INTRODUCTION:Practice guidelines recommend early consideration for palliative care for patients with advanced malignancies, and there has been limited research regarding the use of palliative care for patients with advanced bladder cancer. Our aim is to describe the rate and determinants of the use of palliative care consultation for patients treated with radical cystectomy at our institution. METHODS:A retrospective review was performed to identify patients who underwent cystectomy for bladder cancer between September 2014 and June 2019 at our institution. Our primary outcome was receipt of palliative care, defined as receiving a palliative care consult. We tested for associations between factors and our outcome of interest, and then estimated the impact on various determinants of palliative care use by fitting a multivariable logistic regression model. RESULTS:Over the study period, 294 patients underwent radical cystectomy. Of those patients, 29 (9.9%) received palliative care. Mean time from surgery to palliative care consult was 11.4 months. Palliative care consults were initiated by urologists in 32.1% of cases. On multivariable analysis, patients were more likely to receive palliative care if they had pT3+ disease (P < 0.001), were readmitted after surgery (P = 0.028), or had any major complication after surgery (P = 0.025). CONCLUSION:Rates of palliative care consults in patients with advanced bladder cancer at our institution are higher than other population-based estimates nationally. The majority of palliative care consults were requested by medical oncologists, highlighting an opportunity for educational initiatives for urologic oncologists to promote earlier consideration of palliative care referrals.

Background: Water irrigant is discouraged in ureteroscopy due to risks demonstrated in more invasive endoscopic procedures. However, water is not well studied in ureteroscopy and may provide better visualization than standard saline. Objective: To determine whether water irrigant increases the risk of hyponatremia compared with saline and provides better visualization in ureteroscopy. Design, setting, and participants: A randomized, prospective, double-blinded trial was conducted. In 2017, eligible adult ureteroscopy patients at a university hospital were recruited for the study. Intervention: Participants randomized to water or saline irrigant in ureteroscopy. Outcome measurements and statistical analysis: Serum sodium and osmolality, body temperature, subjective surgeon visualization, and objective turbidity clarity were analyzed. Chi-square or Fisher's exact tests for categorical variables and analysis of variance test for continuous variables were performed. Results and limitations: A total of 121 individuals (mean age 57 f 15 yr) underwent ureteroscopy (mean time 35 f 18 min) with a mean irrigation volume of 839 f 608 ml. For the 101 (83%) patients who had nephrolithiasis, the mean number of stones was 2 f 1 and the mean stone burden was 13 f 7 mm. There were no significant differences in demographic, clinical, and intraoperative variables between water and saline groups, except for a higher body mass index in the saline group (p = 0.01). There was no significant difference between groups in the incidence of hyponatremia, hypo-osmolality, or hypothermia. The median surgeon visualization score was significantly higher using water (p < 0.01). The mean turbidity was significantly lower with water (p = 0.02). Limitations were not objectively assessing hemolysis or fluid absorption. Conclusions: Water irrigant does not increase the incidence of hyponatremia in uncomplicated ureteroscopy and provides clearer visualization than saline. Patient summary: We compared safety and clarity of water and saline irrigation, which aid surgeon visualization, in ureteroscopy, which can treat kidney stones. We found that water irrigant does not reduce blood sodium levels significantly compared with saline in ureteroscopy and provides better visualization. (c) 2020 Published by Elsevier B.V. on behalf of European Association of Urology.

OBJECTIVE To evaluate the relationship between dynamic changes in the modified Glasgow Prognostic Scale (mGPS) and postnephrectomy survival among localized clear cell renal cell carcinoma (ccRCC) patients. METHODS We retrospectively identified patients who underwent nephrectomy for localized ccRCC with pre-operative mGPS = 0 from 2005 to 2018. The primary exposure of interest was Delta mGPS between 2 points - 60 days prior to surgery and 1 year after surgery. We assessed the relationship between DmGPS and survival outcomes. Kaplan-Meier curves were generated to determine survival estimates and Cox proportional hazards models were fit to estimate hazard ratios (HRs). Multivariable models were constructed using both DmGPS and clinical variables known to be associated with differences in survival. RESULTS We identified 313 patients for our analytic cohort with a median follow-up time of 20.2 months. Thirty-seven (11.9%) patients died and 39 (12.54%) showed recurrence during follow-up. Two hundred sixty-three (84.6%) patients had unchanged mGPS before and after surgery, while 48 (15.4%) patients showed an increase in postoperative mGPS from preoperative mGPS. Compared to patients with unchanged mGPS, patients with a higher postoperative mGPS had an increased risk of death (HR = 3.05 [1.39-6.68], P=.005) and recurrence (HR = 2.98 [1.34-6.64], P=.008). CONCLUSION Patients with an increase in mGPS following nephrectomy for ccRCC were more likely to die and experience cancer recurrence. Assessing dynamic changes in this cheap, validated, and reproducible test may be useful in identifying patients at higher risk for more aggressive disease or for counseling patients regarding risk of cancer recurrence. (C) 2020 Elsevier Inc.

Background: Malakoplakia is a rare benign lesion, usually associated with deficient intralysosomal degradation of microorganisms, more commonly, Escherichia coli. Malakoplakia occurs in various organ systems, the most frequently affected site being the urinary bladder. We report a rare case of isolated extensive malakoplakia involving the prostate, diagnosed on transurethral resection performed for radiologically suspected prostatic abscesses. Case Presentation: A 61-year-old African American male presented with symptoms of urinary obstruction for the past 2 months. His medical history was significant for immunosuppression (liver transplantation 3 months prior and diabetes mellitus). He reported four episodes of E. coli-associated urinary tract infection after his liver transplantation. Serum prostate specific antigen was 1.83 ng/cc (normal inferior to 4 ng/cc), and urine culture was positive for E. coli sensitive to ceftriaxone. Pelvic magnetic resonance imaging was suggestive of prostatitis with prostatic abscesses; cystoscopy was unremarkable. The patient was started on intravenous ceftriaxone therapy. A standard bipolar transurethral resection of the prostate was performed, and purulent-like material was encountered in the resected tissue. Histologic examination demonstrated extensive infiltration and replacement of the prostatic tissue by sheets of pink histiocytes with targetoid inclusions consistent with Michaelis-Gutmann bodies, ultimately confirming malakoplakia of the prostate. Conclusion: Prostatic malakoplakia is an unexpected diagnosis in patients suspected of having malignancy or prostatitis. Its exact pathogenesis is unknown, but it involves defective bacterial degradation after phagocytosis. E. coli is often cultured from the patients' urine. Immunosuppression, present in our patient, is a well-known associated factor. Prostatic malakoplakia can radiologically masquerade as prostatic adenocarcinoma, despite the use of cutting-edge imaging technology. With the growing use of multiparametric 3T prostate magnetic resonance imaging to screen for prostate cancer, it is possible that urologists, radiologists, and pathologists will encounter prostatic malakoplakia more frequently in the future.

You have accessJournal of UrologyKidney Cancer: Epidemiology & Evaluation/Staging/Surveillance II (PD45)1 Apr 2020PD45-02 EVALUATION OF RENAL CELL CARCINOMA INFLAMMATORY SCORE IN PATIENTS WITH LOCALIZED CLEAR CELL RENAL CELL CARCINOMA: AN INTERNATIONAL, MULTI-INSTITUTIONAL ANALYSIS Dattatraya Patil*, Alexandra Medline, Kazutaka Saito, Aaron Lay, Fady Ghali, Mehmet Asim Bilen, Devin Patel, John Pattaras, Margaret Meagher, Shohei Fukuda, Yosuke Yasuda, Yasuhisa Fujii, Kenneth Ogan, Ithaar Derweesh, and Viraj Master Dattatraya Patil*Dattatraya Patil* More articles by this author , Alexandra MedlineAlexandra Medline More articles by this author , Kazutaka SaitoKazutaka Saito More articles by this author , Aaron LayAaron Lay More articles by this author , Fady GhaliFady Ghali More articles by this author , Mehmet Asim BilenMehmet Asim Bilen More articles by this author , Devin PatelDevin Patel More articles by this author , John PattarasJohn Pattaras More articles by this author , Margaret MeagherMargaret Meagher More articles by this author , Shohei FukudaShohei Fukuda More articles by this author , Yosuke YasudaYosuke Yasuda More articles by this author , Yasuhisa FujiiYasuhisa Fujii More articles by this author , Kenneth OganKenneth Ogan More articles by this author , Ithaar DerweeshIthaar Derweesh More articles by this author , and Viraj MasterViraj Master More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000932.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Several inflammatory markers have been known to be associated with worse outcomes in clear cell renal cell carcinoma (ccRCC), however few analyzed prognostic value in aggregate. We hypothesize that a combination of C-Reactive Protein (CRP), Albumin, Neutrophil-Lymphocyte ratio (NLR), corrected calcium, and AST/ALT ratio into a RCC Inflammatory Score (RISK) could serve as a rigorous prognostic indicator. METHODS: Multicenter retrospective analysis of RCC patients undergoing nephrectomy for localized ccRCC. The optimal threshold for individual biomarkers was determined using grid search and receiver operating characteristic (ROC) analysis. Each patient was assigned to a RISK group based on sum of each marker score. Primary outcome was overall survival (OS) and secondary outcome was recurrence-free survival (RFS). Prognostic value of RISK was analyzed using the Kaplan-Meier (KM) method and multivariable Cox proportional regression models. Multivariable models adjusted for Age, sex, race, BMI, T and N-stage, tumor size, necrosis, grade, partial or radical surgery. RESULTS: 2,591 patients with localized ccRCC were identified with mean follow-up of 46 months. 812 (31%) patients were found to be in baseline risk group, while 1300 (50%) in low risk, 456 (18%) to intermediate, and 23 (0.9%) in high risk group. Higher RISK group were significantly associated with larger tumor size, necrosis, higher T- an N-stage, RCC grade. Multivariable models showed RISK to be an independent and significant predicter of both OS and RFS. In adjusted models for OS, compared to baseline risk, patients with Low [HR: 1.4, p=0.01], intermediate [HR:2.5, p=<.001], and High risk [HR: 5.4, p=<.001] had higher risk of death. In models for RFS, patients with intermediate [HR:1.6, p=0.02] had higher risk recurrence. CONCLUSIONS: RISK is an independent and significant predictor of overall survival in localized clear cell RCC while adjusting for established predictive histological factors. Notably, RISK is composed of standardized laboratory markers easily and cost-effectively obtained preoperatively and requires no surgical specimen, allowing crucial prognostic information to be integrated into medical decision making prior to surgery. Source of Funding: Robinson & Churchill family foundation © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e913-e914 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Dattatraya Patil* More articles by this author Alexandra Medline More articles by this author Kazutaka Saito More articles by this author Aaron Lay More articles by this author Fady Ghali More articles by this author Mehmet Asim Bilen More articles by this author Devin Patel More articles by this author John Pattaras More articles by this author Margaret Meagher More articles by this author Shohei Fukuda More articles by this author Yosuke Yasuda More articles by this author Yasuhisa Fujii More articles by this author Kenneth Ogan More articles by this author Ithaar Derweesh More articles by this author Viraj Master More articles by this author Expand All Advertisement PDF downloadLoading ...

Robot-assisted laparoscopic radical prostatectomy (RALP) relies heavily on the bedside assistant (BA). Currently, the relationship between BA experience and surgical outcomes in robotic surgery is not clear. We examined whether bedside assistant experience can significantly affect positive margin rate and peri-operative outcomes for RALP for surgeons within their learning curve. A retrospective cohort study of a single surgeon’s peri-operative outcomes during RALP was examined and compared with and without an experienced bedside assistant. Patient demographic data and peri-operative data, margin rate, and length of stay (LOS), were collected and analyzed. Univariate and multivariable analyses were performed to determine if expert BA was a predictor of post-operative outcomes. In total, 170 consecutive cases over three years were analyzed. 111 (65%) were performed without an expert BA. The two groups were not significantly different with regards patient demographics (p > 0.05). On univariate analysis, having an expert BA was associated with a significantly lower LOS (31 h ± 21 vs. 42 h ± 26, p = 0.004), EBL (296 ml ± 180 vs. 441 ml ± 305, p < 0.0001) and positive margin rate (20% vs. 37%, p = 0.03). Other surgical outcomes were comparable between groups. On multivariable analysis, expert BA remained a predictor of, EBL (B stat = − 146, 95% CI − 240 to − 52, p = 0.003) and positive margin rate (OR 0.4, 95% CI 0.2–0.96, p = 0.04). Our results demonstrate that the use of an expert BA may result in improved patient outcomes early in the learning curve of RALP, most notably, positive margin rate and estimated blood loss.

You have accessJournal of UrologyStone Disease: Surgical Therapy III (MP23)1 Apr 2019MP23-02 RISK OF PROLONGED OPIOID USE AMONG OPIOID-NAïVE PATIENTS FOLLOWING UROLOGIC STONE SURGERY Mohammed Said*, Andrew Leung, Dattaraya Patil, Kenneth Ogan, Akanksha Mehta, Christopher Filson, and Aaron Lay Mohammed Said*Mohammed Said* More articles by this author , Andrew LeungAndrew Leung More articles by this author , Dattaraya PatilDattaraya Patil More articles by this author , Kenneth OganKenneth Ogan More articles by this author , Akanksha MehtaAkanksha Mehta More articles by this author , Christopher FilsonChristopher Filson More articles by this author , and Aaron LayAaron Lay More articles by this author View All Author Informationhttps://doi.org/10.1097/01.JU.0000555608.90055.77AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVES: The USA is in the midst of an opioid epidemic, the scope of which is currently being elucidated. Given the widespread use of postoperative opioids, identifying patients at risk for prolonged opioid use is an important avenue for prevention. Thus, we evaluated the risk and incidence of prolonged opioid use in opioid-naïve patients after kidney stone surgeries. METHODS: We studied insurance claims from the Truven MarketScan to identify opioid-naive patients, age 18-64, who underwent shockwave lithotripsy (SWL), ureteroscopy (URS), or percutaneous nephrolithotomy (PCNL) between 2009 and 2015. Patients were observed for 6 months to determine the number and oral morphine equivalent (OME) dosage of postoperative opioid prescriptions. We assessed prolonged opioid use, defined as patients who filled a perioperative opioid prescription followed by a prescription between 90 and 180 days after surgery, and evaluated risk factors using logistic regression. RESULTS: 50,249 opioid-naive patients filled a perioperative. Of these, 8.1% of patients continued to fill prescriptions between 90 and 180 days after surgery. In multivariate models there was no significant difference between URS, SWL, or PCNL in prolonged opioid use. There was an association between greater total OME prescribed peri-operatively and prolonged opioid use; patients receiving the 80th percentile of OMEs were more likely than patients receiving <20th percentile, OR 1.28 (1.15-1.41, p<0.01). Pain and mental health disorders were associated with prolonged opioid use, OR 1.31 (1.22-1.41, p<0.01) and OR 1.24 (1.13-1.36, p < 0.01), respectively. Substance and alcohol abuse as well as tobacco use also associated, OR 1.80 (1.38-2.35) and OR 1.26 (1.06-1.49). Other variables that were associated with prolonged opioid use include female gender, multiple procedures, higher Charlson comorbidity index, and region. CONCLUSIONS: 8.1% of opioid-naive patients continue to fill opioid prescriptions 90 days after stone surgery. Surgery was not associated with prolonged use. Receiving relatively large doses of opioids relative to the lowest quintile was associated with prolonged use. Preoperative interventions centered on opioid alternatives and early cessation, particularly among patients at risk for long-term use, such as those with pain and mental health disorders as well alcohol, substance and tobacco use, are critical to addressing the prescription opioid crisis in the USA. Source of Funding: none Atlanta, GA; Atlanta, GA© 2019 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 201Issue Supplement 4April 2019Page: e325-e325 Advertisement Copyright & Permissions© 2019 by American Urological Association Education and Research, Inc.MetricsAuthor Information Mohammed Said* More articles by this author Andrew Leung More articles by this author Dattaraya Patil More articles by this author Kenneth Ogan More articles by this author Akanksha Mehta More articles by this author Christopher Filson More articles by this author Aaron Lay More articles by this author Expand All Advertisement PDF downloadLoading ...

INTRODUCTION AND OBJECTIVES: Recent studies have shown that opioid prescribing in the postoperative setting remains a significant source of opioids in the community. More specifically, they have demonstrated that there is considerable variability in the amount prescribed after routine procedures and that patients generally use much less opioid medication than they are prescribed. Defining the minimum number of opioids that can be supplied without an increasing rate of refill following surgery may help standardize opioid prescribing guidelines and reduce the excess supply of opioids. Thus, we attempted to determine the correlation between the rate of postoperative opioid prescription refills and the amount of opioid prescribed. METHODS: We studied insurance claims from the Truven MarketScan database to identify opioid-naïve patients (no opioid exposure 12 months-6 days before surgery), age 18-64, who underwent shockwave lithotripsy (SWL), ureteroscopy (URS), or percutaneous nephrolithotomy (PCNL) between 2009 and 2015. Our primary outcome was the occurrence of an opioid refill between 6-31 days postoperatively after receipt of a single perioperative prescription within 5 days before to 5 days after surgery. Our primary explanatory variable was the total oral morphine equivalents (OMEs) provided in the initial postoperative prescription. We used logistic regression to examine the probability of an additional refill by initial prescription strength, adjusting for patient factors. RESULTS: Among 23,749 opioid-naïve patients, 79% filled a perioperative opioid prescription. The median initial perioperative prescription was 225 OMEs for all surgery types. 10% of patients refilled their prescriptions. Across procedures, the probability of a postoperative refill did not change with increasing initial OMEs prescribed. Patients undergoing PCNL were more likely to require a refill (OR 1.42, 95% CI 1.02-1.97). History of mental health and pain disorders trended toward association with refill (OR 1.14, 95% CI 1.00-1.30) and (OR 1.10, 95% CI 1.00-1.20) respectively. CONCLUSIONS: The rate of opioid prescription refill after urologic stone surgery was not correlated with initial prescription strength. Given the lack of impact of initial OMEs prescribed on the rate of refill clinicians could begin patients on a lower initial prescription to decrease the potential for leftover pills in the home, diversion of those drugs elsewhere, or chronic opioid use. Source of Funding: none

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Quality Improvement & Patient Safety II (MP15)1 Apr 2019MP15-03 RISK OF PROLONGED OPIOID USE AMONG OPIOID-NAïVE PATIENTS FOLLOWING UROLOGIC-MINIMALLY INVASIVE SURGERY Mohammed Said*, Dattaraya Patil, Kenneth Ogan, Akanksha Mehta, Christopher Filson, and Aaron Lay Mohammed Said*Mohammed Said* More articles by this author , Dattaraya PatilDattaraya Patil More articles by this author , Kenneth OganKenneth Ogan More articles by this author , Akanksha MehtaAkanksha Mehta More articles by this author , Christopher FilsonChristopher Filson More articles by this author , and Aaron LayAaron Lay More articles by this author View All Author Informationhttps://doi.org/10.1097/01.JU.0000555319.05289.17AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVES: The USA is in the midst of an opioid epidemic, the scope of which is currently being elucidated. Given the widespread use of postoperative opioids, identifying patients at risk for prolonged opioid use is an important avenue for prevention. Thus, we evaluated the risk and incidence of prolonged opioid use in opioid-naïve patients after minimally-invasive urologic surgery. METHODS: We studied insurance claims from the Truven MarketScan to identify opioid-naïve patients, age 18-64, who underwent laparoscopic or robotic radical prostatectomy, nephrectomy, partial nephrectomy, pyeloplasty, and sacrocolpopexy between 2009 and 2015. Patients were observed for 6 months to determine the number and oral morphine equivalent (OME) dosage of postoperative opioid prescriptions. We assessed prolonged opioid use, defined as patients who filled a perioperative opioid prescription followed by a prescription between 90 and 180 days after surgery, and evaluated risk factors using logistic regression. RESULTS: 17,713 opioid-naïve patients filled a perioperative prescription. Of these, 4.9% of patients continued to fill prescriptions between 90 and 180 days after surgery. In multivariate models there was no significant difference between surgery type for prolonged opioid use. Compared to a reference value of < 20th percentile, higher OME quintiles showed a significant effect. Pain and mental health disorders were associated with prolonged opioid use, OR 1.35 (1.15-1.58, p<0.01) and OR 1.39 (1.18-1.64, p < 0.01), respectively. Other variables that were associated with prolonged opioid use include female gender, higher Charlson comorbidity index, and Southern region. CONCLUSIONS: 4.9% of opioid-naïve patients continue to fill opioid prescriptions 90 days after stone surgery. Surgery type was not associated with prolonged use. Receiving large doses of opioids relative to the lowest quintile was associated with prolonged use. Preoperative interventions centered on opioid alternatives and early cessation, particularly among patients at risk for long-term use, such as those with pain and mental health disorders are critical to addressing the prescription opioid crisis in the USA. Source of Funding: none Atlanta, GA; Atlanta, GA© 2019 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 201Issue Supplement 4April 2019Page: e197-e197 Advertisement Copyright & Permissions© 2019 by American Urological Association Education and Research, Inc.MetricsAuthor Information Mohammed Said* More articles by this author Dattaraya Patil More articles by this author Kenneth Ogan More articles by this author Akanksha Mehta More articles by this author Christopher Filson More articles by this author Aaron Lay More articles by this author Expand All Advertisement PDF downloadLoading ...

INTRODUCTION AND OBJECTIVES: Von Hippel-Lindau (VHL) disease is a hereditary cancer syndrome with poor survival.The current recommendations have proposed uniform surveillance strategies for all patients, which neglected the obvious inter and intra familial phenotypic varieties.In this study, we aim to confirm the phenotypic heterogeneity in VHL disease and the underlying mechanism.METHODS: A total of 151 parent-child pairs were enrolled for genetic anticipation analysis, and 77 sibling pairs for birth order effect analysis.Four statistical methods were used to compare the onset age of patients among different generations and different birth orders.RESULTS: The average onset age was 18.9 years earlier in children than that in their parents, which was statistically significant in paired t test (p<0.001),RY1 (p<0.05),RY2 (p<0.01) and CPH model (p<0.001).Furthermore, the first-born siblings were affected 8.3 years later than the other ones among the maternal patients.Telomere shortening was confirmed to be associated with genetic anticipation in VHL families, while it failed to explain the birth order effect.Moreover, no significant difference was observed for overall survival between parents and children (p[0.834) and between the first-born patients and the other siblings (p[0.390).CONCLUSIONS: This study provides definite evidence and possible mechanisms of intra-familiar phenotypic heterogeneity in VHL families, which is helpful to the update of surveillance guidelines.

You have accessJournal of UrologyStone Disease: Surgical Therapy II1 Apr 2018MP55-02 RANDOMIZED TRIAL COMPARING THE SAFETY AND CLARITY OF WATER VERSUS SALINE IRRIGANT IN URETEROSCOPY Farha Pirani, Salima Makhani, Frances Kim, Aaron Lay, Cara Cimmino, Lindsey Hartsell, Ashley Spence, Viraj Master, and Kenneth Ogan Farha PiraniFarha Pirani More articles by this author , Salima MakhaniSalima Makhani More articles by this author , Frances KimFrances Kim More articles by this author , Aaron LayAaron Lay More articles by this author , Cara CimminoCara Cimmino More articles by this author , Lindsey HartsellLindsey Hartsell More articles by this author , Ashley SpenceAshley Spence More articles by this author , Viraj MasterViraj Master More articles by this author , and Kenneth OganKenneth Ogan More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.1773AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Risks of using sterile water irrigant in endoscopic procedures include development of hyponatremia and transurethral resection syndrome. For these concerns, AUA stone treatment guidelines recommend use of 0.9% saline in ureteroscopy (URS). However, water may provide better visualization, and a prospective study has indicated that fluid absorption in URS is minimal. We hypothesize that water irrigant will not significantly change serum sodium and osmolality compared to saline and that water will provide better visualization in URS. METHODS In 2017, 106 adult patients undergoing URS were prospectively randomized to receive sterile water or 0.9% saline irrigant. Patients and surgeons were blinded to fluid type. Pulsed irrigation was used. Serum sodium and osmolality were assessed before and after surgery. Fluid clarity was measured subjectively by surgeon scores and objectively by turbidity analysis with a turbidimeter of renal fluid collected in surgery. A p-value < 0.05 was considered statistically significant for bivariate analyses. RESULTS 106 patients (mean age 56 years) underwent URS (mean time 35 min) with median irrigation volume of 598 mL (IQR 349-1106). For the 87 (82%) patients who had URS for nephrolithiasis, median stone number was 1, and mean stone burden was 13 mm. There were no significant differences in demographic, clinical, and intraoperative variables between water and saline groups, except higher BMI in the saline group (p=0.0023). The difference in mean change in serum sodium between water and saline groups was statistically significant but not clinically meaningful (-0.46 ± 2.09 vs. 0.52 ± 2.25, p=0.022) (Table 1). Difference in change in osmolality was not significant. Of note, the water group had fewer postoperative hyponatremia (serum Na ≤135 mEq/L) events (2) than the saline group (4). Median surgeon visualization score was significantly higher for the water group (p=0.001). Measured turbidity was significantly lower for the water group (p=0.027). CONCLUSIONS Water irrigant does not cause clinically significant changes in serum sodium and osmolality or increase risk of hyponatremia compared to saline in URS. Water also appears to give clearer endoscopic visualization. Thus, water irrigant is safe in uncomplicated URS and may be preferred in cases with suboptimal visualization. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e747 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Farha Pirani More articles by this author Salima Makhani More articles by this author Frances Kim More articles by this author Aaron Lay More articles by this author Cara Cimmino More articles by this author Lindsey Hartsell More articles by this author Ashley Spence More articles by this author Viraj Master More articles by this author Kenneth Ogan More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

You have accessJournal of UrologyStone Disease: Surgical Therapy III1 Apr 2018PD45-02 NATURAL HISTORY OF RESIDUAL FRAGMENTS CONFIRMED BY COMPUTED TOMOGRAPHY AFTER URETEROSCOPY Igor Sorokin, Noah Canvasser, Aaron Lay, Jodi Antonelli, and Margaret Pearle Igor SorokinIgor Sorokin More articles by this author , Noah CanvasserNoah Canvasser More articles by this author , Aaron LayAaron Lay More articles by this author , Jodi AntonelliJodi Antonelli More articles by this author , and Margaret PearleMargaret Pearle More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.2138AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES We recently reported that despite aggressive fragment retrieval, ureteroscopy (URS) for renal calculi yields surprisingly low stone free rates using computed tomography to identify residual fragments (RFs). We followed a prospective cohort of patients who underwent URS and were imaged with CT at 6-8 weeks to determine the outcome of patients left with RFs. METHODS We prospectively evaluated 167 patients (209 renal units) undergoing URS for renal and ureteral stones from December 2015 to February 2017. CT was obtained at 6-8 weeks post-operatively in all patients. Patients with residual fragments of any size who had at least 12 months of follow-up comprised our study group. Patients were evaluated at followup office visits with KUBs and all patients were contacted by phone to determine if they had experienced any symptomatic stone events attributable to their RF(s). A stone event was defined as stone passage, need for intervention, symptoms requiring emergency department (ED) visit, or stone growth. Fisher′s exact test was used for categorical variables. Statistical significance was set at p≤0.05 RESULTS Among 81 patients (94 renal units) with RF, 29 (36%) had a ≥12 months of follow-up (mean follow-up 16.7 ± 4.5 months). The largest mean residual fragment per patient was 3.6 ± 1.9 mm. Overall, stone events occurred in 12 (41%) patients. Stone passage was noted in 4 (14%), ED visit without surgical intervention occurred in 3 (10%), and surgical intervention was required when the RF obstructed the ureter in 5 (17%) patients. RFs larger than 4 mm were associated with increased need for surgical intervention (4/13, 31%) but this was not statistically significant (p=0.14). CONCLUSIONS Residual fragments of any size pose a risk of causing a stone-related event after ureteroscopy. The high rate of residual fragments after ureteroscopy is consequential, and perhaps better patient selection is necessary to assure higher stone free rates and lower secondary morbidity after this treatment modality. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e886 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Igor Sorokin More articles by this author Noah Canvasser More articles by this author Aaron Lay More articles by this author Jodi Antonelli More articles by this author Margaret Pearle More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Laganosky, Dean D. MD; Khan, Amir I. BA; Patil, Dattatraya MBBS, MPH; Lay, Aaron H. MD; Pattaras, John G. MD, FACS; Bilen, Mehmet A. MD; Kucuk, Omer MD; Ogan, Kenneth MD; Master, Viraj MD, PhD Author Information

690 Background: Multiple inflammatory markers have been evaluated in predicting preoperative risk in patient’s undergoing curative nephrectomy for Clear cell renal cell carcinoma. We propose that ratio of C-Reactive Protein to albumin (CA-ratio) would prove to be a good prognostic indicator for assessment of overall survival and comparable to established nomograms in clear call RCC. Methods: Patients that underwent nephrectomy for localized clear cell RCC between 2007 and 2016 were retrospectively identified. The optimal threshold for individual biomarkers among the panel was determined using grid search methodology, receiver operating characteristic (ROC) analysis, and sensitivity-specificity trade-off analysis. Prognostic value of CA-ratio was analyzed using the Kaplan-Meier method and Cox proportional regression models. ROC and chi-square analyses were performed to compare the predictive ability of CA-ratio to SSIGN, and UISS. Results: Among the 433 clear cell RCC patients treated with nephrectomy, mean age at surgery was 58.4±12, and mean BMI was 30.6±6.8. 158 (36.5%) had CA-ratio < 0.1, while 164 (37.9%) were between 0.1-0.2, and 111 (25.6%) were 0.2+. Pathological T-stage was distributed as follows: T1: 294 (67.9%), T2: 29 (6.7%), T3: 106 (24.5%), and T4: 4 (0.9%). Overall, 60 (13.9%) patients died before end of the follow-up. Area under the curve (AUC) for CA-ratio was 0.72, comparable to SSIGN (AUC 0.73, p = 0.12). On multivariate COX proportional hazards analysis, patients with ratio 0.2 or more were more likely to die compared to patients with ratio < 0.1 [HR:3.45 95%CI:1.68-7.10, p = < 0.001], while adjusting for T-stage, grade, necrosis, and age. Conclusions: CA-ratio is an cost-effective , independent and significant predictor of overall survival in clear cell RCC with accuracy at least as good as other established prognostic tools including SSIGN and UISS. [Table: see text]