Which objective emergency department parameters leads to expedited intervention in patients with acute urinary tract calculi.

Objectives: To retrospectively determine which objective measurements had an increased likelihood of requiring immediate surgical intervention in patients presenting to the emergency department (ED) with acute ureteral calculi. Materials and methods: Employing our institution's electronic medical record system, we conducted a retrospective cohort study of 4366 patients who presented to the ED with an acute ureteral calculus over an 8-year period. Data consisting of relevant demographic information, vital signs, laboratory parameters, and interventional history was obtained and analyzed. Results: This study consisted of 4366 patients presenting to the ED with acute ureteral calculi, of whom 312 (7%) required a procedure prior to being discharged. Of these 312 patients, 290 (6.6%) underwent cystoscopy with ureteral stent placement and 22 (0.5%) were sent to interventional radiology for percutaneous nephrostomy tube placement. Patients who tested positive for nitrites in their urine had a relative risk of 3.48 of receiving intervention when compared to the nitrite negative group. Conclusions: Through this retrospective cohort study, we were able to find what objective measurements were associated with an increased need for immediate surgical intervention in patients who presented to the ED with acute ureteral calculi. With this data, urologists can be better equipped to identify the patients that present in the emergency setting that will require urgent intervention.

Robotic-assisted nephrectomy with level II IVC thrombectomy using Rummel Tourniquets

ABSTRACT Background: Inferior vena cava (IVC) invasion from renal cell carcinoma (RCC) occurs at a rate of 4-10% (1). IVC thrombectomy (IVC-TE) can be an open procedure because of the need for handling of the IVC (2). The first reported series of robotic management of IVC-TE started in 2011 for the management of Level I - II thrombi with subsequent case reports in recent years (2-5). Materials and Methods: The following is a patient in his 50's with no significant medical history. Magnetic resonance imaging and IR venogram were performed preoperatively. The tumor was clinical stage T3b with a 4.3cm inferior vena cava thrombus. The patient underwent robotic assisted nephrectomy and IVC-TE. Rummel tourniquets were used for the contralateral kidney and the IVC. The tourniquets were created using vessel loops, a 24 French foley catheter and hem-o-lock clips. Results: The patient tolerated the surgical procedure well with no intraoperative complications. Total surgical time was 274 min with 200 minutes of console time and 22 minutes of IVC occlusion. Total blood loss in the surgery was 850cc. The patient was discharged from the hospital on post-operative day 3 without any complications. The final pathology of the specimen was pT3b clear cell renal cell carcinoma Fuhrman grade 2. The patient followed up post-operatively at both four months and six months without disease recurrence. The patient continues annual follow-up with no recurrence. Conclusions: Surgeon experience is a key factor in radical nephrectomy with thrombectomy as patients have a reported 50-65% survival rate after IVC-TE (4).

How we do it: robotic-assisted distal ureterectomy with ureteral reimplantation

ABSTRACT Background: High risk upper tract urothelial carcinoma (UTUC) is typically managed with radical nephroureterectomy, however, renal preservation can be attempted when UTUC is localized to the distal ureter in the presence of chronic kidney disease (1-3). Distal ureterectomy is typically managed with a ureteral reimplantation and psoas hitch in order to maintain urothelial continuity, to avoid comprising the contralateral ureter, and reducing risk of chronic urinary tract infections and electrolyte abnormalities (4). We present our case of distal ureteral UTUC managed robotically with a distal ureterectomy with ureteral reimplantation. Technique and Follow-Up: Initially, an Orandi needle on a resectoscope circumscribed the left ureteral orifice. Next, robotically, the retroperitoneum was exposed and a left sided pelvic lymphadenectomy was completed. The left ureter was mobilized and the diseased ureteral segment was transected. The mobilized bladder was sutured to psoas fascia. After a cystotomy, the ureter was re-anastomosed to the bladder. The patient was discharged on postoperative day three and re-evaluated one week later with a cystogram. Final pathology was downgraded to non-invasive low-grade papillary urothelial carcinoma with negative lymph nodes and margins. Conclusion: High risk UTUC localized to the distal ureter in the setting of chronic kidney disease can be managed with a distal ureterectomy (3). Robotic distal ureterectomy with ureteral reimplantation can be assisted by an Orandi needle to achieve negative margins. Utilizing a robotic technique can offer challenges with the ureteral spatulation and reanastomosis (5-7). By fixating the ureter to the bladder prior to reanastomosis, our technique offers a solution for these difficulties.

Are Postoperative Laboratory Studies Following Robotic Assisted Radical Prostatectomy Necessary?

INTRODUCTION: We evaluated the necessity of obtaining routine postoperative laboratory studies, such as complete blood count and basic metabolic panel, after robotic assisted radical prostatectomy. METHODS: This study is a retrospective review of 200 robotic assisted radical prostatectomy cases performed over a year and a half at our institution. The incidences of laboratory abnormalities were examined along with any clinical intervention. Patient demographics, tumor stage, Gleason score, operative time, estimated blood loss, length of hospital stay, presence of comorbidities and postoperative laboratory studies were extracted from the electronic medical record. The costs of laboratory studies were tabulated to further analyze potential savings to patients. RESULTS: Only 15 (7.5%) patients demonstrated laboratory abnormalities that required medical intervention. Of these 15 patients, all demonstrated hypokalemia that was treated with potassium supplementation. Patients with longer lengths of stay demonstrated higher percentages of medical intervention. The costs of these laboratory studies were calculated at $8,840. CONCLUSIONS: Lower blood loss and transfusion rates with the advent of robotic assisted radical prostatectomy along with the results described in this study provide greater evidence that postoperative laboratory studies may be futile. By eliminating these laboratory studies, substantial cost savings are realized if extrapolated across the United States. This study is limited in its evaluation of complications from different types of medical centers, higher risk patients, postoperative laboratory studies impact on symptomatic patients, and absence of emergency room visits or hospital readmissions.

The impact of low pressure pneumoperitoneum in robotic assisted radical prostatectomy: a prospective, randomized, double blinded trial.

BACKGROUND: Robotic surgery has revolutionized postoperative outcomes across surgical specialties. However, the use of pneumoperitoneum comes with known risks given the change in physiological parameters that accompany its utilization. A recent internal review found a 7% decrease in postoperative ileus rates when utilizing a pneumoperitoneum of 12 mmHg over the standard 15 mmHg in robotic assisted radical prostatectomies (RARP). OBJECTIVE: The purpose of this study is to prospectively evaluate the utility of lower pressure pneumoperitoneum by comparing 8 mmHg and 12 mmHg during RARP. DESIGN, SETTING AND PARTCIPANTS: Patients were randomly assigned to undergo robotic assisted radical prostatectomy at a pneumoperitoneum pressure of 12 mmHg or 8 mmHg. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary outcome was development of postoperative ileus and secondary outcomes were length of operation, estimated blood loss and positive surgical margin status. RESULTS AND LIMITATIONS: A total of 201 patients were analyzed; 96 patients at 8 mmHg and 105 patients at 12 mmHg. The groups were adequately matched as there were no differences between demographic parameters or medical comorbidities. There was a decrease in postoperative ileus rates with lower pneumoperitoneum pressures; 2% at 8 mmHg and 4.8% at 12 mmHg. There were no clinically significant differences in estimated blood loss, total length of operative time and positive margin status. CONCLUSIONS: Lower pressure pneumoperitoneum during robotic assisted radical prostatectomy is non-inferior to higher pressure pneumoperitoneum levels and the experienced surgeon may safely perform this operation at 8 mmHg to take advantage of the proposed benefits.

Robotic management of large stone disease: a case series.

The gold standard for urologic management of large stone disease traditionally has been percutaneous nephrolithotomy (PCNL). An alternative to PCNL is robotic pyelolithotomy (RP), which continues to gain traction. This study is a retrospective review of ten cases performed over a 2 year period presenting operative outcomes for large stone disease treated with RP. The mean and standard deviation were calculated for age, body mass index, stone volume, stone diameter, pre-operative creatinine, operative time, robot-docked time, length of stay, post-operative creatinine, and estimated blood loss. In addition, results were collected for post-operative complications and secondary procedure requirements. Complete stone clearance was successful in 9 of 10 cases. The average renal function remained stable from a pre-operative creatinine of 0.917 mg/dL to a post-operative creatinine level of 0.943 mg/dL. This case series demonstrates that robotic assisted surgery has practical application when managing large stone disease.

Patient navigation for overactive bladder improves access to care.

INTRODUCTION AND HYPOTHESIS: Patients with overactive bladder (OAB) become discouraged with medication therapy because of the side effects, minimal subjective improvement and costs of therapy. With the implementation of a patient navigation pathway there is increased communication, subsequently leading to increased patient retention rates and utilization of third-line therapies. METHODS: This was a quality improvement study carried out over a 17-month period comparing utilization of a navigation pathway versus patients without navigation. The data were obtained using an online database (PPS Analytics) to compare medication use, cystoscopy, urodynamic studies, use of third-line therapy, and return visits. RESULTS: A total of 535 patients were included in the analysis and broken down into two respective groups. Group 1 were those placed on the navigation pathway and able to be reached via telephone (n = 431). Group 2 were those started on the navigation pathway who were not able to be reached via telephone, but were chart reviewed by a navigator (n = 104). Third-line therapy usage for groups 1 and 2 was 24% and 11% respectively. Return visits for additional OAB management for groups 1 and 2 were found to be 71% and 50% respectively. CONCLUSION: Patient retention levels and utilization of third-line therapies are significantly improved when utilizing a navigation pathway. With 24% of the patients included in this study opting for third-line therapy, this represents a 600% increase in third-line therapies over national averages.

A rare case of metastatic sigmoid adenocarcinoma to the ureter.

Colorectal cancer is a very common disease process, as is ureteral obstruction, but the two are typically mutually exclusive. The case report presented details a 35-year-old male with left sided flank pain and hydroureteronephrosis caused by metastatic spread of previously diagnosed and treated sigmoid adenocarcinoma. About two years previously, he had been diagnosed with Stage IV, T4a sigmoid colon cancer with liver metastasis and had resection of his primary tumor as well as metastatic sites and several rounds of chemotherapy. This case is an example of the different ways that cancer can grow, evading detection by spreading in atypical patterns.

Reduction in postoperative ileus rates utilizing lower pressure pneumoperitoneum in robotic-assisted radical prostatectomy.

Robotic-assisted radical prostatectomy (RARP) is the most commonly performed surgery for prostate cancer. This is a study comparing differences in postoperative outcomes between pneumoperitoneum pressures of 15 mmHg and 12 mmHg. Retrospective chart review was performed on 400 patients undergoing RARP over a 5 year period. A combination of Fisher's exact test and ANOVA were utilized for statistical analysis. Age, BMI, Gleason score, positive margin rate, complication rates, blood loss, and operative times were similar in both groups. Length of stay and postoperative ileus rates were significantly less in the 12 mmHg group (p < 0.05). RARP can be safely performed utilizing a lower pressure pneumoperitoneum. Decreasing insufflation pressures from 15 to 12 mmHg can further lead to decreased rates of postoperative ileus.

Which Objective Parameters Are Associated with a Positive Urine Culture in the Setting of Ureteral Calculi: The Ureteral Calculi Urinary Culture Calculator.

OBJECTIVE: To determine associations between laboratory values and subsequent culture positivity in the acute ureteral calculi patient. Specifically, we aim to develop a predictive model to assist with optimization of patient outcomes and improvement of antimicrobial stewardship. METHODS: Utilizing the electronic medical record system, we conducted a retrospective review of 3888 patients with ureteral calculi. Relevant demographic information, vital signs, and laboratory parameters obtained in the emergency department were tabulated. We applied a combination of analysis of variance and Pearson Fisher's Exact test for the analysis. RESULTS: A total of 3888 patients were included in the analysis of whom 3171 (81.6%) had a negative urine culture and 717 (18.4%) had a positive urine culture. Basic vital signs and laboratory parameters, such as heart rate, temperature, white blood cell (WBC) count, platelet count, and neutrophil differential only varied slightly in the positive and negative culture groups. Urinary nitrite was found to have specificity of 97.2% with a negative predictive value of 83.7%. Urinary leukocyte esterase was found to have a sensitivity of 86.8% and positive predictive value of 46.9%. On microscopy analysis, WBCs per high power field (WBCs/hpf) varied directly with likelihood of a positive urine culture; >150 WBCs/hpf had an 86.1% likelihood of positive urine culture. CONCLUSION: With the data provided from this large cohort analysis, we were able to create the ureteral calculi urinary culture calculator. With this calculator, urologists are better equipped to stratify a patient's risk of having a positive urine culture in the setting of a ureteral calculus.

Robotic Assisted Common Sheath Ureteroneocystostomy of an Injured Ectopic Ureter Diagnosed in the Acute Post-operative Setting after Robotic Assisted Radical Prostatectomy.

Radical prostatectomies are one of the most commonly performed operations for the robotic urologist. When a rare anatomic anomaly leads to an unrecognized intraoperative injury, standard postoperative management becomes complicated. We present the case of a patient with an iatrogenic injury to an ectopic ureter that under went a robotic assisted common sheath ureteroneocystostomy three days post robotic assisted radical prostatectomy.

Candida Bezoars in Adults: Determining Optimal Management.

Fungal bezoars, or fungal balls, are rare pathologic consequences of funguria in immunocompromised patients. Current treatment recommendations are based on expert opinion and low level evidence. We present a case of a Candida glabrata bezoar that was effectively treated with percutaneous amphotericin B instillations. A subsequent literature review is presented to assess the available case reports and treatment outcomes of Candida spp. bezoars in adults.

Large bowel obstruction resulting from bladder transitional cell carcinoma metastasis: a common cancer presenting in an uncommon manner.

Transitional cell carcinoma (TCC) and large bowel obstructions are both common disease processes typically considered unrelated. Presented below is the case of a 49-year-old male with a large bowel obstruction caused by a bladder TCC metastasis. One year prior to large bowel obstruction presentation, the patient had a T2, Grade III TCC of the bladder with no nodal involvement or metastasis, which was removed via radical cystoprostatectomy. This case serves as a reminder that cancer, despite common pathogenesis patterns, can present in atypical ways.