Shockwave Lithotripsy Use in the State of Michigan: American Urological Association Guideline Adherence and Clinical Implications.

OBJECTIVE: To understand how treatment of patients with urinary stones by shockwave lithotripsy (SWL) aligns with current published practice guidelines. METHODS: We used the Michigan Urologic Surgery Improvement Collaborative Reducing Operative Complications for Kidney Stones registry to understand SWL use in the state of Michigan. This prospectively maintained clinical registry includes data from community and academic urology practices and contains clinical and operative data for patients undergoing SWL and ureteroscopy (URS). We identified patients undergoing SWL from 2016 to 2019. In accordance with AUA guidelines, we evaluated practice patterns in relation to recommendations for treatment selection for SWL as well as clinical implications of guideline nonadherence. RESULTS: Four thousand, two hundred and nine SWL procedures performed across 34 practices were analyzed. Perioperative antibiotics were administered to 61.3% of patients undergoing SWL. A ureteral stent was placed at the time of SWL in 2.7% of patients. For lower pole renal stones >1 cm or large (>2 cm) renal stones in the registry, 32.2% and 58.9% of patients, respectively, underwent SWL, while the remainder were treated with URS. In these instances, SWL was associated with inferior stone-free rate (SFR) relative to URS. In patients with residual stones after SWL, 34.6% were treated with repeat SWL with lower SFR than those treated with subsequent URS. Postoperatively, 42.1% of patients were prescribed alpha-blockers with no benefit seen in terms of SFR. CONCLUSION: Substantial variation exists among urology practices with regard to SWL use. These data serve to inform quality improvement efforts regarding appropriateness criteria for SWL in Michigan.

Characteristics of the Peritumoral Pseudocapsule Vary Predictably With Histologic Subtype of T1 Renal Neoplasms.

OBJECTIVE: To determine characteristics of the peritumoral pseudocapsule (PC) between renal tumor subtypes. METHODS: The peritumoral PCs of 160 pT1 renal tumors were examined, including 60 clear cell renal cell carcinomas (RCCs), 50 papillary RCCs, 25 chromophobe RCCs, and 25 oncocytoma. Pathologic features (presence or absence of PC, mean thickness, continuity, and invasion by tumor) were analyzed. PC thickness was measured using an ocular micrometer to the nearest 1/10 mm. RESULTS: A complete PC was found in 77% of clear cell tumors, 74% of papillary, 28% of chromophobe, and 4% of oncocytomas. Tumor PC was present but incomplete in 18% of clear cell, 18% of papillary, 44% of chromophobe, and 56% of oncocytoma. The PC was entirely absent in no clear cell tumors, 6% of papillary, 28% of chromophobe, and 40% of oncocytoma. Mean PC thickness and presence of invasion beyond the PC differed significantly by tumor subtype. Clear cell RCC possessed the thickest PC showing invasion through the capsule in 8% of tumors compared to 30% of papillary tumors. Complete PC invasion was not seen in chromophobe RCC or renal oncocytoma. Oncocytoma and chromophobe RCC characteristically exhibited an incomplete or absent PC. CONCLUSION: The characteristics of peritumoral PC vary predictably with histologic subtype of renal neoplasms. Clear cell RCC shows the most consistent PC, with a lower rate of invasion beyond it compared to papillary RCC. Chromophobe and oncocytoma characteristically have an incomplete or absent PC.

Robot-Assisted Radical Prostatectomy in Patients with a History of Holmium Laser Enucleation of the Prostate: Feasibility and Evaluation of Initial Outcomes.

PURPOSE: To evaluate outcomes of post-holmium laser enucleation of the prostate (HoLEP) robot-assisted radical prostatectomy (RARP). PATIENTS AND METHODS: Using an institutional database, we identified 11 HoLEP patients who subsequently underwent RARP. These were matched 1:2 to RARP patients without a previous transurethral surgical procedure. Variables matched were age, pre-RARP prostate-specific antigen level, and biopsy Gleason score. Urinary continence and sexual function were evaluated by physician questioning, American Urological Association symptom score, and Sexual Health in Men (SHIM) scores. Descriptive statistics were used to compare cohorts. RESULTS: RARP pathologic outcomes were similar between cases and controls. Twenty-seven percent of previous HoLEP patients reached strict urinary continence (leak free, pad free) at last follow-up compared with 64% of matched controls (P=0.071). The average (range) SHIM score at last follow-up was 2.6 (1-5) for previous HoLEP patients compared with 13.9 (5-20) (P<0.001). The posterior bladder neck and apical dissections were significantly more challenging in the setting of previous HoLEP and necessitated a low threshold for wider resection to minimize positive surgical margins. CONCLUSIONS: Post-HoLEP RARP is challenging but preliminarily appears safe and feasible when performed by an experienced robotic surgeon. Patients should be counseled regarding expectations of urinary continence and sexual function in this setting.