Ureteral Strictures Following Ureteroscopy for Kidney Stone Disease: A Population-based Assessment.

PURPOSE: As the prevalence of urolithiasis increases and ureteroscopy is used more frequently, the risks of uncommon complications such as ureteral stricture may become more notable. Our objective is to assess the rate and associated risk factors of ureteral stricture formation in patients undergoing ureteroscopy. MATERIALS AND METHODS: Utilizing the IBM MarketScan research database, we evaluated data from 2008 to 2019 and compared ureteral stricture rates and their management following ureteroscopy to subjects who had shock wave lithotripsy. Shock wave lithotripsy was used as a comparison group to represent the rate of stricture from stone disease alone. A third group of those having both shock wave lithotripsy and ureteroscopy was included. Patients and secondary procedures were identified using Current Procedural Terminology, and International Classification of Diseases-9 and -10 codes. RESULTS: A total of 329,776 patients received ureteroscopy, shock wave lithotripsy, or shock wave lithotripsy+ureteroscopy between 2008 and 2019. Stricture developed in 2.9% of patients after ureteroscopy, 1.5% after shock wave lithotripsy, and 2.6% after shock wave lithotripsy+ureteroscopy. In the multivariable model, rates of stricture were 1.7-fold higher after ureteroscopy vs shock wave lithotripsy (OR:1.71, 95% CI 1.62-1.81). Preoperative hydronephrosis, age, prior stones/intervention, and concurrent kidney and ureteral stones were associated with increased risk of stricture. Of those with strictures incurred after ureteroscopy, 35% required drainage, 21% had endoscopic intervention, 4.8% required reconstructive surgery, and 1.7% underwent nephrectomy. CONCLUSIONS: Ureteral stricture rate after ureteroscopy of nearly 3% was higher than expected and approximately twice the rate attributable to stone disease alone. Factors associated with the stone as well as instrumentation were found to be risk factors. The morbidity of stricture disease following ureteroscopy was significant.

Fragmentation of Stones by Burst Wave Lithotripsy in the First 19 Humans.

PURPOSE: We report stone comminution in the first 19 human subjects by burst wave lithotripsy (BWL), which is the transcutaneous application of focused, cyclic ultrasound pulses. MATERIALS AND METHODS: This was a prospective multi-institutional feasibility study recruiting subjects undergoing clinical ureteroscopy (URS) for at least 1 stone ≤12 mm as measured on computerized tomography. During the planned URS, either before or after ureteroscope insertion, BWL was administered with a handheld transducer, and any stone fragmentation and tissue injury were observed. Up to 3 stones per subject were targeted, each for a maximum of 10 minutes. The primary effectiveness outcome was the volume percent comminution of the stone into fragments ≤2 mm. The primary safety outcome was the independent, blinded visual scoring of tissue injury from the URS video. RESULTS: Overall, median stone comminution was 90% (IQR 20, 100) of stone volume with 21 of 23 (91%) stones fragmented. Complete fragmentation (all fragments ≤2 mm) within 10 minutes of BWL occurred in 9 of 23 stones (39%). Of the 6 least comminuted stones, likely causative factors for decreased effectiveness included stones that were larger than the BWL beamwidth, smaller than the BWL wavelength or the introduction of air bubbles from the ureteroscope. Mild reddening of the papilla and hematuria emanating from the papilla were observed ureteroscopically. CONCLUSIONS: The first study of BWL in human subjects resulted in a median of 90% comminution of the total stone volume into fragments ≤2 mm within 10 minutes of BWL exposure with only mild tissue injury.

Vesico-ureteric reflux (VUR) management and screening patterns: are paediatric urologists following the 2010 American Urological Association (AUA) guidelines?

OBJECTIVE: To evaluate the current practice patterns of vesico-ureteric reflux (VUR) management and screening among paediatric urologists and their relationship with the current American Urological Association (AUA) guidelines in managing and treating VUR. SUBJECTS AND METHODS: A 17-question survey was sent out to 476 paediatric urologists who are members of the Society for Pediatric Urology (SPU). In all, 133 respondents answered the survey and results were included for all questions. RESULTS: Paediatric urologists who were surveyed were consistent with the 2010 AUA guidelines in the initial evaluation of children with VUR, continuous antibiotic prophylaxis for the child aged < or >1 year, and follow-up evaluation in children with VUR. Most paediatric urologists do not obtain a serum creatinine on initial screening of children with VUR. The new guidelines address screening of siblings of patients with VUR and most paediatric urologists were consistent with these recommendations. Almost one third of responders screened all neonates diagnosed with prenatal hydronephrosis regardless of clinical history or findings on imaging despite the recommendations of the new guidelines. CONCLUSION: We conclude that based on our present sample, most paediatric urologists follow the 2010 AUA guidelines on VUR management.

Penile prostheses and the litigious patient: a legal database review.

INTRODUCTION: Erectile dysfunction (ED) is a common problem with significant impact on patient quality of life. Penile prosthesis implantation provides an effective treatment for ED but as an invasive procedure carries with it an increased risk of medicolegal liability. AIM: To investigate factors associated with malpractice litigation surrounding penile prosthesis implantation. METHODS: The Westlaw legal database was used to perform an advanced search for case reports using the term "medical malpractice" in combination with "penile" or "penis" and "prosthesis" or "implant" with dates between the January 1990 and December 2013. MAIN OUTCOME MEASURES: Each report was examined for trial information including patient demographics, device model and indications, alleged breach of duty, alleged damages, progression to trial, case outcome, and plaintiff award(s). RESULTS: The initial search yielded 76 cases that were narrowed to 40 after exclusions. There were 23 (57.5%) cases that were found in favor of the defendant, while 17 (42.5%) cases led to indemnity payment to the plaintiff including two cases (5.0%) that were settled out of court and 15 (37.5%) favoring the plaintiff in front of a jury. The mean settlement received was $335,500 compared with the mean indemnity award of $831,050 for verdicts decided in favor of the plaintiff (P = 0.68). The most common breach of duty was error in surgical decision making, present in 20 cases (48.8%). Informed consent was an issue in 13 filings (31.7%), and postoperative infection was seen in 13 cases (31.7%). In cases that identified the type of implant used, 58.3% were malleable implants, and 41.7% were inflatable devices. CONCLUSIONS: The main issues involved in malpractice litigation for penile prosthesis implants included surgical performance, informed consent, and postoperative management. Urologists must be aware of these potential issues in order to minimize their malpractice liability.

A multi-institutional analysis of 263 hilar tumors during robot-assisted partial nephrectomy.

Hilar tumors pose unique challenges during partial nephrectomy. We present the characteristics and outcomes of 263 patients with hilar tumors undergoing robot-assisted partial nephrectomy (RPN) in the largest series to date. Perioperative, pathologic, functional, and oncological outcomes were compared between 1467 (84.8%) patients with a non-hilar tumor and 263 (15.2%) patients with a hilar tumor undergoing RPN. Variables were compared in univariable (unadjusted) analysis and using multivariable linear, logistic, poisson, cox proportional hazards and linear mixed effects regression models adjusting for tumor diameter and RENAL Nephrometry score. Hilar tumors were larger (3.7 vs. 3.0 cm, p < 0.001) and more complex (RENAL Score 9 vs. 7, p < 0.001), leading to longer operative time (186 vs. 161 min, p < 0.001), ischemia time (18 vs. 15, p < 0.001), greater blood loss (150 vs. 100 ml, p < 0.001), eGFR decline at discharge (∆ = 3.9%, p = 0.035) and eGFR decline per month up to 36 months post-RPN (ß = - 0.25; p = 0.017). In multivariable analysis, hilar tumors were only associated with a 10% increase in operative time (p ≤ 0.001) and marginally worse eGFR decline over time (ß = - 0.19, p = 0.076), with no differences in other outcomes analyzed including ischemia time, blood loss, complication rate, recurrence-free survival, or eGFR decline at discharge. Although hilar tumors were found to be larger and more anatomically complex, there were only marginal differences in outcome when compared to non-hilar tumors. A hilar renal tumor should be considered for partial nephrectomy when feasible without an expected increase in complications or adverse events.

Malpractice Litigation in the Setting of Prostate Cancer Diagnosis.

INTRODUCTION: Medical malpractice and prostate cancer screening are important issues in the current landscape of health care. We identified factors contributing to litigation in the diagnosis of prostate cancer. METHODS: We used the Westlaw® database to search for jury verdict reports using the term medical malpractice combined with prostate cancer with dates ranging from January 2000 to December 2013. Each case was examined for trial year, patient age, prostate specific antigen at alleged breach of duty and at diagnosis, defendant specialty, alleged cause of malpractice, whether there was metastasis, the outcome of cases that went to trial or were otherwise settled, and the plaintiff award. RESULTS: The initial search produced 256 results, which was narrowed to 106 cases. Of these cases 64.1% went to trial, including 66.2% that were decided for the defendant. The mean out of court settlement was $945,000, significantly lower than the mean plaintiff verdict award of $2.1 million (p = 0.0009). Primary care physicians (74.1%) were the most commonly named defendants, followed by urologists (19.6%). The most common cause was failure to perform an initial prostate specific antigen test (26.8%), followed by failure to follow elevated prostate specific antigen (22.3%). CONCLUSIONS: Causes of malpractice revolved mostly around prostate specific antigen testing. Primary care physicians and urologists must continue to educate patients to minimize malpractice claims made in this setting. It will be important to follow data to see trends following recent guidelines.

Expert witness testimony in urology malpractice litigation.

OBJECTIVE: To evaluate the credentials of urologists choosing to testify as expert witnesses. As health care reform has become an increasingly important topic in national debate, medical malpractice and related issues have come to the forefront of topics for discussion by the medical community. Physicians are often recruited to testify as expert witnesses in malpractice cases. Defining what constitutes an expert in this setting has been an area of controversy. METHODS: The Westlaw legal database was searched for medical malpractice litigation. Data regarding number of years of experience and practice setting were obtained for urologists using private practice and hospital listings, academic faculty profiles, and state medical licensing databases. Scholarly impact, as measured by the h-index, was calculated by the Scopus database. RESULTS: Plaintiff expert witnesses were found to have slightly more years of experience vs defendant expert witnesses (35.7 vs 32.2 years, P = .01), but had a lower h-index (6.8 vs 10.2, P = .03), were less likely to practice in the academic setting (39% vs 60%, P = .001), and were more likely to testify multiple times. CONCLUSION: Urologists testifying for plaintiffs and defendants both had over 30 years of experience on average, with those in the latter having slightly less experience. Defendant witnesses, however, had greater scholarly impact and were more likely to practice in an academic setting. Organizations such as the American Urological Association may wish to re-evaluate guidelines on expert witness testimony, particularly regarding those who testify frequently.

Schwannomas of the sinonasal tract and anterior skull base: a systematic review of 94 cases.

BACKGROUND: Schwannomas of the anterior skull base (ASB) and sinonasal tract are extremely rare. These lesions mimic other pathologies such as olfactory groove meningiomas, hemangiopericytomas, and esthesioneuroblastomas. Because of their low incidence, ASB and sinonasal tract schwannomas have not been well characterized. A systematic review of ASB and sinonasal tract schwannomas was conducted to further elucidate the presentation and surgical management of these lesions. METHODS: A MEDLINE/PubMed search was performed, identifying 71 articles representing 94 cases of ASB and sinonasal schwannomas. Each case was analyzed for demographics, clinical presentation, anatomic location, radiographic features, and surgical treatment. RESULTS: In 94 patients with ASB and sinonasal schwannomas, 44 (46.8%) were exclusively sinonasal, 30 cases (31.9%) were exclusively intracranial, 12 (12.8%) were primarily intracranial with extension into the paranasal sinuses, and 8 (8.5%) were primarily sinonasal with intracranial extension. Headaches and nasal obstruction were the most common presenting symptoms occurring in 30.9 and 29.8% of cases, respectively. Magnetic resonance imaging typically showed a hyperintense mass on T2-weighted imaging (70%) and hypointense (41%) on T1-weighted imaging. Most patients underwent surgical gross total resection via craniotomy, endoscopic endonasal approach, rhinotomy, or other sinonasal approaches. Recurrence occurred in three cases ranging from 4 months to 13 years. Postoperative complications included cerebral spinal fluid leakage, bacterial meningitis, epidural hematoma, and pneumocranium. CONCLUSION: ASB and sinonasal schwannomas are rare lesions and should be considered in the differential diagnosis of ASB masses involving the cribriform plate with sinonasal extension. Gross total resection of these lesions should be considered the goal of operative management.

Characterizing liability for cranial nerve injuries: a detailed analysis of 209 malpractice trials.

OBJECTIVES/HYPOTHESIS: The potential for adverse events with lasting functional effects makes cranial nerve (CN) injury a target for litigation. Our objective was to comprehensively examine records of malpractice trials and detail issues influencing outcomes. STUDY DESIGN: Retrospective analysis. METHODS: The Westlaw database (Thomson Reuters, New York, NY) was searched for jury verdict reports related to medical malpractice and CN injury. After excluding nonrelevant cases, we examined 209 trials for characteristics including nerve(s) injured, alleged causes of malpractice, demographic information, specialty, and outcome. RESULTS: The most commonly litigated CNs were VII (24.4%) and II (19.6%). Sixty-nine (33.0%) trials resulted in damages awarded. Outcomes varied, ranging from a 29.2% plaintiff success rate for CN XI injury to 48.4% for CN II injury. Plaintiffs had less success with increasing age. Average damages awarded were $1.7 million. The most commonly named defendants were otolaryngologists and general surgeons. Individual considerations varied but commonly included alleged deficits in informed consent (25.4%), unnecessary procedures (14.8%), undergoing additional surgery (25.8%), and untimely recognition of complications (23.9%). CONCLUSIONS: Malpractice trials were resolved in the defendant's favor the majority of the time. In cases where plaintiffs were successful, however, awards were considerable, averaging nearly $2 million. Factors influencing case outcome included age, location, perceived deficits in informed consent, allegedly unnecessary surgery, requiring additional surgery to repair a complication, and untimely recognition of complications. Although specific factors should be taken into consideration with each procedure, providing detailed informed consent and communicating with patients regarding expectations may minimize liability.