Prospective Multicenter Evaluation of Pain Before and After Removal of Nonobstructing Renal Calculi: A CoRE Initiative.

PURPOSE: Flank pain associated with stone disease is typically caused by a stone that obstructs urine flow. However, it is plausible that nonobstructing kidney stones may still cause pain. We performed a multicenter, observational trial to evaluate whether treatment of small nonobstructing calyceal stones improves pain and kidney stone-specific health-related quality of life. MATERIALS AND METHODS: Patients aged 18 years or older with nonobstructing renal stone(s) up to 10 mm in longest diameter and moderate to severe pain were recruited. All participants completed 3 questionnaires: the Brief Pain Inventory (BPI), the Patient-Reported Outcomes Measurement Information System pain interference form 6a, and the Wisconsin Stone Quality of Life questionnaire. Thereafter, all participants underwent ureteroscopy for renal stone treatment. All 3 questionnaires were repeated at 2, 6 to 8, and at 12 weeks postprocedure. The primary outcomes were change in preoperative to 12-week postoperative mean BPI score and worst BPI pain score. RESULTS: A total of 43 patients with nonobstructing kidney stones and associated flank pain were recruited. All stones were removed. Preoperatively, BPI scores for mean pain and worst pain were 5.5 and 7.2, respectively which decreased to 1.8 and 2.8 respectively at 12 weeks postoperatively. Wisconsin Stone Quality of Life questionnaire mean score increased from 70.4 to 115.3 at 12 weeks postoperatively. A total of 86% and 69% of patients had at least a 20% and 50% reduction in their mean pain scores, respectively. CONCLUSIONS: This study determined that patients benefit significantly from the removal of calyceal nonobstructing kidney stones for at least 12 weeks with a reduction in pain and an increase in quality of life. Therefore, surgical removal of these stones in this patient population should be offered as a treatment option.

Robotic Simulation in Urologic Surgery.

Robotic surgery continues to revolutionize the field of urologic surgery, and thus it is crucial that graduating urologic surgery residents demonstrate proficiency with this technology. The large learning curve of utilizing robotic technology limits resident immediate participation in real-life robotic surgery, and skill acquisition is further challenged by variable case volume. Robotic simulation offers an invaluable opportunity for urologic trainees to cultivate strong foundational skills in a non-clinical setting, ultimately leading to both competence and operative confidence. Several different simulation technologies and robotic assessment protocols have been developed and demonstrate validity in several domains. However, despite their demonstrable utility, there is no formal robotic curricula within US urologic surgery residencies. In this article, we will review the current state of robotic simulation training in urologic surgery and highlight the importance of its widespread utilization in urologic surgery residency training programs.

Development of an Automated Composite Ureteroscopic Efficiency Score Through Simulated Ureteroscopic Skills Assessment.

Introduction: Flexible ureteroscopy (fURS) is the most common procedure for treatment of urolithiasis. We previously utilized kinematic evaluations of simulated fURS to demonstrate that certain body movements are associated with efficient ureteroscopic manipulation for complex tasks. In this study, we incorporated computer vision to create an efficiency score using the ureteroscope travel distance (DIST), task time (TIME), spectral arc length (SPARC), and percentage of purposeful wall collisions (COLL). The goal is a simulation-based system that can abstract these automated performance metrics (APMs) to differentiate between novice and expert ureteroscope handling. Methods: A ureteroscopic simulation box was used. Body kinematics, task time, and ureteroscopic movements were analyzed using a motion capture system and video camera. Optical flow computer vision was used to track the ureteroscope. DIST, TIME, and SPARC were automatically calculated. Wall collisions were automatically captured and independently judged by two authors; an algorithm was developed to automatically determine the COLL variable. A mixed-effects model was used to aggregate these variables and distinguish between surgeons' first and final task attempts. Normalized values of these metrics were added to create a composite ureteroscopic efficiency score (CUES). Results: Twelve urologists completed the simulated tasks. The COLL assessment algorithm determined beneficial wall collisions with an accuracy of 77%. Normalized values of TIME, DIST, SPARC, and COLL were combined to create a composite ureteroscopic efficiency score (CUES). Compared with the first attempt, both the second and third attempts showed statistically significant improvements in CUES. The ROC-AUC score reached 0.86, suggesting excellent discrimination between attempts. There was also a statistically significant difference in CUES when comparing resident and attending performance. Conclusions: APMs can be abstracted using computer vision and artificial intelligence; an aggregate composite score (CUES) may be a promising method for evaluation of ureteroscopic efficiency.

Feasibility of multi-section continuum robotic ureteroscope in the kidney.

Our objective was to evaluate the feasibility of a multi-section continuum robotic ureteroscope to address the difficulties with access into certain renal calyces during flexible ureteroscopy. First, the robotic ureteroscope developed in previous research, which utilizes three actuated bendable sections controlled by wires, was modified for use in this project. Second, using phantom models created from five randomly selected computer tomography urograms, the flexible ureteroscope and robotic ureteroscope were evaluated, focusing on several factors: time taken to access each renal calyx, time taken to aim at three targets on each renal calyx, the force generated in the renal pelvic wall associated with ureteroscope manipulation, and the distance and standard deviation between the ureteroscope and the target. As a result, the robotic ureteroscope utilized significantly less force during lower pole calyx access (flexible ureteroscope vs. robotic ureteroscope; 2.0 vs. 0.98 N, p = 0.03). When aiming at targets, the standard deviation of proper target access was smaller for each renal calyx (upper pole: 0.49 vs. 0.11 mm, middle: 0.84 vs. 0.12 mm, lower pole: 3.4 vs. 0.19 mm) in the robotic ureteroscope group, and the distance between the center point of the ureteroscope image and the target was significantly smaller in the robotic ureteroscope group (upper: 0.49 vs. 0.19 mm, p < 0.001, middle: 0.77 vs. 0.17 mm, p < 0.001, lower: 0.77 vs. 0.22 mm, p < 0.001). In conclusion, our robotic ureteroscope demonstrated improved maneuverability and facilitated accuracy and precision while reducing the force on the renal pelvic wall during access into each renal calyx.

Promoting the use of the PI-QUAL score for prostate MRI quality: results from the ESOR Nicholas Gourtsoyiannis teaching fellowship.

OBJECTIVES: The Prostate Imaging Quality (PI-QUAL) score is a new metric to evaluate the diagnostic quality of multiparametric magnetic resonance imaging (MRI) of the prostate. This study assesses the impact of an intervention, namely a prostate MRI quality training lecture, on the participant's ability to apply PI-QUAL. METHODS: Sixteen participants (radiologists, urologists, physicists, and computer scientists) of varying experience in reviewing diagnostic prostate MRI all assessed the image quality of ten examinations from different vendors and machines. Then, they attended a dedicated lecture followed by a hands-on workshop on MRI quality assessment using the PI-QUAL score. Five scans assessed by the participants were evaluated in the workshop using the PI-QUAL score for teaching purposes. After the course, the same participants evaluated the image quality of a new set of ten scans applying the PI-QUAL score. Results were assessed using receiver operating characteristic analysis. The reference standard was the PI-QUAL score assessed by one of the developers of PI-QUAL. RESULTS: There was a significant improvement in average area under the curve for the evaluation of image quality from baseline (0.59 [95 % confidence intervals: 0.50-0.66]) to post-teaching (0.96 [0.92-0.98]), an improvement of 0.37 [0.21-0.41] (p < 0.001). CONCLUSIONS: A teaching course (dedicated lecture + hands-on workshop) on PI-QUAL significantly improved the application of this scoring system to assess the quality of prostate MRI examinations. KEY POINTS: • A significant improvement in the application of PI-QUAL for the assessment of prostate MR image quality was observed after an educational intervention. • Appropriate training on image quality can be delivered to those involved in the acquisition and interpretation of prostate MRI. • Further investigation will be needed to understand the impact on improving the acquisition of high-quality diagnostic prostate MR examinations.

The Uniform grading tooL for flexIble ureterorenoscoPes (TULIP-tool): a Delphi consensus project on standardised evaluation of flexible ureterorenoscopes.

OBJECTIVE: To develop a standardised tool to evaluate flexible ureterorenoscopes (fURS). MATERIALS AND METHODS: A three-stage consensus building approach based on the modified Delphi technique was performed under guidance of a steering group. First, scope- and user-related parameters used to evaluate fURS were identified through a systematic scoping review. Then, the main categories and subcategories were defined, and the expert panel was selected. Finally, a two-step modified Delphi consensus project was conducted to firstly obtain consensus on the relevance and exact definition of each (sub)category necessary to evaluate fURS, and secondly on the evaluation method (setting, used tools and unit of outcome) of those (sub)categories. Consensus was reached at a predefined threshold of 80% high agreement. RESULTS: The panel consisted of 30 experts in the field of endourology. The first step of the modified Delphi consensus project consisted of two questionnaires with a response rate of 97% (n = 29) for both. Consensus was reached for the relevance and definition of six main categories and 12 subcategories. The second step consisted of three questionnaires (response rate of 90%, 97% and 100%, respectively). Consensus was reached on the method of measurement for all (sub)categories. CONCLUSION: This modified Delphi consensus project reached consensus on a standardised grading tool for the evaluation of fURS - The Uniform grading tooL for flexIble ureterorenoscoPes (TULIP) tool. This is a first step in creating uniformity in this field of research to facilitate future comparison of outcomes of the functionality and handling of fURS.

Analysis of Flexible Ureteroscopic Motion and Kinematic Efficiency: A Simulation-Based Pilot Study.

Introduction: Flexible ureteroscopy (fURS) is the most common surgical procedure for treatment of urolithiasis. Various surgical disciplines and subspecialties have examined surgeon kinematics to improve assessment and generate measures of skill. Despite frequency of utilization, there is no undisputed method for evaluating fURS skills. Our pilot study utilized kinematic evaluations of fURS simulation to determine whether specific surgeon movements, techniques, and strategies correlate with measures of ureteroscopic (URS) efficiency. Methods: A motion capture system and standard video camera were employed to characterize surgeon movement variables. A URS simulation box was used by practicing urologists at various skill levels to perform a series of simple and complex URS movement tasks. Two tasks were chosen for this initial pilot analysis. Body kinematics, time to task completion, and URS movements were analyzed. Task efficiency was defined as quicker time to task completion and smaller ureteroscope end effector travel distance. A combined performance efficiency score (PES) was calculated using the root sum square of these two measures. Results: Twelve practicing urologists were enlisted. Average urologist age was 37 years with an average of 10.1 years of training; 50% were women, 50% were residents; and 33% had completed an Endourology fellowship. For the simple task, no kinematic data correlated with PES; for the complex task, participant head and torso movement correlated with PES (r = 0.60, p = 0.04 for head; r = 0.65, p = 0.02 for torso), with decreased body movement associated with higher efficiency. Conclusion: Our findings suggest that movement economy measures are associated with efficient URS manipulation for complex tasks. Decreased head and torso movement were associated with higher efficiency, suggesting that excess body movement may signal extraneous or improper URS movements. Additional assessment of these variables, including analysis in a clinical setting, is warranted as this may serve as a basis for improvement in endoscopic training and evaluation.

Assessment of conservative dietary management as a method for normalization of 24-h urine pH in stone formers.

Low urine pH is a metabolic risk factor for stone formation. While medical therapy is typically prescribed (as urinary alkalinization), patients typically prefer dietary modifications. We aimed to assess capacity to alter urine pH with dietary management alone. We analyzed a retrospective cohort of stone formers seen between 2000 and 2015 with multiple 24-h urine collections (24hUC). Patients ≥ 18 years old with low urine pH (< 6.0) were included; those prescribed alkalinizing agents or thiazides were excluded. Demographic data, 24hUC parameters, and medications were abstracted. 24hUC was utilized to calculate gastrointestinal alkali absorption (GIAA). The primary outcome was urine pH ≥ 6.0 on second 24hUC. Predictors were selected utilizing multivariable logistic regression. The database consisted of 2197 stone formers; 224 of these met inclusion criteria. On second 24hUC, 124 (55.4%) achieved a favorable pH ≥ 6.0. On univariable analysis, a second pH ≥ 6.0 was associated with high initial pH, low initial sulfate, younger age, increase in citrate/GIAA/urine volume, and decrease in ammonium (P < 0.02). On multivariable analysis, high initial pH (OR = 23.64, P < 0.001), high initial GIAA (OR = 1.03, P = 0.001), lower initial sulfate (OR = 0.95, P < 0.001), increase in urine volume (OR = 2.19, P = 0.001), increase in GIAA (OR = 8.6, P < 0.001), increase in citrate (OR = 2.7, P = 0.014), decrease in ammonium (OR = 0.18, P < 0.001), and younger age (OR = 0.97, P = 0.025) were associated with a second pH ≥ 6.0. The analysis demonstrated a corrected AUC of 0.853. These data suggest that certain dietary recommendations (increases in urine volume, citrate, GIAA, and decreased acid load) may normalize urine pH in a select group of patients. This may allow urologists to counsel patients with low urine pH on possibility of success with dietary modification alone.

Emerging Technologies in Ultrasonic and Pneumatic Lithotripsy.

Percutaneous nephrolithotomy is the treatment of choice for large renal stones. Larger, straight access tracts allow for use of rigid pneumatic and ultrasonic lithotripsy devices. Through advanced technologies, more efficient fragmentation has become possible, allowing for a variety of treatment options depending on stone location, size, and composition. As novel methods of lithotripsy enter the clinical sphere, it is a requirement that the operating urologist understand the available surgical options and the associated mechanisms used to best treat their patients. This article discusses the mechanisms of basic pneumatic and ultrasonic devices, and examines the data regarding current and novel combination lithotrites.

An in vitro evaluation of laser settings and location in the efficiency of the popcorn effect.

To examine different locations and laser settings' effects on the efficiency of the "popcorn" method of laser lithotripsy, which consists of placing the laser in a group of small stones and firing continuously to break them into smaller particles. Pre-fragmented BegoStones were created between 2 and 4 mm to mimic typical popcorning conditions. A 0.5 g collection of fragments was placed into 3D-printed models (a spherical calyx and ellipsoid pelvis model) and a 200-µm laser fiber was positioned above the stones. The laser was fired for 2 min with irrigation, with 5 trials at each setting: 0.2 J/50 Hz, 0.5 J/20 Hz, 0.5 J/40 Hz, 1 J/20 Hz, 0.2 J/80 Hz, 0.5 J/80 Hz. After drying, fragmentation efficiency was determined by calculating the mass of stones reduced to sub-2 mm particles. Statistical analysis was performed with ANOVA and Student's t test. The trials within the calyx model were significantly more efficient compared to the pelvis (0.19 vs 0.15 g, p = 0.01). When comparing laser settings, there was a difference between groups by one-way ANOVA [F(5,54) = 8.503, p = 5.47 × 10-6]. Post hoc tests showed a power setting of 0.5 J/80 Hz was significantly more efficient than low-power settings 0.2 J/50 Hz and 0.5 J/20 Hz (p < 0.05). Additionally, 0.2 J/50 Hz was significantly less efficient than 0.5 J/40 Hz, 1 J/20 Hz, and 0.2 J/80 Hz. Popcorning is most efficient in smaller spaces; we recommend displacement of stones into a calyx before popcorning. No difference was seen between high-power settings, although 0.5 J/40 Hz and 0.5 J/80 Hz performed best, suggesting that moderate energy popcorning methods with at least 0.5 J per pulse are most efficient.

Psychiatric Diagnoses and Other Factors Associated with Emergency Department Return within 30 Days of Ureteroscopy.

PURPOSE: Emergency department visits after ureteroscopy are costly and inconvenient. To better understand those at risk we aimed to identify patient demographic, medical and surgical factors associated with 30-day emergency department presentation following ureteroscopy for urolithiasis with particular attention to those with a history of a psychiatric diagnosis. MATERIALS AND METHODS: We retrospectively reviewed 1,576 cases (1,395 adults) who underwent stone related ureteroscopy during 3 years at a total of 2 hospitals. We collected patient demographics, medical history and operative details. The primary outcome was return to the emergency department within 30 days of ureteroscopy. Logistic regression was performed to examine factors associated with emergency department presentation. RESULTS: Of the patients 613 (43.9%) had a history of psychiatric diagnosis. Of those with ureteroscopy encounters 12.6% returned to the emergency department within 30 days of ureteroscopy, including 58.8% with a history of psychiatric diagnosis. On multivariable analysis variables associated with emergency department return included a history of psychiatric diagnosis (OR 1.57, p = 0.012), uninsured status (OR 2.46, p = 0.001) and a stone only in the kidney (OR 1.76, p = 0.022). Patients who returned to the emergency department had had more emergency department visits in the year prior to surgery (OR 1.40, p <0.001). On univariable analysis older patients and those with longer operative time were more frequently admitted from the emergency department (OR 1.03, p = 0.002 and OR 1.96, p = 0.03. respectively) while uninsured patients were admitted less frequently (OR 0.19, p = 0.013). No difference was noted in admissions between those with a psychiatric diagnosis and all others (60.7% vs 55.8%, p = 0.48). CONCLUSIONS: We identified factors associated with emergency department return after ureteroscopy, including a history of psychiatric diagnosis, uninsured status and emergency department visits in the year before surgery. These patients may benefit from targeted interventions to help avoid unnecessary emergency department visits.

Let's Get to the Point: Comparing Insertion Characteristics and Scope Damage of Flat-Tip and Ball-Tip Holmium Laser Fibers.

INTRODUCTION: A ball-tip holmium laser fiber (TracTip; Boston Scientific) has been developed to theoretically reduce damaging friction forces generated within a ureteroscope working channel. We compared the insertional forces and damage with a ureteroscope inner lining when inserting standard flat-tip and ball-tip laser fibers. MATERIALS AND METHODS: A standard ureteroscope channel liner was placed in a 3D-printed plastic mold. Molds were created at four angles of deflection (30°, 45°, 90°, and 180°) with a 1 cm radius of curvature. New 200 µm ball-tip (TracTip; Boston Scientific) and 200 µm flat-tip (Flexiva; Boston Scientific) laser fibers were advanced through the liner using a stage controller. A strain gauge was used to measure force required for insertion. Each fiber was passed 600 times at each angle of deflection. The ureteroscope liner was changed every 150 passes. Leak testing was performed every 50 passes or when the insertional force increased significantly to assess damage to the liner. RESULTS: At all deflection angles, the average insertional force was significantly lower with the ball-tip laser fibers compared with flat-tip laser fibers (p < 0.001). All trials with the ball-tip lasers were completed at each angle without any leaks. Two of four trials using flat-tip fibers at 45° deflection caused liner leaks (at 91 and 114 passes). At 90° deflection, all flat-tip trials caused liner leaks on first pass. The 180° trials could not physically be completed with the flat-tip laser fiber. Within the flat- and ball-tip groups, an increasing amount of force was needed to pass the fiber as the degree of deflection increased (p < 0.001). CONCLUSIONS: The ball-tip holmium laser fiber can be safely passed through a deflected ureteroscope without causing liner perforation. The standard flat-tip fiber requires greater insertion force at all angles and can cause the ureteroscope liner to leak if it is deflected 45° or more.

Defining metabolic activity of nephrolithiasis - Appropriate evaluation and follow-up of stone formers.

Considering the variation in metabolic evaluation and medical management of kidney stone disease, this consensus review was created to discuss the metabolic activity of nephrolithiasis, define the difference between single and recurrent stone formers, and develop a schema for metabolic and radiologic follow-up. A systematic review of the literature was performed to identify studies of metabolic evaluation and follow-up of patients with nephrolithiasis. Both single and recurrent stone formers share many similarities in metabolic profiles. The study group determined that based on an assessment of risk for stone recurrence and metabolic activity, single and recurrent stone formers should be evaluated comprehensively, including two 24 h urine studies on a random diet. Targeted medication and dietary recommendations are effective for many patients in reducing the risk of stone recurrence. Follow-up of those with stone disease should be obtained depending on the level of metabolic activity of the patient, the risk of chronic kidney disease and the risk of osteoporosis/osteopenia. A standard scheme includes a baseline metabolic profile, a repeat study 3-6 months after initiation of treatment, and then yearly when stable, with abdominal imaging obtained every 1-2 years.

Antibiotic Utilization Before Endourological Surgery for Urolithiasis: Endourological Society Survey Results.

INTRODUCTION: Ureteroscopy (URS) and percutaneous nephrolithotomy (PCNL) are common procedures performed to treat kidney stones. Despite advances in technology/technique, serious infectious complications can occur. To better understand the preoperative antibiotic administration patterns and adherence to guidelines from the American Urological Association (AUA) and the European Association of Urology (EAU), members of the Endourological Society were sent a clinical vignette-based survey to assess the antibiotic use in a variety of pre-URS and pre-PCNL scenarios. METHODS: Endourological Society members were e-mailed a survey that queried antibiotic therapy duration before uncomplicated URS and PCNL with negative and asymptomatic positive preoperative urine cultures (PUCs). For negative PUC questions, selecting more perioperative antibiotics was considered a "prolonged" course as it extends past the maximum of 24-hour perioperative prophylaxis recommended by both the AUA and EAU. RESULTS: The response rate was 16.3% for a total of 326 responders. Twenty-one percent to 39% of respondents reported giving prolonged courses of preoperative antibiotics before a URS or PCNL with a negative PUC (p < 0.0001). When presented with a negative PUC, more prolonged antibiotic courses were reported with the following hierarchy: PCNL for 2 cm intrarenal stones (39%) > URS for 12 mm renal pelvis stone (28%) > URS for 7 mm distal ureteral stones (21%) (p < 0.0001). In both negative and positive PUC questions, differences were noted in preoperative antibiotic prescribing patterns among site of practice (United States, Canada, Europe, Asia, South America, and Others), type of practice (academic vs all others), years in practice (<10 or ≥10 years), and surgical volume (URS and PCNL >100 or ≤100 annual cases). CONCLUSIONS: Adherence to guidelines on antibiotic administration before PCNL and URS with a negative PUC varies by scenario and provider. In 21% to 39% of negative PUC cases, reported antibiotic use before a URS or PCNL is not consistent with recommendations from the AUA and EAU. Before a positive PUC URS or PCNL, nearly all surveyed provide preoperative antibiotics; however, the regimen length is variable.

Abdominal Radiography With Digital Tomosynthesis: An Alternative to Computed Tomography for Identification of Urinary Calculi?

OBJECTIVE: To compare the accuracy of plain abdominal radiography (kidneys, ureter, and bladder [KUB]) with digital tomosynthesis (DT) to noncontrast computed tomography (NCCT), the gold standard imaging modality for urinary stones. Due to radiation and cost concerns, KUB is often used for diagnosis and follow-up of nephrolithiasis. DT, a novel technique that produces high-quality radiographs with less radiation and/or cost than low-dose NCCT, has not been assessed in this situation. MATERIALS AND METHODS: Seven fresh tissue cadavers were implanted with stones of known size and/or composition and imaged with KUB, DT, and NCCT. Four blinded readers (2 urologists, 2 radiologists) evaluated KUBs for presence and/or location of calculi. They then re-evaluated with addition of tomograms to assess additional value. After a memory extinction period, readers evaluated NCCT images. Accuracy of detection was determined using nearest-neighbor match with generalized linear mixed modeling. RESULTS: Total of 59 stones were identified on reference read. Overall, NCCT and DT were both superior to KUB alone (P < .001) while the difference between DT and NCCT was not significant (P = .06). When evaluating uric acid stones, NCCT and DT outperformed KUB (P < .01 and P < .05, respectively) while DT and NCCT were similar (P = .16). Intrarenal stones were better evaluated on DT and NCCT (P < .001 compared to KUB), while DT and NCCT were similar (P = 1.00). Accuracy was lower than anticipated across modalities due to use of the cadaver model. CONCLUSION: Our study demonstrates DT is superior to KUB for identification of intrarenal calculi and could replace routine use of KUB or NCCT for detecting renal stones, even those composed of uric acid.

In Vitro Comparison of a Novel Single Probe Dual-Energy Lithotripter to Current Devices.

PURPOSE: The LithoClast Trilogy is a novel single probe, dual-energy lithotripter with ultrasonic (US) vibration and electromagnetic impact forces. ShockPulse and LithoClast Select are existing lithotripters that also use a combination of US and mechanical impact energies. We compared the efficacy and tip motion of these devices in an in vitro setting. MATERIALS AND METHODS: Begostones, in the ratio 15:3, were used in all trials. Test groups were Trilogy, ShockPulse, Select ultrasound (US) only, and Select ultrasound with pneumatic (USP). For clearance testing, a single investigator facile with each lithotripter fragmented 10 stones per device. For drill testing, a hands-free apparatus with a submerged balance was used to apply 1 or 2 lbs of pressure on a stone in contact with the device tip. High-speed photography was used to assess Trilogy and ShockPulse's probe tip motion. RESULTS: Select-USP was slowest and Trilogy fastest on clearance testing (p < 0.01). On 1 lbs drill testing, Select-US was slowest (p = 0.001). At 2 lbs, ShockPulse was faster than Select US (p = 0.027), but did not significantly outpace Trilogy nor Select-USP. At either weight, there was no significant difference between Trilogy and ShockPulse. During its US function, Trilogy's maximum downward tip displacement was 0.041 mm relative to 0.0025 mm with ShockPulse. Trilogy had 0.25 mm of maximum downward displacement during its impactor function while ShockPulse had 0.01 mm. CONCLUSIONS: Single probe dual-energy devices, such as Trilogy and ShockPulse, represent the next generation of lithotripters. Trilogy more efficiently cleared stone than currently available devices, which could be explained by its larger probe diameter and greater downward tip displacement during both US and impactor functions.

Effect of Malnutrition on Radical Nephroureterectomy Morbidity and Mortality: Opportunity for Preoperative Optimization.

INTRODUCTION: Nutritional status has been increasingly recognized as an important predictor of prognosis and surgical outcomes for cancer patients. We evaluated the effect of preoperative malnutrition on the development of surgical complications and mortality after radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC). MATERIALS AND METHODS: Using data from the American College of Surgeons National Surgical Quality Improvement Program, we evaluated the association of poor nutritional status with 30-day postoperative complications and overall mortality after RNU from 2005 to 2015. The preoperative variables suggestive of poor nutritional status included hypoalbuminemia (< 3.5 g/dL), weight loss within 6 months before surgery (> 10%), and a low body mass index. RESULTS: A total of 1200 patients were identified who had undergone RNU for UTUC. The overall complication rate was 20.5% (n = 246), and mortality rate was 1.75% (n = 21). On univariate analysis, patients who experienced a postoperative complication were more likely to have hypoalbuminemia (25.0% vs. 11.4%; P < .001) and weight loss (3.7% vs. 1.0%; P = .003). After controlling for baseline characteristics and comorbidities, hypoalbuminemia was found to be a significant independent predictor of postoperative complications (odds ratio, 2.09; 95% confidence interval, 1.29-3.38; P = .003). Hypoalbuminemia was also a significant independent predictor of mortality (odds ratio, 4.31; 95% confidence interval, 1.45-12.79; P = .008) on multivariable regression analysis. CONCLUSION: Our results have shown that hypoalbuminemia is a significant predictor of surgical complications and mortality after RNU for UTUC. This finding supports the importance of patients' preoperative nutritional status in this population and suggests that effective nutritional interventions in the preoperative setting could improve patient outcomes.

Effect of Laser Settings and Irrigation Rates on Ureteral Temperature During Holmium Laser Lithotripsy, an In Vitro Model.

PURPOSE: Ureteroscopic laser lithotripsy requires irrigation for adequate visualization and temperature control during treatment of ureteral stones. However, there are little data on how different irrigation and laser settings affect the ureteral wall and surrounding tissues. This effect has become an important consideration with the advent of high-powered lasers. We therefore evaluated the effect of laser settings and irrigation flow on ureteral temperature in an in vitro setting. MATERIALS AND METHODS: To mimic ureteroscopic laser lithotripsy, we simulated clinically relevant irrigation flow rates and fired a Holmium:Yttrium-aluminum-garnet (Ho:YAG) laser while monitoring "intraureteral" temperature. The probe tip of a thermometer was placed 1 mm from the tip of a 200 µm laser fiber, which was fired for 60 seconds at 0.2 J/50 Hz, 0.6 J/6 Hz, 0.8 J/8 Hz, 1 J/10 Hz, and 1 J/20 Hz within a tubing system that allowed for specified room temperature flow rates (100, 50, and 0 mL/minute). We recorded temperatures every 5 seconds. The maximum temperature was noted, and each laser/flow trial was duplicated. Averaged maximum temperatures were compared using analysis of variance across irrigation settings. RESULTS: At 100 cc/minute, only the 1 J/20 Hz laser setting produced a significantly higher maximum temperature (p < 0.01), although this finding was not clinically significant at a maximum of 30.7°C. At a lower irrigation rate of 50 cc/minute, the 1 J/20 Hz setting was again the only significantly higher maximum temperature (p < 0.05), although this temperature crossed the toxic threshold at a maximum of 43.4°C. With no flow, all maximum temperatures reached over 43°C, with 0.8 J/8 Hz, 1 J/10 Hz, and 1 J/20 Hz each statistically higher than the lower-energy settings (p < 0.05). The maximum temperature at 1 J/20 Hz with no irrigation was over 100°C. CONCLUSIONS: Despite increasing laser settings, adequate irrigation can maintain relatively stable temperatures within an in vitro ureteral system. As irrigation rates decrease, even lower power laser settings produce a clinically significant increase in maximum temperature, potentially causing ureteral tissue injury.

Percutaneous nephrolithotomy: complications and how to deal with them.

Percutaneous nephrolithotomy is a common surgical treatment for large and complex stones within the intrarenal collecting system. A wide variety of complications can result from this procedure, including bleeding, injury to surrounding structures, infection, positioning-related injuries, thromboembolic disease, and even death. Knowledge of the different types of complications can be useful in order to prevent, diagnose, and treat these problems if they occur. This review describes the diversity of complications with the goal of improving their avoidance and treatment.