Assessment of conservative dietary management as a method for normalization of 24-h urine pH in stone formers.

Low urine pH is a metabolic risk factor for stone formation. While medical therapy is typically prescribed (as urinary alkalinization), patients typically prefer dietary modifications. We aimed to assess capacity to alter urine pH with dietary management alone. We analyzed a retrospective cohort of stone formers seen between 2000 and 2015 with multiple 24-h urine collections (24hUC). Patients ≥ 18 years old with low urine pH (< 6.0) were included; those prescribed alkalinizing agents or thiazides were excluded. Demographic data, 24hUC parameters, and medications were abstracted. 24hUC was utilized to calculate gastrointestinal alkali absorption (GIAA). The primary outcome was urine pH ≥ 6.0 on second 24hUC. Predictors were selected utilizing multivariable logistic regression. The database consisted of 2197 stone formers; 224 of these met inclusion criteria. On second 24hUC, 124 (55.4%) achieved a favorable pH ≥ 6.0. On univariable analysis, a second pH ≥ 6.0 was associated with high initial pH, low initial sulfate, younger age, increase in citrate/GIAA/urine volume, and decrease in ammonium (P < 0.02). On multivariable analysis, high initial pH (OR = 23.64, P < 0.001), high initial GIAA (OR = 1.03, P = 0.001), lower initial sulfate (OR = 0.95, P < 0.001), increase in urine volume (OR = 2.19, P = 0.001), increase in GIAA (OR = 8.6, P < 0.001), increase in citrate (OR = 2.7, P = 0.014), decrease in ammonium (OR = 0.18, P < 0.001), and younger age (OR = 0.97, P = 0.025) were associated with a second pH ≥ 6.0. The analysis demonstrated a corrected AUC of 0.853. These data suggest that certain dietary recommendations (increases in urine volume, citrate, GIAA, and decreased acid load) may normalize urine pH in a select group of patients. This may allow urologists to counsel patients with low urine pH on possibility of success with dietary modification alone.

Psychiatric Diagnoses and Other Factors Associated with Emergency Department Return within 30 Days of Ureteroscopy.

PURPOSE: Emergency department visits after ureteroscopy are costly and inconvenient. To better understand those at risk we aimed to identify patient demographic, medical and surgical factors associated with 30-day emergency department presentation following ureteroscopy for urolithiasis with particular attention to those with a history of a psychiatric diagnosis. MATERIALS AND METHODS: We retrospectively reviewed 1,576 cases (1,395 adults) who underwent stone related ureteroscopy during 3 years at a total of 2 hospitals. We collected patient demographics, medical history and operative details. The primary outcome was return to the emergency department within 30 days of ureteroscopy. Logistic regression was performed to examine factors associated with emergency department presentation. RESULTS: Of the patients 613 (43.9%) had a history of psychiatric diagnosis. Of those with ureteroscopy encounters 12.6% returned to the emergency department within 30 days of ureteroscopy, including 58.8% with a history of psychiatric diagnosis. On multivariable analysis variables associated with emergency department return included a history of psychiatric diagnosis (OR 1.57, p = 0.012), uninsured status (OR 2.46, p = 0.001) and a stone only in the kidney (OR 1.76, p = 0.022). Patients who returned to the emergency department had had more emergency department visits in the year prior to surgery (OR 1.40, p <0.001). On univariable analysis older patients and those with longer operative time were more frequently admitted from the emergency department (OR 1.03, p = 0.002 and OR 1.96, p = 0.03. respectively) while uninsured patients were admitted less frequently (OR 0.19, p = 0.013). No difference was noted in admissions between those with a psychiatric diagnosis and all others (60.7% vs 55.8%, p = 0.48). CONCLUSIONS: We identified factors associated with emergency department return after ureteroscopy, including a history of psychiatric diagnosis, uninsured status and emergency department visits in the year before surgery. These patients may benefit from targeted interventions to help avoid unnecessary emergency department visits.

Let's Get to the Point: Comparing Insertion Characteristics and Scope Damage of Flat-Tip and Ball-Tip Holmium Laser Fibers.

INTRODUCTION: A ball-tip holmium laser fiber (TracTip; Boston Scientific) has been developed to theoretically reduce damaging friction forces generated within a ureteroscope working channel. We compared the insertional forces and damage with a ureteroscope inner lining when inserting standard flat-tip and ball-tip laser fibers. MATERIALS AND METHODS: A standard ureteroscope channel liner was placed in a 3D-printed plastic mold. Molds were created at four angles of deflection (30°, 45°, 90°, and 180°) with a 1 cm radius of curvature. New 200 µm ball-tip (TracTip; Boston Scientific) and 200 µm flat-tip (Flexiva; Boston Scientific) laser fibers were advanced through the liner using a stage controller. A strain gauge was used to measure force required for insertion. Each fiber was passed 600 times at each angle of deflection. The ureteroscope liner was changed every 150 passes. Leak testing was performed every 50 passes or when the insertional force increased significantly to assess damage to the liner. RESULTS: At all deflection angles, the average insertional force was significantly lower with the ball-tip laser fibers compared with flat-tip laser fibers (p < 0.001). All trials with the ball-tip lasers were completed at each angle without any leaks. Two of four trials using flat-tip fibers at 45° deflection caused liner leaks (at 91 and 114 passes). At 90° deflection, all flat-tip trials caused liner leaks on first pass. The 180° trials could not physically be completed with the flat-tip laser fiber. Within the flat- and ball-tip groups, an increasing amount of force was needed to pass the fiber as the degree of deflection increased (p < 0.001). CONCLUSIONS: The ball-tip holmium laser fiber can be safely passed through a deflected ureteroscope without causing liner perforation. The standard flat-tip fiber requires greater insertion force at all angles and can cause the ureteroscope liner to leak if it is deflected 45° or more.

In Vitro Comparison of a Novel Single Probe Dual-Energy Lithotripter to Current Devices.

PURPOSE: The LithoClast Trilogy is a novel single probe, dual-energy lithotripter with ultrasonic (US) vibration and electromagnetic impact forces. ShockPulse and LithoClast Select are existing lithotripters that also use a combination of US and mechanical impact energies. We compared the efficacy and tip motion of these devices in an in vitro setting. MATERIALS AND METHODS: Begostones, in the ratio 15:3, were used in all trials. Test groups were Trilogy, ShockPulse, Select ultrasound (US) only, and Select ultrasound with pneumatic (USP). For clearance testing, a single investigator facile with each lithotripter fragmented 10 stones per device. For drill testing, a hands-free apparatus with a submerged balance was used to apply 1 or 2 lbs of pressure on a stone in contact with the device tip. High-speed photography was used to assess Trilogy and ShockPulse's probe tip motion. RESULTS: Select-USP was slowest and Trilogy fastest on clearance testing (p < 0.01). On 1 lbs drill testing, Select-US was slowest (p = 0.001). At 2 lbs, ShockPulse was faster than Select US (p = 0.027), but did not significantly outpace Trilogy nor Select-USP. At either weight, there was no significant difference between Trilogy and ShockPulse. During its US function, Trilogy's maximum downward tip displacement was 0.041 mm relative to 0.0025 mm with ShockPulse. Trilogy had 0.25 mm of maximum downward displacement during its impactor function while ShockPulse had 0.01 mm. CONCLUSIONS: Single probe dual-energy devices, such as Trilogy and ShockPulse, represent the next generation of lithotripters. Trilogy more efficiently cleared stone than currently available devices, which could be explained by its larger probe diameter and greater downward tip displacement during both US and impactor functions.

In pursuit of the perfect penis: Hypospadias repair outcomes.

Hypospadias is commonly assessed and repaired by pediatric urologists. Mild, distal hypospadias is generally more a cosmetic problem than a functional one and is more frequently encountered than severe, proximal hypospadias. Outcomes following repair, especially of mild phenotypes, are important to understand, but range widely in timing and measurability. Surgical complications, postoperative satisfaction of parents, patients, surgeons and even lay observers, urinary function, sexual function, and quality of life all may be considered as relevant outcomes of hypospadias repair. Existing studies examining these outcomes are diverse in their conclusions, but are important to understand when counseling parents and patients prior to any surgical intervention.