Multimodal Pain Control Utilizing Buprenorphine for Robotic-assisted Laparoscopic Prostatectomy: A Quality Improvement Comparison to Conventional Opioid Management.

INTRODUCTION: This study investigated the effectiveness of buprenorphine as an alternative to the use of conventional opioids perioperatively in an effort to help mitigate the impact of the use of perioperative conventional opioids for patients undergoing robotic-assisted laparoscopic prostatectomy. METHODS: Outcomes of patients with localized prostate cancer undergoing robotic-assisted laparoscopic prostatectomy were examined before and after implementation of novel quality improvement study that included receiving buprenorphine compared to conventional opioids for pain control intraoperatively and postoperatively. The primary end point was adequate pain control with secondary end points being analgesic consumption at home, opioid-related side effects, and patient satisfaction. RESULTS: When analyzing the secondary end point of oral morphine milligram equivalents, the buprenorphine group received significantly less morphine milligram equivalent compared to the conventional opioid group (15.19 vs 47.91, P = .006). The buprenorphine group also had lower reported pain scores at discharge (4.3; scale 1-10) compared to the conventional opioid group (5.4), though this did not reach significance (P = .069). In the buprenorphine group, 76.9% strongly agreed that their pain was adequately controlled in the hospital compared to 57.5% of the conventional opioid group (P = .223). There was no difference in overall satisfaction at postoperative day 5 (P = .358). CONCLUSIONS: Our study demonstrates buprenorphine's analgesic capabilities to maintain adequate pain control and patient satisfaction compared to conventional opioids during robotic-assisted laparoscopic prostatectomy, while decreasing perioperative opioid use.

The Impact of Caffeine Intake on Mental Health Symptoms in Postmenopausal Females with Overactive Bladder Symptoms: A Randomized, Double-Blind, Placebo-Controlled Trial.

Background: Caffeine has been associated with a dose-dependent variety of mental health changes, which have been found to precede or be a complication of overactive bladder (OAB) symptoms after menopause. The current study examines the effects of low and moderate caffeine intake on anxiety, depression, sleep, and stress in postmenopausal females with OAB. Materials and Methods: Eighty-one females were randomized in a prospective, double-blind, placebo-controlled study. Participants were allocated to 200 mg/day caffeine, 400 mg/day caffeine, and placebo capsules for 1 week each in a crossover design and evaluated using validated mental health questionnaires. Symptoms during each treatment phase were measured using Beck Anxiety and Depression Inventory, Insomnia Severity Index, and Perceived Stress Scale. Linear regression models were used to examine the impact of low (200 mg/day) and moderate (400 mg/day) dose of caffeine and placebo on mental health. Results: Fifty-six female participants finished the study. The mean age was 69.2 years (58.0-84.0 years). Two females dropped out during the treatment phase with 400 mg/day caffeine intake due to side effects associated with headaches and nausea. Moderate dose of caffeine showed a small positive effect on mental health, specifically a decrease in anxiety during 7 days of exposure (p < 0.05). Conclusions: Moderate caffeine use may decrease anxiety in postmenopausal patients with underlying OAB, whereas depression, insomnia, and perceived stress were not affected by low-to-moderate caffeine intake. Our results support that counseling efforts on moderate caffeine consumption in postmenopausal patients underline that low-to moderate caffeine intake may be appropriate and possibly beneficial unless contraindicated due to other underlying conditions. Clinical Trials Registration: clinicaltrials.gov (NCT02180048).

Single-stage Simultaneous Retrograde and Antegrade Endoscopic Treatment of Giant Prostatic and Bladder Urethral Calculi.

INTRODUCTION: Calculi encountered in the lower urinary tract typically reside within the bladder, less often in the urethra. In this video, we present a minimally invasive endoscopic approach for removal of the largest total stone volume in the lower urinary tract reported in the literature to date. METHODS: A 25-year-old male (body mass index 61 kg/m2) with neurogenic bladder presented with urosepsis and acute kidney injury secondary to obstructive uropathy. Computerized tomography (CT) of the abdomen and pelvis demonstrated bilateral severe hydroureteronephrosis, a 4.2-cm bladder stone, and 3 urethral stones, including a 7.7-cm prostatic urethral stone and 2 membranous urethral stones (Fig. 1). Urgent bilateral percutaneous nephrostomy tubes were placed. The patient elected for endoscopic management. RESULTS: The patient was placed in the supine lithotomy position. His buried penis and narrow urethra only accommodated a 16-French flexible cystoscope. Multiple stones were encountered in the membranous urethra. A 60-W SuperPulse Thulium Fiber laser at 2 J and 30 Hz was utilized to dust the urethral stones efficiently. Simultaneous ultrasound-guided percutaneous access into the bladder was obtained and ultrasonic lithotripsy via shockpulse was used to clear the bladder stone and prostatic stone from above. Total stone treatment time was 240 minutes. Suprapubic and urethral catheters were placed at the conclusion. Postoperative day 1 CT scan confirmed stone-free status and he was discharged postoperative day 2. Outpatient nephrostogram demonstrated patency of bilateral ureters and nephrostomy tubes were removed. CONCLUSION: Higher morbidity procedures including open or laparoscopic approaches have been described for management of large lower urinary tract stones. In this video, we demonstrate a minimally invasive approach of combined simultaneous antegrade and retrograde lithotripsy to achieve a stone-free status in this morbidly obese and complicated patient.

Excision and Reconstruction for Urachal Adenocarcinoma: A Case Report With an Emphasis on Cosmesis.

OBJECTIVE: We report a urachal adenocarcinoma case managed surgically with two incisions and an emphasis on cosmesis while maintaining oncologic principles. INTRODUCTION: Depending upon the cancer, excision of the urachal remnant and umbilectomy may require abdominal wall reconstruction and potentially could leave the patient with an altered anterior abdominal wall. Restoring function and cosmesis after surgery can be very important to oncologic quality of life. Therefore, we present a patient with urachal adenocarcinoma who underwent open partial cystectomy, urachal ligament excision with umbilectomy, and neo-umbilicoplasty via two incisions. CONCLUSION: This case demonstrates the feasibility of performing an oncologically-sound operation for urachal adenocarcinoma while maintaining an emphasis on cosmesis.

What Guidewire Is the Best for Bypassing an Impacted Ureteral Stone?

Introduction and Objectives: To determine the optimal guidewire for bypassing an impacted ureteral stone. Materials and Methods: Three different benchtop models of varying impaction (300, 362, and 444 mm Hg pressure) were used to compare the ability of 13 different guidewires to bypass an impacted ureteral stone. In the first and second models, we recorded the maximum force required to bypass the stone. In the first model (300 mm Hg) 10 new wires for each of the 13 types were advanced past a ureteral stone using a series 5 digital force gauge. In the second model (362 mm Hg), the top 5 performing guidewires were similarly tested. In the third model (444 mm Hg), 5 attending urologists and 5 urology residents (blinded to wire type) compared the 13 guidewires and rated the wire performance using a Likert scale. Statistical analysis was performed with analysis of variance and the chi-square test. Results: In the first model, there was a significant difference between wires (p < 0.001) with the lowest mean force to bypass a stone seen in the Glidewire (0.117 ± 0.02 lbs) and HiWire (0.130 ± 0.01 lbs). Of the five wires tested in the second model, the Glidewire (0.24 ± 0.09 lbs) and UltraTrack (0.40 ± 0.35 lbs) both required less force than the other three wires (p = 0.018). In the third model, only two wires (Roadrunner and Glidewire) bypassed the impacted stone in 100% of trials. When comparing standard, hybrid, and hydrophilic wires, the hydrophilic had the highest success rate (standard = 0%, hybrid = 36.67%, and hydrophilic = 70.67%; p = 0.000) and Likert score (standard = 1.03, hybrid = 2.38, and hydrophilic = 3.24; p = 0.000). Hydrophilic wires required the least time to bypass the stone (hybrid = 82.81 seconds vs hydrophilic = 45.37 seconds, p = 0.000). Conclusions: In this benchtop study, standard wires performed poorly and hybrid wires were not as effective as hydrophilic wires. The Glidewire required the least force, the shortest insertion time, and had the highest surgeon satisfaction rating.

Diagnosis of clinical and subclinical varicocele: how has it evolved?

In this review, we examine the evolution and application of various diagnostic modalities for varicoceles starting with venography, scintigraphy, and thermography and their role in the evaluation of a varicocele patient. Some of these methods have been supplanted by less invasive and more easily performed diagnostic modalities, especially ultrasound and Doppler examination of the scrotum. Advances in ultrasound and magnetic resonance imaging hold the potential to expand the role of imaging beyond that of visual confirmation and characterization of varicoceles. The ability to identify the early indicators of testicular dysfunction based on imaging findings may have implications for the management of varicoceles in the future.