Development of an Integrated Mobile Application for Evaluating Voiding Dysfunction: A Proof of Concept Study.

INTRODUCTION: Bladder voiding diaries are an important part of evaluating and managing lower urinary tract symptoms but are subject to poor data quality and diary completion rates. Mobile health technology is increasingly prevalent and can help overcome the problems of traditional paper and electronic diaries. METHODS: We identified proof of concept design principles based on a literature review and needs assessment. An electronic application was developed to improve self-assessment and symptom management for patients with voiding dysfunction. We analyzed application distribution and use patterns for 12 consecutive months. RESULTS: We designed an electronic application with complete mobile device integration containing a voiding diary, incontinence tracker and AUA Symptom Score questionnaire. Users could enter and modify details about the volume and frequency of voiding events, including leakage and pad use. Data could be electronically shared with providers. Integrating the application on the Apple® iOS and Android™ mobile operating systems eliminated the need for patients to carry or learn to use a separate device. During the 12-month study period 1,868 unique visitors from 18 countries downloaded the mobile application and made a total of 13,145 subsequent visits. CONCLUSIONS: This application for evaluating voiding dysfunction leverages mobile technology to overcome the limits of paper and standalone electronic formats. Domestic and international users downloaded the application and consistently logged return visits. Using mobile health in urology practices may help patients and providers better manage lower urinary tract symptoms and achieve improved control.

Ultrasound guided ureteroscopy for the definitive management of ureteral stones: a randomized, controlled trial.

PURPOSE: Ureteroscopy is central to the surgical management of ureteral stones. Fluoroscopy is conventionally used for intraoperative guidance, although there is growing effort to decrease the exposure of patients and staff to ionizing radiation. We developed a radiation-free approach to ureteroscopy using ultrasound guidance to manage ureteral stones. To our knowledge we present the first randomized trial to study its safety and efficacy. MATERIALS AND METHODS: This single center, randomized clinical trial from 2011 to 2013 enlisted patients who presented with symptomatic ureteral stones 8 mm or less without a significant ipsilateral stone burden. Patients were randomly assigned to ultrasound or fluoroscopic guided ureteroscopy after temporizing ureteral stent placement. Intraoperative ultrasound guidance was performed using real-time imaging with the transducer placed at the patient flank to visualize the collecting system of the ipsilateral kidney. We compared operative time, stone size, stone-free status and complication rates between the 2 groups. RESULTS: A total of 50 patients were enrolled in study with 25 per arm. There was no difference in stone size (5.9 vs 5.7 mm), patient age (56 vs 52 years) or body mass index (31 vs 30 kg/m(2)) in the test group compared to controls. The ultrasound guidance cohort showed no significant difference in the stone-free rate (86% vs 86%) or the complication rate (8% vs 16%) compared to controls. Operative time was no longer in the ultrasound guidance cohort. CONCLUSIONS: In this feasibility study we found that ureteral stones may be definitively managed in a timely, effective and safe fashion without ionizing radiation in the general population using this novel technique of ultrasound guided ureteroscopy.

Ambulatory pathway laser prostate surgery in severely ill patients--feasibility and short-term outcomes.

OBJECTIVE: To assess readmissions, complications, and outcomes of a rapid ambulatory discharge pathway (RADP) in high anesthetic risk patients who have undergone laser prostate surgery. METHODS: Medical records of patients who underwent holmium laser ablation of the prostate between 2007 and 2012 by a single surgeon were retrospectively reviewed. Patients with American Society of Anesthesiologists category ≥3 ("severe systemic disease") were included. All patients were scheduled for a rapid ambulatory discharge pathway, which involved discharge on the day of surgery with a urethral catheter, with a voiding trial on postoperative day 3. RESULTS: Fifty-seven patients met the inclusion criteria. Fifty patients (88%) were successfully discharged on rapid ambulatory discharge pathway. Six patients (11%) were later readmitted for hematuria (3), urinary retention (1), or cardiac events (2). Two patients (4%) had emergency department visits for catheter-related problems. Increasing length of surgery, increasing amount of laser energy used, and a surgical indication indicative of more advanced disease were associated with postoperative hospitalization and readmissions on univariate analysis. No patient operated on for lower urinary tract symptoms was hospitalized or needed a readmission. The mean change in International Prostate Symptom Score and quality of life at 3 months were -12.5 ± 8.2 (P <.001) and -2.6 ± 1.7 (P <.001), respectively. CONCLUSION: It is safe to use a rapid ambulatory discharge pathway for laser prostatectomy in high anesthetic risk patients with good short-term outcomes, especially in men operated on for lower urinary tract symptoms.

Insurance status, stone composition, and 24-hour urine composition.

UNLABELLED: Abstract Purpose: We examined the stone composition, 24-hour urinary risk factors, and insurance status in patients evaluated in two regional stone clinics to further investigate the relationship between the socioeconomic status and kidney stone formation. MATERIALS AND METHODS: We performed a retrospective review of stone formers who completed a 24-hour urinalysis as part of a metabolic evaluation for nephrolithiasis. Insurance status was determined by billing records and those with state-assisted insurance (SAI) were compared to patients with private insurance (PI). Multivariate analyses were performed adjusting for known risk factors for stones. RESULTS: Three hundred forty-six patients were included. Patients with SAI (16%) were significantly more likely to be female (55% vs.38%, p=0.026) and younger (43.5 vs.49.2, p=0.003). Among those with stone composition data (n=200), SAI patients were as likely to form calcium phosphate (CaPhos) as calcium oxalate (CaOx) stones (46.9% vs.31.3%, p=0.44). PI patients were significantly less likely to form CaPhos than CaOx stones (10.1% vs.77.4%, p<0.001). On multivariate analysis, among those with calcium stones, the odds of forming CaPhos stones over CaOx stones were ten times higher among SAI patients compared to PI, odds ratio 10.2 (95% CI 3.6, 28.6, p<0.001). Further, patients with SAI had significantly higher urine sodium, pH, and supersaturation of CaPhos, and a lower supersaturation of uric acid compared to patients with PI. CONCLUSIONS: SAI was associated with a greater likelihood of a CaPhos stone composition and increased urinary risk factors for CaPhos stones. These findings may reflect dietary or other unmeasured differences, and have important implications for resource allocation and counseling, as treatment may differ for these groups.

It is safe to teach residents laser prostate surgery in the private practice setting.

OBJECTIVE: To examine the effect of resident involvement on laser prostate surgery outcomes within a urology group in a private practice setting. MATERIALS AND METHODS: Patients with ≥ 6 months of follow-up data who had undergone holmium laser ablation of the prostate by a single surgeon (R.L.Y.) within a private urology group were included in the present study. The patients were divided into 2 groups, with resident involvement in 1 group and no resident involvement in 1 group. The preoperative, intraoperative, and postoperative parameters were reviewed. The outcomes variables included changes in the International Prostate Symptom Score, quality of life scores, postvoid residual urine volumes, and reoperation rates. Statistical analysis used a 2-tailed Student t test with a significance level of .05. RESULTS: Of 153 holmium laser ablations of the prostate, 79 (52%) met the inclusion criteria. Of the 79 cases, 42 (53%) involved a resident. No statistically significant differences were found among the 2 groups in preoperative patient characteristics, including age, Society of Anesthesiologists score, prostate-specific antigen level, postvoid residual urine volume, International Prostate Symptom Score, or quality of life. The operative times were significantly longer in the resident group (57 vs 46 minutes, P = .05). Postoperatively, no differences in the mean values were found in postvoid residual urine volume (56 vs 64 mL, P = .73), change in International Prostate Symptom Score (11.5 vs 9.7, P = .44), change in quality of life score (-2.1 vs -1.3, P = .13), or reoperation rate (5% vs 11%, P = .19). CONCLUSION: The operative times were longer in the resident group, reflecting the inherent time taken to teach the residents the procedure. The results from the present study suggest that it is feasible to safely teach residents new surgical technology such as holmium laser ablation of the prostate in a nonacademic private practice setting without adversely affecting surgical performance or outcomes.

Successful transcloacal ureteral stent removal.

We report a percutaneous transcloacal approach for removal of a ureteral stent in a 15-year-old girl with a cloacal anomaly, spinal dysraphism, and complex pelvic anatomy, including a bicornuate uterus, reconstructed hindgut neobladder, and duplicated left pelvic kidney. The patient had undergone 3 previous unsuccessful attempts at stent removal, 2 endoscopic attempts by way of her neobladder, and 1 percutaneous transcloacal attempt before successful removal.