Septic Shock Immediately following Percutaneous Suprapubic Catheterization.

Suprapubic catheterization (SPC) is considered a safe and effective procedure for long-term bladder decompression. With proper technique and appropriate patient selection, significant complications of SPC are rare. Immediate postoperative septic shock (i.e., within the first 24 hours of surgery) is rarely reported. We report a case of an 83-year-old patient who developed septic shock within one hour of suprapubic catheterization for a chronic hypotonic bladder, highlighting the importance of early recognition of complications from SPC and prompt management to ensure positive outcomes.

Impact of body mass index on perioperative outcomes during the learning curve for robot-assisted radical prostatectomy.

INTRODUCTION: Previous studies of robotic-assisted radical prostatectomy (RARP) have suggested that obesity is a risk factor for worse perioperative outcomes. We evaluated whether body mass index (BMI) adversely affected perioperative outcomes. METHODS: A prospective database of 153 RARP (single surgeon) was analyzed. Obesity was defined as BMI >/= 30 kg/m(2); normal BMI < 25 kg/m(2); and overweight as 25 to 30 kg/m(2). Two separate analyses were performed: the first 50 cases (the initial learning curve) and the entire cohort of 153 RARP. RESULTS: In the initial cohort of 50 cases (14 obese patients), there was no statistically significant difference with regards to operative times, port-placement times and estimated blood loss (EBL). Length of stay (LOS) was longer in the obese group (4.3 vs. 2.9 days); BMI remained an independent predictor of increased LOS on multivariate linear regression analysis (p = 0.002). There was no statistically significant difference in the postoperative outcomes of leak rates, margin rates and incisional herniae. In the entire cohort, when comparing obese patients to those with a normal BMI, there was no statistically significant difference in operative times, EBL, LOS, or immediate postoperative outcomes. However, on multivariate linear regression analysis, BMI was an independent predictor of increased operative time (p = 0.007). CONCLUSION: Obese patients do not have an increased risk of blood loss, positive margins or the postoperative complications of incisional hernia and leak during the learning curve. They do, however, have slightly longer operative times; we also noted an increased LOS in our first 50 cases.

Effect of prostate gland size on the learning curve for robot-assisted laparoscopic radical prostatectomy: does size matter initially?

BACKGROUND AND PURPOSE: Widespread introduction of robot-assisted laparoscopic radical prostatectomy (RALRP) has led to multiple surgeons going through the learning curve (LC). One of the recommendations for surgeons on the LC for RALRP is to choose patients with smaller glands. We evaluated our LCs to determine whether prostate size influenced intraoperative outcomes and positive surgical margin rates. PATIENTS AND METHODS: Data were obtained from a prospective database for the first 154 cases of RALRP performed by a single surgeon. Patients were divided into three groups based on prostate volume (PV): <40 cc (group 1), 40 to 60 cc (group 2), or >60 cc (group 3). PV was estimated by preoperative transrectal ultrasonography (TRUS) and correlated with pathologic weight (PW). Perioperative and immediate postoperative outcomes were evaluated. RESULTS: A statistically significant difference in total operative times between the groups (206 minutes vs 201 minutes vs 233 minutes for groups 1, 2, and 3, respectively) was noted. With regard to individual intraoperative steps, the bladder neck reconstruction and anastomosis time was longer in group 3. No other statistically significant differences were noted. The Pearson correlation coefficient between PV estimation by TRUS and PW was r = 0.785, and an additional analysis based on PW supports the results of our study. CONCLUSIONS: Prostate size influenced total operative times and the bladder neck reconstruction and anastomosis time. Our data support the use of preoperative TRUS to estimate PV and recommendations for surgeons starting on their LC to choose glands less than 60 cc.

Anti-adhesive coating and clearance of device associated uropathogenic Escherichia coli cystitis.

PURPOSE: A previous study showed decreased uropathogen adherence using a novel anti-fouling coating consisting of mussel adhesive protein mimics conjugated to poly(ethylene glycol). We assessed the ability of methoxy polyethylene glycol-dihydroxyphenylalanine (Nerites Corp. Ltd., Madison, Wisconsin) coated ureteral stents to resist bacterial adherence, infection development and encrustation in a rabbit model of uropathogenic Escherichia coli cystitis. MATERIALS AND METHODS: Sof-Flex stent curls that were uncoated and coated with 3 coatings, including Surphys 002, 008 and 009, respectively, and uncoated Percuflex Plus stents were inserted transurethrally into the bladder of 50 male New Zealand White rabbits (Charles River Laboratories, Montreal, Quebec, Canada), followed by instillation of uropathogenic E. coli strain GR12 (10(7) cfu). Urine was examined for bacteria on days 0, 1, 3 and 7, and for cytokine levels on day 7. On day 7 the animals were sacrificed. Stent curls and bladders were harvested for analysis. In a parallel experiment stents were challenged in vitro for 7 days with GR12 in human urine. RESULTS: Surphys 009 coated devices showed decreased urine and stent bacterial counts compared to those in controls. Eight of 10 rabbits in the Surphys 009 group had sterile urine by day 3 vs 1 in each control group (p = 0.013), while stent adherent organisms were decreased by more than 75%. While no statistical differences were found in encrustation and bladder inflammation across the groups, immune scoring was lowest in the uncoated Sof-Flex control and Surphys 009 groups (p = 0.030). CONCLUSIONS: Surphys 009 strongly resisted bacterial attachment, resulting in improved infection clearance over that of uncoated devices. However, this did not translate to decreased encrustation, which appeared to be independent of infection in this model.

Use of triclosan-eluting ureteral stents in patients with long-term stents.

BACKGROUND AND PURPOSE: Long-term use of ureteral stents is prevented by biofilm-related infection and encrustation mandating stent changes every few months. Triclosan is a broad-spectrum antimicrobial in numerous consumer and medical products and has been incorporated into a ureteral stent. We sought to determine the clinical effects of the triclosan-eluting stent in patients who needed long-term ureteral stenting. PATIENTS AND METHODS: Eight patients with long-term stents were enrolled prospectively. All received a control stent for 3 months along with preoperative and postoperative antibiotics. After 3 months, the control stent was removed, and a triclosan-eluting stent was placed for 3 months with no antibiotics administered. For both indwelling periods, urine cultures were obtained weekly and biweekly for the first and last 6 weeks, respectively, and antibiotics were prescribed when patients had both a positive urine culture and symptoms of urinary tract infection. On removal, stents were assessed for microorganisms and encrustation. RESULTS: Overall, similar microorganisms were isolated during each indwell period, although Staphylococcus and Enterococcus strains were isolated more frequently during control and triclosan stenting, respectively. Significantly fewer antibiotics were used during triclosan stenting, coinciding with a slightly higher number of positive urine cultures and significantly fewer symptomatic infections. No bacterial isolates developed antibiotic resistance during triclosan stent placement. CONCLUSIONS: Antibiotic use with control stents resulted in bacterial antibiotic resistance, which was not the case with the triclosan-eluting stents. Although triclosan-eluting stents did not show a clinical benefit in terms of urine and stent cultures or overall subject symptoms compared with controls, their use did result in decreased antibiotic usage and significantly fewer symptomatic infections. The triclosan-eluting stent alone is not sufficient to reduce device-associated infections in this difficult patient population.

Coherent scatter computed tomography for structural and compositional stone analysis: a prospective comparison with infrared spectroscopy.

INTRODUCTION: Infrared spectroscopy (IRS) is a standard method of stone analysis that yields relative proportions of stone materials within a sample. IRS is destructive, as it analyzes only powdered samples, with only a fraction of the stone being analyzed. This leads to sampling bias with components over- or underestimated or even missed entirely. IRS fails to provide structural composition such as that at the stone core. Coherent scatter computed tomography (CSCT) uses diagnostic X-rays to provide detailed structural and compositional analysis of intact specimens, including detailed imaging of the stone core. METHODS: Consecutive patients undergoing surgical treatment for stone disease were recruited for the study. Stones or fragments collected during surgery were subjected to both CSCT and IRS. The two methods were compared with respect to overall bulk composition of the stone and the ability to identify the material at the core. RESULTS: CSCT and IRS agreed on the primary component in the majority (84.8%) of samples. CSCT detected additional components in 88.8% of stones identified as uniform by IRS. CSCT also identified a distinct stone core in 78.8% of samples, while IRS failed to detect the core component in 21.2% of these stones. In 30.3% of the stones with a core component, IRS did not identify the core mineral as the primary component. CONCLUSION: CSCT provides superior quantitative stone analysis and is not prone to issues such as sampling error as the entire specimen is analyzed. CSCT offers excellent structural imaging of stone samples, including detailed analysis of core composition.

Kinetics of calcium oxalate crystal growth in the presence of osteopontin isoforms: an analysis by scanning confocal interference microcopy.

Proteins that inhibit the growth and aggregation of calcium oxalate crystals play important roles in the prevention of kidney stone disease. One such protein is osteopontin (OPN), which inhibits the formation of calcium oxalate monohydrate (COM) in a phosphorylation-dependent manner. To determine the role of phosphate groups in the inhibition of COM growth by OPN, we used scanning confocal interference microscopy to compare the effects of highly phosphorylated OPN from cow milk, less phosphorylated OPN from rat bone, and nonphosphorylated recombinant OPN. COM growth was measured in the principal crystallographic directions <001>, <010>, and <100>, representing lattice-ion addition to {121}, {010}, and {100} faces, respectively. While the shapes of growth curves were very consistent from crystal to crystal, absolute growth rates varied widely. To control for this, results were expressed as changes in the aspect ratios <010>/<001> and <100>/<001>. Compared to control, bone OPN increased <010>/<001> and had no effect on <100>/<001>; milk OPN had no effect on <010>/<001>and decreased <100>/<001>; recombinant OPN had no significant effect on either aspect ratio. These findings indicate that milk OPN interacts with COM crystal faces in order of preference {100} > {121} approximately {010}, whereas bone OPN interacts in order of preference {100} approximately {121} > {010}. As {100} is the most Ca(2+)-rich face of COM, while {010} is the least Ca(2+)-rich, it appears that the OPN-mediated inhibition of COM growth occurs through a nonspecific electrostatic interaction between Ca(2+) ions of the crystal and phosphate groups of the protein.

The effects of triclosan on uropathogen susceptibility to clinically relevant antibiotics.

INTRODUCTION: Triclosan is a broad-spectrum antimicrobial agent currently used in numerous products including surgical scrubs and ureteral stents. Unfortunately, studies have shown triclosan resistance among several bacterial species. Our objective was to characterize resistance patterns of common uropathogens to triclosan and determine whether triclosan exposure would alter their susceptibility to common antibiotics. We hypothesized that triclosan exposure induces a metabolic stress rendering some bacterial strains more susceptible to other antibiotics. METHODS: Using largely clinical isolates comprising seven uropathogenic species, we conducted 24 hour growth experiments to determine triclosan minimal inhibitory concentrations (MIC) for each strain. Based upon these MICs, triclosan was added to agar plates at escalating sublethal concentrations and antibiotic disk diffusion assays were conducted using a range of clinically-relevant antibiotics. RESULTS: Varying susceptibility patterns were observed across all antibiotics studied. Several antibiotics demonstrated increased efficacy in conjunction with triclosan. The combined effect of triclosan with amoxicillin and gentamicin was superior when considering significant increases in susceptibility, with 6 (86%) and 5 (71%) of the 7 bacterial strains displaying enhanced sensitivity, respectively. The antimicrobial effects of nitrofurantoin and the fluoroquinolones were significantly enhanced for 4 (57%), 4 and 3 (42%) of the 7 pathogens, respectively. The two fluoroquinolones were the only antibiotics where susceptibility was negatively impacted (in one strain each) in combination with triclosan. CONCLUSIONS: The synergistic effects of triclosan and several antibiotics are consistent with a triclosan-dependent metabolic strain and/or membrane disruptive effect, and offers important insight into the combined use of antimicrobial compounds in clinical practice.

Minimally invasive approaches to upper urinary tract urolithiasis.

The surgical management of urolithiasis is an ever-changing discipline that presents unique challenges to the urologist. This article reviews the current minimally invasive treatment options for upper urinary tract urolithiasis. First it examines several factors that influence stone-free rates, including Hounsfield units of calculi, obesity, and lower pole factors. Surgical management of ureteral calculi is reviewed along with a discussion of stone management in high-risk patients including those who are pregnant. Surgical technique of shockwave lithotripsy, ureteroscopy, percutaneous nephrolithotomy, and laparoscopy is discussed in depth, with attention paid to possible variations in technique.

Surgical simulation: a urological perspective.

PURPOSE: Surgical education is changing rapidly as several factors including budget constraints and medicolegal concerns limit opportunities for urological trainees. New methods of skills training such as low fidelity bench trainers and virtual reality simulators offer new avenues for surgical education. In addition, surgical simulation has the potential to allow practicing surgeons to develop new skills and maintain those they already possess. We provide a review of the background, current status and future directions of surgical simulators as they pertain to urology. MATERIALS AND METHODS: We performed a literature review and an overview of surgical simulation in urology. RESULTS: Surgical simulators are in various stages of development and validation. Several simulators have undergone extensive validation studies and are in use in surgical curricula. While virtual reality simulators offer the potential to more closely mimic reality and present entire operations, low fidelity simulators remain useful in skills training, particularly for novices and junior trainees. Surgical simulation remains in its infancy. However, the potential to shorten learning curves for difficult techniques and practice surgery without risk to patients continues to drive the development of increasingly more advanced and realistic models. CONCLUSIONS: Surgical simulation is an exciting area of surgical education. The future is bright as advancements in computing and graphical capabilities offer new innovations in simulator technology. Simulators must continue to undergo rigorous validation studies to ensure that time spent by trainees on bench trainers and virtual reality simulators will translate into improved surgical skills in the operating room.