Adherence to AUA guidelines for the work-up, medical management, surgical evaluation and treatment of BPH: Work from a quality improvement collaborative.

INTRODUCTION: Previous studies noted varied adherence to clinical practice guidelines (CPGs), but studies are yet to quantify adherence to American Urological Association BPH guidelines. We studied guideline adherence in the context of a new quality improvement collaborative (QIC). METHODS: Data were collected as part of a statewide QIC. Medical records for patients undergoing select CPT codes from January 2020 to May 2022 were retrospectively reviewed for adherence to selected BPH guidelines. RESULTS: Most men were treated with transurethral resection of the prostate. Notably, 53.3% of men completed an IPSS and 52.3% had a urinalysis. 4.7% were counseled on behavioral modifications, 15.0% on medical therapy, and 100% on procedural options. For management, 79.4% were taking alpha-blockers and 59.8% were taking a 5-ARI. For evaluation, 57% had a PVR, 63.6% had prostate size measurement, 37.4% had uroflowmetry, and 12.3% were counseled about treatment failure. Postoperatively, 51.6% completed an IPSS, 57% had a PVR, 6.50% had uroflowmetry, 50.6% stopped their alpha-blocker, and 75.0% stopped their 5-ARI. CONCLUSIONS: There was adherence to preoperative testing recommendations, but patient counseling was lacking in the initial work-up and preoperative evaluation. We will convey the data to key stakeholders, expand data collection to other institutions, and devise an improvement implementation plan.

Any Questions? Understanding the Functional Health Literacy in Patients Who Underwent Ureteroscopy.

OBJECTIVE: To correlate health literacy of patients undergoing ureteroscopy and identify gaps within current patient education practices in order to better tailor the preoperative experience. METHODS: Eighteen patients were retrospectively recruited to complete an in-depth semistructured interview and the Test of Functional Health Literacy for Adults (TOFHLA). All interviews were recorded, transcribed, and then coded and analyzed using the grounded theory of analysis. RESULTS: The average participant age was 56.2 ± 12.8years, and 10 (55.6%) identified as female. Education level ranged from some high school to a professional degree. The average TOFHLA score was 88.1 ± 11.7. Irrespective of score, all participants felt they understood the purpose and basic elements of a ureteroscopy. The use of nontechnical language, repetition, and previous healthcare experiences were identified as positive aspects of the education experience. However, 72.2% (n = 13) identified the primary gap in understanding revolved around the use, purpose, and pain associated with stents. CONCLUSION: Functional health literacy is an essential element, but not the only factor informing patient education and comprehension. Current practices are effective in explaining the basics of a ureteroscopy, but even when identified health literacy is higher than expected, a gap remains in stent education. Efforts should be made to better understand how stents can be effectively explained to patients in addition to continuing to refine education practices to elicit true comprehension.

Influencing Factors of Preference Signaling in the 2022 Urology Residency Match.

OBJECTIVE: To evaluate influencing factors of preference signaling (PS) among urology residency applicants during the 2022 American Urological Association (AUA) Match. METHODS: We emailed an anonymous, deidentified questionnaire survey to applicants to our institution for the 2022 AUA Match. The main question asked to applicants was "What factor(s) went into your decision to send 'Program X' a preference signal?" Certain questions allowed the selection of multiple options, and applicants were further asked to specify these by selecting a single most important option. Descriptive statistical analyses were conducted using IBM SPSS software. RESULTS: Out of 601 registrants to the AUA match, 324 individuals applied to our institution and therefore received a survey; 77 responded for a 24% response rate. A total of 383 PS were sent by the 77 applicants. Overall, 73% and 49% of the total 383 PS had program location and reputation, respectively, selected as an influencing factor. More than 1 influencing factor was considered in 73% of PS selections, with program location (45%) considered the most important factor. In relation to applicant competitiveness, 35% of PS were sent to perceived "target" programs, 31% to "reach" programs, and 8% to "safety" programs. Among respondents who matched, 75% matched at a home, away, or signaled program. CONCLUSION: Program location appears to be the most influential factor in sending a program a PS. Programs were also signaled based on applicant's perception of their own competitiveness. PS appears to have a possible beneficial impact on obtaining interviews and successfully matching.

Demographic disparities of penile cancer in Appalachian Kentucky.

INTRODUCTION: Appalachian Kentucky is a region characterized by poor healthcare literacy and access. We investigate the disparities in demographic distribution and outcomes of penile squamous cell carcinoma (pSCC) in rural Kentucky. MATERIALS AND METHODS: Data were retrieved for patients with pSCC from 1995-2015 from the Kentucky Cancer Registry and the Surveillance, Epidemiology and End Results Program (SEER) and were used to investigate differences between Appalachian Kentucky and the remainder of the state and country. RESULTS: The incidence of pSCC from 1995-2015 in Appalachian Kentucky was over 60% higher than non-Appalachian regions (2.6 vs. 1.6 cases/100,000 people). Nearly 40% were from Appalachian counties. They presented with similar grade and pT stage at diagnosis but were more likely to have pN+ disease (p < 0.001). Rates of cancer-specific mortality (CSM) were similar between the two regions, but patients with CSM exhibited shorter survival interval from diagnosis in Appalachia (median 20 vs. 26 months, p = 0.016). Compared to national SEER data, patients from Appalachian Kentucky presented with similar grade and stage but exhibited higher rates of CSM (24.0% vs. 20.1%, p = 0.029). African Americans (AA) comprised only 5% of patients but exhibited high pathologic stage at presentation (p = 0.041) and shorter survival intervals (median 12 vs. 23 months, p = 0.023) compared to Caucasians. CONCLUSIONS: There is a disproportionately high rate of pSCC in Appalachian Kentucky. Both Appalachian and AA men exhibited more advanced disease at presentation and shorter survival, identifying socioeconomic and racial disparities which can be targeted to improve outcomes in high risk individuals.

Identifying a Break in the Chain: An Analysis of Where Ureteroscope Damage Occurs in the Hospital Cycle.

OBJECTIVE: To assess the timing and variables associated with damage to flexible ureteroscopes (fURS) at our institution. Flexible ureteroscopy is an important modality in the treatment of benign and malignant conditions of the upper urinary tract. While the durability and versatility of fURS have improved considerably, repair costs remain high and time out of commission diminishes workflow. After purchasing new digital fURS, we studied how and when these instruments were being damaged. MATERIALS AND METHODS: Between September 1, 2017 and June 30, 2018, we performed leak testing on fURS both before and after use. We gathered intraoperative data related to the user, the surgical indication, and the associated tools used in all cases that employed a digital or fiber optic fURS. Categorical and continuous variables were analyzed to identify risk factors for intraoperative fURS damage. RESULTS: During the study period, complete data was gathered for 281 cases. Twenty-two fURS failed leak testing indicating an overall leak failure rate of 7.8%. Of these, 15 failed leak testing preoperatively indicating nonoperative damage occurring sometime during transport, handling, or sterile processing. The other 7 failures occurred during the procedures. No intraoperative variables were significantly associated with failures. CONCLUSION: Our institutional leak failure rate is 8% (22/281). The majority of these failures did not occur during surgery. Of the 7 that occurred during surgery, larger stone burden and higher wattage showed mild association. Ongoing evaluation will target minimizing fURS damage outside of the operating room.

Implementing a Root Cause Analysis Program to Enhance Patient Safety Education in Urology Residency.

OBJECTIVE: To describe and assess the implementation and effectiveness of a RCA based program in Urology residency. The Accreditation Council for Graduate Medical Education states programs should encourage patient safety (PS) and provide formal PS education. However, data suggests most programs fall short. Root Cause Analysis (RCA) has been established as an effective method for event analysis and PS. METHODS: A RCA program was designed to analyze and discuss PS events in our department. This began with an educational session about RCA methodology. Subsequently, teams composed of faculty and residents were charged with selecting an adverse event to present at our monthly PS conference. Over a 6-month period, each team presented a recent complication, event timeline, and fish bone diagram. RESULTS: A RCA was completed and presented following adverse outcomes: fascial dehiscence, neonatal urosepsis, superior mesenteric artery ligation, pyelonephritis after ureteroscopy, and surgical site infection. Quantitative peer assessment of the presentations demonstrated aptitude in selecting an appropriate case (mean Likert scale score of 4.8/5), prioritizing important factors (score: 4.85), defining root causes (score: 4.9/5), and proposing solutions (score: 4.65/5). The qualitative feedback assessment noted the value of critical thinking to reduce complications, with the greatest limitation being time constraints. In addition, suggestions for improving the process included inclusion of ancillary staff involvement and selection of topics with modifiable solutions. CONCLUSION: RCA can be used as an educational tool for practice-based learning and improvement education. The program was well received and will continue in our department.

Increased Operative Duration of Minimally Invasive Prostatectomy is Associated with Significantly Increased Risk of 30-Day Morbidity.

INTRODUCTION: We examined the effect of operative duration on morbidity in minimally invasive radical prostatectomy. Operative duration has been shown to be a risk factor for negative outcomes in multiple surgical procedures but minimal data exist regarding urological procedures. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried by CPT code from 2011 to 2016. Standard NSQIP morbidities were used. Univariable and multivariable analysis was performed to determine risk factors for complications. RESULTS: A total of 35,105 patients were studied. Operative duration was broken into deciles, by minutes. Several variables were significantly associated with operative duration. The values stated represent variables in the shortest and longest deciles, respectively, including body mass index 27.6 kg/m2 and 29.7 kg/m2, diabetes 11.6% of patients and 14.7%, and smoking 12.5% of patients and 14.5%. Several morbidities were significantly associated with operative duration, with shortest and longest deciles reported respectively, including complications 4.1% and 9.9%, surgical site infection 0.6% and 1.9%, transfusion 0.9% and 3.2%, sepsis 0.3% and 1.2%, pulmonary embolism/deep vein thrombosis 0.6% and 1.8%, renal insufficiency 0.2% and 1.1%, and urinary tract infection 1.5% and 2.9%. The longest 3 deciles were significantly more likely to have complications with increasing odds ratios with increasing operative duration, with an adjusted OR of 1.6, 1.7 and 2.3. CONCLUSIONS: Operative duration is an independent predictor of morbidity, even when adjusting for patient specific preoperative factors. Patients in the longest decile were more than twice as likely to have complications. Further study on ideal operative duration, such as nomograms, as well as causation of longer operative duration and ways to increase operating room efficiency is needed.

Increased Operative Duration in Minimally Invasive Partial Nephrectomy Is Associated with Significantly Increased Risk of 30-Day Morbidity.

Introduction: Operative duration (OD) is associated with complications but has been poorly studied in minimally invasive partial nephrectomy (MIPN). We seek to examine the relationship between OD and complications in MIPN. Methods: The American College of Surgeons National Surgical Quality Improvement Program database was queried from 2011 to 2016 by CPT code. Risk factors for complications were determined using univariable and multivariable analysis. Results: In all, 12,018 patients were examined. OD was broken into deciles, ∼1200 patients in each, by minutes, <111, 111 to 131, 132 to 149, 159 to 164, 165 to 180, 181 to 196, 197 to 215, 216 to 238, 239 to 276, >276. Variables significantly associated with OD (values stated are shortest and longest deciles, respectively) include: male 47.8% and 68.2% of patients; body mass index 28.5 and 31.3 kg/m2; diabetes 13.4% and 23.7%; smoking 20.4% and 22.0%; taking medication for hypertension 53.1% and 64.2%. Morbidities significantly associated with OD (shortest and longest deciles reported, respectively) include: complications 4.2% of patients and 14.2%; postoperative transfusion 1.3% and 7.8%; pulmonary embolism (PE)/deep vein thrombosis 0.5% and 1.2%; renal insufficiency 0.3% and 1.7%; cardiac arrest or stroke 0.3% and 1.4%. On multivariable analysis, patients with OD >180 minutes were significantly more likely to have complications odds ratio of 2.0, 2.3, 2.3, 3.2, and 3.7 for deciles 181 to 196, 197 to 215, 216 to 238, 239 to 276, >276, respectively, p < 0.001. Conclusions: Even when adjusting for patient-specific preoperative factors, OD is an independent predictor of significant morbidity. Patients in the longest decile were nearly four times as likely to have complications. Further study is needed to determine reasons for prolonged OD.

Assessment of Radiation Safety Knowledge Among Urology Residents in the United States.

Introduction: Urologists are increasingly exposed to fluoroscopy, which can cause cellular damage. Appropriate awareness and safety precautions concerning fluoroscopy are necessary and likely should be a focus during training. We sought to assess radiation safety knowledge among Urology residents in the United States. Methods: A 19-question survey was constructed to assess radiation safety training, knowledge, behavior, and attitudes. The survey was sent through REDCap™ (Research Electronic Data Capture) to all Urology program directors and coordinators in the United States with a request to distribute to their residents. The survey was closed after 3 weeks. Results: One hundred thirty-six urology trainees responded during the study period. Thirteen percent learned fluoroscopic radiation safety formally, 46% informally, 35% both informally and formally, and 6% no education. Forty-six percent reported radiation safety being part of their curriculum. When asked about directional X-ray travel and exposure, only 54% answered correctly. Regarding conditions related to radiation exposure, 94% believe infertility is potentially related, 83% cataracts, 93% leukemia and lymphoma, 57% central nervous system tumors, 77% birth defects, and 4% diabetes. Regarding protection, 9% wear lead-lined glasses, 30% dosimeters, 99% thyroid shields, 0% lead gloves, 97% lead apron, 26% lead shield, and 0% nothing. Regarding fluoroscopy machine settings, 7% knew the machine used was set to continuous, 73% pulse, and 21% were unsure. Sixty-six percent had awareness of the directional travel of the machine routinely used. Regarding safety techniques, 99% knew decreasing time and 100% knew wearing protective materials decrease exposure. However, when asked about distance and exposure, 55% answered incorrectly. Most respondents believe radiation safety is important (89%) and desire more formal education (64%). Conclusions: Trainees lack sufficient knowledge in several key areas regarding radiation safety. Formal education may be considered during training and is desired by trainees. This education is likely needed to ensure trainees learn methods to keep them safe during their career.

Examining and Understanding Value: The Impact of Preoperative Characteristics, Intraoperative Variables, and Postoperative Complications on Cost of Robot-Assisted Laparoscopic Radical Prostatectomy.

Introduction and Objective: Quality-based reimbursement continues to gain popularity as value-based care becomes more prominent. Our goal is to describe the impact of preoperative characteristics, intraoperative variables, and postoperative complications on the cost of robot-assisted laparoscopic radical prostatectomy (RALP). Materials and Methods: Using our institution's National Surgical Quality Improvement Program (NSQIP) data, we identified minimally invasive prostatectomies performed from January 2012 to March 2017. A retrospective chart review was done to collect perioperative data; financial data were collected from the business office. Results: Two hundred seventy-five patients were identified during this time period. Median total cost was $16,600 (interquartile range $15,100-$18,300), and median direct cost (DC) was $11,200 ($10,100-$12,400). Among preoperative characteristics, body mass index (BMI) ≥30 kg/m2, diabetes, hypertension, and blood urea nitrogen >21 were associated with increased DCs of $500, $500, $200, and $600, respectively (p < 0.05). American Society of Anesthesiologists (ASA) class III was associated with increased DC of $200 compared with ASA classes I-II (p < 0.05). Considering intraoperative characteristics, increasing operative times and estimated blood loss (EBL) were associated with increased DC (p < 0.001, p < 0.05, respectively). Occurrence of any postoperative complication was associated with increased DC of $1400 (p < 0.05). On multivariable analysis, a 1-U increase in BMI was associated with a $129 increase in DC (p < 0.001), a length of stay (LOS) greater than 3 days was associated with a $4099 increase in DC (p < 0.001), a 30-minute increase in operating room duration was associated with a $410 increase in DC (p < 0.05), any postoperative complication was associated with a $5397 increase in DC (p < 0.01), and treatment for diabetes was associated with a $1860 increase in DC (p < 0.05). Conclusion: BMI, diabetes, operative duration, EBL, LOS, and postoperative complications were associated with significantly increased DC of RALP. Understanding perioperative factors affecting cost contributes to understanding value in prostatectomy and improving quality in urologic care.

Assessment of Radiation Safety Knowledge among House Staff Exposed to Fluoroscopic Radiation.

INTRODUCTION: Urologists are increasingly exposed to fluoroscopy as minimally invasive techniques continue to proliferate. Fluoroscopy, or electromagnetic radiation, can cause cellular damage. Appropriate knowledge of safety precautions for fluoroscopy are necessary and ideally should be taught to physicians in training. METHODS: A 20-question survey was created to assess radiation safety training, knowledge, behavior and attitudes. The survey was sent via REDCap™ to house staff routinely involved in fluoroscopic cases, including urology, orthopedic surgery, neurosurgery, radiology, general surgery, anesthesia, plastic surgery, cardiology, vascular surgery, and gastroenterology residents and fellows. RESULTS: Of 218 participants 61 (28%) responded during the 3-week study period. Overall 57% reported learning fluoroscopic radiation safety informally, with 28% receiving informal as well as formal education. Concerning directional x-ray travel and exposure only 20% answered correctly. In terms of conditions potentially related to radiation exposure 86% selected infertility, 87% cataracts, 87% leukemia and lymphoma, 59% central nervous system tumors and 71% birth defects. Twenty percent wear lead lined glasses, 23% dosimeters, 92% thyroid shields, 2% lead gloves, 92% lead apron, 48% lead shield and 1.6% nothing. Of the respondents 49% were unsure if the machine was set to continuous or pulse. Ninety-eight percent knew decreasing time and 100% knew wearing protective materials were ways to decrease exposure. However, concerning distance and exposure only 56% answered correctly. The majority of respondents believe radiation safety is important and would like more formal education. CONCLUSIONS: Fluoroscopic radiation safety knowledge is low among house staff routinely exposed to fluoroscopy. Further study and likely increased formal education are warranted.

Examining and Understanding Value: The Cost of Preoperative Characteristics, Intraoperative Variables and Postoperative Complications of Minimally Invasive Partial Nephrectomy.

INTRODUCTION: As value based health care gains favor and reimbursement models move toward quality rather than quantity of care, a better understanding of cost and its predictors becomes increasingly important. We identified how preoperative characteristics, intraoperative variables and postoperative complications impact the cost of partial nephrectomy. METHODS: Our institution's ACS NSQIP® (American College of Surgeons National Surgical Quality Improvement Program) database was accessed for minimally invasive partial nephrectomy performed from January 2012 to March 2017. Perioperative and financial data were collected through retrospective chart review. Total cost and direct cost were analyzed relative to clinical variables. RESULTS: A total of 215 minimally invasive partial nephrectomies were included in the study. Median total cost was $17,000 and median direct cost was $11,500. Among preoperative characteristics age 56 to 65 years and diabetes were associated with an increased median direct cost of $2,000 and $800, respectively. ASA® (American Society of Anesthesiologists®) class III was associated with an increased direct cost of $1,400 compared to ASA class I-II. Among intraoperative variables increased operative duration was associated with increased direct cost. Robot-assisted cases increased direct cost by $3,000. Estimated blood loss greater than 250 cc was associated with an increased direct cost of $800. R.E.N.A.L. score did not affect cost parameters. Patients who experienced any postoperative complications had an increased direct cost compared to those who did not. Blood transfusions were associated with an increased direct cost of $3,700 and unplanned reintubation $14,500. On multivariable analysis age, operative duration, robot use and complications retained significance. CONCLUSIONS: Age, diabetes, ASA class, operative duration, estimated blood loss, robot use and postoperative complications are associated with increased cost. Increased understanding of cost predictors can be used to optimize perioperative care and value, and contribute to improved alternative reimbursement models.

Concomitant Renal Cell Carcinoma and Hematologic Malignancy in Immunosuppressed Patients.

OBJECTIVES: Treatment of a renal mass in patients with hematologic malignancy or on immunosuppression can be complex and is not well defined. Surgical excision or thermal ablation of renal mass is generally recommended in view of concern for tumor progression in immunosuppressed patients. We report our management decision experience in patients and literature review on concomitant renal and hematologic malignancy. MATERIALS AND METHODS: A retrospective medical record review of patients with renal cell carcinoma (RCC) and a hematologic malignancy over 3 years at our University Hospital was performed. Data were collected including patient׳s demographics, renal tumor and hematologic malignancy characteristics (stage, pathologic subtype, time of diagnosis, treatment type and prognosis). Surgical and medical management of each malignancy was reviewed and perioperative and overall outcomes are reported. RESULTS: In total, 6 patients were identified with RCC and a hematologic malignancy of which 4 were on immunosuppressive therapy. A total of 5 patients had leukemia and 1 patient had multiple myeloma. Most kidney tumors were stage I, 83%; and 80% were Fuhrman grade II. There was equal distribution of clear cell and papillary-type RCC. All but 1 patient had undergone nephron-sparing surgery. Overall, 50% of our patients died within 1 year after renal surgery for pT1a tumors from causes that are unrelated to renal cancer. CONCLUSIONS: Our small cohort showed significant mortality in patients with hematologic malignancy on immunosuppression, who had their renal mass treated with surgical excision or thermal ablation. However, this mortality was not secondary to surgical procedure itself. The prognosis of the hematologic malignancy might dictate the management of RCC.

Trends in the management of male urethral stricture disease in the veteran population.

OBJECTIVE: To evaluate the relative use of urethral dilation, urethrotomy, and urethroplasty for male stricture disease in the Veterans Affairs (VA) population and examine trends over time in this cohort. METHODS: A retrospective chart review was performed using the VA Informatics and Computing Infrastructure database to access the Corporate Data Warehouse. The current procedural terminology codes were used to define a cohort of all men who underwent procedures for urethral stricture disease between October 1999 and August 2013. RESULTS: A total of 92,448 procedures were performed: 50,875 urethral dilations (55.03%), 39,785 urethrotomies (43.03%), and 1788 urethroplasties (0.19%). Over the course of the study, there was a shift in the management of male stricture disease. The relative percentage of urethral dilations performed decreased in each quintile (71.27, 58.03, 45.61, 44.39, and 38.67). The relative percentage of urethrotomies increased in each quintile (27.89, 40.80, 52.18, 53.04, and 56.95) as did the relative percentage of urethroplasties performed (0.85, 1.17, 2.21, 2.57, and 4.38). A total of 80.4% of these urethroplasties were performed in locations with a residency program. CONCLUSION: Although urethroplasty is still underused, there is a trend toward increased use of urethroplasty for male urethral stricture disease in the VA population. The majority of urethroplasties were performed at VA medical centers in locations with a residency program. We predict continued increases in utilization of urethroplasty for male urethral stricture disease as the number of fellowship-trained reconstructive urologists increases.

Association of clinical and radiographic features with perinephric "sticky" fat.

BACKGROUND AND PURPOSE: The discovery of thick, adherent, perinephric sticky fat (PSF) is relatively common during open or laparoscopic retroperitoneal surgery. To our knowledge, however, there has been no previous analysis of clinical or radiographic features associated with the development of PSF or of perioperative outcomes for those patients in whom it is found. Our objective is to analyze potential predictive features and determine whether there is any effect on clinical or pathologic outcomes for patients with perinephric sticky fat. PATIENTS AND METHODS: Patients undergoing partial nephrectomy or laparoscopic cryoablation with available preoperative imaging were identified from 2005 to 2011. Operative records were reviewed to identify patients with and without PSF. Preoperative images and medical records were examined to obtain patient data regarding potential predictors as well as clinical and pathologic outcomes. RESULTS: A total of 29 patients were identified-16 with PSF and 13 controls. Statistically significant factors associated with PSF included sex, tumor size, presence of perinephric stranding, tumor >50% exophytic, and thickness of perinephric fat (P<0.05). Median total operative time for patients with sticky fat was nearly 40 minutes longer than the control group (228 min vs 190 min, P<0.05). All four (17%) patients with Fuhrman grade 3 or 4 renal-cell carcinoma were from the sticky fat group (P=0.09). CONCLUSIONS: Despite the small sample size, multiple possible factors associated with perinephric sticky fat were identified and may provide guidance for future investigation of this phenomenon.

Association of tumor size, location, R.E.N.A.L., PADUA and centrality index score with perioperative outcomes and postoperative renal function.

PURPOSE: Multiple scoring systems have been proposed to standardize the description of anatomical features of renal tumors. However, it remains unclear which of these systems, if any, is most useful, or whether any performs better than simply reporting tumor size or location in patients undergoing partial nephrectomy. To clarify these issues we evaluated the association of tumor size, location, R.E.N.A.L. (Radius/Exophytic/Nearness to collecting system/Anterior/Location), PADUA (Preoperative Aspects and Dimensions Used for an Anatomical classification) and centrality index scores with perioperative outcomes. MATERIALS AND METHODS: Patients undergoing partial nephrectomy with available preoperative imaging were identified from 2005 to 2011. R.E.N.A.L., PADUA and centrality index scores were assigned according to the described protocols for those systems. Associations between each variable and ischemia time, estimated blood loss, total operative time and change in estimated glomerular filtration rate were examined. RESULTS: A total of 162 patients were identified with a median tumor size of 3.1 cm (IQR 2.2 to 4.6). Median estimated blood loss, ischemia time and total operative time were 200 ml (IQR 100 to 300), 24 minutes (IQR 20 to 30) and 211 minutes (IQR 179 to 249), respectively. Each scoring system was found to have a statistically significant (p <0.001) correlation with ischemia time, with the centrality index system showing the strongest correlation. Furthermore, each of the scoring systems showed a stronger correlation with ischemia time than tumor size or tumor location. CONCLUSIONS: Each scoring system outperformed tumor size and location, and may be useful when describing the surgical complexity of renal tumors treated with partial nephrectomy.

Hand-assisted laparoscopic partial nephrectomy without formal collecting system closure: perioperative outcomes in 104 consecutive patients.

BACKGROUND AND PURPOSE: Laparoscopic partial nephrectomy (LPN) paralleling open techniques, particularly closure of the collecting system, can be technically challenging for the novice laparoscopist. We describe operative results and complications of a single surgeon, retrospectively reviewed series using a simplified method of hand assistance and a fibrin glue patch for hemostasis without formal collecting system closure. PATIENTS AND METHODS: We identified 104 consecutive patients between September 2003 and January 2009 who underwent hand-assisted laparoscopic partial nephrectomy (HALPN). Our technique involves routine hilar clamping after isolation of the tumor and mobilization of the kidney. After resection of the mass, a fibrin glue patch is placed within the surgical defect and secured with bolstering sutures. No attempt is made to suture the collecting system, nor are ureteral catheters placed when the collecting system is entered during resection of the tumor. RESULTS: Mean tumor size was 2.8 cm (median 2.5 cm, range 0.7-7.0 cm). With hilar clamping, warm ischemia time averaged 24.5 minutes (range 11-39 min). Estimated blood loss averaged 220 mL (range 50-1500 mL), and five (4.8%) patients received transfusions either intraoperatively or postoperatively. Urine leak occurred in 1.9% (n=2) of patients overall and 4.3% (2/47) of patients with documented collecting system entry. Both urine leaks resolved with conservative management only. CONCLUSIONS: HALPN without formal collecting system closure is a safe and effective technique with similar urine leak and transfusion rates compared with other series. This technique may allow more urologists to perform minimally invasive partial nephrectomy or to do so with potentially shorter ischemia times.

Novel approach for removal of heavily encrusted ureteral stent.

OBJECTIVES AND BACKGROUND: We describe a novel approach for removal of a retained, heavily encrusted ureteral stent via combined laparoscopic cystolithotomy and pyelolithotomy. Due to noncompliance, our patient with a history of nephrolithiasis returned with large proximal and distal stones 2.5 years after placement of a left ureteral stent. METHODS: Laparoscopy was performed using three 12 mm ports and two 5 mm ports. The bladder was opened in the midline and the stent divided at the ureteral orifice. The bladder stone (4.7 cm x 4 cm) was placed in a retrieval bag and the cystotomy closed with vicryl suture. The proximal ureter and renal pelvis were dissected free and incised. The stent with 2.3 cm x 1.5 cm stone on the proximal curl was removed. The incision was closed transversely with vicryl suture. RESULTS: The patient's recovery was uneventful, including drain removal prior to discharge on postoperative day 3. The foley was removed after a negative cystogram 7 days later. Analysis revealed calcium phosphate and struvite stones. Left ureteroscopy 2 months later revealed a widely patent proximal ureter. No complications have been identified. CONCLUSIONS: Laparoscopic cystolithotomy with stent division combined with pyelolithotomy can be performed safely and successfully as a single procedure to remove the heavily encrusted ureteral stent.