How I Do It: ERAS protocol featuring erector spinae plane block for percutaneous nephrolithotomy.

Percutaneous nephrolithotomy (PCNL) is the gold-standard treatment for large and complex renal stones. Though associated with higher stone-free rates compared to other minimally invasive stone procedures, this comes at the expense of increased morbidity including postoperative pain and discomfort. We describe our enhanced recovery after surgery (ERAS) protocol for PCNL with emphasis on the use of erector spinae plane blocks to improve patient satisfaction and reduce postoperative opioid use and bother.

Prospective Randomized Trial of Antibiotic Prophylaxis Duration for Percutaneous Nephrolithotomy in Low-Risk Patients.

Introduction and Objective: Postoperative infection and sepsis account for the most common complications following percutaneous nephrolithotomy (PCNL), as high as 14% in low-risk patients. Although the American Urological Association (AUA) recommends perioperative antibiotics for 24 hours or less for PCNL, practice patterns vary regarding duration of antibiotic therapy. We aimed to compare the efficacy of 24-hour antibiotic coverage vs short-course protocol of antibiotic prophylaxis for PCNL. Materials and Methods: Low-risk patients with a sterile preoperative urine culture undergoing PCNL were prospectively randomized to antibiotics for up to 24 hours after procedure (24Hr) or continued until external urinary catheters were removed (CR) study groups. Patients were given a first generation cephalosporin, or ciprofloxacin in patients with penicillin allergy. Exclusion criteria included age <18 years, receiving antibiotics immediately before the procedure, history of urosepsis, presence of indwelling catheter >1 week, multistage procedure, immunosuppression, pregnancy, multiple antibiotic allergies, and patients who are breastfeeding. Results: Ninety-eight patients were randomized to either 24Hr (n = 49) or CR (n = 49). Mean duration of antibiotic administration was 20.6 and 34.0 hours in the 24Hr and CR groups (p = 0.04), respectively. Age, comorbidities, stone size, operative time, number of punctures, dilations, and proportion of "tubeless" procedures were similar between groups. There were no differences in febrile episodes, rates of systemic inflammatory response syndrome, bacteremia, or culture-proven postoperative urinary tract infection between the 24Hr and CR groups. Overall complication rates were similar between groups. In a subgroup analysis which excluded "tubeless" patients (24 and 29 patients in 24Hr and CR groups, respectively), no differences were seen in postoperative outcomes. Conclusions: In a randomized, prospective study, we found that a 24-hour protocol for antibiotic prophylaxis is not associated with increased risk of infection-related events compared to giving antibiotics until external catheters are removed in patients with low infectious risk undergoing PCNL. Clinicaltrials.gov: NCT02579161.

Heterogeneity in stone culture protocols and endourologist practice patterns: a multi-institutional survey.

Kidney stone cultures can be beneficial in identifying bacteria not detected in urine, yet how stone cultures are performed among endourologists, under what conditions, and by what laboratory methods remain largely unknown. Stone cultures are not addressed by current clinical guidelines. A comprehensive REDCap electronic survey sought responses from directed (n = 20) and listserv elicited (n = 108) endourologists specializing in kidney stone disease. Questions included which clinical scenarios prompt a stone culture order, how results influence post-operative antibiotics, and what microbiology lab protocols exist at each institution with respect to processing and resulting stone cultures. Logistic regression statistical analysis determined what factors were associated with performing stone cultures. Of 128 unique responses, 11% identified as female and the mean years of practicing was 16 (range 1-46). A specific 'stone culture' order was available to only 50% (64/128) of those surveyed, while 32% (41/128) reported culturing stone by placing a urine culture order. The duration of antibiotics given for a positive stone culture varied, with 4-7 days (46%) and 8-14 days (21%) the most reported. More years in practice was associated with fewer stone cultures ordered, while higher annual volume of percutaneous nephrolithotomy was associated with ordering more stone cultures (p < 0.01). Endourologists have differing practice patterns with respect to ordering stone cultures and utilizing the results to guide post-operative antibiotics. With inconsistent microbiology lab stone culture protocols across multiple institutions, more uniform processing is needed for future studies to assess the clinical benefit of stone cultures and direct future guidelines.

Utility of Frailty Assessment in Urologic Stone Surgery: A Review of the Literature.

Introduction and Objective: As life expectancy continues to rise, the prevalence of frailty is also increasing. The idea of frailty and its effect on the operative patient has been previously studied, but not regularly incorporated into routine practice. We present a review on frailty metrics in the literature, validated assessment methods, and simplified screening tools to better predict and optimize patient outcomes. Methods: An online PubMed search was conducted by three authors (T.A., T.G.R.B., M.M.) for overall frailty, frailty assessment, and preoperative risk assessment. Only English publications were included in the analysis. Full-text analysis was then conducted by all three authors to validate the data. Results: An abundance of literature was found on frailty. Even though some methods are validated as extremely effective for assessing frailty, they may be time-consuming and require a specialist. Various quick screening methods are also presented, many already validated, and should be utilized by urologists more regularly. Conclusions: Multiple studies demonstrate the relationship between frailty and surgical patients' outcome. Many quick, office-based, validated tools to screen for frailty are described, and should be incorporated into our practice in appropriate patients. Future research is now focused on the concept of "prehabilitation" to improve patient frailty status in the preoperative setting, and consequently operative outcomes.

Frailty as predictor of complications in patients undergoing percutaneous nephrolithotomy (PCNL).

INTRODUCTION & OBJECTIVE: Surgical complications are difficult to predict, despite existing tools. Frailty phenotype has shown promise estimating postoperative risk among the elderly. We evaluate the use of frailty as a predictive tool on patients undergoing percutaneous renal surgery. METHODS: Frailty was prospectively analyzed using the Hopkins Frailty Index, consisting of 5 components yielding an additive score: patients categorized not frail, intermediate, or severely frail. Primary outcomes were complications during admission and 30-day complication rate. Secondary outcomes included overall hospital length of stay (LOS) and discharge location. RESULTS: A total of 100 patients recruited, of whom five excluded as they did not need the procedure. A total of 95 patients analyzed; 69, 10, and 16 patients were not frail, intermediate, and severely frail, respectively. There were no differences in blood loss, number of dilations, presence of a staghorn calculus, laterality, or location of dilation. Severely frail patients were likely to be older and have a higher American Society of Anesthesiologists score and Charlson comorbidity index. Patients of intermediate or severe frailty were more likely to exhibit postoperative fevers, bacteremia, sepsis, and require ICU admissions (P < 0.05). Frail patients had a longer LOS (P < 0.001) and tended to require skilled assistance when discharge (p < 0.0001). CONCLUSIONS: Frailty assessment appears useful stratifying those at risk of extended hospitalization, septic complications, and need for assistance following percutaneous renal surgery. Risks of sepsis, bacteremia, and post-operative hemorrhage may be higher in frail individuals. Preoperative assessment of frailty phenotype may give insight into treatment decisions and represent a modifiable marker allowing future trials exploring the concept of "prehabilitation".

Novel Irrigation Protocol for Renal Pelvis Sterilization During Percutaneous Nephrolithotomy: A Pilot Study.

While percutaneous nephrolithotomy (PCNL) remains the treatment modality of choice for kidney stones larger than 2 cm, infectious complications are most common, ranging from 5% to 32%. We present here a novel technique for potentially improving collecting system sterility during PCNL and initial postoperative outcomes. Retrospective chart analysis data of our irrigation protocol were collected from our first 56 patients between February and July 2019. Traditional prone PCNL was performed in a standard manner using fluoroscopic guidance. Using a ureteral catheter that was placed cystoscopically, a renal pelvis urine culture was taken and subsequently 10 mL of betadine solution was instilled into the collecting system. Gentamicin in normal saline (80 mg/3 L) was utilized as the irrigant fluid for the first 6 L of irrigation. From this cohort, 57% patients were women and mean age was 60 ± 14 years. About 23% of patients were diabetic and 55% were hypertensive. Seventy percent of patients had stone burden >2 cm and no patients had stone burden <1 cm. Fifteen patients had positive urine cultures treated preoperatively, while four patients had contaminated cultures. All patients were treated with our antibiotic irrigation and betadine protocol regardless of preoperative cultures or antibiotics. Mean baseline creatinine level was 0.95 ± 0.41, with a mean change of 0.18 at postoperative day 1. Of the 15 (26%) of 56 patients with a systemic inflammatory response syndrome response (two of following four criteria: white blood cells <4 or >12; heart rate >90; hypothermia <96.8°F or hyperthermia >100.4°F; and respiratory rate >20), only six patients (11%) were febrile and two patients had positive blood cultures (3%). There were no adverse reactions to the betadine or antibiotic irrigation. We present here our initial experience of a new technique for renal pelvis sterilization and its safety and feasibility using intrarenal instillation of betadine and antibiotic irrigation. No Clinical Trial Registration number applicable.

Management and treatment options when facing malignant ureteral obstruction.

Malignant ureteral obstruction is an unfortunate finding that can be caused by a wide-ranging number of malignancies with a prognosis of limited survival. Given its presentation and progression, it can be refractory to treatment by traditional single polymeric ureteral stents. With a higher failure rate than causes of benign ureteral obstruction, a number of other options are available for initial management, as well as in cases of first-line therapy failure, including tandem stents, metallic stents, percutaneous nephrostomies and extra-anatomic stents. We reviewed the literature and carried out a PubMed search including the following keywords and phrases: "malignant ureteral obstruction," "tandem ureteral stents," "metallic ureteral stents," "resonance stent," "metal mesh ureteral stents" and "extra-anatomic stents." The vast majority of studies were small and retrospective, with a large number of studies related to metallic stents. Given the heterogenous patient population and diversity of practice, it is difficult to truly assess the efficacy of each method. As there are no guidelines or major head-to-head prospective trials involving these techniques, it makes practicing up to the specific provider. However, this article attempts to provide a framework with which the urologist who is presented with malignant ureteral obstruction can plan in order to provide the individualized care on a case-by-case basis. What is clear is that prospective, randomized clinical trials are necessary to help bring evidence-based medicine and guidelines for patients with malignant ureteral obstruction.

Conservative Management of Liver Perforation During Percutaneous Nephrolithotomy: Case Couplet Presentation.

Percutaneous nephrolithotomy (PCNL) remains the recommended intervention for large kidney stones, major complications, although rare, are between 1% and 7%. Literature regarding liver injury during PCNL is sparse, and many incidences occur unnoticed. In general, most liver injuries can be treated conservatively when compared with other organ injury sustained during PCNL. Despite this, there is still significant potential for intraperitoneal bleeding as well as possible hemodynamic instability that may result secondary to the inadvertent access. Our team describes two cases of liver injury during PCNL with focus on presentation and injury management. Both cases were treated conservatively through close clinical monitoring and delayed removal of nephrostomy tube. Both liver injuries were diagnosed primarily through postprocedure axial CT imaging. In general, risk factors include supracostal access, particularly at or above the 11th rib, as well as hepatomegaly. Despite that liver injury is a rare complication of right-sided PCNL, outcomes can result in significant blood loss not diagnosed. We present in this study two instances of effective conservative management of liver injury after PCNL.

Management of Splenic Injury During Percutaneous Nephrolithotomy: Report of Two Cases.

Percutaneous nephrolithotomy (PCNL) has become the standard of care for the removal of kidney stones >2 cm. Major complications, although rare, are between 1% and 7%. Splenic injury during PCNL is rare and can often be managed conservatively, but has the potential to be devastating, necessitating the importance of early diagnosis. Our team describes two cases of splenic injury during PCNL with emphasis on diagnosis and management. Although both cases were managed conservatively through close monitoring and prolonged nephrostomy tube presence, one case had a concurrent pneumothorax. Both cases were diagnosed primarily through postprocedure CT imaging. Risk factors primarily include supracostal access and splenomegaly. Splenic injury is a rare complication that can often be managed conservatively; however, prompt recognition of injury is important. We present in this study two cases of conservative splenic injury management sustained during PCNL.

Management of Colon Perforation During Percutaneous Nephrolithotomy in Patients with Complex Anatomy: A Case Series.

Percutaneous nephrolithotomy (PCNL), first described in 1976, is the gold standard for the management of large kidney stones, with stone-free rates as high as 95% in contemporary literature. Colonic injuries during PCNL are a rare complication with an estimated incidence of 0.3%-0.5%. However, given the high morbidity incurred and the necessity of prompt operative intervention, it is imperative that practitioners have a low suspicion threshold for such injuries, particularly in those patients with altered or complex anatomy. This case series addresses peri- and postoperative outcomes of colon perforation during PCNL in patients with complex anatomy and reviews the technical challenges of surgery with potential methods to avoid injury in the future. Herein we review three instances of colonic injuries and their subsequent management to highlight both the presentation and the optimal management of these rare occurrences.

Endoscopic Management of Upper Urinary Tract Urothelial Carcinoma.

INTRODUCTION: Endoscopic management of upper tract urothelial carcinoma has become more popular over the last few decades as there has been an impetus for renal preservation in these patients. While radical nephroureterectomy has been the gold standard in treatment of this disease, ureteroscopic and percutaneous management has become a viable option for select patients. METHODS AND MATERIALS: The literature on endoscopic management of upper urinary tract tumors was explored. Different management methods are discussed, both from published literature and experience of the authors of this chapter. RESULTS: We review the indications, details of the procedure, and troubleshooting methods in the endoscopic management of upper tract urothelial carcinoma. Imperative indications as well as controversial indications are discussed. The role and efficacy of adjuvant intrarenal topical agents are examined as well as the protocol for administering these agents. Follow-up protocols are also reviewed. DISCUSSION: In select patients, endoscopic management with ureteroscopy and/or percutaneous resection of upper tract urothelial tumors is appropriate and can preserve renal function while obtaining comparable oncologic control compared with radical surgery.

Incorporation of the fluoroless C-Arm Trainer at the American Urological Association hands on training percutaneous renal access.

OBJECTIVES: To assess for usefulness and validity evidence for incorporating the C-Arm Trainer (CAT) simulator into the annual AUA hands on course for training percutaneous nephrolithotomy (PCNL). MATERIALS AND METHODS: The course started with a didactic session followed by four stations for training the "bull's eye" technique using the CAT simulator. Each station included a pre-test, 30-min practice on the simulator, and post-test. All participants were assessed using a 4-item checklist. All participants were asked to fill in a qualitative self-assessment questionnaire after the pre- and the post-test, and respond to a course evaluation questionnaire and post-course survey. RESULTS: A total of 38 physicians, who attended the hands on course, voluntarily participated in the study. Only 21.1% had previous practice on PCNL simulators. Compared with the results of the checklist total score and the qualitative self-assessment questionnaire scores after the pre-test, there was significant improvement in the checklist total score (p < 0.001), temporal demands (p = 0.003), situational stress (p = 0.003, and performance (0.003) after the post-test. A total of 14 (36%) participants responded to the course evaluation questionnaire, 50% evaluated the course as excellent, 28.6% as very good, and 21.4% as good. Unfortunately, only five (13%) participants responded to the post-course survey, 4/5 implemented the new competencies and knowledge into their practice, and 3/5 have attempted to obtain fluoroscopic guided PCA without assistance. CONCLUSION: The CAT simulator was considered useful for training the percutaneous renal access procedure. There was significant improvement in the qualitative and quantitative assessment parameters after the post-test compared with the pre-test.

The genetic framework for development of nephrolithiasis.

Over 1%-15% of the population worldwide is affected by nephrolithiasis, which remains the most common and costly disease that urologists manage today. Identification of at-risk individuals remains a theoretical and technological challenge. The search for monogenic causes of stone disease has been largely unfruitful and a technological challenge; however, several candidate genes have been implicated in the development of nephrolithiasis. In this review, we will review current data on the genetic inheritance of stone disease, as well as investigate the evolving role of genetic analysis and counseling in the management of nephrolithiasis.

Renal functional outcomes are not adversely affected by selective angioembolization following percutaneous nephrolithotomy.

OBJECTIVE: Selective angioembolization (SAE) effectively diagnoses and treats iatrogenic vascular complications following percutaneous nephrolithotomy (PCNL). METHODS: We retrospectively reviewed 1329 consecutive PCNLs and identified patients who underwent SAE following PCNL with at least 12-month follow-up. Estimated glomerular filtration rate (eGFR) was calculated for all patients preoperatively, postoperatively and at last follow-up. A 1:2 matched cohort analysis was performed. RESULTS: Twenty-three patients underwent SAE and matched to 46 controls. There was no statistically significant difference in preoperative, postoperative, and follow-up eGFR when comparing patients who underwent SAE and those with an uneventful course. CONCLUSION: Long-term eGFR is comparable in patients who undergo uncomplicated PCNL and those requiring SAE.

Current clinical scoring systems of percutaneous nephrolithotomy outcomes.

Percutaneous nephrolithotomy has become the preferred treatment modality for patients with large renal calculi. The technique provides excellent stone clearance, but complication rates are higher than those of minimally invasive techniques, such as ureteroscopy and shockwave lithotripsy. Guy's stone score, S.T.O.N.E. nephrolithometry, the CROES nomogram, and S-ReSC are contemporary scoring systems introduced to provide standardized grading of stone complexity and outcomes of percutaneous stone surgery. Guy's stone score is easy to apply and has been validated in multiple studies. The S.T.O.N.E. score is based on factors determined through CT imaging, which is the currently preferred imaging modality for patients with nephrolithiasis. The CROES nomogram was developed from data in a large multicentre database and has high statistical power. Determination of the S-ReSC score relies on stone location only, providing a simple approach to grading disease complexity. Each system has advantages and disadvantages, but several studies suggest that their ability to predict stone-free rate is comparable. The optimal system should have a high predictive ability, should be simple to use and should be widely applicable. Additional studies are required to evaluate patient clinical factors that influence stone complexity and are predictive of outcomes. A future unified scoring system might incorporate the strengths of each currently available system and optimize care of patients with nephrolithiasis.

Stones in special situations.

There are several special situations in which urinary lithiasis presents management challenges to the urologist. An in-depth knowledge of the pathophysiology, unique anatomy, and treatment options is crucial in order to maintain good health in these patients. In this review, we summarize the current literature on the management of the following scenarios: bladder stones, stones in bowel disease, during pregnancy, in association with renal anomalies, with skeletal deformities, in urinary diversions, and in children.

Conservative Management of Combined Pleural and Splenic Injury During Percutaneous Nephrostolithotomy.

Splenic injuries related to percutaneous nephrostolithotomy (PCNL) are infrequent. Herein, we report a combined splenic and pleural injury incurred during PCNL along with radiographic images documenting the complication. A review of management techniques for similar injuries is included.

A Randomized Controlled Comparison of Nephrostomy Drainage vs Ureteral Stent Following Percutaneous Nephrolithotomy Using the Wisconsin StoneQOL.

OBJECTIVE: We compared postoperative outcomes and quality of life (QoL) between patients who received a nephrostomy tube vs a ureteral stent following percutaneous nephrolithotomy (PCNL) in a prospective, double-blind, randomized manner. MATERIALS AND METHODS: Between September 2015 and March 2016, we randomized 30 patients undergoing PCNL to receive nephrostomy drainage (Group 1: 8F or 10F) or Double-J ureteral stent (Group 2) at conclusion of surgery. Nephrostomy tubes were removed within 48 hours (before discharge) and ureteral stents were removed at least 2 weeks after surgery. Patients' QoL was assessed with the Wisconsin StoneQOL questionnaire preoperatively and then 7 to 10 days and 30 days following surgery. Inclusion criteria included an uncomplicated procedure, normal preoperative renal function, and clinically insignificant residual stone fragments on postoperative imaging. We calculated the preoperative and postoperative QoL score difference between the two groups. We also evaluated perioperative characteristics, inpatient analgesic requirements, length of stay (LOS), and postsurgical complications. OUTCOME: Patient characteristics between Groups 1 and 2 were comparable with similar age (58.3 vs 54.7, p = 0.534), gender ratio, and stone burden (276.6 mm2 vs 259 mm2, p = 0.84) and composition. There was no significant difference between perioperative outcomes, including stone-free rate (93.3% vs 86.7%), operative times (125.7 minutes vs 115 minutes, p = 0.29), estimated blood loss (103.3 mL vs 100.7 mL, p = 0.9), LOS (3.2 days vs 1.9 days, p = 0.1), and complications (2 in each group). Inpatient analgesic requirements were also the same (both 21.1 mg, p = 1.0). Assessment of QoL using the Wisconsin StoneQOL questionnaire showed significant differences between preoperative and postoperative health-related QoL in 18 of the 28-question instrument at 7 to 10 days. Patients in Group 2 had significantly worse QoL change and a multitude of negative responses on the StoneQOL assessment, not only those commonly associated with stent irritation. Eighty percent of participants in Group 2 also attributed their complaints to having a stent placed. Both groups had similar QoL status at 30 days after surgery. CONCLUSION: Despite the literature advocating "tubeless" PCNL with ureteral stent placement at conclusion of surgery, our randomized prospective study shows that QoL is significantly worse with stent placement than with temporary nephrostomy drainage in the immediate aftermath following PCNL, using a validated QoL assessment instrument specific for nephrolithiasis.

Nephrolithometric Scoring Systems to Predict Outcomes of Percutaneous Nephrolithotomy.

Currently, there is no single agreement upon an ideal predictive model that characterizes the complexity of renal stones and predicts surgical outcomes following percutaneous nephrolithotomy (PCNL). New predictive tools have recently emerged to systematically and quantitatively assess kidney stone complexity to predict outcomes following PCNL: the Guy's Stone Score, the CROES nomogram, S.T.O.N.E. nephrolithometry, and S-ReSC score. An ideal scoring system should include variables that both influence surgical planning and are predictive of postoperative outcomes. This review discusses the strengths, weaknesses, and commonalities of each of the above scoring systems. Additionally, we propose future directions for the development and analysis of surgical treatment for stone disease, namely, the importance of assessing radiation exposure and patient quality of life when counseling patients on treatment options.