The Uniform grading tooL for flexIble ureterorenoscoPes (TULIP-tool): a Delphi consensus project on standardised evaluation of flexible ureterorenoscopes.

OBJECTIVE: To develop a standardised tool to evaluate flexible ureterorenoscopes (fURS). MATERIALS AND METHODS: A three-stage consensus building approach based on the modified Delphi technique was performed under guidance of a steering group. First, scope- and user-related parameters used to evaluate fURS were identified through a systematic scoping review. Then, the main categories and subcategories were defined, and the expert panel was selected. Finally, a two-step modified Delphi consensus project was conducted to firstly obtain consensus on the relevance and exact definition of each (sub)category necessary to evaluate fURS, and secondly on the evaluation method (setting, used tools and unit of outcome) of those (sub)categories. Consensus was reached at a predefined threshold of 80% high agreement. RESULTS: The panel consisted of 30 experts in the field of endourology. The first step of the modified Delphi consensus project consisted of two questionnaires with a response rate of 97% (n = 29) for both. Consensus was reached for the relevance and definition of six main categories and 12 subcategories. The second step consisted of three questionnaires (response rate of 90%, 97% and 100%, respectively). Consensus was reached on the method of measurement for all (sub)categories. CONCLUSION: This modified Delphi consensus project reached consensus on a standardised grading tool for the evaluation of fURS - The Uniform grading tooL for flexIble ureterorenoscoPes (TULIP) tool. This is a first step in creating uniformity in this field of research to facilitate future comparison of outcomes of the functionality and handling of fURS.

Estimating the health-related quality of life of kidney stone patients: initial results from the Wisconsin Stone Quality of Life Machine-Learning Algorithm (WISQOL-MLA).

OBJECTIVE: To build the Wisconsin Stone Quality of Life Machine-Learning Algorithm (WISQOL-MLA) to predict urolithiasis patients' health-related quality of life (HRQoL) based on demographic, symptomatic and clinical data collected for the validation of the Wisconsin Stone Quality-of-Life (WISQOL) questionnaire, an HRQoL measurement tool designed specifically for patients with kidney stones. MATERIAL AND METHODS: We used data from 3206 stone patients from 16 centres. We used gradient-boosting and deep-learning models to predict HRQoL scores. We also stratified HRQoL scores by quintile. The dataset was split using a standard 70%/10%/20% training/validation/testing ratio. Regression performance was evaluated using Pearson's correlation. Classification was evaluated with an area under the receiver-operating characteristic curve (AUROC). RESULTS: Gradient boosting obtained a test correlation of 0.62. Deep learning obtained a correlation of 0.59. Multivariate regression achieved a correlation of 0.44. Quintile stratification of all patients in the WISQOL dataset obtained an average test AUROC of 0.70 for the five classes. The model performed best in identifying the lowest (0.79) and highest quintiles (0.83) of HRQoL. Feature importance analysis showed that the model weighs in clinically relevant factors to estimate HRQoL, such as symptomatic status, body mass index and age. CONCLUSIONS: Harnessing the power of the WISQOL questionnaire, our initial results indicate that the WISQOL-MLA can adequately predict a stone patient's HRQoL from readily available clinical information. The algorithm adequately relies on relevant clinical factors to make its HRQoL predictions. Future improvements to the model are needed for direct clinical applications.

Diagnostic Performance and Interreader Agreement of a Standardized MR Imaging Approach in the Prediction of Small Renal Mass Histology.

Purpose To assess the diagnostic performance and interreader agreement of a standardized diagnostic algorithm in determining the histologic type of small (≤4 cm) renal masses (SRMs) with multiparametric magnetic resonance (MR) imaging. Materials and Methods This single-center retrospective HIPAA-compliant institutional review board-approved study included 103 patients with 109 SRMs resected between December 2011 and July 2015. The requirement for informed consent was waived. Presurgical renal MR images were reviewed by seven radiologists with diverse experience. Eleven MR imaging features were assessed, and a standardized diagnostic algorithm was used to determine the most likely histologic diagnosis, which was compared with histopathology results after surgery. Interreader variability was tested with the Cohen κ statistic. Regression models using MR imaging features were used to predict the histopathologic diagnosis with 5% significance level. Results Clear cell renal cell carcinoma (RCC) and papillary RCC were diagnosed, with sensitivities of 85% (47 of 55) and 80% (20 of 25), respectively, and specificities of 76% (41 of 54) and 94% (79 of 84), respectively. Interreader agreement was moderate to substantial (clear cell RCC, κ = 0.58; papillary RCC, κ = 0.73). Signal intensity (SI) of the lesion on T2-weighted MR images and degree of contrast enhancement (CE) during the corticomedullary phase were independent predictors of clear cell RCC (SI odds ratio [OR]: 3.19; 95% confidence interval [CI]: 1.4, 7.1; P = .003; CE OR, 4.45; 95% CI: 1.8, 10.8; P < .001) and papillary RCC (CE OR, 0.053; 95% CI: 0.02, 0.2; P < .001), and both had substantial interreader agreement (SI, κ = 0.69; CE, κ = 0.71). Poorer performance was observed for chromophobe histology, oncocytomas, and minimal fat angiomyolipomas, (sensitivity range, 14%-67%; specificity range, 97%-99%), with fair to moderate interreader agreement (κ range = 0.23-0.43). Segmental enhancement inversion was an independent predictor of oncocytomas (OR, 16.21; 95% CI: 1.0, 275.4; P = .049), with moderate interreader agreement (κ = 0.49). Conclusion The proposed standardized MR imaging-based diagnostic algorithm had diagnostic accuracy of 81% (88 of 109) and 91% (99 of 109) in the diagnosis of clear cell RCC and papillary RCC, respectively, while achieving moderate to substantial interreader agreement among seven radiologists. © RSNA, 2018 Online supplemental material is available for this article.

Do Urinary Cystine Parameters Predict Clinical Stone Activity?

PURPOSE: An accurate urinary predictor of stone recurrence would be clinically advantageous for patients with cystinuria. A proprietary assay (Litholink, Chicago, Illinois) measures cystine capacity as a potentially more reliable estimate of stone forming propensity. The recommended capacity level to prevent stone formation, which is greater than 150 mg/l, has not been directly correlated with clinical stone activity. We investigated the relationship between urinary cystine parameters and clinical stone activity. MATERIALS AND METHODS: We prospectively followed 48 patients with cystinuria using 24-hour urine collections and serial imaging, and recorded stone activity. We compared cystine urinary parameters at times of stone activity with those obtained during periods of stone quiescence. We then performed correlation and ROC analysis to evaluate the performance of cystine parameters to predict stone activity. RESULTS: During a median followup of 70.6 months (range 2.2 to 274.6) 85 stone events occurred which could be linked to a recent urine collection. Cystine capacity was significantly greater for quiescent urine than for stone event urine (mean ± SD 48 ± 107 vs -38 ± 163 mg/l, p <0.001). Cystine capacity significantly correlated inversely with stone activity (r = -0.29, p <0.001). Capacity also correlated highly negatively with supersaturation (r = -0.88, p <0.001) and concentration (r = -0.87, p <0.001). Using the suggested cutoff of greater than 150 mg/l had only 8.0% sensitivity to predict stone quiescence. Decreasing the cutoff to 90 mg/l or greater improved sensitivity to 25.2% while maintaining specificity at 90.9%. CONCLUSIONS: Our results suggest that the target for capacity should be lower than previously advised.

Axial Abdominal Imaging after Partial Nephrectomy for T1 Renal Cell Carcinoma Surveillance.

PURPOSE: The overall recurrence rate of T1 renal cell carcinoma is low. We evaluated abdominal imaging after partial nephrectomy based on current guidelines for T1 renal cell carcinoma surveillance. MATERIALS AND METHODS: We retrospectively reviewed the records of patients with T1 renal cell carcinoma who underwent partial nephrectomy between 2006 and 2012 followed by abdominal imaging at our institution. Primary and secondary outcomes were the incidence and timing, respectively, of imaging diagnosed abdominal recurrences. A literature review was performed to summarize prior reports of recurrence incidence and timing after partial nephrectomy for T1 disease. RESULTS: A total of 160 patients with stage T1a and 37 with T1b underwent partial nephrectomy. Seven patients had an abdominal recurrence, including 3 with local and distant recurrences, and 4 with a metachronous contralateral kidney recurrence. The incidence of abdominal recurrence detected by imaging was higher in the T1b than in the T1a group (10.8% vs 1.9%, p = 0.024). Although it was not significant, median time to recurrence was earlier in T1b vs T1a cases (13 vs 37 months, p = 0.480). In each group recurrences developed after 3 years of suggested guideline surveillance. In the literature combined with the current study the time to median recurrence for T1b vs T1a was 24 vs 29 months (p = 0.226). CONCLUSIONS: Recurrences detected by abdominal imaging developed earlier and more frequently in T1b than in T1a cases. Future recommendations for surveillance strategies after partial nephrectomy should distinguish T1a from T1b with less intense frequency of imaging for T1a. A longer period of surveillance should be considered since recurrences can develop beyond 3 years.

Diagnostic Accuracy of Multiparametric Magnetic Resonance Imaging to Identify Clear Cell Renal Cell Carcinoma in cT1a Renal Masses.

PURPOSE: The detection of small renal masses is increasing with the use of cross-sectional imaging, although many incidental lesions have negligible metastatic potential. Among malignant masses clear cell renal cell carcinoma is the most prevalent and aggressive subtype. A method to identify such histology would aid in risk stratification. Our goal was to evaluate a likelihood scale for multiparametric magnetic resonance imaging in the diagnosis of clear cell histology. MATERIALS AND METHODS: We retrospectively reviewed the records of patients with cT1a masses who underwent magnetic resonance imaging and partial or radical nephrectomy from December 2011 to July 2015. Seven radiologists with different levels of experience who were blinded to final pathology findings independently reviewed studies based on a predefined algorithm. They applied a clear cell likelihood score, including 1-definitely not, 2-probably not, 3-equivocal, 4-probably and 5-definitely. Binary classification was used to determine the accuracy of clear cell vs all other histologies. Interobserver agreement was calculated with the weighted κ statistic. RESULTS: A total of 110 patients with 121 masses were identified. Mean tumor size was 2.4 cm and 50% of the lesions were clear cell. Defining clear cell as scores of 4 or greater demonstrated 78% sensitivity and 80% specificity while scores of 3 or greater showed 95% sensitivity and 58% specificity. Interobserver agreement was moderate to good with a mean κ of 0.53. CONCLUSIONS: A clear cell likelihood score used with magnetic resonance imaging can reasonably identify clear cell histology in small renal masses and may decrease the number of diagnostic renal mass biopsies. Standardization of imaging protocols and reporting criteria is needed to improve interobserver reliability.

Irreversible electroporation of small renal masses: suboptimal oncologic efficacy in an early series.

PURPOSE: To report on the first short-term oncologic outcomes of percutaneous irreversible electroporation for small renal masses. METHODS: Patients with cT1a renal masses treated with irreversible electroporation from April 2013 through December 2016 were reviewed. Small, low complexity tumors were generally selected for irreversible electroporation using the NanoKnife® System (Angiodynamics, Latham, NY, USA). Surveillance imaging was performed post-operatively, and survival analysis was completed using the Kaplan-Meier method. RESULTS: A total of 42 tumors in 41 patients underwent irreversible electroporation. Mean tumor size was 2.0 cm with a median R.E.N.A.L nephrometry score of 5. Twenty-nine patients (71%) were discharged the same day of the procedure and no major (Clavien grade II or higher) intraoperative or post-operative complications occurred. Initial treatment success rate was 93%; our three failures (7%) underwent salvage radiofrequency ablation. With a mean follow-up of 22 months, 2-year local recurrence-free survival was 83% for patients with biopsy confirmed renal cell carcinoma, 87% with biopsy confirmed or a history of renal cell carcinoma, and 92% for the intent-to-treat cohort. CONCLUSIONS: Although with low morbidity, in comparison to extirpation and conventional thermal ablation technologies, irreversible electroporation has suboptimal short-term local disease control results in this series of small, low complexity tumors. Larger series and longer follow-up will determine the durability of this modality.

The economics of stone disease.

The rising prevalence of kidney stone disease is associated with significant costs to healthcare systems worldwide. This is in part due to direct procedural and medical management costs, as well as indirect costs to health systems, patients, and families. A number of manuscripts evaulating the economics of stone disease have been published since the 2008s International Consultation on Stone Disease. These highlight costs associated with stone disease, including acute management, surgical management, and medical management. This work hopes to highlight optimization in care by reducing inefficient treatments and maximizing cost-efficient preventative strategies.

Likelihood of Incomplete Kidney Tumor Ablation with Radio Frequency Energy: Degree of Enhancement Matters.

PURPOSE: Larger size and clear cell histopathology are associated with worse outcomes for malignant renal tumors treated with radio frequency ablation. We hypothesize that greater tumor enhancement may be a risk factor for radio frequency ablation failure due to increased vascularity. MATERIALS AND METHODS: A retrospective review of patients who underwent radio frequency ablation for renal tumors with contrast enhanced imaging available was performed. The change in Hounsfield units (HU) of the tumor from the noncontrast phase to the contrast enhanced arterial phase was calculated. Radio frequency ablation failure rates for biopsy confirmed malignant tumors were compared using the chi-squared test. Multivariate logistic analysis was performed to assess predictive variables for radio frequency ablation failure. Disease-free survival was calculated using Kaplan-Meier analysis. RESULTS: A total of 99 patients with biopsy confirmed malignant renal tumors and contrast enhanced imaging were identified. The incomplete ablation rate was significantly lower for tumors with enhancement less than 60 vs 60 HU or greater (0.0% vs 14.6%, p=0.005). On multivariate logistic regression analysis tumor enhancement 60 HU or greater (OR 1.14, p=0.008) remained a significant predictor of incomplete initial ablation. The 5-year disease-free survival for size less than 3 cm was 100% vs 69.2% for size 3 cm or greater (p <0.01), while 5-year disease-free survival for HU change less than 60 was 100% vs 92.4% for HU change 60 or greater (p=0.24). CONCLUSIONS: Biopsy confirmed malignant renal tumors, which exhibit a change in enhancement of 60 HU or greater, experience a higher rate of incomplete initial tumor ablation than tumors with enhancement less than 60 HU. Size 3 cm or greater portends worse 5-year disease-free survival after radio frequency ablation. The degree of enhancement should be considered when counseling patients before radio frequency ablation.

The Usefulness of Chest X-Rays for T1a Renal Cell Carcinoma Surveillance.

PURPOSE: The overall incidence of pulmonary metastasis of T1 renal cell carcinoma is low. We evaluated the usefulness of chest x-rays based on the current AUA (American Urological Association) guidelines and NCCN Guidelines® for T1a renal cell carcinoma surveillance. MATERIALS AND METHODS: Between 2006 and 2012, 258 patients with T1a renal cell carcinoma were treated with partial nephrectomy, radical nephrectomy or radio frequency ablation with surveillance followup at our institution. A retrospective chart review was performed to identify demographics, pathological findings and surveillance records. The primary outcome was the incidence of asymptomatic pulmonary recurrences diagnosed by chest x-ray in cases of T1a disease. Our secondary outcome was a comparison of diagnoses by treatment modality (partial nephrectomy, radical nephrectomy or radio frequency ablation). RESULTS: Pulmonary metastases developed in 3 of 258 patients (1.2%) but only 1 (0.4%) was diagnosed by standard chest x-ray surveillance. Median followup in the entire cohort was 36 months (range 6 to 152) and 193 of 258 patients (75%) had greater than 24 months of followup. A mean of 3.3 surveillance chest x-rays were completed per patient. When assessed by treatment type, there was no significant difference in the recurrence rate for partial nephrectomy (0 of 191 cases), radical nephrectomy (0 of 22) or radio frequency ablation (1 of 45 or 2.2%) (p = 0.09). CONCLUSIONS: Chest x-rays are a low yield diagnostic tool for detecting pulmonary metastasis in patients treated for T1a renal cel carcinoma. Treatment mode does not appear to influence the need for chest x-ray surveillance.

The Impact of Bilateral Stone Disease on Patients' Disease Progression and Health-Related Quality of Life.

Purpose: Patients with recurring kidney stone events can expect significant morbidity and functional impairment. Few studies have evaluated the effect of bilateral kidney stones on disease progression and quality of life. We wanted to determine the association of bilateral stone disease on age of onset, and the impact on number of stone events and individual kidney stone disease-specific health-related quality of life (HRQOL) by analyzing the validated and prospectively collected Wisconsin Stone Quality of Life (WISQOL) database. Materials and Methods: We studied 2906 stone patients from 16 centers in North America after having completed the WISQOL questionnaire from 2014 to 2019. Kidney stone formers were assessed if kidney stones were bilateral or unilateral on imaging. Analysis with a chi-square test compared categorical variables. Bilateral kidney stone disease and its impact on HRQOL were evaluated through a multivariable linear regression model. Results: Of 2906 kidney stone formers, 1340 had unilateral kidney stones and 1566 had bilateral kidney stones. We observed more frequently that patients with bilateral stones had an increased number of depression/anxiety symptoms, renal tubular acidosis, and rheumatoid arthritis (all p < 0.05). Patients with bilateral stones had a younger mean (standard deviation [SD]) age of kidney stone disease onset (37.2 ± 15.8 vs 46.4 ± 15.9 years of age, p < 0.001). Bilateral kidney stone formers had a higher mean (SD) number of stone events (11.3 ± 21.8) than unilateral kidney stone formers (3.0 ± 5.1) (p < 0.001). Within our multivariable analysis, we found that HRQOL was negatively affected by the presence of bilateral stones for kidney stone patients (ß = -11.2 [confidence interval: -19.5 to -3.0] points, p < 0.05). Conclusions: Bilateral kidney stone formers had a younger age of kidney stone disease onset and a higher number of stone events compared with unilateral kidney stone disease formers. The presence of bilateral kidney stone disease negatively impacted HRQOL.

Over-the-Counter Alkali Agents to Raise Urine pH and Citrate Excretion: A Prospective Crossover Study in Healthy Adults.

OBJECTIVE: To assess the effect of 2 over-the-counter alkalizing agents on 24 hour urinary parameters. MATERIALS AND METHODS: Ten healthy volunteers without a history of kidney stones were recruited to complete a baseline 24 hour urinalysis with a 4 day diet inventory. Participants then maintained the same diet on either LithoLyte (20 mEq 2 times per day) or KSPtabs (1 tablet 2 times per day) and submitted another 24 hour urinalysis. The process was repeated with the other supplement. Urinary alkali parameters were compared to baseline, and side effects were elicited with a questionnaire. RESULTS: LithoLyte intake resulted in a non-significant increase in citrate (597-758 mg/day, P =.058, an increase in urine pH (6.46-6.66, P =.028), and a decrease in urine ammonium (41-36 mmol/day, P =.005) compared to baseline. KSPtabs resulted in an increase in citrate (597-797 mg/day, P =.037) and urine pH (6.46-6.86, P =.037), with a non-significant decrease in ammonium (41-34 mmol/day, P =.059). No significant differences were seen comparing urinary analytes between LithoLyte and KSPtabs. With Litholyte, no side effects, mild, moderate, and severe side effects were seen in 50%, 40%, 10%, and 0%, respectively. With KSPtabs, rates were 60%, 20%, 10%, and 10%, respectively. CONCLUSION: In healthy participants without a history of kidney stones, LithoLyte and KSPtabs are effective over-the-counter alkali supplements, with a similar side effect profile to prescription potassium citrate.

The Duration of Stone Disease and the Impact of a Stone Event on Patients' Quality of Life.

Introduction: With a 5-year stone recurrence rate of 30% to 50%, kidney stone formers are subject to significant morbidity that negatively impacts their health-related quality of life (HRQOL). We sought to determine the impact of age at kidney stone onset, duration of stone disease, and kidney stone event (surgery or stone passage) on HRQOL of individual patients by querying the validated and prospectively collected Wisconsin Stone Quality of Life (WISQOL) database. Patients and Methods: Cross-sectional data were obtained from a total of 2438 kidney stone formers from 14 institutions in North America who completed the WISQOL questionnaire during the period from 2014 to 2019. The 28-question survey has a 1- to 5-point scale for each item (total score range 0-140). Multivariable linear regression models assessed the impact of age at kidney stone onset, duration of stone disease, and time since most recent surgery or stone passage on HRQOL. Results: Of 2438 patients, older age at kidney stone onset and longer duration of disease were both independent predictors of better WISQOL scores (ß = 0.33 points/year; confidence interval [CI] 0.17-0.49; p < 0.001; and ß = 0.50 points/year; CI 0.32-0.68; p < 0.001, respectively). Of 1376 patients who underwent surgery between 2010 and 2019, longer time since most recent surgery was an independent predictor of better WISQOL scores (ß = 2.28 points/year; CI: 1.47-3.10; p = <0.001). Of 1027 patients with spontaneous stone passage occurring between 2010 and 2019, longer time since most recent stone passage was an independent predictor of better WISQOL scores (ß = 1.59 points/year; CI: 0.59-2.59; p = <0.05). Conclusions: Our study demonstrates that older age at onset, longer duration of disease, and longer time since most recent surgery or stone passage were independent predictors of better HRQOL in kidney stone formers. Results of future studies that focus on optimizing stone-related modifiable risk factors to decrease the number of recurrent stone episodes and thus the need for recurrent surgeries will be essential.

Heterogeneity in stone culture protocols and endourologist practice patterns: a multi-institutional survey.

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.

Stenting of Malignant Urinary Tract Obstructions in Humans and Companion Animals.

Urine retention secondary to neoplastic obstructions of the upper and lower urinary tracts is a life-threatening condition in both humans and companion animals. Stents can be placed to temporarily or permanently open obstructed urinary tract lumens and are often able to be placed using minimally invasive techniques with guidance via ultrasonography or fluoroscopy. The literature for these techniques is vast for humans and growing for companion animals. The below review provides a discussion of the principles of stenting and types of ureteral and urethral stents, as well as the techniques for placing these stents in humans and companion animals.

The impact of the number of lifetime stone events on quality of life: results from the North American Stone Quality of Life Consortium.

To evaluate the impact of chronic stone recurrence on an individual's quality of life using the validated Wisconsin Stone Quality of Life (WISQOL) questionnaire. We collected cross-sectional data on patients with kidney stones from 14 institutions in North America. A stone event was defined as renal colic, stone-related procedure or emergency department visit. The regression analyses using general linear models and pairwise comparison determined the impact of the number of stone events on quality of life. The median number of stone events among the 2205 patients who completed the questionnaire was 3 (IQR 1-6). The mean total score was 107.4 ± 28.7 (max 140 points). The number of lifetime stone events was an independent predictor of lower quality of life (p < 0.001), specifically, score declined significantly beyond five events. Compared with patients who experienced a single stone event, there was a 0.4, 2.5, and 6.9 point decline in the adjusted mean WISQOL score after 2-5, 6-10, or > 10 events, respectively. The cumulative number of lifetime stone events was associated with a lower quality of life when more than five stone events were occurred. These findings underscore the importance of efforts to determine the underlying metabolic etiology of urolithiasis in the recurrent stone former, and the institution of a regimen to place their stone disease in remission.

Initial Clinical Experience with Swiss LithoClast Trilogy During Percutaneous Nephrolithotomy.

Introduction and Objective: Current available lithotrites have clinical stone clearance rates averaging 24 to 32 mm2/minute. The objective of this study was to critically evaluate the initial experience with the Swiss LithoClast® Trilogy lithotrite during percutaneous nephrolithotomy (PCNL). Methods: We prospectively enrolled patients with a minimum of 15 mm of stone in axial diameter at three locations (Indiana University, University of California Davis, and University of California San Diego) scheduled to undergo PCNL for nephrolithiasis over a 60-day trial period. We assessed objective measures of stone clearance time, stone clearance rate, device malfunction, stone-free rate, and complications. Each surgeon also evaluated subjective parameters from each case related to the use of Trilogy on a 1 to 10 scale (10 = extremely effective), and compared it with their usual lithotrite on a 1 to 5 scale (5 = much better). Results: We included 43 patients and had 7 bilateral (16.3%) cases, for a total of 50 renal units. One case was a mini-PCNL. Two cases experienced device malfunctions requiring troubleshooting but no transition to another lithotrite. The mean stone clearance rate was 68.9 mm2/minute. The stone-free rate on postoperative imaging was 67.6% (25 of 37 patients with available imaging). The lowest subjective rating was the ergonomic score of 6.7, and the highest subjective rating was the ease of managing settings score of 9.2. The surgeon impressions of ultrasound (7.3), ballistics (8.1), combination of ultrasound and ballistics (8.7), and suction (8.4) were high. One patient experienced an intraoperative renal pelvis perforation, one patient required a blood transfusion, one patient had a pneumothorax requiring chest tube placement, and one patient had a renal artery pseudoaneurysm requiring endovascular embolization. Conclusions: This multi-institutional study evaluated a new and efficient combination lithotrite that was perceived by surgeons to be highly satisfactory, with an excellent safety and durability profile.

Metabolic Syndrome Negatively Impacts Stone-Specific Quality of Life.

Purpose: Metabolic syndrome (MetS) is a cluster of metabolic diseases that is linked to atherosclerotic cardiovascular disease. MetS has also been linked to increased nephrolithiasis. However, limited research has been conducted on MetS and its impact on stone-specific health-related quality of life (HRQOL). This study aims to examine the hypothesis that the presence of MetS is associated with decreased HRQOL. Materials and Methods: The Wisconsin Stone Quality of Life Questionnaire, a stone-specific HRQOL questionnaire, was used to survey 3051 patients with kidney stones. Medical history was collected from patients. These data were used to distinguish MetS patients from non-MetS patients. Among patients with current stones, a Wilcoxon rank sum test was used to compare HRQOL scores from MetS patients and non-MetS patients. HRQOL from patients with and without individual MetS components were also compared, and a multivariate analysis was conducted. Results: Statistical comparison between MetS patients (median score 102/140) and non-MetS patients (median score 106/140) demonstrated a lower stone-specific HRQOL in patients with MetS (p = 0.049). Among individual MetS components, patients with diabetes mellitus (DM) or body mass index (BMI) >30 had significantly lower HRQOL than patients without DM or BMI <30 (p = 0.028 and p < 0.001, respectively). The multivariate analysis supported this trend as MetS remained a significant predictor of decreased HRQOL (p = 0.002) after controlling for other variables assessed. Conclusions: This study indicates an association between MetS and a lower stone-specific QOL. This has important implications for stone prevention strategies in patients with MetS. Clinical Trial Registration number: H14-01143.

Effect of Differing Parameters on Irreversible Electroporation in a Porcine Model.

INTRODUCTION AND OBJECTIVE: Irreversible electroporation (IRE) is a new ablative technology to treat small renal masses. We evaluated differed ablation settings on lesion size and temperature changes in a porcine model. MATERIALS AND METHODS: After Institutional Animal Care and Use Committee approval, 36 laparoscopy-guided and 16 open ablations were performed on 13 domestic female pigs. Ablation parameters studied were voltage (1000 V/cm, 1500 V/cm, or 2000 V/cm), probe exposure (1.0 or 1.5 cm), and lesion size over time (survival) (0-, 7-, or 14 day). Temperature changes were monitored during open ablations with differed settings. Gross lesion size was measured, and histologic analysis with hematoxylin and eosin and nicotinamide adenine dinucleotide staining was performed. RESULTS: The 1000 V/cm ablations had no gross or histologic lesions. A factorial analysis of variance demonstrated that day (p = 0.56), exposure (p = 0.33), and voltage (p = 0.06) did not demonstrate statistical significance for affecting lesion size. For 1.0 cm probe exposure, 2000 V/cm did more closely approximate expected lesion size (p = 0.02) compared with 1500 V/cm. While significance was not seen for 1.5 cm probe exposure, 2000 V/cm often exceeded expected lesion volume. Only 1 of 4 temperature sensors, located adjacent to one of the IRE probes, noted a significant increase with increased voltage. However, all maximum temperatures remained less than 70°C. CONCLUSIONS: Variation in lesion volume was seen with different ablation settings in this porcine model. Maximal energy and probe exposure settings should be utilized to ensure full coverage of target volume/mass, potentially without concern for thermal injury to renal collecting system or nearby structures.

The Decline of Laparoendoscopic Single-Site Surgery: A Survey of the Endourological Society to Identify Shortcomings and Guidance for Future Directions.

INTRODUCTION: To analyze the most recent temporal trends in the adoption of urologic laparoendoscopic single-site (LESS), to identify the perceived limitations associated with its decline, and to determine factors that might revive the role of LESS in the field of minimally invasive urologic surgery. MATERIALS AND METHODS: A 15 question survey was created and sent to members of the Endourological Society in September 2016. Only members who performed LESS procedures in practice were asked to respond. RESULTS: In total, 106 urologists responded to the survey. Most of the respondents were from the United States (35%) and worked in an academic hospital (84.9%). Standard LESS was the most popular approach (78.1%), while 14.3% used robotics, and 7.6% used both. 2009 marked the most popular year to perform the initial (27.6%) and the majority (20%) of LESS procedures. The most common LESS procedure was a radical/simple nephrectomy (51%) followed by pyeloplasty (17.3%). In the past 12 months, 60% of respondents had performed no LESS procedures. Compared to conventional laparoscopy, respondents only believed cosmesis to be better, however, this enthusiasm waned over time. Worsening shifts in enthusiasm for LESS also occurred with patient desire, marketability, cost, safety, and robotic adaptability. The highest rated factor to help LESS regain popularity was a new robotic platform. CONCLUSION: The decline of LESS is apparent, with few urologists continuing to perform procedures attributed to multiple factors. The availability of a purpose-built robotic platform and better instrumentation might translate into a renewed future interest of LESS.