Radiating for Two: Quantifying Radiation Exposure to Pregnant Urologists During Percutaneous Nephrolithotomy.

PURPOSE: Current occupational recommendations limit fetal radiation dose to 1 mSv. With increased gender diversity in urology, understanding radiation exposure during pregnancy is crucial. The purpose of this study was to determine surgeon uterine radiation dose during percutaneous nephrolithotomy (PCNL) and compare effectiveness of several radiation reduction strategies in a cadaver model. MATERIALS AND METHODS: Two cadavers were used to simulate the surgeon and patient in a PCNL model. An ion chamber was placed behind the surgeon's anterior uterine wall to measure radiation dose. Three radiation reduction methods were compared: pulsed fluoroscopy (1, 4, 8, 15, 30 pps), low-dose (LD) fluoroscopy, and surgeon shielding (none, 0.35, 0.50, 0.70 mm lead equivalents). The average radiation dose/second was recorded for 20 trials per combination. Assuming 5 minutes of fluoroscopy per PCNL, the number of cases required to exceed the fetal occupational limit was determined. RESULTS: Decreasing pulse frequency from 30 to 1 pps reduced dose by 96% (p<0.001). The LD setting decreased dose by 56% (p<0.001). A 0.35 mm lead apron resulted in a 94% dose reduction (p<0.001), and the 0.50 and 0.70 mm lead aprons further reduced dose by 12% and 47%, respectively. At conventional fluoroscopy settings of automatic exposure control and 30 pps, a surgeon could perform 12 PCNLs using no lead or 189 PCNLs using a 0.35 mm lead apron before reaching the 1 mSv limit. In addition to shielding, employing 1 pps with LD further decreased radiation exposure, allowing over 6000 cases to be performed with <1 mSv uterine radiation exposure. CONCLUSIONS: Within the limitations of this cadaver study, these data support that high volume pregnant surgeons employing active radiation reduction techniques such as pulsed, LD fluoroscopy and appropriate shielding can maintain surgical volume with relatively low risk. Fetal dosimeter use with monthly monitoring is still encouraged to confirm safety throughout pregnancy.

Liposomal versus plain bupivacaine for pain control following vaginal reconstruction.

INTRODUCTION: Liposomal bupivacaine (LB) is a depot formulation of bupivacaine, which releases the drug over 72 hours to prolong local pain control. This retrospective study compares the effect of using LB versus plain bupivacaine on postoperative pain control, length of hospital stay and cost among patients undergoing vaginal reconstructive surgery. MATERIALS AND METHODS: Patients who underwent vaginal reconstructive surgery with levatorplasty and received an injection of 20 cc of either plain bupivacaine or LB for pudendal nerve block were included. The primary outcomes included postoperative narcotic use and subjective pain score. The secondary outcome was postoperative length of stay. Comparisons between groups were performed using the T test, Mann Whitney U and Chi-square tests with p < 0.05 considered significant. RESULTS: Between June 2016 and December 2021, 25 patients had received LB as a pudendal nerve block and 25 had received plain bupivacaine. Demographics between groups were similar. There was no difference between postoperative morphine equivalent dose (MED) for plain bupivacaine versus LB (25.3 ± 65.8 vs. 24.9 ± 31.7 MED; p = 0.159) or length of hospital stay (15.8 ± 12.0 hours vs. 23.8 ± 20.0; p = 0.094). Furthermore, subjective pain was also similar between groups (0 vs. 1.6 ± 2.6, p = 0.68), (4.6 ± 2.3 vs. 4.9 ± 2.0 average POD 1 pain, p = 0.534) and (4.3 ± 2.1 for vs. 4.9 ± 2.1 average POD 2 pain, p = 0.373). CONCLUSION: LB is not superior to plain bupivacaine for controlling pain following vaginal reconstructive surgery, and justification for the exponentially greater cost of LB is not supported. Prospective investigations with larger sample sizes are needed to determine the optimal pain management for levatorplasty in vaginal reconstructive surgery.

Detailed cadaveric analysis of perivesical lymph nodes in cystectomy specimens.

INTRODUCTION: Perivesical lymph nodes were added to the 8th edition of American Joint Committee on Cancer (AJCC) staging for bladder cancer. Currently, these nodes are inconsistently evaluated at the time of radical cystectomy. The objective of this study was to provide a detailed anatomic evaluation of perivesical lymph nodes. MATERIALS AND METHODS: A radical cystectomy was performed on six un-embalmed cadavers with wide resection of perivesical tissue and meticulous care to separate the pelvic sidewall lymph nodes (e.g. obturator, external iliac) from the bladder and perivesical en-bloc specimen. Perivesical tissue dissection in 2 mm slices was performed with a board-certified pathologist. Lymph node size and location were recorded. RESULTS: Gross tissue resembling lymph nodes were identified in the perivesical tissue in 50% (3/6) of the specimens, with a total of six grossly identified lymph nodes. The mean size was 7.5 mm (2-16 mm). On histologic analysis, 4 of 6 (66%) putative gross lymph nodes had confirmed lymphoid tissue. The mean distance of the lymph nodes from bladder wall was 9 mm (3-15 mm). Eight anatomic locations for perivesical nodes were developed: urachal, anterior bladder wall, posterior peritoneum, bladder neck, bilateral pedicle, bilateral lateral bladder wall. CONCLUSION: This cadaveric study with meticulous dissection of the perivesical space confirms that perivesical lymph nodes are a distinct entity and separate from other lymph nodes in the true pelvis. Perivesical lymph nodes are not present in all subjects and pathologic evaluation is more difficult owing to the surrounding fat. We herein propose perivesical regions for evaluation which can serve as a foundation for future studies and anatomic grossing techniques.

Thulium versus holmium for in situ lower pole laser lithotripsy.

INTRODUCTION: During in situ lower pole laser lithotripsy, the dependent location may result in increased challenge fragmenting stones and a risk for stone regrowth if residual fragments remain. The purpose of this study was to compare the thulium fiber laser (TFL) with the holmium laser (HL) for in situ lower pole lithotripsy. MATERIALS AND METHODS: In a 3D printed kidney benchtop model, sixty 1 cm BegoStones were placed in the lower pole and fragmented in situ until fragments passed through a 2 x 2 mm mesh. Laser lithotripsy was performed using twelve energy, frequency and fiber size combinations and residual fragments were compared. In addition, laser fiber diameters and subsequent ureteroscope deflections and flow rates were compared between fibers. RESULTS: The TFL resulted in decreased residual fragments compared to the HL (11% vs. 17%, p < 0.001) and the three settings with least residual fragments were all TFL. Compared to the 150 µm TFL (265° deflection), there was a loss of 9° and 34° in the 200 µm TFL and 272 µm HL fibers, respectively. The measured fiber sizes were greater than manufacturer specified fiber size in every instance. Irrigation rates inversely correlated with fiber size. CONCLUSION: The TFL resulted in 35% less residual stone fragments, up to 34° additional deflection, and an increased irrigation rate when compared to the HL. Optimal fragmentation settings are identified to further improve lower pole lithotripsy. The combination of reduced residual fragments, improved deflection, and better flow rates make the TFL advantageous for in situ lower pole lithotripsy.

Does qSOFA score predict ICU admission and outcomes in patients with obstructed infected ureteral stones?

INTRODUCTION: Obstructing stones with infection represent a true urologic emergency requiring prompt decompression. Historically the systemic inflammatory response syndrome (SIRS) criteria has been used to predict outcomes in patients with sepsis. The quick Sequential Organ Failure Assessment (qSOFA) score has been proposed as a prognostic factor in patients with acute pyelononephritis associated with nephrolithiasis. However there has been limited application of qSOFA to patients undergoing ureteral stenting with obstructive pyelonephritis. The purpose of this study was to evaluate the predictive value of the qSOFA score for postoperative outcomes following renal decompression in this patient population. MATERIALS AND METHODS: A retrospective review was conducted at three medical centers within one academic institution to identify patients with obstructive pyelonephritis secondary to ureteral stones. All patients underwent emergent ureteral stent placement for decompression. The primary outcome was the predictive value of preoperative qSOFA score ≥ 2 for intensive care unit (ICU) admission postoperatively. Univariate analysis and multivariate regression analysis were performed to identify factors associated with postoperative outcomes, with p < 0.05 considered significant. RESULTS: Of the 289 patients who had ureteral stents placed, 147 patients met inclusion criteria. Twenty-four (16.3%) patients required ICU admission and there were 3 (2%) mortalities, all of these within the ICU admission group. The sensitivity and specificity of the qSOFA score ≥ 2 for ICU admission was 70.8% and 79.5% respectively which outperformed SIRS criteria, which had a sensitivity and specificity of 100% and 33.6% respectively. CONCLUSION: A preoperative qSOFA score ≥ 2 was a significant predictor for postoperative ICU admission in patients undergoing ureteral stent placement for obstructive pyelonephritis. The qSOFA score can be used to determine which patients will require ICU admission.

'Fake News' in urology: evaluating the accuracy of articles shared on social media in genitourinary malignancies.

OBJECTIVES: To evaluate the accuracy of the most popular articles on social media platforms pertaining to genitourinary malignancies, and to identify the prevalence of misinformation available to patients. MATERIALS AND METHODS: The 10 most shared articles on popular social media platforms (Facebook, Twitter, Pinterest, and Reddit) were identified for prostate cancer, bladder cancer, kidney cancer, testis cancer, and PSA testing using a social media analysis tool (August 2017 and August 2018). Articles were reviewed for accuracy by comparing the article information against available scientific research and consensus data. They were classified as accurate, misleading or inaccurate. The Mann-Whitney U-test was used for statistical comparison. RESULTS: Articles pertaining to prostate cancer were the most shared across all social media platforms (399 000 shares), followed by articles pertaining to kidney cancer (115 000), bladder cancer (17 894), PSA testing (8827) and testicular cancer (7045). The prevalence of inaccurate or misleading articles was high: prostate cancer, 7/10 articles; kidney, 3/10 articles; bladder, 2/10 articles; testis, 2/10 articles; and PSA testing, 1/10 articles. There was a significantly higher average number of shares for inaccurate (54 000 shares; P < 0.01) and misleading articles (7040 shares; P < 0.01) than for accurate articles (1900 shares). Inaccurate articles were 28 times more likely to be shared than factual articles. CONCLUSION: Misleading or inaccurate information on genitourinary malignancies is commonly shared on social media. This study highlights the importance of directing patients to appropriate cancer resources and potentially argues for oversight by the medical and technology communities.

Role of Contrast Enhancement and Corrected Attenuation Values of Renal Tumors in Predicting Renal Cell Carcinoma (RCC) Subtypes: Protocol for a Triphasic Multi-Slice Computed Tomography (CT) Procedure.

BACKGROUND: To distinguish RCC subtypes based on contrast enhancement features of CT images. MATERIAL/METHODS: In total, 59 lesions from 57 patients were included. All patients underwent multi-slice CT imaging with a triphasic protocol, which included non-contrast, corticomedullary, nephrographic and urographic phases. Contrast enhancement features of renal masses were evaluated in terms of CT attenuation values (AV) and differences in contrast density; the aorta or renal parenchyma were evaluated based on corrected or relative values. RESULTS: Clear cell RCC (ccRCC) showed more intense contrast enhancement than other RCC subtypes. When differentiating ccRCC from other RCC subtypes, a cut-off AV of 86-89 HU, aorta-based corrected AV of 89-95 HU and renal parenchyma-based corrected AV of 87-95 HU showed a diagnostic accuracy of 81-86%, 86-88% and 74-78%, respectively, in the corticomedullary phase. Furthermore, a cutoff of 2.42-2.72 for the relative contrast enhancement ratio, a cutoff of 2.59-2.74 for the aorta-based corrected relative contrast enhancement ratio and a cutoff of 2.63-2.76 for the renal parenchyma-based attenuation ratio showed a diagnostic accuracy of 83-88%, 88-90% and 81%, respectively. CONCLUSIONS: The most reliable parameters for differentiating ccRCC from other RCC subtypes are aorta-based corrected AV and aorta-based corrected relative contrast enhancement values in the corticomedullary phase.

Protective effect of 2-APB on testicular ischemia-reperfusion injury in rats.

PURPOSE: We performed biochemical and histopathological evaluations to assess the effects of 2-APB on ischemia-reperfusion induced testicular damage. MATERIALS AND METHODS: A total of 28 rats were randomly divided into 4 groups, including sham treated, ischemia-reperfusion, ischemia-reperfusion plus 2 mg/kg 2-APB and ischemia-reperfusion plus 4 mg/kg 2-APB. Testicular tissue superoxide dismutase, glutathione, malondialdehyde, total antioxidant capacity and DNA fragmentation levels were determined. Testicular tissue samples were examined by histopathology and TUNEL staining. RESULTS: Mean superoxide dismutase, total antioxidant capacity and glutathione were significantly higher in the sham treated group than in the ischemia-perfusion group (p <0.05). Mean malondialdehyde and DNA fragmentation levels were significantly lower in the sham treated group than in the ischemia-reperfusion group (p <0.05). After 2-APB treatment superoxide dismutase, total antioxidant capacity and glutathione were significantly increased but malondialdehyde and DNA fragmentation levels were significantly decreased compared to the ischemia-reperfusion group (p <0.05). The number of TUNEL positive cells was significantly lower in the 2-APB treatment groups than in the ischemia-reperfusion group (p <0.05). CONCLUSIONS: In rats 2-APB reduced the oxidative stress and apoptosis caused by testicular ischemia-reperfusion injury. The testicular protective effect of 2-APB appears to be mediated through its antiapoptotic and antioxidative effects.

Do Flat Panel Detector C-Arms Decrease Radiation Exposure Compared to Conventional Image Intensifiers?

OBJECTIVE: To compare the radiation dose and image quality between flat panel detector (FPD) and traditional image intensifier (II) C-arms at their lowest radiation settings. METHODS: In a ureteroscopy simulation using a cadaver model, the radiation exposure was compared between FPD and II at 4 pulses-per-second (pps) using both low dose and automatic exposure control (AEC) settings. Additionally, the lowest dose settings for each machine were compared (4 pps with low dose in the FPD and 1 pps with low dose in the II). Five trials of 5 minutes were conducted for each setting. Four new optically stimulated luminescent dosimeters were used in each trial to record radiation exposure. Ten blinded urologists completed a survey rating image quality for each setting. RESULTS: When comparing the FPD and II at their lowest possible settings, the FPD produced significantly more radiation (P <.05). Using both machines at 4 pps in low dose mode resulted in no significant difference between C-arms (P >.05). Conversely, operating the C-arms at 4 pps and AEC resulted in significantly higher radiation exposure from the FPD compared to the II (P <.05). There was no significant difference in image quality at each setting. CONCLUSION: FPDs produce significantly more radiation at the lowest settings compared to IIs. Surgeons should employ IIs when reducing radiation exposure as low as possible is imperative, such as when operating on pediatric and pregnant patients.

Does Blacklight Illumination Improve Speed and Accuracy of Foot Pedal Activation in the Low-Light Operating Room?

Background: Urologists frequently activate foot pedals in a low-light operating room (OR). Pedal activation in low-light conditions poses the potential for incorrect pedal activation, potentially leading to increased radiation exposure, patient burns, or OR fires. This study compares speed, accuracy, dark adaptation, and surgeon preference for pedal activation in 4 lighting conditions. Materials and Methods: During a simulated percutaneous nephrolithotomy (PCNL), pedals for C-arm, laser, and ultrasonic lithotripter (USL) were randomized to 3 different positions. Urology attendings, residents, and medical students activated pedals in a randomized order in 4 settings: a dark OR with no illumination, an OR with overhead illumination, a dark OR with glowstick illumination, and a dark OR with blacklight illumination. Endpoints included pedal activation time; number of attempted, incomplete, and incorrect activations; dark adaptation; and subjective pedal preference. ANOVA was used for analysis with p < 0.05 considered significant. Results: In our study with 20 participants, the mean pedal activation times were significantly faster when using glowstick illumination (6.77 seconds) and blacklight illumination (5.34 seconds) compared with the no illumination arm (8.47 seconds, p < 0.001). Additionally, individual pedal activations for the C-arm, laser, and USL were significantly faster with glowstick and blacklight illumination compared with a dark OR (p < 0.001 for all). The blacklight illumination arm demonstrated decreased attempted (0.30 vs. 3.45, p < 0.001), incomplete (1.25 vs. 7.75, p < 0.001), and incorrect activations (0.35 vs. 1.25, p < 0.001) compared with the dark setting, while demonstrating no difference compared with having room lights on. Dark adaptation was significantly improved with blacklight illumination compared with having the room lights on (134.5 vs. 140.5 luminance, p < 0.001). All participants (100%) preferred illuminated pedals compared with the dark OR, with 90% favoring the blacklight illumination. Conclusions: During a simulated PCNL, blacklight illumination significantly improved accuracy and efficiency of pedal activation compared with the conventional dark OR, while maintaining the surgeon's dark adaptation.

Time Efficiency and Performance of Single-Use vs Reusable Cystoscopes: A Randomized Benchtop and Simulated Clinical Assessment.

Introduction: A flexible cystoscope is an indispensable tool for urologists, facilitating a variety of procedures in both the operating room and at bedside. Single-use cystoscopes offer benefits including accessibility and decreased burden for reprocessing. The aims of this study were to compare time efficiency and performance of single-use and reusable cystoscopes. Methods: Ten new Ambu® aScope™ 4 Cysto single-use and two Olympus CYF-5 reusable cystoscopes were compared in simulated bedside cystoscopy and benchtop testing. Ten urologists performed simulated cystoscopy using both cystoscopes in a randomized order. Times for supply-gathering, setup, cystoscopy, cleanup, and cumulative time were recorded, followed by a Likert feedback survey. For benchtop assessment, physical, optical, and functional specifications were assessed and compared between cystoscopes. Results: The single-use cystoscope demonstrated shorter supply-gathering, setup, cleanup, and cumulative times (824 vs 1231 seconds; p < 0.05) but a comparable cystoscopy time to the reusable cystoscope (202 vs 212 seconds; p = 0.32). The single-use cystoscope had a higher image resolution, but a narrower field of view. Upward deflection was greater for the single-use cystoscope (214.50° vs 199.45°; p < 0.01) but required greater force (2.5 × ). The working channel diameter and irrigation rate were greater in the reusable cystoscope. While the single-use cystoscope lacked tumor enhancing optical features, it had higher Likert scale scores for Time Efficiency and Overall Satisfaction. Conclusion: The single-use cystoscope demonstrates comparable benchtop performance and superior time efficiency compared to reusable cystoscopes. However, the reusable cystoscope has superior optical versatility and flow rate. Knowledge of these differences allows for optimal cystoscope selection based on procedure indication.

Not All Flat-Panel C-Arms Are Created Equal: A Comparison of Three Major Manufacturers.

Introduction: Flat-panel detector C-arms (FCs) are reported to reduce radiation exposure and improve image quality compared with conventional image intensifier C-arms (CCs). The purpose of this study was to compare radiation exposure and image quality between three commonly used FCs. Materials and Methods: A cadaver model was placed in the prone position to simulate percutaneous nephrolithotomy. We compared the following three FCs: OEC Elite CFD from GE HealthCare, Zenition 70 from Philips, and Ziehm Vision RFD from Ziehm Imaging. To measure the radiation dose, optically stimulated luminescence dosimeters (OSLDs) were utilized during five 300-second trials, conducted under three settings: automatic exposure control (AEC), AEC with low dose (LD), and LD with the lowest pulse rate (LDLP). Ten blinded urologists evaluated the image quality. Data were statistically analyzed using the analysis of variance (ANOVA) and Tukey's B post hoc tests. Results: In the AEC setting, the Philips C-arm demonstrated lower ventral OSLD exposure (42,446 mrad) compared with both the GE (51,076 mrad) and Ziehm (83,178 mrad; p < 0.001) C-arms. Similarly, in the LD setting, the Philips C-arm resulted in less ventral OSLD exposure (25,926 mrad) than both the Ziehm (30,956 mrad) and GE (38,209 mrad; p < 0.001) C-arms. Meanwhile, in the LDLP setting, the Ziehm C-arm showed less ventral OSLD exposure (4019 mrad) than both the GE (7418 mrad) and Philips (8229 mrad; p < 0.001) C-arms. All three manufacturers received adequate image quality ratings at the AEC and LD settings. However, at LDLP, the Ziehm C-arm received inadequate ratings in 8% of images, whereas both the GE and Philips C-arms received 100% adequate ratings (p = 0.016). Conclusions: Radiation produced by flat-panel C-arms varies dramatically, with the highest exposure (Ziehm) being almost double the lowest (Philips) in AEC. Improved picture quality at the lowest settings may come at the cost of increased radiation dose. Surgeons should carefully select the machine and settings to minimize radiation exposure while still preserving the image quality.

Is Bigger Better? Comparison of 150 µm and 200 µm Thulium Fiber for In Situ Lower-Pole Lithotripsy.

Introduction: The thulium fiber laser (TFL) generates a focused beam, which can be transmitted to laser fibers with small core diameters and may facilitate in situ lower-pole lithotripsy. This study compares lithotripsy performance of the 150 and 200 µm TFL in a lower pole benchtop kidney model. Materials and Methods: Using a 3D model printed from an actual kidney, in situ laser lithotripsy was performed on 1 cm lower-pole BegoStones (calcium oxalate monohydrate consistency) using four different settings (all 20W) and two fiber sizes (150 and 200 µm). Procedure time, laser time, total pulse energy, and fiber stripping were compared between the two fibers using an ANOVA or independent t-test. Results: The 150 µm fiber at 0.2 J × 100 Hz had the shortest lasing and procedure time (17.3 and 18.5 minutes) and lowest total pulse energy (20.75 kJ) compared with other study arms (p < 0.001). Overall procedure time, lasing time, and total pulse energy were significantly different between the 8 settings (p < 0.001 for all). At higher frequency (100 and 200 Hz), lasing time was significantly faster compared with 20 and 50 Hz (19.9 vs 27.3 minutes; p < 0.001). Furthermore, the average total procedure time was shorter with 150 µm compared with 200 µm regardless of settings (23.2 vs 29.8 minutes; p < 0.001). Conclusion: The 150 µm fiber results in shorter procedure and lasing time at lower total energy levels during lower-pole in situ lithotripsy. Overall, the fastest setting was 0.2 J and 100 Hz with the 150 µm fiber. Smaller laser fibers can potentially allow more efficient in situ laser lithotripsy with better irrigation and visibility at higher deflection angles.

Prone vs supine percutaneous nephrolithotomy: does position affect renal pelvic pressures?

The purpose of this study was to measure and compare renal pelvic pressure (RPP) between prone and supine percutaneous nephrolithotomy (PCNL) in a benchtop model. Six identical silicone kidney models were placed into anatomically correct prone or supine torsos constructed from patient CT scans in the corresponding positions. A 30-Fr renal access sheath was placed in either the upper, middle, or lower pole calyx for both prone and supine positions. Two 9-mm BegoStones were placed in the respective calyx and RPPs were measured at baseline, irrigating with a rigid nephroscope, and irrigating with a flexible nephroscope. Five trials were conducted for each access in both prone and supine positions. The average baseline RPP in the prone position was significantly higher than the supine position (9.1 vs 2.7 mmHg; p < 0.001). Similarly, the average RPP in prone was significantly higher than supine when using both the rigid and flexible nephroscopes. When comparing RPPs for upper, middle, and lower pole access sites, there was no significant difference in pressures in either prone or supine positions (p > 0.05 for all). Overall, when combining all pressures at baseline and with irrigation, with all access sites and types of scopes, the mean RPP was significantly higher in the prone position compared to the supine position (14.0 vs 3.2 mmHg; p < 0.001). RPPs were significantly higher in the prone position compared to the supine position in all conditions tested. These differences in RPPs between prone and supine PCNL could in part explain the different clinical outcomes, including postoperative fever and stone-free rates.

Reducing hand radiation during renal access for percutaneous nephrolithotomy: a comparison of radiation reduction techniques.

Percutaneous nephrolithotomy confers the highest radiation to the urologist's hands compared to other urologic procedures. This study compares radiation exposure to the surgeon's hand and patient's body when utilizing three different techniques for needle insertion during renal access. Simulated percutaneous renal access was performed using a cadaveric patient and separate cadaveric forearm representing the surgeon's hand. Three different needle-holding techniques were compared: conventional glove (control), a radiation-attenuating glove, and a novel needle holder. Five 300-s fluoroscopy trials were performed per treatment arm. The primary outcome was radiation dose (mSv) to the surgeon's hand. The secondary outcome was radiation dose to the patient. One-way ANOVA and Tukey's B post-hoc tests were performed with p < 0.05 considered significant. Compared to the control (3.92 mSv), both the radiation-attenuating glove (2.48 mSv) and the needle holder (1.37 mSv) reduced hand radiation exposure (p < 0.001). The needle holder reduced hand radiation compared to the radiation-attenuating glove (p < 0.001). The radiation-attenuating glove resulted in greater radiation produced by the C-arm compared to the needle holder (83.49 vs 69.22 mGy; p = 0.019). Patient radiation exposure was significantly higher with the radiation-attenuating glove compared to the needle holder (8.43 vs 7.03 mSv; p = 0.027). Though radiation-attenuating gloves decreased hand radiation dose by 37%, this came at the price of a 3% increase in patient exposure. In contrast, the needle holder reduced exposure to both the surgeon's hand by 65% and the patient by 14%. Thus, a well-designed low-density needle holder could optimize radiation safety for both surgeon and patient.

Does renal failure worsen radiation cystitis following radical prostatectomy?

OBJECTIVE: To investigate the impact of renal function on the risk, severity, and management of radiation cystitis in patients who underwent postoperative radiation therapy for prostate cancer. METHODS: Retrospective data was assessed from patients treated with adjuvant/salvage radiation therapy at a single academic institution between 2006 and 2020. The incidence, severity, and management of radiation cystitis were compared between three groups: CKD 0-2, CKD 3-4, and CKD 5. Associations of clinicopathologic factors with radiation cystitis were assessed in univariate and multivariate Cox regression models. RESULTS: A total of 110 patients who underwent radiation therapy following robot-assisted laparoscopic radical prostatectomy were included. The incidence of radiation cystitis following postoperative radiation therapy was 17% with a median presentation time of 34 months (interquartile range 16-65 months). The incidence of radiation cystitis was 100% in CKD 5 patients compared to 15% in CKD 0-2 and 17% in CKD 3-4 patients (p < 0.001). CKD 5 patients required more treatments, emergency department visits, and longer hospitalization times than CKD 0-4 patients (all p < 0.001). Multivariate analyses identified CKD 5 as the only significant factor associated with radiation cystitis (HR = 10.39, p = 0.026). CONCLUSION: End-stage renal failure is associated with the risk and severity of radiation cystitis in patients receiving postoperative radiation therapy. Knowledge of the potential morbidity of this complication in this population could guide physicians and patients as they evaluate risks and benefits prior to selecting adjuvant or salvage radiation therapy.

Which Laser System Is Optimal for Cystolithotripsy of Large Bladder Calculi?

Introduction and Objective: A variety of laser sources are available to treat bladder stones. The aim of this study was to compare time and cost efficiency of the thulium fiber laser (TFL) to four holmium lasers (HLs) with different powers or technologies, including MOSES™ during simulated cystolithotripsy. Materials and Methods: In a benchtop simulation of laser cystolithotripsy, 25 identical 4-cm BegoStones (calcium oxalate monohydrate consistency) were placed on a grid within a 3D-printed bladder model. Lasers were operated at maximal energy, using a 550 µm fiber. Lasers compared were as follows: 60 W TFL, 120 W HL with MOSES, and conventional 120, 100, and 30 W HLs. Five trials were performed for each laser with endpoints of laser time, total time, number of fiber strippings, and total energy. Cost-effectiveness was modeled using laser purchase price, fiber, and operating room (OR) time cost. ANOVA with Tukey's B post hoc was performed to compare outcomes. Spearman's test was used to assess correlation between laser power and procedure time. Results: The laser and total operating times were significantly different between the five systems (p < 0.001). The 120 W HL with MOSES was the fastest with 60.9 minutes of laser and 68.3 minutes of procedure times, while the 30 W HL was the slowest with 281.2 minutes of laser and 297.5 minutes of procedure times. The 60 W TFL was faster than the 30 W HL, but slower than the higher power HLs. Higher laser power was associated with shorter procedure time (Rs = -0.98; p = 0.002). When estimating cost per procedure, the MOSES HL was the cheapest, but had the highest purchase cost. The TFL was not cost-effective for large bladder stones compared with the 100 W HL. Conclusions: When treating large bladder stones, total laser power was highly correlated with laser and procedure times and the TFL was limited by its total power. The most cost-effective laser for use will depend on the case volume.

Multimodal Pain Control Utilizing Buprenorphine for Robotic-assisted Laparoscopic Prostatectomy: A Quality Improvement Comparison to Conventional Opioid Management.

INTRODUCTION: This study investigated the effectiveness of buprenorphine as an alternative to the use of conventional opioids perioperatively in an effort to help mitigate the impact of the use of perioperative conventional opioids for patients undergoing robotic-assisted laparoscopic prostatectomy. METHODS: Outcomes of patients with localized prostate cancer undergoing robotic-assisted laparoscopic prostatectomy were examined before and after implementation of novel quality improvement study that included receiving buprenorphine compared to conventional opioids for pain control intraoperatively and postoperatively. The primary end point was adequate pain control with secondary end points being analgesic consumption at home, opioid-related side effects, and patient satisfaction. RESULTS: When analyzing the secondary end point of oral morphine milligram equivalents, the buprenorphine group received significantly less morphine milligram equivalent compared to the conventional opioid group (15.19 vs 47.91, P = .006). The buprenorphine group also had lower reported pain scores at discharge (4.3; scale 1-10) compared to the conventional opioid group (5.4), though this did not reach significance (P = .069). In the buprenorphine group, 76.9% strongly agreed that their pain was adequately controlled in the hospital compared to 57.5% of the conventional opioid group (P = .223). There was no difference in overall satisfaction at postoperative day 5 (P = .358). CONCLUSIONS: Our study demonstrates buprenorphine's analgesic capabilities to maintain adequate pain control and patient satisfaction compared to conventional opioids during robotic-assisted laparoscopic prostatectomy, while decreasing perioperative opioid use.

Nitric oxide synthase (eNOS4a/b) gene polymorphism is associated with tumor recurrence and progression in superficial bladder cancer cases.

PURPOSE: We investigated the relationship between the distribution of the eNOS4a/b polymorphism and the clinical features of superficial bladder cancer. MATERIALS AND METHODS: This study included 201 healthy controls with a mean ± SD age of 62.35 ± 7.96 years and 123 patients with a mean age of 64.03 ± 11.00 years diagnosed with histopathologically confirmed superficial bladder cancer. The eNOS4a/b polymorphism genotype (aa, bb or ab) was identified by polymerase chain reaction. Blood glutathione and plasma malondialdehyde levels were measured by spectrophotometry as an indicator of oxidative stress. We estimated total plasma levels of nitric oxide metabolites using a colorimetric assay kit. RESULTS: There were no significant differences in age or body mass index between patients and controls. Malondialdehyde and nitric oxide metabolite levels were statistically significantly increased (p = 0.000 and 0.024, respectively) and glutathione levels were decreased (p = 0.000) in patients with superficial bladder cancer. The bb genotype of the eNOS4a/b polymorphism is the most frequent one in the Turkish population and the aa genotype was significantly more common in patients with superficial bladder cancer (p = 0.000). Also, the aa plus ab genotype was significantly more common in patients with high grade tumors (p = 0.013) and in those with more progression to muscle invasive disease (p = 0.000). This genotype was also a significant independent risk factor for recurrence after adjusting for smoking status, stage, grade and the presence of carcinoma in situ on logistic regression analyses (OR 3.095, 95% CI 1.21-7.86, p = 0.018). CONCLUSIONS: The current study suggests that a genotype containing the a allele of the eNOS4a/b polymorphism may be a risk factor for bladder cancer. Additionally, patients harboring the aa plus ab genotype are more likely to experience tumor recurrence and progression.

Does the Novel Thulium Fiber Laser Have a Higher Risk of Urothelial Thermal Injury than the Conventional Holmium Laser in an In Vitro Study?

Introduction and Objective: The novel thulium fiber laser (TFL) has been shown to break stones more rapidly than the holmium:YAG laser (HL). However, some evidence suggests that the TFL generates more heat. The purpose of this study is to compare ureteral temperatures generated by these lasers during ureteroscopic laser lithotripsy in a benchtop model. Methods: A 1-cm BegoStone was manually impacted in the proximal ureter of a three-dimensional printed kidney-ureter model and submerged in 35.5°C saline. Lithotripsy was performed using a 7.6F flexible ureteroscope and a 200 µm laser fiber without a ureteral access sheath. The Dornier 30 W HL, Olympus 100 W HL, and Olympus 60 W TFL were compared. A needle thermocouple to measure temperature was inserted 2 mm from the laser tip. Irrigation was maintained at 35 cc/minute at room temperature using the Thermedx FluidSmart System. Intraluminal temperature was continuously recorded for 60 seconds of laser activation. Five trials were performed for each of four different power settings: 3.6, 10, 20, and 30 W. Analysis of variance and Mann-Whitney U tests were performed with p < 0.05 considered significant. Results: Intraureteral fluid temperature increased as laser power settings increased for all lasers (p < 0.05). The TFL generated higher average ureteral fluid temperatures than the Dornier and Empower HL at all power settings tested (p < 0.001). The maximum temperature for the TFL was higher than the Dornier and Empower HL at all power settings tested (p < 0.001), except at 20 W with the Empower HL. At 30 W, the TFL exceeded 43°C, the threshold for tissue damage. Conclusions: The TFL generated more heat at all settings tested. Supraphysiologic ureteral temperatures may be generated with extended use at high energy settings and low irrigation rates. Understanding the heat generation properties of both lasers could help improve the safety of ureteroscopic laser lithotripsy.