Holmium Laser Enucleation of the Prostate

Introduction: Holmium laser enucleation of the prostate (HoLEP) offers superior voiding outcomes to traditional transurethral resection and less morbidity than open simple prostatectomy. Likewise, HoLEP has been determined to result in excellent outcomes regardless of gland size. We present a step-by-step surgical approach to HoLEP describing both the traditional enucleation technique and a modified “top-down” surgical technique. Materials and Methods: In this video, two techniques are presented that were performed by two (A.E.K., J.E.L.) surgeons at our institution. Results: In the examples of the two enucleation techniques mentioned, outcomes are similar with regard to surgical and functional outcomes. Conclusions: HoLEP as a treatment for BPH with associated lower urinary tract symptoms (LUTS) results in excellent patient outcomes and can be offered to patients regardless of prostate volume

Best practice in the management of benign prostatic hyperplasia in the patients requiring anticoagulation

In today's aging population, urologists are often treating older patients with multiple comorbidities. Lower urinary tract symptoms from benign prostate hyperplasia (LUTS/BPH) is a common condition that affects men, with increasing prevalence as men age. In a subset of patients, the symptoms are too severe or refractory to medical therapy and, therefore, surgical therapy is required to improve their LUTS. The use of medical therapy often delays the need to intervene surgically in men with LUTS/BPH and with advances in the management of cardiovascular disease, urologists are increasingly encountering more men requiring BPH surgery on chronic anticoagulation therapy. The decision of when to offer surgical intervention and how to manage anticoagulation medication in the perioperative setting is a dilemma with which surgeons are dealing with increasing frequency. The purpose of this review is to clarify the optimal approach to the surgical patient with LUTS/ BPH requiring anticoagulation therapy

Cost-effectiveness analysis of the management of distal ureteral stones in children

Objective To determine the most cost-effective approach to the management of distal ureteral stones in children given the potential for recurrent renal colic during a trial of passage versus potential stent discomfort and complications of ureteroscopy. Methods We developed a decision tree to project costs and clinical outcomes associated with observation, medical explusive therapy (MET), and ureteroscopy for the management of an index patient with a 4mm distal ureteral stone. We determined which strategy would be least costly and offer the most pain-free days within 30 days of diagnosis. We performed a one-way sensitivity analysis on the probability of successful stone passage with MET. We obtained probabilities from the literature and costs from the 2016 Pediatric Health Information System Database. Results Ureteroscopywas the costliest strategy but maximized the number of pain-free days within 30 days of diagnosis ($5,282/29 pain-free days). MET was less costly than ureteroscopybut also less effective ($615/21.8 pain-free days). Observation cost more than MET and was also less effective ($2,139/15.5 pain-free days). The one-way sensitivity analysis on the probability of successful stone passage with MET demonstrated that ureteroscopyalways has the highest net monetary benefits value and is therefore the recommended strategy given a fixed WTP. Discussion Using a rigorous decision-science approach, we found that ureteroscopy is the recommended strategy in children with small distal ureteral stones. Although it cost more than MET, it resulted in more pain-free days in the first 30 days following diagnosis given the faster resolution of the stone episode

A Survey of Morcellator Preference and Cost Comparison of the Lumenis VersaCut and Wolf Piranha Morcellators

Objective To evaluate operating room (OR) costs associated with the 2 available morcellators in the United States in a matched cohort and to determine benign prostatic hyperplasia surgeon's morcellator preference. Materials and Methods Patients from 2013, the last year our institution exclusively used the VersaCut device, were matched 1:1 with the most recent patient cohort, utilizing the Wolf Piranha morcellator. Cost of morcellation including the expense of OR time and disposable instrument costs were calculated. A survey to the Endourological Society e-mail listserv was sent to determine morcellator preference. Results We identified 142 patients who underwent holmium laser enucleation of the prostate in 2013. When compared with the VersaCut group, morcellation efficiency (4.4 vs 7.0 g/min, P <.01) and expense of OR time ($1420.80 vs$992.21, P <.005) both favored the Piranha morcellator system even when the costs of disposable instruments were factored into the analysis ($1338.81 vs$1637.50, P <.05). A total of 126 urologists responded to the survey. Of these, 56 (44.5%) perform transurethral prostate enucleations, which included 48 (86%) holmium. More endourologists use the VersaCut (n = 33, 59%) than the Piranha (n = 24, 43%) morcellator. Qualities that impacted the preference of morcellator included the preferred device is safer, faster, easier to use, reusable, and less expensive. Conclusion We identified a significant improved efficiency and improved cost savings utilizing the Piranha morcellator even when controlling for disposable costs. Of the endourologists who responded to the survey, less than half perform transurethral enucleation. Morcellator preference is largely based on safety, efficiency, and ease of use, whereas cost and reusablility were of lesser importance

Comparison of newly optimized Moses technology vs standard holmium: YAG for endoscopic laser enucleation of the prostate

Introduction: The purpose of this study was to describe our initial experience of using a newly optimized Moses technology that is part of the second-generation Moses platform specifically designed for holmium laser enucleation of the prostate (M2-HoLEP) and compare it with patients undergoing HoLEP using standard holmium:YAG technology (S-HoLEP). Materials and Methods: We retrospectively collected data on patients who underwent M2-HoLEP and compared it with the last 50 patients in whom we performed S-HoLEP. Specifically, we compared preoperative symptom scores for lower urinary tract symptoms (LUTS) and erectile dysfunction (ED), preoperative objective voiding metrics, as well as intraoperative characteristics, perioperative characteristics, postoperative complications, postoperative symptom scores for LUTS and ED, and postoperative objective voiding metrics. Additionally, we evaluated the ability for same-day discharge following surgery in the M2-HoLEP group. Results: We included 104 total patients for analysis. We compared the first 54 patients undergoing M2-HoLEP with 50 patients undergoing S-HoLEP. Both groups had similar age, body mass index, use of anticoagulation medication, LUTS and ED scores, and objective voiding metrics. Operations performed with M2-HoLEP had faster mean hemostasis time (8.7 vs 10.6 ± 6 minutes, p = 0.03) as well as hemostasis rate (0.13 vs 0.30 min/g, p = 0.01). Same-day discharge was achieved in 69.4% of patients in the M2-HoLEP group. Postoperatively, both groups also had similar and low rates of urinary retention and complications. At follow-up, both groups had similar symptom scores for LUTS and ED, as well as similar objective voiding metrics. Conclusions: The newly optimized Moses pulse modulation technology is safe and efficient for the treatment of benign prostate hyperplasia. Such technologic improvements in the laser have greatly enhanced the feasibility of same-day discharge of patients undergoing HoLEP

The ability of a limited metabolic assessment to identify pediatric stone formers with metabolic abnormalities

Introduction American Urological Association guidelines recommend a urinary metabolic evaluation after the first stone event in all pediatric stone patients. Prior studies identified hypercalciuria and urine hypovolemia as the most common abnormalities in children with urolithiasis. Recent data suggest that hypocitraturia is most prevalent. It was hypothesized that a limited evaluation would detect the majority of clinically significant metabolic abnormalities in pediatric stone formers. Material and methods A retrospective analysis of all children (<18 years of age) with renal/ureteral calculi evaluated at the study institution from 2005 to 2015 was performed. Children with ≥ one 24-h urinary metabolic profile after a clinical visit for renal/ureteral calculi were included. Those with bladder stones and those with undercollection or overcollection or missing urinary creatinine were excluded. Demographics and data from the first urinary metabolic profile and stone analyses were collected. The sensitivity, specificity, and positive and negative predictive value (NPV) of a limited urinary metabolic evaluation consisting of four parameters (24-h calcium, citrate, and oxalate and low urinary volume) were compared to a complete urinary metabolic profile. The number and type of metabolic abnormalities that would have been missed with this limited evaluation weredetermined. Results Of 410 patients, 21 were excluded for age ≥18 years, 13 for bladder stones, 248 for overcollections, 38 for undercollections, and 10 for missing creatinine. This left 80 patients for inclusion: median age 11.4 years, 60% female, and 96.3% white. Of the entire cohort, 69.6% had hypocitraturia, 52.5% had low urine volume, and 22.5% had hypercalciuria. Sensitivity was 87.5%. Specificity could not be calculated because no patients had a normal complete metabolic evaluation. The NPV was zero, and the positive predictive value was 100%, but these are artifacts resulting from the absence of patients with a normal complete metabolic evaluation. Of the 80 patients, 10 had at least one abnormality missed by a limited metabolic evaluation (Table 1). The missed abnormalities were high pH (n = 6), abnormal 24-h phosphorus (low in 1 patient and high in 1 patient), low 24-h magnesium (n = 3), low 24-h potassium (n = 3), and high 24-h sodium (n = 4). Discussion A limited urinary metabolic evaluation would have detected the vast majority of clinically significant metabolic abnormalities in the study sample. Approximately two-thirds of the study patients submitted inadequate 24-h urine specimens. Conclusions A simplified approach to metabolic evaluation in first-time stone formers with a stone analysis available was proposed. This streamlined approach could simplify the metabolic evaluation and reduce health care costs

Understanding, justifying, and optimizing radiation exposure for CT imaging in nephrourology

An estimated 4-5 million CT scans are performed in the USA every year to investigate nephrourological diseases such as urinary stones and renal masses. Despite the clinical benefits of CT imaging, concerns remain regarding the potential risks associated with exposure to ionizing radiation. To assess the potential risk of harmful biological effects from exposure to ionizing radiation, understanding the mechanisms by which radiation damage and repair occur is essential. Although radiation level and cancer risk follow a linear association at high doses, no strong relationship is apparent below 100 mSv, the doses used in diagnostic imaging. Furthermore, the small theoretical increase in risk of cancer incidence must be considered in the context of the clinical benefit derived from a medically indicated CT and the likelihood of cancer occurrence in the general population. Elimination of unnecessary imaging is the most important method to reduce imaging-related radiation; however, technical aspects of medically justified imaging should also be optimized, such that the required diagnostic information is retained while minimizing the dose of radiation. Despite intensive study, evidence to prove an increased cancer risk associated with radiation doses below ~100 mSv is lacking; however, concerns about ionizing radiation in medical imaging remain and can affect patient care. Overall, the principles of justification and optimization must remain the basis of clinical decision-making regarding the use of ionizing radiation in medicine

Using Low-calorie Orange Juice as a Dietary Alternative to Alkali Therapy

Purpose: The pursuit of a dietary source to increase urine pH and citrate in stone formers has been ongoing for more than 30 years. Early evidence showed that orange juice (OJ) contains alkali and citrate but high sugar and ascorbic acid content limited the use of OJ as a viable daily source of alkali. Recently, novel low calorie OJs have emerged and could potentially be a better option. Methods: Beverages with high concentrations of alkali citrate and malate were identified using ion chromatography. Two low calorie OJ beverages, in addition to Crystal Light Lemonade (CLLB) were chosen. Healthy volunteers (5 men, 5 women) drank 1L of OJ or CLLB with 1L water daily for 7 days and then completed a 24-hour urinalysis. A washout week was instituted between trial weeks. The study design is a prospective randomized cross over control trial. A paired analysis using comparison of means was used to evaluate low calorie OJ and CLLB. Volunteers had no prior history of kidney stones and maintained a journal with beverage compliance, side effect, and dietary consumption data. Results: Tropicana 50 (TRP50), Kroger low calorie OJ (KLCO) and CLLB were found to have a total alkali content of 56.60, 47.9, and 17.3 mEq/L, respectively, based on ion chromatography. Consumption of all three beverages raised urinary citrate (116.6 [-118 to 373, 177.9 [-3 to 359], 155.6 [-4 to 237] mg/d 95% CI) and urinary pH (0.25 [0.08-0.53], 0.74 [0.41-1.07 p<0.05], 0.25 [0.25-0.64]) respectively, compared to water phase. Based on volunteer journal entries , TRP50 had the most side effects (90% participants) felt to be a result of the artificial sweetener (Stevia ®). Conclusion: Low-calorie orange juice, and to a lesser extent CLLB, have alkali and citrate based on ion chromatography. Daily consumption, by healthy volunteers of KLCO can raise urinary pH

Stone free outcomes of flexible ureteroscopy for renal calculi utilizing CT imaging

Objectives To assess stone free rates following URS for renal calculi at our institution using low dose renal only CT (LDCT). Methods A retrospective review of patients undergoing flexible URS for renal stones only with subsequent CT scan within 3 months. Meticulous basketing of all stone fragments was performed whenever possible. A “true” zero fragment SFR was determined by reviewing the CT scan and radiologist's report. Patients with nephrocalcinosis (as determined by visual inspection of papilla at the time of URS) were assigned the “stone free” category. Results Flexible URS was performed in 288 renal units of 214 patients with renal calculi from 2013 to 2016. Median pre-operative stone size was 6.2mm with the average kidney containing 6.4 stones. An access sheath was used in 92% of cases. A total of 73% (209/288) renal units were completely stone free by CT assessment. Patients with residual fragments were as follows: 1mm in 2% (7/288), 2-4 mm in 16% (46/288), and >4 mm in 9% of kidneys (26/288). Conclusions The true stone free rate in patients undergoing flexible URS for renal calculi utilizing active basketing of fragments as determined by strict CT assessment was 73%. In patients with residual fragments, the majority are 2-4 mm in size making URS a treatment option for renal calculi with excellent stone free results

Initial collection of an inadequate 24-hour urine sample in children does not predict subsequent inadequate collections

Introduction Approximately half of adult stone formers submit specimens that are either under or over collections as determined by 24-h creatinine/kg. Previously identified predictors of inadequate collection in adults include female sex, older age, higher body mass index (BMI), vitamin D supplementation, and weekday collection. Objective The objective of this study is to determine risk factors for inadequate 24-h urinary specimen collection in the pediatric population. Study design A retrospective analysis of all children (<18 years of age) with renal and/or ureteral calculi evaluated at the study tertiary care pediatric center from 2005 to 2015 was performed. Those who had at least one 24-h urinary metabolic profile after a clinical visit for kidney and/or ureteral stones were included; children with bladder stones were excluded. Adequate collections had a urine creatinine of 10–15 mg/kg/24 h. A bivariate analysis of potential factors associated with inadequate collection of the initial urinary metabolic profile, including child demographics, parental socio-economic factors, history of stone surgery, and weekday vs. weekend urine collection, was performed. A mixed-effects logistic regression, controlling for correlation of specimens from the same patient, was also performed to determine whether an initial inadequate collection predicted a subsequent inadequate collection. Results Of 367 patients, 80 had an adequate collection (21.9%): median age, 13 years (interquartile range, 8–16); 61.1% female; 93.5% white; 19.5% obese; and 13.0% overweight. No parental or child factors were associated with inadequate collection (Summary Table). Of inadequate collections, more than 80% were over collections. In the 175 patients with more than one 24-h urinary specimen collection, the effect of an initial inadequate collection on subsequent inadequate collections was not significant after controlling for the correlation of samples from the same patient (p = 0.8). Discussion Any parental or child factors associated with the collection of inadequate 24-h urine specimens in children were not found. An initial inadequate collection does not predict subsequent inadequate collections. It was surprising that >80% of the inadequate collections were over collections rather than under collections. Possible explanations are that children collected urine samples for longer than the 24-h period or that stone-forming children produce more creatinine per 24-h period than healthy children due to hyperfiltration. Conclusion Inadequate collections are very common, and the risk factors for them are unclear. A repeat collection would be suggested if the first is inadequate. Further studies must be planned to explore barriers to accurate specimen collection using qualitative research methodology