The prone ureteroscopic technique for managing large stone burdens.

Percutaneous nephrolithotomy (PCNL) is the standard treatment for patients with large stone burdens, but can be associated with significant complications. Flexible ureteroscopy is an alternative approach that is less invasive, but often requires multiple procedures. Typically, many factors play a role in the decision to perform PCNL or ureteroscopy. The challenge is that it is difficult to predict which stone burdens will be able to be cleared ureteroscopically. We describe our approach using initial prone ureteroscopy with the transition to standard prone PCNL if required.

A nephrolithometric nomogram to predict treatment success of percutaneous nephrolithotomy.

PURPOSE: Imaging is routinely done preoperatively and postoperatively to assess patients treated with percutaneous nephrolithotomy. We developed a nomogram for percutaneous nephrolithotomy success. MATERIALS AND METHODS: From November 2007 to December 2009 the CROES (Clinical Research Office of the Endourological Society) collected data on consecutive patients at 96 centers globally. Patients were evaluated for stone-free status using plain x-ray of the kidneys, ureters and bladder. Treatment success was defined as no visible stones or residual fragments less than 4 mm. Multivariate regression was used to model the relationship between preoperative descriptors and the stone-free rate. Variables included case load, prior treatment, body mass index, staghorn stones, renal anomalies, and stone burden, location and count. Bootstrapping techniques were used to validate the model. Adjusted chi-square statistic values were used to rank the prognostic value of variables. A nomogram was developed using significant predictors from the model. We assessed the predictive accuracy of the nomogram using the ROC curve AUC. The nomogram was calibrated. RESULTS: Stone burden was the best predictor of the stone-free rate (chi-square = 30.27, p <0.001). Other factors associated with the stone-free rate were case volume (chi-square = 35.75, p <0.001), prior stone treatment (chi-square = 14.55, p <0.012), staghorn stone (adjusted chi-square = 4.73, p <0.029), stone location (chi-square = 14.74, p <0.001) and stone count (chi-square = 4.78, p <0.004). A nephrolithometric nomogram was developed with predictive accuracy (AUC 0.76). CONCLUSIONS: The percutaneous nephrolithotomy stone-free rate can be predicted using preclinical data and radiological information. We present a nephrolithometric nomogram for percutaneous nephrolithotomy.

Treatment of BCG failures with intravesical BCG/Interferon: the University of Montreal experience.

OBJECTIVE: Bacillus Calmette-Guerin (BCG) has shown promise in large scale studies. We assessed recurrence-free survival in patients treated with intravesical BCG/Interferon (IFN) for non-muscle invasive, BCG refractory, transitional cell carcinoma (TCC) of the urinary bladder at our local institution. METHODS: Cancer control data were gathered for patients enrolled in a BCG/Interferon protocol at the University of Montreal. The main inclusion criteria consisted of pathologically proven evidence of intravesical BCG failure, and of complete transurethral resection of latest post BCG recurrence. Induction consisted of eight intravesical BCG/Interferon instillations. Select patients were treated with BCG/Interferon maintenance therapy. RESULTS: Thirteen patients aged from 45 to 81 years (mean: 65) were included. Stages at TCC diagnosis were distributed as follows: 6 (46%) CIS, 3 (23%) Ta, and 4 (31%) T1. Induction BCG consisted of an average of 11 weekly instillations (range 3-24). Prior to BCG/Interferon stage distribution was as follows: 9 (69%) CIS, and 4 (31%) T1. BCG/Interferon maintenance was administered to 5 (38%) patients. Follow-up ranged from 1.5 to 32 months (mean=15, median=12). Recurrence was diagnosed in 5 patients (38%). Recurrence free survival (RFS) at 24 months was 66%. When stratified according to T stage prior to BCG/IFN, patients with CIS fared worse than T1 patients (50% versus 100%). Maintenance had no effect on RFS (75% versus 69%). CONCLUSIONS: Our results corroborate previous BCG/IFN reports. In selected patients, intravesical BCG/IFN offers a valid alternative to definitive therapy.

Same-Day Discharge for Patients Undergoing Robot-Assisted Laparoscopic Radical Prostatectomy Is Safe and Feasible: Results of a Pilot Study.

INTRODUCTION: With healthcare reform, cost and patient satisfaction will directly affect hospital reimbursement. We present data on same-day discharge (SDD) for patients who underwent robot-assisted laparoscopic radical prostatectomy (RALP). METHODS: Patient data were gathered in an IRB-approved database. In April 2015, the surgeon (S.J.) began SDD. The SDD protocol for RALP includes multimodal anesthesia/analgesia and extended recovery. Interim analysis revealed that government insurance (CMS) refused hospital reimbursement for SDD. As of that time, only patients with commercial insurance were offered SDD. The demographic and peri-operative data were compared between the two cohorts (Group 1, SDD; Group 2, Admitted patients) by using Mann-Whitney U, chi-squared, or fisher exact tests, where appropriate. RESULTS: During the study period, 21 patients had undergone RALP. Eleven of 21 patients were offered SDS, and nine (81.8%) were discharged. Both those who elected to stay were successfully discharged on the next day. Patient age, body mass index (BMI), prostate-specific antigen, operative time, estimated blood loss (EBL), prostate weight, distance from home to hospital, margin status, marital status, and household income were not statistically significantly different between the two groups. The same is true between patients who underwent RALP both before and after initiation of the SDD protocol with the exception of EBL (greater in the SDD group). There have been no reported complications or readmissions for any of the patients in Group 1. CONCLUSION: Our novel pilot study reveals that SDS is safe and feasible. We are currently conducting a further evaluation of patient satisfaction. Future research is needed to verify these conclusions.

Nephropleural Fistula Effectively Managed with Serial Thoracentesis: A Case Report.

Nephropleural fistulae are rare but serious thoracic complications of percutaneous nephrolithotomy (PCNL). Herein, we present the management of a 54-year-old female with a delayed presentation of nephropleural fistula. The role of serial thoracentesis as a safe, less invasive, less painful alternative to tube thoracostomy is highlighted. In select cases, this may represent an attractive management strategy for nephropleural fistula after PCNL.

Application of long-acting VLHL PAI-1 during sutureless partial nephrectomy in mice reduces bleeding.

PAI-1 prevents lysis of blood clot by inhibiting the urokinase and tPA induced conversion of plasminogen to plasmin. VLHL PAI-1 protein mutant was created to extend half-life over 700 hours. The objective of this paper was to test VLHL PAI-1 effects on bleeding during partial nephrectomy in mice. All animals had a left partial nephrectomy after intravenous infusion of saline or tPA. The animals were divided into four groups. Group 1 was infused with saline and kidney was exposed to saline too; Group 2 was infused with saline and kidney was exposed to PAI-1. Group 3 was infused with tPA and kidney was exposed to saline, while Group 4 was infused with tPA and kidney was exposed to PAI-1. Preweighed gauze containing PAI-1 or saline was then applied to the kidney for 30 minutes. The gauze was afterward weighed and blood loss was measured by subtracting the preweight of gauze from the final weight. We have observed a statistically significant (P ≤ 0.05) reduction of bleeding in PAI-1-treated group in comparison to saline and tPA-treated groups. Based on these results we propose that VLHL PAI-1 can be used therapeutically in limiting the flow of blood from renal wounds.

Abdominal implantation of testicles in the management of intractable testicular pain in Fournier gangrene.

Fournier gangrene (FG) is a necrotizing soft tissue infection involving the superficial and fascial planes of the perineum. In many cases of FG, debridement of the scrotum is necessary, leaving definitive management of the exposed testicles a significant surgical challenge. Frequent incidental trauma to the testicles can cause severe pain, especially in laborers. Practical surgical solutions are few and not well detailed. Various options exist, including creating a neoscrotum with adjacent thigh tissue, split-thickness skin grafts (STSGs), or even creating a subcutaneous thigh pocket. We describe a case of abdominal implantation of bilateral testicles for persistent testicular pain in a case where STSGs did not provide adequate protection, adjacent thigh skin was not available for creation of a neoscrotum, and significant cord contracture occurred. We detail the advantages and disadvantages of the commonly described techniques, including this approach, and how in select individuals this may be a suitable alternative.

Predictors of immediate postoperative outcome of single-tract percutaneous nephrolithotomy.

OBJECTIVE: To evaluate the efficacy of single tract percutaneous nephrolithotomy (sPCNL) and investigate the preoperative predictive factors associated with stone clearance after sPCNL. METHODS: A retrospective review of 351 cases of sPCNL performed at a single institution by 1 of 2 endourologists between January 2000 and March 2010 was performed. The primary outcome evaluated was stone-free rate (SFR) as assessed immediately after either an initial procedure or a second-look nephroscopy performed on postoperative day 2. Preoperative patient and stone factors, including age, sex, body mass index (BMI), preoperative hematocrit and creatinine, previous surgeries, comorbidities, renal anomalies, stone size, shape, location, and history of any previous treatment to the active stone burden were included in the univariate analysis. Significant or clinically relevant factors on univariate analysis were included in a logistic regression the multivariate analysis. RESULTS: SFR after either an initial procedure or a second-look nephroscopy was 76%. On univariate analysis, rising preoperative creatinine, hypertension, increasing stone diameter, complete staghorn stone, presence of stones in the upper pole and absence of prior SWL were associated with lower SFR. Stone size, presence of stones in the upper pole, and prior SWL for the active burden were independent predictors of SFR on multivariate analysis. CONCLUSION: sPCNL is an efficient procedure to clear renal stones, especially when used in conjunction with routine second-look nephroscopy. Increasing stone size and upper pole stones are associated with lower rates of stone clearance, whereas SWL performed before percutaneous nephrolithotomy (PCNL) is associated with improved stone clearance. The role of SWL before PCNL warrants further prospective investigation.

Needle steering system using duty-cycled rotation for percutaneous kidney access.

The authors present ongoing work on the use of a variable curvature flexible needle steering system to gain percutaneous access to the kidney for medical interventions. A nonlinear control law is introduced which drives the needle to track a predetermined planar path using a steering approach based on duty-cycled rotation during insertion. Renal access is performed in simulation and tested in vitro in a tissue phantom to validate the proposed control method.