The Role of Experience: How Case Volume and Endourology-Fellowship Training Impact Surgical Outcomes for Ureteroscopy.

Introduction: Surgical experience is associated with superior outcomes in complex urologic cases, such as prostatectomy, nephrectomy, and cystectomy. The question remains whether experience is predictive of outcomes for less complex procedures, such as ureteroscopy (URS). Our study examined how case volume and endourology-fellowship training impacts URS outcomes. Methods: We retrospectively reviewed URS cases from 2017 to 2019 by high ureteroscopy volume urologists (HV), low ureteroscopy volume urologists (LV), endourology-fellowship trained (FT), and non-endourology FT (NFT) urologists. Surgical outcomes including stone-free rate (SFR), complication and reoperation rates, and postoperative imaging follow-up were analyzed between groups. Results: One thousand fifty-seven cases were reviewed across 23 urologists: 6 HV, 17 LV, 3 FT, and 20 NFT. Both FT and HV operated on more complex cases with lower rates of pre-stented patients. HV also operated on patients with higher rates of renal stones, lower pole involvement, and prior failed procedures. Despite this, FT and HV showed between 11.7% and 14.4% higher SFR, representing 2.7- to 3.6-fold greater odds of stone-free outcomes for primary and secondary stones. Additionally, HV and FT had a 4.9% to 7.8% lower rate of postoperative complications and a 3.3% to 4.3% lower rate of reoperations, representing 1.9- to 4.0-fold lower odds of complications. Finally, their patients had a 1.6- to 2.1-fold higher odds of postoperative imaging follow-up with a greater proportion receiving postoperative imaging within the recommended 3-month postoperative period. Conclusions: More experienced urologists, as defined by higher case volume and endourology-fellowship training, had higher SFR, lower complication and reoperation rates, and better postoperative imaging follow-up compared with less experienced urologists. Although less experienced urologists had outcomes in-line with clinical and literature standards, continued training and experience may be a predictor of better outcomes across multiple URS modalities.

Outcomes over 20 years performing robot-assisted laparoscopic prostatectomy: a single-surgeon experience.

OBJECTIVE: To evaluate a single surgeon's 20-year experience with robotic radical prostatectomy. METHODS: Patients who had undergone robot-assisted laparoscopic prostatectomy by a single surgeon were identified via an IRB approved prospectively maintained prostate cancer database. Patients were divided into 5-year cohorts (cohort A 2001-2005; cohort B 2006-2010; cohort C 2011-2015; cohort D 2016-2021) for analysis. Oncologic and quality of life outcomes were recorded at the time of follow-up visits. Continence was defined as 0-1 pad with occasional dribbling. Potency was defined as intercourse or an erection sufficient for intercourse within the last 4 weeks. RESULTS: Three thousand one hundred fifty-two patients met criteria for inclusion. Clavien ≥ 3 complication rates decreased from 5.9% to 3.2%, p = 0.021. There was considerable Gleason grade group (GG) and stage migration to more advanced disease between cohort A (6.4% GG4 or GG5, 16.2% pT3 or pT4, 1.2% N1) and cohort D (17% GG4 or GG5, 45.5% pT3 or pT4, 14.4% N1; p < 0.001). Consistent with this, an increasing proportion of patients required salvage treatments over time (14.6% of cohort A vs 22.5% of cohort D, p < 0.001). 1-year continence rates improved from 74.8% to greater than 92.4%, p < 0.001. While baseline potency and use of intraoperative nerve spare decreased, for patients potent at baseline, there were no significant differences for potency at one year (p = 0.065). CONCLUSIONS: In this 20-year review of our experience with robotic prostatectomy, complication rates and continence outcomes improved over time, and there was a migration to more advanced disease at the time of surgery.

Use of a preoperative checklist reduces risk of penile prosthesis infection.

PURPOSE: Infection of a penile prosthesis is a devastating complication that necessitates the removal of all device components. Many aspects of preoperative and intraoperative infection prophylaxis practices have been examined but the specific relevant factors remain unknown. We determined whether use of a mandatory checklist of perioperative practices believed to reduce the risk of prosthesis infection would impact patient safety. MATERIALS AND METHODS: We retrospectively reviewed men with erectile dysfunction who underwent penile prosthesis insertion. Only patients who had not previously undergone penile prosthesis surgery were included in the study. After an outbreak of infections, a mandatory checklist comprised of best infection prophylaxis practices was developed and was required for all subsequent implant surgeries. Patient cohorts were divided into 3 groups of baseline period, outbreak period and intervention period. Statistical analysis was performed using the chi-square test, Fisher's exact test and ANOVA. RESULTS: During the baseline period 2 of 68 (2.9%) inflatable penile prosthesis devices became infected. During the outbreak period 6 of 11 (54.5%) devices became infected, representing an incidence risk ratio 18.55 times that of the baseline period. After the implementation of the preoperative checklist the incidence risk ratio decreased to 0.0 in the intervention period with 0 of 52 devices (0%) becoming infected. CONCLUSIONS: After an outbreak of an unusually high number of penile prosthesis infections, implementation of a required checklist brought the rate down to zero. Although the specific factors that led to the infection outbreak and subsequent cessation of infections are unknown, we have shown that use of a checklist was associated with a dramatic impact on patient safety.

Monthly variations in urolithiasis presentations and their association with meteorologic factors in New York City.

INTRODUCTION: Nephrolithiasis in the United States has been on the rise during the past several decades. Temperature has been shown to directly correlate with increased stone disease. We examine the association between climactic factors and monthly urolithiasis presentation rates for 6 years at a single institution in New York City. METHODS: Emergency department (ED) data on patient visitations were collected along with patient demographics. Meteorological data were collected using the website "Weather Underground" ( www.wunderground.com ). Average monthly temperature, dew point, precipitation, and sea level pressure were obtained and relative humidity was calculated using the dew point. Monthly urolithiasis visitations and the correlation of atmospheric factors were analyzed using an autoregressive integrated moving average (ARIMA) model. RESULTS: The total number of renal colic visits to the hospital's ED from January 2007 through December 2012 tallied 3647 visits. The lowest average monthly rate per 1000 ED visits occurred in the month of February (28.8) and the highest in the month of August (43.8). There was a strong correlation between monthly presentation rate and temperature (P<0.01) and relative humidity (P=0.06) but no correlation with precipitation and sea level pressure. On multivariate ARIMA analysis, only average monthly temperature was significantly associated with monthly urinary calculi presentation rate among all comers (P<0.01). The crude correlations held true for both sexes with respect to temperature but not for females in regard to relative humidity. The age groups of 21 to 44 and 45 to 64 had a rate correlation with temperature and all races correlated with temperature, but only Caucasians had a weak correlation with relative humidity. CONCLUSIONS: This is the first study examining the role of climate on stone presentation rate in a large city above the Southern "stone belt" states. Temperature has a strong correlation with calculi presentation rate, and relative humidity has a trend toward overall calculi presentation rate.

What is the "true" incidence of active surveillance and brachytherapy candidates in men undergoing robot-assisted radical prostatectomy?

PURPOSE: To correlate clinical low-risk prostate cancers with pathologic outcomes in men who are considered for active surveillance (AS), interstitial radiation therapy, or radical prostatectomy (RP). PATIENTS AND METHODS: Clinical and pathologic data of 76 consecutive patients who underwent RP by a single surgeon between October 2001 and July 2008 were reviewed. The retrospective review identified men with clinical low-risk disease--defined as a prostate-specific antigen (PSA) level <10 ng/mL, no Gleason pattern >3, no >2 cores positive, and no core >50%--who would also have been considered for AS and/or brachytherapy based on these features. Pathologic specimens were examined for Gleason primary, secondary, and tertiary patterns, perineural invasion, capsular involvement, margins, nodal disease, and seminal vesicle involvement. RESULTS: Of the patients who underwent RP, 42/76 (55%) had low-risk clinical staging; 8/76 (19%) had low-risk features on final pathologic staging. Fifty-four of 76 (71%) were pT2c; 10% were pT3. Gleason 6 was seen in 41/76 (53%) of RP specimens; Gleason 7 and 8 in 41% and 4%, respectively. Favorable brachytherapy parameters were identified in 63% of those who underwent surgery, but 39 of 48 (81%) would have been inappropriately selected based on features of the pathologic specimen. CONCLUSION: Clinical staging based on PSA level and biopsy findings correlates poorly with pathologic outcome when stratifying for low-risk features in men who may be candidates for brachytherapy and/or AS.

Resume fraud: unverifiable publications of urology training program applicants.

PURPOSE: We examined the incidence of resume fraud among urology residency applicants by determining the rate of misrepresented publications listed in applications to a urology residency program. MATERIALS AND METHODS: Applications from all 147 urology residency applicants to a program from the 2007 application cycle were analyzed. Verification of listed publications was attempted by querying PubMed, Google Scholar and MEDLINE. Univariate analysis was conducted to assess associations between unverifiable publications and applicant demographics. RESULTS: Of the applicants who submitted publications 19% (14 of 71) had at least 1 unverifiable publication, which represented 9% (14 of 147) of the entire applicant pool. There were no statistically significant associations between misrepresented publications and applicant demographics. CONCLUSIONS: Applicants had a low but still unacceptable rate of misrepresented publications and this trend in academic medicine is of great concern.

Robot-assisted laparoscopic dismembered pyeloplasty.

OBJECTIVE: Advanced laparoscopic skills limit the implementation of laparoscopic pyeloplasty to centers with extensive experience. The introduction of robotic technology into the field of minimally invasive surgery has facilitated complex surgical dissection and genitourinary reconstruction. We report our experience with robot-assisted laparoscopic pyeloplasty using the da Vinci Robotic Surgical System at 3 New York City medical centers. METHODS: A review of all robot-assisted laparoscopic Anderson-Hynes dismembered pyeloplasty cases in 38 patients (21 females, 17 males) between April 2001 and January 2004 was performed. All patients had symptoms or radiographic evidence of ureteropelvic junction obstruction. Robotic assistance with the da Vinci Robotic Surgical System was used after preparation of the ureteropelvic junction with a standard laparoscopic approach. RESULTS: The average patient age was 39.3 years (range, 15 to 69). The mean operative time and suturing time were 225.6+/-59.3 minutes and 64.2+/-14.6 minutes. The average estimated blood loss was minimal at 77.3+/-55.3 mL. The mean length of hospitalization was 69.6 hours (range, 28 to 310). The average use of intravenous morphine was 26.5 mg (range, 0 to 162). No intraoperative complications occurred, and open conversions were not necessary. A mean follow-up of 12.2 months revealed a success rate of 94.7% with 2/38 patients requiring further treatments. CONCLUSIONS: This combined multi-institutional series reveals that robot-assisted pyeloplasty with the da Vinci Surgical System is safe and reproducible. These intermediate results appear comparable to results with open and laparoscopic pyeloplasty repairs.

Laparoscopic retrieval of retroperitoneal vas deferens in vasovasostomy for postinguinal herniorrhaphy obstructive azoospermia.

OBJECTIVE: Iatrogenic injury to the vas deferens is a well-documented complication of inguinal hernia repair. Recently obstruction related to the use of polypropylene mesh for hernia repair has been reported. We describe a case using laparoscopy to mobilize the retroperitoneal vas and deliver it to the healthy vas proximal to the vas trapped in the cicatrix induced by mesh thus allowing a tension-free microsurgical repair. DESIGN: Case report. SETTING: Outpatient male infertility practice. PATIENT(S): Obstructed azoospermic men with polypropylene mesh. INTERVENTION(S): Laparoscopic retrieval of retroperitoneal vas segment for primary microsurgical anastomosis. MAIN OUTCOME MEASURE(S): Patency of vas and presence of sperm. RESULT(S): A tension-free, patent anastomosis was performed. CONCLUSION(S): Polypropylene mesh-induced fibrosis of the vas deferens can result in obstructive azospermia. Laparoscopy can be used to permit a microsurgical bypass of the obstructed segment.

Robot-assisted laparoscopic dismembered pyeloplasty: a combined experience.

BACKGROUND AND PURPOSE: The need for advanced laparoscopic skills limits the implementation of laparoscopic pyeloplasty to centers with extensive experience. The introduction of robotic technology into the field of minimally invasive surgery has facilitated complex surgical dissection and genitourinary reconstruction. We report our experience with robot-assisted laparoscopic pyeloplasty using the daVinci Surgical System at three New York City medical centers. PATIENTS AND METHODS: A retrospective review of all robot-assisted laparoscopic Anderson-Hynes dismembered pyeloplasty cases in 18 female and 17 male patients between April 2001 and January 2004 was performed. The average patient age was 39.0 years (range 15-69 years). All patients had symptoms or radiographic evidence of ureteropelvic junction (UPJ) obstruction. Robotic assistance with the daVinci Surgical System was employed after preparation of the UPJ with a standard laparoscopic approach. RESULTS: The mean operative time and suturing time was 216.4 +/- 52.9 minutes and 63.0 +/- 14.2 minutes, respectively. The average estimated blood loss was minimal at 73.9 +/- 58.3 mL. The mean length of hospitalization was 69.4 hours (range 28-310 hours). The average use of intravenous morphine was 28.4 mg (range 0-162 mg). There were no intraoperative complications or open conversions. A mean follow-up of 7.9 months revealed a success rate of 94%, with two patients requiring further treatment. CONCLUSIONS: This combined multi-institutional series reveals that robot-assisted pyeloplasty with the daVinci Surgical System is safe and reproducible. These intermediate results appear comparable to those of open and laparoscopic pyeloplasty repairs.

Laparoscopic adrenalectomy for isolated adrenal metastasis.

BACKGROUND: Laparoscopic adrenalectomy is accepted by many as the standard of care for the majority of adrenal masses less than 8 cm. The question exists whether laparoscopic removal of metastatic lesions to the adrenal is more difficult than laparoscopic removal of primary adrenal lesions. METHODS: We performed a retrospective analysis of all laparoscopic adrenalectomies performed at a single institution from 1998 to 2001, comparing laparoscopic adrenalectomies for primary lesions of the adrenal gland versus isolated metastatic lesions to the adrenal gland. RESULTS: Fourteen laparoscopic adrenalectomies were attempted, 10 for primary disease and 4 for metastatic disease. All 10 laparoscopic procedures were completed successfully for primary disease (average operative time=218 minutes, average tumor size=4 cm, median hospital stay=2 days). Only one of the 4 laparoscopic adrenalectomies for metastatic disease was completed successfully (average operative time=332 minutes, average tumor size=7.3 cm, median hospital stay=2 days). No major complications occurred in either group. CONCLUSIONS: We feel laparoscopic adrenalectomy is the preferred approach for primary adrenal masses less than 8 cm. Based on our experience and a review of the literature, isolated metastatic lesions to the adrenal gland appear less amenable to laparoscopic removal than do primary lesions of the same size.

Laparoscopic heminephrectomy for benign disease of the horseshoe kidney.

BACKGROUND AND OBJECTIVE: Minimally invasive surgery plays a definitive role in the management of complications associated with the horseshoe kidney (HK). Aberrant vessels, the renal isthmus, and renal ectopia are all unique features of this anomaly that make the laparoscopic approach a challenge. We report our experience with this technique in 2 patients. METHODS: Two patients with an HK were evaluated for recurrent urinary tract infection. In both cases, the nonfunctioning renal moiety was demonstrated by renal scan. A transperitoneal laparoscopic heminephrectomy was performed. The Endostapler device was used to divide the renal isthmus. RESULTS: The operative time was less than 3 hours. Blood loss was negligible. No intraoperative complications occurred. The hospital stay was 48 hours. Postoperative discomfort was minimal. CONCLUSION: Laparoscopic heminephrectomy is a safe and feasible approach for benign diseases of the HK. The Endostapler is a useful adjunct in the division of the renal isthmus.

Ureteral ischemia model: an explanation of ureteral dysfunction after chronic obstruction.

BACKGROUND AND PURPOSE: Many models of smooth muscle ischemia have been developed to explain organ insufficiency or failure. Ureteral decompensation may also be described in these terms. We anticipate that ureteral ischemia will result from overdistention brought about by obstruction. A preliminary model to create an ischemic ureter is described herein. MATERIALS AND METHODS: Six white New Zealand female rabbits were used for this study. All had their left ureters surgically ligated at the level of the urinary bladder. The right ureters served as controls. In the acute-phase group, the ureters were all reexplored 2 weeks postobstruction. Exploration of the other rabbits was delayed for 3 more weeks. A laser Doppler needle (Transonics Inc.) was used to measure tissue perfusion in the rental artery, renal vein, renal parenchyma, renal pelvis, ureteropelvic junction, upper ureter, mid ureter, lower ureter, and lateral wall of the bladder. Baseline and postobstructive measurements of tissue perfusion were collected and compared. RESULTS: In both the acute and the chronic obstruction groups, there was a demonstrable drop-off in perfusion of the ureteral sidewall. A more notable loss of perfusion was seen in the distal ureter. CONCLUSION: The increased wall tension in the obstructed ureter results in a significant decrease in smooth muscle perfusion. This ischemia may result in the same functional and histologic changes that occur in other smooth muscle organs. Ultimately, the poor outcomes of some restorative/reconstructive procedures on the ureter may be explained in terms of smooth muscle ischemia.

Tail stent versus re-entry tube: a randomized comparison after percutaneous stone extraction.

OBJECTIVES: To evaluate the efficacy of a 7F tail stent with an 18F Councill nephrostomy tube and compare it to a 24F re-entry Malecot nephrostomy tube after percutaneous nephrolithotomy. METHODS: Forty patients were prospectively randomized to receive either a 24F re-entry Malecot nephrostomy tube (group A, n = 20) or a 7F tail stent with an 18F Councill nephrostomy tube (group B, n = 20) for postoperative drainage. Patients were evaluated with an analogue scale questionnaire 15 days after percutaneous nephrolithotomy at the routine office follow-up visit asking them to rate the flank pain on a 0 to 10 scale, urinary urgency on a 0 to 10 scale, and quality of life, while the external drainage tubes were still in place. RESULTS: The mean length of stay was 4.5 and 3.5 days for groups A and B, respectively. Flank urine leakage was present in all patients in group A for a period of 6 to 12 hours, and no patient in group B had any significant flank drainage. A statistically significant reduction of flank pain in favor of group B was observed (P = 0.0002). We did not observe any statistically significant difference when evaluating the urgency (P = 0.1) and quality-of-life scores (P = 0.09) between the two groups, even though a trend was noted toward amelioration in favor of group B patients. CONCLUSIONS: The results of the present study suggest that the 7F tail stent is certainly better tolerated by the patients after percutaneous nephrolithotomy compared with the standard 24F re-entry Malecot nephrostomy tube.