Laser suction effect: Zero-basket technique for dusting ureteral stones with pulse modulation

Introduction and Objectives: In the laser suction effect, collapse of the vapor bubble leads to a change in pressure which produces a suction effect on the stone. In the Venturi effect, a vacuum is produced in front of the stone as the endoscope is withdrawn and the irrigating fluid helps push the stone out. During semi-rigid ureteroscopy (URS) and laser lithotripsy, it may be possible to use a combination of these two phenomena to help attract and evacuate stone fragments. In this video, we demonstrate our technique of dusting ureteral stones using pulse modulation for laser suction effect, along with Venturi effect, for evacuation of fragments without the need for basket retrieval. Materials and Methods: We present three patients with distal to mid ureteral stones (7 to 12 mm) undergoing semi-rigid URS and laser lithotripsy. Dusting settings of low pulse energy and moderate frequency with pulse modulation (Moses Contact mode) using a 230 µm core fiber was used to treat the stones (P120Moses, Lumenis). Each stone was able to be broken into dust and small fragments, which were sequentially evacuated out of the ureter. Results: Principles for this technique include: (1) Patient in reverse Trendelenburg position, (2) Semi-rigid ureteroscopy, (3) Safety guidewire, (4) Irrigation modulated by surgeon, (5) Low power (\u3c10 W) 0.3 J x 30 Hz dusting settings, (6) Pulse modulation (Moses Contact mode) to reduce retropulsion and keep fragments close to fiber tip for laser suction effect, (7) Activating laser on center of stone, (8) Advancing scope beyond fragments and withdrawal of scope for Venturi effect and fragment expulsion, (9) Manipulation of guidewire to help tease fragments out of ureteral orifice. In all three patients, the stone could be dusted and fragments expelled without the need for basketing. There were no complications and follow-up imaging showed no hydronephrosis or residual fragments. Conclusions: We present a method of dusting stones in the ureter with the semirigid ureteroscope using low pulse energy (0.3 J), and moderate frequency (30 Hz). Use of pulse modulation aids this approach, by reducing retropulsion and keeping fragments close to the scope while withdrawing it out of the ureter. A combination of fluid irrigation and scope withdrawal helps evacuate fragments from the ureter without the use of a basket

The Use of Social Media in Endourology: An Analysis of the 2013 World Congress of Endourology Meeting

Objective: To examine the use of social media within Endourology by reporting on its utilization during the 2013 World Congress of Endourology (WCE) annual meeting. Materials and Methods: Two social media platforms were analyzed for this study: Twitter (San Francisco, CA) and LinkedIn (Mountain View, CA). For Twitter, a third-party analysis service (Tweetreach) was used to quantitatively analyze all tweets with the hashtags #WCE2013 and #WCE13 during a 7-day period surrounding the WCE. Two reviewers independently classified tweet content using a predefined Twitter-specific classification system. Tweet sentiment was determined using sentiment analysis software (Semantria, Inc., Amherst, MA). Finally, the penetration of Twitter and LinkedIn within the WCE faculty was assessed by means of a manual search. Results: During the study period, 335 tweets had the hashtag #WCE2013 or #WCE13. Content originated from 68 users resulting in a mean of 47 tweets/day and 4.9 tweets/contributor. Conference-related tweets had a reach of 38,141 unique Twitter accounts and an online exposure of 188,629 impressions. Physicians generated the majority of the content (63%), of which 55.8% were not attending the meeting. More tweets were informative (56.7%) versus uninformative (43.3%), and 17.9% had links to an external web citation. The mean sentiment score was 0.13 (range ?0.90 to 1.80); 13.1%, 57.0%, and 29.9% of tweets were negative, neutral, and positive in sentiment, respectively. Of 302 WCE meeting faculty, 150 (49.7%) had registered LinkedIn accounts while only 52 (17.2%) had Twitter accounts, and only 19.2% tweeted during the meeting. Conclusions: Despite a relatively low number of Twitter users, tweeting about the WCE meeting dramatically increased its online exposure with dissemination of content that was mostly informative including engagement with physicians not attending the conference. While half of faculty at WCE 2013 had LinkedIn accounts, their social media footprint in Twitter was limited.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/140078/1/end.2014.0329.pd

Understanding the Use of Prostate Biopsy Among Men with Limited Life Expectancy in a Statewide Quality Improvement Collaborative

BACKGROUND: The potential harms of a prostate cancer (PCa) diagnosis may outweigh its benefits in elderly men. OBJECTIVE: To assess the use of prostate biopsy in men with limited life expectancy (LE) within the practices comprising the Michigan Urological Surgery Improvement Collaborative (MUSIC). DESIGN, SETTING, AND PARTICIPANTS: MUSIC is a consortium of 42 practices and nearly 85% of the urologists in Michigan. From July 2013 to October 2014, clinical data were collected prospectively for all men undergoing prostate biopsy. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: We calculated comorbidity-adjusted LE in men aged ≥66 yr and identified men with(limited LE) undergoing a first biopsy. Our LE calculator was not designed for men agedyr; thus these men were excluded. Multivariable models estimated the proportion of all biopsies performed for men with limited LE in each MUSIC practice, adjusting for differences in patient characteristics. We also evaluated what treatments, if any, these patients received. RESULTS AND LIMITATIONS: Among 3035 men aged ≥66 yr undergoing initial prostate biopsy, 60% had none of the measured comorbidities. Overall, 547 men (18%) had limited LE. Compared with men with a longer LE, these men had significantly higher prostate-specific antigen levels and abnormal digital rectal examination findings. The adjusted proportion of biopsies performed for men with limited LE ranged from 3.8% to 39% across MUSIC practices (p \u3c 0.001). PCa was diagnosed in 69% of men with limited LE; among this group, 74% received any active treatment. Of these men, 46% had high-grade cancer (Gleason score 8-10). CONCLUSIONS: Among a large and diverse group of urology practices, nearly 20% of prostate biopsies are performed in men with limited LE. These data provide useful context for quality improvement efforts aimed at optimizing patient selection for prostate biopsy. PATIENT SUMMARY: In this report, nearly 2 of every 10 men undergoing prostate biopsy had a life expectancy (LE)biopsy

Statin Use and Risk of Sepsis After Percutaneous Nephrolithotomy

Purpose: To examine the association between statin medication use and sepsis risk after percutaneous nephrolithotomy (PCNL). Materials and Methods: Using medical claims data, we identified working-age adults with urinary stone disease who were treated with PCNL. Among this cohort, we determined which patients had a prescription fill for a statin agent that encompassed their surgery date. We then fitted logistic regression models to examine for differences in rates of postoperative sepsis between statin users and nonusers. In addition, we evaluated the frequency of nonfebrile urinary tract infections (UTIs) and intensive care unit (ICU) services utilization and hospital length of stay (LOS) as a function of statin use. Results: During the study period, at total of 2046 patients underwent PCNL, 382 (18.7%) of whom had a prescription fill for a statin agent preceding their surgery. The overall rate of sepsis in this population was 3.8%. After adjusting for patient health status and sociodemographic factors, the rate of postoperative sepsis was comparable between statin users and nonusers (5.3% vs 3.5%, respectively; P=0.105). In addition, UTI and ICU utilization rates did not relate to statin use (P>0.05 for all associations). Adjusted hospital LOS was shorter among statin users, but the difference was clinically trivial (3.6 vs 4.1 days; P=0.007). Conclusions: Statin use is not associated with reductions in postoperative sepsis, nonfebrile UTIs, ICU utilization, or hospital LOS after PCNL. To increase the safety of PCNL, urologists will have to consider other processes of care (e.g., clinical care pathways).Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/140081/1/end.2015.0042.pd

Contemporary Practice Patterns of Flexible Ureteroscopy for Treating Renal Stones: Results of a Worldwide Survey

Introduction: Flexible ureteroscopy (fURS) is increasingly used in the treatment of renal stones. However, wide variations exist in technique, use, and indications. To better inform our knowledge about the contemporary state of fURS for treating renal stones, we conducted a survey of endourologists worldwide. Methods: An anonymous online questionnaire assessing fURS treatment of renal stones, consisting of 36 items, was sent to members of the Endourology Society in October 2014. Responses were collected through the SurveyMonkey system over a 3-month period. Results: Questionnaires were answered by 414 surgeons from 44 countries (response rate 20.7%). U.S. surgeons accounted for 34.4% of all respondents. fURS was routinely performed in 80.0% of institutions, with 40.0% of surgeons performing >100 cases/year. Respondents considered fURS to be first-line therapy for patients with renal stones 2?cm. Basket displacement for lower pole stones was routinely performed by 55.8%. Ureteral access sheaths (UAS) were preferred for every case by 58.3%. Respondents frequently utilized high-power lasers and dusting techniques. Criteria for determining stone-free rate were defined as zero fragments or residual fragment (RF) <1, <2, <3, and <4?mm by 30.9%, 8.9%, 31.5%, 15.8%, and 11.2% of respondents, respectively. Conclusion: The overwhelming majority of endourologists surveyed consider fURS as a first-line treatment modality for renal stones, especially those <2?cm. Use of UAS, high-power holmium lasers, and dusting technique has become popular among practitioners. When defining stone free after fURS, the majority of endourologists used a zero fragment or RF <2?mm definition.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/140082/1/end.2015.0260.pd

Evaluation of a needle disinfectant technique to reduce infection‐related hospitalisation after transrectal prostate biopsy

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/142074/1/bju13982_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/142074/2/bju13982.pd

Laser Ablation Efficiency, Laser Ablation Speed, and Laser Energy Consumption During Lithotripsy: What Are They and How Are They Defined? A Systematic Review and Proposal for a Standardized Terminology

Context Laser performance for lithotripsy is currently reported using units of measurement such as J/mm3, mm3/J, mm3/s, s/mm3, and mm3/min. However, there are no current standardized definitions or terminology for these metrics. This may lead to confusion when assessing and comparing different laser systems. Objective The primary objective was to summarize outcome values and corresponding terminology from studies on laser lithotripsy performance using stone volume in relation to time or energy. The secondary objective was to propose a standardized terminology for reporting laser performance metrics. Evidence acquisition A systematic review of the literature was conducted using the search string (“j*/mm3” OR “mm3/j*” OR “mm3/s*” OR “s*/mm3” OR “mm3/min*” OR “min*/mm3” AND “lithotripsy”) on Scopus, Web of Science, Embase, and PubMed databases. Study selection, data extraction, and quality assessment were performed independently by two authors. Evidence synthesis A total of 28 studies were included, covering holmium:yttrium-aluminum-garnet (Ho:YAG), MOSES, and thulium fiber laser (TFL) technologies. Laser energy consumption values reported for the studies ranged from 2.0 – 43.5 J/mm3 in vitro and from 2.7 – 47.8 J/mm3 in vivo, translating to laser ablation efficiency of 0.023 – 0.500 mm3/J and 0.021 – 0.370 mm3/J, respectively. Laser ablation speeds ranged from 0.3 – 8.5 mm3/s in vivo, translating to lasing time consumption of 0.12 – 3.33 s/mm3. Laser efficacy ranged from 4.35 – 51.7 mm3/min in vivo. There was high heterogeneity for the terminology used to describe laser performance for the same metrics. Conclusions The range of laser performance metric values relating stone volume to energy or time is wide, with corresponding differing terminology. We propose a standardized terminology for future studies on laser lithotripsy, including laser ablation efficiency (mm3/J), laser ablation speed (mm3/s), and laser energy consumption (J/mm3). Laser efficacy (mm3/min) is proposed as a broader term that is based on the total operative time, encompassing the whole technique using the laser. Patient summary We reviewed studies to identify the units and terms used for laser performance when treating urinary stones. The review revealed a wide range of differing units, outcomes, and terms. Therefore, we propose a standardized terminology for future studies on laser stone treatment. Keywords UreteroscopyPercutaneous nephrolithotomyLaserStone diseaseLithotripsyPerformanceUrolithiasi

Morbidity and Mortality After Benign Prostatic Hyperplasia Surgery: Data from the American College of Surgeons National Surgical Quality Improvement Program

Background and Purpose: With the aging population, it is becoming increasingly important to identify patients at risk for postsurgical complications who might be more suited for conservative treatment. We sought to identify predictors of morbidity after surgical treatment of benign prostatic hyperplasia (BPH) using a large national contemporary population-based cohort. Methods: Relying on the American College of Surgeons National Surgical-Quality Improvement Program (ACS-NSQIP; 2006?2011) database, we evaluated outcomes after transurethral resection of the prostate (TURP), laser vaporization of the prostate (LVP), and laser enucleation of the prostate (LEP). Outcomes included blood-transfusion rates, length of stay, complications, reintervention rates, and perioperative mortality. Multivariable logistic-regression analysis evaluated the predictors of perioperative morbidity and mortality. Results: Overall, 4794 (65.2%), 2439 (33.1%), and 126 (1.7%) patients underwent TURP, LVP, and LEP, respectively. No significant difference in overall complications (P=0.3) or perioperative mortality (P=0.5) between the three surgical groups was found. LVP was found to be associated with decreased blood transfusions (odds ratio [OR]=0.21; P=0.001), length of stay (OR=0.12; P30%) levels were the only predictors of lower overall complications and perioperative mortality. Conclusions: All three surgical modalities for BPH management were found to be safe. Advanced age and non-Caucasian race were independent predictors of adverse outcomes after BPH surgery. In patients with these attributes, conservative treatment might be a reasonable alternative. Also, preoperative hematocrit and albumin levels represent reliable predictors of adverse outcomes, suggesting that these markers should be evaluated before BPH surgery.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/140378/1/end.2013.0805.pd