Outcomes of Holmium Laser Enucleation of the Prostate in the Re-Treatment Setting.

PURPOSE: Holmium laser enucleation of the prostate can also be applied in the re-treatment setting when other benign prostatic hyperplasia therapies fail. We compared outcomes in men who underwent holmium laser enucleation of the prostate in the primary vs the re-treatment setting. MATERIALS AND METHODS: We retrospectively reviewed the records of 2,242 patients who underwent holmium laser enucleation of the prostate at a total of 4 academic hospitals between 2003 and 2015. Patient demographics, and operative and perioperative outcomes were compared between re-treatment and primary holmium laser enucleation of the prostate. RESULTS: Of the 360 of 2,242 men (16%) who underwent re-treatment holmium laser enucleation of the prostate the procedure was done for residual urinary symptoms in 71%. The most common primary procedure was transurethral resection of the prostate in 42% of cases. Mean time between prior benign prostatic hyperplasia surgery and re-treatment was 68 months (range 1 to 444). There were no significant differences in age, prostate size, AUA (American Urological Association) symptom score or average flow rate between the cohorts. Perioperatively, re-treatment holmium laser enucleation of the prostate was associated with significantly shorter operative time, reduced blood loss, lower specimen weight and shorter length of stay. The AUA symptom score improved in both groups, although it remained higher in men who underwent re-treatment (6.5 vs 5.0, p <0.001). The likelihood of clot retention (4.7% vs 1.8%, p = 0.01) and urethral stricture (3.3% vs 1.5%, p = 0.043) was slightly higher in the re-treatment group. CONCLUSIONS: Immediate perioperative outcomes of holmium laser enucleation of the prostate performed in the re-treatment setting were no different from those in the primary setting. While re-treatment was associated with an increased likelihood of clot retention, urethral stricture and higher AUA symptom score, these minimal differences must be considered against the overall favorable symptom improvement across both cohorts.

Comparison of Holmium Laser Prostate Enucleation Outcomes in Patients with or without Preoperative Urinary Retention.

PURPOSE: We determine whether outcomes of holmium laser enucleation of the prostate are similar in patients with and those without preoperative urinary retention. MATERIALS AND METHODS: From May 2008 to July 2014, 231 patients underwent holmium laser prostate enucleation for symptomatic benign prostatic hyperplasia. Retrospective analysis was performed to evaluate for differences in postoperative outcomes for patients with and those without preoperative urinary retention. RESULTS: Overall 95 patients (41%) had urinary retention before holmium laser prostate enucleation while 136 (59%) did not. Mean followup for all patients was 15.3 months. Patients with retention tended to be older, have larger prostates, and have higher scores on the AUA SS and bother questionnaires (all p <0.05). Postoperatively there was no difference in rates of complications, including urinary retention. Both groups showed significant improvement in AUA SS and bother score after the procedure at all postoperative points. Median post-void residual was less than 60 ml and median maximum flow rate on uninstrumented uroflow was greater than 18 ml per second at all postoperative points for all patients regardless of preoperative retention status. No patients required long-term catheterization and rates of postoperative complications did not differ significantly during the followup period. CONCLUSIONS: This study represents the first direct comparison to our knowledge of holmium laser prostate enucleation outcomes in patients with or without urinary retention. There was no increased risk of postoperative urinary retention in patients with preoperative retention, and both groups demonstrated significant postoperative improvement in subjective and objective voiding measures.

Natural History, Complications and Re-Intervention Rates of Asymptomatic Residual Stone Fragments after Ureteroscopy: a Report from the EDGE Research Consortium.

PURPOSE: Fragments 4 mm or smaller after ureteroscopy historically have been considered clinically insignificant but there is a reported 20% event rate on followup even with stones 4 mm or smaller. In this study we examine the natural history, complications and re-intervention rates of fragments after ureteroscopy. MATERIALS AND METHODS: Data from 6 centers were collected retrospectively from members of the Endourology Disease Group for Excellence in 232 patients who had residual fragments after ureteroscopy between 2006 and 2013. Patients with fragment(s) of any size on imaging within 12 months were eligible. The primary outcome measured was stone events, and secondary outcomes included stone growth, stone passage, re-intervention and complications. RESULTS: Of the 232 subjects with fragments 131 (56%) required no further intervention and remained asymptomatic, 34 (15%) experienced complications requiring no intervention and 67 (29%) required intervention, ie the primary outcome stone event rate was 44%. Fragments larger than 4 mm were more likely to grow with time (p <0.001) and were associated with more complications (p=0.039). Fragments larger than 2 mm were more likely to grow (p <0.001) but were not associated with complications or re-intervention. Re-intervention was predictable based on fragment size (p=0.017). In a multivariable logistic regression model there was no significant difference between the techniques of dusting stones or basket extraction. CONCLUSIONS: This study suggests that fragment size larger than 4 mm after ureteroscopy is associated with significantly higher rates of stone growth, complications and the need for re-intervention. Ensuring complete stone-free status is the most effective strategy to reduce stone events after ureteroscopy.

Outcomes of robotic-assisted laparoscopic upper urinary tract reconstruction: 250 consecutive patients.

OBJECTIVE: To evaluate the long-term outcomes of robotic-assisted laparoscopic (RAL) upper urinary tract (UUT) reconstruction performed at a tertiary referral centre. MATERIALS AND METHODS: Data from 250 consecutive patients undergoing RAL UUT reconstruction, including pyeloplasty with or without stone extraction, ureterolysis, uretero-ureterostomy, ureterocalicostomy, ureteropyelostomy, ureteric reimplantation and buccal mucosa graft ureteroplasty, were collected at a tertiary referral centre between March 2003 and December 2013. The primary outcomes were symptomatic and radiographic improvement of obstruction and complication rate. The mean follow-up was 17.1 months. RESULTS: Radiographic and symptomatic success rates ranged from 85% to 100% for each procedure, with a 98% radiographic success rate and 97% symptomatic success rate for the entire series. There were a total of 34 complications, none greater than Clavien grade 3. CONCLUSION: Robotic-assisted laparoscopic UUT can be performed with few complications, with durable long-term success, and is a reasonable alternative to the open procedure in experienced robotic surgeons.

Benign multicystic mesothelioma masquerading as a urachal cyst.

Benign multicystic mesothelioma (BMM) is a benign intra-abdominal lesion that generally occurs in women in their reproductive years. A urachal cyst occurs when the epithelial-lined urachal canal fails to completely obliterate. We report a case of a 38-year-old female presenting with abdominal pain found to have a lesion highly suspicious for a urachal cyst. On pathologic evaluation the lesion was identified as a BMM. This is the first report of BMM presenting as a lesion suspected to be a urachal cyst.

Predictive value of current imaging modalities for the detection of urolithiasis during pregnancy: a multicenter, longitudinal study.

PURPOSE: We determined the optimal imaging study by which to diagnose and treat pregnant patients with suspected urolithiasis. MATERIALS AND METHODS: A retrospective, multicenter study was performed to determine the comparative accuracy of imaging modalities used before the surgical management of suspected urolithiasis in pregnant patients. Patients with a clinical suspicion of urolithiasis were evaluated with directed imaging including renal ultrasound alone, renal ultrasound and low dose computerized tomography, or renal ultrasound and magnetic resonance urography. When indicated, patients underwent therapeutic ureteroscopy. The rate of negative ureteroscopy was determined and the positive predictive values of the imaging modalities were calculated. RESULTS: A total of 51 pregnant patients underwent ureteroscopy. The mean age of the cohort was 27 years. Mean gestational age was 24.4 weeks. Of the women 24 (47%) underwent renal ultrasound and low dose computerized tomography, 22 (43%) underwent ultrasound alone, and 5 (10%) underwent renal ultrasound and magnetic resonance urography. Negative ureteroscopy occurred in 7 of the 51 patients (14%). The rate of negative ureteroscopy among patients who underwent renal ultrasound alone, renal ultrasound and low dose computerized tomography, and renal ultrasound and magnetic resonance urography was 23%, 4.2% and 20%, respectively. The positive predictive value of computerized tomography, magnetic resonance and ultrasound was 95.8%, 80% and 77%, respectively. CONCLUSIONS: The rate of negative ureteroscopy was 14% among pregnant women undergoing intervention in our series. Of the group treated surgically after imaging with ultrasound alone, 23% had no ureteral stone, resulting in the lowest positive predictive value of the modalities used. Alternative imaging techniques, particularly low dose computerized tomography, offer improved diagnostic information that can optimize management and obviate unnecessary intervention.

Near-infrared fluorescence imaging to facilitate super-selective arterial clamping during zero-ischaemia robotic partial nephrectomy.

UNLABELLED: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: There is concern that warm ischaemia time during partial nephrectomy may have an adverse impact on postoperative renal function. As a result, there is increased interest in developing a safe and effective method for performing non-ischaemic partial nephrectomy. Several novel approaches have recently been described. We present our initial experience performing zero-ischaemia partial nephrectomy using near-infrared fluorescence imaging to facilitate super-selective arterial clamping. We report the operative and early postoperative outcomes from such cases as compared with a matched cohort of patients undergoing traditional partial nephrectomy with clamping of the main renal artery. We show that this technique is both safe and effective and may lead to improved renal preservation at short-term follow-up. OBJECTIVE: To describe a novel technique of eliminating renal ischaemia during robotic partial nephrectomy (RPN) using near-infrared fluorescence (NIRF) imaging. PATIENTS AND METHODS: Over an 8-month period (March 2011 to November 2011), 34 patients were considered for zero-ischaemia RPN using the da Vinci NIRF system. Targeted tertiary/higher-order tumour-specific branches were controlled with robotic bulldog(s) or neurosurgical aneurysm micro-bulldog(s). Indocyanine green dye was given, and NIRF imaging used to confirm super-selective ischaemia, defined as darkened tumour/peri-tumour area with green fluorescence of remaining kidney. Matched pair analysis was performed by matching each patient undergoing zero-ischaemia RPN (n = 27) to a previous conventional RPN (n = 27) performed by the same surgeon. RESULTS: Of 34 patients, 27 (79.4%) underwent successful zero-ischaemia RPN; seven (20.6%) required conversion to main renal artery clamping (ischaemia time <30 min) for the following reasons: persistent tumour fluorescence after clamping indicating inadequate tumoral devascularization (n = 5), and parenchymal bleeding during RPN (n = 2). Matched-pair analysis showed comparable outcomes between cohorts, except for longer operating time (256 vs 212 min, P = 0.02) and superior kidney function (reduction of estimated glomerular filtration rate (-1.8% vs -14.9%, P = 0.03) in the zero-ischaemia cohort. All surgical margins were negative. CONCLUSIONS: In this pilot study, we show that zero-ischaemia RPN with NIRF is a safe alternative to conventional RPN with main renal artery clamping. Eliminating global ischaemia may improve functional outcomes at short-term follow-up.

Bladder outlet procedures in the setting of anticoagulation therapy.

PURPOSE OF REVIEW: To assess the safety and bleeding risk in men on chronic oral anticoagulation, including antiplatelet therapies, undergoing bladder outlet procedures for the treatment of benign prostatic hyperplasia (BPH). RECENT FINDINGS: There are conflicting findings; however, most recent series show that when treating bladder outlet obstruction from BPH in patients on chronic anticoagulants, there is an increased risk of hemorrhagic complications for these men. There is also an increased risk of cardiovascular and cerebrovascular complications, especially when antithrombotic therapy is used for secondary prevention and is withdrawn perioperatively. Some have found bipolar electrosurgical vaporization of the prostate, laser vaporization, and enucleation of the prostate to provide superior hemostatic outcomes compared to classic monopolar transurethral resection of the prostate. SUMMARY: Extra caution should always be given to patients on chronic anticoagulation undergoing surgical procedures, given increased risk of bleeding and cardiovascular and cerebrovascular complications. For men with BPH undergoing bladder outlet procedures, photoselective vaporization of the prostate, Holmium laser enucleation of the prostate, and vaporization of the prostate with bipolar electrosurgical instruments may result in less bleeding complications. Further prospective randomized studies are needed to elucidate which methods provide better hemostasis and lower postoperative bleeding to best manage men with BPH on chronic antithrombotic therapy, especially when the anticoagulation therapy cannot be discontinued prior to therapy.

Simplified approach to estimating renal function based on computerized tomography.

INTRODUCTION: To determine whether a simplified approach to estimate renal function based on preoperative computerized tomography (CT) imaging correlates with nuclear renography (NR) following surgical treatment of ureteropelvic junction obstruction (UPJO). MATERIALS AND METHODS: We reviewed the charts of 47 patients who underwent robotic assisted laparoscopic pyeloplasty (RALP) for UPJO who had performed preoperative and postoperative NR and preoperative CT imaging. Twenty patients satisfied our inclusion criteria. We calculated differential renal function by measuring parenchymal thickness at the upper pole, midpole and lower pole regions of the kidney on the preoperative CT. Distances were measured from the edge of the collecting system to the capsule at the midpoint of the kidney in the coronal plane. After parenchymal thickness measurements were calculated bilaterally, a differential parenchymal thickness was obtained, and the ratio of parenchymal area was compared to the observed function on NR. Measurements were taken by three blinded observers and compared to preop and postop differential renal function as measured by NR to assess if preoperative CT renal parenchymal thickness correlates well with differential function of the affected and contralateral kidneys. RESULTS: Estimated renal function was predicted with excellent accuracy and minimal interobserver variability. Pearson correlation coefficients for Observers 1, 2 and 3 were 0.89, 0.88 and 0.91, respectively when compared to the postoperative differential function on NR. The interclass correlation coefficient between the three observers was 0.957, which indicates an almost perfect correlation and reproducibility of the formula. CONCLUSIONS: Estimating differential renal function based on renal parenchymal thickness on preoperative CT imaging correlates very well with observed postoperative differential renal function on NR following RALP.

Obstetric complications of ureteroscopy during pregnancy.

PURPOSE: During pregnancy a ureteral stone and its management may pose risks for the mother and fetus. Definitive ureteroscopic management of an obstructing stone during pregnancy has been increasingly used without a reported increased incidence of urological complications. However, the rate of obstetric complications of ureteroscopy during pregnancy remains undefined. MATERIALS AND METHODS: Charts of pregnant women who had undergone ureteroscopy at 5 tertiary centers were reviewed. Patient and procedure characteristics were collected. Records were evaluated for the occurrence of obstetric complications in the postoperative period. RESULTS: A total of 46 procedures were performed in 45 patients at 5 institutions. There were 2 obstetric complications (4.3%), including 1 preterm labor managed conservatively and 1 preterm labor resulting in preterm delivery. There was no fetal loss. No statistically significant characteristics were identified differentiating those patients having obstetric complications. CONCLUSIONS: Ureteroscopy performed during pregnancy has been previously reported to be urologically safe and effective for addressing ureteral stones. In our multi-institutional series a 4% rate of obstetric complications was observed. Based on this risk a multidisciplinary approach is prudent for the pregnant patient undergoing ureteroscopy.

Comprehensive preoperative evaluation and repair of inguinal hernias at the time of open radical retropubic prostatectomy decreases risk of developing post-prostatectomy hernia.

UNLABELLED: What's known on the subject? and What does the study add? Some studies have evaluated preoperative and intraoperative examination for inguinal hernias and their repair, noting a decrease in the rate of post-prostatectomy hernias. However, this did not eradicate post-prostatectomy hernias, indicating that this method probably missed subclinical hernias. Other studies looked at prophylactic procedures to prevent the formation of inguinal hernias at the time of prostatectomy and showed a decrease in the rate of postoperative hernias. To our knowledge this is the only series evaluating a multi-modal approach with magnetic resonance imaging, ultrasonography and examination to identify all clinical and subclinical hernias and repair them at the time of prostatectomy. This approach only subjects those patients at risk for symptomatic hernias to an additional procedure and decreases the post-prostatectomy hernia rate to <1%. OBJECTIVE: • To assess if a comprehensive evaluation to diagnose clinical and subclinical hernias and repair of these hernias at the time of open radical retropubic prostatectomy (ORRP) decreases the incidence of clinical inguinal hernias (IHs) after ORRP. PATIENTS AND METHODS: • Between 1 July 2007 and 31 July 2010, 281 consecutive men underwent ORRP by a single surgeon. • Of these men, 207 (74%) underwent comprehensive preoperative screening for IH, which included physical examination, upstanding ultrasonography and magnetic resonance imaging. • Between 12 and 24 months after ORRP, 178 (86%) of these men completed a questionnaire designed to capture development of clinical IHs. RESULTS: • Of the 178 evaluable patients, 92 (52%) were diagnosed preoperatively with IH by at least one diagnostic modality. • Forty-one and 51 of the men had bilateral or unilateral IHs, respectively for a total of 133 IHs. • No preoperative factor was significantly associated with the presence of an IH before prostatectomy. • No groin subjected to IH repair (IHR) at the time of ORRP developed a clinical IH compared with four of the 21 patients with postoperative IHs who did not undergo repair of their preoperatively diagnosed IH at the time of ORRP (P= 0.024). • Only one (0.4%) clinical IH developed in a groin that had no evidence of IH by physical examination, upstanding ultrasonography and magnetic resonance imaging before prostatectomy. CONCLUSIONS: • Our comprehensive evaluation increases the detection of IHs before ORRP. • Repair of these IHs at the time of ORRP significantly decreases the risk of developing post-prostatectomy clinical IHs.

Comparison of health-related quality-of-life outcomes for African-American and Caucasian-American men after radical prostatectomy.

UNLABELLED: What's known on the subject? and What does the study add? In addition to a higher prevalence and biological aggressiveness of prostate cancer, African-Americans tend towards narrower pelvises than Caucasians resulting in a potentially more difficult surgical dissection doing radical prostatectomy and increased positive surgical margins. In this study, there was no difference in urinary or sexual HRQL or overall satisfaction between African-Americans and Caucasians 2 years after radical prostatectomy, suggesting that the potential technical challenges of a narrower pelvis do not translate into poorer outcomes for African-Americans. OBJECTIVE: To determine if any differences exist in postoperative health-related quality-of-life (HRQL) outcomes, e.g. erectile function and continence, after radical prostatectomy (RP) in African-American (AA) vs Caucasian-American (CA) men. PATIENTS AND METHODS: Between October 2000 and July 2008, 1338 CA and 56 AA men underwent open RP by a single surgeon and signed informed consent to participate in a prospective longitudinal outcomes study. The American Urological Association Symptom Score (AUA-SS) and University of California, Los Angeles, Prostate Cancer Index (UCLA-PCI) and a global assessment of satisfaction were self-administered at baseline and after RP 24 months. Urinary, sexual, and satisfaction outcomes were compared at 24 months. RESULTS: AA men had significantly higher rates of hypertension and diabetes. There were no other significant baseline differences in age, co-morbidities, body mass index, phosphodiesterase type 5 inhibitor use, preoperative prostate-specific antigen level, AUA-SS, and UCLA-PCI scores. There were no differences in the percentage of men undergoing nerve-sparing procedures, estimated blood loss, transfusion rates, or complication rates between the groups. At 24 months after RP the mean UCLA-PCI urinary and sexual function and bother scores and global satisfaction scores were similar between the groups. CONCLUSION: AA and CA men experience no significant differences in urinary and sexual HRQL or overall satisfaction after open RP when performed by a single experienced surgeon.

Optimizing the detection of subclinical inguinal hernias in men undergoing open radical retropubic prostatectomy.

OBJECTIVE: To evaluate the role of magnetic resonance imaging (MRI) and up-standing ultrasonography (USUS) for the detection of inguinal hernias (IHs) before open radical retropubic prostatectomy (ORRP) and to assess factors associated with the presence of IHs in these men. PATIENTS AND METHODS: From 1 July 2007 to 1 February 2009, 164 men underwent preoperative evaluation for ORRP by one surgeon. Of these men 113 (69%) were evaluated for IHs by physical examination (PE), USUS and MRI. In all 226 groins were examined. Any IH diagnosed by any method was considered a true positive. The sensitivity, negative predictive value (NPV), and concordance were calculated for the three diagnostic methods. Possible predictive factors of IHs were evaluated. RESULTS: Of the 226 groins evaluated, 72 (32%) IHs were diagnosed. USUS had the greatest sensitivity (69.4%) and the highest NPV (87.5%). MRI had fair agreement with PE and USUS, while USUS and PE had moderate agreement with each other. No factor was associated with an increased likelihood of preoperative diagnosis of IH. CONCLUSIONS: This study was limited by the lack of a reference standard to diagnose IH. USUS was the most sensitive method for the detection of IH. We recommend that all men undergoing ORRP should be evaluated for IHs by PE and at least one imaging method and that IHs be repaired at the time of ORRP, obviating the need for a second surgical procedure.

Initial Results from the M-STONE Group: A Multi-Center Collaboration to Study Treatment Outcomes in Nephrolithiasis Evaluation.

Introduction: Despite proven effectiveness of medications in preventing stone recurrence, compliance with pharmacotherapy (PT) is often poor because of cost, side effects, and impact on lifestyle. We sought to compare the risk of stone recurrence between patients managed with conservative therapy (CT) vs PT controlling for aggressiveness of stone disease. Materials and Methods: The Multi-center collaboration to Study Treatment Outcomes in Nephrolithiasis Evaluation (MSTONE) database contains patient data and outcomes from July 2001 to April 2015 across four centers. The database was queried for patients whose stone disease was managed with CT alone (fluid and dietary recommendations) vs PT. Patients were risk stratified according to number of previous passed stones. Within each risk group, we compared CT vs PT with respect to 2-year stone event rate and stone event-free survival (SEFS) using the Kaplan-Meier method. Results: A total of 245 patients, with a median follow-up of 29 months (interquartile range = 16-44), were identified, including 93 on CT and 152 on PT. The overall 2-year stone event rate was 38% for all patients. Stone events at 2 years occurred less frequently in the PT group compared with the CT group (31% vs 44%, p = 0.043), with the difference most pronounced in the high-risk group (71% vs 32% for CT and PT, respectively, p = 0.058). The 30-month SEFS was significantly higher for PT (58%) than CT (46%) overall. When stratified by risk group, 30-month SEFS was statistically significantly higher for PT than CT in the intermediate risk group (65% vs 45% for PT and CT, respectively). Conclusion: Controlling for aggressiveness of stone disease, PT was more effective than CT in reducing and delaying stone-related events. However, CT appeared to be as effective as PT in low-risk patients. PT is best reserved for recurrent stone formers, regardless of metabolic background.

Factors predicting preservation of erectile function in men undergoing open radical retropubic prostatectomy.

PURPOSE: The development of erectile dysfunction represents a major concern for potent men with localized prostate cancer undergoing open radical retropubic prostatectomy. We identified factors predicting the preservation of erectile function in men undergoing open radical retropubic prostatectomy. MATERIALS AND METHODS: Between October 2000 and September 2005 a total of 1,110 men underwent open radical retropubic prostatectomy by a single surgeon. The UCLA-PCI was self-administered at baseline, and at 3, 6, 12 and 24 months postoperatively. The 728 (66%) men who responded that they engaged in sexual intercourse with or without taking phosphodiesterase type 5 inhibitors in the month before surgery and who were not dependent on intracavernous injections, intraurethral suppositories, vacuum devices or penile prostheses were considered potent. Followup was available for 659 men. Of the evaluable men 25 received salvage radiation therapy, adjuvant chemotherapy or hormonal therapy and were excluded from the study. Univariate and multivariate analyses using a logistic regression model were used to identify factors predicting the preservation of potency. RESULTS: Age, coronary artery disease, diabetes mellitus, quality of preoperative erections, frequency of intercourse, hypertension, neurovascular bundle preservation and the use of phosphodiesterase type 5 inhibitors preoperatively predicted the preservation of potency. On multivariate analysis age, no history of diabetes mellitus and nerve sparing were independent predictors of the preservation of potency. CONCLUSIONS: We identified many factors that were predictors of the preservation of potency after open radical retropubic prostatectomy. Only age, no history of diabetes mellitus and neurovascular bundle preservation were independent predictors. These parameters should be considered when counseling surgical candidates so that erectile function expectations are realistic.

Single Session Bilateral Vs Staged Bilateral Ureteroscopy for Nephrolithiasis: An Assessment of Safety and Efficacy.

OBJECTIVE: To compare outcomes of patients undergoing single session bilateral ureteroscopy (SSBU) to those undergoing planned staged ureteroscopy (URS) for bilateral nephrolithiasis. While SSBU has the advantage of 1 anesthetic procedure, some may pursue a staged approach due to the potential higher risk of complications and patient discomfort with 2 ureteral stents. METHODS: We retrospectively identified patients undergoing SSBU and planned staged URS for nephrolithiasis between December 2007 and December 2014. Preoperative characteristics, intraoperative techniques, and postoperative outcomes were compared. Stone burden was calculated as cumulative stone diameter. Residual stone fragments were defined as any stone visible on postoperative imaging. RESULTS: Sixty-three patients underwent SSBU and 37 underwent planned staged URS. Both cohorts had a relatively large cumulative stone burden (30.9 mm vs 32.4 mm, P = .71). Total operative time was significantly longer for planned staged URS (139 vs 86 minutes, P <.0001). There were no significant differences in complications or emergency room visits between the 2 cohorts despite bilateral ureteral stents being placed in the majority of the SSBU cohort (73%). There were no differences in stone-free rates or the need for additional procedures. CONCLUSION: SSBU is safe and effective with overall shorter operative times and similar stone-free rates compared to planned staged URS. Bilateral ureteral stent placement did not increase the rate of unplanned emergency visits. For patients with bilateral nephrolithiasis, urologists should strongly consider SSBU to limit anesthetic exposure, overall operative time, and health care costs.

Renal Papillary Mapping and Quantification of Randall's Plaque in Pediatric Calcium Oxalate Stone Formers.

Introduction: Randall's plaque (RP) with attached stones is recognized as a primary mechanism for stone formation in adult calcium oxalate stone formers (CaOx SFs). The role of RP in pediatric stone pathogenesis is unknown, with no reported studies to date. The purpose of this study is to investigate renal papillary abnormalities and quantify RP in pediatric CaOx SFs. Methods: Eight pediatric CaOx SFs underwent ureteroscopy for symptomatic urolithiasis. The collecting system was mapped using a digital ureteroscope. Video for each patient was then reviewed using a retrograde pyelogram to confirm the location of each papilla. A single investigator (N.L.M.) reviewed the video to quantify RP. Each papilla was graded as having mild, moderate, or severe amount of RP. Patient history was recorded. Results: An average of nine papillae were mapped per patient. RP was present in 100% of patients and in 88.8% (64/72) of all papillae examined. When present, RP was uniformly distributed throughout the kidney without preferential distribution to a region or pole. The amount of RP on the papillae was graded as mild in 60%, moderate in 20.8%, and severe in 8.3%. The mean fractional RP coverage ranged from 0.39% to 9.34%. No correlation was found between the amount of plaque and age at first stone episode or number of prior stone episodes (p = 0.84). Attached stones were rare (1/8 patients). The two patients with severe RP had a small amount of calcium phosphate in their stone analysis. Conclusions: RP is common in pediatric CaOx SFs. Compared with adult CaOx SFs wherein up to 75% of stones are found attached to RP, attached stones were rare. The significance of these findings in the pathogenesis of pediatric stone formation remains unclear and will require longer term follow-up.

A Decision Analysis of Observation vs Immediate Reintervention for Asymptomatic Residual Fragments Less than 4 mm Following Ureteroscopic Lithotripsy.

INTRODUCTION: We performed a decision analysis model of the cost-effectiveness of observation vs intervention for asymptomatic residual fragments less than 4 mm in diameter following ureteroscopic holmium laser lithotripsy. METHODS: Outcomes data from a retrospective analysis evaluating the natural history, complications and reintervention rates of asymptomatic residual stone fragments performed by the EDGE (Endourology Disease Group for Excellence) Research Consortium were used. A decision analysis model was constructed to compare the cost-effectiveness of initial observation of residual fragments to immediate intervention. Cost of observation included emergency room visits, hospitalizations and reinterventions. The cost analysis model extended to 3 years to account for delayed reintervention rates for fragments less than 4 mm. Costs of emergency department visits, readmissions and reinterventions were calculated based on published figures from the literature. RESULTS: Decision analysis modeling demonstrated that when comparing initial observation to immediate reintervention, the cost was $2,183 vs $4,424. The difference in cost was largely driven by the fact that over 3 years, approximately 55% of all patients remained asymptomatic and did not incur additional costs. This represents an approximate annual per patient savings of $747, and $2,241 over 3 years when observation is selected over immediate reintervention. CONCLUSIONS: Our decision analysis model demonstrates superior cost-effectiveness for observation over immediate reintervention for asymptomatic residual stones less than 4 mm following ureteroscopic lithotripsy. Based on these findings careful stratification and selection of patients may enable surgeons to improve cost-effectiveness of managing small, asymptomatic residual fragments following ureteroscopic lithotripsy.

Does a nerve-sparing technique or potency affect continence after open radical retropubic prostatectomy?

OBJECTIVE: To characterize the effect of preserving the neurovascular bundle (NVB) and of potency on urinary continence after open radical retropubic prostatectomy (ORRP). PATIENTS AND METHODS: Between October 2000 to September 2005, 1110 consecutive continent men had ORRP by one surgeon. The University of California Los Angeles Prostate Cancer Index was self-administered at baseline and 3, 6, 12, and 24 months after ORRP. Men were considered continent if they responded that they had total urinary control or had occasional urinary leakage. Men were considered potent if they engaged in sexual intercourse with or without the use of phosphodiesterase inhibitors at least once in the month before or after ORRP. Of the 1110 men, 728 (66%) were potent and continent at baseline. Men undergoing adjuvant hormonal therapy, radiation therapy or chemotherapy were excluded. The potency status was evaluated in 610 men at 24 months after ORRP, and the number of NVBs preserved was recorded at the time of ORRP. RESULTS: Of men who were potent at baseline and had bilateral vs unilateral nerve sparing, 96% and 99% were continent at 24 months, respectively (P = 0.50). Of the men who were potent and impotent at 24 months, 98% and 96% were continent at 24 months, respectively (P = 0.25). Continence did not depend on whether men regained potency or whether they had a bilateral or a unilateral nerve-sparing procedure. CONCLUSION: Our observation that only 60% of men undergoing bilateral nerve-sparing ORRP regain potency suggests that the NVBs are often inadvertently injured, despite efforts to preserve them. We feel that potency status is the best indicator of the true extent of NVB preservation. That men undergoing bilateral vs unilateral nerve-sparing procedures, and that potent vs impotent men at 24 months have similar continence rates, provides compelling evidence that nerve-sparing is not associated with better continence. Based on these findings, NVBs should not be preserved in men with baseline erectile dysfunction, with the expectation of improving continence.

Ureteral Stone Diameter on Computerized Tomography Coronal Reconstructions Is Clinically Important and Under-reported.

OBJECTIVE: To compare the maximum stone diameter of ureteral stones in the coronal plane to that of stones in the axial plane and to determine the clinical significance of the coronal diameter. MATERIALS AND METHODS: A retrospective chart review was performed on patients seen in the clinic between September 2013 and November 2015. Patients were included if they had a history of ureteral stone noted on computerized tomography (CT) performed with coronal reconstructions. Patients were excluded if they had multiple ureteral stones, a history of upper urinary tract abnormalities, a need for urgent intervention, or no follow-up. Management of the ureteral stone and pertinent medical history related to patients' stone disease, including stone diameter on axial and coronal CT imaging, were captured. Multivariate regression was performed to identify predictive factors for stone passage. RESULTS: A total of 150 patients met inclusion criteria. Fifty-four patients spontaneously passed stones and 96 required surgery. The reading radiologist reported the stone measurement in the coronal dimension in 17% of the cases. In 75% of the cases, the coronal diameter was larger than the axial diameter by an average of 1.2 mm. On univariate analysis, stone passage was associated with axial diameter (P <.001), coronal diameter (P <.001), stone location (P = .001), age (P <.001), and medical expulsive therapy (P = .008). On multivariate analysis, only coronal diameter (P <.001), stone location (P = .01), and age (P = .03) remained significant factors associated with spontaneous passage. CONCLUSION: In the current series, only stone size as measured in the coronal diameter was associated with stone passage vs need for surgical intervention on multivariate analysis. We strongly recommend obtaining coronal reconstructions when CT is performed for ureteral stone to guide management decisions and appropriately counsel patients on the probability of stone passage.