Perinephric fat stranding is associated with increased age and stone size but not with serum creatinine in patients with obstructing ureterolithiasis.

Previous reports show increased severity of perinephric fat stranding (PFS) with elevated serum creatinine in obstructing ureterolithiasis. We sought to investigate this association with our institution's patient population.We reviewed charts of patients diagnosed with obstructive ureterolithiasis or nephrolithiasis in our emergency department between January and October 2018. Patient demographics, lab results, and computed tomography (CT) imaging were reviewed. A blinded radiologist reviewed all CTs and graded hydronephrosis and PFS. Subjects were stratified by degree of PFS and compared via paired t-test, chi-squared test, univariate analysis, and multivariate analysis.We identified 141 patients; 114 had no-mild (Group 1) PFS, while 27 had moderate-severe (Group 2) PFS. Group 1 had a mean age of 56 (SD = 16.1) and mean stone size of 7.3 mm (SD = 4.22); 77% of the cohort had symptoms under 24 h. Group 2 was older with a mean age of 65 (SD = 16.2, p = 0.01) and mean stone size of 10.1 mm (SD = 6.07, p < 0.01); 50% had symptoms less than 24 h (p = 0.01). PFS did not correlate with change in serum creatinine. Univariate and multivariate analysis showed increasing age increased the odds of moderate-severe PFS by 3.5% (OR = 1.035, p < 0.05) while increased stone size increased the odds of moderate-severe PFS by 13.7% (OR = 1.137, p = 0.01).Although increased PFS correlated with increased age and stone size, no correlation was found with presenting creatinine or change in creatinine. Degree of PFS is likely a poor predictor of renal disease severity in acute ureterolithiasis.

Clinical and Genetic Characteristics of Calvarial Doughnut Lesions with Bone Fragility in Three Families with a Reccurent SGMS2 Gene Variant.

Calvarial doughnut lesions (CDL) with bone fragility with or without spondylometaphyseal dysplasia (MIM: #126550) is a rare autosomal dominant skeletal disorder characterized by low bone mineral density, spinal and peripheral fractures, and specific sclerotic lesions of the cranial bones. In the current classification of skeletal disorders, the disease is included in the group of bone fragility disorders along with osteogenesis imperfecta. The disease is caused by pathogenic variants in the SGMS2 gene, the protein product of which is sphingomyelin synthase 2, which primarily contributes to sphingomyelin (SM) synthesis-the main lipid component of the plasma membrane essential for bone mineralization. To date, 15 patients from eight families with CDL with bone fragility have been described in the literature, and a recurrent variant c.148C>T (p.Arg50Ter) in the SGMS2 gene has been identified, which was found in patients from six families. We diagnosed the disease in 11 more patients from three unrelated families, caused by the same heterozygous nonsense variant c.148C>T (p.Arg50Ter) in the SGMS2 gene. Our results show wide interfamilial and intrafamilial phenotypic variability in patients with a detected recurrent variant in the SGMS2 gene, the presence of which must be taken into consideration in the diagnosis of the disease. The primary analysis of this variant will contribute to optimal molecular genetic diagnostics, which can reduce diagnostic costs and time.

Needle Aligned Ultrasound Image-Guided Access Through Dual-Segment Array.

Ultrasound (US) guided access for percutaneous nephrolithotomy (PCNL) is gaining popularity in the urology community as it reduces radiation risk. The most popular technique involves manual image-needle alignment. A misaligned needle however needs to be retracted and reinserted, resulting in a lengthened operation time and complications such as bleeding. These limitations can be mitigated through the co-registration between the US array and needle. The through-hole array concept provides the primary solution, including a hole at the center of the array. Because of the central opening, the image-needle alignment is achieved inherently. Previous literature has described applications that are limited to superficial and intravascular procedures, suggesting that developing a through-hole array for deeper target applications would be a new breakthrough. OBJECTIVE: Here, we present a dual-segment array with a central opening. As the prototype development, two segments of 32-element arrays are combined with an open space of 10 mm in length in between them. METHOD: We conducted phantom and ex-vivo studies considering the target depth of the 80-100 mm range. The image quality and needle visibility are evaluated by comparing the signal-to-noise ratio (SNR), full width at half maximum (FWHM), and contrast-to-noise ratio (CNR) results measured with a no-hole linear array under equivalent conditions. An ex-vivo study is performed using porcine kidneys with ceramic balls embedded to evaluate the needle access accuracy. RESULTS AND CONCLUSION: The mean needle access error of 20 trials is found to be 2.94 ±1.09 mm, suggesting its potential impact on realizing a simple and intuitive deep US image-guided access.

Ex-vivo ureteroscopy, laser lithotripsy, and stone basketing extraction of deceased donor kidney stones during machine perfusion preservation.

The incidence of nephrolithiasis in kidney donors is rare. The timing and treatment of nephrolithiasis in deceased donor kidneys are not well established. While some programs have proposed ex-situ rigid or flexible ureteroscopy treatment before transplantation, we report on two cases of kidney stones in the same deceased donor that we treated by flexible ureteroscopy and laser lithotripsy performed during the storage time on a hypothermic perfusion machine. Two deceased donor kidneys were found to have multiple kidney stones discovered on preprocurement CT imaging. The right kidney had less than five 2-3 mm stones, whereas the left had five to ten 1 mm stones with a single 7 mm stone. Both organs were placed on a hypothermic perfusion machine and maintained at a temperature of 4°C. An ex-vivo flexible ureteroscopy with laser lithotripsy and basket extraction was performed while the kidneys were maintained on Lifeport* perfusion machine. The cold ischemia time was 16.9 and 23.1 h. After 12 months of observational follow-up, neither recipient had nephrolithiasis, UTI, or other urologic complications. The creatinine values now are 1.17 and 2.44 mg/dL (103.4 and 215.7 µmol/L), respectively. Ex-vivo flexible ureteroscopy with laser lithotripsy and stone removal on machine-perfused kidneys appears to be safe and offers a good option to treat graft nephrolithiasis and prevent posttransplant complications. Ureteroscopy serves as a minimally invasive treatment option with direct stone removal. Performing this while on machine perfusion minimizes the ischemic time of the kidney and resultant complications or delays in graft function.

Efficacy of Intramuscular Ketorolac for Preventing Renal Colic Post Stent Removal: Randomized Controlled Trial.

PURPOSE: The treatment of stones ureteroscopically is associated with postoperative pain, thought to be due largely to the use of ureteral stents. In some, stent removal precipitates renal colic that can last from minutes to hours. We sought to determine if intramuscular ketorolac could reduce post-stent removal renal colic. MATERIALS AND METHODS: We performed a prospective, randomized, double-blind, placebo-controlled trial assessing the effects of ketorolac administered at time of stent removal. Patients were randomized to receive an intramuscular ketorolac 30 mg or placebo immediately prior to stent removal. Patients were contacted 1 and 7 days after stent removal to assess pain, need for opioids, emergency department or clinic visits and the need for surgical/medical interventions. RESULTS: A total of 124 patients (62 patients each in the control and treatment groups) were included in the study. The groups were comparable in demographic/operative characteristics. No difference in mean pain scores or proportion of patients who experienced severe pain at 1 and 7 days post stent removal was detected between groups. However, use of ketorolac resulted in significantly fewer renal colic-related unplanned emergency department/clinic visits in the treatment group (2%) compared with the control group (13%, p=0.032). CONCLUSIONS: Although administration of ketorolac prior to stent removal does not significantly reduce overall subjective pain experienced post stent removal compared to placebo, it does reduce the likelihood of severe renal colic requiring emergency department or office visits. Eligible patients may benefit from routine use of ketorolac injection at the time of stent removal.

Single-port robotic-assisted simple prostatectomy is associated with decreased post-operative narcotic use in a propensity score matched analysis.

Robotic-assisted simple prostatectomy (RASP) has proven to be an effective minimally invasive option for benign prostatic enlargement (BPE) in recent years. Single-site surgery is theorized to reduce post-operative pain beyond traditional minimally invasive approaches. We sought to assess whether use of a single-port robotic platform decreases post-operative opioid use in patients undergoing robotic-assisted simple prostatectomy (RASP). A retrospective review was performed of all patients undergoing RASP our institution from November 2017 to July 2019. Demographic, intraoperative, and post-operative data, including morphine equivalent (ME) use, were collected. Patients were stratified by robotic platform utilized. Propensity score matching using nearest neighbor method was performed using prostate volume, Charlson comorbidity index (CCI), and post-op ketorolac use in 4:1 fashion. Chi-squared analysis and Kruskal-Wallis analyses were utilized. Two-hundred-and-seven men underwent RASP. After matching, 80 patients (64 multi-port, 16 single-port) were included in the analysis. Groups were comparable for age, body mass index, CCI, prostate volume, prior opioid use, and use of scheduled ketorolac post op. The single-port approach was associated with a reduction in MEs once admitted to the floor (5 vs. 11 mg, p = 0.025) and an increase in the proportion of patients who did not require any narcotics post-operatively (44 vs. 19%, p = 0.036). In a propensity matched cohort of patients undergoing RASP at a single institution, use of the single-port robotic system conferred a significant decrease in post-operative narcotic use by approximately 50%.

Neutron Source Based on Vacuum Insulated Tandem Accelerator and Lithium Target.

A compact accelerator-based neutron source has been proposed and created at the Budker Institute of Nuclear Physics in Novosibirsk, Russia. An original design tandem accelerator is used to provide a proton beam. The proton beam energy can be varied within a range of 0.6-2.3 MeV, keeping a high-energy stability of 0.1%. The beam current can also be varied in a wide range (from 0.3 mA to 10 mA) with high current stability (0.4%). In the device, neutron flux is generated as a result of the 7Li(p,n)7Be threshold reaction. A beam-shaping assembly is applied to convert this flux into a beam of epithermal neutrons with characteristics suitable for BNCT. A lot of scientific research has been carried out at the facility, including the study of blistering and its effect on the neutron yield. The BNCT technique is being tested in in vitro and in vivo studies, and the methods of dosimetry are being developed. It is planned to certify the neutron source next year and conduct clinical trials on it. The neutron source served as a prototype for a facility created for a clinic in Xiamen (China).

Irreversible Electroporation for Renal Ablation Does Not Cause Significant Injury to Adjacent Ureter or Bowel in a Porcine Model.

Objective: To evaluate the safety of irreversible electroporation (IRE) for renal ablation adjacent to the ureter or bowel. Materials and Methods: Six adult pigs each underwent bilateral IRE of the kidney. To simulate adjacence, the left proximal ureter and duodenum were secured onto the left and right kidney capsule, respectively. Two IRE probes were placed into the renal parenchyma and configured to bridge the ureter and bowel. Therapeutic IRE was delivered at 2000 V/cm for 70 pulses in both forward and reverse polarity. The animal was survived and euthanized at 1, 3, or 14 days. Histopathology was obtained for all potentially injured bowel and ureteral segments. Retrograde pyelogram (RPG) was performed on each left-sided ureter. Results: Histologic analysis of the ureter identified reactive changes at the level of the periureteral adipose tissue, which progressed from acute inflammation on day 1 to focal fibrosis by day 14. Urothelial mucosa and surrounding smooth muscle layers were unaffected at all time points. RPGs did not show any abnormalities in all specimens. Histologic analysis of the bowel demonstrated acute inflammation in the serosa and subserosal tissue on day 1. Three days after IRE, inflammation and crypt abscesses were focally present in the deep aspects of the bowel mucosa. Inflammation in the mucosal layer resolved 14 days after IRE. Conclusions: In a porcine model of renal IRE, no significant injury was apparent after intentional ablation adjacent to the ureter and bowel. IRE may be a safe alternative to thermal ablation for tumors near the ureter or bowel.

Expression of Small Noncoding RNAs in Urinary Exosomes Classifies Prostate Cancer into Indolent and Aggressive Disease.

PURPOSE: This is the first report of the development and performance of a platform that interrogates small noncoding RNAs (sncRNA) isolated from urinary exosomes. The Sentinel™ PCa Test classifies patients with prostate cancer from subjects with no evidence of prostate cancer, the miR Sentinel CS Test stratifies patients with prostate cancer between those with low risk prostate cancer (Grade Group 1) from those with intermediate and high risk disease (Grade Group 2-5), and the miR Sentinel HG Test stratifies patients with prostate cancer between those with low and favorable intermediate risk prostate cancer (Grade Group 1 or 2) and those with high risk (Grade Group 3-5) disease. MATERIALS AND METHODS: sncRNAs were extracted from urinary exosomes of 235 participants and interrogated on miR 4.0 microarrays. Using proprietary selection and classification algorithms, informative sncRNAs were selected to customize an interrogation OpenArray™ platform that forms the basis of the tests. The tests were validated using a case-control sample of 1,436 subjects. RESULTS: The performance of the miR Sentinel PCa Test demonstrated a sensitivity of 94% and specificity of 92%. The Sentinel CS Test demonstrated a sensitivity of 93% and specificity of 90% for prediction of the presence of Grade Group 2 or greater cancer, and the Sentinel HG Test demonstrated a sensitivity of 94% and specificity of 96% for the prediction of the presence of Grade Group 3 or greater cancer. CONCLUSIONS: The Sentinel PCa, CS and HG Tests demonstrated high levels of sensitivity and specificity, highlighting the utility of interrogation of urinary exosomal sncRNAs for noninvasively diagnosing and classifying prostate cancer with high precision.

Ten-Year Outcomes of Renal Tumor Radio Frequency Ablation.

PURPOSE: We reviewed long-term oncologic outcomes in patients with renal tumors treated with radio frequency ablation more than 10 years ago. MATERIALS AND METHODS: We retrospectively reviewed the records of patients with renal tumors who underwent radio frequency ablation from November 2000 to August 2007. Demographic, clinical and radiological data were assessed to determine evidence of disease recurrence. Patients with familial renal cell carcinoma syndromes were excluded from study. We calculated disease-free, metastasis-free, cancer specific and overall survival with the Kaplan-Meier method. Subgroup analysis of patients who had at least 10 years followup was performed to determine actual 10-year survival. Analysis was also performed based on tumor size. RESULTS: A total of 112 tumors in 106 patients were treated with radio frequency ablation. Median followup was 79 months (IQR 28.9-121.1) and mean ± SD tumor size was 2.5 ± 0.8 cm. Initial technical success was achieved in 97% of cases. There were 10 recurrences. Kaplan-Meier 6-year disease-free and cancer specific survival rates were 89% and 96%, respectively. Disease-free survival decreased to 68% for tumors greater than 3 cm. In the subgroup with at least 10-year followup the actual disease-free, cancer specific and overall survival rates were 82%, 94% and 49%, respectively. No patient experienced recurrence after 5 years. CONCLUSIONS: Radio frequency ablation is a safe and effective treatment option for small renal masses less than 3 cm in diameter. We report good oncologic outcomes with actual 10-year survival data. No recurrence developed after 5 years. Tumors greater than 3 cm have significantly poorer outcomes.

Surgical Outcomes of Three vs Four Arm Robotic Partial Nephrectomy: Is the Fourth Arm Necessary?

OBJECTIVE: To compare the cost, efficacy, and safety of 3-arm versus 4-arm technique in robotic partial nephrectomy (RPN). Surgeons may either elect to utilize three vs four robotic instruments depending on preference. The purpose of this study is to compare the outcomes between the two techniques. METHODS: RPNs from June 2016 to August 2017 were retrospectively reviewed. Tumor features, surgical parameters, and operative outcomes were evaluated. The number of arms used was determined. Statistical analysis was performed with the Student's t test, chi-squared, and Mann-Whitney test. RESULTS: A total of 61 consecutive 3-arm RPNs and 59 consecutive 4-arm RPNs were evaluated. Mean tumor diameter and median nephrometry score were 3.4 cm (± 1.1 SD) and 7 (6-8 IQR) for the 3-arm group and 3.3 cm (±1.2 SD) and 6 (5-8 IQR) for the 4-arm group, respectively (size: p = 0.7, nephrometry: p = 0.07). Hospital length of stay, operative time, estimated blood loss, complication rate, blood transfusion rate, and readmission rate all demonstrated no statistically significant difference between 3-arm and 4-arm groups (p >0.05). Mean ischemia time was shorter by 5.1 minutes in the 4-arm group (p = 0.02). Rate of margin positivity was higher in the 4-arm group (0% vs 10%, p = 0.03). CONCLUSION: RPN can be safely and effectively completed with 3-robotic arms. While there was increased ischemia time, the difference was small and likely not of clinical significance. The routine addition of the fourth robotic arm in RPN is not necessary.

Development and Evaluation of a Novel Endoscopic Sack to Facilitate Tissue Prostate Adenoma Morcellation.

INTRODUCTION: Morcellation of the adenoma after laser enucleation of the prostate (LEP) is both time-consuming and prone to complications. We have designed a novel polyethylene sack (ProSac) to improve the morcellation process following LEP. Both silicone and cadaver models were utilized to evaluate the safety and efficacy of ProSac. METHODS: The inanimate model used tissue-mimicking silicone to accurately approximate bladder volume and compliance. The second model was developed using a fresh cadaver. Heat-fixed chicken breast was used to mimic enucleated prostatic adenoma. Morcellation of the simulated adenoma tissue was tested in both models with and without the ProSac. Morcellated tissue was removed from the filter, desiccated, and weighed after each run to establish morcellation efficiency. Visual inspection was used to evaluate for mucosal injury or bladder perforation. A hydromanometer was placed in the cadaveric bladder to measure bladder pressure. RESULTS: The device was able to capture up to 30 g of tissue with good closure while maintaining good distention and visualization during morcellation. In the silicone model, morcellation efficiency with the device was 4.6 g/minute, while efficiency without the device was 2.6 g/minute (p = 0.03). In the cadaveric model, mean entrapment time was 22 ± 11 seconds. Morcellation efficiency with the device was 2.1 g/minute when excluding entrapment time and 1.9 g/minute including entrapment time. Without the ProSac, morcellation efficiency was 1.2 g/minute (p = 0.05). In both models, multiple mucosal injuries occurred without the device, while none occurred with the device. Bladder pressure was similar between study arms. CONCLUSIONS: The ProSac is a novel device that can provide additional safety during adenoma morcellation. It may also achieve clinically and statistically significant improvement in morcellation efficiency without increasing bladder pressure.

Medical therapy for nephrolithiasis: State of the art.

The prevalence of nephrolithiasis is increasing worldwide. Understanding and implementing medical therapies for kidney stone prevention are critical to prevent recurrences and decrease the economic burden of this condition. Dietary and pharmacologic therapies require understanding on the part of the patient and the prescribing practitioner in order to promote compliance. Insights into occupational exposures and antibiotic use may help uncover individual risk factors. Follow-up is essential to assess response to treatment and to modify treatment plans to maximize therapeutic benefit.

Determining the Learning Curve for Robot-Assisted Simple Prostatectomy in Surgeons Familiar with Robotic Surgery.

PURPOSE: Robot-assisted simple prostatectomy (RASP) has excellent outcomes when treating large volume prostates and incorporates the already familiar skills to most robotic surgeons. Our objective was to determine the learning curve for RASP. MATERIALS AND METHODS: A retrospective review of RASP on 120 consecutive cases performed by two experienced robotic surgeons from 2014 to 2017 was conducted. We defined "learning curve" as the point at which operative parameters transition from logarithmic to linear improvement. Scatter plots of operative outcomes were constructed and logarithmic and linear best-fit line were estimated to determine the point of transition from logarithmic to linear improvement. RESULTS: Surgeon 1 operated on 76 cases and surgeon 2 on 44 cases. The median age of the 120 patients who underwent RASP was 70.0 years (interquartile range [IQR] 65.0-74.0 years) and median prostate mass was 121.5 g (IQR = 102.0-149.3). Overall, high-grade complication rate was 7.5%; median hematocrit change was 5.4% (IQR = 3.2-7.7) and tissue yield was 61.2 g (IQR = 49.7-76.9). Tissue yield demonstrated logarithmic improvement over the first 12 cases and then transitioned to a linear patter for one surgeon. Operative time in the last 10 cases was statistically different from the first 10 cases (p < 0.01). Drop in hematocrit (ΔHct) for surgeon 2 demonstrated logarithmic improvement for the first 10 cases and then transitioned to a linear pattern. CONCLUSION: The learning curve for RASP varied depending on the variable examined. Blood loss (ΔHct) and tissue yield showed the greatest improvement over time, but neither showed significant improvement beyond 12 cases. We estimated the learning curve for RASP to be ∼10 to 12 cases for experienced robotic surgeons.

Comparison of Robot-Assisted Versus Open Simple Prostatectomy for Benign Prostatic Hyperplasia.

PURPOSE OF REVIEW: Recent advancements in minimally invasive approaches for prostate surgery have provided numerous options for surgical management of benign prostatic hyperplasia (BPH). In the setting of a large prostate, an open simple prostatectomy was previously considered the gold standard surgical treatment. However, the recently updated American Urological Association (AUA) guidelines on surgical management of BPH now consider both open and minimally invasive approaches to simple prostatectomy viable alternatives for treating large glands, depending on expertise with the techniques. The purpose of our review is to discuss the minimally invasive robot-assisted approach and compare it to the classic open approach to simple prostatectomy. RECENT FINDINGS: Despite longer operative times, the robotic approach is associated with shorter hospital stay and lower morbidity profile. The morbidity of an open approach remains significant. Blood transfusions are 3-4 times as likely compared to a robotic approach and major complications are twice as likely. Consistent with previous literature, our review shows functional outcome improvements like flow rate and symptom score to be comparable between the robotic and open approach. The amount of adenoma resected and PSA decline is also similar among robotic and open cases. Robot-assisted simple prostatectomy is a safe and effective procedure for BPH secondary to a large prostate gland. Appropriately, it is no longer deemed "investigational" by the latest AUA guidelines on BPH and recommended as an alternative to the open approach.

Robotic Laparoendoscopic Single Site: Pyeloplasty and Nephrectomy Chapter.

Robotic laparoendoscopic single site (RLESS) for upper tract procedures is safe and feasible in the correctly selected patient. An ideal candidate is young, has a low body mass index, and is undergoing surgery for benign indications. For RLESS procedures, we utilize a GelPOINT® access platform for "single-port" placement and ports are configured in a diamond shape. Five millimeter EndoWrist® robotic instruments are placed under direct vision. Range of motion is increased by utilizing the chopstick technique. The surgeon must always be aware of the orientation of each instrument to prevent counter-springing associated with their crossing at the level of the abdominal wall. The robotic camera lens and instruments must be moved synchronously, given their coaxial orientation relative to each other. In this chapter, we describe our technique for two of the most common RLESS upper tract procedures: pyeloplasty and nephrectomy.