Selling blood and gametes during tough economic times: insights from Google search.

INTRODUCTION: To use Google Insights search volume and publicly available economic indicators to test the hypothesis that sperm, egg, and blood donations increase during economic downturns and to demonstrate the feasibility of using Google search volume data to predict national trends in actual sperm, egg, and blood donations rates. MATERIALS AND METHODS: Cross-correlation statistical analysis comparing Google search data for terms relating to blood, egg, and sperm donations with various economic indicators including the S&P 500 closing values, gross domestic product (GDP), the U.S. Index of Leading Indicators (U.S. Leading Index), gross savings rate, mortgage interest rates, unemployment rate, and consumer price index (CPI) from 2004-2011. A secondary analysis determined the Pearson correlation coefficient between Google search data with actual sperm, egg, and blood donation volume in the U.S. as measured by California Cryobank, the National Assisted Reproductive Technology Surveillance System, and the National Blood Collection and Utilization Survey, respectively. Significance of cross-correlation and Pearson correlation analysis as indicated by p value. RESULTS: There were several highly significant cross-correlation relationships between search volume and various economic indicators. Correlation between Google search volume for the term 'sperm donation,' 'egg donation,' and 'blood donation' with actual number of sperm, egg and blood donations in the United States demonstrated Pearson correlation coefficients of 0.2 (p > 0.10), -0.1 (p > 0.10), and 0.07 (p > 0.10), respectively. Temporal analysis showed an improved correlation coefficient of 0.9 (p < 0.05) for blood donation when shifted 12 months later relative to Google search volume. CONCLUSION: Google search volume data for search terms relating to sperm, egg, and blood donation increase during economic downturns. This finding suggests gamete and bodily fluid donations are influenced by market forces like other commodities. Google search may be useful for predicting blood donation trends but is more limited in predicting actual semen and oocyte donation patterns.

MXD3 regulation of DAOY cell proliferation dictated by time course of activation.

BACKGROUND: MXD3 is a basic-helix-loop-helix-leucine-zipper transcription factor involved in cellular proliferation. In previous studies we demonstrated that knock-down of MXD3 in the human medulloblastoma cell line DAOY resulted in decreased proliferation. Surprisingly, overexpression of MXD3 in DAOY cells also decreased proliferation and increased cell death, suggesting that persistent expression of MXD3 triggers an apoptotic response, perhaps as a fail-safe mechanism. To investigate this apparent paradox in detail we developed a tamoxifen inducible system to analyze the temporal effects of MXD3 in the proliferation and transcriptional response of DAOY cells upon acute induction compared with long-term expression of MXD3. RESULTS: We find that acute induction of MXD3 initially promotes cell cycle progression as assessed by a transient increase in bromodeoxyuridine incorporation. However, persistent induction of MXD3 ultimately results in decreased proliferation based on cell counts. Finally, with microarray expression profiling and gene ontology analysis we identify several major pathways enriched in response to acute (immune response, apoptosis, cell cycle) versus persistent (cell adhesion) MXD3 activation. CONCLUSIONS: In this study, we demonstrate that acute MXD3 activation results in a transient increase in cell proliferation while persistent activation of MXD3 eventually results in an overall decrease in cell number, suggesting that the time course of MXD3 expression dictates the cellular outcome. Microarray expression profiling and gene ontology analysis indicate that MXD3 regulates distinct genes and pathways upon acute induction compared with persistent expression, suggesting that the cellular outcome is specified by changes in MXD3 transcriptional program in a time-dependent manner.

Estimating the risk of chronic kidney disease after nephrectomy.

INTRODUCTION: To identify factors associated with the development of chronic kidney disease (CKD) after nephrectomy and to create a clinical model to predict CKD after nephrectomy for kidney cancer for clinical use. MATERIALS AND METHODS: We identified 144 patients who had normal renal function (eGFR > 60) prior to undergoing nephrectomy for kidney cancer. Selected cases occurred between 2007 and 2010 and had at least 30 days follow up. Sixty-six percent (n = 95) underwent radical nephrectomy and 62.5% (n = 90) developed CKD (stage 3 or higher) postoperatively. We used univariable analysis to screen for predictors of CKD and multivariable logistic regression to identify independent predictors of CKD and their corresponding odds ratios. Interaction terms were introduced to test for effect modification. To protect against over-fitting, we used 10-fold cross-validation technique to evaluate model performance in multiple training and testing datasets. Validation against an independent external cohort was also performed. RESULTS: Of the variables associated with CKD in univariable analysis, the only independent predictors in multivariable logistic regression were patient age (OR = 1.27 per 5 years, 95% CI: 1.07-1.51), preoperative glomerular filtration rate (GFR), (OR = 0.70 per 10 mL/min, 95% CI: 0.56-0.89), and receipt of radical nephrectomy (OR = 4.78, 95% CI: 2.08-10.99). There were no significant interaction terms. The resulting model had an area under the curve (AUC) of 0.798. A 10-fold cross-validation slightly attenuated the AUC to 0.774 and external validation yielded an AUC of 0.930, confirming excellent model discrimination. CONCLUSIONS: Patient age, preoperative GFR, and receipt of a radical nephrectomy independently predicted the development of CKD in patients undergoing nephrectomy for kidney cancer in a validated predictive model.

Prostate size does not predict high grade cancer.

PURPOSE: Several radical prostatectomy series have linked small prostates with high grade cancer based on the hypothesis that a small prostate results from a low androgen milieu that selects for less hormone dependent, more aggressive tumors. We previously reported that this association resulted from ascertainment bias from the performance characteristics of prostate specific antigen rather than from tumor biology in our radical prostatectomy cohort. In this study we analyzed this association in a more generalized population of men who underwent prostate needle biopsy. MATERIALS AND METHODS: The prostate needle biopsy database at our institution was queried for all initial biopsies. Included patient characteristics were age, race, family history of prostate cancer, prostate specific antigen, abnormal digital rectal examination and prostate volume in ml on transrectal ultrasound. Multivariate logistic regression was used to determine the influence of prostate volume on the odds of high grade cancer. RESULTS: The study population included 1,295 patients during 2000 to 2010, of whom 582 (44.9%) had prostate cancer and 398 (30.7%) had high grade cancer. When all patients were pooled, the OR for high grade cancer was 0.85 (95% CI 0.78-0.92) for each 10 ml increase in prostate volume. When patients were divided by clinical T stage, the corresponding ORs for those with T1c disease was 0.83 (95% CI 0.74-0.93) and for those with T2 or greater disease it was 0.99 (0.98-1.00). CONCLUSIONS: The association between small prostates and high grade cancer exists only in men with clinical T1c (normal digital rectal examination) prostate cancer. It likely resulted from ascertainment bias due to the performance characteristics of prostate specific antigen rather than tumor biology.

Radiation exposure during pediatric videourodynamics.

PURPOSE: Videourodynamics is useful for evaluating and treating neurological disorders in children. Traditional urodynamic parameters can be obtained while simultaneous visualization of the urinary system can reveal anatomical anomalies. This additional information comes at the cost of radiation exposure to the child. We characterized radiation exposure from videourodynamics. MATERIALS AND METHODS: We reviewed all recent videourodynamic studies and recorded patient demographics, urological diagnoses, physical attributes, total fluoroscopy time, total radiation exposure in mGy, bladder capacity and the number of filling cycles performed. Multivariate linear regression was used to identify patient factors that independently influenced total radiation exposure. RESULTS: A total of 64 videourodynamic studies were performed in 34 female and 28 male patients with a mean age of 8.6 years (95% CI 7.2-10.0). The most common diagnosis was neurogenic bladder in 40 patients, although 49 had multiple diagnoses. Mean total fluoroscopy time was 1.8 minutes (95% CI 1.4-2.1) and mean total radiation exposure was 10 mGy (95% CI 7.5-13.3). On multivariate linear regression patient weight and bladder capacity were the only independent predictors of total radiation exposure. CONCLUSIONS: Videourodynamics entail significant radiation exposure. Patient weight and bladder capacity were independent predictors of total radiation exposure. Physician awareness of radiation exposure may result in the judicious use of fluoroscopy and aid in counseling parents on the risk of videourodynamics. Further research is needed to quantify organ specific doses of radiation due to medical imaging in children and the associated cancer risks.

Sacral nerve stimulator revision due to somatic growth.

PURPOSE: Sacral nerve modulation is a Food and Drug Administration approved treatment for refractory urgency, frequency, urge incontinence and nonobstructive urinary retention in adults. The sparse literature on sacral nerve modulation in children focuses on its initial efficacy in patients with neurogenic bladder and dysfunctional elimination. We describe our initial experience with sacral nerve modulation and the phenomenon of growth spurts associated with lead malfunction that necessitates revision. MATERIALS AND METHODS: After receiving institutional review board approval we retrospectively reviewed the charts of pediatric patients who underwent sacral nerve modulation surgery at our institution. Charts were examined for patient demographics, subjective success, the need for further surgery and success after revision. RESULTS: Four patients underwent sacral nerve modulation at an average age of 12.1 years. All patients reported initial success, defined as greater than 50% symptom improvement. Subsequently 3 patients required a total of 5 revisions due to lead malfunction with an average of 1.5 years between surgeries. In those requiring revision the average somatic growth between revisions was 8.1 cm. Return of efficacy was reported after each revision. All patients had functioning nerve stimulators in place and continued to have a positive subjective response. CONCLUSIONS: The sparse data on sacral nerve modulation in children shows efficacy and safety similar to those in adults. Somatic growth may be associated with lead malfunction and require surgical revision. We report a small series showing that revision can be done successfully and safely. Informed consent for sacral nerve modulation in pediatric patients should include a discussion of somatic growth as a possible cause of lead malfunction necessitating revision.

The prostate cancer risk calculator from the Prostate Cancer Prevention Trial underestimates the risk of high grade cancer in contemporary referral patients.

PURPOSE: The prostate cancer risk calculator from the Prostate Cancer Prevention Trial estimates the risk of positive biopsy and 1 containing high grade disease (Gleason score 7 or greater) based on prostate specific antigen, digital rectal examination, family history, race and prior negative biopsy. Since data used to create the calculator came from an unreferred population that underwent mainly sextant biopsy, to our knowledge its usefulness in the contemporary urology practice is unknown. MATERIALS AND METHODS: We performed the same multivariate logistic regression used to derive the prostate cancer risk calculator in a cohort of men from the Stanford Prostate Needle Biopsy Database who underwent initial prostate needle biopsy using an extended 12-core scheme. RESULTS: Our predictions of overall prostate cancer risk did not differ significantly from those of the calculator. Prostate specific antigen, abnormal digital rectal examination and family history were independent risk factors. However, our model predicted a much greater risk of high grade disease than the prostate cancer risk calculator. Prostate specific antigen, abnormal digital rectal examination and age were independent risk factors for high grade disease. CONCLUSIONS: The difference between our estimated risk of high grade prostate cancer and that of the prostate cancer risk calculator can be potentially explained by 1) differences between the cohorts (referred vs unreferred) or 2) the difference in grading, ie grading accuracy due to the difference in biopsy schemes or to temporally related grade shifts. Caution should be used when applying the prostate cancer risk calculator to counsel patients referred for suspicion of prostate cancer since it underestimates the risk of high grade disease.

A rare case of adult Wilms' tumor.

Although Wilms tumor is the most common primary renal malignancy in children, it is exceedingly rare in adults and has an estimated incidence of less than 0.2 cases per million. Little is known about the biology of this tumor in adults and clinicians have had to rely on pediatric treatment protocols. Overall, prognosis is worse in adults, though like in children, unfavorable histology and higher stage at presentation confer a worse prognosis.

Alternative Splicing of MXD3 and Its Regulation of MXD3 Levels in Glioblastoma.

The transcription factor MXD3 is an atypical member of the MYC/MAX/MXD transcriptional network and has been previously shown to be an important regulator of cell proliferation. MXD3 has been shown to be overexpressed and to be required for medulloblastoma and acute lymphoblastic leukemia cell proliferation. In this study we leveraged datasets from The Cancer Genome Atlas to examine MXD3 across several cancers. We find that MXD3 transcripts are significantly overexpressed in ~72% of the available datasets. The gene itself is not frequently altered, while the promoter appears to be hypomethylated. We examine the possibility that aberrant regulation of the MXD3 message is the cause of abnormal MXD3 expression across cancers. Specifically, we looked at MXD3 alternative splicing in glioblastoma multiforme (GBM) and find notable functional differences between the splice variants. The 3'UTR confers differential message stability. Furthermore, the different coding sequences lead to different protein stabilities and localizations. Altogether, these data extend our knowledge of MXD3 in the context of human cancers while characterizing a previously unstudied splice variant of MXD3.

Is Neurogenic Bladder a Risk Factor for Febrile Urinary Tract Infection After Ureteroscopy and, if so, Why?

OBJECTIVE: To characterize the rate of febrile urinary tract infections (UTIs) after ureteroscopy in patients with neurogenic bladder compared with those with physiologically normal bladders. Although generally considered safe and effective, there is a growing body of evidence suggesting that patients with neurogenic bladder are at an increased risk of infectious complications following ureteroscopy. METHODS: We performed a retrospective chart review of those undergoing ureteroscopy in a single academically affiliated hospital system between June 2013 and May 2016. Information regarding neurogenic bladder status, culture results, bladder management, and the presence of upper tract decompression was collected. Postoperative febrile UTI was defined as a hospital admission within 1 week of surgery because of fever not attributable to another source. RESULTS: Of 467 ureteroscopies, 44 (9.5%) were performed in the setting of neurogenic bladder. Febrile UTI rates were higher in patients with neurogenic bladder compared with control patients (9% vs 1.4%, P = .01) with significantly higher rates in those dependent on bladder catheterization. Interestingly, the presence of a nephrostomy tube in patients with physiologically normal bladders increased the risk of postoperative febrile UTI to levels comparable with patients with neurogenic bladder who were catheter dependent (10.5% vs 12.5%, respectively). CONCLUSION: Although infectious complications in the neurogenic population are likely multifactorial, the reliance on catheterization and thus colonization appears to be a significant factor and extends to non-neurogenic patients. These data suggest that bacterial colonization may be the significant underlying risk factor for febrile UTI after ureteroscopy.

Preclinical Testing of a Combination Stone Basket and Ureteral Balloon to Extract Ureteral Stones.

We have developed the Peralta Stone Extraction System to increase the safety of ureteral stone extraction. The device combines a nitinol stone basket and low-pressure balloon into a single device. After visualization, the stone is captured in the tipless nitinol basket and enveloped by a low-pressure balloon. We tested the performance of device prototypes in a porcine model using stone mimics with diameters ranging from 4.2 to 6.2 mm. Stones extracted with the device required less force when compared with stones in a standard ureteral stone basket. The force reduction was most pronounced for stones greater than 4.2 mm in diameter, and when traversing a ureteral stenosis model. In conclusion, a combination stone basket and balloon device may provide a new and safer way to extract ureteral stones.

In vitro assessment of chemotherapy-induced neuronal toxicity.

Neurotoxicity is a major concern during drug development, and together with liver and cardio-toxicity, it is one of the main causes of clinical drug attrition. Current pre-clinical models may not sufficiently identify and predict the risk for central or peripheral nervous system toxicity. One such example is clinically dose-limiting neuropathic effects after the administration of chemotherapeutic agents. Thus, the need to establish novel in vitro tools to evaluate the risk of neurotoxicities, such as neuropathy, remains unmet in drug discovery. Though in vitro studies have been conducted using primary and immortalized cell lines, some limitations include the utility for higher throughput methodologies, method reproducibility, and species extrapolation. As a novel alternative, human induced-pluripotent stem cell (iPSC)-derived neurons appear promising for testing new drug candidates. These iPSC-derived neurons are readily available and can be manipulated as required. Here, we describe a novel approach to assess neurotoxicity caused by different classes of chemotherapeutics using kinetic monitoring of neurite dynamic changes and apoptosis in human iPSC-neurons. These studies show promising changes in neurite dynamics in response to clinical inducers of neuropathy, as well as the ability to rank-order and gather mechanistic insight into class-specific compound induced neurotoxicity. This platform can be utilized in early drug development, as part of a weight of evidence approach, to screen drug candidates, and potentially reduce clinical attrition due to neurotoxicity.

Biomarkers of renal cell carcinoma.

The incidence of renal cell carcinoma (RCC) has increased steadily in past few decades and is partially attributable to the increased utilization of cross-sectional imaging. Many of these carcinomas are small incidental discoveries, although a subset leads to locally advanced or distant disease. Although its molecular pathophysiology is not completely understood, knowledge of hereditary RCCs has shed light on some of the pathways involved. More recently, the rapid advances in genomics, proteomics, and metabolomics have allowed for a deeper and more nuanced understanding of the genetic aberrations that lead up to and result from the transformation of a renal tubular epithelial cell into a carcinoma. These discoveries have allowed for the development of novel therapeutics that target these pathways. They have also led to the development of diagnostic, prognostic, and predictive biomarkers that could radically change the way RCC is diagnosed and treated. Although some of the current investigations are nascent and it remains to be seen which biomarkers will become clinically available, many candidate biomarkers show promise and require external validation. Ultimately, biomarkers may allow for cost-effective screening of high-risk patients, the identification of aggressive cancers among small renal masses, the identification of high-risk patients, the detection of recurrences postoperatively with minimal imaging, and the ability to choose appropriate targeted therapies for patients with metastatic disease.

Complications of intravesical bacillus calmette-guérin.

Intravesical Bacillus Calmette-Guérin (BCG) is an important treatment for the management of non-muscle invasive bladder cancer because of its proven efficacy and favourable safety profile. The most common complications associated with BCG treatment are relatively minor. They include urinary frequency, cystitis, fever, and hematuria. Although serious complications are rare, patients can develop severe, life-threatening sepsis with disseminated mycobacterial infection. We report a rare case of periurethral diverticulum formation after intravesical BCG and review the literature on the potential complications of this treatment modality.

A comparison of calcium hydroxyapatite and dextranomer/hyaluronic Acid for the endoscopic treatment of vesicoureteral reflux.

Purpose. Minimal data exists comparing dextranomer/hyaluronic acid (Dx/HA) and calcium hydroxyapatite (CaHA) for the endoscopic treatment of VUR in the hands of a single user. Materials and Methods. We reviewed our consecutive single-user case series of 27 children (42 ureters) receiving endoscopic treatment with CaHA and 21 children (33 ureters) who received Dx/HA injection. Children receiving CaHA injections were divided into two groups of 13 and 14 patients (Coaptite I and II) to assess the learning curve effects. Postoperatively, RBUS and VCUG were performed. Multiple regression analysis was performed to assess statistical significance of success rates. Results. The total CaHA group had a per-ureter success rate (Grade 0) of 52% after one injection. When separated into two cohorts, the single injection per-ureter success rates were 43% for Coaptite I and 62% for Coaptite II. In contrast, the Dx/HA series had a single injection per-ureter success rate (Grade 0) of 78%. Conclusions. Our consecutive case experience shows improved results for Dx/HA compared to CaHA, though the learning curve effects and evolution of injection technique likely played a role in the improved outcomes in the Dx/HA cohort. A randomized controlled multicenter trial would provide the most accurate data comparing these two agents.

The accordion antiretropulsive device improves stone-free rates during ureteroscopic laser lithotripsy.

PURPOSE: The Accordion is a novel endoscopic device that prevents retropulsion of ureteral stones and their fragments during ureteroscopic laser lithotripsy. We describe our experience with its use focusing on three main endpoints: operating time, fluoroscopy time, and stone-free rates. METHODS: Of 308 consecutive cases of unilateral ureteroscopic laser lithotripsy from 2006-2010, we analyzed 235 cases of ureteral stones. Chart review was performed to document patient demographics (age, sex, and race), stone characteristics (stone size, density, laterality, location, and multiplicity), operative characteristics (use of preoperative and/or postoperative stents, ureteral balloon dilators, ureteral access sheaths, the Holmium laser, and the Accordion device), and surgical outcomes (operative time, fluoroscopy time, stone-free status, and complications). RESULTS: The baseline characteristics between the Accordion and non-Accordion group were statistically similar. In univariate nonparametric tests of medians, Accordion device usage was not associated with a significant reduction in fluoroscopy time (median 1.68 vs. 1.95 minutes, p=0.28) or operating time (median 52.5 vs. 61 minutes, p=0.19). However, the stone-free rate for the Accordion group was significantly higher compared to the non-Accordion group (84.2% vs. 53.6%, p=0.001). In multivariate generalized linear models, Accordion usage was not associated with decreased operating or fluoroscopy times. Accordion use was associated with statistically significant greater odds of stone-free status (odds ratio 4.35, 95% confidence interval 2.36-8.00). Complication severity and rates were comparable between the two groups. CONCLUSIONS: The Accordion antiretropulsive device improves stone-free rates during ureteroscopic laser lithotripsy. Prospective studies are needed to validate these results.

Smoking and adverse outcomes at radical prostatectomy.

BACKGROUND: Multiple large epidemiologic studies have examined the relationship between smoking and prostate cancer incidence and mortality only to arrive at contradictory results. In this series, we studied the effect of smoking on pathologic outcomes and biochemical recurrence in a cohort of men undergoing radical prostatectomy. METHODS: We identified 630 men who underwent radical prostatectomy between 1989 and 2005 who had detailed smoking histories. There were 321 smokers and 309 nonsmokers. Pathologic outcomes included prostate weight, volume of cancer, volume of high grade cancer, margin status, seminal vesicle involvement, extraprostatic extension, perineural invasion, angiolymphatic invasion, and the presence of nodal metastasis. Biochemical recurrence was defined as a postoperative PSA ≥ 0.1 ng/ml. Univariate analysis and multivariate linear and Cox regression were used to study the impact of smoking on these outcomes. RESULTS: The volume of cancer (2.54 vs. 2.16 ml, P = 0.016) and the volume of high grade cancer (0.58 vs. 0.28 ml, P = 0.004) were greater in smokers compared with nonsmokers. Smoking independently predicted greater volumes of cancer and high grade cancer in multivariate analysis. Heavy smokers (≥20 pack-year history) had a greater risk of biochemical recurrence on univariate survival analysis. Smoking also predicted a greater risk of biochemical recurrence on Cox regression, the magnitude of which was approximately 1% per pack-year smoked. CONCLUSIONS: Smoking is associated with adverse pathologic features and a higher risk of biochemical recurrence in men undergoing radical prostatectomy. If confirmed by additional studies, smoking history may need to be included into risk assessment models.

Role of MXD3 in proliferation of DAOY human medulloblastoma cells.

A subset of medulloblastomas, the most common brain tumor in children, is hypothesized to originate from granule neuron precursors (GNPs) in which the sonic hedgehog (SHH) pathway is over-activated. MXD3, a basic helix-look-helix zipper transcription factor of the MAD family, has been reported to be upregulated during postnatal cerebellar development and to promote GNP proliferation and MYCN expression. Mxd3 is upregulated in mouse models of medulloblastoma as well as in human medulloblastomas. Therefore, we hypothesize that MXD3 plays a role in the cellular events that lead to medulloblastoma biogenesis. In agreement with its proliferative role in GNPs, MXD3 knock-down in DAOY cells resulted in decreased proliferation. Sustained overexpression of MXD3 resulted in decreased cell numbers due to increased apoptosis and cell cycle arrest. Structure-function analysis revealed that the Sin3 interacting domain, the basic domain, and binding to E-boxes are essential for this activity. Microarray-based expression analysis indicated up-regulation of 84 genes and down-regulation of 47 genes. Potential direct MXD3 target genes were identified by ChIP-chip. Our results suggest that MXD3 is necessary for DAOY medulloblastoma cell proliferation. However, increased level and/or duration of MXD3 expression ultimately reduces cell numbers via increased cell death and cell cycle arrest.

Tracking intraoperative fluoroscopy utilization reduces radiation exposure during ureteroscopy.

PURPOSE: Recent studies have demonstrated deleterious effects of ionizing radiation from diagnostic and therapeutic imaging procedures. One of the barriers to minimizing patient exposure is physician awareness. We prospectively studied whether providing surgeons with feedback on their fluoroscopy utilization would affect intraoperative fluoroscopy times. MATERIALS AND METHODS: In 2007, we prospectively began to track fluoroscopy usage for all urology cases. Nine months later, surgeons started to receive periodic reports with their mean fluoroscopy time compared with their peers. We reviewed all ureteroscopic cases for nephrolithiasis from the date tracking began (2006-2010, n = 311). Using the initial 9-month period as a control, we studied the effect of providing feedback on mean fluoroscopy times in subsequent periods and analyzed patient factors that may affect radiation exposure. RESULTS: Mean fluoroscopy times for unilateral ureteroscopy decreased by 24% after surgeons received feedback (2.74-2.08 minutes, p = 0.002). On multivariate analysis, factors that independently predicted decreased fluoroscopy times included female sex (p = 0.02), stones in the distal ureter (p = 0.04), and if the surgeon had received feedback (p = 0.0004). Factors that increased fluoroscopy times included the presence of hydronephrosis (p = 0.001), use of a ureteral access sheath (p = 0.04), ureteral balloon dilation (p = 0.0001), and placement of a postoperative stent (p = 0.002). CONCLUSIONS: Providing surgeons with feedback on their fluoroscopy usage reduces patient and surgeon radiation exposure. Implementing such a tracking system requires minimal changes to existing operating room staff workflow. Further study is warranted to study the impact of this program on other procedures that utilize fluoroscopy in urology and other specialties.