PURPOSE:The ASPiration to Improve Renal Calculi Removal Effectiveness study showed steerable ureteroscopic renal evacuation (SURE) with CVAC that significantly reduced residual stone volume at 30 days vs standard ureteroscopy (URS). This report presents 2-year health care consumption and stone events (SE) and their link to residual stone volume and other variables (n = 101 at primary end point; n = 93 at 2 years). MATERIALS AND METHODS:Logistic regression identified predictors of health care consumption events (HCEs), that is, emergency department visits, hospitalization, surgical retreatment, and SE across the study population. Incidence was compared between the treatment groups with Kaplan-Meier survival analysis. RESULTS:At 2 years, residual stone volume was significantly associated with both HCEs and SE. For every 100 mm3 increase in residual stone volume, the HCE risk increased by 50% to 54%, and the SE risk increased by 70%. Stone-free rate, the number of residual fragments (RFs), and RF total stone burden (based on diameter) were not predictors. Significantly fewer HCEs occurred in the SURE group (3 vs 20 events, p = 0.0004). Survival analysis confirmed this (4.3% vs 20%, log-rank p = 0.02), with a 73% risk reduction (hazard ratio 0.27, 95% Cl 0.09-0.80, p = 0.02). Fewer SE occurred in the SURE group, although not statistically significant. These subjects also had longer event-free survival. CONCLUSION:High-quality volumetric analysis supports evaluation of stone removal therapies, as residual stone volume predicts HCEs and SE. SURE significantly reduces the downstream incidence and risk of HCEs compared with standard URS.

Purpose: We report the first multicenter, prospective, randomized noninferiority controlled trial of steerable ureteroscopic renal evacuation (SURE) for nephrolithiasis treatment. Materials and Methods: Candidates for laser lithotripsy >= 18 years with >= 1 renal stone >= 7 mm and 7-20 mm stone burden were randomized 1:1 SURE vs ureteroscopy (URS). SURE was performed using the CVAC Aspiration System, a novel steerable irrigation-aspiration catheter. The primary efficacy end point was noninferiority in stone-free rate (SFR) based on zero residual fragments (RFs) 30 days postprocedure on noncontrast computed tomography. Secondary end points were superiority tests, stone clearance (percent stone volume reduction), residual stone volume (RSV), SFR (no RF >2 mm), and SFR (no RF >4 mm) 30 days postprocedure. Results: Of the subjects, 123 were randomized and 101 qualified for efficacy analysis (SURE 46 vs URS 55). Despite randomization, baseline URS stone volume was higher (SURE 485.0 +/- 432.5 mm(3) vs URS 713.3 +/- 558.5 mm(3)). The primary noninferiority end point was achieved (SURE SFR 48% vs URS SFR 49%, p = 0.027, -1.3% [90% confidence interval; -18%, 15%]). Stone clearance was significantly higher for SURE vs URS subjects (SURE 96.9 +/- 5.6% vs URS 92.9 +/- 11.6%, p = 0.036); RSV was significantly lower (SURE 14.3 +/- 3 0.9 mm(3) vs URS 70.2 +/- 144.9 mm(3), p = 0.012). SURE stone clearance and RSV were independent of baseline stone volume, but for URS degraded with increasing baseline stone volume. Safety was comparable between groups. Conclusions: SFR for SURE subjects was noninferior compared with URS subjects; stone clearance and RSV were significantly better with SURE, independent of baseline stone volume.

You have accessJournal of UrologyStone Disease: Surgical Therapy III (MP15)1 Apr 2020MP15-03 NEPHROSTOMY TUBES PLACED PRIOR TO PERCUTANEOUS RENAL STONE SURGERY ARE PRACTICAL FOR OBTAINING ACCESS-- AN ANALYSIS OF THE UTILITY OF PRE-EXISTING NEPHROSTOMY TUBES AT A SINGLE INSTITUTION Aaron Bradshaw*, Seth Bechis, Kaitlan Cobb, Dave Friedlander, and Roger Sur Aaron Bradshaw*Aaron Bradshaw* More articles by this author , Seth BechisSeth Bechis More articles by this author , Kaitlan CobbKaitlan Cobb More articles by this author , Dave FriedlanderDave Friedlander More articles by this author , and Roger SurRoger Sur More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000840.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Renal access in percutaneous nephrolithotomy may be obtained via a pre-existing nephrostomy tube (NT) tract; however, emergently placed NTs are not always ideal for subsequent surgery. We sought to compare the usability of emergently and non-emergently placed NTs. METHODS: A retrospective review was performed of UC San Diego subjects undergoing percutaneous renal surgery between January 2016 and October 2018. Demographics and peri-operative variables were collected. The primary outcome was the usability of NT tract for dilation and instrumentation and was a composite of “usable” and “partially usable” tracts. “Usable” indicated a tract in which PCNL could be completed without the need for additional tract creation; “partially usable” indicated a tract which was dilated and used but required at least one additional tract dilation, and “unusable” indicated the absence of tract dilation or usage. RESULTS: 65 PCNL cases had previously placed indwelling NT at time of percutaneous renal surgery (35 emergent, 30 non-emergent). Demographic and peri-operative data were similar. There was no significant difference between emergent vs. non-emergent groups in tract usability (emergent 51% vs. non-emergent 63% usable, difference in proportions 95% CI, -13% to 37%, p=0.34), location of NTs (p=0.29), or location of ultimate PCNL access (p=0.86). Total number of access tracts was greater in the cohort with unusable NT tracts (p<0.01). The need for subsequent upper pole access for completion of PCNL occurred in 57% of unusable NT tracts, 33% of partially usable NT tracts, and 6% of usable of NT tracts (p<0.01). There was no difference in stone location between those NT tracts deemed usable, partially usable, or unusable (p=0.40) CONCLUSIONS: Pre-existing NT, regardless of indication for placement, served as sufficient PCNL access tracts in over half of recorded cases. Contrary to recently published reports, the utility of pre-existing NT appears to vary among health systems. Other variables, including the desired location of PCNL appear to directly influence the likelihood of NT tract usability. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e204-e205 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Aaron Bradshaw* More articles by this author Seth Bechis More articles by this author Kaitlan Cobb More articles by this author Dave Friedlander More articles by this author Roger Sur More articles by this author Expand All Advertisement PDF downloadLoading ...

You have accessJournal of UrologyStone Disease: Surgical Therapy III (MP15)1 Apr 2020MP15-06 INDICATIONS FOR STENT OMISSION AFTER URETEROSCOPIC LITHOTRIPSY: A PROSPECTIVE TRIAL FROM THE REGISTRY FOR STONES OF THE KIDNEY AND URETER (RESKU) Robert Fisher*, Kaitlan Cobb, David Friedlander, David Bayne, Seth Bechis, Helena Chang, Thomas Chi, Brian Duty, Jonathan Harper, Ian Metzler, Mathew Sorensen, Marshall Stoller, David Tzou, and Roger Sur Robert Fisher*Robert Fisher* More articles by this author , Kaitlan CobbKaitlan Cobb More articles by this author , David FriedlanderDavid Friedlander More articles by this author , David BayneDavid Bayne More articles by this author , Seth BechisSeth Bechis More articles by this author , Helena ChangHelena Chang More articles by this author , Thomas ChiThomas Chi More articles by this author , Brian DutyBrian Duty More articles by this author , Jonathan HarperJonathan Harper More articles by this author , Ian MetzlerIan Metzler More articles by this author , Mathew SorensenMathew Sorensen More articles by this author , Marshall StollerMarshall Stoller More articles by this author , David TzouDavid Tzou More articles by this author , and Roger SurRoger Sur More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000840.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Ureteral stent complications including pain, infection and discomfort are a significant source of emergency room visits in the post-operative period. Per AUA Guidelines, placement of a ureteral stent following ureteroscopy (URS) is at the urologist’s discretion. The risk/benefit calculation for routine use of ureteral stents following uncomplicated URS is controversial. We performed a multi-institutional study to investigate if ureteral stent omission is safe following URS compared to routine stenting. METHODS: From November 2018 to June 2019, a stent omission protocol was instituted at 5 academic centers for patients undergoing URS with laser lithotripsy and/or basketing by 6 fellowship trained endourologists. Inclusion criteria included: age ≥18 years, solitary ureteral stone ≤10 mm, total renal stone burden ≤15 mm with largest stone ≤10cm. Patients were excluded for solitary kidney or if a ureteral access sheath was used without pre-stenting. Data was collected prospectively via ReSKU (The Registry for Stones of the Kidney and Ureter) and was retrospectively reviewed. Analyzed outcomes included event rates of patient phone calls, unplanned emergency department or clinic visits, and unplanned operation. Bivariate differences in categorical and continuous variables between stented and unstented groups were examined using the Pearson's chi-squared and the students t-test, respectively. RESULTS: A total of 344 URS procedures were performed and 134/344 (39.0%) patients met inclusion criteria for ureteral stent omission. Of these candidates, 90 subjects (67%) had their stents omitted, while 44 (33%) deviated from the stent-less protocol. Deviation from the stent protocol did not vary by institution (20% vs. 37.5% vs. 60% vs. 50% vs. 40%; P>0.05). The total event rate (phone call, ED, OR, or clinic) was 19.1% for subjects with a stent versus 20.0% for subjects with a stent omitted (P>0.05); with the majority (30.7%) of these events being phone calls. CONCLUSIONS: In a multi-center prospectively collected study involving 344 individuals undergoing URS for nephrolithiasis, there was a similar proportion of stented and unstented subjects who called, presented to the ED or clinic, or required a return trip to the operating room following uncomplicated ureteroscopy for stone disease. Our findings suggest that ureteral stents can be safely omitted in properly selected adult patients. Source of Funding: National Institutes of Health grant (NIH P20-DK-116193). © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e206-e206 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Robert Fisher* More articles by this author Kaitlan Cobb More articles by this author David Friedlander More articles by this author David Bayne More articles by this author Seth Bechis More articles by this author Helena Chang More articles by this author Thomas Chi More articles by this author Brian Duty More articles by this author Jonathan Harper More articles by this author Ian Metzler More articles by this author Mathew Sorensen More articles by this author Marshall Stoller More articles by this author David Tzou More articles by this author Roger Sur More articles by this author Expand All Advertisement PDF downloadLoading ...

INTRODUCTION:Current American Urological Association (AUA) Best Practice Statement recommends antibiotic prophylaxis for cystoscopy with manipulation, including stent removal; although no Level 1b trials explicitly address prophylaxis for stent removal. We sought to determine the efficacy of prophylactic antibiotics to prevent infectious complications after stent removal. MATERIALS AND METHODS:Following institutional review board approval, patients undergoing removal of ureteral stent placed during stone surgery were recruited from July 2016 to March 2019. Patients were recruited at the time of stent removal and randomized to treatment (single dose 500 mg oral ciprofloxacin) or control group (no antibiotics). Telephone contact was attempted within 14 days of stent removal to assess for urinary tract infection (UTI) symptoms, antibiotic prescriptions, or Emergency Department visits. Primary outcome was UTI within 1 month of stent removal - defined by irritative voiding symptoms, fever or abdominal pain associated with positive urine culture (Ucx) (>100k colony-forming units/mL). RESULTS:Seventy-seven patients were enrolled, with 58 meeting final inclusion criteria for the analysis (33 treatment, 25 controls). No differences were seen with clinical and demographic variables, except a higher body mass index in the treatment group (P = 0.007). Positive Ucx rate before stone surgery (16.7% vs. 11.8%, P = 0.819) and at the time of stent removal (16.0% vs. 11.1%, P = 0.648) was not significantly different in treatment versus control groups, respectively. Primary outcome: No patients in either cohort developed symptomatic culture-diagnosed UTI within 1 month of stent removal. Of patients with documented phone follow-up (treatment n = 29, control n = 22), only one patient (control) reported any positive response on phone survey. CONCLUSIONS:We found a low infectious complication rate regardless of antibiotic prophylaxis use during cystoscopic stent removal. The necessity of antibiotics during routine cystoscopic stent removal warrants possible reevaluation of the AUA best practice statement.

Introduction and Objective: Current available lithotrites have clinical stone clearance rates averaging 24 to 32 mm(2)/minute. The objective of this study was to critically evaluate the initial experience with the Swiss LithoClast (R) Trilogy lithotrite during percutaneous nephrolithotomy (PCNL). Methods: We prospectively enrolled patients with a minimum of 15 mm of stone in axial diameter at three locations (Indiana University, University of California Davis, and University of California San Diego) scheduled to undergo PCNL for nephrolithiasis over a 60-day trial period. We assessed objective measures of stone clearance time, stone clearance rate, device malfunction, stone-free rate, and complications. Each surgeon also evaluated subjective parameters from each case related to the use of Trilogy on a 1 to 10 scale (10 = extremely effective), and compared it with their usual lithotrite on a 1 to 5 scale (5 = much better). Results: We included 43 patients and had 7 bilateral (16.3%) cases, for a total of 50 renal units. One case was a mini-PCNL. Two cases experienced device malfunctions requiring troubleshooting but no transition to another lithotrite. The mean stone clearance rate was 68.9 mm(2)/minute. The stone-free rate on postoperative imaging was 67.6% (25 of 37 patients with available imaging). The lowest subjective rating was the ergonomic score of 6.7, and the highest subjective rating was the ease of managing settings score of 9.2. The surgeon impressions of ultrasound (7.3), ballistics (8.1), combination of ultrasound and ballistics (8.7), and suction (8.4) were high. One patient experienced an intraoperative renal pelvis perforation, one patient required a blood transfusion, one patient had a pneumothorax requiring chest tube placement, and one patient had a renal artery pseudoaneurysm requiring endovascular embolization. Conclusions: This multi-institutional study evaluated a new and efficient combination lithotrite that was perceived by surgeons to be highly satisfactory, with an excellent safety and durability profile.

You have accessJournal of UrologySurgical Technology & Simulation: Instrumentation & Technology III1 Apr 2018PD40-09 A MULTIPARAMETRIC MAGNETIC RESONANCE IMAGING – BASED VIRTUAL REALITY SURGICAL AID FOR ROBOTIC – ASSISTED RADICAL PROSTATECTOMY Sherif Mehralivand, Abhishek Kolagunda, Chandra Kambhamettu, Kai Hammerich, Kaitlan Cobb, Vladimir Valera Romero, Jonathan Bloom, Gustavo Pena Lagrave, Vikram Sabarwal, Samuel Gold, Graham Hale, Kareem Rayn, Marcin Czarniecki, Bradford Wood, Peter Choyke, Baris Turkbey, and Peter Pinto Sherif MehralivandSherif Mehralivand More articles by this author , Abhishek KolagundaAbhishek Kolagunda More articles by this author , Chandra KambhamettuChandra Kambhamettu More articles by this author , Kai HammerichKai Hammerich More articles by this author , Kaitlan CobbKaitlan Cobb More articles by this author , Vladimir Valera RomeroVladimir Valera Romero More articles by this author , Jonathan BloomJonathan Bloom More articles by this author , Gustavo Pena LagraveGustavo Pena Lagrave More articles by this author , Vikram SabarwalVikram Sabarwal More articles by this author , Samuel GoldSamuel Gold More articles by this author , Graham HaleGraham Hale More articles by this author , Kareem RaynKareem Rayn More articles by this author , Marcin CzarnieckiMarcin Czarniecki More articles by this author , Bradford WoodBradford Wood More articles by this author , Peter ChoykePeter Choyke More articles by this author , Baris TurkbeyBaris Turkbey More articles by this author , and Peter PintoPeter Pinto More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.1934AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Robotic-assisted radical prostatectomy (RARP) has become a more popular approach for prostate cancer (PCa) recently. Its 3D stereo-laparoscopic view allows for optimal spatial awareness. Recently, multiparametric magnetic resonance imaging (mpMRI) is more commonly used at pre-operative stage, where surgeons need to evaluate MRI scans prior to surgery and try to utilize mpMRI cognitively to guide their procedures. In this study, we use mpMRI data and intraoperative stereo captures of RARP to create 3D virtual reality (VR) models which can guide surgeons during RARP to optimize spatial awareness. METHODS All RARP procedures were performed using the da Vinci® surgical system. Prostate, bladder, rectum, neurovascular bundles (NVB), seminal vesicles, urethra and PCa lesions were manually contoured on T2W MRI preoperatively. The contours were then used to create 3D mesh models for a commercially available VR platform with head mounted display (HMD) and touch controls (Oculus Rift®). Prior to RARP procedure, surgeons checked the MRI derived 3D models for spatial awareness. During RARP, stereo images of the laparoscopic views were extracted using the da Vinci′s DVI outputs to create live 3D mesh model. These models were then aligned with the MRI models by an automated alignment algorithm. When needed surgeons withdrew from the console and interacted with the 3D models using the HMD. All surgeons (1 experienced urologic surgeon, 3 clinical fellows, 3 urology residents) were polled for usability of the system after each RARP. RESULTS VR system was used during 9 RARPs. All models were successfully generated and integrated into the VR system. The time between the stereo image capture to full applicability of the model was approximately 3 minutes. The VR system was utilized at 4 steps: General check before the surgery, prior to bladder neck separation, apical dissection and during separation of nerves from the prostate capsule in lesions with proximity to the NVB. The system was used for one minute during each step and did not interfere with routine workflow. All surgeons found the system usable for improved spatial awareness. The automatic alignment was considered accurate although having the option of manual alignment was also counted useful by surgeons. Main criticism was switching between console and HMD. CONCLUSIONS Our study demonstrates feasibility of interactive visualization of 3D mpMRI data during in vivo laparoscopic RARP. Future goals include use of the robot′s stereo image viewer instead of HMD and advancement of the MRI-stereo image alignment for direct intraoperative use of mpMRI. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e807-e808 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Sherif Mehralivand More articles by this author Abhishek Kolagunda More articles by this author Chandra Kambhamettu More articles by this author Kai Hammerich More articles by this author Kaitlan Cobb More articles by this author Vladimir Valera Romero More articles by this author Jonathan Bloom More articles by this author Gustavo Pena Lagrave More articles by this author Vikram Sabarwal More articles by this author Samuel Gold More articles by this author Graham Hale More articles by this author Kareem Rayn More articles by this author Marcin Czarniecki More articles by this author Bradford Wood More articles by this author Peter Choyke More articles by this author Baris Turkbey More articles by this author Peter Pinto More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

You have accessJournal of UrologyImaging Based Techniques & Uroradiology1 Apr 2018V12-07 IMPLEMENTATION OF MULTIPARAMETRIC MAGNETIC RESONANCE IMAGING INTO ROBOTIC – ASSISTED RADICAL PROSTATECTOMY USING VIRTUAL REALITY Sherif Mehralivand, Abhishek Kolagunda, Chandra Kambhamettu, Kai Hammerich, Kaitlan Cobb, Vladimir Valera Romero, Jonathan Bloom, Gustavo Pena Lagrave, Vikram Sabarwal, Samuel Gold, Graham Hale, Kareem Rayn, Stephanie Harmon, Clayton Smith, Marcin Czarniecki, Bradford Wood, Peter Choyke, Baris Turkbey, and Peter Pinto Sherif MehralivandSherif Mehralivand More articles by this author , Abhishek KolagundaAbhishek Kolagunda More articles by this author , Chandra KambhamettuChandra Kambhamettu More articles by this author , Kai HammerichKai Hammerich More articles by this author , Kaitlan CobbKaitlan Cobb More articles by this author , Vladimir Valera RomeroVladimir Valera Romero More articles by this author , Jonathan BloomJonathan Bloom More articles by this author , Gustavo Pena LagraveGustavo Pena Lagrave More articles by this author , Vikram SabarwalVikram Sabarwal More articles by this author , Samuel GoldSamuel Gold More articles by this author , Graham HaleGraham Hale More articles by this author , Kareem RaynKareem Rayn More articles by this author , Stephanie HarmonStephanie Harmon More articles by this author , Clayton SmithClayton Smith More articles by this author , Marcin CzarnieckiMarcin Czarniecki More articles by this author , Bradford WoodBradford Wood More articles by this author , Peter ChoykePeter Choyke More articles by this author , Baris TurkbeyBaris Turkbey More articles by this author , and Peter PintoPeter Pinto More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.3015AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Multiparametric magnetic resonance imaging (mpMRI) of the prostate has been proven to improve cancer detection and staging. It has been more commonly used during urology practice at several stages of urologic management, one of which is pre-surgical planning. Currently, urologists check mpMRI data at picture archiving and storing systems (PACS) before or during robotic-assisted radical prostatectomy (RARP) to deliver better care. In this video, we demonstrate implementation of mpMRI data into intraoperative stereo imaging during a laparoscopic RARP procedure using the da Vinci® surgical system in 72-year-old patient with Gleason 4+4 prostate cancer (PCa). METHODS mpMRI revealed a 1.8cm tumor in the left apical-mid peripheral zone which was assigned a category 5 according to the Prostate Imaging-Reporting and Data System version 2. The lesion showed aggressive features with possible extraprostatic extension and invasion of the left neurovascular bundle (NVB). T2W MRI component of mpMRI was utilized to create 3D models of the prostate, bladder, rectum, NVBs, seminal vesicles, urethra and PCa lesions by manually contouring process. These contours were then used to create 3D mesh models for a commercially available VR platform with head mounted display (HMD) and touch controls (Oculus Rift®). Prior to RARP procedure, surgeons checked the MRI derived 3D model of prostate and its surrounding anatomy. During RARP, stereo images of the laparoscopic views were extracted using the da Vinci® DVI outputs. Both models were then aligned to each other using an in-house algorithm and provided to urologists during RARP. RESULTS Invivo imaging derived 3D models of the prostate, index lesion and periprostatic anatomy was successfully delivered to urologist during RARP procedure. This interactive visualization method enabled the surgeon to conduct a wider excision of the NVB at this spot without increasing the procedure′s time significantly. The final histopathology revealed clean margins at the wide excision zone. CONCLUSIONS Realtime use of in-vivo mpMRI derived 3D prostate and periprostatic anatomy information during laparoscopic RARP procedure via the da Vinci® surgical system can be advantageous to better tailor the surgery procedure and can potentially improve spatial awareness. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e1238 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Sherif Mehralivand More articles by this author Abhishek Kolagunda More articles by this author Chandra Kambhamettu More articles by this author Kai Hammerich More articles by this author Kaitlan Cobb More articles by this author Vladimir Valera Romero More articles by this author Jonathan Bloom More articles by this author Gustavo Pena Lagrave More articles by this author Vikram Sabarwal More articles by this author Samuel Gold More articles by this author Graham Hale More articles by this author Kareem Rayn More articles by this author Stephanie Harmon More articles by this author Clayton Smith More articles by this author Marcin Czarniecki More articles by this author Bradford Wood More articles by this author Peter Choyke More articles by this author Baris Turkbey More articles by this author Peter Pinto More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

METHODS: Frailty was prospectively analyzed prior to surgery in all consenting patients using the Hopkins Frailty Index, consisting of 5 components yielding an additive score.Patients were categorized as not frail, intermediate, or severely frail, depending on overall score.Primary outcomes assessed were complications during admission and the 30-day complication rate.Secondary outcomes included overall hospital length of stay (LOS) and discharge disposition.RESULTS: The analysis included 78 patients who underwent percutaneous renal surgery.In total, 58 (74%), 13 (17%), and 7 (9%) patients were in the not frail, intermediate, and frail categories.Overall, intermediate or frail patients were more likely to have underlying chronic kidney disease (p < 0.05), anemia (p < 0.01), or prior abdominal surgery (p < 0.04).Intraoperatively, intermediate or frail patients were not more likely to experience higher blood loss or to have a higher stone burden.Of the five frailty metrics, grip strength alone was predictive of post-operative complications (p < 0.01).When compared with the American Society of Anesthesiologists (ASA) score and Charlson comorbidity index (CCI), frailty class alone was predictive of the incidence of complications during admission (p < 0.03), but not 30-day postoperative complications (p ¼ 0.33).Extended length of stay (p < 0.001), along with specific complications like fever (p < 0.0063), sepsis (p < 0.0001), bacteremia (p < 0.0004), hemorrhage requiring embolization (p < 0.03), and hemodynamic instability requiring intensive care (ICU) admission (p < 0.0008) were more common with in individuals with higher frailty scores.Frailer individuals tended to require higher level of care upon hospital discharge (p < 0.0001).CONCLUSIONS: While established preoperative assessment tools (ASA and CCI) were not predictive of complication rates in our cohort, higher frailty scores were associated with immediate postoperative complications.The frailty phenotype may give better insight into prediction of post-operative outcomes and may represent potentially modifiable factors for patient optimization prior to surgery.Moreover, it provides additional data in preoperative patient counseling.

INTRODUCTIONAlthough prostate cancer is the most common non-cutaneous cancer in men, it is traditionally diagnosed with a non-targeted, systematic transrectal ultrasound prostate biopsy (TRUS-Bx). This technique has been demonstrated to both under-detect clinically significant (CS) cancer and over-detect clinically insignificant cancer, and performs poorly in patients with a prior negative biopsy. With recent advances in MRI technology, most prominently the advent of multiparametric MRI, MRI-targeted prostate biopsy (MRI-TB) has been gaining favor as a more accurate alternative to TRUS-Bx. In this review, we attempt to summarize the current literature on MRI-TB and to determine if there is evidence supporting the use of MRI-TB alone.MATERIALS AND METHODSThe literature was reviewed for articles pertaining to MRI-TB and its performance compared to systematic biopsy.RESULTSMost studies support the increased sensitivity of MRI-TB (0.90, 95% CI 0.85-0.94) compared to TRUS-Bx (0.79, 95% CI 0.68-0.87) for the detection of CS prostate cancer, as MRI-TB can detect up to 30% more high risk and 17% fewer low risk cancers. MRI-TB also tends to perform better than TRUS-Bx in patients with prior negative biopsy, as TRUS-Bx may miss up to half of CS cancers detected by MRI-TB, and in those with lesions at atypical locations. However, as the technology for imaging and image-guided biopsies continues to develop, there is still a role for TRUS-Bx in the management of patients with prostate cancer.CONCLUSIONSOur analysis of the literature suggests that although MRI-TB is superior to TRUS-Bx, there is still a role for traditional systematic biopsy.

You have accessJournal of UrologyProstate Cancer: Detection & Screening VII1 Apr 2016MP53-14 COST EFFECTIVENESS OF MAGNETIC RESONANCE/ULTRASOUND FUSION PROSTATE BIOPSY VS STANDARD OF CARE (TRANSRECTAL ULTRASOUND (TRUS)-GUIDED BIOPSY) Kaitlan Cobb, Amichai Kilchevsky, John Michael DiBianco, Daniel Su, Thomas Frye, Vikram Sabarwal, Baris Turkbey, Peter Choyke, Bradford Wood, and Peter Pinto Kaitlan CobbKaitlan Cobb More articles by this author , Amichai KilchevskyAmichai Kilchevsky More articles by this author , John Michael DiBiancoJohn Michael DiBianco More articles by this author , Daniel SuDaniel Su More articles by this author , Thomas FryeThomas Frye More articles by this author , Vikram SabarwalVikram Sabarwal More articles by this author , Baris TurkbeyBaris Turkbey More articles by this author , Peter ChoykePeter Choyke More articles by this author , Bradford WoodBradford Wood More articles by this author , and Peter PintoPeter Pinto More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.511AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Studies have shown magnetic resonance imaging / ultrasound (MR/US) fusion prostate biopsies to be to be comparable and superior to standard TRUS-guided biopsy in diagnosing prostate cancer (PCa). MRI of the prostate as a possible initial diagnostic tool has been postulated. We sought to explore the cost-effectiveness of prostate MRI as an initial diagnostic tool as compared to TRUS-guided biopsy. METHODS Using a cost analysis model, the total cost and outcomes for biopsy naïve men presenting with an elevated PSA >4.0 ng/ml was compared. A theoretical cohort was subdivided into those undergoing TRUS prostate biopsy and those undergoing prostate MRI with subsequent MR/US fusion biopsy only if when a target lesion is present. A cancer incidence of 28%, additional 32% non-infectious complication rate cost, 1.73% infectious complication cost, sensitivities and specificities for TRUS-guided biopsy at 53% and 66% respectively, prostate MRI set at 75% and 88% respectively and MR/US fusion biopsy set at 77% and 68% respectively, were based off current literature. Cost of TRUS biopsy, prostate MRI and MR/US fusion biopsy were based of the current AUA recommended CPT and Medicare reimbursement. Added cost for the MR/US fusion cohort included the system cost, determined by the average cost of the commercially available system. RESULTS Using a total cost for 1 patient undergoing TRUS prostate biopsy of $1,410.35, a contrast enhanced prostate MR of $633.36 and MRI fusion biopsy of $2,138.95, TRUS guided biopsy in 100 men would cost $141,035, and would be falsely negative in 13.16 men and falsely positive 24.48 men. The total cost of obtaining initial prostate MRI in 100 men with only patients with target lesion(s) undergoing MR/US fusion biopsy, was determined to be $107,961.69 given that 70.36 men would undergo prostate MRI alone, and 29. 64 men would have a subsequent MR/US fusion biopsy. Within the group of men only undergoing prostate MRI, 7 men would have falsely negative results and 8.64 would have falsely positive results. If MR/US fusion biopsy were performed without the addition of the standard 12-core template, false positivity would occur in 0.521 men, and false negativity in 6.44 men. CONCLUSIONS 100 men with PSA elevation who undergo prostate MRI with MR/US fusion biopsy if indicated, would cost ~25% less than undergoing an initial standard TRUS guided biopsy. Prostate MRI alone would result in fewer biopsies performed, thereby decreasing the cost of diagnosing PCa and reducing biopsy associated complications. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e702-e703 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Kaitlan Cobb More articles by this author Amichai Kilchevsky More articles by this author John Michael DiBianco More articles by this author Daniel Su More articles by this author Thomas Frye More articles by this author Vikram Sabarwal More articles by this author Baris Turkbey More articles by this author Peter Choyke More articles by this author Bradford Wood More articles by this author Peter Pinto More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

You have accessJournal of UrologyStone Disease: Surgical Therapy I1 Apr 2016MP22-12 THE RELATIONSHIP BETWEEN OPERATIVE TIMES AND COMPLICATION RATES IN PERCUTANEOUS NEPHROSTOLITHOTOMY PROCEDURES Julie Stein, Kaitlan Cobb, John Michael DiBianco, and Patrick Mufarrij Julie SteinJulie Stein More articles by this author , Kaitlan CobbKaitlan Cobb More articles by this author , John Michael DiBiancoJohn Michael DiBianco More articles by this author , and Patrick MufarrijPatrick Mufarrij More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.700AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Prolonged operative time has long been associated with postoperative complications. Percutaneous nephrostolithotomy (PCNL) is a common approach for the treatment of complex stone disease, often requiring lengthy operative times and/or multiple surgical stages. Complications of PCNL, including hemorrhage, injury to adjacent organs/structures, and infection, have been reported to occur at higher rates in procedures that have had prolonged operative times. Additionally, some of these complications may limit the duration of PCNL procedures, thereby decreasing stone-free rates or requiring more surgical stages. We aimed to investigate the relationship between operative times and postoperative complications as classified by the Clavien-Dindo System of Surgical Complications. METHODS A retrospective review was performed on 66 patients who underwent PCNL by a single endourologist at George Washington University Hospital and Sibley Memorial Hospital in Washington, D.C. from October 2012 to December 2014. Data on basic patient demographics and characteristics, operative times, and complications were collected. Operative time was defined by surgery start time and stop time as recorded by the anesthesiologist. Complications were classified by the Clavien-Dindo system on a scale of 0 to 5. RESULTS Mean age of patients was 57.3 +/- 12.2 years. Overall complication rate was 14.9% with 0% Clavien I, 9.0% Clavien II, 0% Clavien III, 6.0% Clavien IV, and 0% Clavien V. Mean operative time was 232.0 +/- 72.7 minutes. A simple linear regression model revealed that operative time accounted for 6.1% of the variance in Clavien score (R2 = .061, p < 0.05). One-way Analysis of Variance (ANOVA) demonstrated that the presence of infection stones differed significantly between Clavien classes (F(2, 60) = 3.32, p = 0.043). Post-hoc analyses showed that infection stones were associated with a Clavien II complication (p = 0.05), but not with a Clavien IV complication (p > 0.05). CONCLUSIONS In our investigation, increased operative time of PCNL procedures was not associated with an increase in complications. The increase in mid-level complications observed in patients identified to have infection-based stones corroborates previous data on this particular group of stone patients. While, in general, it is advisable to minimize operative duration, this data does not suggest an increased complication risk with lengthier PCNL procedures. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e257-e258 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Julie Stein More articles by this author Kaitlan Cobb More articles by this author John Michael DiBianco More articles by this author Patrick Mufarrij More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Purpose: Ureteroureterostomy (UU) is a useful surgical option for the management of duplication anomalies as well as obstructed single system ureters for children. We aimed to evaluate the safety, efficacy, and outcomes of robot-assisted laparoscopic UU (RALUU) compared with open UU (OUU) in the pediatric population.Patients and Methods: A retrospective review was performed at two institutions including six surgeons' experience with all cases of RALUU and OUU from January 2005 to June 2014. Indications for a surgical procedure included duplex systems with an upper pole ectopic ureter, obstructed ureterocele or lower pole vesicoureteral reflux, and obstruction in a single system. Transureteroureterostomy, laparoscopic UU, and major reconstruction cases where UU was the secondary procedure were excluded.Results: There were 25 RALUU and 19 OUU cases included. All cases involved duplex systems except two proximal to distal anastomoses in single system obstructed kidneys. RALUUs were more likely to be performed proximally (P=0.01) and with the use of cystoscopy and stent placement (P=<0.0001). Operative times and estimated blood loss were similar between the two groups. Postoperative complications included four febrile urinary tract infections in each group, one recurrence of nonfebrile urinary tract infection in the open group, and one postoperative obstruction at the ureterovesical junction because of attempted stent placement necessitating nephrostomy tube placement in the open group. This OUU patient was the only one to demonstrate more severe hydronephrosis after surgery on initial follow-up imaging that was again unrelated to the open UU procedure. RALUU had shorter hospital stays by 0.5 days (P=0.04).Conclusion: Robot-assisted laparoscopic UU is a safe and effective alternative to open UU in children with duplication anomalies and single system obstructed ureters. Operative times and complication rates were comparable with slightly shorter length of hospitalization in robotic cases.