The Effect of Pre-Stenting on Bleeding-Related Complications Following Ureteroscopy in Patients on Anticoagulation or Antiplatelet Therapy.

Introduction: The American Urological Association guidelines state that continuing anticoagulant (AC) and antiplatelet (AP) agents during ureteroscopy (URS) is safe. Through a multi-institutional retrospective study, we sought to determine whether pre-stenting in patients on AP or AC was associated with fewer URS bleeding-related complications. Methods: A series of 8614 URS procedures performed across three institutions (April 2010 to September 2017) was electronically reviewed for AC/AP use at time of URS. Records indicating AC or AP use at time of URS were then manually reviewed to characterize intraoperative and 30-day postoperative (intraoperative bleeding, postoperative hematuria, emergency department visits, hospital readmission, unplanned reoperation, phone calls, and other minor 30-day complications). Results: A total of 293 identified URS procedures were completed on patients on AC/AP therapy-112 cases were on AC only (38 were pre-stented), 158 on AP only (51 pre-stented), and 23 on both AP and AC (8 pre-stented). Patient characteristics and comorbidities were similar between the pre-stented and non-pre-stented groups. For AC and AP subjects, pre-stenting did not decrease the composite risk of bleeding complications (10.3% pre-stent vs 12.2% non-prestent, p = 0.6). Pre-stented patients did have a significantly lower likelihood of requiring an unplanned reoperation (1.0% vs 5.6%, p = 0.04). In the subgroup of patients on AP alone, pre-stented patients had significantly fewer episodes of intraoperative bleeding (0% vs 9%, p = 0.04), unplanned reoperations (0% vs 6.5%, p = 0.02), and 30-day complications (14% vs 27%, p = 0.05). In the subgroup of patients on AC alone, there were no significant differences in outcomes based on stent status. Conclusions: In this multi-institutional study, we found that pre-stenting before URS was not associated with fewer bleeding complications. However, pre-stenting appeared to be associated with improved outcomes for those patients on AP therapy. These results suggest a need for prospective studies to clarify the role of pre-stenting for URS.

Erector spinae plane blocks for analgesia after percutaneous nephrolithotomy A pathway to reduce opioids.

INTRODUCTION: Despite its minimally invasive nature, percutaneous nephrolithotomy (PCNL ) may be associated with significant pain. Challenges in pain control may prevent timely discharge (and expose patients to adverse effects of opioid use). We sought to evaluate whether our patients who underwent erector spinae plane (ESP) regional blocks experienced improved postoperative pain control and decreased opioid use after PCNL (compared with those who did not receive blocks). METHODS: We retrospectively reviewed consecutive PCNL cases on patients admitted for greater than 24 hours without pre-existing opioid regimens for chronic pain. Cases were completed by a single high-volume surgeon. Patients who accepted an ESP block were compared to those who did not receive a block. Patients received either a single injection or a disposable pump delivering intermittent boluses of ropivacaine 0.2%. Demographic and perioperative data were analyzed. The primary outcomes were opioid use measured in morphine milligram equivalent (MME ) and patient-reported pain scores during the first 24 hours of hospitalization. RESULTS: From March 2019 to August 2021, 44 patients were identified who met criteria - 28 of whom received an ESP block (including 14 continuous blocks). The patients who received blocks had significantly decreased opioid use (18.3 vs. 81.3 MME, p=0.004) and a longer mean time to first non-zero pain score (p=0.004). Continuous blocks had similar opioid use to single shot blocks (21.0 vs. 15.6 MME, p=0.952). CONCLUSIONS: ESP regional blocks appear to offer an effective adjunct method for pain control after PCNL and may reduce post-PCNL opioid use while maintaining adequate patient analgesia.

Quick Sequential Organ Failure Assessment Score Is a Better Predictor of Septic Shock After Percutaneous Nephrolithotomy: A Secondary Analysis of Two Multicenter Prospective Trials.

Introduction: Recent retrospective literature suggests that the quick sequential organ failure assessment (qSOFA) scoring tool is a potentially superior tool over use of the systemic inflammatory response syndrome (SIRS) criteria to predict septic shock after percutaneous nephrolithotomy (PCNL) surgery. Here we examine use of qSOFA and SIRS to predict septic shock within data series collected prospectively on PCNL patients as part of a greater study of infectious complications. Materials and Methods: We performed a secondary analysis of two prospective multicenter studies including PCNL patients across nine institutions. Clinical signs informing SIRS and qSOFA scores were collected no later than postoperative day 1. The primary outcome was sensitivity and specificity of SIRS and qSOFA (high-risk score of greater-or-equal to two points) in predicting admission to the intensive care unit (ICU) for vasopressor support. Results: A total of 218 cases at 9 institutions were analyzed. One patient required vasopressor support in the ICU. The sensitivity/specificity was 100%/72.4% (McNemar's test p < 0.001) for SIRS and was 100%/90.8% (McNemar's test p < 0.001) for qSOFA. Conclusion: Although positive predictive value for both qSOFA and SIRS in prediction of post-PCNL septic shock is low, prospectively collected data demonstrate use of qSOFA may offer greater specificity than SIRS criteria when predicting post-PCNL septic shock.

Long-term follow-up on dusting versus basketing during ureteroscopy: a prospective multicenter trial from the EDGE Research Consortium.

In 2018, the Endourology Disease Group for Excellence (EDGE) published a prospective trial comparing dusting versus basketing during ureteroscopy. One hundred fifty-nine patients were included in the original analysis, which found no difference in stone-free rate at 3 months. We report the intermediate and long-term outcomes of patients included in the original trial. Two analyses were performed. At 1-year, a retrospective chart review was performed, and data collected on stone episodes, Emergency Department (ED) visits, hospital admissions and surgical interventions. To obtain long-term outcomes, the four sites with the largest initial accrual were included in a second phase of data collection with updated analyses. The patients from those sites were contacted, re-consented, and data were collected on stone surgical interventions, stone episodes, stone recurrences on imaging, emergency department (ED) visits, and hospital admissions for stone-related care since their original procedure. One-year follow-up data were collected in 111 of the original 159 (69.8%) patients from the nine sites. There were no statistically significant differences in the number of painful episodes, ED visits, hospital admissions, or surgical interventions. 94 patients from four sites were included in the long-term analysis. There were no statistically significant differences in surgical interventions, painful stone episodes, stone recurrence on imaging, ED visits or hospitalizations for stone-related events between the two groups. Long-term outcomes of dusting versus basketing during ureteroscopy indicate that there are no significant differences in clinical outcomes between the two surgical modalities.

Clinical Evaluation of Miniature Flexible Scope for Diagnosis of Ureteroscope Working Channel Defects.

Introduction: To evaluate flexible ureteroscope working channels with a 1.06 mm digital borescope (Clarus Medical, Minneapolis, MN) and identify factors contributing to ureteroscope damage over time. Materials and Methods: We performed a single institutional prospective study of patients undergoing stone surgery using a nondisposable flexible ureteroscope. A 1.06 mm borescope was used to evaluate ureteroscopes before and after surgery. Borescope videos were reviewed by two independent researchers to quantify average pre- and postprocedural damage. Results: Twenty-five procedures were performed with pre- and postprocedural borescope assessment between August 2021 and February 2022. All patients received preoperative CT imaging depicting a mean axial stone size of 14.1 ± 8.4 mm and density of 923.4 ± 458.1 HU. Mean operative time was 63.8 ± 34.0 minutes. The average number an instrument passes through the working channel was 2.1 ± 1.6. Laser was used in 11 cases with mean laser time of 18.8 ± 19.7 minutes and mean total energy of 5.8 ± 4.2 KJ. On preoperative assessment, all ureteroscopes had some form of defect (24% shave, 32% pinhole, 96% dents and scratches, and 28% discolorations). During postoperative assessment, 23/25 (92%) ureteroscopes showed additional damage with an average of 3.7 ± 2.8 imperfections acquired after one use. Significant differences were seen in acquired shavings (p = 0.028) and scratches or dents (p = 0.018). Of the 355 imperfections seen on postoperative evaluation, 0.4% were shave, 3% were pinhole, 85.8% were dents and scratches, and 10.8% were discolorations. Conclusion: The Clarus borescope observed defects after the majority of flexible ureteroscopy procedures for nephrolithiasis. Although such disruptions may not immediately render ureteroscopes nonfunctional, they are more common than previously described and could increase maintenance costs. Further studies are needed to investigate the burden of unit damage per procedure to raise operator awareness and reduce preventable ureteroscope imperfections.

Health-related quality of life disparities among Hispanic/Latinx patients with nephrolithiasis.

It is documented that Hispanic/Latinx kidney stone formers have inferior health-related quality of life (HRQoL) compared to the general population. We hypothesized that socioeconomic factors drive HRQoL disparities. Specifically, we sought to determine if medical insurance type is associated with HRQoL disparities among Hispanic/Latinx stone formers. This was a prospective cohort observational study of patients with kidney stones across the University of San Diego Health Care System. Patients enrolled from June 2018 to August 2020 completed a validated Wisconsin Stone Quality of Life questionnaire (WISQoL). Patient characteristics and self-reported HRQoL were compared between Hispanic/Latinx and non-Hispanic/Latinx stone formers using MANCOVA and ordinal logistic regression. Matched group comparisons were performed based on age, gender, body mass index, stone symptoms, and insurance type using MACOVA. A total of 270 patients were enrolled (Hispanic/Latinx n = 88; non-Hispanic/Latinx n = 182). Hispanic/Latinx stone formers had higher rates of public insurance at baseline (p < 0.001) with significantly lower HRQoL [social impact (p = 0.007)]. However, a matched cohort comparison demonstrated no differences. On multivariate analysis, private insurance increased the likelihood of having higher HRQoL (OR 2.21, p = 0.021), while stone symptoms (OR = 0.06, p < 0.001) and emergency department visits (OR = 0.04, p = 0.008) decreased chances of higher HRQoL. Ethnicity was not a significant factor in HRQoL scores on multivariate analysis. Our analysis suggests that differences in HRQoL among Hispanic/Latinx stone formers may be primarily driven by socioeconomic factors as opposed to clinical or racial differences. Specifically, source of insurance appears to have significant effect on HRQoL in this ethnic group.

Software-Estimated Stone Volume Is Better Predictor of Spontaneous Passage for Acute Nephrolithiasis.

Purpose: To evaluate whether computer program-estimated urolith stone volume (SV) was a better predictor of spontaneous passage (SP) compared with program-estimated stone diameter (PD) or manually measured stone diameter (MD), and whether utilizing SV and MD together provided additional value in SP prediction compared with MD alone. Materials and Methods: Retrospective analysis of patients with acute renal colic and single renal/ureteral stone on CT from July 2017 to April 2020. Diameter obtained from radiology reports or manually measured when report not available. Semiautomated stone analysis software (qSAS) was used to estimate SV and PD. ROC analysis was performed to compare accuracy of SV vs MD vs PD in predicting SP by 2, 4, and 6 weeks. Subgroup analysis was performed by stone size (

Understanding Causes for Admission in Planned Ambulatory Percutaneous Nephrolithotomy.

Introduction: For treatment of nephrolithiasis, ambulatory percutaneous nephrolithotomy (aPCNL) is growing in popularity for select patients. The aim of this study was to investigate the safety and efficacy of a set of aPCNL selection criteria as well as search for predictors of failed aPCNL resulting in inpatient admission. Materials and Methods: We reviewed all percutaneous nephrolithotomy (PCNL) patients from 2016 to 2020. A total of 175 met selection criteria for aPCNL and were included. Primary outcome was safety and efficacy, and secondary outcome was to identify predictors of inpatient stay. Demographic and perioperative data were analyzed with both descriptive and inferential statistics. Results: In total, between 2016 and 2020, 552 patients underwent PCNL, with 175 of them meeting criteria for aPCNL. One hundred thirty-four of the 175 (76.6%) of these patients were discharged the same day as the surgery and 41 patients were admitted. On univariate analysis, patients who required upper pole access or multiple accesses (p = 0.038) American Society of Anesthesiologists >2 (p = 0.005), or postoperative nephrostomy (PCN) tube (p < 0.001) were more likely to be admitted after surgery. On multivariate analysis, only postoperative PCN was significantly associated with admission (p = 0.015). Regarding reasons for unsuccessful aPCNL, 19.5% of admissions were attributed to intraoperative complications, 7% to social causes, 12.2% to postoperative complications, 14.6% to uncontrolled pain, and 34.1% to unexpected intraoperative procedures. Conclusions: aPCNL using selection criteria is safe and effective, with postoperative PCN predicting the possible necessity for conversion to inpatient admission. Furthermore, our study provides a practical algorithm for those opting to provide aPCNL to patients.

Standardizing Perioperative Medications to Be Used in an Enhanced Recovery After Surgery Program Is Feasible in Percutaneous Nephrolithotomy Patients.

Introduction: The objective of this process improvement project was to determine the effect of enhanced recovery after surgery (ERAS) protocol for percutaneous nephrolithotomy (PCNL) patients with respect to quality of life (QOL) and pain management in the postoperative recovery period. Methods: An electronic-based medical record ERAS orders protocol for PCNL was instituted at an academic medical center in July 2020. The protocol utilized a pain control regimen designed to minimize opioid medication use postoperatively. We prospectively evaluated PCNL patients' QOL through the Wisconsin Stone Quality of Life (WISQOL) survey and Patient-Reported Outcomes Measurement System (PROMIS) at routine perioperative visits. To assess any opioid reduction benefit of the ERAS protocol, we reviewed an age-matched historical cohort n = 66 (before ERAS implementation) to serve as a comparison cohort with respect to opioid usage. Results: After an inception cohort of 95 patients, 55 ERAS patients remained available for assessment with the WISQOL and PROMIS surveys. In comparison with the non-ERAS cohort, the ERAS cohort represented larger stones, more supine positioning, higher blood loss, shorter hospital stay, and more use of access sheath. ERAS patients received a significantly lower amount of opioids compared with non-ERAS patients upon discharge narcotic usage (116.13 morphine milliequivalent [MME] vs 39.57 MME, p = 0.0001). Compared with their preoperative evaluation, the ERAS cohort had significantly improved QOL scores at 1 week, which sustained through 8 weeks postoperatively. Moreover, pain intensity and pain interference scores were improved at 8 weeks postoperatively for ERAS patients compared with their preoperative time point. Conclusions: We demonstrate that standardizing medications in early efforts toward a PCNL ERAS protocol is feasible and allows for reduced opioid use by patients while achieving early and sustained postprocedure QOL.

Survey of Sexual Function and Pornography.

INTRODUCTION: We aimed to explore and describe the pornography habits of young men and women. Given recent upward trends in pornography use and erectile dysfunction, along with a plausible pathophysiology, we hypothesized that pornography use would correlate with sexual dysfunction. MATERIALS AND METHODS: Institutional Review Board approval was obtained. Surveys were distributed to 20-40 year old men and women presenting to a urology clinic. Information was collected on demographics and medical history. Sexual function was evaluated with the International Index of Erectile Function (IIEF) in men and the Female Sexual Function Index in women. Extent of potential addiction to pornography was measured with the pornography craving questionnaire and the obsessive passion scale. Pornography use was measured based on both frequency and duration, and analyzed relative to sexual dysfunction. RESULTS: Men used pornography significantly more frequently than women (81.1% vs. 39%). Computer and cellular phone image viewing were the most popular modalities in both sexes. There was no association between IIEF and craving for, or obsessive passion for, pornography. Preference for pornography with masturbation was found to be significantly associated with erectile dysfunction (p = 0.001). Rates of erectile dysfunction were lowest in those preferring partnered sex without pornography (22.3%) and increased significantly when pornography was preferred over partnered sex (78%). No correlation was found between any variables and female sexual dysfunction. CONCLUSIONS: Pornography and sexual dysfunction are common among young people. No clear relationship exists between extent of addiction to pornography and sexual dysfunction in either gender. However, men who prefer masturbation with pornography to partnered sex have a significantly increased risk of sexual dysfunction. Given sexual dysfunction may be associated with mental health concerns, further evaluation of its causes and impact on military operational readiness are warranted.

First Do No Harm: Predicting Surgical Morbidity During Humanitarian Medical Missions.

BACKGROUND: Despite good intentions, humanitarian surgical missions are unavoidably linked to some degree of complication. We hypothesized that the American College of Surgeons Surgical Risk Calculator (ACS-SRC) could estimate the risk of complications of procedures performed during the US Navy's Pacific Partnership 2015 (PP15) mission. METHODS: Patient information and surgical details recorded during PP15 were entered into the ACS-SRC. Risks of complications for each procedure were calculated. Receiver operating characteristics and Brier scores were calculated to compare the predicted outcomes to the observed complications. RESULTS: Of the 174 unique procedures performed during PP15 (representing 465 patients), 99 were found in the ACS-SRC (representing 256 patients). Risk calculations for PP15 were: 1.5% risk (IQR 0.9, 2.4) of "serious" complications and 2.0% risk (IQR 1.3, 2.8) of "any" complication. ACS-SRC specific risks were calculated as follows: pneumonia 0.1%, cardiac 0.0%, surgical site infection (SSI) 0.6%, urinary tract infection 0.2%, venous thromboembolism 0.1%, renal failure 0.0%, OR return 0.9%, and death 0.0%. The only specific ACS-SRC complication observed was "OR return" (0.35%) and SSI (0.35%). The observed PP15 rates for "serious" or "any" complications (ACS-SRC definition) were 0.70% (2/285) each. Receiver operating characteristics for ACS-SRC for predicting "serious" or "any" complication were 0.743 (p = 0.118) and 0.654 (p = 0.227), respectively. CONCLUSIONS: Although the ACS-SRC over-predicted risk compared to observed outcomes, it may offer a good starting point for humanitarian surgery risk calculation. Observed outcomes may be limited by loss-to-follow-up bias. Emphasis should be placed on establishing patient follow-up as part of humanitarian surgical mission planning and execution.

Biopsy Detected Gleason Pattern 5 is Associated with Recurrence, Metastasis and Mortality in a Cohort of Men with High Risk Prostate Cancer.

PURPOSE: We evaluated the relative risk of biochemical recurrence, metastasis and death from prostate cancer contributed by biopsy Gleason pattern 5 among men at high risk with Gleason 8-10 disease in the SEARCH (Shared Equal Access Regional Cancer Hospital) cohort. MATERIALS AND METHODS: Men with biopsy Gleason sum 8-10 prostate cancer treated with radical prostatectomy were evaluated. The cohort was divided into men with Gleason 4 + 4 vs those with any pattern 5 (ie Gleason 3 + 5, 5 + 3, 4 + 5, 5 + 4 or 5 + 5). Predictors of biochemical recurrence, metastases, and prostate cancer specific and overall survival were analyzed using Kaplan-Meier, log rank test and Cox proportional hazards models. RESULTS: We identified 634 men at high risk in the SEARCH database, of whom 394 (62%) had Gleason 4 + 4 and 240 (38%) had Gleason pattern 5 on biopsy. Baseline characteristics did not significantly differ between the groups. On multivariable analysis relative to Gleason 4 + 4 men at high risk with Gleason pattern 5 showed no difference in the risk of biochemical recurrence (HR 1.26, 95% CI 0.99-1.61, p = 0.065). However, they were at significantly greater risk for metastasis (HR 2.55, 95% CI 1.50-4.35, p = 0.001), prostate cancer specific mortality (HR 2.67, 95% CI 0.1.26-5.66, p = 0.010) and overall mortality (HR 1.60, 95% CI 1.09-2.34, p = 0.016). CONCLUSIONS: Preoperative subclassification of high risk prostate cancer by biopsy Gleason grade (4 + 4 vs any Gleason pattern 5) identified men at highest risk for progression. Any Gleason 5 on biopsy is associated with a greater risk of metastasis, and prostate cancer specific and overall mortality. Grouping all Gleason 8-10 tumors together as high risk lesions may fail to fully stratify men at highest risk for poor outcomes.

Robot-assisted vasovasostomy using a single layer anastomosis.

Of all patients who have vasectomies performed in the United States, upwards of 6% will pursue a vasectomy reversal. Currently, the gold-standard reversal procedure is a microscopic vasovasostomy utilizing either a one or two-layer vasal anastomosis. Unfortunately, most urologists do not perform these procedures as they require extensive training and experience in microsurgery. The objective of our study was to evaluate the feasibility and success rate of robot-assisted vasovasostomy performed at our institution. We completed a retrospective review of our experience with vasectomy reversal utilizing the da Vinci® Surgical System and a single layer vasal anastomosis. A successful reversal was defined as a return of sperm on semen analysis or light microscopy. Since 2009 we have completed 79 robotic vasectomy reversals, 60 of which utilized a single-layer vasal anastomosis. The average obstructive interval was 5.7 ± 2.2 years. Average operative time was 192 min. 42 patients returned for a post-operative semen evaluation at an average time of 4.3 months post-procedure revealing a success rate of 88% (37 out of 42). Post-operative semen parameters were significant for an average sperm density of 31.0 million/mL with an average motility of 29.1%. Robot-assisted vasovasostomy with a single layer anastomosis has overall success rates that are similar to that of reported microscopic vasovasostomy rates. Although more study is warranted with regard to cost, we feel as though our study demonstrates an alternative approach to vasectomy reversal that can be performed successfully by urologists trained in robotic surgery.

Youth varicocele and varicocele treatment: a meta-analysis of semen outcomes.

OBJECTIVE: To study youth who have a varicocele or are undergoing varicocele treatment, in relation to changes in semen, as measured by semen analysis (SA). DESIGN: Meta-analysis of studies identified via a search of PubMed, Medline, and the Cochrane Library covering the last 40 years. SETTING: Not applicable. PATIENT(S): Youth from studies that assessed the presence and/or treatment of varicocele with SA. INTERVENTION(S): Selected studies were analyzed in two separate meta-analyses: one for the effect of varicocele on semen, as measured by SA (hypothesis #1), the other for the effect of treatment on semen, as measured by SA (hypothesis #2). MAIN OUTCOME MEASURE(S): A random-effects model was used to calculate weighted mean difference (WMD) of semen outcomes. Heterogeneity was calculated. Bias was assessed with funnel plots and Egger's test. RESULT(S): The initial literature search returned 1,180 potentially relevant articles. For hypothesis #1, 10 studies with a total of 357 varicocele and 427 control subjects were included. Sperm density, motility, and morphology were significantly decreased when associated with a varicocele, with a WMD of -24.0×10(6)/mL (95% confidence interval [CI; -39.5 to -8.6]), -7.5% (95% CI [-12.3% to -2.7%]), and -1.7% (95% CI [-2.4% to -1.1%]), respectively. Another 10 studies with 379 treated and 270 untreated subjects were analyzed for hypothesis #2. Sperm density and motility were significantly improved following treatment, with a WMD of 14.6×10(6)/mL (95% CI [7.1-22.1]) and 6.6% (95% CI [2.1%-11.2%]), respectively. CONCLUSION(S): The presence of varicocele in youth appears to negatively affect sperm density, motility, and morphology. Treatment appears to result in moderate improvement of sperm density and mild improvement in sperm motility.