Initial single centre experiences of a radiographer advanced practitioner led nephrostomy exchange programme.

INTRODUCTION: To evaluate the technical success, radiation dose, complications and costs from the introduction of a radiographer-led nephrostomy exchange service. METHODS: Post-graduate qualified interventional radiographers with several years' experience in performing other interventional procedures began performing nephrostomy exchanges. Training was provided by an interventional radiologist. Each radiographer performed ten procedures under direct supervision followed by independent practice with remote supervision. Each radiographer was then responsible for the radiological report, discharge, re-referral for further exchange and, where indicated, sending urine samples for culture and sensitivity. Data extraction included the time interval between exchanges, radiation dose/screening time and complications. RESULTS: Thirty-eight long-term nephrostomy patients had their histories interrogated back to the time of the initial insertion. The mean (range) age at nephrostomy insertion was 67 (35-93) years and 65% were male. Indications for nephrostomy were prostatic or gynaecological malignancy, ureteric injury, bulky lymphoma and post-transplant ureteric stricture. A total of 170 nephrostomy exchanges were performed with no statistically significant differences in the radiation dose, fluoroscopy time nor complication rates between consultants and radiographers. There was, however, a statistically significant reduction in the time interval between nephrostomy exchanges for the radiographer group (P = 0.022). CONCLUSION: Interventional radiographers can provide a safe, technically successful nephrostomy exchange program with radiation doses equivalent to radiologists. This is a cost-effective solution to the capacity issues faced in many departments, whilst providing career progression, job satisfaction and possibly improved care. IMPLICATIONS FOR PRACTICE: Radiographer-led interventional services should be considered by other institutions as a means of providing effective nephrostomy exchanges.

An easy risk stratification to recommend the optimal patients with 2-3 cm kidney stones to receive retrograde intrarenal surgery or mini-percutaneous nephrolithotomy.

To create an easy risk stratification to recommend the optimal subset of patients with 2-3 cm kidney stones to receive retrograde intrarenal surgery (RIRS) or mini-percutaneous nephrolithotomy (MPCNL). A retrospective patient cohort was reviewed and compared (RIRS, n = 147 and MPCNL, n = 129). Overall, RIRS group obtained a lower SFR (66% vs. 93.3%, p < 0.001) compared to MPCNL group. The RIRS group had more overall complication (12.2% vs. 8.5%) and more urosepsis (2.7% vs. 1.6%) than the MPCNL group, although there was no statistical significance. However, two patients in MPCNL group underwent embolization to treat perioperative bleeding. On multivariate analysis for RIRS group, lower calyx involved [OR 2.67], multiple calyces [OR 4.49], severe hydronephrosis [OR 2.38] were three significant predictors of SFR, which decreased from 88.8%, 70.3%, 52.1% to 25% corresponding to patients with 0, 1, 2, 3 risk predictors, respectively (p = 0.008), with a good predictive accuracy (AUC = 0.657; p = 0.002). When patients with no risk factor and patients undergoing RIRS had a similar high SFR and no possibility of bleeding, compared to matched patients undergoing MPCNL. Although generally RIRS showed a lower SFR for 2-3 cm stones compared to MPCNL, our easy risk stratification can recommend the optimal subset of patients with 2-3 cm kidney stones to receive RIRS or MPCNL. When these patients with no above-mentioned risk factors, RIRS can be first considered as an alternative to PCNL because it might be potentially less invasive and achieve a similar very high stone-free rate.

Benchtop and Initial Clinical Evaluation of the ShockPulse Stone Eliminator in Percutaneous Nephrolithotomy.

PURPOSE: Standardized bench testing of the new ShockPulse™ intracorporeal lithotripter was performed against three commercially available lithotripsy systems to determine differences and nuances in performance. MATERIALS AND METHODS: The ShockPulse intracorporeal lithotripter was tested against the LUS-2™, CyberWand,™ and EMS LithoClast™ in a standardized bench setting using hard (Ultracal-30) and soft (plaster of Paris) stone phantoms. An in vitro kidney model was used to record the time needed to fragment stone samples into retrievable-sized pieces. The time needed to fully comminute and evacuate stone samples was also recorded. The efficacy of each device at various applied pressures was determined using a hands-free apparatus, which was used to apply 1.0, 1.5, and 2.0 pounds of fixed force. RESULTS: For hard and soft stones, the time needed to create retrievable fragments was similar among all systems (p = 0.585). The ShockPulse was significantly faster than the LUS-2 and LithoClast at fully fragmenting and evacuating stone samples (p = 0.046), while the CyberWand was significantly slower than all three systems at this task (p = 0.001). When fixed forces were applied to a large stone phantom, the ShockPulse and CyberWand were significantly faster than the LUS-2 and LithoClast (p < 0.0001). When groups of smaller stones were tested, the ShockPulse was significantly faster at 1.0 pound (p < 0.001) and 1.5 pounds (p < 0.002) of force. At 2.0 pounds, no differences were observed (p = 0.09). CONCLUSIONS: The ShockPulse is equally as effective and, in some circumstances, more effective than the three commercially available devices against which it was tested in an in vitro setting.

[Individualized evidence-based interventional stone treatment : One stone, many question marks?] / Individualisierte evidenzbasierte interventionelle Steintherapie : Ein Stein, viele Fragezeichen?

The treatment of urolithiasis is still one of the most frequent tasks in the daily urological practice. Driven by the technological developments, patient demands and also personal experiences of urologists, many interventional treatment options have been established. To identify the most suitable treatment option, it is of utmost importance to consider not only stone size and localization but also the individual situation of the patient and the published evidence, which despite all efforts often lags behind the technical and clinical reality.

Is there a place for virtual reality simulators in assessment of competency in percutaneous renal access?

OBJECTIVE: To assess competency of urology post-graduate trainees (PGTs) in percutaneous renal access (PCA). METHODS: Upon obtaining ethics approval and informed consents, PGTs between post-graduate years (PGY-3 to PGY-5) from all four urology programs in Québec were recruited. PCA competency of each participant was assessed objectively by performing task 4 on the PERC Mentor™ simulator, where they had to correctly access and pop 7 balloons in 7 different renal calyces and subjectively by the validated Percutaneous Nephrolithotomy-Global Rating Scale (PCNL-GRS). RESULTS: A total of 26 PGTs with a mean age of 29.2 ± 0.7 years participated in this study. When compared with the 21 PGTs without practice, all 5 PGTs who had practiced on the simulator were competent (p = 0.03), performed the task with significantly shorter operative time (13.9 ± 0.7 vs. 4.4 ± 0.4 min; p < 0.001) and fluoroscopy time (9.3 ± 0.6 vs. 3.4 ± 0.4 min; p < 0.001), and had significantly higher PCNL-GRS scores (13 ± 0.6 vs. 20.6 ± 1; p < 0.001) and successful attempts to access renal calyces (23 ± 5 vs. 68.7 ± 11; p = 0.001). According to a pass score of 13/25, thirteen PGTs were competent. Competent PGTs performed the task with significantly shorter fluoroscopy time (9.8 vs. 6.5 min; p = 0.01) and higher percentage of successful attempts to access renal calyces (p < 0.001), higher PCNL-GRS scores (p < 0.001), and lower complications (p = 0.01). CONCLUSION: The PCNL-GRS in combination with the PERC Mentor™ simulator was able to differentiate between competent and non-competent PGTs.

EAU Guidelines on Interventional Treatment for Urolithiasis.

CONTEXT: Management of urinary stones is a major issue for most urologists. Treatment modalities are minimally invasive and include extracorporeal shockwave lithotripsy (SWL), ureteroscopy (URS), and percutaneous nephrolithotomy (PNL). Technological advances and changing treatment patterns have had an impact on current treatment recommendations, which have clearly shifted towards endourologic procedures. These guidelines describe recent recommendations on treatment indications and the choice of modality for ureteral and renal calculi. OBJECTIVE: To evaluate the optimal measures for treatment of urinary stone disease. EVIDENCE ACQUISITION: Several databases were searched to identify studies on interventional treatment of urolithiasis, with special attention to the level of evidence. EVIDENCE SYNTHESIS: Treatment decisions are made individually according to stone size, location, and (if known) composition, as well as patient preference and local expertise. Treatment recommendations have shifted to endourologic procedures such as URS and PNL, and SWL has lost its place as the first-line modality for many indications despite its proven efficacy. Open and laparoscopic techniques are restricted to limited indications. Best clinical practice standards have been established for all treatments, making all options minimally invasive with low complication rates. CONCLUSION: Active treatment of urolithiasis is currently a minimally invasive intervention, with preference for endourologic techniques. PATIENT SUMMARY: For active removal of stones from the kidney or ureter, technological advances have made it possible to use less invasive surgical techniques. These interventions are safe and are generally associated with shorter recovery times and less discomfort for the patient.

Uso de la escala de S.T.O.N.E. en pacientes sometidos a nefrolitotomía percutánea / The use of S.T.O.N.E. scale in patients undergoing percutaneous nephrolithotomy

OBJETIVOS: El objetivo del presente trabajo fue aplicar la escala de S.T.O.N.E. a nuestros pacientes sometidos a NLP para predecir el porcentaje de casos libres de litiasis y complicaciones utilizando la escala de Clavien modificada para NLP. MÉTODOS: Se analizó una cohorte histórica de pacientes sometidos a NLP. Se incluyeron pacientes que contaran con tomografía axial computada para evaluar la tasa libre de litiasis con la escala de S.T.O.N.E. y las complicaciones se evaluaron a través de la escala de Clavien modificada. RESULTADOS: En 102 pacientes se realizaron 104 procedimientos de NLP, la edad promedio fue 48.4 años y el 71% fueron mujeres. La distribución de los casos se clasificaron como grado leve: 6.7%, moderado: 63.5% y severo: 29.8%. La tasa libre de litiasis después de un primer procedimiento en forma global alcanzó el 58% y por grados fue: leve 85.7%, moderado 71.2% y severo 25%. El RR para litiasis residual después del primer procedimiento fue de 2.4 para el grado moderado (IC 0.3 - 15, p = 0.03) y 4.9 para el grado severo (IC 0.7 - 30.9, p = 0.08). La tasa global de complicaciones fue del 33%, para Clavien 1 del 14.4%, 2: 9.6%, 3A: 2.9%, 3B: 2.9%, 4:1.9%, 5:1%. CONCLUSIONES: La escala de S.T.O.N.E. aplicada en nuestra población puede predecir de manera correcta y sencilla la tasa libre de litiasis en pacientes sometidos a nefrolitotomía percutánea. No encontramos asociación predictiva en esta escala para las complicaciones

OBJECTIVES: The aim of this study was to apply the S.T.O.N.E. scale on our patients undergoing PCNL to predict stone free rate and complications using the modified Clavien scale. METHODS: A historical cohort of patients undergoing PCNL was analyzed. All patients with computed tomography to assess stone-free rate with the S.T.O.N.E. scale and complications were evaluated by the modified Clavien scale. RESULTS: In 102 patients 104 procedures were performed; the mean age was 48.4 years and 71% were women. The distribution of cases were classified as mild: 6.7%, moderate: 63.5% and severe: 29.8%. The stone free rate after the first procedure globally reached 58% and by grade was: mild 85.7%, moderate 71.2% and severe 25%. The RR for residual stones after the first procedure was 2.4 for moderate grade (CI 0.3 to 15, p = 0.03) and 4.9 for severe grade (CI 0.7 - 30.9, p = 0.08). The overall complication rate was 33%, separately Clavien 1: 14.4%, 2: 9.6%, 3a: 2.9%, 3b: 2.9% 4:1.9%, 5:1%. CONCLUSIONS: The S.T.O.N.E. scale applied in our population can predict accurately and easily stone free rate in patients undergoing PCNL. We found no predictive association for this scale on complications

A standardized scoring system in the prediction of success and complications of percutaneous nephrolithotomy: guy´s Stone scoring system / Utilización de un sistema de puntuación estandarizado en la predicción del éxito y complicaciones de la nefrolitectomía percutanea: escala stone del Guy`s

OBJECTIVES: In this study, our aim was to determine the role of Guy's stone scoring system (GSS) in the prediction of percutaneous nephrolithotomy (PNL) success and its ability to foresee potential complications in consideration of Clavien grading system (CGS). Material and Methodos: The data of 244 patients who underwent PNL between January 2009 and May 2014 were retrospectively examined. Renal stones were evaluated using GSS with the aid of the patients' preoperative radiological evaluations and their postoperative complications were assessed with CGS. Arch. Esp. Urol. 2015; 68 (9): 710-717 Keywords: Guy's Stone score. Percutaneous nephrolithotomy. Modified Clavien grading system. Stone-free rate. RESULTS: Mean age of the patients (men, n=166; 68% and women, n=78; 32%) was 46.50±13.12 years (range, 16-80yrs). Clinically significant residual stones were not detected in 195 (79.9%) patients, while they were found in 49 (20.1%) patients. Guy's stone scores of 1, 2, 3 and 4 points were estimated in 21.3, 37.7, 29.9, and 11.1% of the cases, respectively. Based on modified Clavien complication grading system, complications were categorized as Clavien grade 1, 2 and 3 in 81.9, 17.2, and 0.8% of the cases, respectively. Clavien Grade 4 and 5 complications were not encountered. A statistically significant correlation was found between Guy's Stone scores and Clavien grades (p < 0.05)- A statiscally and highly significant difference was detected between Guy's Stone scores of the cases with respect to residual stones (p = 0.001; p < 0.01). CONCLUSIONS: Our study findings have revealed that GSS is a successful and easily applicable method for the prediction of success and likelihood of complications of PN

OBJETIVOS: En este estudio nuestro objetivo era determinar el papel de la escala de puntuación STONE de Guy`s (GSS) en la predicción del éxito de la nefrolitotomía percutánea (NLP) y su capacidad de preveer potenciales complicaciones considerando el sistema de gradación de Clavien. MATERIAL Y MÉTODOS: Los datos de 244 pacientes sometidos a NLP entre enero del 2009 y mayo del 2014 fueron evaluados retrospectivamente. Las litiasis renales fueron evaluadas utilizando el GSS con la ayuda de las pruebas radiológicas preoperatorias y las complicaciones postoperatorias se evaluaron con la escala de Clavien. RESULTADOS: La edad media de los pacientes (varones n=166, 68%; y mujeres n=78, 32%) fue 46.50±13.12 años (rango, 16-80 años). En 195 pacientes (79.9%) no se detectaron litiasis residuales clínicamente significativas, mientras que en 49 pacientes (20.1%) sí se encontraron. Con la escala STONE de Guy`s se estimaron puntuaciones de 1,2,3 y 4 puntos en 21.3%, 37.7%, 29.9% y 11.1% de los casos respectivamente. En base a la escala de complicaciones de Clavien modificada las complicaciones fueron categorizadas como Clavien grados 1,2 y 3 en 81.9%, 17.2% y 0.8% de los casos respectivamente. No se encontraron complicaciones de Grado 4 y 5 de Clavien. Se encontró una correlación estadísticamente significativa entre las puntuaciones de la escala STONE de Guy`s y los grados de Clavien (p < 0.02). Se detectó una diferencia estadística y altamente significativa entre las puntuaciones del STONE de Guy`s de los casos con respecto a las de las litiasis residuales (p = 0.001; p < 0.01). CONCLUSIONES: Los hallazgos de nuestro estudio han revelado que la escala Stone de Guy`s es un método exitoso y fácilmente aplicable para la predicción del éxito y la probabilidad de complicaciones de la NLP

Comparison of complications associated with standard and totally tubeless percutaneous nephrolithotomy according to modified Clavien grading: a multicenter retrospective study.

The aim of this study was to compare the complications of standard and totally tubeless percutaneous nephrolithotomy (PCNL) based on the modified Clavien complication grading system. We retrospectively evaluated the complications of 290 consecutive patients who had undergone standard or totally tubeless PCNL at four institutes between January 2010 and August 2012 based on the modified Clavien scale. The totally tubeless cases were classified as Group 1 and the cases to which a Malecot re-entry catheter was applied were classified as Group 2. The postoperative complications were recorded according to the modified Clavien complication grading system. Statistically significant differences were observed only in the first-degree injury class between the two groups based on the modified Clavien classification. The requirement for blood transfusion and prolonged percutaneous access site leakage were more frequent in Group 2, but these differences were not statistically significant. We also performed a pain evaluation by monitoring postoperative analgesia demands. In Group 1, the analgesic demand rates in the 1(st) and 6(th) postoperative hours were 64.6% and 31.5%, respectively. In Group 2, the analgesic demand rates were 87.5% and 58.75% in the 1(st) and 6(th) postoperative hours, respectively. The mean ± standard deviation of analgesic doses in the first 6 hours was 0.96 ± 0.7 and 1.46 ± 0.6 in Groups 1 and 2, respectively. These differences were statistically significant. Based on our results, we can conclude that the tubeless technique has fewer complications, improved postoperative patient comfort, shorter hospitalization times, and a reduced need for analgesics, suggesting that tubeless PCNL should be the standard approach. For suitable cases, this technique may be used safely as the standard PCNL approach.

Standardization of patient outcomes reporting in percutaneous nephrolithotomy.

BACKGROUND AND PURPOSE: There exist no global standards for defining patient outcomes in renal stone surgery. The objective of this study was to evaluate the quality of reporting of outcomes in studies investigating percutaneous nephrolithotomy (PCNL) and to propose standardized consensus definitions for common outcomes. METHODS: We performed a literature search in PubMed for randomized controlled studies that investigated PCNL between 2002 and 2012. All outcomes reported were analyzed for each study. Each article was examined to identify the definition of each reported patient outcome. Various aspects of patient outcomes were presented to a panel of 85 experts in a Delphi process consisting of three rounds. The experts were asked to select options that they believed would best describe each outcome. Finally, we composed recommendations for definition of the most common outcomes reported in PCNL studies. RESULTS: Eighty-three RCTs were included in the review of patient outcomes. Stone-free rate (55, 63.9%), length of stay (47, 56.6%), complication rate (44, 53.0%), and changes in hemoglobin (40, 48.2%) were the most frequently reported outcomes in randomized controlled trials of PCNL. Only 24/53 (45.3%) studies had a formal definition of stone-free status. Only 31/40 (77.5%) studies, which reported change in hemoglobin, had a unit of measurement; however, 22/40 (55.0%) did not report the timing of postoperative hemoglobin measurement. A set of recommendations for defining patient outcomes in PCNL is presented for the 15 most commonly reported outcomes in PCNL. CONCLUSIONS: Wide variations and underspecification exist in the definition and reporting of outcomes in PCNL. We propose recommendations for the definition of outcomes based on a review of the literature and expert opinion. Standardization of outcome definition and reporting will improve the quality of urologic research.

Pseudoaneurisma intrarrenal tras nefrolitotomía percutánea. Angiografía renal y embolización selectiva / Intrarenal pseudoaneurysm after percutaneous nephrolitotomy. Renal angiography and selective embolization

OBJETIVO: Presentamos un caso de pseudoaneurisma intrarrenal tras nefrolitotomia percutánea. El tratamiento en este caso fue la embolizacion selectiva. A partir de este caso discutimos la utilidad en el dignóstico de la angiotomografia computerizada y la angiografia renal. Realizamos una revisión de la literatura al respecto. MÉTODOS: Se realizó una angitomografía computerizada (angioTC) por sospecha de lesión vascular diferida tras la nefrolitectomía percutánea. Ante los hallazgos deangioTC, se realizó una arteriografía de la arteria renal izquierda y embolización selectiva de la lesión. RESULTADOS: La angiotomografía evidencia un realce nodular de contraste en el tercio inferior del riñón izquierdo con área hipocaptante a este nivel sugestiva de hemorragia por lesión vascular. Mediante punción de la arteria femoral común derecha, se realiza arteriografía de la arteria renal izquierda objetivando una arteria amputada que corresponde a la situación del sangrado al cáliz. Tras localización del punto de hemorragia se procedió a embolizar el vaso con una microespiral metálica GDC de 3mm y 6cm de longitud Tras la embolización, la evolución del enfermo fue satisfactoria. CONCLUSIONES: El pseudoaneurisma intrarrenal constituye la causa más frecuente de sangrado tardío tras nefrolitotomía percutánea. El síntoma más habitual es la hematuria que puede ser severa y precisar de tratamiento activo para cohibir la hemorragia. En estos casos, cobran un papel muy importante en el diagnostico, la angiotomografía computerizada y la angiografía, ofreciendo esta última la posibilidad de tratar la causa de la hemorragia mediante la embolización selectiva del pseudoaneurisma(AU)

OBJECTIVE: We present a case of intrarrenal pseudoaneuysm after percutaneous nephrolithotomy. The treatment was selective embolization of the pseudoaneurysm. We discuss the role of computerized angiotomography and angiography in these cases. We present a review of the related literature. METHODS: A computerized angiotomography (angio CT) was performed because of suspicion of a delayed vascular lesion after percutaneous nephrolithectomy. Faced with the findings of the angio CT an selective renal artery arteriography and selective embolization was performed. RESULTS: The angiotomography shows an enhanced nodular contrast in the lower third of the left kidney with a scarred area at this level suggestive of hemorrhage due to vascular lesion. Through puncture of the right common femoral artery, arteriography was performed on the left renal artery with, objectifying an amputated artery related to the bleeding situation in the calyx. After localization of the point of hemorrhage, the vessel was embolized with a 3 mm metallic microspiral GCD, 6 cm in length After embolization, the evolution of the patient was satisfactory. CONCLUSIONS: Intrarenal pseudoaneurysm is the most frequent cause of late bleeding after percutaneous nephrolithotomy. The most common symptom is hematuria that can be severe and require active treatment in order to inhibit the hemorrhage. In these cases, computerized angiotomography and angiography take on a very important diagnostic role, the latter offering the possibility to treat the hemorrhage through selective embolization of the pseudoaneurysm(AU)

Designing simulator-based training: an approach integrating cognitive task analysis and four-component instructional design.

Most studies of simulator-based surgical skills training have focused on the acquisition of psychomotor skills, but surgical procedures are complex tasks requiring both psychomotor and cognitive skills. As skills training is modelled on expert performance consisting partly of unconscious automatic processes that experts are not always able to explicate, simulator developers should collaborate with educational experts and physicians in developing efficient and effective training programmes. This article presents an approach to designing simulator-based skill training comprising cognitive task analysis integrated with instructional design according to the four-component/instructional design model. This theory-driven approach is illustrated by a description of how it was used in the development of simulator-based training for the nephrostomy procedure.

The effect of American Society of Anesthesiology scores on percutaneous nephrolithotomy outcomes.

INTRODUCTION: To evaluate the effect of American Society of Anesthesiology (ASA) scores on percutaneous nephrolithotomy (PNL) outcomes. MATERIALS AND METHODS: The records of 186 consecutive patients undergoing PNL procedures from 2006 to 2011 at a single institution were evaluated. Patients were divided into a low-risk group with a preoperative ASA of I or II and a high-risk group with ASA of III or IV. Postoperative complications were classified according to the modified Clavien classification system. RESULTS AND CONCLUSIONS: There were 140 cases in the low-risk and 46 cases in the high-risk groups. The mean operative time was 72 min (40-120 min) and 86 min (55-125 min) and the complication rates were 17.8 and 19.5% for the low- and high-risk groups, respectively. The average duration of nephrostomy tube drainage was 3.3 ± 1 and 4.2 ± 1.5 days for the low- and high-risk groups, respectively. Stone-free rates were 85 and 82% for the low- and high-risk groups, respectively. PNL can be safely performed in the ASA high-risk patient population.

Surgeon fatigue: impact of case order on perioperative parameters and patient outcomes.

PURPOSE: We tested the hypothesis that surgeon fatigue results in worse outcomes for laparoscopic and robot-assisted laparoscopic prostatectomy, and percutaneous nephrolithotomy by comparing outcomes of sequentially scheduled procedures. MATERIALS AND METHODS: We identified days when 2 procedures of the same type were performed by the same surgeon, including 72 laparoscopic and 340 robot-assisted laparoscopic prostatectomies, and 110 percutaneous nephrolithotomies. Clinical data and outcomes were compared. RESULTS: For percutaneous nephrolithotomy multiple access (16% vs 9%, p = 0.2), transfusion (3.6% vs 5.4%, p = 0.5), complication (20% vs 18%, p = 0.5), residual fragment (53% vs 45%, p = 0.3), second look (38% vs 35% p = 0.4) and stone-free (86% vs 89% p = 0.3) rates did not differ for the first and second procedures. For laparoscopic prostatectomy nerve sparing (100% vs 97.1%, p = 0.5), operative complications (0% vs 0%, p = 0.7), drain requirement (36% vs 42%, p = 0.6) and lymphadenectomy (13.5% vs 25.7%, p = 0.16) rates were comparable. Positive margins (19.4% vs 36.1% p = 0.08), continence (66.7% vs 66.7%, p = 0.9), potency (58.3% vs 52.8%, p = 0.76) and prostate specific antigen recurrence (10.8% vs 20%, p = 0.45) did not significantly differ for the first and second procedures. For robot-assisted laparoscopic prostatectomy operative complications (3% vs 3.5%, p = 0.8), drain requirement (7.7% vs 9.8%, p = 0.5), positive margins (41.7% vs 39.3%, p = 0.37), continence (78.6% vs 84.4%, p = 0.12), potency (51% vs 50%, p = 0.15) and prostate specific antigen recurrence (9.5% vs 11.6%, p = 0.2) did not significantly differ. Nerve sparing was more common in the second case cohort (86.9% vs 75.7%, p = 0.03). CONCLUSIONS: Despite concern that surgeon fatigue may impact outcomes, our data suggests that performing several complex urological procedures consecutively is not associated with worse outcomes.