Erosion of embolization coil into the renal collecting system: Retrograde fragmentation of stone and coil via thulium laser lithotripsy.

A 50-year-old female developed kidney stones on an eroded embolization coil 16 months after percutaneous nephrolithotomy (PCNL) related bleeding complications. Retrograde ureteroscopy and thulium laser lithotripsy was performed to fragment the exposed portion of the coil into clinically insignificant pieces. Thulium laser coil fragmentation remains a potential strategy to remove eroded coils and their associated kidney stones; however, recurrent stone formation on the coil stump may necessitate repeat intervention if this conservative approach is pursued over radical antegrade coil removal. This case highlights the importance of continued surveillance and multidisciplinary management in preventing and treating coil erosion after PCNL.

Postoperative events and complications of next-day stent removal following uncomplicated percutaneous nephrolithotomy compared to longer stenting.

INTRODUCTION: Options for renal drainage after percutaneous nephrolithotomy (PCNL) vary and depend primarily on surgeon preference and case considerations. In our practice, patients traditionally returned one week postoperatively to remove the stents in the office via cystoscopy; however, following uncomplicated PCNL with no plans for second-look procedure, a ureteral stent on a tether is currently removed in tandem with the Foley catheter on postoperative day 1 (POD1) prior to patient discharge. This study compared the number of postoperative events between POD1 stent removal and their longer stented counterparts. METHODS: We conducted a retrospective chart review on all patients who had undergone PCNL at our institution from January 1, 2020, to June 31, 2021. Patient demographics, operative metrics, and postoperative events (telephone calls, emergency department [ED ]/clinic visits, and complications) were recorded and compared between the two groups. RESULTS: A total of 243 patients were included in final analysis: 46% (n=111) had their stent removed on POD1 and 54% (n=132) had longer indwelling stent times. Baseline demographics were similar between the two groups. Number of telephone calls (p=0.081), ED /clinic visits (p=0.093), and complications (p=0.647) were similar between groups. There were three (1.3%) unplanned second-look procedures: two (1.8%) in the POD1 stent removal group and one (0.8%, p=0.475) in the later stent removal group. CONCLUSIONS: In this limited, retrospective study, we did not detect a difference in postoperative events or short-term complications for POD1 vs. later stent removal after uncomplicated PCNL.

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.

The Fate of Residual Fragments After Percutaneous Nephrolithotomy: Results from the Endourologic Disease Group for Excellence Research Consortium.

Background: Residual fragments (RFs) after percutaneous nephrolithotomy (PCNL) have a significant impact on patients' quality of life and clinical course. There is a paucity of studies that evaluate the natural history of RFs after PCNL. The objective of this study is to compare rates of reintervention, complications, stone growth, and passage in patients with RFs >4, ≤4, and ≤2 mm after PCNL. Methods: Sites from the Endourologic Disease Group for Excellence (EDGE) research consortium examined data of PCNL patients from 2015 to 2019 with at least 1-year follow-up. RF passage, regrowth, reintervention, and complications were recorded and RFs were stratified into >4 and ≤4 mm groups, as well as >2 and ≤2 mm groups. Potential predictors for stone-related events after PCNL were determined using multivariable logistic regression analysis. It was hypothesized that larger RF thresholds would result in lower passage rates, faster regrowth, and greater clinically significant events (complications and reinterventions) than smaller RF thresholds. Results: A total of 439 patients with RFs >1 mm on CT postoperative day 1 were included in this study. For RFs >4 mm, rates of reintervention were found to be significantly higher and Kaplan-Meier curve analysis showed significantly higher rates of stone-related events. Passage and RF regrowth were not found to be significantly different compared with RFs ≤4 mm. However, RFs ≤2 mm had significantly higher rates of passage, and significantly lower rates of fragment regrowth (>1 mm), complications, and reintervention compared with RFs >2 mm. On multivariable analysis, older age, body mass index, and RF size were found to be predictive of stone-related events. Conclusions: With the largest cohort to date, this study by the EDGE research consortium further confirms that clinically insignificant residual fragment is problematic for patients after PCNL, particularly in older more obese patients with larger RFs. Our study underscores the importance of complete stone clearance post-PCNL and challenges the use of Clinically insignificant residual fragment (CIFR).

Improving Access and Quality of Care for Kidney Stone Patients in an Underserved Community.

There is a call to improve Medicaid patient access to health care, enhance quality and outcomes of care, and reduce overall financial burden. We sought to build a comprehensive kidney stone program to help patients navigate through the acute and preventive aspects of stone disease by increasing multidisciplinary referrals and compliance with recommendations and decreasing no-show rates at first follow-up and repeat stone encounters after initial evaluation. A collaborative multidisciplinary program was established at our single institution consisting of urology, nephrology, and dietary specialists to be piloted over a 3-year period. Medicaid-designated patients were evaluated during new patient encounters by urology specialists and then followed for outpatient follow-up, including specialty referrals to nephrology specialists and dietitians, for targeted preventive measures. Subjective compliance reports by patients following interventions and no-show rates at subsequent follow-ups were documented. We also followed patients 6 months beyond the initial encounter to assess repeat Emergency Department (ED) visits for acute stone episodes. One hundred eighty-three Medicaid-designated stone patients were evaluated from 2018 to 2021. Sixty-eight percent of patients identified as White, 18% identified as Black/African American, and 14% identified as "Other." Patients underwent specialty referrals to nephrology or a dietician in 47% and 42% of cases, respectively. Since the program's implementation, reported patient compliance and referrals to multidisciplinary specialists increased from 72.9% to 81.30% and 21.2% to 56.20%, respectively. Repeat ED visits for stone-related encounters within 6 months of initial presentation remained relatively stable (from 17.60% to 18.9%), while no-show rates at first follow-up decreased from 20.0% to 6.30% by study conclusion. There is continued supporting evidence for the importance of a comprehensive kidney stone program specifically for patients of lower socioeconomic status following a 3-year implementation at our institution. Encouraging results indicate increased access to multidisciplinary specialty referrals, with improvement in follow-up and reported compliance related to stone prevention strategies.

Fellowship training in endourology: Impact on percutaneous nephrolithotomy access patterns.

INTRODUCTION: Percutaneous nephrolithotomy (PCNL) remains the treatment of choice for kidney stones larger than 2 cm. Few studies have examined the reasons why some urologists obtain their own PCNL access while others prefer to have interventional radiology (IR) obtain access. The objective of this study was to investigate what factors influence this decision. METHODS: A survey was posted to the American Urological Association's (AUA) Young Urologist Community. Descriptive statistics and exploratory analyses were used to summarize practice trends and motivating factors. RESULTS: All 99 respondents began practicing within the past 11 years. Ninety-two currently perform PCNLs and 47% of them obtain their own access. Endourology fellowship-trained physicians were more likely to currently obtain their own access (75%) compared to urologists who completed non-endourology fellowships (75% vs. 23%, p=0.58) and non-fellowship-trained urologists (75% vs. 45%, p=0.01). Logging >50 cases during training also predicted physicians obtaining their own access and having a larger annual number of PCNL cases. The most common motivator for obtaining one's own access was preference to control their own access point (95%). CONCLUSIONS: Urologist-obtained PCNL access was associated with greater training experience (endourology fellowship) and current annual PCNL case volume. Urologist-reported factors that influenced the decision to obtain one's own access include control of access, comfort level, and both physician and patient convenience. By identifying the factors that influence practice patterns, we may better address barriers, improve education to make urologistobtained PCNL access feasible even without fellowship training, and ultimately improve outcomes and quality of care.

Multi-Institutional Prospective Randomized Control Trial of Novel Intracorporeal Lithotripters: ShockPulse-SE vs Trilogy Trial.

Introduction: Currently, there are multiple intracorporeal lithotripters available for use in percutaneous nephrolithotomy (PCNL). This study aimed to evaluate the efficiency of two novel lithotripters: Trilogy and ShockPulse-SE. Materials and Methods: This is a prospective multi-institutional randomized trial comparing outcomes of PCNL using two novel lithotripters between February 2019 and June 2020. The study assessed objective measures of stone clearance time, stone clearance rate, device malfunction, stone-free rates, and complications. Device assessment was provided through immediate postoperative survey by primary surgeons. Results: There were 100 standard PCNLs completed using either a Trilogy or ShockPulse-SE lithotrite. Using quantitative Stone Analysis Software to estimate stone volume, the mean stone volume was calculated at 4.18 ± 4.79 and 3.86 ± 3.43 cm3 for the Trilogy and ShockPulse-SE groups, respectively. Stone clearance rates were found to be 1.22 ± 1.67 and 0.77 ± 0.68 cm3/min for Trilogy vs ShockPulse-SE (p = 0.0542). When comparing Trilogy to ShockPulse-SE in a multivariate analysis, total operative room time (104.4 ± 48.2 minutes vs 121.1 ± 59.2 minutes p = 0.126), rates of secondary procedures (17.65% vs 40.81%, p = 0.005), and device malfunctions (1.96% vs 34.69%, p < 0.001) were less, respectively. There was no difference in final stone-free rates between devices. Conclusion: Both the Trilogy and ShockPulse-SE lithotripters are highly efficient at removing large renal stones. In this study, we noted differences between the two devices including fewer device malfunctions when Trilogy device was utilized. Clinical Trial ID number: NCT03959683.

A Randomized Controlled Trial of Preoperative Prophylactic Antibiotics for Percutaneous Nephrolithotomy in Moderate to High Infectious Risk Population: A Report from the EDGE Consortium.

PURPOSE: Postoperative infectious related complications are not uncommon after percutaneous nephrolithotomy. Previously, we noted that 7 days of antibiotics did not decrease sepsis rates compared to just perioperative antibiotics in a low risk percutaneous nephrolithotomy population. This study aimed to compare the same regimens in individuals at moderate to high risk for sepsis undergoing percutaneous nephrolithotomy. MATERIALS AND METHODS: Patients were prospectively randomized in this multi-institutional study to either 2 days or 7 days of preoperative antibiotics. Enrolled patients had stones requiring percutaneous nephrolithotomy and had either a positive preoperative urine culture or existing indwelling urinary drainage tube. Primary outcome was difference in sepsis rates between the groups. Secondary outcomes included rate of nonseptic bacteriuria, stone-free rate and length of stay. RESULTS: A total of 123 patients at 7 institutions were analyzed. There was no difference in sepsis rates between groups on univariate analysis. Similarly, there were no differences in nonseptic bacteriuria, stone-free rate and length of stay. On multivariate analysis, 2 days of antibiotics increased the risk of sepsis compared to 7 days of antibiotics (OR 3.1, 95% CI 1.1-8.9, p=0.031). Patients receiving antibiotics for 2 days had higher rates of staghorn calculus than the 7-day group (58% vs 32%, p=0.006) but post hoc subanalysis did not demonstrate increased sepsis in the staghorn only group. CONCLUSIONS: Giving 7 days of preoperative antibiotics vs 2 days decreases the risk of sepsis in moderate to high risk percutaneous nephrolithotomy patients. Future guidelines should consider infectious risk stratification for percutaneous nephrolithotomy antibiotic recommendations.

Trends in Acute Pain Management for Renal Colic in the Emergency Department at a Tertiary Care Academic Medical Center.

Introduction: Renal colic secondary to kidney stone disease is a common reason for emergency department (ED) visits and often leads to patients receiving narcotic medications. The objective of this study was to describe longitudinal analgesia prescribing patterns for kidney stone patients acutely managed in the ED. Methods: This was a retrospective chart review of patients who presented to the ED between 2013 and 2018 and were subsequently diagnosed with a kidney stone. Encounters during which opioids and nonopioids were administered in the ED and prescribed at discharge were stratified by year, race, ethnicity, insurance status, gender, and location of ED (main academic campus and community-based campus). Patients were excluded if they required hospital admission or a stone-related procedure related to the ED encounter. Results: We reviewed 1620 total encounters for 1376 unique patients. Frequency of patients receiving opioids in the ED decreased from 81% in 2013 to 57% in 2018 (p < 0.001). During the same time period, nonopioid administration in the ED remained relatively unchanged (64% vs 67%). The proportion of patients prescribed opioids at discharge decreased from 77% to 59% (p < 0.001), while nonopioid prescriptions at discharge increased from 32% to 41% (p = 0.010). Frequency of administering both a narcotic and non-narcotic during the same ED encounter decreased over the 5-year period from 27% to 8% (p < 0.001). Conclusion: Opioids are being given less both during the ED encounter and at discharge for acute renal colic, while nonopioid prescribing is increasing. These trends may be due to increasing physician awareness to opioid addiction, or as a result of stricter legislation prohibiting opioid prescribing.

Single-Use Grasper Integrated Flexible Cystoscope for Stent Removal: A Micro-Costing Analysis-Based Comparison.

Background: A single-use flexible cystoscope with integrated grasper (Isiris; Coloplast, Denmark) has recently become commercially available. The objective of our study is to compare the costs of stent removal in an outpatient clinical environment between the single-use Isiris system (Coloplast) to our existing approach using a reusable cystoscope and stent grasper. Materials and Methods: The number of stent removal procedures at our tertiary center was recorded as a proportion of all cystoscopic procedures performed between February 2016 and February 2017. Elements in the micro-cost assessment included original purchasing price of an Olympus digital reusable cystoscope, repair fee (based on a 1-year contract), sterilization equipment and accessory costs, reprocessing costs of the cystoscope, and labor costs. The costs were estimated on a per-use basis and compared to the purchasing price of Isiris. Results: A total of 1775 cystoscopic procedures were performed, and the reusable cystoscope was used for stent removal in 871 (49%) cases. The per-use cost for stent removal procedures using the reusable cystoscope was estimated to be $161.85. The single per-use purchasing price for the Isiris device is $200. Based on the current volume, the break-even point was calculated to be 704 stent pulls. After 704 stent pulls, the cost benefit favors the reusable cystoscope. Conclusion: Based on this micro-cost analysis, per-use costs appear to favor the reusable cystoscope for stent removal. It appears that centers with high volumes of stent pulls may find the reusable cystoscope and stent grasper more cost beneficial than the single-use system.

The Impact of Ureteral Access Sheath Use on the Development of Abnormal Postoperative Upper Tract Imaging after Ureteroscopy.

PURPOSE: Ureteral access sheaths are commonly used during ureteroscopy to facilitate stone removal, improve visibility and maintain low intrarenal pressures. However, the use of a ureteral access sheath can cause ureteral wall ischemia and ureteral tears, potentially increasing the risk of postoperative ureteral stricture and obstruction. We studied the impact of ureteral access sheath use on postoperative imaging studies. Secondary objectives included studying the impact of other intraoperative parameters on postoperative imaging studies. MATERIALS AND METHODS: A retrospective chart review was conducted of cases that underwent ureteroscopy for nephroureterolithiasis across 2 high volume institutions between January 2012 and September 2016. Patient demographics, cumulative stone size, operative time, use of ureteral access sheath, laser lithotripsy, basket extraction, preoperative ureteral stent and postoperative ureteral stent placement were extracted from the electronic medical record. Findings of followup renal ultrasound, kidney-ureter-bladder x-ray and/or computerized tomography at approximately 8 weeks after surgery were recorded. RESULTS: A total of 1,332 ureteroscopies were performed with 1,060 cases (79.6%) returning for routine upper tract imaging after ureteroscopy. Postoperative hydronephrosis was noted following 127 cases (12.0%). Factors predicting presence of hydronephrosis after ureteroscopy include lower body mass index (p=0.0016), greater cumulative stone size (p=0.0003), increased operative time (p <0.0001), preoperative ureteral stent (OR 1.49, p=0.0299) and postoperative ureteral stent placement (OR 6.43, p=0.0031). Postoperative hydronephrosis was not associated with use of ureteral access sheath, age, laser lithotripsy or basket extraction. CONCLUSIONS: Use of ureteral access sheath did not have a significant impact on development of postoperative hydronephrosis, suggesting ureteral access sheath is safe for use during ureteroscopy. Ureteral strictures remain rare following ureteroscopy, seen in only 1.0% of our cohort. With an observed prevalence of hydronephrosis of 12.0% on followup imaging at 8 weeks, routine upper tract imaging after ureteroscopy remains a valuable prognostic tool.

Reducing Fluoroscopy Time in Percutaneous Nephrolithotomy.

Introduction: Reducing fluoroscopy time (FT) during percutaneous nephrolithotomy (PCNL) is an opportunity for stewardship of ionizing radiation in stone patients. We present our initial results of a radiation reduction protocol (RRP) used during PCNL with fluoroscopy-guided access by the urologist. Materials and Methods: Retrospective chart review of all PCNL cases performed between January and October 2017, divided in two groups: pre-RRP (group 1) and post-RRP (group 2). Fluoroscopy was performed using low-dose and pulsed mode. Measures implemented to reduce FT include (1) one-spot images, (2) reliance on tactile feedback, and (3) using shorter segments of live fluoroscopy. The primary outcome was FT. Results: Eighty-nine PCNL procedures were performed in 89 patients, 45 in group 1 and 44 in group 2. Overall median (interquartile range) age, body mass index (BMI), and stone burden (largest axial diameter) was 56 (45-66) years, 31.3 (27-37.4) kg/m2, and 27.7 (19-41) mm, respectively, and were comparable in both the groups. The median (range) FT in group 1 and group 2 was 240 (56.0-916.0) and 65.5 (13.0-561.0) seconds (p < 0.0001), respectively. There was no correlation between FT and increasing BMI and stone burden. Overall stone-free rate was 57% (58% and 57% in group 1 and group 2, respectively, p = 0.5995), with 10 patients (11%) undergoing ancillary procedures. Overall and major (Clavien 3a+) complications occurred in 10 (11%) and 5 (6%) cases, respectively, in the overall cohort. Conclusion: FT in PCNL can be significantly reduced by adapting simple techniques and being increasingly vigilant of its usage, thereby reducing radiation exposure to the surgeon and the patient.

Use of the Quick Sequential Organ Failure Assessment Score for Prediction of Intensive Care Unit Admission Due to Septic Shock after Percutaneous Nephrolithotomy: A Multicenter Study.

PURPOSE: Recent studies have demonstrated that quick sequential organ failure assessment criteria may be more accurate than systemic inflammatory response syndrome criteria to predict postoperative sepsis. In this study we evaluated the ability of these 2 criteria to predict septic shock after percutaneous nephrolithotomy. MATERIALS AND METHODS: We performed a retrospective multicenter study in 320 patients who underwent percutaneous nephrolithotomy at a total of 8 institutions. The criteria for quick sequential organ failure assessment and systemic inflammatory response syndrome were collected 24 hours postoperatively. The study primary outcome was postoperative septic shock. Secondary outcomes included 30 and 90-day emergency department visits, and the hospital readmission rate. RESULTS: Three of the 320 patients (0.9%) met the criteria for postoperative septic shock. These 3 patients had positive criteria for quick sequential organ failure assessment and systemic inflammatory response syndrome. Of the entire cohort 23 patients (7%) met quick sequential organ failure assessment criteria and 103 (32%) met systemic inflammatory response syndrome criteria. Specificity for postoperative sepsis was significantly higher for quick sequential organ failure assessment than for systemic inflammatory response syndrome (93.3% vs 68.4%, McNemar test p <0.001). The positive predictive value was 13% for quick sequential organ failure assessment criteria and 2.9% for systemic inflammatory response syndrome criteria. On multivariate logistic regression systemic inflammatory response syndrome criteria significantly predicted an increased probability of the patient receiving a transfusion (ß = 1.234, p <0.001). Positive quick sequential organ failure assessment criteria significantly predicted an increased probability of an emergency department visit within 30 days (ß = 1.495, p <0.05), operative complications (ß = 1.811, p <0.001) and transfusions (p <0.001). The main limitation of the study is that it was retrospective. CONCLUSIONS: Quick sequential organ failure assessment criteria were superior to systemic inflammatory response syndrome criteria to predict infectious complications after percutaneous nephrolithotomy.

Medical dissolution therapy for the treatment of uric acid nephrolithiasis.

INTRODUCTION: Uric acid (UA) nephrolithiasis represents 10% of kidney stones in the US with low urine pH and high saturation of UA as the main risk factors for stone development. Dissolution therapy for UA kidney stones via urinary alkalization has been described as a treatment option. We present our experience in treating UA nephrolithiasis with medical dissolution therapy. METHODS: A retrospective review was performed of UA stone patients referred for surgery but treated with dissolution therapy between July 2007 and July 2016. Patients were identified using ICD-9 codes. Patients were treated with potassium citrate alone or in combination with allopurinol. Serial imaging and urine pH were obtained at follow-up. Demographics, aggregate stone size, time to stone clearance, urine pH (office dip), and complications were recorded. RESULTS OBTAINED: Twenty-four patients (14 men and 10 women) were identified that started medical dissolution therapy for UA nephrolithiasis after initial referral for surgical management. Three patients (13%) did not tolerate the initiation of dissolution therapy and discontinued this treatment. Of the 21 patients that were maintained on dissolution therapy, 14 patients (67%) showed complete resolution of nephrolithiasis and 7 patients (33%) showed partial reduction. Patients with partial response had a mean reduction in stone burden of 68%. There were 3 recorded complications (UTI, GI upset with therapy, and throat irritation) and 4 recorded stone recurrences among these 21 patients. CONCLUSION: Based on our study population, medical dissolution therapy is a well-tolerated, non-invasive option for UA nephrolithiasis.

Supracostal access tubeless percutaneous nephrolithotomy: minimizing complications.

INTRODUCTION AND OBJECTIVE: Supracostal access in percutaneous nephrolithotomy (PCNL) may be avoided due to concern for thoracic complications. The objective of the study is to report the safety and efficacy of supracostal access utilizing a tubeless (stent only) PCNL technique. PATIENTS AND METHODS: Retrospective review of perioperative outcomes of 70 patients (76 renal units) who underwent a supracostal tubeless PCNL. No nephrostomy tubes were left. All patients had a 7F ureteral stent and Foley catheter placed. The nephrostomy sheath was removed with the patient held in end-expiration, and the incision closed. RESULTS: Median (IQR) age was 62 (48.3-67) years. Median stone size was 20 × 21 mm, and 14 (18%) patients had complete staghorn stones. The upper calyx was the site of access in 52 (68.4%) cases. Access was above the 12th and 11th rib in 63 (83%) and 12 (16%) cases, respectively. Median (IQR) length of stay was 30 (28-32) hours. Fifty (68.5%) patients had no residual fragments (< 2 mm) on postoperative imaging. Eight (11%) patients underwent an ancillary procedure (7 URS and 1 ESWL), with an additional seven patients becoming stone free after this procedure (78%). Thoracic complications occurred in two (2.6%) patients: one small pneumothorax, and one pleural effusion, both managed conservatively. Other complications occurred in nine patients (11.8%): bleeding requiring transfusion (1), fever (4), urinary retention (2), and syncope (2). CONCLUSION: Compared to historical controls, our approach to upper tract PCNL utilizing a nephrostomy tube-free approach resulted in an overall low thoracic complication rate and facilitated hospital discharge.

Holmium-YAG laser: impact of pulse energy and frequency on local fluid temperature in an in-vitro obstructed kidney calyx model.

During laser lithotripsy, energy is transmitted to both the stone and the surrounding fluid. As the energy is delivered, the temperature will rise. Temperatures ≥60 ° C can cause protein denaturation. The objective of this study is to determine the time it takes from body temperature (37°C) to 60°C at various laser power settings. A Flexiva TracTip 200 optical fiber was submerged alongside a negative temperature coefficient-type thermistor in 4 mL of saline in a glass test tube. A Lumenis VersaPulse Powersuite 100-W holmium:yttrium aluminum garnet laser was activated at 0.2- to 1.5-J pulse energies, 6- to 50-Hz frequencies, and 2- to 22.5-W average power. Temperature readings were recorded every second from 37°C until 60°C. Time and heating rate were measured. The procedure was repeated three times for each setting. Average time from 37°C to 60°C for settings (1) 0.2 J/50 Hz, (2) 0.6 J/6 Hz, (3) 1 J/10 Hz, and (4) 1.5 J/10 Hz was 60.3, 172.7, 58, and 43.3 s, respectively. Time from 37°C to 60°C decreased as frequency increased for every given pulse energy. Average heating rate increased proportionally to power from 0.06°C/s at 2 W to 0.74°C/s at 22.5 W. During laser lithotripsy, there is a rapid increase in the temperature of its surrounding fluid and temperatures ≥60 ° C may be reached. This could have local tissue effects and some caution with higher power settings should be employed especially where irrigation is limited. Further studies incorporating irrigation and live tissue models may aid to further define the risks.

Mitomycin-C and urethral dilatation: A safe, effective, and minimally invasive procedure for recurrent vesicourethral anastomotic stenoses.

PURPOSE: To report the safety and efficacy of mitomycin-C (MMC) injection followed by urethral dilatation for the treatment of recurrent vesicourethral anastomotic stenosis (VUAS) post-radical prostatectomy, and to report the outcome for patients treated for concomitant postprostatectomy incontinence. MATERIALS AND METHODS: A total of 29 patients with postprostatectomy incontinence and diagnosed with recurrent VUAS were recruited between March 2009 and January 2014 in this longitudinal case series. Under sedation, MMC was injected at the 3, 6, and 9 o'clock position, followed by urethral dilatation to 26F. Cystoscopy was performed to evaluate for patency at set intervals. Patients had the possibility to receive a salvage MMC injection if recurrence was noted. Patients with resolved VUAS were offered an anti-incontinence surgery. RESULTS: Median (interquartile range [IQR]) patient age was 67 years (63-72). Overall, 17 patients had ≥2 prior treatments for the VUAS (median = 2, IQR: 1-3 treatments); 23 patients (79%) had a patent bladder neck at the 12 months follow-up cystoscopy after a single MMC injection and dilatation. Overall, 3 patients opted for a salvage MMC injection for recurrence, and 2 of those were salvaged, improving the success rate to 86%. No adverse events were reported. Overall, 20 patients (69%) opted for an anti-incontinence surgery, and all were either cured or improved of their incontinence after a median (IQR) follow-up of 58 months (48-77). CONCLUSIONS: MMC injection with urethral dilatation is a safe, effective, and minimally invasive treatment option for recurrent VUAS after radical prostatectomy. Favorable long-term results can be expected even after anti-incontinence procedures.

Retrograde leak point pressure measurement improves outcomes of the Virtue male sling for postprostatectomy incontinence.

INTRODUCTION: We aimed to compare the efficacy of two different sling tensioning approaches, and to report our experience, including safety and impact on quality of life (QoL) of the Virtue® male sling for the treatment of postprostatectomy incontinence (PPI). METHODS: From our prospectively maintained database, we retrospectively identified all men treated with the Virtue male sling for PPI between March 2009 and February 2014 by two urologists in two institutions. Baseline demographic data and the sling tensioning method were abstracted from the database. Likewise, the Patient Global Impression of Improvement (PGI-I) scale, severity of incontinence, and clinical outcomes were also abstracted. RESULTS: 48 patients were treated with the Virtue quadratic male sling. Sling tensioning was done using cystoscopy in the first 18 patients (Group 1), while per-operative retrograde leak point pressure (RLPP) measurement was done in the last 30 patients (Group 2). The median (interquartile range [IQR]) followup from the day of surgery was 22 (15-41) months. At the last followup visit, 7 (39%) patients in Group 1 were cured or improved of their PPI, compared to 21 (70%) patients in Group 2 (p=0.03). The final median (IQR) RLPP in these patients was 41 (37-48) cm H2O. Transient pain was the most common adverse event, occurring in 23 (48%) of patients. Twenty-one (70%) patients in Group 2 were "much better" or "very much better" with their device, compared to 7 (39%) in Group 1 (p=0.0008). CONCLUSIONS: The Virtue male sling is a valuable treatment option for PPI. Per-operative RLPP measurement significantly improves cure and satisfaction rates.

Genitourinary tuberculosis in North America: A rare clinical entity.

INTRODUCTION: Although tuberculosis (TB) is the most common cause of mortality from infectious diseases worldwide, genitourinary TB in North America is rare. We review 3 cases of genitourinary TB diagnosed within the last 5 years. CASES: The first case is that of a 76-year-old African-Canadian woman who was referred for percutaneous nephrolithotomy of right lower pole renal stones. Although renal TB was suspected, her initial urinary TB culture was negative. On follow-up imaging, she developed bilateral ureteral thickening and ureteroscopic biopsy confirmed necrotizing granulomata. Repeat urine cultures were positive for M. tuberculosis. The second case is a 73-year-old Italian-Canadian woman who was referred for ureteroscopic biopsy of left thickened ureter to rule out urothelial carcinoma. Initial urine TB cultures were negative, despite biopsies confirming granulomatous inflammation. She was closely followed with urine cytologies and TB cultures. Repeat urine culture was positive for M. tuberculosis. Both patients were treated with a course of anti-tuberculous agents and indwelling ureteral stents to relieve ureteral obstruction. The third case is a 70-year-old Cree woman who was referred for percutaneous nephrolithotomy of a left "staghorn stone" in an atrophic left kidney. Thirty years earlier she had been treated for pulmonary TB in addition to ileocystoplasty for a "thimble" bladder. A computed tomography scan showed autonephrectomized left kidney. Her urine TB cultures were negative. She was placed on prophylactic antibiotics for her recurrent bacterial urinary tract infections. CONCLUSION: Genitourinary TB may present in various subtle ways, and the astute clinician must have a high index of suspicion for this disease in patients with atypical clinical and radiologic findings. In addition, TB urine cultures should be repeated when there is high index of suspicion.

Adrenal lymphangioma: a rare cystic lesion of the adrenal.

We herein report the case of a left adrenal lymphangioma in a 52-year-old asymptomatic female and review the pertinent literature relatable to this rare, benign lesion.