Obstructing ureteral calculus causing massive hydronephrosis in a renal allograft.

Nephrolithiasis is a rare complication of renal transplantation. Patients with an obstructing calculus in a renal allograft often lack the usual renal colic symptoms, and therefore present with atypical symptoms. Treatment of obstructing calculi is imperative to prevent renal allograft failure and other complications. We report the case of a 46-year-old man who presented 28 years after renal transplant with renal failure and massive hydronephrosis secondary to an obstructing calculus.

Perceptions and Experiences of Gender Equity Among Endourologists.

Introduction: Only 9.9% of practicing urologists in the United States are women. This percentage is even smaller in leadership positions and high-ranking appointments. Endourology is one of the least reported fellowships completed by women urologists. We sought to evaluate how endourologists perceived the climate for women physicians and compare perceptions and experiences of gender equity. Materials and Methods: An IRB approved and validated survey, Culture Conducive to Women's Academic Success (CCWAS) questionnaire was sent out to the Endourological Society listserve. Subcategories of equal access, work-life balance, freedom of gender bias, and leadership support were analyzed. An open comment section was provided for respondents to include their own experiences. Wilcoxon rank-sum and Kruskal-Wallis tests were used to compare CCWAS scores between groups. Results: A total of 104 completed surveys were received. Response rate was 7% (104/1492), 26.9% of which were female. There was a statistically significant difference between male and female respondent CCWAS scores; p < 0.05. The male CCWAS score median was 196.0 (interquartile range [IQR] 176.75-214.0) vs female CCWAS score median of 166.5 (IQR 127.5-210.0). There was no significant difference in CCWAS scores based on years in practice, parental status, or academic vs private practice. Discussion: In this study, male endourologists' perceptions of gender equity were incongruent with the reported experiences of their female colleagues. This indicates that male respondents perceive the culture in their department toward women more positively than their female colleagues. This is suggestive that there are gender-based differences in how gender inequities are perceived and potentially experienced.

Business and Practice Readiness of Early Career Urologists: an Unmet Need.

INTRODUCTION: Business education in surgical residency, defined as contract negotiation, investing, financial planning and information on practice types, is currently lacking, and it is unknown if early career urologists possess this business education. Thus, we investigated how young urologists perceive their business knowledge and which vehicles of education they most prefer. METHODS: A 12-question survey was distributed to all urology residents, fellows and recent graduates to assess their self-reported business preparedness. Questions were administered concerning financial planning, familiarity with business models, ancillary income opportunities, coding and billing, contract negotiation, and awareness/use of AUA (American Urological Association) resources. Data were stratified by training year and practice type. The respondents were also asked their most preferred format for business education. RESULTS: A response rate of 10% was obtained with 230 total responses, including 89 (38.7%) from practicing urologists and 141 (61.3%) from trainees. The majority (88.3%) of respondents were not comfortable planning the business side of their practice and 71% were not aware of the AUA resources. Only 8% of practicing urologists and trainees were extremely comfortable with contract negotiation and 70% were not comfortable with assessing their own financial value. A majority was interested in podcasts, websites and online education. CONCLUSIONS: The survey results demonstrate a significant unmet need among early career urologists regarding business education. This self-reported lack of business literacy presents a blind spot in urological training. The development of an accessible business curriculum along with practical resources may have a vital role in the promotion of wellness and financial success among early career urologists.

Radiation Mitigation Techniques in Kidney Stone Management.

Patients with nephrolithiasis are exposed to significant quantities of ionizing radiation with the potential to cause secondary malignancy. This risk is magnified by the high recurrence rate of nephrolithiasis. In this article, we identify the risks of ionizing radiation as they pertain to patients with nephrolithiasis. We then identify evidence-based techniques for mitigating patient radiation exposure in the preoperative, intraoperative, and postoperative settings. Key factors include limiting the use of computed tomographic imaging, appropriate modulation of fluoroscopy settings, and minimizing rates of stone recurrence.

Outcomes of Endourologic Interventions in Patients with Preoperative Funguria.

Introduction: Funguria is encountered in 1% to 5% of cultured urine specimens and may be a result of specimen contamination, colonization, or invasive infection. The characteristics and outcomes of patients with funguria undergoing endourologic intervention have not been evaluated. Materials and Methods: Patients with preoperative funguria undergoing endourologic intervention were retrospectively identified. Preoperative funguria was defined as a urine culture containing >10,000 colony forming units of fungus within 30 days of the operative intervention. Univariable and multivariable regression was performed to identify predictors of postoperative systemic inflammatory response syndrome (SIRS). Results: A total of 65 patients with preoperative funguria were identified, of whom 49 (75.4%) underwent ureteroscopy and 16 (24.6%) underwent percutaneous nephrolithotomy. Average patient age was 55.1 ± 18.3 years, body mass index was 31.8 ± 11.0, and Charlson comorbidity index was 2.52 ± 2.0. Twenty-three patients (35.4%) carried a diagnosis of neurogenic bladder, of whom 18 (27.7%) required indwelling or intermittent catheterization. In total 57 patients (87.7%) had been exposed to antibiotics in the 3 months before intervention. Eighteen (27.7%) patients met SIRS criteria postoperatively, of whom 11 (16.9%) required intensive care unit (ICU) admission. Three (4.6%) and two (3.1%) patients developed postoperative fungemia and bacteremia, respectively. All cases of fungemia were caused by Candida glabrata. On univariable analysis, presence of an indwelling catheter (p = 0.009), presence of a known neurological diagnosis (p = 0.02), presence of C. glabrata on preoperative culture (p = 0.04), and longer operative time (p = 0.04) were predictive of development of postoperative SIRS. No significant predictors were identified on multivariable analysis. Conclusions: Patients with preoperative funguria have high rates of comorbid illness, urinary catheterization, and recent exposure to antibiotics. This patient population is at high risk of perioperative infectious complications after endourologic intervention.

Contemporary best practice in the management of staghorn calculi.

Staghorn calculi are complex renal stones that occupy the majority of the renal collecting system. These stones are associated with high morbidity and can lead to recurrent urinary tract infections, urosepsis, renal deterioration, and death if left untreated. Managing patients with staghorn calculi can be challenging. Fortunately, advances in technology and endourology techniques have enabled urologists to effectively treat these stones with minimal morbidity to the patient. This article describes the contemporary best practices in the initial evaluation, management, and follow up of patients with staghorn calculi to help the practicing urologist navigate this complex condition.

Conservative Management of Staghorn Calculi: When Is It Safe?

BACKGROUND: To describe the clinical characteristics, infectious and kidney function patterns, and overall outcomes in a cohort of patients with staghorn calculi treated conservatively. METHODS: Staghorn calculi treated nonoperatively between January 2009 and January 2017 were identified. A retrospective analysis was completed. RESULTS: Twenty-nine patients were identified with a median age of 74 years (interquartile range [IQR] 61-81). Mean follow-up was 24 months. Fifty-nine percent (17/29) had complete staghorn calculi with 6/29 (21%) bilateral. Mean body mass index was 29.4 (IQR 24.8-31.7). Of the 29 patients, 14 were treated conservatively due to comorbidities, 12 refused treatments, and 3 were due to aberrant anatomy. The age-adjusted Charlson Comorbidity Index (CCI) score demonstrated 8 patients in our cohort with a CCI of <3, 11 patients with a CCI of 4 or 5, 7 patients with a CCI of 6 or 7, and 3 patients with a CCI of >8. Overall, kidney function remained stable for 19/29 patients (66%) and the glomerular filtration rate decreased by <10% for 4/29 (14%), by 10%-29% for 2/29 (7%), and >30% for 4/29 patients (14%) over the study period. None of the study patients required hemodialysis. No patients in the cohort developed an abscess, nor were any patients on daily prophylactic antibiotics. There was only one related admission for a complication during the study; this was for pyelonephritis. There were two deaths during the study period. One death was an unrelated cardiac death and the other was from urosepsis; this patient had been noncompliant with follow-up. CONCLUSIONS: Outcomes for patients treated conservatively were reasonable in this select group. There is a need for future prospective studies to show whether conservative treatment of these patients is safe.

Strategies to optimize shock wave lithotripsy outcome: Patient selection and treatment parameters.

Shock wave lithotripsy (SWL) was introduced in 1980, modernizing the treatment of upper urinary tract stones, and quickly became the most commonly utilized technique to treat kidney stones. Over the past 5-10 years, however, use of SWL has been declining because it is not as reliably effective as more modern technology. SWL success rates vary considerably and there is abundant literature predicting outcome based on patient- and stone-specific parameters. Herein we discuss the ways to optimize SWL outcomes by reviewing proper patient selection utilizing stone characteristics and patient features. Stone size, number, location, density, composition, and patient body habitus and renal anatomy are all discussed. We also review the technical parameters during SWL that can be controlled to improve results further, including type of anesthesia, coupling, shock wave rate, focal zones, pressures, and active monitoring. Following these basic principles and selection criteria will help maximize success rate.

Radiation Practice Patterns and Exposure in the High-volume Endourologist.

OBJECTIVE: To define radiation exposure among high-volume endourologists and characterize surgeon exposure patterns as previous literature has focused primarily on patient exposure. METHODS: Surveys were obtained from the Research on Calculus Kinetics Society members from 14 different institutions across North America. All surgeons practice at high-volume academic institutions as surgical stone specialists. Protective equipment, fluoroscopy variables, and practice patterns were recorded. Dosimeter readings from the past year were analyzed when available. RESULTS: Fifteen surveys were returned, with a response rate of 94%. Fluoroscopic procedures comprised 87% of surgeon cases. Surgeon mean experience was 12.4 years (range, 1-32 years). Lead aprons were worn in 99.3% of cases, thyroid shields in 98.7%, radiation glasses in 52.7%, and lead gloves in 9.7%. Only 33.3% of surgeons regularly wore dosimeters. Of these surgeons, average deep-dose equivalent was 816.6 mrem/y. Lens dose equivalent was 1303.4 mrem/y. Shallow-dose equivalent was 1286 mrem/y. CONCLUSION: Endourologists receive moderate radiation exposure, and dosimetry use remains low. As Low As Reasonably Achievable principles should be in place and judiciously followed. Improved monitoring and education should assist with reduction of radiation exposure to both the patient and the endourologist.

Nephrolithiasis and pregnancy: has the incidence been rising?

INTRODUCTION: The incidence of nephrolithiasis has consistently been increasing over recent decades. This has been attributed to diet, obesity, environmental temperature changes, and comorbid diseases such as diabetes. Incidence change has not been studied in the pregnant population. Herein, we report our experience with stone diagnosis in this unique patient population over the past 2 decades. METHODS: Hospital data from a tertiary women's hospital were examined for international classification of diseases, ninth revision (ICD-9) codes for pregnancy (640-648, V22.0, V22.1, V22.2), and urolithiasis (592.0, 592.1, 592.9) between 1991 and 2011. The change in incidence in nephrolithiasis, pregnancy, and the combination of both was examined. RESULTS: In the 21-year period studied, 876 pregnant patients were given a diagnosis of nephrolithiasis at our hospital. Over the same time, 204,034 pregnant patients and 3262 patients with stones were treated. Comparing patients seen from 1991-2000 to those seen from 2001-2011 revealed a significant increase in patients with stones (78 vs. 226/year, p=0.004), but no change in pregnant patients (9467 vs. 9942/year, p=0.3) or pregnant patients with stones (36 vs. 47, p=0.1). Evaluating patients at 5-year intervals confirmed the expected increase in patients with stones, but no change in incidence of nephrolithiasis in pregnant patients was noted. CONCLUSION: There was no change in incidence of nephrolithiasis in pregnant patients over a 2-decade period. Further research is warranted to determine why the pregnant population does not have the expected increase in nephrolithiasis. Larger, multi-institutional studies are needed to validate our results.

Management of urolithiasis in pregnancy.

Kidney stones are very common and unfortunately do not spare the pregnant population. Anatomical and pathophysiological changes occur in the pregnant female that alter the risk for development of nephrolithiasis. Acute renal colic during pregnancy is associated with significant potential risks to both mother and fetus. Diagnosis is often challenging because good imaging options without radiation use are limited. Management of diagnosed nephrolithiasis is unique in the pregnant population and requires multi-disciplinary care. Herein, we review the metabolic alterations during pregnancy that may promote kidney stone formation, the complications associated with acute renal colic in the pregnant state, and our proposed diagnostic and management algorithms when dealing with this clinical scenario.

Novel technique for fragment removal after percutaneous management of large-volume neobladder calculi.

OBJECTIVE: To describe a novel method for fragment evacuation after percutaneous lithotripsy of neobladder calculi. METHODS: The technique was developed using a Urovac bladder evacuator, which was attached to a standard 30F Amplatz working sheath. RESULTS: The attachment of the Urovac evacuator to the Amplatz sheath rapidly evacuated large quantities of stone material. Careful attention should be paid to maintaining low-pressure irrigation by ensuring the bladder is not overly full and the Urovac device is not vigorously manipulated, to minimize the likelihood of bladder injury. CONCLUSION: Percutaneous ultrasonic/hydraulic lithotripsy for large-volume neobladder calculi often results in a substantial burden of stone fragments that can be difficult to clear using standard techniques. Attaching a Urovac bladder evacuator to the 30F Amplatz sheath can simplify the management of this task.

Critical analysis of the miniaturized stone basket: effect on deflection and flow rate.

BACKGROUND AND PURPOSE: As surgical technology continues to advance, stone baskets are becoming increasingly miniaturized. We performed a study to define the effect of miniaturized stone baskets on ureteroscope irrigation flow and deflection. MATERIALS AND METHODS: We compared the three smallest available stone baskets: Boston Scientific 1.3F OptiFlex, Cook 1.5F N-Circle, and Sacred Heart 1.5F Halo, measuring their effect on irrigant flow and deflection of three flexible ureteroscopes. RESULTS: All devices adversely affected irrigation flow and active deflection of all of the ureteroscopes (P<0.05). The 1.3F device, however, exhibited significantly less of an effect on both parameters. Irrigation flow was 28% greater with the 1.3F device than it was for the 1.5F devices. The device's effect on active deflection was 43% less with the 1.3F device than it was for the 1.5F devices. CONCLUSION: Any device placed through the working channel of a ureteroscope will have a deleterious effect on the ureteroscope's irrigant flow and active deflection. As the caliber of the device decreases, however, its effect on these parameters appears to be reduced. Our present data suggest that the 1.3F basket has significantly less of an effect on both the irrigant flow and deflection of a flexible ureteroscope than do the 1.5F devices.

Multicenter analysis of postoperative CT findings after percutaneous nephrolithotomy: defining complication rates.

OBJECTIVES: To perform a multi-institutional study to characterize CT-detected complications after PNL. Computed tomography (CT) is commonly performed after percutaneous nephrolithotomy (PNL). One benefit of this imaging modality is the detection of procedure-related complications. Presently, the incidence of such complications is not well-defined. PATIENTS AND METHODS: PNL procedures performed at 5 stone referral centers between July 2007 and June 2008 were reviewed. All patients undergoing CT within 24 hours after surgery were selected for further analysis. All CT studies were reviewed by a staff radiologist. RESULTS: One-hundred ninety-seven patients satisfied the study inclusion criteria. A body mass index >30 was present in 27.5% of patients. Treated stone burden was staghorn in 70 (35.5%), >2 cm in 72 (36.5%), and <2 cm in 55 (28%). Six treated renal units (3%) were ectopic; 45.4% of calculi were predominantly lower pole. Thoracic complications encountered were atelectasis in 88 (44.7%), pleural effusion in 17 (8.6%), pneumothorax in 3 (1.5%), hemothorax in 2 (1%), and hydrothorax in 1 (0.5%). Renal complications were perinephric hematoma in 15 (7.6%), collecting system perforation in 4 (2%), subcapsular hematoma in 3 (1.5%), urinoma in 2 (1%), and pseudoaneurysm in 1 (0.5%). There was 1 trans-splenic nephrostomy without splenic hematoma. No injuries to hollow viscera were detected. Two patients (1%) were found to have ascites. CONCLUSIONS: Major post-PNL complications detected by CT are uncommon, and when encountered, they are generally amenable to conservative management.

Medical evaluation and management of urolithiasis.

Nephrolithiasis is a highly prevalent condition with a high recurrence rate that has a large impact on the quality of life of those affected. It also poses a great financial burden on society. There have been great advancements in the surgical treatment of stone disease over the past several decades. The evolution of surgical technique appears to have overshadowed the importance of prevention of stone disease despite evidence showing medical therapies significantly decreasing stone recurrence rates. Herein we review the metabolic evaluation of stone formers with the use of specific blood and urine tests. We complete our discussion with a review of the medical management of stone formers providing both general recommendations as well as reviewing focused therapies for specific metabolic abnormalities and medical conditions.

Ureteroscope cleaning and sterilization by the urology operating room team: the effect on repair costs.

BACKGROUND AND PURPOSE: Flexible ureteroscopes are fragile devices, and the costs associated with their repair and replacement can be considerable. Although surgical use can degrade ureteroscope function, the cleaning and sterilization process can also cause great damage. We performed a study to define the effect of having the urology nursing staff process and sterilize all ureteroscopes, rather than the central processing core; the total repair cost and cost per use were analyzed. MATERIALS AND METHODS: From April 2007 to March 2008, all ureteroscopes were processed by the urology nursing staff. We analyzed the average cost per use as a measure of the effectiveness of this strategy. For all endoscopic stone removal cases, a flexible ureteroscope is opened onto the operative field; therefore, after every endoscopic procedure, the flexible ureteroscope needs processing and sterilizing. The number of times each ureteroscope was processed and the type and cost of repairs were recorded. RESULTS: From April 2007 to March 2008, 11 ureteroscopes were processed 478 times; average uses before repair was 28.1. Seven ureteroscopes were returned for repair because of: loss of deflection (2); loss of fiberoptic bundles (2); failed leak test (3). No ureteroscope damage was because of processing. The total repair cost in this 12-month period was $57,664.50. Amortizing repair costs over use gives a value of $120.63 cost per use. CONCLUSIONS: Training the urology nursing staff to clean and sterilize ureteroscopes is a reasonable means to reduce processing-related damages.

The effect of shock wave rate on the outcome of shock wave lithotripsy: a meta-analysis.

PURPOSE: Although experimental evidence suggests that the rate of shock wave delivery can affect the outcome of shock wave lithotripsy, clinical studies produce conflicting results. We performed a systematic review and meta-analysis to define the effect of shock wave rate on the outcome of shock wave lithotripsy. MATERIALS AND METHODS: A search of MEDLINE and EMBASE was performed and all randomized controlled trials comparing SWL treatment at 60 shocks per minute to 120 shocks per minute were included in the analysis. Data from 4 trials (589 patients) were pooled. The primary outcome measure was treatment outcome (success, failure), as defined by the authors of the source studies. The difference in the proportion of patients with a successful treatment outcome was compared between the 60 and 120 shocks per minute groups as a risk difference, and risk differences were pooled across the 4 trials with a fixed effects model. RESULTS: Patients treated at a rate of 60 shocks per minute had a significantly greater likelihood of a successful treatment (risk difference 10.2, 95% CI 3.7-16.8, p = 0.002). CONCLUSIONS: Our meta-analysis suggests that patients treated at a rate of 60 shocks per minute have a significantly greater likelihood of a successful treatment outcome than patients treated at a rate of 120 shocks per minute.