Appendicular flap transposition in case of the left ureters defects

Introduction & Objectives: The frequency of involvement in the oncological process of the ureters in case of pelvis tumors ranges from 15 to 20%. The use of the appendix as a plastic material for the reconstruction of extended ureteral defects (EUD), including left-sided ones, remains debatable. The main goal of this study is evaluating the clinical and functional results after EUD repair using patchy transposition of the appendix. Material(s) and Method(s): Since August 2019 to June 2021, 8 laparoscopic surgeries were performed to replace the EUD using flap transposition of the appendix. Of these, 6 on the left (75%), 2 on the right (25%). 7 women (87.5%) and 1 man (12.5%) were operated on. Mean age 53+/-10.6 years. Average BMI 25.9 kg/m2. Etiology EUD: 25% radiotherapy (n2), 50% iatrogenic surgery (n4), 12.5% (n1) primary ureteral cancer, 12.5% (n1) non-Hodgkin's lymphoma. In all cases, the first stage was a wide mobilization of the ileocecal angle, the appendix was disconnected with a 45 mm hardware suture, in case of left-sided lesion, the appendix was moved isoperistaltically under the mesentery of the sigmoid colon to the left side after preliminary maximum mobilization of the process on the vascular pedicle in the form of a "triangle". All patients received a 7Fr ureteral stent. CT urography was performed on the 3rd, 7th, 11th days. Dynamic nephroscintigraphy was performed on the 90th day. Result(s): The average length of diastasis is 4.6+/-1.7 cm. The average length of the mobilized appendix was 8+/-1.8 cm. Replacement of the ureter with an appendix and a flap of the bladder according to the Demel method was performed in 1 case (12.5%), according to the Boari method in 1 case (12.5%), in 6 (75%) cases an anastomosis was formed according to the "end-to-end" type. the end". The average duration of the operation was 251+/-40.9 min, blood loss was 121+/-56.7 ml. Median removal of the ureteral stent was 36+/-18.28 days. Duration of hospital stay was 14+/-5.2 days. Median follow-up 10+/-5.3 months. Early complications (<30 days): 2 cases of urinary edema (Clavien-Dindo II), 2 cases of ipsilateral hydronephrosis (Clavien-Dindo I-II). Late complications (>30 days): 1 case of partial failure of ureterocystoanastomosis against the background of Sars-Cov-2 infection (Clavien-Dindo IIIa), 1 case of non-functioning left kidney (Clavien-Dindo IVa). Dynamic nephroscintigraphy was performed in 68.4% of patients, the average isotope accumulation time was 4.23+/-0.25 minutes, the duration of the half-life was 14.26+/-0.52 minutes. Conclusion(s): Flap transposition with the appendix is a technically difficult but possible option for extended ureteral strictures. However, various pathological processes that have developed against the background of previous treatment potentially increase the risk of developing repeated strictures or anastomotic leaks. Therefore, given the small sample of patients, further research on this issue is required.Copyright © 2023.

Patterns of use for Retrograde pyelogram across Australia: What are the regional differences?

Background: Retrograde pyelograms (RPG's) are a key component of numerous endoscopic urological procedures. They provide a vital role in defining anatomy of the urological tract and assessing structural and functional obstruction of upper tracts. Method(s): Retrospective review of Medicare data published for item number 36818 cystoscopy and ureteric catheterisation guided by fluoroscopic imaging. We also considered item number for endoscopic insertion of ureteric stent (36821). Data collected over 10 year period from 2012 to 2021 inclusive. State population data collected from Australian Bureau of Statistics to calculate the rates per 100 000 people. Result(s): The nationwide median rate of RPG for the period 2012-2021 was 104.2 per 100 000 (interquartile range 100.6-112.9). The rate between states varied widely (Table 1). NSW and Tasmania consistently recorded higher than average RPG uptake across the study period. Queensland, WA, ACT and NT all reported lower than average RPG usage. All states reported a sharp downturn in numbers during 2021 presumably due to the coronavirus pandemic. For ureteric stent insertion, NSW and Tasmania were above average, while Queensland, WA, ACT and NT were consistently below average. Conclusion(s): Use of retrograde pyelogram is variable according to geography, the reasons for which are unclear. Practice patterns, patient demographics and financial considerations are all likely to be contributors. Future research is encouraged to assess the basis for this variation, but also considering use of other imaging (CT intravenous pyelography) and patient factors (e.g. renal disease).

Minor Procedures in Patients with Congenital Bleeding Disorders - One Centre Experience

Introduction: Patients with congenital bleeding disorders (CBD) have an increased bleeding tendency, which varies according to the factor deficiency and severity. In most cases, prolonged bleeding is observed after trauma, surgery and/or invasive procedures. Haemostatic treatment is needed to prevent bleeding complications and allow a good clinical outcome. Our aim is to evaluate the management of patients with CBD in minor procedures. Method(s): Retrospective study of patients with CBD who performed minor procedures over a 7-year period, through review of clinical files. Result(s): Between January 2015 and December 2021, 249 minor procedures were performed in 113 patients with CBD: 42 had diagnosis of Haemophilia A (HA) (15 severe without inhibitors;3 severe with inhibitors;4 moderate and 20 mild);12 had Haemophilia B (HB) (7 severe without inhibitors;2 moderate and 3 mild);5 were carriers of HA and 2 of HB. 35 had von Willebrand disease (VWD);15 had rare bleeding disorders (8 FVII deficiency;6 FXI deficiency;1 FX deficiency) and 2 had diagnosis of inherited platelet glycoprotein deficiencies (1 Glanzmann thrombasthenia and 1 Bernard Soulier syndrome). Most procedures were dental treatments (189);synoviorthesis/ infiltration/mesotherapy (17);endoscopies and colonoscopies (15);skin lesions excision (8);COVID-19 vaccination (5);sebaceous cyst excision (4);cardiac catheterization (3);ureteral stent removal (3);bone marrow biopsy (2);cystoscopy (2) and breast fibroadenoma excision (1). Prophylactic treatment was performed in 237 (95%) of the procedures, respectively FVIII concentrate factor (59);FIX concentrate factor (27);DDAVP (66);von Willebrand factor/factor VIII concentrates (44);bypassing agents (24);platelet (6);inactivated human plasma (9);tranexamic acid (47) and epsilon-aminocaproic acid (161). No side effects were reported. Discussion/Conclusion: Most patients that underwent minor procedures had Haemophilia and VDW(83%). The most common procedure was dental treatment (76%). Patients with CBD require attention and special care in dental practice. The haemostatic prophylactic treatment varies according to the specific haemostatic defect, severity and type of procedure. The treatment performed has been demonstrated safe and effective, with low incidences of haemorrhagic and treatment-related complications. These patients' treatment requires multidisciplinary teams and reference centres.

Finding an Answer for an Adolescent with Back Pain

Case report - Introduction: This is the case of an adolescent referred to rheumatology following 5 years of back pain. After years of trying a number of treatments without much success, the cause was found to be a previously undiagnosed urological pathology. The case highlights awareness of non-rheumatological causes and incidental findings which can redirect a patient towards more appropriate treatment and reduce the potential for long-term adverse health issues and anxiety. Case report - Case description: B was referred age 16 to rheumatology with a 5-year history of lower back pain. She had previously seen paediatricians with symptoms initially attributed to constipation due to intermittent straining and hard stool. However, constipation remedies had not relieved the pain which progressed gradually to a more persistent dull ache with impact on daily activities. Various analgesics (including paracetamol and non-steroidal anti-inflammatories), exercises and acupuncture had not helped. There was no history of recurrent urinary tract infections or symptom correlation with fluid intake, menstruation or bowel habit. No inflammatory features or connective tissue disease symptoms were noted and family history was unremarkable Clinical examination was normal apart from mild tenderness in the lumbar region. Rheumatoid factor was borderline positive (15 iu/mL) with the rest of blood tests normal including renal function, inflammatory markers (CRP, ESR), anti CCP and ANA. She had minimal microscopic haematuria without proteinuria. MRI spine in 2015 was normal. In view of her young age and symptoms affecting daily activities, STIR sequence spinal MRI was requested. This excluded any new or old inflammatory changes but incidentally identified a dilated left pelvi-calyceal system. Renal ultrasound confirmed a grossly hydronephrotic left kidney with hydroureter and minimal renal tissue suggesting longstanding obstruction. No calculi were seen. The patient was referred to urologists. Further investigations (including MRI abdomen) confirmed similar findings and a distal ureteric stricture. A MAG 3 renogram showed a normal right kidney but only 12% functioning of the left kidney. Urologists have advised surgery (removal of left kidney and ureter) which may relieve symptoms or a conservative non-surgical approach (continue analgesia, physiotherapy and monitoring). The patient and her family are relieved to have a possible cause identified and are considering the surgical option due to ongoing flank discomfort. Case report - Discussion: This was an interesting finding of hydroureter and hydronephrosis causing longstanding back pain presenting to rheumatologists. Until completion of the spondyloarthropathy protocol MRI (STIR images), aetiology had been unclear. Hydronephrosis and hydroureter has no specific age or racial predilection. Signs and symptoms may depend on whether obstruction is acute/chronic. Chronic cases may be asymptomatic or present as a dull discomfort (like this case). Some cases may only present in adulthood with pain precipitated by fluid intake. Blood tests may show impaired kidney function. Post-mortem studies suggest 50% of people have at least one renal abnormality (e.g., renal cysts, duplex ureters) with autopsy series incidence of hydronephrosis reported as 3.1%. Causes include anatomical abnormalities such as vesico-ureteric reflux, urethral strictures (usually present in childhood), calculi, benign prostatic hyperplasia, or intrapelvic neoplasms, pregnancy and infections (e.g., TB). Sudden onset unilateral renomegaly was reported in one case of primary Sjogren's with lymphocytic interstitial nephritis and positive Sjogren's autoantibodies. Our patient has no clinical or serological evidence of connective tissue disease. Minor pelvi-calyceal distension can occur as a normal finding in wellhydrated patients and pregnancy. However, significant hydronephrosis requires assessment to determine cause as it may affect long term renal function. Imaging via computed tomography, ultrasound and urograms can help guide further management. In this case the preceding cause and duration of pathology is unknown. Sterile, giant hydronephrosis treatment options include observation and ureteric stent or nephrostomy in patients unfit for surgery. Nephrectomy is advised for pain and recurrent infection in a non-functioning kidney. Complications may include bowel perforation, vascular injury and urine leakage. Both open and minimally invasive procedures have good reported outcomes. The COVID-19 pandemic and exams have affected timing of any elective procedures and the patient understands surgery may or may not offer complete symptom resolution. Case report - Key learning points: . Non-inflammatory causes of back pain should always be considered in cases of persistent back pain, particularly in young people to ascertain if there is a treatable cause . Hydronephrosis cases can be asymptomatic or present with vague, intermittent, non-specific abdominal symptoms with normal physical examination with or without haematuria. This can cause diagnostic uncertainty and delay referral to urology and appropriate renal investigations . Assessment of renal function (including MAG 3 renogram) is important to guide further management . Surgical interventions (pyeloplasty/nephrectomy) may ease symptoms long term but there is no guarantee of a successful outcome and operative risks need to be considered too . Left undiagnosed, potentially this patient could have had further disruption to daily activities and both physical and mental well being.

Bacterial Infections After Kidney Transplant Before and After the COVID-19 Pandemic

Purpose: Infectious complications are a major cause of mortality and morbidity after kidney transplantation. During the COVID-19 pandemia there were several changes in the management and behavior of patients after transplant. These included measures such as universal masking, social distancing and reinforcing hand hygiene. Our objective was to evaluate if these differences affected the incidence of infections after kidney transplant. Method(s): This is a retrospective cohort study of all kidney transplants performed in our institution from March 2017 to November 2020. We examined the incidence of wound infection, urinary tract infection (UTI), pneumonia, and gastrointestinal (GI) infections. Pediatric and multi-organ transplants were excluded. We used the Fisher test, Chi-squared test of independence and logistic regression models in the analysis. All tests were based on a level of significance of alpha=0.05. Result(s): A total of 185 deceased donor kidney transplant patients were reviewed, 153 before and 54 after the beginning of the COVID-19 pandemic in the United States. The incidence of wound infection, pneumonia and GI infection were similar before and after COVID (Table 1). There was a significant increase in UTI after the COVID pandemic, the main organisms isolated were Klebsiella pneumonia (50%) and E. coli (25%). Overall the presence of UTI and wound infection were significantly related (OR 4.2, p = 0.06). Other clinical variables such as age, BMI, KDPI, EPTS, and the occurrence of delayed graft function were not associated with UTI. COVID infection was present with similar incidence: 12% in patients transplanted before and 14.8% in patients transplanted after the onset of the pandemic. Induction with Thymoglobulin or Basiliximab was not significantly different before and after COVID, and the choice of induction was not associated with the rate of UTI. Conclusion(s): While multiple changes in the management of patients and patient behavior are different before and after the onset of the COVID-19 pandemic, this analysis did not find significant change in the incidence of infections except for UTI in comparative cohorts of kidney transplant recipients. This study did not identify specific factors associated with the increase of UTI in our population. However, in response certain measures were implemented, such as reducing the time to ureteral stent removal and giving 24 hrs of prophylactic antibiotics at the time of stent removal.

Establishing outpatient ureteric stent changes under local aesthetic in the Northeast region;a safety and feasibility study

Introduction: The COVID19 pandemic has led to unprecedented pressures on theatre waiting lists. The numbers of patients requiring regular ureteric stent changes under general anesthetic (GA) can be significant. We performed a regional study of these patients to assess;i) suitability for procedures under local anaesthetic (LA) and ii) outcomes for those then having LA rather than GA procedures. Patients and Methods: A retrospective cohort study from 3 urology centres was performed. Feasibility criteria for transition to LA stent change was determined on;comorbidities, indication for stent placement and operative factors. 2 centres subsequently initiated regular out-of-theatre LA stent change lists and outcomes were reviewed. Results: 216 cases were included. Median age was 68 and sex ratio 1:1 (M:F). Commonest indications for indwelling stents included benign strictures (37%), non-urological malignancy (24.1%) and urological malignancy (22.2%). 34 patients were suitable for/awaiting definitive procedures. Average number of changes was 2.4/year with 49% of patients being ASA3 or higher. LA stent changes were deemed feasible in 70 patients. 63 procedures were performed under LA with a 98% success rate. Complications (30d) included stent migration (2), haematuria (2) and infection (1). Conclusion: Innovation is required to deal with significant COVID-19 related problems. LA ureteric stent changes are safe and tolerable in appropriately selected patients. Performing these outside of the theatre environment increases capacity on surgical waiting lists. Patient benefits include reduced risks of multiple GA procedures in elderly and co-morbid patients. This data encourages expansion of this initiative.

IMPACT OF SARS-COV-2 PANDEMIC ON THE DIAGNOSIS AND SURGICAL INTERVENTION OF COMMON UROLOGICAL CONDITIONS: RESULTS FROM A MULTI-INSTITUTIONAL DATABASE FROM THE UNITED STATES

INTRODUCTION AND OBJECTIVE: The SARS-CoV-2 (COVID) pandemic threatened access to healthcare, raising concerns that patients were going underdiagnosed and undertreated. The aim of our study was to understand the impact of the COVID pandemic on diagnosis and surgical management of common urological conditions. METHODS: Using a large multi-center electronic health record network (TRINETx) consisting of 46 healthcare organizations, we conducted an epidemiological study investigating the number of patients newly diagnosed with common urological conditions and those undergoing urologic surgeries at yearly intervals from March 1st, 2016 to March 1st, 2021. Relevant international classification of diseases (ICD) codes used to identify urologic conditions are elaborated on in Table 1. Current procedural terminology (CPT) codes used to identify surgeries are detailed in Figure 1. We then determined the percentage of newly diagnosed patients who underwent surgery for each specific year. RESULTS: We saw a decrease in number of all urologic surgeries being performed during the initial year of the pandemic (Figure 1). From March 2020-2021, there was a >20% decrease in surgical case load for benign prostatic hyperplasia procedures (-29.5%), prostate biopsies (-30.1%), incontinence procedures (-33.6%), and vasectomies (-22.8%), compared to the preceding year. Radical cystectomies and orchiectomies saw the lowest decrease, -5.9% and -8.6%, respectively. A similar trend was seen in the number of individuals newly diagnosed with urologic conditions and percentage of patients undergoing surgical intervention. The lowest drops were seen with ureteral stent placements (-5.0%) and prostate biopsies (-3.1%). CONCLUSIONS: The number of people receiving urologic diagnoses and surgical case load for urologic procedures significantly reduced during the first year of the COVID pandemic. Providers should be aware of this healthcare disparity, and greater efforts made to identify these missed patients moving forward.

Ureteric stent insertion under local anaesthesia (LA): An effective, safe, and welltolerated alternative to general anaesthesia

Background: The placement of ureteric stents under local anaesthesia (LA) offers the potential for an effective and safe alternative to general anaesthesia in the context of an increasingly co-morbid population and the ongoing COVID-19 pandemic. Objectives: (1) To assess the outcomes for patients with acute ureteric stones managed with the insertion of an emergency ureteric stent under LA. (2) To report the key procedural and logistical elements required to undertake successful LA stent placement. Methods: Patients presenting with CT confirmed, obstructing ureteric stones between 17/04/2020 and 06/07/2021 were included where insertion of an LA ureteric stent was undertaken as an emergency. The primary outcome was procedure success rate and secondary outcomes were serious post-procedure complication rate (defined as Clavien-Dindo. 3), time from CT diagnosis to stent placement, and patient tolerability (defined as pain from the procedure measured on a numerical rating scale 0-10, and reported concern regarding undergoing the same procedure in the future with the options of: no problem/minor problem/moderate problem/major problem). Results: Twenty-three patients underwent emergency LA ureteric stent placement for obstructing calculi with sepsis (73.9%, n = 17), uncontrolled pain (17.4%, n = 4) or acute kidney injury (8.7%, n = 2). The procedural success rate was 95.7% (n = 22/23), and the total number of serious complications was one (4.3%) (ureteric stent migration in duplex system). The median time from diagnosis to stent was 5.3 hours (interquartile range (IQR) = 16.3). The median pain score was 2 (IQR = 5.8), and most patients (73.9%, n = 17/23) reported they would have no problem or a minor problem undergoing the same procedure again. Conclusion: The placement of ureteric stents under LA represents an effective, safe, and well-tolerated alternative to general anaesthesia. The 24/7 availability of a flexible cystoscopy suite, C-arm, and fluoroscopy and specialist urology nurse within a dedicated urology unit has facilitated the delivery of this service.

Post-ureteroscopy febrile urinary tract infections are linked to pre-operative stent dwell time: Results from three European endourology centres

Introduction & Objectives: Indwelling ureteric stents are valuable devices used in emergency drainage of upper urinary tract obstruction due to ureteric stones. However, stents can cause significant morbidity with infections, encrustations and blockages. In the study we look at the outcomes of pre-operative stent dwell time on infectious complications following ureteroscopy and laser fragmentation (URSL). Materials & Methods: Data was retrospectively collected for outcomes of URSL from 3 European endourology centres for patients with preoperative indwelling ureteric stents. We included data for patient details, stone demographics, operative details, stone free rate (SFR), outcomes and complications between 2011 and 2020. Patients were divided into two groups based on the stent dwell time: group 1 (<6 months) and group 2 (≥6 months). Descriptive statistics were used to determine the rate of early post-operative infectious complications (defined as the presence of fever?) and ICU access. Binomial logistic regression analysis were used to explore the relationship between stent dwelling time and post-operative early infectious complications. (SPSS v.24). Results: There were 501 patients undergoing URSL in the study period, with 429 and 72 patients in groups 1 and 2 respectively (Table 1). The mean age and operative time in groups 1 and 2 were 71±30 years and 64±22 years, and 51±28 minutes and 59±31 minutes respectively. Infectious complications and ICU admissions were seen in 32 (8%) and 3 (0.7%), and 22 (31%) and 1 (1.4%) in groups 1 and 2 respectively. Stent dwell time of ≥6 months carried significantly higher risk for febrile UTI post URSL (RR=5.45, 95% CI: 2.94-10.10, p<0.001). (Table Presented) Conclusions: Although the overall risk of infectious complication rates from URSL were low, longer indwelling stent time significantly increases the risk of post-operative infections, of which a small proportion of patients end up in ICU. We would recommend having the stent dwell time as short as possible and not to exceed a 6 months’ time period, and our findings will help prioritise these patients in the post-COVID era.

Evaluation of outcomes of a new advanced cancer unit: Results of 47 cases

Purpose/Background: Pelvic exenteration (PE), or “beyond-TME” surgery has become an established treatment for locally-advanced, or recurrent colorectal cancer, with the aim of achieving a complete (R0) resection and improve survival. We have established a regional centre for the management of advanced colorectal cancer and pelvic sarcoma. Methods/Interventions: This was a retrospective, observational study using electronic health records (EHR). Patients were identified from a prospectively managed database and from multi-disciplinary team minutes. Data was gathered for 47 patients operated on by our Advanced Cancer service between November 2016 and March 2021 by four surgeons. EHR were searched for tumour and operation characteristics, complications, survival, oncological and recurrence data. During the COVID-19 pandemic, some patients had their operations at a separate, private hospital. Eligible patients were those that had pelvic exenteration (defined as removal of colon/rectum with additional organs such as bladder, prostate, vagina, sacrum, kidney), or large pelvic dissection for sarcoma. Results/Outcomes: 47 patients (23 male, 24 female) underwent operation, with a median age of 64 and ASA II. 33 (70%) patients presented with a primary tumour and 14 with a recurrent tumour. 37 (79%) had a locally advanced rectal or sigmoid cancer, 2 (4%) anal cancers, 2 gastro-intestinal stromal tumours and 6 (13%) pelvic sarcomas. One patient with recurrent rectal cancer had inoperable disease found at time of surgery so proceeded with only a palliative resection. Resection type is presented in Table 1. 43 patients had recorded status for margins, of which 33 (77%) had R0 resection and 10 (23%) R1. Mean operating time was 499 minutes (range 130-1020). Median time in critical care post-op was 2.5 days (IQR 1-6) and length of stay 13 days (IQR 13-20.5). 30-day Clavien-Dindo complications were: none (15, 32%), Grade I/II (17, 36%), Grade III (6, 13%), Grade IV (8, 17%). One patient operated on in the independent sector could not have inpatient records assessed. 10 patients had a return to theatre, the majority (5) for wound washout, 1 for each of the following indications: replacement of ureteric stent, ureteric reimplantation, revision of ischaemic colostomy, revision of flap, planned return for removal of haemostatic packs. There was no 90 day mortality. At a median of 25.6 months follow-up, 32 (68%) patients remain alive. In the 15 patients who have died, the mean time to death from procedure was 16.7 months. Recurrence was seen in 11 (23%) patients, of which 6 (13%) were distant, 3 (6%) local and 2 (4%) both. Conclusion/Discussion: This data shows that it is possible to set up a new advanced cancer unit and achieve outcomes, in terms of mortality, margin status and recurrence that are comparable with those previously published by other centres during their set-up phase. (Table Presented).

The acute stone clinic model: Improving waiting times and patient care in a public funded health care system

Introduction & Objective: The management of patients with ureteric stones can be logistically challenging in large volume centres with long waits for outpatient clinics and definitive interventions. Many units in publicly funded health systems resort to temporising obstructed kidneys with stent insertion and a subsequent plan for elective ureteroscopy at a later date. This can result in unnecessary stent insertions, repeated attendances to the emergency department and an overall poor experience for patients. We aimed to reorganise resources to improve waiting times for definitive intervention, reduce the need for pre-stenting, reduce emergency department re-attendance and improve the overall patient experience. Methods: All patients diagnosed with ureteric stones between March-September 2017 were collected as baseline data. Time to clinic review and definitive treatment were measured. By collaborating with the emergency department, radiology and operation schedulers, our intervention for improvement where a consultant led acute stone clinic (ASC) with a pathway for primary ureteroscopy was implemented and a second cycle was performed June 2018-January 2019. Further data was collected January-October 2020 to assess performance during the COVID-19 pandemic. Results: After implementing the ASC model, median time from diagnosis to clinic consultation reduced from 77 to 9 days. Median time to definitive procedure reduced from 56 to 25 days. Emergency ureteric stent insertion reduced from 69.1% to 27.9%. Reattendance to the emergency department reduced from 3.0 to 1.6 episodes/month. Primary definitive treatment increased from 31.0% to 72.1%. Patients receiving definitive treatment within 4 weeks improved from 26.2% to 51.2% post intervention and sustained at 54.5% during the pandemic period. Conclusions: Implementation of the ASC model has led to a reduced time from diagnosis to clinic review and from diagnosis to definitive treatment. Further improvement is limited by the lack of extra operating lists to reduce the waiting times for ureteroscopy. The ASC model can provide a blueprint for other hospitals to improve outcomes and care of patients with acute ureteric stones.

Ambulatory percutaneous nephrolithotomy is safe and effective in extended criteria patients

Introduction & Objective: Ambulatory tubeless percutaneous nephrolithotomy (aPCNL) has been shown to be safe and effective in highly selected patients. However, these selection criteria preclude the vast majority of patients that undergo PCNL. The objective of our study was to compare complication and stone free rates after aPCNL in standard selection criteria vs. extended criteria patients. Methods: Retrospective review of prospective data on all patients who underwent aPCNL at one academic center from 2007-2018. Extended criteria patients were defined as any: Age >75 years, BMI >30 kg/m2, ASA >2, bilateral stones, solitary kidney, staghorn calculi, stone burden >40 mm, multiple tracts, or prior nephrostomy tubes/stents. Primary outcomes were complication rates (Clavien-Dindo classification) and stone free rates (no fragments >/ = 3 mm). All patients were discharged with a ureteric stent and no nephrostomy tube after meeting discharge criteria which included hemodynamic stability, no fever, and no significant pain. Results: We identified 118 patients of which 92 (78%) met extended criteria. Mean BMI was 31 kg/m2 and 45% were ASA 3 or higher. Mean sum maximum stone diameter was 24 mm. Multiple stones were present in 25%, bilateral stones in 7%, staghorn stones in 4%, and pre-existing tubes/stents in 4%. There was no difference in complication (12% vs. 18%, p = 0.56), Emergency department visit (12% vs 18%, p = 0.56), or readmission (4% vs. 5%, p = 1) rates between standard and extended criteria patients respectively (Table 1). Of the complications, 85% were Clavien-Dindo grade 1. Stone free rates were not different between standard (84%) and extended (83%) criteria patients (p = 1). No extended criteria variables were associated with complications in univariate analysis. Stone burden >40mm (OR 5.8, 95% CI 1.4-25.2, p = 0.018) and multiple tracts (13.1, 95% CI 1.1-154.7, p = 0.041) were associated with residual stone fragments. Conclusions: Complication and stone free rates were not different between standard and extended selection criteria patients undergoing aPCNL. This data supports the safety and efficacy of aPCNL in patients using extended selection criteria. As the COVID-19 pandemic continues to strain hospital resources, aPCNL offers a solution to deal with a growing backlog of patients with complex stone disease.

Cross-sectional survey of patients awaiting nephrolithiasis surgery during the covid-19 pandemic onset: A multi-center study from the registry for stones of the kidney & ureter group

Introduction & Objective: The Coronavirus pandemic led to wide-spread reductions in surgical volume. Many patients were hesitant to undergo surgery, despite appropriate hospital precautions. Kidney stone patients pending surgical intervention have distinct risks associated with surgical delay including pain, infection, and loss of renal function. It is important to understand the risks of surgical delay during the pandemic and to better understand patient concerns and preferences for undergoing surgery. Methods: A prospective, multi-institutional patient survey during April and May 2020 was performed. Nephrolithiasis patients pending stone removal surgery including ureteroscopy, shockwave lithotripsy, percutaneous nephrolithotomy, and nephrectomy were interviewed at clinical encounters regarding their symptoms, unplanned clinical events, presence of nephrostomy tubes /double J stents, concerns and reassurances for coming to the hospital, and willingness to undergo surgery. The association of patient demographics, stone burden, renal function, stonerelated symptoms, and COVID risk factors with willingness to undergo surgery, and concerns for contracting COVID were examined. Results: 142 patients pending stone surgery completed surveys, with 66% willing to proceed with surgery, while 34% requested to delay. There was no statistical difference in patients willing versus unwilling to proceed with surgery, with regards to patient demographics, type of surgical procedure, stone burden, stonerelated symptoms, renal function compromise, presence of hydronephrosis, unplanned clinical events, or COVID risk factors. Those willing to proceed were more likely to have a ureteral stone (32% vs 15%, p = 0.03) or have a ureteral stent or nephrostomy tube in place (35% vs 6%, p < 0.01). Willingness to proceed with surgery was inversely correlated with COVID19 concerns. COVID19 concern was not impacted by age, sex, clinical site, distance to hospital, or COVID 19 risk factors. Conclusions: Kidney stone patients pending surgical treatment weremore willing to proceed with surgery based on the presence of a ureteral stone, upper urinary tract drainage tube, or low concern for COVID. Patient demographic, symptoms, kidney function, and other stone risk factors were not associated with willingness for surgery. Patients that are hesitant to proceed with surgery, despite appropriate hospital precautions should be educated appropriately regarding their risks with regards to COVID and nephrolithiasis.