Search

Objectives: To compare the enucleation efficiency of Moses 2.0 with non‐Moses technology in patients undergoing holmium laser enucleation of the prostate (HoLEP). Patients and Methods: A double‐blinded, randomised study of patients undergoing HoLEP at the Mayo Clinic in Arizona, using the Lumenis Pulse™ 120H laser system. Patients were randomised to either right lobe enucleation using Moses 2.0 and left lobe enucleation using non‐Moses, or the opposite. The primary outcome was individual lobe enucleation efficiency. Secondary outcomes included individual lobe laser time, laser energy, individual enucleation and haemostasis laser energies, and fibre burn back. Two independent reviewers watched videos of the procedures and provided a subjective evaluation of the technologies. Results: A total of 27 patients were included in the study. For the entire cohort, Moses 2.0 had less fibre degradation (3.5 vs 16.8 mm, P < 0.01) compared to non‐Moses. When HoLEP procedures were performed by an expert, Moses 2.0 resulted in shorter enucleation time (21 vs 36.7 min, P = 0.016) and higher enucleation efficiency (1.75 vs 1.05 g/min, P = 0.05) compared to non‐Moses. When HoLEP was performed by trainees, the Moses 2.0 cohort had a shorter haemostasis laser time (4.1 vs 9 min, P = 0.035) compared to the non‐Moses. Fibre degradation was lower with Moses 2.0 compared to non‐Moses for both experts and trainees. Moses 2.0 received a higher score than the standard technology for the incision sharpness, fibre control, tissue separation, tissue damage, haemostasis, visibility, and charring. The overall inter‐observer correlation coefficient was 0.63. Conclusion: Moses 2.0 has higher enucleation efficiency compared to non‐Moses when used by experts. The subjective evaluation favoured Moses 2.0. [ABSTRACT FROM AUTHOR]

The article focuses on the coupling of the resident salaries with the funds for graduate medical education (GME). Topics discussed include the structural change undergone by the U.S. urology residencies since the opening of the first program in 1915, the origin of the funding from indirect medical education (IME) and direct graduate medical education (DGME), and the uncertainty of the future of the funding for graduate medical education.

Introduction: Benign prostatic hyperplasia (BPH) is a common condition affecting aging men. While holmium laser enucleation of the prostate (HoLEP) is one of the most effective treatments for BPH, variations of the procedure, such as median lobe HoLEP (MLHoLEP), are rarely reported. Here, we report our institution's experience with partial HoLEP. Methods: Our institutional prospective database was queried for patients having undergone median or individual lateral lobe enucleation between 2007 and 2018. A control cohort of patients who underwent standard HoLEP (sHoLEP) was identified using 1:2 propensity score matching based on age, prostate size, maximal flow rate (Qmax), postvoid residual volume (PVR), and American Urological Association symptom score (AUAss). Three and 12-month AUAss, PVR, and Qmax were compared. Results: Forty-seven patients were identified as having undergone MLHoLEP. At three-month followup, AUAss (p<0.01) and incontinence rates (p=0.045) were lower for MLHoLEP patients, in addition to them having shorter operative (36.5 mins vs. 64.5 mins, p<0.01) and enucleation (13.8 mins vs. 37 mins, p<0.01) times as compared to sHoLEP patients. No difference was noted between MLHoLEP and sHoLEP cohorts with respect to age, prostate volume, PVR, or Qmax. Significant improvement in AUAss, PVR, and Q max from baseline to three and 12 months was noted overall in both groups. Conclusions: MLHoLEP could provide a surgical option with reduced operative time, quicker improvement in AUAss, and restored continence in appropriately selected patients. Ultimately, MLHoLEP represents a safe and effective treatment option to select patients who may not be eligible for or face potential morbidity concerns associated with sHoLEP. [ABSTRACT FROM AUTHOR]

Introduction: Effective medical dissolution therapy (MDT) for uric acid stones is more cost-effective than surgical treatment; however, treatment failure may be associated with increased cost. We aimed to study the cost-effectiveness of MDT for uric acid stones vs. surgical management. Methods: We performed a retrospective study within our institution of all patients receiving MDT for uric acid stones from 2008-2019. All patients had a known history of uric acid stones, urine pH =5.5, and <500 Hounsfield units on preoperative computed tomography (CT). The cost of treatment in the dissolution group was compared to the cost of primary surgical treatment in a theoretical matched cohort. Cost was estimated using local Medicare reimbursement scales. Statistical analysis was performed with SPSS Statistics. Results: A total of 28 patients were identified, of which 18 were included in the study. Complete and partial dissolution occurred in six (33%) and four (22%) patients, respectively. Five (28%) patients developed symptoms and underwent ureteral stent placement. Ureteroscopy and percutaneous nephrolithotomy (PCNL) were each performed in three (17%) patients in whom dissolution treatment was not effective on followup CT. Following dissolution trial, six (33%) patients had residual stone burden requiring surgical intervention. The average cost of treatment, including surgeries, was $14 604 in the dissolution group vs. $17 680 in the surgical cohort. The average cost to achieve stone-free status in patients with complete, partial, or no response to dissolution were $1675, $10 124, and $21 584, respectively, while primary surgical treatment for the same patients would cost $15 037, $10 901, and $20 511, respectively. Conclusions: Successful MDT is highly cost-effective. Incomplete response to dissolution can stem from several reasons and contributes to higher costs and likely decreased quality of life. [ABSTRACT FROM AUTHOR]

Background: Residual fragments (RFs) after percutaneous nephrolithotomy (PCNL) have a significant impact on patients' quality of life and clinical course. There is a paucity of studies that evaluate the natural history of RFs after PCNL. The objective of this study is to compare rates of reintervention, complications, stone growth, and passage in patients with RFs >4, ≤4, and ≤2 mm after PCNL. Methods: Sites from the Endourologic Disease Group for Excellence (EDGE) research consortium examined data of PCNL patients from 2015 to 2019 with at least 1-year follow-up. RF passage, regrowth, reintervention, and complications were recorded and RFs were stratified into >4 and ≤4 mm groups, as well as >2 and ≤2 mm groups. Potential predictors for stone-related events after PCNL were determined using multivariable logistic regression analysis. It was hypothesized that larger RF thresholds would result in lower passage rates, faster regrowth, and greater clinically significant events (complications and reinterventions) than smaller RF thresholds. Results: A total of 439 patients with RFs >1 mm on CT postoperative day 1 were included in this study. For RFs >4 mm, rates of reintervention were found to be significantly higher and Kaplan-Meier curve analysis showed significantly higher rates of stone-related events. Passage and RF regrowth were not found to be significantly different compared with RFs ≤4 mm. However, RFs ≤2 mm had significantly higher rates of passage, and significantly lower rates of fragment regrowth (>1 mm), complications, and reintervention compared with RFs >2 mm. On multivariable analysis, older age, body mass index, and RF size were found to be predictive of stone-related events. Conclusions: With the largest cohort to date, this study by the EDGE research consortium further confirms that clinically insignificant residual fragment is problematic for patients after PCNL, particularly in older more obese patients with larger RFs. Our study underscores the importance of complete stone clearance post-PCNL and challenges the use of Clinically insignificant residual fragment (CIFR).

INTRODUCTION Bladder stones have historically been associated with urinary stasis secondary to bladder outlet obstruction (BOO). Recent studies indicate that the role of BOO in bladder stone formation is minor. We evaluate the role of urinary lithogenic factors in bladder stone formation by comparing the compositions of bladder stones and kidney stones in patients with multi-site urinary calculi., Materials and Methods: We identified patients who were treated for concomitant bladder stones and kidney stones between 2008-2019, and had both stone compositions available. Patients with bladder stone size < 10 mm, urinary foreign bodies, encrusted stents or tumors were excluded. Data regarding urinary symptoms, residual volumes, stone composition and 24-hours urine data were collected., Results: We identified 40 males with a median age of 72 years (IQR 6-14), median residual volume of 76 mL (IQR 41-200), and a median prostate volume of 52 mL (IQR 32-102). Bladder outlet procedures were performed concomitantly with cystolitholapaxy in 21 (53%) patients. The most common bladder stone and kidney stone compositions were CaOx (47.5% and 65%), uric acid (32.5% and 22.5%), calcium phosphate (15% and 10%), and struvite (5% and 2.5%), respectively. Bladder stone and kidney stone compositions were identical in 70% of patients. Bladder stone composition was predictive of kidney stone composition, regardless of the PVR, bladder stone size, or whether an outlet procedure was performed., Conclusion: We found a high concordance between bladder stone and kidney stone composition, suggesting that metabolic abnormalities have a significant role in bladder stone formation. Bladder stone composition can be used to guide surgical and medical treatment for kidney stones in metabolically active stone patients.

Introduction: Studies indicate that with a safety wire in the ureter, an increased amount of force is necessary to advance ureteral access sheaths up to the proximal ureter. Theoretically, the compression of the ureter with the wire could lead to an increase in number and severity of ureteral injuries secondary to placement of a sheath. This prospective study aims to evaluate if there is a correlation between the use of a safety wire and ureteral injury from sheath placement by evaluating the location of the wire in relation to the injury after ureteroscopy., Materials and Methods: Fifty-nine consecutive patients underwent ureteroscopy for upper tract urinary stone disease. A 12/14 French ureteral access sheath was used with a safety wire in place. Ureteroscopy during withdrawal of the sheath was video recorded and reviewed by a blinded observer. Visible ureteral injuries were graded per the Traxer ureteral injury scale and the proximity of the wire to the injury was noted., Results: Thirty-one of 59 patients (52.4%) had a ureteral injury secondary to access sheath placement. Eighteen (30.5%) injuries were low-grade, 13 (22.0%) were high-grade (grade 2 and 3) and there were no grade 4 injuries. A total of 10 (32.3%) injuries occurred on the same side as the wire while 67.7% were on the contralateral side of the ureter. Of the injuries that occurred on the same side as the wire, 80% were grade 1 injuries and 2 (20%) were grade 3. Statistical analysis did not show a significant relationship between high/low injury grade and side of injury (p value = 0.088). This suggests that there is no association of between the safety wire and development of high injury., Conclusion: There is no association between the location of the safety wire and ureteral injury if injury occurs during the placement of a ureteral access sheath. This suggests that the use of a safety wire does not add significant morbidity to the procedure.

Introduction: The Moses technology of the holmium laser has been shown to decrease retropulsion in the ureter and procedural time in kidney stones during laser lithotripsy. Theoretically, these improvements could lead to cost savings for the patient., Materials and Methods: All patients with total laser energy data recorded who underwent ureteroscopy with laser lithotripsy by a single surgeon at a tertiary care center were included. Total lasing time was calculated from the total laser energy. Sub-analyses were done on stone size and stone composition. The procedure time using Moses technology was projected to be approximately 35% less than procedure time without the Moses technology based on prior in vitro studies. The projected cost savings was then utilized to predict cost-effectiveness of the Moses technology., Results: Forty patients underwent ureteroscopy with laser lithotripsy. Mean stones size was 10.2 mm and mean lasing time was 3.02 minutes. Linear regression showed a positive association between stone size and laser time, p = 0.01. There was no significant correlation between stone composition or stone Hounsfield units and lasing time. On cost analyses, for stones of all sizes the Moses system has a price differential of an increase in $292.36 when compared to the standard Holmium TracTip system. Specifically for stones larger than 10 mm, the price differential is an increase in $253.16 for the Moses technology., Conclusion: The decrease in lasing time achieved by the Moses system does not translate into sufficient cost savings to off-set the higher cost of the laser fiber and software.

Introduction: To systemically measure the impact of trainees' participation on the perioperative and functional outcomes after holmium laser enucleation of the prostate (HoLEP)., Materials and Methods: Benign prostatic hyperplasia patients who underwent HoLEP at our department between January 2007 and January 2013 were classified based on trainee's level. Perioperative outcomes and complications were collected. Functional outcomes were assessed using the Sexual Health Inventory for Men (SHIM), International Prostate Symptom Score (IPSS), and International Continence Society-Short Form (ICSmaleSF) questionnaires. Voiding and incontinence domains of ICSmaleSF were assessed separately. Patients were divided into group 1 if no trainee participated in the operation, group 2 if a senior trainee performed the operation, and group 3 if a junior trainee participated in the operation. The patient's baseline characteristics, complications, and perioperative outcomes were compared., Results: There were no differences in the baseline characteristics. There were significant differences in overall operative and enucleation time (p = 0.0186, p = 0.0047, respectively) with shorter times noticed with more experienced operators. There were no differences in resected tissue weight, hemoglobin change, and transfusion rates. Postoperatively, all patients had a similar length of stay and catheterization. Complications (graded by Clavien grading system) were not different. All patients were followed up at regular intervals starting at 6 weeks, 3 months , 6 months, 1 year, and every year after that and there were no differences in flow rates or post void residual volumes at any time point. There were no differences in SHIM, IPSS, and ICSmale voiding scale among the groups. However, ICSmale continence scale was significantly different where the highest score seen in group 2., Conclusion: Trainee participation in HoLEP in a controlled training environment does not compromise the safety of the procedure.