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Introduction We sought quantify racial disparities in use of analgesia amongst patients seen in Emergency Departments for renal colic. Methods We identified all individuals presenting to the Emergency Department with urolithiasis from 2003 to 2015 in the nationally representative Premier Hospital Database. We included patients discharged in ≤1 day and excluded those with chronic pain or renal insufficiency. We assessed the relationship between race/ethnicity and opioid dosage in morphine milligram equivalents (MME), and ketorolac, through multivariable regression models adjusting for patient and hospital characteristics. Results The cohort was 266,210 patients, comprised of White (84%), Black (6%) and Hispanic (10%) individuals. Median opioid dosage was 20 MME and 55.5% received ketorolac. Our adjusted model showed Whites had highest median MME (20 mg) with Blacks (−3.3 mg [95% CI: −4.6 mg to −2.1 mg]) and Hispanics (−6.0 mg [95% CI: −6.9 mg to −5.1 mg]) receiving less. Blacks were less likely to receive ketorolac (OR: 0.72, 95% CI: 0.62–0.84) while there was no difference between Whites and Hispanics. Conclusions Black and Hispanic patients in American Emergency Departments with acute renal colic receive less opioid medication than White patients; Black patients are also less likely to receive ketorolac.

Introduction:We sought to identify predictors of index surgical care setting and to determine if care setting influences risk adjusted perioperative costs and/or 30-day revisits following e...

To determine whether TRT in men with hypogonadism is associated with an increased risk of urolithiasis. We conducted a population-based matched cohort study utilizing data sourced from the Military Health System Data Repository (a large military-based database that includes beneficiaries of the TRICARE program). This included men aged 40–64 years with no prior history of urolithiasis who received continuous TRT for a diagnosis of hypogonadism between 2006 and 2014. Eligible individuals were matched using both demographics and comorbidities to TRICARE enrollees who did not receive TRT. The primary outcome was 2-year absolute risk of a stone-related event, comparing men on TRT to non-TRT controls. There were 26,586 pairs in our cohort. Four hundred and eighty-two stone-related events were observed at 2 years in the non-TRT group versus 659 in the TRT group. Log-rank comparisons showed this to be a statistically significant difference in events between the two groups (p

Problem Subinternships are integral to medical education as tools for teaching and assessing fourth-year medical students. Social distancing due to COVID-19 has precluded the ability to offer in-person subinternships – negatively impacting medical education and creating uncertainty surrounding the residency match. With no precedent for the development and implementation of virtual subinternships, the Society of Academic Urologists (SAU) developed an innovative and standardized curriculum for the Virtual Subinternship in Urology (vSIU). Methods The vSIU committee's mandate was to create a standardized curriculum for teaching foundational urology and assessing student performance. Thirty-three members from 23 institutions were divided into working groups and given 3 weeks to develop 10 modules based on urologic subspecialties, Accreditation Council for Graduate Medical Education core competencies, technical skills training and student assessment. Working groups were encouraged to develop innovative learning approaches. The final curriculum was assembled into the “vSIU Guidebook.” Results The vSIU Guidebook contains 212 pages – 64 pages core content and 2 appendices (patient cases and evaluations). It outlines a detailed 4-week curriculum with a sufficient volume of resources to offer a completely adaptable virtual course with the same rigor as a traditional subinternship. Modules contain curated teaching resources including journal articles, lectures, surgical videos and simulated clinical scenarios. Innovative learning tools include reflective writing, mentorship guidelines, videoconference-based didactics, surgical simulcasting and virtual technical skills training. The guidebook was disseminated to program directors nationally. Next Steps The vSIU is the first virtual subinternship in any specialty to be standardized and offered nationally, and it was implemented by at least 19 urology programs. This curriculum serves as a template for other specialties looking to develop virtual programs and feedback from educators and students will allow the curriculum to evolve. As the pandemic continues to challenge our paradigm, this rapid and innovative response exemplifies that the medical community will continue to meet the needs of an ever-changing educational landscape.

Objective To characterize full cycle of care costs for managing an acute ureteral stone using time-driven activity-based costing. Methods We defined all phases of care for patients presenting with an acute ureteral stone and built an overarching process map. Maps for sub-processes were constructed through interviews with providers and direct observation of clinical spaces. This facilitated calculation of cost per minute for all aspects of care delivery, which were multiplied by associated process times. These were added to consumable costs to determine cost for each specific step and later aggregated to determine total cost for each sub-process. We compared costs of eight common clinical pathways for acute stone management, defining total cycle of care cost as the sum of all sub-processes that comprised each pathway. Results Cost per sub-process included $920 for emergency department (ED) care, $1665 for operative stent placement, $2368 for percutaneous nephrostomy tube placement, $106 for urology clinic consultation, $238 for preoperative center visit, $4057 for ureteroscopy with laser lithotripsy (URS), $2923 for extracorporeal shock wave lithotripsy, $169 for clinic stent removal, $197 for abdominal x-ray, and $166 for ultrasound. The lowest cost pathway ($1388) was for medical expulsive therapy, whereas the most expensive pathway ($8002) entailed a repeat ED visit prompting temporizing stent placement and interval URS. Conclusion We found a high degree of cost variation between care pathways common to management of acute ureteral stone episodes. Reliable cost accounting data and an understanding of variability in clinical pathway costs can inform value-based care redesign as payors move away from pure fee-for-service reimbursement.

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INTRODUCTION AND OBJECTIVE:Recent evidence suggests that basket extraction of stone fragments after ureteroscopic lithotripsy is time-consuming and may result in poorer-than-expected stone free rat...

INTRODUCTION AND OBJECTIVES:Medicaid expansion is a key provision by which the Affordable Care Act seeks to improve access to health insurance. However, there is concern over the quality and cost o...

INTRODUCTION AND OBJECTIVES:Medicaid expansion is a key provision by which the Affordable Care Act seeks to improve access to health insurance. However, there is concern over the quality and cost o...

To create a tissue-based simulator that allows practice of key steps of robot-assisted radical prostatectomy (RARP) in a sequential fashion.A model was created from female porcine genitourinary tract tissue to represent the male pelvic genitourinary anatomy. The following steps of RARP were simulated: dorsal venous complex ligation, division of bladder neck, seminal vesicle dissection, prostatic pedicle ligation with nerve sparing, urethral division, bladder neck reconstruction, and vesicourethral anastomosis. Ten novices and 10 experts performed RARP on the model. Face validity was calculated by ratings of realism. Content validity was calculated by experts' rating of usefulness of the model as a training tool. Construct validity was calculated by comparison of time to complete the simulator and rating of performance on the objective structured assessment of technical skill (OSATS) questionnaire, between novices and experts.The model was determined to have good face and content validity with an average score of 3.7/5 and 4.8/5, respectively. The mean time for completion of the simulator was 121.5 minutes for the novice and 62 minutes for the expert group (P0.001), and the mean overall OSATS performance ratings were 4.6/5 for experts and 2.6/5 for novices (P0.001), yielding good construct validity.We created and validated a realistic, tissue-based simulator to allow for training of key surgical steps of RARP in a sequential fashion. Ultimately, this simulator could be incorporated into urology training, credentialing, and facilitate surgeon transitioning from open prostatectomy to RARP.

Robot-assisted laparoscopic partial nephrectomy (RALPN) and laparoscopic partial nephrectomy (LPN) have become standard for the surgical management of small renal masses (SRMs). However, no studies have evaluated the short-term outcomes or cost of RALPN as compared with hand-assisted laparoscopic partial nephrectomy (HALPN) in a standardized fashion.A retrospective review of all patients who underwent HALPN or RALPN from 2006 to 2010 were assessed for patient age, body mass index (BMI), American Society of Anesthesiologists (ASA) score, radiographic tumor size, nephrometry (radius, endo/exophytic, nearness to collecting system, anterior/posterior, lines of polarity [RENAL]) scores, operative and room times, hospital length of stay (LOS), estimated blood loss (EBL), requirement of hilar vessel clamping, warm ischemia time (WIT), pre- and postprocedural creatinine and hemoglobin levels, and complications. Total costs of the procedures were estimated based on operating room component (operative staff time, anesthesia, and supply) and hospital stay cost (room and board, pharmacy). A robotic premium cost, estimated based on the yearly overall cost of the da Vinci S surgical system divided by the annual number of cases, was included in the RALPN cost. Cost figures were obtained from hospital administration and applied to the mean HALPN and RALPN patient.Forty-seven patients underwent HALPN since 2006 and 21 patients underwent RALPN since 2008. ASA, BMI, EBL, tumor size, nephrometry score, positive margin rate, change in creatinine, change in hemoglobin, morphine equivalents used, and complication rate were all similar in both groups (p0.05). Room time and operative time were significantly shorter for the HALPN cohort (p=0.001) whereas LOS was significantly shorter in the RALPN cohort (p=0.019). Despite the shorter LOS, RALPN was associated with a $1165 increased cost, mainly due to increased operating room time and premium cost of the robot.While early in our experience, RALPN offered no significant advantage in short-term outcomes over HALPN and was associated with an increased cost of over $1150.

To examine the relationship between serum 25-OH vitamin D and 24-hour urine calcium in patients with nephrolithiasis.A retrospective review was performed. Patients evaluated in 2 metabolic stone clinics were included for analysis. Multivariate linear regression models were adjusted for known risk factors for stone disease (age, gender, body mass index, hypertension, diabetes mellitus, gout, relevant medications, and 24-hour urine composition).One-hundred sixty-nine patients were included in the study. Female to male ratio was 69:100, mean age was 50.9 years (SD 13.7), and mean body mass index was 27.4 (SD 6.4). Vitamin D deficiency (25-OH vitamin D20 ng/mL) was present in 18.9% of patients, vitamin D insufficiency (20,30 ng/mL) was present in 34.9% of patients, and vitamin D was within normal limits (≥ 30 ng/mL) in 46.1% of patients. On age-adjusted and multivariate linear regression, serum 25-OH vitamin D was not related to 24-hour urine calcium (age adjusted β = -0.31 m 95% CI -1.9 to 1.3; multivariate adjusted β = 0.08, 95% CI -1.3 to 1.5).Although 25-OH vitamin D is involved in the body's calcium homeostasis, our study does not show a relationship between serum vitamin D level and 24-hour urine calcium excretion in stone-formers. This information may have implications regarding the safety of vitamin D repletion in patients with nephrolithiasis.

Background and purpose While the power needed to initiate bipolar vaporization is higher than conventional monopolar resection, the energy needed to maintain bipolar vaporization is significantly lower and may result in less thermal tissue injury. This may have implications for hemostasis, scarring, and perioperative morbidity. The objective of this study is to assess histopathologic changes in prostatic tissue after bipolar transurethral vaporization of the prostate. Patients and methods Male patients older than 40 years with a diagnosis of benign prostatic hyperplasia (BPH) who elected to undergo bipolar transurethral vaporization of the prostate were included in this study. Patients were excluded if they had a previous transurethral resection of the prostate (TURP) or prostate radiation therapy. An Olympus button vaporization electrode was used to vaporize prostate tissue. A loop electrode was then used to obtain a deep resection specimen. The vaporized and loop resection surfaces were inked and sent for pathologic analysis to determine the presence of gross histologic changes and the depth of penetration of the bipolar vaporization current. Results A total of 12 men underwent bipolar TURP at standard settings of 290 W cutting and 145 W coagulation current. Mean patient age was 70±10.2 years (range 56-88 years). Mean surgical time was 48.7±20.2 minutes (range 30-89 min). Mean depth of thermal injury was 2.4±0.84 mm (range 0.3-3.5 mm). Histopathologic evaluation demonstrated thermal injury in all specimens, but no gross char was encountered. Conclusions In bipolar systems, resection takes place at much lower peak voltages and temperatures compared with monopolar systems. Theoretically, this leads to less collateral thermal damage and tissue char. Our tissue study illustrates that the button vaporization electrode achieves a much larger depth of penetration than previous studies of bipolar TURP. This may be because thermal injury represents a gradual continuum of histologic changes.

Objectives To analyze and classified our single-institution experience with the perioperative complications associated with robot-assisted laparoscopic radical prostatectomy (RALRP). Methods A total of 239 patients with a mean age of 60.6 years were evaluated (January 2007 to June 2008). Data were collected through an institutional review board–approved blinded prospective database by an independent third party committee. The data-points accrued were set forth by a 5-member panel including 3 robotic urological surgeons (J. R., G. H., G. P.), the chief of general surgery (H. S.), and a member of the hospital's outcomes committee. The Modified Clavien system was used to grade complications, with grade I and II representing minor and grade III, IV, and V major complications. Results Of our 239 patients, 198 (82.9%) had an uneventful postoperative course, defined as discharged home from the hospital within 2 days postoperatively with no unscheduled procedures/studies/hospital admissions or emergency room visits. On review of the remaining 41 patients, 55 complications were found. Of these, 24 were grade I, 17 grade II, 7 grade IIIa, 5 grade IIIb, 1 grade IVa, and 1 grade V complications. There was 1 perioperative mortality (0.4%) attributed to a pulmonary embolism on autopsy. Blood loss data revealed 1 (0.4%) intraoperative transfusion and 9 (3.8%) postoperative transfusions. Conclusions RALRP is associated with major and minor complication rates of 5.0% and 14.6%, respectively. Prospective and blinded data on complications associated with RALRP are lacking in the published data. Our prospective, unbiased data provide an important tool to help counsel patients on complications associated with robot-assisted laparoscopic radical prostatectomy.

To determine whether percutaneous nephrolithotomy (PCNL) can be safely performed in the high-risk patient.The records of 84 patients undergoing 98 consecutive PCNL procedures from January 2005 to January 2007 at a single institution were examined. Patients were divided into a high-risk preoperative group, which comprised patients having American Society of Anesthesiologist scores of III or IV (n = 25) and a low-risk preoperative group of patients with an American Society of Anesthesiologist score of II or less (n = 59).A total of 33 and 65 procedures were performed in the high- and low-risk groups, respectively. The high-risk group had significantly more comorbidities than the low-risk group (5.4 vs 1.5) (P.001). No significant difference was noted in the mean cumulative stone size for single or multiple stones in either group. A significant difference was observed between the average anesthesia time (45 vs 25 minutes) and average length of hospital stay (4.0 +/- 3.5 vs 2.7 +/- 1.2 days) but no significant difference in estimated blood loss (132 vs 150 mL) or mean operative time (118 vs 100 minutes) between the high- and low-risk groups, respectively. The overall complication rate was similar between the high-risk (12.1%) and low-risk (12.3%) groups (P = .41). The stone-free rate for the high-risk group was 61% compared with 92% for the low-risk group (P = .028).PCNL can be safely performed in the high-risk preoperative patient population.

Potassium citrate therapy has become one of the cornerstones of medical stone management. We elucidated the long-term effects of potassium citrate on urinary metabolic profiles and its impact on stone formation rates.We performed a retrospective cohort study in patients treated at the Comprehensive Kidney Stone Center at our institution between 2000 and 2006. Patients with pre-therapy and post-therapy 24-hour urinary profiles available who remained on potassium citrate for at least 6 months were included in the analysis.Of the 1,480 patients with 24-hour urinary profiles 503 met study inclusion criteria. Mean therapy duration was 41 months (range 6 to 168). Overall a significant and durable change in urinary metabolic profiles was noted as soon as 6 months after the onset of therapy. These changes included increased urinary pH (5.90 to 6.46, p0.0001) and increased urinary citrate (470 to 700 mg a day, p0.0001). The stone formation rate also significantly decreased after the initiation of potassium citrate from 1.89 to 0.46 stones per year (p0.0001). There was a 68% remission rate and a 93% decrease in the stone formation rate.Potassium citrate provides a significant alkali and citraturic response during short-term and long-term therapy with the change in urinary metabolic profiles sustained as long as 14 years of treatment. Moreover, long-term potassium citrate significantly decreases the stone formation rate, confirming its usefulness in patients with recurrent nephrolithiasis.

Dietary intake of citrate in the form of citrus juices (eg, lemonade, orange juice) will enhance urinary citrate excretion, a valuable benefit for patients with hypocitraturic calcium oxalate nephrolithiasis. While information on citrate concentrations in select citrus juices is available, data on citrate concentrations of commercially available beverages (juice and otherwise) are limited. Using nuclear magnetic resonance spectroscopy (1H NMR), we report citrate concentrations of several beverages to help guide dietary recommendations aimed at increasing urinary citrate excretion and correcting hypocitraturia.Citrate concentrations of a squeezed lemon, several fruit juices, and common beverages were measured using 1H NMR. Spectra for each sample were obtained in duplicate; citrate peak was identified, measured, and quantified and compared with the citrate concentration in the juice of 1 medium lemon.Quantitative analysis revealed the highest concentration of citrate was in grapefruit juice (64.7 mmol/L), followed in decreasing concentrations by lemon juice (47.66 mmol/L), orange juice (47.36 mmol/L), pineapple juice (41.57 mmol/L), reconstituted lemonade (38.65 mmol/L), lemonade flavored Crystal Light (38.39 mmol/L), ready to consume not from concentrate lemonade (38.24 mmol/L), cranberry juice (19.87 mmol/L), lemon-flavored Gatorade (19.82 mmol/L), homemade lemonade (17.42 mmol/L), Mountain Dew (8.84 mmol/L), and Diet 7Up (7.98 mmol/L), respectively.According to 1H NMR, all of the tested "natural" citrus juices have high concentrations of citrate (38.3-67.4 mmol/L), with grapefruit juice having the highest concentration of the beverages chosen. Lemonade flavored Crystal Light had the highest concentration of citrate in the nonjuice category of tested beverages. In patients with mild to moderate hypocitraturia, dietary supplementation with citrus-based juices may be an effective alternative to medical management while not requiring large serving sizes. Further prospective studies are warranted to evaluate the clinical significance of these findings.

We evaluated the learning curves and perioperative outcomes of an experienced laparoscopic surgeon and his trainees to assess our structured teaching program.We retrieved 383 patients undergoing robot-assisted laparoscopic prostatectomy (RALP) from our database. Trainees completed a structured teaching program and were categorized as early (days 0 to 232), mid (days 566 to 797), and late (days 825 to 1218) according to the time period in which they were working with the mentor. We compared operative times, estimated blood loss (EBL), and positive surgical margin (PSM) rates between the trainees and the mentor (Mann-Whitney and Chi-square test). Association of EBL, body mass index (BMI), and prostate weight with operative time was evaluated in multivariate linear regression analysis.Median operative times of the early, mid, and late trainees (258, 220, and 200 minutes) significantly decreased and were similar to the corresponding senior surgeon's (254, 242, and 180 minutes). Operative times decreased with lower BMI, EBL, and prostate weight (P = 0.006, P0.001, and P0.001, respectively). Overall, EBL (150 mL vs. 150 mL, P = 0.215) and PSM rates (20% vs. 18.6%, P = 0.741) did not differ between the mentor and the trainees.A structured teaching program for RALP is effective and trainees are able to adopt the increased efficiency and skills of their mentor. Lower BMI, EBL, and prostate weight were associated with shorter operative times. Trainees performing the procedure did not negatively affect EBL and positive surgical margin rate.

Purpose: Ureteral stents are widely used in many urological procedures. We evaluated the recent literature, providing an update on materials and stent designs, and indications for stent placement and stent complications, including the management of such stent related problems. Materials and Methods: A thorough literature search on ureteral stents was performed. Pertinent new and review/updated articles published in the English literature from 2000 through 2006 were systematically reviewed. Results: Following uncomplicated ureteroscopy or shock wave lithotripsy routine stenting does not appear to affect the stone-free rate. However, stent related morbidity is often seen. Patients at greatest risk for complications are those undergoing bilateral stentless ureteroscopy, those with recent or recurrent urinary tract infections and pregnant patients. The placement of indwelling stents in these patients should be considered. The development of stent materials and designs has been directed toward decreasing stent related morbidity, such as pain, discomfort, bladder irritability, infection and encrustation. Changes in stent design and materials show great promise. Initial evaluations suggest improvements in patient comfort as well as decreased encrustation. Forgotten stents can lead to significant morbidity as a result of severe encrustation. Most cases can be managed endoscopically, often requiring multiple procedures. Conclusions: Stenting is not mandatory after uncomplicated simple ureteroscopy and shock wave lithotripsy. Patients with stents seem to have significantly more bladder and lower urinary tract symptoms than those in whom stents are not placed. However, there is a subgroup of patients who likely benefit from stenting following a procedure because of the increased risk of complications. The ideal ureteral stent biomaterial has yet to be discovered and an area of promising development is the drug eluting stent to prevent infection and encrustation

Benign prostatic hyperplasia (BPH) primarily affects middle-aged and elderly men. Consequently, medical and surgical treatments for this condition are some of the most common therapies administered in medical practice. Many minimally invasive techniques for the treatment of BPH have been introduced over the past several years to achieve comparable efficacy without the morbidity and mortality associated with transurethral resection of the prostate (TURP), the current gold standard for the surgical management of BPH. Many procedures have not sustained satisfactory results over time, whereas others have been reported as possible alternatives, in selected cases, to TURP. It may not be a simple question of comparative efficacy with TURP for these less invasive treatments, but rather a question of whether lower complication and side-effect rates are a suitable tradeoff for somewhat reduced symptom relief and possibly a need for future retreatment. This article reviews current minimally invasive therapies, addressing methods of tissue ablation, short-and long-term results, and comparisons with TURP.

Purpose: Recent studies have shown a significant decrease in patient reported pain scores when the nephrostomy tube size is decreased from 22 to 10Fr. We hypothesize that patient reported pain and narcotic use could be further decreased for patients with post-percutaneous nephrolithotomy nephrostomy tubes if the incision is infiltrated with a local anesthetic.Materials and Methods: A randomized prospective trial was designed to assess the impact of Marcaine® infiltration of the nephrostomy tract following percutaneous stone removal. Patients undergoing single access percutaneous nephrolithotomy were randomized to have a fixed volume of saline or weight based concentration of Marcaine infiltrated into the nephrostomy tube tract at the conclusion of the procedure. Postoperative narcotic use and patient reported pain scores were then obtained at 2, 4, 24 and 48 hours postoperatively.Results: A total of 25 patients were enrolled in the study with 3 excluded from analysis due to incomplete data collection (2) ...

Objective Heminephrectomy in the pediatric population remains a popular open surgical procedure. We describe our experience with laparoscopic heminephrectomy using a retroperitoneoscopic approach. Materials and methods Data were collected retrospectively and prospectively on all patients undergoing laparoscopic heminephrectomy by a single surgeon using a prone retroperitoneoscopic approach. Information relating to the age, sex, laterality, duration of surgery, analgesic requirements, duration of hospital stay, postoperative complications and outcome was recorded. Results Between March 2001 and August 2005 54 laparoscopic heminephrectomies were performed in 48 children (34 girls and 14 boys). The median age at surgery was 14 months (range 2–112 months). Forty-four upper and 10 lower moieties were removed. The median operative time was 105 min (range 50–150 min). There were no intraoperative complications and no conversions. There were four minor complications, comprising haematuria ( n = 1) and postoperative pyrexia ( n = 3). The median length of follow up was 22 months (range 3–57 months). All patients remained asymptomatic at last follow up. Ultrasound findings included presence of a visible ureteric stump ( n = 7) and cysts at the resection margin of the remaining remnant ( n = 17); none of these patients manifested clinical symptoms (e.g. infection, pain). Conclusions With advanced laparoscopic skills, laparoscopic heminephrectomy is a feasible operation for the treatment of non-functioning duplex renal units in children and infants.

Scant information has been published describing the effect of laser fiber distance from the stone target on the mechanism of calculus fragmentation. Using high speed photography and acoustic emission measurements we characterized the impact of laser fiber proximity on stone comminution. We evaluated the effect of laser fiber distance from the stone target on resultant cavitation bubble formation and shock wave generation.Stone fragmentation was assessed using a FREDDY (frequency doubled double pulse Nd:YAG) (World of Medicine, Orlando, Florida) laser and a holmium laser. The FREDDY laser was operated using a 420 microm fiber at an output energy of 120 and 160 mJ in single and double pulse settings, and a pulse repetition rate of 1 Hz. The holmium laser was operated using a 200 microm fiber at an output energy of 1 to 3 J and a pulse repetition rate of 1 Hz. The surface of a 1 cm square BegoStone (Bego, Bremen, Germany) attached to an X-Y-Z translational stage was aligned perpendicular to the laser fiber, which was immersed in a Lucite tank filled with water at room temperature. An Imacon 200 high speed camera was used to capture transient cavitation bubbles at a framing rate of up to 1,000,000 frames per second. Acoustic emission signals associated with shock waves generated during the rapid expansion and collapse of the cavitation bubble were measured using a 1 MHz focused ultrasound transducer.At laser fiber distances of 3.0 mm or less cavitation bubbles and shock waves were observed with the FREDDY laser. In contrast to the holmium laser, the bubble size and shock wave intensity of the FREDDY laser was inversely related to the fiber-to-stone distance over the range tested (0.5 to 3.0 mm).While bubble size was noted to increase with a larger stone-to-fiber distance using the holmium laser, to consistently generate cavitation bubbles and shock waves using the FREDDY laser the laser fiber should be operated within 3.0 mm of the target stone. These findings have significant implications during clinical laser stone fragmentation.

Citrus fruits and juices are a known natural source of dietary citrate. Of all the citrus juices, lemon juice appears to have the highest concentration of citrate. Therefore, lemonade therapy has been proposed as a potential treatment for patients with hypocitraturia. We retrospectively evaluated the impact of long-term lemonade therapy on urinary metabolic parameters and stone formation in patients with hypocitraturic nephrolithiasis.A total of 32 patients were identified as being on long-term lemonade therapy for hypocitraturic nephrolithiasis. The 11 patients on lemonade therapy who met the entrance criteria for evaluation were compared to an age and sex matched control group of patients treated with oral slow release potassium citrate. Pre-therapy and post-therapy urinary parameters were recorded for both groups. The effect of lemonade therapy on stone burden and stone formation rate was calculated. New stone formation was defined as passage, surgical removal or appearance of new stones, or an increase in the size of existing stones on radiographic imaging.Four males and 7 females (mean age 52.7 years) were treated with lemonade therapy for a mean of 44.4 months. The control group consisted of 4 males and 7 females (mean age 54.5 years) treated with potassium citrate for a mean of 42.5 months. Of the 11 patients on lemonade 10 demonstrated increased urinary citrate levels (mean increase +383 mg per day, p0.05). All potassium citrate therapy subjects demonstrated an increase in urinary citrate (mean increase +482 mg per day, p0.0001). Mean pretreatment and posttreatment stone burden in the lemonade group was 37.2 and 30.4 mm(2), respectively (p0.05). During lemonade therapy the stone formation rate decreased from 1.00 to 0.13 stones per patient per year (p0.05).Due to its significant citraturic effect, lemonade therapy appears to be a reasonable alternative for patients with hypocitraturia who cannot tolerate first line therapy. Future study in the form of a prospective, randomized trial is needed to validate these findings.

OBJECTIVE: To present a single series of Y-type duplication with an analysis of the presenting features, the management and outcome, as complete Y-type urethral duplication in the male is a rare congenital anomaly that presents many challenges. PATIENTS AND METHODS: We retrospectively reviewed patient charts, identifying those with urethral duplication, and then those with complete Y-type duplication. The age at presentation, investigations, management and outcomes were reviewed. RESULTS: Of 49 patients with a diagnosis of urethral duplication, 13 had the complete Y-type. Three were lost to follow-up and were therefore excluded from the study. The median (range) age at presentation was 2 months (birth to 10 years). All patients had other comorbidities, with anorectal malformations in seven, renal agenesis in four, sacral agenesis/partial agenesis in two, and unilateral/bilateral cryptorchidism in four. Presenting features included passage of urine perineally or rectally in seven, and dribbling from the orthotopic urethral meatus in one. The diagnosis was confirmed by micturating cysto-urethrography. A mean of 14 procedures was required to achieve a final complete repair, and included urethral reconstruction, repair of fistulae, urethral dilatation, and evaluative cystoscopy. Excluding cystoscopy and urethral dilatation, a mean (range) of 3 (1-5) reconstructive procedures was required in each patient. The median follow-up was 8 years. Five boys developed urethral strictures and one developed multiple fistulae. The best outcomes were in boys who had a staged urethral reconstruction. CONCLUSION: Due to the strong association with other congenital anomalies we recommend that all patients should be evaluated thoroughly, including a detailed physical examination, renal tract ultrasonography and spinal radiography. Surgical management remains a significant challenge, requiring many procedures with unpredictable outcomes, the goals of which should be to maintain continence and reconstruct the urethra with good cosmesis. The optimum management scheme must be individualized in this rare condition

The application of robotic-assisted radical prostatectomy has increased considerably over the past decade, but there remains a paucity of standardized complications reporting associated with this procedure. The complications literature regarding robotic prostatectomy is wrought with limitations, variability, and bias making meaningful comparisons between surgical series difficult.From November 2006 to December 2010, a total of 575 patients were evaluated. Data were assimilated through an IRB-approved blinded prospective database by an independent third party committee. Patients were followed prospectively for 30 days postoperatively. The Modified Clavien system was utilized to grade complications. Grade I and II complications were classified as minor, while grade III, IV, and V were considered major complications. Multiple complications in individual patients were recorded as separate events. Our initial experience and that of our most recent were compared. Age, body mass index, American Society of Anesthesiologists score, Gleason grade, prostate specific antigen, prostate volume, and complications were evaluated.Of the 575 patients, 482 (83.8%) had an ideal perioperative course. In the remaining 93 (16.2%) patients, there were 117 complications. Minor complications occurred in 84 (14.6%) and major complications arose in 15 (2.6%) patients. When the first 500 patients were divided into subsets of 100 patients, a linear regression analysis demonstrated no significant difference in overall complications among the five quintiles (p=0.17). The first quintile was found to have a significantly higher major complication rate compared with the second quintile (p=0.05). The subsequent quintiles exhibited no significant change in major complication rate.As a surgeon progresses through the learning curve, there is a stable overall complication rate with a drop in major complications after the first 100 cases.

Background and Purpose: While the power needed to initiate bipolar vaporization is higher than conventional monopolar resection, the energy needed to maintain bipolar vaporization is significantly lower and may result in less thermal tissue injury. This may have implications for hemostasis, scarring, and perioperative morbidity. The objective of this study is to assess histopathologic changes in prostatic tissue after bipolar transurethral vaporization of the prostate. Patients and Methods: Male patients older than 40 years with a diagnosis of benign prostatic hyperplasia (BPH) who elected to undergo bipolar transurethral vaporization of the prostate were included in this study. Patients were excluded if they had a previous transurethral resection of the prostate (TURP) or prostate radiation therapy. An Olympus button vaporization electrode was used to vaporize prostate tissue. A loop electrode was then used to obtain a deep resection specimen. The vaporized and loop resection surfaces were inked...

Calcium metabolism and homeostasis are highly regulated and maintained within a narrow physiologic range. An understanding of its metabolism and various disorders in absorption and excretion is essential to the understanding of nephrolithiasis. In this chapter, an overview of calcium metabolism in the nephron is presented. The role of diuretic effects on calcium transport is reviewed. Hormonal effects on calcium metabolism are discussed. Various medical treatment options for calcium nephrolithiasis are also presented along with guidelines for therapy.