Detailed cadaveric analysis of perivesical lymph nodes in cystectomy specimens.

INTRODUCTION: Perivesical lymph nodes were added to the 8th edition of American Joint Committee on Cancer (AJCC) staging for bladder cancer. Currently, these nodes are inconsistently evaluated at the time of radical cystectomy. The objective of this study was to provide a detailed anatomic evaluation of perivesical lymph nodes. MATERIALS AND METHODS: A radical cystectomy was performed on six un-embalmed cadavers with wide resection of perivesical tissue and meticulous care to separate the pelvic sidewall lymph nodes (e.g. obturator, external iliac) from the bladder and perivesical en-bloc specimen. Perivesical tissue dissection in 2 mm slices was performed with a board-certified pathologist. Lymph node size and location were recorded. RESULTS: Gross tissue resembling lymph nodes were identified in the perivesical tissue in 50% (3/6) of the specimens, with a total of six grossly identified lymph nodes. The mean size was 7.5 mm (2-16 mm). On histologic analysis, 4 of 6 (66%) putative gross lymph nodes had confirmed lymphoid tissue. The mean distance of the lymph nodes from bladder wall was 9 mm (3-15 mm). Eight anatomic locations for perivesical nodes were developed: urachal, anterior bladder wall, posterior peritoneum, bladder neck, bilateral pedicle, bilateral lateral bladder wall. CONCLUSION: This cadaveric study with meticulous dissection of the perivesical space confirms that perivesical lymph nodes are a distinct entity and separate from other lymph nodes in the true pelvis. Perivesical lymph nodes are not present in all subjects and pathologic evaluation is more difficult owing to the surrounding fat. We herein propose perivesical regions for evaluation which can serve as a foundation for future studies and anatomic grossing techniques.

Does qSOFA score predict ICU admission and outcomes in patients with obstructed infected ureteral stones?

INTRODUCTION: Obstructing stones with infection represent a true urologic emergency requiring prompt decompression. Historically the systemic inflammatory response syndrome (SIRS) criteria has been used to predict outcomes in patients with sepsis. The quick Sequential Organ Failure Assessment (qSOFA) score has been proposed as a prognostic factor in patients with acute pyelononephritis associated with nephrolithiasis. However there has been limited application of qSOFA to patients undergoing ureteral stenting with obstructive pyelonephritis. The purpose of this study was to evaluate the predictive value of the qSOFA score for postoperative outcomes following renal decompression in this patient population. MATERIALS AND METHODS: A retrospective review was conducted at three medical centers within one academic institution to identify patients with obstructive pyelonephritis secondary to ureteral stones. All patients underwent emergent ureteral stent placement for decompression. The primary outcome was the predictive value of preoperative qSOFA score ≥ 2 for intensive care unit (ICU) admission postoperatively. Univariate analysis and multivariate regression analysis were performed to identify factors associated with postoperative outcomes, with p < 0.05 considered significant. RESULTS: Of the 289 patients who had ureteral stents placed, 147 patients met inclusion criteria. Twenty-four (16.3%) patients required ICU admission and there were 3 (2%) mortalities, all of these within the ICU admission group. The sensitivity and specificity of the qSOFA score ≥ 2 for ICU admission was 70.8% and 79.5% respectively which outperformed SIRS criteria, which had a sensitivity and specificity of 100% and 33.6% respectively. CONCLUSION: A preoperative qSOFA score ≥ 2 was a significant predictor for postoperative ICU admission in patients undergoing ureteral stent placement for obstructive pyelonephritis. The qSOFA score can be used to determine which patients will require ICU admission.

What Guidewire Is the Best for Bypassing an Impacted Ureteral Stone?

Introduction and Objectives: To determine the optimal guidewire for bypassing an impacted ureteral stone. Materials and Methods: Three different benchtop models of varying impaction (300, 362, and 444 mm Hg pressure) were used to compare the ability of 13 different guidewires to bypass an impacted ureteral stone. In the first and second models, we recorded the maximum force required to bypass the stone. In the first model (300 mm Hg) 10 new wires for each of the 13 types were advanced past a ureteral stone using a series 5 digital force gauge. In the second model (362 mm Hg), the top 5 performing guidewires were similarly tested. In the third model (444 mm Hg), 5 attending urologists and 5 urology residents (blinded to wire type) compared the 13 guidewires and rated the wire performance using a Likert scale. Statistical analysis was performed with analysis of variance and the chi-square test. Results: In the first model, there was a significant difference between wires (p < 0.001) with the lowest mean force to bypass a stone seen in the Glidewire (0.117 ± 0.02 lbs) and HiWire (0.130 ± 0.01 lbs). Of the five wires tested in the second model, the Glidewire (0.24 ± 0.09 lbs) and UltraTrack (0.40 ± 0.35 lbs) both required less force than the other three wires (p = 0.018). In the third model, only two wires (Roadrunner and Glidewire) bypassed the impacted stone in 100% of trials. When comparing standard, hybrid, and hydrophilic wires, the hydrophilic had the highest success rate (standard = 0%, hybrid = 36.67%, and hydrophilic = 70.67%; p = 0.000) and Likert score (standard = 1.03, hybrid = 2.38, and hydrophilic = 3.24; p = 0.000). Hydrophilic wires required the least time to bypass the stone (hybrid = 82.81 seconds vs hydrophilic = 45.37 seconds, p = 0.000). Conclusions: In this benchtop study, standard wires performed poorly and hybrid wires were not as effective as hydrophilic wires. The Glidewire required the least force, the shortest insertion time, and had the highest surgeon satisfaction rating.

The Impact of Patient, Procedural, and Staffing Factors Upon Ureteroscopy Cost.

Introduction: The purpose of this study was to evaluate factors during ureteroscopy that can potentially impact procedure cost. Materials and Methods: A retrospective review of 129 consecutive elective ureteroscopy cases was performed to determine direct procedure cost. Direct cost was defined as cost incurred because of operating room expenses, including operating room time, staffing expenses, equipment, and supply costs. Data regarding patient, procedural, and operating room staffing characteristics were compared between the most and least expensive cases. Univariate and logistic regression analysis were performed to identify factors predictive of higher costs. Results: The average direct ureteroscopy cost was $3298/case. On univariate analysis, ureteroscopies in the highest 50th cost percentile had larger stone burden (170.1 vs 146 mm2; p = 0.03) and longer operative times (95.3 vs 49.9 minutes; p < 0.01), were more likely performed for non-stone indications (21.4% vs 7.2%; p = 0.03), more likely to include a resident (65.5% vs 43.6%; p = 0.02), and less likely to have a dedicated urology scrub technician (38.2% vs 61.8%; p = 0.01) compared to cases in the lowest 50th percentile. The presence of a resident, larger stone burden, absence of a dedicated scrub technician, and longer operative time were associated with an average cost increase of $516, $700, $1122, and $1401, respectively. Logistic regression analysis showed that operating room time was the only factor predicting higher cost (OR [odds ratio] 12.8, 95% confidence interval [CI] 2.0-84.0). A post-hoc logistic regression analysis demonstrated that the presence of a resident during ureteroscopy (OR 2.9, 95% CI 1.1-8.0) and larger stone burden (OR 1.01, 95% CI 1.0-1.013) were significantly associated with longer operative times. Conclusion: Operating room time is the primary determinant of ureteroscopy case cost. All efforts should be made to decrease operative time, although balancing patient safety and maintaining a quality training environment.

'Fake News' in urology: evaluating the accuracy of articles shared on social media in genitourinary malignancies.

OBJECTIVES: To evaluate the accuracy of the most popular articles on social media platforms pertaining to genitourinary malignancies, and to identify the prevalence of misinformation available to patients. MATERIALS AND METHODS: The 10 most shared articles on popular social media platforms (Facebook, Twitter, Pinterest, and Reddit) were identified for prostate cancer, bladder cancer, kidney cancer, testis cancer, and PSA testing using a social media analysis tool (August 2017 and August 2018). Articles were reviewed for accuracy by comparing the article information against available scientific research and consensus data. They were classified as accurate, misleading or inaccurate. The Mann-Whitney U-test was used for statistical comparison. RESULTS: Articles pertaining to prostate cancer were the most shared across all social media platforms (399 000 shares), followed by articles pertaining to kidney cancer (115 000), bladder cancer (17 894), PSA testing (8827) and testicular cancer (7045). The prevalence of inaccurate or misleading articles was high: prostate cancer, 7/10 articles; kidney, 3/10 articles; bladder, 2/10 articles; testis, 2/10 articles; and PSA testing, 1/10 articles. There was a significantly higher average number of shares for inaccurate (54 000 shares; P < 0.01) and misleading articles (7040 shares; P < 0.01) than for accurate articles (1900 shares). Inaccurate articles were 28 times more likely to be shared than factual articles. CONCLUSION: Misleading or inaccurate information on genitourinary malignancies is commonly shared on social media. This study highlights the importance of directing patients to appropriate cancer resources and potentially argues for oversight by the medical and technology communities.

The Effect of Operative Field Instrument Clutter During Intraoperative Fluoroscopy on Radiation Exposure.

Introduction and Objectives: Fluoroscopy units are routinely operated in the automatic brightness control (ABC) mode to optimize image quality. During ureteroscopy, objects may be placed within the fluoroscopy beam and the effect upon radiation exposure is unknown. The purpose of this study is to investigate the effects of equipment within the fluoroscopy beam during simulated ureteroscopy. Methods: ABC fluoroscopy of a cadaver was performed in eight clinical scenarios, including a control (no equipment), and seven groups with different equipment within the fluoroscopy beam. Equipment tested included electrocardiogram (EKG) leads, a Kelly clamp, camera and light cords (straight and coiled configurations), flexible ureteroscope, rigid cystoscope, and the lateral table support beam. Ten 145-second fluoroscopy trials were performed for each arm. The primary outcome was radiation dose (mGy) compared using the Mann-Whitney test with p < 0.05 considered significant. Results: Compared with control (18.5 mGy), radiation exposure was significantly increased with the presence of a straight camera and light cords (19.3 mGy), Kelly clamp (19.4 mGy), coiled camera and light cords (20.2 mGy), a flexible ureteroscope (21.0 mGy), a rigid cystoscope (21.2 mGy), and when the lateral table support beam was in the path of the X-ray (25.0 mGy; a 35% increase; p < 0.007 for all). The EKG leads did not affect the radiation dose. Conclusions: Avoiding equipment within the fluoroscopy beam using ABC mode can reduce radiation exposure. Adjusting the table and patient position to exclude the lateral table support beam will reduce radiation exposure by 35%.

How a Donor Nephrectomy Population Can Help Give Perspective to the Effects of Renal Parenchymal Preservation During Partial Nephrectomy.

Introduction: Volume of renal parenchymal loss is known to affect postoperative renal function after partial nephrectomy (PN). We utilize a novel comparison using donor nephrectomy (DN) patients to demonstrate the primary effect parenchymal volume loss plays on postoperative renal function following PN. Materials and Methods: Records of 250 living donor (DN) and 118 PN patients were retrospectively reviewed. Baseline characteristics and preoperative estimated glomerular filtration rate (eGFR)s were recorded. Percent changes in eGFR and incidences of surgically induced chronic kidney disease (CKD-S) in short, intermediate, and long-term postoperative periods were compared. Univariate and multivariate analyses of prognostic factors for development of CKD-S were performed. The PN group was further divided into subgroups with different lengths of warm ischemia time (WIT) and compared with DN patients. Results: At baseline, DN patients were younger, less likely to be male, had lower body mass index, lower American Society of Anesthesiologists, and higher preoperative eGFR (all p < 0.001). At hospital discharge, intermediate follow-up, and latest follow-up, renal function changes in DN and PN groups were -40.5% vs. -3.6%, -34.1% vs. -5.5%, and -33.2% vs. -4.4%, respectively (all p < 0.001). More DN than PN patients developed CKD-S (p < 0.001). DN was a significant risk factor for the development of chronic kidney disease on univariate and multivariate analyses (p < 0.001). On subgroup analysis, both subgroups with WIT 1 to 30 minutes and 31 to 60 minutes had less renal function decline at all time points compared with DN (p < 0.001). Conclusions: Volume of renal parenchyma retained is the dominant driver of postoperative renal function after nephrectomy, compared with all other factors. Surgeons should minimize parenchymal loss during PN to optimize postoperative renal function.

Ureteropelvic Junction Obstruction in a Polycystic Kidney with Duplicated System: Successful Outcome with Endoscopic Management.

Background: Autosomal dominant polycystic kidney disease is the most prevalent hereditary renal disease, associated with progressive renal insufficiency, usually leading to dialysis. It is rarely diagnosed with other renal abnormalities. We present a case of a 35-year-old woman with a duplicated left polycystic kidney, who had recurrent pain and pyelonephritis because of ureteropelvic junction (UPJ) obstruction of the upper moiety. Case Presentation: A 35-year-old female patient initially presented with left flank pain for 7 days. Evaluation demonstrated enlarged bilateral polycystic kidneys with the appearance of a duplicated system of the left kidney and UPJ obstruction of the upper moeity. She underwent endoscopic management, including balloon dilatation and stent placement. After stent removal she had no symptoms, and ultrasonography showed resolution of the upper pole hydronephrosis. Conclusion: Minimally invasive nephron sparing approaches for UPJ obstruction could delay the process of end-stage renal disease development in polycystic kidney disease patients who have additional congenital renal anomalies. Balloon dilatation should be considered as a feasible therapy for UPJ obstruction in polycystic kidney disease patients with duplicated systems.

Traumatic Penile Pseudoaneurysm After Straddle Injury Presenting With Life Threatening Anemia: A Unique Case and a Diagnostic Challenge.

Partial urethral disruption after blunt perineal trauma can be initially managed with urethral catheterization. Lower urinary tract symptoms after catheter removal should raise suspicion for urethral stricture and requires further investigation. Lesser known complications require high index of suspicion to prevent life threatening sequelae. In this report, we describe a case of blunt perineal trauma and partial urethral disruption in a pediatric patient presenting with refractory anemia due to a penile artery pseudoaneurysm. We discuss an unusual presentation, challenging diagnosis and management of this rare condition.

Comparative Effectiveness of Second Vasoactive Agents in Septic Shock Refractory to Norepinephrine.

OBJECTIVE: We aim to identify the appropriate vasoactive agent in patients with septic shock who are refractory to optimal doses of norepinephrine. METHODS: In this retrospective observational cohort study over a 4-year period, patients who received norepinephrine within 24 hours of ICU admission and a second agent within 48 hours were enrolled. RESULTS: Among 2640 patients screened, 234 patients were enrolled, aged 60.8 ± 17.8 years, Acute Physiology and Chronic Health Evaluation IV 98.3 ± 27.5, 81.6% mechanically ventilated, and 65.8% in-hospital mortality. Within 96 hours, 2.8 ± 1.0 vasoactive agents were administered. Fifty, 50, 66, and 68 patients received dobutamine, dopamine, phenylephrine, and vasopressin as the second agent, with crude in-hospital mortality 40.0%, 66.0%, 74.2%, and 76.5%, respectively, P < .001. Survival analysis showed a statistically significant difference in survival time by second vasoactive agent, P < .001. After adjusting for confounding variables, dobutamine showed significant decreased odds ratio (OR) for mortality compared to vasopressin: OR 0.34 (95% confidence interval 0.14-0.84, P = .04). The relative risk of dying was 55.8% lower in patients receiving dobutamine versus vasopressin, P < .01. CONCLUSION: Dobutamine is associated with decreased mortality compared to other second vasoactive agents in septic shock when norepinephrine is not sufficient. A prospective randomized trial examining the outcome impact of the second vasoactive agent is needed.

Real-time sonographically guided percutaneous dilatational tracheostomy using a long-axis approach compared to the landmark technique.

OBJECTIVES: Sonographic evaluation of neck anatomy before performing percutaneous dilatational tracheostomy (PDT) has been shown to predict PDT success. In this study, we compared the real-time, long-axis, in-plane approach to the traditional bronchoscopically guided landmark technique. METHODS: Data were analyzed from a prospectively maintained PDT database at a university tertiary care medical intensive care unit. A convenience sample of adult patients requiring PDT for prolonged mechanical ventilation dependence was enrolled. Critical care fellows, under direct supervision of an attending intensivist, performed all PDTs. Tracheostomy performance from the sonographically guided and landmark techniques was compared. RESULTS: Twenty-three patients were enrolled: 11 in the sonography group and 12 in the landmark group. Initial midline introducer needle puncture was achieved in 72.7% in the sonography group compared to 8.3% in the landmark group (P< .001). The mean number of introducer needle punctures ± SD was significantly lower in the sonography group compared to the landmark group (1.4 ± 0.7 versus 2.6 ± 0.9; P < .001). The total tracheostomy time was 11.4 ± 4.2 minutes in the sonography group versus 15.3 ± 6.8 minutes in the landmark group (P = .12). Sonography accurately predicted tracheal ring space insertion in 90.9% of patients. Procedural complications did not differ significantly between the groups. CONCLUSIONS: Percutaneous dilatational tracheostomy under real-time sonographic guidance using a long-axis approach may increase the rate of midline punctures and decrease the number of needle punctures when compared to the landmark technique. Sonographic guidance can also help guide accurate and efficient placement of a tracheostomy tube into the desired tracheal ring space.