Clinical Considerations for Patients Experiencing Acute Kidney Injury Following Percutaneous Nephrolithotomy.

Acute kidney injury (AKI) is a common postoperative outcome in urology patients undergoing surgery for nephrolithiasis. The objective of this study was to determine the prevalence of postoperative AKI and its degrees of severity, identify risk factors, and understand the resultant outcomes of AKI in patients with nephrolithiasis undergoing percutaneous nephrolithotomy (PCNL). A cohort of patients admitted between 2012 and 2019 to a single tertiary-care institution who had undergone PCNL was retrospectively analyzed. Among 417 (n = 326 patients) encounters, 24.9% (n = 104) had AKI. Approximately one-quarter of AKI patients (n = 18) progressed to Stage 2 or higher AKI. Hypertension, peripheral vascular disease, chronic kidney disease, and chronic anemia were significant risk factors of post-PCNL AKI. Corticosteroids and antifungals were associated with increased odds of AKI. Cardiovascular, neurologic complications, sepsis, and prolonged intensive care unit (ICU) stay percentages were higher in AKI patients. Hospital and ICU length of stay was greater in the AKI group. Provided the limited literature regarding postoperative AKI following PCNL, and the detriment that AKI can have on clinical outcomes, it is important to continue studying this topic to better understand how to optimize patient care to address patient- and procedure-specific risk factors.

Understanding Patient Expectations and Determinants of Satisfaction in an Outpatient Urology Clinic at an Academic Medical Center.

OBJECTIVE: To examine and better understand expectations and facilitators of satisfaction amongst patients presenting to an ambulatory urology clinic at an academic medical center. METHODS: Patients completed an anonymous survey regarding expectations for their clinic visit. Patients were included in the investigation if they were aged 18-89 years and had the ability to complete informed consent. Chi-square analysis was then used to analyze the collected data. RESULTS: A total of five hundred patients were enrolled in the study. Patients were predominantly white males and were older than 60 years of age. Most patients had at least a college education and drew an annual household income between $40,000-$99,999. Most enrollees were return patients (74.8%). Most expected to be seen within 3-7 days of referral and expected 16-30 minutes with their provider. Patients noted they would not be equally satisfied seeing a physician vs advanced practice provider on their initial visit but would on a return visit. About half (52%) of the cohort stated they would be dissatisfied with their clinic experience if their expectations were not met. Significance was found between variables including age, race, gender and type of visit and their survey responses. CONCLUSION: Patient satisfaction remains an important measure for the quality and safety of patient care. This investigation highlighted patient prioritization of time to be seen after referral and the provider that cares for them at both initial and follow-up visits. Future research is needed to enhance stakeholder understanding of precisely how expectations impact overall satisfaction.

Lessons from rodent gastric bypass model of enteric hyperoxaluria.

PURPOSE OF REVIEW: The aim of the article is to review studies on bone health and oxalate metabolism/therapeutics in the obese rodent model of Roux-en-Y gastric bypass (RYGB) and examine pathways to decrease procedural morbidity. RECENT FINDINGS: Compared with controls, RYGB rodents have up to 40-fold more fat in their stool (steatorrhea) which positively correlates to increased urinary oxalate. These unabsorbed intestinal fatty acids bind calcium and prevent gut calcium oxalate formation, increasing soluble luminal oxalate availability and absorption (enteric hyperoxaluria). When intraluminal fecal fat exceeded about 175 mg/24 h in our model, more paracellular and transcellular oxalate transport across the distal colon occurred. Increasing dietary calcium and colonization with Oxalobacter formigenes reduced hyperoxaluria, whereas vitamin B6 supplementation did not. RYGB animals, when severely calcium deficient, had bone mineral density loss that could not be rescued with vitamin D supplementation. SUMMARY: The findings of hyperoxaluria, steatorrhea, and decreased bone mineral density are seen in both human and rodent RYGB. Our model suggests that a low-fat, low-oxalate diet combined with calcium supplementation can decrease urinary oxalate and improve skeletal bone health. Our model is a useful tool to study renal and bone RYGB effects. Studies of longer duration are required to further evaluate mechanisms of disease and durability of therapeutics.

Evaluation of Patient Factors That Influence Predictive Formulas for Determining Ureteral Stent Length When Compared to Direct Measurement.

Objectives: To compare direct ureteral length measurements with predictive formulas used for the preoperative assessment of ureteral length, and to evaluate patient factors that impact the accuracy of these predictive formulas. Methods: Patients undergoing ureteral stenting for benign and malignant indications were included. Clinical factors analyzed were gender, race, height, weight, prior abdominal or pelvic surgery, radiation therapy, pelvic organ prolapse (POP), laterality, hydronephrosis, and pre-existing ureteral stent. Three predictive formulas and a common height-based formula were used. Direct ureteral measurements were obtained with a ruled 5F ureteral catheter. Predictive formulas were compared with direct ureteral measurements using scatterplot and Spearman's correlation coefficient. Univariate and multivariate logistic regressions were used to evaluate patient factors associated with ≥2 cm deviation from direct ureteral measurements. Results: A total of 108 patients (134 ureters) were analyzed. All predictive formulas correlated poorly with direct ureteral measurements, although as much as 60% of ureteral stent lengths were accurately predicted. Several patient factors significantly impacted accuracy of formulas: male gender (p = 0.04), POP (p = 0.05), body mass index (BMI) ≥25 (p = 0.03), and pre-existing ureteral stent (p = 0.05). Conclusion: Our study suggests that predictive formulas for ureteral stent length have poor accuracy when compared to direct measurement, especially for patients with elevated BMI and POP. Our institution considers direct ureteral measurement the gold standard for determining ureteral stent length-a method that is universally applicable and independent of patient factors.

Percutaneous Removal of Retained Metallic Ureteral Stent with a Looped Polytetrafluoroethylene-Coated Guidewire.

Background: Ureteral stricture disease is a troubling urologic issue that can be managed with surgical reconstruction or, more conservatively, with chronic nephrostomy tubes or ureteral stents. These indwelling tubes require exchanges and are prone to complications such as encrustation or stent failure. Metallic ureteral stents are designed to be more resistant to extrinsic compression and allow for exchanges at longer intervals. However, encrustation or tissue ingrowth can occur with these stents as well. The removal of encrusted or embedded metallic ureteral stents poses a difficult clinical scenario. We present a case of an encrusted metallic stent embedded in a proximal ureteral stricture requiring percutaneous endoscopic removal with a novel looped-wire technique. Case Presentation: A 50-year-old Caucasian man with bilateral ureteral stricture disease, managed with chronic indwelling metallic stents, failed retrograde removal on the right during routine exchange. Staged procedures with percutaneous nephrostomy, followed by combined percutaneous antegrade and retrograde endoscopy were required to observe and access the embedded stent. The exposed metallic surface was unable to be grasped by available instruments through flexible endoscopy. Under endoscopic control with fluoroscopic guidance, a polytetrafluoroethylene (PTFE)-coated guidewire was looped around the metallic stent. With gentle traction on the wire loop, the embedded stent curl was delivered out of the stricture and into the renal pelvis from where it was extracted carefully with graspers inserted through a rigid nephroscope. Follow-up antegrade fluoroscopic studies with contrast showed no extravasation. Conclusion: Percutaneous removal of metallic stents retained within the ureter has unique challenges. We present a novel method of extraction of a retained metallic stent with a looped PTFE-coated guidewire, which may safely and effectively be used in complex situations.

Endoscopic Management of Chyluria Caused by Pyelolymphatic Fistula After Robot-Assisted Laparoscopic Pyeloplasty.

Background: Chyluria is a rare diagnosis classically associated with milky-appearing urine. It involves the leakage of chyle into the urinary tract. Although the most common cause of chyluria worldwide is infectious in nature, other noninfectious etiologies have been described. Classically chyluria resolves spontaneously or with conservative management. Surgical treatments have been described but are not often required. We present a case of iatrogenic pyelolymphatic fistula after robot-assisted laparoscopic dismembered pyeloplasty that was treated with endoscopic electrocautery of the fistulous tract. Case Presentation: A 50-year-old Caucasian man underwent a robot-assisted laparoscopic dismembered pyeloplasty with stent insertion for radiographically demonstrated left ureteropelvic junction obstruction. His postoperative course was uneventful until 4-week follow-up at which time he began to notice intermittent passage of milky-appearing urine. Urinalysis was notable for large protein and elevated urine triglycerides. He was initially managed conservatively dietary modifications without success. He then underwent endoscopic management with cystoscopy and ureteroscopy with fulguration of suspected pyelolymphatic fistula. He was maintained on a low-fat medium-chain triglyceride diet and octreotide injections while inpatient for 1 week postoperatively. His postoperative course was unremarkable and no return of chyluria was observed. His chyluria remained resolved at 9 months postoperatively. Conclusion: Pyelolymphatic fistula after robot-assisted laparoscopic pyeloplasty is a theoretical complication of perirenal dissection and has not been previously described in the literature. It should be considered as a rare iatrogenic cause of chyluria. Endoscopic management with fulguration is technically feasible and may obviate the need for more invasive surgical management.

Asymptomatic Obstructive Ureterolithiasis Due to a Periureteral Venous Ring.

Background: Periureteral venous rings are a rare congenital anomaly involving the inferior vena cava (IVC) and the right ureter, where the ureter courses through a venous ring made by the duplication of the IVC during embryogenesis. This anatomic anomaly is also referred to as a transcaval ureter. Although most patients are asymptomatic and radiographic findings are incidental, some patients can be symptomatic. We present the first reported case of asymptomatic obstructive ureterolithiasis at the level of a periureteral venous ring that was effectively treated with endoscopic management. Case Presentation: A 47-year-old woman was found to have right hydroureteronephrosis on MRI. Further CT imaging showed an obstructing ureteral stone at the level of a periureteral venous ring. After initial decompression with ureteral stenting, she underwent ureteroscopy that revealed the ureteral stone at the level of the venous anomaly. The stone was fragmented and removed with laser lithotripsy and stone basket manipulation. After a period of ureteral stenting and removal, she had improved hydroureteronephrosis, no symptoms of ureteral obstruction, and stable renal function. Given these findings, she elected for surveillance with imaging in lieu of any reconstructive procedure to transpose the ureter around the venous anomaly. Conclusions: We present the first reported case of obstructive ureterolithiasis at the level of a periureteral venous ring. Our experience suggests that, with preoperative ureteral stenting, obstructing ureteral stones in the setting of an IVC anomaly can be managed with retrograde flexible ureteroscopy. Conservative laser settings and minimal torqueing of the ureteroscope are advised given adjacent vascular anomaly. Cases wherein the affected ureteral segment is too constricted or tortuous to allow for stone passage or for ureteroscopy may require management by percutaneous antegrade intervention. Surgical reconstruction of the ureter should also be considered.

Genital Neurofibromatosis Presenting as Painful Clitoromegaly.

Neurofibromatosis type 1 (NF1) is a neurocutaneous disorder caused by a mutation on chromosome 17 of the gene for neurofibromin. Patients with this condition are prone to develop benign and malignant tumors of the central and peripheral nervous systems. Genitourinary involvement in children with NF1 is uncommon and primarily affects the bladder. External genital manifestations of NF1 are rare with sporadic reports of children presenting with enlargement of their penis, clitoris, or labia due to a neurofibroma. We present a case of painful clitoromegaly due to a plexiform neurofibroma in a child.

Career Expectations and Preferences of Urology Residency Applicants.

OBJECTIVE: To survey the characteristics, career goals, and practice preferences of current urology applicants. METHODS: An anonymous survey was emailed to applicants pursuing a residency position at the University of Florida for the 2017-2018 academic year Urology Match. The survey included questions on demographics, motivating factors to pursue urology, plans for fellowship training, and anticipated and desired practice patterns. RESULTS: A total of 151 of 295 applicants completed the survey, mean age 26.9± SD 2.3. Males had a higher interest in academics/research, cancer, men's health, and minimally invasive surgery technology. Females had a higher interest in public health, surgery, and mixture of surgical and medical management. A total of 64.1% planned on completing a fellowship. Males had a higher interest in urologic oncology and endourology. Females had a higher interest in female pelvic medicine and reconstructive surgery, andrology and sexual medicine, and pediatric urology. A total of 76.9% anticipated having an academic affiliation, 68.9% working in an urban setting, and 98% working full-time, with no difference based on gender. For desired quality of life after residency, maximum number of hours considered acceptable was 51-60 (36.4%) and 61-70 (35.1%). Regarding an acceptable call schedule, most considered 2-4 nights per month reasonable. Most felt an acceptable starting salary was $250,000-$400,000 and $200,001-$350,000 for private practice and academic urology, respectively. CONCLUSION: Current urology applicants desire to work in academics, urban settings, and pursue subspecialty fellowship training. What they consider acceptable work hours, call schedule, and financial compensation appear compatible with the current practice of urology.

Laser Therapy for Genitourinary Syndrome of Menopause.

PURPOSE OF REVIEW: The purpose of this article is to review the available data regarding the application and therapeutic outcomes of laser therapy for the treatment of genitourinary syndrome of menopause (GSM). RECENT FINDINGS: There have been several studies regarding the use of laser therapy for the treatment of GSM. Most of these studies show a trend toward safe and effective treatment in the short term (less than or equal to 12 weeks). However, these studies are lacking in randomization, blinding, placebo, and comparison groups. Although laser therapy for the treatment of the symptoms of GSM appears promising, there is currently a lack of high-level and long-term evidence regarding its safety and efficacy. There is also a lack of professional guidelines in the USA regarding this modality of treatment, specifically for GSM. Opportunities exist for future research in this area, specifically to determine safety and long-term outcomes of therapy.

Analysis of Complications of Pelvic Mesh Excision Surgery Using the Clavien-Dindo Classification System.

PURPOSE: We describe and categorize complications using the Clavien-Dindo classification system in patients who underwent vaginal mesh excision surgery. MATERIALS AND METHODS: With institutional review board approval we retrospectively reviewed the records of 277 patients who underwent vaginal mesh extraction between 2007 and 2015 at a single institution. Surgical complications were stratified using the Clavien-Dindo classification system. Complications were perioperative (prior to discharge) or postoperative (within 90 days). Indications for initial mesh placement, mesh revision procedure, time to resolution and medical comorbidities were assessed. RESULTS: Of the 277 patients 47.3% had at least 1 surgical complication, including multiple complications in 7.2%. A total of 155 complications were identified, which were grade II in 49.0% of cases, grade I in 25.8%, grade IIIb in 18.7%, grade IIIa in 5.2% and grade IVa in 1.3%. No grade IVb or V complications were identified. The indication for initial mesh placement did not significantly affect complication frequency. Patients who underwent combined stress urinary incontinence and pelvic organ prolapse mesh revision surgeries had an increased frequency of complications compared to those treated with mesh revision surgery for pelvic organ prolapse or stress urinary incontinence alone (p = 0.045). Most complications occurred postoperatively and resolved by 90 days. Age, body mass index, smoking status and diabetes were not associated with increased complications. CONCLUSIONS: Despite the complexity of mesh revision surgery most complications are minor. Serious complications may develop, emphasizing the need for proper patient counseling and surgical experience when performing these procedures.

A case of uncomplicated urinary myiasis in a healthy female.

Myiasis is the infestation of a mammal by fly larvae which thrive by feeding on, and occupying the host. Largely a problem in livestock, human infestations in rural tropical areas of the globe are not uncommon. Myiasis may involve the skin, eyes, nasal passages, gastrointestinal and genitourinary tracts. Cases of urinary myiasis are rare in the USA; however, it may occur in immunocompromised hosts, those with previous urologic instrumentation or those with poor socioeconomic status. We present a case of successful outpatient treatment of urinary myiasis in an immunocompetent female without prior urological history.