Surgical Stone Trends from 2013 to 2021 in the US Medicare Population: Before and after the COVID-19 Pandemic.

Introduction and Objective: In early 2020, as the SARS-Cov-2 (COVID-19) pandemic progressed, many institutions limited nonurgent surgical care. This coincided with a decade-long trend of increasing percutaneous nephrolithotomy (PCNL) and ureteroscopy (URS) and decreasing shock wave lithotripsy (SWL) for surgical management of urolithiasis. Herein, we evaluate temporal stone surgery rates and surgeon volumes in the Medicare population and suggest how COVID-19 contributed to them. Methods: Retrospective analysis was conducted using the "Medicare Physician & Other Practitioners" database containing data from January 2013 to December 2021. Adult patients who underwent stone surgery were included. We evaluated surgeon characteristics and changes in case volumes over time adjusted for population. Results: In 2013, urologists performed 68,910 stone surgeries: SWL 42,903 (62%); URS 25,321 (37%); PCNL 686 (1%). Over the next 8 years, there was an average annual increase in URS (+13%) and PCNL (+13%) and decrease in SWL (-2%). In 2020, there was a 14% reduction in all stone cases: SWL (-25%); URS (-6%); PCNL (-8%). By 2021, case volumes recovered to pre-2020 levels, though SWL remained low: SWL 33,974 (34%); URS 64,541 (64%); PCNL 1764 (2%). From 2013 to 2021, the number of urologists performing SWL decreased (1718 to 1361) while URS and PCNL providers doubled (1,347 to 2,914 and 28 to 76, respectively). Conclusions: From 2013 to 2021, there was an increase in URS and PCNL and a decrease in SWL in the US Medicare population. The COVID-19 pandemic was associated with a decline in stone surgeries, particularly SWL. By 2021, PCNL and URS case numbers increased significantly with a smaller increase in SWL.

Higher Risk of Repeat Stone Surgery in Stone Formers With Concomitant Bowel Disease: Single-Center Long-Term Analysis.

OBJECTIVE: To identify the need for repeat stone surgery in patients with and without bowel disease. Few studies have compared risks between different types of bowel disease and whether their need for repeat stone surgery differs. METHODS: From our IRB-approved study, we identified patients with and without bowel disease. We categorized patients' bowel disease into 4 categories: inflammatory bowel disease (IBD), bypass procedures, bowel resection, and bowel disease not otherwise specified (eg, irritable bowel syndrome, celiac disease). Differences between patient demographics, stone disease, and recurrent stone events for patients with and without bowel disease were compared using univariate and multivariate survival analyses (SPSS 25). RESULTS: Of all surgical stone patients (2011), 484 (24%) had some type of bowel disease. Compared to patients without bowel disease, patients with bowel disease presented with stones at an older age (62.2 ± 14.5 vs 58.4 ± 15.3 years; P <.001) and were more likely to be female (56 vs 46%; P <.001). Patients with bowel disease required more repeat stone surgery than those without bowel disease (31% vs 23%, P <.001). In multivariate analysis, patients with bypass and bowel resection were associated with more repeat surgery than patients without bowel disease (P <.001, P = .002, respectively). Patients with IBD and bowel disease not otherwise specified did not have higher risk for repeat surgery than patients without bowel disease. CONCLUSION: Surgical stone patients with bowel disease, specifically those with prior bowel resection and bypass, had a higher risk of repeat stone surgery over time than stone formers without bowel disease. DATA AVAILABILITY: The data sets generated and analyzed during the current study are available from the corresponding author on reasonable request.

Quantifying the Educational History of the Endourological Society Fellowship Programs in the United States.

Introduction: We examined the history of the Endourological Society through the lens of its fellowship programs in the United States (U.S.). Methods: A review of the list of fellowship programs published annually in the Journal of Endourology from 1987 to 2015 allowed us to track the growth in fellowship programs over time. We reviewed the Endourological Society fellowship database and the websites for each of the fellowship programs for the names of graduates from each program. A survey was sent to each fellowship program director with a list of their graduates asking them to verify the names and to identify those graduates who had pursued a career in academic urology, and whether they had served as fellowship program director, residency program director or department chairperson. Seventeen of the 52 U.S. program directors (33%) responded to the survey. For those programs that did not respond to the survey each graduate's name was searched via Google, LinkedIn, and/or Doximity to determine if they had pursued a career in academic urology and served in a leadership position. Results: The number of U.S. Endourological Society fellowships has increased from 11 in 1987 to 52 in 2021. Five hundred and seventy-seven fellows have graduated from an Endourological Society Fellowship in the United States from 1987 to 2021. Two hundred and fifty fellows have pursued a career in academic urology (43.3%), 46 have served as fellowship program director (8.0%), 9 as residency program director (1.6%), and 13 have served as department chairperson (2.3%). Conclusions: The progress of the Endourological Society can be directly tied to the historical growth of its fellowship programs and the pursuit of an academic career by many of its graduates leading them to become the current and future educational leaders in the field.

Incidental Prostate Cancer Diagnosis Is Common After Holmium Laser Enucleation of the Prostate.

OBJECTIVE: To determine the incidence of incidental prostate cancer detection (iPCa) after holmium laser enucleation of the prostate (HoLEP). The published rate of iPCa after HoLEP is widely variable from 7% to 23% and we aim to define preoperative risk factors for iPCa to inform risk-adjusted preoperative evaluation for PCa. METHODS: Consecutive patients undergoing HoLEP from 2018 to 2022 were included and comprehensive clinical data abstracted from a prospectively maintained database. iPCa was defined as a diagnosis of PCa on pathologic examination of the HoLEP specimen. Patients with and without iPCa were compared with respect to preoperative clinical variables. RESULTS: Of 913 HoLEP patients, 183 (20%) were diagnosed with iPCa. Most patients (95%) had a preoperative prostate-specific antigen (PSA), 9% had negative MRI, and 30% had negative prostate biopsy. On multivariable analysis, PSA density (OR 1.06; 95% CI 1.03, 1.10; P < .001), preoperative biopsy status (OR 0.47, CI 0.30, 0.75; P = .002), and current 5-alpha reductase inhibitor use (OR 0.64, CI 0.43, 0.97; P = .034), were associated with iPCa diagnosis. CONCLUSION: In a significantly prescreened population, we identified a 20% rate of iPCa after HoLEP. Preoperative characteristics associated with iPCa diagnosis included increasing age, increasing PSA density, and current 5-alpha reductase inhibitor use. However, these factors alone may be of limited clinical utility to prospectively identify patients at high risk of iPCa diagnosis. We suggest and advocate for development of a standardized, risk-adapted evaluation focused on expanded use of imaging and selective biopsy to prioritize identification of clinically significant PCa prior to nononcologic surgery.

Development and Preliminary Validation of the 6-Item Short Form of the Wisconsin Stone Quality of Life Questionnaire.

OBJECTIVE: To develop a short form of the Wisconsin Stone Quality of Life (WISQOL): 1) identify the smallest subset of items from WSIQOL that accurately predict patients' health-related quality of life (HRQOL), and 2) in a clinical patient population, test these items-grouped together to form the WISQOL-short form (SF) - and assess its convergent validity. MATERIALS AND METHODS: The items for the WISQOL-SF were identified based on classic item analysis theory. Patients who previously completed the original 28-item WISQOL were randomly split into 2 groups of equal size. Scores for the WISQOL were calculated for one group while those for the WISQOL-SF were calculated for the other. Cronbach's alpha coefficients were calculated. Impacts of demographic and clinical factors as well as stone and symptom status at the time of WISQOL completion were examined. RESULTS: Patients (n = 740) who completed the WISQOL between 6/2017 and 11/2021 were included. Patients were 48% male, 54.1 ± 14.6 years old, and had a BMI of 31.2 ± 8.1. After item analysis and reduction, the six items ultimately included in the WISQOL-SF represented 2 of the 4 domains (social and emotional) of the original WISQOL. The internal consistency of the WISQOL-SF was similar to the original (Cronbach's alpha 0.943 vs. 0.973). No differences for health-related quality of life were found between groups (P = .567). CONCLUSION: The WISQOL-SF demonstrated the expected differences for gender and between patients with and without stone-related symptoms at the time of WISQOL completion. The WISQOL-SF showed good consistency and produced similar HRQOL scores to the full-form WISQOL.

Pulse-modulated Holmium:YAG Laser vs the Thulium Fiber Laser for Renal and Ureteral Stones: A Single-center Prospective Randomized Clinical Trial.

PURPOSE: We sought to compare the clinical effectiveness of the pulse-modulated Ho:YAG (holmium:yttrium-aluminum-garnet) laser and the thulium laser fiber for ureteroscopic stone management in a randomized clinical trial. The primary outcome was the ureteroscope time required to adequately fragment stones to 1 mm or less. Secondary outcomes were stone-free rate, complications, subjective surgeon measurement of laser performance, patient related stone quality of life outcomes, and measurements of laser efficiency. MATERIALS AND METHODS: An Institutional Review Board-approved randomized clinical trial was conducted to randomize patients to outpatient treatment with either the Moses 2.0 or thulium laser fiber in a 1:1 manner after stratification into groups based on the maximal diameter of treated stone (3-9.9 mm or 10-20 mm). Patient, stone, and operative parameters were compared using the appropriate categorical/continuous and parametric/nonparametric statistical tests (SPSS 25). RESULTS: From July 16, 2021 to March 11, 2022, 108 patients were randomized and had primary endpoint data available for analysis; 52 patients were randomized to Ho:YAG and 56 patients to thulium laser fiber. Groups were well balanced with no significant differences observed for patient or stone characteristics. Ureteroscope time was not significantly different between modalities (Ho:YAG mean 21.4 minutes vs thulium laser fiber mean 19.9 minutes, P = .60), or within subgroup analysis by stone size, median Hounsfield units, or stone location. There were no significant differences observed in the stone-free rate and complications rate between the 2 lasers. CONCLUSIONS: This randomized clinical trial suggests no significant clinical advantage of one laser technology over the other. Surgeon and institutional preference are the best approach when selecting one or the other.

Ureteroscopy and Shock Wave Lithotripsy Trends from 2012 to 2019 Within the US Medicare Dataset: Sharp Growth in Ureteroscopy Utilization.

Introduction and Objective: Both ureteroscopy (URS) and shock wave lithotripsy (SWL) are cornerstones in the surgical management of urolithiasis in the United States. We hypothesized that URS utilization outpaced SWL utilization in recent years and quantified the magnitude of change over time for caseloads of URS and SWL among urologists from a national Medicare database. Methods: Using the public "Medicare Physician & Other Practitioners" database (https://data.cms.gov), we determined case numbers of SWL (current procedural terminology [CPT] 50590) and URS (CPT 52356 or 52353) from 2012 to 2019. In a subanalysis, we identified "high-volume stone urologists" as those in the upper quartile of case numbers for both SWL and URS in baseline years of either 2012 or 2013 and trended their caseload from 2012 to 2019. Linear estimation models assessed annual rates of change and their statistical significance. Results: In 2012, urologists performed 41,135 SWL procedures vs 21,184 URS. URS overtook SWL in 2017 and by 2019 was the dominant modality (60,063 URS vs 43,635 SWL). Between 2012 and 2019, total URS cases annually increased by 5700 (15%/year, p < 0.001), while the number of SWL cases peaked in 2015 and has since declined on average -1.6%/year (p = 0.020). The number of urologists performing URS steadily rose from 1147 in 2012 to 2809 in 2019, reflecting an additional 246 urologists (21%/year) performing URS annually. The caseload of high-volume stone urologists showed similar trends with average URS cases increasing by 2.9/year/urologist (9.8%/year, p < 0.001) and average SWL cases declining by 0.9/year/urologist (-1.7%/year, p = 0.023). Conclusions: URS utilization has increased dramatically and outpaced SWL utilization from 2012 to 2019 within the Medicare population. URS was increasingly used by both the general urologist population and high-volume stone urologists while SWL utilization has begun to decline.

Clinical Impact of the Institution of Moses Technology on Efficiency During Retrograde Ureteroscopy for Stone Disease: Single-Center Experience.

Objective: To evaluate the clinical benefits of Moses technology compared with the regular mode with the Lumenis® Pulse™ P120H holmium laser during ureteroscopy for stone disease. Patients and Methods: An IRB-approved database of patients with urolithiasis was analyzed for ureteroscopies from January 2020 to December 2020 at an outpatient surgery center. Patients who underwent ureteroscopy with the Lumenis Pulse P120H holmium laser system with the Moses or regular mode were included. Patient characteristics and stone parameters were collected. Operative room parameters were compared, including procedural time, fragmentation/dusting time, lasing time, and total energy used. Complication rates and stone-free rates were also analyzed. Univariate analysis and multiple analysis of covariance controlling for cumulative stone size were performed. Patients with staged procedures were excluded. Results: Of 197 surgical cases, 176 met the inclusion criteria. Moses was utilized in 110 cases and regular mode in 66. There was no difference in cumulative stone size between Moses and regular modes (11.8 ± 7.9 vs 11.6 ± 9.2 mm, p = 0.901). Procedural time (43.5 ± 32.1 vs 39.8 ± 24.6 minutes, p = 0.436), fragmentation/dusting time (20.5 ± 25.3 vs 17.1 ± 16.1 minutes, p = 0.430), lasing time (7.5 ± 11.1 vs 6.7 ± 7.9 minutes, p = 0.570), and total energy used (5.1 ± 6.7 vs 3.8 ± 4.8 kJ, p = 0.093) were also similar. Complications (6.4% vs 6.1%, p = 0.936) and stone-free rates (52.3% vs 65.3%, p = 0.143) did not differ. Conclusion: At our institution, Moses technology did not significantly change the procedural time, fragmentation/dusting time, lasing time, or total energy used. Moreover, there were no differences in complications or stone-free rates. There may be technical benefits to the Moses technology not captured in this analysis.

Disposable Ureteroscopes in Urology: Current State and Future Prospects.

Ureteroscopy is the most common surgical modality for stone treatment. Reusable flexible ureteroscopes are delicate instruments that require expensive maintenance and repairs. Multiple single use ureteroscopes have been developed recently to combat the expensive and time-intensive sterilization and repair of ureteroscopes. Although multiple studies have looked at different aspects of reusable and single use ureteroscopes, there is significant heterogeneity in performance measures and cost between the 2 categories, and neither has a clear advantage. Both can be used successfully, and individual and institution level factors should be considered when deciding which ureteroscope to use.

Transrectal ultrasound guided prostate biopsy performed by supervised junior and senior residents is safe and does not result in inferior outcomes.

PURPOSE: To compare transrectal ultrasound guided prostate biopsy (TRUSBx) cancer detection and complication rates between residents at different levels of training and attending physicians at a single academic center. METHODS: We performed a retrospective review of consecutive series of 623 men undergoing TRUSBx from June 2014 to February 2017. The procedure was performed either by resident physicians under direct supervision by an attending physician or by an attending physician. In total, junior residents, senior residents and attending physicians performed 244, 212, and 167 biopsies, respectively. Prostate cancer detection, 30-day complications, and 30-day hospitalizations rates were the outcomes of interest. We performed multivariable logistic regression analysis to identify predictors of these outcomes and examined the hypothesis that TRUSBx performed by trainees would not be associated with inferior outcomes. RESULTS: There was no statistically significant difference in patient populations between the three groups when stratified by age, BMI, Charleston co-morbidity index, aspirin use, PSA level and palpable nodule on DRE. Prostate cancer was detected in 43.8% of the biopsies and there was no difference in detection rates (P = 0.53), Gleason score (P = 0.11), number of positive cores (P = 0.95), 30-day hospitalization (P = 0.86), and 30-day complication rates (P = 0.67) between TRUSBx performed by trainees and attending physicians. CONCLUSIONS: TRUSBx performed by residents and attending physicians yielded equivalent rates of cancer detection with no significant difference in 30-day complications or 30-day hospitalizations rates. There was no difference in outcomes between junior and senior residents suggesting that with adequate faculty supervision, it is safe for trainees at all levels to perform prostate biopsies.

Intraprostatic injection of tranexamic acid to control refractory bleeding while maintaining therapeutic anticoagulation.

Tranexamic acid (TXA) has been used to manage menstrual bleeding and reduce bleeding during orthopedic procedures, but has not been widely used in urology. We present a patient with refractory gross hematuria with required therapeutic anticoagulation who failed multiple other measures to control prostatic bleeding. This patient's hematuria abated with endoscopic localized injection of tranexamic acid into the prostate. The effects were durable with no bleeding recurrence reported while maintaining therapeutic anticoagulation.

Effectiveness of a transrectal prostate needle biopsy protocol with risk-tailored antimicrobials in a veterans cohort.

PURPOSE: To prospectively implement a prostate biopsy protocol to identify high-risk patients for bleeding or infectious complications and use risk-tailored antimicrobials, patient education, and postbiopsy monitoring with the objective of reducing complications. MATERIALS AND METHODS: Overall, 637 consecutive patients from June 2014 to August 2016 underwent prostate biopsy at our Veterans Affairs hospital. In the protocol cohort, patients were screened before biopsy and prophylaxis was tailored (high risk = ceftriaxone; low risk = ciprofloxacin). Patients were also provided additional education about bleeding and monitored for up to 1-hour. We defined complications as any deviation from normal postbiopsy activities. Comparisons were made between preprotocol/postprotocol cohorts. Logistic regression was used to identify risk factors for admissions or complications. RESULTS: Median age was 67 years (IQR: 64-69, P = 0.29) in both groups (pre n = 334, post n = 303). Preprotocol, 99% patients received ciprofloxacin; postprotocol, 86% received ciprofloxacin and 14% received ceftriaxone (P<0.001). There were no deaths in either group. There were decreased 30-day complication and hospitalization rates in the postprotocol group (pre 15% vs. post 8.9%, P = 0.025; 3.3% vs. 1.0%, P = 0.048). Sepsis occurred in 2 patients preprotocol and no patients postprotocol. Postprotocol group was associated with decreased 30-day complications on multivariable logistic regression (OR = 0.58, 95% CI: 0.35-0.95, P = 0.031). CONCLUSIONS: A screening protocol before prostate biopsy is a targeted approach for selecting prophylactic antimicrobials and closer monitoring postbiopsy for bleeding. Our results suggest that the protocol has a favorable effect on complication and hospitalization rates.

Digital Identity in Academic Urology: Assessment of Female Pelvic Medicine and Reconstructive Surgery, and Opportunity for Improvement.

INTRODUCTION: We describe the digital identity of academic urologists in FPMRS (Female Pelvic Medicine and Reconstructive Surgery) by assessing their visible online information. METHODS: A Google™ search of SUFU (Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction) board members, past presidents and fellowship directors was completed. Hits on the first page of results were categorized as institutional page, group/society page, ratings site, interview/multimedia, journal article or book, social media, professional profile or another person. Sites were subclassified as physician controllable content or not controllable. Descriptive statistics, comparisons among SUFU roles and site type associations were calculated. RESULTS: First page results contained a median (Q1-Q3) of 11 (10-11) hits with 2 (2-3) institutional pages and 1 (1-2) group/society. Ratings sites were frequent returns, with 4 hits (3-5) in 98% of searches (60). Only 1 (1-1) social media, 1 (1-2) professional profile and 1 (1-2) interview/multimedia hits occurred. Overall 6 (5-7) sites were physician controllable content with all but 1 physician having at least 1 such result. Institutional (correlation coefficient -0.38, p = 0.001) or group/society (-0.34, p = 0.023) pages were associated with fewer ratings sites. Group/society pages were 3.41 times more prevalent (mean 11.7% vs 3.44%, p = 0.009) among SUFU board members, while past presidents had 3.03 (6.8% vs 2.3%, p = 0.046) times more journal articles or books and fellowship directors had 1.43 (25.6% vs 18.6%, p = 0.021) times more institutional pages. CONCLUSIONS: For active SUFU members ratings sites comprise a substantial portion of their search results. More online engagement or social media use could increase the visibility of physician controllable content in their digital identities.

Pioglitazone Enhances Survival and Regeneration of Pelvic Ganglion Neurons After Cavernosal Nerve Injury.

OBJECTIVE: To investigate the effects of pioglitazone on pelvic ganglion neurons in a rat model of bilateral cavernosal nerve crush injury (BCNI), thereby elucidating the actions of pioglitazone in preventing post-prostatectomy neurogenic erectile dysfunction. METHODS: Sprague-Dawley rats aged 12 weeks were divided into four groups: (a) sham procedure, (b) BCNI, (c) BCNI + postsurgical pioglitazone, and (d) BCNI + pre and postsurgical pioglitazone (preventive therapy). Preoperative injection of Fluoro-Gold (FG) fluorescent tracer into the cavernosal tissue was performed for retrograde labeling of pelvic ganglion cells. Pelvic ganglia were resected at 2 weeks in all rats and processed for real-time polymerase chain reaction, immunohistochemistry, and Western blot to examine the expression of FG, neuronal nitric oxide synthase, ß-III tubulin, neurturin, and glial cell line-derived neurotrophic factor family receptor alpha-2 (GFRα2). RESULTS: Animals treated with pre- and postsurgical pioglitazone demonstrated increased staining for FG similar to sham levels. Gene expression of neuronal nitric oxide synthase, neurturin, GFRα2, and ß-III tubulin was also upregulated in the group receiving preventive therapy. CONCLUSION: Pioglitazone provides a protective effect on pelvic ganglion neurons after BCNI.

Intralesional Injection of Interferon-α2b Improves Penile Curvature in Men with Peyronie's Disease Independent of Plaque Location.

PURPOSE: Collagenase clostridium histolyticum is the only FDA (Food and Drug Administration) approved treatment for Peyronie's disease. However, to our knowledge collagenase clostridium histolyticum has not been studied in men with ventral plaques. Given this limitation and the paucity of literature on ventral plaque outcomes, we compared the results of Peyronie's disease treatment in men with different plaque locations treated with intralesional interferon-α2b. MATERIALS AND METHODS: We retrospectively analyzed the records of men treated with intralesional interferon-α2b for Peyronie's disease at 1 institution from 2001 to 2014. The men received 2 million U interferon-α2b injected every 2 weeks for 6 to 24 treatments. All men underwent penile duplex Doppler ultrasound before and after interferon-α2b treatment. Patient characteristics, penile duplex Doppler ultrasound and objective measurements were reviewed. Patients were stratified into ventral and dorsal/lateral plaque cohorts with a positive response defined as a 20% or greater reduction in curvature. RESULTS: A total of 131 patients with a mean±SD age of 53.8±9.5 years underwent a median of 12 intralesional interferon-α2b injections (range 6 to 24). Mean pretreatment dorsal curvature was 42.5±18.6 degrees in group 1 of 111 men and mean ventral curvature was 44.5±21.5 degrees in group 2 of 21 men (p=0.66). Overall 91% of patients responded to therapy. No significant difference was noted between the 2 groups in response rate (54% vs 52%, p=0.92) or absolute change in curvature (mean 8.7±12.6 vs 9.3±17.7 degrees, p=0.84). CONCLUSIONS: Treatment with intralesional interferon-α2b provided a greater than 20% reduction in curvature in the majority of men with Peyronie's disease. This improvement was independent of plaque location.

Individualized Physical 3-dimensional Kidney Tumor Models Constructed From 3-dimensional Printers Result in Improved Trainee Anatomic Understanding.

OBJECTIVE: To evaluate the effect of 3-dimensionally (3D) printed physical renal models with enhancing masses on medical trainee characterization, localization, and understanding of renal malignancy. METHODS: Proprietary software was used to import standard computed tomography (CT) cross-sectional imaging into 3D printers to create physical models of renal units with enhancing renal lesions in situ. Six different models were printed from a transparent plastic resin; the normal parenchyma was printed in a clear, translucent plastic, with a red hue delineating the suspicious renal lesion. Medical students, who had completed their first year of training, were given an overview and tasked with completion of RENAL nephrometry scores, separately using CT imaging and 3D models. Trainees were also asked to complete a questionnaire about their experience. Variability between trainees was assessed by intraclass correlation coefficients (ICCs), and kappa statistics were used to compare the trainee to experts. RESULTS: Overall trainee nephrometry score accuracy was significantly improved with the 3D model vs CT scan (P <.01). Furthermore, 3 of the 4 components of the nephrometry score (radius, nearness to collecting system, and location) showed significant improvement (P <.001) using the models. There was also more consistent agreement among trainees when using the 3D models compared with CT scans to assess the nephrometry score (intraclass correlation coefficient, 0.28 for CT scan vs 0.72 for 3D models). Qualitative evaluation with questionnaires filled out by the trainees further confirmed that the 3D models improved their ability to understand and conceptualize the renal mass. CONCLUSION: Physical 3D models using readily available printing techniques improve trainees' understanding and characterization of individual patients' enhancing renal lesions.