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Introduction Holmium Laser Enucleation of the Prostate (HoLEP) is a size-independent treatment option for the management of benign prostatic hypertrophy. While advancements in laser technology have led to clinical improvements in the enucleation portion of HoLEP, the morcellation aspect of HoLEP is often the rate-limiting step. We sought to compare efficiency and surgeon satisfaction in four commercial morcellators. Methods This was an ex vivo study comparing four commercial morcellators: the Wolf Piranha, the Lumenis VersaCut, the JenaSurgical MultiCut Solo, and the Hawk Morcellator. Four surgeons with significant experience performing HoLEPs participated. Surgeons tested each device to morcellate two different prostate models 1) morcellating as much microwave-cooked chicken breast in 10 minutes and 2) timed morcellation of bull testicles. Surgeons completed subjective surveys after each morcellator trial. Objective outcomes included: morcellation efficiency (g/min morcellated) and aspiration power (time to aspirate 1 L of saline). Means of continuous variables were compared using ANOVA. Categorical variables were compared using chi-square tests. Statistical analyses were performed using SAS 9.4 (2019). Results Comparing subjective outcomes, the Piranha was chosen as the safest morcellator (p=0.0058). The least safe morcellator was thought to be the MultiCut by 75% of surgeons (p=0.046). The Piranha was chosen as the most effective morcellator by 75% of surgeons (p=0.046). Comparing objective parameters between the morcellators, the Piranha had the fastest aspiration time (43.50±10.34 s, p=0.0116). There were no significant differences in morcellation efficiency when using chicken breast (p=0.3096). However, when comparing the morcellation efficiency using bull testicles, the Piranha had the highest efficiency at 39.68±3.57 g/min (p=0.0268). Conclusion In this ex-vivo study comparing four different commercially available morcellators, the Piranha had the highest aspiration power. No significant differences were found in morcellation efficiency using microwave-cooked chicken breast. The Piranha was felt to be the safest and most effective morcellator.

To define risk factors and perioperative outcomes for matrix stones and compare these outcomes with struvite and calcium stone cohorts.A retrospective cohort study comparing matrix stones (n=32), struvite stones (n=23) and a matched, calcium stone control group (n=32) was performed. Two-way ANOVA was used to compare the groups for continuous variables. Chi-square tests were used to compare categorical variables. Significance was set at P.05. All statistical tests were performed using R (v1.73).We identified no differences in age, gender, or BMI between the three groups. Matrix and struvite stones were more likely to have a history of prior stone surgery and recurrent UTIs compared to calcium stones (P=.027 and P.001, respectively). Struvite stones were more likely to present as staghorn calculi compared to matrix or calcium stones (56.5% vs 21.7% vs 18.8%, P=.006). There were no significant differences in postoperative stone free rates (P=.378). No significant differences in postoperative infectious complications were identified. Matrix stones were more likely to have Candida on stone culture compared to the struvite or calcium stones (P.0001).Matrix and struvite stones were more likely have a history of stone surgery and preoperative recurrent UTIs. Struvite stones were more likely to present as staghorn calculi. Matrix stones were more likely to have Candida present in stone cultures. However, no difference in postoperative infectious outcomes or stone free rates were identified. Further study with larger cohorts is necessary to distinguish matrix stone postoperative outcomes from struvite and calcium stones.

Introduction:Ureteral stents are commonly placed after ureteroscopy. We examined the rate of cystoscopy-based stent removal (CBSR) following ureteroscopy for stone disease and its economic ...

Background Limited research has focused on success with hospital discharge on the same day of surgery after holmium laser enucleation of the prostate (HoLEP). Objective To determine the success of same-day discharge in our HoLEP cohort and factors associated with this approach. Design, setting, and participants A retrospective review of our prospectively maintained HoLEP database demonstrated that 473 adult males underwent HoLEP from July 2018 to December 2019 at a tertiary referral center and high-volume HoLEP hospital. Patients were divided into groups according to planned inpatient admission (PIA), successful same-day discharge (SDD), or unplanned admission (UA). Outcome measurements and statistical analysis The PIA, SDD, and UA groups were assessed for differences in preoperative demographic data, perioperative surgical data, and postoperative follow-up data. SDD and UA were then compared to determine if any specific factors predicted UA, including univariate and multivariate logistic regression analyses. Results and limitations Age (p = 0.0049), use of anticoagulation (p = 0.037), American Society of Anesthesiologists score of 3–4 (p = 0.0017), and enucleation time (p=0.0178) were significantly higher in the PIA group. Morcellation time (p = 0.0059) and the rate of bedside catheter irrigation (p = 0.04) were higher in the UA group. The SDD group had the highest rate of successful voiding trial (p = 0.0001). Among the three groups, there was no difference in the rate of postoperative complications (p = 0.141). In a comparison of the SDD and UA groups, morcellation time (p = 0.041), the rate of bedside clot evacuation (p = 0.004), and successful voiding trial (p = 0.003) all favored SDD. There was no difference in 90-d complications (p = 0.536). A limitation is the retrospective nature of this study. Conclusions HoLEP can be successfully performed as day surgery without an increase in postoperative complications. HoLEP as day surgery is possible for any patient who does not require admission for medical comorbidities. Patient summary Same-day discharge (SDD) after holmium laser enucleation of the prostate (HoLEP) is possible and is successful in 87.4% of patients. Patients with longer morcellation times and with post-procedure hematuria with clots are more likely to have an unplanned admission. Use of a 120-W modulated-pulse laser resulted in a higher rate of SDD success. The culture change to day surgery is time-intensive owing to education of the postsurgical care units and clinic staff, and in our experience took approximately 9 mo to seamlessly integrate SDD as our HoLEP standard of care.

Holmium laser enucleation of the prostate (HoLEP) is one of only two AUA guideline-recommended prostate size-independent surgeries for benign prostate hyperplasia (BPH). The significant variation in gland size treated results in a wide range of enucleation and morcellation times. We sought to understand the effect of prostate size on HoLEP efficiency to better educate patients and improve operative room utilization. After IRB approval, we identified patients from 1 July 2016 to 1 January 2020 who underwent HoLEP by two endourologists. Our primary objectives were to assess the effects of increasing increments (25 g) of mean enucleated prostate tissue weight on enucleation and morcellation efficiency (g/min). One-way Kruskal–Wallis ANOVA with Dunn’s post hoc test was used, with significant p &lt, 0.05. We included 675 HoLEPs with all comers mean tissue weight resected of 72.1 g (Range 1–448 g), energy used 110.00 kJ (10.73–340 kJ), enucleation time 48.6 min (5–151 min), and morcellation time 10.1 min (0.5–113 min). Average enucleation efficiency increased with increasing prostate size categories (e.g., &lt, 25 g–0.48 g/min, &gt, 325 g–3.91 g/min) (K-W ANOVA p = 0.004, Dunn’s post hoc p = 0.004). The combined average enucleation and morcellation efficiency was ≥5 g/min between 55 and 271 g. Inefficiency for cases &lt, 55 g was driven by enucleation, while &gt, 271 g case inefficiency was driven by morcellation. Increasing tissue weight at the time of HoLEP is associated with a linear relationship of increasing enucleation and decreasing morcellation efficiencies.

Introduction:Holmium laser enucleation of the prostate (HoLEP) is a size-independent treatment option for the treatment of benign prostatic hyperplasia. HoLEP has been shown to have excelle...

Introduction: Currently, there are multiple intracorporeal lithotripters available for use in percutaneous nephrolithotomy (PCNL). This study aimed to evaluate the efficiency of two novel lithotripters: Trilogy and ShockPulse-SE. Materials and Methods: This is a prospective multi-institutional randomized trial comparing outcomes of PCNL using two novel lithotripters between February 2019 and June 2020. The study assessed objective measures of stone clearance time, stone clearance rate, device malfunction, stone-free rates, and complications. Device assessment was provided through immediate postoperative survey by primary surgeons. Results: There were 100 standard PCNLs completed using either a Trilogy or ShockPulse-SE lithotrite. Using quantitative Stone Analysis Software to estimate stone volume, the mean stone volume was calculated at 4.18 ± 4.79 and 3.86 ± 3.43 cm3 for the Trilogy and ShockPulse-SE groups, respectively. Stone clearance rates were found to be 1.22 ± 1.67 and 0.77 ± 0.68 cm3/min for Trilogy vs ShockPulse-SE (p = 0.0542). When comparing Trilogy to ShockPulse-SE in a multivariate analysis, total operative room time (104.4 ± 48.2 minutes vs 121.1 ± 59.2 minutes p = 0.126), rates of secondary procedures (17.65% vs 40.81%, p = 0.005), and device malfunctions (1.96% vs 34.69%, p

Background With the heterogeneous distribution of novel surgical technologies and variable physician training, there is a need to re-evaluate contemporary outcomes of percutaneous nephrolithotomy (PCNL) for complex staghorn stones. Objective To evaluate contemporary outcomes of guideline-supported treatment for patients with staghorn kidney stones using single-access PCNL in multiple North American centers. Design, setting and participants We performed a multi-institutional retrospective review of staghorn stones managed from January 1, 2017 to January 1, 2019, inclusive. We excluded patients with more than a single percutaneous access per renal unit and those who underwent a concomitant contralateral procedure. Outcome measurements and statistical analysis Safety (Clavien-Dindo complications) and efficacy in terms of a strictly defined stone-free rate were examined for single-access PCNL performed on staghorn stones with a Guy’s stone score of 3–4. Results and limitations We evaluated 301 patients meeting the inclusion criteria with an average age of 57 yr (range 18–87). All stones had a Guy’s stone score of 3 (36.2%) or 4 (63.8%). The mean (± standard deviation) stone burden was 191.4 ± 49.8 mm2. Of the 297 patients (98.6%) who underwent computed tomography on postoperative day 1, 132 (44.4%) showed no residual stone, 111 (37.3%) had a largest fragment Conclusions Single-access PCNL for complex staghorn stones is safe and effective. High stone-free rates with minimal morbidity are achievable with current techniques. Patient summary This study confirms that single-access percutaneous nephrolithotomy provides excellent outcomes in the treatment of complex kidney stones. This surgical technique has both safe and effective outcomes that are reproducible across multiple centers in North America.

Background: Holmium laser enucleation of the prostate (HoLEP) is a highly effective procedure for benign prostatic hyperplasia that is size independent and has been recommended for patients necessi...

To perform a global survey to identify contemporary practice patterns of transurethral therapies for benign prostatic hypertrophy. A REDCap survey was distributed to the ~ 3500 members of the Endourological Society. Surgeons completed demographic information and then selected the BPH therapies they perform 10 cases/year. There were four categories of BPH therapies: ablation, enucleation, resection/vaporization, and MIST (minimally invasive surgical technique). Within each category, there were subcategories to account for different energy modalities. All statistical analyses were performed using SAS 9.4. A total of 175 surgeons responded to our survey. Prostate resection/vaporization remained the most commonly utilized technique (51.9%, n = 147/283) followed by enucleation (22.6%, n = 64/283). Bipolar TURP (bTURP) was the most common modality for prostate resection (69.4%, n = 102/147). Holmium laser enucleation (HoLEP) was the most common modality for enucleation (46.9%, n = 30/64). Urolift® was performed more often than Rezūm™ (55.9% vs. 44.1%, n = 19/34 vs. 15/34, respectively). Among surgeons performing ablation, country of practice was a significantly associated with length of stay (LOS), p

Although the automatic synthesis of molecules has been established, each reaction class uses bespoke hardware. This means that the connection of multi-step syntheses in a single machine to run many different protocols and reactions is not possible, as manual intervention is required. Here we show how the Chemputer synthesis robot can be programmed to perform many different reactions, including solid-phase peptide synthesis, iterative cross-coupling and accessing reactive, unstable diazirines in a single, unified system with high yields and purity. Developing universal and modular hardware that can be automated using one software system makes a wide variety of batch chemistry accessible. This is shown by our system, which performed around 8,500 operations while reusing only 22 distinct steps in 10 unique modules, with the code able to access 17 different reactions. We also demonstrate a complex convergent robotic synthesis of a peptide reacted with a diazirine-a process requiring 12 synthetic steps.

Purpose: The pursuit of a dietary source to increase urine pH and citrate in stone formers has been ongoing for >30 years. Early evidence showed that orange juice (OJ) contains alkali and citrate, ...

Introdução: A prematuridade pode desencadear alterações no crescimento, desenvolvimento, linguagem, cognição e aprendizagem do lactente, principalmente quando este apresenta baixa idade gestacional e peso ao nascer. A evolução tecnológica e a inserção de programas terapêuticos precoces conhecidos como follow-up, tem auxiliado na redução de sequelas neurológicas e respiratórias em prematuros, prevenindo danos ou agravos ao seu desenvolvimento. Objetivo: verificar o efeito da intervenção precoce no desenvolvimento neuromotor de lactentes prematuros durante follow-up de um ano. Materiais e Método: Foram avaliados, acompanhados e estimulados 08 lactentes prematuros, com idade gestacional entre 27 e 36 semanas gestacionais, peso entre 695g e 2490g, de ambos os sexos, encaminhados ao setor de Pediatria da Clínica de Fisioterapia das Faculdades Integradas Einstein de Limeira. Todos os lactentes inicialmente tiveram sua idade cronológica corrigida e foram avaliados com a escala neuromotora Amiel-Tison Neurological Assessment at Term e as etapas motoras que foram reaplicadas após 2 meses de intervenção e aos 12 meses de idade corrigida. Todos os lactentes receberam intervenção duas vezes por semana, 40-50 minutos, sendo aplicado técnicas de estimulação sensório-motora, tátil e etapas motoras. Resultados: 100% dos lactentes avaliados apresentaram atraso motor podendo variar de um discreto até um atraso moderado. A melhora do desenvolvimento motor foi estatisticamente significativa aos 12 meses de idade corrigida após intervenção (p

The incidence and prevalence of kidney stones have increased over the past four decades. However, the diagnosis of 'kidney stone' can range from an incidental asymptomatic finding of limited clinical significance to multiple painful episodes of ureteral obstruction with eventual kidney failure. Some general strategies may be useful to prevent the recurrence of kidney stones. In particular, greater attention to kidney stone classification, approaches to assessing the risk of recurrence and individualized prevention strategies may improve the clinical care of stone formers. Although there have been some advances in approaches to predicting the recurrence of kidney stones, notable challenges remain. Studies of kidney stone prevalence, incidence and recurrence have reported inconsistent findings, in part because of the lack of a standardized stone classification system. A kidney stone classification system based on practical and clinically useful measures of stone disease may help to improve both the study and clinical care of stone formers. Any future kidney stone classification system should be aimed at distinguishing asymptomatic from symptomatic stones, clinically diagnosed symptomatic stone episodes from self-reported symptomatic stone episodes, symptomatic stone episodes that are confirmed from those that are suspected, symptomatic recurrence from radiographic recurrence (that is, with radiographic evidence of a new stone, stone growth or stone disappearance from presumed passage) and determine stone composition based on mutually exclusive categories.

Objective To compare perioperative outcomes between lower, mid, and upper pole access locations for patients undergoing single-access, unilateral percutaneous nephrolithotomy (PCNL). Methods We queried our institutional PCNL database to include patients who had unilateral, single access procedures. We excluded patients who had a contralateral procedure during the same admission or multiaccess procedures. Patients were grouped by the site of PCNL access (lower, mid, or upper pole). Among groups, we compared postoperative day 1 (POD1) stone-free rates as measured by abdominal CT scan or plain-film X-ray and consequent need for a secondary procedure. We further compared postoperative complication rates. Results We included 767 patients for analysis, with the majority of access locations being in the lower pole (80.2%). Patients across groups had similar age, body mass index, and stone laterality. Patients with horseshoe kidneys more commonly had mid or upper pole access compared to lower pole. The percentage of patients with no residual stone fragments seen on POD 1 imaging was similar for lower, mid, and upper pole groups (57.7% vs 65.0% vs 61.6%, respectively; P = .526). Additionally, we observed no difference in the percentage of patients requiring a secondary procedure among the above groups (33.5% vs 22.5% vs 31.3%, respectively; P = .337). Patients experienced no difference in complications among groups. Conclusion When performing unilateral PCNL using a single site of access, we observed no difference in stone-free rates or complications between lower, mid, and upper pole locations. Appropriate selection of access location in PCNL should be individualized to patient factors and surgeon experience.

Objective To compare the PERC-tic technique, described as placement of dual wires under fluoroscopic guidance adjacent to the stone within the obstructed calyx, to standard percutaneous nephrolithotomy (PCNL) with working wires secured down the ureter. Materials and Methods This is a retrospective cohort study of patients who underwent a PCNL procedure between October 2016 and November 2018. Patients undergoing the PERC-tic technique were compared to patients undergoing standard PCNL. Regression models evaluated if PERC-tic PCNL was associated with equivalent stone-free rates to standard PCNL at 90 days, need for secondary procedures, and 90-day hospital readmission. Results This study involved 126 PCNL cases of which 63 were done using the PERC-tic technique and 63 with standard PCNL. In multivariate analysis, there was no statistical difference in 90-day stone-free rate between standard PCNL and PERC-tic cohorts (P = .08). We did note a 6 times higher likelihood of needing secondary procedures for residual stones in the PERC-tic vs standard PCNL groups (71% vs 30% P Conclusion Our findings suggest similar stone-free rate at 90 days and higher rates of secondary procedures after PERC-tic PCNL compared to the standard approach; however, there was no difference in complications. These findings may reflect decreased visualization with the PERC-tic technique or simply be reflective of the case difficulty requiring the use of the PERC-tic technique. These findings can be used for patient counseling when considering this technique for complex stone disease.

Purpose: To characterize the role of perineal urethrostomy in patients undergoing HoLEP for BPH symptom relief. Methods: We identified all patients who required the creation of a perineal urethrostomy from a prospectively maintained institutional database between 1998-2017. Patient demographics, as well as operative and postoperative records, were analyzed to evaluate differences in those patients requiring a perineal urethrostomy. Results Obtained: We identified 7 patients who underwent HoLEP and required a perineal urethrostomy. The mean age was 70 years old (range: 61-82 years old). Within this subset of patients, four had previously aborted BPH procedures; two had penile prosthesis and two were morbidly obese. The mean final prostate specimen weight was 111 grams (range: 23-319). The duration of catheterization varied from 37-600 hours. In patients with BMI ≥40kg/m2 , the average duration of catheterization was 588 hours compared 119 hours in patients with BMI

Background COVID-19 changed the practice of medicine in America. During the March 2020 lockdown, elective cases were cancelled to conserve hospital beds/resources resulting in financial losses for health systems and delayed surgical care. Ambulatory percutaneous nephrolithotomy (aPCNL) has been shown to be safe and could be a strategy to: ensure patients receive care that has been delayed, conserve hospital resources, and maximize cost-effectiveness. We aimed to compare the safety and cost-effectiveness of patients undergoing ambulatory percutaneous nephrolithotomy (aPCNL) against standard PCNL (sPCNL). Materials and Methods 98 patients underwent PCNL at Indiana University Methodist hospital, a tertiary referral center, by three expert surgeons from January 2020 to September 2020. The primary outcome of the study was to compare the 30-day rates of ED-visits, readmissions, and complications between sPCNL and aPCNL. Secondary outcomes included: cost analysis and stone free rates (SFRs). Prospensity-score matching was performed to ensure the groups were balanced. Statistical analyses were performed using SAS 9.4 using independent t-tests for continuous variables and chi-square analyses for categorical variables. Results 98 patients underwent PCNL during the study period (sPCNL=75 and aPCNL=23). After propensity-score matching, 42 patients were available for comparison (sPCNL=19 and aPCNL=23). We found no difference in 30-day ED-visits, readmissions, or complications between the two groups. aPCNL resulted in cost savings of $5327±442 per case. Stone free rates were higher for aPCNL compared to sPCNL. Conclusions aPCNL appears safe to perform and does not have a higher rate of ED-visits or readmissions compare to sPCNL. aPCNL may also be cost-effective compared to sPCNL.

To compare perioperative and post-operative outcomes for holmium laser enucleation of the prostate (HoLEP) between cases performed with a 550 µm or 1000 µm fiber. We retrospectively reviewed the most recent 50 patients undergoing HoLEP with a 550 µm fiber and the most recent 50 patients with a 1000 µm fiber. The length of exposed laser fiber after stripping was measured pre- and post-enucleation, with the difference being our primary outcome of degradation length. We compared operative and clinical characteristics between patients undergoing HoLEP using 550 and 1000 µm laser fibers. All 100 patients met inclusion for analysis. Overall, the 550 µm fiber experienced more degradation than the 1000 µm fiber (2.9 vs 1.9 cm, respectively; p = 0.01). The 1000 µm fiber utilized significantly less energy compared to the 500 µm fiber (81 vs 109 kJ, respectively; p

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...

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.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.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 p0.001). 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, p0.001). Positive quick sequential organ failure assessment criteria significantly predicted an increased probability of an emergency department visit within 30 days (β = 1.495, p0.05), operative complications (β = 1.811, p0.001) and transfusions (p0.001). The main limitation of the study is that it was retrospective.Quick sequential organ failure assessment criteria were superior to systemic inflammatory response syndrome criteria to predict infectious complications after percutaneous nephrolithotomy.

This comprehensive review updates the advances in extracorporeal lithotripsy, including improvements in external shockwave lithotripsy and innovations in ultrasound based lithotripsy, such as burst wave lithotripsy, ultrasonic propulsion, and histotripsy. Advances in endoscopic technology and training have changed the surgical approach to nephrolithiasis; however, improvements and innovations in extracorporeal lithotripsy maintain its status as an excellent option in appropriately selected patients.

INTRODUCTION AND OBJECTIVE:Use of flexible cystoscopy for hospital based urologic care (Emergency Department, intra-operative, inpatients) is invaluable for many urologic diseases. Reusable flexibl...

Introduction: Although holmium laser enucleation of the prostate (HoLEP) is a highly effective surgery, there is a variable recovery period where patients may experience hematuria, dysuria, or urinary incontinence (UI). Despite preoperative consultation, there is a paucity of literature examining the effectiveness of physician-patient communication in preparing the patient for the postoperative recovery period. We sought to examine recovery expectations as a patient-reported outcome (PRO) metric for HoLEP. Methods: With institutional review board approval, we queried our electronic medical record and retrospective clinical registry to identify 50 consecutive patients that underwent HoLEP from November 2019 to March 2020 by two endourologists. Patients were provided questionnaires via Twistle© ≥6 months postoperatively. Patient demographics and perioperative course was examined in the context of responses. Our primary objective was determining whether patients felt they had a reasonable understanding of the recovery process. Results: We observed a 92% (46/50) response rate, with an average patient age of 69.4 years (range 55–88). Overall, 91.3% (42/46) felt they had a reasonable understanding of the recovery. Additionally, 97.8% (45/46) were aware of temporary UI, with 87% having ≥1 episodes of UI after catheter removal. We found 47.8% (22/46) of patients expected UI to resolve within 30 days, while 8.6% expected >90 days of UI. All patients were aware of the risk of hematuria, with 93.5% (43/46) expecting resolution within 30 days (

INTRODUCTION AND OBJECTIVE: In March 2020, hospitals across America locked down to prevent the spread of COVID-19. This resulted in catastrophic financial losses and massive surgical backlog. While multiple groups have shown that ambulatory percutaneous nephrolithotomy (aPCNL) is safe and feasible, to our knowledge, a cost-analysis comparing aPCNL against standard PCNL (sPCNL) has not been performed. Prior to March 2020, our group was not performing routine aPCNL, but to conserve hospital resources, we performed aPCNL more often. Our objective was to compare the safety and cost-effectiveness of sPCNL vs. aPCNL. METHODS: 98 patients underwent PCNL at Indiana University Methodist hospital, a tertiary referral center, by three expert surgeons from January 2020 to September 2020. sPCNL (n=75) and aPCNL (n =23). All patients had at least 30-days of follow up.The primary outcome of the study was to compare the 30-day rates of ED-visits, readmissions, and complications between sPCNL and aPCNL. Secondary outcomes included: cost analysis and stone free rates (SFRs). Statistical analysis was performed using SPSSv26 using independent t-tests for continuous variables and chi-square analyses for categorical varaibles. RESULTS: We found no difference in 30-day ED-visits, readmissions, or complications between the two groups. aPCNL resulted in cost savings of $5689±237 per case, a 29.6% reduction. CONCLUSIONS: aPCNL appears safe to perform and does not have a higher rate of ED-visits or readmissions compare to sPCNL. aPCNL also is also cost-effective compared to sPCNL. Patients undergoing same-day discharge were not at higher risk of ED-visits or readmission to the hospital.

INTRODUCTION AND OBJECTIVE:Although holmium laser enucleation of the prostate (HoLEP) is a highly effective surgery for BPH; there is a variable period of recovery where patients may experience hem...

INTRODUCTION AND OBJECTIVE:Holmium Laser Enucleation of Prostate (HoLEP) is a size-independent treatment for benign prostate hypertrophy (BPH). Moses™ is a new technology developed by Lumenis® for ...

INTRODUCTION AND OBJECTIVE:To compare perioperative and post-operative outcomes for holmium laser enucleation of the prostate (HoLEP) between cases performed with a 550um standard laser fiber versu...

INTRODUCTION AND OBJECTIVE:Traditionally, holmium laser enucleation of the prostate (HoLEP) has required an inpatient hospital stay post-operatively. However, advances in technology with MOSES 2.0 ...

INTRODUCTION AND OBJECTIVE:In an effort to combat the alarming amount of postoperative opioid prescribing in the United States (U.S.), many surgical specialties are implementing pathways to limit t...

With increased use of sodium-glucose co-transporter 2 (SGLT2) inhibitors as antidiabetic agents, the risk of serious fungal urinary tract infection (UTI) may be increased. We present the case of a 67-year-old Caucasian female who was admitted for emphysematous pyelitis and found to have a fungal ball in the renal pelvis. Candida glabrata was cultured and the patient was managed with percutaneous nephrostomy tube placement and antifungal treatment. The fungal ball persisted and required surgical removal with ureteroscopy and basket extraction. Fungal balls can be a difficult sequelae of UTIs requiring a combination of antifungal and surgical intervention for definitive management.

Objectives To determine if patients were obtaining opioids after HoLEP from other sources – despite our opioid-free postoperative pathway – we utilized a national prescription drug monitoring program (PDMP) to review all patients who underwent HoLEP at our institution. Methods We performed a retrospective review of all HoLEPs completed by two fellowship-trained surgeons. We utilized a national PDMP to determine the true rate of postoperative opioid use. The primary outcome was filling of an opioid prescription within 31 postoperative days. Student t-tests and chi-square tests were used to compare continuous and categorical variables, respectively. Results From July 2018-July 2020, 284 men underwent HoLEP. Despite our opioid-free pathway, 35 men (12.4%) received postoperative opioids. Unfortunately, 41.2% of opioids were prescribed by our inpatient physician assistant on his own accord. To prevent confounding, these patients were excluded from primary analyses. Thus, only 7.4% of patients received postoperative opioids. On univariate analysis, surgeon experience, chronic opioid use, any opioid exposure, benzodiazepine use, and chronic pain were associated with postoperative opioid use. On multivariate analysis, only preoperative opioid exposure (OR 41.9, P = 0.0383) was identified as a significant variable. Conclusion 92.6% of patients did not obtain postoperative opioids on our opioid-free post-HoLEP pathway, but 7.4% of patients did obtain opioids from outside sources. Proper education of the surgical team is key to prevent inappropriate opioid prescribing. On multivariate analysis, we identified that any preoperative opioid exposure was associated with an increased risk of obtaining postoperative opioids.

Background: There are multiple stone types, with each forming under different urinary conditions. We compared clinical and metabolic findings in pure stone formers (SFs) to understand whether there...

Background: Holmium laser enucleation of the prostate (HoLEP) is a highly effective and durable minimally invasive surgery for benign prostatic hyperplasia. Historically, alternative treatments for...

Background: Our aim was to compare microorganism detection between standard culture (Ctx) and next generation sequencing (NGS) in patients undergoing surgery for nephrolithiasis; we prospectively compared both urine and stone culture results using these two techniques. Methods: We prospectively compared microorganism detection of urine and stone cultures using Ctx versus NGS in patients undergoing surgery for nephrolithiasis. We analyzed preoperative voided urine (Voided) using both Ctx and NGS. Intraoperatively, renal stone (Stone) cultures were analyzed with Ctx and NGS. The primary outcome was concordance in microorganism detection between Voided Ctx and Stone NGS, as well as between Stone Ctx and Stone NGS. Results: We prospectively evaluated 84 patients. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of Voided Ctx predicting Stone Ctx were 66.7%, 73.7%, 54.5%, and 82.4%, respectively. Concordance of Voided Ctx microorganisms to Stone microorganisms decreased when NGS was used for the Stone compared with Ctx. The sensitivity, specificity, PPV, and NPV of Voided NGS to predict Stone Ctx microorganisms were 85.2%, 24.6%, 34.8%, and 77.8%, respectively. The concordance of Voided NGS to Stone microorganisms improved when the Stone was analyzed via NGS compared with Ctx. Conclusion: NGS has a higher detection rate of microorganisms than standard culture for both preoperative urine and stone cultures. Voided NGS was the most sensitive in predicting a positive Stone sample, but the specificity and PPV were, overall, low. Further correlation of NGS microorganism detection with patient outcomes will determine which clinical situations may benefit most from NGS versus standard culture in patients with urinary-tract 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.

Background Human kidney stones form via repeated events of mineral precipitation, partial dissolution, and reprecipitation, which are directly analogous to similar processes in other natural and manmade environments, where resident microbiomes strongly influence biomineralization. High-resolution microscopy and high-fidelity metagenomic (microscopy-to-omics) analyses, applicable to all forms of biomineralization, have been applied to assemble definitive evidence of in vivo microbiome entombment during urolithiasis. Methods Stone fragments were collected from a randomly chosen cohort of 20 patients using standard percutaneous nephrolithotomy (PCNL). Fourier transform infrared (FTIR) spectroscopy indicated that 18 of these patients were calcium oxalate (CaOx) stone formers, whereas one patient formed each formed brushite and struvite stones. This apportionment is consistent with global stone mineralogy distributions. Stone fragments from seven of these 20 patients (five CaOx, one brushite, and one struvite) were thin sectioned and analyzed using brightfield (BF), polarization (POL), confocal, super-resolution autofluorescence (SRAF), and Raman techniques. DNA from remaining fragments, grouped according to each of the 20 patients, were analyzed with amplicon sequencing of 16S rRNA gene sequences (V1–V3, V3–V5) and internal transcribed spacer (ITS1, ITS2) regions. Results Bulk-entombed DNA was sequenced from stone fragments in 11 of the 18 patients who formed CaOx stones, and the patients who formed brushite and struvite stones. These analyses confirmed the presence of an entombed low-diversity community of bacteria and fungi, including Actinobacteria, Bacteroidetes, Firmicutes, Proteobacteria, and Aspergillus niger. Bacterial cells approximately 1 μm in diameter were also optically observed to be entombed and well preserved in amorphous hydroxyapatite spherules and fans of needle-like crystals of brushite and struvite. Conclusions These results indicate a microbiome is entombed during in vivo CaOx stone formation. Similar processes are implied for brushite and struvite stones. This evidence lays the groundwork for future in vitro and in vivo experimentation to determine how the microbiome may actively and/or passively influence kidney stone biomineralization.

Objective To determine the true failure rate of opioid free ureteroscopy (OF-URS) and rates of new-persistent opioid use utilizing a national prescription drug monitoring program. Material and Methods We identified 239 patients utilizing our retrospective stone database who underwent OF-URS from Februrary 2018-March 2020. In Feb 2018, we initiated a OF-URS pathway (diclofenac, tamsulosin, acetaminophen, pyridium and oxybutynin). Patients who had a contraindication to NSAIDs were excluded from primary analyses. A prescription drug monitoring program was then utilized to determine the number of patients who failed OF-URS (defined as receipt of an opioid within 31 days of surgery) as well as rates of new-persistent opioid use (defined as receipt of opioid 91-180 days after surgery). All statistical analyses were performed using SAS 9.4. Tests were 2-sided and statistical significance was set at P Results We found a OF-URS failure rate of 16.6% and 14.0% in the total and opioid naive cohorts, respectively. Rates of new-persistent opioid use were 0.9% and 1.2%, respectively (lower than published expected rate of ~6% after URS with postoperative opioids). 91% of patients obtained opioid from alternative sources. Uni/multivariate analyses were performed for both cohorts. In the total cohort, benzodiazepine users had a higher risk of OF-URS failure on multivariate analysis. No variables were associated with OF-URS failure in the opioid naive cohort. Conclusion The true failure rate of OF-URS is higher than previously thought at 16.6% and 14.0%. However, efforts to reduce opioid prescriptions with OF-URS pathways have successfully reduced new-persistent opioid use.

An estimated 4–5 million CT scans are performed in the USA every year to investigate nephrourological diseases such as urinary stones and renal masses. Despite the clinical benefits of CT imaging, concerns remain regarding the potential risks associated with exposure to ionizing radiation. To assess the potential risk of harmful biological effects from exposure to ionizing radiation, understanding the mechanisms by which radiation damage and repair occur is essential. Although radiation level and cancer risk follow a linear association at high doses, no strong relationship is apparent below 100 mSv, the doses used in diagnostic imaging. Furthermore, the small theoretical increase in risk of cancer incidence must be considered in the context of the clinical benefit derived from a medically indicated CT and the likelihood of cancer occurrence in the general population. Elimination of unnecessary imaging is the most important method to reduce imaging-related radiation; however, technical aspects of medically justified imaging should also be optimized, such that the required diagnostic information is retained while minimizing the dose of radiation. Despite intensive study, evidence to prove an increased cancer risk associated with radiation doses below ~100 mSv is lacking; however, concerns about ionizing radiation in medical imaging remain and can affect patient care. Overall, the principles of justification and optimization must remain the basis of clinical decision-making regarding the use of ionizing radiation in medicine. Investigation of nephrourological diseases is a common indication for CT examination. However, concerns remain regarding the potential risks associated with exposure to ionizing radiation despite a lack of convincing evidence for any such effect at the low doses used for CT scanning. In this Review, experts in the field explain the data in this area and consider how elimination of unnecessary imaging and optimization of medically justified imaging must remain the basis of clinical decision-making.

Objective To assess stone-free rates following ureteroscopy (URS) for renal calculi at our institution using low-dose renal only computed tomography (CT). Methods A retrospective review of patients undergoing flexible URS for renal stones only with subsequent CT scan within 3 months. Meticulous basketing of all stone fragments was performed whenever possible. A “true” zero-fragment stone-free rate was determined by reviewing the CT scan and radiologist's report. Patients with nephrocalcinosis (as determined by visual inspection of papilla at the time of URS) were assigned the “stone-free” category. Results Flexible URS was performed in 288 renal units of 214 patients with renal calculi from 2013 to 2016. Median preoperative stone size was 6.2 mm with the average kidney containing 6.4 stones. An access sheath was used in 92% of cases. A total of 73% (209/288) renal units were completely stone free by CT assessment. Patients with residual fragments were as follows: 1 mm in 2% (7/288), 2-4 mm in 16% (46/288), and >4 mm in 9% of kidneys (26/288). Conclusion The true stone-free rate in patients undergoing flexible URS for renal calculi utilizing active basketing of fragments as determined by strict CT assessment was 73%. In patients with residual fragments, the majority are 2-4 mm in size making URS a treatment option for renal calculi with excellent stone-free results.

Introduction and Objective: Preoperative anxiety has been shown to correlate with certain urinary symptoms in patients with certain types of voiding dysfunction, particularly overactive bladder. Th...

Objective To determine if same day catheter removal is feasible in a select population after holmium laser enucleation of the prostate (HoLEP). Methods We performed an analysis of patients undergoing HoLEP at our institution who underwent same-day catheter removal after HoLEP. All HoLEPs were performed with Moses 2.0 Optimized for BPH. Patients were dismissed from postoperative recovery unit to the clinic for catheter removal and voiding trial. Results To date, 30 patients have undergone same day catheter removal. Median age is 68.6 years (interquartile range [IQR] 61.8-73.3) and preoperative prostate volume 81 mL (IQR 53-114.8). Median enucleation time was 39.5 minutes (IQR 30.5-53), morcellation time was 5 minutes (IQR 4-12 minutes), and enucleated specimen weight was 52.5 g (IQR 33-81). Twenty-seven (90%) patients successfully voided on the same day without requiring catheter replacement. All patients were catheter free by POD1. For patients who successfully passed their voiding trial, the median time from the end of the procedure to hospital discharge was 2.6 hours (IQR [2.1-2.9]) and from the end of the HoLEP to catheter removal was 4.9 hours (IQR [3.5-6.0]). Conclusion We present for the first time that same day catheter removal is a feasible option in a select population of patients undergoing HoLEP. With more study, this has the potential for transforming the management of BPH, especially larger glands.

Aims To investigate the main reasons for use of opioids during acute episodes of renal colic and for ureteral stent symptoms post-operatively. Material and methods A survey assessing the impact of decreased quality of life and use of opioid pain medication was distributed to patients with a history of ureteral stent at seven academic centers between July 2016 and June 2018. Results A total of 365 surveys were completed. Opioid use for stone (63.9%) and stent-related pain (39.0%) was common among respondents. When assessing whether patients used more opioids for stone or stent-related pain, 47.7% reported using more for stone pain while 15.0% reported using more for stent pain. 22.6% of patients required opioids for stent-related pain and not stone pain. Increasing patient age was found to be negatively associated with using opioids for stent-related pain (OR: 0.4, 95% CI: 0.3 - 0.6). Increasing age was also found to be negatively associated with opioid use for stone pain (OR: 0.6, 95% CI: 0.4 - 0.8). Patients with a greater number of prior stones had 3.2 times the odds of using opioids for stone pain, in our adjusted model (95% CI: 2.1 - 4.7). Conclusion Patients with more prior stone episodes are more likely to have used opioids for their most recent episode. Although ureteral stents have been shown to be associated with a decreased quality of life, we showed that the use of opioids for stent-related pain is less than that for stone pain. Younger patients are less likely to tolerate a stent without opioid analgesics.

INTRODUCTION AND OBJECTIVE:Holmium laser enucleation of the prostate (HoLEP) has traditionally required an overnight stay for continuous bladder irrigation. With the introduction of new laser techn...

INTRODUCTION AND OBJECTIVE:Current AUA guidelines recommend a 24-hour urine collection be obtained in high-risk and recurrent stone formers. While 24-hour urines are valuable in guiding stone preve...

INTRODUCTION AND OBJECTIVE:Given the substantial burdens of the current opioid crisis, clinicians are tasked with reducing excessive narcotic analgesia. The purpose of this study was to evaluate if...