Ureteral catheters for colorectal surgery: Influence on operative times and complication outcomes: An observational study.

Purpose: Placement of pre-operative ureteral catheters for colorectal surgery can aid in the identification of ureteral injuries. This study investigates whether simultaneous ureteral catheterization with surgery skin preparation can minimize operating room times without increasing post-operative complications. Materials and Methods: Patients undergoing simultaneous colorectal surgery skin preparation and placement of pre-operative ureteral catheters (n=21) were compared to those who underwent these events sequentially (n=28). Operative time-points of anesthesia ready (AR), surgery procedure start (PS), dorsal lithotomy and catheter insertion (CI) times were compared to assess for differences between groups. Complications were compared between groups. Results: There were no differences in age, gender, body mass index (BMI), American Society of Anesthesiologists (ASA), comorbidities, current procedure terminology (CPT) or International Classification of Diseases, 9th revision (ICD-9) codes between groups. Simultaneous catheterization saved 11.82 minutes of operative time between CI to PS (p=0.005, t-test). There was a significant difference in mean time between CI to PS (11.82 minutes, p=0.008) between simultaneous and sequential ureteral catheterization groups in a linear regression multivariate analysis controlling for age, BMI, CPT and ICD-9 codes. There were 4 complications in the simultaneous (19%) and 3 in the sequential group (11%) (p=0.68). Conclusions: Ureteral catheterization and colorectal surgery skin preparation in a simultaneous fashion decreases the time between CI and PS without significant increase in complications. Mean time saved with simultaneous ureteral catheterization was 11.82 minutes per case. Simultaneous ureteral catheterization may be an option in colorectal surgery and may result in cost savings without additional complications.

Risk of recurrent spontaneous preterm birth: a systematic review and meta-analysis.

OBJECTIVE: To determine the risk of recurrent spontaneous preterm birth (sPTB) following sPTB in singleton pregnancies. DESIGN: Systematic review and meta-analysis using random effects models. DATA SOURCES: An electronic literature search was conducted in OVID Medline (1948-2017), Embase (1980-2017) and ClinicalTrials.gov (completed studies effective 2017), supplemented by hand-searching bibliographies of included studies, to find all studies with original data concerning recurrent sPTB. STUDY ELIGIBILITY CRITERIA: Studies had to include women with at least one spontaneous preterm singleton live birth (<37 weeks) and at least one subsequent pregnancy resulting in a singleton live birth. The Newcastle-Ottawa Scale was used to assess study quality. RESULTS: Overall, 32 articles involving 55 197 women, met all inclusion criteria. Generally studies were well conducted and had a low risk of bias. The absolute risk of recurrent sPTB at <37 weeks' gestation was 30% (95% CI 27% to 34%). The risk of recurrence due to preterm premature rupture of membranes (PPROM) at <37 weeks gestation was 7% (95% CI 6% to 9%), while the risk of recurrence due to preterm labour (PTL) at <37 weeks gestation was 23% (95% CI 13% to 33%). CONCLUSIONS: The risk of recurrent sPTB is high and is influenced by the underlying clinical pathway leading to the birth. This information is important for clinicians when discussing the recurrence risk of sPTB with their patients.

Total Phosphate Influences the Rate of Hydrocarbon Degradation but Phosphate Mineralogy Shapes Microbial Community Composition in Cold-Region Calcareous Soils.

Managing phosphorus bioaccessibility is critical for the bioremediation of hydrocarbons in calcareous soils. This paper explores how soil mineralogy interacts with a novel biostimulatory solution to both control phosphorus bioavailability and influence bioremediation. Two large bore infiltrators (1 m diameter) were installed at a PHC contaminated site and continuously supplied with a solution containing nutrients and an electron acceptor. Soils from eight contaminated sites were prepared and pretreated, analyzed pretrial, spiked with diesel, placed into nylon bags into the infiltrators, and removed after 3 months. From XAS, we learned that three principal phosphate phases had formed: adsorbed phosphate, brushite, and newberyite. All measures of biodegradation in the samples (in situ degradation estimates, mineralization assays, culturable bacteria, catabolic genes) varied depending upon the soil's phosphate speciation. Notably, adsorbed phosphate increased anaerobic phenanthrene degradation and bzdN catabolic gene prevalence. The dominant mineralogical constraints on community composition were the relative amounts of adsorbed phosphate, brushite, and newberyite. Overall, this study finds that total phosphate influences microbial community phenotypes whereas relative percentages of phosphate minerals influences microbial community genotype composition.

Prostate-specific antigen screening and prostate cancer treatment in renal transplantation candidates: A survey of U.S. transplantation centers.

INTRODUCTION: Renal transplantation candidates are a highly screened population. There are currently no guidelines or consensus on prostate cancer (CaP) screening in these patients. In light of the recent United States Preventive Services Task Force recommendations against prostate-specific antigen (PSA) screening, we conducted a survey of transplantation surgeons to gain a better understanding of practice patterns among U.S. centers. MATERIALS AND METHODS: A 14-question multiple-choice online survey was e-mailed to 195 U.S. renal transplantation centers. The questionnaire assessed CaP screening and treatment practices. The survey also evaluated characteristics of the respondent's institution. Descriptive statistics were used for each of the responses, and associations were made with program characterization using logistic or linear regression models. RESULTS: A total of 90 surgeons responded, representing 65 of 195 programs (33% response rate). Overall, 89% of respondents reported routinely screening for CaP in renal transplantation candidates and 71% had set guidelines for PSA screening. The most common age to start PSA screening was 50 years (51%) and 79% of respondents reported no age limit to stop PSA screening. Definitive treatment of CaP was required before proceeding to transplantation in 45% of respondents. Active surveillance was a viable option in 67% of responders. Most respondents (73%) replied that the waiting time for eligibility after treatment depended on the CaP stage and risk. CONCLUSIONS: Although most programs have guidelines on PSA screening in renal transplantation candidates, there is still variation nationwide in screening and treatment practices. AS is a viable treatment option in most of the programs. Our results suggest a benefit of a consensus panel to recommend guidelines in this population.

Aqueous Cu(II)-organic complexation studied in situ using soft X-ray and vibrational spectroscopies.

In situ aqueous solutions containing copper-ligand mixtures were measured at the Cu L-edge using X-ray absorption near edge structure (XANES) and with attenuated total reflectance infrared (ATR-FTIR) spectroscopies. Copper complexation with environmentally relevant ligands such as EDTA, citrate, and malate provided a bridge between spectroscopic studies and general environmental behavior and will allow for future study of complex environmental samples. XANES results show that the lowest unoccupied molecular orbital (LUMO) energy is governed by the ligand field strength and is related to Lewis acid/base properties of the ligand functional groups. Complementary ATR-FTIR studies confirmed the importance of water molecules in the structure of these Cu-ligand complexes and provided in-depth structural analysis to support the XANES data. Copper-malate is shown to have a 5/6-O-ring structure, and Cu-ethylenediaminetetraacetate has pentadentate coordination. Cu L-edge XANES also revealed direct Cu-N coordination in these aqueous solutions with amide functional groups.

Is Grover's disease an autoimmune dermatosis?

Grover's disease (GD) is a transient or persistent, monomorphous, papulovesicular, asymptomatic or pruritic eruption classified as non-familial acantholytic disorder. Contribution of autoimmune mechanisms to GD pathogenesis remains controversial. The purpose of this study was to investigate antibody-mediated autoimmunity in 11 patients with GD, 4 of which were positive for IgA and/or IgG antikeratinocyte antibodies by indirect immunofluorescence. We used the most sensitive proteomic technique for an unbiased analysis of IgA- and IgG-autoantibody reactivities. Multiplex analysis of autoantibody responses revealed autoreactivity of all 11 GD patients with cellular proteins involved in the signal transduction events regulating cell development, activation, growth, death, adhesion and motility. Semiquantitative fluorescence analysis of cultured keratinocytes pretreated with sera from each patient demonstrated decreased intensity of staining for desmoglein 1 and/or 3 and PCNA, whereas 4 of 10 GD sera induced BAD expression, indicating that binding of autoantibodies to keratinocytes alters expression/function of their adhesion molecules and activates apoptosis. We also tested the ability of GD sera to induce visible alterations of keratinocyte shape and motility in vitro but found no specific changes. Thus, our results demonstrated that humoral autoimmunity in GD can be mediated by both IgA and IgG autoantibodies. At this point, however, it is impossible to conclude whether these autoantibodies cause or are caused by the disease. Antidesmoglein antibodies may be triggered by exposure to immune system of sequestered antigens due to disintegration of desmosomes during primary acantholysis. Clarifying aetiology of GD will help improve treatment, which currently is symptomatic and of marginal effectiveness.

Novel cholinergic peptides SLURP-1 and -2 regulate epithelialization of cutaneous and oral wounds.

It is well established that auto/paracrine acetylcholine (ACh) is essential for wound epithelialization, and that the mechanisms include regulation of keratinocyte motility and adhesion via nicotinic ACh receptors (nAChRs). Keratinocyte nAChRs can be also activated by non-canonical ligands, such as secreted mammalian Ly-6/urokinase-type plasminogen activator receptor-related protein (SLURP)-1 and -2. In this study, we determined effects of recombinant (r)SLURP-1 and-2 on migration of human epidermal and oral keratinocytes under agarose and epithelialization of cutaneous and oral mucosal excisional wounds in mice, and also identified nAChRs mediating SLURP signals. Both in vitro and in vivo, rSLURP-1 decreased and SLURP-2 increased epithelialization rate. The mixture of both peptides accelerated epithelialization even further, indicating that their simultaneous signaling renders an additive physiologic response. The specificity of rSLURP actions was illustrated by similar effects on cutaneous and oral wounds, which feature distinct responses to injury, and also by abrogation of rSLURP effects with neutralizing antibodies. rSLURP-1 acted predominantly via the α7 nAChR-coupled up-regulation of the sedentary integrins α2 and α3 , whereas SLURP-2--through α3, and α9 nAChRs up-regulating migratory integrins α5 and αV . The biologic effects of rSLURPs required the presence of endogenous ACh, indicating that auto/paracrine SLURPs provide for a fine tuning of the physiologic regulation of crawling locomotion via the keratinocyte ACh axis. Since nAChRs have been shown to regulate SLURP production, cholinergic regulation of keratinocyte migration appears to be mediated by a reciprocally arranged network. The cholinergic peptides, therefore, may become prototype drugs for the treatment of wounds that fail to heal.

Auto/paracrine nicotinergic peptides participate in cutaneous stress response to wounding.

Restoration of epidermal barrier (epithelialization), is a major component of cutaneous response to stress imposed by wounding. Learning physiologic regulation of epithelialization may lead to novel treatments of chronic wounds. The non-canonical ligands of nicotinic acetylcholine receptors SLURP (secreted mammalian Ly-6/urokinase-type plasminogen activator receptor-related proteins)-1 and -2 are produced by keratinocytes (KCs) and inflammatory cells to augment physiologic responses to non-neuronal acetylcholine, suggesting that they can affect wound epithelialization and inflammation. In this study, recombinant (r)SLURP-1 and -2 exhibited dose dependent effects on migration of cultured KCs, and monoclonal antibodies inactivating auto/paracrine SLURPs in mouse skin delayed wound epithelialization. While effects of rSLURPs on migration were opposite, with rSLURP-1 inhibiting and rSLURP-2 stimulating migration of KCs, each anti-SLURP antibody produced a negative effect on epithelialization in vivo, suggesting their more extensive than regulation of keratinocyte migration involvement in wound repair. Since inflammation plays an important role in stress response to wounding, we measured inflammation biomarkers in wounds treated with anti-SLURP antibodies. Both anti-SLURP-1 and -2 antibodies, or their mixture, caused significant elevation of wound myeloperoxidase, IL-1ß, IL-6 and TNFα. Taken together, results of this study demonstrated that SLURP-1 slows crawling locomotion of KCs, and exhibits a strong anti-inflammatory activity in wound tissue. In contrast, SLURP-2 facilitates lateral migration of KCs, but shows a lesser anti-inflammatory capacity. Thus, combined biologic activities of both SLURPs may be required for normal stress response to skin wounding, which favors clinical trial of rSLURP-1 and -2 in wounds that fail to heal.

Is surveillance of small renal masses safe in the elderly?

OBJECTIVE: To determine if preoperative variables, including gender, age and tumour size, influence the decision for active surveillance of renal masses, as due to the increasing detection of incidental renal masses within the ageing population there is a need to identify reliable means of selecting patients who require therapy. PATIENTS AND METHODS: We retrospectively identified all renal masses resected at our institution between 1 December 1999, and 1 October 2005. The size of tumour, patient age and gender were compared between those with and without malignancy on final pathology. The influence of these variables in predicting malignancy, high grade, and high stage were assessed by univariate and multivariate analysis using logistic regression models, with a significance level of P < 0.05. Subsets were analysed for the groups of patients with tumours of ≤ 3 or > 3 cm and those aged ≤ 75 or > 75 years. RESULTS: Among 466 of 501 patients with evaluable data, univariate analysis showed that both male gender and increasing size positively predicted malignancy (odds ratio 1.13 and 1.40, respectively), but age, treated as a continuous variable, did not. On multivariate analysis both remained independent predictors of malignancy (odds ratio 1.13 and 1.40, respectively). Size was the only independent predictor of high-stage and high-grade disease on both univariate and multivariate analysis. Among 156 patients with tumours of ≤ 3 cm, on multivariate analysis, male gender was only weakly associated with the risk of malignancy, whereas size remained strongly predictive (odds ratio 1.98, P = 0.076; and 2.16, P = 0.015, respectively). Neither male gender, size nor age increased the risk of high-stage or high-grade disease in this cohort. Patients who were aged > 75 years had a greater risk of high-stage disease than those aged < 75 years (odds ratio 2.64, P = 0.008). On multivariate analysis, age > 75 years remained an independent predictor of malignancy and high-stage, along with size (odds ratio 2.75, P = 0.014; and 1.35, P < 0.001). CONCLUSIONS: Increased size of tumour increases the risk of malignancy and the likelihood of high-stage and high-grade disease. Among patients aged > 75 years there was a higher risk of malignancy and high-stage disease than in those aged ≤ 75 years. As such, the decision for observation should not be based upon age alone, and should be approached with caution in patients aged >75 years, particularly for larger lesions.

Evaluation of bladder insufflants for transurethral cryoablation of the bladder.

OBJECTIVES: To compare helium and carbon dioxide gas insufflation for the creation of pneumocystis during bladder cryoablation in an effort to optimize the technique. METHODS: Nine pigs were divided into 3 groups. The pigs in groups 1, 2, and 3 underwent bladder cryoablation in a normal saline, carbon dioxide gas, and helium gas environment, respectively. Each group underwent 2 freeze-thaw cycles of the bladder dome. The bladder pressure measurements were recorded every 5 seconds throughout the cryoablation procedure. Bladder integrity was evaluated with both cystoscopic and laparoscopic visualization. All pigs were killed at the completion of the procedure, and the bladders were harvested for histopathologic evaluation. RESULTS: All 9 pigs successfully underwent bladder wall cryoablation. Bladder integrity was maintained in all 6 pigs in groups 1 and 3. In group 2, 2 bladder ruptures were documented. All group 2 pigs had a significantly increased bladder pressure during the 2 thaw cycles of the cryoablation procedure, with the peak pressure >70-100 mm Hg before venting of the excess carbon dioxide gas. No intervention was required to stabilize the bladder pressure in groups 1 and 3. The average change in pressure per 5-second interval during both thaw cycles for groups 1, 2, and 3 was 0.16, 6.96, and 0.42 mm Hg/s, respectively (P = .0003). Group 3 showed mild hemorrhage on histologic examination. CONCLUSIONS: The creation of pneumocystis with helium gas reduces sublimation and eliminates the problems of rapidly fluctuating bladder pressures and decreased visibility previously noted with carbon dioxide gas during bladder cryoablation.

Erythropoietin-induced optimization of renal function after warm ischemia.

BACKGROUND AND PURPOSE: Recent preclinical data have indicated that erythropoietin (Epo) can protect organs from ischemic damage. We evaluated the ability of Epo to protect the kidney from the effects of ischemia. METHODS: Thirty dogs underwent a laparoscopic nephrectomy and were allowed to recover for 2 weeks. The dogs were then divided into five groups. Animals in groups 1 and 2 underwent 1.5 hours of abdominal insufflation with placebo (saline) injection (group 1) or Epo injection (group 2) before; groups 3 to 5 underwent 1 hour of laparoscopic renal artery clamping after placebo injection (group 3), Epo injection (group 4), or mannitol injection (group 5). Serum evaluations and 24-hour urine collections were performed weekly. After 28 days, the animals were sacrificed. Statistical analysis was performed with the Kruskal-Wallis test. RESULTS: After recovery from the initial nephrectomy, all dogs had similar serum hematocrit and creatinine levels. Hematocrit was not significantly affected by Epo administration at any time point. Immediately after the second surgery, dogs that underwent renal artery clamping (groups 3-5) had significantly lower 24-hour urine creatinine levels than those that were not clamped (groups 1-2). After 4 weeks of recovery, the dogs that had received Epo before ischemia (group 4) had recovered significantly more renal function than the dogs that received placebo or mannitol before ischemia (urine creatinine level = Epo 149.1 mg/dL v placebo 70.7 mg/dL v mannitol 80.7 mg/dL). At sacrifice, microalbuminuria was also significantly less in dogs receiving Epo before ischemia than their mannitol or placebo counterparts. CONCLUSION: The current study demonstrates that administering Epo before warm ischemia can improve the recovery of renal function after ischemia better than placebo or mannitol.

Pilot study evaluating ureteric physiological changes with a novel 'ribbon stent' design using electromyographic and giant magnetoresistive sensors.

OBJECTIVE: To test a novel 'ribbon stent' (RS) design using an extraluminal bipolar electromyographic (EMG) and giant magnetoresistive (GMR) sensor system to characterize ureteric responses. MATERIALS AND METHODS: In all, 11 female domestic pigs were divided into three groups to evaluate ureteric physiology: group 1 (two pigs) with an unstented ureter, group 2 (three) with a standard 6 F ureteric stent, and group 3 (six) with the RS. For all groups EMG/GMR evaluation was performed at baseline, immediately after stenting, and at 3 and 7 days after stenting. All pigs underwent standardized retrograde ureteropyelogram evaluation at these time points, and after the final evaluation the pigs were killed and the urinary tract was harvested for histopathological evaluation. RESULTS: One stent in group 3 could not be deployed due to a problem with ureteric access. For groups 1, 2 and 3 the ureteric peristaltic activity was 109, 63, 72 events/h at baseline (P = 0.49); 61, 70, and 66 events/h immediately after stenting (P = 0.97); 66, 0, 8 events/h at 3 days after stenting (P = 0.002); and 61, 12, 0 events/h at 7 days after stenting, respectively (P = 0.049). CONCLUSION: The RS was deployed easily and safely in the porcine model using a standard technique. As with a standard stent, there was significant ureteric dilation and decrease in peristalsis with the RS.

Evaluation of a novel temperature-sensitive polymer for temporary ureteral occlusion.

PURPOSE: Proximal stone migration during ureteroscopic procedures increases operative time and risk. This study was designed to evaluate the ability of a new temperature-sensitive polymer to prevent proximal stone migration during ureteroscopic procedures. MATERIALS AND METHODS: Porcine urinary systems were harvested en bloc. The volume of gel needed to occlude the ureter, time to achieve a solid state, length of ureter filled, and pressure needed to dislodge the gel from the ureter were recorded. Radio opacity of the polymer was evaluated. Endoscopic laser lithotripsy was the performed after deploying the urologic polymer, and, after gel application and stone manipulation, all ureters were examined for histologic changes. RESULTS: At 36.7 degrees C, 0.5 mL and 1 mL of polymer sufficiently occluded the ureter. Both amounts solidified in 25 to 40 seconds. The mean length of ureter occluded was 56.3 mm, and the mean pressure needed to dislodge the polymer was 159.2 mm Hg. The polymer was radiopaque and did not cause histologic alterations in the ureter. Proximal migration of stone fragments was not observed during any of the procedures performed. CONCLUSIONS: Our in vitro study indicates that this radiopaque, thermosensitive polymer is able to transiently occlude the ureter without damaging the urothelium while withstanding the pressure of ureteroscopic irrigation, stone motion, and laser energy.

The effect of intraluminal content on the bursting strength of vessels ligated with the harmonic ACE and LigaSure V.

PURPOSE: Energy-based surgical devices (ESDs) are critical for maintaining hemostasis during laparoscopy; however, there are no studies that have evaluated the function of ESDs under different physiologic conditions. We evaluated the effect of intraluminal vessel content on bursting pressure (BP) after ligation with two ESDs: the Harmonic ACE and the LigaSure V. MATERIALS AND METHODS: Bursting trials were performed on the vasculature of 24 pigs. Blood vessels were distended with blood of different hematocrit concentrations or an albumin solution of varying protein content. The vessel size and BP of each vessel was recorded after ligation with each ESD. RESULTS: In arteries 0 to 3 mm and veins 0 to 3 mm in size ligated with the Harmonic ACE or the LigaSure V, there were significantly elevated vessel BPs with supraphysiologic intraluminal hematocrits. In arteries and veins ligated with the Harmonic ACE, increasing albumin concentrations also led to increasing BPs, though these maximal BPs were lower than those obtained with supraphysiologic hematocrit levels. Increasing albumin concentrations did not increase the BP of the LigaSure V. Within the ranges tested, there was no decrease in vessel BP associated with anemia. CONCLUSION: In small vessels, a supraphysiologic hematocrit increased the BP of both arteries and veins when using the Harmonic ACE or the LigaSure V. With the devices tested, anemia did not seem to affect BP. While factors such as intraluminal protein concentration may play a role with ultrasonic energy devices, the mechanism of the increased BP remains unclear. Better understanding of ESDs will help in the design of future devices.

First Prize (tie): Laparoscopic renal cryoablation: efficacy and complications for larger renal masses.

BACKGROUND AND PURPOSE: In expanding our indications for cryoablation of renal cortical neoplasms, there was an increased morbidity with laparoscopic cryoablation. As such, we evaluated our single institution experience with laparoscopic renal cryoablation for complications and oncologic effectiveness as a function of tumor size. MATERIALS AND METHODS: We retrospectively evaluated our prospectively established urologic oncology database and identified 44 laparoscopic cryoablation procedures performed for the management of 51 renal masses. Measured parameters included patient age, tumor size and location, estimated blood loss, complications, and recurrences. Patients were stratified into two groups. In group 1, the patients presented with a maximum tumor diameter less than 3.0 cm. Group 2 patients had a maximum tumor diameter of 3.0 cm or larger. RESULTS: Group 1 included 30 tumors in 23 patients, and group 2 had 21 tumors in 21 patients. The mean tumor size for groups 1 and 2 were 1.8 cm (range 0.7 to 2.8 cm) and 4.0 cm (range 3.0 to 7.5 cm), respectively (P < 0.0001). The average patient age for group 1 was 70.2 and group 2 was 77.6 years (P = 0.04). The mean American Society of Anesthesiologists score was 1.8 and 2.1 for groups 1 and 2, respectively (P = 0.06). There were no complications in group 1. Group 2 had 13 (62%) complications, including two mortalities. The most common complication was blood transfusions at 38%. With a mean follow-up of 9 months, there were no recurrences in group 1. With a mean follow-up of 11 months, there was a single (4.8%) recurrence in group 2. Biopsy histopathology revealed renal cell carcinoma variants in 46.7% in group 1 and 66.7% in group 2, respectively (P = 0.079). CONCLUSION: Renal cryoablation of renal cortical neoplasms smaller than 3.0 cm is effective and safe. Our initial experience, however, demonstrates that cryoablation of larger renal masses may be associated with increased morbidity.

Risk factors associated with renal parenchymal fracture during laparoscopic cryoablation.

OBJECTIVE: To assess the risk factors for haemorrhage and renal fracture associated with renal cryoablation. MATERIALS AND METHODS: In a porcine model, 120 cryoablations were administered in 26 pigs, with five groups of 24 ice-balls each; in groups 1 and 2 asynchronous cryoprobe activation was evaluated for the 1.47- and 3.4-mm cryoprobes (IceRods, Galil Medical, Plymouth Meeting, PA, USA), respectively; in group 3, three-3.4 mm cryoprobes were used to examine synchronous probe activation; in group 4 the 1.47-mm cryoprobe was used to examine single-probe activation with premature cryoprobe extraction; and in group 5 we used a new 'guillotine' technique for upper-pole renal cryoablation. Ice-ball fractures and haemorrhage were characterized by the location, length and depth of each fracture, was well as the degree of bleeding. RESULTS: In all, 26 domestic pigs successfully had renal cryoablation procedures. In group 1 and 4 there were no episodes of renal fracture; in group 2 renal fracture occurred in 10 (42%) trials. Group 3 had 22 (92%) renal fractures during the freeze/thaw cycle. Group 5 had 13 (54%) renal fractures during the freeze/thaw cycle, and there was an additional ice-ball fracture during probe removal once in 24 times. CONCLUSIONS: Renal fracture is most common with the application of larger 3.4-mm cryoprobes in the synchronous and asynchronous setting. Under standard application, smaller (1.47-mm) cryoprobes result in little renal fracture or bleeding. The use of the guillotine technique is associated with a greater risk of renal fracture.

An assessment of urologists' training and knowledge of energy-based surgical devices.

OBJECTIVE: To assess surgeons' training and current understanding of existing energy-based surgical instrumentation (ESI), we disseminated an online questionnaire to urology residents, fellows and attending urologists. SUBJECTS AND METHODS: A two part 24-question survey was disseminated to 1000 urology residents, fellows and attending physicians. The first part of the questionnaire assessed the respondents' demographics and education about ESI; the second part evaluated the respondent's knowledge of surgical energy methods and ESI, and was stratified into nine basic- and six advanced-knowledge questions. RESULTS: In all, 136 people (13.6%) viewed the survey and it was completed by 63 (6.3%). Respondents comprised 27 (43%) attending physicians, 14 (22%) minimally-invasive urology fellows and 22 (35%) urology residents. Among participants, 41 (64%) had received no formal didactic training on ESI, and a further 14% of respondents' didactic experience was limited to one lecture. Of the respondents, 70% said that monopolar energy was the mode most often used in surgery. Overall, the participants correctly answered 41% of the questions. Of the nine questions classified as 'basic' knowledge, respondents correctly answered 49%. Of the six questions classified as 'advanced' knowledge, 29% were answered correctly. The highest percentage score was obtained by the attending urologists, with a mean (range) score of 41 (29-86)%, followed by the fellows, with a mean score of 39.5 (29-57)%, and then the residents, at 34 (14-64)%. CONCLUSION: Despite widespread and growing use of ESI, there is currently minimal formal training on energy modes and current energy devices being provided to urological surgeons. Both practising and training urologists have a limited understanding of surgical energy modes and of existing ESI.

Evaluation of cryoprobe deployment precision with body surface and in situ templates.

OBJECTIVE: To evaluate the precision of cryoprobe targeting with a surface template, an in situ template (on the target organ), or a combined approach. MATERIALS AND METHODS: Fourteen participants placed five 17 G cryoprobes into porcine kidneys in a laparoscopic trainer using a surface template (group 1), an in situ template (group 2) or a combination of the two templates (group 3). The distance from the ideal probe placement was measured both on the anterior and posterior aspect of the kidney. The sequence of attempts was randomized. The distances were compared across the three groups using anova with the adjustment for multiple comparisons. RESULTS: The mean distance from the ideal probe placement was 1.58 cm (anterior) and 1.81 cm (posterior) in group 1, 0.05 cm and 0.39 cm in group 2, and 0.07 cm and 0.22 cm in group 3, respectively. The placement of the probes was significantly more accurate in groups 2 (P < 0.001 anteriorly and P < 0.002 posteriorly) and 3 (P = 0.001 anteriorly and P < 0.001 posteriorly) compared with group 1. There was no significant difference between groups 2 and 3. CONCLUSION: In this in vitro model, the use of internal or combined internal and external templates allows for significantly more precise deployment of 17-G cryoprobes than a standard external template alone.

Tissue response to surgical energy devices.

OBJECTIVES: There is little data available on the effects of energy-based surgical devices (ESD) on tissues other than arteries and veins. As such, we quantified the lateral thermal damage associated with contemporary ESD: the Harmonic ACE, a prototype bipolar device known as the Gyrus Trisector, the Harmonic LCS-C5, and the LigaSure V. METHODS: We divided 24 domestic pigs into 4 groups, 1 group for each ESD tested. Segments of bladder, stomach, small bowel, colon, ureter, peritoneum, arteries, and veins were exposed to each ESD. The tissues were stained with hematoxylin and eosin and evaluated by an experienced pathologist to quantitate the lateral energy spread associated with each device. We measured blade temperatures of each device using the IR-Flex thermal camera. RESULTS: The Trisector developed the lowest mean blade temperature (97.84 degrees F), whereas the LigaSure's was the second lowest (103.14 degrees F). The ACE and LCS-C5 created the highest blade temperatures, measuring 220.5 degrees F and 205.6 degrees F, respectively. The Trisector's mean full thickness and superficial lateral energy damage were 6.3 mm and 7.0 mm, respectively, whereas the Ligasure's was 4.5 mm and 5.9 mm, respectively. For the ACE, however, mean full thickness and superficial energy spread were 2.4 mm and 2.8 mm, respectively, whereas the LCS-C5's were 3.1 mm and 4.3 mm, respectively. CONCLUSIONS: The Harmonic ACE and LCS-C5 produced the least thermal damage in the tissues tested. ESD-associated tissue energy damage is not directly related to blade temperature, but is likely the result of several factors including blade temperature, transection time, tissue properties, and the vascularity of each transected tissue.

Prospective randomized comparison of a combined ultrasonic and pneumatic lithotrite with a standard ultrasonic lithotrite for percutaneous nephrolithotomy.

PURPOSE: To compare the efficiency and cost effectiveness of a combined pneumatic and ultrasonic lithotrite (Lithoclast Ultra) and a standard ultrasonic lithotrite, (LUS-1) during percutaneous nephrolithotomy. MATERIALS AND METHODS: In a prospective randomized trial, 30 patients undergoing percutaneous nephrolithotomy (PCNL) were randomized to PCNL with either the combined pneumatic and ultrasonic lithotrite (PUL) or a standard ultrasonic lithotrite (SUL). Patient demographics, stone composition, location, pre- and post-operative stone burden, fragmentation rates, and device failures were compared. RESULTS: There were 13 patients in the PUL group and 17 patients in the SUL group. Stone burden and location were equal. Overall, 64% of the PUL group had hard stones (defined as stones that were either pure or a mixture of cystine [3], calcium oxalate monohydrate [CaOxMono; 2], and calcium phosphate [CaPO4; 2]), and four had soft stones (3 struvite and 1 uric acid [UA]). In the SUL group, there were eight hard stones (5 CaOxMono and 3 CaPO4), and six soft stones (4 calcium oxalate dihydrate [CaOxDi] and 2 UA) (P = 0.51). Stone composition data were unavailable for five patients. Fragmentation time for the PAL was 37 minutes versus 31.5 minutes for the SUL (P = 0.22). Stone retrieval and mean operative times were similar for both groups. There were a total of three (23.1%) device-related problems in the PUL group, and eight (47%) in the SUL group. There was one (7.7%) device malfunction in the PUL group due to probe fracture. There were two (11.7%) device failures in the SUL group; one failure required the device to be reset every 30 minutes, and the second was an electrical failure. Suction tubing obstruction occurred twice (15.3%) in the PUL group and 35.3% in the SU group (P = 0.35). The stone-free rates for the PUL and SUL were 46% and 66.7%, respectively (P = 0.26). CONCLUSION: Although the PUL was more costly, stone ablation and clearance rates were similar for both the combined pneumatic and ultrasonic device and the standard ultrasonic device. When stratified with respect to stone composition, the PUL was more efficient for harder stones, and the SUL was more efficient for softer stones.