steps(Modified Andersen Hynes plyeloplasty. The various options that were used for the stone clearance included irrigation and flushing out stone, picking up stone with laparoscopic instrument, using Rigid ureteroscopes, flexible ureteroscopes and use of lithoclast energy. Stone extraction was performed using……basket. Post‐operatively clearance of stones was verified radiologically.
Results: All the 12 patients were rendered stone free in the immediate post‐operative period. There were 5 male patients and 7 female patients in this retrospective study. The mean age group was 35.8 years (Maximum of 62 years and minimum 6 years). There were 7 cases where stone retrival was done directly with the help of irrigation and pick up with laparoscopic instruments , 3 via semirigid URS with help of forcep and basket .Lithoclast was used in one case to break the stone and FURS was used in 2 cases . The mean operative period was 160+/‐22 minutes. The longest diameter of stone ranged form 4mm to 15mm(mean of 6.63mm) and an average of 2.5 stones per patient was removed (1‐4 stones). Complications included prolonged urine output from the drain in one case (Clavien grade I) . The mean postoperative follow‐up was 30.2 (7–51) months. No patient has experienced stone or UPJO recurrence during that follow up period.
Conclusion: Laparoscopy for the management of UPJO along with renal stone removal seems a very appealing treatment, with all the advantages of minimally invasive surgery. Various Concomitant renal stones do not affect the outcome of laparoscopic pyeloplasty, at least in the midterm. According to our results, we advocate laparoscopic management as the treatment of choice for these cases.
Placement of Double J Catheters: Unglorious Procedures
1Hospital de Clinicas Jose de San Martin, 2Hospital de Clinicas Jose de San Martin
Presented By: Horacio Sanguintti, PhD
Introduction and Objective: The double J catheter is a commonly used device in the treatment of urological problems, but it can present complications during its placement and subsequent use. The main objective of this video is to present, in an unorthodox manner, a series of cases with uncommon complications arising from a routine practice.
Methods: This video presents three uncommon clinical cases associated with the placement of the double J catheter. For each case, the actions taken to effectively manage these complications are described.
Results: The obtained results showcase clinical cases involving complicated double J catheters. These cases include renal perforation of the catheter, treated by nephroscopy; the impossibility of extraction, requiring the placement of a second catheter, which was endoscopically treated with laser fragmentation of the calcified catheter; and the obliteration of a double J catheter following nephrectomy, which was successfully removed for proper recovery.
Conclusions: Although the placement of the double J catheter is generally considered a safe and effective procedure, it is crucial to consider the possibility of uncommon complications, as presented in this video. Additionally, the measures that can be taken to address the occurrence of these complications are presented, thus expanding the existing knowledge in this field.
Robotic (Assisted Laparoscopic) Pyelolithotomy with Pyeloplasty and Transportal Flexible Nephoscopy for Pelviureteric Junction Obstruction with Partial Secondary Staghorn Calculus and Caliceal Calculi ‐ Technical Tips
Ramalingam Manickam1, Senthil Kallappan1, Sivasankaran Nachimuthu1, Sri Sai Harsha P2
1Hindusthan Hospital, Consultant Urologist, 2Continental Hospitals in Gachibowli, Consultant Urologist
Introduction: Pelvi Ureteric Junction obstruction with secondary partial staghorn and multiple caliceal calculi needs management of UPJ and removal of calculi. To achieve fair clearance of secondary calculi, Flexible nephroscopy through assistant port is needed. This video illustrates the technique.
Materials and Methods: A 28 years old male presented with left loin pain. Contrast CT revealed moderate left hydronephrosis bilateral renal calculi. He had a marginally elevated renal bio chemical parameters (Sr creatinine 1.7 mg) Urine culture was negative . In the first stage, right RIRS, Left RGP (showed left UPJ obstruction) and left stenting were done. 2 days later second procedure was done. With patient in loin position using 3 Robotic arms and 2 assistant ports left colon was reflected and UPJ and pelvis were mobilised. An oblique pyelotomy for 3 cm length was made and largecalculus in pelvis was retrieved. Flexible nephroscope was introduced through subumbilical assistant port and manovered through pyelotomy to remove most of the lower caliceal smaller calculi (As acute angulation of nephroscope was not feasible few of the tiny calculi in minor calices could not be removed). Subsequently pyelotomy incision was extended across the posterolateral aspect of UPJ and further 2 cm down the ureter (in preparation for Non dismembered pyeloplasty_) Antegrade stenting was done. Anterior wall of pelvis was pulled downwards across ureterotomy and using 4 – 0 vicryl interrupted sutures nondismembered pyeloplasty was reconstructed. Tube drain was placed.
Results: Patient made a smooth recovery one month post operatively renal function improved (Sr Creatinine 1.1) Plain CT KUB revealed fairly decompressed pelvi caliceal system and few tiny calculi. Flexi URS was done after 6 weeks which revealed fairly patent UPJ allowing 7.5 F Flexi URS easily. Residual calculi were retrieved.
Conclusion: Robotic Pyelolithotomy with Pyeloplasty and intraoperative RIRS/ Flexi Nephroscopy is challenging but feasible. The Video illustrates the technique.
Video Session 2: Reconstruction: Upper Tract
Robotic Assisted Laparoscopic Transureteropyelostomy: A Novel Technique for Management of Long‐Segment Radiation Induced Strictures
Matthew Lee1, Julienne Jeong1, Brian Chao1, Elizabeth Nagoda1, Daniel Eun1
1Temple University Hospital
Presented By: Matthew Lee, MD, MBA
Introduction and Objective: Surgical management of long segment ureteral strictures after prior radiation therapy may be challenging due to increased fibrosis and damage to the periureteral blood supply. Traditionally, ileal ureter reconstruction has been utilized in this setting, however this approach may result in significant morbidity. We describe the case of a patient with a radiation‐induced left sided pan ureteral stricture who underwent a transureteropyelostomy.
Methods: The patient is a 62‐year‐old female with history of a left sided pan ureteral stricture secondary to radiation for cervical cancer. She was previously managed with chronic ureteral stent exchanges. Preoperative renal scan demonstrated a split function of 60% and 40% in the right and left kidney, respectively, with a mildly delayed nephrogram on the left side. A left percutaneous nephrostomy tube was placed 4 weeks prior to definitive management. Preoperative antegrade and retrograde pyelograms demonstrated a pan ureteral left sided stricture with normal caliber in the proximal left ureter. Cystogram demonstrated a 250‐milliliter bladder capacity. Patient elected to undergo a robotic transureteropyelostomy which involves transection of the left ureter at the proximal end of the stricture and an end‐to‐side anastomosis of the transected end to the right renal pelvis.
Results: Intraoperatively, estimated blood loss was 200 milliliters and operative time was 178 minutes. There were no intraoperative complications and the patient was discharged on postoperative day one. The patient's ureteral stent was removed 6 weeks postoperatively. The patient had no flank pain and did not experience any postoperative complications. The patient's 12‐week postoperative renal scan demonstrated post lasix half time of 7 minutes on left and differential renal function of 54% of right kidney and 46% of left kidney.
Conclusions: Robotic transureteropyelostomy is a novel technique for management of patients with long‐segment radiation induced strictures with small bladder capacities. Anastomosing the ureter to the contralateral renal pelvis may offer a more robust blood supply versus a transureteroureterostomy. Transureteropyelostomy may also avoid the morbidity associated with ileal ureter reconstruction and serves as an alternative approach for these patients.
Source of Funding
None
A Novel Method for Removing Calyceal During Single‐Port Robotic Assisted Laparoscopic Dismembered Pyeloplasty
Catherine Ingram1, Angeline Johny1, Brenna Briles1, Richard Link1
1Baylor College of Medicine
Presented By: Catherine Ingram, MD
A Novel Method for Removing Calyceal During Single‐Port Robotic Assisted Laparoscopic Dismembered Pyeloplasty
Catherine F. Ingram, Angeline Johny, Brenna L. Briles, Richard E. Link Department of Urology, Baylor College of Medicine
Introduction and Objective: This video demonstrates a novel method for removal of calyceal stones at the time of pyeloplasty on the new da Vinci SP surgical system.
Methods: Our patient is an 18‐year‐old male with intermittent right flank pain for several months. A computed tomography (CT) scan showed moderate hydronephrosis with narrowing at the UPJ concerning for UPJ obstruction. It also revealed two 6‐8 mm non‐obstructing lower pole stones.
A retrograde pyelogram performed in lithotomy position before the robotic portion of our case showed a dilated right renal collecting system with tapering at the UPJ. We placed a ureteral stent and positioned the patient into right anterior flank position.
We made a 2.7 cm incision to the right of the umbilicus and inserted the Intuitive® AirDock system. After reflection of the right colon and ureteral mobilization, the right renal pelvis was identified. The UPJ showed a markedly narrowed segment. The renal pelvis was incised anteromedially. Complete dismemberment was not performed yet to keep a point of fixation for stone removal later. The incision was extended so that the entrance of the inferior calyx, in which the stones had been seen on CT, was able to be visualized.
The outer portion of a 12/14 Fr x 36 cm access sheath was inserted through the AirDock. The robotic forceps directed the distal end of the sheath to the renal pelvis incision by grasping a a 2 cm silk suture tied at its distal end. A ureteroscope was driven through the sheath and into the inferior calyx without irrigation. A tipless basket was used to capture a stone there. Because the stone diameter was larger than the sheath's, the ureteroscope and sheath were retracted simultaneously for stone retrieval. The same was done for the second stone.
Afterward, full dismemberment of the ureter from the renal pelvis was completed. The narrowed segment was excised, the posterior ureter was spatulated, and the anastomosis was completed in a running watertight manner.
Results: Two calyceal stones were removed successfully at the time of robotic pyeloplasty on the SP platform. The patient was discharged on the day of surgery, and his stent was removed one month later without complication. His pain is much improved.
Conclusions: Calyceal stone removal at the time of robotic dismembered pyeloplasty on the SP system for UPJ obstruction can be performed safely with the aid of an access sheath through the AirDock system and a ureteroscope.
Robotic Lower Pole Partial Nephrectomy in a Duplicated Collecting System
Ketch Cowan1, Mark Mikhail1, Benjamin Waldorf1
1University of Tennessee College of Medicine Chattanooga Urology
Presented By: Alex Hwang, MD
Introduction And Objective: In this video, we present our experience with robotic assisted laparoscopic partial nephrectomy for an obstructive left lower pole moiety in a duplicated collecting system, utilizing intravenous indocyanine green (IV ICG), as well as retrograde injection of the left upper pole ureter with methylene blue to rule out collecting system leaks at the end of the procedure. The patient is a 52‐year‐old male who was referred to our facility for a duplicated collecting system with hydronephrosis, and subsequently underwent a MAG3 renogram with Lasix, which demonstrated findings consistent with an obstructed left lower pole moiety.
Methods: Prior to docking the da Vinci Xi Robotic System, cystoscopy with left retrograde pyelogram was performed, which demonstrated a single left ureteral orifice with normal‐appearing ureter extending proximally to the level of the lower pole, where a bifurcation of the ureter was noted. The upper pole ureter was noted to be normal‐appearing, while the lower pole ureter appeared smaller in caliber. A ureteral catheter was placed into the upper pole moeity before the patient was repositioned for the robotic portion of the case.
Results: Gerota's fascia was first freed from surrounding structures. The renal hilum was dissected out and the lower pole vessels were identified. The left ureter was dissected caudally until the junction of the upper and lower pole ureters was identified. The lower pole ureter and renal pelvis were dissected, with the lower pole vessels controlled and transected with a stapler and the lower pole ureter clipped and transected with cautery, allowing the entire lower pole moiety to be lifted away from the upper pole moiety. IV ICG was then administered and allowed for a dissection plane to be marked out along the renal capsule using electrocautery. A lower pole partial nephrectomy was then performed, removing the entire lower pole parenchyma and collecting system. Once hemostasis was achieved, intraluminal methylene blue was injected in a retrograde manner up to remaining ureter via ureteral catheter, which allowed for visual confirmation that there was no leakage from the upper pole collecting system. Renorrhaphy was performed. The specimen was extracted and port sites were closed. The patient was discharge on POD1 without complications and remained complication free at his 2 week follow‐up.
Conclusions: Robotic assisted laparoscopic partial nephrectomy for a duplicated collecting system can be facilitated with intra‐operative techniques including, IV ICG administration, and intraluminal methylene blue. These techniques proved to be effective in ensuring the preservation of viable renal parenchyma, as well as confirming no urinary leak was present.
Single‐Port Robotic Revision of Ureteroenteric Anastomosis with Buccal Mucosa Graft
Jasmin Capellan1, Kevin Chua1, Alain Kaldany1, Sai Krishnarya Doopalapudi1, Benjamin Lichtbroun1, Hiren Patel1, Sammy Elsamra1
1Robert Wood Johnson Medical School
Presented By: Jasmin Capellan, Medical Student
Introduction and Objective: In this case, a robotic left ureteroenteric anastomosis (UEA) stricture repair and parastomal hernia repair of an ileal conduit was performed. On postoperative day one, the patient was found to have an anastomotic leak and subsequently underwent a single port robotic re‐revision of the UEA with a buccal mucosa graft.
Methods: A side‐to‐side left UEA stricture repair and Sugarbaker parastomal hernia repair was performed with the da Vinci Xi® robotic system. Post‐operatively there was a leak and re‐revision of the UEA was performed with the da Vinci SP robotic system. A 2x4 cm buccal mucosa graft was used to repair an anterior defect of the UEA. An omental flap was placed onto the buccal mucosa ureteral onlay and a single J ureteral stent was left in place.
Results: The operative time of the single port robotic re‐revision of UEA was 5 hours with 50mL of blood loss. Foley catheter in the ileal conduit fell out 2 weeks after the procedure. Antegrade nephrostogram 3 weeks postoperatively showed drainage into the ileal conduit and left PCN was removed. Drain was removed 5 weeks postoperatively and renal scan 6 weeks postoperatively demonstrated no evidence of obstruction.
Conclusion: Repair of a UEA stricture should be performed in a separate procedure after a parastomal hernia repair since the parastomal hernia repair can create tension on the UEA which can lead to an anastomotic leak. Revision of the UEA with buccal mucosa is feasible and effective with the single port robot.
Ureteral Stricture Disease After Administration of Mitomycin‐Containing Reverse Thermal Gel
Gregory Mullen1, Zeph Okeke1, Arthur Smith1
1Smith Institute for Urology Northwell Health
Presented By: Gregory Mullen, MD
Per European Association of Urology and American Urological Association guidelines, tumor ablation is the preferred treatment option for patients with low risk upper tract urotheial carcinoma. Following tumor ablation, instillation of adjuvant chemotherapy can be done to decrease risk of recurrence. A mitomycin‐ containing reverse thermal gel has showed promise to increase dwell time and effectiveness of the medication, however, initial studies show a high rate of ureteral stricture. This video will highlight the progression of upper tract urothelial carcinoma in a patient treated with multiple agents, including mitomycin‐containing reverse thermal gel, which ultimately results in ureteral stricture disease.
Management of Complex Ureteric Strictures‐the Robotic Way
Management of complex ureteric strictures‐The Robotic way.
Dr. Arvind Ganpule, Abhishek Singh, Coelho Victor, Abhijit Patil, Rohan Batra, Ravindra B Sabnis, Mahesh Desai Muljibhai Patel Urological Hospital , Nadiad, Gujarat, India. Introduction and Objectives: The developments in robotic ureteric stricture repair have led to similar success rates to open techniques. The management of ureteric strictures is based on the length, site and the aetiology of the strictures. Complex ureteric strictures defined as long segment strictures greater than 2 cm, strictures in a solitary kidney or those in patients with chronic kidney diseases and strictures associated with inflammatory conditions like retroperitoneal fibrosis or tuberculosis. There is a plethora of options available for the treatment of ureteric strictures which include end‐to end‐ ureterostomy and buccal mucosal patch ureterostomy.
In this video we will allude to and demonstrate certain technical nuances in the management of such complex ureteric strictures.
Methods: In the first case we demonstrate the use of the indigo‐cyanine dye and the Fire fly technology in the identification of the upper ureteric stricture in an 18 year old man, who had developed an upper ureteric stricture 3 months after a URS procedure. This video highlights the importance of the placement of a ureteric catheter and a percutaneous nephrotomy tube. The jiggling of the ureteric catheter and the distension of the renal pelvis through the nephrostomy tube, helped us to identify the exact location of the stricture.
In certain complex strictures, the options are limited. The second case demonstrates a 60 year old lady with diabetes and recurrent pyelonephritis, who was diagnosed to have a right upper ureteric long segment stricture. In this video we describe the use of a buccal mucosa that was used in a onlay and overlay method to bridge the intervening segment of the strictured ureteric segment.
Results: All the t patients had an uneventful recovery period and were discharged by the fourth post‐operative day.
Conclusion: Robotic uretero‐ureterostomy is a feasible option for the definitive treatment of proximal and mid ureteral strictures. The use of the accessory technology like the Firefly mode in the Davinci X platform and use of percutaneous nephrostomies and use of pre‐placed ureteric catheters helped us in accurate location of the stricturous segment and plan our further operative management.
Source of funding: None
Conflict of interests and disclosure statement: All authors declare no conflict of interests.
Lost Armamentarium in Pelvi‐Calyceal System in Endourology: Unforeseen Complications
Introduction and Objective: The armamentarium in urology has many delicate instruments like glide wires, nitinol baskets, delicate forceps and others. Sometimes, malfunctioning and breakage of these instruments may lead to unforeseen intra operative technical complications which may lead to serious consequences. We describe and discuss prevention and management of three cases in which there were complications due to malfunction of armamentarium.
Methods: We describe three cases. First case is a case of a PCNL in a left kidney. After the insertion of nephroscope, few clots were seen. The clots were taken out with the help of an endoscopic forceps. But during the course of removal of clots, one of the jaws got broken and got lost in the PCS. Immediately, a new forceps was taken and without much manipulation, the broken jaw of the forceps was identified and retrieved.
Second case is of microPCNL done for a left small renal calculus. The puncture was done by ultrasonography guidance. After confirming the position of the needle with the help of fluoroscopy, guide wire was inserted in the PCS. A soft fascial dilator was inserted and over it and 8 Fr metal sheath was inserted. During the removal of dilator over the sheath, the metal sheath cut a part of the fascial dilator as it bent during the removal. This was realized when the dilator was taken out. Nephroscopy was done and the broken part was seen but it could not be retrieval through the basket. So, it was converted to mini perc and the broken dilator part was extracted.
The third case id of a 7 month child who had left renal and left ureteric calculi. During left ureteroscopy, the stone was entrapped in nitinol basket and laser fragmentation was done. But, the distal end of nitinol fiber broke into the ureter and got migrated higher up. The basket fragment was retrieved with another basket. Take home message from this case is that surgeon should be careful with the laser firing when used along with the baskets.
Result: We could retrieve our broken armamentarium in all cases but proper care should be taken so that we do not lose the instrument pieces inside and cause morbidity to the patient.
Conclusion: Proper care of instruments is of utmost importance. The instruments must be properly checked before and after a case for any loose parts or damage. Broken or mal functioning instruments must not be used. There should be only optimal force applied while pushing in the sheath over dilators otherwise, they may get damaged and break. There should be minimal manipulation when part of instrument is lost so that the search of instrument will become easy.
Laparoscopic Management of Distal Ureteral Stricture Following Open Radical Cystectomy and Orthotopic Neobladder
Murat Gülşen2, Murat Gülşen1, Ender Özden1, Ertuğrul Köse1, Yarkın Kamil Yakupoğlu1
1Ondokuz Mayıs University, School of Medicine, Department of Urology, Samsun, Turkey, 2Ondokuz Mayıs University, School of Medicine, Department of Urology,
Presented By: Mehmet Necmettin Mercimek, MD
Introduction and Objective: To share our laparoscopic transureteroureterostomy (LTU) experience after open radical cystectomy (RC) and orthotopic neobladder.
Methods: A 62‐year‐old man who was operated on for urothelial carcinoma with an open RC (pT1, N0) and orthotopic bladder at a different hospital presented with flank pain and fever. CT revealed grade 3 hydroureteronephrosis (HUN) on the right side and grade 2 HUN on the left side. The creatinine level was 1.3 mg/dl and had no comorbidities. Bilateral nephrostomy tubes were inserted and antibiotic treatment started. After obtaining sterile urine, the antegrade pyelogram indicated a right distal urethral stricture of about 3 cm with no contrast passage. The left ureter was mildly dilated, and contrast passage was normal. LTU was scheduled.
First, endoscopy was performed. The guidewire was unable to pass through the end of the right ureter, but the guidewire inserted through the left nephrostomy reached the bladder. Flexible cystoscopes and ureteroscopes reached the stump but were unable to see the ureteral tissue. After the endoscopy, the patient was placed in the supine position. After the achievement of pneumoperitoneum, a 4‐port trocar configuration was used as shown in the video. After medialization of the sigmoid colon, anastomosis site with severe adhesions was seen. With the help of intraoperative ultrasound, the left and right ureters were identified for safe dissection. After sufficient dissection, the right ureter was transected with cold scissors. To establish "tension free" anastomosis, both ureters were detached from their surrounding tissues and the right ureter was spatulated. The end‐to‐side anastomosis was performed by 5/0 polyglactin sutures in continuous fashion. A double j stent was inserted into the right ureter via guidewire.
Results: Endoscopy and insufflation times were 40 and 190 minutes, respectively. Estimated blood loss was insignificant. Nephrostomy tubes and drain were removed on the postoperative 2nd and 3rd days, respectively. The patient was discharged on post‐operative 3rd day. The stent was removed 4 weeks after the procedure. The patient's follow‐up was uneventful for the first year.
Conclusion: The management of ureteral strictures with pure laparoscopy is technically challenging, especially when previous major surgery has already been performed. Despite its difficulty, LTU is safe and effective, with minimal bleeding, a rapid recovery, and favorable cosmetic outcomes.
Technical Tips of Laparoscopic Buccal Mucosal Graft Ureteroplasty Using 3D Camera
Introduction & Objectives: Laparoscopic buccal mucosal graft ureteroplasty(BMG Ureteroplasty) is a technically challenging procedure. 3D camera and haptics of laparoscopy make the complex procedure feasible. There is scarce literature and video on BMG ureteroplasty especially with technical tips. Here we illustrate the technical tips of BMG Ureteroplasty using 3D laparoscopy.
Materials & methods: A 54 year old male diabetic patient presented with stricture in the left upper ureter following three ureteroscopic surgeries. General anaesthesia with nasotracheal intubation was done as buccal mucosal graft ureteroplasty was planned. Patient was placed in the lithotomy position and retrograde Pyelogram(RGP) was done to assess the site and length of ureteric stricture. Then patient was changed to loin position keeping the ureteric catheter as guide as there can be lot of adhesions. Using 4 ports(10 mm camera port at a point 5 cm above and lateral to umbilicus; two 5 mm ports 4 fingers breath away from camera port in midclavicular line; and one more 10 mm port in left flank) left colon was mobilised. 5 cm of upper ureter, densely adherent pelvi‐ureteric junction and about a cm of pelvis were mobilised, taking care not to skeletonise ureter more than necessary. Endoknife was used to make a pyelotomy for a cm just above the strictured area on the posterolateral aspect of the pelvis. This step was done so that pyelotomy can admit the tip of the scissor. Potts scissor was then used to continue the pyelotomy onto strictured ureter. As there was no space around ureteric catheter, the ureteric catheter was pulled out leaving the guidewire alone to accommodate tip of potts scissors. A part of an infant feeding tube was used to measure the length of stricture. The stricture measured about 4 cm and hence a 4.5 cm x 1.5 cm buccal mucosal graft was harvested and brought inside the abdomen through 10 mm flank port. The graft was placed onlay and ureteroplasty was started at the cranial end of pyelotomy using 4‐0 polydioxanone suture (which slides easier than polyglactin) and then continued on the posterior layer of ureterotomy as a continuous suture. Antegrade stenting was done using Verres needle in the flank. The initially placed guide wire was pulled out. Subsequently the continuous suture was done on the anterior layer. Redundant part of the buccal mucosal graft was excised. As the graft could not be quilted, a generously mobilised thick omentum was wrapped around the whole graft. A tube drain was placed through flank port.
Results: The procedure took 180 minutes. Blood loss was insignificant. There was no intraoperative or immediate postoperative complications. Drain was removed on the 5th postoperative day. Contrast enhanced CT scan done at 6 weeks did not show any extravasation and there was fair decompression of pelvicalyceal system.
Conclusions: Laparoscopic BMG Ureteroplasty using 3D camera makes the procedure feasible, safe and comfortable due to depth perception. This video demonstrates the technical tips precisely. This is the first video report of 3D laparoscopic BMG Ureteroplasty to our knowledge.
Novel Hybrid Technique of Laparoscopic Nipple Valve Reimplantation with Portsite RIRS through Exteriorised Distal Ureter in Pom with Renal Calculus
Introduction & Objective: Laparoscopic Nipple valve ureteric reimplantation of ureter with portsite RIRS is a innovative minimally invasive management of renal calculus and Primary Obstructive Megaureter.
Methods: A 42 years old male, presented with 7‐month history of left loin pain. CET scan of abdomen revealed 14mm left upper calyceal calculus with primary obstructive mega ureter. By a transperitonial approach using 4 ports lower ureter was dissected and divided above level of obstruction. The ureter was brought out through the 10mm port in the left iliac fossa and flexi URS passed through the ureter and laser lithotripsy was done.
Nipple valve ureteric reimplantation was done. Procedure was completed in 160 minutes.
Results: Postoperative period was uneventful. Foley catheter was removed 10th day, and stent was removed at the end of 4th week
Conclusions: Portsite RIRS during laparoscopic nipple valve reimplantation of ureter is a useful innovative minimally procedure.
Robotic Nephropexy and Left Ureteroenteric Anastomosis Revision for a Complex Obliterated Ureteral Stricture Following Ileal Conduit Creation
William Langbo2, Han Hee Kim1, Daniel Roadman2, Scott Brockman2, Alexander Chow2
1University of California, Davis, 2Rush University Medical Center
Presented By: William Langbo, MD
Introduction and Objective: Radiation cystitis is an unfortunate complication of pelvic radiation therapy. Cystectomy with urinary diversion is the preferred therapy for patients with end stage bladder. However, prior radiation puts these patients at increased risk for ureteroenteric anastomotic stricture. We present the case of a 68 year old gentleman with a history of radiation induced end stage bladder status post open radical cystectomy with creation of an ileal conduit. The patient developed a 5cm obliterated left ureteral stricture. He elected to proceed with robotic left nephropexy and revision of the left ureteroenteric anastomosis.
Methods: The patient was positioned in lateral decubitus and the robot was docked in standard fashion over the left flank. The descending colon was mobilized and the splenorenal ligaments, lateral, and posterior attachments of the kidney were divided. Indocyanine green (ICG) was injected into the patient's nephrostomy tube and ureterolysis was carried out extensively. The lateral wall of the peritoneum was stitched to Gerota's fascia.
The robot was undocked and lysis of adhesions was performed laparoscopically.
The patient was repositioned in supine with steep Trendelenburg and the robot was re‐docked in a standard pelvic configuration. The distal end of the left ureter was clipped and divided. A mesenteric window was created and the free end of the ureter was transposed under the bowel. Conduitoscopy allowed for visualization of the cystoscope light within the conduit, confirming the correct position for the ureteroenteric re‐anastomosis. The ureter was spatulated and the enterotomy opened. Interrupted sutures were placed at the apex of the ureter and the anastomosis appeared tension‐free. A double J ureteral stent was placed in antegrade fashion and the anastomosis was completed with a series of interrupted ties.
Results: Total operative time was 8 hours. The patient's postoperative course was complicated by ileus requiring a nasogastric tube, removed on POD#2. He was discharged on POD#5. At 3 months follow up, conduitoscopy and retrograde pyelogram showed no evidence of stricture recurrence.
Conclusions: This video demonstrates robotic techniques to effectively perform a primary reimplantation of a ureteroenteric anastomosis for a long complex stricture. Ipsilateral nephropexy allows for greater ureteral length to aid with a tension‐free anastomosis. Both ICG and light from the conduitoscopy can be utilized to help identify the intra‐abdominal ileal conduit.
The Role of Endoluminal Indocyanine Green in Delineating Ureteral Pathologies in Robotic Surgery Using Firefly System: Point of Technique and Demonstration of Three Cases
Introduction: Robotic surgery offers unparalleled advantages in reconstructive urological procedure. But there are some disadvantages too such as loss of haptic feedback. To overcome this, one of the techniques that evolved was the use of near‐infrared laser that helps ICG fluoresce and subsequent filtering by lens, called as Firefly Fluorescence Endoscop system which converts the fluorescing ICG to a bright green color. ICG dye can be used intraoperatively through intravenous or endoluminal route to help differentiate ureteral pathology. We aim to show the usefulness of endoluminal ICG in delineating ureteral pathological lesion and in further reconstruction.
Materials and Methods: We have selected three cases for video demonstration and noted their perioperative and postoperative details. We used the Da Vinci X Robotic system (Intuitive Surgical) with Firefly mode for delineation of ureteral pathology after injection of ICG endoluminally.
Results: Case 1 was a 53 years old gentleman with right upper ureteral stricture who underwent uretero‐ureterostomy after excision of stricture segment with the help of Firefly system. Case 2 was a 69 years old gentleman with left lower ureteral mass lesion who underent excision and ureteroneocystostomy under Firefly guidance. Case 3 was a 51 years old lady with left lower ureteral mass lesion who underwent excision and Boari flap for ureteral reimplantation. All patients are had good postoperative recovery and are doing well on follow‐up with normal investigations.
Conclusion: Use of Firefly mode in Da Vinci surgical Robot with ICG dye is a very useful modality to accurately delineate the extent of ureteral pathology and helps in ureteral reconstruction.
Robotic Repair of Retrocaval Ureter‐Tips and Technique
Nitish Aggarwal2, Prabhjot Singh1
1AIIMS New Delhi, 2AIIMS New Delhi
Presented By: Nitish Aggarwal, M.Ch
Introduction & Objectives: Retrocaval ureter is a rare condition which leads to obstruction of the kidney , being more common in male and usually become symptomatic by 3rd decade. Minimally‐invasive surgical options has emerged as the method of choice for repair‐ varying from laproscopic( which can be transperitoneal or retroperitoneoscopic) to robotic approach. The use of the surgical robot facilitates the most challenging part of the procedure, which is intracorporeal suturing .
Methods: A 18‐year‐old boy developed right sided flank pain for last 4 years. In the course of evaluation for the cause, he was diagnosed as having right retrocaval ureter. He underwent right robot assisted ureteroureterostomy. Pneumoperitoneum was created using a Veress needle. The Da Vinci robot was then docked from the back of the patient. The hepatic flexure of the right colon was identified mobilized and dropped.The right renal pelvis and inferior vena cava were identified. The right renal pelvis and proximal ureter were freed of soft tissue attachments. The proximal ureter was seen disappearing behind the inferior vena cava. Transection was performed at the level of the proximal ureter. With further dissection retrocaval part was delivered from behind vena cava. Then ureteroureterostomy was performed using a 4‐0 continuous polyglactin suture. After completion of posterior layer of the anastomosis, antegrade stenting was done using a 6F DJ stent.
Results: Entire procedure took around 2hr. Blood Loss was less than 100ml. Patient had uneventful postoperative course and was discharged on POD3.
Conclusions: Robotic retrocaval ureter repair with ureteroureterostomy without excision of the retrocaval segment is an effective and safe procedure with results equivalent to that of laparoscopic and open retrocaval ureter repair.
It is associated with minimal postoperative morbidity and short hospital stay
Single‐Port Robotic‐Assisted Laparoscopic Dismembered Pyeloplasty with Spiral Flap
Jennifer Nguyen2, Michael Stifelman1, Katerina Lembrikova2, Scott Durham2, Nathan Cheng2, Suzannah Sorin2
1Hackensack Meridian School of Medicine, 2Hackensack University Medical Center
Presented By: Jennifer Nguyen, MD
Introduction and objective: The dismembered pyeloplasty with spiral flap technique has been successfully performed robotically since the early 2000s. Given the advent of the single port robot, the practicality of such an approach has yet to be truly explored. We report the case of a young woman with symptomatic ureteropelvic junction (UPJ) obstruction. The objective of this study was to report a novel reconstructive approach and determine its feasibility as an adjunctive mobility technique.
Methods: A 32 year old woman was found to have right hydronephrosis secondary to UPJ obstruction after workup for right flank pain where she was also found to have a history of recurrent UTIs. The UPJ stricture was identified on retrograde pyelogram (RPG) during this initial workup. A month later, a MAG‐3 renal scan was done, which showed a poorly functioning right kidney. Despite the low renal function, there was still good parenchyma seen on CT scan which may have been underestimated due to obstruction. As a result, a joint decision between the patient and surgeon was made to undergo repair over nephrectomy. The patient was particularly concerned about abdominal scarring, and preferred minimal incisions.
Results: The step‐by‐step reconstructive technique is presented in our video guide. The main focus of the procedure was to successfully obtain enough length to create a proper and tension‐free anastomosis. Prior to the reconstruction, the right kidney functionality was 12% and the T½ was 25 minutes. After the reconstruction, the functionality was 19% and the T½ was 14 minutes. The patient had complete resolution of symptoms and minimal scarring at the incision site.
Conclusions: Robotic single‐port dismembered pyeloplasty with spiral flap is a feasible adjunctive mobility technique. This case also shows that it has the potential for positive outcomes despite low functioning kidney on renal scan, when ample parenchyma is visible on CT.
Robotic Uretero‐Ureterostomy After Previous Ureteral Transection
Hayden Hill1, Shilpa Argade1, Susan Talamini1, Ethan Vargo1, Gregory Murphy1, R Sherburne Figenshau1
1Washington University School of Medicine in St. Louis
Presented By: Hayden Hill, MD
Introduction and Objective: Ureteral injury and transection is an unfortunate potential complication of retroperitoneal surgery. We present the case of a 64‐year‐old male who had previously undergone a retroperitoneal lymph node dissection for advanced testicular cancer. He then subsequently required aortic endarterectomy for atherosclerosis. Shortly after surgery he presented with left flank pain and new left hydronephrosis. Ureteral stenting was not possible and he underwent placement of left nephrostomy tube. He then underwent delayed robotic reconstruction of his transected ureter.
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 line along the lateral edge of the rectus with a 12 mm assistant port in the midline. Extensive lysis of adhesions was performed and the ureteral ends were identified with the assistance of indocyanine green. A ureteroureterostomy was performed using interrupted Vicryl suture. A 6 French JJ stent was placed across the anastomosis and an omental wrap was performed.
Results: Procedural time was 3 hours and 24 minutes. The patient was discharged on post operative day one. His stent was removed 8 weeks post operatively. At 6 months follow up his ureter was patent and without recurrence.
Conclusions: This case represents utilization of robotic repair of a complete ureteral transection with ureteroureterostomy. The usage of intra ureteral indocyanine green is highlighted and can be essential for ureteral identification in difficult upper tract reconstruction. Further long term follow up is warranted to ensure a durable repair.
Revision of Ileal Loop‐Renal Pelvis Anastomotic Stricture
Hayden Hill1, Grant Henning1, Susan Talamini1, Ethan Vargo1, R. Sherburne Figenshau1
1Washington University School of Medicine in St. Louis
Presented By: Hayden Hill, MD
Introduction and Objective: Uretero‐ileal strictures after ileal conduit are common and robotic repair has been described and disseminated in the literature. Ileal conduit‐renal pelvis strictures are less common and to our knowledge a robotic approach has not been previously implemented for repair. We present the case of a 74‐year‐old male who had previously undergone radical cystoprostatectomy, left nephroureterectomy, and right ureterectomy for bilateral upper tract urothelial cell carcinoma and muscle invasive bladder cancer. His right renal pelvis was anastomosed to an ileal conduit. He subsequently developed a stricture near his renal pelvis‐ileal loop anastomosis 12 years after his initial surgery.
Methods: The patient was placed in standard left decubitus position with the right flank flexed. Pneumoperitoneum was achieved with a Veress needle, and 4 robotic 8 mm ports were placed in a line along the lateral edge of the rectus with a 12 mm assistant port in the midline. The caudal most robotic port was cheated laterally to avoid the patient's stoma. Extensive lysis of adhesions was performed and the ileal conduit and renal pelvis were identified. The renal pelvis was mobilized and the stenotic segment was excised. The proximal end of the conduit was spatulated and anastomosed to the renal pelvis using interrupted vicryl suture. A 10.2 French AUD catheter was placed across the anastomosis as a stent and an omental wrap was performed.
Results: Procedure time was 4 hours and 5 minutes. Pathology revealed benign urothelium and benign small intestinal mucosa. The patient was discharged on post operative day 1 and his drain was removed. His renal function nadired. His stent was removed after 6 weeks and loop‐o‐gram at that time showed a widely patent anastomosis.
Conclusion: Uretero‐ileal strictures after ileal conduit are a common occurrence and multiple strategies for repair have been proposed and implemented. Renal pelvis‐ileal conduit strictures are a rare entity as this anastomosis is rarely indicated. This case represents a successful robotic repair of a renal pelvis‐ileal conduit stricture. Further long term follow up is warranted to ensure a durable repair.
Single Port Robotic Kidney Autotransplantation (SP‐KAT): Description of Novel Technique and Initial Outcomes
Mark Noble1, Jaya Sai Chavali1, Mohamed Eltemamy1, Alvin Wee1, Jihad Kaouk1
1Cleveland Clinic
Presented By: Mark Noble, MD
Introduction and Objectives: We aim to demonstrate the technique and feasibility of the novel minimally invasive technique for efficient, multi‐quadrant robotic kidney transplantation using the Da Vinci single‐port robot platform (SP‐KAT). The study patient had a good split renal function and complete ureter avulsion.
Methods: Ten consecutive patients underwent SP KAT using the DaVinci SP platform between January 2020 and December 2022. We demonstrate our technique in a 41‐year‐old female with long segment right ureteral stricture that failed prior pyeloplasty and buccal graft reconstructive surgeries. She had persistent flank pain, radiological evidence of obstruction, and good split renal function on imaging.
Technical steps of the surgery included (1) Robotic Nephrectomy; (2) Kidney Benching; (3) Dissection of Iliac vessels and Kidney placement; (4) Vascular anastomosis; (5) Ureteral reimplant. The SP robot is redirected to the ipsilateral pelvis using the same periumbilical incision for dissection of iliac vessels for later transplant. The extracorporeal kidney benching was performed at the same time while the iliac vessels are prepared robotically. Overall patient clinicopathologic variables and perioperative outcomes were recorded.
Results: All SP KAT cases were successfully performed without repositioning or conversion to open. The total operative time was 547 minutes. The estimated blood loss was 100 cc. The Foley and stent were removed at 2 and 4 weeks postoperatively. The patient had complete preservation of renal function. No documented postoperative complications and no evidence of obstruction on the latest follow‐up at 2 years post‐surgery.
The intraoperative and postoperative outcomes of the patients in our series were recorded in Table 1.
Conclusion: We demonstrate our single‐port efficient, multi‐quadrant robotic kidney autotransplantation technique performed through a single incision reducing surgical morbidity. All the cases were completed successfully without loss of graft function or conversion.
Video Session 3: Oncology, Prostate, Bladder and Other Miscellaneous Cancers
Concomitant Single‐Port Robotic Adrenalectomy, Radical Prostatectomy, and Pelvic Lymph Node Dissection with a Single Incision
Victor Abdullatif2, Chase Cavayero1, Jared Davis1, Jesse Rockmore1
1McLaren Macomb, 2Ascension
Presented By: Victor Abdullatif, D.O.
Introduction: A 67‐year‐old male presented to the urology clinic following referral for an elevated PSA. He underwent a standard 12 core prostate biopsy which revealed Gleason grade 4 prostate carcinoma and was found to have an enhancing adrenal mass on imaging. Following a diagnosis of prostate cancer with concomitant pheochromocytoma, the patient was schedule for adrenal gland and prostate removal. We present our technique using the Single‐Port DaVinci robot to perform an adrenalectomy, radical prostatectomy, and pelvic lymph node dissection consecutively with a single incision.
Methods: A left‐sided adrenalectomy was performed using robotic assisted single‐port (SP) laparoscopy with the DaVinci Single‐Site platform. With the same incision, the robot was re‐docked and a bilateral pelvic lymph node dissection was performed. Following the lymph node dissection, a radical prostatectomy was performed. All procedures were performed with the same initial incision.
Results: Following the procedure, the patient was awoken from anesthesia and transferred to PACU in stable condition. His postoperative course was unremarkable. He was discharged home on postoperative day number 2. Repeat CT scan confirmed no evidence of adrenal or prostate lesions.
Conclusion: We present a successful surgical outcome of three procedures performed consecutively with the Single‐Port DaVinci robot and a single incision. This case highlights the challenges of surgical management of pheochromocytoma as well as the unique ability to perform multi‐organ surgeries through a single minimally invasive single‐port incision.
Hood Technique for Single Port Robot‐Assisted Radical Prostatectomy
Narmina Khanmammadova1, Narmina Khanmammadova1, Tuan Thanh Nguyen2, Andrei D. Cumpanas1, Rafael Gevorkyan1, Catherine Fung1, Caroline Nguyen1, Jacob Basilius1, Sohrab Naushad Ali1, Mohammed Shahait3, David I Lee1
1University of California, Irvine, Department of Urology, 2University of Medicine and Pharmacy at Ho Chi Minh City, 3Clemenceau Medical Center, Department of Surgery
Presented By: Narmina Khanmammadova, MD
Introduction: The hood technique emphasizes the preservation of periurethral anatomical structures in preperitoneal space including endopelvic fascia, puboprostatic ligaments, anterior vessels, detrusor apron as well as some detrusor muscle during robot‐assisted radical prostatectomy (RARP). We describe our modified hood technique for single port‐RARP, which aims to develop a reproducible procedure with a short learning curve (Figure 1), without compromising oncological outcomes, as well as offering early recovery of functional outcomes.
Methods: All data were prospectively collected into an IRB‐approved registry database. Eight consecutive patients with localized prostate cancer underwent transperitoneal SP‐RARP. Postoperative status of sexual function was defined by the percentage of erection fullness as the patient‐reported ability to have a full and hard erection. Continence recovery was defined as the patient reported no use of pads or using only one security pad.
Results: Preoperative characteristics of the cohort are demonstrated in Table 1. The median operative time of 8 SP RARP cases was 144.5 (136.5 ‐ 168) mins and the median console time was 93 (91 – 109.25) mins. The mean estimated blood loss was 50 (50 ‐ 87.5) mL. There were no patients with PSA persistence at 3 months. No blood transfusion and conversion to open surgery were needed and no perioperative complications occurred. No postoperative complications were recorded except for one patient who developed a urinary tract infection. All patients were discharged home on the same day. There was no readmission during the postoperative 30 days. 62.5% of patients (n = 5) reported early continence. The median percentage of the fullness of erection at 3 months was 60% (50% ‐ 70%).
Conclusions: This report demonstrates that the hood technique for SP RARP is reproducible with a short learning curve, and favorable perioperative, and intermediate functional outcomes.
Use of Synchroseal for Multi‐Port Radical Cystectomy with Intra‐Corporeal Ileal Conduit Can Potentially Reduce Cost and Operative Time
Laurence Hou1, Mubashir Billah1, Ernest Tong1, Michael Stifelman1, Mutahar Ahmed1
1Hackensack University Medical Center
Presented By: Laurence Hou, MD
Introduction and Objective: The SynchroSeal, developed by Da Vinci Energy, represents a remarkable advancement in bipolar energy vessel sealing devices specifically designed for the Da Vinci X and Xi systems (Intuitive Surgical, Inc., Sunnyvale, CA, USA). This innovative tool not only enables seamless vessel sealing and cutting with a single‐step pedal, but also offers excellent grasping capabilities. At our institution, we have successfully incorporated the SynchroSeal into our surgical workflow, particularly for radical cystectomy and intracorporeal ileal conduit procedures. The objective of this presentation is to highlight the utility of the SynchroSeal as the primary left‐arm instrument for multi‐port radical cystectomy with intracorporeal ileal conduit (RCIC).
Methods: In this video, we demonstrate our modified techniques of using SynchroSeal for major steps of the radical cystectomy and intracorporeal ileal conduit procedure. These steps include: retroperitoneal lymph node dissection, transecting vascular pedicles, seminal vesicle dissection, dorsal venous complex ligation, Wallace Anastomosis creation, and closure of the ureteroileal anastomosis over a stent. We also obtained hospital costs for many of the instruments commonly used in this procedure for comparison purposes.
Results: The SynchroSeal offers several notable advantages: 1) effortless sealing and cutting of large vascular structures, 2) reliable achievement of hemostasis, 3) versatility in delicate tissue dissection and suturing, 4) elimination of the need for additional instruments, and 5) improved efficiency by reducing instrument exchanges. In multi‐port radical cystectomy with intracorporeal ileal conduit, the SynchroSeal can effectively replace bipolar forceps, bowel graspers, handheld/robotic staplers, and clip appliers, resulting in substantial cost savings. One minor drawback is that the SynchroSeal is slightly bulkier compared to other bipolar graspers, which may pose challenges when maneuvering in tight spaces. However, these challenges can be overcome.
Conclusions: The SynchroSeal is a versatile tool that excels in handling delicate tissues, cauterizing large vessels, and facilitating fine suturing. Its utilization leads to enhanced hemostasis, reduced costs, and shorter operative times. We strongly recommend that urologic robotic surgeons consider incorporating this invaluable tool into their armamentarium. By embracing the SynchroSeal, surgeons can optimize their procedural outcomes and elevate the quality of care provided to patients.
Side‐by‐Side Comparison of Techniques in Single‐Port (SP) Robotic Radical Prostatectomy
Jennifer Nguyen2, Michael Stifelman1, Nathan Cheng2, Suzannah Sorin1, Mubashir Billah2, Mutahar Ahmed2
1Hackensack Meridian School of Medicine, 2Hackensack University Medical Center
Presented By: Jennifer Nguyen, MD
Introduction and Objective: Single‐port (SP) robotics has been popularized in urologic surgery over the past few years. Its many advantages, particularly the ability to stay extraperitoneal, have made it a useful tool in radical prostatectomy. In this split‐screen video demonstration between two high volume SP surgeons, nuances in techniques for SP robotic radical prostatectomy are illustrated in a step‐by‐step fashion.
Methods: There are many similarities in techniques between Surgeons A and B. Variations as shown in the video include posterior versus lateral release during bladder neck dissection, rearrangement of camera positioning for posterior dissection, retrograde versus antegrade nerve sparing, and clip versus bipolar electrocautery pedicle ligation. A review of the institution's retrospective and prospective database was also performed.
Results: There were a total of 255 SP radical prostatectomies performed. Average operative time was 128 minutes, estimated blood loss 50 mL, length of stay 1 day, 30‐day readmission rate 2.7%, and Clavien‐Dindo III or higher complications 1.6%.
Conclusions: The single‐port robotic technique for radical prostatectomy has proven to be feasible and with excellent outcomes. There are multiple nuances in technique between surgeons, as shown in the video demonstration.
Trans‐Vaginal Bowel Stapling Technique for Female Cystectomy and Intracorporeal Urinary Diversion
Dipak Rajyaguru2, Vipulkumar Tilva1, Hemang Bakshi1, Josef Pachikara1
1HCG Cancer Center, Ahmedabad, India, 2URO‐CARE Hospital, Mehsana, Ahmedabad
Presented By: Dipak Rajyaguru, MBBS , MS, MCh
Introduction and Objective: Open radical cystectomy (ORC) is still the standard treatment for muscle invasive bladder cancer(MIBC) as well as recurrent and/or high‐grade non muscle invasive bladder cancer (NMIBC). Robotic assisted radical cystectomy (RARC) is an established and safe procedure within minimally invasive urologic oncology techineques. In recent studies RARC has shown lower rate of intra‐ and peri operative complications, with oncological results comparable to ORC, but with a longer operative time. In fact, recent evidence in the literature shows that RARC compared to ORC allows reduced blood losses and a shorter post‐ operative stay. After RARC, neo bladder can be fashioned out of the distal ileum by extra corporeal and intra corporeal techniques. Extra corporeal techniques has advantage of an easier learning curve and reduced operating times, but necessitates a larger abdominal incision. Total intracorporeal techniques require smaller or no incision at all but takes longer to perform and has a steeper learning curve. Intracorporeal neo‐bladder can be created via various techniques as described by The university of Florence Group, The Karolinska Group, The USC group etc. Here in this video we aspire to describe a modification of the Karolinska technique in which bowel staplers are fired through the open vaginal cuff to create a neobladder, without the need for any extra abdominal incisions. Method: we operated on a 73 year old woman with muscle invasive bladder cancer. RARC was performed. After the extirpative component of the procedure specimen was removed via the vaginal cuff, the left ureter was brought under the sigmoid colon mesentery. Stay stitches were placed on the proximal and distal segments of a 50 cm segment of ileum, 15cm proximal to the ileocecal valve. An avascular segment of the mesentery is identified using Indo cyanin green(ICG) dye and firefly technique, and taken down at the proximal and distal aspect. Electrocautery was used to divide the ileal loop. We then reconstituted the bowel prior to the uretero‐ileal anastomosis (UIA). After ensuring proper orientation with the use of stay stiches, two 60 mm Endo‐GIA staple loads passed into the peritoneal cavity through the vagina were used to complete the side‐to‐side anastomosis. One staple load was used for the transverse component. Urethro‐ileal anastomosis was performed at a point 12cm away from the distal cut end of the isolated ileum.. The distal 40 cm is detubularized. Rotation and double folding was performed to obtain a spherical reservoir, and a 10 cm of isoperistaltic afferent limb is left as a chimmney.. Vasculatiy was confirmed by using ICG dye and Firefly technique.Continuous absorbable suture was used over 6 Fr DJ stent, and ureters were anastomosed in Wallace fashion. Leak test was done and abdominal drain was placed.
Result: Console time was 7h 10 minutes. Estimated blood loss was 450ml. No intra operative or post operative complications were encountered.. Abdominal drain was removed on POD5. Patient was discharged on POD 6. final histology showed T2a with negative surgical margins. 12 nodes on left side and 15 from riight side were negative for malignancy.
Conclusion: We used this technique in 17 cases with neobladder urinary diversion in femal patients. Use of Transvaginal staplers in Female cystectomy is a time saving, ergonomically sound and easily reproducible method for intracorporeal neo‐bladder and/or ileal conduit. It will not increase any post‐ operative complications like infections, incisional hernia also.. This technique also alleviates the need for separate incisions for specimen removal as well as extra trochar placement for bowel stapling, decreased post‐operative pain and provides better cosmesis.
Robot‐Assisted Intracorporeal Orthotopic Neobladder: A New Gold Standard in Making
1Resident, 2Professor, Postgraduate Institute of Medical Education and Research
Presented By: Anuj Sharma, MCh
We present case of 44 year old male withhistory of hematuria for 9 months. He underwent TURBT with histopahtology of muscle invasive bladder cancer. After recieving 3 cycles of neoadjuvant chemotherapy. He underwent Radical cystectomy with bilateral ePLND with orthotopic neobladder (Modified Kelly's) Pouch (RAIONB).
A total of 9 patients have been operated for RAIONB with mean duration of 395 minutes. Mena blood loss of 200ml and post‐operative stay of 6.5 days. Per urethral catheter was removed on an average 3 weeks. No patient had more than 2 Clavien‐Dindo complications.
Outcome of Robotic Radical Cystectomy with Intracorporeal J‐Pouch Neobladder in Muscle‐ Invasive Bladder Cancer Patients
Ming‐Wei Hsu1
1China medical university hospital
Presented By: Ming‐Wei Hsu, MD
Robot‐assisted radical cystectomy with intracorporeal modified J‐pouch neobladder in patient in patients with localized Muscle‐Invasive Bladder Cancer
Ming‐Wei Hsu, Li‐Hsien Tsai, Chi‐Ping Huang
Department of Urology, China Medical University Hospital, Taichung, Taiwan
Purpose: Radical cystectomy with urinary diversion is the standard treatment for localized muscle‐invasive bladder cancer (MIBC). Robotic surgery has been used for the past 20 years. Different techniques of totally intracorporeal orthotopic neobladder have been developed. In this study, we share the initial results of robotic radical cystectomy with intracorporeal J‐pouch neobladder at China Medical University Hospital.
Materials and Methods: We included 17 patients with MIBC who received robotic‐assisted radical cystectomy with bilateral pelvic lymph node dissection and intracorporeal J‐pouch orthotopic neobladder at China Medical University Hospital. We will present preliminary results regarding oncological outcomes, functional outcomes, and adverse effects.
Results: The median age of the 17 patients was 63 years old (ranging from 36 to 81). There were 13 males and 4 females. The median operative time was 620 minutes, and the median length of hospital stay was 19 days. The median duration of indwelling foley catheter was 19 days.
Regarding the preoperative staging, the cT stage ranged from T2 to T4, and one patient had cN2 disease. Fourteen patients received neoadjuvant systemic therapy, and one patient received adjuvant systemic therapy. In terms of the pathological staging, the pT stage ranged from T0 to T3, with two patients having nodal metastasis.
During a median follow‐up of 32.8 months (ranging from 17.4 to 59.0), two patients experienced recurrence, including one case of nodal metastasis and one case of nodal plus lung metastasis. There were two deaths recorded and one of them was cancer‐specific.
Regarding urinary function, no patients need long‐term intermittent catheterization. Two patients experienced daytime incontinence, and seven patients experienced nighttime incontinence. The median number of pads or diapers used per day was one.
As for complications beyond Clavien‐Dindo grade III, a single patient developed urosepsis, while three patients experienced acute kidney injury. Additionally, two patients encountered hydronephrosis resulting from ureteral strictures. Among the two patients with hydronephrosis, one underwent ureteral reimplantation, while the other received the placement of a percutaneous nephrostomy tube and a Double J ureteral stent.
Notably, none of the cases exhibited any decline in renal function after a one‐year follow‐up.
Conclusion: Robotic assisted J‐pouch neobladder is a feasible technique for reconstructing an intracorporeal orthotopic neobladder.
Laparoscopic Anterior Pelvic Exenteration – a How‐to Video Demonstration
Ana Sofia Araújo1, Andreia Cardoso1, Catarina Laranjo Tinoco1, Ricardo Matos Rodrigues1, Mariana Dias Capinha1, Luís Pinto1, Ana Sofia Araújo1, Paulo Mota1, Luís Vale1, João Pimentel Torres1, Emanuel Carvalho‐Dias1
1Urology Department, Hospital de Braga, Portugal
Presented By: Ana Sofia Araújo, MD
Introduction and Objective: Anterior pelvic exenteration is a morbid procedure, that remains a main option both for urologic as well as gynecologic neoplasms. Although classically performed through an open approach, minimally invasive techniques in this setting have been arising. However, due to technical difficulties in this multistage complex procedure, it is still not widely diffused and performed. Thus, we aim to present a step‐by‐step video demonstration of our technique for laparoscopic anterior pelvic exenteration, in order to make it feasible for others.
Methods: A 46‐year‐old woman, obese, former smoker, presented with a 4 months history of dysuria, haematuria, pelvic and lumbar pain. Physical examination, cystoscopy, CT and MRI revealed a 53*45*30mm retrotrigonal mass suspicious for muscle‐invasive bladder cancer (MIBC) cT4a cN0 cM0. A transurethral resection of the bladder (TURB) diagnosed a MIBC high‐grade urothelial carcinoma with partial squamous and sarcomatoid differentiations. Two months later we performed the demonstrated video, of a 5‐port laparoscopic anterior pelvic exenteration.
Our technique main steps are the following. Patient is positioned in steep Trendelenburg. We start with ureteral bilateral dissection until the bladder, ligate it with Hem‐O‐Loks, and place a reference suture. Then, ovarian suspensory, broad and round uterus' ligaments are sectioned. Lateral dissection continues until endopelvic fascia exposure, with vesical and vaginal vascular pedicles secure ligation. Posterior plane, followed by anterior plane dissection are next, with careful urethra dissection. Vagina is closed with running suture. Lymph node (LN) dissection (LND) is next. Lastly, mesosigmoid tunnelization for left ureter transposition and ileal reference for urinary diversion.
Results: Laparoscopy time was 150min. There were no complications, no need for blood transfusions, and patient was discharged on day 8. Histopathological analysis confirmed a bladder sarcomatoid (90%) urothelial carcinoma, pT4a (uterus invasion), pN1 (1/10 LN), R0. Adjuvant chemotherapy was initiated.
Conclusions: Laparoscopic anterior pelvic exenteration is a safe and feasible surgery, even for histologically aggressive and locally advanced bladder tumors. We emphasize the relevance of performing it in a step‐by‐step and standardized fashion, as shown, keeping fascial plane dissection, anatomical landmarks identification, and procedure decomposition in simple and sequential moves, each one aiming to simplify and assist the next one.
Robotic Repair of Right External Iliac Vein Injury During Robotic Cystectomy with Root Cause Analysis of Injury
Sina Monfared1, Utsav Bansal1, Kenneth Softness1, Philip Kim1, Peter Steinberg1, Peter Chang1, Andrew Wagner1
1Beth Israel Deaconess Medical Center
Presented By: Sina Monfared, MD
Introduction and Objective: We present the case of a 68‐year‐old male with a known history of extensive high grade T1 urothelial carcinoma of the bladder with new CT findings concerning for right upper tract disease who presented for robotic nephroureterectomy and radical cystoprostatectomy. During the right pelvic lymph node dissection, sudden monopolar scissor motion created an injury to the right external iliac vein. We performed a repair of the injury as well as a root cause analysis (RCA).
Methods: After completing the right nephroureterectomy, we began the robotic pelvic lymph node dissection. During dissection, the right external iliac vein was punctured through and through by the robotic monopolar scissors during an exchange of the monopolar cautery cords. We gained proximal and distal vessel control using bulldog clamps and repaired both the anterior and posterior defects with 5‐0 Prolene suture. We then completed an RCA by speaking with all team members, reviewing case video, performing field testing of Davinci Xi robot arm movement, evaluating raw clutching data from the robot, and comparing the clutching data to the surgery video.
Results: The operative time was 8 hours and 3 minutes with an estimated blood loss of 1.5L. The patient required 2 units of packed red blood cells intraoperatively. Following repair no further complications occurred and the patient was discharged on day 5, after our standard robotic radical cystectomy post‐operative pathway. Our RCA showed that that an assistant at the bedside unintentionally clutched the arm while placing the monopolar cautery cord with the instrument inside the patient, leading to sudden and unexpected forward scissor movement without resistance.
Conclusions: Robotic repair of near‐catastrophic pelvic vessel injury is possible using proximal and distal vascular control and robotic suturing techniques. The available second‐by‐second robotic motion data can assist with root cause analysis of robotic complications. The bedside assistants should always remove an instrument prior to inserting cautery cords.
Robotic Assisted Partial Cystectomy and Bilateral Pelvic Lymph Node Dissection for Bladder Adenocarcinoma
Yakup Kordan1, Yakup Kordan1, Baris Esen1, İbrahim Can Aykanat1
1Koc University School of Medicine Department of Urology
Presented By: Yakup Kordan, MD
Introduction and Objectives: Primary adenocarcinoma of the bladder is a rare clinical entity accounting for 0.5‐2% of all bladder tumors. In this video, the technique of robot‐assisted partial cystectomy for bladder adenocarcinoma performed in two consequent patients is presented.
Methods: Our first patient was a 41‐year‐old female who presented with macroscopic hematuria at another center. Further CT examination revealed a 2 cm‐sized papillary bladder lesion. She underwent a TURB which revealed an enteric‐type bladder adenocarcinoma invasive to lamina propria but muscularis propria was not present in the specimen. The second case was a 39‐year‐old female with an incidentally detected 1.2 cm‐sized papillary bladder lesion. TURB revealed adenocarcinoma originated from the urachal remnant. Treatment options including radical cystectomy with or without neoadjuvant chemotherapy, radiotherapy, and partial cystectomy with bilateral extended pelvic lymph node dissection (PLND) were discussed with the patients.
Both patients decided to preserve their bladder and underwent robotic‐assisted partial cystectomy with bilateral PLND.
Results: The console time was 3 hours in the first case and 2 hours in the second case. The estimated blood loss was 50 mL and 100 mL, respectively. A Jackson Pratt surgical drain was placed which was removed on the postoperative first day. There were no intra or post‐operative complications. Diet was resumed on postoperative day 1 and the patients were discharged on postoperative day 2. Pathological examination revealed no residual tumor at partial cystectomy and also dissected lymph nodes in the first case, and adenocarcinoma originated from urachus located at detrusor and perivesical fat tissue in the second case.
Conclusions: Robotic‐assisted partial cystectomy is a technically feasible procedure and represents an alternative to open and conventional laparoscopic approaches in patients with bladder adenocarcinoma.
Laparoscopic Transperitoneal Radical Prostatectomy for Renal Transplant Recipient
Murat Gülşen3, Ertuğrul Köse1, Murat Gülşen1, Mehmet Necmettin Mercimek2, Yakup Bostancı1, Yarkın Kamil Yakupoğlu1, Şaban Sarıkaya1, Ender Özden1
1Ondokuz Mayıs University, School of Medicine, Department of Urology, Samsun, Turkey, 2Atasam Hospital Urology Clinic, Samsun, TURKEY, 3Ondokuz Mayıs University, School of Medicine, Department of Urology
Presented By: Mehmet Necmettin Mercimek, MD
Introduction and Objective: Radical prostatectomy involves a unique challenge due to changes in pelvic anatomy, presence of adhesions, the possible compromise to graft function and the risk of surgical site infection, risk of ureteral injury, and to impossibility to perform a complete lymph node dissection (LND). In this case, we aimed to present our experience with laparoscopic radical prostatectomy (LRP) in a renal transplant recipient (RTR) with locally advanced prostate cancer.
Methods: A 62‐year‐old male patient who underwent kidney transplantation 13 years ago due to diabetes mellitus related end‐stage renal disease, had prostate‐specific antigen (PSA) elevation (27.15 ng/ml) in his routine control. There is no pathological finding in digital rectal examination. Magnetic resonance imaging revealed a mass invading the left seminal vesicle, continuing in the peripheral zone from the apex to the base. Cognitive fusion biopsy performed with transrectal ultrasonography was reported as Gleason 3 + 4 prostate cancer in 5 of 10 core. No metastases were detected in Prostate Spesicif Membrane Antigen scintigraphy.
LRP was planned for the patient. Surgical steps as incision of the posterior peritoneum and left lateral pelvic lymph node dissection, incision of both vas deferens and dissection of the seminal vesicles, incision of the anterior peritoneum, opening of the endopelvic fascia, incision of the bladder neck, opening of Denonvilliers' fascia, controlling and cutting of the lateral prostatic pedicles, puboprostatic ligament dissection, control of the dorsal vein complex, incision of the urethra, controlling of the rectum integrity, and performing the vesicourethral anastomosis were performed, respectively.
Results: The mean operative time and anastomosis time were 170 min and 30 min, respectively. The estimated blood loss was 200 cc. Non nerve‐sparing method was performed. There were no perioperative and postoperative complications. Hospitalization was 3 days. The urethral catheter was removed on post‐operative day 7 after cystogram. The pathologic examination was revealed Gleason 4 + 3 prostate adenocancer, pT3b, 1 metastatic and 1 reactive lymph node, with negative surgical margins. The patient treated with androgen deprivation therapy and adjuvant radiation therapy. No biochemical recurrence was observed, and graft function was stable in first year follow‐up.
Conclusion
Transperitoneal LRP is a safe, feasible, and alternative treatment modality for locally advanced prostate cancer in RTR.
A Challenging Case of Robot‐Assisted Radical Prostatectomy with a Large Median Lobe
Muhammet Demirbilek2, Bulent Onal1, Ugur Aferin1, Goktug Kalender1
1Istanbul University‐Cerrahpasa, Cerrahpasa Faculty of Medicine, 2Istanbul University‐Cerrahpasa, Cerrahpasa School of Medicine
Presented By: Muhammet Demirbilek, MD
Introduction: Robot‐assisted laparoscopic radical prostatectomy (RALRP) has become a minimally invasive technique widely used to treat localized prostate cancer. Various challenging situations may be encountered during RALRP. One of them is the presence of a large median lobe. Patients with large median lobes often have larger prostates, which makes it challenging to visualize anatomical planes during RALRP.
Methods: A 65‐year‐old male patient was admitted to the emergency department with the complaint of inability to urinate. A urethral catheter was inserted due to globe vesical in physical examination. Urinary system ultrasound revealed bilateral grade 3 hydroureteronephrosis and prostate gland with a large median lobe. Serum creatinine and prostate‐specific antigen levels were 10 mg/dL and 27 ng/ml, respectively. Bilateral double‐J stents were inserted because serum creatinine levels did not decrease. Transrectal ultrasound (TRUS)‐guided prostate biopsy was performed, and a Gleason score of 3 + 3 prostatic adenocarcinoma was detected. Prostate volume was calculated at 140 g at TRUS. No lymph node of pathologic size and metastasis were determined at prostate‐specific membrane antigen positron emission tomography (PSMA PET) scan. In this video presentation, we will discuss the challenging situations that may be encountered during RALRP for a patient with a large median lobe.
Results: The patient underwent RARP. During RALRP, a 2/0 Vicryl suture was applied on the median lobe for traction to provide a better view of the bladder neck and exposure to the large median lobe. Due to double‐j stents, we could visualize the bilateral ureteral orifices and avoid orifice damage. The estimated blood loss was 250 mL. Postoperative prostate weight was measured as 145 g. Postoperative follow‐up was uneventful, and the patient was discharged on day 3. The pathology report was pT2a with negative surgical margins. The Double‐ J stents were removed in the second month.
Conclusion: RARP can be challenging due to the large median lobe, and preoperative double‐j stent placement may prevent damage to the ureteral orifice.
Robotic Approach to the Excision of a Rare Solitary Fibrous Tumor of the Pelvis: A Case Series
Jonathan Yu1, Tom Feng1, David Wei1
1Kaiser Permanente Moanalua
Presented By: Jonathan Yu, MD
Introduction and Objective: A solitary fibrous tumor (SFT) is a rare soft tissue neoplasm that is most commonly seen in the pleura, but in rare cases can also occur within the pelvis. SFTs account for less than 2% of all soft tissue tumors. Currently, there are no clear evidence‐based guidelines for the diagnostic and therapeutic management of these tumors. This video aims to provide a step‐by‐step approach for robot‐ assisted excision of a rare pelvic mass.
Methods: We demonstrate the feasibility and safety of robotic approach to pelvic mass excision through two cases. Both cases were referred for an incidentally found pelvic mass on CT imaging. CT guided biopsy of the mass demonstrated spindle cell neoplasm favoring SFT. The patients opted for Robot‐assisted excision of pelvic mass. The patients were placed in supine position and standard robotic prostatectomy 5 port configuration was used. First, we incised the posterior peritoneum and dissected the overlying fat to clarify surrounding structures. In the first case, the mass was readily identified after incision of the peritoneum.
Given the proximity of the ureter to the pelvic mass, a lighted ureteral stent was placed for identification. The pelvic mass is able to be circumferentially dissected away from surrounding structures with excellent visualization. In the second case, the seminal vesicles were identified and dissection was carried caudally until the prostate was identified. A margin of prostate was sent for frozen section due to the proximity of the mass.
Results: All cases were successfully completed without the need for open conversion. There were no intraoperative complications. The average estimated blood loss was 25cc. Operative time ranged from 80 to 140 minutes. Patients were discharged on post operative day 1. No major complications occurred within 90 days of discharge. The final pathology for both cases resulted as SFT. Patients obtained reimaging within 6 months of surgery without evidence of recurrence.
Conclusions A robotic approach to the excision of a pelvic SFT is feasible and safe. To our knowledge, this is only the second robot assisted excision of a pelvic SFT described in the literature.
Source of Funding: None
A Lateral Approach for Radical Video‐Endoscopic Inguinal Lymphadenectomy (VEIL)
Ana Sofia Araújo1, Ricardo Rodrigues1, Catarina Tinoco1, Andreia Cardoso1, Mariana Capinha1, Luís Pinto1, Vera Marques1, Paulo Mota1
1Hospital de Braga
Presented By: Ana Sofia Araújo, MD
Introduction: VEIL is a more recent technique with decreased morbidity when compared to standard open lymphadenectomy. However, some concerns regarding excessive crowding and clashing of the instruments were raised with this technique. Here, we aim to demonstrate the feasibility and safety of a lateral approach for VEIL that could minimize these problems.
Materials and methods: First, patient was placed in supine position with bilateral 45° knees flection and leg abduction. Surgeon was positioned on the lateral aspect of the leg's patient and the assistant on the medial, without crossing arms. Then, a 10‐mm camera trocar was inserted through an incision in the apex of the femoral triangle under the fascia lata after balloon dissecting. Next, a lateral 5mm‐trocar was inserted as it is usually done in the conventional approach, and then another 5mm‐trocar was introduced 3‐4cm below the anterior superior iliac spine. The procedure started with dissection of the deep lymph nodes from the femoral artery to the saphenous‐femoral junction. After this, the camera was turned 180° and a fascia lata incision was done to start the dissection of the superficial lymph nodes with sparing of the saphenous vein. Finally, the lymph nodes were removed and a suction drain was placed.
Results: We present a case of a 65‐year‐old male who underwent a partial penectomy which revealed a usual squamous cell carcinoma, pT3 G2. The physical examination shows palpable, mobile, multiple, and bilateral inguinal lymph nodes. The MRI and CT reveal bilateral suspicious inguinal nodes but no suspicious pelvic nodes. So, we proposed the patient for radical VEIL by a lateral approach. The total operative time for both sides was 120 minutes. The postoperative period was uneventful. The patient was discharged on the 4th day postoperative with drains in situ for 1 month and elastic stockings for 3 months. He had a post‐drain‐ removal right side infection treated with 1 week of endovenous antibiotic. The histology reveals 4/6 metastatic nodes on the right side and 1/6 metastatic nodes on the left side.
Conclusions: This lateral approach seems to have multiple advantages. In terms of patient positioning, there is less need for leg abduction since it is not necessary two arms in the middle. Furthermore, it is more ergonomic with more space for the surgeon and assistant with fewer clashes between the camera, operating instruments, and patient kneeallowing easy identification and dissection of the landmarks, resembling the positioning of laparoscopic radical nephrectomy that urologists are so used to.
Laparoscopic Retroperitoneal Lymph Node Dissection for Extensive Lymph Node Metastasis in Testis Cancer
Mehmet Necmettin Mercimek2, Murat Gülşen1, Mehmet Necmettin Mercimek2, Yarkın Kamil Yakupoğlu1, Ender Özden1
1Ondokuz Mayıs University, School of Medicine, Department of Urology, Samsun, Turkey, 2Atasam Hospital Urology Clinic, Samsun, Turkey
Presented By: Mehmet Necmettin Mercimek, Associate professor
Introduction and Objective: In this video, we aimed to present our laparoscopic retroperitoneal lymph node dissection (L‐RPLND) operation for metastatic testicular cancer.
Methods: A left radical orchiectomy was performed on a 17‐year‐old patient due to a mass in the left testicle. The pathology report revealed pT2 mixed germ cell carcinoma. Postoperative CT revealed 9 cm lymph nodes between the left external iliac vein and renal vein in the retroperitoneum, along with liver and bilateral lung metastases. Postoperatively, tumor markers remained elevated. Four cycles of bleomycin, etoposide, and cisplatin chemotherapy were given for stage 3C disease. After four cycles of BEP chemotherapy, L‐RPLND was scheduled for the patient whose lung and liver metastases had regressed and whose retroperitoneal lymph nodes were shrinking with normal tumor marker levels.
The patient was placed in a low lithotomy position so that the surgeon was able to perform the procedure between the patient's legs, allowing for a perpendicular and closer approach to the patient's midline structures. 12 mm optical port was positioned over the umbilicus after the creation of the pneumoperitoneum. On both paramedian lines, 5 mm working ports were subsequently inserted. The left ureter was isolated, and a left external iliac and obturator lymph node dissection was performed. Later, a 12‐mm optic port was inserted from the suprapubic region for paraaortic and common iliac lymph nodes, and a 10‐mm trocar substituted the 5‐mm working port on the left paramedian side. For retraction, 12 mm optical port on the umbilicus was used. The peritoneum was incised at the level of the common iliac artery after the Trendelenburg position led the small intestines to deviate superiorly. Along the inferior mesenteric artery, paraaortic lymph nodes were initially dissected. The paraaortic lymph nodes were dissected up to the level of the left renal vein, while the ureter was preserved laterally. After removing the para‐aortic and interaortocaval lymph nodes, the inferior vena cava (IVC) was suspended for dissection of the masses detected in the posterior aspect of the IVC. After completion of the dissection, Tisseel® was administered to the surgical area, specifically around the renal vein, to reduce postoperative chylous drainage.
Results: Gas insufflation duration and estimated blood loss was 390 minutes and 200 cc, respectively. Due to minimal chylous drainage, the patient was followed up and discharged on the 7th day. The outcomes of the pathology revealed 30 tumor‐negative reactive lymph nodes. Tumor markers remained negative in the first year and no recurrence was shown by radiological imaging.
Conclusion: Even in patients with extensive metastases, L‐RPLND can be safely applied in experienced centers.
Single Port Bilateral Inguinal Lymph Node Dissection
Mubashir Billah1
1Hackensack University Medical Center/Attending Physician
Presented By: Mubashir Billah, MD
Introduction: Single Port Robotic Assisted Laparoscopic Surgery was first introduced by Intuitive in 2018. This technology helped pave the way for single site minimally invasive surgery by allowing for several surgical instruments to enter while allowing fully wristed motions. Robotic inguinal lymph node dissection is increasing in popularity and may allow for a decrease in postoperative complications such as lymphedema, though there can be a steep learning curve and an increase in costs associated with the procedure. We sought to determine if and how single port bilateral inguinal lymph node dissection can be performed efficaciously and present our data as well as tips & tricks in a video format.
Methods: Patient is a 79‐year‐old male diagnosed with penile cancer. He had a well‐differentiated T2 squamous cell carcinoma of the penis with invasion into the corpora spongiosum. Imaging revealed bilateral prominent superficial inguinal lymph nodes. A single port bilateral inguinal lymph node dissection was elected. A video was recorded and data were gathered to ascertain the efficacy of this approach and techniques to optimize for outcomes. The robot was docked below the umbilicus.
Results: The attached video demonstrates the ability to perform a bilateral inguinal lymph node dissection through one incision. The key advantages of the single port approach are simultaneous access to bilateral inguinal lymph nodes, greater surgeon familiarilty with a transperitoneal appraoch and strength fo the single port platform to work in small spaces. The patient tolerated this procedure well and was discharged on postoperative day 1.
Conclusion: Single‐port robotic laparoscopic surgery is a relatively novel technique that holds possibilities for implementation in bilateral inguinal lymphadenectomy for urologic cancers. This video demonstrates the feasability of utilizing the single port robot for this case. Further prospective studies can help elucidate how to optimize this technique and review patient outcomes.
Benefit of Increasing Pneumatic Insufflation Pressure During Deep Dissection in Robot Assisted Video Endoscopic Inguinal Lymph Node Dissection for Penile Cancer
Vipulkumar Tilva1, Hemang Bakshi1, Dipak Rajyaguru2, Josef Pachikara1
1HCG Cancer Center Ahmedabad, India, 2URO CARE Hospital
Presented By: VIPULKUMAR TILVA, MBBS, MS, MCh
Introduction and Objective: Inguinal lymph node dissection(ILND) is an integral part of penile cancer management and it is a great prognostic indicator. Open ILND is associated with about 45 to 55% morbidity. The Robotic assisted approach has been described with oncological outcoimes which are non‐inferior to open approach and associated with less surgery related morbidity. Standard three port robotic technique is widely used . We used same method with modification in insufflation pressure up to 20 mmHg after incising Fascia Lata to reduce operative time and attain better hemostasis. This video shows our method for RA ‐ VEIL using Da‐ Vinci xi three port system.
Method: A 42 ‐year male patient underwent partial penectomy for poorly differentiated squamous cell carcinoma of glans penis with corpus sponsiosum involvement and single palpable left inginal node positve(FNAC). Planned for RA‐VEIL, three 8 mm port were used after surface marking by line joining ASIS to medial femoral condyle and pubic tubercle to lateral femoral condyle. Camera port was fixed at apex of triangle after finger guided blunt dissection just below the scarpa's fascia and two additional port placed 7 cm proximal on lateral and medial side of triangle. After incising Fascia Lata insuffulation pressure raised up to 20 mmHg and deep(first) dissection carried out and then followed by superficial node dissection. Pressure reduced back to 12 mm of Hg once dissection continued above the inguinal ligament. Intraoperatively continuous ETCO2 was measured and ABG was done at 30 minutes, which did not show change..
Result: standard radical template dissection was done on both sides with left side console time of 1hour 23 minutes and estimated blood loss was 25 ml on each side. Nodal yield 10 on left and 12 on right side were achieved. No post operative complications noticed and patient discharged on post‐ operative day 2. Drain removed on POD 7. Final histology showed bilateral single positive lymph node without extranodal extension.
Conclusion: Deep dissection with high insufflator pressure is very effective and makes dissection easy and blood less . It also reduces operative time without affecting intraoperative heamodynamic stability and provides a shorter learning curve for bigginers. Also there is less need for camera cleaning and
easier instrumentation for assistant. We used this modification in 20 patient with 36 ILND . It reduced operative time about 23+/‐ 5 minute each side. .
Key word: ILND, RA‐VEIL, FNAC
Video Session 4: BPH, Pediatrics and Miscellaneous Procedures
Aquablation: Tips and Tricks to Utilizing This Novel Approach for Benign Prostatic Hyperplasia
1University of New England College of Osteopathic Medicine, 2Rutgers New Jersey Medical School, 3Hackensack University Medical Center
Presented By: Mubashir Billah, MD
Introduction and Objective: In recent years, Aquablation has emerged as a safe and efficacious modality that has shown promising results for the management of benign prostatic hyperplasia (BPH). This latest technology utilizes real‐time image guidance with ultrasound (US) that offers personalized treatment planning for each individual prostate. The automated robotic execution of this heat‐free ablative therapy enables precise and effective tissue removal. Despite optimistic published data on Aquablation, this newer technology still requires further investigation to confirm its durability as an alternative or adjunct to traditional BPH treatments. We sought to demonstrate how Aquablation can be performed more efficiently by presenting our ideas, techniques, and outcomes in a video format.
Methods: A video of our surgical approach was recorded for a case involving a 57‐year‐old male with BPH who elected for Aquablation. The operative setup, robotic execution of our treatment plan, and hemostasis protocol were all featured. Data was collected to determine if our technique promoted lower operative times with feasible outcomes for both large and small prostates.
Results: The video presented highlights our tips and tricks to ensure efficient Aquablation. Visualization was enhanced by placing a Toomey syringe with US jelly to clear the rectum. It was necessary to obtain an adequate US image and park the cystoscope at the verumontanum. Personalized treatment planning with contour mapping facilitated the creation of customized resection plans to optimize treatment outcome. Two passes of the waterjet enhanced procedural efficiency and reproducibility. Hemostasis was successfully achieved through quick resection of the circumferential bladder neck and by placing the foley on heavy traction. Additional maneuvers are highlighted in the video. The patient described in our video tolerated the procedure well and was discharged home on postoperative day 1. After the first 24 cases by a single surgeon, average operative time was 38.8 minutes with a range of 27‐69 minutes and a median of 35 minutes. Average prostate size was 52.5g with a range of 34‐112g. Prostate size did not significantly add to treatment time.
Conclusions: The novel Aquablation technique documented in our study could serve to benefit patients by significantly reducing operative times while also maintaining favorable outcomes. Utilizing these steps, large and small prostate resections can be achieved consistently in under 45 minutes, and patients can be discharged the same day following appropriate hemostasis protocol.
A Novel Method of Simultaneous Treatment of Bladder Calculus and Benign Enlargement of Prostate – Point of Technique and Video Demonstration of Two Cases
Introduction: Bladder stone formation in 88% of adults is due to Bladder outlet obstruction generally due to Benign enlargement of prostate. There is controversy regarding the sequence of treatment of both. It is generally accepted that if appropriate resources are available, then simultaneous treatment of both should be considered. There is controversy also regarding the treatment approach for bladder stone, whether by transurethral cystolithotripsy (TUCL) or Percutaneous Cystolithotripsy (PCCL) alongwith transurethral resection of prostate (TURP). It is generally accepted that for small prostates and small calculi, simultaneous TURP with TUCL is preferred and for those with large prostates and large bladder stones, TURP and PCCL is preferred. We aim to show our modified technique of simultaneous bipolar TURP and PCCL for large prostate and large bladder calculi. The modification is the use of Suction sheath and mini PCNL scope and stone lithotripsy with thulium fibre laser.
Materials and Methods: We have selected two cases for video demonstration and noted their perioperative and postoperative details. The PCCL was done using 14 Fr ClearPetra (Well Lead Medical, China) suction sheath and 12 Fr Wolff miniperc nephroscope (Richard Wolf, Germany) and Olympus Bipolar TURis system. The laser used was UROLASE SP Thulium fibre laser 35 W (IPG Photonics). With stone fragmentation mode settings of 1.5J,10 Hz and 2J,10 Hz and dusting mode settings of 0.15J and 200 Hz.
Results: The above modification was found to have the advantages of less operating times, specially in large prostate volumes and stone burden, less risk of urethral injury since the instrument indwelling time is reduced and multiple perurethral instrumentations are avoided. There is low pressure irrigation and good vision since there is continuous egress of fluid from the suction sheath. Since the incision size is smaller than conventional PCCL, there is less bleeding risk and, less risk of postoperative urine leak from around the catheter or in the extraperitoneal space. It is also good for patients with comorbidities, since the anesthesia times are less and there is less fluid absorption in TURP. The disadvantages were as follows – requirements of two endovision systems, two surgeons and cumbersome OR set‐up, more operating cost, ergonomics problem for the surgeon doing PCCL and if suction is applied, there is a theoretical risk of loss of bladder pressure and risk of bladder perforation.
Conclusion: Simultaneous TURP and PCCL using miniPCNL technique with Suction sheath and Thulium fibre laser is an easy, safe and highly efficacious minimally invasive procedure for patients with large prostates with large bladder stones as a single surgery with minimal patient morbidity.
Video Technique of Hybrid Enucleation: Bipolep‐Assisted HoLEP
Ahmet Gudeloglu1, Mujdat Ayva1, Onuralp Ergun2, Cenk Yucel Bilen1, Mario Sofer3
1Hacettepe University Faculty of Medicine Department of Urology, 2Cleveland Clinic Department of General Surgery, 3Tel Aviv Sourasky Medical Center
Presented By: Ahmet Gudeloglu, MD
Introduction and Objective: Endoscopic enucleation of the prostate (EEP) could be performed using various energy modalities. Although holmium laser energy (Holep) is the first and most commonly used energy for EEP, bipolar energy (Bipolep) has been recently shown to be safe and feasible for the same technique. This video demonstrates the technique of prostate enucleation using both bipolar energy and holmium laser energy in a hybrid fashion.
Methods: We have developed a novel endoscopic enucleation procedure by incorporating Bipolep into the Holep technique. The en‐bloc endoscopic enucleation procedure was initiated with Bipolep for early apical release, and then it was switched to the Holep. Holep was utilized to release the anterior and lateral whole glands. Once the posterior bladder neck was reached, the energy source was switched back to the Bipolep to complete the enucleation procedure. We used the new bipolar vapo‐enucleation electrode (Karl‐Storz, Tuttlingen, Germany) for Bipolep phases and the 100‐watt holmium YAG laser (Lumenis Be Ltd. Yokneam, Israel) for the Holep phase of the procedure. The morcellation part of the surgery was performed by using a morcellator.
Results: A total of 51 patients underwent a Bipolep‐assisted Holep procedure between January 2022 and October 2022. The mean age was 51 ± 7.7 years, the mean prostate volume was 113.7 ± 45.6 grams, the mean IPSS score was 24.3 ± 3.2 (19‐32), and the median quality of life score (QoL) was 5 (4‐6). The mean procedure time was 7.8 ± 3.5 mins, 32.2 ± 13.9 mins, and 11.9 ± 17.4 mins for the first Bipolep, Holep, and the last Bipolep phases. The mean 50.02 ± 22.7 gram prostate tissue was morcellated within a mean 17.5 ± 14.4 mins. The urethral catheter was removed at the first, second, third, and fourth days postoperatively in 30, 19, 1, and 1 patients, respectively. After the median 4‐month follow‐up, the median IPSS score and median QoL went down to 3 (1‐5) and 1 (0‐2). We have seen two complications; one patient on aspirin medication needed a blood transfusion, and the other developed bladder hematoma requiring a cystoscopy. The duration of the early apical release (the first Bipolep phase) was less correlated with the weight of the resected tissue than the total enucleation time (Rho:458 vs. Rho:678).
Conclusions: Hybrid enucleation: Bipolep‐assisted Holep technique seems feasible and safe. The mechanical force of the bipolar vapo‐enucleation electrode may enable the surgical capsule to be reached within a time that is minimally dependent on the prostate size. Comparative studies with larger numbers of patients are needed to demonstrate the true clinical benefit of the hybrid technique.
Robot‐Assisted Simple Prostatectomy with Bladder Neck‐Sparing Technique
Narmina Khanmammadova1, Narmina Khanmammadova1, Jacob Basilius1, Tuan Thanh Nguyen2, Andrei D. Cumpanas1, Rafael Gevorkyan1, Catherine Fung1, Caroline Nguyen1, Sohrab Naushad Ali1, Mohammed Shahait3, David I Lee1
1University of California, Irvine, Department of Urology, 2University of Medicine and Pharmacy at Ho Chi Minh City, 3Clemenceau Medical Center, Department of Surgey
Presented By: Narmina Khanmammadova, MD
Introduction and Objective: Management of benign prostatic hyperplasia (BPH) with robot‐assisted simple prostatectomy (RASP) has been shown to have favorable and durable outcomes such as low perioperative morbidity rates, short recovery time, and learning curve. RASP technique is applicable with the same‐day discharge (SDD) pathway which does not intervene with sexual function and aims to preserve urinary continence at its highest level with the bladder‐neck sparing approach is described.
Methods: Data were prospectively recorded from 24 patients who underwent outpatient RASP from September 2021 to October 2022. Patient baseline demographics, perioperative data, and surgical outcomes were collected.
Patients follow a preoperative ERAS protocol. We use a transperitoneal approach. After the removal of the anterior prostatic fat, the runoff of the dorsal venous complex is oversewn. The lateral bladder is dropped away from the prostate first to isolate the bladder neck. After anterior retraction of the Foley catheter, the prostate adenoma is enucleated, and the removed specimen is placed in the endobag. The bladder neck and urethra are re‐anastomosed in a running fashion starting at the 5 o'clock position up until the 12 o'clock position. After ensuring no leak, the remaining lateral bladder incision is closed with a running 3‐0 V loc suture. The peritoneum is injected in a transversus abdominis plane block fashion with bupivacaine.
Results: Mean age was 71.41 ± 7.86 years, mean BMI was 28.44 ± 4.5, median preoperative PSA was 6.9 (3.3 ‐ 11), mean preoperative AUA score was 21.20 ± 7.47, median prostate size was 136 mL (105 – 165.5), and 5 (20.8%) patients had history of transurethral resection of the prostate (TURP). 11 (45.8%) patients were in retention before surgery, mean operative time was 140.9 ± 37 mins, mean console time was 79.2 ± 18.8 mins, estimated blood loss was 100 mL (62.5 – 100), median weight of the removed specimen was 72.25 mL (42.2 – 95.65), median hospital stay was 154.5 minutes (116.25 – 193.5), length of catheterization was 6.87 ± 0.95 days. There were no perioperative complications, blood transfusion, or conversion to open. All patients were able to urinate after the catheter removal and were discharged on the day of surgery. Two patients were readmitted in 30 days postoperatively; 1 for infected intraabdominal hematoma and urinary tract infection and 1 for clot retention.
Conclusions: Outpatient RASP is safe with the described technique and is an excellent option for men with very enlarged prostates while also eliminating routine hospital stays.
Robotic‐Assisted Retroperitoneoscopic Approach for Management of Rare Right Ureteral Diaphragmatic Hernia Repair
Katie Yang1, Corey Efros1, Akhil Saji2, David Ambinder2, John Phillips2, Tracey Weigel2
1New York Medical College, 2Westchester Medical Center
Presented By: Katie Yang, MPH
Introduction and Objective: Ureteral diaphragmatic herniations are a rare type of ureteral herniation and may present as an asymptomatic finding or be the cause of renal obstruction, recurrent urinary tract infections, pyelonephritis, and sepsis. Asymptomatic cases have been managed with active surveillance, while obstructive uropathies have been managed with chronic indwelling ureteral stents or surgical repair. We report a combined thoracic and urologic retroperitoneal robotic‐assisted surgical repair of a right sided ureteral diaphragmatic herniation.
Methods: A 77 year old female presented with recurrent UTIs. Chronic right hydroureteronephrosis was found during the work up of GERD due to bilateral diaphragmatic hernias through the diaphragmatic crus. A right ureteral stent was initially placed, but at 3‐month follow up it could not be exchanged in a retrograde fashion due to the intrathoracic portion of the herniated ureter. A nephrostomy was placed. She underwent a combined effort by thoracic and urologic surgery to perform a right retroperitoneal hernia repair and ureteral reduction dismembered pyeloplasty. We surveyed all reported cases of ureteral diaphragmatic herniation to determine etiology, laterality, management, and outcomes.
Results: A right sided retroperitoneoscopic approach exposed by the ipsilateral ureter, renal pelvis, and suprarenal portion of the ureter herniating into a retrocaval defect in the diaphragm. Ureteral reduction, thoracic repair of the diaphragmatic defect, and reduction dismembered ureteropyeloplasty required 37 minutes. Total case time was 72 minutes, estimated blood loss was <50 cc, and hospital admission was 3 days. Post operative creatinine improved from 1.5 mg/dL to 1.1 mg/dL. In a literature review, we found that a total of 15 prior cases of ureteral diaphragmatic hernia have been reported since 1958, all occurring on the right side. Herniation most often (67%) occurred through the Bochdalek foramen, with only one prior case of herniation through the diaphragmatic crus. Of these reported cases, 9 proceeded with conservative management or indwelling ureteral stents, 4 completed surgical repair, and 2 did not include information on treatment.
Conclusions: We describe a novel case of a ureteral diaphragmatic hernia repair conducted via a retroperitoneal robot assisted approach. This case demonstrates that a robotic‐assisted approach is a viable and safe option for concomitant surgical repair of diaphragmatic hernia and ureteral redundancy.
Risk Reduction Strategies to Prevent Vascular Complications in Donor Nephrectomies.
Risk reduction strategies to prevent vascular complications in donor nephrectomies.
Dr. Arvind Ganpule, Coelho Victor, Abhishek Singh Abhijit Patil, Rohan Batra, Ravindra B Sabnis, Mahesh Desai
Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India.
Introduction: Laparoscopic donor nephrectomy (LDN) has become the standard of care in most of the transplant centres across the globe. The aim of this video is to report different vascular injuries, their management and propose risk reduction strategies. In this video we allude to how these complications occurred and how we managed them.
Materials and Methods: The first video demonstrates a LDN in a 46year old lady. The donor had two renal arteries, one each at the upper and lower pole. The arteries were secured and the vein was clipped. While the vein was being snipped, there was a “red out” visualized, due to a rent in the aorta. The scissors snipped off a portion of the upper pole artery, proximal to the point of application of the hem‐o‐lock clip. The situation was salvaged in a timely and appropriate manner.
The second video demonstrates a vascular complication in a 54 year old lady occurring due to an improper use of the hook. The lower pole kidney had been dissected and lifted up and the upper pole has yet to be dissected. The shoulder of the hook, which was not completely in view during the dissection, made contact with the renal vein, resulting in torrential hemorrhage through the rent in the vein. The bleeding was controlled laparoscopically with the help of a forceps and clip application. The same procedure could have been salvaged with the use of a rescue stitch which is depicted in the video below.
The third video demonstrates the need for a surgeon to familiarize himself with the donor anatomy prior to the operation. We demonstrate a case where the surgeon has missed the presence of a retro‐aortic renal vein and the artery was clipped. The bluish hue in the upper pole of the kidney is well visualized. The renal vein was then identified dissected and clipped and the situation was salvaged.
Results: We describe management of the following patients, one each of the aortic injury,renal vein injury, and presence of a circum‐aortic vein. All these three situations were salvaged in a timely manner.
Conclusions: Being calm and well versed with the risk reduction strategies of laparoscopy is of paramount importance while performing a laparoscopic donor nephrectomy. Careful evaluation of computed tomography angiography just before operation will act like a global positioning system (GPS) for the operating surgeon. Rescue stitch is a saviour.
Catarina Laranjo Tinoco2, Grenha Vânia1, Viviana Azevedo1, Rui Versos1, José Preza Fernandes1, Pedro Passos1, Ricardo Ramires1
1Hospital da Senhora da Oliveira, Guimarães, 2Hospital de Braga
Presented By: Catarina Laranjo Tinoco
Introduction: Urethral stricture is a recurrent disease with a challenging management. One of the most recent treatment options for this condition is the use of a paclitaxel drug‐coated balloon (Optilume®) for stricture dilation. Paclitaxel is an antiproliferative drug with fibrosis inhibition properties, which is already used in endovascular procedures. We present a video describing our step‐by‐step technique for urethral balloon dilation and our initial experience.
Results: Fourteen patients were submitted to 30Fr paclitaxel drug‐coated balloon dilation in Hospital da Senhora da Oliveira, Guimarães, Portugal, between July 2022 and April 2023 Among them, only one patient was female, and the median age was 66 years (IQR 63‐79). All patients on the first postoperative day and had their urethral catheter removed after a median of 5 days.
The median pre‐operative Qmax was 5.8 mL/s (IQR 2.0‐8.1) and the median post‐operative Qmax at 1 month was 11.8 mL/s (IQR 6.4‐15.9). The mean difference between pre and post‐operative Qmax was 4.8, with statistically significant differences by the Wilcoxon test (p = .009). All patients had negligible post‐void residues after the procedure and reported subjective improvement in urinary symptoms.
Two patients (14%) experienced stricture relapse, one at 3 months and the other at 8 months post‐procedure; however, neither patient was submitted to subsequent surgery thus far. It is noteworthy that both patients had multiple strictures, one of which was dilated with the drug‐coated balloon and the other mechanically. This might have contributed to the observed recurrence of symptoms. No postoperative complications were reported.
Conclusion: Paclitaxel drug‐coated balloon dilation is a simple procedure with good results in our patients with recurrent urethral short strictures that have failed previous procedures and should be considered one of the treatment options in this setting.
Laparoscopic Donor Nephrectomy in a Crossed Fused Ectopic Kidney – Technical Challenges
Introduction: Laparoscopic doner nephrectomy has to be done with utmost care as otherwise individual is normal and complications are unwelcome
Materials and Methods: A 42 years old female was evaluated and found to he matching renal donor for her husband. On further CT Renal angio evaluation, the left kidney was found to be a left to right crossed, The left renal artery was seen crossing IVC anteriorly, vein was short, ureter was crossing and ending in left UVJ . Isotope scan showed split renal function of 46 on Right side and 39 on ectopic left kidney, with patient in lateral position using 5 ports were placed at a little lower level as ectopic kidney was a little low. Left kidney was separated and dissected away from Rt kidney. Left renal artery ,vein and crossing ureter (mobilised with difficulty) were mobilised. A 6 cm Pfennestiel incision was made leaving the peritoneum unopened. The ureter, renal Artery and vein were divided serially graft was retrieved .Tube drain was placed . Wound was closed in layers.
Result: Patient recovered well and got discharged on 3rd post‐operative day. 3 months post operatively patient creatinine was 1.1 and comfortable
Conclusion: Though donor nephrectomy in a crossed ectolic kidney with altered vascular and ureteric anatomy is technically challenging, it is feasbile if done with atmost care.
Robotic‐Assisted Laparoscopic Excision of a Paracaval Lymphocele with Ureterolysis and Bioregenerative Umbilical Cord Amniotic Membrane Allograft Ureteral Wrap
Eitan Glucksman1, Ernest Tong1, Yu Zhang1, Ravi Munver1
1Hackensack University Medical Center
Presented By: Eitan Glucksman, MD
Introduction: Lymphocele formation is a challenging complication that can occur after radical surgery in the retroperitoneum. This complication is often difficult to manage, and percutaneous drainage is typically used as the first line management strategy. However, lymphoceles will often recur following drainage and can affect surrounding structures. We present a case of a 73‐year‐old patient with ovarian cancer who underwent a radical debulking surgery that was complicated by postoperative lymphocele formation leading to ureteral obstruction which persisted despite percutaneous drainage. We describe a technique for robotic‐assisted laparoscopic excision of a large retroperitoneal lymphocele with placement of a bioregenerative umbilical cord amniotic membrane allograft ureteral wrap.
Methods: A transperitoneal robotic approach was used. After incising the white line of Toldt and reflecting the colon, the retroperitoneum was entered. Precise dissection was required to identify the lymphocele amidst dense retroperitoneal fibrosis. The lymphocele was meticulously dissected free from the lateral aspect of the ureter. Laparoscopic ultrasonography confirmed the presence of a thick walled cystic structure lateral to the ureter. The lymphocele was entered, and its wall was excised. Extensive ureterolysis was performed to adequately dissect the ureter free from the lymphocele and surrounding structures. Indocyanine green and near‐infrared fluorescence imaging was used to ensure the integrity of the ureteral blood supply. Due to prior omentectomy, a bioregenerative umbilical cord amniotic membrane allograft ureteral wrap was placed as an omental substitute.
Results: Operative time was 168 minutes with an estimated blood loss of 50 mL. The patient was discharged on the first postoperative day. Pathology revealed benign dilated cystic spaces with mild chronic inflammation and was negative for carcinoma.
Conclusion: Excision of a paracaval lymphocele following extensive open surgery can be performed via a minimally invasive robotic‐assisted approach. Additionally, the assistance of near‐infrared fluorescence imaging is invaluable in evaluating vascular perfusion of the involved ureter following ureterolysis. Finally, in the absence of adequate omentum, a bioregenerative umbilical cord amniotic membrane allograft can be utilized to promote ureteral tissue healing and serve as an adhesion barrier to prevent recurrence of retroperitoneal fibrosis.
Single Port Robotic‐Assisted Bilateral Second Stage Fowler‐Stephens Orchiopexy in a Pediatric Patient
Benjamin Lichtbroun1, Alain Kaldany1, Kevin Chua1, Sai Krishnaraya Doppalapudi1, Haris Ahmed1, Joseph Barone1, Sammy Elsamra1
1Rutgers Robert Wood Johnson Medical School
Presented By: Benjamin Lichtbroun, MD
Introduction and Objective: The single port robot has allowed urologists to do even the most complex of cases through a 4cm incision, often through the umbilicus, making it virtually invisible in most settings. When dealing with pediatric patients, in which cosmesis is a major priority, the single port robot can be used in order to obtain seemingly comparable outcomes all while hiding the incision. Here we present the case of a single port robot‐assisted bilateral second stage Fowler‐Stephens orchiopexy in a morbidly obese 12‐year‐old patient.
Methods: This is a morbidly obese 12‐year‐old patient who previously underwent a left first stage Fowler‐Stephens orchiopexy and subsequently underwent a right first stage Fowler‐Stephens orchiopexy with the initial plan to undergo a concomitant left second stage Fowler‐Stephens orchiopexy. This was initially attempted laparoscopically but due to the patient's body habitus and lack of length, we were concerned that too much manipulation might damage the testicle or disrupt the blood supply. Therefore, we opted to abort the second stage portion of the laparoscopic procedure and instead opt to perform the second stage of both sides robotically.
Results: Using the single port robot, we located a healthy appearing right testicle adjacent to the right internal ring. We cut the gubernaculum and the residual gonadal artery and created an adequate peritoneal flap. The testicle was ultimately passed into the scrotum medial to the medial umbilical ligament on the right side. On the left side, the testicle was initially challenging to locate but ultimately a nubbin was found, which was significantly lacking in terms of length. We dissected it all the way down to the ureter and created a long peritoneal flap. Again, via the Prentiss maneuver, we were able to place the testicle into the scrotum. Both testis were secured to the scrotum via a sub‐dartos pouch using 3‐0 Vicryl.
Conclusions: The single port robot is both safe and effective for use in most pediatric patients. It can provide enhanced cosmesis over traditional open surgery as well as laparoscopic surgery.
Laparoscopic Appendicostomy: A Novel Technique for Appendiceal Stoma Creation
Eric Kurzrock1
1UC Davis School of Medicine
Presented By: Eric Kurzrock, MD
Introduction and Objectives: After laparoscopic ACE Malone or Mitrofanoff, stomal stenosis has been reported to occur in 12% to 45% of patients. The standard stoma technique entails excision of the distal appendix, spatulation and anastomosis to a triangular skin flap. The objective of this investigation is to analyze outcomes after the utilization of a novel stoma technique that preserves the appendiceal tip and vessels and opens the lumen in a more proximal and vascular area to improve perfusion and decrease stenosis.
Methods: Medical records of patients who underwent the novel stoma technique during ACE or urinary diversion with the appendix were retrospectively evaluated. We included cases in which the distal portion of the appendix was oriented for use as the stomal end with a minimum follow up of 1 year. Variables such as open or laparoscopic approach, age, gender, body mass index, antegrade continence enema or urinary diversion, cecal and appendiceal adhesions, retrocecal position, cecal imbrication, technique, frequency of catheterization and stenosis were recorded. Stenosis is defined by need for revision surgery and/or indwelling catheter for any length of time. Cox proportional hazards analyses were performed to determine association of covariates.
Results: A total of 44 patients met inclusion criteria. Surgery was at a median age of 9.0 years. The novel stoma was used in 6 patients who had continent urinary diversion and 38 ACE procedures of which 25 were done laparoscopically. The appendix was imbricated in 10% of ACE procedures and 100% of continent diversions. Patients with continent diversion perform catheterization every 2 to 4 hours during the day, whereas those with an ACE catheterize for enema instillation from 3 to 7 nights per week. No patient has developed stomal stenosis or obstruction after a median follow up of 4.8 years (range 1 to 10 years). There was no association of stenosis with any variable including surgical approach, laparoscopic or open.
Conclusions: Stomal stenosis after appendicostomy is lessened by preservation of the distal appendiceal vasculature and tip and opening the lumen in a more proximal location.
Lymphatic Sparing Laparoscopic Varicocelectomy in Pediatric Patients Using Indocyanine Green (Icg) and Immunofluorescence Imaging: A Case Series
Osama Al‐Omar1, Amr Elbakry1, Katharina Mitchell1, Ahmed Abdelhalim1
1Department of Urology, West Virginia University
Presented By: Osama Al‐Omar, MD, MBA, FEBU, FACS
Objective: To demonstrate the use of indocyanine green (ICG) and immunofluorescence imaging for identification of the lymphatic vessels during laparoscopic lymphatic sparing varicocelectomy in pediatric patients.
Methods: Our standard technique includes using three 5mm laparoscopic ports in linear configuration across the abdomen at the level of the umbilicus. We place the patient in Trendelenburg position. After identification of the gonadal vessels, the posterior peritoneum over the vessels is incised until adequate window is created. Next, we inject 2 cc of indocyanine green (ICG) into the parenchyma of the testicle. Next, we switch to the Overlay Imaging Mode that provides a combination of the immunofluorescence imaging that visualize the ICG, with a background of the standard white light view. This imaging mode allows for detection of the ICG in the lymphatic vessels with the background of the normal laparoscopic view of the surrounding anatomy. This provides an excellent real time identification of the lymphatic vessels during dissection. The lymphatic vessels are dissected and isolated from the gonadal vessels. After creating an adequate window, we perform en bloc ligation of the gonadal veins using three metal clips.
Results: We performed this procedure in 5 patients. Age was ranging from 12 to 18 years old. Average operative time was 59 minutes (range: 49 – 68). All cases were done as an outpatient procedure. No complications were reported.
Conclusion: The use of ICG via intraparenchymal injection in the testicle in combination overlay immunofluorescence imaging provides excellent view of the lymphatic vessels in real time which facilitates their identification and sparing during laparoscopic varicocelectomy procedure. In our limited case series, this technique was found to safe, effective and reproducible.
Cystinuria Complicated by Anuria from Bilateral Obstructing Stones Requiring Bilateral Mini Percutaneous Nephrolithotomy in a 22‐Month‐Old
Alexander Chait1, Stephen Hassig1, Jimena Cubillos1, Scott Quarrier1
1University of Rochester Medical Center, Department of Urology
Presented By: Alexander Chait
Introduction and Objective: Presentation of stones differs in pediatric populations from adults, often with abdominal pain, gross hematuria, or urinary tract infections. We present a case of cystinuria leading to bilateral obstructing stones causing anuria and subsequent bilateral mini percutaneous nephrolithotomy (PCNL).
Methods: A 22‐mo‐old female with no known past medical or surgical history presented with 24 hours of anuria, abdominal distension, emesis, decreased appetite, and fever. On arrival, she was in acute renal failure with a creatinine of 5.6, BUN of 70, hyperkalemia of 7.8 with peaked T waves on ECG, pH of 7.26 on VBG, HCO3 of 17, and WBC count of 15.3. Her physical exam noted mild abdominal distension. She was treated for hyperkalemia, acidosis, presumed infection, and hypertension. Renal ultrasound showed bilateral nephrolithiasis with several calculi in the ureteropelvic junctions causing moderate bilateral hydronephrosis. She underwent bilateral percutaneous nephrostomy tube placements emergently.
Results: 24‐hr urine testing via catheter yielded a diagnosis of cystinuria. Bilateral prone mini PCNL was performed as follows: antegrade nephrostograms were performed via the existing nephrostomy tubes. A Sensor wire was introduced through the left nephrostomy tube into the collecting system. This was then exchanged for an Amplatz wire with an angled glide catheter, and a second Amplatz wire placed via a Lieberman B catheter.
The tract was dilated with an 18 Fr 15 cm Cook balloon dilator and an access sheath was placed. A rigid Wolf mini nephroscope was introduced and the stone was visualized, fragmented, and extracted with a Trilogy Lithotripter (Boston Sci.) with a 1.9 mm Trilogy probe. A pediatric Flex‐X cystoscope was then used to perform a full nephroscopy with fluoroscopic assistance, and a sensor wire was placed down the ureter after confirming the full extraction of the stone. This same procedure was then completed on the right. Bilateral 8.5 French pediatric nephrostomy tubes were placed, and final antegrade nephrostograms confirmed positioning. Stone analysis was significant for cysteine stones. Post‐PCNL ultrasound demonstrated complete stone clearance.
Conclusions: Cystinuria has a prevalence of about 1 in 7000 births and accounts for about 5 percent of kidney stones in children. It is caused by mutations in the SLC3A1 or SLC7A9 genes. Pediatric patients with sudden onset anuria and renal failure should be considered for obstructive and bilateral nephrolithiasis.
Robot‐Assisted Laparoscopic Upper Pole Heminephrectomy in Children
Goktug Kalender3, Bülent Onal1, Elif Altınay Kırlı2, Aferin Uğur2, Mustafa Özkaya2, Kadir Şahin2, Muhammet Demirbilek2
1Istabul University‐Cerrahpasa, Cerrahpasa Faculty of Medicine, 2Istanbul University‐Cerrahpasa, Cerrahpasa Faculty of Medicine, 3Istanbul University‐Cerrahpasa, Cerrahpasa School of Medicine
Presented By: Goktug Kalender, MD
Introduction: We aim to present the points of the technique of robot‐assisted laparoscopic surgery for heminephrectomy (RALS‐H) for the upper pole in children with duplicated systems.
Methods: The operations were performed with 8‐mm ports of the da Vinci XI robotic surgery system by the presented technique. Patients' data were collected via a retrospective chart (2018‐2023) review, including demographics, preoperative and postoperative imaging, operative time, estimated blood loss, length of hospitalization, complications, and renal outcomes.
Results: A total of 4 patients with a mean 6,5 y/o underwent RALS‐H for indications including continuous incontinence and recurrent urinary tract infection secondary to vesicoureteral reflux with a non‐functioning upper pole. The mean operative time was 136 minutes (90‐175 minutes) for upper pole heminephrectomy. The mean estimated blood loss during the procedure was 15 mL (10‐20 mL). Early and late follow‐up periods were uneventful.
Conclusion: RALS‐H is a safe surgical treatment for children with duplicated systems.
Treatment of Bilateral Encrusted Ureteral Stents, Bilateral Large Volume Renal Stone Disease, and Ureteral Stricture Disease in a Complex Pediatric Patient: A Video Abstract
Ryan Blake1, Neha Malhotra1, Mantu Gupta1, Johnathan Khusid1
1Icahn School of Medicine at Mount Sinai
Presented By: Ryan Blake, MD
Introduction and objective: Retained stents with concurrent large volume renal calculi and ureteral stricture disease in a pediatric patient is an extremely challenging and complex scenario. Here, we present a novel, minimally invasive, nephron‐sparing surgical approach in such a patient.
Methods: We present the case of a 13‐year‐old prepubescent female with a history of myotonic dystrophy, developmental delay, scoliosis, hip dysplasia, restrictive lung disease, recurrent urinary tract infections, recurrent kidney stone disease, right ureteropelvic junction (UPJ) obstruction secondary to stricture disease, and retained ureteral stents who presented to an outside institution with urosepsis and was transferred to our pediatric hospital for surgery.
Results: The patient was transferred to our pediatric intensive care unit and optimized for the operating room (OR). On hospital day 4 the patient was taken to the OR. The encrusted right stent was removed. The patient was noted to have two proximal strictures. Cannulation with a wire was challenging but accomplished, and a 6 Fr stent was placed. On the left, the patient's retained ureteral stent was unable to be extracted as the proximal curl was completely encrusted. Percutaneous access was obtained and PCNL was performed to clear the patient's left sided stone burden and extract the encrusted left ureteral stent. On hospital day 17 the patient underwent right PCNL, and the patient's stone burden was fully cleared. Contrast studies revealed a short, pinpoint UPJ stricture. Laparoscopic shears were used via the nephroscope to incise the stricture. The UPJ was wide open after incision and an 8 Fr stent was placed. The right ureteral stent was removed on hospital day 45. Postoperative imaging showed persistent chronic hydronephrosis, however no significant stone burden, and the patient remained infection free.
Conclusions: PCNL with concurrent endopyelotomy using laparoscopic shears is a possible treatment alternative for a pediatric patient with retained stents, high volume stone disease, and ureteral stricture disease. Though staged treatment of the stricture and stones can be considered, concurrent endopyelotomy and PCNL can help avoid multiple anesthesia exposures in high risk patients. Such cases are rare, and thus further follow up is required to determine the long term clinical validity of this technique.
Laparoscopic Partial Nephrectomy in a Pediatric Patient with Pelvic Ectopic Kidney
Murat Gülşen3, Murat Gülşen1, Ender Özden1, Beytullah Yağız2, Onur Kalaycı1, Şaban Sarıkaya1
1Ondokuz Mayıs University, School of Medicine, Department of Urology, Samsun, Turkey, 2Ondokuz Mayıs University, School of Medicine, Department of Pediatric Surgery, Samsun, Turkey, 3Ondokuz Mayıs University, School of Medicine, Department of Urology
Presented By: Mehmet Necmettin Mercimek, MD
Introduction and Objective: We aimed to present our experience of laparoscopic partial nephrectomy (LPN) in a pediatric patient with pelvic ectopic kidney.
Methods: During the evaluation of a 14‐year‐old girl's prolonged menstrual haemorrhage, an ultrasound scan and pelvic computed tomography detected a 52x50 mm mass in the posterior upper pole of the pelvic ectopic kidney. The RENAL nephrometry score was 10p and creatinine level was 0,6 mg/dl. The patient was assessed in the multidisciplinary tumor review board and a LPN was planned.
In order to prevent ureteral injury during kidney mobilization, a ureteral catheter was initially placed and after creating the pneumoperitoneum in the supine position with a Veress needle, an optic, and four working ports were placed as described in the video. After achieving bowel retraction with a T‐lift organ retractor, vascular disection were performed. After securing the vascular structures, the kidney was completely mobilized. Using intraoperative ultrasound guidance, the mass's margins were subsequently identified, and markings were made with hook cautery. Then, ischemia was induced with endo‐bulldog clamps and the mass was enucleated using cold scissors. In medullary renorrhaphy, 2/0 monofilament absorbable sutures were used, while in cortical renorrhaphy, 2/0 braided polyglactin sutures were employed along with the sliding clip technique to complete the procedure. After renorraphy was completed, endo‐bulldog clamps were removed and medullar renorraphy sutures were tightened to enhance hemostasis. The posterior peritoneum was closed with a 2/0 barbed absorbable suture on the kidney. The mass was placed in the endobag and taken out of the body with the Pfannenstiel incision.
Results: Insuflation time, warm ischemia time and estimated blood loss were 120 min, 23 min and 20 cc, respectively. The patient was discharged on the second day after an uneventful postoperative course. The pathology revealed papillary renal cell carcinoma, nuclear grade 2 with negative surgical margins. The genetic counseling did not show any inherited pathology.
Conclusions: LPN allows for a thorough evaluation of the ectopic kidney and its associated anatomical structures, as well as precise resection of the renal mass while preserving renal function and reducing the risk of complications, despite the technical challenges posed by the unique anatomy of the pelvic ectopic kidney.
Indocyanine Green Assists Robotic Pyeloplasty for Ureteropelvic Junction Obstruction in a 14‐Year‐Old Boy with Horseshoe Kidney
Cheng Yen Tsai1
1China Medical University hospital
Presented By: Cheng Yen Tsai, MD
Introduction: Ureteropelvic junction obstruction (UPJO) is the most common cause of hydronephrosis in neonates. The causes of UPJO can be classified into intrinsic etiology, including insufficient emptying, valvular mucosal folds, persistent fetal convolutions, upper ureteral lesions, high insertion of the ureter, and extrinsic etiology, such as crossing vessels or secondary to vesicoureteral reflux (VUR). With the advancements in robotic surgery, upper urinary tract reconstruction can be performed with increased safety and a higher chance of successful surgical outcomes. This is achieved by minimizing ureteral manipulation, preserving blood supply, and ensuring precise spatulation of the ureter. Indocyanine green (ICG), which initially received FDA approval in 1959 and has been used off‐label for urologic surgery since 2006, can be intravenously injected to clearly demarcate the vasculature of the target organ.
We would like to present a case of a 14‐year‐old boy with a horseshoe kidney who underwent an ICG test to assist in robotic pyeloplasty due to crossing vessel caused right hydronephrosis, which resulted in a successful outcome.
Case report: This is a 14‐year‐old male with a previous history of recurrent urinary tract infections (UTIs) over the past year. He presented with symptoms of fever, dysuria, and right flank pain, for which he had previously received oral amoxicillin at a clinic without improvement. Upon examination at our outpatient department, we observed right flank knocking pain and tenderness in the right upper abdomen. Urine analysis revealed the presence of pyuria and hematuria (white blood cell count >1000/uL, red blood cell count >1000/uL). A kidney sonography was performed, which showed severe hydronephrosis on the right side and mild hydronephrosis on the left side, indicating acute pyelonephrosis bilaterally.
In light of these findings, the patient was admitted for further treatment. A percutaneous nephrostomy was performed as a temporary measure to alleviate the severe hydronephrosis on the right side. Empiric antibiotic treatment with Cefotaxime was prescribed, resulting in a gradual resolution of the fever. Antegrade pyelography was also conducted, revealing an obstruction at the right ureteropelvic junction. Furthermore, an effective renal plasma flow (ERPF) study was arranged, whilch indicated delayed parenchymal transit without scintigraphic evidence of urinary outflow obstruction in the right kidney. The Tc‐99m‐DMSA renal scan demonstrated a general decrease in cortical uptake throughout the entire right kidney, suggesting impaired renal cortical function, possibly due to acute pyelonephritis or residual effects from previous pyelonephritis. Additionally, the patient was found to have a horseshoe kidney. The relative split renal cortical function of the right and left kidney was determined to be 42.1% and 57.9% of the total, respectively. Following these evaluations, the patient was referred to our urologic outpatient department. An abdominal CT scan was performed, confirming the presence of a horseshoe kidney and hydronephrosis in the right kidney. The obstruction was located at the ureteropelvic junction, potentially related to vascular compression. After thorough discussion with the patient, we decided to proceed with indocyanine green (ICG)‐assisted right robotic pyeloplasty, accompanied by the insertion of biotect 6‐26 double J stents.
Following the surgical procedure, the right double J (DJ) stent was retained, and the right percutaneous nephrostomy (PCN) was removed. We performed regular changes of the right DJ stent on April 23, 2022, and August 13, 2022. Ultimately, the right DJ stent was removed on September 26, 2022. Subsequently, the patient did not experience any right flank pain or fever after the removal of the right DJ stent. To evaluate the progress of the right kidney, a diuretic renography was scheduled on November 16, 2022. The results indicated an improvement in effective renal plasma flow (ERPF) for the right kidney, with no scintigraphic evidence of urinary outflow obstruction.
Discussion: The success of upper urinary tract reconstructions relies on several key factors, including the removal of the obstruction or strictured segment caused by scarring or inflammation, reconstruction of healthy and well‐ perfused ureteral segments, and achieving a tension‐free anastomosis. Previous studies have demonstrated the favorable outcomes and high safety of robotic‐assisted upper urinary tract reconstruction. Zhu et al. have highlighted the benefits of using indocyanine green (ICG) as an assistant in this procedure, aiding in structural identification, perfusion assessment, and delineation of the anastomotic stricture margins. In our case, we employed ICG to identify the healthy ureteral segments with adequate vascularity, ensuring a successful anastomosis. The overall outcome was favorable.
Conclusion: The utilization of intraoperative indocyanine green (ICG) assistance is a safe and effective method for upper urinary tract reconstruction.
Video Session 5: Oncology: Kidney and Adrenal
A Partial Nephrectomy Removing Multiple Masses Using Three Surgical Techniques
Courtney Yong3, Morgan Black1, Chandru Sundaram2
1Indiana University School of Medicine, 2Indiana University, 3Indiana Unviersity
Presented By: Courtney Yong, MD
Introduction: In this video, we present a case of a patient with multiple renal masses who underwent single‐ stage partial nephrectomy. This video highlights three different methods of partial nephrectomy.
Methods: The patient was a 65 year old male who was incidentally found to have multiple left sided renal masses on imaging for baseline chronic kidney disease (CKD). His past medical history was significant for CKD stage 3 with preoperative creatinine 1.47 mg/dl and preoperative glomerular filtration rate of 53 ml/min. Past surgical history notable only for cholecystectomy. He elected for robotic left partial nephrectomy. During the procedure, four solid masses were identified on the left kidney by ultrasound and were removed using a combination of enucleation, enucleoresection, and on‐clamp partial nephrectomy with varied reconstructive techniques including no reconstruction, single‐layer, and two‐layer renorrhaphy.
Results: The patient was discharged on postoperative day 4 with no complications. Warm ischemia time was 15 minutes. The patient's postoperative creatinine at discharge was 1.51 mg/dl. Final pathology showed both papillary and clear cell renal cell carcinoma.
Conclusion: In this patient with baseline CKD and multiple left sided renal masses, the ability to resect using a variety of excision and reconstructive techniques allowed good preservation of renal function status‐post partial nephrectomy.
Robotic Upper Pole Hemi‐Nephroureterectomy Distal Common Sheath Ureterectomy and Bladder Cuff with Reimplantation of Lower Moiety Ureter in a Duplex System with Upper Tract Carcinoma
Yarden Zohar1, Nicola Mabjeesh1, Ben Hefer1, Ishai Mintz1, Bezalel Sivan1
1Department of Urology, Faculty of Health Sciences, Soroka University Medical Center , Ben‐ Gurion University of the Negev, Be'er‐Sheva,
Presented By: Yarden Zohar, MD
Introduction: NU is the standard of care for high‐grade upper tract UC, but there is no consensus regarding the recommended procedure in case of a tumor in a one of the moieties on a kidney with complete DS. We describe a case of a 69‐year‐old female patient with a mass in the renal pelvis of the upper moiety in complete DS left kidney. Herein, we introduce a robot‐assisted renal sparing hemi‐nephroureterectomy (NU) in a case of urothelial cancer (UC) involving upper pole renal pelvis of a complete duplex system (DS).
Methods: Diagnostic ureteroscopy revealed high‐grade UC of upper moiety renal pelvis; lower moiety and both ureters were tumor‐free. A small ureterocele of the upper moiety ureteral orifice was identified. A robotic‐assisted nephron sparing NU of the upper moiety was planned. Upper moiety ureter was identified and marked, followed by peri‐renal dissection. Renal vessels were identified as main vein and artery which ran towards the lower moiety, then bifurcate to provide blood supply of the upper moiety. The upper pole artery was clamped showing the demarcation line between two moieties, and then resected, followed by a double‐layer suture line for the remaining lower moiety. The upper pole ureter was dissected caudally towards the bladder, where ureters enveloped within a common sheath piercing bladder wall. The ureters within the common sheath and a bladder cuff including the ureterocele were resected. The distal end of lower moiety ureter was then re‐implanted to the bladder over a double J stent.
Results: Overall surgery time was 184 minutes with estimated blood loss of 400CC. Hemoglobin levels dropped by 2 gr/dL but no blood transfusion was needed. Postoperative course was uneventful with a score 0 in a Clavien‐ Dindo system classification. Creatinine level did not change (0.8 mg/dL). Patient was mobilized and resumed diet on post‐operative day (POD) 1. The drain was removed on POD 2 and urinary catheter was removed on POD 3, and the patient was discharged on the same day. The histopathology revealed high‐grade mucinous UC invading renal calyx, with no involvements of surgical margins, both distal ureters and the bladder cuff.
Conclusion: To best of our knowledge, this is the first case describing a robot‐assisted renal sparing surgery for UC of the upper moiety renal pelvis in a patient with complete DS.
Cephalic Inferior Vena Cava Non‐Clamping Technique Versus Standard Procedure for Robot‐ Assisted Laparoscopic Level II‐III Thrombectomy: A Prospective Cohort Study
Lulin Ma1, Yu Zhang1
1Peking University Third Hospital
Presented By: LuLin Ma, MD
Background: Renal tumor can invade the venous system and approximate 4% to 10% patients with renal tumor had venous thrombus. Though the feasibility of robot‐assisted laparoscopic inferior vena cava thrombectomy (RAL‐IVCT) in patients with inferior vena cava (IVC) thrombus has been validated, the wide application is still a challenge due to the complexity of IVC control. The objective was to describe our novel cephalic IVC non‐clamping technique and to compare the outcomes versus standard RAL‐IVCT.
Materials and methods: A prospective single‐center cohort containing 30 patients with level II‐III IVC thrombus was established since August 2020. Fifteen patients underwent cephalic IVC non‐clamping approach and 15 patients received standard RAL‐IVCT. We decided the surgical technique according to the echocardiographic assessment of the right heart and IVC.
Results: The non‐clamping group had less operative time (median 148min vs 185min, P = 0.04), and lower Clavien‐grade II complication rate (26.7% vs 80.0%, P = 0.003). The median intraoperative blood loss were 400 ml (IQR 275‐615 ml) and 800 ml (IQR 350‐1300 ml), respectively (P = 0.05). The most common complication in standard RAL‐IVCT group was liver dysfunction. No gas embolism, hypercapnia or tumor thrombus dislodgment occurred in non‐clamping group. After a median follow‐up of 17.0 mon (IQR 13.5‐ 18.5 mon) and 15.5 mon (IQR 13.0‐17.0 mon), two patients (16.7%) in the non‐clamping group and 3 patients (20.0%) in the standard RAL‐IVCT group died (HR 0.59, 95% CI 0.10‐3.54, P = 0.55).
Conclusions: The cephalic IVC non‐clamping technique can be performed safely with acceptable surgical outcomes and short‐term oncologic outcomes in patients with level II‐III IVC thrombus. Compared with standard procedure, it had less operative time and lower complication rate.
Robotic‐Assisted Laparoscopic Transperitoneal Adrenalectomy: The Single Port Ahmed Modification (SPAM) Approach
Mubashir Billah2, Evan Jones1, Vincent Wong2, Benjamin Rudnick2, Mutahar Ahmed2
1University of New England College of Osteopathic Medicine, 2Hackensack University Medical Center
Presented By: Mubashir Billah, MD
Introduction and Objective: After gaining FDA approval in 2018, several high‐volume centers have reported their experience using the da Vinci single port (SP) robotic system for a variety of urologic surgeries. This latest robotic platform enables multiple separate working instruments to be placed through a single 25 mm port. Procedures such as the radical and simple prostatectomy, partial nephrectomy, cystectomy, and other upper urinary tract reconstructive procedures are now routinely performed using the SP robotic system. However, the published experience of single port robotic adrenalectomy (SP‐RA) among surgeons has been sparse. Therefore, we sought to describe our institution's initial experience performing SP‐ RA by presenting our surgical technique as well as perioperative outcomes in a video format.
Methods: A video of our Single Port Ahmed Modification (SPAM) surgical approach was recorded for two separate cases involving patients with adrenal masses. Data was gathered to determine the feasibility of this technique and if it works just as well as a multiport system. The primary outcomes of this study were patient safety, operative times, and hospital length of stay.
Results: The video presented shows the possibility to perform both left and right SP‐RA procedures using the SPAM approach. This technique places both the adrenal gland and hilum along the same line of entry as the robot. Access to the retroperitoneum was achieved using a lateral lower quadrant incision. Airseal was used for insufflation which allowed working pressures as low as 8 mmHg. Using the SPAM approach, the gonadal vein was traced towards the hilum on the left side, while the IVC was used as a landmark to march up to the hilum and the adrenal vein on the right side. Clips, staplers, and Remotely Operated Suction Irrigation (ROSI) could be passed directly through the da Vinci SP access port kit without requiring a plus one port. Additional maneuvers are highlighted in the video. Over 20 SP‐RA cases were successfully performed at our institution and approached similar operative times as the multiport robotic‐assisted adrenalectomy.
Conclusions: The novel SPAM surgical technique highlighted in our video demonstrates that SP‐RA can be safely performed with favorable perioperative outcomes and low risk of complications. Operative times and length of stay appeared lower than previously described. Following the correct steps, SP‐RA using the SPAM approach can be performed as seamlessly as the multiport.
Non‐Closure Technique in Robotic Assisted Partial Nephrectomy for Hilar Renal Tumors
Ronald Cadillo‐Chavez1, Hector Lopez‐Huertas1
1University of Puerto Rico
Presented By: Ronald Cadillo‐Chavez, MD
Introduction and Objectives:
•Hilar tumors represent a complex scenario in terms of resection and reconstruction.
•Deep or large hilar tumors (>50% of the hilar surface) are specially challenge scenarios.
Demonstrate our technique and experience using this approach for the management of this cases.
Material and Methods:
•From a total of 405 robotic partial nephrectomies (RPN) done by a single surgeon (RC): 34 cases
•Between October 2017 and April 2022
•After tumor resection:
•A running suture of the cortico‐medullar junction with individual suture of the sinus vessels was done using V‐loc 3‐0 and PDS 4‐0 respectively
Results: Median age: 59.9 yrs. (range from 35 to 72 yrs. ), mean BMI: 29.9 (range 21.6 to 41.6). Median tumor size was: 3.8 cm (range from 2.7 to 7.5cm). Median console time was: 157.3 min. (range from 78 to 245min ). Pathology showed renal cell carcinoma in . 38% patient has stage T1b/T2a. No positive margins. No post‐ operative complications. Minimal follow up of 1 year. No recurrence or metastasis
Conclusion: This technique is a good alternative to do a RPN in large and deep hilar tumors with extension into the renal sinus
Three Dimensional Visualization with Augmented Reality Imaging Facilitates Surgical Planning for Challenging Pelvic Kidney Robotic Nephrectomy
Adnan Fazili1, Michael Maddox1
1Ochsner Health
Presented By: Adnan Fazili, MD
Introduction and Objective: Pelvic kidney occurs due to an abberation in the normal ascent of the kidney in early fetal development and usually results in malrotation and unconventional vascular supply. This poses a challenge in safely
treating suspected renal cell carcinoma in a pelvic kidney with radical surgery. We describe a novel 3‐ dimensional virtual reality (3D VR) technology as a method to better understand the anatomy of a pelvic kidney with a large renal mass, facilitating surgical planning during a robotic assisted radical nephrectomy.
Methods: To aid our understanding of the vasculature of the pelvic kidney and it's relationship to the surrounding major vessels, we performed a CT angiography of the pelvic kidney. This CT angiogram images were segmented to create a 3‐dimensional (3D) model that could be visualized in an augmented virtual reality (VR) environment.
Results: We demonstrate the utility of a 3D VR kidney model as applied to a case of a 52‐year‐old man with a 7.8 cm renal mass on his right renal pelvic kidney. The CTA imaging of the abdominopelvic cavity was deidentified in conjunction with the Ochnser Radiology Department 3D Slicer. An open‐source software was used to segment the images to create a 3D stereolithograhy (STL) object which could be viewed on a commercially available software. The 3D VR model was used preoperatively and intraoperatively to assist in robotic nephrectomy and heightened our knowledge of the blood supply to the kidney and it's relationship to the major vessels, ultimately allowing us to perform the operation safely and effectively.
Conclusion: Application of 3D VR models is feasible and beneficial in expanding our understanding of complex anatomy in a pelvic kidney as provided by conventional CT imaging and can influence surgical planning for the better.
Single Port Ahmed Modification (SPAM) Incision for Both Transperitoneal and Retroperitoneal Partial Nephrectomy
Vincent Wong2, Benjamin Rudnick1, Mubashir Billah1, Mutahar Ahmed1
1Hackensack University Medical Center, 2Westchester Medical Center
Presented By: Vincent Wong, MD
Introduction and Objective: The objective is to describe the Single Port Ahmed Modification (SPAM) incision for both transperitoneal and retroperitoneal partial nephrectomy.
Methods: The SPAM incision is an approximately 4cm incision at McBurney's point, 1/3 of the way between the anterior superior iliac spine and the umbilicus. Through this incision, access can be obtained to both the peritoneal space by incising through the peritoneum, or to the retroperitoneal space. For a retroperitoneal partial nephrectomy, the retroperitoneal space is developed with finger blunt dissection lateral to the peritoneum over the psoas muscle until the inferior pole of the kidney is palpated.
Through this incision, the hilum is accessed in standard fashion in the transperitoneal approach. In the retroperitoneal approach, the hilum is identified by following the IVC on the right side and the ureter on the left side.
Results: The first patient is a 56 year old man with a 4.9cm anterolateral right renal mass who underwent single port transperitoneal robotic partial nephrectomy. Warm ischemia time was 20 minutes, estimated blood loss (EBL) was 100cc. He was discharged on post operative day (POD) 1 without complications. Pathology showed chromophobe type renal cell carcinoma (RCC) with negative margins.
The second patient is a 76 year old female with a 4cm posterior left renal mass who underwent single port retroperitoneal robotic partial nephrectomy. Warm ischemia time was 22 minutes, EBL was <50cc. She was discharged on POD 1 without complications. Pathology showed clear cell RCC with negative margins.
Conclusions: Transperitoneal and retroperitoneal partial nephrectomy are feasible through the same SPAM incision and can be accomplished with appropriate ischemia time, blood loss, post operative recovery, and achieve negative margins.
Role of 3D Reconstruction in Complex T1b Tumors for Robotic Partial Nephrectomy
Hemang Bakshi1, Josef Pachikara1, Vipulkumar Tilva1, Dipak Rajyaguru2
1HCG Cancer Center, Ahmedabad, India, 2URO‐CARE Hospital
Presented By: Hemang Bakshi, MBBS , MS, MCh
Inroduction and Objective: Partial nephrectomy is increasingly been used as a preferred modality of treatment in renal tumours where feasible, using robotic technology .In T1b tumours,between 4 to 7 cms in size ,partial nephrectomy can be challenging. Preoperative software based virtual 3D reconstruction of the renal anatomy and type tumour can help in planning and execution of a robotic partial nephrectomy in such cases.The objective of this video is to demonstrate the utility of high quality preoperative 3D reconstruction in complex T1b renal tumors.
Method: We present a video of a 78 years old male patient who had an incidentally detected 7cms x 6cms complex posterior hilar T1b left renal mass in posterior hilar region abutting renal pelvis and hilar vessels. Preoperatively 3D reconstruction of his CECT images was done by InnerSight labs(UK). The 3D model was cognitively used during robotic resection of lesion.We used Da Vinci xi system in our institute with conventional 5 port transperitoneal approach with patient in left kidney position. Renal hilar vessels were dissected out completely. As much as possible hilar dissection was completed by using 3d
reconstruction and all supplying vessels and calyces were identified and taken care of. At last bulldog clamps were used for clamping renal artery and vein. Resection was performed and parenchymal renorraphy was done in single layer. Warm ischemia time was 36 minutes. Console time was 1hour 24 minutes. Intraoperative usage of 3D reconstucted images was correlated during Robot Assisted Partial Nephrectomy(RAPN) with various anatomical parameters like arterial, venous and calyceal anatomy. Apart from this depth and margin of resection and remanant kidney volume can be assessed..
RESULTS: Patient was discharged on POD 2 with drain. Drain was removed on POD 7. There were no post operative or intraoperative comnplications. Final histology showed Clear cell carcinoma Grade 2 with negative surgical margins. We used this technique in 8 patients with T1b complex renal hilar tumors and evaluated the role of 3D reconstruction in the management of such cases. We were able to perform Partial nephrectomy in 6 cases sucessfully according to preop plan. But in 2 cases which were scheduled for radical nephrectomy intraoperative use of this software made it possble to perform partial nephrectomy. ,
Conclusion: We were able to conclude that 3 D reconstruction software helps us by providing a clearer cognitive map for intraoperative navigation,better understanding of anatomy which leads to reduced warm ischemia times and postoperative complications like urine leak and hemorrage. Main advantage is a reduced rate of change of surgical plan‐ ie conversion from partial to radical nephrectomy in borderline T1b complex tumors. With help of 3D reconstruction, more challenging and complex tumors can be excised in a safe and oncologically sound manner.
Laparoscopic Inferior Vena Cava Thrombectomy for a Right Kidney Tumor with Level II Thrombus
Mehmet Necmettin Mercimek2, Murat Gülşen1, Mehmet Necmettin Mercimek2, Ertuğrul Köse1, Ender Özden1
1Ondokuz Mayıs University, School of Medicine, Department of Urology, Samsun, Turkey, 2Atasam Hospital Urology Clinic, Samsun, Turkey
Presented By: Mehmet Necmettin Mercimek, MD
Introduction and Objective: The purpose of this video presentation is to share our experience performing laparoscopic tumor thrombectomy for a level 2 tumor thrombus extending into the inferior vena cava (IVC) in a right kidney tumor.
Methods: A 58‐year‐old asymptomatic male patient presented with a 14 cm solid mass infiltrating lower pole of the right kidney and 41x31 mm tumor thrombus extending into the IVC on MRI. Laparoscopic radical nephrectomy and IVC tumor thrombectomy was scheduled.
The patient was positioned in a 60‐degree lateral decubitus position, and after the establishment of pneumoperitoneum, a 12 mm optical port, a 12 mm working port, and three 5 mm working ports were placed. After medializing the colon and duodenum, the IVC was dissected to access the interaortocaval level. Left renal vein (LRV) and right renal artery were dissected. The renal artery was clipped using hem‐o‐lok clips at the interaortacaval level. The renal vein draining the upper pole was clipped and dissected. The borders of the thrombus on the proximal and distal part of the IVC were dissected and secured with vascular tapes. At this point, the renal vein was the only structure attached to the kidney. Nearly a 4 cm cavatomy was performed with a laparoscopic Potts scissors starting from the right renal vein's ostium point on the IVC. Tumor thrombus was released from the IVC wall completely, IVC was checked by direct observation after removal of the tumor. There was no visual indication of vena cava infiltration or residual tumor. A right modified Gibson incision was performed and a 15‐mm endo‐bag was introduced into abdominal cavity. The specimen was carefully placed into the endo‐bag avoiding contact with the thrombus. Cavatomy was closed with 4/0 monofilament suture in a continuous fashion. After releasing the endo‐bulldog clamp on LRV, distal and proximal clamps were released respectively. No bleeding was observed.
Results: Insufflation and total clamping time was 210 and 25 minutes, respectively. The estimated blood loss was 150 cc. The patient's drain was removed on postoperative day 2 and discharged. Pathological examination revealed clear cell type renal cell carcinoma, WHO Grade 3, pT3b, with negative surgical margins.
Conclusions: Our experience demonstrates the feasibility of laparoscopic tumor thrombectomy for level 2 VCI tumor thrombi in selected cases. The procedure can be performed while adhering to oncological principles, and it offers favorable outcomes with minimally invasive approach.
Laparoscopic Radical Nephrectomy for Large Renal Mass with Level I Renal Vein Thrombus
Ahmed Abouelkhair1, Ayman Aboushmeila1
1Damanhour Oncology Center
Presented By: Ahmed Abouelkhair, MD
Introduction and Objectives: Venous involvement develops in 5% to 10% of patients with renal cell carcinoma and it is generally considered a relative contraindication to laparoscopic radical nephrectomy. Recent reports have suggested that laparoscopy is feasible option of treatment. However, the procedure may be technically difficult in patients with large renal tumors and in the presence of renal vein thrombus. In this video we present the step by step technique of Laparoscopic radical nephrectomy of a large renal tumor with renal vein thrombus.
Methods: We present a 62 years old male who presented with accidently discovered right renal mass with renal invasion. Her body mass index was 39 kg/m2. Triphasic Computed tomography of the abdomen with renal angiogram revealed an enhanced right renal lower polar mass that measured 10 x 9 X 7 cm compressing the lower and middle calyces with renal vein invasion and patent IVC. Invading renal vein showing dilated lumen distended with enhancing tumoral tissue. The RENAL nephrometry score was 10. The patient had no associated co‐morbidities. Laparoscopic radical nephrectomy was done using the four conventional ports 1st one was 10 mm inserted at para rectal line opposite to umbilicus for 30 degree laparoscopy, 12 mm port at mid clavicular line 4 finger breadth caudal to the 1st port, 12 mm port at mid clavicular line 4 finer breadth cranial to the 1st port and the 4th one was inserted at midline just below xiphisternum for usage of needle holder as liver retractor. Dissection started by incision of the posterior peritoneum that was followed medial reflection of the right ascending colon and the duodenum. Then the lower pole of the kidney was mobilized. Dissection of IVC was started below level of the lower pole and continued upwards along the medial aspect of the kidney by combining both sharp and blunt dissection. The main renal vein was located upwards behind the liver. Two renal arteries were found being located posterior and below the renal vein, they were dissected then clipped by the Hem‐O‐Lock and divided by LigaSure™. Then the main renal vein was dissected to be free of surrounding, vascular tape was used for milking of renal thrombus toward the kidney and away from IVC gate, until there was a good stump for usage of Endo GIA vascular stapler (Echelon Flex 35 ETHICON) for division of renal vein including the thrombus. Then the ureter was divided by LigaSure™. En‐block dissection of the kidney with the tumor was done using both sharp and blunt dissection. The specimen was entrapped in custom‐made bag (our innovation) and the site of insertion of the caudal port was extended through which the specimen was extracted.
Results: The operative time was 83 minutes. Blood loss was 100 c.c. There were no intraoperative or postoperative complications. The skin incision after retrieval of the specimen was 6 cm. Hospital stay was 2 days. Visual analogue pain scale at discharge was 2. Histopathology confirmed the diagnosis of clear cell renal cell carcinoma PT2bG3, occluded renal vein by tumor thrombus with free safety margins. The specimen size measured 17x12x7 cm while tumor size measured 11x10.5x5 cm
Conclusions: Laparoscopic radical nephrectomy is feasible and safe option for treatment of large renal tumors with renal vein thrombus. Although technically difficult, the procedure has low morbidity and high patient satisfaction.
Complex Partial Nephrectomy
Paul Kogan1, Julie Solomon1, James Gross1
1Washington University School of Medicine
Presented By: Paul Kogan, MD
Introduction and Objective: The gold standard treatment for renal carcinomas is surgical excision. In select candidates, partial nephrectomy is preferable over completion nephrectomy due to decreased morbidity and all‐cause mortality. Robotic partial nephrectomy is a relatively new methodology, and skepticism remains as to whether complex cases may be treated with robotic surgery. In this video abstract, we demonstrate a successful robotic partial nephrectomy of an endophytic renal tumor invading the collecting system.
Methods: The patient was draped and given prophylactic antibiotics. Formal timeout was performed. Insufflation was obtained at the umbilicus via Veress needle after a negative saline drop test. A 12 mm AirSeal port and four 8 mm robotic trocars were placed under direct visualization. The robot was docked, and the laparoscopic camera recorded the surgery. After the surgery, the robot was undocked, and the specimen was extracted from the AirSeal port. This was then closed with one PDS suture.
Results: The colon was reflected medially, and the left renal vessels were identified. The kidney was reflected medially, and ultrasound inspection was performed to delineate the margins of the tumor. It was purely endophytic and posterior. A bulldog clamp was placed on the renal artery, but Doppler signal persisted on ultrasound. A second renal artery was then dissected cranial to the previously dissected artery. The tumor was excised with a normal margin of parenchyma. The renal pelvis was entered in several locations and the tumor was noted to invade into a section of the collecting system. This was excised with the tumor. Once the tumor was freed, inspection of the tumor base revealed an upper pole calyx that was detached from the renal pelvis. This defect was anastomosed to the renal pelvic defect with two running 3‐0 VICRYL sutures. A second opening in the pelvicalyceal system was closed with running 3‐0 VICRYL sutures. The tumor base was oversewn with 2‐0 V‐Loc sutures. The renal arteries were unclamped and warm ischemia time was 90 minutes. The renorrhaphy was closed with 0 VICRYL sliding clip sutures and hemostasis was achieved. Gerota's fascia was closed with 3‐0 V‐Loc and a 19 French round JP drain was placed through the lateral inferior port.
Conclusions: Robotic partial nephrectomy is a suitable solution for complex renal masses in the hands of experienced surgeons.
Single‐Port Robotic‐Assisted Laparoscopic Right Nephroureterectomy
Angela Estevez1, Utsav Bansal1, Philip Kim1, Andrew A. Wagner1, Peter Chang1
1Beth Israel Deaconess Medical Center
Presented By: Angela Estevez, MD
Introduction: We present the case of a 73 year‐old female with a history of gross hematuria. CT scan showed a right ureteral lesion and severe right hydroureteronephrosis with cortical thinning. She was taken for ureteroscopy and biopsy, which showed a papillary tumor. Pathology was inconclusive and cytology was suspicious for malignancy. In the context of a presumptive diagnosis of upper tract urothelial carcinoma and chronically obstructed kidney, we recommended to proceed with robotic‐assisted laparoscopic right nephroureterectomy.
Methods: The patient was placed in a right side up modified lateral decubitus position. We made a 3 cm incision on the right side lateral to the umbilicus. Lateral to the previous incision, we placed a 12 mm Airseal and superiorly, we placed a 5 mm port for the liver retractor. We initiated the procedure by mobilizing both the right colon medially and the lower pole of the kidney anteriorly off the psoas muscle. We then divided the right renal hilar vessels, followed by right upper pole mobilization. After the lateral attachments were transected, we circumferentially dissected the ureter from surrounding tissue to the level of the ureteral orifice. We then closed the bladder defect in two layers using 3‐0 V‐loc suture.
Results: The operative time was 268 minutes with an estimated blood loss of 50 cc. There were no intraoperative complications. The patient tolerated the procedure well, the hospital course was unremarkable, and the patient was discharged on post‐operative day 3. The patient was seen in follow‐up four weeks after surgery and has been recovering well. Final pathology showed high grade T1 upper tract urothelial carcinoma in the right ureter with negative margins.
Conclusion: Single‐port robotic assisted laparoscopic right nephroureterectomy is a feasible and well tolerated procedure for the management of upper tract urothelial carcinoma.
Robotic‐Assisted Salvage Partial Nephrectomy After Prior Surgical Resection
Carol Feng1, Antonio Franco1, Riccardo Autorino1, Alexander Chow1
1Rush University Medical Center
Presented By: Carol Feng, MD
Introduction & Objective: Robotic‐assisted partial nephrectomies in the salvage setting often involve difficult clinical decision making, represent technically challenging cases to perform, and remain underreported in the literature. In this video, we present a case that demonstrates the feasibility, safety, and challenges of salvage robotic partial nephrectomy after prior partial nephrectomy.
Methods: A 55 year‐old man with past medical history of right renal cell carcinoma previously treated with robotic‐assisted right partial nephrectomy presented with local recurrence on CT imaging. His initial partial nephrectomy four years prior to presentation was further complicated by a urine leak requiring percutaneous drain placement and an urinothorax requiring chest tube placement. He also experienced a post‐operative ventral hernia from the previous extraction site that was repaired with mesh two years prior to referral to our tertiary center. CT imaging demonstrated local recurrence with a 2.5 cm largely endophytic involving the upper pole and interpolar polar region, abutting both the collecting system and renal hilum. Imaging also revealed two renal veins and two renal arteries, between which the mass would need to be accessed.
Results: The patient underwent salvage robotic‐assisted redo right partial nephrectomy. Intraoperative findings included extensive intraabdominal adhesions due to prior surgical history and inflammation for previous urine leak, which complicated identification of key structures. Intraoperative ultrasound was utilized to identify the inferior vena cava. Two renal veins and two renal arteries were then identified and skeletonized with care given surrounding dense inflammation. Intraoperative ultrasound was again utilized to identify the renal mass and its margins closely abutting the collecting system. Clamp time was 22 minutes to allow for complete enucleation of the right renal mass. Deep renorrhaphy was performed using 2‐0 V‐Loc suture in single running layer. Total operative time was 149 minutes. Estimated blood loss was 20 mL. The patient was discharged on post‐operative day 2 after an uncomplicated post‐operative course. Pathology demonstrated pT1a grade 1 clear cell renal cell carcinoma with negative margins.
Conclusions: Although salvage procedures after prior surgical resection can be technically difficult, re‐do robotic partial nephrectomy is a safe and viable option with good surgical outcomes in order to treat local recurrence of renal cell carcinoma after prior partial nephrectomy.
Robotic Radical Hemi‐Nephroureterectomy for Upper Tract Urothelial Carcinoma in a Horseshoe Kidney: Key Considerations
Han Jie Lee1, Jin Yong1, Russell Tan1, John Yuen1, Kenneth Chen1
1Singapore General Hospital
Presented By: Han Jie Lee, MBBS, MRCS (Edin)
Introduction and Objective: There are several technical factors that increase the complexity of performing a nephrectomy in a horseshoe kidney. We present a case of a 54‐year‐old male with an upper tract urothelial carcinoma diagnosed in the left UTUC moiety of a horseshoe kidney, and demonstrate key considerations during a robotic‐assisted laparoscopic hemi‐nephroureterectomy.
Methods: A 54‐year‐old gentleman presented with painless gross haematuria, and a computed tomography (CT) urography scan performed revealed a 4cm soft tissue mass spanning the entire upper and midpole of the left moiety of the horseshoe kidney, as well as several 5mm lesions in his bladder. A transurethral resection of bladder tumour (TURBT) and a flexible left ureteroscopy and biopsy revealed the presence of Ta high‐grade (HG) urothelial carcinoma of the bladder and left renal pelvis. Pre‐operative CT angiography confirmed a complex arterial anatomy with at least 4 discreet arterial branches to the kidney.
Results: The patient underwent robotic left radical hemi‐nephroureterectomy using the da Vinci Xi surgical system (Intuitive Surgical, Sunnyvale, CA, USA). All arterial branches supplying the left moiety of the kidney were divided between hem‐o‐lok clips. The isthmus was identified just inferior to the IMA, and was ligated between pre‐placed Stratafix sutures over sliding hemoloks. The distal ureterectomy and excision of a bladder cuff was completed using the standard extra‐vesical approach. Intravesical mitomycin C was instilled at the end of the procedure. Operative time was 225 minutes with an estimated blood loss of 100ml. Final histology demonstrated a multi‐focal TaHG urothelial carcinoma of the left renal pelvis with clear margins.
Conclusions: We demonstrate a successful robotic‐assisted laparoscopic left hemi‐nephroureterectomy, but several challenges have to be elucidated – the complex and unpredictable arterial anatomy associated with horseshoe kidneys, need for medial dissection to the level of the aorta, as well as dissection and subsequent division of the isthmus. A robotic system may be useful as it allows the surgeon to tackle these hurdles in a minimally‐ invasive manner due to improved optics and dexterity.
Robotic Salvage Partial Nephrectomy After Failed Cryotherapy
Carol Feng1, Antonio Franco1, Savio Domenico Pandolfo2, Riccardo Lombardo3, Antonio Cicione3, Cosimo De Nunzio3, Riccardo Autorino1
1Rush University Medical Center, 2University of Naples Federico II, 3Sant'Andrea Hospital of Sapienza University
Presented By: Carol Feng, MD
Introduction & Objective: Robotic partial nephrectomy in the salvage setting represents a challenging procedure which remains under reported. Aim of this video is to demonstrate its feasibility and safety for a kidney cancer after failed primary cryotherapy.
Methods: A 59 year‐old man with past medical history of right renal cell carcinoma initially treated with cryoablation in 2020 presented with local recurrence. CT imaging demonstrated 2.6 cm (cT1a) right renal mass underwent a robotic partial nephrectomy. To note, previous pathology report (biopsy percutaneous cryoablation) showed G1 RCC. Preoperative creatinine and eGFR were 1.3 mg/dL and 62 (mL/min/1.72m^2), respectively. Steps of the procedure are illustrated in the present video.
Results: After robot docking, the surgeon identified the IVC and the renal vein. Dissection of the hilum was then performed to expose the renal artery. The kidney was then freed within the Gerota's fascia, which was notably difficult due to intense inflammation and adhesions of the previous cryoablative treatment.
Intraoperative ultrasound was used to confirm and assess mass's margins and labels. Enucleo‐resection was performed with cold scissors. Early unclamping was performed with a warm ischemia time (WIT) of 25 min. Renorrhaphy was then performed in a single layer fashion, due to the proximity of the renal mass to the hilar structures. The tumor was bagged. Operative time was 180 min. Estimated blood loss was 550 ml. No perioperative complications occurred. Patient was discharged on postoperative day 1. Pathology showed a pT1a, G3 ccRCC with negative margins.
Conclusions: Salvage robotic partial nephrectomy should be considered as treatment option after initial failure of primary ablative therapy. While the procedure is more challenging than its standard counterpart, it can be safely carried out with good surgical outcomes.
Single‐Port Robot‐Assisted Laparoscopic Right Off‐ Clamp Partial Nephrectomy
Angela Estevez1, Utsav Bansal1, Philip Kim1, Andrew a. Wagner1, Peter Chang1
1Beth Israel Deaconess Medical Center
Presented By: Angela Estevez, MD
Introduction: We present the case of a 54 year‐old male with a Bosniak 4 cyst of the right kidney measuring
3.6 cm on MRI. The patient was referred to our institution to discuss further management and we performed a single‐port robotic assisted laparoscopic right partial nephrectomy off‐clamp.
Methods: The patient was placed in a right side‐up modified lateral decubitus position and a 3cm incision made along McBurney's point. An additional 12 mm Airseal port was placed infraumbilically along the midline as an assistant port. We began by mobilizing the colon medially and subsequently developed a space posterolateral to the kidney, lifting the kidney anteromedially. Afterwards, we dissected through Gerota's fascia to identify the renal mass and used intraoperative ultrasound to delineate the boundaries. The mass was excised off clamp and a 3‐0 V‐loc suture was used to oversow the base of the resection bed. 0‐Vicryl sutures were then used to reapproximate the parenchyma using a sliding clip renorrhaphy technique.
Results: The operative time was 214 minutes with an estimated blood loss of 750 cc. There were no intraoperative complications. The patient tolerated the procedure well and was discharged post‐operative day one. The patient was evaluated one month after surgery and was recovering well. Pathology reported low grade clear cell renal cell carcinoma with negative margins.
Conclusions: The patient underwent a successful procedure with no complications and showed excellent recovery during the follow‐up period.
The Successfully Use of Fluorescence‐Guided Laparoscopic Partial Adrenalectomy in Adrenal Medullary Hyperplasia Mimicking Pheochromocytoma
Altug Tuncel1, Altug Tuncel1, Serdar Basboga1, Ali Yasin Ozercan2, Cagdas Senel3, Altug Tuncel1
1University of Health Sciences School of Medicine, Ankara State Hospital, Department of Urology, 2Ministry of Health, Sirnak State Hospital, Department of Urology, 3Balıkesir University School of Medicine, Department of Urology
Presented By: Altug Tuncel, Prof.
Introduction and Objective: Fluorescence imaging has been used in a few cases during laparoscopic partial adrenalectomy (LPA). We aimed to present our experience on LPA using indocyanine green (ICG) dye with near‐infrared fluorescence (NIRF) in a patient who suffered from adrenal medullary hyperplasia mimicking pheochromocytoma in clinical appearance and laboratory findings without a clearly visible lesion on conventional radiological images.
Methods: A 30‐year‐old male that suffered from arterial hypertension and syncope attacks with an adrenal lesion. Abdominal magnetic resonance imaging did not suggest the presence of a suspicious lesion in adrenal organs. Galium‐68 DOTA‐peptides positron emission tomography was performed with ongoing clinical suspicion, and it revealed a suspicious nodular lesion of 7‐mm in diameter, presenting with thickening involving the left adrenal gland. Iodine 123‐ MIBG scintigraphy showed an increased uptake in the left adrenal gland. Diagnostic laboratory parameters were in normal ranges, except for 24‐hour urine collection for normetanephrine (patient's result: 556.85 μg/d; normal range, 88‐444) and homovanillic acid (patient's result: 10.29 mg/d; normal range, 0.5‐6.2). In light of above findings, we planned organ confined fluorescence‐guided LPA.
Results: During the surgery, the adrenal lesion was observed as hypofluorescent relative to normal adrenal tissue. We succesfully performed partial resection without complication. The histopathological result was reported as adrenal medullary hyperplasia (AMH) with negative resection margin. The patient's biochemical parameters and clinical symptoms resolved after surgery. He is still alive with no health problems or recurrence in 15 months follow‐up duration.
Conclusion: To our knowledge, this is the first report on the use of organ confined fluorescence‐guided LPA in a patient with AMH presenting with pheochromocytoma‐like symptoms. We are the first to define the fluorescence pattern of AMH as hypofluorescent in this case report. We consider that this technology could be safely used in this type of adrenal lesions which can not be visualized using conventional radiological techniques.
Nathan Cheng1, Mutahar Ahmed1, Benjamin Rudnick1, Mubashir Billah1
1Hackensack University Medical Center
Presented By: Nathan Cheng, MD
Introduction and Objective: Vesicovaginal fistulas in developed countries are mostly commonly secondary to iatrogenic causes. Reconstructive techniques for fistula repair have traditionally involved either transvaginal or transabdominal approaches. In this video demonstration, the feasibility and advantages of a transvesical approach via the single‐port (SP) robot is shown, with excellent visualization of the fistula tract, good approach for proximal fistulas that may make transvaginal repair difficult, and good approach for patients with multiple prior surgeries that may make transabdominal repair difficult.
Methods: The patient is a 49‐year‐old female who presented with urinary incontinence and 6‐7 daily pad use with complex gynecologic history including a laparoscopic hysterectomy 7 years prior. Just 6 months prior to presentation, she had undergone an aborted robotic sacrocolpopexy due to extensive bowel adhesions in pelvis, converted to open enterolysis, bilateral salpingectomy, uterosacral ligament repair, and transvaginal anterior and posterior colporrhaphy, complicated by immediate post‐operative vaginal cuff dehiscence and takeback to OR for closure. Cystoscopy, vaginoscopy, and CT urogram demonstrated clear fistula tract. The video demonstration shows transvesical docking of the SP robot, excision of the fistula tract, closure of the vagina, interposition with cryopreserved umbilical cord allograft, and two‐layered closure of the bladder.
Results: Patient was discharged to home on post‐operative day 0 with a Foley catheter for two and a half weeks. At 3 month follow up, she has been dry without any pad usage.
Conclusions: SP transvesical vesicovaginal repair offers excellent visualization and exposure of the fistula. It is a technique that may be particularly helpful in proximal fistulas that are difficult to repair transvaginally and those with hostile abdomens that are difficult to repair transabdominally.
Robotic Partial Cystectomy with Studer‐Type Neobladder Augmentation and Bilateral Ureteral Reimplantation for Ketamine‐Induced Bladder Syndrome
Introduction and Objective: Chronic ketamine use is associated with urinary tract pathologies including decreased bladder capacity, vesicoureteral reflux and renal function impairment. Here we demonstrate a bladder augment with a Studer‐ type neobladder and bilateral ureteral reimplant for severe urinary dysfunction due to chronic ketamine use.
Methods: This procedure was performed with da Vinci Xi® robotic system. Ports were placed in standard position for robot‐assisted laparoscopic pelvic procedure. The patient was positioned in steep Trendelenburg position and the robot was docked. During dissection, the right ureter was noted to have a transition point consistent with a stricture as it entered the pelvic inlet. This ureter was then dissected down to the UVJ, clipped and ligated. Distension of the bladder revealed a diminished capacity of 80 mL. A partial cystectomy was performed with the dome of the bladder completely removed. A 44 cm segment of small bowel was measured, harvested, and de‐tubularized, and a side‐to‐side bowel‐bowel anastomosis was performed. A running 3‐O V‐Loc suture was used to perform anastomosis between the ileal neobladder and the bladder. End‐to‐side spatulated Bricker type anastomoses with 4‐O Vicryl suture in a running fashion were performed for the ureteroenteric anastomoses. Both anastomoses were stented. The neobladder was noted to distend, accommodate a larger volume and was watertight.
Results: The operative course was roughly seven hours, with minimal blood loss. The patient was discharged on post‐ operative day four. Cystoscopy 4 weeks post‐operatively revealed bladder capacity >400 mL with no evidence of leakage. The ureteral stents were removed at 4 weeks post‐operatively.
Conclusion: This case demonstrate the use of the da Vinci Xi® robotic system for the creation of a Struder‐type neobladder augment and reimplant for bilateral ureteral strictures in the setting of severe urinary dysfunction with chronic ketamine use.
Single Port Da Vinci Robotic Uterine Sparing Sacrocolpopexy
Rogerio Huang1, Akhil Saji1, Mubashir Billah2, Benjamin Rudnick2, Michael Stifelman3, Mutahar Ahmed2
1Westchester Medical Center‐New York Medical College, 2New Jersey Urology ‐ Hackensack University Medical Center, 3Hackensack University Medical Center
Presented By: David Ambinder, MD
Introduction and Objective: By the year 2050, an estimated 4.9 million women will have symptomatic pelvic organ prolapse. Abdominal sacrocolpopexy (ASC) is considered the gold standard for the surgical correction of high grade symptomatic prolapse. Laparoscopy has provided a minimally invasive option with improved pain and shorter hospital stays. Robotic assisted laparoscopic surgery has 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. We aim to demonstrate a single port robotic uterine sparing sacrocolpopexy.
Methods: An IRB approval was obtained at our institution and prospective data was collected on all patients undergoing a single port robotic ASC from January 2019 ‐ April 2022. This case demonstration involves a 27 year old G2P2 female with grade 3 apical pelvic organ prolapse. She has had a bothersome bulge since her last delivery. She desired children in the future and was counseled to defer repair until completion of childbearing. However, due to a poor quality of life, she opted for a single port uterine sparing ASC.
Results: The total operative time was 98 minutes and the estimated blood loss was 10 mL. The patient's pain was minimal and she was discharged on the same day as surgery. The incision healed with excellent cosmetic results. She had improvement in prolapse symptoms. No surgical site infections, incisional hernias, mesh erosion, prolapse recurrence or other postoperative complications were observed. In a preliminary review, a single surgeon performed a single port ASC on eight patients. Mean operative time was 85.7 minutes and estimated blood loss was 50 mL. 100% of patients were discharged within 24 hours and the 30‐day postoperative complication rate was 0%.
Conclusions: The single port Da Vinci robotic uterine sparing ASC is a novel technique that can be performed safely and efficiently. The single periumbilical incision enables easy access to the pelvis and heals with excellent cosmetic results. The single port platform offers superior precision in tight working spaces, especially during the anterior and posterior dissection. There is a potential for reduced pain which may enable more same day discharges. Further refinement of the technique will hopefully add to the urologists' armamentarium to help patients with pelvic organ prolapse.
Endoscopic Urethroplasty Using Buccal Graft for Male Membranous Urethral Stricture
Jonathan Warner1, Garrett Ungerer1, Jayson Kemble1, Michael Sischka1, Felicia Balzano1
1Mayo Clinic
Presented By: Jonathan Warner, M.D.
Background and Objective: Urethral stricture disease remains a challenging urologic problem, often requiring open urethroplasty. Endoscopic management traditionally includes urethral dilation and/or urethrotomy but has less durable outcomes than open techniques. In this video, we demonstrate a new minimally invasive endoscopic approach to urethroplasty.
Methods: The procedure was performed in a male patient with prior history of prostate cancer managed by radiation who subsequently developed an 8mm flow limiting membranous urethral stricture. After stricture dilation a 1cm wide strip of superficial mucosa was resected from the bladder neck past the area of stricture, creating a bed for the graft to lay. Buccal mucosa graft was harvested in standard fashion. With the graft outside the urethra and using the RD 180 endoscopic suturing device, a suture is placed in the proximal end of the graft, then through the bladder neck, and back through the graft. As the suture is pulled, the pulley phenomenon advances the graft into place on the bladder neck. The graft is then anchored to the posterior urethra with secure straps. A catheter is placed to hold the graft flat during the healing process.
Results: The procedure lasted 2.5 hours without any complications. Estimated blood loss was 50cc, and the patient was discharged after the procedure. Catheter was removed at 4 weeks. Cystoscopy at 10 weeks post‐op showed good graft viability, with peak flow improving to 20 ml/sec compared to 4 ml/sec pre‐operatively. At six months, he continues to do well without evidence of recurrent urethral stricture.
Conclusion: Endoscopic urethroplasty using buccal graft appears to offer a safe and effective repair option that could be considered for management of ureteral strictures.
Robotic Bladder Augmentation for Management of Recurrent Urinary Tract Infections Associated with Small Capacity Bladder
Kyle T. Moore1, Benjamin J. Lichtbroun1, Alain Kaldany1, Krishna Doppalapudi1, Kevin Chua1, Sammy Elsamra1
1Rutgers Robert Wood Johnson Medical School
Presented By: Kyle T. Moore, BA
Introduction and Objective: Minimally invasive surgery provides numerous benefits that have caused it to rise in popularity over recent years. Depending on the surgery, some benefits of robotic surgery include reduced blood loss, complications, and morbidity. This video demonstrates a unique, robot‐assisted bladder augmentation for a young patient with recurrent urinary tract infections (UTIs) associated with a small capacity bladder, which contrasts with the traditional open approach utilized by most urologists.
Methods: The patient is a 22‐year‐old female who initially presented with recurrent UTIs. She had been hospitalized approximately 3‐6 times for urosepsis in the year leading up to surgery. She was also experiencing severe urinary frequency, small‐volume voids, dysuria, and pressure with urination. She had been taking hiprex and vitamin C, but these treatments did not improve her condition. She was later started on mirabegron as well as intravesical instillations for suspected interstitial cystitis. Voiding cystourethrogram eventually demonstrated a small capacity bladder with bilateral vesicoureteral reflux (VUR). This was consistent with reflux nephropathy. Cystoscopy and urodynamics helped to confirm a small capacity bladder. The patient would undergo a robotic‐assisted bladder augmentation for definitive management of her small capacity bladder and VUR.
Results: First, a 20‐centimeter (cm) segment of terminal ileum was harvested 20 cm from the ileocecal junction. A bowel‐bowel anastomosis was then formed anteriorly using a 45 mm robotic GIA stapler, and the apical defect was closed anteriorly using 3‐O V‐Loc sutures. The harvested bowel segment was then detubularized and cross folded before its medial walls were sewn together using 3‐O V‐Loc sutures. A 10 cm incision was made into the bladder dome, and the harvested bowel segment was mobilized and sewn onto the cystotomy using 3‐O V‐Loc sutures. The postoperative course was uneventful. The patient was discharged on postoperative day (POD) 3, and the Foley catheter was removed POD 15. By POD 123, the patient had reported no UTIs or lower urinary tract symptoms. Renal bladder ultrasound showed a bladder volume of 378 milliliters (mL) and a post void residual of 68 mL.
Conclusions: Robotic‐assisted bladder augmentation is feasible for recurrent UTIs associated with small capacity bladder, and this approach may serve to limit the complications associated with open surgery and can provide enhanced cosmesis in appropriate patients.
Robotic Bladder Neck Reconstruction Using a Double‐Faced Buccal Mucosal Graft ‐ a Novel Approach to Complete Bladder Neck Obliteration.
Kapilan Ravichandran4, Kale Munien1, Devang Desai2, Benjamin Namdarian3
A complete bladder neck obliteration is a rare complication of surgery for benign prostatic hyperplasia. In this submission we present our novel experience, and first of a kind – a robot assisted laparoscopic reconstruction of a completely obliterated bladder neck using a double‐faced buccal mucosal graft.
The patient presented with a bladder neck obliteration two years after a Transurethral resection of Prostate (TURP) which was recalcitrant to four endoscopic interventions, and was dependent on a suprapubic catheter (SPC) for 18 months.
The patient's procedure was undertaken with a Da Vinci Xi Surgical System®. For step 1, the patient was positioned in lithotomy with standard ports and docking. For step 2, a transvesical approach was taken through the bladder dome and the SPC pulled through the defect and left under traction. In step 3, the bladder neck is assessed and opened at 5 and 7 o'clock towards the ureteric orifices and extended distally towards the verumontanum. In step 4, Firefly FluorescenceÒ is used to assist the excision of extensive scar tissue. In step 5, a cystoscope is passed into the urethra, and the robotic lights turned off to assist with cutting toward the cystoscopic urethral light. In step 6, a guidewire is inserted into the bladder via a cystoscopic needle with the position confirmed under robotic vision, and the tract serially dilated using coaxial S‐shaped dilators. Further scar tissue is removed. In step 7, the bladder neck is opened anteriorly at 12 o'clock, and the cystoscope inserted all the way to the bladder to ensure the scar tissue has been excised. In step 8, a 6cm x 1.5cm buccal mucosal graft is harvested, defatted and divided into two separate 3cm grafts. In step 9 the posterior graft is anchored to the bladder neck and prostatic urethra using 3‐0 V‐LocÔ sutures. Further quilting sutures using VicrylÒ are used to reduce the dead space between the graft and underlying bladder neck. For step 10, we completed the scar excision and passed a 30 French metal dilator through the urethra. This was the final assessment of the urethral lumen. In step 10, we placed anterior apical V‐LocÔ sutures within the prostatic urethra and anchored the second graft here, and to the bladder neck. This graft was also quilted with VicrylÒ. Placing a buccal mucosal graft to the anterior and posterior bladder neck creates a double‐faced reconstruction. To complete the procedure, an indwelling catheter and a pelvic drain is placed, the bladder closed in two layers, good haemostasis is confirmed and the bladder successfully leak tested. The ports are closed in the usual fashion. The patient recovered and was discharged uneventfully.
Progress at the 3‐month mark has been promising with the patient voiding spontaneously, and the SPC removed. On Uroflowmetry, his maximum flowrate was 14ml/s, with an average of 5.6ml/s and post void residual bladder volume of 120ml.
Round Ligament Vaginal Colpopexy for Prevention of Post Anterior Exenteration Pelvic Organ Prolapse
Aaron Dahmen1, Piyush Agarwal1, Steven Sidelsky1
1University of Chicago
Presented By: Aaron Dahmen, MD
Introduction and Objective Bladder cancer is the most common genitourinary malignancy. The preferred choice of treatment for women with muscle‐invasive bladder cancer is radical cystectomy and urinary diversion. However, for patients with locally advanced disease, organ‐sparing surgery may not be feasible, leading to concomitant hysterectomy with anterior vaginectomy. In doing so destruction of the original structure of the pelvic cavity combined with the loss of structural tissues leads to the absence of support for the vagina and vulvar region of the patient increasing the risk of pelvic organ prolapse (POP). In this population of patients, while not extensively studied nor evaluated, the risk of POP following radical surgery for bladder cancer is thought to be as high as 6%.
Methods At our institution, we began performing round ligament colpopexy at the time of anterior exenteration either through a robotic or open approach. Round ligaments were preserved bilaterally and at the time of vaginal reconstruction were incorporated at the lateral apex of the vaginal closure bilaterally.
An IRB‐approved retrospective analysis was then performed, which identified 31 patients between 2020‐ 2023 who underwent anterior exenteration with colpopexy which were then used in our initial analysis. Age in this cohort was between 36‐83.
Results A total of 31 patients were identified who underwent anterior exenteration with round ligament colpopexy. Of these, 1 patient (3%) developed prolapse that was subsequently managed conservatively with the use of a pessary device. No adverse events related to the incorporation of round ligament colpopexy were identified in this population.
Conclusion Prolapse following female anterior exenteration is a known risk, with prior series demonstrating an approximately 6% risk. Here we present a novel technique that appears to be both safe, effective and does not increase operative time significantly. Further study of this technique in a larger population is necessary to confirm a reduced incidence of symptomatic pelvic organ prolapse moving forward in order to allow for this to become implemented more widely.
Single Port Robotic Ureteral Reimplantation with a Boari Flap in a Transplant Kidney
Daniella Portal1, Shane Kronstedt1, Sai Krishna Doppalapudi1, Benjamin Lichtbroun1, Sammy Elsamra1
1Division of Urology, Rutgers Robert Wood Johnson Medical School
Presented By: Daniella Portal, BS
Introduction and Objective: Robotic assisted laparoscopic ureteral reimplantation has been shown to be an effective method of repairing ureteric strictures. The da Vinci single port (SP) platform has been widely integrated into urological surgery with the goal of reducing post operative hospital stay and pain. In this video, we present a case of a distal ureteral stricture in a transplanted kidney repaired with the da Vinci single port platform.
Methods: The patient was placed in the dorsolithotomy position. The single port access wound retractor was inserted periumbilically into the peritoneum and the da Vinci single port robot was docked. After transecting the peritoneum lateral to the medial umbilical ligament, the transplanted kidney was identified in the left lower quadrant. The patient's nephrostomy tube was distended with saline allowing proper identification the collecting system. Further dissection revealed the left ureter. After mobilizing the bladder, the stricture in the left ureter was identified and transected. A boari flap was created in the bladder, and a spatulated end to end anastomosis was made using a 4‐0 Vicryl suture. A 7 Fr by 15 cm double‐J stent was placed into the renal pelvis of the transplanted kidney and into the bladder. The boari flap cystotomy was closed in a Heineke‐ Mikulicz fashion. The bladder was then distended and noted to be watertight. A 15‐ Blake drain was placed into the pelvis and the robot was undocked.
Results: Robotic operative time was 2 h 15 mins. There was minimal blood loss. The patient was discharged on post operative day one with a 16 F foley catheter. Patient's post operative course was complicated by obstructive pyelonephritis requiring IV antibiotics and percutaneous nephrostomy tube (PCN) and subsequent urinary tract infection. PCN was maintained until post operative antegrade nephrostogram showed contrast in the bladder confirming patency.
Conclusions: This video features key components of single port robot‐ ureteral reimplantation with a boari flap in a transplant kidney. Overall, a single port approach to transplant strictures is feasible and beneficial due the small single incision, which is associated with less post operative pain and convalescence. Further, the single port capabilities of operating in a small field is well suited for focused surgical procedures such as a distal ureteral repairs.
Endoscopic Urethroplasty Using Buccal Graft for Male Bulbar Urethral Stricture
Jonathan Warner1, Elizabeth Olive1, Jayson Kemble1, Eileen Byrne1
1Mayo Clinic
Presented By: Jonathan Warner, MD
Introduction and Objective: Urethral stricture disease remains a challenging urologic problem, often requiring open urethroplasty for definitive management. Endoscopic management traditionally includes urethral dilation and/or urethrotomy but has less durability compared to open techniques. In this video, we demonstrate a new minimally invasive endoscopic approach to treating male bulbar stricture.
Methods: The endoscopic urethroplasty procedure was performed in a male patient with prior history of bulbar stricture after TURP. He had previously undergone two DVIU procedures with subsequent stricture recurrence involving the bulbar and membranous urethra. The stricture was 3 cm in length and 8 Fr in caliber. We first made a ventral urethrotomy through the extent of the scar in the bulbar urethra, but only through the mucosa in the membranous urethra. Buccal mucosa graft was harvested in the standard fashion. With the graft outside the urethra and using the RD 180 endoscopic suturing device, 2‐0 monoglide sutures were placed at the proximal portion of the graft running from mucosa to anti mucosa. The RD 180 was then passed into the urethra through the JNW Urtrac where a bite was taken at the level of the verumontanum. Externally another bite was taken through the buccal graft 1 cm distal to the previous stitch, running from anti mucosa to mucosa. The suture was then used as a pulley system to advance the graft into place over the urethrotomy. A TK knot pusher was used to secure the proximal portion of the graft, and secure straps anchored the remainder of the graft to the underlying spongiosum tissue. A 22 Fr catheter was then placed to hold the graft flat during the healing process.
Results: The procedure lasted 2 hours without any complications. Estimated blood loss was 5 cc, and the patient was discharged after the procedure. Catheter was removed at 4 weeks. Cystoscopy at 14 weeks post‐op showed good graft viability and a widely patent urethra. At 5 months, the patient continues to do well without evidence of recurrent urethral stricture.
Conclusion: Endoscopic urethroplasty using buccal graft appears to offer a safe and effective option for definitive management of bulbar urethral strictures.
Robotic Single‐Port Transperineal Urethroplasty with Buccal Mucosa Graft
1The Smith Institute for Urology, Northwell Health
Presented By: Charan Mohan, MD
Background: Open transperineal urethroplasty has been traditionally difficult amongst obese patients (BMI ≥ 45) and has shown to have higher rates of complications including recurrent strictures, long term failure, and higher estimated blood loss. Morbidly obese patients often have long skin to urethra distance at times exceeding hand length, making open urethral repair difficult. Our objective is to describe our initial experience using a novel transperineal urethroplasty approach utilizing buccal mucosa for obese patients utilizing the daVinci Single Port (SP) Robotic Surgical System.
Materials and Methods: A 37‐year‐old morbidly obese male (BMI of 54) with CKD Stage IV and Diabetes Mellitus presented to the office for evaluation of recurrent 4 cm bulbar urethral stricture after prior failed stricture repair attempts. Due to stricture length, location, and co‐morbidities, patient elected to undergo robotic SP transperineal urethroplasty with buccal mucosa graft. The SP system was air‐docked to the perineum using the SP Access Port kit allowing for surgical access to the urethra. Buccal mucosa was harvested to perform a ventral onlay urethroplasty using the SP system.
Results: The patient was discharged on postoperative day 1 with a successful voiding trial in clinic 3 weeks later. At our institution, this surgery has been performed twice now for morbidly obese patients. Relevant data pertaining to both cases is summarized in Table 1.
Conclusions: SP robotic transperineal urethroplasty with buccal mucosa graft is a safe and successful technique for proximal urethral stricture repair, particularly in morbidly obese patients. Adaptations of this technique can be employed for other difficult cases in lower urinary tract reconstruction.
Robotic Revision Vaginoplasty with Peritoneal Fixation of Full Thickness Skin Graft
Morgan Salkowski1, Alexander Chow1, Scott Brockman1, Jamaal Jackson1, Brielle Weinstein1, Loren Schechter1
1Rush University Medical Center
Presented By: Morgan Salkowski, MD
Introduction and Objective: The goal of this video is to describe a case of robotic assisted vaginoplasty with peritoneal fixation of a full thickness skin graft in a patient with a history of prior vaginoplasty.
Methods: Our patient was a 39‐year‐old transgender female with a history of prior penile inversion vaginoplasty complicated by partial nonadherence of the skin graft. Her primary goal of the operation was receptive intercourse with phallus, and secondary goals included redirection of urine stream. The patient was prepped and draped in lithotomy position. The plastic surgery team initiated the procedure by developing a posterior flap via a perineal approach. A 24 cm x 6 cm full thickness skin graft was harvested through an abdominoplasty type resection. Access was achieved and ports were placed in the standard pelvic configuration. A transverse peritoneal incision in the posterior cul‐de‐sac was made, and the bilateral vas deferens and seminal vesicles were identified and dissected. A plane over Denonvillier's fascia was identified and reflected off the posterior edge of the prostate. This dissection was continued until the perineal and abdominal dissections communicated. The skin graft was then sewn in place over a dilator and advanced through the dissected space until it was able to be seen and grabbed robotically. The peritoneal flaps were sutured to the proximal end of the vaginal graft anteriorly and posteriorly using 3‐0 vicryl suture, and a 2‐0 V‐loc suture was used to reapproximate the peritoneum at the apex. A 3‐0 V‐loc suture was used to imbricate and approximate the anterior and posterior peritoneal flaps to seal off the apex of the vaginal vault. The surgical bed was inspected for hemostasis, the robotic was undocked, and the ports were removed without incident.
Results: The procedure was completed with a total operative time of 8 hours and 38 minutes. The patient's post‐operative course was uncomplicated. She was discharged on post‐operative day 8 with foley catheter, and underwent a successful outpatient void trial on post‐operative day 12. She was instructed to do twice daily vaginal dilation, and was ultimately able to have successful receptive intercourse.
Conclusions: Robotic assisted vaginoplasty using peritoneal flaps has been described as a useful technique for increasing neovaginal dimensions in transwomen. The robotic approach is particularly advantageous in patients who may have complex anatomy, are undergoing revision surgery, or are obese. Collaboration amongst a multidisciplinary team is crucial to ensure the optimal outcome for the patient.
Fibroepithelial Polyps of the Ureter: An Unusual Case of Ureteropelvic Junction (UPJ) Obstruction
Charan Mohan1, Reza Ghavamian1, Tareq Aro1
1The Smith Institute for Urology, Northwell Health
Presented By: Charan Mohan, MD
Introduction and Objective: Accounting for up to 6% of all ureteral tumors, fibroepithelial polyps of the ureter are a benign neoplasm of mesodermal origin. Presenting often with flank pain or gross hematuria, we describe a rare case of multiple elongated fibroepithelial polyps of the ureter causing a UPJ obstruction in a malrotated kidney.
Methods: A 45‐year‐old female with a past history of stones initially presented with recurrent episodes of severe right flank pain. Initial CT imaging demonstrated severe right hydronephrosis in a malrotated right kidney. Subsequent CT urography confirmed obstruction of the right kidney with contrast retained in the collecting system along with malrotation, and was suspected for a UPJ obstruction with concern for a double collecting system. A retrograde ureterogram showed a long filling defect in the proximal ureter extending to UPJ. Ureteroscopy confirmed the presence of multiple fibroepithelial polyps in the proximal ureter emanating from its mucosa. Obstruction was further demonstrated on a NM Lasix scan, with T1/2 of the right and left kidneys at 14 minutes and 4 minutes respectively along with a 40%/60% differential function of the right and left kidney.
Patient underwent robotic surgery for resection of the numerous fibroepithelial polyps followed by pyeloplasty. Intraoperatively, the right ureter was spatulated, all polyps were excised and unhealthy mucosa resected. Dismembered Pyeloplasty was performed.
Results: On postoperative NM Lasix scan, the T1/2 of the right kidney normalized to 7 minutes demonstrating resolution of obstruction with retained renal differential function of 35%/65% on the right and left respectively.
Conclusions: Fibroepithelial polyps of the ureter can present in a wide variety of ways. When linked with upper tract obstruction, management options can include ureteroscopic management, percutaneous resection, or primary excision and ureteral reconstruction. Here presented a rare case of multiple long polyps, undiagnosed previously, in an abnormally malrotated kidney with suspected UPJ requiring surgical excision and reconstruction
Laparoscopic Boari Flap with Port Site RIRS in a Case of Midureteric Stricture with Large Renal Stone
Introduction: Laparoscopic Boari Flap ureteric reimplantation for ureteric strictures is a complex reconstructive procedure involving lower urinary tract. To additionally treat a large renal stone, exteriorized ureter and port site RIRS is technically a demanding procedure.
Materials and Methods: 36‐year‐old female presented with complaints of right renal colicky abdominal pain and on evaluation with Contrast Enhanced CT abdomen she had right side large renal stone of size 2 X2 cms in the upper calyx along with right mid ureteric stricture. She did not have any comorbidities. She had past history of Ureterorenoscopy for ureteric stone on the right side. Under General Anaesthesia, she underwent Cystoscopy and RGP which revealed long segment ureteric stricture from pelvic brim upto bladder. Laparoscopy was done through four ports and right ureter was divided above the strictured segment. The ureteric end was brought out through flank‐10mm port and spatulated. Flexible Ureteroscope was introduced through the exteriorized ureter and stone in the upper calyx fragmented with laser energy source. After satisfactory fragmentation, 6F double J stent was placed and ureter was returned into the abdomen and laparoscopy was resumed. Boari Flap raised from the bladder in the routine fashion and Ureteric reimplantation into the boary flap was completed.Bladder was tubularised with barbed sutures. Drain was placed.
Results: Patient recovered well and drain was removed on fourth post operative day. Catheter was removed after two weeks from procedure.
Conclusion: Laparoscopic Boari Flap ureteric reimplantation though a complex procedure is widely performed one. To combine RIRS through exteriorized ureter is technically demanding one but a feasible procedure.
Introduction& Objectives: Bilateral Ileal ureter reconstruction is a complex procedure reserved for unrepairable strictures of the ureter. Here we present a case of Carcinoma Cervix who underwent Radical Hystrectomy and Radiation following the surgery, developed bilateral lower ureteric stricture and left ureterovaginal fistula presenting with continuous vaginal urinary leak for past 2 months. This video demonstrate the technique of bilateral laparoscopic ileal ureter reconstruction intracorporeally in a reverse 7 manner.
Materials & methods: Patient under general anaesthesia and lithotomy position, cystoscopy revealed bladder capacity of 200 ml and bilateral retrograde pyelogram revealed bilateral lower ureteric stricture upto pelvic brim. Three‐way foley catheter was placed in bladder. Changing to left loin position, Laparoscopy was done through five ports (3x10mm and 2 x 5mm) and adhesions were released, left mesocolon was incised to identify upper ureter.Left colon was not mobilise. Left side upper ureter isolated and transacted above the stricture level. Then 40cm of proximal ileum isolated with help of intracorporeal endo GI staplers and ileo‐ilieal continuity restored using the same. The proximal end of isolated ileum was anastomosed end to end to the left upper ureter using 4‐0 vicryl suture over 6F stent. . Changing to right loin position and with additional two ports, the right upper ureter was mobilized and divided at the pelvic brim level. The distal end of the isolated ileum was anastomosed to the fundus of the bladder using 3‐0 barbed sutures The middle segment of ileal loop was moved to the right pelvic brim area and 1.5cm incision was made over the antimesenteric area. The right side proximal healthy ureter was anastomosed to incised area of the ileum with vicryl sutures over 6F stent. After the anastomosis the bladder integrity was checked and tube drains were placed on both flanks. Fair hemostasis was secured. Blood loss during the procedure was 300 ml. Patient underwent without any intraoperative complications.
Results: Patient recovered well,vaginal leak settled and was started on oral diet on third post‐operative day. Urinary leak settled promptly. Drain was removed on fifth day and patient was discharged home with urethral catheter. She was continued on oral antibiotics and catheter was removed after two weeks with CT cystogram showing no contrast extravasation. She is on follow up for three months and voiding comfortable with no urinary leak.
Conclusions: Bilateral laparoscopic ileal ureter reconstruction for complex ureteric strictures are technically demanding but a viable, feasible and a safe procedure with the help of 3D technology. To our knowledge reverse 7 configured pure laparoscopic bilateral ileal ureter is the first report.
Laparoscopic Modified Lich Gregoir
Bernardo Teixeira1, Paulo Principe1
1Centro Hospitalar Universitário de Santo António
Presented By: Bernardo Teixeira, MD
Introduction and Objectives: Vesicoureteral reflux can lead to urinary tract infections and renal damage. Several techniques have been described for the treatment of vesicoureteral, both endoscopically and open/laparoscopic. The Lich Gregoir technique describes an extravesical ureteral reimplantation, with the creation of an antireflux intramural tunnel. However, this technique becomes more challenging in the presence of a duplicated ureter. A modified Lich Gregoir technique has been described, allowing the surgical development of the intramural tunnel, without transecting the ureter. Our objective is to describe the technique, using a laparoscopic approach.
Methods: We present the case of a 23‐year‐old female with bilateral duplicated ureters and a past medical history of vesicoureteral reflux. She underwent endoscopic treatment with bulking agents five times. She maintained, however, recurrent urinary tract infections, namely with right‐sided pyelonephritis. Cystography confirmed reflux to the lower renal moiety. The bulking agents could be seen on CT scans. A laparoscopic modified Lich Gregoir was proposed to the patient. We present the main surgical steps in a video format
Results: A surgical video of a laparoscopic modified Lich Gregoir technique is presented. Pre‐operative anatomic planning is shown, with cystography and CT scan. The surgery was performed using three 5mm ports and one 12 mm port for the camera. The ureter was identified in its pelvic portion and was dissected caudally, towards the bladder. An ultrasonic device was used for dissection. A vessel Loop locked with a hem‐o‐lock was used to provide traction and mobilized the ureter without trauma. To allow easier posterior dissection of the ureter and the creation of the intramural tunnel, the bladder was suspended with transabdominal suture. The intramural tunnel was created, and the herniated bladder mucosa could be easily identified. A detrussorraphy was performed with 2.0 vicryl over the ureter, completing the antireflux mechanism. The surgery and post‐operative period were uneventful. The patient is free from urinary tract infection until this moment.
Conclusions: Laparoscopic Lich Gregoir Technique is a safe procedure and represents a useful approach for the treatment of refractory vesicoureteral reflux in a duplicated ureter. This non‐transecting technique allows quicker recovery, without the need to use a ureteral catheter.
Robotic‐Assisted Laparoscopic Bladder Diverticulectomy: A Cystoscopic Guided Approach Facilitates Extravesical Resection Without Bladder Mobilization
Yu Zhang1, Yu Zhang1, Laurence Hou1, Eitan Glucksman2, Ravi Munver1
1Hackensack University Medical Center, 2Westchester Medical Center
Presented By: Yu Zhang, MD
Introduction and Objective: Bladder diverticulectomy presents unique challenges and can be disorienting depending on the location and size of the diverticulum. Posterolateral diverticula pose a risk of ureteral injury, while dissection of large diverticula can be complicated without bladder mobilization. We present a technique for robotic‐assisted laparoscopic bladder diverticulectomy in two scenarios. In the first case, a large diverticulum was located at the right posterolateral wall of the bladder, while in the second case, a very large diverticulum was located at the bladder dome. Intraoperative flexible cystoscopic guidance and near‐infrared fluorescence (NIRF) imaging were utilized to define the location, borders, and aid in precise directed dissection of the diverticulum, without mobilization of the bladder.
Methods: A transperitoneal robotic approach was used. Flexible cystoscopy was performed, and the diverticulum was identified and entered with the scope. As the right posterolateral diverticulum was in close proximity to the right ureter, a 5F open ended catheter was advanced into the right ureter to assist with ureteral identification. The cystoscopic and robotic views were simultaneously visualized by the console surgeon, and the diverticulum illuminated using NIRF, which aided in locating the diverticulum borders. The peritoneum was dissected from the bladder diverticulum. The ureter was mobilized, and the diverticulum was freed from surrounding tissues. The dissection was carried to the neck of the diverticulum, which was confirmed via cystoscopy, thus facilitating precise extravesical resection of the diverticulum. Cystorrhaphy was performed in a running fashion with barbed suture. A similar technique was employed for the diverticulum that was located at the bladder dome, with the exception of ureteral catheterization.
Results: Operative time was 152 minutes for the posterolateral bladder diverticulum and 132 minutes for the bladder dome diverticulum. Estimated blood loss was <10 cc for each procedure. Patients were discharged on the first postoperative day with urethral catheter removal after 7 days and 13 days respectively.
Conclusion: Robotic‐assisted bladder diverticulectomy can be routinely performed without mobilizing the bladder through the use of flexible cystoscopy and NIRF to aid in identification of the location, borders, and neck of large bladder diverticula. This approach is reproducible regardless of the diverticulum size or location.
Robotic Partial Cystectomy Via a Transvesical Approach
Matthew Lee1, Julienne Jeong1, Matthew Loecher1, Brian Chao1, Daniel Eun1
1Temple University Hospital
Presented By: Matthew Lee, MD, MBA
Introduction and Objective: Endoscopic management of extensive tumor burden within a bladder diverticulum may be technically difficult. Robotic partial cystectomy via a transvesical approach may be utilized to reduce the risk of incomplete transurethral resection and bladder perforation in this setting.
Methods: We describe the case of a 70 year old male with history of high grade T1 non muscle invasive bladder cancer who was referred for management of extensive tumor burden found within a left lateral wall diverticulum. We performed a robotic partial cystectomy via a transvesical approach. After a vertical cystotomy was made along the midline at the dome of the bladder, the left lateral wall diverticulum was identified. Electrocautery was used to circumferentially incise the bladder diverticulum until perivesical fat was encountered. The opening of the bladder diverticulum was closed with braided absorbable suture to reduce the risk of tumor spillage. Once the diverticulum was dissected free off the perivesical fat, the bladder defect was closed in two layers using braided absorbable suture. The cystotomy was closed in a two‐layer running fashion and was confirmed to be water‐tight.
Results: Operative time was 91 minutes and estimated blood loss was 25 milliliters. There were no intraoperative complications and the patient was discharged on the same day with a foley catheter in place. Postoperative pathology demonstrated high grade Ta non muscle invasive bladder cancer. The patient had a successful trial of void two weeks postoperatively and the patient has not experienced any major postoperative complications.
Conclusions: Robotic partial cystectomy via a transvesical approach may be utilized for management of extensive tumor burden within a bladder diverticulum that is not able to be resected fully endoscopically and may help reduce tumor spillage intraoperatively.
