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Purpose: There are limited data on ablation effects of thulium fiber laser (TFL) settings with varying stone composition. Similarly, little is known surrounding the photothermal effects of TFL lithotripsy regarding the chemical and structural changes after visible char formation. We aim to understand the TFL's ablative efficiency across various stone types and laser settings, while simultaneously investigating the photothermal effects of TFL lithotripsy., Materials and Methods: Human specimens of calcium oxalate monohydrate, calcium oxalate dihydrate, uric acid, struvite, cystine, carbonate apatite, and brushite stones were ablated using 13 prespecified settings with the Coloplast TFL Drive. Pre- and postablation mass, ablation time, and total energy were recorded. Qualitative ablative observations were recorded at 1-minute intervals with photographs and gross description. Samples were analyzed with Fourier-transform infrared spectroscopy pre- and postablation and electron microscopy postablation to assess the photothermal effects of TFL., Results: Across all settings and stone types, 0.05 J × 1000 Hz was the best numerically efficient ablation setting. When selected for more clinically relevant laser settings (ie, 10-20 W), 0.2 J × 100 Hz, short pulse was the most numerically efficient setting for calcium oxalate dihydrate, cystine, and struvite stones. Calcium oxalate monohydrate ablated with the best numerical efficiency at 0.4 J × 40 Hz, short pulse. Uric acid and carbonate apatite stones ablated with the best numerical efficiency at 0.3 J × 60 Hz, short pulse. Brushite stones ablated with the best numerical efficiency at 0.5 J × 30 Hz, short pulse. Pulse duration impacted ablation effectiveness greatly with 6/8 (75%) of inadequate ablations occurring in medium or long pulse settings. The average percent of mass lost during ablation was 57%; cystine stones averaged the highest percent mass lost at 71%. Charring was observed in 36/91 (40%) specimens. Charring was most often seen in uric acid, cystine, and brushite stones across all laser settings. Electron microscopy of char demonstrated a porous melting effect different to that of brittle fracture. Fourier-transform infrared spectroscopy of brushite char demonstrated a chemical composition change to amorphous calcium phosphate., Conclusions: We describe the optimal ablation settings based on stone composition, which may guide urologists towards more stone-specific care when using thulium laser for treating renal stones (lower energy settings would be safer for ureteral stones). For patients with unknown stone composition, lasers can be preset to target common stone types or adjusted based on visual cues. We recommend using short pulse for all TFL lithotripsy of calculi and altering the settings based on visual cues and efficiency to minimize the charring, an effect which can make the stone refractory to further dusting and fragmentation.

Purpose: 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., Materials and Methods: 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., Results: 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., Conclusions: 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.

Introduction: Many urology practices offer after-hours answering services through which patients or outside providers may access an on-call provider. These lines of communication are often unfiltered, allowing for a combination of urgent and non-urgent matters to reach the provider. The objective of this study was to evaluate the nature and frequency of after-hours phone calls among urological subspecialties., Methods: Phone calls occurring after-hours during the week (5 pm-7:59 am), weekends, and federal holidays were captured over 2019. The patient's provider and reason for calling were captured. The adult subspecialties included were endourology, oncology, reconstructive urology, female urology/voiding dysfunction, andrology/sexual medicine, and multispecialty/general. The reason for calling was categorized as either urgent/non-avoidable or non-urgent/avoidable, and the volume of after-hours and overnight calls was compared amongst subspecialties using the number of calls per 100 unique patients., Results: There were 2,224 after-hours calls over the 1-year period; 48% of telephone calls were regarding urgent matters, while the remainder were non-urgent or potentially avoidable. Reconstructive and endourology had the highest number of after-hours calls (34.8 calls and 17.3 calls per 100 patients, respectively). Reconstructive received the most urgent overnight phone calls at 3 calls per 100 patients, followed by oncology (1.55 per 100 patients) and endourology (1.35 per 100 patients)., Conclusions: Each urological subspecialty has varying acuity, which may influence the number of after-hours calls. Providers and their staff should optimize their work flow through triaging, counseling, and education in order to reduce the number of non-urgent after-hours calls.

Purpose: Obstructive pyelonephritis is considered a urological emergency but there is limited evidence regarding the importance of prompt decompression. We sought to investigate whether delay in decompression is an independent predictor of in-hospital mortality. Secondarily, we aimed to determine the impact of patient, hospital and disease factors on the likelihood of receipt of delayed vs prompt decompression., Materials and Methods: Using the National Inpatient Sample from 2010 to 2015, all patients 18 years old or older with ICD-9 diagnosis of urinary tract infection who had either a ureteral stone or kidney stone with hydronephrosis (311,100) were identified. Two weighted sample multivariable logistic regression models assessed predictors of the primary outcome of death in the hospital and secondly, predictors of delayed decompression (2 or more days after admission)., Results: After controlling for patient demographics, comorbidity and disease severity, delayed decompression significantly increased odds of death by 29% (OR 1.29, 95% CI 1.03-1.63, p=0.032). Delayed decompression was more likely to occur with weekend admissions (OR 1.22, 95% CI 1.15-1.30, p <0.001), nonwhite race (OR 1.34, 95% CI 1.25-1.44, p <0.001) and lower income demographic (lowest income quartile OR 1.25, 95% CI 1.14-1.36, p <0.001)., Conclusions: While the overall risk of mortality is fairly low in patients with obstructing upper urinary tract stones and urinary tract infection, a delay in decompression increased odds of mortality by 29%. The increased likelihood of delay associated with weekend admissions, minority patients and lower socioeconomic status suggests opportunities for improvement.

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 ureteroscopic holmium laser lithotripsy., Methods: Outcomes data from a retrospective analysis evaluating the natural history, complications and reintervention rates of asymptomatic residual stone fragments performed by the EDGE (Endourology Disease Group for Excellence) Research Consortium were used. A decision analysis model was constructed to compare the cost-effectiveness of initial observation of residual fragments to immediate intervention. Cost of observation included emergency room visits, hospitalizations and reinterventions. The cost analysis model extended to 3 years to account for delayed reintervention rates for fragments less than 4 mm. Costs of emergency department visits, readmissions and reinterventions were calculated based on published figures from the literature., Results: Decision analysis modeling demonstrated that when comparing initial observation to immediate reintervention, the cost was $2,183 vs $4,424. The difference in cost was largely driven by the fact that over 3 years, approximately 55% of all patients remained asymptomatic and did not incur additional costs. This represents an approximate annual per patient savings of $747, and $2,241 over 3 years when observation is selected over immediate reintervention., Conclusions: Our decision analysis model demonstrates superior cost-effectiveness for observation over immediate reintervention for asymptomatic residual stones less than 4 mm following ureteroscopic lithotripsy. Based on these findings careful stratification and selection of patients may enable surgeons to improve cost-effectiveness of managing small, asymptomatic residual fragments following ureteroscopic lithotripsy.

Purpose: Recent studies have demonstrated that quick sequential organ failure assessment criteria may be more accurate than systemic inflammatory response syndrome criteria to predict postoperative sepsis. In this study we evaluated the ability of these 2 criteria to predict septic shock after percutaneous nephrolithotomy., Materials and Methods: We performed a retrospective multicenter study in 320 patients who underwent percutaneous nephrolithotomy at a total of 8 institutions. The criteria for quick sequential organ failure assessment and systemic inflammatory response syndrome were collected 24 hours postoperatively. The study primary outcome was postoperative septic shock. Secondary outcomes included 30 and 90-day emergency department visits, and the hospital readmission rate., Results: Three of the 320 patients (0.9%) met the criteria for postoperative septic shock. These 3 patients had positive criteria for quick sequential organ failure assessment and systemic inflammatory response syndrome. Of the entire cohort 23 patients (7%) met quick sequential organ failure assessment criteria and 103 (32%) met systemic inflammatory response syndrome criteria. Specificity for postoperative sepsis was significantly higher for quick sequential organ failure assessment than for systemic inflammatory response syndrome (93.3% vs 68.4%, McNemar test p <0.001). The positive predictive value was 13% for quick sequential organ failure assessment criteria and 2.9% for systemic inflammatory response syndrome criteria. On multivariate logistic regression systemic inflammatory response syndrome criteria significantly predicted an increased probability of the patient receiving a transfusion (β = 1.234, p <0.001). Positive quick sequential organ failure assessment criteria significantly predicted an increased probability of an emergency department visit within 30 days (β = 1.495, p <0.05), operative complications (β = 1.811, p <0.001) and transfusions (p <0.001). The main limitation of the study is that it was retrospective., Conclusions: Quick sequential organ failure assessment criteria were superior to systemic inflammatory response syndrome criteria to predict infectious complications after percutaneous nephrolithotomy.

Purpose: We evaluated the discordance between ureteroscopic biopsy and surgical pathology findings for grading and staging upper tract urothelial carcinoma. We also sought to establish preoperative predictors of aggressive tumors., Materials and Methods: We retrospectively reviewed the records of 314 patients who underwent ureteroscopic biopsy followed by surgical management of upper tract urothelial carcinoma from 2000 to 2016 at a total of 3 institutions. Our primary outcomes were muscle invasive (pT2 or greater) disease at surgical pathology and upgrading of clinical low grade tumors to pathological high grade., Results: At biopsy 61% of the patients had clinical high grade tumors and 21% had subepithelial connective tissue invasion (cT1+). On final pathology 79% of the patients had pathological high grade tumors and 45% had stage pT2 or greater. On multivariate analysis advanced patient age, clinical high grade and cT1+ were independently associated with pT2 or greater. The combined presence of clinical high grade and cT1+ had 86% positive predictive value for muscle invasion while the combined absence of clinical high grade and cT1+ had 80% negative predictive value. The likelihood of missing invasion on biopsy in patients with muscle invasive disease was increased when biopsy fragments were limited to 1 mm or less. Of clinical low grade cases on biopsy 51% were upgraded at surgery. The presence of positive urine cytology was associated with an increased risk of upgrading but this was not statistically significant., Conclusions: Clinical high grade, cT1+ on biopsy and advanced patient age are independent risk factors for muscle invasive upper tract urothelial carcinoma. There is a significant risk of upgrading in patients with clinical low grade tumors on biopsy, especially when urine cytology is positive. The predictive value of biopsy can likely be improved by more extensive ureteroscopic sampling., (Copyright © 2018 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: 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., Materials and Methods: 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., Results: 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 mm 2 , p <0.001). The stone-free rate was significantly higher in the basketing group on univariate analysis (74.3% vs 58.2%, p = 0.04) but not on multivariate analysis (1.9 OR, 95% CI 0.9-4.3, p = 0.11). In patients who underwent a basketing procedure operative time was 37.7 minutes longer than in those treated with a dusting procedure (95% CI 23.8-51.7, p <0.001). There was no statistically significant difference in complication rates, hospital readmissions or additional procedures between the groups., Conclusions: The 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., (Copyright © 2018 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: This Guideline is intended to provide a clinical framework for the surgical management of patients with kidney and/or ureteral stones. The summary presented herein represents Part I of the two-part series dedicated to Surgical Management of Stones: American Urological Association/Endourological Society Guideline. Please refer to Part II for an in-depth discussion of patients presenting with ureteral or renal stones., Materials and Methods: A systematic review of the literature (search dates 1/1/1985 to 5/31/2015) was conducted to identify peer-reviewed studies relevant to the surgical management of stones. The review yielded an evidence base of 1,911 articles after application of inclusion/exclusion criteria. These publications were used to create the Guideline statements. Evidence-based statements of Strong, Moderate, or Conditional Recommendation were developed based on benefits and risks/burdens to patients. Additional directives are provided as Clinical Principles and Expert Opinions when insufficient evidence existed., Results: The Panel identified 12 adult Index Patients to represent the most common cases seen in clinical practice. Three additional Index Patients were also created to describe pediatric and pregnant patients with such stones. With these patients in mind, Guideline statements were developed to aid the clinician in identifying optimal management., Conclusions: Proper treatment selection, which is directed by patient- and stone-specific factors, remains the greatest predictor of successful treatment outcomes. This Guideline is intended for use in conjunction with the individual patient's treatment goals. In all cases, patient preferences and personal goals should be considered when choosing a management strategy., (Copyright © 2016 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: This Guideline is intended to provide a clinical framework for the surgical management of patients with kidney and/or ureteral stones. The summary presented herein represents Part II of the two-part series dedicated to Surgical Management of Stones: American Urological Association/Endourological Society Guideline. Please refer to Part I for introductory information and a discussion of pre-operative imaging and special cases., Materials and Methods: A systematic review of the literature (search dates 1/1/1985 to 5/31/2015) was conducted to identify peer-reviewed studies relevant to the surgical management of stones. The review yielded an evidence base of 1,911 articles after application of inclusion/exclusion criteria. These publications were used to create the Guideline statements. Evidence-based statements of Strong, Moderate, or Conditional Recommendation were developed based on benefits and risks/burdens to patients. Additional directives are provided as Clinical Principles and Expert Opinions when insufficient evidence existed., Results: The Panel identified 12 adult Index Patients to represent the most common cases seen in clinical practice. Three additional Index Patients were also created to describe the more commonly encountered special cases, including pediatric and pregnant patients. With these patients in mind, Guideline statements were developed to aid the clinician in identifying optimal management., Conclusions: Proper treatment selection, which is directed by patient- and stone-specific factors, remains the greatest predictor of successful treatment outcomes. This Guideline is intended for use in conjunction with the individual patient's treatment goals. In all cases, patient preferences and personal goals should be considered when choosing a management strategy., (Copyright © 2016 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: Percutaneous nephrolithotomy has high potential for morbidity or failure. There are limited data regarding risk factors for failure and to our knowledge no published reports of surgical outcomes in patients with prior failed attempts at percutaneous stone removal., Materials and Methods: We identified patients referred to 3 medical centers after prior failed attempts at percutaneous nephrolithotomy. A retrospective chart review was performed to analyze reasons for initial failure and outcomes of salvage percutaneous nephrolithotomy. Outcomes were compared to those in a prospectively maintained database of more than 1,200 patients treated with a primary procedure., Results: Salvage percutaneous nephrolithotomy was performed in 31 patients. Unsuitable access to the stone was the reason for failure in 80% of cases. Other reasons included infection, bleeding and inadequate instrument availability in 6.5% of cases each. Compared to patients who underwent primary percutaneous nephrolithotomy those treated with salvage were more likely to have staghorn calculi (61.3% vs 31.4%, p <0.01) and a larger maximum stone diameter (3.7 vs 2.5 cm, p <0.01), and require a secondary procedure (65.5% vs 42.1%, p <0.01). There was no significant difference between the cohorts in the remaining demographics or perioperative outcomes. All patients were deemed completely stone free except one who elected observation for a 3 mm nonobstructing fragment., Conclusions: Despite the more challenging nature and prior unsuccessful attempts at treatment, the outcomes of salvage percutaneous nephrolithotomy were no different from those of primary percutaneous nephrolithotomy when performed by experienced surgeons., (Copyright © 2016 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: Delivering the recommended care is an important quality measure that has been insufficiently studied in urology. Obstructive pyelonephritis is a suitable case study for this focus because many patients do not receive such care, although guidelines advocate decompression. We determined the influence of hospital factors, particularly familiarity with urolithiasis, on the likelihood of decompression in such patients., Materials and Methods: We used the NIS from 2002 to 2011 to retrospectively identify patients admitted to community hospitals with severe infection and ureteral calculi. Hospital familiarity with nephrolithiasis was estimated by calculating hospital stone volume (divided into quartiles) and hospital treatment intensity (the decompression rate in patients with ureteral calculi and no infection). After calculating national estimates we performed logistic regression to determine the association between the receipt of decompression and hospital stone volume, controlling for treatment intensity and other covariates thought to be associated with receiving recommended care., Results: Of an estimated 107,848 patients with obstructive pyelonephritis 27.4% failed to undergo decompression. Discrepancies were greatest between hospitals with the highest and lowest stone volumes (76% vs 25%, OR 2.77, 95% CI 1.94-3.96, p <0.01) as well as high and low treatment intensity (78% vs 37%, p <0.01)., Conclusions: High hospital stone volume and treatment intensity were associated with an increased likelihood of receiving decompression. Such findings might be useful to identify hospitals and regions where access to quality urological care should be augmented., (Copyright © 2015 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: Flexible ureteroscopy is rapidly becoming a first line therapy for many patients with renal and ureteral stones. However, current understanding of treatment outcomes in patients with isolated proximal ureteral stones is limited. Therefore, we performed a prospective, multi-institutional study of ureteroscopic management of proximal ureteral stones smaller than 2 cm to better define clinical outcomes associated with this approach., Materials and Methods: Adult patients with proximal ureteral calculi smaller than 2 cm were prospectively identified. Patients with concomitant ipsilateral renal calculi or prior ureteral stenting were excluded from study. Flexible ureteroscopy, holmium laser lithotripsy and ureteral stent placement was performed. Ureteral access sheath use, laser settings and other details of perioperative and postoperative management were based on individual surgeon preference. Stone clearance was determined by the results of renal ultrasound and plain x-ray of the kidneys, ureters and bladder 4 to 6 weeks postoperatively., Results: Of 71 patients 44 (62%) were male and 27 (38%) were female. Mean age was 48.2 years. ASA(®) score was 1 in 12 cases (16%), 2 in 41 (58%), 3 in 16 (23%) and 4 in 2 (3%). Mean body mass index was 31.8 kg/m(2), mean stone size was 7.4 mm (range 5 to 15) and mean operative time was 60.3 minutes (range 15 to 148). Intraoperative complications occurred in 2 patients (2.8%), including mild ureteral trauma. Postoperative complications developed in 6 patients (8.7%), including urinary tract infection in 3, urinary retention in 2 and flash pulmonary edema in 1. The stone-free rate was 95% and for stones smaller than 1 cm it was 100%., Conclusions: Flexible ureteroscopy is associated with excellent clinical outcomes and acceptable morbidity when applied to patients with proximal ureteral stones smaller than 2 cm., (Copyright © 2015 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: The combination of sepsis and ureteral calculus is a urological emergency. Traditional teaching advocates urgent decompression with nephrostomy tube or ureteral stent placement, although published outcomes validating this treatment are lacking. National practice patterns for such scenarios are currently undefined. Using a retrospective study design, we defined the surgical decompression rate in patients admitted to the hospital with severe infection and ureteral calculi. We determined whether a mortality benefit is associated with this intervention., Materials and Methods: Patient demographics and hospital characteristics were extracted from the 2007 to 2009 Nationwide Inpatient Sample. We identified 1,712 patients with ureteral calculi and sepsis. Multivariate logistic regression was performed to determine the association between mortality and surgical decompression., Results: Of the patients 78% underwent surgical decompression. Mortality was higher in those not treated with surgical decompression (19.2% vs 8.82%, p <0.001). Lack of surgical decompression was independently associated with an increased OR of mortality even when adjusting for patient demographics, comorbidities and geographic region of treatment (OR 2.6, 95% CI 1.9-3.7)., Conclusions: Absent surgical decompression is associated with higher odds of mortality in patients with sepsis and ureteral calculi. Further research to determine predictors of surgical decompression is necessary to ensure that all patients have access to this life saving therapy., (Copyright © 2013 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: We determined the optimal imaging study by which to diagnose and treat pregnant patients with suspected urolithiasis., Materials and Methods: A retrospective, multicenter study was performed to determine the comparative accuracy of imaging modalities used before the surgical management of suspected urolithiasis in pregnant patients. Patients with a clinical suspicion of urolithiasis were evaluated with directed imaging including renal ultrasound alone, renal ultrasound and low dose computerized tomography, or renal ultrasound and magnetic resonance urography. When indicated, patients underwent therapeutic ureteroscopy. The rate of negative ureteroscopy was determined and the positive predictive values of the imaging modalities were calculated., Results: A total of 51 pregnant patients underwent ureteroscopy. The mean age of the cohort was 27 years. Mean gestational age was 24.4 weeks. Of the women 24 (47%) underwent renal ultrasound and low dose computerized tomography, 22 (43%) underwent ultrasound alone, and 5 (10%) underwent renal ultrasound and magnetic resonance urography. Negative ureteroscopy occurred in 7 of the 51 patients (14%). The rate of negative ureteroscopy among patients who underwent renal ultrasound alone, renal ultrasound and low dose computerized tomography, and renal ultrasound and magnetic resonance urography was 23%, 4.2% and 20%, respectively. The positive predictive value of computerized tomography, magnetic resonance and ultrasound was 95.8%, 80% and 77%, respectively., Conclusions: The rate of negative ureteroscopy was 14% among pregnant women undergoing intervention in our series. Of the group treated surgically after imaging with ultrasound alone, 23% had no ureteral stone, resulting in the lowest positive predictive value of the modalities used. Alternative imaging techniques, particularly low dose computerized tomography, offer improved diagnostic information that can optimize management and obviate unnecessary intervention., (Copyright © 2013 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: During pregnancy a ureteral stone and its management may pose risks for the mother and fetus. Definitive ureteroscopic management of an obstructing stone during pregnancy has been increasingly used without a reported increased incidence of urological complications. However, the rate of obstetric complications of ureteroscopy during pregnancy remains undefined., Materials and Methods: Charts of pregnant women who had undergone ureteroscopy at 5 tertiary centers were reviewed. Patient and procedure characteristics were collected. Records were evaluated for the occurrence of obstetric complications in the postoperative period., Results: A total of 46 procedures were performed in 45 patients at 5 institutions. There were 2 obstetric complications (4.3%), including 1 preterm labor managed conservatively and 1 preterm labor resulting in preterm delivery. There was no fetal loss. No statistically significant characteristics were identified differentiating those patients having obstetric complications., Conclusions: Ureteroscopy performed during pregnancy has been previously reported to be urologically safe and effective for addressing ureteral stones. In our multi-institutional series a 4% rate of obstetric complications was observed. Based on this risk a multidisciplinary approach is prudent for the pregnant patient undergoing ureteroscopy., (Copyright © 2012 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: While percutaneous nephrostolithotomy is the standard of care for renal stones greater than 2 cm, recent studies have shown that staged ureteroscopy/holmium laser lithotripsy may be a reasonable option. Stones 2 to 3 cm may be amenable to ureteroscopy as well as to 1-stage treatment based on their intermediate size. We compared clinical outcomes and the estimated cost of percutaneous nephrostolithotomy vs ureteroscopy for 2 to 3 cm renal stones., Materials and Methods: We retrospectively identified patients who underwent percutaneous nephrostolithotomy and ureteroscopy at our institution from 2004 to 2008 with a maximal renal stone diameter of 2 to 3 cm. Demographic information, disease characteristics, intraoperative and postoperative data, and complications were recorded. Stone clearance was reported as a residual stone burden of 0 to 2 mm and less than 4 mm. Cost was estimated using local Medicare reimbursements for surgeon, anesthesia, hospital and outpatient services., Results: A total of 20 patients underwent percutaneous nephrostolithotomy and 19 underwent ureteroscopy for 2 to 3 cm renal stones. The estimated cost of percutaneous nephrostolithotomy was significantly greater than that of ureteroscopy ($19,845 vs $6,675, p <0.0001). There were significantly more second stage procedures among percutaneous nephrostolithotomy cases (11 vs 1, p = 0.003). Stone clearance (0 to 2 mm) was superior for percutaneous nephrostolithotomy vs ureteroscopy (89% vs 47%, p = 0.01). Using a less than 4 mm threshold stone clearance improved to 100% vs 95% (p not significant). Two patients (10.5%) with ureteroscopy required subsequent ipsilateral stone surgery. They were noncompliant with medical/dietary therapy or radiographic surveillance., Conclusions: While percutaneous nephrostolithotomy achieves superior stone clearance, ureteroscopy achieves acceptable treatment outcomes with a low risk of subsequent stone related events or interventions. The lower relative cost of ureteroscopy in this population may have implications for the development of treatment guidelines.

Purpose: The introduction of the da Vinci Surgical System to perform complex reconstructive procedures, such as repair of ureteropelvic junction obstruction, has helped to overcome some of the technical challenges associated with laparoscopy. We review our large multi-institutional experience with long-term followup of robotic dismembered pyeloplasty., Materials and Methods: A total of 140 patients from 3 university medical centers underwent robotic dismembered pyeloplasty. An institutional review board approved retrospective chart review was performed to collect demographic, preoperative, operative and postoperative data. Patients were analyzed as an entire cohort and then divided into various subgroups., Results: Of the cases 117 (84.6%) were primary repairs and 23 (16.4%) were secondary repairs. There were 13 (9.3%) patients who underwent concomitant stone extraction and 5 (3.6%) procedures were performed on patients with solitary kidneys. A crossing vessel was found in 77 (55%) patients. Mean operative time was 217 minutes (range 80 to 510), estimated blood loss was 59.4 ml (range 10 to 600), mean length of hospital stay 2.1 days (range 0.75 to 7) and mean followup was 29 months (range 3 to 63). Radiographic resolution of obstruction on first postoperative diuretic renal scan or excretory urogram was noted in 134 patients (95.7%). There was a 7.1% major complication rate and a 2.9% minor complication rate. No statistically significant differences were found in any parameters among patients from the various cohorts., Conclusions: To our knowledge this review represents the largest multi-institutional experience of robotic dismembered pyeloplasty with long-term followup. Robotic pyeloplasty appears to be safe, durable and efficacious for primary and secondary ureteropelvic junction obstruction with or without concomitant stone extraction, and for patients with a solitary kidney.

Purpose: Reconstructive surgery of the upper urinary tract can be complicated. During the last 2 decades minimally invasive techniques have emerged as viable options for these complex procedures. We reviewed our experience with robotic surgery for upper urinary tract reconstruction., Materials and Methods: Between May 2002 and December 2006, a single surgeon performed certain robotic reconstructions on the upper urinary tract in 26 males and 37 females (65 renal units), including dismembered pyeloplasty, dismembered pyeloplasty with stone extraction, ureteroureterostomy, ureterolysis with omental wrap, ureterocalicostomy, ureteral reimplantation and upper pole nephroureterectomy. We compared demographic, preoperative, intraoperative and postoperative data on patients undergoing these various procedures., Results: Across all cases mean blood loss was 125 cc, mean operative time was 244.8 minutes and mean length of stay was 2.8 days. The rate of radiographic and symptomatic improvement was 97.3% and 100%, respectively. We observed 2 major complications during a mean followup of 18.7 months., Conclusions: Our data illustrate that robotics can be successfully and safely used for virtually any type of upper urinary tract reconstruction. Robotic techniques are a viable option for upper urinary tract reconstruction.

Purpose: Percutaneous nephrostolithotomy (PNL) is commonly used to treat patients with complex renal calculi. A goal at our medical center is to discharge patients home less than 24 hours after PNL. We performed a study to determine factors that caused patients to be hospitalized longer than this period., Material and Methods: The available hospital records and office charts of 133 consecutive patients undergoing initial PNL at our institution between January 1, 1999 and December 31, 2000 were reviewed. All PNL procedures were performed by one of us using a (DGA) 1-stage technique. Mean patient age was 52 years (range 25 to 84). Of the subjects 85 were male and 48 were female., Results: A total of 91 patients (68%) were discharged home less than 24 hours after surgery. The overall stone-free rate was 91%. Mean length of stay in the entire group was 1.97 days. Mean length of stay in those hospitalized longer than 24 hours was 4.12 days. Mean operative time, including time to obtain access, was 188.6 minutes. Multivariate analysis demonstrated that neurogenic bladder, endocrine comorbidity and perioperative complications were factors associated with a length of stay of greater than 24 hours. Univariate analysis demonstrated that preoperative urinary tract infection and infection related calculi were also associated with a length of stay of greater than 24 hours., Conclusions: The majority of patients undergoing PNL can be discharged home less than 24 hours after surgery. Patients with neurogenic bladder, those with endocrine comorbidity, those who sustain significant perioperative complications and those harboring stones associated with urinary tract infection or preoperative urinary tract infection are more likely to require longer hospitalization.

Purpose: Access for percutaneous nephrostolithotomy (PNL) using conventional fluoroscopic guidance may carry an increased risk of damage to surrounding organs in patients with renal calculi and aberrant anatomy. In these situations cross-sectional anatomical imaging may facilitate safe percutaneous access. We describe our experience with computerized tomography (CT) guided percutaneous access for such patients undergoing PNL., Materials and Methods: Between June 2000 and December 2001, 154 patients underwent PNL at our institution. Five of these patients (3%) required a total of 6 percutaneous access tracks under CT guidance. All patients in this group had anatomical abnormalities precluding standard access to the collecting system without risk to adjacent organs. These abnormalities included a retrorenal colon in 2 and a severely distorted body habitus due to spinal dysraphism in 3., Results: Percutaneous access was achieved without complication in all cases. At subsequent PNL 5 of the 6 renal units (83%) were rendered completely stone-free., Conclusion: CT guided percutaneous access is infrequently required for PNL. However, there is a select group of patients with anatomical anomalies that may predictably require this procedure to facilitate safe and efficacious PNL.

Purpose: We developed an algorithm that prospectively defines when to excise the neurovascular bundles during radical retropubic prostatectomy with the goal of maximizing the performance of nerve sparing procedures while minimizing positive surgical margins., Materials and Methods: From January 1 to December 31, 2000 a single surgeon performed 272 radical retropubic prostatectomies and 263 were performed from January 1 to December 31, 2001. A single pathologist analyzed all specimens with positive margins. There were no prospectively defined criteria to guide decisions regarding excision of the neurovascular bundles in the 2000 study cohort. Gleason score, percent tumor volume and perineural invasion were independently analyzed in the biopsy specimens according to the site of origin (right versus left side) for the 2001 group only. The ipsilateral neurovascular bundle was excised for Gleason 6 or less tumors when there were 50% or greater tumor volume in the biopsy specimen and perineural invasion, for Gleason 7 tumors when there was 30% or greater tumor volume, or perineural invasion and for Gleason 8 to 10 tumors when there was 10% or greater tumor volume, or perineural invasion., Results: There were no statistically significant differences between the 2000 and 2001 groups in regard to preoperative prostate specific antigen, clinical and pathological stage, biopsy Gleason score and percent tumor volume in the surgical specimen. There was a statistically significant decrease in the incidence of positive margins between the 2000 and 2001 groups (14% versus 8%, p = 0.027). The lower positive margin rate was not achieved because of a tendency to excise more neurovascular bundles since a significantly greater percent of neurovascular bundles was preserved in the 2001 group. The sensitivity, specificity, positive and negative predictive values, and accuracy of our algorithm were 18%, 93%, 28%, 89% and 84%, respectively. In sides of the prostate with extraprostatic extension ipsilateral wide excision of the neurovascular bundle was associated with positive margins in 33% of cases compared with 22% when the neurovascular bundle was preserved (p = 0.42)., Conclusions: The New York University nerve sparing algorithm prospectively defines when to excise the neurovascular bundle based on Gleason score, perineural invasion and tumor volume in the biopsy specimen. Use of this algorithm decreases positive surgical margin rates, while significantly increasing the preservation of neurovascular bundles.