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Introduction: Urinary stone disease is responsible for more than 1 million emergency department (ED) visits annually. There is increasing regulatory and cost pressure to reduce unplanned episodes o...

Objective To gain insight from the experience of learning Holmium laser enucleation of the prostate (HoLEP), teaching HoLEP, and the current HoLEP practice patterns of fellowship-trained endourologists. Methods Surveys were electronically distributed to United States (U.S.) practicing urologists who completed American Endourology fellowships (that included HoLEP) within the past 6 years. Questions focused on HoLEP training and current practice patterns. Results As of September 2019, 12% (6/49) of U.S. endourology fellowships reported including HoLEP as a component of training. With a 73% response rate (16 of 22), 81% participated in over 20 cases during training, while 50% participated in over 50. A total of 25% independently completed over 50 cases from start to finish. At training completion, most (80%) felt comfortable/somewhat comfortable completing an entire HoLEP independently and managing post-op complications. Seventy-five percent practice HoLEP currently, and 25% teach to trainees. When asked “What is most challenging about HoLEP in current practice?” common responses were: efficiency/profitability concerns, poor reimbursement, educating OR/hospital staff, establishing case volume, minimizing sphincter trauma, and large glands (>200gm). Conclusion With diverse exposure in fellowship, most incorporate HoLEP into their practice after training. Aspects of the procedure remain challenging after several years of experience. Profitability/reimbursement concerns should be further explored to increase HoLEP adoption.

Author(s): Fedrigon, Donald; Alshara, Luay; Monga, Manoj | Abstract: INTRODUCTION:Two automated irrigation systems have been released for use during endoscopic procedures such as ureteroscopy: the Cogentix RocaFlow® (CRF) and Thermedx FluidSmart® (TFS). Accurate pressure control using automated systems may help providers maintain irrigation pressures within a safe range while also providing clear visualization. Our objective was to directly compare these systems based on their pressure accuracy, pressure-flow relationships, and fluid heating capabilities in order to help providers better utilize the temperature and pressure settings of each system. MATERIALS AND METHODS:An in vitro ureteroscopy model was used for testing, consisting of a short semirigid ureteroscope (6/7, 5F, 31cm Wolf 425612) connected to a continuous digital pressure transducer (Meriam m1550). Each system pressure output and flow-rate, via 100mL beaker filling time, was measured using multiple trials at pressure settings between 30 and 300mmHg. Output fluid temperature was monitored using a digital thermometer (Omega DP25-TH). RESULTS:The pressure output of both systems exceeded the desired setting across the entire tested range, a difference of 15.7±2.4mmHg for the TFS compared to 5.2±1.5mmHg for the CRF (p l 0.0001). Related to this finding, the TFS also had slightly higher flow rates across all trials (7±2mL/min). Temperature testing revealed a similar maximum temperature of 34.0⁰C with both systems, however, the TFS peaked after only 8 minutes and started to plateau as early as 4-5 minutes into the test, while the CRF took over 18 minutes to reach a similar peak. CONCLUSIONS:Our in vitro ureteroscopy testing found that the CRF system had better pressure accuracy than the TFS system but with noticeably slower fluid heating capabilities. Each system provided steady irrigation at safe pressures within their expected operating parameters with small differences in performance that should not limit their ability to provide steady irrigation at safe pressures.

Introduction: This study sought to characterize delays and estimate resulting costs during nephrolithiasis surgery. Methods: Independent observers documented delays during ureteroscopy (URS) and percutaneous nephrolithotomy (PCNL) procedures. Fifty index cases over a period of three months was considered sufficient to observe the generalizable trends. Operating room staff, excluding the surgeons, were blinded. Time-related metrics and delays preventing case progression were recorded using a smartphone-accessible data collection instrument. Delays were categorized as: 1) missing equipment; 2) missing personnel; 3) equipment malfunction; or 4) delay due to case complexity. The first two categories were regarded as preventable and the latter two non-preventable. Results: Forty URS and 18 PCNL cases were included. There was a total of 56 delays in 35 (65%) cases. Twelve (67%) PCNLs and 23 (58%) URSs had delays (p=0.57). The mean cumulative delay per case was 3.5±3.2 minutes. Pre-start delays (n=17) were 4.5±3.5 minutes on average while intraoperative delays (n=39) were 3.1±2.9 minutes (p=0.167). Delays were evenly spread among the four categories. Thirty-one (55%) delays were preventable (mean 3.7±3.2 minutes) while 25 (45%) were non-preventable (mean 3.2±3.2 minutes) (p=0.58). This translates to $137 per case in preventable costs. Conclusions: Preventable operative delays are encountered frequently in nephrolithiasis surgery, translating to significant additional charges and costs. We demonstrate a rationale for the development of improved communication and workflow protocols to increase efficiency in endourological surgeries. Key limitations are the observational nature of the study and sample size.

Introduction. Both elevated testosterone and polycystic ovary syndrome (PCOS) have been speculated as possible risk factors for kidney stone formation; however, the details of this potential relationship with regards to 24-hour urine metabolic panels and stone composition have not previously been characterized. Methods. A total of 74 PCOS patients were retrospectively identified and matched with a cohort of female stone formers at a 3 : 1 ratio (by age and BMI). All patients had 24-hour urinary metabolic panels and stone compositions. These groups were compared using Pearson chi-square and Student t-tests. Additionally, the PCOS group was differentiated based on free testosterone using multivariate analysis. Results. The case-control cohort showed that PCOS patients had significantly lower sodium excretion p=0.015 and hypernatriuria rates (28.9% vs 50.9%, p=0.009). The PCOS-testosterone cohort demonstrated that high testosterone patients had significantly higher citrate values p=0.041 and significantly lower odds of hypocitraturia (36.7% vs 54.2%, OR = 0.2, p=0.042). The high testosterone group also had higher sodium excretion p=0.058 with significantly higher odds of having hypernatriuria (40.0% vs 13.6%, OR = 13.3, p=0.021). No significant patterns were revealed based on stone composition analysis. Conclusions. Compared to healthy stone formers, PCOS patients did not demonstrate significant differences in 24-hour urine and stone composition values. Elevated free testosterone in PCOS patients has a significant association with higher urinary citrate and sodium values: findings that in and of themselves do not confirm the hypothesized increased risk of stone formation. This patient cohort may provide deeper insight into the interplay between androgens and stone formation; however, further study is needed to fully characterize the possible relationship between PCOS and stone formation.

Introduction: We aimed to characterize current practice patterns among endourologists on medical expulsive therapy (MET) for treatment of ureteral calculi.Methods: An online survey was administered to Endourological Society members. Respondents’ MET usage, index case management, and awareness of recent guidelines and literature were compared based on international status, practice setting, interval since training, and endourological fellowship training.Results: Of the 237 complete responses, 65% were international, 61% were academic, 66% had >10 years in practice, and 71% were endourology fellowship-trained. MET was used by 88%, with no differences between international, academic, practice length, and fellowship-trained groups. MET was used more frequently for