The impact of kidney stone disease on quality of life in high-risk stone formers.

OBJECTIVE: To assess the impact of kidney stone disease (KSD) and its treatment on the health-related quality of life (HRQOL) of high-risk stone formers with hyperparathyroidism, renal tubular acidosis, malabsorptive disease, and medullary sponge kidney. PATIENTS AND METHODS: The Wisconsin Stone Quality of Life questionnaire was used to evaluate HRQOL in 3301 patients with a history of KSD from 16 institutions in North America between 2014 and 2020. Baseline characteristics and medical history were collected from patients, while active KSD was confirmed through radiological imaging. The high-risk group was compared to the remaining patients (control group) using the Wilcoxon rank-sum test. RESULTS: Of 1499 patients with active KSD included in the study, the high-risk group included 120 patients. The high-risk group had significantly lower HRQOL scores compared to the control group (P < 0.01). In the multivariable analyses, medullary sponge kidney disease and renal tubular acidosis were independent predictors of poorer HRQOL, while alkali therapy was an independent predictor of better HRQOL (all P < 0.01). CONCLUSIONS: Among patients with active KSD, high-risk stone formers had impaired HRQOL with medullary sponge kidney disease and renal tubular acidosis being independent predictors of poorer HRQOL. Clinicians should seek to identify these patients earlier as they would benefit from prompt treatment and prevention.

A Nuclear Magnetic Resonance (NMR)- and Mass Spectrometry (MS)-Based Saturation Kinetics Model of a Bryophyllum pinnatum Decoction as a Treatment for Kidney Stones.

Bryophyllum pinnatum (BP) is a medicinal plant used to treat many conditions when taken as a leaf juice, leaves in capsules, as an ethanolic extract, and as herbal tea. These preparations have been chemically analyzed except for decoctions derived from boiled green leaves. In preparation for a clinical trial to validate BP tea as a treatment for kidney stones, we used NMR and MS analyses to characterize the saturation kinetics of the release of metabolites. During boiling of the leaves, (a) the pH decreased to 4.8 within 14 min and then stabilized; (b) regarding organic acids, citric and malic acid were released with maximum release time (tmax) = 35 min; (c) for glycoflavonoids, quercetin 3-O-α-L-arabinopyranosyl-(1 → 2)-α-L-rhamnopyranoside (Q-3O-ArRh), myricetin 3-O-α-L-arabinopyranosyl-(1 → 2)-α-L-rhamnopyranoside (M-3O-ArRh), kappinatoside, myricitrin, and quercitrin were released with tmax = 5-10 min; and (d) the total phenolic content (TPC) and the total antioxidant capacity (TAC) reached a tmax at 55 min and 61 min, respectively. In summary, 24 g of leaves boiled in 250 mL of water for 61 min ensures a maximal release of key water-soluble metabolites, including organic acids and flavonoids. These metabolites are beneficial for treating kidney stones because they target oxidative stress and inflammation and inhibit stone formation.

Radical nephroureterectomy for UTUC conferred survival benefits irrespective of age and comorbidities.

PURPOSE: We investigated the effects of age, American Society of Anesthesiologists Physical Status Classification (ASA) grading and Charlson Comorbidity Index (CCI) on the survival outcomes of upper tract urothelial carcinoma (UTUC). METHODS: The CROES-UTUC registry was an international, multicenter study on patients with UTUC. Primary outcomes were overall survival (OS) and disease-free survival (DFS). Kaplan-Meier and multivariate Cox regression analyses were performed by stratifying patients according to their age (≤ 70 and > 70 years old) and ASA grade (I-II and III-V)/CCI (0-1 and ≥ 2). RESULTS: A total of 2352 patients were included in this study. Patients aged ≤ 70 years with ASA grading of I-II (p = 0.002), and patients aged ≤ 70 years with a CCI of 0-1 (p = 0.002) had the best OS. Upon multivariate analysis, both in patients aged ≤ 70 and > 70 years, ASA grading and CCI were not significantly associated with OS. Patients aged ≤ 70 years with ASA grading of III-IV (p = 0.024) had the best DFS. When stratified according to age and CCI, no significant difference in DFS was noted. Upon multivariate analysis, radical nephroureterectomy (RNU) was significantly associated with better DFS in patients aged ≤ 70 and > 70 years; CCI of ≥ 3 was significantly associated with worse DFS in patients ≤ 70 years; ASA grading was not associated with DFS in patients aged ≤ 70 and > 70 years. CONCLUSIONS: A high ASA grading and CCI should not be considered contraindications for RNU. RNU should be considered even in elderly patients when it is deemed feasible and achievable after a geriatric assessment.

Estimating the health-related quality of life of kidney stone patients: initial results from the Wisconsin Stone Quality of Life Machine-Learning Algorithm (WISQOL-MLA).

OBJECTIVE: To build the Wisconsin Stone Quality of Life Machine-Learning Algorithm (WISQOL-MLA) to predict urolithiasis patients' health-related quality of life (HRQoL) based on demographic, symptomatic and clinical data collected for the validation of the Wisconsin Stone Quality-of-Life (WISQOL) questionnaire, an HRQoL measurement tool designed specifically for patients with kidney stones. MATERIAL AND METHODS: We used data from 3206 stone patients from 16 centres. We used gradient-boosting and deep-learning models to predict HRQoL scores. We also stratified HRQoL scores by quintile. The dataset was split using a standard 70%/10%/20% training/validation/testing ratio. Regression performance was evaluated using Pearson's correlation. Classification was evaluated with an area under the receiver-operating characteristic curve (AUROC). RESULTS: Gradient boosting obtained a test correlation of 0.62. Deep learning obtained a correlation of 0.59. Multivariate regression achieved a correlation of 0.44. Quintile stratification of all patients in the WISQOL dataset obtained an average test AUROC of 0.70 for the five classes. The model performed best in identifying the lowest (0.79) and highest quintiles (0.83) of HRQoL. Feature importance analysis showed that the model weighs in clinically relevant factors to estimate HRQoL, such as symptomatic status, body mass index and age. CONCLUSIONS: Harnessing the power of the WISQOL questionnaire, our initial results indicate that the WISQOL-MLA can adequately predict a stone patient's HRQoL from readily available clinical information. The algorithm adequately relies on relevant clinical factors to make its HRQoL predictions. Future improvements to the model are needed for direct clinical applications.

Temporal Effects of Quercetin on Tight Junction Barrier Properties and Claudin Expression and Localization in MDCK II Cells.

: Kidney stones affect 10% of the population. Yet, there is relatively little known about how they form or how to prevent and treat them. The claudin family of tight junction proteins has been linked to the formation of kidney stones. The flavonoid quercetin has been shown to prevent kidney stone formation and to modify claudin expression in different models. Here we investigate the effect of quercetin on claudin expression and localization in MDCK II cells, a cation-selective cell line, derived from the proximal tubule. For this study, we focused our analyses on claudin family members that confer different tight junction properties: barrier-sealing (Cldn1, -3, and -7), cation-selective (Cldn2) or anion-selective (Cldn4). Our data revealed that quercetin's effects on the expression and localization of different claudins over time corresponded with changes in transepithelial resistance, which was measured continuously throughout the treatment. In addition, these effects appear to be independent of PI3K/AKT signaling, one of the pathways that is known to act downstream of quercetin. In conclusion, our data suggest that quercetin's effects on claudins result in a tighter epithelial barrier, which may reduce the reabsorption of sodium, calcium and water, thereby preventing the formation of a kidney stone.

Teaching and evaluation of basic urodynamic skills in urology residency programs: Randomized controlled study.

AIMS: Considering the growing role of urodynamic studies (UDS) in urology, we aimed to determine the most effective teaching method with objective evaluation for urodynamic skills, to improve training and patient care. METHODS: Urology residents (n = 20) post-graduate years 3-5 were randomized to receive either a UDS video training module or a standard UDS teaching document one week prior to an objective structured clinical examination (OSCE). The OSCE was a validated visual recognition exam with interpretation of 12 UDS tracing scenarios. Participants rated their proficiency to interpret UDS tracings before doing the OSCE. Total interpretation score was determined by the accuracy of their response to each question ranging from 0 to 2. RESULTS: The mean total interpretation score was 13.3 of 24 (55%). The video group achieved significantly higher interpretation scores (15.1 ± 2.08 vs 11.4 ± 2.41, P = 0.0017), and cumulative certainty scores (P = 0.0341). Overall interpretation scores significantly correlated with self-reported proficiency scores prior to the exam (r = 0.502, P < 0.05), and total certainty scores (r = 0.531, P < 0.05). CONCLUSIONS: Reviewing a UDS video training module resulted in significantly better scores on objective assessment of urology residents' UDS interpretation skills when compared with a standard teaching document. These findings must be interpreted with caution in light of sample size and short knowledge retention required for the assessment within a week. Therefore, using a UDS video training module could be more effective review tool for urology residents. These findings highlight the need to incorporate multimedia teaching into urology training curriculum.

Basic Laparoscopic Skills Assessment Study: Validation and Standard Setting among Canadian Urology Trainees.

PURPOSE: As urology training programs move to a competency based medical education model, iterative assessments with objective standards will be required. To develop a valid set of technical skills standards we initiated a national skills assessment study focusing initially on laparoscopic skills. MATERIALS AND METHODS: Between February 2014 and March 2016 the basic laparoscopic skill of Canadian urology trainees and attending urologists was assessed using 4 standardized tasks from the AUA (American Urological Association) BLUS (Basic Laparoscopic Urological Surgery) curriculum, including peg transfer, pattern cutting, suturing and knot tying, and vascular clip applying. All performances were video recorded and assessed using 3 methods, including time and error based scoring, expert global rating scores and C-SATS (Crowd-Sourced Assessments of Technical Skill Global Rating Scale), a novel, crowd sourced assessment platform. Different methods of standard setting were used to develop pass-fail cut points. RESULTS: Six attending urologists and 99 trainees completed testing. Reported laparoscopic experience and training level correlated with performance (p <0.01). Attending urologists were significantly better than trainees (p <0.05), demonstrating construct validity evidence for the 4 AUA BLUS tasks. The C-SATS method of assessment correlated well with the traditional methods of time and error based scoring, and the global rating scale. We were able to use relative and absolute standard setting methods to define pass-fail cut points for all 4 AUA BLUS tasks. CONCLUSIONS: The 4 AUA BLUS tasks demonstrated good construct validity evidence for use in assessing basic laparoscopic skill. Performance scores using the novel C-SATS platform correlated well with traditional time-consuming methods of assessment. Various standard setting methods were used to develop pass-fail cut points for educators to use when making formative and summative assessments of basic laparoscopic skill.

Urolithiasis: evaluation, dietary factors, and medical management: an update of the 2014 SIU-ICUD international consultation on stone disease.

PURPOSE: The aim of this review was to provide current best evidence for evaluation, dietary, and medical management of patients with urolithiasis. METHODS: Literature addressing evaluation, dietary, and medical management of urolithiasis was searched. Papers were analyzed and rated according to level of evidence (LOE), whereupon a synthesis of the evidence was made. Grade of recommendation (GOR) was judged from individual clinical experience and knowledge of the evidence according to the Oxford Centre for Evidence-based Medicine. RESULTS: It is obvious that different stone diseases influence the life of stone-forming individuals very differently, and that evaluation and medical management should be personalized according to risk of recurrence, severity of stone disease, presence of associated medical conditions, and patient's motivation. With regard to evaluation, dietary and medical management of patients with urolithiasis evidence from the literature suggest that selective metabolic evaluation may lead to rational dietary and medical management. Statements based on LOE and GOR are provided to guide clinical practice. CONCLUSION: The provided evidence for evaluation of patients with urolithiasis aims at defining patients at high risk for recurrent/complicated stone disease. Based on this approach, evidence-based dietary and medical management regimes are suggested.

Lifetime Radiation Exposure in Patients with Recurrent Nephrolithiasis.

Patients presenting with nephrolithiasis often undergo repeated imaging studies before, during, and after management. Considering the significant risk of stone recurrence in primary stone-formers, repeated imaging studies are not uncommon. Cumulative effects of ionizing radiation exposure from various imaging studies could potentially increase the risk for developing cataracts and solid malignancies in urolithiasis patients. Therefore, practitioners planning or performing imaging studies with ionizing radiation are compelled to keep radiation exposure to humans and the environment as low as possible, thus strictly adhering to the ALARA (As Low as Reasonably Achievable) principles. This chapter will review the latest literature on lifetime radiation exposure of nephrolithiasis patients and present the latest recommendations in minimizing radiation exposure to them pre-, intra-, and postoperatively. For patients presenting with acute renal colic, especially those with body mass index of < 30, low-dose noncontrast computed tomography is the current gold standard of imaging. Patients with opaque stones are followed with ultrasonography (US) and plain radiography (kidney, ureter, and bladder or KUB). Intraoperatively, pulsed fluoroscopy could be used to significantly reduce radiation during ureteroscopy and percutaneous nephrolithotomy. Immediately postoperatively and in the long term, US and KUB could be used to follow up patients with nephrolithiasis. Only symptomatic patients suspected of ureteral stricture should obtain tri-phasic CT urography. Following these latest imaging guidelines from the American Urological Association will dramatically reduce lifetime radiation exposure to patients with nephrolithiasis.

Is there a place for virtual reality simulators in assessment of competency in percutaneous renal access?

OBJECTIVE: To assess competency of urology post-graduate trainees (PGTs) in percutaneous renal access (PCA). METHODS: Upon obtaining ethics approval and informed consents, PGTs between post-graduate years (PGY-3 to PGY-5) from all four urology programs in Québec were recruited. PCA competency of each participant was assessed objectively by performing task 4 on the PERC Mentor™ simulator, where they had to correctly access and pop 7 balloons in 7 different renal calyces and subjectively by the validated Percutaneous Nephrolithotomy-Global Rating Scale (PCNL-GRS). RESULTS: A total of 26 PGTs with a mean age of 29.2 ± 0.7 years participated in this study. When compared with the 21 PGTs without practice, all 5 PGTs who had practiced on the simulator were competent (p = 0.03), performed the task with significantly shorter operative time (13.9 ± 0.7 vs. 4.4 ± 0.4 min; p < 0.001) and fluoroscopy time (9.3 ± 0.6 vs. 3.4 ± 0.4 min; p < 0.001), and had significantly higher PCNL-GRS scores (13 ± 0.6 vs. 20.6 ± 1; p < 0.001) and successful attempts to access renal calyces (23 ± 5 vs. 68.7 ± 11; p = 0.001). According to a pass score of 13/25, thirteen PGTs were competent. Competent PGTs performed the task with significantly shorter fluoroscopy time (9.8 vs. 6.5 min; p = 0.01) and higher percentage of successful attempts to access renal calyces (p < 0.001), higher PCNL-GRS scores (p < 0.001), and lower complications (p = 0.01). CONCLUSION: The PCNL-GRS in combination with the PERC Mentor™ simulator was able to differentiate between competent and non-competent PGTs.

Pyelocystostomy for treatment of recurrent nephrolithiasis and ureteropelvic junction obstruction in a pelvic kidney.

Patients with pelvic kidneys are at an increased risk of developing ureteropelvic junction obstruction (UPJO) and nephrolithiasis with limited endourologic options. A 54-year-old man with a left pelvic kidney, recurrent nephrolithiasis, and 12 previous ureteroscopies presented with left UPJO and lower pole calyceal stones. After two failed ureteroscopic attempts, an open pyelolithotomy and pyelocystostomy were performed. After 30 months, he continues to be asymptomatic without recurrence of nephrolithiasis. This constitutes the fifth such reported case. Therefore, pyelocystotomy is a good option for patients with pelvic kidneys, UPJO and recurrent nephrolithiasis refractory to endourologic procedures.

Incorporation of the da Vinci Surgical Skills Simulator at urology Objective Structured Clinical Examinations (OSCEs): a pilot study.

INTRODUCTION: To incorporate the da Vinci Surgical Skills Simulator (dVSSS) into Objective Structured Clinical Examinations (OSCEs) and to assess basic robotic skills of urology Post-Graduate Trainees (PGTs). MATERIALS AND METHODS: PGTs in post-graduate years (PGY-3 to PGY-5) from two Quebec urology training programs were recruited. During a 20 minute OSCE station, PGTs were asked to fill in a questionnaire and perform two tasks: pick and place, and energy dissection level 1. For each exercise, the norm-referenced method was used to establish a passing score to determine competency. The participant was considered competent in these two basic dVSSS exercises if he/she gained the passing score on both tasks. RESULTS: All nine PGTs who attended the OSCE voluntarily participated in the study. They had performed a median of 10 (IQR: 2.5-16) laparoscopic procedures, 2 (0-8) robotic procedures, and assisted 10 (IQR: 0-15) robotic procedures at the bedside prior to this OSCE. Based on a passing score of 90 for task 1 and 72 for task 2, there were 3 (33%) competent PGTs, all of whom were from PGY-5 level. Therefore, there was significant difference among PGY levels in terms of competency for the basic robotic skills tested (p = 0.01). When compared with PGTs, experts had performed significantly higher numbers of robotic procedures (5.2 +/- 2.4 versus 25 +/- 8.7; p = 0.02). However, there was no significant difference in the performance parameters between PGTs and experts in both tasks. CONCLUSION: This study confirms the feasibility of incorporating dVSSS into OSCEs to assess basic robotic skills of urology PGTs. Future studies need to include more complex exercises and larger sample size to expand on these results.

Which is better? Guy's versus S.T.O.N.E. nephrolithometry scoring systems in predicting stone-free status post-percutaneous nephrolithotomy.

INTRODUCTION AND OBJECTIVE: The aim of the present study was to compare the accuracy of the Guy's and S.T.O.N.E. scoring systems in predicting percutaneous nephrolithotomy (PCNL) outcomes. METHODS: After obtaining ethics approval, medical records of patients undergoing PCNL between 2009 and 2013 at a tertiary stone center were retrospectively reviewed. Guy's and S.T.O.N.E. scoring systems were calculated. Regression analysis and ROC curves were performed. RESULTS: A total of 185 PCNLs were reviewed. The overall stone-free rate was 71.9 % with a complication rate of 16.2 %. When compared to patients with residual fragments, stone-free patients had significantly lower Guy's grade (2.7 vs. 2; p < 0.001) and S.T.O.N.E. score (8.3 vs. 7.4; p = 0.004). Logistic regression analysis showed that both Guy's and S.T.O.N.E. systems were significantly associated with stone-free status, OR 0.4 (p < 0.001), and OR 0.7 (p = 0.001), respectively. Furthermore, both scoring systems were significantly associated with the estimated blood loss (p = 0.01 and p = 0.005). There was good correlation between both scoring systems and operative time (r = 0.3, p < 0.001 and r = 0.4, p < 0.001) and length of hospital stay (r = 0.2, p = 0.001 and r = 0.3, p < 0.001). However, there were no significant associations between both scoring systems and complications (p = 0.7 and p = 0.6). There was no significant difference in the areas under the curves for the Guy's and S.T.O.N.E. scoring systems (0.74 [95 % CI 0.66-0.82] vs. 0.63 [95 % CI 0.54-0.72]; p = 0.06). CONCLUSION: Both Guy's and S.T.O.N.E scoring systems have comparable accuracies in predicting post-PCNL stone-free status. Other factors not included in either scoring system may need to be incorporated in the future to increase their accuracy.

How we made professionalism relevant to twenty-first century residents.

The complexity of the current medical trainee work environment, including the impact of social media participation, is underappreciated. Despite rapid adoption of social media by residents and the introduction of social media guidelines targeted at medical professionals, there is a paucity of data evaluating practical methods to incorporate social media into professionalism teaching curricula. We developed a flipped classroom program, focusing on the application of professionalism principles to challenging real-life scenarios including social media-related issues. The pre-workshop evaluation showed that the participants had a good understanding of basic professionalism concepts. A post-workshop survey assessed residents' comfort level with professionalism concepts. The post-workshop survey revealed that the postgraduate trainees perceived significant improvement in their understanding of professionalism (p < 0.05). Resident responses also exposed some challenges of real-life clinical settings. There was an apparent contradiction between placing a high value on personal health and believing that physicians ought to be available to patients at any time. Participants' satisfaction with the course bodes well for continual modification of such courses. Innovative flipped classroom format in combination with simulation-based sessions allows easy incorporation of contemporary professionalism issues surrounding social media.

Incidence and trends in the treatment of kidney stones in Canada A population-based cohort study.

INTRODUCTION: Our objective was to assess the incidence of kidney stones requiring acute care, trends in the surgical treatment of stones, and the demographics of stone formers in Canada. METHODS: We conducted a population-based, retrospective cohort study using administrative data from the Canadian Institute for Health Information. We included Canadian residents age >18 years, outside of Quebec, who presented between January 1, 2013, and December 31, 2018, with a kidney stone episode. This was defined as a kidney stone resulting in hospital admission, emergency department visit, or stone intervention, specifically shockwave lithotripsy (SWL), ureteroscopy (URS), or percutaneous nephrolithotomy (PCNL). RESULTS: There were 471 824 kidney stone episodes, including 184 373 interventions. The number of kidney stone episode increased from 277/100 000 in 2013 to 290/100 000 in 2018. The median age was 53 (interquartile range 41-65) years and 59.9% were male. The crude rate for stone intervention was 877/100 000. The age- and gender-standardized rate for interventions was highest in Nova Scotia and Newfoundland and Labrador, and lowest in Prince Edward Island. The most common intervention in Canada was URS (73.5%), followed by SWL (19.8%) and PCNL (6.7%). The percent utilization of SWL was highest in Manitoba, whereas for URS, it was highest in Prince Edward Island and Alberta. CONCLUSIONS: Our study provides the first population-based data on the demographics of stone formers and treatment trends across Canada. There has been a 4.7% increase in kidney stone episodes over the study period. Those presenting to hospital or requiring intervention for a kidney stone are more likely to be male, aged 41-65, and undergo URS.

Understanding current ergonomics setup for urologists conducting anatomical endoscopic enucleation of the prostate surgeries: Survey analysis from the endourological society.

BACKGROUND: Ensuring ergonomic posture and safety for surgeons is key to preventing work-related injuries and promoting sustained practice. We evaluated ergonomic aspects of Anatomic Endoscopic Enucleation of the Prostate (AEEP) and its relation to musculoskeletal injuries. METHOD: A two-month online survey involving 119 Endourological Society members provided an in-depth analysis of AEEP practices and their musculoskeletal impacts. RESULTS: The sample experienced general (65.5%), back (32.8%), neck (35.3%) and shoulder (37%) pain. Female AEEP surgeons reported greater back pain. Experience and age were inversely related to MSK injuries, and operative times over 2 â€‹h increased back pain. AEEP procedures predominantly involved sitting (86%) on backless stools (58%), with most surgeons wearing protective eyewear (75.6%) and using large resectoscopes (76.5%). Monitors were usually above eye-level (57%) and beyond 1 â€‹m (68.9%). CONCLUSION: Musculoskeletal complaints are prevalent among AEEP endourologists. More awareness and further studies on risk factors are necessary to limit work-related injuries in urology.

Pfannenstiel laparoendoscopic single-site (LESS) vs conventional multiport laparoscopic live donor nephrectomy: a prospective randomized controlled trial.

OBJECTIVE: To present outcomes of a randomized, patient-blinded controlled trial on Pfannenstiel laparoendoscopic single-site (LESS) vs conventional multiport laparoscopic live donor nephrectomy. PATIENTS AND METHODS: Patients presenting as left kidney donors between January 2009 and November 2011 were randomized to LESS donor nephrectomy (LESS-DN: n = 15) or conventional laparoscopic donor nephrectomy (LDN: n = 14). Patients were blinded to the surgical approach preoperatively and attempts to continue patient blinding postoperatively were made by applying dressings consistent with multiple conventional laparoscopic incisions for all patients. De-identified data related to the operation, peri-operative course and postoperative follow-up were prospectively collected and compared between the two groups with an intention-to-treat analysis. RESULTS: There were no significant differences between the groups when comparing operating time, estimated blood loss (EBL), i.v. fluid administration, renal allograft warm ischaemia time (WIT), length of hospital stay (LOS) and total inpatient analgesic requirements. Quantitative pain assessment was not significantly different on postoperative day (POD) #0, however, it was significantly lower in the LESS-DN group, beginning on POD #1 (P < 0.05). The changes in haematocrit and serum creatinine in the two groups were not significantly different, and there were no blood transfusions in either group, nor was there a decline in estimated glomerular filtration rate to <60 mL/min per 1.73 m² of body surface area in any patients. Two patients in the LESS-DN group were converted to conventional LDN, both because of failure to progress effectively. All allografts were functional at the time of transplantation and revascularization, with no cases of hyperacute rejection. CONCLUSIONS: Peri-operative variables including EBL, WIT and LOS were equivalent when comparing Pfannenstiel LESS-DN with conventional LDN. Patient-reported visual analogue pain scale scores were significantly lower in the LESS-DN group beginning on the first postoperative day.

Management of infected indwelling ureteral stents An international survey of urologists.

INTRODUCTION: There are no clinical guidelines for the manipulation of chronic indwelling ureteral stents. The goal of this study was to survey, through a simulated case, how urologists initially manage a patient with a chronic ureteral stent presenting with urosepsis. METHODS: An online questionnaire was shared from July 1 to August 31, 2021, through social media (Twitter) and email lists. The scenario described a 50-year-old female, known for a chronic indwelling ureteral stent, presenting to the emergency department with fever, tachycardia, and flank pain. In the scenario, the stent was in adequate position and the last exchange had been performed one month prior. Respondents could choose between treating with antibiotics and keeping the same exchange schedule, urgent stent exchange, or an alternative management that they defined. P<0.05 was considered significant. RESULTS: A total of 396 participants completed the survey. Responses from 48 countries were collected, with 135 (34.1%) respondents from Canada. Half (50%) of respondents had more than 10 years of experience. Most (79.3%) respondents opted for initial empiric antibiotic therapy, while 16.2% opted for urgent stent exchange. A total of 19 (4.9%) medical specialists completed the survey. Non-urologists opted more frequently than urologists (42.1% vs. 16.2%) for urgent stent exchange (p=0.0111). CONCLUSIONS: This questionnaire allowed us to explore the various managements proposed by urologists in a patient with urosepsis and chronic indwelling ureteral stent. Most urologists opted for initial medical management. Further clinical studies could help determine the necessity for ureteral stent manipulation in urosepsis, and, if present, its ideal timing.

Which renal access technique for PCNL is more difficult to teach using simulation?

INTRODUCTION: Percutaneous nephrolithotomy (PCNL) is a challenging procedure that urology trainees should be familiar with during residency. Simulators, such as the PERC Mentor, allow the development of this competency in a safer, stress-free environment. There are two primary fluoroscopic methods of gaining percutaneous renal access: the triangulation method and the bull's eye method. Our goal was to assess which method is easier to teach novices by using the PERC Mentor simulator. A secondary goal was to assess differences in subjective and objective outcomes. METHODS: Fifteen simulator and procedure-naive medical trainees were randomized into two groups using a crossover, randomized study design. Participants were provided with written, video, in-person demonstrations and hands-on practice for each technique. They then performed each method and were assessed objectively using the PERC Mentor performance data report and subjectively using the PCNL global rating scale (GRS) scoring system. Statistical analysis was performed using Student's T-test and non-parametric Wilcoxon signed rank test. RESULTS: There was no statistical difference in the outcomes and complication rates between the two methods. The bull's eye method of obtaining percutaneous access was associated with a significant decrease in operative time (91 seconds vs. 128 seconds, p=0.03) and fluoroscopy time (87 seconds vs. 123 seconds, p=0.03) compared to the triangulation method. CONCLUSIONS: Teaching of both techniques was equally well acquired by students. Both techniques had similar outcomes; however, the bull's eye method was associated with less operative and fluoroscopy time when compared to the triangulation method among novices.