Objective: Equipment and personnel contribute to the overall noise level in the operating room (OR). This study aims to determine intraoperative noise levels during percutaneous nephrostolithotomy (PCNL) and the effects of this noise upon intraoperative communication. Methods: A PCNL benchtop model was used to measure intraoperative noise and determine its effect upon communication in three progressively increasing sound environments (baseline ambient noise, ambient noise with PCNL equipment, and ambient noise with both PCNL equipment and music). Five trials with 20 different medical words/phrases were spoken by the surgeon and responses were recorded by the first assistant, anesthesiologist, and circulating nurse. In addition, noise levels during PCNL were compared to common environmental noise levels. Results: In the bench top model, noise levels were 53.49A-weighted decibels (dBA) with ambient noise, 78.79dBA with equipment in use, and 81.78dBA with equipment and music. At the ambient noise level, the first assistant, anesthesiologist, and circulator correctly recorded 100%, 100%, and 96% of the words, respectively. The correct response rate by the subjects decreased to 97% (p=0.208), 81% (p=0.012), and 56% (p<0.001) upon addition of PCNL equipment, and 90% (p=0.022), 48% (p=0.002), and 13% (p<0.001) upon addition of music and PCNL equipment in the first assistant, anesthesiologist, and circulator, respectively. In the simulated OR model, PCNL noise level (81.78dBA) was comparable to a passing freight train at 30 feet (82.2dBA, p=0.44). Conclusion: Noise pollution decreases effective intraoperative communication during PCNL. It is important for surgeons to understand the effect noise can have on attempted communication to prevent errors due to miscommunication. In addition, methods to decrease intraoperative noise pollution and improve communication in the OR could improve patient safety and outcomes.

Background and Objective: The ideal hemostatic agent for laparoscopic partial nephrectomy (LPN) would provide complete hemostasis and sealing of the collecting system at a low cost. Chitosan (CS) is an established topical hemostatic agent, but standard sterilization techniques affect its functional and biologic properties, thereby preventing parenteral uses. This study sought to characterize the safety and efficacy of an implanted CS hemostat sterilized with either a standard technique, electron beam (e-beam) irradiation, or a novel technique, nonthermal nitrogen plasma, in a porcine LPN model. Methods: Laparoscopic partial nephrectomies were performed on six farm pigs and hemostasis achieved using only a CS hemostatic agent (Clo-Sur P.A.D.) that was e-beam (n = 3) or plasma sterilized (PS) (n = 3). Number of pads needed to achieve hemostasis, estimated blood loss, operative time, mass of kidney resection, and warm ischemia time were measured. Animals were monitored for 14 weeks and at harvest, retrograde ureteropyelography and histologic analysis were performed. Results: Complete hemostasis and collection system sealing were achieved in both groups. There was a trend toward less pads required for hemostasis (p = 0.056) and reduced blood loss (p = 0.096) with PS pads, although this did not achieve statistical significance. No complications were observed for 14 weeks and gross examination showed the implanted CS was encapsulated in a fibrous capsule. Histologic analysis revealed a healed nephrectomy site with residual CS and associated chronic inflammation, reactive fibrosis, and foreign body giant cell formation. Importantly, the adjacent renal tissue was intact and viable with no residual parenchymal inflammation or cytologic damage. Conclusion: CS pads alone provided safe and effective hemostasis in a porcine LPN model. PS may enhance hemostatic efficacy and resorption compared with e-beam.

OBJECTIVE:To compare the outcomes between laparoendoscopic single-site (LESS) and a novel percutaneous externally assembled laparoscopic (PEAL) nephrectomy in an in vivo porcine model.MATERIALS AND METHODS:Ten female farm pigs were randomized to LESS nephrectomy (5) or PEAL nephrectomy (5). Operative times, estimated blood loss, and intraoperative and postoperative complications were compared. The surgeons used a Likert scale to grade difficulty of peritoneal access, port placement, tool assembly, hilar dissection, closure, and overall difficulty of surgery. Scar assessment was performed by a blinded plastic surgeon using the Vancouver Scar Scale. Descriptive statistics were reported as median and range. The Mann-Whitney U test was used for continuous and ordinal variables. A p value <0.05 was considered significant.RESULTS:Median operative time was significantly shorter in the PEAL group vs the LESS group (85 minutes vs 127 minutes, p = 0.03). Median Likert scores showed overall hilar dissection and nephrectomy to be significantly easier using PEAL compared with LESS (2 vs 9, p < 0.01 for both). The PEAL instruments left no visible scar at 5 feet in any animal, and only 1 out of 10 scars could be identified on physical examination.CONCLUSIONS:The PEAL surgical paradigm demonstrates nearly scarless outcomes while providing shorter operative times and easier performance than LESS nephrectomy in a porcine model.

Aims Translabial ultrasound (TUS) is a useful tool for identifying and assessing synthetic slings. This study evaluates the ability of urology trainees to learn basic pelvic anatomy and sling assessment on TUS. Methods Eight urology trainees (six residents and two medical students) received a lecture reviewing basic anatomy and sling assessment on TUS followed by review of two training cases. Next, they underwent a 126-question examination assessing their ability to identify anatomic planes and structures in those planes, identify the presence of slings, and assess the location and intactness of a sling. The correct response rate was compared to that of an attending radiologist experienced in reading TUS. Non-parametric tests (Fisher's exact, chi-squared tests, and Yates correction) were used for statistical analysis, with P < 0.05 considered significant. Results 847/1008 (84.0%) of questions were answered correctly by eight trainees compared to 119/126 (94.4%) by the radiologist (P = 0.001). The trainees’ correct response rates and Fisher's exact test P values associated with the difference in correct answers between radiologist and trainee were as follows: identification of anatomic plane (94.4%; P = 0.599), identification of structure in sagittal view (80.6%; P = 0.201), identification of structure in transverse view (88.2%; P = 0.696), presence of synthetic sling (95.8%; P = 1.000), location of sling along the urethra in (71.5%; P = 0.403), intactness of sling (82.6%; P = 0.311), and laterality of sling disruption (75.0%; P = 0.076). Conclusions Urology trainees can quickly learn to identify anatomic landmarks and assess slings on TUS with reasonable proficiency compared to an experienced attending radiologist.

Purpose: Various cleave techniques have recently been shown to significantly impact initial laser fiber power output during holmium laser lithotripsy. The impact of cleave technique on long-term power output has not been well characterized. The purpose of this study was to determine the effect of laser cleave technique on power output over time.Materials and Methods: In this randomized single-blinded study, five cleave techniques were tested on two holmium laser fiber diameters (200, 365 mu m) over 15 minutes of laser lithotripsy with calcium oxalate monohydrate stones. Comparisons between cleave techniques and fiber diameters were performed using independent samples Mann-Whitney U, Kruskal-Wallis, and homogeneity of variance tests with a significance of p < 0.05.Results: The 365-mu m fiber was more durable and less affected by burnback degradation than the 200-mu m fiber (p < 0.05). While initial power output varied between cleave techniques, all significance disappeared by 3 minutes. Power output decreased rapidly by a mean of 0.62 W over 4 minutes (p < 0.05), following which there was no significant change.Conclusion: These findings confirm that initial laser fiber power output is significantly influenced by cleave technique, and the ceramic scissor is the optimal tool for cleaving between procedures. However, because of rapid fiber tip degradation and power loss, this study argues against routine cleaving to improve procedural efficiency in lengthy ureteroscopy cases.

Purpose: Percutaneous nephrolithotomy access may be technically challenging and result in significant radiation exposure. In an attempt to reduce percutaneous nephrolithotomy radiation exposure, a novel technique combining ultrasound and direct ureteroscopic visualization was developed and reviewed.Materials and Methods: Ureteroscopy without fluoroscopy was used to determine the optimal calyx for access, which was punctured with a Chiba needle under percutaneous ultrasound guidance. Next a wire was passed into the collecting system and ureteroscopically pulled into the ureter using a basket. Tract dilation and sheath and nephrostomy tube placement were performed under direct ureteroscopic visualization. Twenty consecutive patients undergoing this novel technique were reviewed and compared to 20 matched patients treated with conventional percutaneous nephrolithotomy. Mann-Whitney U and Pearson chi-square tests were used for comparisons with p < 0.05 considered significant.Results: Using this novel technique mean fluoroscopy access time was 3.5 seconds (range 0 to 27.9) and mean total fluoroscopic time was 8.8 seconds (range 0 to 47.1). Mean operative time was 232 minutes (range 87 to 533), estimated blood loss was 111 ml, the stone-free rate was 65% and the complication rate was 25%. Compared to 20 matched conventional percutaneous nephrolithotomy cases, there was no difference in operative time (p = 0.76), estimated blood loss (p = 0.64), stone-free rate (p = 0.50) or complications (p = 1.00). However, the novel technique resulted in a significant reduction in fluoroscopy access time (3.5 vs 915.5 seconds, p < 0.001) and total fluoroscopy time (8.8 vs 1,028.7 seconds, p < 0.001).Conclusions: This study demonstrates the feasibility of combined ultrasound and ureteroscopic assisted access for percutaneous nephrolithotomy. A greater than 99% reduction in fluoroscopy time was achieved using this technique.

Purpose: Previous benchtop studies have shown that robotic bulldog clamps provide incomplete vascular control of a Penrose drain. We determined the efficacy of robotic and laparoscopic bulldog clamps to ensure hemostasis on the human renal artery. The effect of clamp position on vascular control was also examined.Materials and Methods: Fresh human cadaveric renal arteries were used to determine the leak point pressure of 7 bulldog clamps from a total of 3 manufacturers. Five trials were performed per clamp at 4 locations, including the fulcrum, proximal, middle and distal positions. Comparison was done using the Kruskal-Wallis test with p < 0.05 considered significant.Results: None of the bulldog clamps leaked at a pressure less than 215 mm Hg when applied at the proximal, middle or distal position. In general leak point pressure decreased as the artery was positioned more distal along the clamp. The exception was when the vessel was placed at the fulcrum position. At that position 80% to 100% of trials with the Klein laparoscopic, 100% with the Klein robotic (Klein Robotic, San Antonio, Texas) and 60% to 80% with the Scanlan robotic (Scanlan International, Saint Paul, Minnesota) clamp leaked at pressure below 215 mm Hg.Conclusions: Each vascular clamp adequately occluded flow at physiological pressure when placed at the proximal, middle or distal position. Furthermore, these results demonstrate that there is leakage at physiological pressure when the artery is placed at the fulcrum of certain clamp types. These results suggest that applying a bulldog clamp at the fulcrum could potentially lead to inadequate vessel occlusion and intraoperative bleeding.

OBJECTIVES Laparoendoscopic single-site surgery (LESS) and natural orifice transluminal endoscopic surgery (NOTES) produce excellent cosmetic outcomes, but are technically challenging. The objective of this study was to test the functionality and feasibility of a novel minimally invasive surgical paradigm, which maintains triangulation but uses special externally assembled instruments to minimize the postoperative cosmetic impact. METHODS Percutaneous Externally Assembled Laparoscopic (PEAL) instruments have specialized 2.96-mm shafts with interchangeable 5-mm working tips that are assembled externally. First, 5-mm laparoscopic, PEAL, and 2-mm needlescopic instruments were tested to determine piercing force on fresh human cadaver organs. In a bench-top study, 20 subjects assembled and used PEAL instruments in five different skills tests that were also compared with the same tasks using conventional laparoscopic instruments. Finally, PEAL instrument functionality was tested in a four-porcine nephrectomy feasibility study. RESULTS PEAL (2.80 lbF) and 5-mm laparoscopic instruments (2.28 lbF) had a significantly higher mean organ piercing perforation force compared with needlescopic instruments (1.39 lbF, p < 0.05). Average assembly time of PEAL instruments was 31.08 seconds (range: 19.83-43.85). There were no significant differences in the amount of time needed for completion of the bench-top tasks between laparoscopic and PEAL instruments (p > 0.05 for all tasks). Four-porcine PEAL nephrectomies were completed with no complications and minimal blood loss (mean 7.5 mL). Mean operative time was 98.25 minutes (range 79-116). CONCLUSION PEAL tools are easily assembled, have similar safety and efficacy compared with standard laparoscopic tools, and are less likely to injure organs compared with needlescopic instruments. They function well during laparoscopic nephrectomy and may decrease the invasiveness of conventional laparoscopic instrumentation.

You have accessJournal of UrologyTechnology & Instruments: Laparoscopy and Robotics: Malignant Disease I1 Apr 2015PD15-09 EFFECT OF RENAL VASCULAR CLAMP TYPE AND POSITION UPON LEAK POINT PRESSURE IN HUMAN RENAL ARTERIES David Tryon, Kristene Myklak, Muhannad Alsyouf, Brandon Peplinski, Javier L. Arenas, Daniel Faaborg, Carol Conceicao, Herbert C. Ruckle, and D. Duane Baldwin David TryonDavid Tryon More articles by this author , Kristene MyklakKristene Myklak More articles by this author , Muhannad AlsyoufMuhannad Alsyouf More articles by this author , Brandon PeplinskiBrandon Peplinski More articles by this author , Javier L. ArenasJavier L. Arenas More articles by this author , Daniel FaaborgDaniel Faaborg More articles by this author , Carol ConceicaoCarol Conceicao More articles by this author , Herbert C. RuckleHerbert C. Ruckle More articles by this author , and D. Duane BaldwinD. Duane Baldwin More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1326AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Attempts to clamp the renal artery during a partial nephrectomy are sometimes unsuccessful in achieving complete vascular control. Recently, it has been shown that robotic bulldog clamps were not effective at preventing leakage in a penrose drain model. The purpose of this study was to determine the efficacy of robotic and laparoscopic bulldog clamps at controlling blood flow from the renal artery. In addition, the effect of clamp position was also studied. METHODS Using a novel bench top model, fresh human cadaveric renal arteries were connected to a pressure gauge, and continuously infused with saline. Leak point pressures (LPP) of seven different bulldog vascular clamps from three manufacturers (see table) were determined. Five separate trials were performed at four different locations along the clamp including: the fulcrum, proximal, middle, and distal positions. Analysis was performed using the Kruskall-Wallis procedure with multiple comparisons of post hoc hypotheses adjusted for multiple testing. P values < 0.05 were considered significant. RESULTS The lowest LPP observed in all clamps when applied at the proximal, middle or distal position was 220 mmHg. In general LPP decreased as the artery was positioned more distally along the clamp. However, the exception was that when the vessel was placed at the fulcrum position, the Klein and Scanlan clamps had significantly lower LPP when compared to the mean LPP for the other positions (p<.001), with 87% Klein trials and 60% of Scanlan trials leaking at pressures below 180mmHg. CONCLUSIONS Each vascular clamp tested resulted in adequate control of the renal artery when applied at the proximal, middle, or distal positions. To our knowledge this is the first study to use fresh human arteries to compare vascular bulldog clamps, and to demonstrate leakage at physiologic pressures when the artery is placed at the fulcrum of the Klein and Scanlan clamps. These results suggest that application of a bulldog clamp at the fulcrum could potentially lead to inadequate vessel occlusion and catastrophic intraoperative bleeding. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e328 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information David Tryon More articles by this author Kristene Myklak More articles by this author Muhannad Alsyouf More articles by this author Brandon Peplinski More articles by this author Javier L. Arenas More articles by this author Daniel Faaborg More articles by this author Carol Conceicao More articles by this author Herbert C. Ruckle More articles by this author D. Duane Baldwin More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

You have accessJournal of UrologyKidney Cancer: Surgical Therapy IV1 Apr 2015MP63-02 HOW A DONOR NEPHRECTOMY POPULATION CAN HELP CLARIFY THE EFFECTS OF WARM RENAL ISCHEMIA DURING PARTIAL NEPHRECTOMY Roger Li, Herbert C. Ruckle, Muhannad Alsyouf, Michelle Lightfoot, Jared Schober, David Tryon, Kristene Myklak, David Culpepper, Daniel Faaborg, Phillip Stokes, Javier L. Arenas, and D. Duane Baldwin Roger LiRoger Li More articles by this author , Herbert C. RuckleHerbert C. Ruckle More articles by this author , Muhannad AlsyoufMuhannad Alsyouf More articles by this author , Michelle LightfootMichelle Lightfoot More articles by this author , Jared SchoberJared Schober More articles by this author , David TryonDavid Tryon More articles by this author , Kristene MyklakKristene Myklak More articles by this author , David CulpepperDavid Culpepper More articles by this author , Daniel FaaborgDaniel Faaborg More articles by this author , Phillip StokesPhillip Stokes More articles by this author , Javier L. ArenasJavier L. Arenas More articles by this author , and D. Duane BaldwinD. Duane Baldwin More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.2334AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The most important modifiable risk factors for kidney function after partial nephrectomy (PN) are the quantity of parenchyma removed and the length of warm ischemia time (WIT) although the relative importance of these two factors has been debated. In this study, the effects of WIT on renal function were investigated by comparing PN patients to completely healthy patients undergoing donor nephrectomy (DN). METHODS A retrospective review was performed of 119 PN and 250 DN patients at a single academic institution. Baseline characteristics, WIT, and follow-up serum creatinine (sCr) at discharge, 1-7months and at last follow-up were compared. Estimated GFR (eGFR) was calculated using sCr and the Modification of Diet on Renal Disease (MDRD) formula. Data was analyzed using the Mann-Whitney U and Chi-square tests as appropriate. RESULTS The DN patients were younger (37.5 vs. 60.8; p<0.01), had lower BMI (26.6 vs. 30.9; p<0.01), lower ASA scores (p<0.01) and higher preoperative eGFR (101.7 vs. 78.4; p<0.01). In the PN cohort, the median tumor size was 3.6 cm and mean WIT was 27.8 minutes. DN patients were found to have greater eGFR decline upon discharge (-42.7% vs. -1.5%, p<0.01), at 1-7 mos postoperatively (-36.9% vs. -6.4%; p<0.01) and at the latest follow-up (-36.3% vs. -2.4%; p<0.01). The percentage decrease in eGFR was also significantly greater in donor nephrectomy patients than partial nephrectomy patients with WIT > 30 minutes at all time points including discharge (-42.7% vs. -4.1%; p<0.01) at 1-7 mos (-36.9% vs. -3.8%; p<0.01) and at latest follow-up (-36.3% vs. -6.9%; p<0.01). CONCLUSIONS Despite being younger and healthier, the donors had a much greater decrease in GFR than all PN patients including those with > 30 min WIT. This dramatic benefit of partial nephrectomy compared with radical nephrectomy in all patients emphasizes the benefit to GFR derived from renal parenchymal preservation. Surgeons should utilize warm renal ischemia when indicated if it facilitates the preservation of renal parenchyma. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e789 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Roger Li More articles by this author Herbert C. Ruckle More articles by this author Muhannad Alsyouf More articles by this author Michelle Lightfoot More articles by this author Jared Schober More articles by this author David Tryon More articles by this author Kristene Myklak More articles by this author David Culpepper More articles by this author Daniel Faaborg More articles by this author Phillip Stokes More articles by this author Javier L. Arenas More articles by this author D. Duane Baldwin More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

You have accessJournal of UrologyStone Disease: Surgical Therapy II1 Apr 2015MP28-15 THE EFFECT OF LASER FIBER TIP CLEAVING TECHNIQUE UPON RISK FOR URETEROSCOPE DAMAGE OR URETERAL INJURY Daniel Faaborg, Edna Miao, Herbert Hodgson, Brandon Peplinski, Kristene Myklak, Muhannad Alsyouf, and D. Duane Baldwin Daniel FaaborgDaniel Faaborg More articles by this author , Edna MiaoEdna Miao More articles by this author , Herbert HodgsonHerbert Hodgson More articles by this author , Brandon PeplinskiBrandon Peplinski More articles by this author , Kristene MyklakKristene Myklak More articles by this author , Muhannad AlsyoufMuhannad Alsyouf More articles by this author , and D. Duane BaldwinD. Duane Baldwin More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1238AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES It has previously been shown that the method of cleaving employed for holmium laser fibers has a significant impact upon initial power output. Poorly cleaved quartz fibers may also have sharp edges which are more likely to injure or perforate the ureter or damage the lining of the flexible ureteroscope. The purpose of this study was to determine the effect of laser fiber cleaving technique upon the force required to perforate a porcine ureter and the lining of a flexible ureteroscope. METHODS Three reusable laser fibers including the Cook Optilite 273, Lumenis Slimline 200, and the Dornier Meditech RFID 270 were cleaved 10 times using one of 5 different cleaving techniques including the ceramic scissor, a straight Mayo scissor, a scribe pen cleave tool, a diamond cleave wheel, and an #11 blade scalpel. The cleaved fibers were secured to a Mark 10 digital force gauge which was then used to measure perforation force for the working channel of an Olympus URF-P6 flexible ureteroscope and a fresh porcine ureter. Thirty perforation force measurements were recorded on both the ureter and ureteroscope for each fiber type and were also compared to uncleaved fibers (control). An Independent-Samples Kruskal-Wallis test was used for statistical analysis, with p<0.05 considered significant. RESULTS The mean pound force (lbf) necessary for perforation of the ureter was low and varied greatly by cleave technique (p-values reported for comparison to control); control =0.152, ceramic scissors= 0.132 (p=0.19), scribe pen= 0.122 (p=0.058), diamond wheel= 0.121 (p=0.048), scalpel=0.117 (p=0.019), and suture scissor =0.106 (p=0.02). The diamond wheel, suture scissor, and scalpel cleaves had significantly lower ureteral perforation forces than the control in pairwise comparisons. In comparing the force required to perforate the ureteroscope lining to the control; the results reported as lbf were as follows; control= 0.411, ceramic scissors=0.328 (p<0.01) scribe pen= 0.327 (p<0.01) scalpel= 0.321 (p=<0.01), diamond wheel= 0.300 (p<0.01) suture scissor= 0.281 (p<0.01). CONCLUSIONS The forces required to perforate the ureter or the lining of a flexible ureteroscope are relatively low. Poor cleaving of laser fiber tips may increase the risk of ureteral wall perforation and the risk of damage to the lining of the flexible ureteroscope. Cleaving with the ceramic scissor or scribe pen may reduce the risk of ureteral injury compared to other cleaving techniques. New uncleaved fibers are less likely to injure the ureteroscope lining than all types of cleaved fibers. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e316 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Daniel Faaborg More articles by this author Edna Miao More articles by this author Herbert Hodgson More articles by this author Brandon Peplinski More articles by this author Kristene Myklak More articles by this author Muhannad Alsyouf More articles by this author D. Duane Baldwin More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

You have accessJournal of UrologyStone Disease: Surgical Therapy III1 Apr 2015MP30-10 INTRAOPERATIVE NOISE POLLUTION AND ITS EFFECT UPON COMMUNICATION DURING PERCUTANEOUS NEPHROSTOLITHOTOMY Kristene Myklak, Hayley Mowery, Muhannad Alsyouf, Roger Li, Michelle Lightfoot, Chase Atiga, David Tryon, Herbert Hodgson, Carol Conceicao, Daniel Faaborg, Javier L. Arenas, Nazih Khater, Herbert C. Ruckle, D. Daniel Baldwin, and D. Duane Baldwin Kristene MyklakKristene Myklak More articles by this author , Hayley MoweryHayley Mowery More articles by this author , Muhannad AlsyoufMuhannad Alsyouf More articles by this author , Roger LiRoger Li More articles by this author , Michelle LightfootMichelle Lightfoot More articles by this author , Chase AtigaChase Atiga More articles by this author , David TryonDavid Tryon More articles by this author , Herbert HodgsonHerbert Hodgson More articles by this author , Carol ConceicaoCarol Conceicao More articles by this author , Daniel FaaborgDaniel Faaborg More articles by this author , Javier L. ArenasJavier L. Arenas More articles by this author , Nazih KhaterNazih Khater More articles by this author , Herbert C. RuckleHerbert C. Ruckle More articles by this author , D. Daniel BaldwinD. Daniel Baldwin More articles by this author , and D. Duane BaldwinD. Duane Baldwin More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.592AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Tools and equipment utilized during endourologic surgery contribute significantly to noise pollution in the operating room (OR) during percutaneous nephrostolithotomy (PCNL). The purpose of this study was to determine OR baseline noise and noise contributed by endourologic equipment during PCNL; then, to determine the effect of this noise upon the effectiveness of communication. METHODS Ambient noise in the operating room was measured using a digital decibel meter. Noise levels were determined by the sequential addition of normal conversation, high-pressure suction, ultrasonic lithotripter, and background music. Three subjects—the surgical assistant (0.8m from the surgeon), anesthesiologist (1.8m), and the circulator (2.5m) were placed in the operating room to simulate positioning during PCNL. Five trials of 20 different medical words/phrases were spoken by the surgeon. Trials were performed with three sound categories. The first category included ambient sound alone, the second included ambient sound, suction and lithotryptors, and the third included ambient sound, suction, lithotripsy and loud music. In addition, the OR noise was compared to commonly encountered environmental noise; including cars (n=12) and trucks (n=18) driving 40 mph at 30 ft, and freight trains (n=8) traveling 55 mph at 30 and 45 feet. Statistical analyses were performed using a student t-test. RESULTS The average baseline noise was 53.49dB(A). As conversation, suction/lithotripsy, and music were added, noise levels were 61.82dB(A), 77.96dB(A), and 87.33dB(A), respectively. At baseline noise, the surgical assistant, anesthesiologist and circulating nurse correctly recorded 100%, 100% and 96% of the words, respectively. The correct response rate by the subjects decreased to 97%(p=0.172), 81%(p<0.001) and 56%(p<0.001) with suction/lithotripsy and 90%(p=0.006), 48%(p<0.001) and 13%(p<0.001) with suction/lithotripsy/music. By comparison, total PCNL noise (conversation/suction/lithotripsy/music) [87.33 dB(A)] was louder than the measured car [67.8 dB(A); p<0.001] and pickup truck noise [69.2 dB(A); p<0.001] but similar to a freight train at 30 feet [82.2 dB(A); p=0.44]. CONCLUSIONS Endourologic instruments and music utilized during PCNL may significantly contribute to noise pollution in the operating room environment and this noise may significantly degrade the effectiveness of communication. An understanding of the role that noise and distance play in affecting the success of communication may reduce operating room errors and patient complications. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e351 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kristene Myklak More articles by this author Hayley Mowery More articles by this author Muhannad Alsyouf More articles by this author Roger Li More articles by this author Michelle Lightfoot More articles by this author Chase Atiga More articles by this author David Tryon More articles by this author Herbert Hodgson More articles by this author Carol Conceicao More articles by this author Daniel Faaborg More articles by this author Javier L. Arenas More articles by this author Nazih Khater More articles by this author Herbert C. Ruckle More articles by this author D. Daniel Baldwin More articles by this author D. Duane Baldwin More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

You have accessJournal of UrologyUrodynamics/Incontinence/Female Urology: Female Urology1 Apr 2015MP81-08 HOW WELL CAN UROLOGY TRAINEES DETECT SUBURETHRAL MESH USING TRANSLABIAL ULTRASOUND IN COMPARISON TO A RADIOLOGIST? Daniel Faaborg, Andrea Staack, Glen Rouse, Muhannad Alsyouf, Kristene Myklak, and Roger Li Daniel FaaborgDaniel Faaborg More articles by this author , Andrea StaackAndrea Staack More articles by this author , Glen RouseGlen Rouse More articles by this author , Muhannad AlsyoufMuhannad Alsyouf More articles by this author , Kristene MyklakKristene Myklak More articles by this author , and Roger LiRoger Li More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.2886AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Suburethral mesh implantation for stress urinary incontinence can result in erosion, extrusion, infection, pain, and irritative voiding symptoms. Surgical mesh removal can be challenging when operative records are not available, portions of mesh have been removed, mesh position has changed, or it's not palpated on physical exam. Translabial ultrasonography is a diagnostic tool that can detect synthetic mesh. The purpose of this study was to compare a group of Urology trainees' and a radiologist's ability to identify pelvic landmarks, localize and assess completeness of suburethral mesh. METHODS Eight urology trainees received a 15-minute lecture on anatomical landmarks and techniques of translabial ultrasound as well as instruction on detection of suburethral mesh. The trainees then reviewed 18 different US studies. Trainees were asked a total of 126 questions including identification of anatomical planes, pelvic structures in different planes, mesh presence, disruption of mesh, and its location along the urethra. The overall correct response rate of all questions was compared to a Board-certified radiologist specialized in translabial ultrasound, which served as our control. The radiologist and trainees were blinded to patient history, clinical, and operative findings. RESULTS Overall, trainees answered correct on average 83.9% (105/126) of all questions compared to the radiologist 94.4% (119/126; p=0.023). Per category the average trainee was able to correctly identify the anatomical plane in 94.4% (17/18) of questions, detect presence or absence of mesh in 95.8% (17/18), determine mesh disruption in 83.3% (15/18), correctly identify pelvic anatomical structures in 83.3% (15/18), and determine location of mesh in correspondence to the urethra in 72.2 % (13/18). CONCLUSIONS Urology trainees can learn in a reasonable time how to identify anatomical landmarks on translabial ultrasound and consistently detect the presence of suburethral mesh. Translabial ultrasound can be utilized by urologists to aid in preoperative planning for mesh removal or clinical diagnostics for symptomatic mesh. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e1031 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Daniel Faaborg More articles by this author Andrea Staack More articles by this author Glen Rouse More articles by this author Muhannad Alsyouf More articles by this author Kristene Myklak More articles by this author Roger Li More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

You have accessJournal of UrologyStone Disease: Surgical Therapy IV1 Apr 2015MP38-04 IMPACTED STONE MODEL USED TO COMPARE HYDROPHILIC GUIDEWIRE EFFICACY Daniel Faaborg, Jacob Khouri, Kristene Myklak, Muhannad Alsyouf, and Duane Baldwin Daniel FaaborgDaniel Faaborg More articles by this author , Jacob KhouriJacob Khouri More articles by this author , Kristene MyklakKristene Myklak More articles by this author , Muhannad AlsyoufMuhannad Alsyouf More articles by this author , and Duane BaldwinDuane Baldwin More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1379AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Guide wire passage beyond impacted stones is the first step of either stone treatment or decompression of infected obstructed systems. The optimal guidewire for use with impacted ureteral stones has not been previously determined. The purpose of this study was to develop an in-vitro impacted ureteral stone model and to use this model to compare efficacy between several commercially available guide wires. METHODS An in-vitro impacted ureteral stone model was constructed to simulate actual ureteral diameter, length, and angulation. Next, a calcium oxalate monohydrate stone was placed into the ureter and impacted to resist passage of fluid at 300 mm Hg. A ureteral catheter was positioned 2 cm below the impacted stone. In a randomized single blinded fashion, five attending urologists tested the model using 0.038 inch versions of the angle-tipped ZIPwire (Boston Scientific), angle-tipped Glidewire (Terumo), angle-tipped Hiwire (Cook), straight-tipped Roadrunner hydrophilic PC (Cook), and the straight-tipped Standard Teflon coated wire (Cook). In addition, in a separate benchtop trial the force required to pass the impacted stone was measured. Outcomes included time for wire passage (sec), number of attempts, force required for wire passage and attending blinded subjective preference ratings. An Independent-Samples Kruskal-Wallis test was used for statistical analysis, with p<0.05 considered significant. RESULTS The mean pound force (lbf) for wire passage (with comparison to Glidewire) was; Glidewire =0.025, ZIPwire (0.036; p=0.08), Hiwire (0.2; p=0.01), Standard wire (0.6; p<0.01), and the Roadrunner did not pass. Pairwise comparisons showed significant differences between the ZIPwire and Hiwire (p=0.01), and ZIPwire vs. standard wire (p<.01). The mean time(sec) to pass the stone (with comparison to Glidewire) was; Glidewire (12.9 sec), ZIPwire (14.5 sec; p= 0.6) Hiwire (23.5 sec; p<0.01), standard Teflon coated guidewire (23.3 sec; p=<0.01) and the Roadrunner did not pass. The mean number of attempts to pass each wire was Glidewire (1.9), ZIPwire (2.5), Hiwire (3.5), Standard teflon coated (4.1), and the Roadrunner did not pass (trend not significant). The attending staff reported the order of preference for wires as Glidewire, ZIPwire, Hiwire, Standard Teflon coated wire, and the Roadrunner in this impacted stone model. CONCLUSIONS The guidewire employed may have a significant effect upon the ease of passage beyond a tightly impacted ureteral stone. This may have significant implications upon operative time, surgical ease, and safety. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e447 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Daniel Faaborg More articles by this author Jacob Khouri More articles by this author Kristene Myklak More articles by this author Muhannad Alsyouf More articles by this author Duane Baldwin More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

INTRODUCTION AND OBJECTIVES: Tools and equipment utilized during endourologic surgery contribute significantly to noise pollution in the operating room (OR) during percutaneous nephrostolithotomy (PCNL). The purpose of this study was to determine OR baseline noise and noise contributed by endourologic equipment during PCNL; then, to determine the effect of this noise upon the effectiveness of communication. METHODS: Ambient noise in the operating room was measured using a digital decibel meter. Noise levels were determined by the sequential addition of normal conversation, highpressure suction, ultrasonic lithotripter, and background music. Three subjectsdthe surgical assistant (0.8m from the surgeon), anesthesiologist (1.8m), and the circulator (2.5m) were placed in the operating room to simulate positioning during PCNL. Five trials of 20 different medical words/phrases were spoken by the surgeon. Trials were performed with three sound categories. The first category included ambient sound alone, the second included ambient sound, suction and lithotryptors, and the third included ambient sound, suction, lithotripsy and loud music. In addition, the OR noise was compared to commonly encountered environmental noise; including cars (n1⁄412) and trucks (n1⁄418) driving 40 mph at 30 ft, and freight trains (n1⁄48) traveling 55 mph at 30 and 45 feet. Statistical analyses were performed using a student t-test. RESULTS: The average baseline noise was 53.49dB(A). As conversation, suction/lithotripsy, and music were added, noise levels were 61.82dB(A), 77.96dB(A), and 87.33dB(A), respectively. At baseline noise, the surgical assistant, anesthesiologist and circulating nurse correctly recorded 100%, 100% and 96% of the words, respectively. The correct response rate by the subjects decreased to 97%(p1⁄40.172), 81%(p<0.001) and 56%(p<0.001) with suction/lithotripsy and 90%(p1⁄40.006), 48%(p<0.001) and 13%(p<0.001) with suction/lithotripsy/music. By comparison, total PCNL noise (conversation/suction/lithotripsy/music) [87.33 dB(A)] was louder than the measured car [67.8 dB(A); p<0.001] and pickup truck noise [69.2 dB(A); p<0.001] but similar to a freight train at 30 feet [82.2 dB(A); p1⁄40.44]. CONCLUSIONS: Endourologic instruments and music utilized during PCNL may significantly contribute to noise pollution in the operating room environment and this noise may significantly degrade the effectiveness of communication. An understanding of the role that noise and distance play in affecting the success of communication may reduce operating room errors and patient complications.

You have accessJournal of UrologyStone Disease: Surgical Therapy III1 Apr 2015MP30-01 PATIENTS ARE AT RISK FOR PYELOVENOUS BACKFLOW DURING PERCUTANEOUS NEPHROSTOLITHOTOMY Muhannad Alsyouf, Roger Li, Michelle Lightfoot, Herbert Hodgson, Nigel Gillespie, Kristene Myklak, Daniel Faaborg, Javier L. Arenas, Gaudencio Olgin, and D. Duane Baldwin Muhannad AlsyoufMuhannad Alsyouf More articles by this author , Roger LiRoger Li More articles by this author , Michelle LightfootMichelle Lightfoot More articles by this author , Herbert HodgsonHerbert Hodgson More articles by this author , Nigel GillespieNigel Gillespie More articles by this author , Kristene MyklakKristene Myklak More articles by this author , Daniel FaaborgDaniel Faaborg More articles by this author , Javier L. ArenasJavier L. Arenas More articles by this author , Gaudencio OlginGaudencio Olgin More articles by this author , and D. Duane BaldwinD. Duane Baldwin More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.583AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The pressure in the renal pelvis may have a significant effect upon patient outcomes during percutaneous nephrostolithotomy (PCNL). Pressures greater than 30 mm Hg can cause pyelovenous backflow with its increased risk for urosepsis. Meanwhile, low renal pelvic pressure (RPP) can lead to collapse of the collecting system, impaired visualization and greater blood loss. The purpose of this study was to determine the influence of nephroscope type and the use of suction upon renal pelvic pressures obtained during PCNL. METHODS During PCNL performed in the prone split leg position, ureteroscopic directed US guidance was utilized to establish a 30 Fr access sheath. Once the access was established the working channel of the ureteroscope was connected to a pressure transducer and utilized to determine RPP at baseline, when irrigating using a 26 Fr rigid nephroscope with and without suction, and during irrigation with a 16 Fr flexible nephroscope. Pressure readings were randomly obtained during the case. Patient demographics and access location were also recorded. A Mann-Whitney U test was used to compare the RPP during rigid and flexible nephroscopy, with p<0.05 considered statistically significant. RESULTS A total of 148 measurements were recorded in 16 patients undergoing PCNL. Mean patient age was 53.6 years (20-71) and BMI was 33.0 (18-53.3). All patients had single tract access including 14 patients with upper pole and 2 patients with lower pole access. Rigid nephroscopy resulted in significantly higher average RPP compared to flexible nephroscopy (30.4 vs. 11.6 mmHg; p<0.001). The mean RPP was greater than 30 mmHg (the threshold for pyelovenous backflow) in 5 patients (31.3%) using the rigid nephroscope and in no patient using the flexible nephroscope. The use of suction resulted in significantly lower renal pelvic pressure (1.0 mmHg) when compared to both rigid (p<0.001) and flexible nephroscopy (p<0.001). CONCLUSIONS Use of the rigid nephroscope resulted in renal pelvic pressure greater than the threshold for pyelovenous backflow in 31.3% of patients. The RPP is significantly lowered by the use of the flexible nephroscope or suction. Knowledge of the factors that influence RPP and methods to control the pressure extremes may improve patient safety during PCNL. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e347 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Muhannad Alsyouf More articles by this author Roger Li More articles by this author Michelle Lightfoot More articles by this author Herbert Hodgson More articles by this author Nigel Gillespie More articles by this author Kristene Myklak More articles by this author Daniel Faaborg More articles by this author Javier L. Arenas More articles by this author Gaudencio Olgin More articles by this author D. Duane Baldwin More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

You have accessJournal of UrologyStone Disease: New Technology1 Apr 2015PD42-07 THE EFFECT OF CLEAVE TECHNIQUE AND LITHOTRIPSY DURATION ON LASER FIBER POWER OUTPUT Brandon Peplinski, Daniel Faaborg, Edna Miao, Muhannad Alsyouf, Kristene Myklak, and D. Duane Baldwin Brandon PeplinskiBrandon Peplinski More articles by this author , Daniel FaaborgDaniel Faaborg More articles by this author , Edna MiaoEdna Miao More articles by this author , Muhannad AlsyoufMuhannad Alsyouf More articles by this author , Kristene MyklakKristene Myklak More articles by this author , and D. Duane BaldwinD. Duane Baldwin More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.2592AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Efficient laser lithotripsy is dependent on laser fiber tip power output. Burnback degradation is a well-documented cause of decreased power output, which may increase operative time. Reusable fibers are cleaved to remove the degraded tip and restore power output. The rate of power output loss during lithotripsy after cleaving with various techniques is not known. Such information is necessary to determine the optimal cleaving frequency and technique. The purpose of this study is to evaluate power output degradation with increasing lithotripsy duration following various cleave techniques. METHODS In this randomized, prospective, single-blinded study 330 calcium oxalate monohydrate calculi were fragmented in a ureteral tube model submerged in normal saline using 200 and 365 μm diameter Lumenis reusable fibers. A Dornier Medilas H20 Ho:YAG pulsed laser was utilized at 8 Hz and 800 mJ (6.4 W). Fibers were cleaved using a ceramic scissor, a straight Mayo scissor, a scribe pen cleave tool, a diamond cleave wheel, and a #11 blade scalpel. Power output was measured at baseline and subsequently at 1 min intervals during stone ablation up to 15 min by an investigator blinded to the cleave technique. One hundred,15 min trials were performed including 10 per cleave technique on each fiber diameter. Independent-samples Mann-Whitney U, Kruskal-Wallis, and homogeneity of variances tests were used for statistical analysis with a significance of p<0.05. RESULTS Both fibers showed similar ranked trends in initial power output: new fibers (6.54 W); ceramic scissor (6.20 W); scribe pen (5.95 W); scalpel (5.68 W); suture scissor (5.39 W); diamond wheel (4.74 W). Degradation analyses revealed a significant decrease of 0.85 W in the 200 μm fiber compared to the 365 μm fiber after 1 min (p<0.05). The mean power output of all cleave techniques in the 200 μm fiber decreased significantly by 0.73 W (13.25%) over the first 7 min (p<0.05), after which there was no further change. This constituted an average loss of 0.1 W (2.0%) per min, although the power decreased rapidly by 0.62 W (11.34%) over the first 4 min. The 365 μm fiber showed no significant decrease in power output (p=0.908). CONCLUSIONS The ceramic scissor is the optimal device for cleaving between cases. Cleaving increased power output by only 11.34% for approximately 4 min in the 200 μm fiber therefore, these results do not imply a benefit to intra-operative cleaving to increase power output. The 365 μm fiber maintained a significantly higher power output over 15 min of lithotripsy, emphasizing greater durability compared to the 200 μm fiber for all cleave techniques. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e888 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Brandon Peplinski More articles by this author Daniel Faaborg More articles by this author Edna Miao More articles by this author Muhannad Alsyouf More articles by this author Kristene Myklak More articles by this author D. Duane Baldwin More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...