Patient Reported Outcomes Predicting Spontaneous Stone Passage May Not Have Acceptable Accuracy.

PURPOSE: We assessed the accuracy of patient reported outcomes for predicting spontaneous ureteral stone passage. MATERIALS AND METHODS: Patients with new unilateral ureteral calculi were prospectively assessed regarding current symptoms and whether they believed their stone had passed. The primary outcome was successful spontaneous stone passage as confirmed by ultrasound, and kidney, ureter and bladder x-ray. Spontaneous stone passage was compared to patient reported outcome responses to assess accuracy. RESULTS: Of the 212 patients 105 (49.5%) had successful spontaneous stone passage at a mean followup of 17.6 days. Compared to the unsuccessful spontaneous stone passage group, those with successful spontaneous stone passage had significantly smaller (mean 5.4 vs 7.6 mm), more distal (71.4% vs 34.6%) stones with slightly longer average time to followup at first visit (19.2 vs 16.0 days). Additionally, there was more patient reported cessation of pain (77.1% vs 44.9%) and perceived stone passage (55.2% vs 13.1%) in this group. Cessation of pain was 79.7% (95% CI 67.1-89.0) sensitive and 55.8% (95% CI 44.0-67.1) specific for successful spontaneous stone passage. Likewise, patient reported stone passage was 59.3% (95% CI 45.7-71.9) sensitive and 87.0% (95% CI 77.4-93.5%) specific. In the multivariable logistic regression analysis cessation of pain (OR 4.02, 95% CI 1.91-8.47, p <0.01) and reported stone passage (OR 3.79, 95% CI 1.73-8.28, p <0.01) were independent predictors of successful spontaneous stone passage. CONCLUSIONS: Cessation of pain and patient reported stone passage are independent predictors of successful spontaneous stone passage. However, both assessments may incorrectly gauge spontaneous stone passage, which raises concern for their validity as a sole clinical end point.

Are renal stone protocol computed tomography reports giving us enough information?

INTRODUCTION: Non-contrast computed tomography (CT) is the gold-standard diagnostic test for urolithiasis. Little is published regarding which information needs to be included in the report for it to be most useful to the healthcare team for efficient triage and high-quality patient care. This study aimed to assess the quality and variability of CT scan reporting at a single Canadian tertiary academic medical center. METHODS: We completed a retrospective review of 100 consecutive renal colic CT scans. Descriptive statistics were used to report the frequency with which specific elements commonly used by urologists to triage and treat patients were included in radiology reports. RESULTS: Our sample had a mean age of 51.4±13.1 years. Stone size was universally reported for obstructing stones but was less frequently reported for non-obstructing stones (100% vs. 86.8%). A similar trend was observed for the exact stone number (100% vs. 93.4%). Non-obstructing stones were more likely than obstructing stones to be reported in one dimension (77.5% vs. 47%). Obstructing stones were reported in three dimensions 27% of the time. CT reports commonly include the presence or absence of hydronephrosis status (98%) but are less likely to include renal size (32%) and periureteral stranding (16%). Hounsfield units (HU) were reported in 3% of the reports, but skin-to-stone distance (SSD) and radiation dose were never reported. CONCLUSIONS: Reports routinely included assessments of stone size, location, and number (although not uniformly). HU, SSD, and radiation dose were rarely reported. This provides insight into opportunities for standardized reporting to optimize knowledge transfer that may result in clinical efficiency and improved quality of patient care.

Ureteric wall thickness as a novel predictor for failed retrograde ureteric stent placement.

INTRODUCTION: We sought to identify predictors of failed retrograde ureteric stent (FRS) placement in the setting of obstructing ureteric calculi. In addition to patient- and stone-specific characteristics, we also considered computed tomography (CT) measures of ureteric wall thickness (UWT), as it has shown clinical potential in predicting outcomes of shockwave lithotripsy, ureteroscopy, and spontaneous stone passage. METHODS: We performed a retrospective, case-control study comparing patients who had successful retrograde stent (SRS) insertions with those who failed stent placement and ultimately required nephrostomy tube (NT) insertion (2013-2019). Patients were identified using administrative data from a shared electronic medical record (capturing all urology patients in our geographic area) and a prospective database capturing all institutional interventional radiology procedures. Patient demographics, as well as clinical and stone characteristics were then collected, and imaging manually reviewed. Statistical analysis was performed using univariate and multivariate logistic regression analysis in collaboration with a statistician. RESULTS: A total of 109 patients met inclusion for analysis (34 FRS, 75 SRS). The most common indication for stent insertion included sepsis (79%). On multivariate analysis both acute kidney injury as primary indication for stent insertion (odds ratio [OR] 9.16, 95% confidence interval [CI] 1.91-44.00, p=0.006) and UWT (OR 0.34, 95% CI 0.15-0.74, p=0.007) were found to be significantly associated with failed retrograde stent placement. A receiver operator characteristic curve analysis demonstrates an optimal UWT cutoff of 3.2 mm (sensitivity 60.6%, specificity 83.3%). CONCLUSIONS: Elevated UWT and acute kidney injury as an indication for urgent urinary decompression in the setting of obstructing ureteric stones are predictive of failed retrograde stent placement. These patients may benefit from upfront nephrostomy tube insertion.

Endoplasmic reticulum stress-mediated inhibition of NSMase2 elevates plasma membrane cholesterol and attenuates NO production in endothelial cells.

Chronic exposure of blood vessels to cardiovascular risk factors such as free fatty acids, LDL-cholesterol, homocysteine and hyperglycemia can give rise to endothelial dysfunction, partially due to decreased synthesis and bioavailability of nitric oxide (NO). Many of these same risk factors have been shown to induce endoplasmic reticulum (ER) stress in endothelial cells. The objective of this study was to examine the mechanisms responsible for endothelial dysfunction mediated by ER stress. ER stress elevated both intracellular and plasma membrane (PM) cholesterols in BAEC by ~3-fold, indicated by epifluorescence and cholesterol oxidase methods. Increases in cholesterol levels inversely correlated with neutral sphingomyelinase 2 (NSMase2) activity, endothelial nitric oxide synthase (eNOS) phospho-activation and NO-production. To confirm that ER stress-induced effects on PM cholesterol were a direct consequence of decreased NSMase2 activity, enzyme expression was either enhanced or knocked down in BAEC. NSMase2 over-expression did not significantly affect cholesterol levels or NO-production, but increased eNOS phosphorylation by ~1.7-fold. Molecular knock down of NSMase2 decreased eNOS phosphorylation and NO-production by 50% and 40%, respectively while increasing PM cholesterol by 1.7-fold and intracellular cholesterol by 2.7-fold. Furthermore, over-expression of NSMase2 in ER-stressed BAEC lowered cholesterol levels to within control levels as well as nearly doubled the NO production, restoring it to ~74% and 68% of controls using tunicamycin and palmitate, respectively. This study establishes NSMase2 as a pivotal enzyme in the onset of endothelial ER stress-mediated vascular dysfunction as its inactivation leads to the attenuation of NO production and the elevation of cellular cholesterol.

PEG-coated patch parenchymal closure technique and initial outcomes during minimally invasive partial nephrectomy.

INTRODUCTION: The Hemopatch® is a novel polyethylene glycol-coated (PEG-coated) collagen patch that acts as a topical hemostatic agent. It has been applied to a variety of surgical techniques. Here, we present our series and technique using a PEG-coated patch for minimally invasive partial nephrectomy (MIPN). METHODS: We conducted a retrospective chart review of all patients undergoing MIPN by a single surgeon at a tertiary Canadian medical center between July and December 2018. We included patients if a PEG-coated patch was used to close the renal parenchymal defect. We also describe in detail our technique for laparoscopic patch deployment. RESULTS: A total of 17 patients met inclusion criteria, of whom 12 were male. Mean age was 63 years old. Median size of renal mass was 2.85 cm in largest dimension and median RENAL score was 6. Hilar clamping was carried out in 12 (70.9%) cases, with an average warm ischemic time of 16.1 minutes. The remainder of cases were performed off-clamp. Median estimated blood loss was 238 mL and the mean change in hemoglobin on postoperative day 1 compared to preoperatively was 21.2 g/L. The average length of stay was 1.76 days. No patient required blood transfusion or underwent angioembolization or re-operation for bleeding within 90 days. There were no Clavien-Dindo grade 3 or greater complications. CONCLUSIONS: A PEG-coated patch can be used safely and effectively in lieu of traditional two-layer renorrhaphy with acceptable outcomes. Larger, prospective series are required to ascertain its true value and cost-effectiveness.

Timing of pharmacologic venous thromboembolism prophylaxis initiation for trauma patients with nonoperatively managed blunt abdominal solid organ injury: a systematic review and meta-analysis.

BACKGROUND: Blunt abdominal solid organ injury is common and is often managed nonoperatively. Clinicians must balance risk of both hemorrhage and thrombosis. The optimal timing of pharmacologic venous thromboembolism prophylaxis (VTEp) initiation in this population is unclear. The objective was to evaluate early (< 48 h) compared to late initiation of VTEp in adult trauma patients with blunt abdominal solid organ injury managed nonoperatively. METHODS: Embase, MEDLINE, and the Cochrane Central Register of Controlled Trials were searched from inception to March 2021. Studies comparing timeframes of VTEp initiation were considered. The primary outcome was failure of nonoperative management (NOM) after VTEp initiation. Secondary outcomes included risk of transfusion, other bleeding complications, risk of deep vein thrombosis (DVT) and pulmonary embolism, and mortality. RESULTS: Ten cohort studies met inclusion criteria, with a total of 4642 patients. Meta-analysis revealed a statistically significant increase in the risk of failure of NOM among patients receiving early VTEp (OR 1.76, 95% CI 1.01-3.05, p = 0.05). There was no significant difference in risk of transfusion. Odds of DVT were significantly lower in the early group (OR 0.36, 95% CI 0.22-0.59, p < 0.0001). There was no difference in mortality (OR 1.50, 95% CI 0.82-2.75, p = 0.19). All studies were at serious risk of bias due to confounding. CONCLUSIONS: Initiation of VTEp earlier than 48 h following hospitalization is associated with an increased risk of failure of NOM but a decreased risk of DVT. Absolute failure rates of NOM are low. Initiation of VTEp at 48 h may balance the risks of bleeding and VTE.

Improving Knowledge Transfer by Using a Summative Patient Handout for Cystoscopy.

INTRODUCTION: Despite cystoscopy being among the most commonly performed urological procedures, there is a paucity of information on patient comprehension and retention of cystoscopy outcomes. A quality assessment performed at our center revealed low rates of patient understanding in our current care model. Therefore, we assessed patient comprehension of outpatient cystoscopy outcomes before and after the implementation of a formal written communication tool in the form of a summative patient handout to improve physician-patient communication. METHODS: Consecutive patients reporting for cystoscopy at a Canadian tertiary care center were assessed with postprocedure questionnaires before and after the implementation of a summative patient handout to facilitate the communication of results and followup plans. Comparisons were made with the Chi-squared test (p <0.05). RESULTS: A total of 650 questionnaires were analyzed (500 baseline and 150 postsummative patient handout). Of the respondents 448 (69%) were male and the mean age was 66 years old (total range 21 to 94 years) with 32% being under 60 years old. The proportion of patients who felt their results were discussed with them after implementation of the summative patient handout improved (94% vs 87%, p=0.02). Similarly, we improved concordance of patient reported and urologist reported cystoscopy results (75% vs 56%, p <0.001). Finally, we improved patient identification of their postcystoscopy followup plan (80% vs 51%, p <0.001). CONCLUSIONS: The implementation of a summative patient handout after local cystoscopy improved patient understanding of their procedural results and postcystoscopy followup plans.

Direct to cystoscopy: A prospective quality assessment of patient preferences.

INTRODUCTION: Cystourethroscopy is one of the most common procedures performed by urologists in both office and operative settings. With the recent centralization of cystoscopy at our center, we looked to assess our current delivery model, to determine whether patients prefer their initial visit to be in cystoscopy or in the clinic, followed by a cystoscopy appointment later. METHODS: We administered 500 prospective questionnaires to adults undergoing cystoscopy by 14 urologists at our center in 2017. Patient demographics were collected, along with their questionnaire results that we compared to their urologist-reported indication, results, and plan. Our primary objective was to assess whether patients prefer to be seen direct to cystoscopy (DTC) vs. a clinic appointment (CA) before cystoscopy. RESULTS: A total of 500 questionnaires were analyzed, with 336/500 (67%) patients being male. Mean age was 66 years (21-93), with 30% under 60 years. Thirty-nine percent (n=193) were undergoing their first cystoscopy, with 85% preferring DTC. There was no difference in age, gender, first-time cystoscopy, or indication for cystoscopy when comparing those who preferred DTC vs. CA. Patients who had an accurate understanding of the indication for their cystoscopy had 6.23 times higher odds of preferring DTC (p<0.05). We also identified a deficiency in patient comprehension of cystoscopy results and followup plans. CONCLUSIONS: With limited health resources, a large patient catchment area, and the majority of patients preferring to be seen DTC, there is evidence to implement a default DTC approach to booking cystoscopy clinics.

Oncological outcomes of salvage cryotherapy after primary radiation therapy vs. primary cryotherapy: 10-year experience at a large Canadian referral center.

INTRODUCTION: Salvage cryotherapy is a guideline-recommended treatment of localized prostate cancer recurrence after radiation therapy. There is little published evidence analyzing the outcomes of salvage cryotherapy for recurrent prostate cancer following different primary therapy energy modalities. METHODS: We performed a retrospective analysis of patients who received whole gland salvage cryotherapy from 2007-2017 at a large tertiary referral center after either primary radiation therapy (RT) or primary whole gland cryotherapy. Primary outcome was biochemical failure, defined as per the Phoenix criteria (prostate-specific antigen [PSA] nadir + 2.0 ng/ml). Secondary outcomes included time to biochemical failure and development of metastatic disease. RESULTS: Fifty-eight of 391 patients who received cryotherapy were identified as having received salvage cryotherapy (after RT, n=37; after primary cryotherapy, n=21). Biochemical recurrence occurred in 21 (57%) patients with previous RT and in 17 (81%) patients with previous cryotherapy (p=0.001). Median time to biochemical recurrence was 18 months for patients with previous RT and 13 months for patients with previous cryotherapy (p=0.002). The biochemical-free survival rate for primary radiation therapy patients was 71% at two years compared to 23% at two years for patients who underwent primary cryotherapy (p<0.01). There was no difference in the development of metastatic disease between groups (19% vs. 18%, cryo vs. radiation, p=0.34). CONCLUSIONS: These results suggest that salvage cryotherapy may offer more durable oncological control to patients after radiation compared to primary cryotherapy, with a lower rate and longer duration before biochemical recurrence.

Are urologic surgeons performing robot-assisted radical prostatectomy at the University of Alberta meeting surgical quality performance benchmarks? The PROCURE-02 quality assurance study.

INTRODUCTION: Robot-assisted radical prostatectomy (RARP) is a standard of care primary treatment for men with clinically localized prostate cancer (CLPC). The 2010 Canadian Urological Association (CUA) consensus guideline examining surgical quality performance for radical prostatectomy suggested benchmarks for surgical performance. To date, no study has examined whether Canadian surgeons are achieving these benchmarks. We determined the proportion of University of Alberta (UA) urologic surgeons achieving the CUA surgical quality performance outcome (SQPO) benchmarks. METHODS: A retrospective quality assurance analysis of prospectively collected data from the PROstate Cancer Urosurgery Repository of Edmonton (PROCURE) was performed. Men who underwent RARP for CLPC between September 2007 and May 2018 by one of seven surgeons were analyzed. SQPO were an unadjusted pT2-R1 resection rate <25%, blood transfusion rate <10%, rectal injury rate <1%, and 90-day mortality rate <1%. Descriptive statistics were used to determine the proportion of surgeons achieving the benchmarks. RESULTS: Data were evaluable for 2821 men. Seven of seven (100%) surgeons achieved a blood transfusion rate <10%, rectal injury rate <1%, and 90-day mortality rate <1%. However, only six of seven surgeons achieved an unadjusted pT2-R1 resection rate <25%; one surgeon had an unadjusted pT2-R1 resection rate of 27.9%. Limitations include the lack of centralized pathology review for surgical margin status by a dedicated genitourinary pathologist. CONCLUSIONS: UA surgeons are achieving the CUA SQPO benchmarks for blood transfusion, rectal injury, and perioperative mortality. However, not all UA urologists are achieving a pT2-R1 resection rate <25%. Surgical quality performance initiatives designed to improve cancer control may be warranted.