Endoscopic Stone Composition Identification: Is Accuracy Improved by Stone Appearance During Laser Lithotripsy?

OBJECTIVE: To evaluate if videos during laser lithotripsy increase accuracy and confidence of stone identification by urologists compared to still pictures. METHODS: We obtained representative pictures and videos of 4 major stone types from 8 different patients during ureteroscopy with holmium laser lithotripsy. A REDCap survey was created and emailed to members of the Endourological Society. The survey included a picture followed by the corresponding video of each stone undergoing laser lithotripsy and additional clinical information. Each picture and video included multiple-choice questions about stone composition and response confidence level. Accuracy, confidence levels, and rates of rectification (change from incorrect to correct answer) or confounding (correct to incorrect) after watching videos were analyzed. RESULTS: One hundred eighty-seven urologists responded to the survey. The accuracy rate of stone identification with pictures was 43.8% vs 46.1% with videos (P = .27). Accuracy for individual stones was low and highly variable. Video only improved accuracy for 1 cystine stone. After viewing videos, participants were more likely to rectify vs confound their answers. Urologists were more likely to be confident with videos than pictures alone (65.4% vs 53.7%, respectively; P <.001); however, confident answers were not more likely to yield accurate predictions with videos vs still pictures. CONCLUSION: Stone identification by urologists is marginally improved with videos vs pictures alone. Overall, accuracy in stone identification is low irrespective of confidence level, picture, and lithotripsy video visualization. Urologists should be cautious in using endoscopic stone appearance to direct metabolic management.

Outcomes and Costs Following Mini-percutaneous Nephrolithotomy or Flexible Ureteroscopic Lithotripsy for 1-2-cm Renal Stones: Data From a Prospective, Randomized Clinical Trial.

PURPOSE: We evaluate the outcomes of ureteroscopy vs prone mini-percutaneous nephrolithotomy for 1-2-cm renal stones using a 2-group parallel randomized control trial. MATERIALS AND METHODS: Adult patients presenting with renal stones between 1 and 2 cm were randomized. Exclusion criteria included solitary kidney, multiple stones, and comorbidities precluding prone positioning. Block randomization was performed and was opened to the surgeon the morning of the procedure. Stone-free rate was evaluated by computed tomography 1-30 days postoperatively. Complications, re-treatment rates, and costs were evaluated. RESULTS: A total of 51 mini-percutaneous nephrolithotomy and 50 ureteroscopy patients were included. Baseline demographics were similar. Using a 2-mm cutoff, stone-free rate was higher in the mini-percutaneous nephrolithotomy group (76 vs 46%, P = .0023). The residual stone burden was significantly higher in the ureteroscopy group than the mini-percutaneous nephrolithotomy group (3.6 vs 1.4 mm, P = .0026). Fluoroscopy time was significantly higher in the mini-percutaneous nephrolithotomy group (273 vs 49 seconds, P < .0001). There were no differences in postoperative complications within 30 days, the necessity of a secondary procedure within 30 days, and pre- to postoperative creatinine change (P > .05). Surgical time did not vary significantly (P = .1788). Average length of stay was higher in the mini-percutaneous nephrolithotomy group (P < .0001). Both net revenue and direct costs were higher in mini-percutaneous nephrolithotomy procedures (P < .05), though they offset each other with a nonsignificant operating margin (P = .2541). CONCLUSIONS: In a prospective, randomized, controlled clinical trial using a 2-mm residual stone burden cutoff, mini-percutaneous nephrolithotomy was more likely to render patients stone-free than flexible ureteroscopy. Complications, surgical times, and operating margins did not vary between the approaches.

Comparative outcomes and cost of ambulatory PCNL in select kidney stone patients.

Limited hospital resources and access to care during the COVID-19 pandemic led us to implement a quality-improvement study investigating the feasibility, safety, and costs of same-day discharge after PCNL. The outcomes of 53 consecutive first-look PCNL patients included in a same-day discharge protocol during COVID-19 were compared to 54 first-look PCNL patients admitted for overnight observation. Control group had a similar comorbidity profile. Demographics, operative details, 30 day outcomes and readmissions, complications, and cost were compared between the two groups. Same-day discharge and one-day admission post-PCNL patients did not have significantly different baseline characteristics. The study group were more likely to have mini-PCNL (81% vs 50%, p < 0.01). Operative characteristics including median pre-operative stone burden (1.4 vs 1.7 cm3, p = 0.47) and post-operative stone burden (0.14 vs 0.18 cm3, p = 0.061) were similar between the two groups. Clavien-Dindo complication rates were lower in the study group compared to controls (0 vs 7%, p = 0.045). Readmission rates (2 vs 4%, p = 0.569) and ED visits (4 vs 6%, p = 0.662) were similar between the two groups. Total cost ($6,648.92 vs $9,466.07, p < 0.01) was significantly lower and operating margin ($4,475.96 vs $1,742.16, p < 0.01) was significantly higher for the same-day discharge group. Percutaneous nephrolithotomy may be performed in select patients without an increase in short-term complications, ED visits, or readmissions. Patients undergoing mini-PCNL are particularly amenable to same-day discharge, however, standard PCNL patients should not be excluded from consideration. Avoiding overnight admission decreases total cost and increased hospital operating margin.

A PEDOT nano-composite for hyperthermia and elimination of urological bacteria.

Novel modalities for overcoming recurrent urinary tract infections associated with indwelling urinary catheters are needed, and rapidly induced hyperthermia is one potential solution. PEDOT nanotubes are a class of photothermal particles that can easily be incorporated into silicone to produce thin, uniform coating on medical grade silicone catheters; subsequent laser stimulation therein imparts temperature elevations that can eliminate bacteria and biofilms. PEDOT silicone coatings are stable following thermal sterilization and repeated heating and cooling cycles. Laser stimulation can induce temperature increases of up to 55 °C in 300 s, but only 45 s was needed for ablation of UTI inducing E. coli biofilms in vitro. This work also demonstrates that mild hyperthermia of 50 °C, applied for only 31 s in the presence of antibiotics could eliminate E. coli biofilm as effectively as high temperatures. This work culminates in the evaluation of the PEDOT NTs for photothermal elimination of E. coli in an in vivo model to demonstrate the safety and effectiveness of a photothermal nanocomposite (16 s treatment time) for rapid clearance of E. coli.

Photothermal nanoparticles for ablation of bacteria associated with kidney stones.

OBJECTIVE: To determine whether photothermal polymer nanoparticles (NPs) can interface with bacteria associated with kidney stones, generate heat when stimulated with near infrared (NIR) light, and aid in reducing bacterial burden. METHODS: Two types of kidney stones, artificial, and those removed during percutaneous nephrolithotomy (PCNL), were inoculated with Escherichia coli (E. coli) and then incubated with NPs composed of FITC-labeled Poly[4,4-bis(2-ethylhexyl)-cyclopenta[2,1-b;3,4-b']-dithiophene-2,6-diyl-alt-2,1,3-benzoselenadiazole-4,7-diyl] (PCPDTBSe). Association of the PCPDTBSe NPs was evaluated using fluorescence microscopy. Infected stones were incubated with NPs and exposed to 800 nm light to generate temperature increases from 25.4 to 68.6 °C on the stones. Following photothermal treatment, the stones were homogenized and the bacteria was enumerated via colony counting assays to evaluate the bactericidal effect. The photothermal effect was also evaluated using scanning electron microscopy of the treated biofilms. RESULTS: Both kidney stone types sequestered E. coli. Control stones and stones treated with laser only had growth of numerous bacterial colonies, while stones exposed to NPs and laser grew significantly less, or none (p = 0.02). CONCLUSIONS: The polymer NPs interface with E. coli on artificial and patient-derived kidney stones, and they can impart a bactericidal effect, when stimulated with NIR to generate heat. This technique may possibly be extended to treating infected kidney stones in patients.

Preoperative imaging in staghorn calculi, planning and decision making in management of staghorn calculi.

OBJECTIVE: Staghorn calculi present a particular and challenging entity of stone morphology. Treatment is associated with lower stone-free rates and higher complication rates compared to non-staghorn stones. In this review we looked for the most relevant data on preoperative imaging and access planning to help decision making for percutaneous surgery with this complex condition. METHODS: We conducted a PubMed search of publications in the past 2 decades that include relevant information on the planning for management of staghorn stones. Non-contrast computerized tomography (NCCT) is indeed the standard imaging tool for percutaneous nephrolithotomy (PCNL); additional tools such as three-dimensional computed tomography (CT) reconstruction of the staghorn calculus may help plan access in complex cases. Ultrasound guided percutaneous access may be considered for staghorn stones when planning upper pole access in kidney malposition or complex intrarenal anatomy or with complex body habitus. Wideband doppler ultrasound and real-time virtual sonography can assist. New technologies to improve kidney access such as Uro Dyna-CT or electromagnetic sensor have been reported, but have not shown utilization in staghorn cases. Staghorn morphometry-based prediction algorithms may predict the number of tract(s) and stage(s) for PCNL monotherapy. Lower pole access can be equally effective as upper pole when planning for staghorn and complex stones, with significantly less complications rate; Stone-Tract length-Obstruction-Number of involved calyces-Essence of stone density (STONE) nephrolithometry seems to be the best system to predict outcomes of PCNL in staghorn cases. There is a growing trend of endoscopic combined intrarenal surgery (ECIRS) in concordance with PCNL to treat larger stones. Conservative management of staghorn calculi is an undesired option, but can be an alternative for a carefully selected group of high-risk patients. CONCLUSION: Staghorn stones may lead to deterioration of renal function and life-threatening urosepsis. This entity should be managed aggressively with planning ahead for surgery using the different tools available as the cornerstone for a successful outcome.

Robotic-assisted radical prostatectomy: The teaching. / Formación del personal en la prostatectomía radical laparoscópica asistida por robot.

OBJECTIVE OF THE REVIEW: Robot assisted Radical prostatectomy (RARP) has generated a new trend in the binomial teaching/learning, grouping these techniques in training modules such as theoretical learning, practice, personalized counseling, and modern tools like simulation and practice in virtual models. This review summarizes the current trend in the teaching process of RARP. RECENT FINDINGS: Current trends in the acquisition of the RARP learning curve is to provide the Urologist with a well-structured teaching process, implementing gradual training modules, which make possible to understand all aspects of the development of prostate surgery with a robotic system. This process consists in analyzing the theoretical aspects, perform training with high quality simulators and proctorization, in both cases in vivo and as assistant, until completion of the advanced phase in console with haptic training and proctor's direct advice, while the learning curve is being completed. The evidence shows that student and proctor feedback with the use of virtual models, immediately post-procedure video analysis, and a high-volume center are able to shorten the teaching process. The learning process never culminates, in other words, the final phase of the student, is when he is prepared to teaching the multiplier effect of his learning curve. CONCLUSIONS: Virtual models in Robotic surgery has changed the perspective teaching process of medicine. Theoretical knowledge, virtual training and Proctor's advice are essential steps in the learning curve. Future directions,evolution of virtual models in a similar fashion to the real scenario.

OBJETIVO: La Prostatectomía Radical asistida por Robot (PRAR) ha generado una nueva tendencia en el binomio enseñanza/aprendizaje agrupando estastécnicas en módulos de entrenamiento como aprendizaje teórico, practico, asesoramiento personalizado y herramientas modernas como simulación y práctica en modelos virtuales. Esta revisión resume la tendencia actual en el proceso de enseñanza de la PRAR. HALLAZGOS RECIENTES: La tendencia actual en la adquisición de la curva de la PRAR es proporcionar al urólogo un proceso de enseñanza bien estructurado,implementando módulos de entrenamiento graduales, que le permitan comprender en todos los aspectos el desenvolvimiento de la cirugía radical de próstata con un sistema robótico. Dicho proceso consiste en analizarlas bases teóricas, realizar entrenamiento con simulado res de alta calidad, interactuar con él supervisor tanto en casos in vivo como en ayudantía de cirugías, hasta completar la fase avanzada en consola con entrenamientoháptico y asesoramiento directo del supervisor, mientras se adquiere la curva de aprendizaje. La evidencia demuestra que la retroalimentación del alumno yproctor supervisor con el uso de modelos virtuales, análisis de videos inmediatamente posterior al procedimiento y un centro de alto volumen logran acortar el proceso de enseñanza. La formación en cirugía robótica nunca culmina, por el contrario, la fase final del alumno, es cuando se encuentra preparado para realizar el efecto multiplicador de su curva de aprendizaje.CONCLUSIÓN: La Cirugía Robótica ha cambiado la perspectiva de la  enseñanza de la Medicina, mediante el uso de modelos virtuales. Conocimientos teóricos, entrenamiento virtual y el asesoramiento del supervisor son pasos necesarios en la curva de aprendizaje. Direccionesfuturas esperadas son la evolución de los modelos virtuales similares al escenario real.

Formación del personal en la prostatectomía radical laparoscópica asistida por robot / Staff training in robotic-assisted laparoscopic radical prostatectomy

Objetivo: La Prostatectomía Radical asistida por Robot (PRAR) ha generado una nueva tendencia en el binomio enseñanza/aprendizaje agrupando estas técnicas en módulos de entrenamiento como aprendizaje teórico, practico, asesoramiento personalizado y herramientas modernas como simulación y práctica en modelos virtuales. Esta revisión resume la tendencia actual en el proceso de enseñanza de la PRAR. Hallazgos recientes: La tendencia actual en la adquisición de la curva de la PRAR es proporcionar al urólogo un proceso de enseñanza bien estructurado, implementando módulos de entrenamiento graduales, que le permitan comprender en todos los aspectos el desenvolvimiento de la cirugía radical de próstata con un sistema robótico. Dicho proceso consiste en analizar las bases teóricas, realizar entrenamiento con simulado res de alta calidad, interactuar con él supervisor tanto en casos in vivo como en ayudantía de cirugías, hasta completar la fase avanzada en consola con entrenamiento háptico y asesoramiento directo del supervisor, mientras se adquiere la curva de aprendizaje. La evidencia demuestra que la retroalimentación del alumno y proctor supervisor con el uso de modelos virtuales, análisis de videos inmediatamente posterior al procedimiento y un centro de alto volumen logran acortar el proceso de enseñanza. La formación en cirugía robótica nunca culmina, por el contrario, la fase final del alumno, es cuando se encuentra preparado para realizar el efecto multiplicador de su curva de aprendizaje. Conclusión: La Cirugía Robótica ha cambiado la perspectiva de la enseñanza de la Medicina, mediante el uso de modelos virtuales. Conocimientos teóricos, entrenamiento virtual y el asesoramiento del supervisor son pasos necesarios en la curva de aprendizaje. Direcciones futuras esperadas son la evolución de los modelos virtuales similares al escenario real

Objective of the review: Robot assisted Radical prostatectomy (RARP) has generated a new trend in the binomial teaching/learning, grouping these techniques in training modules such as theoretical learning, practice, personalized counseling, and modern tools like simulation and practice in virtual models. This review summarizes the current trend in the teaching process of RARP. Recent findings: Current trends in the acquisition of the RARP learning curve is to provide the Urologist with a well-structured teaching process, implementing gradual training modules, which make possible to understand all aspects of the development of prostate surgery with a robotic system. This process consists in analyzing the theoretical aspects, perform training with high quality simulators and proctorization, in both cases in vivo and as assistant, until completion of the advanced phase in console with haptic training and proctor’s direct advice, while the learning curve is being completed. The evidence shows that student and proctor feedback with the use of virtual models, immediately post-procedure video analysis, and a high-volume center are able to shorten the teaching process. The learning process never culminates, in other words, the final phase of the student, is when he is prepared to teaching the multiplier effect of his learning curve. Conclusions: Virtual models in Robotic surgery has changed the perspective teaching process of medicine. Theoretical knowledge, virtual training and Proctor’s advice are essential steps in the learning curve. Future directions, evolution of virtual models in a similar fashion to the real scenario

The role of extracorporeal shock wave lithotripsy in the future of stone management.

PURPOSE OF REVIEW: The most relevant recent findings on the use of extracorporeal shock wave lithotripsy (ESWL) in adult population to provide an insight of its role in the current and future of stone treatment. Comparing ESWL with other modalities is not in the scope of this review. RECENT FINDINGS: We conducted a PubMed/Embase search and reviewed recent publications that include relevant information on the development of ESWL. Low-rate shock waves improve stone breakage, ramping energy modalities improve stone fragmentation and have lower incidence of hematoma and kidney injury. Transgluteal approach is suggested to improve stone-free rates for distal ureteral stones in a single session. Proper coupling is the most important technical aspect of the treatment and coupling improvement can be achieved by optical monitorization. Triple D score is a promising tool in proper patient selection, but external validation is needed. Predictive information arising from computed tomography scans has been refined by the variant coefficient of stone density and 3D texture analysis that might improve outcomes in the future. SUMMARY: Recent evidence suggests that modifying techniques and protocols, and better patient selection are the current trends for improving ESWL outcomes. EWSL will keep its role as the single noninvasive treatment in stone management with room for outcome improvement in the future.

Evaluation of Clinical Use and Cost-Effectiveness of a Flexible Cystoscope System with a Disposable Sheath: A Randomized Clinical Trial.

INTRODUCTION: Flexible cystoscopy is routinely performed as an outpatient procedure. The use of disposable sheaths can increase cystoscope life span and reduce staff costs. The primary end point of this study was to evaluate procedure related discomfort and pain, physician maneuverability, residual bioburden and reprocessing time. The secondary end point was to analyze the cost-effectiveness of a flexible cystoscope with a disposable sheath compared to a standard flexible cystoscope. METHODS: This randomized clinical trial was performed with women older than 18 years, with intact cognition and 7 days antibiotic-free who were referred to outpatient clinic for cystoscopy. Patients underwent cystoscopy with a standard flexible cystoscope or flexible cystoscope with disposable sheath. Urinalysis and culture were performed before and 14 days after cystoscopy. Patients filled out a pain/discomfort visual analog scale. Physicians filled out a 5-point Likert scale for the elements of ease of insertion, manipulation, optical quality and overall use. Reprocessing time and costs were compared between both cystoscopes. RESULTS: A total of 60 patients were included in the study, comprised of 30 who underwent standard flexible cystoscopy and 30 who underwent flexible cystoscopy with a protective sheath. Patient discomfort/pain was equivalent in both groups. The Likert scores were similar except for ease of insertion, which was higher with protective sheaths (p <0.02). Protective sheaths were associated with lower reprocessing time and costs (p <0.001). CONCLUSIONS: The use of protective sheaths effectively reduced procedure and staff related costs without causing any additional patient discomfort or pain. The learning curve of the sheathed scope may explain the difference reported by physicians regarding the ease of insertion.

[Current status of urological training in Latin America.] / Estado actual de la formación urológica en América Latina.

OBJECTIVE: Achieving residents' medical training of quality is a constant concern in the Confederación Americana de Urología (CAU), the third Urological Society worldwide. We aim to analyze the diversity of state training programs, with the intention to identify opportunities for global improvement within them and also to analyse the professional reality in different countries. METHODS: Data from 2nd and 3rd Foro Educativo CAU regarding postgraduate training and labour implications are reviewed. This information is complemented by the opinion of representatives involved with the academic training in Confederación Americana de Urología, who have analyzed the reality and current status of the urological training through a 10-question survey that describes different aspects of residency program in the countries confederated in CAU. RESULTS: A total of 3,000 graduate doctors train as residents in Urology at the CAU environment. Each year 670 residents begin their training program in Latin America, Spain and Portugal, a territory that serves nearly 650 million people, with an active professional force of around 16.800 professionals. Detailed data on training, employment and supporting reality in the countries that comprise the CAU are presented. We also discuss the proportion of residents who carry out research and doctorate during the residency program. Finally, we examine the proportion of professionals who receive specific training at the end of their residence, the relative importance of this training and what are the most popular environments to carry it out. CONCLUSIONS: Current postgraduate training in CAU environment is heterogeneous in their programs, as well as in the modes of accreditation and recertification. Academic activities do not seem to be properly valued. However, specific training offers better expectations of professional development.

Comparative Outcomes of Conventional and Miniaturized Percutaneous Nephrostolithotomy for the Treatment of Kidney Stones-Does a Miniaturized Tract Improve Quality of Care?

INTRODUCTION: Percutaneous nephrostolithotomy is the method of choice to treat renal stones larger than 2 cm due to its high stone-free rates but it has potentially increased blood loss, postoperative pain and hospital stay compared to other treatments. Miniaturizing the percutaneous tract has recently gained interest. We performed a quality improvement study to investigate whether mini percutaneous nephrostolithotomy would reduce postoperative analgesic use, blood loss, operative time and/or hospital stay relative to the conventional approach while maintaining stone-free rates in our patient population. METHODS: The outcomes of 29 consecutive mini percutaneous nephrostolithotomies were compared to 27 conventional procedures performed by a single surgeon at our institution. Inclusion criteria were age 18 years or older, body mass index 18 to 40 kg/m2 and first look percutaneous nephrostolithotomy for stones 1 to 3.5 cm. Conventional percutaneous nephrostolithotomy was performed through a 30Fr tract, whereas the mini approach was done through a 16.5Fr tract. All percutaneous access was performed by the surgeon. RESULTS: A total of 17 patients in the conventional percutaneous nephrostolithotomy group and 19 in the mini approach group were stone-free after 1 procedure. There was no significant difference in residual stone burden, operative time or postoperative analgesic use between groups. There was significantly less blood loss (p = 0.02) in the mini percutaneous nephrostolithotomy group. CONCLUSIONS: Conventional and mini percutaneous nephrostolithotomies are effective methods of removing renal stones 1 to 3.5 cm in greatest dimension. There is no difference in residual stone volume, postoperative analgesic use or operative time between the 2 modalities, but blood loss is less in the mini percutaneous nephrostolithotomy group.

Ureteroscopic Urinary Stone Treatment Among Patients With Renal Anomalies: Patient Characteristics and Treatment Outcomes.

OBJECTIVE: To evaluate patients' characteristics, surgical procedure data, and outcomes of ureterorenoscopy (URS) stone treatment in patients with a horseshoe kidney (HSK), ectopic kidney (EK), and malrotated kidney (MK). MATERIALS AND METHODS: This study is a subanalysis of the Clinical Research Office of the Endourological Society URS Global Study, which was a prospective multicenter observational study, collecting data on URS stone treatment from consecutive patients over a 1-year period. A total of 114 centers in 32 countries participated. This analysis acuminated on URS stone treatment in the specified renal anomalies: HSK, EK, and MK. For each group, patient characteristics, operation data, and treatment outcomes were evaluated. RESULTS: Of the 11,885 patients included in the Clinical Research Office of the Endourological Society URS study, 43 patients had HSK, 27 EK, and 16 MK. The stone-free rate (SFR) in the HSK group was 77% for renal stones and 85% for ureteral stones. In the HSK group, the intraoperative complication rate was 11.6% and the postoperative complication rate was 7%, including 1 Clavien grade IIIa and 1 IIIb complication. In the EK group, the SFR was 20% for renal stones and 94% for ureteral stones, with an intraoperative complication rate of 14.8% and a postoperative complication rate of 7.4%. One Clavien IVa complication was reported. In the MK group, the SFR was 71% for renal stones and 88% for ureteral stones, with an intraoperative complication rate of 6.3%. No postoperative complications occurred in this group. CONCLUSION: URS is an effective and safe treatment modality to remove ureteral and renal stones in patients with HSK and MK. The effectiveness of URS for renal stones in EK was low.

Factors Associated with Trial Outcomes in the Management of Nephrolithiasis: A Legal Database Review.

INTRODUCTION: Domestically the estimated annual cost of medical malpractice is $55.6 billion. As surgical providers in a high risk subspecialty, urologists are at particularly high risk. Interventions for nephrolithiasis are especially common in practice, and understanding the risks associated with high volume procedures is critical for quality improvement and cost containment. METHODS: Using the Westlaw legal database we identified all legal briefs with the search terms "medical malpractice" and "kidney stone" or "nephrolithiasis" for dates between January 2000 and December 2015. Each case was evaluated for alleged cause of malpractice, resulting injury and indemnity payments. RESULTS: The initial search yielded 55 cases, which was decreased to 29 after exclusions. Most cases (15, 52%) were decided in favor of the defendant, while the remaining suits led to indemnity payments, including 6 cases that were settled and 8 with verdicts for the plaintiff. Of named defendants 75% were urologists. The mean settlement amount was $158,400 while the mean indemnity payment for verdicts decided in favor of the plaintiff was $124,400. The most commonly alleged breach of duty was negligent performance in surgery (15 cases), followed by negligent postoperative care (6 cases), and failure to diagnose and treat (5 cases). The most commonly claimed damage was death (13 cases). CONCLUSIONS: Malpractice cases related to the management of nephrolithiasis most commonly involve allegations of negligent performance in surgery, negligent postoperative care, or failure to diagnose or treat. Urologists account for 75% of named defendants and should be aware of factors that increase the risk of litigation.

Evaluation of Renal Function after Percutaneous Nephrolithotomy-Does the Number of Percutaneous Access Tracts Matter?

PURPOSE: Renal function following percutaneous nephrolithotomy has long been a concern to urologists, especially in the setting of multi-tract access. We determined whether the risk of renal injury after multi-tract percutaneous nephrolithotomy was greater than after a single access approach. MATERIALS AND METHODS: We retrospectively reviewed the records of 307 consecutive patients treated with percutaneous nephrolithotomy from 2011 to 2012 at Wake Forest Health. Perioperative (99m)Tc-mercaptoacetyltriglycine nuclear renogram parameters along with serum creatinine values were assessed within 1 year of the procedure. Patients were stratified by single access vs multi-access (2 or more). RESULTS: We identified 110 cases in which renography was done before and after percutaneous nephrolithotomy. A total of 74 patients (67.3%) underwent single access percutaneous nephrolithotomy while 36 (32.7%) underwent multi-access percutaneous nephrolithotomy. Serum creatinine did not significantly differ between the 2 cohorts postoperatively (p = 0.09). There was a significant 2.28% decrease in renal function based on mercaptoacetyltriglycine nuclear renogram results after percutaneous nephrolithotomy of the affected kidney in patients with multiple accesses (p <0.01). This relationship was not observed when patients were stratified by multiple comorbidities associated with nephrolithiasis. CONCLUSIONS: Multi-access percutaneous nephrolithotomy is associated with a small reduction in the function of the targeted kidney compared to a single access approach.

Percutaneous renal access: the learning curve of a simplified approach.

BACKGROUND AND PURPOSE: Fluoroscopically guided techniques to access the kidney percutaneously with low exposure to radiation have been used successfully for many years in our training center. The purpose of this study was to analyze the learning process and to establish the number of procedures necessary for a nonexperienced urologist to achieve competence at performing percutaneous renal access. MATERIALS AND METHODS: Eighty-two percutaneous renal accesses in patients with renal stones or ureteropelvic junction obstruction were evaluated. The time needed to perform a correct puncture and the fluoroscopic screening time were recorded for each renal access. Descriptive analysis, analysis of variance, and a Markov chain were used to analyze the results. RESULTS: The rate of success increased from 82.5% to 97.6% after the first 40 punctures. Puncture time and fluoroscopy time decreased as the number of procedures increased. Incidence of complications was 30% for the first 20 cases, decreasing to 10% in the next 20 cases and 3.7% in the last 33 cases. CONCLUSIONS: The fluoroscopy-guided approach used in this study is an effective and reproducible technique. Our analysis revealed that at least 50 procedures are needed to acquire reliable competence in obtaining access to the kidney.

Management of infectious complications in percutaneous nephrolithotomy.

Infectious complications are one of the most frequent and feared adverse medical events in percutaneous nephrolithotomy. They represent a dangerous and life-threatening condition, especially when postoperative septicemia or severe sepsis develops. In order to limit morbidity and mortality it is crucial to recognize preoperative and intraoperative risk factors that could be clear contributors to an adverse infectious event; those factors are mainly immunosuppression caused by some comorbidities, presence of urinary infection or colonization, stone characteristics, obstruction, long-lasting operation, and high intrapelvic pressure during nephrolithotomy. Close observation during the immediate and early postoperative period must be established and a high index of suspicion must be maintained to identify a major complication. The early recognition and prompt multidisciplinary management of sepsis is mandatory to optimize the final outcome. Appropriate therapy is a continuum of management of infection, ranging from adequate drainage and broad-spectrum antibiotics to aggressive fluid resuscitation and invasive monitoring with medical management in the intensive care setting until the causative agent is found and eradicated.

Endoureterotomía para el tratamiento de la estrechez ureteral: seguimiento a largo plazo / Endoureterotomy for treatment of ureteral stricture: long-term surveillance

Se revisaron los resultados a largo plazo de 17 estenosis ureterales, en 13 pacientes, tratadas endoscópicamente con endoureterotomía. El acceso quirúrgico, utilizado fue anterógrado o combinado, según la localización y el origen de las estenosis. Se encontraron siete estenosis ureterales en vías urinarias reconstruidas después de la realización de derivaciones urinarias. En general, se obtuvo un resultado satisfactorio en 10 de 17 estenosis (58.8 por ciento). En dos estenosis no fue posible realizar el procedimiento endoscópico, por incapacidad técnica, para canalizar el uréter estenótico con alambre de guía. No hubo diferencias en términos de resultados en las estenosis de vías urinarias reconstruidas. El seguimiento promedio fue de 34.8 meses, con variación de 7 a 56 meses. No ocurrieron complicaciones mayores durante las operaciones quirúrgicas. Los factores de buen pronóstico para el resultado final son las estenosis menores de 2 cm de longitud, de corto tiempo de evolución y de etiología compresiva extrínseca sin lesión extensa del uréter

Nefrolitotomía anatrófica en comparación con el procedimiento endourológico combinado para el tratamiento de la litiasis renal coraliforme / Anatrophic nephrolitotomy compared with combined endourologic procedure for the treatment of staghom renal litiasis.

Se hace una comparación de la nefrolitotomía anatrófica y el procedimiento endourológico combinado con nefrolitotripsia percutánea y litotripsia extracorporal en el tratamiento de la litiasis renal coraliforme. El tiempo requerido para la intervención quirúrgica, la estancia en el hospital y la morbilidad fueron menores para el grupo de pacientes tratados con la forma combinada, además de haber mejor tolerancia a este tratamiento. La eficacia global, en término de pacientes libres de cálculos, fue como sigue: 75 por ciento de los sujetos sometidos sólo a operación abierta, y 68 por ciento de los enfermos tratados con el método endourológico. Hubo 20 por ciento más de pacientes que continuaron con cálculos menores de 4mm, lo que da una eficacia global del tratamiento de 88 por ciento. El procedimiento endourológico combinado puede considerarse como el tratamiento inicial en la mayoría de los cálculos renales coraliformes