Alana Desai

Splenic Injury During Percutaneous Nephrolithotomy: A Case Report with Novel Management Technique

We describe a case of a splenic injury caused by a transsplenic percutaneous nephrostomy tract. The case was completed without incident and the nephrostomy tube was noted to traverse the spleen on routine postoperative imaging. This rare complication was managed by deposition of Gelfoam((R)) pledgets along the transsplenic nephrostomy tract and placement of a ureteral stent. This novel management technique has not been previously described in the literature and was successful in the conservative treatment of the uncommon complication of splenic injury during percutaneous nephrolithotomy.

Antibody-Based Therapy for Enterococcal Catheter-Associated Urinary Tract Infections

ABSTRACT Gram-positive bacteria in the genus Enterococcus are a frequent cause of catheter-associated urinary tract infection (CAUTI), a disease whose treatment is increasingly challenged by multiantibiotic-resistant strains. We have recently shown that E. faecalis uses the Ebp pilus, a heteropolymeric surface fiber, to bind the host protein fibrinogen as a critical step in CAUTI pathogenesis. Fibrinogen is deposited on catheters due to catheter-induced inflammation and is recognized by the N-terminal domain of EbpA (EbpANTD), the Ebp pilus’s adhesin. In a murine model, vaccination with EbpANTD confers significant protection against CAUTI. Here, we explored the mechanism of protection using passive transfer of immune sera to show that antisera blocking EbpANTD-fibrinogen interactions not only is prophylactic but also can act therapeutically to reduce bacterial titers of an existing infection. Analysis of 55 clinical CAUTI, bloodstream, and gastrointestinal isolates, including E. faecalis, E. faecium, and vancomycin-resistant enterococci (VRE), revealed a diversity of levels of EbpA expression and fibrinogen-binding efficiency in vitro. Strikingly, analysis of 10 strains representative of fibrinogen-binding diversity demonstrated that, irrespective of EbpA levels, EbpANTD antibodies were universally protective. The results indicate that, despite diversity in levels of fibrinogen binding, strategies that target the disruption of EbpANTD-fibrinogen interactions have considerable promise for treatment of CAUTI. IMPORTANCE Urinary catheterization is a routine medical procedure, and it has been estimated that 30 million Foley catheters are used annually in the United States. Importantly, placement of a urinary catheter renders the patient susceptible to developing a catheter-associated urinary tract infection, accounting for 1 million cases per year. Additionally, these infections can lead to serious complications, including bloodstream infection and death. Enterococcus strains are a common cause of these infections, and management of enterococcal infections has been more difficult in recent years due to the development of antibiotic resistance and the ability of strains to disseminate, resulting in a major threat in hospital settings. In this study, we developed an antibiotic-sparing treatment that is effective against diverse enterococcal isolates, including vancomycin-resistant enterococci, during catheter-associated urinary tract infections. Urinary catheterization is a routine medical procedure, and it has been estimated that 30 million Foley catheters are used annually in the United States. Importantly, placement of a urinary catheter renders the patient susceptible to developing a catheter-associated urinary tract infection, accounting for 1 million cases per year. Additionally, these infections can lead to serious complications, including bloodstream infection and death. Enterococcus strains are a common cause of these infections, and management of enterococcal infections has been more difficult in recent years due to the development of antibiotic resistance and the ability of strains to disseminate, resulting in a major threat in hospital settings. In this study, we developed an antibiotic-sparing treatment that is effective against diverse enterococcal isolates, including vancomycin-resistant enterococci, during catheter-associated urinary tract infections.

Long-Term Impact of Laparoscopic Cyst Decortication on Renal Function, Hypertension and Pain Control in Patients with Autosomal Dominant Polycystic Kidney Disease

PURPOSE Cyst proliferation in patients with autosomal dominant polycystic kidney disease is associated with renal failure, hypertension and pain. We examined the long-term impact of laparoscopic cyst decortication on renal function, hypertension and pain control in patients with adult dominant polycystic kidney disease presenting with refractory pain. MATERIALS AND METHODS Between 1994 and 2003, 37 patients with adult dominant polycystic kidney disease underwent laparoscopic cyst decortication at Barnes-Jewish Hospital. A total of 19 patients (4 male, 15 female) with at least 3-year followup were included in the study. Renal function was evaluated using the CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) estimated glomerular filtration rate formula. End stage renal disease was defined as progression to transplant, dialysis or stage 5 chronic kidney disease. Hypertension was evaluated using the antihypertensive therapeutic index. Pain assessment was based primarily on a telephone questionnaire. RESULTS At a mean followup of 10.9 years (range 6.4 to 16.9), 67% of evaluable patients reported more than 50% improvement in pain. Ten patients had progression to end stage renal disease--3 dialysis, 6 transplant, and 1 chronic kidney disease stage 5. Two patients had stage 5 chronic kidney disease at initial presentation. A comparison of preoperative estimated glomerular filtration rate between patients with and those without end stage renal disease revealed a lower preoperative estimated glomerular filtration rate in the former group (43.4 vs 75.4 ml/minute/1.73 m(2), p = 0.01). Of the patients 53% had an improved or stable antihypertensive therapeutic index at last followup, although no improvement in mean overall antihypertensive therapeutic index was noted (4.7 pre-laparoscopic cyst decortications vs 7.0 post-laparoscopic cyst decortications, p = 0.28). CONCLUSIONS Durable pain relief but not hypertension control was seen at 10-year followup. Preoperative estimated glomerular filtration rate is a strong predictor of post-laparoscopic cyst decortication progression to end stage renal disease. A cautious approach with laparoscopic cyst decortication should be taken in patients with poor preoperative renal function.

Open Versus Laparoscopic Retroperitoneal Lymph Node Dissection : Assessing Adequacy of Dissection in a Porcine Model

BACKGROUND AND PURPOSE Laparoscopic retroperitoneal lymph node dissection (L-RPLND) is emerging as a viable alternative to traditional open retroperitoneal lymph node dissection (O-RPLND). Despite numerous reports confirming clinical oncologic equivalency between the two approaches, however, concerns still remain over the adequacy of laparoscopic dissection. We therefore sought to compare the completeness of dissection between O-RPLND and L-RPLND in a porcine model. MATERIALS AND METHODS Fourteen domestic swine were divided into two equivalent groups. Both groups underwent bilateral retroperitoneal lymph node dissection, approximating templates used in human dissection. In one group, the procedure was performed through an open midline incision, while the other group underwent completely laparoscopic dissection. Tissue was independently analyzed by a pathologist, who recorded lymph node yield based on microscopic evaluation. RESULTS All animals in the L-RPLND group underwent successful procedures, without the need for conversion. Two open procedures were aborted because of hemorrhage. Mean lymph node yield from O-RPLND was 32, while the mean yield for L-RPLND was 29. This difference was not statistically significant (P=0.65). CONCLUSIONS In the porcine model, L-RPLND is capable of providing a quality of dissection equivalent to that of O-RPLND, in terms of absolute lymph node yield on microscopic examination. The applicability of this data to human patients, however, may be limited by significant anatomic differences between the human and the pig. Further prospective comparison in human patients is critically needed.

Catheterization alters bladder ecology to potentiate Staphylococcus aureus infection of the urinary tract

Significance Staphylococcus aureus is a cause of catheter-associated urinary tract infections (CAUTIs). S. aureus CAUTIs are problematic because they are usually caused by antibiotic-resistant strains, and patients who develop these infections have a high risk of developing serious complications. Catheterization in humans and mice causes damage in the bladder that results in the release of host protein fibrinogen (Fg). This study suggests that S. aureus exploits the presence of Fg via interactions mediated by the Fg-binding protein ClfB to facilitate colonization of the bladder and the catheter to cause a persistent infection in both mice and humans. Insights into S. aureus CAUTI pathogenesis is facilitating the development of more-targeted therapies to better treat these infections. Methicillin-resistant Staphylococcus aureus (MRSA) is an emerging cause of catheter-associated urinary tract infection (CAUTI), which frequently progresses to more serious invasive infections. We adapted a mouse model of CAUTI to investigate how catheterization increases an individual’s susceptibility to MRSA UTI. This analysis revealed that catheterization was required for MRSA to achieve high-level, persistent infection in the bladder. As shown previously, catheter placement induced an inflammatory response resulting in the release of the host protein fibrinogen (Fg), which coated the bladder and implant. Following infection, we showed that MRSA attached to the urothelium and implant in patterns that colocalized with deposited Fg. Furthermore, MRSA exacerbated the host inflammatory response to stimulate the additional release and accumulation of Fg in the urinary tract, which facilitated MRSA colonization. Consistent with this model, analysis of catheters from patients with S. aureus-positive cultures revealed colocalization of Fg, which was deposited on the catheter, with S. aureus. Clumping Factors A and B (ClfA and ClfB) have been shown to contribute to MRSA–Fg interactions in other models of disease. We found that mutants in clfA had significantly greater Fg-binding defects than mutants in clfB in several in vitro assays. Paradoxically, only the ClfB− strain was significantly attenuated in the CAUTI model. Together, these data suggest that catheterization alters the urinary tract environment to promote MRSA CAUTI pathogenesis by inducing the release of Fg, which the pathogen enhances to persist in the urinary tract despite the host’s robust immune response.

Mitochondrial DNA induces Foley catheter related bladder inflammation via Toll-like receptor 9 activation

Bladder instrumentation engages the innate immune system via neutrophil activation, promoting inflammation and pain. Elevated levels of mitochondrial DNA (mtDNA) have been associated with tissue damage and organ dysfunction. We hypothesized that local bladder trauma induced by a Foley catheter (FC) will result in mtDNA release, migration of neutrophils into the bladder lumen, and activation of the Toll-like receptor 9 (TLR9) and nuclear factor kappa B (NF-κB) pathway leading to bladder tissue damage. We randomized 10 swine into two groups receiving uncoated, or chloroquine/N-Acetylcysteine (CQ/NAC)-coated FCs. Urine samples were analyzed for mtDNA activation of TLR9/NF-κB as demonstrated by indicators of neutrophil adhesion, migration, and activation. We found that uncoated FCs resulted in a unique active neutrophil phenotype that correlated with bladder epithelial injury, neutrophilia, necrosis, mtDNA release, TLR9/NF-κB activation, transcription and secretion of pro-inflammatory cytokines, and enhanced respiratory burst. In our study we observed that the high levels of mtDNA and elevated TLR9/NF-κB activity were ameliorated in the CQ/NAC-coated FC group. These findings suggest that post-migrated bladder luminal neutrophils are involved in local tissue damage and amelioration of the mtDNA/TLR9/NF-κB inflammatory axis may represent a therapeutic target to prevent inflammation, and bladder tissue injury.

Unplanned 30-Day Encounters After Ureterorenoscopy for Urolithiasis

OBJECTIVE To identify avoidable predictors of postureteroscopy (URS) unplanned encounters and to minimize 30-day encounters. MATERIALS AND METHODS We performed retrospective chart review and telephone surveys on patients who underwent URS for urolithiasis between January and June 2016. Univariate and multivariable analyses evaluated for potential predictors of unplanned encounters. RESULTS Of 157 patients, there were 44 (28.0%) unplanned patient-initiated clinical phone calls, 23 (14.6%) emergency department (ED) visits, and 8 (5.1%) readmissions, with pain being the most common complaint during the encounters. Factors associated with a higher rate of phone calls include first-time stone procedure (36.6% vs 20.9%, p = 0.029), outpatient status (30.3% vs 0%, p = 0.021), intraoperative stent placement (31.2% vs 0%, p = 0.006), and stent removal at home (58.8% vs 28.8%, p = 0.014). Factors associated with increased rate of ED visits were first-time stone procedure (22.5% vs 8.1%, p = 0.011) and ureteral access sheath (UAS) usage (29.6% vs 11.8%, p = 0.018). Factors associated with a higher rate of readmissions were lower body mass index (23.9 vs 29.7, p = 0.013), bilateral procedure (20.0% vs 2.9%, p = 0.010), and UAS usage (14.8% vs 3.1%, p = 0.032). Stone burden, operative time, Charlson comorbidity index, and preoperative urinary tract infection were not significantly associated with postoperative encounters. CONCLUSIONS Pain, first-time stone treatment, presence of a ureteral stent, outpatient status, bilateral procedures, and UAS usage were common reasons for postoperative encounters after URS. Appropriate perioperative patient education and counseling and adequate pain management may minimize these encounters and improve treatment quality and patient satisfaction.

MP23-19 FIBRINOGEN DEPOSITS ON URINARY CATHETERS IN A TIME-DEPENDENT MATTER AND CO-LOCALIZES WITH E. FAECALIS IN PATIENTS WITH POSITIVE E. FAECALIS URINE CULTURES

INTRODUCTION AND OBJECTIVES: There is mounting evidence that fibrinogen deposition on urinary catheters is a key step in the pathogenesis of catheter-associated urinary tract infection (CAUTI). The aim of this study was to investigate whether fibrinogen and Enterococcus faecalis co-localize on catheters acquired from patients with post-operative urine cultures positive for E. faecalis. METHODS: Urinary catheters from a series of 50 patients undergoing elective urologic procedures were collected post-operatively and analyzed via immunofluorescence to detect deposited fibrinogen. Pearson correlation was performed to measure the correlation between fibrinogen deposition and dwell time. Additional catheters and urine cultures were collected at time of catheter removal. Catheters from patients with positive Enterococcus cultures were probed for fibrinogen and Enterococcus via immunofluorescence. RESULTS: A total of 50 adult patients undergoing urinary catheterization as standard of care were prospectively identified at our institution. Fibrinogen concentration quantified as mg/catheter using a standard curve was highly correlated with catheter dwell time (r1⁄40.63; p<0.0001) (Figure 1). E. faecalis was capable of binding to fibrinogen on these catheters ex vivo.Five additional catheters were obtained from patients with E. faecalis-positive post-operative urine cultures. Fibrinogen was present at all time points (18 hours, 1 day, 1 day, 8 days, 9 days) and co-localized with E. faecalis (Figure 2) in vivo. CONCLUSIONS: We have previously shown that fibrinogen deposits on urinary catheters, and that E. faecalis is capable of binding to these catheters ex vivo. In this study, we demonstrate that E. faecalis co-localizes with fibrinogen in catheterized patients with urine cultures positive for E. faecalis. This data strengthens the clinical association of fibrinogen deposition with CAUTI and suggests that targeting the binding of E. faecalis with fibrinogen may help reduce the rate of Enterococcus CAUTI. Source of Funding: 1F32DK104516-01 (ALF-M), and National Institute of Allergy and Infectious Diseases and National Institute of Diabetes and Digestive and Kidney Diseases Grants R01-DK051406, R01-AI108749-01 and P50DK0645400 (ALF-M, JNW, HLS, JSP, MGC, SJH).

PNFLBA-07 BLADDER INJURY ACTIVATES INNATE IMMUNITY DURING SHORT-TERM FOLEY CATHETERIZATION IN A SWINE MODEL

INTRODUCTION AND OBJECTIVES: The advent of electronic health records (EHR) has been determined to be a major cause of physician frustration and burnout. One strategy has been the use of scribes to assist with completion of medical records during office visits. Although data suggests that patients accept the presence of scribes and scribes can improve physician satisfaction, there is conflicting data on whether scribes improve productivity and no studies on the impact of scribes specifically in urology. We sought to determine whether the use of scribes improved provider productivity in our urology practice. METHODS: We instituted a voluntary scribe program at our multi-site large urology practice. A total of 20 providers participated in the scribe program (user group, UG). 18 providers practicing in the same physical offices who declined the use of scribes served as a control group (non-user group, NUG). Provider productivity as measured by total evaluation and management (E&M) visits and relative value units (RVUs) visits were aggregated and compared for the 6 months preand post-adoption of the scribe. The month the scribe started was considered a training month and excluded from analysis. Coding patterns were assessed for UG and NUG preand post-scribe as well. Statistical analysis preand post-scribe for each provider was performed using Student’s paired t-test. RESULTS: Pre-scribe E&M visits for UG and NUG were 1613.8 and 1661.1, respectively (difference 47.3, p1⁄40.72). Pre-scribe RVUs for UG and NUG were 11567.7 and 10475.6, respectively (difference 1092.1, p1⁄40.22). For UG post-scribe, significant increases in both E&M visits and total RVUs were observed (E&M visits 1836.9, +13.8%, p1⁄40.00; RVUs 12467.7, +7.8%, p1⁄40.05). Conversely, there was no significant change in either E&M visits or RVUs for NUG (E&M visits 1651.6, -0.6%, p1⁄40.76; RVUs 10576.0, +1.0%, p1⁄40.67). Post-scribe, the difference in RVUs betweenUGandNUGwassignificant (1891.7,p1⁄40.05)while thedifference in RVUs approached, but did not reach, significance (185.3, p1⁄40.08). CONCLUSIONS: To date, there has been no analysis on the impact that the addition of scribes has on productivity in the urology office. Our data suggests that productivity as measured by both office E&M visits as well as total RVUs is significantly improved by the addition of scribes. When combined with other data regarding scribe acceptance by patients and improvements in physician satisfaction, the utilization of scribes is a viable option for urology practices seeking to manage EHR fatigue in their providers.

Is extended preoperative antibiotic prophylaxis for high-risk patients necessary before percutaneous nephrolithotomy?

Purpose The goal of this study was to compare the rate of systemic inflammatory response syndrome (SIRS) in high-risk patients undergoing percutaneous nephrolithotomy (PCNL) between patients who received 7, 2, or 0 days of preoperative antibiotics. Materials and Methods We retrospectively reviewed a series of consecutive PCNLs performed at our institution. Patients with infected preoperative urine cultures were excluded. High-risk patients were defined as those with a history of previous urinary tract infection (UTI), hydronephrosis, or stone size ≥2 cm. Patients were treated with 7, 2, or 0 days of preoperative antibiotic prophylaxis prior to PCNL. All patients received a single preoperative dose of antibiotics within 60 minutes of the start of surgery. Fisher exact test was used to compare the rate of SIRS by preoperative antibiotic length. Results Of the 292 patients identified, 138 (47.3%) had sterile urine and met high-risk criteria, of which 27 (19.6%), 39 (28.3%), and 72 (52.2%) received 7, 2, and 0 days of preoperative antibiotics, respectively. The 3 groups were similar in age, sex, and duration of surgery (p>0.05). There was no difference in the rate of SIRS between the groups, with 1 of 27 (3.7%), 2 of 39 (5.1%) and 3 of 72 patients (4.2%) meeting criteria in the 7, 2, and 0 days antibiotic groups (p=~1). Conclusions Extended preoperative antibiotic prophylaxis was not found to reduce the risk of SIRS after PCNL in our institutional experience of high-risk patients. For these patients, a single preoperative dose of antibiotics is sufficient.