Antibiotic use, best practice statement adherence, and UTI rate for intradetrusor onabotulinumtoxin-A injection for overactive bladder: A multi-institutional collaboration from the SUFU Research Network (SURN).

INTRODUCTION: Onabotulinumtoxin A (BTX-A) is a well-established treatment for overactive bladder (OAB). The American Urological Association (AUA) 2008 Antibiotic Best Practice Statement (BPS) recommended trimethoprim-sulfamethoxazole or fluoroquinolone for cystoscopy with manipulation. The aim of the study was to evaluate concordance with antibiotic best practices at the time of BTX-A injection and urinary tract infection (UTI) rates based on antibiotic regimen. METHODS: Men and women undergoing first-time BTX-A injection for idiopathic OAB with 100 units in 2016, within the SUFU Research Network (SURN) multi-institutional retrospective database were included. Patients on suppressive antibiotics were excluded. The primary outcome was concordance of periprocedural antibiotic use with the AUA 2008 BPS antimicrobials of choice for "cystoscopy with manipulation." As a secondary outcome we compared the incidence of UTI among women within 30 days after BTX-A administration. Each outcome was further stratified by procedure setting (office vs. operating room; OR). RESULTS: Of the cohort of 216 subjects (175 women, 41 men) undergoing BTX-A, 24 different periprocedural antibiotic regimens were utilized, and 98 (45%) underwent BTX-A injections in the OR setting while 118 (55%) underwent BTX-A injection in the office. Antibiotics were given to 86% of patients in the OR versus 77% in office, and 8.3% of subjects received BPS concordant antibiotics in the OR versus 82% in office. UTI rates did not vary significantly among the 141 subjects who received antibiotics and had 30-day follow-up (8% BPS-concordant vs. 16% BPS-discordant, CI -2.4% to 19%, p = 0.13). A sensitivity analysis of UTI rates based on procedure setting (office vs. OR) did not demonstrate any difference in UTI rates (p = 0.14). CONCLUSIONS: This retrospective multi-institutional study demonstrates that antibiotic regimens and adherence to the 2008 AUA BPS were highly variable among providers with lower rates of BPS concordant antibiotic use in the OR setting. UTI rates at 30 days following BTX-A did not vary significantly based on concordance with the BPS or procedure setting.

The Correlation of Diabetes Mellitus and Urinary Retention From Intravesical OnabotulinumtoxinA Injection for Overactive Bladder.

IMPORTANCE AND OBJECTIVES: The objective was to determine whether patients with diabetes mellitus (DM) treated with intravesical onabotulinumtoxinA (BoNT) injection for overactive bladder (OAB) had increased urinary retention requiring clean intermittent catheterization (CIC), as well as the impact of disease duration and severity. We hypothesize that patients with DM will have higher rates of retention after BoNT injection. STUDY DESIGN: We performed a retrospective cohort analysis of women in the Kaiser Permanente Southern California Health System who underwent BoNT injection for OAB, excluding women with a history of urinary retention or neurogenic bladder. RESULTS: We identified 565 patients, 410 in the control group and 155 in the DM group. No significant difference was found in the rate of CIC (9% in the control group versus 5.8% in the DM group, P = 0.2), voiding dysfunction, and peak postprocedure postvoid residual volume (PVR). Patients with diabetes had a significantly increased rate of postprocedure urinary tract infection (UTI; 27.6% versus 38.1%, P = 0.02). Urinary tract infection was significantly associated with urinary retention (adjusted odds ratio [OR], 2.26; 95% confidence interval [CI], 1.02-4.99; P = 0.045) and peak PVR ≥200 mL (adjusted OR, 2.42; 95% CI, 1.15-5.06; P = 0.019). Diabetic disease duration and severity were not a predictor of urinary retention, elevated PVR, or voiding dysfunction; however, the presence of ≥1 disease-related complication was a predictor of UTI (adjusted OR, 2.81; 95% CI, 1.34-5.91; P = 0.006). CONCLUSIONS: Diabetic patients had a similar rate of urinary retention requiring CIC after BoNT injection for OAB compared with nondiabetic patients. Diabetic patients had an increased risk of UTI based on disease severity.

Cystectomy for Benign Indications.

PURPOSE OF REVIEW: This article evaluates the historical influences, current use, surgical techniques, and recent evidence on outcomes for cystectomy performed for benign indications. RECENT FINDINGS: At the population level, cystectomy for benign indications has similar perioperative morbidity to radical cystectomy for cancer. Postoperative patient satisfaction is high and functional outcomes appear good, including sexual function. Patient regret about diversion choice is low provided decisions are well informed. Cystectomy is important both as a primary procedure for benign disease and as an adjunct to primary urinary diversion. Early morbidity remains high but long-term results are encouraging. Further studies are needed to guide patient decision-making, to help inform diversion choice, and to understand the long-term impact of surgery and diversion choice on quality of life.

Combination and Novel Pharmacologic Agents for OAB.

PURPOSE OF REVIEW: To evaluate recent literature on combination and novel pharmacologic therapies for overactive bladder (OAB). RECENT FINDINGS: Combination therapies demonstrating greater efficacy than monotherapy include combination anticholinergics, anticholinergic plus ß-3 agonist, and anticholinergic with behavioral modification, percutaneous tibial nerve stimulation, or sacral neuromodulation. Promising novel therapies include new bladder selective anticholinergics, new ß-3 agonists, and gabapentin. OAB is a symptom complex caused by dysfunction in the interconnected neural, muscular, and urothelial systems that control micturition. Although several therapeutic targets and treatment options exist, complete resolution is not always achieved, discontinuation rate for medical therapy is high, and few patients subsequently progress to third-line treatment options. Recent literature suggests combination therapy diversifying therapeutic targets is more effective than targeting a single pathway and novel treatments targeting additional pathways have promising results.

Incomplete bladder emptying and urinary tract infections after botulinum toxin injection for overactive bladder: Multi-institutional collaboration from the SUFU research network.

INTRODUCTION: Onabotulinumtoxin A (BTX-A) is an effective therapy for overactive bladder (OAB), however, adverse events may prevent patients from initiating therapy. The study objective was to report real-world rates of incomplete emptying and urinary tract infection (UTI) in men and women undergoing BTX-A for OAB. METHODS: Eleven clinical sites performed a retrospective study of adults undergoing first-time BTX-A injection (100 units) for idiopathic OAB in 2016. Exclusions included: postvoid residual (PVR) > 150 ml, prior BTX-A, pelvic radiation, or need for preprocedure catheterization. Primary outcomes at 6 months were incomplete emptying (clean intermittent catheterization [CIC] or PVR ≥ 300 ml without the need for CIC); and UTI (symptoms with either positive culture or urinalysis or empiric treatment). We compared rates of incomplete emptying and UTI within and between sexes, using univariate and multivariable models. RESULTS: 278 patients (48 men and 230 women) met inclusion criteria. Mean age was 65.5 years (range: 24-95). 35% of men and 17% of women had incomplete emptying. Men had 2.4 (95% CI: 1.04-5.49) higher odds of incomplete emptying than women. 17% of men and 23.5% of women had ≥1 UTI, the majority of which occurred within the first month following injection. The strongest predictor of UTI was a history of prior UTI (OR: 4.2 [95% CI: 1.7-10.3]). CONCLUSIONS: In this multicenter retrospective study, rates of incomplete emptying and UTI were higher than many previously published studies. Men were at particular risk for incomplete emptying. Prior UTI was the primary risk factor for postprocedure UTI.

Antibiotic regimen and route of administration do not alter rates of urinary tract infection after intravesical botulinum toxin injection for overactive bladder.

INTRODUCTION AND HYPOTHESIS: Guidelines vary on antibiotic prophylaxis for onabotulinumtoxinA (Botox) treatment for overactive bladder (OAB). Our primary objective was to determine whether any prophylactic regimen is more effective in preventing urinary tract infection (UTI) after Botox. The secondary objective was to identify prophylactic practice patterns among female pelvic medicine and reconstructive surgery (FPMRS) providers of different training backgrounds as well as general urologists. METHODS: This was a secondary analysis of a retrospective cohort study on urinary retention after Botox injection in women with and without diabetes mellitus and OAB. Women > 18 years old who underwent Botox injection for OAB between January 2013 and September 2018 were included. Exclusion criteria were history of urinary retention and neuromuscular bladder dysfunction. RESULTS: A total of 565 patients were included. Two hundred eighty (49.6%) were treated by OB-GYN FPMRS, 209 (37.0%) by urology FPMRS and 76 (13.5%) by general urologists. The majority (92.9%) received antibiotic prophylaxis: 44.4% received intravenous (IV) only, 8.9% received oral (PO) only, and 39.7% received combination IV and PO prophylaxis. Urology FPMRS used antibiotic prophylaxis less frequently (p = 0.003). Within 3 months, 171 patients developed UTI (30.4%). There was no difference in post-procedural UTI for any antibiotic regimen compared to no prophylaxis. No route of antibiotic administration was superior at preventing UTI. CONCLUSIONS: In this cohort, no route of antibiotic administration was more effective in the prevention of UTI. Antibiotic prophylaxis did not lower the rate of post-procedural UTI compared to no antibiotics.

Variation in SARS-CoV-2 molecular test sensitivity by specimen types in a large sample of emergency department patients.

BACKGROUND: Provider-collected nasopharyngeal specimens for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) molecular testing are the standard of care in many clinical settings, but patient-collected saliva and anterior nares specimens are less invasive and more flexible alternatives. Prior studies comparing specimen types for SARS-CoV-2 molecular testing have been limited by small sample sizes and low pretest probability. We conducted a large observational study among symptomatic adults at 7 emergency departments of Kaiser Permanente Southern California to examine sensitivity of SARS-CoV-2 molecular tests by specimen type and patient characteristics. METHODS: Provider-collected nasopharyngeal/oropharyngeal (NP/OP) specimens and patient-collected saliva and anterior nares specimens were collected at the same visit and analyzed with the Roche cobas® SARS-CoV-2 assay. Patients were considered truly positive for SARS-CoV-2 if any of the three specimens was positive and negative if all three specimens were negative. Factors associated with discordant and missed positive results were examined with multivariable logistic regression. RESULTS: Of 2112 patients, 350 (16.6%) were positive for SARS-CoV-2. Sensitivity of NP/OP was 93.7% (95% confidence interval [CI] 90.6%-96.0%), sensitivity of saliva was 87.7% (83.8%-91.0%), and sensitivity of anterior nares was 85.4% (81.3%-89.0%). Patients ages 18-39 years versus ≥40 years were more likely to have discordant results [adjusted odds ratio (aOR) 1.97 (1.12-3.45)], as were patients with <4 symptoms versus ≥4 [aOR 2.43 (1.39-4.25)]. Cycle threshold values were higher for saliva and anterior nares than NP/OP specimens, as well as for specimens in discordant versus concordant sets and patients with fewer symptoms. CONCLUSION: This study provides robust evidence that patient-collected saliva and anterior nares are sensitive for SARS-CoV-2 molecular testing in emergency department settings, particularly among adults ages ≥40 years and those with multiple symptoms. Higher sensitivity of provider-collected NP/OP specimens must be weighed against the benefits of patient-collected specimens in tailored strategies for SARS-CoV-2 testing.

Single Institutional Experience with Single Stage Sacral Neuromodulation: Cost Savings and Outcomes in a Contemporary Case Series.

PURPOSE: Sacral neuromodulation is traditionally performed in 2 stages. Studies have projected that 1-stage sacral neuromodulation is cost-effective if the conversion rate is 61.3% or greater. To our knowledge we present the first case series in the literature to evaluate the cost of 1-stage sacral neuromodulation. The objective of our study was to evaluate outcomes and analyze cost using our institutional experience with 1-stage sacral neuromodulation. MATERIALS AND METHODS: A total of 15 consecutive 1-stage sacral neuromodulation procedures were performed at a self-insured, integrated health care institution. Cost data were determined using 2019 Medicare reimbursement rates for CPT codes 64581, 64585, 64590 and 64595. Median operative time was derived from actual institutional data. RESULTS: One-stage sacral neuromodulation implantation was performed in 15 patients. Median followup was 14.6 months (IQR 6.9-22.5). Of the 15 cases 14 (93.3%) were successful, defined as a 50% or greater improvement from baseline. Total reimbursement for the 15 patients who underwent 1-stage implantation was $329,430. If these patients had undergone traditional 2-stage implantation with equivalent outcomes, the overall reimbursement was determined to be $414,796. Single-stage sacral neuromodulation implantation provided a calculated total cost savings of $85,366 (p <0.01). Moreover, a projected 233 minutes in operative time was saved by performing 1-stage sacral neuromodulation (p <0.01). CONCLUSIONS: This study demonstrates the potential health care savings of a 1-stage sacral neuromodulation procedure. Moreover, 1-stage sacral neuromodulation may have other added benefits, such as reduced infection rates, patient satisfaction and other indirect cost savings, including reduced time off from work.

Anastomotic Urethroplasty for an Obstructing Calculus Within a Bulbar Urethral Diverticulum and Urethral Stricture.

A 61-year-old male with prior history of endoscopic urethral calculus removal presented to the emergency room with urinary retention and a palpable perineal mass. A CT showed a large calcification within the bulbar urethra. After multiple unsuccessful attempts at foley catheter insertion, the urology service was consulted. The patient was taken to the operating room where an obstructing urethral calculus with associated urethral stricture was visualized on cystoscopy. We present an exceedingly rare case of recurrent urethrolithiasis with associated urethral stricture managed with initial suprapubic tube and delayed primary end-to-end urethroplasty, excision of urethral stricture and urethral diverticulectomy.

Evaluation of patients' perceptions of mesh usage in female pelvic medicine and reconstructive surgery.

OBJECTIVE: To evaluate if new patients presenting to a female pelvic medicine and reconstructive surgery clinic are aware of the US Food and Drug Administration (FDA) announcement regarding transvaginal mesh placement for pelvic organ prolapse repair and do they believe there is a mesh recall. METHODS: A voluntary anonymous 25-question survey was administered to new-clinic patients. Participants were aged at least 18 years and had either urinary incontinence or pelvic organ prolapse. Appropriate statistical tests were performed for continuous and categorical variables. Logistic regression was used for univariate and multivariable analysis. Significance was considered for P values <.05. RESULTS: Two hundred fourteen surveys were included for final analysis. Of the 214 patients, 157 (73.4%) had urinary incontinence as their sole presentation. Of 204 patients, 126 (61.8%) were aware the FDA-released information regarding mesh use in transvaginal surgery, and 88 of 169 (52%) believed there is a "recall" on mesh being used for transvaginal surgery. Of 156 patients, 108 (69.2%) listed television as a source of information. On multivariable analysis, television as a source was significantly associated with awareness of the FDA announcement (odds ratio, 7.12; 95% confidence interval, 2.69-18.84; P = .0001) and belief in a "recall" (odds ratio, 3.01; 95% confidence interval, 1.28-7.06; P = .01). CONCLUSION: Although almost 2 of 3 participants were aware of the FDA announcement, more than half falsely believed there was a recall. Television was significantly associated with both awareness of the FDA announcement and belief in a recall suggesting patients derive most of their perceptions from the television.

Advances in minimally invasive repair of vesicovaginal fistulas.

Over the past 20 years, the discussion concerning vesicovaginal fistula (VVF) repair has evolved from strictly transabdominal/transvaginal to including minimally invasive surgeries. The original natural orifice approach through the vagina allows for VVF repair with decreased morbidity and minimal convalescence with success rates upwards of 90 %. For surgeries that involve a narrowed/stenotic vagina or a need for a concomitant abdominal procedure, transadominal surgery can be performed by laparoscopic or robot-assisted laparoscopic approaches. Success rates in large series are upwards of 86 %. Difficulties such as an increased learning curve and vesicovaginal plane dissection have been overcome with innovations such as the robotic platform and cutting to the light with vaginoscopy. While still in its infancy in VVF repair, single site surgery has also been utilized with reasonable success. Although minimally invasive surgery offers numerous advantages, the most successful approach will still be the surgery with which the VVF surgeon is most familiar.

Donor Smoking Negatively Affects Donor and Recipient Renal Function following Living Donor Nephrectomy.

Background. While tobacco use by a renal transplant recipient has been shown to negatively affect graft and patient survival, the effect of smoking on the part of the kidney donor remains unknown. Methods. 29 smoking donors (SD) and their recipients (SD-R) as well as 71 non-smoking donors (ND) and their recipients (ND-R) were retrospectively reviewed. Preoperative demographics and perioperative variables including serum creatinine (Cr) and glomerular filtration rate (GFR) were calculated and stratified by amount of tobacco exposure in pack-years. Clinical outcomes were analyzed with a Student's t-test, chi-square, and multiple linear regression analysis (α = 0.05). Results. At most recent followup, SD-R's had a significantly smaller percent decrease in postoperative Cr than ND-R's (-57% versus -81%; P = 0.015) and lower calculated GFR's (37.0 versus 53.0 mL/min per 1.73 m(2); P < 0.001). SD's had a larger percent increase in Cr than ND's at most recent followup (57% versus 40%; P < 0.001), with active smokers having a larger increase than those who quit, although this difference was not statistically significant (68% versus 52%; P = 0.055). Conclusions. Use of tobacco by kidney donors is associated with decreased posttransplant renal function, although smoking cessation can improve outcomes. Kidneys from donors who smoke should be used with caution.

Robot-assisted radical prostatectomy in patients with previous renal transplantation.

PURPOSE: To evaluate the outcomes of robot-assisted radical prostatectomy (RARP) in patients with previous renal transplantation. PATIENTS AND METHODS: We retrospectively identified all patients who had undergone RARP for localized prostate cancer between 2005 and 2008 at a single institution (N=228). Of these, three patients were renal transplant recipients. A four-arm robotic configuration was used in all patients. Port placement was modified in two of the three renal transplant recipients to avoid trauma to the renal allograft. Preoperative demographics, perioperative parameters, and postoperative outcomes were reviewed. RESULTS: RARP was completed successfully in all three renal transplant recipients. As expected, the American Society of Anesthesiologists score (3.3 vs 2.4) and Charlson weighted index of comorbidity (4.7 vs 2.4) were greater in previous transplant patients. There were no major differences in mean age, Gleason score, body mass index, estimated blood loss, operative time, complications, or oncologic outcomes between the two groups. Each of the patients with renal allografts had an undetectable prostate-specific antigen level and was continent (needing no pads) at 13 months of follow-up. CONCLUSIONS: RARP is feasible in patients with a previous renal transplant. Although technically more challenging, RARP can be performed in previous transplant patients with acceptable morbidity and oncologic outcomes similar to those of other prostate cancer patients.

A prospective randomized comparison of traditional laparoendoscopic single-site surgery with needlescopic-assisted laparoscopic nephrectomy in the porcine model.

BACKGROUND AND PURPOSE: Laparoendoscopic single-site (LESS) surgery produces virtually no scar but is technically challenging because of the loss of triangulation. The objective of this study is to compare classic transumbilical LESS nephrectomy with needlescopic-assisted laparoscopy (NAL) surgery. In doing so, we evaluated whether the addition of a single 2-mm subcostal port could restore triangulation while not jeopardizing recovery or cosmetic outcome in the porcine model. MATERIALS AND METHODS: Ten female farm pigs were randomized to laparoscopic nephrectomy with either LESS or NAL. In LESS, a TriPort was placed through a single 2.5-cm umbilical incision. In NAL, 5- and 10-mm ports were placed in the umbilicus and a 2-mm port was placed in the midclavicular line. Preoperative, perioperative, and postoperative parameters were compared. Variables were analyzed with the Wilcoxon signed-rank test and two-tailed Fisher exact test. Cosmesis was evaluated objectively using the Vancouver Scar Scale and subjectively by a blinded dermatologist. A cost analysis was performed. RESULTS: Estimated blood loss was minimal in both groups (28.8 mL in LESS and 9.4 mL in NAL). Operative time was significantly shorter in NAL (103 vs 150 min; P<0.001). There was no difference in complications (2 vs 1; P=0.500), objective cosmesis (3.9 vs 3.8; P>0.2), or subjective cosmesis (2 vs 3; P=0.500). The NAL protocol had significantly lower disposable equipment costs ($363 vs $1696). CONCLUSIONS: The addition of a 2-mm subcostal port and the restoration of triangulation in the NAL protocol enable shorter operative times, increased surgeon comfort, improved technical ease, and lower costs while maintaining the scarless cosmesis of the traditional LESS protocol.

Patients with end-stage renal disease are candidates for robot-assisted laparoscopic radical prostatectomy.

BACKGROUND AND PURPOSE: Patients with end-stage renal disease (ESRD) have multiple comorbidities that place them at increased risk for surgical complications. Consequently, patients with both ESRD and prostate cancer (PCa) have rarely been considered candidates for radical prostatectomy. The objective of this study is to compare ESRD patients who are undergoing robot-assisted laparoscopic prostatectomy (RALP) with a cohort of patients with no history of dialysis. PATIENTS AND METHODS: A retrospective review was conducted of 430 patients who were undergoing RALP, including 12 receiving dialysis at the time of surgery. Preoperative demographics, perioperative parameters, and postoperative outcomes were compared using a two-tailed Student t test and a chi-square test, with significance at P<0.05. RESULTS: Patient demographics including body mass index, Gleason score, and prostate-specific antigen (PSA) value were similar between the two groups. Patients with ESRD had younger age (55.5 vs 62.9 years; P<0.01), higher American Society of Anesthesiologists scores (3.7 vs 2.5; P<0.01), and higher age-adjusted Charlson Comorbidity Index scores (6.2 vs 4.2; P<0.01). Patient outcomes including operative time, estimated blood loss, complication rate, postoperative stay, and positive margins did not differ significantly between groups. No ESRD patients needed pads or had a detectable PSA level using an ultrasensitive assay. CONCLUSIONS: This series represents the largest series of patients with ESRD undergoing RALP. These patients experienced similar outcomes compared with patients with no history of dialysis despite greater preoperative comorbidity. RALP produces minimal fluid shifts, low blood loss, and excellent cancer control, making it an ideal treatment option to prepare patients with both ESRD and PCa for renal transplantation.

Hybrid transureteral natural orifice translumenal endoscopic nephrectomy: a feasibility study in the porcine model.

BACKGROUND AND PURPOSE: Natural orifice approaches for nephrectomy have included access via the stomach, vagina, bladder, and rectum. The use of the ureter as a natural orifice for natural orifice translumenal endoscopic surgery (NOTES) nephrectomy has not been previously reported. The purpose of this study is to test the feasibility of transureteral laparoscopic NOTES nephrectomy. MATERIALS AND METHODS: Three female farm pigs (29.2-30.8 kg) were placed into the lithotomy position. A cystoscopically placed extra-stiff guidewire was used to place a prototype dilating sheath into the left ureter. After dilation of the ureter and urethra, the sheath was exchanged for a 12-mm bariatric laparoscopic trocar. A 10.5-inch long 10-mm offset operating laparoscope with an internal 5-mm working port was used for the nephrectomy. One 2-mm and one 2/3-mm port were placed transabdominally to facilitate in situ morcellation. The kidney was cut into slices using the bipolar device and extracted via the ureteral port using the housing of a 12-mm bariatric stapling device. RESULTS: All three transureteral nephrectomies were successfully completed. The total mean operative time was 220 minutes (range 113-346 min). Component portions of the procedure were: Ureteral access (mean 21 min), nephrectomy (mean 70 min), and kidney morcellation (mean 103 min). Mean estimated blood loss was 20 mL (range 5-50 mL). There were no intraoperative complications. CONCLUSIONS: This nonsurvival porcine feasibility study demonstrates the successful performance of transureteral nephrectomy. This approach shows promise as a way to decrease the invasiveness of NOTES nephrectomy by using the ureteral orifice as an access site.

Hemostatic sandwich to control percutaneous nephrolithotomy tract bleeding.

BACKGROUND AND PURPOSE: Significant bleeding necessitating use of a tamponade balloon, embolization, or renal exploration is a rare but catastrophic complication after percutaneous nephrolithotomy (PCNL). The purpose of this study is to review the success of a novel, minimally invasive technique for controlling percutaneous tract bleeding that is refractory to conventional measures. MATERIALS AND METHODS: A retrospective review was performed on four patients with refractory tract hemorrhage that was managed with a novel gelatin matrix hemostatic sandwich technique. In this technique, a 5F angiographic reentry catheter was placed through the kidney into the bladder and a 22F Councill-tip catheter balloon was passed over this catheter and positioned so that the inflated balloon would occlude the inner surface of the nephrostomy tract. Next, a 16F Councill-tip catheter was placed over a second wire so that the uninflated balloon was just underneath the skin surface. Gelatin matrix hemostatic sealant was then injected to fill the tract. Inflation of the outer balloon completely sealed the tract, completing the hemostatic sandwich. RESULTS: This technique was successfully applied to four patients with tract bleeding that would not stop with pressure or a conventional nephrostomy tube alone. The average estimated blood loss was 562 mL, and three of four patients avoided transfusion. All postoperative hemoglobin values stabilized within 2 days of surgery. There were no major or minor complications after use of this technique. No patients needed angioembolization or renal exploration. CONCLUSIONS: This novel hemostatic sandwich technique should be considered as an option for the control of refractory tract hemorrhage after PCNL.

Fluoroscopic organ and tissue-specific radiation exposure by sex and body mass index during ureteroscopy.

INTRODUCTION: Although radiation exposure from CT and plain film imaging has been characterized, the radiation received by patients during modern-era fluoroscopy has not been well described. The purposes of this study were to measure absolute organ and tissue-specific radiation doses during ureteroscopy and to determine the influence of body mass index (BMI) and sex on these doses. MATERIALS AND METHODS: Eight cadavers underwent a simulated left ureteroscopy. Using a modern C-arm with automatic exposure control settings, thermoluminescent dosimeters were exposed for a fluoroscopy time of 145 seconds (mean time of clinical ureteroscopies from 2006 to 2008). Total tissue exposures were compared by BMI and between sexes using the Wilcoxon signed ranks test and the Mann-Whitney test with p < 0.05 considered significant. RESULTS: Among all cadavers, radiation doses were significantly lower in all contralateral organs excluding the gonad (p < 0.012). Doses were similar bilaterally in the gonad in cadavers with BMI <30, and in all organs in cadavers with BMI >30 (p > 0.05). There were significantly higher mean bilateral gonadal doses in female cadavers (3.4 mGy left and 1.9 mGy right) compared with male cadavers (0.36 mGy left and 0.39 mGy right). The highest cancer risk increase was seen at the posterior skin equivalent to 104 additional cancers per 100,000 patients. CONCLUSION: Contralateral doses were lower for all organs except the gonad when the BMI was <30. In contrast, when the BMI was >30, there was no difference in radiation dose delivered to the ipsilateral and contralateral organs. Gonadal doses were significantly higher in female cadavers. Modern-era fluoroscopy remains a significant source of radiation exposure and steps should be taken to minimize exposure during ureteroscopy.