Improved stone quality of life in patients with an obstructing ureteral stone on alpha-blocker medical expulsive therapy.

PURPOSE: Though controversial, alpha blockers are used widely for ureteral stone passage. However, its effects on the patient-reported Quality of life (QOL) is unknown. We compared the QoL of patients on alpha-blocker medical expulsive therapy (MET) to patients not on MET (noMET) utilizing the validated Wisconsin Stone Quality of Life (WISQOL). METHODS: This prospective study included patients prescribed either MET or noMET after presentation with symptomatic, obstructing ureteral stones. The treatment arm was decided at the point of care by the initial treating physician and included analgesia and antiemetics. Tamsulosin (0.4 mg daily) was prescribed for the MET group. The WISQOL survey was administered at baseline, 7-, 14-, 21- and 28-days following discharge from the ED or until stone expulsion. RESULTS: 197 patients were enrolled, of which 116 (59.2%) completed questionnaires for analysis, 91 in the MET group and 25 in noMET. Average ureteral stone size was 4.7 mm (SD 1.8) and 3.1 mm (SD 1.0) for MET and noMET, respectively. Of completed surveys, 105 (90%) were completed at day 7, 67 (57.6%) at day 14, 53 (45.7%) at day 21, and 40 (34.5%) at day 28. MET was associated with improved QoL scores across all WISQOL domains compared to noMET. Stone size, age, race, sex, comorbidity score and a prior stone history were not associated with reduced QoL. CONCLUSIONS: The use of MET was associated with improved QOL on all WISQOL metrics compared to noMET patients. Improved stone QOL may be an indication of alpha-blocker therapy in patients with ureteral stone colic.

A Multi-Institutional Matched-Pair Analysis of Robotic Partial Nephrectomy for Single vs Multiple Ipsilateral Renal Masses.

Introduction: Nephron-sparing surgery is important in patients with multiple renal tumors, especially if associated with a solitary kidney or hereditary syndrome. Prior studies have shown partial nephrectomy (PN) of multiple ipsilateral renal masses to have good oncologic and renal function outcomes. We aim to compare renal function changes, complications, and warm ischemia time (WIT) of partial nephrectomy of a single renal mass (sPN) vs those of partial nephrectomy of multiple ipsilateral renal masses (mPN). Materials and Methods: We retrospectively reviewed our multi-institutional PN database. We matched robotic sPN and mPN patients ∼3:1 using "nearest neighbor" propensity score matching based on age, Charlson comorbidity index (CCI), total tumor size, and nephrometry score. Univariate analysis was performed, and multivariable models were fit controlling for age, gender, CCI, and tumor size. Results: Fifty mPN and 146 sPN patients were matched. The mean total tumor size was 3.3 and 3.2 cm, respectively (p = 0.363). The mean nephrometry score in both groups was 7.3 and 7.2, respectively (p = 0.772). Estimated blood loss (EBL) was 137.6 and 117.8 mL, respectively (p = 0.184). The mPN group had higher operative time (174.6 vs 156.4 minutes, p = 0.008) and WIT (17.0 vs 15.3 minutes, p = 0.032). There was no significant difference in the change in glomerular filtration rate (mPN -6.4% vs sPN -8.7%, p = 0.712). Complications (Clavien 2+) occurred in 10.2% of mPN and 11.3% of sPN patients (p = 0.837). A multivariable linear model predicts a nonstatistically significant difference of 1.4 minutes of additional WIT in the mPN group (p = 0.242). There was no statistical difference in complication rates between groups in a multivariable model (odds ratio 1.00, p = 0.991). Conclusions: Robotic PN in our multi-institutional matched comparison of mPN and sPN showed no difference in complications, renal functional outcomes, or EBL. mPN was associated with increased operative time and WIT, though the WIT difference was not significant on multivariable analysis.

Intrarenal Pressure with Vacuum-Assisted Ureteral Access Sheaths Using an In Situ Cadaveric Porcine Model.

Introduction: Vacuum-assisted ureteral access sheaths (V-UASs) are a new tool designed to evacuate dust or small fragments during retrograde intrarenal surgery (RIRS). There are reports of increased stone-free rates, decreased infections, and decreased operative time with V-UAS usage. The optimal technique and setting for V-UAS has yet to be described. Herein, we investigate real-time intrarenal pressure (IRP) throughout a range of settings using V-UAS in a porcine RIRS model. Materials and Methods: Ureteroscopy was performed in three female porcine cadaver kidneys through a ClearPetra V-UAS. IRP was recorded through a percutaneous catheter at different inflow pressures, sheath sizes, sheath distance from the ureteropelvic junction, and suction settings. Magnitude of change in delta IRP (dIRP) was compared at various settings. Results: There was no statistical difference in IRP when comparing no suction with vent inactivated. As expected, IRP decreased with larger sheath size and lower irrigation pressures. Average IRP dropped ∼18 mm Hg with suction activation (42.30 mm Hg, vent inactivated; 24.45 mm Hg IRP, suction activated; p < 0.0001). Irrigation pressure and sheath size did not make a difference in the dIRP. dIRP was significantly greater at lower suction settings compared with max suction (25.44 dIRP at 200 mm Hg suction, 10.26 mm Hg dIRP at max suction, p = 0.04). In a subset of observations, IRP paradoxically increased to higher than IRP with no suction at all after >5 seconds of activated suction. Conclusion: Use of V-UAS during RIRS can lower mean IRP; however, this effect could reverse with extended suctioning especially under conditions of high vacuum (>200 mm Hg) owing to outflow tract collapse. Our results suggest urologists should use lower suction settings and short, <5-second bursts to maximize therapeutic benefit, and minimize potential shortcomings of V-UAS during RIRS.

Factors Associated with Ureteral Stent Failure in Patients with Malignant Ureteral Obstruction.

Introduction: Management of malignant ureteral obstruction (MUO) with ureteral stents remains a clinical challenge, often involving frequent stent exchanges attributable to stent failure or other urological complications. We report our institutional experience with ureteral stents for management of MUO, including analysis of clinical factors associated with stent failure. Methods: We performed a retrospective review of patients treated with indwelling ureteral stents for MUO in nonurothelial malignancies at our tertiary-care institution between 2008 and 2019. Univariate Cox proportional hazards analysis was performed to identify clinical variables associated with stent failure and stent-related complications. Stent failure was defined as need for unplanned stent exchange, placement of percutaneous nephrostomy (PCN), or tandem stents. Results: In our cohort of 78 patients, the median (range) number of stent exchanges was 2 (0-17) during a total stent dwell time of 4.3 (0.1-40.3) months. Thirty-four patients (43.6%) developed a culture-proven urinary tract infection (UTI) during stent dwell time. Thirty-five patients (44.8%) had stent failure. Twenty-two patients (28.2%) underwent unplanned stent exchanges, 23 (29.5%) required PCN after initial stent placement, and 6 (7.7%) required tandem stents. Ten (28.6%) patients with stent failure were treated with upsized stents, which led to resolution in seven patients. Stent failure occurred with 20/44 (45.4%) Percuflex™, 15/27 (55.6%) polyurethane, and 2/3 (66.7%) metal stents. In patients with ≥2 exchanges (N = 45), median time between exchanges was 4.1 (2.0-14.8) months. Bilateral stenting and history of radiation predicted UTI development. Median overall patient survival after initial stent placement was 19.9 months (95% CI 16.5-37.9 months). Conclusions: Ureteral stent failure poses a significant medical burden to patients with MUO. Better methods to minimize stent-related issues and improve patient quality of life are needed. Using a shared decision-making approach, clinicians and patients should consider PCN or tandem stents early in the management of MUO.

Role of the androgen, estrogen, and progesterone receptors in adherent perinephric fat in robotic partial nephrectomy.

To determine whether androgen, estrogen, and/or progesterone signaling play a role in the pathophysiology of adherent perinephric fat (APF). We prospectively recruited patients undergoing robotic assisted partial nephrectomy during 2015-2017. The operating surgeon documented the presence or absence of APF. For those with clear cell renal cell carcinoma (ccRCC), representative sections of tumor and perinephric fat were immunohistochemically stained with monoclonal antibody to estrogen α, progesterone, and androgen receptors. Patient characteristics, operative data, and hormone receptor presence were compared between those with and without APF. Of 51 patients total, 18 (35.3%) and 33 (64.7%) patients did and did not have APF, respectively. APF was associated with history of diabetes mellitus (61.1% vs 24.2%, p = 0.009) and larger tumors (4.0 cm vs 3.0 cm, p = 0.017) but not with age, gender, BMI, Charleston comorbidity index, smoking, or preoperative estimated glomerular filtration rate. APF was not significantly associated with length of operation, positive margins, or 30-day postoperative complications but incurred higher estimated blood loss (236.5 mL vs 209.2 mL, p = 0.049). Thirty-two had ccRCC and completed hormone receptor staining. The majority of tumors and perinephric fat were negative for estrogen and progesterone while positive for androgen receptor expression. There was no difference in hormone receptor expression in either tumor or perinephric fat when classified by presence or absence of APF (p > 0.05). APF is more commonly present in patients with diabetes or larger tumors but was not associated with differential sex hormone receptor expression in ccRCC.

Contemporary Pure Laparoscopic vs Robot-Assisted Laparoscopic Radical Nephrectomy: Is the Transition Worth It?

Introduction: The proportion of robotic procedures continues to rise. The literature reinforces that robotic procedures take longer and are often more costly. We compared cost and perioperative outcomes of laparoscopic radical nephrectomy (LRN) and robot-assisted radical nephrectomy (RARN) at our high-volume center. Materials and Methods: We retrospectively reviewed our 2012-2015 data repository for patients undergoing RARN and LRN for a renal mass. Perioperative and oncologic outcomes were compared. We performed a multivariate analysis of operative time, estimated blood loss, length of stay (LOS), and overall and major 90-day complication rates while controlling for demographic data, Charlson comorbidity index (CCI), tumor size, and surgeon factors. We compared fixed, variable, and distinct procedural costs. Results: We identified 99 LRN and 95 RARN cases. There was no difference in demographic data, tumor size, preoperative renal function, and malignant histology. LRN patients had more comorbidities (49.5% vs 27.3% CCI 2+, p = 0.018). The mean preoperative glomerular filtration rate was higher in the robotic cohort (84.8 vs 75.1, p = 0.48). Mean operative time was 32.7 minutes longer (p = 0.002) and estimated blood loss 145 mL higher (p = 0.007) for the RARN cohort. There was no difference in mean LOS. Major and all 90-day complication rates were no different. The mean procedural cost for RARN was higher by $464 when controlling for operative time (p < 0.001). Fixed costs were not statistically different. Variable costs for RARN were estimated to be $2,310 higher (p = 0.045). Conclusions: Even with cost-conscious, experienced renal surgeons, RARN is associated with a longer procedure, higher supply costs, and higher hospitalization costs. There was no difference in positive surgical margin and complications. There were fewer 30-day readmissions for the RARN cohort, which may represent under-recognized cost savings. With fewer LRN cases in the United States each year, discussion to address cost is warranted. Without better outcomes for robotic surgery, a change in reimbursement to cover costs is unlikely to happen.

Incisional Lumbodorsal Hernias Following Retroperitoneal Robotic Partial Nephrectomies for Small Renal Masses at a High-Volume Tertiary Referral Center.

Introduction: Herein we evaluate the incidence of incisional lumbodorsal hernia (ILDH) after retroperitoneal robotic partial nephrectomy (RRPN) and associated patient-specific and tumor-specific risk factors. Furthermore, we aim to evaluate the role of routine lumbodorsal fascial closure for the prevention of ILDH. Methodology: This is a retrospective review of our robotic partial nephrectomy database of all RRPNs performed at Washington University School of Medicine from 2000 to 2020. Postoperative imaging was reviewed for evidence of ILDH. A clinically significant hernia was defined as the protrusion of visceral organ(s) through the lumbodorsal fascia. Patient and tumor characteristics, and fascial closure techniques were analyzed to determine predictors of ILDH. Results: In total, 150 patients underwent RRPN between 2007 and 2020 with an average follow-up of 4.9 (1-37) months. Twelve (8%) ILDHs were identified. Ten (6.7%) patients had herniated retroperitoneal fat whereas 2 (1.3%) patients had herniated colon. All were asymptomatic and managed conservatively. On matched cohort comparison, patients with ILDH had larger tumors than patients without an incisional hernia (3.9 cm vs 2.8 cm, p = 0.029). In general, patient factors were no different between patients with and without ILDH. However, coronary artery disease (CAD) was more prevalent in patients with ILDH (33.3% vs 10.9%, p = 0.028). Patients with ILDH were more likely to have a port site extended for specimen extraction (66.7% vs 38.2%, p = 0.069). Lumbodorsal fascial closure and type of suture material were not associated with prevention of ILDH (p = 0.545, p = 0.637). Conclusion: The radiographic incidence of lumbar incisional hernias after RRPN without routine fascial closure of the extraction incision was 8%. All were asymptomatic and did not require surgical repair. Larger tumor size and CAD were associated with ILDH.

Racial Comparison of Patients Undergoing Minimally Invasive Partial Nephrectomy for Renal Masses at a Large Volume Tertiary Center.

Introduction and Objective: African American (AA) race has been identified to have a higher incidence of chronic kidney disease (CKD) and worse renal cancer survival compared with Caucasian Americans (CA), irrespective of tumor size, pathologic type, and surgical procedure. We aimed to compare the outcomes between CA and AA patients undergoing minimally invasive partial nephrectomy (PN) at our high-volume center. Materials and Methods: We queried our PN data repository from 2007 to 2017. We identified 981 cases of PN (robotic n = 943 and laparoscopic n = 38), of which there were 852 CA and 129 AA patients. We compared age, sex, body mass index (BMI), operative time, estimated blood loss (EBL), nephrometry score, tumor size, pre- and postoperative estimated glomerular filtration rate (eGFR), length of stay, Charlson Comorbidity Index (CCI), tumor characteristics, and 30-day complication rate. We then estimated the overall survival and disease-specific survival. Results: Age, BMI, operative time, EBL, nephrometry score, tumor size, CCI, length of stay, and sex were not statistically different. The mean preoperative eGFR was higher in the AA cohort (91.4 mL/min/1.73 m2 vs 86.1 mL/min/1.73 m2, p = 0.007); however, at 1 year, there was no mean difference (76.8 mL/min/1.73 m2 vs 74.5 mL/min/1.73 m2, p = 0.428). There was a higher percentage of Fuhrman Grade 3/4 in the AA cohort (33.3% vs 22.5%, p = 0.044). The AA cohort had a 2.66 × higher incidence of papillary renal cell carcinoma (RCC) (34.9% vs 13.1%, p < 0.001) and unclassified RCC (3.9% vs 0.4%, p = 0.001). There was no difference in tumor stage (p = 0.260) or incidence of benign histology (15.3% vs 11.6%, p = 0.278). There were no differences in 30-day complications (p = 0.330). The median follow-up was 43.2 months. By using Kaplan-Meier curves, there was no observed difference in overall survival (p = 0.752) or disease-free survival (p = 0.403). Conclusions: Our cohort of AA and CA patients with intermediate follow-up showed no worse outcomes for CKD or survival when undergoing laparoscopic or robotic PN. For low-stage renal cancer, there was no difference in overall survival and disease-free survival at a median follow-up of 43.2 months among AA patients, despite having higher grade tumors and a higher percentage of unclassified RCC. Our cohort of AA patients did have a higher incidence of papillary RCC. The equivalent overall survival and disease-free survival could be due to the earlier discovery of lower stage renal masses incidentally identified on imaging studies performed equally for other reasons in both AA and CA patients.

The Risks of Stone Diagnosis and Stone Removal Procedure After Different Bariatric Surgeries.

Introduction: Nephrolithiasis is common after malabsorptive bariatric surgery; however, the comparative risk of stone formation after different bariatric surgeries remains unclear. We seek to compare the risk of stone diagnosis and stone procedure after gastric banding (GB), sleeve gastrectomy (SG), short-limb Roux-en-Y (SLRY), long-limb Roux-en-Y (LLRY), and biliopancreatic diversion with duodenal switch (BPDDS). Patients and Methods: Using an administrative database, we retrospectively identified 116,304 patients in the United States, who received bariatric surgery between 2007 and 2014, did not have a known kidney stone diagnosis before surgery, and were enrolled in the database for at least 1 year before and after their bariatric surgery. We used diagnosis and procedural codes to identify comorbidities and events of interest. Our primary analysis was performed with extended Cox proportional hazards models using time to stone diagnosis and time to stone procedure as outcomes. Results: The adjusted hazard ratio of new stone diagnosis from 1 to 36 months, compared to GB, was 4.54 for BPDDS (95% confidence interval [CI] 3.66-5.62), 2.12 for LLRY (95% CI 1.74-2.58), 2.15 for SLRY (95% CI 2.02-2.29), and 1.35 for SG (95% CI 1.25-1.46). Similar results were observed for risk of stone diagnosis from 36 to 60 months, and for risk of stone removal procedure. Male sex was associated with an overall 1.63-fold increased risk of new stone diagnosis (95% CI 1.55-1.72). Conclusions: BPDDS was associated with a greater risk of stone diagnosis and stone procedures than SLRY and LLRY, which were associated with a greater risk than restrictive procedures. Nephrolithiasis is more common after more malabsorptive bariatric surgeries, with a much greater risk observed after BPDDS and for male patients.

Evaluation of Perirenal Anatomic Landmarks on Computed Tomography to Reduce the Risk of Thoracic Complications During Supracostal Percutaneous Nephrolithotomy.

Introduction: Supracostal access for percutaneous nephrolithotomy (PNL) has a known increased risk for thoracic complications (TCs). In this study, we perform a radiological review of preoperative and postoperative abdominal CT scans to assess the relationship of the upper pole of the kidney with surrounding landmarks to determine radiographic predictors of TCs. Methods: We performed a retrospective matched cohort comparison of patients who underwent supracostal PNL with and without TCs from 2012 to 2019. An experienced genitourinary (GU) radiologist reviewed pre- and postoperative CT scans to measure the craniocaudal distance between the upper renal pole and the most superior calix to the upper edge of the tip of the 12th rib, the costophrenic angle, and the posterior insertion of the diaphragm. Results: We identified 19 patients who developed TCs after undergoing PNL and compared their CT scans with 24 control patients without TCs. On a preoperative abdominal CT scan, the relationship of the upper edge of the renal parenchyma or upper pole calix with the superior edge of the tip of the 12th rib or costophrenic angle was not found to be predictive of TCs. On receiver operating characteristic analysis, diaphragmatic insertion of ≤2.5 cm below the upper edge of the renal parenchyma on sagittal and transverse views was predictive of TCs (p = 0.046). On postoperative CT scan, the percutaneous nephrostomy tract traversed the posterior insertion of the diaphragm in 80% of patients who had TCs compared with 20% of patients who had no TCs. Conclusions: The decreased distance between the posterior insertion of the diaphragm (medial and lateral arcuate ligaments) and the superior edge of the renal upper pole on preoperative CT scan was associated with TCs from supracostal puncture during PNL. Critical preoperative recognition of this anatomic relationship can help preoperative planning and patient counseling and may prevent or reduce TCs.

Analysis of Ureteral Diameter and Peristalsis in Response to Irrigant Fluid Temperature Changes in an In Vivo Porcine Model.

Objective: It has been previously reported that warming irrigation fluid higher than body temperature may decrease ureteral spasm and thereby facilitate ureteroscopic access to the proximal ureter. Our objective was to examine the effects on ureteral peristalsis and ureteral diameter if the irrigant was warmed to just under the biological threshold for injury. Materials and Methods: Two female adult Yorkshire pigs were studied in this pilot study. In the first pig, a dilute mixture of contrast and irrigation fluid at 37°C and then at 43°C was instilled for 30 minutes into each renal pelvis through a ureteral catheter at 40 mm Hg. Retrograde pyelogram images were captured for each trial and the caliber of the ureter was measured using Vitrea® software. In the second pig, a lumbotomy was performed, and a magnetic sensor was placed on the extraluminal surface of the ureter to monitor ureteral peristalsis while repeating the aforedescribed regimen. Thirty minutes after the first regimen, the force exerted during placement of a 16F ureteral access sheath (UAS) was recorded at both temperatures using the University of California, Irvine Ureteral Force Sensor. Results: There was no statistically significant difference in ureteral caliber along the length of the ureter at 43°C (p = 0.87, p = 0.32, p = 0.66 for proximal, middle, and distal ureter, respectively). Indeed, there was an increase in peristalsis from baseline with fluid irrigation at 37°C and at 43°C (59% and 65%, respectively). There was no significant difference in the force exerted for UAS placement at either temperature. On histologic analysis, there were no significant changes in ureteral histology or luminal diameter. Conclusions: In a porcine model, warming irrigation fluid to just under the biological threshold for injury did not increase ureteral caliber, decrease ureteral peristalsis, or facilitate UAS placement. As such, during ureteroscopy, we continue to warm our irrigation fluid just to body temperature.

Positive Surgical Margins After Robot-Assisted Partial Nephrectomy Predict Long-Term Oncologic Outcomes for Clinically Localized Renal Masses.

Introduction: For patients with clinically localized renal masses, positive surgical margins (PSMs) after robotic partial nephrectomy (RPN) have been associated with a higher risk of disease recurrence, although some studies have challenged this conclusion. Owing to inconsistent reports and a lack of long-term robotic data, the clinical impact of PSM after RPN remains uncertain. We evaluate long-term (>6 years) survival outcomes after RPN in patients with clinically localized disease with respect to surgical margin status. Methods: We conducted a retrospective review of patients who underwent RPN for clinically localized renal masses from June 2007 to December 2012 at Washington University School of Medicine. Disease recurrence and overall survival (OS) were stratified on the presence or absence of PSM. The cohort was analyzed to identify patient- and tumor-specific characteristics associated with PSM. Results: We identified 374 RPNs performed from 2007 to 2012 with a mean follow-up time of 77.7 months (SD 32.2 months). PSM was identified in 12 (3.2%) patients. Patients with PSM were at 14-fold increased risk for recurrence with no difference in OS (p < 0.001, p = 0.130, respectively). Patients with PSM had higher incidence of chronic obstructive pulmonary disease (COPD) (25% vs 6.4%) and greater blood loss (425 mL vs 203 mL). Conclusion: With an extended follow-up period of 77 months after RPN, we found that PSM substantially increased the risk of recurrence without impacting OS. Our finding that PSM may occur more frequently in older patients with COPD must be confirmed in larger studies.

Ex Vivo Porcine Model for Robot-Assisted Partial Nephrectomy Simulation at a High-Volume Tertiary Center: Resident Perception and Validation Assessment Using the Global Evaluative Assessment of Robotic Skills Tool.

Introduction: With increased demands on surgeon productivity and outcomes, residency robotics training increasingly relies on simulations. The objective of this study is to assess the validity and effectiveness of an ex vivo porcine training model as a useful tool to improve surgical skill and confidence with robot-assisted partial nephrectomy (RAPN) among urology residents. Methods: A 2.5 cm circular area of ex vivo porcine kidneys was marked as the area of the tumor. Tumor excision and renorrhaphy was performed by trainees using a da Vinci Si robot. All residents ranging from postgraduate year (PGY) 2 to 5 participated in four training sessions during the 2017 to 2018 academic year. Each session was videorecorded and scored using the global evaluative assessment of robotic skills (GEARS) by faculty members. Results: Twelve residents completed the program. Initial mean GEARS score was 16.7 and improved by +1.4 with each subsequent session (p = 0.008). Initial mean excision, renorrhaphy, and total times were 8.2, 13.9, and 22.1 minutes, which improved by 1.6, 2.0, and 3.6 minutes, respectively (all p < 0.001). Residents' confidence at performing RAPN and robotic surgery increased after completing the courses (p = 0.012 and p < 0.001, respectively). Overall, residents rated that this program has greatly contributed to their skill (4/5) and confidence (4.1/5) in robotic surgery. Conclusions: An ex vivo porcine simulation model for RAPN and robotic surgery provides measurable improvement in GEARS score and reduction in procedural time, although significant differences for all PGY levels need to be confirmed with larger study participation. Adoption of this simulation in a urology residency curriculum may improve residents' skill and confidence in robotic surgery.

Laparoscopic cytoreductive nephrectomy is associated with significantly improved survival compared with open cytoreductive nephrectomy or targeted therapy alone.

The aim of the present study was to compare the survival outcomes for patients with metastatic renal cell carcinoma (mRCC) who underwent laparoscopic cytoreductive nephrectomy (CN) vs. open CN vs. targeted therapy (TT) alone at our institution. A retrospective chart review was performed at our institution for patients who underwent CN prior to TT (laparoscopic, n=48; open, n=48) or who were deemed unfit for surgery and received TT alone (n=36), between January 2007 and December 2012. Kaplan-Meier estimated survival and Cox proportional hazards analyses were performed. Laparoscopic CN was associated with significantly longer survival compared with open CN or TT alone (median survival 24 vs. <12 months, respectively; P<0.01). On multivariate analysis, laparoscopic CN was an independent predictor of survival [hazard ratio (HR)=0.48, P<0.01), controlling for preoperative risk factors, while survival was similar between open CN and TT alone (HR=0.85, P=0.54). In our experience, laparoscopic CN appears to be a significant predictor of survival in mRCC. Selection bias of the surgeon for patients with improved survival may account for clinical variables that were otherwise difficult to quantify. For patients who were not candidates for laparoscopic CN, open CN did not confer a survival benefit over TT alone, while it was associated with increased morbidity.

Utility of a Pigtail Cope Loop Catheter for Bladder Drainage in Treating a Large/Persistent Urethrovesical Anastomotic Leak Following Radical Prostatectomy.

Background: A large or persistent urethrovesical anastomotic leakage after a laparoscopic or robot-assisted laparoscopic radical prostatectomy (RALRP) although infrequent can be a difficult complication to treat. We describe a simple technique to facilitate resolution of a urethrovesical anastomotic leak by exchanging the in-place bladder Foley catheter for a pigtail drainage catheter. Case Presentation: Between 2014 and 2019, we had three patients who had a large/persistent urine leak after a radical prostatectomy (one laparoscopic and two robot assisted). All three patients had a wide bladder neck requiring bladder neck reconstruction with ureteral orifices close to the anastomosis. The bladder Foley catheter was exchanged to a pigtail Cope loop catheter™ (14F) or an Origin™ self-retaining drainage catheter (16F) under flexible cystoscopic guidance over a guidewire. Placement of a Cope loop bladder catheter stopped anastomotic leakage expeditiously with no need for further intervention. At minimum 3 months follow-up none had bladder neck stricture with 0-1 pad urinary incontinence. Conclusion: Drainage of the bladder through the use of a loop pigtail nephrostomy catheter can be useful in rapidly resolving a large persistent urethrovesical anastomotic leak.

Systemic inflammatory response syndrome in patients with acute obstructive upper tract urinary stone: a risk factor for urgent renal drainage and revisit to the emergency department.

BACKGROUND: In patients seen in the emergency department (ED) with acute stone obstruction many risk factors that indicate need for urgent renal drainage are known. However, in patients discharged from ED without renal drainage factors that can minimize revisit to the emergency department are not fully identified. We evaluated SIRS (systemic inflammatory response syndrome) as a risk factor for urgent renal drainage and revisit to the ED in patients with acute stone colic during their ED visit. METHODS: Retrospective review was performed of patients presenting to a tertiary academic emergency department (ED) from an obstructing ureteral or UPJ stone with hydronephrosis confirmed on an abdominal and pelvic CT scan. Data evaluated over a 3-year period included stone size, presence of UTI, presence or absence of SIRS and other clinical variables as risk factors for urgent renal drainage and ED revisits. RESULTS: 1983 patients with urolithiasis were seen at the ED and 649 patients had obstructive urolithiasis on CT scan. SIRS was diagnosed in 15% (99/649) patients. 54/99 (55%) patients with SIRS underwent urgent renal drainage compared to 99/550 (17%) in non-SIRS patients. In a multivariate analysis SIRS was a predictor of urgent intervention compared to non-SIRS patients (odds ratio 4.6, p < 0.05). SIRS was also associated with increased risk for revisits to the ED (6.9% with SIRS vs. 2.4% with no SIRS, odds ratio 2.9, p = 0.05). CONCLUSIONS: Presence of SIRS in obstructive urolithiasis patients was an independent risk factor of acute urologic intervention and revisits to the ED. A timely consultation with a urologist following discharge from ED for obstructive stone patients with SIRS who had no acute renal drainage may prevent revisit to the ED. Evaluation for SIRS in addition to other clinical risk factors should be considered while making management decision in patients with acute stone obstruction.

Ten-Year Experience with Percutaneous Cryoablation of Renal Tumors: Tumor Size Predicts Disease Progression.

Introduction: Percutaneous cryoablation (PCA) has emerged as an alternative to extirpative management of small renal masses (SRMs) in select patients, with a reduced risk of perioperative complications. Although disease recurrence is thought to occur in the early postoperative period, limited data on long-term oncologic outcomes have been published. We reviewed our 10-year experience with PCA for SRMs and assessed predictors of disease progression. Materials and Methods: We reviewed our prospectively maintained database of patients who underwent renal PCA from March 2005 to December 2015 (n = 308). Baseline patient and tumor variables were recorded, and postoperative cross-sectional imaging was examined for evidence of disease recurrence. Disease progression was defined as the presence of local recurrence or new lymphadenopathy/metastasis. Results: Mean patient age was 67.2 ± 11 years, mean tumor size was 2.7 ± 1.3 cm, and mean nephrometry score was 6.8 ± 1.7. At mean follow-up of 38 months, local recurrence and new lymphadenopathy/metastasis occurred in 10.1% (31/308) and 6.2% (19/308) of patients, respectively. Excluding patients with a solitary kidney and/or von Hippel-Lindau, local recurrence and new lymphadenopathy/metastasis occurred in 8.6% (23/268) and 1.9% (5/268) of cases, respectively. Kaplan-Meier estimated disease-free survival was 92.5% at 1 year, 89.3% at 2 years, and 86.7% at 3 years post-PCA. Increasing tumor size was a significant predictor of disease progression (hazard ratio 1.32 per 1-cm increase in size, p = 0.001). Conclusions: PCA is a viable treatment option for patients with SRMs. Increasing tumor size is a significant predictor of disease progression following PCA.

A Case Series of Delayed Proximal Ureteral Strictures After Nephron-Sparing Treatment of Renal Masses.

Background: Delayed proximal ureteral stricture (DPUS) after nephron-sparing treatment (partial nephrectomy [PN] and image-guided percutaneous ablation) of renal masses is a rare complication that occurs because of an unrecognized injury to the proximal ureter and/or its associated vascular supply. We present a multi-institutional series of patients who developed DPUS after nephron-sparing treatment and review relevant tumor characteristics, timing of DPUS presentation, presenting symptoms, and outcome of stricture management. Case Presentation: Between 2000 and 2019, nine patients (five PN and four ablation) were found to have DPUS diagnosed at an average of 9 (6-119) months after PN and 5.5 (1-6) after ablation. Average tumor size was 4.5 (2.9-7.3) cm and 3.6 (3-4.1) cm for those treated with PN and ablation, respectively. Nephrometry score was 8.3 (6-11) and 6.5 (5-8), respectively. For resected tumors, all were located in the lower pole, but uniformity was not found as far as medial vs lateral (3 vs 2), anterior vs posterior (2 vs 2, 1 N/A), and right vs left (3 vs 2). For ablated tumors, all four tumors were right sided, anterior, medial, and lower pole. Initial signs and symptoms include sepsis (2), flank pain (5), and asymptomatic hydronephrosis (2). Concomitant urinoma (2) and retroperitoneal abscess (1) was found on imaging. Initial management included ureteral stenting (5) and percutaneous nephrostomy tube (4). Three underwent nephrectomy. Two had spontaneous resolution of DPUS after a course of ureteral stenting. Conclusion: Potential risk factors associated with DPUS after nephron-sparing treatment, including medial and lower pole tumors, and particularly right-sided anterior masses for ablation and higher complexity nephrometry score for PN. Recognition of delayed symptoms and imaging abnormalities in the surveillance period should cue clinical suspicion to DPUS.

Dual-frequency setting for urinary stone fragmentation during shock wave lithotripsy: an in vitro study.

Extracorporeal shock wave lithotripsy (SWL) is less invasive compared to the other invasive modalities of stone treatment that are gaining popularity. Hence, methods to improve the efficacy of SWL are desirable. We studied the effectiveness of dual frequency on the efficacy of stone fragmentation, but minimizing treatment time. A phantom 10 mm spherical BegoStone was fragmented in vitro in a kidney model using an electromagnetic lithotripter (Storz MODULITH®SLX-F2). A total of 78 stones were fragmented each with 3000 shocks at 60 Hz or 120 Hz or a dual frequency (DF) of 60-120 Hz. For the DF setting, the first 1000 shocks were delivered at 60 Hz and the next 2000 at 120 Hz. Total weight and number of significant fragments of > 3 mm (TWSF and TNSF, respectively) and also > 2 mm was measured. Results: The mean TWSF was 0.1, 0.16, and 0.08 g for 60 Hz, 120 Hz, and DF 60-120 Hz, respectively. The TWSF of DF 60-120 Hz was significantly lower than that of 120 Hz (p = 0.02), but same as the 60 Hz (p = 0.32). The mean TNSF of > 3 mm was 2.6, 3.0, and 2.0 for 60 Hz, 120 Hz, and DF 60-120 Hz, respectively, without significant differences between each setting. However, increasing trend of TWSF, TW2 mm and TN2 mm was seen in the order of DF, 60 Hz and 120 Hz (p = 0.019, p = 0.004 and 0.017, respectively). Treatment time for 60 Hz, 120 Hz, and DF 60-120 Hz was 50, 25, and 34 min, respectively. Dual-frequency setting produced effective stone fragmentation compared to the recommended 60 Hz, while decreasing treatment time. DF variation is one other factor that may be tailored for effective stone comminution and needs clinical evaluation.