Reducing hand radiation during renal access for percutaneous nephrolithotomy: a comparison of radiation reduction techniques.

Percutaneous nephrolithotomy confers the highest radiation to the urologist's hands compared to other urologic procedures. This study compares radiation exposure to the surgeon's hand and patient's body when utilizing three different techniques for needle insertion during renal access. Simulated percutaneous renal access was performed using a cadaveric patient and separate cadaveric forearm representing the surgeon's hand. Three different needle-holding techniques were compared: conventional glove (control), a radiation-attenuating glove, and a novel needle holder. Five 300-s fluoroscopy trials were performed per treatment arm. The primary outcome was radiation dose (mSv) to the surgeon's hand. The secondary outcome was radiation dose to the patient. One-way ANOVA and Tukey's B post-hoc tests were performed with p < 0.05 considered significant. Compared to the control (3.92 mSv), both the radiation-attenuating glove (2.48 mSv) and the needle holder (1.37 mSv) reduced hand radiation exposure (p < 0.001). The needle holder reduced hand radiation compared to the radiation-attenuating glove (p < 0.001). The radiation-attenuating glove resulted in greater radiation produced by the C-arm compared to the needle holder (83.49 vs 69.22 mGy; p = 0.019). Patient radiation exposure was significantly higher with the radiation-attenuating glove compared to the needle holder (8.43 vs 7.03 mSv; p = 0.027). Though radiation-attenuating gloves decreased hand radiation dose by 37%, this came at the price of a 3% increase in patient exposure. In contrast, the needle holder reduced exposure to both the surgeon's hand by 65% and the patient by 14%. Thus, a well-designed low-density needle holder could optimize radiation safety for both surgeon and patient.

Time Efficiency and Performance of Single-Use vs Reusable Cystoscopes: A Randomized Benchtop and Simulated Clinical Assessment.

Introduction: A flexible cystoscope is an indispensable tool for urologists, facilitating a variety of procedures in both the operating room and at bedside. Single-use cystoscopes offer benefits including accessibility and decreased burden for reprocessing. The aims of this study were to compare time efficiency and performance of single-use and reusable cystoscopes. Methods: Ten new Ambu® aScope™ 4 Cysto single-use and two Olympus CYF-5 reusable cystoscopes were compared in simulated bedside cystoscopy and benchtop testing. Ten urologists performed simulated cystoscopy using both cystoscopes in a randomized order. Times for supply-gathering, setup, cystoscopy, cleanup, and cumulative time were recorded, followed by a Likert feedback survey. For benchtop assessment, physical, optical, and functional specifications were assessed and compared between cystoscopes. Results: The single-use cystoscope demonstrated shorter supply-gathering, setup, cleanup, and cumulative times (824 vs 1231 seconds; p < 0.05) but a comparable cystoscopy time to the reusable cystoscope (202 vs 212 seconds; p = 0.32). The single-use cystoscope had a higher image resolution, but a narrower field of view. Upward deflection was greater for the single-use cystoscope (214.50° vs 199.45°; p < 0.01) but required greater force (2.5 × ). The working channel diameter and irrigation rate were greater in the reusable cystoscope. While the single-use cystoscope lacked tumor enhancing optical features, it had higher Likert scale scores for Time Efficiency and Overall Satisfaction. Conclusion: The single-use cystoscope demonstrates comparable benchtop performance and superior time efficiency compared to reusable cystoscopes. However, the reusable cystoscope has superior optical versatility and flow rate. Knowledge of these differences allows for optimal cystoscope selection based on procedure indication.

Does renal failure worsen radiation cystitis following radical prostatectomy?

OBJECTIVE: To investigate the impact of renal function on the risk, severity, and management of radiation cystitis in patients who underwent postoperative radiation therapy for prostate cancer. METHODS: Retrospective data was assessed from patients treated with adjuvant/salvage radiation therapy at a single academic institution between 2006 and 2020. The incidence, severity, and management of radiation cystitis were compared between three groups: CKD 0-2, CKD 3-4, and CKD 5. Associations of clinicopathologic factors with radiation cystitis were assessed in univariate and multivariate Cox regression models. RESULTS: A total of 110 patients who underwent radiation therapy following robot-assisted laparoscopic radical prostatectomy were included. The incidence of radiation cystitis following postoperative radiation therapy was 17% with a median presentation time of 34 months (interquartile range 16-65 months). The incidence of radiation cystitis was 100% in CKD 5 patients compared to 15% in CKD 0-2 and 17% in CKD 3-4 patients (p < 0.001). CKD 5 patients required more treatments, emergency department visits, and longer hospitalization times than CKD 0-4 patients (all p < 0.001). Multivariate analyses identified CKD 5 as the only significant factor associated with radiation cystitis (HR = 10.39, p = 0.026). CONCLUSION: End-stage renal failure is associated with the risk and severity of radiation cystitis in patients receiving postoperative radiation therapy. Knowledge of the potential morbidity of this complication in this population could guide physicians and patients as they evaluate risks and benefits prior to selecting adjuvant or salvage radiation therapy.

Thulium versus holmium for in situ lower pole laser lithotripsy.

INTRODUCTION: During in situ lower pole laser lithotripsy, the dependent location may result in increased challenge fragmenting stones and a risk for stone regrowth if residual fragments remain. The purpose of this study was to compare the thulium fiber laser (TFL) with the holmium laser (HL) for in situ lower pole lithotripsy. MATERIALS AND METHODS: In a 3D printed kidney benchtop model, sixty 1 cm BegoStones were placed in the lower pole and fragmented in situ until fragments passed through a 2 x 2 mm mesh. Laser lithotripsy was performed using twelve energy, frequency and fiber size combinations and residual fragments were compared. In addition, laser fiber diameters and subsequent ureteroscope deflections and flow rates were compared between fibers. RESULTS: The TFL resulted in decreased residual fragments compared to the HL (11% vs. 17%, p < 0.001) and the three settings with least residual fragments were all TFL. Compared to the 150 µm TFL (265° deflection), there was a loss of 9° and 34° in the 200 µm TFL and 272 µm HL fibers, respectively. The measured fiber sizes were greater than manufacturer specified fiber size in every instance. Irrigation rates inversely correlated with fiber size. CONCLUSION: The TFL resulted in 35% less residual stone fragments, up to 34° additional deflection, and an increased irrigation rate when compared to the HL. Optimal fragmentation settings are identified to further improve lower pole lithotripsy. The combination of reduced residual fragments, improved deflection, and better flow rates make the TFL advantageous for in situ lower pole lithotripsy.

Does the Novel Thulium Fiber Laser Have a Higher Risk of Urothelial Thermal Injury than the Conventional Holmium Laser in an In Vitro Study?

Introduction and Objective: The novel thulium fiber laser (TFL) has been shown to break stones more rapidly than the holmium:YAG laser (HL). However, some evidence suggests that the TFL generates more heat. The purpose of this study is to compare ureteral temperatures generated by these lasers during ureteroscopic laser lithotripsy in a benchtop model. Methods: A 1-cm BegoStone was manually impacted in the proximal ureter of a three-dimensional printed kidney-ureter model and submerged in 35.5°C saline. Lithotripsy was performed using a 7.6F flexible ureteroscope and a 200 µm laser fiber without a ureteral access sheath. The Dornier 30 W HL, Olympus 100 W HL, and Olympus 60 W TFL were compared. A needle thermocouple to measure temperature was inserted 2 mm from the laser tip. Irrigation was maintained at 35 cc/minute at room temperature using the Thermedx FluidSmart System. Intraluminal temperature was continuously recorded for 60 seconds of laser activation. Five trials were performed for each of four different power settings: 3.6, 10, 20, and 30 W. Analysis of variance and Mann-Whitney U tests were performed with p < 0.05 considered significant. Results: Intraureteral fluid temperature increased as laser power settings increased for all lasers (p < 0.05). The TFL generated higher average ureteral fluid temperatures than the Dornier and Empower HL at all power settings tested (p < 0.001). The maximum temperature for the TFL was higher than the Dornier and Empower HL at all power settings tested (p < 0.001), except at 20 W with the Empower HL. At 30 W, the TFL exceeded 43°C, the threshold for tissue damage. Conclusions: The TFL generated more heat at all settings tested. Supraphysiologic ureteral temperatures may be generated with extended use at high energy settings and low irrigation rates. Understanding the heat generation properties of both lasers could help improve the safety of ureteroscopic laser lithotripsy.

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.

Legal Review of Vasectomy Litigation and the Variables Impacting Trial Outcomes.

OBJECTIVE: To demonstrate the substantial litigious risks associated with vasectomy, a common urologic procedure. We examined the risk factors and types of negligence involved in vasectomy cases that go to trial and their associated outcomes. METHODS: Using the Westlaw legal database, we searched all jury verdicts and settlements for the term "vasectomy" from January 1, 1990 to December 31, 2017. Each case was evaluated for defendant specialty, alleged malpractice breach, resulting complications, outcome including verdict and monetary payment, and whether or not a pregnancy was involved. RESULTS: The Westlaw database query returned 67 unique cases which were settled (13.3%) or went to trial in court (86.7%). Of these, the majority (64.2%) were decided in favor of the defending physician. The most commonly alleged breach of duty was negligence in postoperative care (38.8%). This was followed by negligent surgical performance (37.3%) and negligence in performing informed consent (29.9%). The cases filed for negligence in postoperative care, surgical performance, and informed consent were all generally decided in favor of the defendant (61.5%, 56%, and 90%, respectively). Of the 57 cases that specified, 82.5% of the physicians listed in the litigation were urologists. The average settlement won by each plaintiff was $401,913, although most cases were settled for the medical and litigation costs themselves. CONCLUSION: Medical malpractice cases related to the perioperative aspects of vasectomy involve many areas of negligence. This data may guide vasectomists in where to focus time and communication to best serve patients and minimize litigation.

Alvimopan usage increasing following radical cystectomy.

PURPOSE: Alvimopan (Entereg), a peripherally acting opioid receptor antagonist, is effective in reducing the rate of postoperative ileus and length of hospital stay in patients undergoing colorectal surgery, and is now approved for use after radical cystectomy (RC). Using data from Vizient (formerly University Health System Consortium), we assessed the utilization of alvimopan and its effect on perioperative factors after RC. METHODS: The Vizient database, contributed to by over 200 US academic hospitals, was evaluated from 2014 to 2016. Patients who had undergone radical cystectomy were included. Alvimopan exposure and postoperative outcomes were collected. RESULTS: 7472 patients underwent cystectomy in the 3 years examined, with 3391 (45.4%) patients receiving alvimopan over this time period. The use of alvimopan increased from 35 to 59%. The receipt of alvimopan was associated with a decrease in perioperative morbidity (10.53% vs 19.23%, p = 0.027). CONCLUSION: This study, the largest to examine the real-world utilization of alvimopan since FDA approval for RC, shows that alvimopan utilization has increased substantially and is associated with reduced perioperative morbidity in patients undergoing cystectomy.

Delayed severe anaphylactoid reaction following retrograde pyelogram: A case report.

Retrograde pyelography is used to evaluate upper collecting system in patients with hematuria who have contrast allergy. Reported here is a patient who developed severe, late-onset anaphylactoid reaction after retrograde pyelography. Premedication is commonly used to reduce risk of allergic reaction but has limited evidence to support its efficacy. Caution should be used when evaluating microhematuria with retrograde pyelography in patients with prior anaphylactoid reaction to intravenous contrast.