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PURPOSE: During endoscopic stone surgery, Holmium:YAG (Ho:YAG) and Thulium Fiber Laser (TFL) technologies allow to pulverize urinary stones into fine particles, ie DUST. Yet, currently there is no consensus on the exact definition of DUST. This review aimed to define stone DUST and Clinically Insignificant Residual Fragments (CIRF). METHODS: Embase, MEDLINE (PubMed) and Cochrane databases were searched for both in vitro and in vivo articles relating to DUST and CIRF definitions, in November 2023, using keyword combinations: "dust", "stones", "urinary calculi", "urolithiasis", "residual fragments", "dusting", "fragments", "lasers" and "clinical insignificant residual fragments". RESULTS: DUST relates to the fine pulverization of urinary stones, defined in vitro as particles spontaneously floating with a sedimentation duration ≥ 2 sec and suited for aspiration through a 3.6Fr-working channel (WC) of a flexible ureteroscope (FURS). Generally, an upper size limit of 250 µm seems to agree with the definition of DUST. Ho:YAG with and without "Moses Technology", TFL and the recent pulsed-Thulium:YAG (pTm:YAG) can produce DUST, but no perioperative technology can currently measure DUST size. The TFL and pTm:YAG achieve better dusting compared to Ho:YAG. CIRF relates to residual fragments (RF) that are not associated with imminent stone-related events: loin pain, acute renal colic, medical or interventional retreatment. CIRF size definition has decreased from older studies based on Shock Wave Lithotripsy (SWL) (≤ 4 mm) to more recent studies based on FURS (≤ 2 mm) and Percutaneous Nephrolithotomy(PCNL) (≤ 4 mm). RF ≤ 2 mm are associated with lower stone recurrence, regrowth and clinical events rates. While CIRF should be evaluated postoperatively using Non-Contrast Computed Tomography(NCCT), there is no consensus on the best diagnostic modality to assess the presence and quantity of DUST. CONCLUSION: DUST and CIRF refer to independent entities. DUST is defined in vitro by a stone particle size criteria of 250 µm, translating clinically as particles able to be fully aspirated through a 3.6Fr-WC without blockage. CIRF relates to ≤ 2 RF on postoperative NCCT.
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Ureteroscopia , Cálculos Urinários , Humanos , Cálculos Urinários/terapia , Litotripsia a Laser/métodos , Poeira , Tamanho da PartículaRESUMO
PURPOSE OF REVIEW: While urologists are traditionally taught to perform percutaneous nephrolithotomy (PCNL) utilizing exclusively fluoroscopy, ultrasound has emerged as a safe alternative. This article showcases the major reasons why ultrasound-guided access should be considered the first-line approach for performing access for PCNL. RECENT FINDINGS: There continues to be a need to further reduce radiation exposure in the management of kidney stone patients. This review showcases how performing ultrasound-guided PCNL has been associated with a shorter learning curve, increased patient safety, and the ability to perform x-ray free PCNL. Ultrasound-guided PCNL is not only an achievable skill for urologists to learn but provides multiple advantages over traditional fluoroscopic access. As every effort should be given to help reduce radiation exposure for kidney stone patients as well as performing surgeons and operating theater personnel, endourologists should strive to add this technique to their armamentarium.
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Cálculos Renais , Nefrolitotomia Percutânea , Nefrostomia Percutânea , Humanos , Nefrolitotomia Percutânea/métodos , Cálculos Renais/diagnóstico por imagem , Cálculos Renais/cirurgia , Fluoroscopia , Ultrassonografia de Intervenção/métodos , Resultado do TratamentoRESUMO
Kidney stone cultures can be beneficial in identifying bacteria not detected in urine, yet how stone cultures are performed among endourologists, under what conditions, and by what laboratory methods remain largely unknown. Stone cultures are not addressed by current clinical guidelines. A comprehensive REDCap electronic survey sought responses from directed (n = 20) and listserv elicited (n = 108) endourologists specializing in kidney stone disease. Questions included which clinical scenarios prompt a stone culture order, how results influence post-operative antibiotics, and what microbiology lab protocols exist at each institution with respect to processing and resulting stone cultures. Logistic regression statistical analysis determined what factors were associated with performing stone cultures. Of 128 unique responses, 11% identified as female and the mean years of practicing was 16 (range 1-46). A specific 'stone culture' order was available to only 50% (64/128) of those surveyed, while 32% (41/128) reported culturing stone by placing a urine culture order. The duration of antibiotics given for a positive stone culture varied, with 4-7 days (46%) and 8-14 days (21%) the most reported. More years in practice was associated with fewer stone cultures ordered, while higher annual volume of percutaneous nephrolithotomy was associated with ordering more stone cultures (p < 0.01). Endourologists have differing practice patterns with respect to ordering stone cultures and utilizing the results to guide post-operative antibiotics. With inconsistent microbiology lab stone culture protocols across multiple institutions, more uniform processing is needed for future studies to assess the clinical benefit of stone cultures and direct future guidelines.
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Cálculos Renais , Nefrolitotomia Percutânea , Feminino , Humanos , Nefrolitotomia Percutânea/métodos , Cálculos Renais/urina , Urinálise , Bactérias , Estudos Multicêntricos como AssuntoRESUMO
Introduction and Objective: Guidelines from the American Urological Association (AUA) and American College of Radiology (ACR) recommend that patients with suspected nephrolithiasis undergo low-dose CT of the kidney, ureter, and bladder (LD CT KUB) as opposed to higher dose conventional imaging. We hypothesized that even at institutions with established LD protocols, higher dose imaging is common. Materials and Methods: We identified four academic medical centers where LD CT KUB protocols were implemented to yield an effective dose (EDose) consistent with national guidelines. Fifty consecutive adult patients who underwent CT KUB specifically for the evaluation of nephrolithiasis were retrospectively reviewed at each site. Patient age, sex, body mass index (BMI), imaging location, and EDose (millisieverts [mSv]) were recorded. Results: Two hundred patients with a mean age of 54 years were identified. Forty-six patients (23%) underwent CT KUB with an EDose ≤4 mSv, accounting for 10% to 48% of each institution's cohort. One hundred sixteen patients had a BMI <30, and would have been expected to receive LD CTs by the AUA criteria for LD CT KUB. Within this subset, only 37 patients (32%) actually underwent LD CT KUB. The highest dose CT KUB at each institution resulted in an EDose of 33.8 to 44.6 mSv, exceeding the recommended exposure of LD CT KUB by 10-fold. Conclusions: At academic institutions where LD CT KUB was implemented for the evaluation of nephrolithiasis, a minority of patients with BMI <30 received guideline-concordant imaging. Differences in patient BMI did not account for the variation in radiation exposure. Further research is necessary to elucidate barriers to LD CT implementation.
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Cálculos Renais , Exposição à Radiação , Adulto , Humanos , Pessoa de Meia-Idade , Doses de Radiação , Radiografia Abdominal , Estudos Retrospectivos , Tomografia Computadorizada por Raios X/métodosRESUMO
INTRODUCTION: The prevalence of kidney stones is rising and there is an increasing demand for reliable, easy to understand information for patients. To evaluate the readability of common Internet-based resources for kidney stones, we examined whether the most popular online educational materials may be contributing to decreased health literacy for this chronic condition. METHODS: Websites for readability analysis were chosen based on a Google.com search using the search term "kidney stones." The top 10 websites were chosen for analysis and their quality was assessed by the presence or absence of a HONcode certificate. Readability was determined using 6 readability assessment tools: Flesch Reading Ease, FORCAST, Fry, Gunning Fog, Raygor Estimate and Simple Measure of Gobbledygook. Each website was then analyzed by subsections, with emphasis on the treatment and prevention of kidney stones. RESULTS: Of the 10 websites analyzed 8 had HONcode certification. Grade level calculations ranged from 7-13.9. All 10 websites were found to have readability levels above the recommended sixth-grade reading level. Mean Flesch Reading Ease score was 59 (range 47-73). With respect to treatment and prevention sections, 6/10 and 5/10 websites had readability levels above a tenth-grade level, respectively. CONCLUSIONS: The most commonly accessed websites regarding kidney stones have readability scores above what is comprehensible to the general public, with most exceeding grade level recommendations from the American Medical Association. Websites pertaining to kidney stones need to be simplified to facilitate patient understanding, especially with respect to the treatment and prevention of kidney stones.
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Nephrolithiasis is a significant source of morbidity, and its incidence has increased significantly over the last decades. This rise has been attributed to concurrent increasing rates of obesity, associated with a 3-time risk of developing NL. To date, the mechanism by which obesity is linked to stone formation has not been elucidated. We aimed to utilize a transcriptomics approach to discover the missing link between these two epidemic diseases. We investigated gene expression profiling of nephrolithiasis patients by two RNA-sequencing approaches: comparison between renal papilla tissue with and without the presence of calcified Randall's plaques (RP), and comparison between the papilla, medulla, and cortex regions from within a single recurrent stone forming kidney. Results were overlaid between differently expressed genes found in the patient cohort and in the severely lithogenic kidney to identify common genes. Overlay of these two RNA-sequencing datasets demonstrated there is impairment of lipid metabolism in renal papilla tissue containing RP linked to downregulation of fatty acid binding protein (FABP) 4. Immunohistochemistry of human kidney specimens and microarray analysis of renal tissue from a nephrolithiasis mouse model confirmed that FABP4 downregulation is associated with renal stone formation. In a FABP4 knockout mouse model, FABP4 deficiency resulted in development of both renal and urinary crystals. Our study revealed that FABP4 plays an important, previously unrecognized role in kidney stone formation, providing a feasible mechanism to explain the link between nephrolithiasis and metabolic syndrome.
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Cálculos Renais , Regulação para Baixo , Proteínas de Ligação a Ácido Graxo/genética , Humanos , Rim , Cálculos Renais/genética , Medula RenalRESUMO
OBJECTIVE: To assess the safety, feasibility and treatment outcomes of holmium laser enucleation of the prostate (HoLEP) as a same day surgery (SDS). METHODS: HoLEPs performed from November 2013 to December 2018 at our institution were reviewed retrospectively. Inclusion criteria for same day surgery (SDS) included living in the local metropolitan area with access to local hospital and Eastern Cooperative Oncology Group (ECOG) 0-2, regardless of prostate size and anticoagulation status. Those patients who were discharged directly from the postoperative care unit were identified as SDS cases. Patients admitted overnight after HoLEP during the same period were used as a matched cohort. Patient demographics, disease characteristics and treatment outcomes were compared. RESULTS: A total of 377 patients were identified, including 199 SDS and 178 non-SDS patients. No statistical difference was present between the 2 groups regarding the post-op complication and readmission rates. The non-SDS group had a significantly higher percentage of patients with history of urinary retention, lower pre-op Qmax, and larger prostate volume. The SDS group had shorter operative time, length of stay (LOS), and catherization time (all P <.05). At 1-year follow-up, no statistically different change in Qmax, PVR, or IPSS score was noted between the 2 groups. CONCLUSION: Same day outpatient surgery for HoLEP is safe in patients who live in close proximity and have ECOG status 0-2. Our readmission rate and complication rate are comparable to those reported in the literature with markedly decreased LOS. Long-term functional outcome is not compromised by SDS.
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Procedimentos Cirúrgicos Ambulatórios/efeitos adversos , Lasers de Estado Sólido/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Prostatectomia/efeitos adversos , Hiperplasia Prostática/cirurgia , Idoso , Idoso de 80 Anos ou mais , Procedimentos Cirúrgicos Ambulatórios/instrumentação , Procedimentos Cirúrgicos Ambulatórios/métodos , Estudos de Viabilidade , Humanos , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/etiologia , Próstata/patologia , Próstata/cirurgia , Prostatectomia/instrumentação , Prostatectomia/métodos , Estudos Retrospectivos , Resultado do TratamentoRESUMO
OBJECTIVES: To compare clinical outcomes in patients who underwent percutaneous nephrolithotomy (PCNL) with renal tract dilatation performed under fluoroscopic guidance vs renal tract dilatation with ultrasound guidance. PATIENTS AND METHODS: We conducted a prospective observational cohort study, enrolling successive patients undergoing PCNL between July 2015 and March 2018. Included in this retrospective analysis were cases where the renal puncture was successfully obtained with ultrasound guidance. Cases were then grouped according to whether fluoroscopy was used to guide renal tract dilatation or not. All statistical analyses were performed using Stata version 15.1 including univariate (Fisher's exact test, Welch's t-test) and multivariate analyses (binomial logistic regression, ordinal logistic regression, and linear regression). RESULTS: A total of 176 patients underwent PCNL with successful ultrasonography-guided renal puncture, of whom 38 and 138 underwent renal tract dilatation with fluoroscopic vs ultrasound guidance, respectively. There were no statistically significant differences in patient age, gender, body mass index (BMI), preoperative hydronephrosis, stone burden, procedure laterality, number of dilated tracts, and calyceal puncture location between the two groups. Among ultrasound tract dilatations, a higher proportion of patients were placed in the modified dorsal lithotomy position as opposed to prone, and a significantly shorter operating time was observed. Only modified dorsal lithotomy position remained statistically significant after multivariate regression. There were no statistically significant differences in postoperative stone clearance, complication rate, or intra-operative estimated blood loss. A 5-unit increase in a patient's BMI was associated with 30% greater odds of increasingly severe Clavien-Dindo complications. A 5-mm decrease in the preoperative stone burden was associated with 20% greater odds of stone-free status. No variables predicted estimated blood loss with statistical significance. CONCLUSIONS: Renal tract dilatation can be safely performed in the absence of fluoroscopic guidance. Compared to using fluoroscopy, the present study demonstrated that ultrasonography-guided dilatations can be safely performed without higher complication or bleeding rates. This can be done using a variety of surgical positions, and future studies centred on improving dilatation techniques could be of impactful clinical value.
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Dilatação/métodos , Fluoroscopia , Biópsia Guiada por Imagem , Cálculos Renais/cirurgia , Nefrolitotomia Percutânea , Ultrassonografia , Adulto , Idoso , Feminino , Humanos , Hidronefrose/diagnóstico por imagem , Cálculos Renais/diagnóstico por imagem , Cálculos Renais/fisiopatologia , Masculino , Pessoa de Meia-Idade , Nefrolitotomia Percutânea/métodos , Estudos Prospectivos , Reprodutibilidade dos Testes , Resultado do TratamentoRESUMO
Ultrasonography has emerged as an alternative to fluoroscopy for image-guided percutaneous nephrolithotomy (PCNL) in many countries. Compared to fluoroscopy-guided PCNL (F-PCNL), ultrasound-guided PCNL (US-PCNL) is easier to learn and reduces radiation exposure to patients and providers. Despite these advantages, uptake of ultrasound-guided PCNL (US-PCNL) in Canada has been almost nonexistent, largely because it is not incorporated into urologists' training. In this article, we seek to familiarize Canadian urologists with this approach by describing our step-by-step technique for US-PCNL. Additionally, we provide keys to successful implementation of this technique.
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OBJECTIVE: To demonstrate how bladder ultrasound can be useful in completing morcellation during difficult Holmium Laser Enucleation of the Prostate (HoLEP). As HoLEP has emerged as a standard of care for the treatment of benign prostatic hyperplasia, multiple studies have reported the potentially catastrophic complication of bladder injury during morcellation. This video aims to assist any urologist performing HoLEP by providing step-by-step instruction for using ultrasound to complete morcellation safely. METHODS: Enucleation is performed using a 26-French continuous flow scope, off-set laser bridge with a laser stabilization catheter, and a 550 µm holmium laser fiber. Once the median and lateral lobes have been enucleated, the outer sheath is removed and the nephroscope is inserted to facilitate morcellation. Under dual inflow irrigation, the Piranha morcellator (Richard Wolf, Knittlingen, Germany) is introduced and set to the manufacturer's recommended settings of 1500 rpm. A 3.5-MHz convex abdominal ultrasound transducer (Hitachi Prosound Alpha 7; Hitachi Aloka Medical America, Wallingford, CT) under B-mode is used to visualize the bladder, predominantly in the sagittal orientation. Morcellation proceeds under simultaneous ultrasound and direct cystoscopic guidance. RESULTS: The distended bladder is visualized concurrently with the ultrasound and via the nephroscope as the Piranha engages the adenoma and begins morcellation. Once the adenoma is engaged, the operator then drops their hands to place the morcellator in the center of the bladder. Ultrasound provides real-time feedback as to the location of the morcellator in relation to the adenoma and bladder. CONCLUSION: This video highlights the use of intraoperative bladder ultrasound as a visual aid to assist during the morcellation portion of HoLEP. This proof of concept demonstrates that ultrasound can be an additional tool to utilize during difficult cases when cystoscopic visualization during morcellation is limited.
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Complicações Intraoperatórias/prevenção & controle , Terapia a Laser/métodos , Morcelação/métodos , Prostatectomia/métodos , Bexiga Urinária/diagnóstico por imagem , Humanos , Complicações Intraoperatórias/etiologia , Terapia a Laser/efeitos adversos , Terapia a Laser/instrumentação , Lasers de Estado Sólido/efeitos adversos , Lasers de Estado Sólido/uso terapêutico , Masculino , Morcelação/efeitos adversos , Morcelação/instrumentação , Estudo de Prova de Conceito , Próstata/diagnóstico por imagem , Próstata/cirurgia , Prostatectomia/efeitos adversos , Prostatectomia/instrumentação , Hiperplasia Prostática/cirurgia , Ultrassonografia , Bexiga Urinária/lesõesRESUMO
INTRODUCTION: Ultrasound guidance for percutaneous nephrolithotomy (PCNL) has gained acceptance amongst urologists given its numerous advantages over fluoroscopy. While traditionally performed in the prone position, this video demonstrates a step-by-step approach to performing PCNL in the supine position, solely under ultrasound guidance. MATERIALS AND METHODS: Once in the modified supine (Galdakao-modified Valdivia) position, important anatomic landmarks are identified. It is important to first orient the ultrasound probe such that its cranial side corresponds to the left of the ultrasound screen. After optimizing a target calyx, keeping the needle in the imaging plane of the probe facilitates renal access. Tract dilation under ultrasound guidance is then achieved by keeping the wire and dilators in the same imaging plane. RESULTS: The 11th and 12th ribs, paraspinous muscle, iliac crest, midaxillary line, and costal margin are the anatomic landmarks that orient the probe to the location of the kidney. Placing the ultrasound probe in the midaxillary line, parallel to the 11th rib allows the operator to identify key renal landmarks: the renal cortex, peri-pelvic fat, collecting system, kidney stone with its associated postacoustic shadow, and the intended target calyx. Controlling the needle is easiest in the longitudinal view, as the needle can be visualized from skin to target. Dilation under ultrasound relies on keeping the wire in view. The tip of the 10-French dilator is based on the location where the wire image disappears as the dilator advances. The balloon dilator tip is visualized on ultrasound reaching the appropriate depth just inside the collecting system, at which time balloon inflation results in complete dilation of the tract. CONCLUSIONS: This video provides a step-by-step approach demonstrating that PCNL can be performed in the supine position using only ultrasound-guidance. This approach facilitates renal access in this position and obviates the need for radiation exposure.
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Nefrolitotomia Percutânea/métodos , Posicionamento do Paciente/métodos , Ultrassonografia de Intervenção , Dilatação , Humanos , Decúbito DorsalRESUMO
Introduction: American Urological Association (AUA) guidelines recommend percutaneous nephrolithotomy (PCNL) for total stone burden greater than 20 mm, yet it is unclear if the number of stones affects adherence to this guideline. We aim to assess the impact of stone multiplicity on the choice of ureteroscopy (URS) vs PCNL as a first-line therapy for patients with high burden (>20 mm), and examine whether the AUA guideline-discordant care impacts patient outcomes. Materials and Methods: Data were collected from the Registry for Stones of the Kidney and Ureter (ReSKU) database, a prospectively collected registry of patients with stone disease. Multivariate logistic regression (MLR) was used to estimate the association between stone multiplicity and the decision to perform URS for high stone burden (>20 mm) patients. MLR was further used to estimate the association between performing URS and the following outcomes: stone-free rate, need for a second operation, and complications. Postoperative hospital stay was compared between patients receiving URS vs PCNL using Student's t-test. Results: One hundred twenty-five patients were included in this analysis. For patients with total stone burden exceeding 20 mm, those with more than three stones had roughly nine times the likelihood of undergoing URS over PCNL compared with patients with a single stone (adjusted odds ratio 9.21, confidence interval [95% CI] 2.55-40.58, p = 0.001). Stone-free rates, Clavien-Dindo scores, and frequency of second-look operations did not differ significantly between URS and PCNL patients. URS patients were discharged an average of 1.26 days earlier than patients who received PCNL (95% CI 0.72-1.81, p < 0.001). Discussion: Stone multiplicity strongly predicts which patients with stone burden >20 mm will undergo URS and who will undergo PCNL. These deviations from AUA guidelines do not appear to worsen patient outcomes. These results suggest that careful consideration of each patient may warrant deviation from guidelines.
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Cálculos Renais/cirurgia , Tempo de Internação , Nefrolitotomia Percutânea/métodos , Ureterolitíase/cirurgia , Ureteroscopia/métodos , Urologia/organização & administração , Adulto , Idoso , Bases de Dados Factuais , Feminino , Guias como Assunto , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Estudos Prospectivos , Sistema de Registros , Estudos Retrospectivos , Sociedades Médicas , Resultado do Tratamento , Estados Unidos , UreterRESUMO
OBJECTIVE: To determine social factors associated with advanced stone disease (defined as unilateral stone burden >2 cm) at time of presentation to a regional stone referral center. Little is known about social determinants of urolithiasis. We hypothesize that socioeconomic factors impact kidney stone severity at intake to referral centers. METHODS: A retrospective review of the prospectively collected data from the Registry for Stones of the Kidney and Ureter from 2015 to 2018 was conducted to evaluate patient characteristics predictive of having a large (>2 cm) unilateral kidney stone. Data on patient age, gender, body mass index, diabetes, race, language, education level, infection, distance, income, referring regional urologist density, American Society of Anesthesiologists score, and stone analysis were evaluated. RESULTS: Complete imaging and patient variable data was present in 650 of 1142 patients including 197 patients with unilateral stone burden >2 cm. On multivariate analysis, obesity, lower education level, increased distance from the referral center, and symptoms of infection predicted for unilateral stone burden greater than 2 cm. Among 191 patients with stone analysis data present, stone type, income, and urologist density predicted for unilateral stone burden greater than 2 cm. CONCLUSION: In addition to known biological risk factors, patients with lower education levels and from regions of lower mean income were found to be more likely to present to our tertiary care center with stone burden greater than 2 cm. More research is needed to elucidate the social and societal determinants of advanced stone disease and the impact this has on population costs for stone treatment.
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Cálculos Renais/epidemiologia , Cálculos Renais/patologia , Cálculos Ureterais/epidemiologia , Cálculos Ureterais/patologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Sistema de Registros , Estudos Retrospectivos , Fatores Socioeconômicos , Centros de Atenção Terciária , Estados Unidos , Adulto JovemRESUMO
Purpose: Kidney stone patients routinely have CT scans during diagnostic work-up before being referred to a tertiary center. How often these patients exceed the recommended dose limits for occupational radiation exposure of >100 mSv for 5 years and >50 mSv in a single year from CT alone remains unknown. This study aimed to quantify radiation doses from CTs received by stone patients before their evaluation at a tertiary care stone clinic. Methods: From November 2015 to March 2017, consecutive new patients enrolled into the Registry for Stones of the Kidney and Ureter (ReSKU™) had the dose-length product of every available CT abdomen/pelvis within 5 years of their initial visit recorded, allowing for an effective dose (EDose) calculation. Multivariate logistic regression analysis identified factors associated with exceeding recommended dose limits. Models were created to test radiation reducing effects of low-dose and phase-reduction CT protocols. Results: Of 343 noncontrast CTs performed, only 29 (8%) were low-dose CTs (calculated EDose <4 mSv). Among 389 total patients, 101 (26%) and 25 (6%) had an EDose >20 mSv and >50 mSv/year, respectively. Increased body mass index, number of scans, and multiphase scans were associated with exceeding exposure thresholds (p < 0.01). The implementation of a low-dose CT protocol decreased the estimated number of scans contributing to overexposure by >50%. Conclusions: Stone patients referred to a tertiary stone center may receive excessive radiation from CT scans alone. Unnecessary phases and underutilization of low-dose CT protocols continue to take place. Enacting new approaches to CT protocols may spare stone patients from exceeding recommended dose limits.
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Cálculos Renais/diagnóstico por imagem , Doses de Radiação , Tomografia Computadorizada por Raios X/métodos , Cálculos Ureterais/diagnóstico por imagem , Abdome , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Exposição à Radiação , Lesões por Radiação/epidemiologia , Encaminhamento e Consulta , Sistema de Registros , Tomografia Computadorizada por Raios X/estatística & dados numéricosRESUMO
PURPOSE: Kidney stones are a source of significant morbidity which have been shown to negatively impact health related quality of life. We sought to understand the association between health related quality of life, socioeconomic status and race among patients with kidney stones. MATERIALS AND METHODS: Patients with stones at a total of 11 stone centers across the United States completed the WISQOL (Wisconsin Stone Quality of Life questionnaire). The patient ZIP Code™ was used to estimate household income. A mixed effects regression model was constructed for analysis with ZIP Code as the random intercept. RESULTS: A total of 2,057 stone formers completed the WISQOL. Lower income was independently associated with significantly lower health related quality of life (ß = 0.372, p = 0.014), as were nonwhite race (ß = -0.299, p = 0.001), unemployed work status (ß = -0.291, p = 0.008), female gender (ß = -0.204, p <0.001), body mass index greater than 40 kg/m2 (ß = -0.380, p <0.001), 5 or more medical comorbidities (ß = -0.354, p = 0.001), severe recurrent stone formation (ß = -0.146, p = 0.045), enrollment at an acute care visit, or a preoperative or postoperative appointment (ß = -0.548, p <0.001) and recent stone symptoms (ß = -0.892, p <0.001). CONCLUSIONS: Lower income, nonwhite race and unemployed work status were independently associated with lower health related quality of life among patients with kidney stones. While clinical characteristics such as body mass and stone disease severity were also associated with health related quality of life, this study shows that socioeconomic factors are similarly important. Further research to understand the specific mechanisms by which socioeconomic status and race impact health may lend insight into methods to optimize clinical treatment of stone formers and patients with other chronic diseases.
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Disparidades nos Níveis de Saúde , Cálculos Renais/complicações , Pobreza/estatística & dados numéricos , Qualidade de Vida , Doença Crônica , Feminino , Humanos , Renda/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Grupos Raciais/estatística & dados numéricos , Fatores de Risco , Inquéritos e Questionários/estatística & dados numéricos , Desemprego/estatística & dados numéricosRESUMO
Background: Holmium laser enucleation of the prostate (HoLEP) has emerged as an accepted standard of care for the treatment of benign prostatic hyperplasia. This surgery relies on morcellation of the prostate adenoma once enucleation of the transition zone has been completed. Caution is required during this portion of the operation, as engaging bladder mucosa within the morcellator can result in bladder injury, a rare but potentially catastrophic complication of HoLEP. Morcellation of the prostatic tissue can be additionally challenging if visualization is poor from either equipment failure or increased bleeding from a highly vascularized prostate. Case Presentation: We report the case of a 66-year-old Caucasian man with an estimated 158 g prostate who underwent HoLEP at our institution. Enucleation was uneventful; however, upon placement of the nephroscope to begin morcellation, it was immediately evident that the lens of the nephroscope was damaged as there was extremely poor visualization. Without a replacement nephroscope available, this would have normally resulted in aborting the case and returning another day to complete the morcellation. Concurrent bladder ultrasonography was performed and allowed for additional visual feedback to the operator, helping guide the morcellator to safely engage the enucleated adenoma and complete the operation. Conclusion: This case report demonstrates the ability of performing the morcellation portion of HoLEP mainly with the visualization provided by concurrent bladder ultrasonography. By providing additional imaging feedback to the operator, ultrasound can be a complementary tool to assist in safely performing morcellation in situations of suboptimal cystoscopic visualization during HoLEP.
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Inverted papilloma of the prostatic urethra is an especially rare finding. A 75-year-old man with urinary retention wished to proceed with a holmium laser enucleation of the prostate (HoLEP) and was found to have a mass arising from his prostate vs bladder on preoperative imaging. Cystourethroscopy revealed the mass arising from the median lobe of the prostate. After transurethral resection and frozen analysis confirmed the benign pathology of an inverted papilloma, the patient subsequently underwent a successful HoLEP during the same surgical setting. Images of this rare prostatic mass are presented to increase urologist recognition and to assist management during HoLEP.
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Terapia a Laser , Papiloma Invertido/diagnóstico , Hiperplasia Prostática/cirurgia , Ressecção Transuretral da Próstata , Neoplasias Uretrais/diagnóstico , Idoso , Cistoscopia , Humanos , Achados Incidentais , Lasers de Estado Sólido , Masculino , Papiloma Invertido/complicações , Papiloma Invertido/patologia , Cuidados Pré-Operatórios , Hiperplasia Prostática/complicações , Ressecção Transuretral da Próstata/métodos , Neoplasias Uretrais/complicações , Neoplasias Uretrais/patologiaRESUMO
OBJECTIVE: To compare the measured stone burden recorded between urologists and radiologists, and examine how these differences could potentially impact stone management. As current urologic stone surgery guideline recommendations are based on stone size, accurate stone measurements are crucial to direct appropriate treatment. This study investigated the discrepant interpretation that often exists between urologic surgeons and radiologists' estimation of patient urinary stone burden. MATERIALS AND METHODS: From November 2015 through August 2016, new patients prospectively enrolled into the Registry for Stones of the Kidney and Ureter (ReSKU) were included if they had computed tomography images available and an accompanying official radiologic report at the time of their urologist provider visit. Stone number and aggregate stone size were compared between the urologic interpretation and the corresponding radiologic reports. RESULTS: Of 219 patients who met the inclusion criteria, concordance between urologic and radiologic assessment of aggregate stone size was higher for single stone sizing (63%) compared with multiple stones (32%). Statistical significance was found in comparing the mean difference in aggregate stone size for single and multiple stones (P <.01). Over 33% of stone-containing renal units had a radiologic report with an unclear size estimation or size discrepancy that could lead to non-guideline-driven surgical management. CONCLUSION: Significant variation exists between urologic and radiologic computed tomography interpretations of stone burden. Urologists should personally review patient imaging when considering stone surgical management. A standardized method for measuring and reporting stone parameters is needed among urologists and radiologists.