Ho:YAG laser and dusting-high power vs low power: there is no difference.

The introduction of the Ho:YAG laser 3 decades ago revolutionized the endoscopic treatment of urolithiasis. Since then, a variety of innovations have continued to evolve these devices, including the development of high-power lasers capable of high-frequency lithotripsy. The clinical utility of high-frequency lithotripsy, however, has not necessarily lived up to the potential suggested by in vitro studies. A review of the relevant literature, confirming strong similarities between the outcomes associated with high and lower power laser lithotripsy, follows.

Quantifying the Educational History of the Endourological Society Fellowship Programs in the United States.

Introduction: We examined the history of the Endourological Society through the lens of its fellowship programs in the United States (U.S.). Methods: A review of the list of fellowship programs published annually in the Journal of Endourology from 1987 to 2015 allowed us to track the growth in fellowship programs over time. We reviewed the Endourological Society fellowship database and the websites for each of the fellowship programs for the names of graduates from each program. A survey was sent to each fellowship program director with a list of their graduates asking them to verify the names and to identify those graduates who had pursued a career in academic urology, and whether they had served as fellowship program director, residency program director or department chairperson. Seventeen of the 52 U.S. program directors (33%) responded to the survey. For those programs that did not respond to the survey each graduate's name was searched via Google, LinkedIn, and/or Doximity to determine if they had pursued a career in academic urology and served in a leadership position. Results: The number of U.S. Endourological Society fellowships has increased from 11 in 1987 to 52 in 2021. Five hundred and seventy-seven fellows have graduated from an Endourological Society Fellowship in the United States from 1987 to 2021. Two hundred and fifty fellows have pursued a career in academic urology (43.3%), 46 have served as fellowship program director (8.0%), 9 as residency program director (1.6%), and 13 have served as department chairperson (2.3%). Conclusions: The progress of the Endourological Society can be directly tied to the historical growth of its fellowship programs and the pursuit of an academic career by many of its graduates leading them to become the current and future educational leaders in the field.

Prospective Randomized Trial of Single-Use vs Reusable Cystoscope for Ureteral Stent Removal.

Background: Reusable cystoscopes are associated with risks of cross-contamination, need for chemical reprocessing, mechanical breakdown, maintenance costs, and labor for cleaning. A sterile, single-use cystoscope may reduce or eliminate the source of these infections while also decreasing exposure to reprocessing chemical agents. In this multicenter, randomized trial, we sought to compare single use with reusable endoscopes for ureteral stent removal. Methods: A three-center, randomized, dual-arm postmarket clinical trial was performed to compare the single-use cystoscope (Ambu A/S) with standard-of-care flexible reusable cystoscopes for outpatient ureteral stent removal. A total of 102 patients were randomized and evaluated from baseline through day 10 postprocedure. Primary endpoint was successful stent removal. Secondary endpoints were time from preparation to disposal/reprocessing, adverse events (AEs), and clinician satisfaction. Results: A total of 102 subjects were randomized in a 1:1 manner. The successful stent removal rate was 51/51 (reusable) and 50/51 (single use). One patient required the conversion to reusable cystoscope owing to grasper passage issue. Median time from prep for the procedure to disposal/prep for reprocessing was 10.2 minutes for the single use and 18.4 minutes for the reusable (p < 0.001). There was no difference in clinician satisfaction between both arms. There was no difference in AEs between arms and no device causal attribution for any AE reports. There was one serious AE necessitating hospitalization for infection in the reusable arm. Conclusion: The randomized-controlled trial of single-use cystoscopes vs reusables showed comparable device success with significant time savings for single use and equivalent clinician satisfaction. The study was registered on clinicaltrials.gov database (NCT04829461) on April 2, 2021.

Pulse-modulated Holmium:YAG Laser vs the Thulium Fiber Laser for Renal and Ureteral Stones: A Single-center Prospective Randomized Clinical Trial.

PURPOSE: We sought to compare the clinical effectiveness of the pulse-modulated Ho:YAG (holmium:yttrium-aluminum-garnet) laser and the thulium laser fiber for ureteroscopic stone management in a randomized clinical trial. The primary outcome was the ureteroscope time required to adequately fragment stones to 1 mm or less. Secondary outcomes were stone-free rate, complications, subjective surgeon measurement of laser performance, patient related stone quality of life outcomes, and measurements of laser efficiency. MATERIALS AND METHODS: An Institutional Review Board-approved randomized clinical trial was conducted to randomize patients to outpatient treatment with either the Moses 2.0 or thulium laser fiber in a 1:1 manner after stratification into groups based on the maximal diameter of treated stone (3-9.9 mm or 10-20 mm). Patient, stone, and operative parameters were compared using the appropriate categorical/continuous and parametric/nonparametric statistical tests (SPSS 25). RESULTS: From July 16, 2021 to March 11, 2022, 108 patients were randomized and had primary endpoint data available for analysis; 52 patients were randomized to Ho:YAG and 56 patients to thulium laser fiber. Groups were well balanced with no significant differences observed for patient or stone characteristics. Ureteroscope time was not significantly different between modalities (Ho:YAG mean 21.4 minutes vs thulium laser fiber mean 19.9 minutes, P = .60), or within subgroup analysis by stone size, median Hounsfield units, or stone location. There were no significant differences observed in the stone-free rate and complications rate between the 2 lasers. CONCLUSIONS: This randomized clinical trial suggests no significant clinical advantage of one laser technology over the other. Surgeon and institutional preference are the best approach when selecting one or the other.

Perceptions and Experiences of Gender Equity Among Endourologists.

Introduction: Only 9.9% of practicing urologists in the United States are women. This percentage is even smaller in leadership positions and high-ranking appointments. Endourology is one of the least reported fellowships completed by women urologists. We sought to evaluate how endourologists perceived the climate for women physicians and compare perceptions and experiences of gender equity. Materials and Methods: An IRB approved and validated survey, Culture Conducive to Women's Academic Success (CCWAS) questionnaire was sent out to the Endourological Society listserve. Subcategories of equal access, work-life balance, freedom of gender bias, and leadership support were analyzed. An open comment section was provided for respondents to include their own experiences. Wilcoxon rank-sum and Kruskal-Wallis tests were used to compare CCWAS scores between groups. Results: A total of 104 completed surveys were received. Response rate was 7% (104/1492), 26.9% of which were female. There was a statistically significant difference between male and female respondent CCWAS scores; p < 0.05. The male CCWAS score median was 196.0 (interquartile range [IQR] 176.75-214.0) vs female CCWAS score median of 166.5 (IQR 127.5-210.0). There was no significant difference in CCWAS scores based on years in practice, parental status, or academic vs private practice. Discussion: In this study, male endourologists' perceptions of gender equity were incongruent with the reported experiences of their female colleagues. This indicates that male respondents perceive the culture in their department toward women more positively than their female colleagues. This is suggestive that there are gender-based differences in how gender inequities are perceived and potentially experienced.

Imaging in stone diagnosis and surgical planning.

PURPOSE OF REVIEW: Radiological imaging techniques and applications are constantly advancing. This review will examine modern imaging techniques in the diagnosis of urolithiasis and applications for surgical planning. RECENT FINDINGS: The diagnosis of urolithiasis may be done via plain film X-ray, ultrasound (US), or contrast tomography (CT) scan. US should be applied in the workup of flank pain in emergency rooms and may reduce unnecessary radiation exposure. Low dose and ultra-low-dose CT remain the diagnostic standard for most populations but remain underutilized. Single and dual-energy CT provide three-dimensional imaging that can predict stone-specific parameters that help clinicians predict stone passage likelihood, identify ideal management techniques, and possibly reduce complications. Machine learning has been increasingly applied to 3-D imaging to support clinicians in these prognostications and treatment selection. SUMMARY: The diagnosis and management of urolithiasis are increasingly personalized. Patient and stone characteristics will support clinicians in treatment decision, surgical planning, and counseling.

Lincoln Trail District Health Department's Innovative Shift to Public Health 3.0.

The Lincoln Trail District Health Department's (LTDHD) transformation into the Public Health 3.0 model was applied from frameworks established through public health accreditation standards and innovative strategies. The awareness of strengths and weaknesses discovered through strategic planning and a culture of quality improvement built over time has created numerous performance improvement opportunities. Those opportunities established greater collaboration and transparency between departments. The shift to the Public Health 3.0 and focus on Foundational Public Health Services model made for an easier transition into Kentucky's larger plan for public health transformation. LTDHD continues to provide public health protection by preventing the spread of disease, ensuring the safety of food, air, and water quality, supporting maternal and child health, improving access to clinical care services, and preventing chronic disease and injury.

Clinical Impact of the Institution of Moses Technology on Efficiency During Retrograde Ureteroscopy for Stone Disease: Single-Center Experience.

Objective: To evaluate the clinical benefits of Moses technology compared with the regular mode with the Lumenis® Pulse™ P120H holmium laser during ureteroscopy for stone disease. Patients and Methods: An IRB-approved database of patients with urolithiasis was analyzed for ureteroscopies from January 2020 to December 2020 at an outpatient surgery center. Patients who underwent ureteroscopy with the Lumenis Pulse P120H holmium laser system with the Moses or regular mode were included. Patient characteristics and stone parameters were collected. Operative room parameters were compared, including procedural time, fragmentation/dusting time, lasing time, and total energy used. Complication rates and stone-free rates were also analyzed. Univariate analysis and multiple analysis of covariance controlling for cumulative stone size were performed. Patients with staged procedures were excluded. Results: Of 197 surgical cases, 176 met the inclusion criteria. Moses was utilized in 110 cases and regular mode in 66. There was no difference in cumulative stone size between Moses and regular modes (11.8 ± 7.9 vs 11.6 ± 9.2 mm, p = 0.901). Procedural time (43.5 ± 32.1 vs 39.8 ± 24.6 minutes, p = 0.436), fragmentation/dusting time (20.5 ± 25.3 vs 17.1 ± 16.1 minutes, p = 0.430), lasing time (7.5 ± 11.1 vs 6.7 ± 7.9 minutes, p = 0.570), and total energy used (5.1 ± 6.7 vs 3.8 ± 4.8 kJ, p = 0.093) were also similar. Complications (6.4% vs 6.1%, p = 0.936) and stone-free rates (52.3% vs 65.3%, p = 0.143) did not differ. Conclusion: At our institution, Moses technology did not significantly change the procedural time, fragmentation/dusting time, lasing time, or total energy used. Moreover, there were no differences in complications or stone-free rates. There may be technical benefits to the Moses technology not captured in this analysis.

Disposable Ureteroscopes in Urology: Current State and Future Prospects.

Ureteroscopy is the most common surgical modality for stone treatment. Reusable flexible ureteroscopes are delicate instruments that require expensive maintenance and repairs. Multiple single use ureteroscopes have been developed recently to combat the expensive and time-intensive sterilization and repair of ureteroscopes. Although multiple studies have looked at different aspects of reusable and single use ureteroscopes, there is significant heterogeneity in performance measures and cost between the 2 categories, and neither has a clear advantage. Both can be used successfully, and individual and institution level factors should be considered when deciding which ureteroscope to use.

White's operation: the history of 19th century attempts to treat prostate disease with castration.

To understand the roots of 19th century hormonal treatments for BPH in the career of J. William White, a prominent surgeon scientist at the University of Pennsylvania. We reviewed primary and secondary literature available in PUBMED, the University of Pennsylvania Archives, and internet resources. In 1893, Dr. White presented a series of experiments demonstrating atrophy of the canine prostate following castration and advocated for this procedure in men suffering from prostatic hypertrophy. This approach was adopted by many of White's contemporaries. In 1895, White presented findings from 111 patients and reported improvement of urinary symptoms in three quarters of these patients. Improvements in surgical techniques for prostatectomy have predominantly eliminated castration as a clinical procedure for BPH treatment. These early experiments demonstrated the critical dependence of the prostate on testicular androgens and were the basis for subsequent hormonal therapies for BPH. In conclusion, the bold experiments of late 19th century surgeons paved the way for our contemporary understanding of the important role of sex steroid hormones in BPH.

Microwave Ablation of Renal Cell Carcinoma.

Management options for small renal masses include active surveillance, partial nephrectomy, radical nephrectomy, and thermal ablation. For tumors typically ≤3 cm in size, thermal ablation is a good option for those desiring an alternative to surgery or active surveillance, especially in patients who are considered high surgical risk. We favor microwave ablation because of the more rapid heating, higher temperatures that overcome the heat sink effect of vessels, reproducible cell kill, and a highly visible ablation zone formed by water vapor that corresponds well to the zone of necrosis. For central tumors, we favor cryoablation because of the slower formation of the ablation zone and less likelihood of damage to the collecting system. With microwaves, it is important to monitor the ablation zone in real time (ultrasound is the best modality for this purpose), avoid direct punctures of the collecting system, and to place probes tangential to the collecting system to avoid burning open a persistent tract between the urothelium and extrarenal spaces or causing strictures. The surgical steps described in this video cover our use of high-frequency jet ventilation with general anesthesia to minimize organ motion, initial imaging and targeting, probe insertion, hydrodissection (a technique that enables displacement of adjacent structures), the ablation itself, and finally our dressing. Postoperative cares typically consist of observation with a same-day discharge or an overnight stay. Follow-up includes a magnetic resonance imaging abdomen with and without contrast, chest X-ray, and laboratories (basic metabolic panel, complete blood count, and C-reactive protein) 6 months postablation. Overall, percutaneous microwave ablation is an effective and safe treatment option for renal cell carcinoma in both T1a and T1b tumors in selected patients with multiple studies showing excellent oncologic outcomes when compared with partial and radical nephrectomy.

Effect of stone composition on surgical stone recurrence: single center longitudinal analysis.

INTRODUCTION The objective of this study is to explore the association between urinary stone composition and surgical recurrence. MATERIALS AND METHODS: Patients who underwent kidney stone surgeries (between 2009-2017), were followed for > 1 year, and had ≥ 1 stone composition analyses were included in our analysis. Surgical stone recurrence (repeat surgery) was defined as the second surgery on the same kidney unit. Recurrence-free survival analysis was used. RESULTS: A total number of 1051 patients were included (52.7% men, average age 59.1 +/- 15.1 years). Over 4.7 +/- 2.5 years follow up, 26.7% of patients required repeat surgery. Patients' stone compositions were calcium oxalate (66.0%), uric acid (12.2%), struvite (10.0%), brushite (5.7%), apatite (5.1%) and cystine (1.0%). Results suggested that patients with cystine stones had the highest surgical recurrence risk; brushite had the second-highest surgical recurrence risk. Struvite, uric acid, and apatite stones were at higher risk compared with calcium oxalate stones (lowest risk in our cohort). When pre and postoperative stone size was controlled, patients with a history of uric acid, brushite, and cystine stones were at higher surgical risk. After controlling clinical and demographic factors, only brushite and cystine stones were associated with higher surgical recurrence. CONCLUSIONS: Patients with cystine stones had the highest surgical recurrence risk; brushite stones had the second highest surgical recurrence risk. Struvite, uric acid, and apatite stones were at higher risk compared with calcium oxalate stones. When pre and postoperative stone size, clinical and demographic factors were controlled, only those with brushite or cystine stones were at significantly higher risk of surgical recurrence.

Combining Stereotactic Body Radiotherapy and Microwave Ablation Appears Safe and Feasible for Renal Cell Carcinoma in an Early Series.

Microwave (MW) ablation and stereotactic body radiation therapy (SBRT) are both used in treating inoperable renal cell carcinoma (RCC). MW ablation and SBRT have potentially complementary advantages and limitations. Combining SBRT and MW ablation may optimize tumor control and toxicity for patients with larger (> 5 cm) RCCs or those with vascular involvement. Seven patients with RCC were treated at our institution with combination of SBRT and MW ablation, median tumor size of 6.4 cm. Local control was 100% with a median follow-up of 15 months. Four patients experienced grade 2 nausea during SBRT. Three patients experienced toxicities after MW ablation, 2 with grade 1 hematuria and 1 with grade 3 retroperitoneal bleed/collecting system injury. Median eGFR (estimated glomerular filtration rate) preceding and following SBRT and MW ablation was 69 mL/min/1.73 m2 and 68 mL/min/1.73 m2 (P = .19), respectively. In patients who are not surgical candidates, larger RCCs or those with vascular invasion are challenging to treat. Combination treatment with SBRT and MW ablation may balance the risks and benefits of both therapies and demonstrates high local control in our series. MW ablation and SBRT have potentially complementary advantages and limitations.

Transrectal ultrasound guided prostate biopsy performed by supervised junior and senior residents is safe and does not result in inferior outcomes.

PURPOSE: To compare transrectal ultrasound guided prostate biopsy (TRUSBx) cancer detection and complication rates between residents at different levels of training and attending physicians at a single academic center. METHODS: We performed a retrospective review of consecutive series of 623 men undergoing TRUSBx from June 2014 to February 2017. The procedure was performed either by resident physicians under direct supervision by an attending physician or by an attending physician. In total, junior residents, senior residents and attending physicians performed 244, 212, and 167 biopsies, respectively. Prostate cancer detection, 30-day complications, and 30-day hospitalizations rates were the outcomes of interest. We performed multivariable logistic regression analysis to identify predictors of these outcomes and examined the hypothesis that TRUSBx performed by trainees would not be associated with inferior outcomes. RESULTS: There was no statistically significant difference in patient populations between the three groups when stratified by age, BMI, Charleston co-morbidity index, aspirin use, PSA level and palpable nodule on DRE. Prostate cancer was detected in 43.8% of the biopsies and there was no difference in detection rates (P = 0.53), Gleason score (P = 0.11), number of positive cores (P = 0.95), 30-day hospitalization (P = 0.86), and 30-day complication rates (P = 0.67) between TRUSBx performed by trainees and attending physicians. CONCLUSIONS: TRUSBx performed by residents and attending physicians yielded equivalent rates of cancer detection with no significant difference in 30-day complications or 30-day hospitalizations rates. There was no difference in outcomes between junior and senior residents suggesting that with adequate faculty supervision, it is safe for trainees at all levels to perform prostate biopsies.

Flexible Ureteroscopy as the New Standard for the Management of Renal Transplant Urolithiasis <15 mm: A Single-Center Experience.

Objectives: To determine the safety and efficacy of flexible ureteroscopy in the treatment of transplant urolithiasis. Materials and Methods: We reviewed a single-center series of 2652 patients who underwent surgical treatment for nephrolithiasis at our institution from 2009 to the present day to identify all patients undergoing ureteroscopy for treatment of transplant lithiasis. Results: We identified 18 patients who underwent ureteroscopy for treatment of urolithiasis within the transplanted kidney or ureter. The majority of the procedures were performed using a retrograde approach with flexible ureteroscopy, with one patient undergoing antegrade ureteroscopy and two patients requiring semirigid ureteroscopy. Holmium:yttrium-aluminum-garnet laser lithotripsy was utilized in all but one case, which was performed using basket extraction. There were no intraoperative complications reported. Four patients had small stone fragments on postoperative imaging, three of which were observed. One patient required repeat ureteroscopy for persistent distal ureteral stone. Conclusion: Retrograde ureteroscopy is a feasible, safe, and effective intervention for the treatment of transplant lithiasis. Minimal intraoperative or postoperative complications were reported, and only one patient required additional intervention for residual stone burden.

Lower Socioeconomic Status is Associated With Adverse Urinary Markers and Surgical Complexity in Kidney Stone Patients.

OBJECTIVE: To determine if socioeconomic status (SES) correlates with severity of kidney stone disease and 24-hour urine parameters. MATERIALS AND METHODS: An IRB approved prospectively maintained database for nephrolithiasis was retrospectively analyzed for both 24-hour urine results and surgical procedures performed from 2009 to 2019. Severely distressed communities (SDC) were categorized as those with a Distressed Communities Index (DCI), a composite measure of SES, score in the top quartile (lowest for SES). Univariate and multivariate analyses were performed to evaluate the strength of the association of DCI on: stone size at presentation, need for and type of surgical procedure, need for staged surgery and specific stone risk factors in 24-hour urine collections. RESULTS: Surgical procedures were performed on 3939 patients (1978 women) who were not from SDC and 200 (97 women) from SDC. Patients from SDC were older (57.1 years vs 54.2 years; P = .009). Patients from SDC were more likely to undergo proportionally more invasive procedures (17.5% vs 11.6%; P = .011) and require staged surgery at a higher rate (13.0% vs 8.5%; P = .028). Men from SDC had larger stones (12.5 mm vs 9.7 mm; P = .001). Among 24-hour urine results from 2454 patients (1187 women), DCI was not correlated with sodium, calcium, magnesium, volume, oxalate, phosphate, and pH levels. Higher DCI (lower SES) correlated with lower urine citrate (P = .001) and lower urine potassium (P = .002). CONCLUSION: SES correlates with larger stone burden at the time of urologic intervention, requires proportionally more invasive procedures and more staged procedures. Lower SES correlated with lower urine citrate and potassium.