Nocturia within the elderly is a highly prevalent and underdiagnosed condition that significantly affects quality of life. The pathophysiology is multifactorial and may manifest from one or a combination of nonurologic, intrinsic renal, and/or bladder outlet/storage problems. A thorough history, physical examination, and frequency-volume chart are essential to determining etiology and treatment decisions in this vulnerable patient population. Nocturia may represent a primary disease process and/or a secondary effect of undiagnosed maladies that afflict the elderly, such as congestive heart failure (CHF) or obstructive sleep apnea (OSA). Management considerations beyond conservative measures for this frail patient population must take into consideration adverse drug events and the effects of polypharmacy.

You have accessJournal of UrologyUrodynamics/Incontinence/Female Urology: Incontinence - Evaluation & Therapy III1 Apr 20121354 RADIATION EXPOSURE TO THE PATIENT AND PHYSICIAN DURING SACRAL NEUROMODULATION Alana Murphy, Courtney Lee, Kevin Wunderle, Howard Goldman, and Sandip Vasavada Alana MurphyAlana Murphy Cleveland, OH More articles by this author , Courtney LeeCourtney Lee Cleveland, OH More articles by this author , Kevin WunderleKevin Wunderle Cleveland, OH More articles by this author , Howard GoldmanHoward Goldman Cleveland, OH More articles by this author , and Sandip VasavadaSandip Vasavada Cleveland, OH More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.1737AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES In 2010, the FDA launched an initiative to reduce radiation exposure during medical diagnostics and medical procedures. Radiation exposure to the patient and physician during sacral neuromodulation has not been reported in the literature. This study aims to calculate the radiation exposure to both the patient and physician during sacral neuromodulation with the InterStim® device. METHODS We conducted a prospective IRB approved study to determine the radiation exposure to both the patient and physician during sacral neuromodulation. The study population included patients undergoing initial lead placement (stage 1), peripheral nerve evaluation (PNE) or lead revision for urinary frequency, urge incontinence or non-obstructive urinary retention. Each procedure was performed by one of four fellowship trained urologists. The physician's radiation exposure was measured using an electronic radiation dosimeter placed on the outside of their lead apron and the patient's radiation exposure was measured using a radiation sensitive film placed on the lateral hip facing the x-ray source. RESULTS A total of 34 patients have been enrolled. Four patient dose readings were excluded based on improper handling of the radiation sensitive film. The patients were predominantly female (91.2%) with a mean age of 60.7 years old (23.2-90.5) and a mean BMI of 30.2 kg/m2 (17.7-45.7). Indication for sacral neuromodulation included urinary frequency in 9 patients (26.5%), urge incontinence in 14 patients (41.2%) and non-obstructive urinary retention in 11 patients (32.3%). Details of the procedures and radiation exposure for the patient and physician are characterized in table 1. Radiation exposure to both the patient and physician is lowest during a PNE procedure and greatest during the initial lead placement. Procedure Patients No. Leads Procedure Time⁎ Fluoro Time⁎ Physican Dose⁎ Patient Dose⁎ PNE 8 1 n=1; 2 n=7 23min(20-32) 8.3sec(6-16) 0.3mrem(0-1.2) 3.8mGy(0.1-10.5) Stage I 17 1 n=9; 2 n=8 51min(26-79) 29.5sec(6-60) 1.7mrem(0-8.1) 37.2mGy(14.1-64.2) Lead Revision 9 1 n=9 51min(42-74) 13.1sec(6-30) 0.5mrem(0-2.4) 14.0mGy(9.8-21.5) ⁎ values are presented as means. CONCLUSIONS Although our results indicate that radiation exposure is minimal during sacral neuromodulation, the cumulative dose for physicians should not be ignored. With a mean exposure of 1.7 mrem during an initial lead placement, a physician is exposed to the equivalent of one chest x-ray with every 4.7 procedures. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e549 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Alana Murphy Cleveland, OH More articles by this author Courtney Lee Cleveland, OH More articles by this author Kevin Wunderle Cleveland, OH More articles by this author Howard Goldman Cleveland, OH More articles by this author Sandip Vasavada Cleveland, OH More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

OBJECTIVE To evaluate whether the decrease in fluoroscopic images after initiation of a quality assurance (QA) protocol to decrease the amount of fluoroscopy during fluoro urodynamics (FUDS) translates into a significant reduction in radiation.METHODS The number of spot films, fluoroscopy time, air kerma, and dose area product from FUDS performed by our division during the 3 months before the conceptualization of the QA protocol were compared with the parameters of FUDS performed by our division 3 months after the initiation of the protocol. To ensure the protocol did not adversely affect the analysis of FUDS, 10 FUDS studies were evaluated by 4 fellowship-trained female urologists who compared the interpretation when only the images per QA protocol were reviewed with that when the additional images were reviewed.RESULTS A total of 54 FUDS studies performed in the 3 months before the conceptualization of the protocol were compared with 43 FUDS studies performed after initiation of the protocol. The mean number of spot films recorded before and after the QA protocol was 11.2 and 5.6, respectively (P < .001). The mean fluoroscopy time decreased from 40.9 to 11.7 seconds per procedure (P < .001). The mean air kerma decreased from 15.48 to 4.25 mGy, and the mean dose area product decreased from 518.90 to 150.28 mGy . cm(2) (P < .001 and P < .001, respectively). No difference was found in the treatment or diagnosis in 100% of the 40 FUDS evaluations.CONCLUSION Our QA protocol significantly decreased the amount of fluoroscopy time, dose area product, and air kerma during each FUDS without changing the diagnosis or treatment recommendations. UROLOGY 78: 540-543, 2011. (C) 2011 Elsevier Inc.

Overactive bladder (OAB) is a disorder characterized by urinary urgency. In the past, the pathophysiology and treatment of OAB focused on the parasympathetic efferent innervation of detrusor smooth muscle cells. However, recent evidence has provided a clearer understanding of the neurological, chemical, and functional physiology of the bladder and how it relates to the pathophysiology of OAB. Urothelial cells, sensory neurons, and interstitial cells of Cajal have secretory and receptor functions that play an important role in bladder function and dysfunction. As we learn more about bladder function and the mechanism of current OAB treatments, newer forms of therapy are emerging. These include neuromodulation, botulinum toxin, and the development of new drugs based on the pathophysiology of OAB.

You have accessJournal of UrologyUrodynamics/Incontinence/Female Urology: Urodynamic Testing1 Apr 20101625 DECREASE IN RADIATION EXPOSURE DURING FLUORO URODYNAMICS (FUDS) Courtney Lee, Wunderle Kevin, Sandip Vasavada, Rackley Raymond, Moore Courtenay, and Howard B. Goldman Courtney LeeCourtney Lee More articles by this author , Wunderle KevinWunderle Kevin More articles by this author , Sandip VasavadaSandip Vasavada More articles by this author , Rackley RaymondRackley Raymond More articles by this author , Moore CourtenayMoore Courtenay More articles by this author , and Howard B. GoldmanHoward B. Goldman More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.1405AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES In accordance with the As Low As Reasonably Achievable (ALARA) principle for radiation, our institution initiated a quality assurance protocol to decrease the amount of fluoroscopy during FUDS. We compare the radiation emitted from the fluoroscopic unit before and after the protocol to evaluate whether the decrease in fluoroscopic images translates into a significant reduction in radiation. METHODS The quality assurance protocol defined 5 points for fluoroscopic images: a scout image prior to the exam, during the filling phase, during a valsalva maneuver or cough, during voiding, and an optional image while voiding without catheter(if patient was unable to void with catheter). Additional imaging was allowed according to the discretion of the physician performing the FUDS. All fluoroscopic images were performed using the Seimens Arcadis Avantic fluoroscopic unit with the patient seated in the anterior-posterior position. The number of spot films, fluoroscopy time, cumulative dose area product (DAP), and cumulative air kerma (AK) from FUDS performed by our division during the 3 months prior to the conceptualization of the quality assurance protocol were compared to FUDS performed by our division after the initiation of the protocol. RESULTS Fifty- four FUDS performed in the 3 months prior to the conceptualization of the protocol were compared to 24 FUDS that were performed after the initiation of the protocol. There was no significant difference in age, sex, body mass index, and diagnosis. The mean number of spot films recorded before and after the quality assurance protocol was 11.19 and 4.92 respectively (p<0.001). The mean fluoroscopy time decreased from 40.94 seconds to 9.21 seconds per procedure (p<0.001). The mean DAP decreased from 518.90 mGycm2 to 105.60 mGycm2, and the mean AK decreased from 15.48 mGy to 2.95 mGy (p=0.001 and p = 0.001 respectively). CONCLUSIONS Our quality assurance protocol significantly decreased the amount of fluoroscopy time, DAP, and AK during each FUDS. This may be secondary to adherence to the protocol or staff awareness of radiation exposure during FUDS. Further study using a phantom will be required to determine the decrease in actual radiation exposure using our protocol. Cleveland, OH© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e627-e628 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.Metrics Author Information Courtney Lee More articles by this author Wunderle Kevin More articles by this author Sandip Vasavada More articles by this author Rackley Raymond More articles by this author Moore Courtenay More articles by this author Howard B. Goldman More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

INTRODUCTION:The purpose of this study was to evaluate the impact of a radiographer's learning curve on extracorporeal shock wave lithotripsy (SWL) efficacy.METHODS:Five registered technologists who were certified to assist in SWL procedures but had no prior lithotripter experience were evaluated during a 4-year period. Stone-free (no residual fragments on plain radiographic imaging), re-treatment and post-SWL procedure rates were evaluated for the first 3 years of radiographer employment.RESULTS:The overall stone-free rate increased from 55% (efficiency quotient [EQ] 45) in the first year to 68% (EQ 50) in the third year. The treatment success rate for the lower calyx increased from 50% (EQ 41) in the first year to 62% (EQ 44) in the third year. There was no difference in re-treatment or post-SWL procedure rates.CONCLUSION:Efficacy with SWL, as measured by stone-free rates, improved with increasing experience of the radiographer. Ongoing supervision and mentorship might be helpful in the first year of service.

You have accessJournal of Urology1 Apr 2008DIFFERENTIAL DIAGNOSIS OF MEN WITH OVERACTIVE BLADDER SYMPTOMS Jerry G Blaivas, Jeffrey P Weiss, Chandra Somaroo, Ruhee K Sidhu, Brian Marks, and Courtney L Lee Jerry G BlaivasJerry G Blaivas More articles by this author , Jeffrey P WeissJeffrey P Weiss More articles by this author , Chandra SomarooChandra Somaroo More articles by this author , Ruhee K SidhuRuhee K Sidhu More articles by this author , Brian MarksBrian Marks More articles by this author , and Courtney L LeeCourtney L Lee More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(08)61552-9AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "DIFFERENTIAL DIAGNOSIS OF MEN WITH OVERACTIVE BLADDER SYMPTOMS." The Journal of Urology, 179(4S), pp. 527–528 © 2008 by American Urological AssociationFiguresReferencesRelatedDetails Volume 179Issue 4SApril 2008Page: 527-528 Advertisement Copyright & Permissions© 2008 by American Urological AssociationMetricsAuthor Information Jerry G Blaivas More articles by this author Jeffrey P Weiss More articles by this author Chandra Somaroo More articles by this author Ruhee K Sidhu More articles by this author Brian Marks More articles by this author Courtney L Lee More articles by this author Expand All Advertisement PDF downloadLoading ...

Objective: To evaluate trends in safety, efficacy, and practice patterns for shockwave lithotripsy (SWL) procedures performed during a 18-year period and correlate the findings with recent evidence-based practice guidelines.Materials and Methods: From January1988 to June 2006, 66,819 SWLs were performed using the Medstone STS lithotripter in patients with radiologic evidence of stones in the kidney or ureter. Treatment characteristics, such as stone location and size, need of re-treatment, and final success rate were recorded. The procedures were further divided by year for statistical consideration. Statistical analysis was performed using Student t test; P < 0.05 was considered significant.Results: Overall SWL success rate was 85% (39,667/46,669), and the overall re-treatment rate was 7.2% (3,417/46,669). There was no significant change in the overall proportion of lower-pole calculi managed with SWL, although there was a significant decrease in the proportion of SWL used for lower calix stones larger than 16 mm in the time period after 2000 ( P = 0.006). There was a steady increase in the number of procedures performed for renal calculi in other locations per year, in particular for intrarenal calculi smaller than 20 mm. Intrarenal stones larger than 30 mm decreased as a proportion of procedures per year (P = 0.048) There was no significant change in the proportion of upper and distal ureteral stones managed, corresponding to a solid plateau in the percentage of SWL performed per year.Conclusion: Our study did not demonstrate an overall drop in SWL; however, it did show the interference of endoscopic procedures on two case scenarios. There was a significant decrease (P = 0.048) in SWL for renal stones larger than 30 mm, and the same trend was noted for lower calix stones larger than 15 mm (P = 0.06).

Purpose: To evaluate the impact of a slow gated treatment rate on the efficacy of extracorporeal shockwave lithotripsy (SWL).Patients and Methods: From August 1990 to July 2002, 40,462 SWL procedures were performed using the slow frequency electrocardiography (ECG)-gated lithotripter (82.5%) and fast frequency ECG-ungated (17.5%) modes for the Medstone STS lithotripter. Treatment characteristics, including the mode of SWL, location and size of the stone, re-treatment status, auxiliary procedures required, perioperative complications, and treatment outcomes, were recorded. The stone-free rate was reported by the treating physician on the basis of the finding of no residual stone fragments on a plain radiographic image.Results: The treatment rate for the slow mode was a mean of 79.6 shocks/min, while the rate for the fast mode was 120/min. The total procedure time was 47.0 minutes for the slow mode and 40.6 minutes for the fast. The overall stone-free rate was higher for slow (66.9%) than fast (63.6%) procedures (P < 0.001). The stone-free rate for 1- to 10-mm stones was higher for the slow procedures (75.7%) than the fast procedures (70.7%; P < 0.001). Upper-ureteral stones responded better to slow treatment in terms of stone-free rate (79.5 % v 72.6 %; P < 0.001), re-treatment rate (6.5 % v 8.0 %, P = 0.05), auxiliary-procedure rate (6.1 % v 8.9%; P = 0.01), and efficiency quotient (71 and 62). There was no significant difference in complication rates overall between slow and fast treatment.Conclusions: With a minimal increase in procedure time, greater efficacy can be obtained for the treatment of radiopaque stones with a slower shock-delivery rate. In particular, upper-ureteral calculi and calculi < 10 mm benefit from a slower treatment rate.

Purpose: To evaluate the efficacy of three lithotripter configurations that utilize the Medstone STS treatment head.Patients and Methods: From 1999 through 2002, 13,131 patients were treated with the Medstone STS fixed-site unit (STS-FIX; 52%), the mobile coach-transportable unit ( STS-MOB; 26%), or the modular operating-room unit ( STS-T; 22%). All units were staffed by a rotating schedule of the same ten SWL-certified radiological technicians. The treating urologists reported follow-up that included plain abdominal radiography to document stone-free rate ( no residual fragments) and the need for auxiliary procedures or re-treatment. An efficiency quotient (EQ) was calculated for each unit.Results: The overall stone-free rate for the STS-FIX, STS-MOB, and the STS-T was 59%, 62%, and 65%, respectively. The STS-FIX had the lowest stone-free rate for lower-pole stones (48%) and stones 21 mm to 30 mm (30%) compared with the STS-MOB (57% and 62%, respectively) and the STS-T ( 59% and 54%, respectively). However, the STS-FIX had a higher stone-free rate in the middle ureter ( 86%) than the STS-T (67%) and STS-MOB ( 65%). The STS-FIX required more post-SWL procedures overall (12%) than the STS-MOB ( 4%) and STS-T (5%). The re-treatment rates for the STS-FIX, STS-MOB, and STS-T were 7%, 6%, and 6%, respectively. The STS-T had the highest overall EQ ( 59) followed by the STS-MOB ( 56) and the STS-FIX ( 50).Conclusions: New configurations of the STS lithotripter have a significant positive impact on efficacy compared with the original fixed machine. Availability of real-time fluoroscopy with the STS-T may impact the higher EQ of this machine.

PURPOSE To evaluate the impact of the type of anesthesia on treatment efficacy, using a comparison of general anesthesia (GEN) and monitored anesthesia care with intravenous sedation (MAC), for patients undergoing extracorporeal shockwave lithotripsy (SWL) on the Medstone STS lithotripter. PATIENTS AND METHODS A case-control study was conducted of 660 patients treated from 1986 to 2002. General anesthesia and MAC were utilized in 330 procedures each. Case matching was performed for stone size, stone location, and body mass index. All lithotripter units were staffed by a rotating schedule of the same 10 SWL-certified radiologic technicians. Patient characteristics, treatment parameters, complications, repeat procedures, and secondary procedures were recorded. Stone-free success rates (no residual fragments) were reported by the treating physician on the basis of plain radiographs. Chi-square analysis was used to compare patients in the two groups. RESULTS The overall stone-free rate was better with GEN (67%) than MAC (55%; P = 0.04). Stone-free rates were not affected for stones 10 mm or in an upper calix. General anesthesia may decrease excursion of the calculus out of the focal area secondary to breathing or patient movement.

BACKGROUND AND PURPOSE:Adequate urine production and excretion may be important for clearance of stone fragments after extracorporeal shockwave lithotripsy (SWL). This study evaluated the impact of renal function, measured by preoperative serum creatinine concentration, on the efficacy of SWL. PATIENTS AND METHODS:From 1986 to 2001, 27,299 patients with urolithiasis were treated with Medstone STS lithotripters. Seven hundred ninety-eight of these patients (2.92%) had serum creatinine concentrations >or=2.0 mg/dL. Perioperative renal function (serum creatinine), treatment parameters, stone-free success rate (no residual fragments on plain film), and perioperative complications and procedures were recorded. RESULTS:The stone-free rate for patients with serum creatinine values from 2.0 to 2.9 mg/dL (56.69%) was significantly less than that seen in patients with a creatinine concentration <2.0 mg/dL (66.20%). The retreatment rate and secondary-procedure rate were significantly higher in patients with higher serum creatinine values (9.62% and 8.92%, respectively) than in those with serum creatinine within the normal range (6.07% and 4.27%, respectively). There was no significant difference in the stone-free rate, re-treatment rate, and secondary-procedure rate of patients with serum creatinine >or=3.0 mg/dL in comparison with patients with values <2 mg/dL. Complication rates were higher for patients with serum creatinine values >4.0 mg/dL (10.91%) than for patients with creatinine <2.0 mg/dL (2.62%). CONCLUSIONS:The efficacy of SWL is decreased in patients with serum creatinine concentrations of 2.0 to 2.9 mg/dL, and the complication rate is higher in patients with serum creatinine >4.0 mg/dL. Preoperative counseling may include a discussion of the impact of renal insufficiency on success and complication rates associated with SWL.

OBJECTIVE:Conduct a prospective randomized single-blind comparison of two nephrostomy catheter designs, evaluating specifically intraoperative placement and postoperative comfort.MATERIALS AND METHODS:The single-blind, prospective randomized trial was conducted with institutional review board approval. All patients undergoing percutaneous nephrolithotomy who gave informed consent were randomized to placement of either a Boston Scientific Flexima 8.3F pigtail nephrostomy tube #27-180 (PIG) or a Boston Scientific 8.2F nephroureteral stent #410-126 (NUS). Randomization was concealed from the surgeon until time of placement. Subjective intraoperative placement characteristics were rated by the surgeon on a scale of 1 = excellent, 2 = fair, 3 = good and 4 = poor. The patient's postoperative pain intensity was evaluated with a Visual Analog Pain Score (0 = no pain to 10 = worst pain).RESULTS:Nine patients were randomized to each group. The PIG group was rated significantly better than the NUS group with regards to ease of placement (p = 0.007) and radiopacity of the tube (p = 0.007) by surgeon. Visual analog pain scores on postoperative day one, was significantly lower in the PIG group (mean = 2+/-2) than the NUS group (mean = 5+/-1) (p =0.004). The mean amount of intra-venous morphine equivalent given in the PIG group (mean = 1+/4 Eq morphine) was less on average compared to the NUS group (mean = 6+/13 Eq morphine), but the differences did not reach statistical significance (p = 0.06).CONCLUSIONS:Following percutaneous nephrolithotomy, use of a small pig-tail nephrostomy tube results in greater ease of placement and less postoperative pain than a nephroureteral catheter.

Nephrostomy tube pain has a significant impact on the post-operative morbidity of percutaneous nephrolithotomy (PCNL). Our objective was to conduct a prospective randomized single-blind comparison of two nephrostomy catheter designs, evaluating specifically intraoperative placement and post-operative comfort.