Journal of Endourology
ISSN / EISSN: 08927790 / 1557900X
Published by: Mary Ann Liebert Inc
Total articles ≅ 8,062
Latest articles in this journal
Journal of Endourology; https://doi.org/10.1089/end.2022.0564
There is a call to improve Medicaid patient access to healthcare, enhance quality and outcomes of care, and reduce overall financial burden. We sought to build a comprehensive kidney stone program to help patients navigate through the acute and preventative aspects of stone disease by increasing multidisciplinary referrals, compliance to recommendations, no-show rates at first follow-up, and repeat stone encounters after initial evaluation. A collaborative, multi-disciplinary program was established at our single institution consisting of urology, nephrology, and dietary specialists to be piloted over a three-year period. Medicaid-designated patients were evaluated during new patient encounters by urology and then followed for outpatient follow-up including specialty referrals to nephrology and dietitians for targeted preventative measures. Subjective compliance reports by patients following interventions and no-show rates at subsequent follow-ups were documented. We also followed patients 6 months beyond initial encounter to assess for repeat Emergency Department (ED) visits for acute stone episodes. One hundred and eighty-three Medicaid-designated stone patients were evaluated from 2018-2021. Sixty-eight percent of patients identified as white, 18% identified as black/African-American, and 14% identified as “other”. Patients underwent specialty referrals to nephrology or a dietician in 47% and 42% of cases, respectively. Since the program’s implementation, reported patient compliance and referrals to multidisciplinary specialists increased from 72.9% to 81.30% and 21.2% to 56.20%, respectively. Repeat Emergency Department visits for stone related encounters within 6 months of initial presentation remained relatively stable (from 17.60% to 18.9%) while no-show rates at first follow-up decreased from 20.0% to 6.30% by study conclusion. There is continued supporting evidence for the importance of a comprehensive kidney stone program specifically for patients of lower socioeconomic status following a three-year implementation at our institution. Encouraging results indicate increased access to multi-disciplinary specialty referrals, with improvement in follow-up and reported compliance related to stone prevention strategies.
Journal of Endourology; https://doi.org/10.1089/end.2022.0503
OBJECTIVES: To improve care in patients with large kidney stones using advanced intraoperative imaging techniques to reduce perioperative radiation exposure, improve stone-free rates (SFR), and reduce the number of surgical interventions in a quality improvement (QI) study. PATIENTS AND METHODS: Patients with kidney stones appropriate for percutaneous nephrolithotomy (PCNL) treatment were scheduled into a hybrid operating room for endoscopic surgery (PCNL and/or ureteroscopy (URS)) with intent to perform intraoperative CT (ICT). Imaging was performed using an Artis Zeego Care+Clear™ (Siemens) robotic-armed multi-planar fluoroscopy system (RMPFS) with collimation to the level of the affected kidney(s). After the initial case, the proprietary CARE™ (Combined Applications to Reduce Exposure) protocol was used. When the hybrid room was unavailable, a mobile CT scanner (O-Arm, Medtronics) was used in the traditional room (n=2). RESULTS: 31 ICTs were performed in 23 consecutive patients during endoscopic stone procedures with a median effective radiation dose (ERD) of 1.39 mSv per scan, significantly less than the pre-operative non-contrast CT (12.02 mSv) in the same patients (p<0.001). Longitudinal radiation exposure associated with stone treatment significantly decreased by 83% (15.80 to 2.68 mSv, p<0.001) compared to a similar historical PCNL cohort. Clinically significant residual stones (≥3 mm) were identified at initial ICT in eight patients (35%) and further treated in six patients. One patient had missed residual stones diagnosed 34 days afterwards, which was apparent after reviewing ICT. Thus, final verified SFR was 87% for all stages. Mean number of procedures improved from 1.77 to 1.30 (p=0.05) and rate of post-operative CT scans improved from 82% to 26% (p<0.001). CONCLUSION: Ultra-low-dose (ULD) ICT was demonstrated to simultaneously improve SFR and number of staged treatments, and greatly reduce the perioperative radiation dose for our patients. The findings support the continued use of this modality to benefit all patients with large stones.
Journal of Endourology; https://doi.org/10.1089/end.2022.0557
Purpose: To evaluate the effects of ureteral stent duration prior to ureteroscopy (URS) or shockwave lithotripsy (SWL) on infectious complications, healthcare resource utilization (HCRU), and costs. Materials and Methods: Patients who underwent URS/SWL within 6-months of ureteral stent placement were identified from commercial claims, categorized by time from stent placement to URS (0-15, 16-30, 31-60, and >60 days) or SWL (0-15, 16-30, and >30 days), and followed 1-month post-procedure. The relationship between ureteral stent duration and emergency department (ED) visits, inpatient admissions, infectious complications (pyelonephritis/sepsis), imaging, and costs was evaluated. Results: Mean time to URS (n=9,276 patients) was 21.3±24.4 days and SWL (n=4,689 patients) was 19.0±24.8 days. Compared to patients who underwent URS within 15 days of ureteral stent placement, URS 31-60 days after ureteral stent placement was significantly associated with inpatient admissions ( odds ratio [OR]: 2.56,95% confidence interval (CI): 2.03-3.22); infectious complications (OR: 2.82,95% CI: 2.09-3.81); imaging ( OR: 2.12, 95% CI: 1.82-2.46); and medical costs (OR: 1.49, 95% CI: 1.40-1.58). Compared to patients who underwent SWL within 15 days of ureteral stent placement, SWL more than 30 days after ureteral stent placement was significantly associated with ED visits (OR: 1.79, 95% CI: 1.37-2.34); inpatient admissions (OR: 3.34,95% CI: 2.38-4.69); infectious complications (OR: 3.54,95% CI: 2.20-5.70); imaging (OR: 2.65, 95% CI: 2.23-3.15); and medical costs (OR: 1.45, 95% CI: 1.36-1.54). Conclusions: URS or SWL >30 days after ureteral stent placement increased the likelihood of infectious complications, HCRU, and medical costs.
Journal of Endourology; https://doi.org/10.1089/end.2022.0665
Introduction The volume of surgeries including ureteroscopy (URS) performed for urolithiasis is increasing. This includes for the elderly population. The aim of this study was to evaluate the outcomes of URS in extremely elderly patients and identify any lessons that could be learned for clinical practice and treatment planning. Methods Retrospective analysis was performed of consecutive patients aged 85 years and older undergoing URS between 2010-2022 at our tertiary centre. Uni- and multivariable logistic regression analysis was performed to identify possible risk factors for complications Survival analysis, stratified by age-adjusted Charlson Comorbidity index (ACCI), was performed using Kaplan-Meier method as well as the log-rank test. Results 64 URS procedures were performed on 51 patients (mean age 88, range 85-97). Mean ACCI score was 7 (range 4-13) and most patients were ASA 3 (78%). Mean operative time and hospital stay were 60 minutes (range 15-120) and 2 days (range 0-6), respectively. At 3 month follow up imaging, 92% were stone free (zero fragments). Intra-operative complication rate was 14% and in three cases (5%), early termination of the procedure was necessary. Eight patients (13%) suffered a complication prior to discharge. Eighteen patients (28%) had documented late complications after their surgery. The complication rate when combining early and late adverse events was 41%. One year mortality rate was 23%. Multivariable regression analysis revealed that operation time and ACCI >7 were significant predictors of complications after surgery. Survival probability was significantly worse in those patients with ACCI > 7 (p = 0.0083). Conclusion The morbidity burden of URS in the extremely elderly is higher than for other population groups. Risk should be considered carefully and implementation of ACCI can aid this process. High scores should prompt strong consideration of a conservative approach. Operation time should be kept to a minimum wherever possible.
Journal of Endourology; https://doi.org/10.1089/end.2022.0637
Introduction Water vapour intraprostatic injection (Rezum procedure) for benign prostatic hyperplasia (BPH) is one of the more promising minimally invasive surgical treatment. The 5-year outcomes from the multicentre Randomized Controlled Trial (RCT) demonstrated significant and durable urinary and sexual functional results in selected patients. We assessed the sexual and urinary outcomes of this procedure between patients satisfying inclusion criteria for the RCT and real-life patients. Materials and Methods We prospectively followed all patients with symptomatic BPH who underwent Rezum therapy at 8 institutions and analyzed the functional results. Patients were divided into two groups based on clinical characteristics (“selected patients” satisfied the pre-operative inclusion criteria of the 5-year RCT and the “real-life patients”). The pre-and post-operative data, complications, the presence of antegrade ejaculation, the urinary and sexual outcomes were periodically recorded. Results 426 patients were eligible for the study, 232 of these had the inclusion criteria of the RCT (Group A) and 194 were real life patients (Group B). Patients in group B had higher ASA, score, prostate volume and post-void residual measurement (PVR). No difference was found in terms of pre-operative IPSS, IIEF, Qmax and PSA. Longer operative time and number of more vapour injections were required in group B, with no differences in hospital stay, injection density and complications rate. In both groups all the urinary and sexual outcomes improved with no differences between the two groups. The re-intervention rate at the latest follow-up visit was 2.6% in Group A and 3.1% in group B Conclusions In our series, the water vapour intraprostatic injections is a safe, effective and well tolerated procedure in all type of patients.
Journal of Endourology; https://doi.org/10.1089/end.2022.0478
Purpose. To compare outcomes of robotic-assisted partial nephrectomy (RAPN) and percutaneous tumor ablation (PTA) for completely endophytic renal masses. Methods. Data of patients who underwent RAPN or PTA for treatment of completely endophytic (3 points for “E” domain of R.E.N.A.L. score) were collected from seven high-volume US and European centers. PTA included cryoablation, radiofrequency, or microwave ablation. Baseline characteristics, clinical, surgical, and postoperative outcomes were compared. Recurrence-free survival (RFS) was calculated with Kaplan-Maier. Trifecta was used as arbitrary combined outcome parameter as proxy for treatment “quality”. Multivariable logistic regression model assessed predictors of trifecta failure. Results. 152 patients (RAPN, n=60; PTA, n=92) were included in the analysis. RAPN group was younger (p<.001), had lower ASA score (p=0.002) and higher baseline eGFR (p<.001). No difference in clinical tumor size, clinical T stage, and tumor complexity scores. PTA had significantly lower rate of overall (p<0.001) and minor (p<0.001) complications. ΔeGFR at 1-yr was statistically higher for RAPN (-15.5 vs -3.1 ml/min; p=0.005), no difference in ΔeGFR at last follow-up (p=0.22) was observed. No difference in recurrences (RAPN, n=2; PTA, n=6) and RFS was found (p= 0.154). Trifecta achievement was higher for RAPN but not statistically different (65.3% vs 58.8%; p=0.477). RENAL score resulted predictive of trifecta failure (OR=1.47; CI=1.13-1.90; p=0.004). Conclusions. PTA confirms to be an effective treatment for completely endophytic renal masses, offering low complications, good mid-term functional and oncological outcomes. These outcomes compare favorably to those of RAPN, which remains the preferred NSS option for younger and less comorbid patients.
Journal of Endourology; https://doi.org/10.1089/end.2022.0452
Purpose: We report results of a prospective, multicenter, single-arm study of transurethral vapor ablation (TUVA) of prostate tissue in patients with unilateral, intermediate risk localized prostate cancer. Materials and Methods: Men ≥45 years of age with biopsy confirmed unilateral Gleason Grade Group 2 (GGG2) adenocarcinoma of the prostate, prostate volume 20-80 cc, and PSA ≤15 ng/mL were enrolled. Cystoscopy and transrectal ultrasound (TRUS) guidance were used to deliver ~103°C water vapor to prostate zones for unilateral hemi-gland ablation including destruction of cancers suspected by mpMRI and confirmed by biopsy. The primary outcome was device-related serious adverse events (SAEs). At 7 days and 6 months post-procedure, ablation extent was assessed by mpMRI; MRI/TRUS fusion biopsies were completed at 6 months. Quality of life (QOL) was assessed with validated questionnaires. Results: At baseline 8/15 subjects had positive biopsy cores of GGG1 cancer on the targeted treatment side. All subjects successfully underwent a single hemi-gland TUVA procedure. No SAEs occurred. Grade 2 procedure-related AEs included transient urinary retention (n=4) and erectile (n=1) or ejaculatory dysfunction (n=1). At 7 days, mpMRI revealed complete ablation of 14/17 (82%) lesions visible. At 6 months, biopsies showed no Gleason pattern ≥ 4 or ≥ GGG2 cancer on the treated side of prostates in 13/15 (87%) subjects. Ten of 15 (66.7%) subjects had no evidence of cancer; 2/5 biopsy positive subjects had one core each of 3+4 disease, and 3/5 had one core each of 3+3 disease, all ≤5% involvement. Median prostate size was reduced 40.7% and PSA by 58%. Extensive QOL assessments showed on average no appreciable negative effects of treatment. Conclusions: Initial evidence suggests TUVA is safe in men with intermediate-risk prostate cancer. Preliminary results demonstrate the absence of ≥ GGG2 disease on the treated side in 87% of men and a favorable QOL profile.
Journal of Endourology; https://doi.org/10.1089/end.2022.0516
The Endourological Society, the premier urological society encompassing endourology, robotics and focal surgery, is composed of a diverse group of over 1,300 urologists. However, limited information has been collected about society members. Recognizing this need, a survey was initiated to capture data regarding current member practices, as well as help the society shape the future direction of the organization. Presented herein is the inaugural Endourological Society census report as the beginning of a continued effort for global improvement in the field of endourology. Using a REDCap® database, an email survey was circulated to the membership of the Endourological Society from May through June 2021. Twenty questions were posed, categorizing member data in terms of epidemiology/demographics, practice patterns, member opinions, and future educational preferences. Responses were received from 534 members, representing 40.3% of membership. Data demonstrated that the average age, sex, race, and ethnicity of the typical Society member respondent is a 48-year-old Caucasian male working in the United States, with a mean of 25 years in practice. Retrograde endoscopy and percutaneous nephrolithotomy were identified as the most common practice skills, and 50% of members are involved in robotics. Importantly, the census confirmed that the World Congress of Endourology and Technology (WCET) remains popular with Society members as a means of educational advancement. To sustain and advance the Society, information is required to understand the career interests and future educational desires of its members. This inaugural census provides crucial data regarding its membership and how the Society can achieve continued success and adjust its focus. Future census efforts will expand on the initial findings and stratify the data to elucidate changes in the needs of the Society as a whole. Circulating an annual census will allow for continued improvements in the field of endourology, and ultimately, better care for urologic patients.
Journal of Endourology; https://doi.org/10.1089/end.2022.0404
Introduction Simple prostatectomy (SP) and laser enucleation of the prostate (LEP) are treatments for symptomatic benign prostatic hyperplasia (BPH) in men with large glands (e.g. >80 grams). The decision between the two operations is often dependent on surgeon preference/experience and equipment availability. As the use of minimally invasive techniques, such as robotic assisted simple prostatectomy (RASP), has increased for the treatment of large gland BPH, studies comparing the outcomes and cost of these modalities in a contemporary cohort are lacking. Methods All-payer data from Healthcare Cost and Utilization Project (HCUP) State Databases from Florida (FL), New York (NY), California (CA), and Maryland (MD) from 2016 and 2018 were used to identify adults who underwent SP or LEP for BPH. Patient demographics, facility characteristics, revisit rates, and cost of the index hospitalization were examined. Multivariable logistic and gamma generalized linear regression models were utilized to compare predictors of the operation performed, 30-day revisits, and index hospitalization cost amongst the two operations. Results Of the 2,032 patients in the cohort, 1,067 (46.4%) underwent LEP and 965 (41.9%) underwent SP. On multivariable logistic regression analysis, SP patients were younger, had higher comorbidity scores, and were more likely to be uninsured compared with LEP patients. 30-day revisit rates amongst the operations were equivalent (OR 0.89, 95% CI 0.63-1.27, p=0.05). The mean adjusted cost of the index hospital stay for LEP was significantly greater than that of SP ($7,291.23 vs $6442.32, p=0.04). However, our sub-group analysis examining high-volume centers revealed no significant differences in cost ($6,183.93 vs $5352.97, p=0.1). Conclusions Across the four states examined, SP and LEP were performed with comparable volume and had similar rates of 30-day revisits. SP was less expensive than LEP overall; however, among high-volume facilities the cost of both operations were reduced, such that they were equivalent.
Journal of Endourology; https://doi.org/10.1089/end.2022.0371
Introduction. A considerable proportion of PCNL complications occur during renal puncture. An option to decrease the complications rate is needle modification to make the procedure less traumatic. We aimed to evaluate the effectiveness of the novel MG needle in a pre-clinical study. Materials & methods. We developed an original MG needle based on the Veress needle concept containing an atraumatic (blunt) mandrin connected through a spring to the cannula. The MG needle’s properties were compared with those of the conventional Chiba and Trocar needles in two experiments. In the first experiment, we assessed the force required to puncture the model. In the second experiment, we punctured a porcine kidney and analysed histology after the puncture. Results. We performed a series of 30 punctures of polypropylene block by each needle. The force required to make a puncture with the Chiba needle (6.53 ± 0.87 N) was significantly lower compared to the MG needle (7.1 ± 1.07 N), p=0.027. However, the MG needle turned out to be superior to the Trocar needle (8.71 ± 1.08 N), p=0.001. A total of 15 specimen were obtained after 3 renal punctures were made with each needle. A microscopy of the specimen after puncture with the Chiba and Trocar needles showed small fragments of epithelium and erythrocytes inside the canal with uneven margins where the needle passed. A microscopy of the specimen after puncture with a novel MG needle showed a canal with even margins. No tissue fragments inside the canal were observed. Conclusion. The force required to puncture with the novel MG needle is comparable to conventional needles. According to preclinical experiments, histology of porcine kidney indicates that renal puncture with an MG needle is less traumatic. It may reduce the risk of bleeding, and this should be proved during clinical trials.