Bilateral Ureteral Obstruction Secondary to Papillary Necrosis From Non-Steroidal Anti-Inflammatory Drug Use in an Adult Patient.

Prolonged use of non-steroidal anti-inflammatory drugs (NSAIDs) is known to cause renal papillary necrosis and, in rare cases, can cause sloughing of renal papillae with subsequent ureteral obstruction. We report the first documented case of an adult patient presenting with bilateral ureteral obstructions, secondary to bilateral papillary necrosis from chronic NSAID use. He subsequently underwent bilateral ureteral stent placement with rapid recovery of renal function.

A preliminary study of bilateral color mapping of pig bladder vasculature demonstrates potential for acute hemi-ischemic events.

BACKGROUND: Chronic ischemia is a known risk factor for the development of lower urinary tract symptoms (LUTS) and bladder hypocontractility. Less is known, however, about the impact of acute ischemia. Classic teaching suggests that collateral circulation is robust in the bladder and, therefore, loss of a single source of blood flow should have no deleterious effect. This study aims to provide visual evidence that segmental vascular supply is critical for maintaining adequate perfusion to the bladder. METHODS: Ex vivo pig bladders were cannulated bilaterally in the superior vesical arteries and perfused using contrasting red and green dye. Images were collected at each step of the perfusion dyeing process and these images were analyzed using a custom program to calculate the average hue of each side. Statistical analysis was performed using Student's t-test. RESULTS: The two halves being perfused by separate arteries showed a statistically significant difference when compared (P<0.05) on both the outer wall (n=9) and in the mucosal layer (n=4). On the outside wall, the average normalized hue of the green halves was 27.5°±14.3°, while the average normalized hue of the red halves was -58.7°±3.1°. In the mucosa, the average normalized hue of the green halves was 34.5°±17.4°, while the average normalized hue of the red halves was -51.5°±3.5°. CONCLUSIONS: This study identified a novel color mapping method to study pig bladder vascular supply. The results demonstrated a lack of collateral blood flow, highlighting the possibly of acute hemi-ischemic event. However, further research in the effect of acute ischemia on bladder function is necessary.

Robot-Assisted Ureteral Reimplantation: A Single-Center Comparative Study.

Background: Aim of this study was to report a single-center experience with robot-assisted ureteral reimplantation (RAUR) and to compare its outcomes with those of open ureteral reimplantation (OUR). Materials and Methods: Patients who underwent RAUR or OUR for ureteral disease between 2016 and 2020 were identified. Data collected included baseline, pathologic, perioperative, and postoperative features. The RAUR outcomes were compared with those of OUR. Results: Overall, 21 (42.8%) patients underwent RAUR, and 28 (57.2%) underwent OUR. The two groups were similar in terms of baseline and pathologic characteristics. There was a statistically significant difference in favor of RAUR for median operative time (216 vs 317 minutes, p = 0.01) and median blood loss (35 vs 175 mL, p = 0.001). No difference was observed in overall complication rate (33.3% vs 46.4%, p = 0.9), as well as major complications (Clavien-Dindo≥III grade) rate between RAUR and OUR groups. Median length of stay was shorter for RAUR (2 vs 6 days; p = 0.001), as well as median catheterization time (16 vs 28 days; p = 0.005). Conclusions: RAUR is a safe and effective minimally invasive surgical procedure for the management of mid to distal ureteral strictures. It can recapitulate the success rate of the gold standard OUR while offering a benefit in terms of lower surgical morbidity and faster postoperative recovery.

Urologic Complications Requiring Intervention Following High-dose Pelvic Radiation for Cervical Cancer.

OBJECTIVE: To identify the incidence of radiation-induced urologic complication requiring procedural intervention following high-dose radiotherapy for cervical carcinoma, and to identify predictors of complication occurrence. MATERIALS AND METHODS: We performed a retrospective chart review of cervical cancer patients undergoing radiotherapy with primary focus on procedural complications (Clavien-Dindo ≥ III). Clinical data were collected including radiation dose, procedure performed, timing of complication, and need for additional procedures. Univariate and multivariate logistic regression modeling was performed to assess predictive value of demographic and clinical variables. RESULTS: A total of 126 patients with FIGO stage 1A2-4B cervical cancer were included in study analysis, with 18 patients experiencing procedural complication (14.3%). A total of 22 complications were identified, representing an average of 1.2 complications per patient with complication. The most common complications were ureteral stricture and radiation cystitis. The most common nononcologic procedures performed in the treatment of these complications were ureteral stenting, percutaneous nephrostomy tube placement, and cystoscopy. Notably, a total of 259 procedures were performed in the treatment of urologic complications, representing 14.4 procedures per patient and 24.6 procedures per patient with ureteral stricture. Logistic regression demonstrated active smoking at the time of diagnosis to be a predictor of procedural complication. CONCLUSION: Radiotherapy in the treatment of cervical cancer is associated with a high rate of urologic procedural complication. These complications often require numerous procedures and long-term management given their complexity. These findings suggest a need for awareness and plans for multidisciplinary management of urologic complications in this patient population.

New robotic surgical systems in urology: an update.

PURPOSE OF REVIEW: The landscape of robotic surgical systems in urology is changing. Several new instruments have been introduced internationally into clinical practice, and others are in development. In this review, we provide an update and summary of recent surgical systems and their clinical applications in urology. RECENT FINDINGS: Robotic-assisted laparoscopic surgery is increasingly becoming a standard skillset in the urologist's technical armamentarium. The current state of the robotic surgery market is monopolized because of a number of regulatory and technical factors but there are several robotic surgical systems approved for clinical use across the world and numerous others in development. Next-generation surgical systems commonly include a modular design, open access consoles, haptic feedback, smaller instruments, and machine learning. SUMMARY: Numerous robotic surgical systems are in development, and several have recently been introduced into clinical practice. These new technologies are changing the landscape of robotic surgery in urology and will likely transform the marketplace of robotic surgery across surgical subspecialties within the next 10--20 years.

Lower Genitourinary Foreign Bodies: An Institutional Experience and Description of a Novel, Minimally-invasive Extraction Technique for Anterior Urethral Objects.

OBJECTIVE: To describe our experience with management of lower genitourinary foreign bodies (FBs); to introduce our novel, but simple and minimally-invasive retrieval method compared with standard techniques for anterior urethral FBs; and to propose a derived, practical management algorithm. METHODS: We reviewed all male patients presenting with inserted urethral and/or bladder FBs between January2000 and October 2018. Patient characteristics and number of episodes were identified. Episodes were stratified by FB type, FB location, diagnostic modality, and removal method. We performed a subgroup analysis of anterior urethral FB management techniques comparing retrieval outcomes using our novel Retrieval of Anterior urethral Materials Safely (RAMS) technique which utilizes urethral hydrodistension via retrograde injection of lidocaine jelly to expel FBs vs forceps extraction. Cost analyses were performed, and a management algorithm was then derived. RESULTS: We identified 116 episodes. Eighty-seven of 116 (75%) episodes involved items located within the anterior urethra. A subset of episodes (14/116, 12%) was managed using the RAMS technique. There was no difference in FB extraction success rates between RAMS (13/14, 92.9%) and forceps extraction (37/40, 92.7%), P = 1.00. FBs were successfully removed using RAMS when utilized for nonembedded FBs located entirely within the anterior urethra. Among FBs located within the anterior urethra, the median total hospital cost was nearly 10 times less with utilization of RAMS compared with cystoscopic extraction ($379.09 v s$3,214.21, P <.05). CONCLUSION: Because an overwhelming majority of FBs are located within the anterior urethra, the RAMS technique represents a simple, cost-conscious, and minimally-invasive strategy with low risk and potentially high-yield for initial extraction in the emergency department.

Discharge materials provided to patients with kidney stones in the emergency department may be a source of misinformation.

INTRODUCTION: Renal colic is commonly seen in the emergency department (ED), where the focus is on diagnosis and symptom control. Educational materials are sometimes provided upon discharge, however, no standard content has been established. We characterized the educational materials given to patients reporting to EDs in different regions across the U.S. for symptomatic kidney stones, specifically evaluating disease-specific information, symptom management, prevention strategies including dietary recommendations (DRs), and patient follow up plans. MATERIALS AND METHODS: Generic discharge instructions for patients presenting to EDs with renal colic were obtained from community hospitals and academic medical centers between October 2016 and November 2017. Hospitals were called directly. If the same discharge instructions were used by more than one hospital, each was included in our analysis. We assessed the different types of information provided with a focus on stone prevention and DRs by characterizing them into specific nutritional categories. RESULTS: Of 266 hospitals contacted, 79 provided discharge instructions. Of these, 51 (65%) provided some information on diet. While most recommended higher fluid intake, almost 40% endorsed unnecessary fluid restrictions. Recommendations to reduce protein and oxalate intake were common, but erroneous information for both was given. Nearly 1 in 5 EDs recommended lower calcium intake. Less than 30% of EDs mentioned that stones can have different composition or causes. Less than 30% referenced consultation with a registered dietitian nutritionist (RDN) or that dietary approaches to stone prevention are optimally individualized. Only 9 summaries recommended urologic follow up. CONCLUSIONS: Many ED discharge materials contain DRs for stone prevention. These recommendations can be inaccurate and/or inappropriate. Advice on diet and stone prevention is more appropriately addressed in the outpatient setting when more data (stone composition, serum and urine parameters) and expert consultants are available.

A Retrospective Review Demonstrating the Feasibility of Discharging Patients Without Opioids After Ureteroscopy and Ureteral Stent Placement.

PURPOSE: Efforts have begun to implement nonopioid protocols for outpatient urologic surgery. In this study, we report a retrospective review of the feasibility of implementing a nonopioid protocol to manage postoperative pain after ureteroscopy with stent placement. METHODS: Between November 2016 and March 2018, 210 patients underwent ureteroscopy with stent placement by a single surgeon at an academic medical center. A treatment algorithm was used to determine the eligibility and appropriately select patients for the nonopioid pathway. Frequency of postoperative events was reviewed and included visits to the emergency department (ED), telephone calls to the clinic, and requests for prescription refills. RESULTS: Two hundred six of 210 patients met the inclusion criteria. Of these 206 patients, 151 were discharged without opioid medications (73%) and 55 received opioids (27%). Both patients receiving opioids and nonopioids had a low number of postoperative visits to the ED for genitourinary-related concerns (7 patients receiving opioids [13%] and 15 patients without opioids [10%]). Telephone calls made to the urology clinic for concerning symptoms were made by 25 patients receiving opioids (45%) and 32 patients without opioids (21%). The number of pain medication refill requests was low for both groups: 13 patients receiving opioids (24%) and 11 patients without opioids (7%). CONCLUSIONS: Our experience using a nonopioid pathway after ureteroscopy and stent placement reveals that approximately three-fourths of patients can be discharged without opioids. Patients had a low number of visits to the ED for postoperative genitourinary symptoms, a low number of telephone calls to the clinic, and requested few prescription pain medication refills regardless of whether or not they received opioids on discharge.

Separating the Wheat From the Chaff: An Evaluation of Readability, Quality, and Accuracy of Online Health Information for Treatment of Peyronie Disease.

OBJECTIVE: To characterize available information about Peyronie disease online and evaluate its readability, quality, accuracy, and respective associations with HONcode certification and website category. METHODS: The search term "Peyronie disease" was queried on 3 major search engines (Google, Bing, and Yahoo) and the first 50 search results on each search engine were assessed. All websites were categorized as institutional or reference, commercial, charitable, personal or patient support, or alternative medicine, and cross-referenced with the Health on the Net (HON) Foundation. Websites that met the inclusion criteria were analyzed for readability using 3 validated algorithms, for quality using the DISCERN instrument, and for accuracy by a fellowship-trained urologist. RESULTS: On average, online health information about treatment of Peyronie disease is written at or above the 11th grade level, exceeding the current reading guidelines of 6th-8th grade. The mean total DISCERN score for all website categories was 50.44 (standard deviation [SD] 11.94), the upper range of "fair" quality. The mean accuracy score of all online Peyronie treatment information was 2.76 (SD 1.23), corresponding to only 25%-50% accurate information. Both institutional or reference and HONcode-certified websites were of "good" quality (53.44, SD 11.64 and 60.86, SD 8.74, respectively). Institutional or reference websites were 50%-75% accurate (3.13, SD 1.20). CONCLUSION: Most of the online Peyronie disease treatment information is of mediocre quality and accuracy. The information from institutional or reference websites is of better quality and accuracy, and the information from HONcode-certified websites is of better quality. The mean readability of all websites exceeds the reading ability of most US adults by several grade levels.

Creation of a Ureterocystostomy in a Transplanted Cadaveric Kidney with the Use of a Radiofrequency Guide Wire.

A duplicated collecting system (DCS) is a common anatomical variant of the kidney. As surgeons now perform more donor cadaveric transplants than in the past, the discovery of an occluded DCS may occur in the post-transplant setting. Over a dozen articles have reported on the use of DCS in the renal transplant setting. However, to our knowledge, this case report is the first to describe the creation of a ureterocystostomy with the use of a radiofrequency (RF) guide wire, involving a previously unidentified DCS in a transplanted kidney.

Beta-adrenergic receptors are critical for weight loss but not for other metabolic adaptations to the consumption of a ketogenic diet in male mice.

OBJECTIVE: We have previously shown that the consumption of a low-carbohydrate ketogenic diet (KD) by mice leads to a distinct physiologic state associated with weight loss, increased metabolic rate, and improved insulin sensitivity [1]. Furthermore, we identified fibroblast growth factor 21 (FGF21) as a necessary mediator of the changes, as mice lacking FGF21 fed KD gain rather than lose weight [2]. FGF21 activates the sympathetic nervous system (SNS) [3], which is a key regulator of metabolic rate. Thus, we considered that the SNS may play a role in mediating the metabolic adaption to ketosis. METHODS: To test this hypothesis, we measured the response of mice lacking all three ß-adrenergic receptors (ß-less mice) to KD feeding. RESULTS: In contrast to wild-type (WT) controls, ß-less mice gained weight, increased adipose tissue depots mass, and did not increase energy expenditure when consuming KD. Remarkably, despite weight-gain, ß-less mice were insulin sensitive. KD-induced changes in hepatic gene expression of ß-less mice were similar to those seen in WT controls eating KD. Expression of FGF21 mRNA rose over 60-fold in both WT and ß-less mice fed KD, and corresponding circulating FGF21 levels were 12.5 ng/ml in KD-fed wild type controls and 35.5 ng/ml in KD-fed ß-less mice. CONCLUSIONS: The response of ß-less mice distinguishes at least two distinct categories of physiologic effects in mice consuming KD. In the liver, KD regulates peroxisome proliferator-activated receptor alpha (PPARα)-dependent pathways through an action of FGF21 independent of the SNS and beta-adrenergic receptors. In sharp contrast, induction of interscapular brown adipose tissue (BAT) and increased energy expenditure absolutely require SNS signals involving action on one or more ß-adrenergic receptors. In this way, the key metabolic actions of FGF21 in response to KD have diverse effector mechanisms.

Central Fibroblast Growth Factor 21 Browns White Fat via Sympathetic Action in Male Mice.

Fibroblast growth factor 21 (FGF21) has multiple metabolic actions, including the induction of browning in white adipose tissue. Although FGF21 stimulated browning results from a direct interaction between FGF21 and the adipocyte, browning is typically associated with activation of the sympathetic nervous system through cold exposure. We tested the hypothesis that FGF21 can act via the brain, to increase sympathetic activity and induce browning, independent of cell-autonomous actions. We administered FGF21 into the central nervous system via lateral ventricle infusion into male mice and found that the central treatment increased norepinephrine turnover in target tissues that include the inguinal white adipose tissue and brown adipose tissue. Central FGF21 stimulated browning as assessed by histology, expression of uncoupling protein 1, and the induction of gene expression associated with browning. These effects were markedly attenuated when mice were treated with a ß-blocker. Additionally, neither centrally nor peripherally administered FGF21 initiated browning in mice lacking ß-adrenoceptors, demonstrating that an intact adrenergic system is necessary for FGF21 action. These data indicate that FGF21 can signal in the brain to activate the sympathetic nervous system and induce adipose tissue thermogenesis.