Any Questions? Understanding the Functional Health Literacy in Patients Who Underwent Ureteroscopy.

OBJECTIVE: To correlate health literacy of patients undergoing ureteroscopy and identify gaps within current patient education practices in order to better tailor the preoperative experience. METHODS: Eighteen patients were retrospectively recruited to complete an in-depth semistructured interview and the Test of Functional Health Literacy for Adults (TOFHLA). All interviews were recorded, transcribed, and then coded and analyzed using the grounded theory of analysis. RESULTS: The average participant age was 56.2 ± 12.8years, and 10 (55.6%) identified as female. Education level ranged from some high school to a professional degree. The average TOFHLA score was 88.1 ± 11.7. Irrespective of score, all participants felt they understood the purpose and basic elements of a ureteroscopy. The use of nontechnical language, repetition, and previous healthcare experiences were identified as positive aspects of the education experience. However, 72.2% (n = 13) identified the primary gap in understanding revolved around the use, purpose, and pain associated with stents. CONCLUSION: Functional health literacy is an essential element, but not the only factor informing patient education and comprehension. Current practices are effective in explaining the basics of a ureteroscopy, but even when identified health literacy is higher than expected, a gap remains in stent education. Efforts should be made to better understand how stents can be effectively explained to patients in addition to continuing to refine education practices to elicit true comprehension.

Robot-assisted laparoscopic removal of an extraperitoneal pelvic solitary fibrous tumor.

•Pelvic SFTs are rare, typically benign soft tissue neoplasms that pose a diagnostic challenge for gynecologists.•Retroperitoneal pelvic SFTs can mimic gynecologic malignancies and should be considered in diagnosis of a solitary pelvic mass.•Pathologic diagnosis is typically confirmed by immunohistochemistry staining positively for CD34 and STAT6.•Complete surgical excision is recommended for these tumors and can be completed with a minimally invasive approach.•Close long-term follow-up is necessary due to possible recurrence or metastasis, especially for high-risk pathologic features.

Heterogeneity in stone culture protocols and endourologist practice patterns: a multi-institutional survey.

Kidney stone cultures can be beneficial in identifying bacteria not detected in urine, yet how stone cultures are performed among endourologists, under what conditions, and by what laboratory methods remain largely unknown. Stone cultures are not addressed by current clinical guidelines. A comprehensive REDCap electronic survey sought responses from directed (n = 20) and listserv elicited (n = 108) endourologists specializing in kidney stone disease. Questions included which clinical scenarios prompt a stone culture order, how results influence post-operative antibiotics, and what microbiology lab protocols exist at each institution with respect to processing and resulting stone cultures. Logistic regression statistical analysis determined what factors were associated with performing stone cultures. Of 128 unique responses, 11% identified as female and the mean years of practicing was 16 (range 1-46). A specific 'stone culture' order was available to only 50% (64/128) of those surveyed, while 32% (41/128) reported culturing stone by placing a urine culture order. The duration of antibiotics given for a positive stone culture varied, with 4-7 days (46%) and 8-14 days (21%) the most reported. More years in practice was associated with fewer stone cultures ordered, while higher annual volume of percutaneous nephrolithotomy was associated with ordering more stone cultures (p < 0.01). Endourologists have differing practice patterns with respect to ordering stone cultures and utilizing the results to guide post-operative antibiotics. With inconsistent microbiology lab stone culture protocols across multiple institutions, more uniform processing is needed for future studies to assess the clinical benefit of stone cultures and direct future guidelines.

Identifying a Break in the Chain: An Analysis of Where Ureteroscope Damage Occurs in the Hospital Cycle.

OBJECTIVE: To assess the timing and variables associated with damage to flexible ureteroscopes (fURS) at our institution. Flexible ureteroscopy is an important modality in the treatment of benign and malignant conditions of the upper urinary tract. While the durability and versatility of fURS have improved considerably, repair costs remain high and time out of commission diminishes workflow. After purchasing new digital fURS, we studied how and when these instruments were being damaged. MATERIALS AND METHODS: Between September 1, 2017 and June 30, 2018, we performed leak testing on fURS both before and after use. We gathered intraoperative data related to the user, the surgical indication, and the associated tools used in all cases that employed a digital or fiber optic fURS. Categorical and continuous variables were analyzed to identify risk factors for intraoperative fURS damage. RESULTS: During the study period, complete data was gathered for 281 cases. Twenty-two fURS failed leak testing indicating an overall leak failure rate of 7.8%. Of these, 15 failed leak testing preoperatively indicating nonoperative damage occurring sometime during transport, handling, or sterile processing. The other 7 failures occurred during the procedures. No intraoperative variables were significantly associated with failures. CONCLUSION: Our institutional leak failure rate is 8% (22/281). The majority of these failures did not occur during surgery. Of the 7 that occurred during surgery, larger stone burden and higher wattage showed mild association. Ongoing evaluation will target minimizing fURS damage outside of the operating room.

Examining and Understanding Value: The Cost of Preoperative Characteristics, Intraoperative Variables and Postoperative Complications of Minimally Invasive Partial Nephrectomy.

INTRODUCTION: As value based health care gains favor and reimbursement models move toward quality rather than quantity of care, a better understanding of cost and its predictors becomes increasingly important. We identified how preoperative characteristics, intraoperative variables and postoperative complications impact the cost of partial nephrectomy. METHODS: Our institution's ACS NSQIP® (American College of Surgeons National Surgical Quality Improvement Program) database was accessed for minimally invasive partial nephrectomy performed from January 2012 to March 2017. Perioperative and financial data were collected through retrospective chart review. Total cost and direct cost were analyzed relative to clinical variables. RESULTS: A total of 215 minimally invasive partial nephrectomies were included in the study. Median total cost was $17,000 and median direct cost was $11,500. Among preoperative characteristics age 56 to 65 years and diabetes were associated with an increased median direct cost of $2,000 and $800, respectively. ASA® (American Society of Anesthesiologists®) class III was associated with an increased direct cost of $1,400 compared to ASA class I-II. Among intraoperative variables increased operative duration was associated with increased direct cost. Robot-assisted cases increased direct cost by $3,000. Estimated blood loss greater than 250 cc was associated with an increased direct cost of $800. R.E.N.A.L. score did not affect cost parameters. Patients who experienced any postoperative complications had an increased direct cost compared to those who did not. Blood transfusions were associated with an increased direct cost of $3,700 and unplanned reintubation $14,500. On multivariable analysis age, operative duration, robot use and complications retained significance. CONCLUSIONS: Age, diabetes, ASA class, operative duration, estimated blood loss, robot use and postoperative complications are associated with increased cost. Increased understanding of cost predictors can be used to optimize perioperative care and value, and contribute to improved alternative reimbursement models.

Automated Computer Software Compared with Manual Measurements for CT-Based Urinary Stone Metrics: An Evaluation Study.

INTRODUCTION AND OBJECTIVE: Stone size guides treatment decisions, yet there is no standard method for measuring stone size. Prior work has shown significant variability in manual stone measurements. We tested a novel stone software program designed to provide an automated and objective comprehensive CT-based stone profile. METHODS: Urinary stones identified on CT imaging were manually measured to obtain linear size and maximal stone density (in Hounsfield unit [HU]). Manual stone volume was calculated using the formula 0.52 × length × width × height. The same stones were assessed with computer software capable of automatically providing stone length, density, and volume. Computer measurements were compared with manual measurements. RESULTS: Eighty-five stones were identified on 42 CT scans from 17 patients. Manual measurements showed an average length of 8 mm (range 1.9-21 mm), average maximal density of 686 HU (126-1492 HU), and average stone volume of 192 mm3 (2.9-2555 mm3). Automated computer measurements did not differ from manual measurements for density (755 HU vs 686 HU, p = 0.18) and volume (183 mm3 vs 192 mm3, p = 0.86. Automated length was slightly longer then manual length (10 mm vs 8 mm, p < 0.003). The mean percent differences between manual and automated metrics were 14.3% for density, 21.0% for volume, and 25.2% for length. CONCLUSION: Automated stone measurements can be accomplished quickly and precisely with dedicated software that can assess stones of varying size as well as stones with complex geometry. This software eliminates interobserver variability and offers a comprehensive stone profile with which to make clinical decisions.

Prospective evaluation of flexible ureteroscopes with a novel evaluation tool.

INTRODUCTION: Assess the function and handling in the clinical setting of three different types of reusable or disposable ureteroscopes using a novel, comprehensive flexible ureteroscope evaluation tool. MATERIALS AND METHODS: Urologists used a fiberoptic (Olympus URF-P5/P6), digital reusable (Storz Flex Xc), or a new digital disposable ureteroscope (Boston Scientific LithoVue) during ureteroscopic laser lithotripsy. An investigator-designed evaluation tool was used to prospectively assess the performance and handling of the ureteroscopes related to user comfort, maneuverability, efficiency, and various mechanical qualities. After each procedure, surgeons involved in each case who used the ureteroscope completed the written evaluation of the ureteroscope he/she used independently of one another. RESULTS: We reviewed 79 evaluations that were completed after 34 surgical cases; residents and post-graduate MDs were involved in each case. On the characteristics evaluated, significant differences between ureteroscopes were noted. The Storz reusable digital ureteroscope received the highest ratings overall while the new LithoVue disposable ureteroscope generally scored lowest. Our evaluation tool demonstrated good internal consistency, suggesting reliable results. Ureteroscope maneuverability correlated most to overall satisfaction. CONCLUSION: The clinical evaluation of flexible ureteroscopes for stone removal is critical in equipment purchase decision-making and in planning surgical approaches. We created a comprehensive evaluation tool to standardize and quantify the assessment of ureteroscopes used at our institution. Results revealed significant differences between ureteroscopes for several user and performance characteristics and good reliability of the evaluation tool itself.

In Vitro Comparison of Stone Fragmentation When Using Various Settings with Modern Variable Pulse Holmium Lasers.

INTRODUCTION AND OBJECTIVE: There are limited data regarding optimal laser and energy settings during stone fragmentation. We assessed effects on fragmentation using a variety of energy and frequency settings with two laser systems. METHODS: Artificial stones were created using BegoStone. A clear polyvinylchloride (PVC) tube with an inner diameter of 13 mm was closed at one end with a removable plug to create the in vitro ureteral and caliceal environments. The Lumenis Pulse 120H and the Cook Rhapsody H-30 holmium lasers were studied in the caliceal and ureteral models. A single urologist fragmented each stone to <2 mm. The caliceal studies assessed the time to fragmentation (n = 56). The ureteral studies measured the retropulsion distance of each stone phantom after 5 minutes of laser treatment time using different pulse width settings (n = 15). RESULTS: Complete treatment of the stone with the 120H required 10.9 minutes at ≥1 J vs 26.9 minutes at <1 J (p < 0.001). The H-30 showed similar results with treatment times of 11.2 minutes at ≥1 J vs 22.8 minutes at <1 J (p < 0.001). There was no significant difference in treatment time when comparing the two lasers using settings of 0.8 J × 8 Hz and 1.5 J × 10 Hz (25.5 minutes vs 24.8 minutes, p = 0.861; and 13.2 minutes vs 9.5 minutes, p = 0.061; respectively). Retropulsion distances using the 120H were 13.9 cm using long pulse, 25.2 cm using medium pulse, and 56.6 cm using short pulse. Retropulsion distances using the H-30 laser were 7 cm using long pulse and 14.5 cm using short pulse, which differed from the 120H (p < 0.001). CONCLUSIONS: Laser fragmentation was faster with both lasers when energy settings of ≥1 J were used. Treatment times using the 120H and the H-30 lasers were equivalent. Retropulsion distances were less with both lasers when longer pulse widths were used. The H-30 resulted in less stone retropulsion compared with the 120H.

A survey of patient preferences regarding medical expulsive therapy following the SUSPEND trial.

INTRODUCTION: Several recent trials have reported limited benefit for medical expulsive therapy (MET) in terms of stone passage rates, analgesic requirements, or need for intervention. We evaluated patient attitudes regarding MET after explaining these new findings. MATERIALS AND METHODS: Over a 12 week period, an investigator-designed survey was offered to sequential patients during routine appointments in our urologic clinic. A brief summary of the conflicting data for MET was provided. Patients then answered questions about their attitudes toward using MET. RESULTS: Patients (n = 200; 103 M, 97 F) were 56 ± 14 years old (range 20-103 years) and were mostly being seen for management of kidney stones (88%). Forty-nine percent reported they would try tamsulosin despite the new data; 26% said they would not, and 25% were unsure. Of patients indicating they would take tamsulosin, 35% stated they would also be willing to take steroids. Thirty-five percent of patients said they were willing to pay the full price of tamsulosin if needed. Seventy-one percent said they would prefer to try medical therapy prior to pursuing surgical therapy, again, despite new evidence regarding the efficacy of MET. CONCLUSION: In this initial report of patient attitudes about MET after SUSPEND trial results, we found that nearly half of patients would still try MET and that the vast majority of patients prioritize medical over surgical therapy when possible. As new research emerges, ways to translate this information to patients and to assess their attitudes and perceptions should be developed.

In Vitro Comparison of Holmium Lasers: Evidence for Shorter Fragmentation Time and Decreased Retropulsion Using a Modern Variable-pulse Laser.

OBJECTIVE: To compare the performance of variable- and fixed-pulse lasers on stone phantoms in vitro. MATERIALS AND METHODS: Seven-millimeter stone phantoms were made to simulate calcium oxalate monohydrate stones using BegoStone plus. The in vitro setting was created with a clear polyvinyl chloride tube. For each trial, a stone phantom was placed at the open end of the tubing. The Cook Rhapsody H-30 variable-pulse laser was tested on both long- and short-pulse settings and was compared to the Dornier H-20 fixed-pulse laser; 5 trials were conducted for each trial arm. Fragmentation was accomplished with the use of a flexible ureteroscope and a 273-micron holmium laser fiber using settings of 1 J × 12 Hz. The treatment time (in minute) for complete fragmentation was recorded as was the total retropulsion distance (in centimeter) during treatment. Laser fibers were standardized for all repetitions. RESULTS: The treatment time was significantly shorter with the H-30 vs the H-20 laser (14.3 ± 2.5 vs 33.1 ± 8.9 minutes, P = .008). There was no difference between the treatment times using the long vs short pulse widths of the H-30 laser (14.4 ± 3.4 vs 14.3 ± 1.7 minutes, P = .93). Retropulsion differed by laser type and pulse width, H-30 long pulse (15.8 ± 5.7 cm), H-30 short pulse (54.8 ± 7.1 cm), and H-20 (33.2 ± 12.5 cm) (P <.05). CONCLUSION: The H-30 laser fragmented stone phantoms in half the time of the H-20 laser regardless of the pulse width. Retropulsion effects differed between the lasers, with the H-30 causing the least retropulsion. Longer pulse widths result in less stone retropulsion.