Prospective Randomized Trial of Antibiotic Prophylaxis Duration for Percutaneous Nephrolithotomy in Low-Risk Patients.

Introduction and Objective: Postoperative infection and sepsis account for the most common complications following percutaneous nephrolithotomy (PCNL), as high as 14% in low-risk patients. Although the American Urological Association (AUA) recommends perioperative antibiotics for 24 hours or less for PCNL, practice patterns vary regarding duration of antibiotic therapy. We aimed to compare the efficacy of 24-hour antibiotic coverage vs short-course protocol of antibiotic prophylaxis for PCNL. Materials and Methods: Low-risk patients with a sterile preoperative urine culture undergoing PCNL were prospectively randomized to antibiotics for up to 24 hours after procedure (24Hr) or continued until external urinary catheters were removed (CR) study groups. Patients were given a first generation cephalosporin, or ciprofloxacin in patients with penicillin allergy. Exclusion criteria included age <18 years, receiving antibiotics immediately before the procedure, history of urosepsis, presence of indwelling catheter >1 week, multistage procedure, immunosuppression, pregnancy, multiple antibiotic allergies, and patients who are breastfeeding. Results: Ninety-eight patients were randomized to either 24Hr (n = 49) or CR (n = 49). Mean duration of antibiotic administration was 20.6 and 34.0 hours in the 24Hr and CR groups (p = 0.04), respectively. Age, comorbidities, stone size, operative time, number of punctures, dilations, and proportion of "tubeless" procedures were similar between groups. There were no differences in febrile episodes, rates of systemic inflammatory response syndrome, bacteremia, or culture-proven postoperative urinary tract infection between the 24Hr and CR groups. Overall complication rates were similar between groups. In a subgroup analysis which excluded "tubeless" patients (24 and 29 patients in 24Hr and CR groups, respectively), no differences were seen in postoperative outcomes. Conclusions: In a randomized, prospective study, we found that a 24-hour protocol for antibiotic prophylaxis is not associated with increased risk of infection-related events compared to giving antibiotics until external catheters are removed in patients with low infectious risk undergoing PCNL. Clinicaltrials.gov: NCT02579161.

Contemporary diagnosis and management of pelvi-ureteric junction obstruction.

Pelvi-ureteric junction obstruction (PUJO) is defined as a functionally significant impairment of the flow of urine from the kidney's renal pelvis into the proximal ureter. Symptomatically, the patient may experience flank pain, recurrent infections, stone formation, and impairment of renal function. Although many cases of intrinsic PUJO are diagnosed at birth, a minority of patients may present in adulthood with previously silent disease or develop secondary PUJO to other causes. PUJO is therefore broadly categorised into both primary and secondary PUJO. A wide array of diagnostic scans and tests are available to aid in diagnosing and monitoring patients with PUJO. In patients with compromised renal function or symptomatic PUJO that require intervention, minimally invasive techniques are the 'gold standard' for surgical intervention. This review will detail the endoscopic, laparoscopic, and robotic options available to the urologist practicing in 2021, including the use of autografts and other emerging technologies.

Utility of Frailty Assessment in Urologic Stone Surgery: A Review of the Literature.

Introduction and Objective: As life expectancy continues to rise, the prevalence of frailty is also increasing. The idea of frailty and its effect on the operative patient has been previously studied, but not regularly incorporated into routine practice. We present a review on frailty metrics in the literature, validated assessment methods, and simplified screening tools to better predict and optimize patient outcomes. Methods: An online PubMed search was conducted by three authors (T.A., T.G.R.B., M.M.) for overall frailty, frailty assessment, and preoperative risk assessment. Only English publications were included in the analysis. Full-text analysis was then conducted by all three authors to validate the data. Results: An abundance of literature was found on frailty. Even though some methods are validated as extremely effective for assessing frailty, they may be time-consuming and require a specialist. Various quick screening methods are also presented, many already validated, and should be utilized by urologists more regularly. Conclusions: Multiple studies demonstrate the relationship between frailty and surgical patients' outcome. Many quick, office-based, validated tools to screen for frailty are described, and should be incorporated into our practice in appropriate patients. Future research is now focused on the concept of "prehabilitation" to improve patient frailty status in the preoperative setting, and consequently operative outcomes.

Frailty as predictor of complications in patients undergoing percutaneous nephrolithotomy (PCNL).

INTRODUCTION & OBJECTIVE: Surgical complications are difficult to predict, despite existing tools. Frailty phenotype has shown promise estimating postoperative risk among the elderly. We evaluate the use of frailty as a predictive tool on patients undergoing percutaneous renal surgery. METHODS: Frailty was prospectively analyzed using the Hopkins Frailty Index, consisting of 5 components yielding an additive score: patients categorized not frail, intermediate, or severely frail. Primary outcomes were complications during admission and 30-day complication rate. Secondary outcomes included overall hospital length of stay (LOS) and discharge location. RESULTS: A total of 100 patients recruited, of whom five excluded as they did not need the procedure. A total of 95 patients analyzed; 69, 10, and 16 patients were not frail, intermediate, and severely frail, respectively. There were no differences in blood loss, number of dilations, presence of a staghorn calculus, laterality, or location of dilation. Severely frail patients were likely to be older and have a higher American Society of Anesthesiologists score and Charlson comorbidity index. Patients of intermediate or severe frailty were more likely to exhibit postoperative fevers, bacteremia, sepsis, and require ICU admissions (P < 0.05). Frail patients had a longer LOS (P < 0.001) and tended to require skilled assistance when discharge (p < 0.0001). CONCLUSIONS: Frailty assessment appears useful stratifying those at risk of extended hospitalization, septic complications, and need for assistance following percutaneous renal surgery. Risks of sepsis, bacteremia, and post-operative hemorrhage may be higher in frail individuals. Preoperative assessment of frailty phenotype may give insight into treatment decisions and represent a modifiable marker allowing future trials exploring the concept of "prehabilitation".

Novel Irrigation Protocol for Renal Pelvis Sterilization During Percutaneous Nephrolithotomy: A Pilot Study.

While percutaneous nephrolithotomy (PCNL) remains the treatment modality of choice for kidney stones larger than 2 cm, infectious complications are most common, ranging from 5% to 32%. We present here a novel technique for potentially improving collecting system sterility during PCNL and initial postoperative outcomes. Retrospective chart analysis data of our irrigation protocol were collected from our first 56 patients between February and July 2019. Traditional prone PCNL was performed in a standard manner using fluoroscopic guidance. Using a ureteral catheter that was placed cystoscopically, a renal pelvis urine culture was taken and subsequently 10 mL of betadine solution was instilled into the collecting system. Gentamicin in normal saline (80 mg/3 L) was utilized as the irrigant fluid for the first 6 L of irrigation. From this cohort, 57% patients were women and mean age was 60 ± 14 years. About 23% of patients were diabetic and 55% were hypertensive. Seventy percent of patients had stone burden >2 cm and no patients had stone burden <1 cm. Fifteen patients had positive urine cultures treated preoperatively, while four patients had contaminated cultures. All patients were treated with our antibiotic irrigation and betadine protocol regardless of preoperative cultures or antibiotics. Mean baseline creatinine level was 0.95 ± 0.41, with a mean change of 0.18 at postoperative day 1. Of the 15 (26%) of 56 patients with a systemic inflammatory response syndrome response (two of following four criteria: white blood cells <4 or >12; heart rate >90; hypothermia <96.8°F or hyperthermia >100.4°F; and respiratory rate >20), only six patients (11%) were febrile and two patients had positive blood cultures (3%). There were no adverse reactions to the betadine or antibiotic irrigation. We present here our initial experience of a new technique for renal pelvis sterilization and its safety and feasibility using intrarenal instillation of betadine and antibiotic irrigation. No Clinical Trial Registration number applicable.

Percutaneous kidney stone surgery and radiation exposure: A review.

During the past 3 decades, radiation exposure (RE) has increased drastically among patients undergoing percutaneous nephrolithotomy (PCNL), thus potentially causing new cases of cancer each year. The effective dose received by patients comes from pre- and post-operative computed tomography (CT) and intraoperative fluoroscopy (FL). We reviewed literature to find novel techniques and approaches that help to decrease RE of patients and personnel. We performed PubMed search using keywords percutaneous nephrolithotomy, intraoperative fluoroscopy, radiation exposure, imaging, percutaneous access, ultrasound, computed tomography, endoscopy, reconstruction, innovations, and augmented reality. Forty-four relevant articles were included in this review. As much as 20% of patients with first diagnosed urolithiasis exceed background RE level almost 17-fold. For diagnosing purposes using low-dose and ultra-low-dose CT, as well as low-dose dual energy scan protocols can be efficient ways to decrease RE while maintaining decent accuracy. Patients with urinary stones can be effectively monitored with digital tomosynthesis, ultrasound alone or ultrasound combined with plain film of the abdomen. Percutaneous access (PCA) into the kidney can be performed with reduced or even no RE, using novel PCA methods. REs from conventional imaging techniques during diagnosis and treatment increase probability of non-stochastic radiation effects. Urologists should be aware of protocols that decrease RE from CT and FL in diagnosis and management of urinary stones. Consideration of recently developed imaging modalities and PCA techniques will also aid in adherence to the "as low as reasonably achievable" principle.

Conservative Management of Liver Perforation During Percutaneous Nephrolithotomy: Case Couplet Presentation.

Percutaneous nephrolithotomy (PCNL) remains the recommended intervention for large kidney stones, major complications, although rare, are between 1% and 7%. Literature regarding liver injury during PCNL is sparse, and many incidences occur unnoticed. In general, most liver injuries can be treated conservatively when compared with other organ injury sustained during PCNL. Despite this, there is still significant potential for intraperitoneal bleeding as well as possible hemodynamic instability that may result secondary to the inadvertent access. Our team describes two cases of liver injury during PCNL with focus on presentation and injury management. Both cases were treated conservatively through close clinical monitoring and delayed removal of nephrostomy tube. Both liver injuries were diagnosed primarily through postprocedure axial CT imaging. In general, risk factors include supracostal access, particularly at or above the 11th rib, as well as hepatomegaly. Despite that liver injury is a rare complication of right-sided PCNL, outcomes can result in significant blood loss not diagnosed. We present in this study two instances of effective conservative management of liver injury after PCNL.

Management of Splenic Injury During Percutaneous Nephrolithotomy: Report of Two Cases.

Percutaneous nephrolithotomy (PCNL) has become the standard of care for the removal of kidney stones >2 cm. Major complications, although rare, are between 1% and 7%. Splenic injury during PCNL is rare and can often be managed conservatively, but has the potential to be devastating, necessitating the importance of early diagnosis. Our team describes two cases of splenic injury during PCNL with emphasis on diagnosis and management. Although both cases were managed conservatively through close monitoring and prolonged nephrostomy tube presence, one case had a concurrent pneumothorax. Both cases were diagnosed primarily through postprocedure CT imaging. Risk factors primarily include supracostal access and splenomegaly. Splenic injury is a rare complication that can often be managed conservatively; however, prompt recognition of injury is important. We present in this study two cases of conservative splenic injury management sustained during PCNL.

Management of Colon Perforation During Percutaneous Nephrolithotomy in Patients with Complex Anatomy: A Case Series.

Percutaneous nephrolithotomy (PCNL), first described in 1976, is the gold standard for the management of large kidney stones, with stone-free rates as high as 95% in contemporary literature. Colonic injuries during PCNL are a rare complication with an estimated incidence of 0.3%-0.5%. However, given the high morbidity incurred and the necessity of prompt operative intervention, it is imperative that practitioners have a low suspicion threshold for such injuries, particularly in those patients with altered or complex anatomy. This case series addresses peri- and postoperative outcomes of colon perforation during PCNL in patients with complex anatomy and reviews the technical challenges of surgery with potential methods to avoid injury in the future. Herein we review three instances of colonic injuries and their subsequent management to highlight both the presentation and the optimal management of these rare occurrences.

Endoscopic Management of Upper Urinary Tract Urothelial Carcinoma.

INTRODUCTION: Endoscopic management of upper tract urothelial carcinoma has become more popular over the last few decades as there has been an impetus for renal preservation in these patients. While radical nephroureterectomy has been the gold standard in treatment of this disease, ureteroscopic and percutaneous management has become a viable option for select patients. METHODS AND MATERIALS: The literature on endoscopic management of upper urinary tract tumors was explored. Different management methods are discussed, both from published literature and experience of the authors of this chapter. RESULTS: We review the indications, details of the procedure, and troubleshooting methods in the endoscopic management of upper tract urothelial carcinoma. Imperative indications as well as controversial indications are discussed. The role and efficacy of adjuvant intrarenal topical agents are examined as well as the protocol for administering these agents. Follow-up protocols are also reviewed. DISCUSSION: In select patients, endoscopic management with ureteroscopy and/or percutaneous resection of upper tract urothelial tumors is appropriate and can preserve renal function while obtaining comparable oncologic control compared with radical surgery.

A Two-Dimensional Manganese Gallium Nitride Surface Structure Showing Ferromagnetism at Room Temperature.

Practical applications of semiconductor spintronic devices necessitate ferromagnetic behavior at or above room temperature. In this paper, we demonstrate a two-dimensional manganese gallium nitride surface structure (MnGaN-2D) which is atomically thin and shows ferromagnetic domain structure at room temperature as measured by spin-resolved scanning tunneling microscopy and spectroscopy. Application of small magnetic fields proves that the observed magnetic domains follow a hysteretic behavior. Two initially oppositely oriented MnGaN-2D domains are rotated into alignment with only 120 mT and remain mostly in alignment at remanence. The measurements are further supported by first-principles theoretical calculations which reveal highly spin-polarized and spin-split surface states with spin polarization of up to 95% for manganese local density of states.

The genetic framework for development of nephrolithiasis.

Over 1%-15% of the population worldwide is affected by nephrolithiasis, which remains the most common and costly disease that urologists manage today. Identification of at-risk individuals remains a theoretical and technological challenge. The search for monogenic causes of stone disease has been largely unfruitful and a technological challenge; however, several candidate genes have been implicated in the development of nephrolithiasis. In this review, we will review current data on the genetic inheritance of stone disease, as well as investigate the evolving role of genetic analysis and counseling in the management of nephrolithiasis.

Renal functional outcomes are not adversely affected by selective angioembolization following percutaneous nephrolithotomy.

OBJECTIVE: Selective angioembolization (SAE) effectively diagnoses and treats iatrogenic vascular complications following percutaneous nephrolithotomy (PCNL). METHODS: We retrospectively reviewed 1329 consecutive PCNLs and identified patients who underwent SAE following PCNL with at least 12-month follow-up. Estimated glomerular filtration rate (eGFR) was calculated for all patients preoperatively, postoperatively and at last follow-up. A 1:2 matched cohort analysis was performed. RESULTS: Twenty-three patients underwent SAE and matched to 46 controls. There was no statistically significant difference in preoperative, postoperative, and follow-up eGFR when comparing patients who underwent SAE and those with an uneventful course. CONCLUSION: Long-term eGFR is comparable in patients who undergo uncomplicated PCNL and those requiring SAE.

Stones in special situations.

There are several special situations in which urinary lithiasis presents management challenges to the urologist. An in-depth knowledge of the pathophysiology, unique anatomy, and treatment options is crucial in order to maintain good health in these patients. In this review, we summarize the current literature on the management of the following scenarios: bladder stones, stones in bowel disease, during pregnancy, in association with renal anomalies, with skeletal deformities, in urinary diversions, and in children.

Rigid-only versus combined rigid and flexible percutaneous nephrolithotomy: a systematic review.

INTRODUCTION: Percutaneous nephrolithotomy (PNL) is usually performed worldwide with a rigid-only antegrade approach. Daily practice suggests that adding flexible nephroscopy and/or ureteroscopy to conventional rigid PNL might improve its efficacy and safety, but available evidence is weak. Appraisal of reliable outcomes of such PNL techniques would better guide intraoperative choices and optimize surgical results. Therefore, our objective was to systematically review relevant literature comparing the outcomes of rigid-only PNL and combined flexible PNLs (adding flexible nephroscopy and/or flexible ureteroscopy) for the treatment of large and/or complex upper urinary tract calculi, with regard to efficacy and safety. EVIDENCE ACQUISITION: Ovid MedLine, PubMed, Scopus and Web of Science databases were searched in August 2016 to identify relevant studies. Article selection was performed according to the Preferred Reporting Items for Systematic Review and Meta-analysis criteria. EVIDENCE SYNTHESIS: Six articles reporting on 666 patients were included: two randomized controlled trials, two retrospective comparative studies and two case series ≥50 patients (one prospective and one retrospective). A narrative synthesis of minor evidences was also prepared. The adjunct of flexible nephroscopy and/or ureteroscopy provided better stone-free rates (range 86.7-96.97%), through a single percutaneous access most of the times and in any position, reducing the need for second-look procedures. Safety of the combined flexible procedures was improved to a variable degree, with a consensual reduction of the mean hospital stay (range 5.1-7 days). CONCLUSIONS: The current evidence suggests that patients with large and/or complex urolithiasis might benefit from the adjunct of flexible nephroscopy and/or ureteroscopy to rigid PNL.

Minimally Invasive Therapy for Upper Tract Urothelial Cell Cancer.

Minimally invasive therapy for upper tract urothelial cell cancer has assumed an important role in the management of this relatively uncommon genitourinary malignancy. In this review, current standards for patient selection, surgical approach, as well as overall outcomes will be discussed. Moreover, the use of intraluminal agents in upper tract disease is examined along with its efficacy and associated complications.

Conservative Management of Combined Pleural and Splenic Injury During Percutaneous Nephrostolithotomy.

Splenic injuries related to percutaneous nephrostolithotomy (PCNL) are infrequent. Herein, we report a combined splenic and pleural injury incurred during PCNL along with radiographic images documenting the complication. A review of management techniques for similar injuries is included.