Could trainees' finger placement at the surgeon's console affect overall outcomes of robotic surgery in radical prostatectomy? A prospective, blinded, robotic simulation pilot study.

INTRODUCTION: Robotic surgery for localized prostate cancer offers a greater range of motion attributed to the EndoWrist instruments. Postoperative outcomes are linked to the quality of vesico-urethral anastomosis. Trainees frequently complain of suturing difficulty in a back-handed fashion. We aimed to analyze wrist motion using the DaVinci simulator. We hypothesized that using the thumb and index finger would allow superior surgical proficiency when compared to the middle finger. METHODS: After institutional review board approval, we recruited 42 medical students in one academic medical center. Students were randomly assigned to start with their thumb and index finger (1&2) or thumb and middle finger (1&3). Three standardized modules were used with nine metrics calculated, including: score, total time, economy of motion, efficiency score, collisions, inaccurate puncture, wound approximation, out of view, and penalty subtotal. Statistical analysis of the metrics was calculated using SPSS. RESULTS: Three metrics were found to have differences between the finger placement of 1&3 compared to 1&2. The number of collisions, wound approximation, and penalty score where 1&3 were used had a lower score in each. The number of collisions was 5.7 less in the 1&3 finger placement (p=0.046). This metric was found to have statistically significant differences between finger placement where 1&3 had a lower score compared to 1&2. The wound approximation score was 0.2 points lower when using the 1&3 placement (p=0.075). Lastly, the penalty assigned was 6.5 points lower when using 1&3 (p=0.069). CONCLUSIONS: Although finger placement did not affect the overall score of the completed simulation, instrument collisions and unnecessary wound complications may lead to adverse outcomes when using 1&2 despite offering a wider range of motion. This may be due to decreased comfort in hand position. Trainees may be able to improve the effectiveness of their vesico-urethral anastomosis during robotic-assisted radical prostatectomy.

Clinical Considerations and Outcomes of Robotic Urologic Surgery in Obese Patients.

Obesity is associated with many significant physiological changes. These considerations are important to surgery, especially in urological procedures. Obese patients often undergo surgical procedures and are at higher risk of complications. This investigation reviews physiological and anaesthesia considerations for obese and morbidly obese patients. In addition, urological surgeries and procedures should be considered for these higher risk patients. Clinical anaesthesiologists must use detailed assessment and, when appropriate, consultation in developing safe anaesthesia plans for these patients. Newer technologies have improved safety related to airway management, advanced airway devices, and regional anaesthesia with ultrasound-guided nerve blocks, which can reduce the need for opioids postoperatively. Recent developments in drug and monitoring technologies have also been developed and can be effective for obese and morbidly obese patients undergoing urological procedures and perioperative surgery, thus improving the likelihood of safety in this higher risk population.

Ureteral stenting in the clinic: a safe and cost-effective alternative to the operating room.

PURPOSE: Ureteral stent placement is one of the most common procedures performed by urologists, and is typically done in the operating room. At Ochsner-LSU Health Shreveport, urologists have a unique setting allowing them to place ureteral stents for patients present in the outpatient ambulatory clinic without the need for nitrous oxide. This allows patients to avoid being admitted to the hospital and receiving subsequent general anesthesia in the operating room. Therefore, our novel study evaluates the feasibility, safety, and cost-effectiveness of ureteral stents insertion in the clinic. MATERIAL AND METHODS: In this study, we analyzed 240 patients with a total of 279 different ureteral stent insertion encounters to evaluate the safety and costs of stenting in the clinic compared to the operating room. Stents were placed in the outpatient clinic for 126 patients, which required either a new ureteral stent insertion or a scheduled stent exchange. RESULTS: Overall, there was an increased age and length of stent duration among those who were stented in the clinic. We did not observe any increase in narcotics use, pain, adverse injuries, or differences in stent length. The total cost of a stent insertion operating room was $16,349.91 whereas the clinic procedure cost $7,865.69, however: medicare reimbursement remained the same. CONCLUSION: Our findings demonstrate a novel use of stenting in the clinic is feasible as an outpatient alternative. It is a safe alternative to the operating room, and more cost-effective.

Current advances in pain regimens for percutaneous nephrolithotomy A comprehensive review.

INTRODUCTION: Percutaneous nephrolithotomy (PCNL) causes pain and discomfort after surgery. The primary causes of immediate postoperative pain after PCNL are visceral pain from the ureters and kidneys, and body surface discomfort from incisions. Acute, untreated pain has the potential to develop into chronic pain, which remains a considerable burden for the rehabilitation of patients. The goal of this review was to describe the current options for treating pain post-PCNL. METHODS: We conducted a literature review of all published manuscripts on pain protocols for patients undergoing PCNL and related topics; 50 published manuscripts were identified and reviewed. RESULTS: PCNL morbidity must be reduced by an appropriate management of postoperative pain. Opioids, multimodal therapy, tubeless PCNL, reduced size of nephrostomy tube, and regional anesthesia are currently available for reducing postoperative pain. CONCLUSIONS: Implementing successful treatment strategies for postoperative pain after PCNL is key in reducing the morbidity and mortality of PCNL.

Predicting failed access in unstented ureteroscopy.

The risk of failed access (FA) in unstented ureteroscopy ranges from 7.7 to 16%, with young females and those with prior ipsilateral stone surgery, narrow ureteral anatomy, and proximal ureteral stone location carrying higher risk. We aim to determine the rate of failed access at our institution and analyze demographic, clinical, and operative variables associated with FA. We conducted a review of all unstented ureteroscopy procedures at our institution between January 2018 and June 2022. Ureteroscopy for stone, stricture, and neoplasm were included. The primary endpoint was rate of FA, when the unstented ureter failed to accommodate the ureteroscope distal to the target lesion. Demographic, clinical, and operative variables were analyzed to determine if there was an association with FA. Of the 562 ureteroscopies cases reviewed, 221 unstented ureteroscopies fit our inclusion criteria. FA occurred in 34 (15.4%). Previous stone passage (p = 0.039) and distal ureteral location (p = 0.042) were associated with successful access (SA). Proximal ureteral location was associated with FA (p = 0.008). These variables remained statistically significant when analyzed with multivariable logistic regression. There was no association with other demographic, clinical and operative variables. FA occurred at a rate of 15.4% at our institution. Previous stone passage and distal ureteral location were associated with SA, while proximal ureteral location was associated with FA. Prospective studies are needed to better determine predictors of FA.

Dhat Syndrome: Epidemiology, Risk Factors, Comorbidities, Diagnosis, Treatment, and Management.

Dhat syndrome is a culture-bound psychiatric syndrome most commonly found in the Indian subcontinent. It has been characterized as the experiential fear of losing semen through ejaculation, nocturnal emission, or other means. While Dhat syndrome is common in the Indian subcontinent, given the lack of representativeness, generalizability, and closer connection to Ayurvedic system, there have been limited studies or recognition of symptoms among healthcare providers around the world. In this review, we describe Dhat syndrome, its epidemiology, risk factors, comorbidities, diagnosis, treatment, and its management. For patients with Dhat syndrome, it becomes important to appreciate how generalized depression and anxiety may persist alongside the disorder and those symptoms can be common and non-specific. Related to its strong cultural connection with South Asia such as the belief on Dhat's role in health and vitality influence, it also becomes important to recognize that the syndrome can be found in other populations and the importance of cultural humility and nonconfrontational approach for patient care. In summary, this review provides an informative understanding of Dhat syndrome for non-Indian clinicians who may not be prepared for a patient encounter with vague somatic symptoms in the context of semen loss. Treatment for Dhat syndrome is the same as treatments for major depressive disorder.

A Comprehensive Review of Celecoxib Oral Solution for the Acute Treatment of Migraine.

A migraine is a clinical diagnosis with a presentation of one or more severe unilateral or bilateral headache(s) often preceded by an aura and typically accompanied by nausea, vomiting, photophobia, and/or phonophobia. This neurological disease is often debilitating and greatly affects the quality of life of those it inflicts. In fact, a recent study conducted by the Global Burden of Disease and published in The Lancet Neurology revealed that migraines ranked second to only back pain as the most disabling disease. Triggers for migraines have ranged from female sex, low socioeconomic status, and diet to loud noises, sleep hygiene, and stress. Along with its clinical presentation, laboratory tests and imaging help rule out other potential causes of the headache and lead to a diagnosis of migraine. Migraines are typically divided into three phases: prodromal, headache, and postdrome. The pathophysiology of each phase remains under investigation, with differing theories regarding their pathways. Existing therapies are abortive therapies for acute migraines or preventative therapies. Abortive therapy consists of NSAIDs and triptans. Preventative therapies include tricyclic antidepressants, calcium channel blockers, beta-blockers, and anticonvulsants. In this review, we focus on the role of NSAIDs and the COX-2 inhibitor, celecoxib oral solution, for the abortive treatment of acute migraines.

Do ureteral stent diameter and length or patient demographics play a role in stent encrustation?

INTRODUCTION: Retained ureteral stents may constitute a technical challenge. The purpose of this study was to analyze the patient population with retained ureteral stents with regards to stent sizes to better understand if these factors could play a pivotal role in their encrustation. METHODS: After institutional review board approval, we retrospectively analyzed the data of patients who underwent multimodal surgical procedures for the removal of retained ureteral stents from 2010-2018. The primary outcomes analyzed were ureteral stent length and diameter, location of stent placement, and patients' demographics as potential etiologies for encrustation. RESULTS: We included 30 patients with 32 encrusted ureteral stents and 37 patients with 46 forgotten non-retained ureteral stents. Indications for stenting included urolithiasis, malignancy, pregnancy, ureteral stricture, and ureteropelvic junction obstruction. Stent diameters ranged from 6-8.5 Fr. Stent lengths ranged from 22-30 cm, and multilength stents were used too. Smaller diameter stents were less likely to be retained when compared to larger diameter stents (>6 Fr) (p=0.002). Overall stent length was not found to be significant (p=0.251); however, the difference in stent surface area differed by over 1 cm (p<0.001). Patients who were uninsured were more likely to have retained stents (p=0.003). Patients who reside with longer commuting distance to the main academic medical center were more likely to have retained stents (p=0.010). CONCLUSIONS: Retained ureteral stents could be avoided. Taking into consideration ureteral anatomical variation among patients, smaller diameter stents and smaller surface area may prevent encrustation. Uninsured patients with farther distance to seek medical care and females are the most at risk.

Current Strategies in Pain Regimens for Robotic Urologic Surgery: A Comprehensive Review.

Context: Robotic surgery is becoming the most common approach in minimally invasive urologic procedures. Robotic surgery offers less pain to patients because of smaller keyhole incisions and less tissue retraction and stretching of fascia and muscular fibers. Tailored pain regimens have also evolved and allowed patients to feel minimal to no discomfort after robotic urologic surgery, allowing in parallel better surgical outcomes. This study aims to analyze the most current pain regimens in robotic urologic surgery and to evaluate the most current pain protocols and corresponding outcomes. Evidence Acquisition: A literature review was performed of published manuscripts utilizing Pubmed and Google Scholar on pain protocols for patients undergoing robotic urologic surgery. Results: Multimodal analgesia is gaining ground in robotic urologic surgery. Regional analgesia includes four major modalities: Neuroaxial analgesia, intercostal blocks, tranvsersus abdominis plane blocks, and paravertebral blocks. Each approach has a different injection site, region of analgesia coverage, and duration of coverage depending upon local anesthesia and/or adjuvant utilized with advantages and disadvantages that make each modality unique and efficacious. Conclusions: Robotic urologic surgery has offered the advantage of smaller incisions, faster recovery, less postoperative opioid consumption, and better surgical outcomes. Neuraxial, intercostal, transversus abdominis plane, and quadratus lumborum blocks are the best and most adopted approaches which offer optimal outcomes to patients.

Rare Mental Health Disorders Affecting Urologic Care: A Comprehensive Review.

Management of mental health illnesses and needs are important in fostering psychosocial support, interprofessional coordination, and greater adherence to treatment protocols in the field of urology. This can be especially true for mental health conditions that may greatly impact the presentation of a patient in the healthcare setting with urologic symptoms. This review describes the history, epidemiology, pathophysiology, clinical presentation, and treatment of somatic symptom disorder, illness anxiety disorder, compulsive sexual behavior/hypersexuality, factitious disorder, malingering symptoms, and conversion disorder in the realm of urology. Given the newly updated psychiatric diagnoses in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, there has been a lack of studies reviewing how these illnesses may present in a urology patient encounter. Additionally, as these mental health illnesses may carry a rare incidence compared to other well-known mental health illness such as generalized depression or generalized anxiety disorder, we have found that the lack of provisions and recognition of the diseases can prolong the timeline for diagnosis and lead to an increased cost in both healthcare and quality of life of patients with these mental health illnesses. This review provides awareness on these mental health conditions which may greatly impact patient history and presentation within the field of urology. Additionally, urologic care providers may have an improved understanding of interdisciplinary management of such illnesses and the common symptoms patients may present with such diseases.

Prostate cancer metastatic to bilateral testicles: case report and literature review.

PURPOSE: Hormone-refractory prostate cancer (PCa) has a high incidence of metastasis with common secondary site locations. Our case report describes a rare metastatic site of PCa infiltrating bilateral testicles in the absence of definitive radiologic evidence. MATERIALS AND METHODS: Following the patient's consent and IRB exemption, we report the clinical, radiological, and pathological presentation of the patient treated at our institution. We also conducted an inclusive literature review of PCa with bilateral testicular metastases. RESULTS: Our patient is a 54-year-old male who presented to the emergency room with lower urinary tract symptoms and failure to void. A full workup including digital rectal examination, PSA (580 ng/ml), and a transrectal ultrasound (TRUS) biopsy performed afterward revealed an adenocarcinoma of the prostate. The metastatic workup at presentation was negative. After failure to comply with treatment guidelines, the patient was referred back to us with bilateral testicular masses. Without clear evidence of the origin of the masses, bilateral orchiectomy was performed, and pathological analysis confirmed it was metastatic prostate adenocarcinoma. Post-orchiectomy, the patient was again lost to follow up. Three years later the patient returns and placed in palliative care. CONCLUSIONS: This case report highlights that PCa can have a highly variable course and progression can occur in the absence of adherence to treatment. Any evidence of disease relapse and clinical suspicion of metastasis should be investigated, especially in patients with advanced and metastatic disease or poor adherence to surveillance protocol.

Primary Renal Carcinoid: Two Rare Cases at a Single Center.

Renal carcinoid tumors are exceedingly rare. These neuroendocrine masses are most frequently found in the gastrointestinal and respiratory tracts. A renal carcinoid tumor has only been documented in around 100 cases. In this article, we report two additional cases in female patients ages 53 and 63. Both tumors were found incidentally on computed tomography scans. Both women underwent radical nephrectomies. Neither has shown evidence of metastasis nor relapse to date; however, the 63-year-old woman was lost to follow-up. In conclusion, upon discovery of the asymptomatic renal mass, renal carcinoid should be a consideration in the differentiation, and if suspected, may be treated with radical nephrectomy as was done in our hospital.

A 22-Year-Old Retained Ureteral Stent: One of the Oldest Removed Using a Multimodal Endourologic Approach.

Background: Ureteral stent encrustation poses a distinct challenge to urologists. The purpose of our study is to present a patient with one of the oldest retained ureteral stents reported in the literature, effectively treated at our institution with a multimodal endourologic approach. Case Presentation: After IRB approval and patient's consent, we present the case of a 47-year-old man who was referred to our institution for gross hematuria and a right retained ureteral stent, incidentally found on imaging. This patient had a history of traumatic stab wound 22 years prior, requiring an exploratory laparotomy and a ureteral stent insertion. Preoperative CT scan revealed a fragmented and heavily encrusted right ureteral stent. The patient was effectively treated with a multimodal endourologic approach, including a cystolitholapaxy, a right retrograde flexible ureteroscopy (URS), and a prone split-leg right percutaneous nephrolithotomy combined with a right retrograde URS. The patient was rendered stone and stent free. Conclusion: To our knowledge, this 22-year-old retained stent is one of the oldest reported in the literature. As observed in our patient, multimodal endourologic techniques are safe and effective in patients with retained ureteral stents to render then stent and stone free.

Perioperative acute kidney injury: Stratification and risk reduction strategies.

Perioperative acute kidney injury (AKI) is associated with increased morbidity and mortality. Patient comorbidities, the type of surgery, timing of surgery, and exposure to nephrotoxins are important contributors for developing acute kidney injury. Urgent or emergent surgery, cardiac, and organ transplantation procedures are associated with a higher risk of acute kidney injury. Nephrotoxic drugs, contrast dye, and diuretics can worsen preexisting kidney dysfunction or act as an additive and/or synergistic insult to perioperative injury. A history of preoperative chronic kidney disease is the main risk factor for developing AKI, conferring as much as a 10-fold risk. However, beyond the preoperative renal function, the development of AKI is a complex phenomenon that involves a combination of patient-related and surgery-related factors.

Guidewire type and prior use affects ureteral stent insertion force.

INTRODUCTION: To improve the success rate and safety of ureteral stent insertion, we sought to identify the effect of guidewire type and prior use upon the force needed to advance a 6Fr ureteral stent over various guidewires. MATERIALS AND METHODS: Two-hundred forty stent insertion trials were performed in an ex vivo porcine urinary tract model. Ten trials were randomly performed over 12 new and 12 used guidewires. For each trial, the force required to advance a 6Fr Cook double-pigtail ureteral stent was recorded. Guidewires included the Olympus Glidewire, Cook Fixed Core, and Boston Scientific Amplatz Super Stiff, Sensor, ZIPwire, and Zebra wire. RESULTS: The mean force needed for stent advancement was the lowest for the new Glidewire (0.18N) and ZIPwire (0.22N), with no significant difference to each other (p = 0.90). The following new wires required increasingly higher stent insertion forces compared to the Glidewire, the Zebra (0.60N; p < 0.01), Fixed Core (1.25N; p < 0.01), Sensor (1.43N; p < 0.01), and Amplatz Super Stiff wires (2.03N; p < 0.01). There was no statistical difference between new and used Glidewires (0.18N versus 0.29N; p = 0.14) and Zebra wires (0.59N versus 0.60N; p = 0.88). All other used wires required a significantly greater advancement force than their new counterparts (p < 0.01). CONCLUSIONS: For the same stent, the force required for stent advancement varies greatly between guidewire types. In addition, used guidewires typically required more force compared to new guidewires. In long or difficult cases, switching to a new wire may improve the ease of stent placement and reduce potential complications.

Evaluation of a Chitosan Hemostat in a Porcine Laparoscopic Partial Nephrectomy Model: A Pilot Study.

Background and Objective: The ideal hemostatic agent for laparoscopic partial nephrectomy (LPN) would provide complete hemostasis and sealing of the collecting system at a low cost. Chitosan (CS) is an established topical hemostatic agent, but standard sterilization techniques affect its functional and biologic properties, thereby preventing parenteral uses. This study sought to characterize the safety and efficacy of an implanted CS hemostat sterilized with either a standard technique, electron beam (e-beam) irradiation, or a novel technique, nonthermal nitrogen plasma, in a porcine LPN model. Methods: Laparoscopic partial nephrectomies were performed on six farm pigs and hemostasis achieved using only a CS hemostatic agent (Clo-Sur P.A.D.) that was e-beam (n = 3) or plasma sterilized (PS) (n = 3). Number of pads needed to achieve hemostasis, estimated blood loss, operative time, mass of kidney resection, and warm ischemia time were measured. Animals were monitored for 14 weeks and at harvest, retrograde ureteropyelography and histologic analysis were performed. Results: Complete hemostasis and collection system sealing were achieved in both groups. There was a trend toward less pads required for hemostasis (p = 0.056) and reduced blood loss (p = 0.096) with PS pads, although this did not achieve statistical significance. No complications were observed for 14 weeks and gross examination showed the implanted CS was encapsulated in a fibrous capsule. Histologic analysis revealed a healed nephrectomy site with residual CS and associated chronic inflammation, reactive fibrosis, and foreign body giant cell formation. Importantly, the adjacent renal tissue was intact and viable with no residual parenchymal inflammation or cytologic damage. Conclusion: CS pads alone provided safe and effective hemostasis in a porcine LPN model. PS may enhance hemostatic efficacy and resorption compared with e-beam.

Foxa2 activates the transcription of androgen receptor target genes in castrate resistant prostatic tumors.

Prostate cancer (PCa) is the leading cancer among men. Androgen Deprivation Therapy (ADT) is a common treatment for advanced PCa. However, ADT eventually fails and PCa relapses, developing into castration-resistant prostate cancer (CRPCa). Although alternative pathways such as cancer stem-cell pathway and neuroendocrine differentiation bypass androgen receptor (AR) signaling, AR remains the central player in mediating CRPCa. In this study, we identified a mechanism that retains AR signaling after androgen deprivation. The TRAMP SV40 T antigen transgenic mouse is a model for PCa. The expression of SV40 T-antigen is driven by the androgen-responsive, prostate specific, Probasin promoter. It has been recognized that in this model, T-antigen is still expressed even after androgen ablation. It is unclear how the androgen-responsive Probasin promoter remains active and drives the expression of T-antigen in these tumors. In our study, we found that the expression of Foxa2, a forkhead transcription factor that is expressed in embryonic prostate and advanced stage prostate cancer, is co-expressed in T-antigen positive cells. To test if Foxa2 activates AR-responsive promoters and promotes the expression of T-antigen, we established the prostate epithelial cells that stably express Foxa2, NeoTag1/Foxa2 cells. Neotag1 cells were derived from the Probasin promoter driven SV40 T-antigen transgenic mouse. We found ectopic expression of Foxa2 drives the T-antigen expression regardless of the presence of androgens. Using this model system, we further explored the mechanism that activates AR-responsive promoters in the absence of androgens. Chromatin immunoprecipitation revealed the occupancy of both H3K27Ac, an epigenetic mark of an active transcription, and Foxa2 at the known AR target promoters, Probasin and FKBP5, in the absence of androgen stimulation. In conclusion, we have identified a mechanism that enables PCa to retain the AR signaling pathway after androgen ablation.