Assessing Decision Regret in Patients with Same-Day Discharge Pathway After Robot-Assisted Radical Prostatectomy.

Introduction: After the introduction of same-day discharge (SDD) pathways for various surgeries, these pathways have demonstrated comparable complication rates and a reduced overall cost of care. Outpatient robot-assisted radical prostatectomy (RARP) is introduced in high-volume centers; however, patients' perspectives on the SDD RARP protocol are not well understood. Materials and Methods: A questionnaire consisting of 24 questions, including the Likert Decisional Regret Scale, was distributed to patients who underwent RARP at our center. The overall decision regret score was calculated as described in the literature. We used 15 as a cutoff point for differentiating between high- and low-regret rates. Median and interquartile range were determined for non-normally distributed variables, while mean ± standard deviation was calculated for continuous data. Results: Of the 72 patients who completed the questionnaire, 65.7% (n = 44) of patients felt no regret about their decision of choosing the SDD RARP protocol and 90.3% (n = 65) of men stated that they would have made the same decision. At the same time, 97.1% (n = 68) of patients would also recommend this procedure to others. The median decisional regret score of the cohort (n = 67) was 0 (0-10). Fifty-four of 67 (80.6%) patients were in the low-regret score group, while 13 (19.4%) were in the high-regret group. Patients in the high-regret group were more likely to have low household income (<$30,000 a year) and they experienced postoperative pain more frequently compared with patients in the lower regret group (7.7% vs 1.9%, p = 0.626, and 61.5% vs 38.9%, p = 0.212, respectively). Conclusions: Most patients expressed low regret about choosing the SDD pathway for RARP, underscoring the importance of thorough explanation of the procedure and discharge process to enhance patient experience. However, a subset of patients did express regret, possibly due to an interplay of patient- and procedure-related factors.

Electromotive Drug Administration in the Porcine Renal Pelvis: First Report.

Introduction: Electromotive Drug Administration (EMDA) amplifies drug delivery deep into targeted tissues. We tested, for the first time, the ability of EMDA to deliver methylene blue into the urothelium of the renal pelvis. Materials and Methods: In an anesthetized female pig, both proximal ureters were transected two inches distal to the ureteropelvic junction. An 8F dual lumen catheter and a 5F fenestrated catheter with an indwelling silver wire were inserted into both renal pelvises following which methylene blue (0.1%) was infused at a rate of 5 mL/min for 20 minutes. In one pelvis, a 4 mA positive pulsed electrical current was applied to the silver wire. Results: In contrast to the control pelvis, the EMDA side macroscopically exhibited dense homogeneous staining; microscopy revealed penetration of methylene blue into the urothelium/lamina propria. Conclusion: In the porcine renal pelvis, application of EMDA increased the penetration of a charged molecule into the urothelium/lamina propria.

Electromotive Drug Administration in the Ureter in an In Vivo Animal Model: Initial Report.

Introduction: Electromotive drug administration (EMDA) delivers a drug deeply into targeted tissues, such as the bladder. EMDA has never been applied to the ureter. Methods: In four in vivo porcine ureters, a unique EMDA catheter containing a silver conducting wire was advanced for the infusion of methylene blue. In two ureters, a pulsed current was delivered through an EMDA machine, whereas the other two ureters served as a control. After 20 minutes of infusion, the ureters were harvested. Results: In the EMDA ureter, there was diffuse staining of the urothelium; penetration of methylene blue occurred in the lamina propria and muscularis propria. In the control ureter, there was only patchy staining of the urothelium. Conclusion: In this first report of ureteral EMDA, a charged molecule penetrated beyond the urothelium into the lamina propria and muscularis propria of the porcine ureter.

Single-Port Robotic Applications in Urology.

Objective: The da Vinci single-port (SP) platform represents the latest innovation in minimally invasive urologic surgery, and the adoption of this technology by urologists is increasing. In this article, we briefly describe the evolution of minimally invasive and single-site surgery, and offer a comprehensive review of the current literature on the SP platform. Materials and Methods: For relevant articles, three electronic databases, including PubMed, Scopus, and Web of Science, were searched from their inception until August 15, 2022. The published literature to date within SP robotic surgery in urology will be discussed. Evidence Synthesis: There are relatively few high-quality studies on the SP system, but there are multiple case series describing unique indications and surgical approaches with the SP robot, demonstrating safety and feasibility in the hands of experienced robotic surgeons. There also are an increasing number of prospective, larger cohort studies comparing outcomes between SP and multiport (MP) approaches that show benefits of the SP system regarding improved cosmesis, postoperative pain control, and decreased length of stay. Conclusions: Multiple prospective studies have shown benefits regarding cost and pain control for SP platform procedures compared to the traditional MP robotic approach. While its high cost and learning curve represent barriers to adoption, the SP platform represents a critical development in minimally invasive surgery. As this technology is further implemented at more institutions, long-term, high-quality data should accrue that will demonstrate its true value.

The Changing Role of Renal Mass Biopsy.

The incidence and prevalence of small renal masses (SRMs) continues to rise and with increased detection comes increases in surgical management, although the probability of an SRM being benign is upward of 30%. An extirpative treatment first diagnose-later strategy persists and clinical tools for risk stratification such as renal mass biopsy remain severely underutilized. The overtreatment of SRMs has multiple detrimental effects including surgical complications, psychosocial stress, financial loss, and reduced renal function leading to downstream effects such as the need for dialysis and cardiovascular disease.

Retrograde Cystonephroscopy for Complex Renal Calculi Using Novel Dual-Action Aspiration, Irrigation Cystoscope: Initial Case Series.

Introduction: Percutaneous nephrolithotomy is the gold standard treatment for kidney stones ≥2 cm; however, it remains an invasive procedure with significant risks especially in individuals with severe medical comorbidities. In contrast, while ureteroscopy is far less morbid, a major impediment to its use for larger calculi is the inability to evacuate the many fragments created during laser lithotripsy. Herein, we describe two patients with large-volume calculi and a third high-risk patient with a smaller stone who were treated with cystonephroscopy using a recently released, 16F flexible cystoscope equipped with dual aspiration and irrigation capabilities. Materials and Methods: Three consecutive female patients underwent retrograde cystonephroscopy from June 2021 to July 2021 with a novel 16F aspiration-enabled flexible cystoscope. Demographic data were collected. Preoperative and postoperative CT scan images were reviewed to determine linear stone dimensions and scalene ellipsoid volume. Results: The three female patients had an average age of 72.3 years and an American Society of Anesthesiologists (ASA) physical status score of 3. The mean preoperative stone volume was 4950 mm3. The average postcystonephroscopy stone volume was 217 mm3, resulting in a total stone clearance rate of 97%. No major complications occurred. The average procedure time was 176 minutes. Conclusions: Among the three high-risk female patients, two with large-volume calculi, retrograde cystonephroscopy with a novel aspiration-enabled cystoscope allowed for the procedure to be effectively completed solely via a retrograde approach.

Natural History of Residual Fragments After Percutaneous Nephrolithotomy: Evaluation of Factors Related to Clinical Events and Intervention.

OBJECTIVE: To determine the natural history of residual fragments (RF) after percutaneous nephrolithotomy in long-term patient follow-up and to identify possible predictive factors for future intervention. MATERIALS AND METHODS: We assessed all patients from 2006 to 2013 with postoperative computed tomography scan revealing RF, who did not undergo second-look nephroscopy or immediate ancillary procedures, and with at least 12 months of clinical follow-up. We evaluated factors associated with clinical, radiological, and surgical outcomes. Kaplan-Meier curves were used to calculate the proportion of asymptomatic and treatment-free patients during follow-up. RESULTS: From 781 percutaneous nephrolithotomies performed, 202 patients underwent postoperative computed tomography scan and 44 patients with residual stones were included in the analysis. Mean follow-up was 57.9 months. A total of 24 patients (54.5%) developed at least 1 clinical outcome, and 32 (72.7%) patients had a surgical intervention. Only 4 patients had radiological evidence of stone passage. Multivariate analysis found that RF >4 mm and struvite or apatite stones were significant predictors for surgical intervention. The 5-year estimated probability to remain intervention free was 29%. CONCLUSION: Despite the size of the RF, the vast majority of patients required an intervention during long-term follow-up. We identified that RFs of diameter >4 mm associate with the need for a surgical therapy, but the rate of clinical events was not affected by the size or location of the stones. Struvite or apatite composition stones had an increased risk of intervention during follow-up. Spontaneous passage was an uncommon event in this cohort.

MÜNCHAUSEN SYNDROME BY PROXY: THE OVERLOOKED DIAGNOSIS.

Münchausen Syndrome by Proxy (MSBP) is a psychiatric disorder characterised by the adoption of bizarre behavioural-patterns by caregivers in which diseases or disorders are fabricated in individuals, usually children, for purposes which span feelings of superiority derived from deceit of persons deemed superior to the caregiver, or attention seeking. The patient under discussion was a 6 year old male brought to the hospital by his mother with complaints of repetitive and unceasing passing of stones per urethra. Upon inspection of stone specimens brought in by the parents and physical examination, the stones in question were observed to be common stones, with no reason to suggest a urolithiatic origin, leading to the suspicion of MSBP. Further questioning of both the mother and father revealed more information regarding the cause of her child's illness and strongly suggested that the stones were being physically inserted into the child's urethra by the mother--often in the father's absence--after administration of sedative-hynotic drugs.

Ureteral triplication and contralateral duplication with vesicoureteral reflux.

Ureteral triplication is a rare congenital anomaly of the urinary tract. Since the first description by Warny in 1870, approximately 100 known cases have been reported in the literature, often accompanied by a variety of associated anomalies in contralateral kidney. This report presents a case of ureteral triplication with contralateral duplication and vesicoureteral reflux (VUR) of the upper moiety on the triplicate side. The patient was a 10 year old male who presented with a history of recurrent urinary tract infections and right loin pain. ACT urogram was performed which showed a triplicate right ureter with gross hydroureter of the upper moiety. There was a duplex system present on the left side. The patient underwent right upper pole heminephroureterectomy.

Emphysematous pyelonephritis: a review of six cases.

BACKGROUND: Emphysematous pyelonephritis is a severe life threatening necrotising infection of the renal parenchyma. The infection most commonly occurs in the diabetic population, often associated with the organism E. coli Emphysematous pyelonephritis differs from standard pyelonephritis by the bacterial liberation and accumulation of gas in the surrounding tissues. The condition is rarely encountered in clinical practice and since the first description by Kelly et al in 1898, approximately 200 cases have been reported in the literature. METHODS: The case series examines our experience with six diagnosed cases of emphysematous pyelonephritis over a one year period. RESULTS: All patients were female, the mean age of presentation being 53 years. Of the six patients, five were diabetics with hypertension, the one exception being a non-diabetic patient who had undergone renal exploration in the past. Computed tomography confirmed the diagnosis in all patients except one which was confirmed during renal exploration. Urine culture was positive for E. coli in two patients. CONCLUSION: Emphysematous pyelonephritis which used to be a rare disease is now being more readily diagnosed. The cases were diagnosed at a late stage making its conservative management not feasible