Patient Interaction With the Health Care System Following a Nonopioid Discharge Strategy for Anterior Urethroplasty.

INTRODUCTION: Continued efforts have been made to minimize postoperative opioids following urologic interventions. Studies show that patient-reported pain outcomes are similar between those patients discharged with and without opioids following anterior urethroplasty, but we do not know what impact this has on health care utilization. We aim to show that a nonopioid discharge following anterior urethroplasty does not increase postoperative health care utilization. METHODS: Five hundred patients who underwent anterior urethroplasty from January 2016 to October 2022 were identified from retrospective chart review. Patient demographic information, surgical characteristics, and postoperative interactions with the health care system were extracted from the electronic medical record. We then compared these outcomes by discharge opioid prescription status. RESULTS: A total of 253 patients were discharged without an opioid prescription. Patients who received an opioid were more likely to have had a perineal incision (73% vs 64%, P = .02), more likely to have had an overnight hospital stay (30% vs 14%, P < .01), and were more likely to have been prescribed an opioid preoperatively (13% vs 7%, P = .03). There were overall low rates of interaction with the health system in both groups with no significant difference in 30-day unplanned office visits, emergency department visits, or office phone calls. Overall, by the end of our study period 97% were discharged without an opioid and 94% of patients were discharged the same day. CONCLUSIONS: Patients undergoing anterior urethroplasty can safely be discharged home without opioids following surgery without undue postoperative burden on the health care system.

Interdisciplinary planning improves radiologist obtained access for percutaneous nephrolithotomy.

INTRODUCTION: Proper antegrade access for percutaneous nephrolithotomy (PCNL) is essential for success but can be challenging. Previous work evaluating access obtained by interventional radiology (IR), largely in the emergent setting, has shown high rates of additional access at the time of PCNL. We hypothesize that efforts to improve pre-procedural communication between urology and IR can impact the utility of the access for subsequent PCNL. MATERIAL AND METHODS: We conducted a retrospective review of patients undergoing PCNL at a single hospital from January 2011 to December 2022. Adult patients undergoing PCNL with established preoperative access were included. RESULTS: A total of 141 cases were identified with preoperative access. A total of 111 patients had evidence of planning with IR prior to antegrade access. There were high rates of anatomic abnormality (50%) and staghorn calculus (53%). Patients with planned access had higher body mass index (BMI). While preoperative access was initially utilized in 97% of cases, 6% required additional access to be obtained intraoperatively; this included a low rate of new access in those that were previously discussed with IR (4% vs. 17%, p = 0.02). Overall stone free rates (91%), rates of second stage procedures (55%) and complications (14%) were similar between planned and unplanned groups. CONCLUSION: In this retrospective study of complex patients with large stone burden presenting for PCNL with preoperative antegrade access obtained by IR, the rate of new access was far lower than prior reports. This was likely influenced by urologist involvement in planning access.

Accuracy of Radiology Reports for Obstructing Ureteral Stone Size in the Emergency Department.

OBJECTIVE: To evaluate the number of dimensions of obstructing ureteral stones in the emergency department (ED) described in present-day radiology computed tomography reports and assess for measurement discrepancies between radiologist and urologist review. METHODS: We conducted a single-center retrospective study of patients who presented to the ED with unilateral, solitary, obstructing ureteral stones from March 2018 to March 2021. Stone size in each reported dimension recorded by the radiologist was extracted from the chart and then compared to size independently measured by one of our urologists for all 3 stone dimensions. Our primary outcome was the number of stone dimensions included in the radiology report. RESULTS: In total, 181 patients were included for analysis. 82.3% of radiology reports described the stone in one dimension, 15% in two dimensions, and 2.7% in three dimensions. There was a significant difference in median maximal stone size between radiologist and urologist measurement (5.5 vs 6.5 mm, respectively, P < .001). One hundred fourteen stones (62%) had the maximal measurement recorded in the craniocaudal (CC) dimension by urologist review. Only 26% of radiology reports had the CC measurement included in the radiology report. CONCLUSION: Ureteral stone size in a present-day ED cohort is still frequently measured in only 1 or 2 dimensions. In many cases, this is associated with an absence of a reported CC measurement. Inadequate characterization of stone size may affect acute management. This study hopes to encourage reporting of all three dimensions of obstructing ureteral stones in the ED setting for improvements in patient management.

Patient Reported Outcomes of Transperineal Prostate Biopsy With Tumescent Local Anesthesia.

OBJECTIVE: To report the outcomes of performing transperineal prostate biopsy in the office setting using the novel anesthetic technique of tumescent local anesthesia. We report anxiety, pain, and embarrassment of patients who underwent this procedure compared to patients who underwent a transrectal prostate biopsy using standard local anesthesia. MATERIALS AND METHODS: Consecutive patients undergoing either a transperineal prostate biopsy under tumescent local anesthesia or a transrectal prostate biopsy with standard local anesthetic technique were prospectively enrolled. The tumescent technique employed dilute lidocaine solution administered using a self-filling syringe. Patients were asked to rate their pain before, during, and after their procedure using a visual analog scale. Patient anxiety and embarrassment was assessed using the Testing Modalities Index Questionnaire. RESULTS: Between April 2021 and June 2022, 430 patients underwent a transperineal prostate biopsy using tumescent local anesthesia and 65 patients underwent a standard transrectal prostate biopsy. Patients who underwent a transperineal biopsy had acceptable but significantly higher pain scores than those who underwent a transrectal prostate biopsy (3.9 vs 1.6, P-value <.01). These scores fell to almost zero immediately following their procedure. Additionally, transperineal biopsy patients were more likely to experience anxiety (71% vs 45%, P < .01) and embarrassment (32% vs 15%, P < .01). CONCLUSION: Transperineal biopsy using local tumescent anesthesia is safe and well-tolerated. Despite the benefits, patients undergoing a transperineal prostate biopsy under tumescent anesthesia still experienced worse procedural pain, anxiety, and embarrassment. Additional studies examining other adjunctive interventions to improve patient experience during transperineal prostate biopsy are needed.

The Gullwing Technique: A Novel Method of Transcorporal Artificial Urinary Sphincter Placement for the Fragile Urethra.

OBJECTIVE: To describe the novel gullwing technique for artificial urinary sphincter (AUS) placement. The transcorporal technique for AUS placement is beneficial in patients with 'fragile urethras' (previous failed AUS, urethroplasty or history of radiation) however limitations include insufficient lateral and ventral urethral support in addition to potential cinching during corporotomy closure which, in the absence of additional grafting may restrict our ability to conserve internal corporal capacity and limit options for future preservation of erectile function via penile prosthesis placement. The gullwing variation of the technique offers the potential to circumvent these disadvantages. MATERIALS AND METHODS: This case describes the gullwing variation of transcorporal AUS placement in a complex patient with a history of abdominopelvic trauma and prior failed AUS placements secondary to urethral erosion. RESULTS AND CONCLUSION: Transcorporal AUS placement in patients with prior urethral compromise has been shown to result in lower revision and erosion rates. The gullwing modification of the technique is a novel variation providing improved circumferential urethral protection and, with the addition of corporal grafting, aims to enable the preservation of the three-dimensional corporal volume necessary for ease of subsequent penile prosthesis implantation. However, studies assessing the long-term functional outcomes and durability of this technique are needed.

Management of distal ureter and bladder cuff at the time of nephroureterectomy: surgical techniques and predictors of outcome.

Open radical nephroureterectomy (NU) with removal of the ureter and bladder cuff is the 'gold standard' in the treatment of high-grade urothelial cancers of the upper urinary tract. A salient issue is the management of the distal ureter and bladder cuff at time of surgery. Which technique confers superior oncologic benefit is of particular interest since this disease process is notoriously plagued with high intravesical recurrence rates. Although open radical NU is the 'gold standard', the maturation of minimally invasive surgery formidably challenges approaches considered 'gold standard'. We thus sought to critically review the literature comparing perioperative and oncologic outcomes in the approaches used to manage the distal ureter and bladder cuff in patients undergoing radical NU.

Ureteral Polyp Managed by Endoscopic Techniques.

Fibroepithelial polyps (FEPs) are rare benign tumors of mesodermal origin. They are found in the ureters 85% of the time, with the remainder located in the renal pelvis and occasionally the bladder. FEPs can present as flank pain, lower abdominal pain, and/or gross hematuria. Previous literature reports management of these benign lesions using open surgical techniques, laparoscopic techniques, and endoscopic management. In this article, the authors present their pure endoscopic management of a large ureteral polyp and a review of the current literature outlining the etiology, clinical presentations, and management techniques for FEP of the ureter.

A Novel Role for CAMKK1 in the Regulation of the Mesenchymal Stem Cell Secretome.

Transplantation of adult stem cells into myocardial tissue after acute myocardial infarction (AMI), has been shown to improve tissue recovery and prevent progression to ischemic cardiomyopathy. Studies suggest that the effects of mesenchymal stem cells (MSC) are due to paracrine factors released by MSC, as the benefits of MSC can be achieved through delivery of conditioned media (CM) alone. We previously demonstrated that downregulation of Dab2 enhances MSC cardiac protein expression and improves cardiac function after AMI following MSC engraftment. In order to define the molecular mechanisms that regulate MSC secretome, we analyzed gene arrays in MSC following downregulation of Dab2 via TGFß1 pretreatment or transfection with Dab2:siRNA or miR-145. We identified 23 genes whose expressions were significantly changed in all three conditions. Among these genes, we have initially focused our validation and functional work on calcium/calmodulin-dependent protein kinase kinase-1 (CAMKK1). We quantified the effects of CAMKK1 overexpression in MSC following injection of CM after AMI. Injections of CM from MSC with CAMKK1 over-expression correlated with an increase in vascular density (CAMKK1 CM: 2,794.95 ± 44.2 versus Control: 1,290.69 ± 2.8 vessels/mm2 ) and decreased scar formation (CAMKK1 CM 50% ± 3.2% versus Control: 28% ± 1.4%), as well as improved cardiac function. Direct overexpression of CAMKK1 in infarcted tissue using a CAMKK1-encoding plasmid significantly improved ejection fraction (CAMKK1: 83.2% ± 5.4% versus saline: 51.7% ± 5.8%. Baseline: 91.3% ± 4.3%) and decreased infarct size after AMI. Our data identify a novel role for CAMKK1 as regulator of the MSC secretome and demonstrate that direct overexpression of CAMKK1 in infarcted cardiac tissue, results in therapeutic beneficial effects. Stem Cells Translational Medicine 2017;6:1759-1766.