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Objective To describe a new technique for single incision robotic cystectomy and Studer-type ileal neobladder using the single-port (SP) da Vinci SP robotic platform. Methods In April 2021, a 71 year-old patient underwent a single incision robotic cystectomy and orthotopic Studer-type ileal neobladder using the single-port da Vinci SP robotic platform for cT2, cN0 urothelial carcinoma of the bladder. He was not a candidate for neoadjuvant cisplatin-based combination chemotherapy and declined participation in a clinical trial. Results Total operative time was 554 minutes and estimated blood loss was 250 cc. He was discharged on postoperative day six without developing any Clavien complications. He underwent adjuvant chemotherapy for node-positive disease and follow-up through June 2021 was notable for the absence of any significant complications or readmissions. We provide a comprehensive discussion of the required instrumentation, a description of the technique with illustrations, and discuss the advantages and disadvantages of this technology as it pertains to cystectomy and urinary diversion. Conclusion We make no claim regarding the superiority of this technique over others, only that it is technically feasible and that the approach holds promise.

To describe the outcomes and quantify the rate of uric acid stone medical dissolution therapy using automated, software-generated stone volume measurements. A sample of patients treated with oral dissolution therapy was reviewed from a single institution between 2008 and 2019. Baseline patient demographics, metabolic urine testing and stone characteristics were collected. Computed tomography (CT) scan images were evaluated using the quantitative Stone Analysis Software (qSAS) to obtain total stone volume (TSV), maximum diameter (MD) and stone number. Rate of dissolution using total stone volume was calculated over the treatment period. Twenty-seven patients were started on oral dissolution therapy, corrected for renal function. After mean duration of 180 days (range 41–531), 16 patients failed treatment resulting in surgical therapy. Twenty stones in 11 patients showed complete or partial dissolution. Compared to those who failed treatment, patients with complete or partial dissolution had lower 24 h urinary uric acid and higher treatment urine pH. Thirteen (65%) stones showed complete dissolution after a mean 167.6 days. Rate of change for responders was 4.73 mm3 or 0.6% of total stone volume per day. Time to dissolution of one half of stone volume based on total stone volume was 86 days (12.30 weeks). Software-calculated total stone volume may be an effective method of measuring uric acid stone response to oral alkalization therapy. Stone volume decreased by 50% after 12.3 weeks of treatment and could be an important benchmark for oral dissolution therapyoral dissolution therapy. Further studies with a larger sample and validation of the software are needed to confirm if this can be used to guide surveillance schedules for dissolution therapy.

Familial hypomagnesemia with hypercalciuria and nephrocalcinosis (FHHNC) is a rare tubulopathy characterized by renal loss of calcium and magnesium leading to progressive renal failure. The disorder is caused by variants to the tight junction proteins claudin-16 and -19. While rare, this disorder causes a significant burden to patients based on its clinical manifestations of various electrolyte abnormalities, nephrocalcinosis, and early progression to renal failure. In this report we describe the diagnosis of a novel variant of CLDN16 which clinically presented with severe hypomagnesemia, hypocalcemia, nephrocalcinosis, and renal failure.

OBJECTIVES To compare the enucleation efficiency of Moses 2.0 with non-Moses technology in patients undergoing holmium laser enucleation of the prostate (HoLEP). PATIENTS AND METHODS A double-blinded, randomised study of patients undergoing HoLEP at the Mayo Clinic in Arizona, using the Lumenis Pulse™ 120H laser system. Patients were randomised to either right lobe enucleation using Moses 2.0 and left lobe enucleation using non-Moses, or the opposite. The primary outcome was individual lobe enucleation efficiency. Secondary outcomes included individual lobe laser time, laser energy, individual enucleation and haemostasis laser energies, and fibre burn back. Two independent reviewers watched videos of the procedures and provided a subjective evaluation of the technologies. RESULTS A total of 27 patients were included in the study. For the entire cohort, Moses 2.0 had less fibre degradation (3.5 vs 16.8 mm, P

We compared the effect of standard office-based consultation (OC) and phone correspondences (PC) on dietary 24-h urinary parameters. The medical record of all patients treated between January and April 2019 was reviewed. Only patients who had at least two consecutive 24-h urine collections were included. Linear and logistic regressions were used to investigate the difference between the changes in urinary parameters after OC and PC. Forty-three patients underwent 135 OC and 34 PC. Twenty-one received OC and PC, and 22 had only OC. Gender, age, the distance to stone clinic, the number of previous stone episodes, and baseline urinary parameters were similar between the groups. Patients who had both OC and PC had a longer follow-up time (51.7 vs 18.5 months, p

To evaluate the relationship between imperceptible T1 enhancement of papillary renal cell carcinoma (pRCC) on MR and intratumoral hemosiderin deposition. One hundred ten pRCCs (≤ 7 cm) were evaluated by MR with in- and opposed-phase spoiled gradient echo (GRE) and T1-weighted spoiled GRE with fat suppression before and after contrast. Hemosiderin deposition was assessed by SIindex and Dindex on in- and opposed-phase images. SIindex and Dindex are calculated as (SIin − SIopp)/(SIin) × 100, where SIin and SIopp are tumor signal intensities on in- and opposed-phase images and (Din)/(Dopp), where Din and Dopp are tumor diameters on in- and opposed-phase images, respectively. The degree of tumor enhancement was classified as grade 1 (no), grade 2 (subtle), or grade 3 (definite). Tumor enhancement on CT was assessed when available. Five (5%), 10 (9%), and 95 (86%) tumors were categorized as grades 1, 2, and 3 enhancement, respectively. The mean SIindex was − 33.9, − 25.3, and 1.00, whereas the mean Dindex was 1.26, 1.05, and 1.00 in tumors with grades 1, 2, and 3 enhancement, respectively. Tumors with grade 1 enhancement had significantly lower SIindex (p = 0.001) and higher Dindex (p = 0.005) than those with grade 3 enhancement. Among six tumors with grade 1 or 2 enhancement and available CT, four tumors showed > 20 HU enhancement. pRCC with no subjective enhancement on contrast-enhanced MR showed hemosiderin deposition evident by lower SIindex and higher Dindex. Hemosiderin deposition might mask the tumor enhancement on MR. • 5% of papillary renal cell carcinoma showed imperceptible enhancement on contrast-enhanced MR. • Hemosiderin deposition in papillary renal cell carcinoma might mask the tumor enhancement on contrast-enhanced MR due to T2/T2*-shortening effects. • A renal lesion with extensive hemosiderin deposition but no perceptible enhancement on MR should be considered suspicious for papillary renal cell carcinoma.

Objective To assess whether the beneficial perioperative effects of alvimopan differ with surgical approach for patients who undergo open radical cystectomy (ORC) vs robot-assisted radical cystectomy (RARC). Methods This retrospective study reviewed all patients who underwent cystectomy with urinary diversion at our institution between January 1, 2007, and January 1, 2018. Data were collected on demographic characteristics, comorbidities, surgical approach, alvimopan therapy, hospital length of stay (LOS), days until return of bowel function (ROBF), and complications. Outcomes and interactions were evaluated through regression analysis. Results Among 573 patients, 236 (41.2%) underwent RARC, 337 (58.8%) underwent ORC, and 205 (35.8%) received alvimopan. Comparison of 4 cohorts (ORC with alvimopan, ORC without alvimopan, RARC with alvimopan, and RARC without alvimopan) showed that patients who underwent ORC without alvimopan had the highest rate of postoperative ileus (25.6%, P = .02), longest median hospital LOS (7 days, P Conclusion We observed a diminished beneficial effect of alvimopan among patients undergoing RARC and a statistically significant benefit of alvimopan among patients undergoing ORC. The implications of these findings may permit more selective medication use for patients who would benefit the most from this drug.

Patients presenting with prostate gland sizes greater than 200 cc pose a unique surgical challenge to both patients and surgeons. The objective of this study is to critically assess the efficacy and risks associated with performing holmium laser enucleation of the prostate (HoLEP) on glands ≥ 200 cc. Using a prospective maintained database, all consecutive benign prostatic hyperplasia (BPH) patients with gland size ≥ 200 cc who underwent HoLEP were included. We reported patient preoperative, intraoperative, postoperative outcomes and complications. Subgroup analysis of outcomes was stratified by gland sizes 200–299 cc and ≥ 300 cc. Univariate analysis using Kruskal–Wallis and Fisher exact test was performed to compare the two groups. There were 88 patients with a mean preoperative gland size of 255.9 cc (200–770 cc). Mean operative (171 vs 182 min) and enucleation time (77 vs 83 min) were not different between the two subgroups (200–299 cc vs ≥ 300 cc). Enucleation efficiency was greater for glands ≥ 300 cc (2.6 cc/min vs 2.0 cc/min, p = 0.04). Morcellation time was longer in the ≥ 300 cc group (74.5 min vs 46.8 min, p = 0.021). Mean length of stay was 1.8 ± 1.2 days and catheter duration was 2.6 ± 2.7 days. 1 (1.1%) patient required retreatment of BPH at last follow-up. The main limitation of this study is the retrospective data analysis. Holmium laser enucleation for prostate glands volume > 200 cc is feasible with minimal morbidity. These data further reinforce the size independence success of this procedure for BPH.

INTRODUCTION AND OBJECTIVE:Flexible ureteroscopes are routinely used to treat kidney stones. Both single-use and reusable models are available. The high cost of purchase and repair of reusable uret...

INTRODUCTION AND OBJECTIVE:To describe the outcomes and quantify the rate of uric acid stone medical dissolution therapy using automated, software-generated stone volume measurementsMETHODS:A sampl...

INTRODUCTION AND OBJECTIVE:Urothelial cancer is less common, but may be associated with poorer outcomes in women than in men. The literature on gender-based differences in low-grade upper tract uro...

INTRODUCTION AND OBJECTIVE:Residual fragments (RFs) after percutaneous nephrolithotomy (PCNL) are more evident with the increasing use of high-resolution CT-scan. The fate of RFs after PCNL are poo...

Introduction:We performed a decision analysis model of the cost-effectiveness of observation vs intervention for asymptomatic residual fragments less than 4 mm in diameter following uretero...

To evaluate the literature assessing postoperative urinary retention (POUR) after non-urologic surgeries, including risk factors, as well as short- and long-term consequences. POUR is multifactorial; however, several risk factors, such as male sex, advanced age, and preexisting lower urinary tract symptoms are well established. Procedures that do not involve damage to the urinary or nervous system are rarely associated with long-term consequences, as opposed to colorectal surgery in which long-term voiding dysfunction may be experienced. Improved surgical technique may improve results in these cases. Various preventive methods have been studied. While medical prevention has been efficacious in some cases, physical, noninvasive interventions failed to show a benefit. While general risk factors for POUR are known, the literature assessing these factors varies widely and, in many cases, with conflicting results. With the expansion of ambulatory surgery, it is expected that the POUR will become more frequent. Prospective, well-designed studies are needed to guide the management in these cases.

Objective To identify factors that predict kidney stone patient's ability to produce 2.5 L urine volume per day on metabolic evaluation. Patients and Methods In a retrospective chart review, the first analysis evaluated initial 24-hour urine collections with respect to those who achieved or did not achieve a urine volume of 2.5 L/day. The second analysis evaluated those who achieved or did not achieve a daily urine volume of 2.5 L on their subsequent collection. Several variables were assessed. Results Patients' initial collections (n=1100) that achieved 2.5 L/day (n=274) were of younger age and had a higher body mass index, increased urine sodium, phosphorus, calcium levels, increased protein catabolic rate, and decreased supersaturation of calcium oxalate. In the second analysis (n=273), decreased supersaturation of calcium oxalate, increased urine urea nitrogen level, and increased protein catabolic rate were observed in subsequent collections with a urine volume of 2.5 L/day or more. Patients with a diagnosis of hyponatremia were less likely to achieve 2.5 L/day urine volume. Collection date, other comorbidities, and diuretic use were not associated with achieving 2.5 L/day urine volume. Patients' mean creatinine per kilogram for all study cohorts were within the range of adequate collection. Conclusion Predictive factors for a urine volume of 2.5 L/day or more include increased fluid intake, higher salt and animal protein diet, elevated body mass index, and male sex. Patients with these factors may require interventions other than hydration recommendations to optimize their prevention of future kidney.

Introduction: The objective was to analyze the diagnostic value of multiparametric magnetic resonance imaging (MRI) prostate lesion volume (PLV) and its correlation with the subsequent MRI–ultrasound (MRI-US) fusion biopsy results. Materials and Methods: Between March 2014 and July 2016, 150 men underwent MRI-US fusion biopsies at our institution. All suspicious prostate lesions were graded according to the Prostate Imaging Reporting and Data System (PIRADS) and their volumes were measured. These lesions were subsequently biopsied. All data were prospectively collected and retrospectively analyzed. The PLV of all suspicious lesions was correlated with the presence of cancer on the final MRI-US fusion biopsy. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. Results: There were 206 suspicious lesions identified in 150 men. The overall cancer detection rate was 102/206 (49.5%). The mean PLV for benign lesions was 0.63 ± 0.94 cm3 versus 1.44 ± 1.76 cm3 for cancerous lesions (P < 0.01). There was a statistically significant difference between the PLV of PIRADS 5 lesions when compared to PIRADS 4, 3, and 2 lesions (P < 0.0001, < 0.0001, and 0.006, respectively). The area under the curve for volume in predicting prostate cancer (PCa) was 0.66. The optimal volume for predicting PCa was 0.26 cm3 with a sensitivity, specificity, PPV, and NPV of 80.7%, 42.7%, 41.2%, and 74.6%, respectively. Conclusion: PLV may serve as a useful measure to triage patients prior to MRI-US fusion biopsy and help better understand the limits of this technology for individual patients.

Introduction: In the landscape of surgical options for the treatment of benign prostatic hyperplasia (BPH), holmium laser enucleation of the prostate (HoLEP) has risen to the top. Despite ...

Objective To perform a cost-effectiveness evaluation comparing the management options for mid-size (1-2cm) renal stones including percutaneous nephrolithotomy (PCNL), retrograde intrarenal surgery (RIRS), and shockwave lithotripsy (SWL). Methods A Markov model was created to compare cost-effectiveness of PCNL, mini-PCNL, RIRS, and SWL for 1-2cm lower pole (index patient 1) and PCNL, RIRS, and SWL for 1-2 cm non–lower pole (index patient 2) renal stones. A literature review provided stone free, complication, retreatment, secondary procedure rates, and quality adjusted life years (QALYs). Medicare costs were used. The incremental cost-effectiveness ratio (ICER) was compared with a willingness-to-pay(WTP) threshold of $100,000/QALY. One-way and probabilistic sensitivity analyses were performed. Results At 3 years, costs for index patient 1 were $10,290(PCNL), $10,109(mini-PCNL), $5,930(RIRS), and $10,916(SWL). Mini-PCNL resulted in the highest QALYs(2.953) followed by PCNL(2.951), RIRS(2.946), and SWL(2.943). This translated to RIRS being most cost-effective followed by mini-PCNL(ICER $624,075/QALY) and PCNL(ICER $946,464/QALY). SWL was dominated with higher costs and lower effectiveness. For index patient 2, RIRS dominated both PCNL and SWL. For index patient 1: mini-PCNL and PCNL became cost effective if cost ≤$5,940 and ≤$5,390, respectively. SWL became cost-effective with SFR ≥75% or cost ≤$1,236. On probabilistic sensitivity analysis, the most cost-effective strategy was RIRS in 97%, mini-PCNL in 2%, PCNL in 1%, and SWL in 0% of simulations. Conclusion For 1-2cm renal stones, RIRS is most cost-effective. However, mini and standard PCNL could become cost-effective at lower costs, particularly for lower pole stones.

Postoperative infectious related complications are not uncommon after percutaneous nephrolithotomy. Previously, we noted that 7 days of antibiotics did not decrease sepsis rates compared to just perioperative antibiotics in a low risk percutaneous nephrolithotomy population. This study aimed to compare the same regimens in individuals at moderate to high risk for sepsis undergoing percutaneous nephrolithotomy.Patients were prospectively randomized in this multi-institutional study to either 2 days or 7 days of preoperative antibiotics. Enrolled patients had stones requiring percutaneous nephrolithotomy and had either a positive preoperative urine culture or existing indwelling urinary drainage tube. Primary outcome was difference in sepsis rates between the groups. Secondary outcomes included rate of nonseptic bacteriuria, stone-free rate and length of stay.A total of 123 patients at 7 institutions were analyzed. There was no difference in sepsis rates between groups on univariate analysis. Similarly, there were no differences in nonseptic bacteriuria, stone-free rate and length of stay. On multivariate analysis, 2 days of antibiotics increased the risk of sepsis compared to 7 days of antibiotics (OR 3.1, 95% CI 1.1-8.9, p=0.031). Patients receiving antibiotics for 2 days had higher rates of staghorn calculus than the 7-day group (58% vs 32%, p=0.006) but post hoc subanalysis did not demonstrate increased sepsis in the staghorn only group.Giving 7 days of preoperative antibiotics vs 2 days decreases the risk of sepsis in moderate to high risk percutaneous nephrolithotomy patients. Future guidelines should consider infectious risk stratification for percutaneous nephrolithotomy antibiotic recommendations.

Objective To describe the clinicopathologic features of patients with incidental prostatic amyloidosis. Patients and methods We queried the genitourinary pathology database at Mayo Clinic Arizona for prostate specimens which showed amyloid deposits. Congo red stain was used for the diagnosis of amyloidosis and amyloid subtype was performed analysis using Liquid chromatography tandem mass spectrometry. We reviewed the patient's medical charts for past or subsequent diagnosis of systemic amyloidosis and clinical course. Results Prostatic amyloidosis was identified in 7 patients between 2008-2018. Median age was 79 years (range 69-84) and median follow-up was 5 years (range 0-11). Benign prostate tissue was found in 4 patients, and prostate cancer was diagnosed in 3 patients. Amyloid subtyping was available in 6 patients and was consistent with Amyloid transthyretin Amyloidosis. Liquid chromatography tandem mass spectrometry did not detect an amino acid sequence abnormality in the transthyretin protein in any of the patients. Five of 6 patients were diagnosed with cardiac amyloidosis, which preceded and followed the diagnosis of prostatic amyloidosis in 1 and 4 patients, respectively. Of these 4 patients, 2 were diagnosed immediately and as a consequence of the diagnosis of prostatic amyloidosis, and the remaining 2 3 and 4 years later. Conclusion Incidental prostatic amyloidosis should prompt systemic and cardiac evaluation for amyloidosis. In patients with suspected cardiac amyloidosis, prior prostate specimens should be reviewed for the presence of amyloidosis.

Purpose: To develop a prognostic model to estimate postoperative urinary retention (POUR) after lower limb arthroplasty. Methods: One thousand two hundred twenty patients underwent 1,374 joint replacement operations (812 knees and 562 hips) between December 2008 and May 2014. Detailed variables were collected. A multivariable logistic regression model was used to identify the independent predictors for POUR. Boot strapping and stepwise elimination was used to design a predictive nomogram. Results: There were 124 incidents of POUR (9.02%) in 118 patients (90 knee, 34 hip, P = 0.001). On univariate analysis, patients who developed POUR were older (P < 0.001), had higher American Association of Anesthesiology scores (P = 0.007), underwent knee replacement (0.001), were obese (body mass index > 35) (P = 0.04), and were hypertensive (P = 0.029), with a history of benign prostatic hyperplasis (BPH) (P < 0.001) or neurologic disorders (P = 0.024). On multivariable analysis, age (60 to 69 years, P = 0.023, 70 to 79 yrs P = 0.008, >80 years P = 0.003), knee replacement (P = 0.014), and history of BPH (P = 0.013) were the independent predictors of POUR. A score was assigned to each predictor (total = 31). The C-index was 0.65. There were three risk categories as follows: 0 to 50, 51 to 85, and 86+ points resulting in 3.3%, 7.2%, and 14.0% risk of retention, respectively. Discussion: This nomogram reliably predicts the risk of POUR in patients undergoing hip and knee arthroplasties and may help planning preoperative interventions to decrease the risk of this complication.

INTRODUCTION AND OBJECTIVE:Low grade (LG) upper tract urothelial cancer (UTUC) accounts for 40% of all UTUC diagnosed in the US. Although LG UTUC has a low risk of progression, radical nephroureter...

Objectives Cystectomy with urinary diversion is associated with decreased long-term kidney function due to several factors. One factor that has been debated is the type of urinary diversion used: ileal conduit (IC) vs. neobladder (NB). We tested the hypothesis that long-term kidney function will not vary by type of urinary diversion. Methods and Materials We retrospectively identified all patients who underwent cystectomy with urinary diversion at our institution from January 1, 2007, to January 1, 2018. Data were collected on patient demographics, comorbid conditions, perioperative radiotherapy, and complications. Creatinine values were measured at several time points up to 120 months after surgery. Glomerular filtration rate (GFR) (ml/min per 1.73 m2) was calculated using the Chronic Kidney Disease Epidemiology Collaboration equation. A linear mixed model with inverse probability of treatment weighting (IPTW) was used to compare GFR between the IC and NB cohorts over time. Multiple sensitivity analyses were performed based on 2 different calculations of GFR (Chronic Kidney Disease Epidemiology Collaboration equation vs. Modification of Diet in Renal Disease), with and without excluding patients with preoperative GFR less than 40 ml/min per 1.73 m2. Results Among 563 patients who underwent cystectomy with urinary diversion, a NB was used for 72 (12.8%) individuals. Patients who had a NB were significantly younger, had a lower American Society of Anesthesiologists score, greater baseline GFR, better Eastern Cooperative Oncology Group performance status, lower median Charlson comorbidity index, and were less likely to have received preoperative abdominal radiation (all P Conclusions Among highly selected patients with an NB, deterioration of kidney function may potentially be lower over time than among IC patients. However, the statistical significance varied between analyses and we cautiously attribute these observed differences to patient selection.

Most patients with low-grade upper tract urothelial cancer are treated by radical nephroureterectomy. We aimed to assess the safety and activity of a non-surgical treatment using instillation of UGN-101, a mitomycin-containing reverse thermal gel.In this open-label, single-arm, phase 3 trial, participants were recruited from 24 academic sites in the USA and Israel. Patients (aged ≥18 years) with primary or recurrent biopsy-proven, low-grade upper tract urothelial cancer (measuring 5-15 mm in maximum diameter) and an Eastern Cooperative Oncology Group performance status score of less than 3 (Karnofsky Performance Status score40) were registered to receive six instillations of once-weekly UGN-101 (mitomycin 4 mg per mL; dosed according to volume of patient's renal pelvis and calyces, maximum 60 mg per instillation) via retrograde catheter to the renal pelvis and calyces. All patients had a planned primary disease evaluation 4-6 weeks after the completion of initial therapy, in which the primary outcome of complete response was assessed, defined as negative 3-month ureteroscopic evaluation, negative cytology, and negative for-cause biopsy. Activity (complete response, expected to occur in15% of patients) and safety were assessed by the investigator in all patients who received at least one dose of UGN-101. Data presented are from the data cutoff on May 22, 2019. This study is registered with ClinicalTrials.gov, NCT02793128.Between April 6, 2017, and Nov 26, 2018, 71 (96%) of 74 enrolled patients received at least one dose of UGN-101. 42 (59%, 95% CI 47-71; p0·0001) patients had a complete response at the primary disease evaluation visit. The median follow-up for patients with a complete response was 11·0 months (IQR 5·1-12·4). The most frequently reported all-cause adverse events were ureteric stenosis in 31 (44%) of 71 patients, urinary tract infection in 23 (32%), haematuria in 22 (31%), flank pain in 21 (30%), and nausea in 17 (24%). 19 (27%) of 71 patients had study drug-related or procedure-related serious adverse events. No deaths were regarded as related to treatment.Primary chemoablation of low-grade upper tract urothelial cancer with intracavitary UGN-101 results in clinically significant disease eradication and might offer a kidney-sparing treatment alternative for these patients.UroGen Pharma.

There is scant evidence in the literature to support dusting vs active basket extraction during ureteroscopy for kidney stones. We prospectively evaluated and followed patients to determine which modality produced a higher stone-free rate with the fewest complications.Members of the Endourologic Disease Group for Excellence research consortium prospectively enrolled patients with a renal stone burden ranging from 5 to 20 mm in this study. A holmium laser was used and all patients were stented postoperatively. Ureteral access sheaths were used in 100% of basketing cases while sheaths were optional when dusting. The primary study outcome was the stone-free rate at 6 weeks as determined by x-ray and ultrasound.A total of 84 and 75 patients were enrolled in the basketing and dusting arms, respectively. Stones in the dusting group were significantly larger (mean ± SD stone area 96.1 ± 65.3 vs 63.3 ± 46.0 mmThe stone-free rate was higher for active basket retrieval of fragments at short-term followup on univariate analysis but not on multivariate analysis. There was no difference in postoperative complications or procedures. The 2 techniques should be in the armamentarium of the urologist.

Introduction The AUA (American Urological Association) initially published 5 Choosing Wisely® recommendations in 2013 to highlight best practices in urology. In this study we evaluated the impact and adherence to the Choosing Wisely recommendations among AUA members. Methods A survey of the AUA membership was conducted in 2014, 1 year after publication of the Choosing Wisely statements, to determine familiarity with the initiative, influence on practice and potential methods of preferred communication about such efforts. To better understand the desired method of information distribution, questions about AUA guideline communication were used as a standard for comparison. Results There were 605 respondents, representing an 8.1% response rate from all AUA members. The majority were 55 to 64 years old (34.3%), in a urology group practice (41.4%) and in practice for more than 20 years (48.9%). Overall 43.0% of respondents claimed to know of the existence of Choosing Wisely recommendations and 75.8% found the Choosing Wisely recommendations helpful to their practice. Respondents cited lack of publicity (45.0%) as the most common barrier to wider adoption. Conclusions This study highlights the need for improved communication regarding the Choosing Wisely initiative and future updates. Our results show that physicians specifically would be willing to use Choosing Wisely recommendations more in their clinical practice if they were adapted into their electronic medical record. Ongoing work is needed to develop a tool to promote and evaluate adherence to the Choosing Wisely recommendations that could be integrated into an electronic medical record.

Ten percent of patients undergoing prostatic urethral lift (PUL) require repeat surgical treatment within 3 years. We describe the feasibility and considerations of performing holmium laser enucleation of the prostate (HoLEP) as a salvage therapy after previous PUL.Men who had undergone HoLEP after PUL were retrospectively identified from three institutions with surgeons experienced in HoLEP. Subjects were characterized by age, time from PUL procedure (months) to HoLEP surgery, indication for retreatment, and pre-operative prostate volume by ultrasound. Outcomes of interest included enucleation time, morcellation time, morcellator type, weight of tissue resected, and Clavien complications. We also summarize findings related to the location of PUL device implants, and the effect of the implants on the enucleation and morcellation portions of the procedure.From December 15, 2015 to October 31, 2016, seven men aged 51-78 years underwent HoLEP at a median of 8.6 months (range 3-18) after PUL. The median prostate volume by transrectal ultrasound was 80 cmHoLEP can be performed safely and effectively post-PUL; however, device implants may be found in areas other than the intended location, and morcellation of the adenoma tissue is complicated by metallic implants of the PUL device.

Objective To determine whether the recently introduced Lumenis Pulse 120H laser platform, which offers a dual-pedal footswitch and preset energy modes to easily switch among laser settings, facilitates a more efficient process in holmium laser enucleation of the prostate (HoLEP) for surgical treatment of benign prostatic hyperplasia. Patients and Methods Patients at a single institution who underwent HoLEP with the new Lumenis Pulse 120H laser platform were matched 1:2 with patients who underwent the procedure with the previously used 100-watt VersaPulse single-pedal laser platform. Matching was performed by using propensity scores calculated by a logistic model that considered preoperative transrectal ultrasound prostate volume and patient age. The primary outcome was enucleation efficiency of each platform, determined by the weight of prostate tissue resected and enucleation time. The McNemar test and a conditional logistic model were used to associate predictors and cases. Results Twenty-nine patients who underwent HoLEP with the Lumenis Pulse 120H platform were matched with 58 patients who underwent the procedure with the 100-watt platform. We observed statistically significant differences in operating room total time, procedure time, and enucleation time. Other perioperative and postoperative outcomes were comparable between the 2 groups. Enucleation efficiency was similar between the 2 laser platforms (0.89 g per minute in the control group vs 0.84 g per minute in the Lumenis Pulse 120H group). Conclusion The efficiency of the new Lumenis Pulse 120H laser platform is comparable to the 100-watt VersaPulse laser platform in HoLEP when comparing g of tissue enucleated per minute.

The goals for management of ureteropelvic junction obstruction (UPJO) and ureteral stricture are to resolve obstruction, restore continuity, and preserve renal function while minimizing morbidity. The management of UPJO can be challenging and represents a spectrum of options that vary in the invasiveness and effective. These options include observation, long-term internal or external urinary drainage, and endoscopic or minimally invasive management. Mismanagement can potentially results in deterioration of loss of kidney function. This chapter discusses the foundations for successful management of UPJO and ureteral strictures. It also highlights the special clinical situations related to this disease entity and discusses the key advances in the field. This review contains 8 figures, 4 tables, and 73 references. Key Words: Boari flap, dismembered pyeloplasty, endopyelotomy, psoas hitch, pyeloplasty, ureteropelvic junction obstruction, ureteral obstruction, ureteral reconstruction, ureteral stricture, uretero-ureterostomy

INTRODUCTION AND OBJECTIVES:Patients with massive gland benign prostate hyperplasia (BPH) pose a unique challenge to urologists. We present our experience with HoLEP for glands greater than 200 cm3...

INTRODUCTION AND OBJECTIVES:Only 30% of UTUC patients receive endoscopic, nephron-sparing treatments due to (1) high grade histology, (2) tumor burden, or (3) unfavorable tumor location. Endoscopic...

To assess the safety and feasibility of HoLEP as a day-case procedure. We reviewed all consecutive patients who underwent HoLEP at our institution between February 2017 and March 2018. During this time, we began a prospective trial aimed at same-day discharge of specific patients. Baseline and demographic variables, and past medical, past urological, intra-operative and post-operative variables in addition to disposition and readmission data were collected. Bivariate analysis was conducted to compare patients based on the day of discharge and readmission. A multivariable model using multiple-regression analysis was used to assess predictors for early discharge or readmission. There were 179 total HoLEP procedures that were performed during the study period. Forty-seven patients were suitable candidates for same-day discharge. Among this group, 28 (59.5%) patients were successfully discharged home on the same day. Nineteen patients (40.4%) could not be discharged. The most common cause of not to discharge patients was the degree of hematuria without continuous bladder irrigation. Pre-operative prostate volume was different between the two groups (88.4 ± 30.7 cc for discharged patients vs 69.0 ± 30.7 cc for admitted patients, p = 0.033). No other pre-operative differences were identified. There were five readmissions (17.8%) following same-day discharge. Readmitted patients had higher rates of history of urinary tract infection (80% vs 26.2%, p = 0.0304). On multivariable analysis, no statistically significant predictors were identified for early discharge or readmission. Same-day discharge following HoLEP is safe and feasible in well-selected patients.

Modern robotics is an advanced minimally invasive technology with the advantages of wristed capability, three-dimensional optics, and tremor filtration compared with conventional laparoscopy. Urologists have been early adopters of robotic surgical technology: robotics have been used in urologic oncology for more than 20 years and there has been an increasing trend for utilization in benign urologic pathology in the last couple of years. The continuing development and interest in robotics are aimed at surgical efficiency as well as patient outcomes. However, despite its advantages, improvements in haptics, system size, and cost are still desired. This article explores the current use of robotics in urology as well as future improvements on the horizon.

The Internet has placed considerable information at the disposal of patients, but the sources for credible and accurate information may be difficult for a layperson to discern. Benign prostatic hyperplasia (BPH) in elderly men can be treated with different surgical interventions. The purpose of this research was to determine information seeking behaviors (ISB) of BPH patients before and after each type of surgery. All patients who underwent surgical intervention for BPH at a tertiary training center between January 2007 and January 2013 were included in this study. A comprehensive questionnaire regarding their ISB was sent through a third-party survey center. The following areas were examined: (1) the patient’s opinion regarding information sources of BPH and its treatment, (2) the extent of ISB for each patient and its relation to the type of surgical intervention he eventually underwent, and (3) the relationship between the extent of ISB and the patient’s final satisfaction. The results indicated that the majority of patients felt that it is relatively easy to find information about BPH and its treatment. Most of the patient started with either general online search engines or used the hospital website. Patients who explored more sources of information ended up choosing a more specific and sophisticated procedure. Generally, patients used fewer sources postoperatively regardless of the procedure they underwent. There was no correlation between the extent of ISB and overall satisfaction ( r = −0.0719, p = .1610) and regret ( r = −0.0436, p = .3945).

Fragments 4 mm or smaller after ureteroscopy historically have been considered clinically insignificant but there is a reported 20% event rate on followup even with stones 4 mm or smaller. In this study we examine the natural history, complications and re-intervention rates of fragments after ureteroscopy.Data from 6 centers were collected retrospectively from members of the Endourology Disease Group for Excellence in 232 patients who had residual fragments after ureteroscopy between 2006 and 2013. Patients with fragment(s) of any size on imaging within 12 months were eligible. The primary outcome measured was stone events, and secondary outcomes included stone growth, stone passage, re-intervention and complications.Of the 232 subjects with fragments 131 (56%) required no further intervention and remained asymptomatic, 34 (15%) experienced complications requiring no intervention and 67 (29%) required intervention, ie the primary outcome stone event rate was 44%. Fragments larger than 4 mm were more likely to grow with time (p0.001) and were associated with more complications (p=0.039). Fragments larger than 2 mm were more likely to grow (p0.001) but were not associated with complications or re-intervention. Re-intervention was predictable based on fragment size (p=0.017). In a multivariable logistic regression model there was no significant difference between the techniques of dusting stones or basket extraction.This study suggests that fragment size larger than 4 mm after ureteroscopy is associated with significantly higher rates of stone growth, complications and the need for re-intervention. Ensuring complete stone-free status is the most effective strategy to reduce stone events after ureteroscopy.

To assess patient-reported functional and quality-of-life (QoL) outcomes associated with various surgical treatments for benign prostate hyperplasia (BPH).An independent third-party survey was sent to all patients who underwent any surgical treatment for BPH at our institution from January 2007 through January 2013. Overall satisfaction and urinary and sexual outcomes were evaluated using Sexual Health Inventory for Men (SHIM), International Prostate Symptoms Score (IPSS) for urinary function, and International Continence Society-Short Form (ICSmaleSF) questionnaires.Four hundred and seventy-nine respondents (response rate, 55.6%) had undergone holmium laser enucleation of the prostate (HoLEP; n = 214), transurethral resection of the prostate (n = 210), holmium laser ablation of the prostate (n = 21), photoselective vaporization (n = 18), transurethral incision of the prostate (n = 9), and open simple prostatectomy (n = 7). Postoperatively, Sexual Health Inventory for Men scores were not different. However, total IPSS varied significantly among surgical techniques (P.001). Mean (standard deviation) IPSS was lowest for open simple prostatectomy (4.0 [2.6]), followed by HoLEP (5.8 [5.4]). For individual domains, significant differences were in intermittency (P.001), weak stream (P = .003), straining (P.001), and QoL (P = .001). In all these domains, HoLEP had the lowest scores. Regarding International Continence Society-Short Form, we observed a significant difference favoring transurethral resection of the prostate in incontinence (P.001) and favoring HoLEP in voiding (P = .02) and QoL domains (P = .03). Most patients were satisfied with their surgical intervention, independent of the procedure type. Regret was least in patients who underwent HoLEP (P = .02).Patients generally expressed satisfaction with various interventions for BPH. However, those who underwent HoLEP had the best outcomes.

To determine the incidence and distribution of radical prostatectomy (RP) in the United States over time.We conducted a serial cross-sectional analysis of time trends using the Nationwide Inpatient Sample of adult men older than 45 years who underwent RP between January 1, 1998, and December 31, 2011.Weighted estimates revealed that 962,917 men underwent RP during the study period. The annual rate of RP remained relatively stable, from 1425 RPs per million in the period 1998 to 1999 to 1330 RPs per million in the period 2010 to 2011 (7% decrease; P=.90). The annual rate of open RP decreased from 1424 per million to 435 per million (P.001), whereas the annual rate of minimally invasive RP increased from less than 1 per million to 895 per million (P.001). Since 2006, hospitals providing open RP decreased by 18% (from 2288 to 1870; P.001), whereas hospitals providing minimally invasive RP increased by 191% (from 341 to 993; P.001). The median open RP caseload per hospital decreased by 7% (from 68 to 63; P.001), whereas the median caseload for hospitals providing minimally invasive RP declined by 17% (from 122 to 101; P.001). The hospitals providing fewer than 50 minimally invasive RPs per year increased from 12% to 26% (from 144 of 1240 to 3020 of 11,644; P.001).Per capita utilization of RP in the United States has remained stable from 1998 to 2011. Rapid expansion of the use of minimally invasive RP has reduced open RP utilization rates and median annual hospital caseload.

Single institution studies suggest a benefit of a week of preoperative antibiotics prior to percutaneous nephrolithotomy. These studies are limited by lower quality methodology, such as the inclusion of heterogeneous populations or nonstandard definitions of sepsis. The AUA (American Urological Association) Best Practice Statement recommends less than 24 hours of intravenous antibiotics but to our knowledge no other data exist on the duration or benefit of preoperative antibiotics. Using CONSORT (Consolidated Reporting of Trials) guidelines we sought to perform a rigorous multi-institutional trial to assess preoperative antibiotics in patients in whom percutaneous nephrolithotomy was planned and who were at low risk for infection.This randomized controlled trial enrolled patients undergoing percutaneous nephrolithotomy who were at low risk, defined as negative preoperative urine cultures and no urinary drain. Of the subjects 43 were randomized to nitrofurantoin 100 mg twice daily for 7 days preoperatively while a control arm of 43 received no oral antibiotics. All subjects received perioperative doses of ampicillin and gentamicin. Prone percutaneous nephrolithotomy was performed by urologists blinded to randomization. The primary outcome was the development of sepsis.A total of 86 subjects were enrolled. Preoperative patient characteristics were similar in the treatment and control cohorts with a stone size of 19 and 17 mm, respectively (p = 0.47). Intraoperative characteristics also did not differ. The sepsis rate was not statistically different between the treatment and control groups (12% and 14%, respectively, 95% CI -0.163-0.122, p = 1.0). Other infectious parameters and complications were similar, including intensive care admission, fever, hypotension and leukocytosis.Our study demonstrated no advantage to providing 1 week of preoperative oral antibiotics in patients at low risk for infectious complications who undergo percutaneous nephrolithotomy. Perioperative antibiotics according to the AUA Best Practice Statement appear sufficient.

Introduction: Struvite stones account for 15% of urinary calculi and are typically associated with urease-producing urinary tract infections and carry significant morbidity. This study aims to characterize struvite stones based on purity of stone composition, bacterial speciation, risk factors, and clinical features.Methods: Retrospective data was collected from patients diagnosed with infection stones between 2008 and 2012. Stone analysis, perioperative urine cultures, bacterial speciation, and clinical data were collected and analyzed. The purity of struvite stones was determined. Statistical comparisons were made among homogeneous and heterogeneous struvite stones.Results: From the four participating centres, 121 struvite stones were identified. Only 13.2% (16/121) were homogenous struvite. Other components included calcium phosphate (42.1%), calcium oxalate (33.9%), calcium carbonate (27.3%), and uric acid (5.8%). Partial or full staghorn calculi occurred in 23.7% of cases. Ureaseproducing bacteria were only present in 30% of cases. Proteus, E. coli, and Enterococcus were the most common bacterial isolates from perioperative urine, and percutaneous nephrolithotomy was the most common modality of treatment. Only 40% of patients had a urinalysis that was nitrite-positive, indicating that urinalysis alone is not reliable for diagnosing infection stones. The study’s limitation is its retrospective nature; as such, the optimal timing of cultures with respect to stone analysis or treatment was not always possible, urine cultures were often not congruent with stone cultures in the same patient, and our findings of E. coli commonly cultured does not suggest causation.Conclusions: Struvite stones are most often heterogeneous in composition. Proteus remains a common bacterial isolate; however, E. coli and Enterococcus were also frequently identified. This new data provides evidence that patients with struvite stones can have urinary tract pathogens other than urease-producing bacteria, thus challenging previous conventional dogma.

We aimed to determine the best algorithms for renal stone composition characterization using rapid kV-switching single-source dual-energy computed tomography (rsDECT) and a multiparametric approach after dataset expansion and refinement of variables. rsDECT scans (80 and 140 kVp) were performed on 38 ex vivo 5- to 10-mm renal stones composed of uric acid (UA; n = 21), struvite (STR; n = 5), cystine (CYS; n = 5), and calcium oxalate monohydrate (COM; n = 7). Measurements were obtained for 17 variables: mean Hounsfield units (HU) at 11 monochromatic keV levels, effective Z, 2 iodine-water material basis pairs, and 3 mean monochromatic keV ratios (40/140, 70/120, 70/140). Analysis included using 5 multiparametric algorithms: Support Vector Machine, RandomTree, Artificial Neural Network, Naive Bayes Tree, and Decision Tree (C4.5). Separating UA from non-UA stones was 100% accurate using multiple methods. For non-UA stones, using a 70-keV mean cutoff value of 694 HU had 100% accuracy for distinguishing COM from non-COM (CYS, STR) stones. The best result for distinguishing all 3 non-UA subtypes was obtained using RandomTree (15/17, 88%). For stones 5 mm or larger, multiple methods can distinguish UA from non-UA and COM from non-COM stones with 100% accuracy. Thus, the choice for analysis is per the user’s preference. The best model for separating all three non-UA subtypes was 88% accurate, although with considerable individual overlap between CYS and STR stones. Larger, more diverse datasets, including in vivo data and technical improvements in material separation, may offer more guidance in distinguishing non-UA stone subtypes in the clinical setting.

To compare the efficiency (stone fragmentation and removal time) and complications of three models of intracorporeal lithotripters in percutaneous nephrolithotomy (PCNL).Prospective, randomized controlled trial at nine centers in North America from 2009 to 2016. Patients were randomized to one of three lithotripter devices: the Cyberwand, a dual-probe ultrasonic device; the Swiss Lithoclast Select, a combination pneumatic and ultrasonic device; and the StoneBreaker, a portable pneumatic device powered by COTwo hundred seventy patients were enrolled, 69 were excluded after randomization. Two hundred one patients completed the study: 71 in the Cyberwand group, 66 in the Lithoclast Select group, and 64 in the StoneBreaker group. The baseline patient characteristics of the three groups were similar. Mean stone surface area was smaller in the StoneBreaker group at 407.8 mmThe Cyberwand, Lithoclast Select, and the StoneBreaker lithotripters have similar adjusted stone clearance rates in PCNL for stones2 cm. The safety and efficacy of these devices are comparable.