The Effect of Pre-Stenting on Bleeding-Related Complications Following Ureteroscopy in Patients on Anticoagulation or Antiplatelet Therapy.

Introduction: The American Urological Association guidelines state that continuing anticoagulant (AC) and antiplatelet (AP) agents during ureteroscopy (URS) is safe. Through a multi-institutional retrospective study, we sought to determine whether pre-stenting in patients on AP or AC was associated with fewer URS bleeding-related complications. Methods: A series of 8614 URS procedures performed across three institutions (April 2010 to September 2017) was electronically reviewed for AC/AP use at time of URS. Records indicating AC or AP use at time of URS were then manually reviewed to characterize intraoperative and 30-day postoperative (intraoperative bleeding, postoperative hematuria, emergency department visits, hospital readmission, unplanned reoperation, phone calls, and other minor 30-day complications). Results: A total of 293 identified URS procedures were completed on patients on AC/AP therapy-112 cases were on AC only (38 were pre-stented), 158 on AP only (51 pre-stented), and 23 on both AP and AC (8 pre-stented). Patient characteristics and comorbidities were similar between the pre-stented and non-pre-stented groups. For AC and AP subjects, pre-stenting did not decrease the composite risk of bleeding complications (10.3% pre-stent vs 12.2% non-prestent, p = 0.6). Pre-stented patients did have a significantly lower likelihood of requiring an unplanned reoperation (1.0% vs 5.6%, p = 0.04). In the subgroup of patients on AP alone, pre-stented patients had significantly fewer episodes of intraoperative bleeding (0% vs 9%, p = 0.04), unplanned reoperations (0% vs 6.5%, p = 0.02), and 30-day complications (14% vs 27%, p = 0.05). In the subgroup of patients on AC alone, there were no significant differences in outcomes based on stent status. Conclusions: In this multi-institutional study, we found that pre-stenting before URS was not associated with fewer bleeding complications. However, pre-stenting appeared to be associated with improved outcomes for those patients on AP therapy. These results suggest a need for prospective studies to clarify the role of pre-stenting for URS.

Minimally Invasive Percutaneous Nephrolithotomy: Initial North American Experience.

Introduction and Objectives: The goal of this study is to evaluate the outcomes in a cohort of patients who underwent minimally invasive percutaneous nephrolithotomy (MIP) at a single institution from 2017 to 2019. Methods: Sixty patients at a single institution with two different surgeons underwent MIP from 2017 to 2019. The MIP technique uses a proprietary nephroscope with a "vacuum" technique for stone evacuation. Patients were identified who had postoperative CT scan imaging available for direct review. A prospectively maintained database was queried along with retrospective chart review to evaluate the stone-free rate defined as no stones on CT imaging. Preoperative, intraoperative, and postoperative variables were analyzed including initial stone size, access type (fluoroscopic vs ultrasonic), access location, operative positioning (supine vs prone), operative time, and 60-day complications. Results: Forty-six of 60 patients had CT imaging postoperatively that were reviewable. Of these, 43% (n = 20) were stone free as defined by no identifiable fragments seen, 11% (n = 5) had residual fragments 0 to 2 mm, 7% (n = 3) had residual fragments 2 to 4 mm, and 39% (n = 18) had residual fragments >4 mm. Mean initial stone size was 21 mm (1.9-84 mm). Sixty percent (n = 28) of the patients were discharged the same day as surgery. Fifty-one percent (n = 24) of access was achieved through ultrasound alone. Seventeen percent of patients (n = 8) had a complication within 30 days of surgery. All complications were Clavien III or lower with unplanned return to operating room rate of 2% (n = 1). Conclusions: We present North America's first single institution analysis of MIP cases with acceptable outcomes comparable with both retrograde intrarenal surgery and standard percutaneous nephrolithotomy. The exact role of MIP in renal stone disease needs to be determined by future studies that critically assess their outcomes.

Nephrostomy tubes placed emergently prior to percutaneous renal stone surgery are practical for obtaining access. / La colocación de nefrostomía percutánea antes de la cirugía percutánea de la litiasis facilita la obtención del acceso.

OBJECTIVES: Renal access in percutaneous nephrolithotomy (PCNL) may be obtained via a pre-existing nephrostomy tube (NT) tract; however, emergent NTs are not always ideal for subsequent surgery. We sought to determine the rate of NT tract usability and assess factors related to the usability of emergently placed NTs. METHODS: A retrospective review was performed of UC San Diego subjects undergoing percutaneous renal surgery between January 2016 and October 2018. Demographics and peri-operative variables were collected. The primary outcome was the usability of NT tract for dilation and instrumentation. "Usable" indicated a tract in which PCNL could be completed; "unusable" indicated lack of dilation and the requirement of additional tract(s) for PCNL. RESULTS: 35 PCNL cases had previous emergently placed NT which were indwelling at time of percutaneous surgery. 51% of these NT tracts (18/35) were deemed usable and dilated for PCNL. No significant difference was seen between usable and unusable NT groups for number of dilated tracts during PCNL (p=0.13), or either the location of indwelling NT (p=0.96) or renal stones (p=0.95). In the usable NT tract cohort PCNL access was via the lower pole 56% of the time, where as when previous NT tracts were deemed unusable, a separate upper-pole access was obtained intra-operatively 53% of the time (p<0.01). CONCLUSIONS: Pre-existing, emergent NTs served a ssufficient PCNL access tracts in over half of recorded cases. Contrary to recently published reports, the utility of pre-existing NTs appears to vary among health systems. Other variables, including the desired location of PCNL appear to directly influence the like lihood of NT tract usability.

OBJETIVOS: El acceso renal en la nefrolitotomía percutánea puede obtenerse a través de una nefrostomía pre-existente, aunque las nefrostomías urgentes no siempre son ideales para la posterior cirugía. Nosotros intentamos determinar la tasa de uso del tracto de nefrostomía y los factores de acceso relacionados con el uso de la nefrostomía urgente.MÉTODOS: Una revisión retrospectiva se realizó en UC San Diego de los pacientes que habían recibido cirugía renal percutánea entre enero 2016 y octubre 2018. Las variables demográficas y perioperatorias fueron recolectadas. El objetivo primario fue el uso del trayecto de nefrostomía después de dilatación e instrumentación.¨Usable"  indicó un trayecto en el que la nefrolitotomía percutánea se completo. "No usable" indicó falta de dilatación y el requerimiento de un nuevo trayecto para la cirugía percutánea. RESULTADOS: 35 casos de nefrolitotomía percutánea tenían nefrostomías urgentes previamente y presentes al empezar la cirugía. 51% de estos trayectos (18/35) fueron usados y dilatados para la nefrolitotomía percutánea. No hubo diferencias significativas entre los trayectos usables y no usables en el numero de trayectos dilatados durante la cirugía percutánea (p=0,13), ni en la localización de la sonda de nefrostomía (p=0,96) o las litiasis renales (p=0,95). En el grupo de pacientes con nefrostomía usable, en el 56% la nefrostomía accedía por el polo inferior. Cuando el trayecto de nefrostomía se considero no usable, un nuevo acceso intraoperatorio por el polo superior fue obtenido en el 53% de lo scasos (p<0,01). CONCLUSIONES: El trayecto de nefrostomía pre-existente fue suficiente para el acceso percutáneo en la mitad de los casos. Contrario a lo publicado recientemente, la utilidad de la nefrostomía pre-existente parece variar según el Sistema sanitario. Otras variables, incluyendo la localización deseada para la nefrostomía influencia el uso del trayecto.

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.