Successful Percutaneous Ultrasonic Lithotripsy of Gallstones.

Background: Acute calculous cholecystitis is the obstruction of the cystic duct by a gallstone that leads to inflammation of the gallbladder necessitating cholecystectomy. Case Series: We present the cases of 2 patients with acute calculous cholecystitis who were deemed ineligible candidates for cholecystectomy because of their complicating medical histories. Both patients initially underwent cholecystostomy and drain placement with interventional radiology for management of acute calculous cholecystitis. Their large gallstones remained refractory to attempts at removal by electrohydraulic lithotripsy via the cholecystostomy access. The patients' gallstones were successfully removed via percutaneous ultrasonic lithotripsy during a collaborative procedure with interventional radiology and urology. Conclusion: An interdisciplinary approach using percutaneous cholecystolithotomy with rigid ultrasonic lithotripsy is an effective method for removing challenging gallstones in patients for whom traditional approaches fail.

Complications of tubeless versus standard percutaneous nephrolithotomy.

PURPOSE: The necessity of nephrostomy tube after percutaneous nephrolithotomy (PCNL) has been called into question in modern series. We sought to examine differences in postoperative complications and outcomes of tubeless PCNL versus standard PCNL at our institution. METHODS: A retrospective review of our institutional stone database was conducted from January 2016 to December 2021 for patients who had undergone either tubeless PCNL, defined by placement of only an internal ureteral stent, or standard PCNL, which involved placement of an externalized nephrostomy tube. Patients were excluded if they underwent totally tubeless PCNL. RESULTS: A total of 438 patients were included for analysis: 329 patients underwent tubeless PCNL and 109 patients underwent standard PCNL. Between tubeless and standard groups, there was no difference in readmission rates 6.1% vs. 9.2% (p = 0.268), Clavien 2 or > complications 18.5% vs. 19.3% (p = 0.923), and Clavien 3 or > complications 4.0% vs. 7.3% (p = 0.151). The tubeless group experienced shorter operative duration 121.5 vs. 144.8 min (p = 0.012), shorter length of stay 2.5 vs. 3.8 days (p = 0.002), and higher stone-free rates 72.3% vs. 60.2% (p = 0.014), but also increased blood transfusion rates 6.4% vs. 0.9% (p = 0.022). CONCLUSION: In comparing tubeless with standard PCNL, there was no difference in readmission rates, or significant Clavien complication rates. Patients undergoing tubeless PCNL experienced higher stone-free rates, but more number of patients required postoperative blood transfusion. The decision to leave a nephrostomy tube after PCNL appears unlikely to impact overall complication rates and can be left to surgeon experience and case-based discretion.

Single-port vs multi-port robot-assisted renal surgery: analysis of perioperative outcomes for excision of high and low complexity renal masses.

There is emerging but limited data assessing single-port (SP) robot-assisted surgery as an alternative to multi-port (MP) platforms. We compared perioperative outcomes between SP and MP robot-assisted approaches for excision of high and low complexity renal masses. Retrospective chart review was performed for patients undergoing robot-assisted partial or radical nephrectomy using the SP surgical system (n = 23) at our institution between November 2019 and November 2021. Renal masses were categorized as high complexity (7+) or low complexity (4-6) using the R.E.N.A.L. nephrometry scoring system. Adjusting for baseline characteristics, patients were matched using a prospectively maintained MP database in a 2:1 (MP:SP) ratio. For high complexity tumors (n = 12), SP surgery was associated with a significantly longer operative time compared to MP (248.4 vs 188.1 min, p = 0.02) but a significantly shorter length of stay (1.9 vs 2.8 days, p = 0.02). For low complexity tumors (n = 11), operative time (177.7 vs 161.4 min, p = 0.53), estimated blood loss (69.6.0 vs 142.0 mL, p = 0.62), and length of stay (1.6 vs 1.8 days, p = 0.528) were comparable between SP and MP approaches. Increasing nephrometry score was associated with a greater relative increase in operative time for SP compared to MP renal surgery (p = 0.07) using best of fit linear modeling. SP robot-assisted partial and radical nephrectomy is safe and feasible for low complexity renal masses. For high complexity renal masses, the SP system is associated with a significantly longer operative time compared to the MP technique. Careful consideration should be given when selecting patients for SP robot-assisted kidney surgery.

A novel sacral neuromodulation protocol is associated with reduction in removal for device infection.

INTRODUCTION AND HYPOTHESIS: Sacral neuromodulation (SNM) has been established as an effective third-line therapy for non-obstructive urinary retention and urinary urgency-frequency syndrome. Device infection, ranging from 2-10%, is a severe complication usually necessitating device explanation. This study sought to demonstrate an infection protocol founded upon established device implantation risk factors and novel approaches to reduce the incidence of device infection, while maintaining good antibiotic stewardship following best practice statements. METHODS: A single-surgeon protocol was enacted from 2013 to 2022. Preoperatively, nasal swabs were cultured from each patient. If positive for methicillin-resistant Staphylococcus aureus or methicillin-sensitive Staphylococcus aureus, preoperative treatment with intranasal mupirocin was employed. Preoperative cefazolin was administered in patients with negative cultures or MSSA-positive. All protocol patients were given chlorhexidine wipes before surgery and prepped with a chlorhexidine scrub followed by alcohol/iodine paint. Post-procedural antibiotics were not given. Pre-protocol patients from 2011 to 2013 served as controls. RESULTS: Pre-protocol (n = 87) patients had a significantly higher rate of device infection compared to protocol patients (n = 444) in both the percentage of patients experiencing device infection (4.6% vs 0.9%, p = 0.01) and percentage of procedures associated with device infection (2.9% vs 0.5%, p < 0.05). A successful culture of the nares was achieved in 91.4% of protocol patients, with 11.6% MRSA-positive. Risk ratio for infection of pre-protocol/protocol patients was 0.19 (0.05-0.77) with odds ratio 5.1 (1.3-20.0). CONCLUSIONS: Utilization of a novel SNM infection protocol tailored to a patient's preoperative MRSA colonization is associated with a reduction in the overall incidence of explant for device infection while avoiding prolonged postoperative antibiotic regimens. CLINICAL TRIAL REGISTRATION: The study was initiated prior to January 18, 2017 and does not meet the definition of an applicable clinical trial (ACT) as defined in section 402 (J) of the US PHS Act.

A Multi-Institutional Matched-Pair Analysis of Robotic Partial Nephrectomy for Single vs Multiple Ipsilateral Renal Masses.

Introduction: Nephron-sparing surgery is important in patients with multiple renal tumors, especially if associated with a solitary kidney or hereditary syndrome. Prior studies have shown partial nephrectomy (PN) of multiple ipsilateral renal masses to have good oncologic and renal function outcomes. We aim to compare renal function changes, complications, and warm ischemia time (WIT) of partial nephrectomy of a single renal mass (sPN) vs those of partial nephrectomy of multiple ipsilateral renal masses (mPN). Materials and Methods: We retrospectively reviewed our multi-institutional PN database. We matched robotic sPN and mPN patients ∼3:1 using "nearest neighbor" propensity score matching based on age, Charlson comorbidity index (CCI), total tumor size, and nephrometry score. Univariate analysis was performed, and multivariable models were fit controlling for age, gender, CCI, and tumor size. Results: Fifty mPN and 146 sPN patients were matched. The mean total tumor size was 3.3 and 3.2 cm, respectively (p = 0.363). The mean nephrometry score in both groups was 7.3 and 7.2, respectively (p = 0.772). Estimated blood loss (EBL) was 137.6 and 117.8 mL, respectively (p = 0.184). The mPN group had higher operative time (174.6 vs 156.4 minutes, p = 0.008) and WIT (17.0 vs 15.3 minutes, p = 0.032). There was no significant difference in the change in glomerular filtration rate (mPN -6.4% vs sPN -8.7%, p = 0.712). Complications (Clavien 2+) occurred in 10.2% of mPN and 11.3% of sPN patients (p = 0.837). A multivariable linear model predicts a nonstatistically significant difference of 1.4 minutes of additional WIT in the mPN group (p = 0.242). There was no statistical difference in complication rates between groups in a multivariable model (odds ratio 1.00, p = 0.991). Conclusions: Robotic PN in our multi-institutional matched comparison of mPN and sPN showed no difference in complications, renal functional outcomes, or EBL. mPN was associated with increased operative time and WIT, though the WIT difference was not significant on multivariable analysis.

A Nurse-Driven Protocol for Foley Catheter Utilization Decreases the Incidence of Traumatic Foley Catheterization.

Background: Traumatic urethral catheterization is a common reason for urologic consultation in hospitalized patients. The purpose of this study was to determine if a protocol designed to decrease Foley catheter use was effective and if implementation of the protocol decreased the incidence of Foley catheter-associated trauma. Methods: In an effort to decrease catheter use, our institution adopted a nurse-driven Foley catheter protocol in May 2015 that allowed nurses to remove Foley catheters that did not meet criteria. We conducted a retrospective medical records review of patients who had Foley catheter-associated trauma occurring between February 2013 and March 2018 and compiled data concerning Foley catheter use. Using t test statistical analysis, we compared rates of Foley catheter use and Foley catheter-associated trauma before and after protocol implementation. Results: During the 62-month study period, we documented 83 cases of Foley catheter-associated trauma. Prior to protocol implementation, our institution had mean of 2,903 patient-catheterization days per month. Following protocol implementation, the mean decreased to 2,604 patient-catheterization days per month (P<0.01). Prior to protocol implementation, the mean incidence of Foley catheter-associated trauma was 1.81 traumas per month. Following protocol implementation, the mean incidence decreased to 0.97 trauma per month (P<0.05). Conclusion: Implementation of the protocol was successful in decreasing Foley catheter use as well as Foley catheter-associated trauma.

A Contemporary Analysis of the 30-day Morbidity and Mortality Associated With Cytoreductive Nephrectomy.

OBJECTIVE: To examine the rates of adverse surgical outcomes in patients undergoing cytoreductive nephrectomy (CN) compared to patients undergoing radical nephrectomy in the nonmetastatic setting using a large administrative database. METHODS: Patients in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) who underwent a radical nephrectomy between 2011 and 2016 were included. Patients were stratified by the preoperative variable of presence or absence of metastatic cancer. Perioperative outcomes were compared. A multivariable logistic regression analysis was performed to test the association between patients with metastatic cancer and perioperative morbidity and 30-day mortality. RESULTS: There were 15,869 total patients included in this analysis of whom 1322 (8%) patients had metastatic cancer. Of the entire cohort, the majority of patients were over 60 years old (58%) and 9621 (61%) were male. Seventy-three of the patients were Caucasian. Patients with metastatic cancer had more minor (P< .01) and major (P< .01) complications, a higher rate of reoperation (P< .01), and a higher rate of unplanned readmissions (P< .01). Finally, the cohort with metastatic cancer had a higher rate of postoperative 30-day mortality (P< .01) than patients without metastatic cancer. CONCLUSION: Patients undergoing a CN have significantly worse perioperative outcomes than patients undergoing a radical nephrectomy without evidence of metastases. Careful surgical risk stratification and appropriate patient counseling should be undertaken when selecting candidates for CN.

An Enhancing Mass Abutting the Collecting System.

We present a clinical imaging question focusing on a patient with a history of gross hematuria and an enhancing mass abutting the left renal collecting system. In patients with nondiagnostic cytology and imaging, upper tract urothelial carcinoma should be explored as a potential etiology prior to definitive surgical management.

The NLRP3 Inflammasome Mediates Inflammation Produced by Bladder Outlet Obstruction.

PURPOSE: While bladder outlet obstruction is well established to elicit an inflammatory reaction in the bladder that leads to overactive bladder and fibrosis, little is known about the mechanism by which this is initiated. NLRs (NOD-like receptors) and the structures that they form (inflammasomes) have been identified as sensors of cellular damage, including pressure induced damage, and triggers of inflammation. Recently we identified these structures in the urothelium. In this study we assessed the role of the NLRP3 (NACHT, LRR and PYD domains-containing protein 3) inflammasome in bladder dysfunction resulting from bladder outlet obstruction. MATERIALS AND METHODS: Bladder outlet obstruction was created in female rats by inserting a 1 mm outer diameter transurethral catheter, tying a silk ligature around the urethra and removing the catheter. Untreated and sham operated rats served as controls. Rats with bladder outlet obstruction were given vehicle (10% ethanol) or 10 mg/kg glyburide (a NLRP3 inhibitor) orally daily for 12 days. Inflammasome activity, bladder hypertrophy, inflammation and bladder function (urodynamics) were assessed. RESULTS: Bladder outlet obstruction increased urothelial inflammasome activity, bladder hypertrophy and inflammation, and decreased voided volume. Glyburide blocked inflammasome activation, reduced hypertrophy and prevented inflammation. The decrease in voided volume was also attenuated by glyburide mechanistically as an increase in detrusor contraction duration and voiding period. CONCLUSION: Results suggest the importance of the NLRP3 inflammasome in the induction of inflammation and bladder dysfunction secondary to bladder outlet obstruction. Arresting these processes with NLRP3 inhibitors may prove useful to treat the symptoms that they produce.