Tandem Resonance metallic double-J ureteral stents in a single ureter for salvage management of chronic ureteral obstruction.

For chronic malignant and benign ureteral obstruction, the metal construction of the Resonance ureteral stent has been developed to maintain ureteral patency for up to 12 months, obviating the need for the frequent exchange required for conventional plastic ureteral stents. We report our experience placing tandem Resonance stents (TRS) in a single ureter of patients who failed management with a single Resonance stent. A retrospective review of patients who had TRS for management of ureteral obstruction between February 2014 and May 2017 was performed. Seven renal units from four patients with a median age of 62 years were managed with TRS. All but one renal unit was successfully managed with TRS initially. Hydronephrosis resolved in 80% of renal units at a median of 33 days, and creatinine reached its nadir a median of 38 days after placement, with a median improvement of 0.68 ng/mL. However, the median length of management with TRS was only 123.5 days with one exchange, and there was an overall success rate of 28.5% at 1 year. TRS placement is a feasible option for short-term management in a challenging population that would like to avoid nephrostomy and has failed other modalities.

Preoperative ureteral stenting prior to ureteroscopy for management of urolithiasis does not impact the postoperative return for unplanned care.

INTRODUCTION: Return for unplanned postoperative care is an important quality metric in the United States. Most of our postoperative return visits occur after ureteroscopy. Routine preoperative ureteral stenting is not recommended by the American Urological Association due to its impact on the quality of life, despite its proposed operative advantages. We evaluated the association between preoperative ureteral stenting and the resulting perioperative outcomes in the context of quality measures such as return to the emergency department (ED) and readmission rates. MATERIALS AND METHODS: After the Institutional Review Board approval, a retrospective review of patients undergoing ureteroscopy from February 2014 to present was conducted. Patient's demographics and perioperative outcomes were compared based on the presence or absence of a ureteral stent before ureteroscopy. Details and rates of nurse calls, returns to the ED, and readmissions within 90 days were also compared. RESULTS: A total of 421 instances of ureteroscopy, 278 prestented ureteroscopy (psURS), and 143 direct ureteroscopy (dURS) were included for analysis. Preoperative demographics were similar. The psURS cohort was more likely to undergo flexible ureteroscopy, utilized an access sheath more often (P < 0.0001), and had less ureteral dilation (P < 0.0001). Prestenting did not influence operative time (P = 0.8534) or stone-free rates (P = 0.2241). dURS patients were more likely to call the nurse; however, psURS versus dURS yielded no difference in return to the ED or readmission within 90 days. CONCLUSIONS: In this study, preoperative stenting offered few operative advantages and did not meaningfully influence returns to the ED and readmissions within 90 days after ureteroscopy.

Case series: Bladder clot evacuation using a prostate morcellation device.

INTRODUCTION: We sought to provide a technical update on the use of a prostate morcellator device (PMD) to manage organized blood clots of the bladder following laser prostatectomy. METHODS: Herein, we describe our experience in using the Wolf Piranha morcellator in managing organized bladder blood clots supplemented with a retrospective chart review of the patients in whom this procedure was performed. RESULTS: Six patients, all male with a mean age of 75 ± 8.9 years, had organized bladder clots following either holmium laser enucleation or photoselective vaporization of the prostate managed with a PMD. Clots were recognized based on hematuria or urinary retention a median of 3.5 days following the aforementioned procedures. Initial management was attempted with more conservative measures, including a three-way Foley catheter, followed by cystoscopy with an Ellik evacuator, or a glass Tommey syringe. Morcellation times were a mean of 10.2 ± 6.15 minutes (range 2-18). This technique was able to manage clots that were an average of 173.3 ± 115.9 cc in size. The procedure was well-tolerated. No patients experienced intraoperative or morcellator-related complications. CONCLUSIONS: Benign prostatic hypertrophy frequently requires surgical endoscopic management and can be complicated by hematuria and bladder blood clot formation. When these clots become organized, this can lead to urinary retention and the required management, evacuation, may be difficult. The use of a Wolf Piranha PMD is a safe, well-tolerated, and effective in evacuating organized blood clots of the bladder.

Holmium Laser Enucleation of the Prostate After Prostatic Urethral Lift Surgery: Feasibility and Technical Considerations from a Multi-Institutional Case Series.

INTRODUCTION AND OBJECTIVE: Ten percent of patients undergoing prostatic urethral lift (PUL) require repeat surgical treatment within 3 years. We describe the feasibility and considerations of performing holmium laser enucleation of the prostate (HoLEP) as a salvage therapy after previous PUL. METHODS: Men who had undergone HoLEP after PUL were retrospectively identified from three institutions with surgeons experienced in HoLEP. Subjects were characterized by age, time from PUL procedure (months) to HoLEP surgery, indication for retreatment, and pre-operative prostate volume by ultrasound. Outcomes of interest included enucleation time, morcellation time, morcellator type, weight of tissue resected, and Clavien complications. We also summarize findings related to the location of PUL device implants, and the effect of the implants on the enucleation and morcellation portions of the procedure. RESULTS: From December 15, 2015 to October 31, 2016, seven men aged 51-78 years underwent HoLEP at a median of 8.6 months (range 3-18) after PUL. The median prostate volume by transrectal ultrasound was 80 cm3 (range 56-160 cm3). For the 7 patients, 6 out of the 22 device implants were found in aberrant locations. Auxiliary maneuvers were required in five cases. Morcellation devices tended to jam with each implant, requiring a pause for withdrawal of the morcellator and manual removal from the blade or requiring grasper retrieval of device components. There were no Clavien complications. CONCLUSIONS: HoLEP can be performed safely and effectively post-PUL; however, device implants may be found in areas other than the intended location, and morcellation of the adenoma tissue is complicated by metallic implants of the PUL device.

Functional Chimeras of GLIC Obtained by Adding the Intracellular Domain of Anion- and Cation-Conducting Cys-Loop Receptors.

Pentameric ligand-gated ion channels (pLGICs), also called Cys-loop receptors in eukaryotic superfamily members, play diverse roles in neurotransmission and serve as primary targets for many therapeutic drugs. Structural studies of full-length eukaryotic pLGICs have been challenging because of glycosylation, large size, pentameric assembly, and hydrophobicity. X-ray structures of prokaryotic pLGICs, including the Gloeobacter violaceus LGIC (GLIC) and the Erwinia chrysanthemi LGIC (ELIC), and truncated eukaryotic pLGICs have significantly improved and complemented the understanding of structural details previously obtained with acetylcholine-binding protein and Torpedo nicotinic acetylcholine receptors. Prokaryotic pLGICs share their overall structural features with eukaryotic pLGICs for the ligand-binding extracellular and channel-lining transmembrane domains. The large intracellular domain (ICD) is present only in eukaryotic members and is characterized by a low level of sequence conservation and significant variability in length (50-250 amino acids), making the ICD a potential target for the modulation of specific pLGIC subunits. None of the structures includes a complete ICD. Here, we created chimeras by adding the ICD of cation-conducting (nAChR-α7) and anion-conducting (GABAρ1, Glyα1) eukaryotic homopentamer-forming pLGICs to GLIC. GLIC-ICD chimeras assemble into pentamers to form proton-gated channels, as does the parent GLIC. Additionally, the sensitivity of the chimeras toward modulation of functional maturation by chaperone protein RIC-3 is preserved as in those of the parent eukaryotic channels. For a previously described GLIC-5HT3A-ICD chimera, we now provide evidence of its successful large-scale expression and purification to homogeneity. Overall, the chimeras provide valuable tools for functional and structural studies of eukaryotic pLGIC ICDs.