Ultrasound-Only Percutaneous Nephrolithotomy Is Safe and Effective Compared to Fluoroscopy-Directed Percutaneous Nephrolithotomy.

Introduction: Outcomes after ultrasound-only percutaneous nephrolithotomy (PCNL), in which no fluoroscopy is used, are not well known. The goal of this study was to compare outcomes of ultrasound-only and fluoroscopy-directed PCNL. Materials and Methods: Prospectively collected data from the Registry for Stones of the Kidney and Ureter database were reviewed for all patients who underwent PCNL at one academic center from 2015 to 2021. Primary outcomes were complications and stone-free rates (no residual fragments ≥3 mm). Results: Of the 141 patients who underwent ultrasound-only PCNL and 147 who underwent fluoroscopy-directed PCNL, there was no difference in complication rates (15% vs 16%, p = 0.87) or stone-free status (71% vs 65%, p = 0.72), respectively. After adjusting for body mass index, American Society of Anesthesiologists (ASA), stone size, and stone complexity by Guy score, ultrasound-only PCNL was not associated with any increased odds of complications (odds ratio [OR] 0.7, 95% confidence interval [CI] 0.3-1.6, p = 0.41) or residual stone fragments ≥3 mm (OR 1.0, 95% CI 0.5-1.9, p = 0.972) compared with fluoroscopy-directed PCNL. Ultrasound-only PCNL was associated with shorter operative time (median 99.5 vs 126 minutes, p < 0.001), and the use of ultrasound remained a significant predictor of short operative time (<100 minutes) after controlling for supine positioning, stone size, and stone complexity by Guy score (OR 2.31, 95% CI 1.01-5.29, p = 0.048). Patients in the ultrasound-only group were spared a mean radiation exposure dose of 10 mGy per procedure. Conclusions: Ultrasound-only PCNL is safe and achieves similar stone-free rates compared with fluoroscopy-directed PCNL with the added benefit of avoidance of radiation.

Association of vesicoureteral reflux and gastroesophageal reflux disease in children: A population-based study.

INTRODUCTION: Practitioners have anecdotally hinted at a possible association between gastroesophageal reflux disease (GERD) and vesicoureteral reflux (VUR). We sought to identify an association in diagnosis between GERD and VUR using a population-based dataset in a well-defined geographic area covered by a single-payer healthcare system. METHODS: A retrospective review of individuals aged 0-16 years registered in the Nova Scotia Medical Service Insurance database from January 1997 to December 2012 was completed. Presence of GERD and VUR were ascertained based on billing codes. The baseline prevalence of GERD and VUR was calculated for this population for the same time period. Proportions of VUR patients with and without GERD were compared. The risk of being diagnosed with VUR in patients with GERD controlling for sex was calculated. RESULTS: Of 404 300 patients identified, 6.6% had a diagnosis of GERD (n=27 092), 0.33% had a diagnosis of VUR (n=1348), and 0.08% were diagnosed with both (n=327). Among patients with VUR, the prevalence of GERD was 24.3% compared to 6.6% in patients without VUR (p<0.0001). Among patients with GERD, the prevalence of VUR was 1.2% compared to 0.27% in patients without (p<0.0001). The risk of being diagnosed with VUR was higher in the presence of GERD (odds ratio [OR] 4.49; 95% confidence interval [CI] 3.96-5.09; p<0.0001), irrespective of sex. CONCLUSIONS: The odds of being diagnosed with VUR is more than 4.5 times higher in an individual with GERD. The clinical significance of this association remains to be explored.

Increased risk of new persistent opioid use in pediatric and young adult patients with kidney stones.

INTRODUCTION: Adolescents and young adults are a vulnerable patient population for development of substance use disorder. However, the long-term impact of opioid prescribing in young adult patients with renal colic is not known. Our objective was to describe rates of opioid prescription and identify risk factors for persistent opioid use in patients age 25 years or younger with renal colic from kidney stones. METHODS: Using previously validated, linked administrative databases, we performed a population-based, retrospective cohort study of opioid-naive patients age 25 years or younger with renal colic between July 1, 2013 and September 30, 2017 in Ontario. All family practitioner, urgent care, and specialist visits in the province were captured. Our primary outcome was persistent opioid use, defined as filling a prescription for an opioid between 91 and 180 days after initial visit. Ontario uses a narcotic monitoring system, which captures all opioids dispensed in the province. RESULTS: Of the 6962 patients identified, 56% were prescribed an opioid at presentation and 34% of those were dispensed more than 200 oral morphine equivalents. There was persistent opioid use in 313 (8.1%) patients who filled an initial opioid prescription. In adjusted analysis, those prescribed an opioid initially had a significantly higher risk of persistent opioid use (odds ratio [OR] 1.85; 95% confidence interval [CI] 1.50-2.29) and opioid overdose (OR 3.45; 1.08-11.04). There was a dose-dependent increase in risk of persistent opioid use with escalating initial opioid dose. History of mental illness (OR 1.32; 1.02-1.71) and need for surgery (OR 1.71; 1.24-2.34) were also associated with persistent opioid use. CONCLUSIONS: Among patients with kidney stones age 25 years or younger, filling an opioid prescription after presentation is associated with an increased risk of persistent opioid use 3-6 months later and a higher risk of serious long-term complications, such as opioid overdose.

Persistent Opioid Use Among Patients with Urolithiasis: A Population based Study.

BACKGROUND: Urolithiasis can result in acute, short-lived pain for which opioids are often prescribed. The risk of persistent opioid use following an initial presentation for urolithiasis is unknown. OBJECTIVE: To describe rates of opioid prescription and identify risk factors for persistent opioid use among patients with urolithiasis. DESIGN, SETTING, AND PARTICIPANTS: This was a population-based study of all patients diagnosed with urolithiasis in Ontario between 2013 and 2017 using administrative databases. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary outcome was persistent opioid use, defined as dispensing of opioids between 91 and 180 d after presentation. Multivariable logistic regression and Cox proportional hazard models were used to identify factors associated with outcomes. RESULTS AND LIMITATIONS: Of 101 896 previously opioid-naïve patients, 66% were prescribed opioids at diagnosis and 41% of those were dispensed more than 200 oral morphine equivalents (OMEs). For those patients prescribed opioids, 9% had continued use. In adjusted analysis, the number of health care visits and having a stone intervention were associated with a higher risk of persistent opioid use (p< 0.0001). Total OME dispensed at presentation was highly associated with persistent use: for >300 OME the odds ratio (OR) was 1.59 (95% confidence interval [CI] 1.41-1.79). Among those who had an intervention, the number and type of procedure were also associated with persistent use: the OR for shockwave lithotripsy compared to ureteroscopy was 1.65 (95% CI 1.42-1.92). This study is limited by the accuracy of the diagnostic and procedural administrative codes available. CONCLUSIONS: The majority of urolithiasis patients were prescribed opioids and 9% of previously opioid-naïve patients exhibited persistent opioid use 91-180 d after their initial urolithiasis visit. PATIENT SUMMARY: In this study we found that 9% of patients prescribed opioids at presentation for kidney stones filled an additional prescription 3-6 mo later. Risk factors for this continued use included a higher dose of opioids prescribed in the initial period and the type of kidney stone surgery.

Anesthetic technique and oncological outcomes in urology: A clinical practice review.

INTRODUCTION: There is increasing awareness that different anesthetic and analgesic techniques may impact outcomes after oncological surgery, generally through modifying effects on the immune system but potentially via other mechanisms including mitigating the surgical stress response. This narrative review aims to summarize the mechanisms underlying the effect of perioperative factors on oncological outcomes, with an emphasis on the available urologic literature. METHODS: Literature on anesthetic technique (i.e., general vs. regional) and oncological outcomes were reviewed with a particular focus on urological studies. RESULTS: In prostate cancer surgery, the risk of mortality has been reported to be reduced with the use of regional (i.e., neuraxial) anesthesia, but there was no association between anesthetic technique and progression-free or biochemical recurrence-free survival. In nonmuscle invasive bladder cancer, regional anesthesia has been associated with lower recurrence rates and longer time to recurrence following transurethral resection of bladder tumor. CONCLUSIONS: This review highlights the role of regional anesthesia to improve oncoimmunological responses after surgery, potentially through decreased use of volatile anesthetics and opioids, decreased activation of the surgical stress response, and a direct local anesthetic-mediated anti-inflammatory effect. Available urological literature suggests an association of anesthetic type and outcomes for nonmuscle invasive bladder cancer and prostate cancer surgeries but the evidence is limited. Prospective studies are needed to further investigate the relationship between anesthetic technique and urologic oncological outcomes.

Growth rates and outcomes of observed large renal masses.

INTRODUCTION: The natural history of small renal masses has been well defined, leading to the recommendation of active surveillance in some patients with limited life expectancy. However, this information is less clear for large renal masses (LRM), leading to ambiguity for management in the older, comorbid patient. The objective of this study was to define the natural history, including the growth rate and metastatic risk, of LRM in order to better counsel patients regarding active surveillance. METHODS: This was a retrospective review of patients with solid renal masses >4 cm that had repeated imaging identified from an institutional imaging database. Patient comorbidities and outcomes were obtained through retrospective chart analysis. Outcomes assessed included tumour growth and metastatic rates, as well as cancer-specific (CSS) and overall survival (OS) usimg Kaplan-Meier methodology. RESULTS: We identified 69 patients between 2005 and 2016 who met the inclusion criteria. Mean age at study entry was 75.5 years; mean tumour maximal dimension at study entry was 5.6 cm. CSS was 83% and OS 63% for patients presenting without metastasis, with a mean followup of 57.5 months. The mean growth rate of those that developed metastasis during followup (n=15) was 0.98 cm/year (95% confidence interval [CI] 0.33-1.63) as compared to those that did not develop metastasis (n=46), with a growth rate of 0.67 cm/year (95% CI 0.34-1) (non-significant). Seven patients had evidence of metastasis at the baseline imaging of their LRM and had subsequent growth rate of 1.47 cm/year (95% CI 0.37-2.57) (non-significant) CONCLUSIONS: Compared to small renal masses, LRM are associated with higher metastasis rates and lower CSS and more rapid growth rates. Selection criteria for recommending observation of LRM in older, comorbid patients should be more conservative than for small renal masses.

The X-Y factor: Females and males with urological chronic pelvic pain syndrome present distinct clinical phenotypes.

INTRODUCTION: Urological chronic pelvic pain syndrome (UCPPS) in females is often attributed to the bladder (interstitial cystitis/ bladder pain syndrome), while UCPPS in males is often attributed to the prostate (chronic prostatitis/chronic pelvic pain syndrome). However, there is increasing awareness that bladder pain plays a role in both males and females and the degree of overlap of clinical characteristics in males and females with UCPPS is not well known. Our objective was to compare clinical phenotypes of females and males with UCPPS. METHODS: We conducted a retrospective analysis of prospectively collected data from a single-centre patient population presenting between 1998 and 2016 to our UCPPS clinic. Demographics, symptom scores, pain scales, retrospectively described clinical UPOINT (urinary, psychosocial, organ-specific, infection, neurogenic, and tenderness) scoring, and presence of comorbid medical conditions were compared between females and males using comparative analyses. RESULTS: We identified 2007 subjects (1523 males, 484 females) with UCPPS. Females had increased prevalence of irritable bowel syndrome (25% vs. 11.2%), chronic fatigue syndrome (13.6% vs. 1.6%), fibromyalgia (16.9% vs. 1.6%), drug allergies (56.6% vs. 13.5%), diabetes (20.2% vs. 3.9%), depression (31% vs. 18.4%), and alcohol use (44.2% vs. 10.8%) compared to males with UCPPS (all p<0.001). In respect to UPOINT domains, females had a higher "total" (3.2 vs. 2.4), "urinary" (92.8% vs. 67.6%), "organ-specific" (90.1% vs. 51.4%), and "neurogenic" (44.7% vs. 30%) prevalence compared to males (all p<0.001). CONCLUSIONS: Females with UCPPS have greater prevalence of systemic disorders/symptoms and worse urinary symptoms than males with UCPPS. These findings demonstrate that females and males with UCPPS have distinct and different clinical phenotypes.

Attitudes of graduating Canadian urology residents on the job market: Is it getting better or are we just spinning our wheels?

INTRODUCTION: There has been increasing awareness of employment difficulties for physicians, especially surgeons, in Canada over the past few years. Our objective was to elucidate the attitudes and experiences of graduating Canadian urology residents in obtaining employment. METHODS: We surveyed four separate cohorts of graduating urology residents in 2010, 2011, 2016, and 2017. Responses from the 2010 and 2011 cohorts were combined and compared to the combined results of the 2016 and 2017 cohorts. Mean Likert responses were compared using unpaired t-tests. An agreement score was created for those responding with "strongly agree" and "agree" on the Likert scale. RESULTS: A total of 126 surveys were administered with a 100% response rate. The job market was rated as poor or very poor by 64.9% and 58.4% of graduates in 2010/2011 and 2016/2017, respectively (p=0.67). Lack of resources was identified as the biggest barrier to improved employment in both cohorts. Networking at meetings and staff urologists at their institution were the most important factors aiding employment identified by both cohorts. The ideal practice was academic or academically associated community practices in a large urban area, with 5-10 partners for both cohorts. CONCLUSIONS: The majority of graduating urology residents viewed the job market as poor or very poor and this did not change over a six-year period. It is unclear how much personal preference for location and practice type drove the somewhat negative outlook of employment opportunities, as the majority of residents were seeking large urban, academic, or academically associated community practices in competitive locations.

Overactive Bladder and Storage Lower Urinary Tract Symptoms Following Radical Prostatectomy.

OBJECTIVE: To describe the rate of overactive bladder (OAB) and storage lower urinary tract symptoms following radical prostatectomy (RP) and determine if subsequent radiation increases the risk of OAB. METHODS: We reviewed all patients who underwent open RP at our tertiary care institution from January 2006 to June 2011. Primary outcomes were the proportion of patients with new OAB and time to development of OAB in those treated with RP alone vs RP plus radiation. Secondary outcomes included the proportion of patients treated for OAB. A Cox survival analysis was used to assess the impact of radiation on development of OAB. RESULTS: Of the 875 patients who met study criteria, 19% of patients developed de novo OAB defined as urgency with or without frequency and nocturia. A total of 256 patients (29%) developed 1 or more urinary symptoms including nocturia (22%), frequency (21%), urgency (19%), and urge incontinence (6%) following RP. After adjusting for age, body mass index, smoking status, cancer stage, and nerve-sparing status, radiation therapy was associated with an increased relative hazard of OAB (5.59; 95% CI 3.63-8.61, P < .001). Among men classified with de novo OAB, only 41% received treatment. CONCLUSION: OAB and storage lower urinary tract symptoms are prevalent in men post-RP. Adjuvant or salvage radiation therapy increases the risk of developing OAB after RP. OAB may be undertreated in men following prostate cancer treatment.

Transient ischemic attack: management in the emergency department and impact of an outpatient neurovascular clinic.

OBJECTIVES: 1) To evaluate whether transient ischemic attack (TIA) management in emergency departments (EDs) of the Nova Scotia Capital District Health Authority followed Canadian Best Practice Recommendations, and 2) to assess the impact of being followed up in a dedicated outpatient neurovascular clinic. METHODS: Retrospective chart review of all patients discharged from EDs in our district from January 1, 2011 to December 31, 2012 with a diagnosis of TIA. Cox proportional hazards models, Kaplan-Meier survival curve, and propensity matched analyses were used to evaluate 90-day mortality and readmission. RESULTS: Of the 686 patients seen in the ED for TIA, 88.3% received computed tomography (CT) scanning, 86.3% received an electrocardiogram (ECG), 35% received vascular imaging within 24 hours of triage, 36% were seen in a neurovascular clinic, and 4.2% experienced stroke, myocardial infarction, or vascular death within 90 days. Rates of antithrombotic use were increased in patients seen in a neurovascular clinic compared to those who were not (94% v. 86.3%, p<0.0001). After adjustment for age, sex, vascular disease risk factors, and stroke symptoms, the risk of readmission for stroke, myocardial infarction, or vascular death was lower for those seen in a neurovascular clinic compared to those who were not (adjusted hazard ratio 0.28; 95% confidence interval 0.08-0.99, p=0.048). CONCLUSION: The majority of patients in our study were treated with antithrombotic agents in the ED and investigated with CT and ECG within 24 hours; however, vascular imaging and neurovascular clinic follow-up were underutilized. For those with neurovascular clinic follow-up, there was an association with reduced risk of subsequent stroke, myocardial infarction, or vascular death.

Acquired hemophilia A: A rare cause of gross hematuria.

Acquired hemophilia A is a rare condition caused by spontaneous development of factor VIII inhibitor. This condition most commonly presents with multiple hemorrhagic symptoms and isolated hematuria is exceedingly rare. Early diagnosis is important, as this condition carries a high mortality rate (13-22%). We present a case of an 82-year-old man with isolated hematuria caused by a factor VIII inhibitor who was successfully treated with recombinant activated factor VII concentrate, as well as prednisone and cyclophosphamide.