Metabolic evaluation guidelines in patients with nephrolithiasis: Are they being followed? Results of a national, multi-institutional, quality-assessment study.

INTRODUCTION: The significant cost burden of kidney stones underscores the importance of best clinical practice in kidney stone management. We evaluated adherence to kidney stone metabolic evaluation guidelines in a Canadian population and the interest of patients with regard to prevention. METHODS: A questionnaire based on Canadian Urological Association (CUA) best practice guidelines was designed. Patients presenting for extracorporeal shockwave lithotripsy treatment (ESWL) were administered this questionnaire to evaluate risk factors of stone disease and assess the use of metabolic evaluations. Patients were asked if they received explanations about their results and if they were interested in kidney stone prevention. RESULTS: We identified 530 patients at five academic institutions; 79.4% had at least one indication to receive a metabolic evaluation (high-risk stone formers), which increased to 96.6% if first-time stone formers whom reported an interest in metabolic evaluation were included. However, only 41.1 % of these patients had a metabolic evaluation. Endourologists ordered metabolic evaluation more often than other referring urologists (63.6% vs. 36.5%; p<0.001). Furthermore, urologists ordered metabolic evaluations more often than other prescribing physicians (68.9% vs. 31.1%; p<0.001). Sixty-two percent of patients received explanations about their metabolic evaluation results and 77.5% understood them. Regarding prevention, 84.1% and 83.8% were interested in more explanations and in following a diet or taking a medication, respectively. CONCLUSIONS: Adherence to CUA metabolic evaluation guidelines is suboptimal and could be improved by urologists referring patients for ESWL. Communication between physician and patient may not be adequate. The majority of stone formers are interested in kidney stone prevention.

Shockwave Lithotripsy Practice Pattern Variations Among and Between American and Canadian Urologists: In Support of Guidelines.

PURPOSE: Shockwave lithotripsy (SWL) is a widely utilized form of treatment for urolithiasis. There are new evidence-based recommendations regarding pre-SWL patient work-up and the performance of SWL. The purpose of this study is to determine practice patterns for SWL and to determine if regional variation exists between Canada and the United States. MATERIALS AND METHODS: A 19-question survey was prepared. Canadian urologists were surveyed through e-mail correspondence. In the United States, members of the Endourologic Society and members of two large stone management groups were surveyed. Canadian and American results were compared using the chi-square and Fisher's exact tests. RESULTS: Ninety-four Canadian urologists and 187 U.S. urologists completed the survey. Practice patterns differed between countries. Intravenous sedation was more commonly used in Canada (Canada 94.7% vs United States 17.9%, p < 0.001); routine antibiotics were more commonly given in United States (Canada 2.1% vs United States 78.1%, p < 0.001); a shock rate of 2 Hz was more common in Canada (Canada 76.6% vs United States 16.2%, p < 0.00001); rate of discontinuing ASA for renal and ureteral stone treatment was higher in the United States (renal Canada 88.3% vs United States 95.7%, p < 0.02; ureteral Canada 62.4% vs 90.3%, p < 0.0001); and ureteral stents were more commonly used if treating a large stone or patients with solitary kidneys in the United States (large stones Canada 58.2% vs United States 88.8%, p = 0.0001; solitary kidney Canada 50.6% vs 66.3%, p = 0.02). CONCLUSIONS: This study highlights the absence of standardization of SWL. Significant regional differences exist in practice patterns and performance of SWL between Canadian and American urologists.

Lumbar plexopathy as a complication of percutaneous nephrolithotomy in a horseshoe kidney.

Treatment of nephrolithiasis in horseshoe kidneys can be challenging due to anomalies in renal position, collecting system anatomy and vascular supply. We report on a patient who was referred after a failed percutaneous nephrolithotomy for a left moiety staghorn calculus in a horseshoe kidney. Two punctures had been performed involving upper and middle posterior calyces. Both were very medially placed and inadvertently traversed the psoas muscle, resulting in lumbar plexopathy with permanent deficit. This complication presented postoperatively with left leg weakness, paresthesia, and pain which impaired independent ambulation. The patient went on to be successfully treated for her stone disease with robotic-assisted laparoscopic pyelolithotomy.

Simulation-based flexible ureteroscopy training using a novel ureteroscopy part-task trainer.

INTRODUCTION: Simulation-based training (SBT) is being increasingly used for novice trainees as a means of overcoming the early learning curve associated with new surgical skills. We designed a SBT flexible ureteroscopy (fURS) course using a novel inanimate training model (Cook Medical, Bloomington, IN; URS model). We evaluated the course and validated this Cook URS model. METHODS: A 2-week SBT fURS course was designed for junior level urology trainees at 2 Canadian universities. The curriculum included didactic lectures, hands-on training, independent training sessions with expert feedback, and use of the Cook URS part-task model. Baseline and post-course assessments of trainee fURS skills were conducted using a standardized test task (fURS with basket manipulation of a calyceal stone). Performances were video-recorded and reviewed by 2 blinded experts using a validated assessment device. RESULTS: Fifteen residents (postgraduate years [PGY] 0-3) participated in the course. Of the participants, 80% rated the Cook URS model as realistic (mean = 4.2/5) and 5 endourology experts rated it as useful as a training device (mean = 4.9/5), providing both face and content validity. The mean overall performance scores, task completion times, and passing ratings correlated with trainee clinical fURS experience - demonstrating construct validity for the Cook URS model. The mean post-course task completion times (15.76 vs. 9.37 minutes, p = 0.001) and overall performance scores (19.20 vs. 25.25, p = 0.007) were significantly better than at baseline. Post-course performance was better in all domains assessed by the validated assessment device. CONCLUSIONS: This study demonstrates that a SBT curriculum for fURS can lead to improved short-term technical skills among junior level urology residents. The Cook URS model demonstrated good face, content and construct validity.

The association between nerve sparing and a positive surgical margin during radical prostatectomy.

PURPOSE: A positive surgical margin (SM) during radical prostatectomy (RP) increases risk of biochemical recurrence. We evaluated the effect of nerve-sparing procedures on risk of positive SM for pT2- and pT3-category tumors. We hypothesized that nerve sparing would increase rates of pT2 positive margins. METHODS: We evaluated a historical cohort of 9,915 consecutive RP patients treated at The Ottawa Hospital or Memorial Sloan-Kettering Cancer Center from 2000 to 2010. Patients underwent open, laparoscopic, or robotic RP. The primary outcome was presence of a positive SM stratified by pathologic pT2 and pT3 categories. The association between nerve sparing and positive margin was adjusted for prostate-specific antigen, RP Gleason sum, surgical modality, surgical date, and location in the multivariable model. RESULTS: Of 6,120 eligible patients, 3,958 (64.7%) had open RP, 1,566 (25.6%) had laparoscopic RP, and 596 (9.7%) had robotic RP. Approximately 8.6% (363/4,199) of patients with pT2-category disease and 25.2% (485/1,921) of patients with pT3-category disease had a positive margin. Patients with pT2-category disease who underwent a bilateral nerve-sparing procedure were more likely to have a positive margin when compared with those who underwent nerve resection on multivariable analysis (relative risk [RR] = 1.52, 95% CI: 0.97-2.39) after adjusting for confounders. Patients with pT3-category disease who underwent a bilateral nerve-sparing procedure had no associated increase in risk of positive margin after adjustment for other variables (RR = 0.96, 95% CI: 0.80-1.16). Prostate incision into tumor (pT2R1) was significantly more likely in patients treated with robotic surgery (RR = 1.76, 95% CI: 1.25-2.48) than in those with open surgery. There was no difference between laparoscopic and open RP (RR = 0.86, 95% CI: 0.65-1.12). CONCLUSIONS: Bilateral nerve sparing is associated with increased risk of positive SMs in patients with pathologic T2-category disease during RP.

Assessing radiation exposure during endoscopic-guided percutaneous nephrolithotomy.

INTRODUCTION: Percutaneous nephrolithotomy (PCNL) may be associated with significant ionizing radiation exposure for patients and operating room staff. Endoscopic-guided PCNL (ePCNL) is a technique that may be associated with less radiation exposure. This study examines ePCNL-related radiation exposure (fluoroscopy time, effective dose) and investigates variables that may predict increased exposure. METHODS: A retrospective review of all consecutive ePCNLs performed at our institution, by a single surgeon, was conducted between November 2011 and November 2013. Patient demographics, stone characteristics and perioperative details were recorded, including radiation exposure. Pearson and Spearman correlation were used to assess variables correlated with radiation exposure. RESULTS: In total, 55 ePCNL cases were included in the study. The mean age was 60 ± 15 years, mean body mass index (BMI) 30.0 ± 6.4 kg/m(2) and mean stone size 3.2 × 2.1 cm. Seven cases (13%) involved complete staghorn stones, and 69% involved supracostal punctures. The mean fluoroscopy time was 3.4 ± 2.3 minutes, mean ED 2.4 ± 1.9 mSv. The treatment success rate, assessed 1-week postoperatively, was 87.3% and 7.3% of cases required ancillary procedures. The overall complication rate was 29%, but only 3 cases (5.5%) were Clavien ≥3. Longer fluoroscopy time correlated with increased stone size (p < 0.01), longer operative time (p < 0.01) and lower treatment success rates (p < 0.01); higher effective dose correlated with longer fluoroscopy time (p < 0.01) and increased skin-to-stone distance (p < 0.01). BMI did not correlate with fluoroscopy time or effective dose. CONCLUSIONS: Outcomes of ePCNL are comparable to traditional PCNL techniques and may be associated with lower radiation exposure, particularly beneficial for patients with higher BMI.

Baseline urologic surgical skills among medical students: Differentiating trainees.

INTRODUCTION: Urology training programs seek to identify ideal candidates with the potential to become competent urologic surgeons. It is unclear whether innate technical ability has a role in this selection process. We aimed to determine whether there are any innate differences in baseline urologic technical skills among medical students. METHODS: Second-year medical students from the University of Toronto were recruited for this study and stratified into surgical and non-surgical cohorts based on their reported career aspirations. After a pre-test questionnaire, subjects were tested on several urologic surgical skills: laparoscopy, cystoscopy and robotic surgery. Statistical analysis was performed using chi-squared test, student t-tests and Spearman's correlation where appropriate. RESULTS: A total of 29 students participated in the study and no significant baseline differences were found between cohorts with respect to demographics and prior surgical experience. For laparoscopic skills, the surgical cohort outperformed the non-surgical cohort on several exercises: Lap Beans Missed (4.9 vs. 9.3, p < 0.01), Lap Bean Rating (3.8 vs. 3.1, p = 0.01), Lap Rings Error (0.2 vs. 1.22, p < 0.01), Lap Rings Rating (3.9 vs. 2.9, p < 0.01) and LapSim Grasping Score (64.3 vs. 46.4, p = 0.01). For cystoscopic skills, there were no significant differences between cohorts on any of the performance metrics. The surgical cohort also outperformed the non-surgical cohort on all measured robotic surgery performance metrics: Task Time (50.6 vs. 76.3, p < 0.01), Task Errors (0.2 vs. 3.1, p < 0.01), and Task Score (89.5 vs. 72.6, p < 0.01). DISCUSSION: Objective innate technical ability in urological skills, particularly laparoscopy and robotics, may differ between early trainees interested in a surgical career compared to those interested in a non-surgical career. Further studies are required to illicit what impact such differences have on future performance and competence.

Flank bulge following supracostal percutaneous nephrolithotomy: A report of 2 cases.

Damage to intercostal nerves during surgical procedures has been associated with a postoperative flank bulge, due to denervation of the anterolateral abdominal wall musculature. This complication has not been reported following percutaneous nephrolithotomy (PCNL). We are aware of 3 cases, but have details on 2 cases of postoperative flank bulge following supracostal PCNL which are reported here. We also suggest how this complication could potentially be minimized.

Prone versus supine lasix renal scan to assess surgical success after laparoscopic and robot-assisted pyeloplasty.

PURPOSE: Success after laparoscopic pyeloplasty (LP) for ureteropelvic junction obstruction is determined based on renal scan (RS) results and patient symptoms ± ultrasonography. The upright or prone position during RS may facilitate drainage. This study reports on outcomes after LP and robot-assisted pyeloplasty (RALP) and determines if patient position (supine vs prone) alters the results of the postoperative RS and surgical "success." PATIENTS AND METHODS: A retrospective review of LP and RALP performed by one surgeon between 2005 and 2012 was performed. Follow-up consisted of RS ± ultrasonography. The paired t test was used to assess for a significant difference between mean T1/2 for supine vs prone scans in each patient. Linear regression was used to determine if preoperative split renal function on the affected side or degree of preoperative hydronephrosis predicted difference in supine vs prone T1/2. RESULTS: There were 11 LP and 81 RALP performed; 84 had follow-up data. There were four (4.3%) failures. Thirty-eight patients had sufficient supine and prone RS for analysis. The difference in T1/2 between supine and prone RS was significant (mean difference 10.18 ± 27.28 min, P = 0.03). Strict success increased to 65.8% from 44.7% and combined strict plus technical success increased to 78.9% from 63.1% on prone vs supine RS. Split function and degree of hydronephrosis were not predictors of difference in RS results. CONCLUSIONS: LP and RALP have good technical results. Prone position for RS may facilitate drainage and may be a more accurate representation of postoperative outcome after pyeloplasty, particularly in equivocal cases.

Evaluation of potential distractors in the urology operating room.

BACKGROUND AND PURPOSE: Surgical outcomes depend on patient and disease-related factors, as well as the technical skill of the surgeon. Various distractions in the operating room (OR) environment have been shown to negatively impact a surgeon's performance. A survey was conducted with the objective to evaluate and characterize distractions during urologic surgery. METHODS: An Internet-based survey was distributed to 2057 international urologists via email between April and October 2011; questions focused on a variety of disruptive factors postulated to have a negative impact on surgical performance. RESULTS: Of the 523 (25%) respondents, 58% practiced in North America, 42% were from an academic institution, and 68% had completed a clinical fellowship. In an average year, 83% reported having operated at least once while sleep deprived, 84% when significantly ill, 55% with a musculoskeletal injury, and 65% under significant social stress. Up to 38% reported that on at least one occasion, such "internal distractions" had significantly affected surgical performance and 14% perceived that at least one surgical complication was caused mainly by an internal distraction. Less than 50% had ever cancelled surgery because of an internal distraction. Music was routinely played in the OR by 57% of respondents, >67% reported answering pages and discussing consults while operating, and 25% reported "commonly" working with scrub nurses/techs that were unfamiliar with the procedure and/or instruments. Only 44% had consistent individual(s) assisting, and 27% reported that the scrub nurse/tech would "commonly" scrub out during a critical portion of the procedure. Overall, 14.5% reported that at least one complication had occurred mainly because of such "external" or "interactive" distractions. CONCLUSIONS: Urologists face various distractions in the OR that can negatively impact surgical performance, potentially compromising patient outcomes and safety. Further studies are needed to elucidate the true impact of such distractions and to develop strategies to mitigate their effects.

Renal and functional outcomes following cystectomy and neobladder reconstruction.

BACKGROUND: Orthotopic reconstruction following cystectomy has evolved in an attempt to restore anatomy and function to as close as possible to the preoperative state. We review the renal and functional outcomes of patients who underwent cystectomy and neobladder reconstruction at our institution. METHODS: Between December 2003 and October 2007, 31 patients underwent cystectomy with Studer neobladder reconstruction at the Ottawa Hospital, Ottawa, Ontario, Canada. Follow-up data were obtained regarding renal function (serum creatinine, µmol/L), continence, urinary flow rates and post-void residual (PVR) at 3, 6 and 12 months after surgery. Change in creatinine from preoperative baseline was calculated and analyzed by student t-test to determine if there was a significant rise in creatinine. RESULTS: There was a statistically significant increase in creatinine from preoperative baseline, with an average increase of 17.3 µmol/L, 21.8 µmol/L and 26.3 µmol/L at 3, 6 and 12 months, respectively. Six patients developed hydronephrosis. Excluding patients with hydronephrosis, there continued to be a statistically significant rise in creatinine with an average increase of 11.9 µmol/L, 14.7 µmol/L and 19.4 µmol/L at 3, 6 and 12 months, respectively. At 1 year, daytime continence was achieved by 89% of patients; 70% were continent at night. INTERPRETATION: Orthotopic neobladders have excellent functional outcomes with low rates of incontinence, which improved throughout follow-up. A significant proportion of patients developed hydronephrosis, highlighting the need for close follow-up to prevent reversible renal deterioration. Creatinine increased during follow-up irrespective of the development of hydronephrosis, but the clinical significance is unknown.

Malignant lymphoma of the testis: a study of 12 cases.

INTRODUCTION: Testicular lymphoma is a rare and deadly disease representing 1% to 2% of all non-Hodgkin lymphomas (NHLs) and approximately 5% of all testicular neoplasms. Our objective is this study was to identify the presenting signs and symptoms, treatment and outcome of patients with testicular lymphoma diagnosed at our institution from 1992 to 2005, and to identify any differences in survival based on Ann Arbor Stage and International Prognostic Index (IPI). METHODS: A retrospective chart review was performed to identify demographic characteristics, presenting signs and symptoms, treatment and outcomes. Survival was assessed using Kaplan-Meier survival curves and log-rank testing. RESULTS: Thirteen cases were identified; 1 of these cases was ultimately excluded due to a diagnosis of lymphoma a year before he presented with testicular involvement. Of the remaining 12 cases, the mean age was 65 years. Most patients presented with testicular and scrotal swelling or mass. B symptoms (weight loss, fever, night sweats) were present in 1 case. Of the 12 cases, 7 cases were stage I, 1 stage II and 4 stage IV. International Prognostic Index was low risk (1) in 4 cases. Orchiectomy was performed in all cases. Three patients received no further treatment. Of the remaining 9 patients, overall 7 received systemic chemotherapy, and 7 radiation therapy (prophylactic in 6). Three patients received intrathecal chemotheraphy prophylaxis. Seven patients achieved complete remission. Four patients (57%) relapsed following complete remission. Median time to relapse was 32 months (range 11 to 73 months). Six patients died. Median survival was 29 months, and was significantly different between early versus advanced stage (stage I/II disease: 71 months; stage IV: 5 months p = 0.007). CONCLUSION: Testicular lymphoma is a rare and deadly form of extra-nodal lymphoma. Survival was significantly different in early stage I/II and IPI low-risk versus advanced stage IV and IPI high-risk disease. Randomized, prospective treatment trials may help to establish better treatment strategies.

Inflammatory pseudotumor: a rare cause of hematuria and shock.

We report the clinical, radiologic, and pathologic findings of a case of inflammatory pseudotumor in an otherwise healthy 44-year-old woman, who presented with dysuria and hematuria causing hemodynamic instability. Computed tomography revealed a 4.3-cm by 3.5-cm densely enhancing mass arising from the anterior bladder wall. Pathologic examination showed spindle-shaped cells with mild nuclear pleomorphism, rare mitotic activity, and a strong reaction to vimentin, with focal positivity to alpha-actin and S100 protein. Monokeratin, CK7, and CK20 were negative. After two transurethral resections, the patient underwent partial cystectomy.