Prospective, Randomized Comparison of Dual-Lumen vs Single-Lumen Flexible Ureteroscopes in Proximal Ureteral and Renal Stone Management.

Introduction: We sought to compare the safety, efficacy, efficiency, and surgeon experience during upper urinary tract stone management with single-lumen (SLFU) vs dual-lumen flexible ureteroscopes (DLFU). Materials and Methods: Seventy-nine patients with proximal ureteral or renal stone burden <2 cm were randomized to a SLFU or DLFU. We recorded times for ureteroscopy (URS), laser lithotripsy, stone basketing, as well as intraoperative and postoperative complications. The rate of stone clearance and stone free status were calculated using CT imaging. Surgeons completed a survey after each procedure rating various metrics regarding ureteroscope performance. Results: Thirty-five patients from the single-lumen group and 44 patients from the dual-lumen group had comparable median URS time (37 vs 35 minutes, p = 0.984) and basketing time (12 vs 19 minutes; p = 0.584). Median lithotripsy time was decreased in the dual-lumen group (single: 6 vs dual: 2 minutes, p = 0.017). The stone clearance rate was superior in the dual-lumen group (single: 3.7 vs dual: 7.1 mm3/min, p = 0.025). The absolute stone-free rate (SFR) was superior for the dual-lumen group (single: 26% vs dual: 48%, p = 0.045). No differences in intraoperative (single: 0% vs dual: 2%; p = 0.375) and postoperative complications (single: 7% vs dual: 11%, p = 0.474) were observed. Surgeons' ratings of the dual-lumen ureteroscope was superior for visibility, comfort, ease of use, and overall performance. Conclusions: The use of the dual-lumen ureteroscope in patients with renal and proximal ureteral stones <2 cm provided shorter lithotripsy time, higher stone clearance rates, improved SFR, and superior surgeon ratings when compared with SLFUs.

Comparison of Conventional and Triple Bolus Computerized Tomographic Urography Protocols for Radiation Dose Reduction in Hematuria Evaluation: A Randomized Controlled Trial.

PURPOSE: Computerized tomographic urography is the diagnostic tool of choice for evaluating hematuria. In keeping with the ALARA (As Low As Reasonably Achievable) principle, we evaluated a triple bolus computerized tomography protocol designed to reduce radiation exposure. MATERIALS AND METHODS: Patients with macroscopic or microscopic hematuria were prospectively randomized to conventional computerized tomography (100) or triple bolus computerized tomography (100). The triple bolus computerized tomography protocol entails 2 scans: pre-contrast scan followed by 3 contrast injections at 40 seconds, 60 seconds and 20 minutes prior to the second scan to capture all 3 phases. The conventional computerized tomography protocol requires 4 scans: pre-contrast scan, and 3 post-contrast scans at the corticomedullary, nephrographic and excretory phases. Radiation exposure and the detection of urological pathology were recorded based on radiology reports. RESULTS: There were no differences in patient demographics or body mass index between the 2 groups. Triple bolus computerized tomography exposed patients to 33% less radiation (1,715 vs 1,145 mGy*cm for conventional vs triple bolus computerized tomography; p <0.001). For macroscopic hematuria, the pathology detection rates were 70% for triple bolus and 73% for conventional computerized tomography (p=0.72). For microscopic hematuria, the detection rates were 59% for triple bolus and 50% for conventional computerized tomography (p=0.68). In both groups, the rates of detection of urolithiasis, renal cysts, urological masses, bladder pathology and prostate pathology were no different between triple bolus and conventional computerized tomography. CONCLUSIONS: In both the settings of macroscopic and microscopic hematuria evaluation, triple bolus computerized tomography significantly reduces radiation exposure while providing equivalent detection of genitourinary pathology compared to conventional computerized tomography. The ability to detect upper tract filling defects was not specifically tested.

Interactive Virtual Reality Renal Models as an Educational and Preoperative Planning Tool for Laparoscopic Donor Nephrectomy.

OBJECTIVE: To evaluate the efficacy of interactive virtual reality (iVR) in providing a three-dimensional (3D) experience with the donor's anatomy for surgeons and patients, we present a retrospective, case-controlled study assessing the impact of iVR renal models prior to LDN on both surgical outcomes and patients' understanding of the procedure. MATERIALS AND METHODS: Twenty patients undergoing LDN were prospectively recruited; their contrast-enhanced CT scans were transformed into iVR models. An iVR platform allowed the surgeons to rotate and deconstruct the renal anatomy; patients could also view their anatomy as the procedure was explained to them. Questionnaires assessed surgeons' understanding of renal anatomy after CT alone and after CT+iVR. Surgeons also commented on whether iVR impacted their preoperative plan. Patients assessed their anatomical understanding and anxiety level before and after iVR. Surgical outcomes for the iVR cohort were compared to a retrospectively matched, non-iVR cohort of LDN patients. RESULTS: Surgeons altered their preoperative plan in 18 of 20 LDNs after viewing iVR models. Patients reported better understanding of their anatomy (5/5) and noted decreased preoperative anxiety (5/5) after viewing iVR. When compared to the non-iVR group, the iVR group had a 25% reduction in median operative time (P < .001). In terms of surgical outcomes, patients in the iVR group had a 40% lower median relative change in postoperative creatinine (P < .001). CONCLUSION: Preoperative viewing of iVR models altered the operative approach, decreased the operative time, and improved donor patient outcomes. iVR models also reduced patients' preoperative anxiety.

A California Cancer Registry Analysis of Urothelial and Non-urothelial Bladder Cancer Subtypes: Epidemiology, Treatment, and Survival.

INTRODUCTION: We evaluated epidemiologic trends and survival for bladder cancer histologic subtypes in California patients by comparing urothelial carcinoma of the bladder (UCB) and non-urothelial subtypes including squamous cell carcinoma (SCC), adenocarcinoma (ADC), and small-cell carcinoma (SmCC). MATERIALS AND METHODS: The California Cancer Registry (CCR) was queried for incident bladder cancer cases from 1988 to 2012. Epidemiologic trends based on tumor histology were described. The primary outcome was disease-specific survival (DSS). Kaplan-Meier and multivariable Cox regression survival analyses were performed. RESULTS: A total of 72,452 bladder cancer cases (66,260 UCB, 1390 SCC, 587 ADC, 370 SmCC, and 3845 other) were included. The median age was 72 years (range, 18-109 years). ADC was more common in younger patients. Male:female ratios varied among cancer types (3.1:1 in UCB, 2.9:1 in SmCC, 1.6:1 in ADC, and 0.9:1 in SCC). Most non-urothelial cases (> 60%) presented at advanced stages, whereas most UCB cases (80.6%) were localized. Kaplan-Meier analysis revealed the best 5-year DSS and overall survival (OS) in UCB, whereas the worst outcomes were seen with SCC and SmCC (P < .0001). Multivariable analysis controlling for age, gender, tumor stage, and grade demonstrated that non-urothelial histologic subtypes were associated with significantly worse DSS compared with UCB (SCC hazard ratio [HR], 2.612; SmCC HR, 1.641; and ADC HR, 1.459; P < .0001). CONCLUSIONS: Non-urothelial bladder cancers have worse oncologic outcomes than UCB in California patients. SCC and SmCC are associated with the worst DSS based on univariable and multivariable analyses.

Evaluation of a Diuresis Enhanced Non-Contrast Computed Tomography for Kidney Stones Protocol to Maximize Collecting System Distention.

Purpose: In urolithiasis patients, preoperative non-contrast computed tomography (NCCT) commonly fails to provide sufficient distention of the renal collecting system to allow reliable preoperative planning for how best to approach a stone. Our objective was to evaluate the effect of a novel protocol, including oral hydration and an oral diuretic, on the distention of the renal collecting system. Patients and Methods: Twenty patients with a prior NCCT, who were scheduled to undergo a subsequent NCCT for urolithiasis assessment, were enrolled. Each patient was instructed to ingest 1 L of water and 20 mg of oral furosemide 30 to 60 minutes before their scan (DRINK [DiuResIs Enhanced Non-contrast Computed Tomography for Kidney Stones] protocol). Patients' prior NCCT scan (non-DRINK) was used for comparison. Three-dimensional (3D) reconstruction of DRINK and non-DRINK NCCT studies was performed to determine the volume and surface area of the collecting system. In addition, three faculty endourologists measured the width of the upper and lower pole infundibula and renal pelvis in the axial, coronal, and sagittal views. Results: Among the 20 patients, 13 completed the DRINK protocol as specified. For these 13 patients, 3D reconstruction of the DRINK study collecting systems showed a 63% and a 36% increase in collecting system volume and surface area, respectively (p = 0.02 and p < 0.01, respectively). Also, measurements of the CT images demonstrated a significant (p < 0.05) increase in the collecting system widths in 67% of measurements. Conclusion: The DRINK protocol significantly increased the visible collecting system volume and surface area; in the majority of cases, the upper and lower pole infundibular widths and the width of the renal pelvis were also expanded.

Monopolar enucleation versus transurethral resection of the prostate for small- and medium-sized (< 80 cc) benign prostate hyperplasia: a prospective analysis.

AIM: To assess efficacy and safety of monopolar enucleation of the prostate (MEP) and to compare it with the current treatment standard for medium-sized prostates, < 80 cc, transurethral resection of the prostate (TURP). METHODS: A prospective analysis patients undergoing a surgical procedure for their diagnosis of BPH (benign prostatic hyperplasia) (IPSS > 20, Qmax < 10; prostate volume < 80 cc) was performed. IPSS, Qmax were assessed preoperatively, at 6 and 12 months postoperatively. The complications were classified according to the modified Clavien-Dindo grading system. RESULTS: A total of 134 patients were included in the study: 70 underwent MEP and 64 - TURP for BPH (mean prostate volumes were comparable with p = 0.163). The mean surgery time was 44 min in the TURP group and 48.2 min in the MEP group, (p = 0.026). Catheterization time for MEP was 1.7 and 3.2 days for TURP (p < 0.001). Hospital stay for MEP was 3.2 days vs. 4.8 days for TURP (p < 0.001). Both techniques shown comparable efficiency in benign prostatic obstruction relief with IPSS drop in MEP from 23.1 to 5.9 and in TURP group from 22.8 to 7.3, whereas Qmax increased from 8.2 to 20.5 after MEP and from 8.3 and 19.9 after TURP. Urinary incontinence rate after catheter removal in TURP group was 9.0% and 7.8% in MEP group, at 1 year follow-up, it was 1.4% and 3.1% in MEP and TURP, respectively (p = 0.466). CONCLUSIONS: Our experience demonstrated that MEP is an effective and safe BPH treatment option combining the efficacy of endoscopic enucleation techniques and accessibility of conventional TURP.

Prospective Randomized Comparison of Standard Hand Pump Infuser Irrigation vs an Automated Irrigation Pump During Percutaneous Nephrolithotomy and Ureteroscopy: Assessment of Operating Room Efficiency and Surgeon Satisfaction.

Introduction: The objective of this study was to determine if use of an automated irrigation pump (AIP) during ureteroscopy (URS) and percutaneous nephrolithotomy (PCNL) affects circulating nurse labor, irrigation-related issues, and surgeon and nurse satisfaction when compared to manual hand pump (HP) irrigation. Methods: Eighty consecutive adult patients undergoing unilateral URS or PCNL were prospectively randomized to irrigation with the HP or AIP. Preoperative pump setup time, intraoperative pump maintenance time, total pump time (setup+maintenance), and the number of irrigation-related concerns verbalized by the surgeon intraoperatively were recorded; postoperatively, surgeons and nurses rated their satisfaction with the irrigation system (1 = highly dissatisfied to 10 = highly satisfied). Results: Eighty patients were enrolled (39 AIP and 41 HP); 51 patients underwent URS and 29 patients underwent PCNL. On univariate analysis, the AIP resulted in a significantly reduced total pump time for URS (2.9 vs 5.9 minutes) and PCNL (4.6 vs 33.9 minutes; p < 0.001). The number of irrigation-related concerns was significantly lower in the AIP group during URS (1.2 vs 2.8, p < 0.001), but not during PCNL (1.9 vs 4.0, p = 0.07). The AIP was associated with significantly higher nurse satisfaction during URS (9.2/10 vs 6.5/10, p < 0.001) and PCNL (9.4/10 vs 4.4/10, p = 0.001). There was no significant association between pump type and surgeon satisfaction. On multivariate analysis of URS cases controlling for body mass index and number of stones, use of the AIP was a predictor of total pump time <5 minutes (odds ratio 25.8, 95% confidence interval [CI] 4.0-165.4; p < 0.001) and favorable (8-10/10) nurse satisfaction rating (odds ratio 25.4, 95% CI 4.1-164.0; p < 0.001). Operative time, stone-free rate, and liters of irrigant used with the HP and AIP were similar. Conclusions: During URS and PCNL, the AIP was associated with a significant reduction in irrigation pump time and higher nurse satisfaction.

Racial and Socioeconomic Disparities in Bladder Cancer Survival: Analysis of the California Cancer Registry.

PURPOSE: To examine the California Cancer Registry (CCR) for bladder cancer survival disparities based on race, socioeconomic status (SES), and insurance in California patients. PATIENTS AND METHODS: The CCR was queried for bladder cancer cases in California from 1988 to 2012. The primary outcome was disease-specific survival (DSS), defined as the time interval from date of diagnosis to date of death from bladder cancer. Survival analyses were performed to determine the prognostic significance of racial and socioeconomic factors. RESULTS: A total of 72,452 cases were included (74.5% men, 25.5% women). The median age was 72 years (range, 18-109 years). The racial distribution among the patients was 81% white, 3.8% black, 8.8% Hispanic, 5.2% Asian, and 1.2% from other races. In black patients, tumors presented more frequently with advanced stage and high grade. Medicaid patients tended to be younger and had more advanced-stage, higher-grade tumors compared to patients with Medicare or managed care (P < .0001). Kaplan-Meier analysis demonstrated significantly poorer 5-year DSS in black, low SES, and Medicaid patients (P < .0001). When controlling for stage, grade, age, and gender, multivariate analysis revealed that black race (DSS hazard ratio = 1.295; 95% confidence interval, 1.212-1.384), low SES (DSS hazard ratio = 1.325; 95% confidence interval, 1.259-1.395), and Medicaid insurance (DSS hazard ratio = 1.349; 95% confidence interval, 1.246-1.460) were independent prognostic factors (P < .0001). CONCLUSION: An analysis of the CCR demonstrated that black race, low SES, and Medicaid insurance portend poorer DSS. These findings reflect a multifaceted socioeconomic and public health conundrum, and efforts to reduce inequalities should be pursued.

Endockscope: A Disruptive Endoscopic Technology.

Objective: To assess optical performance and diagnostic capability of the Endockscope system (ES) vs the standard endoscopic system (SES) using four rigid/semi-rigid endoscopes. The ES combines a smartphone, lens system, and a rechargeable light-emitting diode (LED) light source to provide a low-cost alternative ($45) to the standard camera and high-powered light source ($45,000) used in endoscopic procedures. Materials and Methods: Video clips (<20 seconds) of standard rigid nephroscopy, semi-rigid ureteroscopy, rigid cystoscopy, and laparoscopy in two adult male cadavers were recorded using the ES combined with either the Apple iPhone X or Samsung Galaxy S9+ and also with the high-definition SES (Karl Storz). Sixteen urologists blinded to the camera modality assessed the image resolution, brightness, color, sharpness, and overall quality using a Likert-type scale; acceptability for diagnostic purposes was judged on a binary scale (yes/no). Results: For rigid cystoscopy, there was no statistical difference between both ES systems and the SES. For semi-rigid ureteroscopy the two ES systems performed equal to or better than the SES. For rigid nephroscopy, the ES plus Galaxy was comparable to the SES, except in brightness (p < 0.05), whereas the ES plus iPhone was inferior in various parameters. For laparoscopy, the ES plus Galaxy was inferior to the SES in brightness and overall quality (p < 0.05); the ES plus iPhone was inferior for all laparoscopic image parameters compared with the SES. For diagnostic purposes, the ES plus Galaxy was equivalent to the SES for all endoscopes; the ES plus iPhone was equivalent to the SES for cystoscopy, ureteroscopy, and nephroscopy. Conclusion: The ES plus the Apple iPhone X or Samsung Galaxy S9+ offers comparable imaging and provides diagnostic information equivalent to the standard system for rigid endoscopy of the kidney, ureter, and bladder; the Galaxy S9+ provides comparable imaging and diagnostic capabilities for evaluation of the abdomen.