Predicting Septic Shock After Emergent Ureteral Stenting in Stone-Related Obstruction and Presumed Infections.

Introduction: Systemic inflammatory response syndrome (SIRS) criteria have long been used to predict septic shock. The sequential organ failure assessment and quick sequential organ failure assessment (qSOFA) scores have been suggested to be more accurate predictors. This study aims to compare SIRS and qSOFA for predicting of septic shock in the setting of retrograde ureteral stenting for obstructing stones and concomitant urinary tract infection. Methods: A retrospective review of records at two centers of consecutive patients was performed. Patients with unilateral ureteral obstruction by a stone who underwent ureteral stent placement and suspicion of urinary tract infection were identified. Primary endpoints were SIRS and qSOFA positive scores, intensive care unit admission, and vasopressor requirements. Results: A total of 187 patients were included. SIRS criteria were met in 103 patients (55.1%) and in 30 patients who experienced septic shock. qSOFA criteria were met for 24 patients (12.8%) and in 18 patients who experienced septic shock. Specificity for postoperative septic shock was significantly higher for qSOFA than for SIRS criteria (75 vs 29.1%, McNemar test p < 0.001). Both SIRS and qSOFA had significant areas under the curve (AUC), qSOFA had a fair AUC of 0.750, p = 0.001, whereas SIRS had a poor AUC of 0.659, p = 0.008. Univariate logistic regression of SIRS and qSOFA for septic shock showed: qSOFA (odds ratio [OR] 46 [0.25-228], p = 0.001) and SIRS (OR 2.29 [0.716-7.37], p = 0.162). Conclusion: Although SIRS offers higher sensitivity, qSOFA score may offer advantages over SIRS criteria in evaluation of risk for septic shock for patients who present with obstructing ureteral stone and urinary tract infection.

Device Malfunctions and Complications Associated with Benign Prostatic Hyperplasia Surgery: Review of the Manufacturer and User Facility Device Experience Database.

Introduction and Objectives: Multiple surgical therapies for benign prostatic hyperplasia (BPH) have been developed to decrease complications and increase provider efficiency. We investigated contemporary BPH treatment device-related adverse events by searching a publicly available database. Materials and Methods: The Manufacturer and User Facility Device Experience (MAUDE) database was queried for contemporary BPH treatments. All devices were evaluated for malfunction, patient complications, and manufacturer review. The MAUDE adverse event classification system was used to standardize complications. Univariate analysis was performed to identify associations between BPH devices and adverse events. Results: A total of 2567 reports were identified: transurethral resection of the prostate (TURP) 197 (7.67%), holmium laser enucleation of the prostate (HoLEP) 39 (1.52%), GreenLight™ 2315 (90.2%), and UroLift® 16 (0.62%). The most common deviations for each modality included cutting loop detachment during TURP 116 (58.9%), morcellator dysfunction for HoLEP 23 (58.9%), tip fracture/detachment for GreenLight (68.8%), and failure to deploy during UroLift 10 (62.5%). Only 18 (0.7%) patients required medical/surgical management (MAUDE II-IV) due to a device complication. No significant relationship was seen between each modality and complications; however, morcellator use (27.8%) was observed in higher grade complications. Manufacturer review occurred in 61.7% of cases, with 41.3% of reviewed cases finding the operator the cause of the malfunction. Conclusion: Each BPH modality investigated had minimal patient harm with over 99% of patients experiencing no complication after device malfunction. Of note, great care should be taken with morcellator use during HoLEP as it had the greatest number of MAUDE II to IV complications among all devices. Manufacturer review revealed that over 40% of cases were due to misuse by the user. Therefore, urologists should select the modalities they are most familiar with to decrease patient harm and prevent device malfunctions.

Penile and Scrotal Strangulation due to Metal Rings: Case Reports and a Review of the Literature.

Penile and scrotal entrapment from a metal ring placed at the base of the penis is a rare, but important clinical dilemma encountered in urology. Emergent presentation to the urologist, after ring placement far longer than safely practiced, risks ischemic and permanent injury to penile, scrotal, and intrascrotal structures. Treating urologists should be aware of the prevalence of metal ring use, their potential complications, and the surgical approach to their safe removal. We present two patients who were identified at our institution with strangulating injuries of retained penile rings. The first patient was a healthy, 43-year-old male with a metal ring retained for 24 hours that was safely removed with industrial bolt cutters. The second patient, a 74-year-old male, died as a result of sepsis from injuries secondary to penoscrotal ischemia after >48 hour ring retention despite prompt removal at emergent presentation. Although rare, sexual practices may include the use of penoscrotal rings. When retained, ischemic injury and edema may lead to strangulation. Emergent removal may require industrial equipment that is not within the confines of normal operating room tools. Tissue injury may be severe and sepsis life-threatening, even after ring removal.

Percutaneous and Endoscopic Management of Nephrolithiasis in a Patient with Five Native Ureters (Trifid Right and Bifid Left Collecting System).

Triplication of the ureter is a rare urologic finding that has been well described in the literature. Patients can present with urinary tract infections, incontinence, and calculi. We present the case of a patient with extensive stone burden with right trifid and left bifid collecting systems. Stone management was performed with a multimodal approach using a combination of endoscopic and percutaneous approaches. Our systematic and staged approach highlights a method for efficacious stone treatment in a complex endourologic case.

Device-Related Adverse Events During Percutaneous Nephrolithotomy: Review of the Manufacturer and User Facility Device Experience Database.

INTRODUCTION AND OBJECTIVES: Percutaneous nephrolithotomy (PCNL) is an established technique for removal of large stones from the upper urinary tract. It is a complex multistep procedure requiring several classes of instruments that are subject to operator misuse and device malfunction. We report device-related adverse events during PCNL from the Manufacturer and User Facility Device Experience (MAUDE) database using a recently developed standardized classification system. MATERIALS AND METHODS: The MAUDE database was queried for "percutaneous nephrolithotomy" from 2006 to 2016. The circumstances and patient complications associated with classes of devices used during PCNL were identified. We then utilized a novel MAUDE classification system to categorize clinical events. Logistic regression analysis was performed to identify associations between device classes and severe adverse events. RESULTS: A total of 218 device-related events were reported. The most common classes included: lithotripter 53 (24.3%), wires 43 (19.7%), balloon dilators 30 (13.8%), and occlusion balloons 28 (12.8%). Reported patient complications included need for a second procedure 12 (28.6%), bleeding 8 (19.0%), retained fragments 7 (16.7%), prolonged procedure 4 (9.5%), ureteral injury 2 (4.8%), and conversion to an open procedure 3 (7.1%). Using a MAUDE classification system, 176 complications (81%) were Level I (mild/none), 26 (12%) were Level II (moderate), 15 (7%) were Level III (severe), and 1 (0.5%) was Level IV (life threatening). On univariate analysis, balloon dilators had the highest risk of Level II-IV complications compared with the other device classes [odds ratio: 4.33, confidence interval: 1.978, 9.493, p < 0.001]. The device was evaluated by the manufacturer in 93 (42.7%) cases, with 54.8% of reviewed cases listing the source of malfunction as misuse by the operator. CONCLUSIONS: PCNL is subject to a wide range of device-related adverse events. A MAUDE classification system is useful for standardized, clinically-relevant reporting of events. Our findings highlight the importance of proper surgeon training with devices to maximize efficiency and decrease harm.