The Absence of a Validated English-Language Survey to Assess Prosthesis Satisfaction: A Prospective Cohort Using the Sexual Quality of Life After Penile Prosthesis.

BACKGROUND: Prior assessments of sexual quality of life (SQoL) after penile prosthesis implantation have been performed without validated implant-specific tools. The Quality of Life and Sexuality with Penile Prosthesis (QoLSPP) questionnaire was designed and validated in Italian to specifically evaluate SQoL after a penile prosthesis is placed. AIM: We aim to better characterize prosthesis-specific SQoL after inflatable penile prosthesis placement using the English translation of the QoLSPP questionnaire. METHODS: A total of 395 consecutive patients received an inflatable penile prosthesis between January 1, 2009 and November 27, 2017, and 270 had functional emails to whom the QoLSPP questionnaire was sent. 90 surveys were completed by 75 first-time implantees and 15 patients who underwent removal/replacement surgery. Responses were considered positive if ≥ 3. Among first-time implantees, subpopulation analysis was carried out by age at survey completion (<55 years, 55-65 years, and ≥66 years), age of penile prosthesis at survey completion (<1 year, 1-5 years, and >5 years), device model (Coloplast Titan, AMS 700 CX, and AMS LGX), history of a psychiatric diagnosis, etiology of erectile dysfunction, total device length > or ≤ 21 cm, diabetes status, and body mass index < /≥ 30. Responses were analyzed in R using t-tests for continuous variables and Chi-squared tests (Fisher's for small counts) for categorical variables. OUTCOMES: The main outcome measure of this study was sexual quality of life assessed by QoLSPP. RESULTS: Patients completed the survey on average 3.15 years from their most recent prosthesis placement. 84% of first-time implantees had positive responses. Among them, there were no significant differences in the proportion of positive responses by device type, age, history of a psychiatric diagnosis, total implanted device length, etiology of erectile dysfunction, diabetes, or body mass index statuses (all P > .05). There was no difference in SQoL between first-time implantees and those who underwent removal/replacement surgery (P = 1.0). CLINICAL IMPLICATIONS: Patients experience a positive impact on their SQoL following implantation of a penile prosthesis. STRENGTHS & LIMITATIONS: Our study is the first to apply the English language QoLSPP which demonstrates high prosthesis specific SQoL but is limited by size and a lack of a validated English language tool. CONCLUSIONS: The positive impact on patients' SQoL with penile prosthesis is 84% when assessed by the English QoLSPP questionnaire. While these results mirror those reported from Italy, the English-speaking patient population is plagued with a lack of a validated tool to assess satisfaction, a void the academic and prosthetic community must fill to better understand the impact prostheses have on their patients. Carlos EC, Nosé BD, Barton GJ, et al. The Absence of a Validated English-Language Survey to Assess Prosthesis Satisfaction: A Prospective Cohort Using the Sexual Quality of Life After Penile Prosthesis. J Sex Med 2020;17:2307-2310.

The Impact of Alternative Alkalinizing Agents on 24-Hour Urine Parameters.

OBJECTIVES: To determine if alternative alkalinizing agents lead to similar changes in 24-hour urine pH and citrate compared to potassium citrate (KCIT). Many stone formers cannot tolerate KCIT due to side effects or cost. In these patients, we have prescribed potassium bicarbonate or sodium bicarbonate as alternative alkali (AA), though their efficacy is unclear. METHODS: We performed a retrospective cohort study of adult stone formers seen from 2000 to 2018 with 24-hour urine analyses. Two analyses were performed. The first evaluated the alkalinizing and citraturic effects in patients with baseline low urine pH or hypocitraturia off of any alkalinizing medications, who were subsequently treated with either KCIT or AA. The second analysis compared the pH and citrate in patients changing from KCIT to an AA. Reasons for switching were abstracted by chart review and cost savings percentages were calculated using GoodRx medication prices. RESULTS: When starting alkali therapy, the median increase in pH from baseline was 0.64 for KCIT and 0.51 for AA (P = .077), and the median increase in citrate from baseline was 231 mg for KCIT and 171 mg for AA (P = .109). When switching alkali therapy, median pH and citrate did not significantly change. Hyperkalemia (24%), GI upset (19%), and cost (17%) were the most common reasons cited for switching to an AA. AA represented a savings of 86%-92% compared to KCIT. CONCLUSION: Alternative alkali appear to offer comparable improvements in 24-hour urine parameters and significant cost-savings compared to KCIT.

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.

Counter incision is a safe and effective method for alternative reservoir placement during inflatable penile prosthesis surgery.

BACKGROUND: Alternative reservoir placement is increasingly popular during inflatable penile prosthesis (IPP) surgery to prevent intraperitoneal positioning, bowel, bladder, or vascular injury in patients with prior pelvic surgeries. Counter incision (CI) can be used for submuscular reservoir placement in high risk patients, however series exploring the safety remain limited. METHODS: A database of IPP surgeries was queried for use of a CI during reservoir placement to compare 90-day clinical outcomes in a retrospective case-control study. Primary outcome was device infections, with secondary outcomes including reservoir herniation, hematoma, device malfunction rates, and operative times. Groups were compared using Kruskal-Wallis and Chi-Squared tests, with multivariate logistic regression models to identify predictors of infectious complications. RESULTS: A total of 534 cases met criteria, of which 51 (9.6%) used a CI for reservoir placement. The CI cohort included significantly more removal and replacements, 45.1% vs. 20.9% (P<0.001). Thirty-one CI patients (61.0%) had undergone prior prostatectomy compared to 134 (27.7%) non-CI patients (P=0.001). The most common reasons for CI were prior prostatectomy and inguinal hernia repair. Median operative time was 17 minutes longer in the CI group (74 vs. 57 minutes, P<0.001). Device infection rates were similar (2.0% vs. 4.1%, P=0.71), as were rates of hematoma (5.9% vs. 2.7%, P=0.19), and device malfunction (0.0% vs. 1.4% P=1.00). CONCLUSIONS: Complication rates were similar between CI and non-CI cohorts, even in a subset where approximately half the cases were removal and replacements. For physicians not comfortable with alternative placement through a penoscrotal or infrapubic incision, this offers a reasonable alternative and permits use of three-piece devices in patients with a hostile pelvis.

Holmium:Yttrium-Aluminum-Garnet Laser Pulse Type Affects Irrigation Temperatures in a Benchtop Ureteral Model.

Introduction: MOSES™ technology is a holmium:yttrium-aluminum-garnet laser pulse mode shown to minimize stone retropulsion. This may facilitate lithotripsy at higher power settings. However, power and heat production are proportional, and temperatures capable of tissue injury may occur during ureteroscopic lithotripsy. Although previous in vitro studies demonstrate the importance of irrigation and activation time on heat production, the impact of pulse type has not been evaluated. Methods: A flexible ureteroscope with a 365 µm laser fiber was placed in an 11/13 F access sheath inserted into a 50 mL saline bag to simulate a ureter, renal pelvis, and antegrade irrigant flow. A thermocouple was placed adjacent to the laser tip, and the laser fired for 30 seconds at 0.6 J/6 Hz, 0.8 J/8 Hz, 1 J/10 Hz, 1 J/20 Hz, and 0.2 J/70 Hz at irrigation pressure of 100 mmHg. Four runs were tested per setting using short pulse, long pulse (LP), MOSES-contact (MC), and MOSES-distance (MD) modes. The mean temperature changes (dT) were compared and thermal dose was calculated in cumulative equivalent minutes at 43°C (CEM43) using an adjusted baseline of 37°C. CEM43 ≥ 120 minutes was considered the tissue injury threshold. Results: At 0.8 J/8 Hz, LP produced the greatest dT, significantly higher than MC (p = 0.041). CEM43 did not exceed the injury threshold. At 1 J/10 Hz, dT was significantly higher for LP versus MC and MD (p = 0.024 and 0.045, respectively). Thermal dose remained below the injury threshold. No differences in dT were seen between pulse types at 0.6 J/6 Hz, 0.2 J/70 Hz, or 1 J/20 Hz. At 1 J/20 Hz, thermal dose exceeded the injury threshold for all pulse types within 3 seconds. Conclusions: Laser pulse type and length seemed to impact heat production in our ureteral model. LP produced significantly greater temperatures at 0.8 J/8 Hz and 1 J/10 Hz relative to MOSES settings. Fortunately, thermal dose remained safe at these settings. Both LP and MOSES technology have been shown to reduce stone retropulsion. At power ≤10 W, the latter may confer this advantage with decreased heat production.

The Rise and Fall of High Temperatures During Ureteroscopic Holmium Laser Lithotripsy.

Introduction: Temperatures over 43°C-the threshold for cellular injury-may be achieved during ureteroscopic holmium laser lithotripsy. The time to reach and subsequently clear high temperatures at variable laser power settings and irrigation pressures has not been studied. Methods: A flexible or semirigid ureteroscope was placed within an 11/13 F ureteral access sheath inserted into a 250-mL saline bag simulating a normal-caliber ureter, renal pelvis reservoir, and antegrade irrigation flow. A thermocouple was placed adjacent to a 365 µm fiber fired for 45 seconds at 0.6 J/6 Hz, 0.8 J/8 Hz, 1 J/10 Hz, 1 J/20 Hz, and 0.2 J/80 Hz. Irrigation pressures of 200, 100, and 0 mm Hg were tested. Mean temperature changes were recorded with 6°C increase as a threshold for injury (as body temperature is 6°C below 43°C). Results: Semirigid scope: At 200 mm Hg no temperature changes >6°C were observed. At 100 mm Hg, changes >6°C occurred with 1 J/20 Hz within 1 second of activation and returned to ≤6°C within 1 second of cessation. At 0 mm Hg, changes >6°C occurred with all settings; within 1 second at power ≥10 W. Temperatures returned to ≤6°C within 5-10 seconds. Flexible scope: At 200 mm Hg, changes >6°C occurred at 1 J/10 Hz (15 seconds), 0.2 J/80 Hz (3 seconds), and 1 J/20 Hz (2 seconds). Temperatures returned within 6°C of baseline within 2 seconds. At 100 mm Hg, changes >6°C occurred in all but 0.6 J/6 Hz. Temperatures returned to ≤6°C in 5-10 seconds. At 0 mm Hg, all settings produced changes >6°C within 3 seconds, except 0.6 J/6 Hz (35 seconds). Temperatures returned to ≤6°C in under 10 seconds. Conclusions: High temperatures were achieved in our in vitro model in as little as 1 second at common irrigation pressures and laser settings, particularly with a flexible ureteroscope and power ≥10 W. However, with laser cessation, temperatures quickly returned to a safe level at each irrigation pressure.

Avoiding a Lemon: Performance Consistency of Single-Use Ureteroscopes.

INTRODUCTION AND OBJECTIVES: Single-use flexible ureteroscopes are increasingly popular because of high repair costs of reusable ureteroscopes. As new single-use ureteroscopes enter the market, the consistency of performance of these devices has been questioned. Our objective was to compare two single-use ureteroscopes: the Pusen PU3022a (Zhuhai Pusen) and the LithoVue (Boston Scientific) with emphasis on physical and optical performance consistency. METHODS: Ten LithoVue and 10 Pusen ureteroscopes were evaluated in never-used condition. The following parameters were recorded: maximal tip deflection with an empty working channel, 200 µm laser fiber, and 1.9F basket; image resolution at 10, 20, and 50 mm; and irrigation flow rate; all ureteroscopes were then fully deflected for 200 cycles. Maximum deflection was remeasured. Mean values for each parameter were compared. To examine within-manufacturer consistency, the variance was calculated and an F-test performed to evaluate for equivalence. RESULTS: Both ureteroscopes provided max deflection over 270°. The Pusen flexed to a greater degree than LithoVue. The Pusen lost more deflection with a laser fiber in the working channel. LithoVue had higher resolution at 10 mm, but the ureteroscopes were similar at 20 and 50 mm. Although the working channel diameter is identical, irrigation flow was higher with the Pusen. However, its working channel was 7 cm shorter than LithoVue. After 200 cycles of deflections, LithoVue had less deflection loss, although one ureteroscope was excluded from analysis because of mechanical failure. Variability was minimal and not significant between manufacturers at all measured parameters. CONCLUSIONS: LithoVue and the newer PU3022a have similar "out-of-the-box" performance characteristics and seem durable. These two single-use flexible ureteroscopes performed consistently regardless of the manufacturer.

Sexual Quality of Life and Satisfaction With Penile Prostheses.

INTRODUCTION: Penile prosthesis (PP) implantation is associated with high patient satisfaction and improved sexual quality of life (SQoL). The SQoL benefits of PP implantation are generalizable across subpopulations of PP implant patients, but the literature is heterogeneous in design and largely without instruments to specifically measure SQoL changes due to PP, requiring extrapolation from less granular measures. AIM: To provide a comprehensive review of available literature regarding SQoL with a penile prosthesis. In addition, the strengths and limitations of each study will be described with respect to design, number of patients included, data acquisition, and clinical significance. METHODS: A PubMed search was performed for articles from 1989 to 2018 related to penile prostheses and SQoL. Emphasis was placed on patient/partner satisfaction scores, quality of life assessments, and patient-reported outcome measures. MAIN OUTCOME MEASURE: The SQoL benefits due to penile prostheses were reviewed. The measurement tools for patient satisfaction and sexual quality of life across multiple subpopulations within patients receiving penile prosthesis implantation were reviewed and the outcomes analyzed. RESULTS: Patient satisfaction rates with penile prostheses are higher than 85%, and SQoL is improved in both patients and their partners. There now is a validated questionnaire that is the first to specifically measure changes in SQoL due to a penile prosthesis. CONCLUSION: Overall, patient satisfaction with a penile prosthesis is high and SQoL is improved. These results are largely generalizable across multiple subpopulations of patients. Although literature is heterogeneous in study design and assessment methods, there now is a validated and specific penile prosthesis SQoL questionnaire that can provide for more granular analysis moving forward. Barton GJ, Carlos EC, Lentz AC. Sexual Quality of Life and Satisfaction With Penile Prostheses. J Sex Med Rev 2019;7:178-188.

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.

Urethral Injury and the Penile Prosthesis.

INTRODUCTION: The relative infrequency of urethral injuries during penile prosthesis implantation has caused the event to be understudied relative to the morbidity and cost associated with their management. AIM: To draw attention to both acute intraoperative and delayed urethral injuries via cylinder erosion by compiling and evaluating the available literature on their cause, diagnosis, and management. METHODS: A literature review was performed through PubMed from 1985 to 2018 regarding urethral injuries in the setting of penile prosthesis implantation. Comorbidities and anatomic factors that predispose a patient to a urethral injury were also queried. MAIN OUTCOME MEASURES: The goal is to identify at-risk populations and assess options for managing distal, mid-pendulous, and proximal acute urethral injuries that occur in the setting of penile prosthesis implantation. We also examine strategies to manage prosthesis erosion into the urethra. RESULTS: Although urethral injuries are rare, certain patient populations are at higher risk for the event. Injuries at various locations along the urethra present unique challenging and morbid clinical scenarios. However, there are a variety of management options available that allow a patient to ultimately void normally and have a successfully implanted penile prosthesis. CONCLUSION: Overall, penile prostheses offer many patients an improved sexual quality of life. In the setting of prosthesis implantation both acute and delayed urethral injuries are rare, but their associated morbidity can undercut the benefits of the device. Our understanding of these injuries has matured, and we now possess management strategies that can mitigate the morbidity and frustration that accompany this complication. Carlos EC, Sexton SJ, Lentz AC. Urethral injury and the penile prosthesis. Sex Med Rev 2019;7:360-368.

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.

Purulent Inflatable Penile Prostheses Can Be Safely Immediately Salvaged in Insulin-Dependent Diabetics.

INTRODUCTION: Historically, contra-indications for immediate salvage of an infected penile prosthesis have included purulence on the device, purulent infections in diabetic patients, and severe diabetes. These clinical principles are from the 1990s to early 2000s and based on limited retrospective series or expert opinion. Since the publication of these contra-indications there have been improvements in device design, surgical technique, corporal washout protocols, and perioperative antibiotic prophylaxis that allow us to re-evaluate whether we can broaden the criteria for immediate salvage of an infected penile prosthesis. AIM: To report whether patients with severe diabetes can safely have a purulent inflatable penile prosthesis (IPP) immediately salvaged. METHODS: We considered a "severe diabetic" as a patient whose disease has progressed past diet control and oral medications and, therefore, has insulin-dependent type 2 diabetes mellitus (IDDM II). We retrospectively reviewed 6 consecutive patients with IDDM II and a purulent IPP who had been immediately salvaged from July 2011 to November 2017. In addition to immediate exchange, each received catheter-directed anti-microbial intracorporal irrigation and device culture. All patients were discharged home the next day with oral antibiotics. MAIN OUTCOME MEASURE: Outcomes included repeat penile prosthesis infection or any other complication following immediate salvage. RESULTS: All 6 patients have healed well and remained infection free at their 6- to 8-week post-operative follow-up appointment. 15-39 months after salvage, no patients have had a repeat infection or any other complication. 5 patients received a malleable replacement device and 1 patient was electively converted to an IPP 7 months after his salvage procedure. 1 patient received an IPP during salvage per patient preference. All patients are currently pleased with either their malleable penile prosthesis or IPP. CLINICAL IMPLICATIONS: Immediate salvage attenuates the morbidity associated with an infected penile prosthesis such as irreversible penile shortening and corporal fibrosis. Our findings suggest that more patients than originally thought may be a candidate for immediate salvage. STRENGTH & LIMITATIONS: To our knowledge, this is the first study evaluating outcomes after immediate salvage of a purulent IPP in patients with advanced diabetes. Limitations of the study include the small sample size and retrospective nature. CONCLUSION: Our results suggest that those with IDDM II who have a purulent penile prosthesis may be candidates for safe and effective immediate salvage. Peters CE, Carlos EC, Lentz AC. Purulent Inflatable Penile Prostheses Can Be Safely Immediately Salvaged in Insulin-Dependent Diabetics. J Sex Med 2018;15:1673-1677.

Dusting Efficiency of the Moses Holmium Laser: An Automated In Vitro Assessment.

INTRODUCTION: Moses technology is a novel Holmium:YAG laser system designed to minimize stone retropulsion and improve stone ablation when the laser is not in direct contact with the stone. Our aim was to assess the efficiency of Moses technology relative to short- and long-pulse lithotripsy using an automated in vitro "dusting model" of stone comminution. METHODS: All tests were conducted using a Lumenis Pulse 120H Holmium:YAG laser with a 365 µm Moses D/F/L fiber. "Hard" (15:3) and "soft" (15:6) Begostones mimicking calcium oxalate monohydrate and uric acid stones, respectively, were used. To assess ablation efficiency and fiber tip degradation, a dusting model was employed: the laser was moved by a three-dimensional positioning system in a spiral motion across a flat Begostone surface submerged in water. Ablation efficiency was measured as stone mass loss after 4 kJ of energy delivery. Fiber tip degradation was measured at 1 kJ intervals. Comparative trials with short pulse, long pulse, Moses contact, and Moses distance settings were completed with the laser tip positioned at 0, 1, and 2 mm distances from the stone at energy settings of 0.4 J delivered at 70 Hz. RESULTS: In our dusting model, stone ablation was significantly greater the closer the laser was to the stone. On hard stones, pulse type did not have a significant impact on ablation at any distance. On soft stones at 0 mm, Moses contact produced the greatest ablation, significantly greater than long pulse (p < 0.05). At 1 mm, Moses distance produced significantly greater ablation than all other settings (p = 0.025) and was as effective as long or short pulse at 0 mm. At 2 mm distance, no pulse type demonstrated significantly different ablation. Fiber tip degradation was minimal and not significant between settings. CONCLUSIONS: Moses technology delivers greater ablation of soft stones when in contact and 1mm from the stone surface.

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.

Wilms Tumor After Orthotopic Liver Transplant in a Patient With Alagille Syndrome.

We present a case of Wilms Tumor in a patient with Alagille syndrome 10 months after liver transplant. We explore a suggested genetic connection between these 2 diseases. In children with Wilms Tumor, we propose a pathoembryologic explanation for not just the tumor, but also for the cause of associated benign ureteral and renal parenchymal aberrancies that are commonly seen in the Alagille population. We also discuss the diagnostic and therapeutic challenges that can arise in a liver transplant patient with Alagille syndrome who subsequently develops a renal mass.

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 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.