Fluoroscopy time during uncomplicated unilateral ureteroscopy for urolithiasis decreases with urology resident experience.

PURPOSE: To determine predictors of fluoroscopy time during uncomplicated, unilateral ureteroscopy for urolithiasis performed by urology residents during the first 2 years of residency. METHODS: The patient charts and computed tomography scans of consecutive, unilateral, uncomplicated ureteroscopy cases for urolithiasis were retrospectively reviewed. The cases were performed by beginning urology residents over the course of their first 2 years of urology residency training. RESULTS: A total of 200 ureteroscopy cases were reviewed. The mean stone diameter was 7.1 (±3.2) mm. Forty-three percent of cases were performed for renal stones and 58 % for ureteral stones. The mean operative time was 80.2 (±36.9) min. The mean fluoroscopy time was 69.1 (±38.2) s. No significant differences existed between cases performed by each of the two residents, and no statistical differences in case difficulty were observed throughout the study period. Linear regression analysis revealed the strongest association with lower fluoroscopy time to be increasing resident experience (p < 0.001). By the end of the 2-year review, fluoroscopy time decreased by 79 % from 135 to 29 s per case. Other significant factors associated with increasing fluoroscopy time were placement of a postoperative stent under fluoroscopic guidance (p < 0.001), utilization of a flexible ureteroscope as opposed to a semirigid ureteroscope (p < 0.001), and balloon dilation of the ureteral orifice (p < 0.001). CONCLUSIONS: Fluoroscopy time during uncomplicated, unilateral ureteroscopy for urolithiasis decreases with increasing urology resident operative experience. Other technical options during ureteroscopy were also found to influence fluoroscopy time.

Robot-assisted laparoscopic nephroureterectomy for urothelial carcinoma with inferior vena cava incision and repair.

Locally advanced urothelial carcinoma of the renal collecting system presents a unique challenge to the urologist performing nephroureterectomy, particularly if the tumor invades the renal vein or the IVC. Preoperative planning and a multidisciplinary approach are important to optimize the outcomes for these patients. The use of robotic assistance for laparoscopic nephroureterectomy has become common, but a simultaneous robotic assisted IVC excision has yet to be reported. This case report describes a robotic assisted laparoscopic right nephroureterectomy with IVC resection and retroperitoneal lymphadenectomy for locally advanced urothelial carcinoma. For a patient with locally advanced urothelial carcinoma of the renal collecting system which obliterates the renal vein, robotic assisted surgery provides a minimally invasive alternative to open surgery.

Spontaneous rupture of continent urinary reservoir with extrophy-epispadias complex.

Spontaneous rupture of a continent urinary reservoir is a rare, but clinically important event. The diagnosis of reservoir rupture should be considered in any patient with peritonitis and a history of continent urinary diversion. A pouchogram may confirm the diagnosis, but ultimately a laparotomy is mandatory in the setting of peritonitis and sepsis. Catheter drainage alone has been reportedly successful for patients who meet certain criteria. This case highlights the key steps in evaluation and management of a ruptured continent urinary reservoir.

A Randomized Controlled Trial for Pain Control in Laparoscopic Urologic Surgery: 0.25% Bupivacaine Versus Long-Acting Liposomal Bupivacaine.

BACKGROUND AND PURPOSE: Liposomal bupivacaine is a delayed-release preparation providing up to 72 hours of local analgesia. It costs much more than standard bupivacaine, however. A prospective, randomized, patient-blinded, controlled trial was performed to assess the efficacy of liposomal bupivacaine versus 0.25% bupivacaine when injected into surgical incisions during laparoscopic and robot-assisted urologic surgery. METHODS: A total of 206 adults were randomized to receive liposomal bupivacaine or 0.25% bupivacaine. All surgical incisions were injected with liposomal bupivacaine or 0.25% bupivacaine with systematic dosing. The primary outcome was total opioid consumption during the postoperative hospital stay. All opioid doses were converted to morphine equivalents. Secondary end points included pain scores using visual analog pain scales, duration of hospital stay, and the time to first opioid use. A subgroup analysis was performed for renal surgery patients. RESULTS: There was no significant difference in median total opioid use during the hospital stay between those who received liposomal bupivacaine (15 [interquartile range (IQR) 6.7-27] mg) and 0.25% bupivacaine (17.3 [IQR 8.3-30.5] mg) (P=0.39). Furthermore, pain scores, length of hospital stay, and time to first opioid use did not differ between groups. Subgroup analysis of laparoscopic renal surgery revealed no difference between liposomal bupivacaine and 0.25% bupivacaine. CONCLUSIONS: For laparoscopic and robot-assisted urologic surgery, there is no significant difference between liposomal bupivacaine and 0.25% bupivacaine for local analgesia at the incision sites.

Safety, minimization, and awareness radiation training reduces fluoroscopy time during unilateral ureteroscopy.

OBJECTIVE: To determine the impact of Safety, Minimization and Awareness Radiation Training (SMART) on fluoroscopy time during unilateral uncomplicated ureteroscopy for urolithiasis performed by urology residents. MATERIALS AND METHODS: All consecutive ureteroscopy cases for urolithiasis meeting inclusion criteria and performed by first-year urology residents over a 2-year period were reviewed. Fluoroscopy times during SMART and without SMART were compared. RESULTS: A total of 202 ureteroscopy cases were reviewed. The mean patient age was 48.7 years. The mean stone diameter was 7.6 ± 3.3 mm. The mean operating time was 79.8 ± 34.3 minutes. The mean cumulative fluoroscopy time was 85.6 ± 36.9 seconds per case. A Spearman rank correlation identified 8 variables significantly correlated with fluoroscopy time, with the most significant correlation between shorter fluoroscopy time and SMART exposure (rho = 0.532; P <.001). Multivariate regression analysis (r = 0.701) revealed that fluoroscopy time was significantly shorter with SMART (P <.001). Post hoc comparisons revealed the fluoroscopy time of the cases performed during SMART (mean, 45 seconds) to be significantly shorter than the fluoroscopy time of cases performed by the same residents before SMART (mean, 102 seconds; P = .005), and the fluoroscopy time of cases performed by residents the previous year with similar ureteroscopic experience but without SMART (mean, 78 seconds; P <.001). CONCLUSION: SMART reduces fluoroscopy time during unilateral uncomplicated ureteroscopy for urolithiasis performed by urology residents by 56%.

Strategies for open reconstruction of upper ureteral strictures.

This article presents a review of the literature regarding surgical techniques and outcomes for reconstruction of strictures involving the upper ureter. The preoperative assessment for proximal ureteral stricture is briefly reviewed, followed by a discussion of ureteroureterostomy, transureteroureterostomy, ureterocalicostomy, bladder flaps, downward nephropexy, bowel interposition grafts, onlay or tubular grafting, renal autotransplantation, and nephrectomy. The future direction for reconstruction of the proximal ureter is proposed.

Pharyngeal perforation masquerading as esophageal atresia.

We present a case of pharyngeal perforation from a nasogastric tube mistakenly diagnosed as esophageal atresia with tracheoesophageal fistula in a full term infant female. The correct diagnosis was identified with rigid bronchoscopy and esophagoscopy immediately prior to the planned thoracotomy which was aborted. After one week of oral restriction and antibiotics, the healed perforation did not demonstrate leakage on a contrasted pharyngoesophagogram and bottle feeds were initiated. The infant was discharged to home on day of life 13 without any further complications.