Randomized Controlled Trial of Single-dose Perioperative Pregabalin in Ureteroscopy.

PURPOSE: Ureteroscopy is a commonly performed procedure, with postoperative pain that can lead to revisits and opioid prescribing. Perioperative gabapentinoids have shown promise in decreasing pain and opioid use. We hypothesized that single-dose perioperative pregabalin would be safe and efficacious for decreasing pain after ureteroscopy. MATERIALS AND METHODS: This was an Institutional Review Board-approved and registered blinded, placebo-controlled trial conducted at a single institution. Patients undergoing ureteroscopy without histories that would limit use of opioids, gabapentinoids, and nonsteroidal medications were enrolled. Either 300 mg pregabalin or placebo was administered 1 hour before ureteroscopy. Pain was assessed using a visual analogue scale before administration and 1 hour after surgery. Clinical factors, pain scores, a proxy for cognition, patient satisfaction, and opioid prescribing were assessed in the first 30 postoperative days. RESULTS: A total of 118 patients were enrolled over a 2-year period. Patients who received pregabalin were younger than those who received placebo (median of 44 years vs 57). Postoperative pain scores were higher in those who received pregabalin (3.7 vs 2.0, P = .004), a finding that remained statistically significant when accounting for patient age and preoperative pain scores. There was no difference in the measure of cognition or in reports of adverse events. CONCLUSIONS: In this trial evaluating the efficacy of single-dose perioperative pregabalin in ureteroscopy, pregabalin did not decrease postoperative pain when compared to placebo. Urologists should not routinely use this adjunctive medication in ureteroscopy, as it is unlikely to provide benefit.

Antegrade Instillation of UGN-101 (Mitomycin for Pyelocalyceal Solution) for Low-Grade Upper Tract Urothelial Carcinoma: Initial Clinical Experience.

PURPOSE: UGN-101 (mitomycin for pyelocalyceal solution) is a recently approved chemoablative treatment for low-grade (LG) upper tract urothelial carcinoma (UTUC). While approved for retrograde or antegrade administration, previous reports discuss only patients treated by retrograde approach. We report our techniques for antegrade administration along with early outcomes from our cohort of patients who have undergone UGN-101 administration via nephrostomy. MATERIALS AND METHODS: UGN-101 is administered as 6 weekly instillations in patients who have undergone endoscopic ablation of LG UTUC. We outline our approach in patients thought to have LG UTUC from initial ureteroscopy to nephrostomy placement, UGN-101 administration and eventual nephrostomy removal. We discuss early durability of response along with adverse events with special attention to ureteral strictures. RESULTS: Eight patients underwent antegrade UGN-101 administration during the study period, all of whom underwent followup ureteroscopy with complete response in 4 patients. Three patients reported 5 adverse events-3 grade 1, 1 grade 2 requiring 1 week delay of treatment and 1 asymptomatic ureteral stricture. Median followup was 7 months. CONCLUSIONS: We outline our approach for antegrade administration of UGN-101 and discuss early results along with adverse events. Future studies should evaluate our method's potential to increase patient comfort, improve logistics and decrease risk of adverse events.

Effect of COVID-19 on Urology Residency Training: A Nationwide Survey of Program Directors by the Society of Academic Urologists.

PURPOSE: Coronavirus disease (COVID-19) has profoundly impacted residency training and education. To date, there has not been any broad assessment of urological surgery residency changes and concerns during the COVID-19 pandemic. MATERIALS AND METHODS: The Society of Academic Urologists distributed a questionnaire to urology residency program directors on March 30, 2020 exploring residency program changes related to the COVID-19 pandemic. Descriptive statistics are presented. A qualitative analysis of free response questions was undertaken. A post hoc analysis of differences related to local COVID-19 incidence is described. RESULTS: The survey was distributed to 144 residency programs with 65 responses for a 45% response rate. Reserve staffing had started in 80% of programs. Patient contact time had decreased significantly from 4.7 to 2.1 days per week (p <0.001). Redeployment was reported by 26% of programs. Sixty percent of programs reported concern that residents will not meet case minimums due to COVID-19. Wellness activities centered on increased communication. All programs had begun to use videoconferencing and the majority planned to continue. Programs in states with a higher incidence of COVID-19 were more likely to report resident redeployment (48% vs 11%, p=0.002) and exposure to COVID-19 positive patients (70% vs 40%, p=0.03), and were less likely to report concerns regarding exposure (78% vs 97%, p=0.02) and personal protective equipment availability (62% vs 89%, p=0.02). CONCLUSIONS: As of April 1, 2020 the COVID-19 pandemic had resulted in significant changes in urology residency programs. These findings inform a rapidly changing landscape and aid in the development of best practices.

Group B Streptococcus and the Vaginal Microbiota.

Background: Streptococcus agalactiae (group B Streptococcus [GBS]) is an important neonatal pathogen and emerging cause of disease in adults. The major risk factor for neonatal disease is maternal vaginal colonization. However, little is known about the relationship between GBS and vaginal microbiota. Methods: Vaginal lavage samples from nonpregnant women were tested for GBS, and amplicon-based sequencing targeting the 16S ribosomal RNA V3-V4 region was performed. Results: Four hundred twenty-eight of 432 samples met the high-quality read threshold. There was no relationship between GBS carriage and demographic characteristics, α-diversity, or overall vaginal microbiota community state type (CST). Within the non-Lactobacillus-dominant CST IV, GBS positive status was significantly more prevalent in CST IV-A than CST IV-B. Significant clustering by GBS status was noted on principal coordinates analysis, and 18 individual taxa were found to be significantly associated with GBS carriage by linear discriminant analysis. After adjusting for race/ethnicity, 4 taxa were positively associated with GBS, and 6 were negatively associated. Conclusions: Vaginal microbiota CST and α-diversity are not related to GBS status. However, specific microbial taxa are associated with colonization of this important human pathogen, highlighting a potential role for the microbiota in promotion or inhibition of GBS colonization.

Within State Variability of Antimicrobial Susceptibility: Missouri as an Archetype to Assess Guidelines for Antimicrobial Prophylaxis for Transurethral Procedures.

OBJECTIVE: To evaluate variability among hospitals in susceptibility of common uropathogens to antimicrobial agents frequently used in transurethral procedures in order to examine whether state-based guidelines might be more appropriate than national prophylactic guidelines. METHODS: Hospital-level antibiograms were requested from all hospitals throughout the state of Missouri. We studied Escherichia coli, Klebsiella, and Proteus sensitivities to evaluate common guideline recommended antimicrobials including trimethoprim sulfamethoxazole (TMP-SMX), third-generation cephalosporins, cefazolin, penicillin combinations, gentamicin, and fluoroquinolones. We evaluated variability and association between hospital characteristics and antimicrobial sensitivities. RESULTS: Data was requested from 81 hospitals across the state and 38 provided the requested data (47% response rate). Susceptibility was highest for third-generation cephalosporins for E. coli (mean of 94%), Proteus (96%), and Klebsiella (96%). Gentamicin also had high susceptibility for the bacteria studied; 94% for E. coli and 96% for Klebsiella. Current first line recommended agents showed more modest coverage for E. coli (cefazolin 84%, TMP-SMX 78%), Proteus (cefazolin 82%, TMP-SMX 71%), and Klebsiella (cefazolin 90%, TMP-SMX 89%). CONCLUSION: Post transurethral procedure infections are common. Rates can be limited with appropriate prophylaxis. Deciding on empirical coverage must take into account local resistance patterns. There is substantial variability among and within states in antimicrobial susceptibility for common uropathogens. When selecting antimicrobial prophylaxis, urologists should consider local- rather than state- or nation-level antibiograms, given the considerable variability. Future studies should consider the merits of very-broad spectrum prophylaxis and the potential role of molecular urinary pathogen (and pathogen-resistance) testing when selecting an optimal regimen.

Holistic Assessment of Quality of Life Predicts Survival in Older Patients with Bladder Cancer.

OBJECTIVE: To determine if clustering methods can use a holistic assessment of health-related quality-of-life after bladder cancer diagnosis to predict survival outcomes independent of clinical characteristics. In the United States, an estimated 81,180 cases of bladder cancer will be diagnosed in 2022. We aim to help address the knowledge gap concerning the impact of patient functional status on outcomes. MATERIALS AND METHODS: This is a cross-sectional, retrospective cohort study of patients in the End Results-Medicare Health Outcomes Survey Registry. Age and 36-Item Short Form Survey (SF-36) responses were used as K-means inputs to identify homogenous clusters of older patients with bladder cancer. We analyzed the association between the identified clusters, patient and disease characteristics, and outcomes. We used Cox proportional hazard regression to compare overall survival. RESULTS: We identified 5 homogenous clusters that exhibited differences in patient characteristics and survival. There was no significant difference in cancer stage or surgery type among the clusters. The Cox proportional hazard regression demonstrated significant associations of cluster with gender, age, education, marital status, smoking status, type of surgery, and cancer stage on overall survival. Cluster independently predicted overall survival. CONCLUSION: Using unsupervised machine learning, we identified clusters of patients with bladder cancer who had similar mental and physical function scores. Cluster grouping suggests that patients' mental and physical function may not be based on disease or treatment. There are significant survival differences between all clusters, demonstrating that a holistic assessment of patient-reported health-related quality-of-life has the potential to predict survival and possible modifiable risk factors in older patients with bladder cancer.

Antimicrobial Selection for Transurethral Procedures Across the United States: A State-by-State Antibiogram Evaluation.

OBJECTIVE: To evaluate optimal regimens for perioperative antimicrobial prophylaxis in transurethral procedures by examining antimicrobial susceptibility patterns in the United States. MATERIALS AND METHODS: Through several methods, we attempted to attain an antibiogram for each state. We focused on microbes known to cause infections after transurethral surgeries and antibiotics referred to in current or prior recommendations and compared susceptibility rates across states using Kruskal Walis tests and the Dwass, Steel, Critchlow-Fligner tests. We also examined susceptibility to (non-ceftazidime) third generation cephalosporins. RESULTS: Data is included from 40 states. For each microbe studied, there was significant variability in sensitivity to antibiotics studied. Current first line recommendations for antimicrobial prophylaxis include first generation cephalosporins with 82%, 80%, and 87% mean coverage for E coli, Proteus, and Klebsiella respectively and trimethoprim-sulfamethoxazole with 74%, 80%, and 93% coverage, respectively. Susceptibility to aminoglycosides is 91%, 92%, and 96%, respectively and to third generation cephalosporin, it is 92%, 99%, and 94%. CONCLUSION: Current first line recommended antimicrobials for prophylaxis in transurethral procedures provide overall poor predicted coverage based on our database of antibiograms. Alternatives exist that have higher predicted susceptibility, though clinical significance of this and risk of resultant antimicrobial resistance is unknown. Urologists should consider local patterns when selecting antimicrobial prophylaxis for their patients.

Straight-Up Approach to Bedside Ureteral Stents.

OBJECTIVE: To demonstrate placement of bedside double-j ureteral stents in an Emergency Department or hospital floor setting. BACKGROUND: Ureteral stent placement is a potentially lifesaving intervention and is one of the most common procedures performed by urologists. Although this procedure is typically performed in the operating room, studies have shown placing ureteral stents at the bedside could potentially decrease delay in stent placement, alleviate financial burdens of operating room use, decrease radiation exposure, and avoid general anesthesia risks1-5. We demonstrate a safe and efficacious method for bedside ureteral stent placement without fluoroscopic guidance. MATERIALS AND METHODS: In the setting of the Emergency Department we use ketamine for conscious sedation and local anesthesia while on the wards, we utilize just local anesthesia. After the patient has been sterilely prepped and draped, the operator passes the flexible cystoscope into the bladder in the standard fashion. The obstructed ureteral orifice is identified, and an extra-long guidewire is used to place a 4.8-French ureteral stent through the scope and beyond the obstruction. A post-operative plain film x-ray of the abdomen confirms proper placement. If significant issues are encountered, the procedure is abandoned, and standard operating room stent placement is undertaken. RESULTS: The technique is simple and reproducible for placing double-j ureteral stents outside of the operating room environment without general anesthesia. CONCLUSION: In select patients, bedside double-j ureteral stent placement using our method is a safe and reproducible way to avoid the costs and risks associated with general anesthesia and to optimize utilization of scarce operating room resources.

Robotic Excision of Recurrent Renal Cell Carcinoma Inferior Vena Cava Tumor Thrombus.

Background: Renal cell carcinoma (RCC) recurrence can present in nearly any location. Rarely, recurrence is within the venous system. Previous reports of such recurrent tumor thrombectomy have all used an open approach. For the first time, we present robotic excision of recurrent RCC tumor thrombus. Case Presentation: This is a 59-year-old man who was referred to us 3 years after right robotic radical nephrectomy and renal vein tumor thrombectomy with positive margins. He had been lost to follow-up after 1 year. He presented again 3 years after surgery and was found to have recurrence with inferior vena cava (IVC) tumor thrombus to the caudal margin of the liver. He was taken for robotic tumor thrombectomy, which was completed with 900 mL of estimated blood loss, requiring a single unit of packed red blood cells. The surgery was complicated by increased bleeding caused by an undiagnosed arteriovenous fistula between the right renal artery and vein remnants. Conclusion: Robotic excision of recurrent RCC IVC thrombus is a potential treatment for selected patients under the care of experienced robotic surgeons.