Understanding Ureteral Access Sheath Use Within a Statewide Collaborative and Its Effect on Surgical and Clinical Outcomes.

Introduction: Ureteral access sheaths (UASs) are frequently used during ureteroscopy (URS), but their use is not without potential risk. We investigated patterns of UAS use and associated outcomes across practices in Michigan within a quality improvement collaborative. Methods: The Michigan Urological Surgery Improvement Collaborative (MUSIC) Reducing Operative Complications from Kidney Stones (ROCKS) initiative maintains a web-based, prospective clinical registry of patients undergoing URS for urinary stone disease (USD). We analyzed all patients undergoing primary URS for renal and ureteral stones from June 2016 to July 2018 in the ROCKS registry. We determined rates of UAS usage across practices and associated outcomes, including 30-day emergency department (ED) visits and hospitalization, as well as stone-free rates. Using multivariate logistical regression, we determined the predictors of UAS use as well as outcomes, including stone-free rates, ED visits, and hospitalizations, associated with UAS use. Results: Of the 5316 URS procedures identified, UASs were used in 1969 (37.7%) cases. Stones were significantly larger and more likely to be located in the kidney in cases with UAS use. UAS use during URS varied greatly across practices (1.9%-96%, p < 0.05). After adjusting for clinical and surgical risk factors, UAS use significantly increased the odds of postoperative ED visits (odds ratio [OR] = 1.50, 95% confidence interval [CI] 1.17-1.93, p < 0.05) and hospitalization (OR = 1.77, 95% CI 1.22-2.56, p < 0.05) as well as decreased the odds of being stone free (OR = 0.75, 95% CI 0.57-0.99, p < 0.05). Conclusions: In the current study, UAS use during URS for USD was not associated with an increased likelihood of being stone free; moreover, it increased the odds of a postoperative ED visit and or hospitalization. Our findings demonstrate that UAS use is not without risk and should be employed judiciously.

Multiplex PCR Based Urinary Tract Infection (UTI) Analysis Compared to Traditional Urine Culture in Identifying Significant Pathogens in Symptomatic Patients.

OBJECTIVE: To evaluate whether multiplex PCR-based molecular testing is noninferior to urine culture for detection of bacterial infections in symptomatic patients. METHODS: Retrospective record review of 582 consecutive elderly patients presenting with symptoms of lower urinary tract infection (UTI) was conducted. All patients had traditional urine cultures and PCR molecular testing run in parallel. RESULTS: A total of 582 patients (mean age 77; range 60-95) with symptoms of lower UTI had both urine cultures and diagnostic PCR between March and July 2018. PCR detected uropathogens in 326 patients (56%, 326/582), while urine culture detected pathogens in 217 patients (37%, 217/582). PCR and culture agreed in 74% of cases (431/582): both were positive in 34% of cases (196/582) and both were negative in 40% of cases (235/582). However, PCR and culture disagreed in 26% of cases (151/582): PCR was positive while culture was negative in 22% of cases (130/582), and culture was positive while PCR was negative in 4% of cases (21/582). Polymicrobial infections were reported in 175 patients (30%, 175/582), with PCR reporting 166 and culture reporting 39. Further, polymicrobial infections were identified in 67 patients (12%, 67/582) in which culture results were negative. Agreement between PCR and urine culture for positive cultures was 90%, exceeding the noninferiority threshold of 85% (95% conflict of interest 85.7%-93.6%). CONCLUSION: Multiplex PCR is noninferior to urine culture for detection and identification of bacteria. Further investigation may show that the accuracy and speed of PCR to diagnose UTI can significantly improve patient outcomes.

Neuroendocrine carcinoma of the urinary bladder: a retrospective study of CT findings.

PURPOSE: The purpose of this study was to evaluate the radiographic features of neuroendocrine carcinoma of the urinary bladder (NECB) on CT and to review the literature regarding carcinogenesis, treatment, and prognosis. METHODS: The presenting CT of patients with pathology-proven NECB were retrospectively reviewed for features including size and appearance of the bladder mass, the presence of hydronephrosis, bladder wall thickening, invasion of perivesical fat, lymph nodes, and distant metastasis. Follow-up imaging and the medical record were reviewed to determine patient treatment and overall survival. RESULTS: Sixteen patients (13 males, 3 females) were diagnosed with NECB with a mean age of 75.5 years (range 48-90). The characteristic CT appearance was a large polypoid bladder mass (average size 4.9 cm). Extension into the perivesical fat, adjacent organ involvement, and distant metastases were common. CONCLUSION: NECB is an aggressive primary neoplasm of the bladder that presents on CT as a large bladder mass with local extension into the perivesical fat, involvement of adjacent organs, and metastasis.

Minimally invasive inguinal lymphadenectomy via endoscopic groin dissection: comprehensive assessment of immediate and long-term complications.

PURPOSE: Open inguinal lymphadenectomy has been associated with significant postoperative morbidity. Recently, small series have demonstrated the feasibility and efficacy of endoscopic groin lymphadenectomy as an alternative to open surgery. Previously we reported the favorable results of our initial experience. Few reports of novel surgical methods include long-term complications. In this report we present a detailed analysis of immediate and long-term complications associated with the procedure using standardized complications reporting methodology including the Clavien classification. MATERIALS AND METHODS: From September 2008 to December 2009, 29 patients underwent endoscopic groin dissection for inguinal lymphadenectomy. The indications for dissection were cutaneous malignancies of the genitourinary area and lower extremities. Endoscopic dissection was performed as previously published. Data were prospectively collected regarding patient demographics and minor/major complications during the perioperative period as well as long-term complications during 1 year. Complications were described using the Clavien classification as well as other complication profiles for open inguinal lymphadenectomy. Minor complications were defined as mild to moderate leg edema, seroma formation not requiring aspiration, minimal skin edge necrosis requiring no therapy and cellulitis managed with antibiotics. Major complications included death, sepsis, venous thromboembolism, re-exploration or other invasive procedures, severe leg edema interfering with ambulation, skin flap necrosis and rehospitalization. RESULTS: A total of 41 endoscopic groin dissections (12 single session bilateral) were performed in 29 patients. Patient characteristics were median body mass index 30 kg/m(2) (range 19 to 53, mean 31.1), median age 61 years (range 16 to 86), median Charlson comorbidity score 4 (range 1 to 11) and median length of stay 1 day (range 1 to 14). Median followup was 604 days (range 177 to 1,172, mean 634). There were no perioperative mortalities. A total of 11 (27%) minor and 6 (14.6%) major complications occurred. CONCLUSIONS: Complications from endoscopic minimally invasive lymphadenectomy have low clinical morbidity. Analysis of the immediate and long-term complication profile using standardized Clavien complications reporting reveals that this procedure is safe, even in patients with a high Charlson comorbidity score and body mass index. Major complications were most often infection requiring intravenous antibiotics.

Same setting laparoscopic antegrade continence enema and antegrade bladder neck injection for constipation and urinary incontinence in the spina bifida population.

PURPOSE: Fecal impaction and urinary incontinence and are among the most important problems in patients with spina bifida. We report our preliminary results with a minimally invasive approach to these 2 problems, that is same setting laparoscopic antegrade continence enema and antegrade bladder neck injection. MATERIALS AND METHODS: We reviewed the charts of all patients who underwent same setting laparoscopic antegrade continence enema and antegrade bladder neck injection between January 1, 2006 and August 1, 2008. Demographic data, surgical indications, operative details and results were recorded. Surgical steps were uniform in all cases. Diagnostic laparoscopy was performed. Two additional 5 mm trocars were placed. The appendix was mobilized to reach skin in the right lower quadrant. The antegrade continence enema channel was matured. A small percutaneous cystotomy was then created via the suprapubic port site. The cystoscope was passed suprapubically and dextranomer/hyaluronic acid was injected in the bladder neck. A suprapubic tube was placed. RESULTS: We performed a total of 10 same setting laparoscopic antegrade continence enemas with antegrade bladder neck injection in 4 males and 6 females with a mean age of 9.4 years (range 6 to 13). All patients had a smooth walled bladder on cystogram, and good capacity, good compliance and low leak point pressure on urodynamics. There were no intraoperative complications and all patients were discharged home within 24 hours. At an average 18-month followup (range 12 to 27) all 10 patients were continent of stool and reported marked improvement in daily care. No patient experienced stool or gas leakage via antegrade bladder neck injection. Seven of 10 patients (70%) were continent of urine and no longer wore diapers. CONCLUSIONS: Same setting laparoscopic antegrade continence enema with antegrade bladder neck injection is a safe, efficacious, reasonably simple minimally invasive approach to severe constipation and urinary incontinence in patients with spina bifida.