Appropriateness Criteria for Ureteral Stent Omission following Ureteroscopy for Urinary Stone Disease.

Objective: To bridge the gap between evidence and clinical judgement, we defined scenarios appropriate for ureteral stent omission after uncomplicated ureteroscopy (URS) using the RAND/UCLA Appropriateness Method (RAM). We retrospectively assessed rates of appropriate stent omission, with the goal to implement these criteria in clinical practice. Methods: A panel of 15 urologists from the Michigan Urological Surgery Improvement Collaborative (MUSIC) met to define uncomplicated URS and the variables that influence stent omission decision-making. Over two rounds, they scored clinical scenarios for Appropriateness Criteria (AC) for stent omission based on a combination of variables. AC were defined by median scores: 1 to 3 (inappropriate), 4 to 6 (uncertain), and 7 to 9 (appropriate). Multivariable analysis determined the association of each variable with AC scores. Uncomplicated URS cases in the MUSIC registry were assigned AC scores and stenting rates assessed. Results: Seven variables affecting stent decision-making were identified. Of the 144 scenarios, 26 (18%) were appropriate, 88 (61%) inappropriate, and 30 (21%) uncertain for stent omission. Most scenarios appropriate for omission were pre-stented (81%). Scenarios with ureteral access sheath or stones >10mm were only appropriate if pre-stented. Stenting rates of 5,181 URS cases correlated with AC scores. Stents were placed in 61% of cases appropriate for omission (practice range, 25% to 98%). Conclusion: We defined objective variables and AC for stent omission following uncomplicated URS. AC scores correlated with stenting rates but there was substantial practice variation. Our findings demonstrate that the appropriate use of stent omission is underutilized.

A Rare Primary Osteogenic Sarcoma of the Prostate and Bladder.

Mesenchymal tumors of the genitourinary tract account for 5% percent of bladder malignancies and there are currently 35 documented cases of osteosarcoma type. Concomitant involvement of the prostate in mesenchymal genitourinary malignancies is even rarer. Herein we describe a case of a 72-year-old male with a history of radiation for prostate cancer who develops hematuria. A hematuria evaluation revealed osteosarcoma of the bladder and prostate. He underwent radical cystoprostatectomy with ileal conduit and adjuvant chemotherapy. His disease progressed despite treatment and he elected palliative care 10 months after initial resection. This case reviews a rare histological variant of genitourinary malignancy.

Office Based Photovaporization of the Prostate for Benign Prostatic Hyperplasia: Outcomes and Patient Satisfaction.

INTRODUCTION: We determined the efficacy, safety and tolerability of photovaporization of the prostate in the office setting for benign prostatic hyperplasia. METHODS: Between 2009 and 2011, 139 men with moderate to severe benign prostatic hyperplasia based on I-PSS (International Prostate Symptom Score) underwent photovaporization of the prostate using a 980 nm diode laser under local anesthesia. We compared preoperative and postoperative post-void residual urine volume, maximum urine flow and I-PSS/quality of life questionnaire responses. We also evaluated postoperative complications and patient satisfaction survey responses. RESULTS: An average ± SD of 782.5 ± 811.1 seconds of laser exposure at maximum power (180 W) resulted in a significant change in median post-void residual urine volume (-126 ml or -81.3%), maximum urine flow (4 ml per second or 40.0%) and I-PSS (-19 or -79.2%, each p <0.001). In men with a prostate greater than 70 ml the median change in post-void residual volume was considerably more pronounced at -232.5 ml (-97.9%, p <0.001) while changes in maximum urine flow (3.0 ml per second or 25%, p = 0.027) and I-PSS (-16.5 or -71.7%, p = 0.003) were also significant. The most common complications were vesicular neck contracture in 7% of cases and urinary retention in 6.4%. CONCLUSIONS: Office based photovaporization of the prostate can be a safe, effective and well tolerated approach to benign prostatic hyperplasia in office settings using local anesthesia. We believe that it can become an attractive low cost treatment option for the rapidly expanding population at risk for benign prostatic hyperplasia.

Upper quadrant port placement for robot-assisted renal surgery: implementation of the Floating Arm and the XL Protype.

UNLABELLED: Abstract Background and Purpose: Placement of the fourth arm (4th arm) in the lower quadrant (LQ) is commonly described for robot-assisted renal surgical procedures but has anatomic restrictions and limited ergonomics. An alternative, upper quadrant (UQ) location is desirable, but patient habitus and spacing may restrict robotic attachment. We investigate current trends in 4th arm port placement and propose an alternative method at attaching the robot-the "Floating Arm" (FLA). METHODS: Robotic surgeons from the Endourological Society were surveyed. A 20-cm extra-long (XL Protype) da Vinci instrument was developed for the FLA technique. A dry lab allowed quantitative comparison of spacing and ranges of motion for standard da Vinci ports (dVP), bariatric dVP, telescoping dVP, and FLA. RESULTS: There were 108 respondents who participated. Half of the respondents avoid using the 4th arm (30% lack of need and 20% because of interference). The majority (90%) typically positions the 4th arm in the LQ, but many reported limitations in this location. Few (5%) place 4th arm in the UQ, while most (73%) have never heard of UQ placement. Existing techniques may increase shoulder height clearance but inversely shorten the working length of the instrument intracorporeally. Alternatively, the XL Protype significantly increased the shoulder length and maintained available working distances intracorporeally. Adjacent arm interference angle was essentially identical (27 degrees) for all ports except a greater range of movement for the XL Protype (35 degrees). CONCLUSION: Few surgeons are using an UQ positioning or use techniques to improve attachment of the 4th arm. The greatest freedom may be obtained by implementing the FLA, but this necessitates production of a longer instrument.