Improved stone quality of life in patients with an obstructing ureteral stone on alpha-blocker medical expulsive therapy.

PURPOSE: Though controversial, alpha blockers are used widely for ureteral stone passage. However, its effects on the patient-reported Quality of life (QOL) is unknown. We compared the QoL of patients on alpha-blocker medical expulsive therapy (MET) to patients not on MET (noMET) utilizing the validated Wisconsin Stone Quality of Life (WISQOL). METHODS: This prospective study included patients prescribed either MET or noMET after presentation with symptomatic, obstructing ureteral stones. The treatment arm was decided at the point of care by the initial treating physician and included analgesia and antiemetics. Tamsulosin (0.4 mg daily) was prescribed for the MET group. The WISQOL survey was administered at baseline, 7-, 14-, 21- and 28-days following discharge from the ED or until stone expulsion. RESULTS: 197 patients were enrolled, of which 116 (59.2%) completed questionnaires for analysis, 91 in the MET group and 25 in noMET. Average ureteral stone size was 4.7 mm (SD 1.8) and 3.1 mm (SD 1.0) for MET and noMET, respectively. Of completed surveys, 105 (90%) were completed at day 7, 67 (57.6%) at day 14, 53 (45.7%) at day 21, and 40 (34.5%) at day 28. MET was associated with improved QoL scores across all WISQOL domains compared to noMET. Stone size, age, race, sex, comorbidity score and a prior stone history were not associated with reduced QoL. CONCLUSIONS: The use of MET was associated with improved QOL on all WISQOL metrics compared to noMET patients. Improved stone QOL may be an indication of alpha-blocker therapy in patients with ureteral stone colic.

Analysis of Ureteral Diameter and Peristalsis in Response to Irrigant Fluid Temperature Changes in an In Vivo Porcine Model.

Objective: It has been previously reported that warming irrigation fluid higher than body temperature may decrease ureteral spasm and thereby facilitate ureteroscopic access to the proximal ureter. Our objective was to examine the effects on ureteral peristalsis and ureteral diameter if the irrigant was warmed to just under the biological threshold for injury. Materials and Methods: Two female adult Yorkshire pigs were studied in this pilot study. In the first pig, a dilute mixture of contrast and irrigation fluid at 37°C and then at 43°C was instilled for 30 minutes into each renal pelvis through a ureteral catheter at 40 mm Hg. Retrograde pyelogram images were captured for each trial and the caliber of the ureter was measured using Vitrea® software. In the second pig, a lumbotomy was performed, and a magnetic sensor was placed on the extraluminal surface of the ureter to monitor ureteral peristalsis while repeating the aforedescribed regimen. Thirty minutes after the first regimen, the force exerted during placement of a 16F ureteral access sheath (UAS) was recorded at both temperatures using the University of California, Irvine Ureteral Force Sensor. Results: There was no statistically significant difference in ureteral caliber along the length of the ureter at 43°C (p = 0.87, p = 0.32, p = 0.66 for proximal, middle, and distal ureter, respectively). Indeed, there was an increase in peristalsis from baseline with fluid irrigation at 37°C and at 43°C (59% and 65%, respectively). There was no significant difference in the force exerted for UAS placement at either temperature. On histologic analysis, there were no significant changes in ureteral histology or luminal diameter. Conclusions: In a porcine model, warming irrigation fluid to just under the biological threshold for injury did not increase ureteral caliber, decrease ureteral peristalsis, or facilitate UAS placement. As such, during ureteroscopy, we continue to warm our irrigation fluid just to body temperature.

Incisional Lumbodorsal Hernias Following Retroperitoneal Robotic Partial Nephrectomies for Small Renal Masses at a High-Volume Tertiary Referral Center.

Introduction: Herein we evaluate the incidence of incisional lumbodorsal hernia (ILDH) after retroperitoneal robotic partial nephrectomy (RRPN) and associated patient-specific and tumor-specific risk factors. Furthermore, we aim to evaluate the role of routine lumbodorsal fascial closure for the prevention of ILDH. Methodology: This is a retrospective review of our robotic partial nephrectomy database of all RRPNs performed at Washington University School of Medicine from 2000 to 2020. Postoperative imaging was reviewed for evidence of ILDH. A clinically significant hernia was defined as the protrusion of visceral organ(s) through the lumbodorsal fascia. Patient and tumor characteristics, and fascial closure techniques were analyzed to determine predictors of ILDH. Results: In total, 150 patients underwent RRPN between 2007 and 2020 with an average follow-up of 4.9 (1-37) months. Twelve (8%) ILDHs were identified. Ten (6.7%) patients had herniated retroperitoneal fat whereas 2 (1.3%) patients had herniated colon. All were asymptomatic and managed conservatively. On matched cohort comparison, patients with ILDH had larger tumors than patients without an incisional hernia (3.9 cm vs 2.8 cm, p = 0.029). In general, patient factors were no different between patients with and without ILDH. However, coronary artery disease (CAD) was more prevalent in patients with ILDH (33.3% vs 10.9%, p = 0.028). Patients with ILDH were more likely to have a port site extended for specimen extraction (66.7% vs 38.2%, p = 0.069). Lumbodorsal fascial closure and type of suture material were not associated with prevention of ILDH (p = 0.545, p = 0.637). Conclusion: The radiographic incidence of lumbar incisional hernias after RRPN without routine fascial closure of the extraction incision was 8%. All were asymptomatic and did not require surgical repair. Larger tumor size and CAD were associated with ILDH.