Advancements in Performance of Percutaneous Nephrolithotomy in Ambulatory Surgery Centers: Outcomes and Lessons From 1250+ Cases.

OBJECTIVE: To evaluate the safety and efficacy of routine ambulatory percutaneous nephrolithotomy (PCNL) in a freestanding ambulatory surgical center. METHODS: Patients were treated between 2015 and 2022 by one of three experienced endourologists in Maryland. The surgery center is free-standing, with the nearest hospital approximately 10 minutes away. Patient characteristics and surgical datapoints, including need for transfer, were gathered prospectively at the time of surgery. Subset analyses were performed in patients with staghorn calculi or elevated body mass index, as they represent higher-risk populations. RESULTS: A total of 1267 patients underwent ambulatory PCNL with a median stone diameter of 32 mm. The average recovery time was 87 minutes, with 1.7% of patients requiring transfer to the hospital, generally for postoperative hypotension or inadequate pain control. 166 patients with body mass index >40 were safely treated, with no significant difference in transfer rate (P = .5). 2.8% of patients had a complication, with the majority being Clavien-Dindo grade I or II. 88 patients with staghorn calculi were treated, with a 6% transfer rate. Staghorn calculi were the only factor found on multivariable analysis to be a significant predictor of transfer (OR 3.56 (1.17-10.82) P < .05). CONCLUSION: Ambulatory PCNL may safely be performed in a surgery center in most patients. These outcomes reflect the real-world experience of high-volume surgeons and demonstrate a multiyear paradigm shift in PCNL from an inpatient procedure to an outpatient procedure in a surgery center.

Quick Sequential Organ Failure Assessment Score Is a Better Predictor of Septic Shock After Percutaneous Nephrolithotomy: A Secondary Analysis of Two Multicenter Prospective Trials.

Introduction: Recent retrospective literature suggests that the quick sequential organ failure assessment (qSOFA) scoring tool is a potentially superior tool over use of the systemic inflammatory response syndrome (SIRS) criteria to predict septic shock after percutaneous nephrolithotomy (PCNL) surgery. Here we examine use of qSOFA and SIRS to predict septic shock within data series collected prospectively on PCNL patients as part of a greater study of infectious complications. Materials and Methods: We performed a secondary analysis of two prospective multicenter studies including PCNL patients across nine institutions. Clinical signs informing SIRS and qSOFA scores were collected no later than postoperative day 1. The primary outcome was sensitivity and specificity of SIRS and qSOFA (high-risk score of greater-or-equal to two points) in predicting admission to the intensive care unit (ICU) for vasopressor support. Results: A total of 218 cases at 9 institutions were analyzed. One patient required vasopressor support in the ICU. The sensitivity/specificity was 100%/72.4% (McNemar's test p < 0.001) for SIRS and was 100%/90.8% (McNemar's test p < 0.001) for qSOFA. Conclusion: Although positive predictive value for both qSOFA and SIRS in prediction of post-PCNL septic shock is low, prospectively collected data demonstrate use of qSOFA may offer greater specificity than SIRS criteria when predicting post-PCNL septic shock.

A Rare Case of a Bladder Neck Abscess Masquerading as a Benign Mass.

Introduction: Bladder neck abscesses are rare urologic pathologies with very few cases published in modern literature. This report explores a case of a bladder neck mass incidentally found on computed tomography (CT) imaging in a patient with an iliopsoas abscess. Case Presentation. We present a case of a 60-year-old woman who was recently treated for sepsis secondary to an iliopsoas abscess in July of 2022. A CT scan revealed an indeterminate structure in the posterior inferior left paramedian bladder wall. During a cystoscopy with transurethral resection of the mass, an abscess was uncovered and evacuated. A postoperative Foley catheter was left in place, and the patient recovered without any complications. Conclusion: At the time of publication, the patient feels well and denies pain or lower urinary tract symptoms. Although bladder abscesses are exceptionally rare, incidental findings during cystoscopy may warrant further investigation in patients with comorbid abscesses.

The Safety and Efficacy of Endoscopic Combined Intrarenal Surgery (ECIRS) versus Percutaneous Nephrolithotomy (PCNL): A Systematic Review and Meta-Analysis.

Purpose: Our aim is to evaluate the safety and efficacy of endoscopic combined intrarenal surgery compared to percutaneous nephrolithotomy to guide practitioners and inform guidelines. Materials and Methods: A detailed database search was performed in PubMed, OVID, Scopus, and Web of Science in October 2021 to identify articles pertaining to ECIRS published between 2001 and 2021. Results: Four nonrandomized comparative studies and one RCT were identified, yielding five studies with a total of 546 patients (ECIRS/mini-ECIRS, n = 277; PCNL/mini-PCNL, n = 269). Subjects in these five studies met the predefined inclusion criteria established by two reviewers (J.E.A. and R.L.S.) and were therefore eligible for analysis. The results demonstrated that ECIRS was associated with a higher SFR (OR: 4.20; 95% CI: 2.79, 6.33; p < 0.00001), fewer complications (OR: 0.63; 95% CI: 0.41, 0.97; p=0.04), and a shorter hospital stay (WMD: -1.27; 95% CI: -1.55, -0.98; p < 0.00001) when compared to PCNL. There were no statistically significant differences in blood transfusions (OR: 0.45; 95% CI: 0.12, 1.68; p=0.24), operative time (SMD: -1.05; 95% CI: -2.42, 0.31; p=0.13), or blood loss (SMD: -1.10; 95% CI: -2.46, 0.26; p=0.11) between ECIRS and PCNL. Conclusions: ECIRS may be a more suitable approach for the surgical management of large and complex kidney stones currently indicating PCNL due to its superior efficacy with comparable surgical time and complication rate, though it is thought that a lack of resources and properly trained personnel may preclude ECIRS from becoming the standard. It is our impression that ECIRS may become the preferred technique in the endourologic community corresponding to the evolutionary sequence of percutaneous stone surgery.

Antibiotics are not necessary during routine cystoscopic stent removal: A randomized controlled trial at UC San Diego.

INTRODUCTION: Current American Urological Association (AUA) Best Practice Statement recommends antibiotic prophylaxis for cystoscopy with manipulation, including stent removal; although no Level 1b trials explicitly address prophylaxis for stent removal. We sought to determine the efficacy of prophylactic antibiotics to prevent infectious complications after stent removal. MATERIALS AND METHODS: Following institutional review board approval, patients undergoing removal of ureteral stent placed during stone surgery were recruited from July 2016 to March 2019. Patients were recruited at the time of stent removal and randomized to treatment (single dose 500 mg oral ciprofloxacin) or control group (no antibiotics). Telephone contact was attempted within 14 days of stent removal to assess for urinary tract infection (UTI) symptoms, antibiotic prescriptions, or Emergency Department visits. Primary outcome was UTI within 1 month of stent removal - defined by irritative voiding symptoms, fever or abdominal pain associated with positive urine culture (Ucx) (>100k colony-forming units/mL). RESULTS: Seventy-seven patients were enrolled, with 58 meeting final inclusion criteria for the analysis (33 treatment, 25 controls). No differences were seen with clinical and demographic variables, except a higher body mass index in the treatment group (P = 0.007). Positive Ucx rate before stone surgery (16.7% vs. 11.8%, P = 0.819) and at the time of stent removal (16.0% vs. 11.1%, P = 0.648) was not significantly different in treatment versus control groups, respectively. Primary outcome: No patients in either cohort developed symptomatic culture-diagnosed UTI within 1 month of stent removal. Of patients with documented phone follow-up (treatment n = 29, control n = 22), only one patient (control) reported any positive response on phone survey. CONCLUSIONS: We found a low infectious complication rate regardless of antibiotic prophylaxis use during cystoscopic stent removal. The necessity of antibiotics during routine cystoscopic stent removal warrants possible reevaluation of the AUA best practice statement.

Endoscopic Combined Intrarenal Surgery Can Accurately Predict High Stone Clearance Rates on Postoperative CT.

OBJECTIVE: To determine stone clearance rates using endoscopic combined intrarenal surgery (ECIRS) and assess the accuracy of intraoperative prediction of stone-free (SF) status compared to postoperative CT scan. METHODS: A single institution, prospectively maintained database of ECIRS was queried for procedures performed 8/2017 to 1/2018. Retrograde access was performed using a ureteral sheath and flexible ureteroscope. Percutaneous nephrolithotomy was performed through a 30fr or 18fr sheath in prone position. Residual stone status was estimated at the end of each procedure and was verified with postoperative CT scan. SF was defined as no single stone >2mm3 on CT. RESULTS: One hundred and ten procedures were reviewed. Average age was 58.9 ± 12.6 years (range 26-87) and 69 (63%) were male. The mean stone size was 33.3 ± 23.5 mm (range 4-140 mm). Ninty-three patients (84.5%) were endoscopically estimated to be SF, of which 84 (90% of predicted SF cohort, 76% of total cohort) were confirmed SF via CT scan. The sensitivity for estimating SF status with ECIRS was 65.4% (95%CI 44.3%-82.8%), specificity was 100% (95%CI 95.7%-100.0%) and accuracy was 91.8% (95%CI 85.0%-96.2%). SF patients had significantly smaller stones than those with residual fragments (28.5 ± 2.1 vs 48.4 ± 5.7mm, P <.0001). On logistic regression, the factors associated with residual stones were preoperative stone burden (OR 1.03 per mm, 95%CI 1.01-1.05, P = .0004) and fluoroscopy time (OR 1.01 per minute, 95%CI 1.0-1.02, P = .0081). CONCLUSION: ECIRS accurately predicts clinical SF status and may obviate the need for additional CT scans. Consistent with prior studies, the primary determinant of residual stone after percutaneous nephrolithotomy is initial stone size.

Outpatient Tubeless Percutaneous Nephrolithotomy Performed in a Freestanding Ambulatory Surgery Center.

Background: Percutaneous nephrolithotomy (PNL) is a procedure that has traditionally been performed in an inpatient or hospital setting. Many surgical procedures have evolved over time from an inpatient/hospital setting to outpatient procedures performed in surgical centers. Outpatient PNL has become an accepted standard in select patients, but to date, the procedure has not been performed in an outpatient surgical center. Case Presentation: We describe our initial experience managing large renal stone burden with PNL performed completely outpatient in a freestanding ambulatory surgery center. The patient was carefully selected as a young, healthy, thin patient with straightforward renal stone burden and favorable anatomy per CT. Access was achieved with a combination of fluoroscopic and endoscopic needle guidance. The procedure was performed with several modifying factors to enable an effective outpatient discharge. Conclusion: Our experience reinforces the outpatient feasibility of PNL and incites the possibility of transitioning the procedure to an ambulatory surgical center in select patients to provide healthcare savings and an improved patient experience.

Predictors of radiation exposure to providers during percutaneous nephrolithotomy.

BACKGROUND: Limited studies have reported on radiation risks of increased ionizing radiation exposure to medical personnel in the urologic community. Fluoroscopy is readily used in many urologic surgical procedures. The aim of this study was to determine radiation exposure to all operating room personnel during percutaneous nephrolithotomy (PNL), commonly performed for large renal or complex stones. MATERIALS AND METHODS: We prospectively collected personnel exposure data for all PNL cases at two academic institutions. This was collected using the Instadose™ dosimeter and reported both continuously and categorically as high and low dose using a 10 mrem dose threshold, the approximate amount of radiation received from one single chest X-ray. Predictors of increased radiation exposure were determined using multivariate analysis. RESULTS: A total of 91 PNL cases in 66 patients were reviewed. Median surgery duration and fluoroscopy time were 142 (38-368) min and 263 (19-1809) sec, respectively. Median attending urologist, urology resident, anesthesia, and nurse radiation exposure per case was 4 (0-111), 4 (0-21), 0 (0-5), and 0 (0-5) mrem, respectively. On univariate analysis, stone area, partial or staghorn calculi, surgery duration, and fluoroscopy time were associated with high attending urologist and resident radiation exposure. Preexisting access that was utilized was negatively associated with resident radiation exposure. However, on multivariate analysis, only fluoroscopy duration remained significant for attending urologist radiation exposure. CONCLUSION: Increased stone burden, partial or staghorn calculi, surgery and fluoroscopy duration, and absence of preexisting access were associated with high provider radiation exposure. Radiation safety awareness is essential to minimize exposure and to protect the patient and all providers from potential radiation injury.

Ureterorenoscopy: current technology and future outlook.

The aim of this paper was to evaluate the current technology and designs of flexible ureterorenoscopes. We will review contemporary fiberoptic and digital ureteroscopes, including a discussion on ureteroscope damage and repair, and lastly present the projected future of flexible ureterorenoscopy. Ureterorenoscopy has evolved dramatically over the past several decades, which has led to landscape reshaping of stone disease treatment and upper tract pathology. Advancements in tip control, miniaturization of scopes, introduction of a digital chip on the tip, disposable devices to augment surgery, surgical experience/familiarity and most recently single use scopes are all independent factors that have increased flexible ureterorenoscopy adoption and success. We therefore detail the aforementioned and provide a view of future innovations. A review of literature from 1980 to 2016 was performed by the two authors focusing on literature that details flexible ureterorenoscopy. Technology has significantly impacted the minimally invasive endourologic management of the urinary system. This review summarizes current literature on advances and modern technical achievements. We include a focus on new perspectives and future outlook in the field of managing upper urinary tract pathology with modern technologies. The advancements in flexible ureterorenoscopy are impressive and yet the challenges of this technology are equally daunting. Obstacles to overcome include improving durability, decreasing cost, further miniaturizing scopes size, and determining the role of single use scopes. Ongoing developments in other technology fields (such as virtual 3D imaging, wireless capsular endoscopy, robotics) continue to create both opportunities to improve the procedure but also threaten to replace ureterorenoscopy over time. This is an exciting time because of past achievements and future innovations in ureterorenoscopy.

Are antibiotics necessary during routine cystoscopic stent removal?

BACKGROUND: The 2008 American Urological Association (AUA) Best Practice Statement on antimicrobial prophylaxis states that prophylaxis is not warranted for subjects with normal risk profile undergoing cystourethroscopy unless manipulation such as ureteral stent removal is performed. To date no studies have specifically assessed the need for antimicrobial prophylaxis during cystoscopic ureteral stent removal. We sought to determine the risk of infectious complications following cystoscopic stent removal with and without antimicrobial prophylaxis. METHODS: A retrospective review identified 70 subjects who underwent cystoscopic ureteral stent removal following kidney stone treatment, under the care of two separate urologists with differing practice patterns. Each cohort consisted of 35 subjects: with and without prophylactic antibiotics. Clinical variables assessed included demographics, type of stone intervention, prior urinary tract infection (UTI) history, immunocompromising comorbidities, antimicrobial class at time of stone intervention, and antimicrobial administration at cystoscopic stent removal. The primary outcome assessed was development of symptomatic UTI within 4 weeks after stent removal. RESULTS: Overall, 35 patients (50%) received antimicrobial prophylaxis at the time of stent removal and 35 (50%) did not receive antimicrobial prophylaxis, with no demographic or clinical differences between cohorts. Two patients in the antimicrobial cohort (6%) developed a UTI and none of the patients who did not receive antimicrobial prophylaxis developed a UTI (P=0.15). CONCLUSIONS: In our cohort study antimicrobial prophylaxis at the time of cystoscopic stent removal did not appear to provide a significant benefit in UTI prevention. Prospective studies would assist in validating these findings.