Partial Gland Ablation of Prostate Cancer: Effects of Repeat Treatment.

OBJECTIVE: To evaluate the near-term clinical and pathological effects of repeat partial gland ablation (PGA) in men with intermediate-risk prostate cancer (PCa). MATERIALS AND METHODS: One hundred seventy men with focal lesions of PCa (all GG2 or GG3) underwent PGA with high-intensity focused ultrasound (HIFU) or cryotherapy (CRYO) in prospective trials. Residual PCa in or near the ablation zone was found in 37 men after a first PGA; 30 went on to receive a second PGA and were the subjects of study. At 3 timepoints, baseline and 6 months after first and second ablations, quality-of-life (QOL) questionnaires (IIEF, IPSS) and MRI-guided biopsies (MRGB) were performed. Biopsies were targeted and systematic at baseline and in follow-up, comprehensively about the ablation zone. RESULTS: All 30 patients completed QOL questionnaires and 26 had MRGB at the 3 timepoints. Mean QOL scores were not significantly different from the baseline after the first or second PGA. No operative complications were encountered; and "decisional regret" was reported in only 2/29 men after the repeat ablation. A decrease in semen volume was reported by 25% of patients. Repeat ablation was successful (absence of csPCa on MRGB) in 14/26 (53%) of men. PSA levels decreased and MRI lesions resolved after ablations, but neither was a reliable predictor of biopsy outcomes. CONCLUSION: When initial PGA fails, repeat PGA is a reasonable consideration, because in near-term follow-up, secondary procedures appear to be safe, causing only minimal detriment to urinary and sexual function, with csPCa becoming undetectable by MRGB in approximately half the patients.

Detection of uric acid stones in the ureter using low- and conventional-dose computed tomography.

OBJECTIVE: To determine the ability of low- and conventional-dose computed tomography (CT) in identification of uric acid stones, which are of lower density than calcium oxalate stones. MATERIALS AND METHODS: Uric acid stones (3, 5, and 7 mm) were randomly placed in human cadaveric ureters and scanned using conventional 140-mAs and low-dose 70-, 50-, 30-, 15-, 7.5-, and 5-mAs settings. A single-blinded radiologist reviewed a total of 523 scanned stone images. Sensitivity and specificity were compared among different settings and stone sizes. RESULTS: Imaging using 140-, 70-, 50-, 30-, 15-, 7.5-, and 5-mAs settings resulted in 97%, 97%, 96%, 93%, 83%, 83%, and 69% sensitivity and 92%, 92%, 91%, 89%, 88%, 91%, and 94% specificity, respectively. There was a significant difference in sensitivity between 140 mAs and 15, 7.5, and 5 mAs (P = .011, P = .011, and P <.001, respectively). Sensitivity for 3-, 5-, and 7-mm stones was 83%, 90%, and 93%, respectively. At ≤ 15 mAs, 3-mm stones had a higher rate of false negatives (P <.001). CONCLUSION: Both low- and conventional-dose CTs demonstrate excellent sensitivity and specificity for the detection of ureteral uric acid stones. However, low-dose CT at ≤ 15 mAs resulted in reduced detection of uric acid stones.

Analgesic use and complications following upper pole access for percutaneous nephrolithotomy.

INTRODUCTION AND OBJECTIVES: Upper pole access (UPA) to the kidney optimizes working angles during percutaneous nephrolithotomy (PCNL). However, many surgeons are hesitant to employ UPA due to concerns for increased postoperative pain and complications. In this study, we compare perioperative pain and outcomes for PCNL performed through UPA with middle and lower pole access (LPA). METHODS: A retrospective review of PCNLs performed at a single academic institution between 2002 and 2012 was performed. Patient demographics, stone burden, operative characteristics, length of hospital stay, and perioperative complications were recorded. Narcotics administered on postoperative days (POD) 1 and 2 were converted to intravenous morphine equivalents. The Mann-Whitney U, Fisher's exact test, and logistic regression analyses were used for statistical comparison. RESULTS: Of 350 PCNLs performed on 269 patients, 125 patients underwent primary PCNL through single tract UPA, while primary LPA was utilized in 138 patients. Patients with multiple access tracts (n=6) were excluded. Baseline characteristics between groups were similar except for age; patients with UPA were older (52.6 vs. 46.2 years; p=0.003). Stone burden, operative time, and initial stone-free rate were comparable between groups. Additionally, analgesic requirements were similar on POD 1 (p=0.54) and 2 (p=0.62). There was no difference in the overall complications (p=0.23) or thoracic complications (p=0.43). Although both groups had equivalent stone-free rates after initial PCNL (p=0.78), those with residual stones had a superior stone-free rate after second-look PCNL through UPA (73.3% vs. 44.3%, p=0.035) and a superior overall stone-free rate (94.4% vs. 86.2%, p=0.037). CONCLUSIONS: Patients undergoing PCNL through UPA had a higher ultimate stone-free rate compared with LPA, while postoperative analgesic requirements and overall complication rates were similar between access sites. A trend toward higher thoracic complication rates was observed in the UPA group, although this did not reach statistical significance. Surgeons should not hesitate to utilize UPA when indicated for patients with large or complex stones.

Reduced fluoroscopy protocol for percutaneous nephrostolithotomy: feasibility, outcomes and effects on fluoroscopy time.

PURPOSE: Radiation exposure from fluoroscopy during percutaneous nephrostolithotomy contributes to patient overall exposure, which may be significant. We compared fluoroscopy times and treatment outcomes before and after implementing a reduced fluoroscopy protocol during percutaneous nephrostolithotomy. MATERIALS AND METHODS: We retrospectively reviewed the charts of patients treated with percutaneous nephrostolithotomy at a single academic institution by a single surgeon. We compared 40 patients treated before implementation of a reduced fluoroscopy protocol to 40 post-protocol patients. The reduced protocol included visual and tactile cues, fixed lowered mAs and kVp, a laser guided C-arm and designated fluoroscopy technician, and single pulse per second fluoroscopy. Preoperative characteristics, fluoroscopy and operative time, complications and treatment success were examined using univariate and multivariate analysis. RESULTS: There was no significant difference in body mass index, stone size, success rate, operative time or complications between the groups. After protocol implementation fluoroscopy time decreased from 175.6 to 33.7 seconds (p<0.001). A longer average hospital stay was seen in the pre-protocol group (3.9 vs 3.6 days, p=0.027). Stays greater than 2 days were associated with a body mass index of greater than 30 kg/m2 on multivariate analysis. No complication in either group was attributable to fluoroscopic technique. CONCLUSIONS: Implementing a decreased fluoroscopy protocol during percutaneous nephrostolithotomy resulted in an 80.9% reduction in fluoroscopy time while maintaining success rates, operative times and complications similar to those of the conventional technique. Adopting this reduced fluoroscopy protocol safely decreased radiation exposure to patients, surgeons and operating room staff during percutaneous nephrostolithotomy.

A prospective analysis of robotic tip cover accessory failure.

BACKGROUND AND PURPOSE: The robotic monopolar scissors tip cover accessory (TCA) is an insulation device that prevents current leak from surfaces on the instrument other than the scissors tip. Reports of insulation failure and patient injury have been made but not systematically studied. We investigate the incidence of TCA failure and potential mechanisms that lead to malfunction. MATERIALS AND METHODS: Eighty TCAs (40 first and 40 second generation) were collected after a single urologic or gynecologic surgery at a single academic institution. Each TCA was inspected for damage under a microscope. Current leak was measured in an electrolysis solution, and electrical arcing was tested in a porcine kidney model. Log-rank and Friedman two-way analysis of variance by ranks compared failure at different angulations and power settings. Chi-square analysis compared failure between first and second generation TCAs (f-TCAs and s-TCAs). RESULTS: Visible insulation defects were detected in 39% of f-TCAs (size range <0.5-2.75 mm). Electrical arcing was observed in 33% of f-TCAs. Arcing increased with greater wrist angulation (P=0.014) and higher power settings (P=0.048). Minor damage was observed in 25% of s-TCAs. No electrical arcing was observed in any of the s-TCAs despite angulation and power strain. s-TCAs demonstrated significantly less failure than f-TCAs (P<0.001). CONCLUSION: In this study, 33% of f-TCAs demonstrated insulation failure after a single surgical use. f-TCA failure increased with greater wrist angulation and electrical power. The improved design of s-TCAs demonstrated no current leak or arcing on ex-vivo testing and appears to have significantly decreased failure potential. Centers still using the f-TCA should transition to the s-TCA and be vigilant in reporting device failures to prevent unnecessary patient morbidity.