Vapor-induced phase-separation-enabled versatile direct ink writing.

Versatile printing of polymers, metals, and composites always calls for simple, economic approaches. Here we present an approach to three-dimensional (3D) printing of polymeric, metallic, and composite materials at room conditions, based on the polymeric vapor-induced phase separation (VIPS) process. During VIPS 3D printing (VIPS-3DP), a dissolved polymer-based ink is deposited in an environment where nebulized non-solvent is present, inducing the low-volatility solvent to be extracted from the filament in a controllable manner due to its higher chemical affinity with the non-solvent used. The polymeric phase is hardened in situ as a result of the induced phase separation process. The low volatility of the solvent enables its reclamation after the printing process, significantly reducing its environmental footprint. We first demonstrate the use of VIPS-3DP for polymer printing, showcasing its potential in printing intricate structures. We further extend VIPS-3DP to the deposition of polymer-based metallic inks or composite powder-laden polymeric inks, which become metallic parts or composites after a thermal cycle is applied. Furthermore, spatially tunable porous structures and functionally graded parts are printed by using the printing path to set the inter-filament porosity as well as an inorganic space-holder as an intra-filament porogen.

Reply to Jue et al. Overcoming Understaging and Undergrading in Upper Tract Urothelial Carcinoma. Comment on "Ghoreifi et al. Modern Kidney-Sparing Management of Upper Tract Urothelial Carcinoma. Cancers 2023, 15, 4495".

We appreciate the comments made by Jue et al [...].

The Impact of Telemedicine in Reducing the Carbon Footprint in Health Care: A Systematic Review and Cumulative Analysis of 68 Million Clinical Consultations.

CONTEXT: Carbon footprint (CF) has emerged as an important factor when assessing health care interventions. OBJECTIVE: To investigate the reduction in CF for patients utilizing telemedicine. EVIDENCE ACQUISITION: The PubMed, Scopus, and Web of Science databases were queried for studies describing telemedicine consultation and reporting on carbon emissions saved and the carbon emissions of telemedicine devices as primary outcomes, and travel distance and time and cost savings and safety as secondary outcomes. Outcomes were tabulated and calculated per consultation. Carbon emissions and travel distances were also calculated for each total study cohort. Risk of bias was assessed using the Newcastle-Ottawa scale, and the Oxford level of evidence was determined. EVIDENCE SYNTHESIS: A total of 48 studies met the inclusion criteria, covering 68 465 481 telemedicine consultations and savings of 691 825 tons of CO2 emissions and 3 318 464 047 km of travel distance. Carbon assessment was mostly reported as the estimated distance saved using a conversion factor. Medical specialties used telemedicine to connect specialists with patients at home (n = 25) or at a local center (n = 6). Surgical specialties used telemedicine for virtual preoperative assessment (n = 9), follow-up (n = 4), and general consultation (n = 4). The savings per consultation were 21.9-632.17 min and $1.85-$325. More studies focused on the COVID-19 time frame (n = 33) than before the pandemic (n = 15). The studies are limited by calculations, mostly for the travel distance for carbon savings, and appropriate follow-up to analyze the real impact on travel and appointments. CONCLUSIONS: Telemedicine reduces the CF of the health care sector. Expanding the use of telemedicine and educating providers and patients could further decrease CO2 emissions and save both money and time. PATIENT SUMMARY: We reviewed 48 studies on the use of telemedicine. We found that people used their cars less and saved time and money, as well as CO2 emissions, if they used teleconsultations. Some studies only looked at how much CO2 from driving was saved, so there might be more to learn about the benefits of teleconsultations. The use of online doctor appointments is not only good for our planet but also helps patients in saving time and money. This review is registered on the PROSPERO database for systematic reviews (CRD42023456839).

Modern Kidney-Sparing Management of Upper Tract Urothelial Carcinoma.

PURPOSE: To review the latest evidence on the modern techniques and outcomes of kidney-sparing surgeries (KSS) in patients with upper tract urothelial carcinoma (UTUC). METHODS: A comprehensive literature search on the study topic was conducted before 30 April 2023 using electronic databases including PubMed, MEDLINE, and EMBASE. A narrative overview of the literature was then provided based on the extracted data and a qualitative synthesis of the findings. RESULTS: KSS is recommended for low- as well as select high-risk UTUCs who are not eligible for radical treatments. Endoscopic ablation is a KSS option that is associated with similar oncological outcomes compared with radical treatments while preserving renal function in well-selected patients. The other option in this setting is distal ureterectomy, which has the advantage of providing a definitive pathological stage and grade. Data from retrospective studies support the superiority of this approach over radical treatment with similar oncological outcomes, albeit in select cases. Novel chemoablation agents have also been studied in the past few years, of which mitomycin gel has received FDA approval for use in low-risk UTUCs. CONCLUSION: KSSs are acceptable approaches for patients with low- and select high-risk UTUCs, which preserve renal function without compromising the oncological outcomes.

A Urine-based DNA Methylation Marker Test to Detect Upper Tract Urothelial Carcinoma: A Prospective Cohort Study.

PURPOSE: We explored the accuracy of a urine-based epigenetic test for detecting upper tract urothelial carcinoma. MATERIALS AND METHODS: Under an Institutional Review Board-approved protocol, urine samples were prospectively collected from primary upper tract urothelial carcinoma patients before radical nephroureterectomy, ureterectomy, or ureteroscopy between December 2019 and March 2022. Samples were analyzed with Bladder CARE, a urine-based test that measures the methylation levels of 3 cancer biomarkers (TRNA-Cys, SIM2, and NKX1-1) and 2 internal control loci using methylation-sensitive restriction enzymes coupled with quantitative polymerase chain reaction. Results were reported as the Bladder CARE Index score and quantitatively categorized as positive (>5), high risk (2.5-5), or negative (<2.5). The findings were compared with those of 1:1 sex/age-matched cancer-free healthy individuals. RESULTS: Fifty patients (40 radical nephroureterectomy, 7 ureterectomy, and 3 ureteroscopy) with a median (IQR) age of 72 (64-79) years were included. Bladder CARE Index results were positive in 47, high risk in 1, and negative in 2 patients. A significant correlation was found between Bladder CARE Index values and tumor size. Urine cytology was available for 35 patients, of whom 22 (63%) results were false-negative. Upper tract urothelial carcinoma patients had significantly higher Bladder CARE Index values compared to the controls (mean 189.3 vs 1.6, P < .001). The sensitivity, specificity, positive predictive value, and negative predictive value of the Bladder CARE test for detecting upper tract urothelial carcinoma were 96%, 88%, 89%, and 96%, respectively.Conclusions:Bladder CARE is an accurate urine-based epigenetic test for the diagnosis of upper tract urothelial carcinoma, with much higher sensitivity than standard urine cytology.

The impact of male infertility faculty on urology residency training.

The objective of this study was to determine the impact of having male infertility on urology residents' infertility training experience, surgical confidence, and In-Service-Exam Infertility/Sexual Medicine subscores. We electronically surveyed urology residents throughout the United States querying exposure to infertility faculty and fertility knowledge. Univariable and multivariable analysis was performed to determine predictors of higher In-Service Exam Infertility/Sexual Medicine sub-scores and self-rated infertility competency. Fifty-four of 72 respondents (75%) reported that male infertility comprises ≤10% of their training. Of the 63 residents who have a reproductive urologist on faculty, 66.7%, 47.6%, and 49.2% have scrubbed/observed a microsurgical varicocelectomy, vasectomy reversal and testicular sperm extraction, respectively. Residents exposed to infertility faculty are more likely to self-rate their infertility understanding as "excellent" or "good" (p = 0.04 and p = 0.02, respectively), and 14.4× more likely to feel confident performing infertility procedures, versus residents lacking faculty (p < 0.001). Residents having formal microsurgical training have better self-rated infertility understanding (p < 0.001), non-obstructive azoospermia management (p = 0.01), and competency performing infertility procedures (p < 0.001). Residents exposed to fertility faculty are more likely to feel confident performing fertility procedures after residency (p = 0.001). In conclusion, infertility comprises a minority of residency training. Most residents anticipate performing infertility procedures in practice, despite two-thirds lacking confidence performing these. Having an infertility faculty and formal microsurgical training improves residents' surgical confidence, non-obstructive azoospermia management, and global male infertility understanding. A structured educational curriculum may improve resident infertility training.

Bladder Recurrence Following Diagnostic Ureteroscopy in Patients Undergoing Nephroureterectomy for Upper Tract Urothelial Cancer: Is Ureteral Access Sheath Protective?

OBJECTIVE: To examine the effect of diagnostic ureteroscopy (URS) and ureteral access sheath usage on bladder recurrence following radical nephroureterectomy (RNU). METHODS: We retrospectively reviewed the records of patients who underwent RNU between 2005 - 2019. Patients with a history of bladder cancer and those without a bladder cuff resection were excluded. Bladder recurrence was the primary outcome and cox regression modeling was used to assess the impact of URS adjusting for other factors. RESULTS: Out of 271 RNU cases, 143 were included with a median age of 73 years (IQR 65 - 80). URS was performed in 104 cases (73%) and a ureteral access sheath was used in 26 (25%). With a median follow-up of 27 months, there were 36 (25%) bladder recurrences. The bladder recurrence rate (median time to recurrence) for patients who had URS vs no URS was 30.8% (9.0 months) and 7.7% (12.1 months), respectively (P = .02). A lower recurrence rate was noted in patients whom a ureteral access sheath was utilized (11.5%) vs those with no access sheath (39.7%, P = .01). Multivariable analysis revealed a significant increase in bladder recurrence if URS was performed prior to RNU (HR 5.6 [1.7 - 18.5], P <.004), however, this effect was mitigated if a ureteral access sheath was used (HR 1.3, [0.3 - 6.4], P = .76). Ureteral stent usage and performing a ureteroscopic biopsy had no significant effect on bladder recurrence. CONCLUSION: Diagnostic URS in patients undergoing RNU for UTUC significantly increases the risk of bladder recurrence. This effect may be mitigated by using a ureteral access sheath.

Trends in Body-Mass Index After Donor Nephrectomy.

The link between obesity and diabetes, hypertension, and eventual kidney dysfunction is well recognized. To evaluate trends in the body-mass index (BMI) of donor nephrectomy patients, the BMI was evaluated in 532 donors over 11 years from 2002 to 2012. Measurements were made preoperatively, at 1 year, and at the present time. The follow-up range varied from 12 months to 11 years dependent on the date of donation. Of the 532 patients queried, 100 patients had long-term results. At 1 year, there was an overall decrease in BMI, however, at anytime after the first year, postoperative BMI trended upward, with more than half of the overweight patients (BMI 25-30), at the time of donation, dipping into the obese range (BMI >30). Given these results and recognizing the attendant risks-especially with the background of a single kidney-we have initiated further lifestyle and nutrition counseling at our center and are considering a more stringent preoperative weight control policy.

Impact of Covid-19 on the urology service in United States: perspectives and strategies to face a Pandemic.

Over the course of several weeks following the first diagnosed case of COVID-19 in the U.S., the virus rapidly spread across our communities. It became evident that the pandemic was going to place a severe strain on all components of the U.S. healthcare system, and we needed to adapt our daily practices, training and education. In the present paper we discuss four pillars to face a pandemic: surgical and outpatients service, tele-medicine and tele-education. In the face of unprecedented risks in providing adequate health care to our patients during this current, evolving public health crisis of COVID-19, alternative patient management tools such as telemedicine services, allow clinicians to maintain necessary patient rapport with their healthcare provider when required. As a subspecialty, urology should take full advantage of telehealth and tele-education at this juncture. As tele-urology and tele-education can obviate the potential drawbacks of "social distancing" as it pertains to healthcare, the platform can also reduce the risk of COVID-19 spread, without compromising quality urological care and educational efforts. Telehealth can bring urologists and their patients together, perhaps closer than ever.

Impact of Covid-19 on the urology service in United States: perspectives and strategies to face a pandemic

ABSTRACT Over the course of several weeks following the first diagnosed case of COVID-19 In the U.S., the virus rapidly spread across our communities. It became evident that the pandemic was going to place a severe strain on all components of the U.S. healthcare system, and we needed to adapt our daily practices, training and education. In the present paper we discuss four pillars to face a pandemic: surgical and outpatients service, tele-medicine and tele-education. In the face of unprecedented risks in providing adequate health care to our patients during this current, evolving public health crisis of COVID-19, alternative patient management tools such as telemedicine services, allow clinicians to maintain necessary patient rapport with their healthcare provider when required. As a subspecialty, urology should take full advantage of telehealth and teleeducation at this juncture. As tele-urology and tele-education can obviate the potential drawbacks of "social distancing" as it pertains to healthcare, the platform can also reduce the risk of COVID-19 spread, without compromising quality urological care and educational efforts. Telehealth can bring urologists and their patients together, perhaps closer than ever.

Thulium-Holmium:YAG Duo Laser in Conservative Upper Tract Urothelial Cancer Treatment: 13 Years Experience from a Tertiary National Referral Center.

Introduction and Objectives: To evaluate ablative safety and efficacy of thulium-holmium:YAG (TL-HL:YAG) duo laser in renal conserving retrograde intrarenal surgery (RC-RIRS) in upper tract urothelial carcinoma (UTUC). Materials and Methods: A retrospective study was performed on 178 consecutive patients referred for consideration of RC-RIRS UTUC-eLA (endoscopic laser ablation) in a tertiary center (January 2005 to December 2018). Key data were recorded using a standardized study proforma. Results: After endodiagnostic procedure, 42 declined rigorous endosurveillance protocol and went elsewhere for alternative treatment, leaving 136 patients, of whom 35 patients dropped out (25.7%) after undergoing primary radical nephroureterectomy (RNU) (unsuitable for renal preservation). This was left with 101 candidates who continued UTUC conservative management (intention-to-treat [ITT] population). Mean follow-up (FU) for these 101 patients was 28.7 months. At last FU (range 3-144 months), 70 patients (69.3%) were recurrence free, 22 (21.8%) had endoscopically treated recurrences, and a further 9 (8.9%) had undergone RNU. In the ITT population, kidney-preserving rate was 91%, whereas in imperative indications, it was 87.5%. Clavien-Dindo grade I complications only (self-limiting hematuria) were reported in 10%. Conclusions: Over a 13-year period, RC-RIRS UTUC treatment with the TL-HL:YAG duo laser was safe and oncologically noninferior to alternative combination laser energy technologies used for this indication.

Long-Term Body Mass Index Trends After Living-Donor Nephrectomy.

OBJECTIVES: As the demand for kidney transplant allografts has increased, many centers are expanding the upper limit of acceptable body mass index for kidney donors. However, obesity is a risk factor for developing renal disease. Our goal was to quantify body mass index trends in donor nephrectomy patients and to institute nutrition counseling to promote sustainable weight loss to reduce the risk of metabolic syndrome-derived renal dysfunction. MATERIALS AND METHODS: Ninety patients who underwent donor nephrectomy between 2007 and 2012 consented to having height and weight data collected at multiple time points. After data collection, each patient underwent a standardized nutrition counseling session. One year later, body mass index was reassessed. RESULTS: Preoperatively, 52% of the patients were overweight or obese. The percentage of overweight and obese patients remained stable for 2 years after surgery. However, at 3, 4, and 5 years after surgery, these rates increased to 59%, 69%, and 91%. Each patient was counseled about obesity-related comorbidities and provided information about lifestyle modification. One year later, 94% of previously overweight patients and 82% of previously obese patients had a decrease in mean body mass index from 27.2 ± 4.0 kg/m2 to 25.1 ± 3.6 kg/m2. CONCLUSIONS: Living-donor nephrectomy patients are at risk of developing obesity, similar to the adult population. Nutrition counseling may be beneficial to help normalize body mass index in patients who have become overweight or obese to potentially prevent obesity-related comorbidities. All patients were evaluated by a nutrition specialist after surgery to review our donor nephrectomy nutrition brochure. Body mass index monitoring and primary care follow-up appear to be appropriate surveillance methods.

Management of stones associated with intrarenal stenosis: infundibular stenosis and caliceal diverticulum.

PURPOSE: To review our experience with retrograde intrarenal surgery (RIRS) for management of conditions associated with intrarenal stricture and present a treatment algorithm based on the series. PATIENTS AND METHODS: RIRS was offered to all patients with symptomatic intrarenal stenosis regardless of location if stone burden was 2 cm or less. With a combined endourology and lithotripsy table, patients with stones between 2 and 3 cm were also offered RIRS using a combined approach of RIRS and shockwave lithotripsy (SWL). A total of 108 patients with symptomatic stones and caliceal diverticulum or infundibular stenosis were included in the data analysis. A standard technique was used in all cases. Failures or patients not suitable for RIRS were treated with either percutaneous nephrolithotomy (PCNL) or laparoscopic surgery. RESULTS: Successful identification and dilation/incision of the stenotic opening was accomplished in 94% of cases. Seventy-five percent of stones were managed with basketing and/or holmium laser ablation. In these patients, 90% were stone free (<2 mm stone fragments). For stones between 2 and 3 cm, the use of holmium laser in combination with SWL provided stone-free rates of 75%. Five percent of patients needed PCNL because of larger stone burden and posterior location. CONCLUSIONS: With the appropriate equipment, RIRS provides a valid treatment option for patients with intrarenal strictures. While upper pole and midrenal lesions are ideal, lower pole segments may be approached as well. A treatment algorithm based on the results provides a simplified approach for the minimally invasive management of intrarenal stenosis.

Improving flexible ureterorenoscope durability up to 100 procedures.

BACKGROUND AND PURPOSE: Controversy exists in the literature regarding flexible ureterorenoscopy (F-URS) durability, with a variable expected number of uses from a new F-URS. In this study, a tertiary center experience with the use of two consecutive F-URS is reported and suggestions as to how to improve durability further are made. MATERIALS AND METHODS: All F-URS performed in the same tertiary care center between July 2009 and February 2011, with two new instruments Flex-X, were reviewed retrospectively. All renal pathology were included. Ureteral cases were excluded. A 9.5F semirigid ureteroscope was always used at the start for a ureteral optical predilation and to explore the upper urinary tract for possible lithotripsy/laser ablation/biopsy. The F-URS was introduced sequentially to explore the remaining calices. Data pertaining to the procedure were collected. The method of sterilization was complete immersion with Cidex®. RESULTS: The instruments were substituted after 113 and 102 procedures, respectively. The first F-URS was used for a total operative time of 79 hours and 10 minutes while the second one was used for 71 hours and 25 minutes (mean 75 hours and 15 min). Procedure duration was 15 to 175 minutes (mean 58 min). The flexible instruments were used for a mean of 42 minutes per procedure (range 13-153 min). The indications for F-URS were therapeutic in 75.4% and diagnostic in 22.8% of the cases. For lower pole calculi, the stone was relocated in 65.2% and managed with the nonflexed flexible instrument 90% of the time. The most common causes of damage of F-URS were: Deflection mechanism impairment, inner sheath damage, and fiberoptic bundle breaks. CONCLUSIONS: Increased durability of F-URS was from a variety of factors, a key element of which was the method of sterilization, while routine use of the semirigid instrument initially further contributed significantly to increase the number of F-URS procedures, saving overall costs.

First collaborative experience with thulium laser ablation of localized upper urinary tract urothelial tumors using retrograde intra-renal surgery.

PURPOSE: Thulium laser ablation (TLA) outcomes with blinded performance evaluation after retrograde intra-renal surgical (RIRS) treatment of upper urinary tract transitional cell carcinomas (UUT-TCC). MATERIALS AND METHODS: A UUT-TCC patient cohort undergoing RIRS-TLA by an international endoscopic surgical collaboration in a European center (April 2005-July 2009), underwent outcomes evaluation. All 4 surgeons were blinded and independently scored both TLA and Holmium:YAG laser ablation performance aspects annually using a Likert scoring system (0-10). RESULTS: All patients (n = 59, median age 66 years, 9 with solitary kidney) had complete UUT inspection. Presenting lesion(s) were intra-renal (n = 30, 51%), ureteral (n = 13, 22%), and combined (n = 16, 27%). Single-stage TLA sufficed in 81.4% (tumors < 1.5 cm). Significant recurrence free survival differences occurred according to primary tumor size >/< 1.5 cm and multi-focality, but location made no difference. Median Likert scores were i) fiber-tip stability --5.5/8.75, p = 0.016; ii) reduced bleeding--5/8.5, p = 0.004; iii)fiber-tip precision--5.5/8.5, p = 0.003; iv) mucosal perforation reduction--3.5/7.5, p = 0.001; v) ablation efficiency tumors < 1.5 cm--6/9, p = 0.017; tumors > 1.5 cm--6.75/6.75, p = 1, and vi) overall efficiency--6/7.5, p = 0.09, for Holmium:YAG and TLA, respectively. CONCLUSIONS: The Thulium laser delivered non-inferior recurrence free survival to RIRS-UUT-TCC Holmium:YAG laser ablation, but better median parameter performance scores in fiber-tip stability, precision, reduced bleeding and mucosal perforation reduction in expert ratings. Despite improved photothermal coagulation, and endo-visualization for tumors < 1.5 cm, both ablation and overall efficiency remained challenging for larger tumors with both existing laser technologies.

A comparison of running suture versus figure-8 sutures as the initial step in achieving hemostasis during laparoscopic partial nephrectomy.

BACKGROUND AND PURPOSE: During laparoscopic partial nephrectomy, the importance of the initial suture placed under warm ischemic conditions cannot be underestimated. Inadequate hemostasis may lead to further surgical complications. Our goal was to determine which method of suture ligation (running vs figure-8 interrupted) provides better initial hemostasis when performing partial nephrectomy in an ex-vivo porcine model. MATERIALS AND METHODS: Deep partial nephrectomy defects were cut in the lateral aspect of six porcine kidneys. The renal artery was cannulated, and the kidneys were perfused from a water reservoir. The level (cm H(2)O) at which parenchymal leakage occurred was measured and recorded in three situations: No parenchymal suture; running suture along the base of the defect; and interrupted figure-8 sutures placed in parallel along the base of the defect. RESULTS: Six kidneys were studied. Using interrupted figure-8 sutures, the mean leak pressure was 56.7 cm H(2)O (over baseline). Using a running suture, the mean leak pressure was 147.5 cm H(2)O (over baseline). Mean values were compared using two-tailed t test and found to be statistically significant (P = 0.05). CONCLUSION: In an ex-vivo porcine kidney model, use of a running suture along the base of a renal tumor defect (simulating that which is seen during partial nephrectomy) appears to allow for better initial hemostatic control, as compared with interrupted figure-8 sutures placed in parallel.

Percutaneous biopsy of renal cell carcinoma underestimates nuclear grade.

OBJECTIVES: To assess the accuracy of renal biopsy for predicting the final nuclear grade and histologic subtype. Small renal masses can be safely observed in select patients who are poor surgical candidates. Renal biopsy may help identify patients who are candidates for observation. METHODS: A total of 81 patients (29 female, 52 male) underwent percutaneous biopsy of their renal mass with ultrasound or computed tomography guidance. Percutaneous 18-gauge biopsy cores were obtained, and all patients subsequently underwent radical nephrectomy or partial nephrectomy. Preoperative biopsy results were compared with postoperative specimens. RESULTS: The mean tumor size was 5.3 cm (range, 1-17). Overall, biopsy correctly identified 71 of 81 (88%) histologic subtypes. The preoperative biopsy correctly identified 62 of 64 (97%) clear cell renal carcinomas, 9 of 10 (90%) papillary carcinomas, 0 of 3 (0%) chromophobe carcinomas, and 1 of 2 (50%) oncocytomas. The final pathologies for 2 nondiagnostic biopsies were clear cell renal carcinoma and inflammatory pseudotumor. For 67 tumors, the pathologists assigned a nuclear grade for both the biopsy and the final specimen. The biopsy correctly identified 29 of 67 (43%) final nuclear grades. The biopsy underestimated the nuclear grade in 37 of 67 (55%) cases. In 7 of 67 (10%) cases, the biopsy nuclear grade increased by 2 when compared with the final grade. The biopsy rarely overestimated the nuclear grade; 1 case (1%) that was assigned a grade 2 on biopsy was assigned a grade 1 after nephrectomy. CONCLUSIONS: Core biopsies for renal masses underestimate nuclear grade in most cases; however, histologic subtype is more reliably assessed, particularly for clear cell renal tumors.