Using ChatGPT-4 to Analyze 24-Hour Urine Results and Generate Custom Dietary Recommendations for Nephrolithiasis.

Purpose: The increasing incidence of nephrolithiasis underscores the need for effective, accessible tools to aid urologists in preventing recurrence. Despite dietary modification's crucial role in prevention, targeted dietary counseling using 24-hour urine collections is underutilized. This study evaluates ChatGPT-4, a multimodal large language model, in analyzing urine collection results and providing custom dietary advice, exploring the potential for artificial intelligence-assisted analysis and counseling. Materials and Methods: Eleven unique prompts with synthesized 24-hour urine collection results were submitted to ChatGPT-4. The model was instructed to provide five dietary recommendations in response to the results. One prompt contained all "normal" values, with subsequent prompts introducing one abnormality each. Generated responses were assessed for accuracy, completeness, and appropriateness by two urologists, a nephrologist, and a clinical dietitian. Results: ChatGPT-4 achieved average scores of 5.2/6 for accuracy, 2.4/3 for completeness, and 2.6/3 for appropriateness. It correctly identified all "normal" values but had difficulty consistently detecting abnormalities and formulating appropriate recommendations. The model performed particularly poorly in response to calcium and citrate abnormalities and failed to address 3/10 abnormalities entirely. Conclusions: ChatGPT-4 exhibits potential in the dietary management of nephrolithiasis but requires further refinement for dependable performance. The model demonstrated the ability to generate personalized recommendations that were often accurate and complete but displayed inconsistencies in identifying and addressing urine abnormalities. Despite these limitations, with precise prompt design, physician oversight, and continued training, ChatGPT-4 can serve as a foundation for personalized medicine while also reducing administrative burden, indicating its promising role in improving the management of conditions such as nephrolithiasis.

Heterogeneity in stone culture protocols and endourologist practice patterns: a multi-institutional survey.

Kidney stone cultures can be beneficial in identifying bacteria not detected in urine, yet how stone cultures are performed among endourologists, under what conditions, and by what laboratory methods remain largely unknown. Stone cultures are not addressed by current clinical guidelines. A comprehensive REDCap electronic survey sought responses from directed (n = 20) and listserv elicited (n = 108) endourologists specializing in kidney stone disease. Questions included which clinical scenarios prompt a stone culture order, how results influence post-operative antibiotics, and what microbiology lab protocols exist at each institution with respect to processing and resulting stone cultures. Logistic regression statistical analysis determined what factors were associated with performing stone cultures. Of 128 unique responses, 11% identified as female and the mean years of practicing was 16 (range 1-46). A specific 'stone culture' order was available to only 50% (64/128) of those surveyed, while 32% (41/128) reported culturing stone by placing a urine culture order. The duration of antibiotics given for a positive stone culture varied, with 4-7 days (46%) and 8-14 days (21%) the most reported. More years in practice was associated with fewer stone cultures ordered, while higher annual volume of percutaneous nephrolithotomy was associated with ordering more stone cultures (p < 0.01). Endourologists have differing practice patterns with respect to ordering stone cultures and utilizing the results to guide post-operative antibiotics. With inconsistent microbiology lab stone culture protocols across multiple institutions, more uniform processing is needed for future studies to assess the clinical benefit of stone cultures and direct future guidelines.

Obstetric outcomes of pregnancy complicated by urolithiasis: a retrospective cohort study.

OBJECTIVES: Evaluate the association between urolithiasis during pregnancy and obstetric outcomes outside the context of urological intervention. METHODS: We conducted a retrospective cohort study of singleton, non-anomalous gestations delivered at 23-42 weeks in California from 2007 to 2011. Maternal outcomes (preterm delivery [early (<32 weeks) and late (<37 weeks)], preeclampsia, gestational diabetes, cesarean deliveries, urinary tract infection [UTI] at delivery, chorioamnionitis, endomyometritis, and maternal sepsis) and newborn outcomes (seizure, respiratory distress syndrome, hypoglycemia, jaundice, and neonatal abstinence syndrome [NAS]) were compared using χ2-tests and multivariable logistic regression. RESULTS: A total of 2,013,767 pregnancies met inclusion criteria, of which 5,734 (0.28%) were complicated by urolithiasis. Stone disease during pregnancy was associated with 30% greater odds of each early (aOR 1.30; 95% CI 1.19-1.43) and late (aOR 1.29; 95% CI 1.18-1.41) preterm delivery. Cesarean delivery, UTI at delivery, gestational hypertension, gestational diabetes, preeclampsia, and sepsis were all significantly positively associated with urolithiasis. Odds of NAS (aOR 2.11; 95% CI 1.27-3.51) and jaundice were significantly greater in the neonates of stone-forming patients (aOR 1.08; 95% CI 1.01-1.16). CONCLUSIONS: Urolithiasis during pregnancy was associated with 30% greater odds of preterm delivery and increased risk of myriad metabolic, hypertensive, and infectious disorders of gestation. Neonates born to stone-forming patients were more than twice as likely to develop neonatal abstinence syndrome but did not have significantly greater odds of complications of prematurity.

Patterns of Industry Payments to Urologists From 2014-2018.

OBJECTIVES: To evaluate the patterns of financial transaction between industry and urologists in the first 5 years of reporting in the Open Payments Program (OPP) by comparing transactions over time, between academic and nonacademic urologists, and by provider characteristics among academic urologists. METHODS: The Center for Medicare & Medicaid Services OPP database was queried for General Payments to urologists from 2014-2018. Faculty at ACGME-accredited urology training programs were identified and characterized via publicly available websites. Industry transfers were analyzed by year, practice setting (academic vs nonacademic), provider characteristics, and AUA section. Payment nature and individual corporate contributions were also summarized. RESULTS: A total of 12,521 urologists - representing 75% of the urology workforce in any given year - received $168 million from industry over the study period. There was no significant trend in payments by year (P = .162). Urologists received a median of $1602 over the study period, though 14% received >$10,000. Payment varied significantly by practice setting (P <.001), with nonacademic urologists receiving more but smaller payments than academic urologists. Among academic urologists, gender (P <.001), department chair status (P <.001), fellowship training (P <.001), and subspecialty (P <.001) were significantly associated with amount of payment from industry. Annual payments from industry varied significantly by AUA section. CONCLUSION: Reporting of physician-industry transactions has not led to a sustained decline in transactions with urologists. Significant differences in industry interaction exist between academic and nonacademic urologists, and values transferred to academic urologists varied by gender, chair status, subspecialty, and AUA section.

Computed Tomography Radiation Exposure Among Referred Kidney Stone Patients: Results from the Registry for Stones of the Kidney and Ureter.

Purpose: Kidney stone patients routinely have CT scans during diagnostic work-up before being referred to a tertiary center. How often these patients exceed the recommended dose limits for occupational radiation exposure of >100 mSv for 5 years and >50 mSv in a single year from CT alone remains unknown. This study aimed to quantify radiation doses from CTs received by stone patients before their evaluation at a tertiary care stone clinic. Methods: From November 2015 to March 2017, consecutive new patients enrolled into the Registry for Stones of the Kidney and Ureter (ReSKU™) had the dose-length product of every available CT abdomen/pelvis within 5 years of their initial visit recorded, allowing for an effective dose (EDose) calculation. Multivariate logistic regression analysis identified factors associated with exceeding recommended dose limits. Models were created to test radiation reducing effects of low-dose and phase-reduction CT protocols. Results: Of 343 noncontrast CTs performed, only 29 (8%) were low-dose CTs (calculated EDose <4 mSv). Among 389 total patients, 101 (26%) and 25 (6%) had an EDose >20 mSv and >50 mSv/year, respectively. Increased body mass index, number of scans, and multiphase scans were associated with exceeding exposure thresholds (p < 0.01). The implementation of a low-dose CT protocol decreased the estimated number of scans contributing to overexposure by >50%. Conclusions: Stone patients referred to a tertiary stone center may receive excessive radiation from CT scans alone. Unnecessary phases and underutilization of low-dose CT protocols continue to take place. Enacting new approaches to CT protocols may spare stone patients from exceeding recommended dose limits.

Cost-Effectiveness of Urolithiasis Management in Pregnancy.

INTRODUCTION: Urolithiasis complicating pregnancy presents a challenge for urology and obstetric teams. The management options of ureteral stenting, percutaneous nephrostomy and ureteroscopy vary significantly with regard to efficacy, complications, impact on quality of life and costs. This analytic model compares these factors to determine an optimal strategy per gestational age at presentation. METHODS: A decision analytic model was built that compared stenting, percutaneous nephrostomy and ureteroscopy. Outcomes included treatment failure, need for re-treatment and complications stratified by severity. Probabilities and utilities were derived from the literature and costs were derived from institutional charge data. The time horizon was 1 year with disutilities limited to gestation length or recovery time for treatment or complication. Multivariate sensitivity analyses and Monte Carlo analysis were performed to evaluate model robustness. RESULTS: In a simulated cohort of 1,000 pregnant women with urolithiasis ureteroscopy would yield 960 quality adjusted life years, compared to 870 with stenting and 880 with percutaneous nephrostomy. Treatment via stenting or percutaneous nephrostomy would fail more than twice as often as ureteroscopy and more than half of patients would require subsequent definitive management. In this cohort ureteroscopy would save $38.8 million compared to stenting and $17.6 million compared to percutaneous nephrostomy. Given its lower costs and improved outcomes, ureteroscopy was the dominant strategy across all gestational ages and remained dominant in all sensitivity analyses and Monte Carlo simulations. CONCLUSIONS: Regardless of gestational age, ureteroscopy was a cost-effective strategy to manage urolithiasis compared to stenting or percutaneous nephrostomy. This result was robust against substantial changes in model parameters.

The Morbidity of Ureteral Strictures in Patients with Prior Ureteroscopic Stone Surgery: Multi-Institutional Outcomes.

PURPOSE: Nephrolithiasis is an increasingly common ailment in the United States. Ureteroscopic management has supplanted shockwave lithotripsy as the most common treatment of upper tract stone disease. Ureteral stricture is a rare but serious complication of stone disease and its management. The impact of new technologies and more widespread ureteroscopic management on stricture rates is unknown. We describe our experience in managing strictures incurred following ureteroscopy for upper tract stone disease. MATERIALS AND METHODS: Records for patients managed at four tertiary care centers between December 2006 and October 2015 with the diagnosis of ureteral stricture following ureteroscopy for upper tract stone disease were retrospectively reviewed. Study outcomes included number and type (endoscopic, reconstructive, or nephrectomy) of procedures required to manage stricture. RESULTS: Thirty-eight patients with 40 ureteral strictures following URS for upper tract stone disease were identified. Thirty-five percent of patients had hydronephrosis or known stone impaction at the time of initial URS, and 20% of cases had known ureteral perforation at the time of initial URS. After stricture diagnosis, the mean number of procedures requiring sedation or general anesthesia performed for stricture management was 3.3 ± 1.8 (range 1-10). Eleven strictures (27.5%) were successfully managed with endoscopic techniques alone, 37.5% underwent reconstruction, 10% had a chronic stent/nephrostomy, and 10 (25%) required nephrectomy. CONCLUSIONS: The surgical morbidity of ureteral strictures incurred following ureteroscopy for stone disease can be severe, with a low success rate of endoscopic management and a high procedural burden that may lead to nephrectomy. Further studies that assess specific technical risk factors for ureteral stricture following URS are needed.

Identifying factors associated with need for flexible ureteroscope repair: a Western Endourology STone (WEST) research consortium prospective cohort study.

Maintenance of flexible ureteroscopes can involve high costs and administrative burden. Instrument fragility necessitates eventual repair, rendering scopes inaccessible during refurbishment. We conducted a multi-institutional prospective cohort study to identify perioperative factors influencing flexible ureteroscope durability. Patients undergoing flexible ureteroscopy (URS) at six United States endourology centers were enrolled between August 2014 and June 2015. Surgeon self-reported concern and satisfaction with scope performance as well as upward and downward angles of deflection for each scope tip were measured before and after each procedure. The need for scope repair was determined by the operating surgeon at the time of the procedure and recorded. 424 URS cases using 74 flexible ureteroscopes were identified. Scope repair was required in 28 cases (6.6%) involving 26 scopes (35.1%). Upon univariate analysis, shorter patient height, absence of guidewire use, presence of a ureteral access sheath (UAS), longer procedure time, larger stone size, lithotrite type, surgeon training level, and self-reported concern were associated with scope repair. Upon multivariate analysis, UAS use (OR = 2.53, p = 0.005) and degree loss of scope upward flexion during a case (OR = 1.02, p = 0.03) increased the odds of a scope needing repair while the use of safety guidewire decreased the odds of a scope repair (OR = 0.50, p = 0.045). Lithotrite use and surgeon concern were associated with degree loss of scope upward flexion. The use of a UAS, absence of a safety guidewire, and the loss of upward ureteroscope flexion should be considered when evaluating means of optimizing reusable ureteroscope durability.

Variation in Radiologic and Urologic Computed Tomography Interpretation of Urinary Tract Stone Burden: Results From the Registry for Stones of the Kidney and Ureter.

OBJECTIVE: To compare the measured stone burden recorded between urologists and radiologists, and examine how these differences could potentially impact stone management. As current urologic stone surgery guideline recommendations are based on stone size, accurate stone measurements are crucial to direct appropriate treatment. This study investigated the discrepant interpretation that often exists between urologic surgeons and radiologists' estimation of patient urinary stone burden. MATERIALS AND METHODS: From November 2015 through August 2016, new patients prospectively enrolled into the Registry for Stones of the Kidney and Ureter (ReSKU) were included if they had computed tomography images available and an accompanying official radiologic report at the time of their urologist provider visit. Stone number and aggregate stone size were compared between the urologic interpretation and the corresponding radiologic reports. RESULTS: Of 219 patients who met the inclusion criteria, concordance between urologic and radiologic assessment of aggregate stone size was higher for single stone sizing (63%) compared with multiple stones (32%). Statistical significance was found in comparing the mean difference in aggregate stone size for single and multiple stones (P <.01). Over 33% of stone-containing renal units had a radiologic report with an unclear size estimation or size discrepancy that could lead to non-guideline-driven surgical management. CONCLUSION: Significant variation exists between urologic and radiologic computed tomography interpretations of stone burden. Urologists should personally review patient imaging when considering stone surgical management. A standardized method for measuring and reporting stone parameters is needed among urologists and radiologists.

Rationale and Design of the Registry for Stones of the Kidney and Ureter (ReSKU): A Prospective Observational Registry to Study the Natural History of Urolithiasis Patients.

OBJECTIVES: Registry-based clinical research in nephrolithiasis is critical to advancing quality in urinary stone disease management and ultimately reducing stone recurrence. A need exists to develop Health Insurance Portability and Accountability Act (HIPAA)-compliant registries that comprise integrated electronic health record (EHR) data using prospectively defined variables. An EHR-based standardized patient database-the Registry for Stones of the Kidney and Ureter (ReSKU™)-was developed, and herein we describe our implementation outcomes. MATERIALS AND METHODS: Interviews with academic and community endourologists in the United States, Canada, China, and Japan identified demographic, intraoperative, and perioperative variables to populate our registry. Variables were incorporated into a HIPAA-compliant Research Electronic Data Capture database linked to text prompts and registration data within the Epic EHR platform. Specific data collection instruments supporting New patient, Surgery, Postoperative, and Follow-up clinical encounters were created within Epic to facilitate automated data extraction into ReSKU. RESULTS: The number of variables within each instrument includes the following: New patient-60, Surgery-80, Postoperative-64, and Follow-up-64. With manual data entry, the mean times to complete each of the clinic-based instruments were (minutes) as follows: New patient-12.06 ± 2.30, Postoperative-7.18 ± 1.02, and Follow-up-8.10 ± 0.58. These times were significantly reduced with the use of ReSKU structured clinic note templates to the following: New patient-4.09 ± 1.73, Postoperative-1.41 ± 0.41, and Follow-up-0.79 ± 0.38. With automated data extraction from Epic, manual entry is obviated. CONCLUSIONS: ReSKU is a longitudinal prospective nephrolithiasis registry that integrates EHR data, lowering the barriers to performing high quality clinical research and quality outcome assessments in urinary stone disease.

Renal Autotransplantation: 27-Year Experience at 2 Institutions.

PURPOSE: Renal autotransplantation is an infrequently performed procedure. It has been used to manage complex ureteral disease, vascular anomalies and chronic kidney pain. We reviewed our 27-year experience with this procedure. MATERIALS AND METHODS: This is a retrospective, observational study of 51 consecutive patients who underwent renal autotransplantation, including 29 at Oregon Health and Science University between 1986 and 2013, and 22 at Virginia Mason Medical Center between 2007 and 2012. Demographics, indications, operative details and followup data were collected. Early (30 days or less) and late (greater than 30 days) complications were graded according to the Clavien-Dindo system. Factors associated with complications and pain recurrence were evaluated using a logistic regression model. RESULTS: The 51 patients underwent a total of 54 renal autotransplants. Median followup was 21.5 months. The most common indications were loin pain hematuria syndrome/chronic kidney pain in 31.5% of cases, ureteral stricture in 20.4% and vascular anomalies in 18.5%. Autotransplantation of a solitary kidney was performed in 5 patients. Laparoscopic nephrectomy was performed in 23.5% of cases. Median operative time was 402 minutes and median length of stay was 6 days. No significant difference was found between preoperative and postoperative plasma creatinine (p = 0.74). Early, high grade complications (grade IIIa or greater) developed in 14.8% of patients and 12.9% experienced late complications of any grade. Two graft losses occurred. Longer cold ischemia time was associated with complications (p = 0.049). Of patients who underwent autotransplantation for chronic kidney pain 35% experienced recurrence and 2 underwent transplant nephrectomy. No predictors of pain recurrence were identified. CONCLUSIONS: The most common indications for renal autotransplantation were loin pain hematuria syndrome/chronic kidney pain, ureteral stricture and vascular anomalies in descending order. Kidney function was preserved postoperatively and 2 graft losses occurred. At a median followup of 13 months pain resolved in 65% of patients who underwent the procedure. Complication rates compared favorably with those of other major urological operations and cold ischemia time was the only predictor of postoperative complications.

Diagnosis and management of ureteral complications following renal transplantation.

When compared with maintenance dialysis, renal transplantation affords patients with end-stage renal disease better long-term survival and a better quality of life. Approximately 9% of patients will develop a major urologic complication following kidney transplantation. Ureteral complications are most common and include obstruction (intrinsic and extrinsic), urine leak and vesicoureteral reflux. Ureterovesical anastomotic strictures result from technical error or ureteral ischemia. Balloon dilation or endoureterotomy may be considered for short, low-grade strictures, but open reconstruction is associated with higher success rates. Urine leak usually occurs in the early postoperative period. Nearly 60% of patients can be successfully managed with a pelvic drain and urinary decompression (nephrostomy tube, ureteral stent, and indwelling bladder catheter). Proximal, large-volume, or leaks that persist despite urinary diversion, require open repair. Vesicoureteral reflux is common following transplantation. Patients with recurrent pyelonephritis despite antimicrobial prophylaxis require surgical treatment. Deflux injection may be considered in recipients with low-grade disease. Grade IV and V reflux are best managed with open reconstruction.

Review of appendiceal onlay flap in the management of complex ureteric strictures in six patients.

OBJECTIVES: To evaluate appendiceal onlay flap ureteroplasty for repairing complex right proximal and mid-ureteric strictures. PATIENTS AND METHODS: Between August 2006 and August 2012 four women and two men (mean age 34.2 years) underwent right laparoscopic appendiceal onlay flap ureteroplasty. The mean stricture length was 2.5 cm. Stricture formation was secondary to impacted ureteric stones in three patients and failed pyeloplasty for congenital pelvi-ureteric junction obstruction in the remaining three. Each patient had ipsilateral flank pain before surgery. RESULTS: The mean operating time, estimated blood loss and hospital stay were 244 min, 175 mL and 3.2 days, respectively. No intra- or peri-operative complications were noted. The objective success rate was 100% (all patients had radiographic and/or endoscopic resolution of their ureteric strictures). The subjective success rate was 66%, (two patients developed recurrent discomfort, which upon exploration was found to be attributable to fibrosis away from the appendiceal onlay graft, where the gonadal vessels crossed the ureter). Both patients with recurrent pain underwent laparoscopic ureterolysis and bladder advancement flap proximal to the appendiceal onlay, which markedly improved one patient's pain but the other patient continued to have discomfort, ultimately resulting in a laparoscopic nephroureterectomy. CONCLUSIONS: Appendiceal onlay ureteroplasty is a viable treatment option for patients with complex right proximal and mid-ureteric strictures, while minimising the potential morbidity of appendiceal and ileal interposition.

Performing in the surgical amphitheater of today: perception of urologists conducting live case demonstrations.

PURPOSE: To evaluate the perception of urologists who have participated in live case demonstrations (LCDs) regarding safety, educational value/benefits, and ethics. METHODS: A 19-question anonymous survey was sent to urologists who performed and/or moderated LCDs at the World Congress of Endourology meetings from 2008 to 2012. E-survey was distributed via e-mail, and automatic reminders were sent 2 weeks after original distribution if no response was obtained. RESULTS: Eighty-one percent (92/113) of the urologists responded to the survey of whom 75% practice full time in an academic setting. Only 48.0% were fellowship trained, however. More than 60% had performed more than five LCDs at their home and/or away institutions. Performing LCD at an away institution was associated with a higher level of anxiety when compared with performing LCDs at a home institution (79.8% vs 34.6%; P<0.01). Respondents considered film equipment and crew; audience and moderator discussions; unfamiliar team, instruments and tools; language barrier; and having to narrate the procedure, as distractors. Seventy-nine percent considered LCD as an ethical practice, and 90.5% regarded LCDs as a "beneficial" and a "great way" to educate. Similarly, considering the various factors and conditions associated with LCDs, 95% would agree to participate in another LCD. CONCLUSION: LCDs are perceived to be an effective mode of education by performers and moderators of LCDs. Standard guidelines and policies are needed, however, for the selection of patient, surgeon and team, equipment, and facility. Studies are needed to evaluate the impact of this education process.

The surgical spectacle: a survey of urologists viewing live case demonstrations.

OBJECTIVE: To evaluate perspectives of urologists viewing live case demonstrations (LCD) and taped case demonstrations (TCD). METHOD: A 15-question anonymous survey was distributed to attendees of the live surgery session at the American Urological Association 2012 national meeting (Atlanta) and the second International Challenges in Endourology meeting (Paris). RESULTS: Of 1000 surveys distributed, 253 were returned completed (response rate 25%). Nearly half of respondents were in the academic practice setting and nearly 75% were beyond training. Just over 30% had performed a LCD previously. The perceived benefit of an LCD was greater than unedited and edited videos (chi-squared P = 0.014 and P < 0.001, respectively). Nearly no one selected 'not helpful' and a few selected 'minimally helpful' for any of the three forms of demonstration. Most respondents identified that opportunity to ask questions (61%) and having access to the full unedited version (72%), two features inherent to LCD, improved upon the educational benefit of edited videos. Most (78%) identified LCD as ethical. However, those that did not perceived lower educational benefit from LCD (P = 0.019). A slim majority (58%) would allow themselves or a family member to be a patient of a LCD and the vast majority (86%) plan to transfer knowledge gained at the LCD session into their practice. CONCLUSIONS: Urologists who attended these LCD sessions identified LCDs as beneficial and applicable to their practice. LCDs are preferred over videos. The large majority considers LCD ethical, although not as many would volunteer themselves for LCD. Further studies are necessary to determine if there is actual benefit from LCD over TCD to patient care.

The current role of endourologic management of renal transplantation complications.

Introduction. Complications following renal transplantation include ureteral obstruction, urinary leak and fistula, urinary retention, urolithiasis, and vesicoureteral reflux. These complications have traditionally been managed with open surgical correction, but minimally invasive techniques are being utilized frequently. Materials and Methods. A literature review was performed on the use of endourologic techniques for the management of urologic transplant complications. Results. Ureterovesical anastomotic stricture is the most common long-term urologic complication following renal transplantation. Direct vision endoureterotomy is successful in up to 79% of cases. Urinary leak is the most frequent renal transplant complication early in the postoperative period. Up to 62% of patients have been successfully treated with maximal decompression (nephrostomy tube, ureteral stent, and Foley catheter). Excellent outcomes have been reported following transurethral resection of the prostate shortly after transplantation for patients with urinary retention. Vesicoureteral reflux after renal transplant is common. Deflux injection has been shown to resolve reflux in up to 90% of patients with low-grade disease in the absence of high pressure voiding. Donor-gifted and de novo transplant calculi may be managed with shock wave, ureteroscopic, or percutaneous lithotripsy. Conclusions. Recent advances in equipment and technique have allowed many transplant patients with complications to be effectively managed endoscopically.

S.T.O.N.E. nephrolithometry: novel surgical classification system for kidney calculi.

OBJECTIVE: To, first, propose a novel scoring system to standardize reporting for percutaneous nephrolithotomy because the instruments currently available to predict the percutaneous nephrolithotomy outcomes are cumbersome, not validated, and of limited clinical utility; and, second, assess and predict the stone-free rates and perioperative parameters applying S.T.O.N.E. nephrolithometry. MATERIALS AND METHODS: Five reproducible variables available from preoperative noncontrast-enhanced computed tomography were measured: stone size (S), tract length (T), obstruction (O), number of involved calices (N), and essence or stone density (E). RESULTS: A total of 117 patients were included. The mean score was 7.7 (range 4-11). The stone-free rate after the first procedure was 80%. There were 18 complications (21%). The most frequent complications were postoperative sepsis and bleeding. The S.T.O.N.E. score correlated with the postoperative stone-free status (P = .001). The patients rendered stone free had statistically significant lower scores than the patients with residual stones (6.8 vs 9.7, P = .002). Additionally, the score correlated with the estimated blood loss (P = .005), operative time (P = .001), and length of hospital stay (P = .001). CONCLUSION: The novel scoring system we have presented was found to predict treatment success and the risk of perioperative complications after percutaneous nephrolithotomy. Reproducible, standardized parameters obtained from computed tomography imaging can be used for preoperative patient counseling, surgical planning, and evaluation of surgical outcomes across institutions and within medical studies.

Supracostal tubeless percutaneous nephrolithotomy: a retrospective cohort study.

PURPOSE: To evaluate the safety of tubeless percutaneous nephrolithotomy in patients undergoing supracostal percutaneous renal access. PATIENTS AND METHODS: Between October 1999 and October 2010, 302 patients underwent percutaneous nephrolithotomy via a supracostal access tract. Two hundred forty-eight (82.1%) patients had a nephrostomy tube placed at the end of the case and 54 (17.9%) did not. The medical records of both cohorts were compared regarding patient demographics (age, sex, body mass index, preoperative creatinine level), operative characteristics (estimated blood loss, length of stay, treatment efficacy), and complication rates (overall, thoracic, hemorrhage necessitating transfusion). RESULTS: Patient demographics did not differ between the tubeless and nephrostomy tube groups. Estimated blood loss was significantly less in the tubeless patients (67 mL vs 123 mL; P=0.019). The tubeless group had a shorter mean length of stay than the nephrostomy tube group (2.5 vs 3.4 days, P<0.01). Treatment success was comparable between the two groups (tubeless 81.5% vs nephrostomy tube 77.8%; P=0.553). Overall complication (P=0.765) and blood transfusion (P=0.064) rates were equivalent. Chest complications were higher in the tubeless group (22.2%) compared with the nephrostomy tube patients (10.9%) (P=0.024). Nevertheless, chest complications necessitating intervention were not different (P=0.152). CONCLUSIONS: Tubeless supracostal percutaneous nephrolithotomy was associated with less intraoperative blood loss and a shorter hospital stay. Although the tubeless group experienced more chest complications overall, the need for intervention was no different among the two cohorts. Tubeless supracostal percutaneous nephrolithotomy appears safe.

Variability of transrectal ultrasound-guided prostate biopsy prophylactic measures.

INTRODUCTION: To assess the variability of pre-prostate biopsy prophylaxis among American urologists. MATERIALS AND METHODS: A survey was electronically mailed to 3355 urologists around the country. Urologists were surveyed on their antibiotic prophylaxis choice, the route and duration of antimicrobial prophylaxis. Additionally they were questioned about their knowledge of local antimicrobial resistance and if rectal enemas were routinely used. RESULTS: There were 679 (21%) responses to the survey. The survey revealed differences in pre-prostate biopsy prophylaxis among urologists. Ten different classes of antibiotics were used orally, 4 classes intramuscular, 5 classes intravenous, and there was also 14 different duration regimens. CONCLUSION: Despite the initiation of the 2008 American Urological Association Guidelines on this topic, there still is a lack of uniformity in prostate biopsy prophylaxis.