INTRODUCTION:Ureteral stent placement after ureteroscopy is a major contributor to patient morbidity. We sought to evaluate postoperative complications and quality of life (QoL) metrics comparing individuals receiving ureteral stent placement vs. stent omission after ureteroscopy. METHODS:A multicenter, randomized controlled trial was performed among patients undergoing ureteroscopy and laser lithotripsy for non-obstructing renal stones with up to 1.5 cm in total stone diameter. Ureteral access sheath use and laser technique were at the discretion of the surgeon. At case end, if no ureteral injury was observed, patients were randomized to stent placement or stent omission. Primary outcome was the 30-day occurrence of emergency department visits, unanticipated provider visits, or hospitalization. Secondary outcomes included QoL measured by the Wisconsin Stone Quality of Life (WISQOL) and the Patient-Reported Outcomes Measurement Information System (PROMIS) pain interference surveys, opiate use, and abnormal imaging findings at followup. RESULTS:Of 103 patients enrolled with mean (standard deviation [SD]) stone diameter 9.6 mm (4.5), 74 were randomized to stent placement (n=36) or stent omission (n=38). Ureteral access sheaths were used in 83% and 61% of patients in the stented and unstented groups, respectively. There was no difference in rate of 30-day complications between stent and stent omission cohorts (8% vs. 11%, absolute risk difference -2%, 95% confidence interval [CI] -15%, 11%, p=0.75). Stent omission showed better adjusted pre- vs. post-surgery WISQOL scaled score (16.7, 95% CI 3.1, 30.4, p=0.02) and PROMIS 6a t-score (-8.5, 95% CI -15.3, -1.6, p=0.02). No differences between groups were observed in the cumulative opiate use, ability to return to work, symptomatic urinary tract infection, or abnormal imaging findings at followup. CONCLUSIONS:Compared to ureteral stent placement, stent omission after ureteroscopy for renal stones appears to be feasible and suggests improved short-term patient-reported outcomes in selected patients. This study was limited by small sample size, and future larger studies are needed.

INTRODUCTION:Percutaneous nephrolithotomy (PCNL) is associated with a significant risk for postoperative urinary tract infection (UTI) and sepsis. Prevention of post-PCNL UTI is dependent on appropriate antibiotic prophylaxis (AP), which relies on preoperative urine cultures. However, studies have demonstrated that preoperative urine cultures are not always concordant with stone cultures (SC), the latter most closely representing the bacterial burden. Accuracy of urine cultures is even more critical in the neurogenic bladder (NB) subpopulation, as they often have infected or infectious stones. In this study, we aim to assess the concordance of preoperative urine cultures and SC in NB patients as compared to non-neurogenic bladder (non-NB) patients undergoing PCNL. METHODS:We performed a retrospective chart review of all patients ≥18 years old undergoing PCNL at our institution between 2022 and 2024. Baseline characteristics, preoperative urine culture, stone culture, concordance rates, perioperative complication, and urosepsis rates were collected and compared between NB and non-NB patients. Numeric variables were compared using t-test and categorical variables using chi-square. RESULTS:A total of 333 patients underwent PCNL between 2022 and 202 were non-NB patients. NB patients had a lower concordance rate between preoperative urine culture and SC compared to non-NB patients (37.7% vs 64.3%, p = < 0.05). Rates of urosepsis were comparable in both groups in the perioperative period (1.8% vs 1.4%, p = 0.51). Enterococcus faecalis was the most common pathogen found in NB SC. CONCLUSION:NB patients are more likely to have discordant preoperative urine culture and SC compared to non-NB patients. Gram-positive organisms such as Enterococcus faecalis also represent a high number of positive SC in this population. Given the high discordance rate and positivity with Enterococcus faecalis in SC, consideration for a larger spectrum AP is warranted in NB patients.

OBJECTIVE:To compare the cost-effectiveness of simultaneous vs staged percutaneous nephrolithotomy (PCNL) during treatment of patients with large, bilateral stone burden. METHODS:A decision-analytic Markov model was used to assess the cost-effectiveness of simultaneous and staged PCNL for large, bilateral stone burden. Model probabilities and outcomes for index procedures were drawn from a large-volume, single-center cohort. Primary outcomes included costs from a Medicare standpoint with the addition of operative time, length-of-stay costs, effectiveness (quality adjusted life years, QALYs), and incremental cost-effectiveness ratios with a willingness-to-pay threshold of $100,000/QALY. RESULTS:At 1year following the index procedure, costs per patient were $52,585 and $61,687 for simultaneous and staged PCNL, respectively. In addition to being less costly, simultaneous PCNL resulted in slightly higher QALYs (0.982) compared to staged PCNL (0.977). On one-way sensitivity analyses, staged PCNL became cost-effective if the stone-free rate increased from 56% to 88% (40% greater per renal unit relative to simultaneous PCNL) or the cost of unilateral PCNL decreased approximately 50% to $4699 ($16,266 less than simultaneous PCNL). CONCLUSION:Even when assuming a modest reduction in stone-free rate and slightly higher major and minor complication rates at index procedure, simultaneous bilateral PCNL was both less costly and more effective at 1year follow up relative to staged bilateral PCNL. This offers further support of simultaneous bilateral PCNL in the proper clinical setting.

INTRODUCTION:Tissue morcellation has become increasingly efficient, yet remains a rate-limiting step in holmium enucleation of the prostate (HoLEP). Limited data exists on how the rate of oscillation by the morcellator blades affects morcellation efficiency (ME). METHODS:We undertook a retrospective review of HoLEP procedures performed by two surgeons from July 1, 2019, to August 25, 2022. All morcellation was performed with the Wolf Piranha device and enucleation was performed with Moses 2.0 technology. Surgeon 1 routinely uses 1500 oscillations/min (low rate [LR]) and surgeon 2 uses a rate of 6000 oscillations/min (high rate [HR]). These rates were confirmed upon electronic medical record review of each case. The primary endpoint was ME (g/minute). Secondary endpoints included enucleation efficiency (EE), mean tissue specimen weight, and preoperative prostate volume. RESULTS:A total of 894 HoLEPs were analyzed, 592 by surgeon 1 and 302 by surgeon 2. Surgeon 1 had larger preoperative prostate volumes (126 vs. 101, p<0.001) and specimen tissue weights (86.0 vs. 61.1, p<0.001). EE was higher in the LR group (1.67 vs. 1.33 g/min, p<0.001). Morcellation time was longer in the LR group (11.3 vs. 6.09 min, p<0.001) and ME was lower in the LR group (9.26 vs. 12.1 g/min, p<0.001). The difference in ME was inversely proportional to specimen weight. CONCLUSIONS:Increased oscillation rate during morcellation may lead to decrease in morcellation time and increased ME during prostate enucleation. The primary limitation of this paper is the inclusion of only two surgeons. Future studies will serve to evaluate this finding across a larger number of institutions, and evaluate ways to increase ME in large prostate cohorts.

Treatment of staghorn calculi in patients with neurogenic bladder is complex and requires special consideration. In this article, we explore the current literature on this topic and give insights from our own practice. Stones appear to be more common in patients with neurogenic bladders for a variety of reasons including increased risk with urinary diversion, bladder augmentations, or other genitourinary (GU) reconstruction, higher spinal cord lesions, and presence of bacteriuria. Given high rates of bacteriuria, perioperative antimicrobial regimen should be determined by preoperative urine culture and stone culture while taking into account organisms which typically grow in these cultures including E. Coli and gram-negative rods, Enterobacter, Proteus, and Pseudomonas. One should be aware of the increased risk of funguria in this patient population as well and treat as indicated. Finally, rates of stone recurrence are higher in this patient population as well. Close follow up with identification and aggressive treatment of risk factors for stone recurrence is imperative. Although there are special considerations, PCNL is safe and effective in patients with neurogenic bladder and staghorn calculi and should be pursued to achieve stone free status when possible.

Introduction: Current American Urological Association guidelines recommend that patients with acute obstructive kidney stone requiring continuous anticoagulation/antiplatelet therapy should not be treated by shockwave lithotripsy or percutaneous nephrolithotomy because of the risk of catastrophic renal hemorrhage possible with those techniques. Currently, ureteroscopy is the only recommended surgical treatment. We evaluated if burst wave lithotripsy (BWL) could be used in these cases by treating pigs with BWL while undergoing anticoagulation therapy. Materials and Methods: Six pigs (31-37 kg) were given 200 units/kg porcine heparin, and then the right kidney of each animal was treated with a dose of BWL (18,000 ultrasound pulses at 10 Hz, 20 cycles/pulse, peak positive pressure of 12 MPa) known to fracture kidney stones. The contralateral kidney served as a control. Therapeutic anticoagulation was confirmed by evaluating activated partial thromboplastin time (aPTT). Microhematuria was checked by urine test strips. Kidneys were subsequently evaluated for hemorrhagic injury via MRI. Results: aPTT was significantly elevated (>100 seconds) throughout the entire treatment period (p = <0.001) indicating therapeutic anticoagulation. Gross hematuria was not observed in any of the pigs. After BWL, microhematuria averaged 145.8 red blood cells (RBC)/mu L in the BWL-treated kidney and 48 RBC/mu L in the control kidneys, and there was no statistically significant difference noted in microhematuria rates between the two groups (p = 0.16). Hemorrhagic injury measured only 0.10 +/- 0.02% of the tissue in the BWL-treated kidneys and 0.12 +/- 0.04% in the control side, with a paired difference of -0.03 +/- 0.05%, showing no significant difference (p = 0.58). Conclusions: A typical clinical dose of BWL causes no hemorrhagic injury to the kidney even during therapeutic anticoagulation therapy. This result suggests that BWL should be safe to use in patients with stone undergoing anticoagulation/antiplatelet therapy.

Simulation-based training (SBT) is designed to mimic real-life surgeries and help surgeons develop skills they can transfer to the operating room in a risk-free environment. With the emergence of numerous surgical therapies for benign prostatic hyperplasia (BPH), a need has developed for new learning tools in addition to standard clinical exposure. In this scoping review, we aimed to provide a comprehensive and updated outline of available endoscopic BPH simulators. We conducted a scoping review in accordance with the Joanna Briggs Institute methodology. References were identified through searches of MEDLINE, Embase, Web of Science, and CINAHL from inception to March 2025. A search of Google Scholar was also conducted to identify grey literature references. Keywords searched included those related to simulators, medical education and BPH surgeries. Studies included were original articles on simulators used for endoscopic BPH surgery. Data pertaining to simulator validity, acceptability and feasibility were collected. Forty-five records were included, with one reference consisting of a multi-modality curriculum used for simulating two BPH surgeries. Thirty studies assessed transurethral resection of prostate (TURP) simulators, six studies for GreenLight laser prostatectomy (PVP), eight studies for anatomic endoscopic enucleation of the prostate (AEEP) procedures, and two articles for Urolift. For TURP simulators, four bench-top models, nine virtual reality simulators, two food-based phantoms, and one porcine model were identified. For HoLEP simulators, three bench-top models, two VR simulators, and one human cadaver prostate model were assessed. Furthermore, virtual simulation was the only modality tested for PVP (two simulators), ThuLEP (one simulator), and Urolift (one simulator). Our results suggest a need for developing SBT models other than TURP. Future iterations of BPH surgical models should be evaluated using the modern definition of validity with the goal of integration into surgical curriculum.

Tranexamic acid (TXA) is an anti-fibrinolytic agent that prevents degradation of fibrin by blocking the ability of plasminogen to bind to fibrin and the proteolytic activity of plasmin. TXA has been proven to be useful in reducing bleeding complications in multiple types of surgery. In this article, we will review the current usage of TXA in endoscopic surgeries for benign prostatic hyperplasia (BPH). The use of TXA for endoscopic BPH surgeries has mainly been studied for transurethral resection of the prostate (TURP). In the clinical trials assessing the use of TXA and TURP, TXA demonstrated reduced intraoperative bleeding independent of administration route. However, this did not consistently translate to reduced hospitalization or catheterization times. Evidence for the use of TXA and holmium laser enucleation of the prostate (HoLEP) has begun to emerge, and to date limited benefit has been demonstrated. This result is likely due to the excellent innate hemostatic control associated with the procedure. However, further studies are required to validate these findings. With recent innovation in new types of endoscopic BPH surgeries, the benefit of TXA during other types of BPH procedures also require more study. Within the context of endoscopic surgeries for BPH, TXA appears to have the most benefit when performing TURP. More evidence is required to conclude on the benefit in other types of BPH surgery including HoLEP.

You have accessJournal of UrologyCME1 May 2022MP26-06 PREVALENCE OF KIDNEY STONE DISEASE IN U.S. HISPANIC/LATINO ADULTS: FINDINGS FROM THE HISPANIC COMMUNITY HEALTH STUDY / STUDY OF LATINOS (HCHS/SOL) Marcelino Rivera, Jinsong Chen, Ana Ricardo, Robert Burk, Jianwen Cai, Martha Daviglus, and James Lash Marcelino RiveraMarcelino Rivera More articles by this author , Jinsong ChenJinsong Chen More articles by this author , Ana RicardoAna Ricardo More articles by this author , Robert BurkRobert Burk More articles by this author , Jianwen CaiJianwen Cai More articles by this author , Martha DaviglusMartha Daviglus More articles by this author , and James LashJames Lash More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002569.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: There is limited data available regarding the prevalence of kidney stone disease history in U.S. Hispanics/Latinos. The objective of this study is to investigate the prevalence of and risk factors for kidney stones among a diverse population of U.S. Hispanic/Latino adults. METHODS: The Hispanic Community Health Study/Study of Latinos (HCHS/SOL) is a community-based cohort of self-identified Hispanic/Latino adults from diverse backgrounds in the U.S. aged 18-74 years at enrollment through a multi-stage probability sampling design. We used data from 10,965 participants who completed a survey on self-reported history of kidney stone disease which was collected at a second study visit (2014-2017). Prevalence estimation accounted for the complex sampling design. Multivariable logistic regression was used to evaluate the association of risk factors with stone disease. RESULTS: The prevalence of kidney stone disease history was 10.6% (95% CI, 9.1%, 12.2%) in men and 7.8% (6.9%, 8.7%) in women. The prevalence varied by Hispanic/Latino background, and was lowest in persons of Mexican background (5.0%, [4.2%, 5.9%]) and highest in persons of Cuban background (16.2 [13.4%, 19.0%]. On multivariable logistic regression analysis, risk factors for prevalent kidney stone disease included older age and male sex (Table). CONCLUSIONS: Kidney stone disease prevalence varied considerably by Hispanic/Latino background. Further investigation is required to determine reasons for these findings, as well as intrinsic and extrinsic causes of stone disease among Hispanic/Latino adults. Source of Funding: The Hispanic Community Health Study / Study of Latinos is sponsored by the National Heart, Lung, and Blood Institute (NHLBI) and six other centers and Institutes of the National Institutes of Health (NIH) © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e440 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Marcelino Rivera More articles by this author Jinsong Chen More articles by this author Ana Ricardo More articles by this author Robert Burk More articles by this author Jianwen Cai More articles by this author Martha Daviglus More articles by this author James Lash More articles by this author Expand All Advertisement PDF downloadLoading ...

OBJECTIVES:Previous studies have shown conflicting results concerning the optimal duration of ureteral stenting after endourologic treatment of stone disease, its effect on patient comfort, and the necessity for emergent, unscheduled care. This study assessed the impact of stent duration, sex, and other patient-associated factors on reported pain scores using a large, international prospective registry. METHODS:A prospective observational patient registry on ureteral stents from 10 institutions in 4 countries (United States, Canada, France, and Japan) from 2020-2023 was assessed. The primary outcome was Patient-Reported Outcomes Measurement Information System (PROMIS) pain intensity scores administered on the day of stent removal, before stent removal. Patients were grouped by indwelling time (short, medium, and long), and pain scores were compared. The impact of sex, height vs. stent length, and presence or absence of tether were assessed. RESULTS:359 patients were enrolled in the database, with outcomes analyzed for 268 patients with a unilateral stent placed after an endourologic procedure for stones. No significant difference was detected in pain scores between the indwelling time groups (p = 0.41). Height for a given stent length was not significantly associated with pain scores. There was no difference in pain scores with or without tether. Men reported lower pain scores than women (p = 0.018). CONCLUSIONS:This study did not detect an overall difference in pain scores reported at stent removal within or between stent duration groups. Men reported less pain than women in this study, suggesting that patient factors may be more important than indwelling time when optimizing pain management.

Objective: We aim to report the learning curve and experience performing holmium laser enucleation of the prostate (HoLEP) from a resident standpoint trained at a tertiary high-volume center. Methods: An electronic survey was distributed to 10 surveyees that included recently graduated chief residents trained at Indiana University in the past 3 years i.e., between 2020 and 2022 with a 100% response rate. The questionnaire focused on HoLEP training experience based on a recently established mentorship curriculum in training the residents through each individual step of the surgery. Results: The average learning curve for performing HoLEP was reported to be greater than 25 cases with 50% of the residents reporting >50 cases to master the technique. The surgical difficulty of steps of the HoLEP were rated on a subjective scale of 1-5: 1 = very easy, 2 = easy, 3 = neutral, 4 = hard, and 5 = very hard. The common challenging steps in decreasing the order of difficulty as reported are performing apical enucleation, joining anterior and posterior planes, and dividing anterior commissure with a mean rating of 3.5, 3.1, and 3.1, respectively. The most difficult aspect of the surgery to master was performing apical dissection (60%). Comparing operative parameters for HoLEP with transurethral resection of the prostate in aspects of resection volume and times, 70% of candidates reported it better for HoLEP whereas 20% had similar times for both procedures. A total of 90% of the residents felt confident to offer HoLEP as part of their practice without the need for any further training. Regarding the initial challenge of including HoLEP surgery in practice, the majority (60%) reported difficulty with equipment set up in their practice while 20% reported difficulty maintaining efficient operating room (OR) times and turnover. Conclusion: We believe HoLEP can be performed immediately after residency training and incorporated into practice with high volume, repeated exposure to HoLEP surgery throughout residency based on study results. The average learning curve reported for performing HoLEP was greater than 25 cases.

Introduction: Kidney stones are a common medical condition that impact approximately 10% of US population. Management of stone disease is based on size and location of stones. Percutaneous nephrolithotomy (PCNL) is typically indicated in patients with large renal stone burden (typically >2 cm) or complex anatomy. In the setting of complex stones, multiple, staged PCNLs are required. We hypothesize that there is no significant difference in the perioperative change in lab values in bilateral PCNLs compared to unilateral PCNLs. Methods: The data was gathered by retrospectively reviewing the electronic medical record of 50 patients in the IU health system who underwent planned staged PCNLs between January and December 2018. We identified patients who underwent both bilateral and unilateral staged procedures. Data for BMI, sex, ethnicity, hemoglobin, estimated glomerular filtration rate (GFR) (typically formula CKD-EPI or MDRD), urine and stone cultures, stone composition, and bilaterality vs. unilaterality was collected. Two-tailed T-tests were performed to analyze data between bilateral and unilateral cases. Results: We identified a total of 50 patients, 19 men vs. 31 women; 9 men and 10 women underwent bilateral PCNLs, while 11 men and 20 women had unilateral PCNLs. BMI ranged from 14.2 to 62.3, and age ranged from 15 to 81. Significant differences were found between the changes in hemoglobin levels in patients who underwent bilateral PCNLs when compared to unilateral PCNLs (p value 0.018). No significant differences were noted when comparing changes of estimated GFR, BMI, age or any other variables. Conclusion: Patients who underwent bilateral staged PCNLs demonstrated a greater drop in perioperative hemoglobin compared to unilateral PCNLs without an increase in blood transfusion. This finding suggests that Bilateral PCNLs requiring multiple stages are safe in complex stone patients.