Case report: Bladder to lumbar spinal hardware fistula managed via partial cystectomy and removal of offending piece of spinal hardware.

A bladder to lumbar hardware fistula has never been reported. We report the case of a 67 year old male who presented with a bladder to lumbar spinal hardware fistula approximately four years following an L4-S1 anterior lumbar internal fixation. It was identified through the use of CT cystogram. His case was managed first with cystoscopy and interrogation of the fistula with a Glidewire followed by partial cystectomy and removal of some of the offending spinal hardware.

Treatment Setting Influences Treatment Modality for Urinary Stone Disease.

OBJECTIVE: To determine whether selection of treatment modality for urinary stone disease differs between primary and outreach healthcare centers, and if patient rurality predicts treatment modality. METHODS: We retrospectively evaluated Extracorporeal shock wave lithotripsy (ESWL) and ureteroscopy (URS) procedural data from the Iowa Office of Statewide Clinical Education Programs (OSCEP) and Iowa Hospital Association (IHA) databases from 2007 to 2014. Geographical data was used to analyze travel metrics and patient proximity to sites of stone treatment. Rural-urban commuting area (RUCA) codes were used to characterize patient rurality. Chi-square tests and t tests were used to compare ESWL and URS patients, and multilevel logistic regression model was used to assess influence of treatment setting on surgical modality. RESULTS: A total of 18,831 stone procedures were performed by urologists in Iowa on patients from Iowa (10,495 URS; 8336 ESWL). Around 2630 procedures occurred at outreach centers. Ureteroscopy comprised 59.7% of procedures at primary centers, but only 31.2% at outreach centers. On multilevel analysis, outreach location was associated with 2.236 OR toward ESWL (P <.001). Individual physician treatment patterns accounted for 32% of treatment variation. Patient rurality was not significantly associated with treatment modality as an independent factor (P = .879). CONCLUSIONS: Wide variation exists in urolithiasis treatment modality selection between outreach and primary centers. Outreach locations perform a significantly higher frequency of ESWL compared to URS, and much of the variation in treatment selection (32%) arises from individual physician practice patterns.

Pilot Study to Determine Optimal Stent Duration Following Ureteroscopy: Three versus Seven days.

BACKGROUND/AIMS: Many providers elect to place a stent following ureteroscopy for nephrolithiasis, but little data exists on the optimal duration to leave a stent. We sought to determine whether there are any differences in post-operative outcomes for patients with a 3 versus 7-day stent following ureteroscopy. METHODS: We retrospectively reviewed 247 patients who underwent unilateral ureteroscopy with lithotripsy, 79 of whom removed a stent with an extraction string at 3 or 7 days post-operatively. These 2 groups were compared with regard to demographic information, pre-operative variables, and post-operative outcomes. RESULTS: Of all patients, 33% experienced a post-procedure related event (phone call, extra clinic visit, and emergency department visit) within 30 days of their procedure, 39% of 3-day stent patients compared to 21% of 7-day patients (p = 0.11). Within the 3 days following stent removal, 3-day stent patients were significantly more likely to have a post-procedure related event than 7-day patients (23 vs. 3%, p = 0.026). CONCLUSION: One third of patients with a post-operative ureteral stent will seek medical care in the 30 days following ureteroscopy. Leaving a stent for 3 versus 7 days may lead to worse outcomes with regard to post-operative events and fank pain.

Increasing the size of ureteral access sheath during retrograde intrarenal surgery improves surgical efficiency without increasing complications.

PURPOSE: To directly compare intraoperative and post-operative outcomes and complications between three groups undergoing ureteroscopy: no ureteral access sheath, 12/14 Fr and larger 14/16 Fr ureteral access sheaths (UAS). METHODS: We retrospectively reviewed demographic, pre-operative, intraoperative, and post-operative data of 257 patients who underwent ureteroscopy for nephrolithiasis by a single surgeon from January 2013 through July 2015. Patients were separated into three groups: no UAS, a 12/14 Fr UAS, or 14/16 Fr UAS. Outcomes included differences in stone-free rate, post-procedure-related events (PRE), ureteral injury rate (measured by early post-operative hydronephrosis), and post-operative complications. RESULTS: A UAS was used in 65.4% (168/257) patients, with 73.8% (124/168) utilizing a 12/14 Fr UAS and 26.2% (44/168) utilizing a 14/16 Fr UAS. Those patients in whom a 14/16 Fr UAS was employed had greater stone burden compared to the 12/14 Fr UAS group (180.8 ± 18.0 vs. 104 ± 9.1 mm2, p < 0.001). When comparing 12/14 Fr and 14/16 Fr ureteral access sheaths, there was no significant difference in ureteral injury rate, complications (10.5 vs. 11.4%, respectively; p = 0.87), or overall stone-free rate (78.1 vs. 81.3%, p = 0.70). The mean amount of stone burden treated per minute of operative time was more than 30% higher in the 14/16 Fr UAS group compared to 12/14 Fr UAS group (2.11 vs. 1.62 mm2/min; p = 0.01). CONCLUSION: The use of a 14/16 Fr UAS allows for similar stone-free rate and improved operative efficiency with no increased risk of ureteral injury or post-operative complications when compared to the 12/14 Fr UAS.

Pushing Stones Uphill: Why Patients Are Lost to Follow-Up After Uncomplicated Ureteroscopy.

INTRODUCTION: We sought to determine the rate of and factors associated with patient nonadherence to prescribed follow-up after uncomplicated ureteroscopy. MATERIALS AND METHODS: The records of 247 consecutive patients who underwent ureteroscopy at a tertiary referral center from November 2010 to February 2016 were reviewed. Bivariate and multivariate analyses were performed to determine the impact of demographic, procedural, socioeconomic, and environmental factors on the rate of compliance with secondary prevention counseling. RESULTS: Forty-five patients (18.5%) were lost to scheduled follow-up for secondary prevention counseling after ureteroscopy. Lost to counseling rates were broad based and not associated with traditional predictors of poor follow-up such as age, gender, marital status, and distance traveled. On multivariate analysis, compared with those using commercial insurance, patients with Medicare (odds ratio [OR] for follow-up 0.48, 95% confidence interval [CI] 0.21, 1.1 p = 0.095) and Medicaid (OR for follow-up 0.25, 95% CI 0.1, 0.6, p < 0.001) were less likely to be adherent to prescribed follow-up. CONCLUSIONS: Nearly one in five patients will be lost to follow-up for secondary prevention counseling after ureteroscopy. Lack of follow-up may prevent the diagnosis of postoperative complications and limit the ability to counsel patients on stone prevention. Efforts to improve follow-up following ureteroscopy should focus on including more postoperative counseling in the preoperative period and a more individualized approach to specific patient populations, particularly those with a lower socioeconomic status.

Taking the Procedure to the Patient: Increasing Access to Urological Procedural Care through Outreach.

INTRODUCTION: We previously showed that urological outreach clinics significantly increase access to urological clinical care in rural populations. How such clinics affect access to urological procedural care is unknown. In this study we analyzed the use of outreach facilities for outpatient hospital based urological procedural care in a rural state. METHODS: Using information from the Office of Statewide Clinical Education Programs and the Iowa Hospital Association database, we analyzed provider level data in Iowa from 2010 to 2013. Based on CPT codes all outpatient urological procedural care was categorized by procedure type and intent. Cities containing an Iowa Hospital Association hospital were characterized as primary vs outreach. Geographic data were used for analysis of travel metrics and proximity to urological procedural care sites. Outreach urological procedures were then compared to urological procedural care at primary centers. RESULTS: During the study period 11,464 outreach urological procedures were performed, accounting for 15.0% of all outpatient urological procedures in the state. The yearly number of outreach procedures remained relatively stable during the study period. The majority (51.7%) of outreach urological procedures were therapeutic and endoscopic (62.9%) in nature. Extracorporeal shock wave lithotripsy was significantly more common for treating stone disease in the outreach setting compared to ureteroscopy (p <0.0001). CONCLUSIONS: A large percentage of the total urological procedural care in our state was done at outreach clinics and, while the majority was of low acuity, it was therapeutic. Changes in health care are projected to affect rural hospitals, which rely heavily on procedural care, and this study is the first to our knowledge to demonstrate the role that urological procedural care can have in such locations.

Definition of Successful Treatment and Optimal Follow-up after Urethral Reconstruction for Urethral Stricture Disease.

The definition of a successful urethroplasty, the lack of need for a secondary procedure, is outdated and must be amended to incorporate objective and subjective outcomes. Success is assigned if a flexible cystoscope can traverse the reconstructed urethra without force. Functional success is assigned if patient-reported outcome measures reveal improvement in voiding symptoms and urinary quality of life. Optimal follow-up strategy allows determination of anatomic and functional outcomes, protects genitourinary health, and prevents excessive invasive testing, unnecessary cost, discomfort, anxiety, and risk. Noninvasive objective uroflowmetry has high sensitivity and specificity for detecting recurrence and replaces invasive anatomic evaluation.

Left Hand-assisted Laparoscopic Nephrectomy With Renal Vein Thrombectomy for Stage T3b Renal Cell Carcinoma.

A 60-year-old male was found to have an 8.0 cm left renal mass and associated renal vein thrombus on computed tomography. The thrombus extended 3 mm beyond the right aortic border to within 1.6 cm of the left border of the inferior vena cava. The patient underwent left nephrectomy with renal vein thrombectomy using a hand-assisted laparoscopic approach. The tumor thrombus was "milked" proximally back into left renal vein, which was then divided with an endovascular stapler. Left renal vein thrombi extending to right margin of the aorta can be managed with hand-assisted laparoscopic approach.

Subpubic cartilaginous cyst presenting as acute urinary retention: a report and review of the literature.

INTRODUCTION: A subpubic cartilaginous cyst is a rare and therefore poorly understood pathologic process involving the symphysis pubis. We describe a case of a postmenopausal female with acute urinary retention secondary to a periurethral cyst, and provide a literature review of previously reported cases of women with presenting complaints of a vulvar mass or pain. The differential diagnoses of a subpubic cartilaginous cyst, as well as management options, are discussed. CASE: A 68-year-old woman presented with acute urinary retention. Physical examination revealed a 4-cm tender cystic mass palpated along the anterior vaginal wall traversing toward the posterior pubic ramus. A pelvic magnetic resonance imaging showed a 4.4 × 3.5 × 4.2-cm well-circumscribed, cystic lesion at the anterior aspect of the lower urethra with no intrinsic contrast enhancement. The cyst was surgically excised through a transvaginal approach with no recurrence to date. CONCLUSIONS: A subpubic cartilaginous cyst is an uncommon lesion thought to originate from the symphysis pubis and to be a result of degenerative changes. Patients have presented with pain, a vulvar/vaginal mass, or both. This case describes a patient who presented with acute urinary retention. In patients with suspected subpubic cartilaginous cyst, the lesion may be excised in symptomatic patient or observed in those who are asymptomatic. Standard of care has not yet been determined regarding management due to the rarity of the lesion.

Free vascularized fibular grafting preserves athletic activity level in patients with osteonecrosis.

Athletic patients with osteonecrosis of the femoral head have few desirable therapeutic options that preserve athletic ability. Because these patients are usually young and healthy, any procedure that avoids total hip arthroplasty would be most desirable. This study prospectively evaluated 15 patients (19 hips) who presented with an average age of 28.5 (range, 12 to 46) years and stages 2 (6/19), 3 (2/19), 4 (9/19), and 5 (2/19) of osteonecrosis of the femoral head. All patients were treated with free vascularized fibular autografting (FVFG) to the femoral head. Postoperative evaluations of pain symptoms and functional activity showed improvements in all patients. The average follow-up time was 8 years. Harris hip scores significantly increased from an average preoperative score of 75.3 to an average postoperative score of 94.8. Seventy-five percent of patients were able to return to their sport after recovery and all patients reported being satisfied with the procedure and would repeat their decision to have surgery. Three patients' hips were converted to arthroplasty at 3, 11, and 17 years post-FVFG. The results demonstrate that FVFG is a successful therapeutic treatment in athletes with osteonecrosis of the femoral head. It reduces pain, increases activity, and allows most patients to return to their sport, an achievement often not possible with other treatment options.