Prospective randomized comparison of a combined ultrasonic and pneumatic lithotrite with a standard ultrasonic lithotrite for percutaneous nephrolithotomy

PURPOSE: To compare the efficiency and cost effectiveness of a combined pneumatic and ultrasonic lithotrite (Lithoclast Ultra) and a standard ultrasonic lithotrite, (LUS-1) during percutaneous nephrolithotomy. MATERIALS AND METHODS: In a prospective randomized trial, 30 patients undergoing percutaneous nephrolithotomy (PCNL) were randomized to PCNL with either the combined pneumatic and ultrasonic lithotrite (PUL) or a standard ultrasonic lithotrite (SUL). Patient demographics, stone composition, location, pre- and post-operative stone burden, fragmentation rates, and device failures were compared. RESULTS: There were 13 patients in the PUL group and 17 patients in the SUL group. Stone burden and location were equal. Overall, 64% of the PUL group had hard stones (defined as stones that were either pure or a mixture of cystine [3], calcium oxalate monohydrate [CaOxMono; 2], and calcium phosphate [CaPO4; 2]), and four had soft stones (3 struvite and 1 uric acid [UA]). In the SUL group, there were eight hard stones (5 CaOxMono and 3 CaPO4), and six soft stones (4 calcium oxalate dihydrate [CaOxDi] and 2 UA) (P = 0.51). Stone composition data were unavailable for five patients. Fragmentation time for the PAL was 37 minutes versus 31.5 minutes for the SUL (P = 0.22). Stone retrieval and mean operative times were similar for both groups. There were a total of three (23.1%) device-related problems in the PUL group, and eight (47%) in the SUL group. There was one (7.7%) device malfunction in the PUL group due to probe fracture. There were two (11.7%) device failures in the SUL group; one failure required the device to be reset every 30 minutes, and the second was an electrical failure. Suction tubing obstruction occurred twice (15.3%) in the PUL group and 35.3% in the SU group (P = 0.35). The stone-free rates for the PUL and SUL were 46% and 66.7%, respectively (P = 0.26). CONCLUSION: Although the PUL was more costly, stone ablation and clearance rates were similar for both the combined pneumatic and ultrasonic device and the standard ultrasonic device. When stratified with respect to stone composition, the PUL was more efficient for harder stones, and the SUL was more efficient for softer stones

Comparison of Two Core Biopsy Techniques Before and After Laparoscopic Cryoablation of Small Renal Cortical Neoplasms

A pre-ablation standard biopsy technique resulted in the most accurate pathologic diagnosis for patients undergoing cryoablation for renal cortical neoplasms

An assessment of urologists\u27 training and knowledge of energy-based surgical devices.

OBJECTIVE: To assess surgeons\u27 training and current understanding of existing energy-based surgical instrumentation (ESI), we disseminated an online questionnaire to urology residents, fellows and attending urologists. SUBJECTS AND METHODS: A two part 24-question survey was disseminated to 1000 urology residents, fellows and attending physicians. The first part of the questionnaire assessed the respondents\u27 demographics and education about ESI; the second part evaluated the respondent\u27s knowledge of surgical energy methods and ESI, and was stratified into nine basic- and six advanced-knowledge questions. RESULTS: In all, 136 people (13.6%) viewed the survey and it was completed by 63 (6.3%). Respondents comprised 27 (43%) attending physicians, 14 (22%) minimally-invasive urology fellows and 22 (35%) urology residents. Among participants, 41 (64%) had received no formal didactic training on ESI, and a further 14% of respondents\u27 didactic experience was limited to one lecture. Of the respondents, 70% said that monopolar energy was the mode most often used in surgery. Overall, the participants correctly answered 41% of the questions. Of the nine questions classified as \u27basic\u27 knowledge, respondents correctly answered 49%. Of the six questions classified as \u27advanced\u27 knowledge, 29% were answered correctly. The highest percentage score was obtained by the attending urologists, with a mean (range) score of 41 (29-86)%, followed by the fellows, with a mean score of 39.5 (29-57)%, and then the residents, at 34 (14-64)%. CONCLUSION: Despite widespread and growing use of ESI, there is currently minimal formal training on energy modes and current energy devices being provided to urological surgeons. Both practising and training urologists have a limited understanding of surgical energy modes and of existing ESI

First Prize (tie): Laparoscopic renal cryoablation: efficacy and complications for larger renal masses.

BACKGROUND AND PURPOSE: In expanding our indications for cryoablation of renal cortical neoplasms, there was an increased morbidity with laparoscopic cryoablation. As such, we evaluated our single institution experience with laparoscopic renal cryoablation for complications and oncologic effectiveness as a function of tumor size. MATERIALS AND METHODS: We retrospectively evaluated our prospectively established urologic oncology database and identified 44 laparoscopic cryoablation procedures performed for the management of 51 renal masses. Measured parameters included patient age, tumor size and location, estimated blood loss, complications, and recurrences. Patients were stratified into two groups. In group 1, the patients presented with a maximum tumor diameter less than 3.0 cm. Group 2 patients had a maximum tumor diameter of 3.0 cm or larger. RESULTS: Group 1 included 30 tumors in 23 patients, and group 2 had 21 tumors in 21 patients. The mean tumor size for groups 1 and 2 were 1.8 cm (range 0.7 to 2.8 cm) and 4.0 cm (range 3.0 to 7.5 cm), respectively (P \u3c 0.0001). The average patient age for group 1 was 70.2 and group 2 was 77.6 years (P = 0.04). The mean American Society of Anesthesiologists score was 1.8 and 2.1 for groups 1 and 2, respectively (P = 0.06). There were no complications in group 1. Group 2 had 13 (62%) complications, including two mortalities. The most common complication was blood transfusions at 38%. With a mean follow-up of 9 months, there were no recurrences in group 1. With a mean follow-up of 11 months, there was a single (4.8%) recurrence in group 2. Biopsy histopathology revealed renal cell carcinoma variants in 46.7% in group 1 and 66.7% in group 2, respectively (P = 0.079). CONCLUSION: Renal cryoablation of renal cortical neoplasms smaller than 3.0 cm is effective and safe. Our initial experience, however, demonstrates that cryoablation of larger renal masses may be associated with increased morbidity

Evaluation of bladder insufflants for transurethral cryoablation of the bladder.

OBJECTIVES: To compare helium and carbon dioxide gas insufflation for the creation of pneumocystis during bladder cryoablation in an effort to optimize the technique. METHODS: Nine pigs were divided into 3 groups. The pigs in groups 1, 2, and 3 underwent bladder cryoablation in a normal saline, carbon dioxide gas, and helium gas environment, respectively. Each group underwent 2 freeze-thaw cycles of the bladder dome. The bladder pressure measurements were recorded every 5 seconds throughout the cryoablation procedure. Bladder integrity was evaluated with both cystoscopic and laparoscopic visualization. All pigs were killed at the completion of the procedure, and the bladders were harvested for histopathologic evaluation. RESULTS: All 9 pigs successfully underwent bladder wall cryoablation. Bladder integrity was maintained in all 6 pigs in groups 1 and 3. In group 2, 2 bladder ruptures were documented. All group 2 pigs had a significantly increased bladder pressure during the 2 thaw cycles of the cryoablation procedure, with the peak pressure \u3e70-100 mm Hg before venting of the excess carbon dioxide gas. No intervention was required to stabilize the bladder pressure in groups 1 and 3. The average change in pressure per 5-second interval during both thaw cycles for groups 1, 2, and 3 was 0.16, 6.96, and 0.42 mm Hg/s, respectively (P = .0003). Group 3 showed mild hemorrhage on histologic examination. CONCLUSIONS: The creation of pneumocystis with helium gas reduces sublimation and eliminates the problems of rapidly fluctuating bladder pressures and decreased visibility previously noted with carbon dioxide gas during bladder cryoablation

Inconsistent Surgical Implant Documentation: A Case Study in Total Knee and Hip Arthroplasty

Value-based care initiatives require accurate quantification of resource utilization. This study explores hospital resource documentation performance for total knee and hip arthroplasty (TKA, THA) implants and how this may differ between hospitals. This retrospective study utilized the Premier discharge database, years 2006 to 2020. TKA/THA cases were categorized into 5 tiers based upon the completeness of implant component documentation: Platinum, Gold, Silver, Bronze, Poor. Correlation between TKA and THA documentation performance (per-hospital percentage of Platinum cases) was assessed. Logistic regression analyses measured the association between hospital characteristics (region, teaching status, bed size, urban/rural) and satisfactory documentation. TKA/THA implant documentation performance was compared to documentation for endovascular stent procedures. Individual hospitals tended to have very complete (Platinum) or very incomplete (Poor) documentation for both TKA and THA. TKA and THA documentation performance were correlated (correlation coefficient = .70). Teaching hospitals were less likely to have satisfactory documentation for both TKA ( P  = .002) and THA ( P  = .029). Documentation for endovascular stent procedures was superior compared to TKA/THA. Hospitals’ TKA and THA-related implant documentation performance is generally either very proficient or very poor, in contrast with often well-documented endovascular stent procedures. Hospital characteristics, other than teaching status, do not appear to impact TKA/THA documentation completeness

Tissue response to surgical energy devices.

OBJECTIVES: There is little data available on the effects of energy-based surgical devices (ESD) on tissues other than arteries and veins. As such, we quantified the lateral thermal damage associated with contemporary ESD: the Harmonic ACE, a prototype bipolar device known as the Gyrus Trisector, the Harmonic LCS-C5, and the LigaSure V. METHODS: We divided 24 domestic pigs into 4 groups, 1 group for each ESD tested. Segments of bladder, stomach, small bowel, colon, ureter, peritoneum, arteries, and veins were exposed to each ESD. The tissues were stained with hematoxylin and eosin and evaluated by an experienced pathologist to quantitate the lateral energy spread associated with each device. We measured blade temperatures of each device using the IR-Flex thermal camera. RESULTS: The Trisector developed the lowest mean blade temperature (97.84 degrees F), whereas the LigaSure\u27s was the second lowest (103.14 degrees F). The ACE and LCS-C5 created the highest blade temperatures, measuring 220.5 degrees F and 205.6 degrees F, respectively. The Trisector\u27s mean full thickness and superficial lateral energy damage were 6.3 mm and 7.0 mm, respectively, whereas the Ligasure\u27s was 4.5 mm and 5.9 mm, respectively. For the ACE, however, mean full thickness and superficial energy spread were 2.4 mm and 2.8 mm, respectively, whereas the LCS-C5\u27s were 3.1 mm and 4.3 mm, respectively. CONCLUSIONS: The Harmonic ACE and LCS-C5 produced the least thermal damage in the tissues tested. ESD-associated tissue energy damage is not directly related to blade temperature, but is likely the result of several factors including blade temperature, transection time, tissue properties, and the vascularity of each transected tissue