David Leavitt

Outcomes of Laparoscopic Partial Nephrectomy in Patients Continuing Aspirin Therapy

PURPOSEnA clinical dilemma surrounds the use of aspirin therapy during laparoscopic partial nephrectomy. Despite reduced cardiac morbidity with perioperative aspirin use, fear of bleeding related complications often prompts discontinuation of therapy before surgery. We evaluate perioperative outcomes among patients continuing aspirin and those in whom treatment is stopped preoperatively.nnnMATERIALS AND METHODSnA total of 430 consecutive cases of laparoscopic partial nephrectomy performed between January 2012 and October 2014 were reviewed. Patients on chronic aspirin therapy were stratified into on aspirin and off aspirin groups based on perioperative status of aspirin use. Primary end points evaluated included estimated intraoperative blood loss and incidence of bleeding related complications, major postoperative complications, and thromboembolic events. Secondary outcomes included operative time, transfusion rate, length of hospital stay, rehospitalization rate and surgical margin status.nnnRESULTSnAmong 101 (23.4%) patients on chronic aspirin therapy, antiplatelet treatment was continued in 17 (16.8%). Bleeding developed in 1 patient in the on aspirin group postoperatively and required angioembolization. Conversely 1 myocardial infarction was observed in the off aspirin cohort. There was no significant difference in the incidence of major postoperative complications, intraoperative blood loss, transfusion rate, length of hospital stay and rehospitalization rate. Operative time was increased with continued aspirin use (181 vs 136 minutes, p=0.01).nnnCONCLUSIONSnLaparoscopic partial nephrectomy is safe and effective in patients on chronic antiplatelet therapy who require perioperative aspirin for cardioprotection. Larger, prospective studies are necessary to discern the true cardiovascular benefit derived from continued aspirin therapy as well as better characterize associated bleeding risk.

Percutaneous nephrolithotomy in super obese patients (body mass index ≥ 50 kg/m2): overcoming the challenges

To analyse our experience with and the outcomes and lessons learned from percutaneous nephrolithotomy (PCNL) in the super obese (body mass index [BMI] ≥50 kg/m2).

Does Peak Inspiratory Pressure Increase in the Prone Position? An Analysis Related to Body Mass Index

PURPOSEnPercutaneous nephrolithotomy is commonly performed with the patient prone. There is concern that the prone position, especially in obese patients, negatively affects ventilation due to the restriction of chest compliance and respiratory mechanics. We analyzed the change in airway resistance between supine and prone positioning of patients undergoing percutaneous nephrolithotomy.nnnMATERIALS AND METHODSnWe retrospectively reviewed the intraoperative respiratory parameters of 101 patients who underwent prone percutaneous nephrolithotomy. Peak inspiratory pressure was assessed with the patient supine, at several time points after being turned prone and at the end of the case. The change in peak inspiratory pressure with time was calculated. Results were stratified based on body mass index and data were compared using the paired t-test and Spearman ρ.nnnRESULTSnOf 101 patients 50 (50%) were obese (body mass index 30 kg/m(2) or greater). Median body mass index was 25.6 kg/m(2) in the nonobese cohort and 38.3 kg/m(2) in the obese cohort. Average peak inspiratory pressure while supine and prone was 18.0 and 18.5 cm H2O in the nonobese cohort, and 25.5 and 26.6xa0cm H2O, respectively, in the obese cohort. Obese patients had significantly higher peak inspiratory pressure in the supine and the prone positions relative toxa0nonobese patients (p <0.0001). However, there was no change in peak inspiratory pressure from the supine to the prone position in either cohort.nnnCONCLUSIONSnObese patients have higher baseline peak inspiratory pressure regardless of position. However, prone positioning does not impact peak inspiratory pressure in either cohort. It remains a safe and viable option.

Association of serum biochemical metabolic panel with stone composition.

To determine the association of the basic metabolic panel with stone type.

Live surgical demonstrations: An endangered species

Despite the increasing controversy surrounding live surgical demonstrations, they remain an incredibly valuable tool for urologic education. Live surgery is the most effective means to demonstrate certain surgical techniques and intraoperative decision making. The many potential benefits far outweigh the potential concerns when live surgical events are performed in a thoughtful regulatory framework. Appropriate patient and surgeon selection is integral to successful live surgical events. Under these circumstances, live surgery should remain safe for the patient and instructive for the urologist.

Does Hypertension Impact 24-Hour Urine Parameters in Patients With Nephrolithiasis?

OBJECTIVEnTo examine the differences in 24-hour urine parameters and stone composition between patients with and without systemic hypertension (HTN) in a large cohort of stone formers.nnnMATERIALS AND METHODSnWe performed a retrospective review over a 10-year period of patients with stone, who had completed a 24-hour urinalysis (Litholink) and for whom demographic information was available, including the presence of HTN. Univariate and multivariate analyses were performed, comparing the 24-hour urinalysis profiles of patients with HTN with that of normotensive patients.nnnRESULTSnOf the 1115 patients eligible for inclusion, 442 patients (40%) had HTN and 673 (60%) did not. Patients with HTN were significantly older, had a higher body mass index, and had a greater number of comorbid conditions than normotensive patients. Univariate analysis revealed significantly lower urine pH, calcium, supersaturation (SS) of calcium oxalate (CaOx) and SS calcium phosphate (all Pxa0<.05) in patients with HTN. Multivariate analysis showed significantly lower calcium, citrate, and SS CaOx in patients with HTN (all Pxa0<.05).nnnCONCLUSIONnOur results demonstrate lower levels of calcium and SS CaOx on univariate and multivariate analysis, as well as lower levels of citrate on multivariate analysis in patients with HTN. These results suggest that lower levels of citrate may contribute to stone formation to a greater degree in patients with HTN than abnormalities in calcium metabolism.

Percutaneous nephrolithotomy during uninterrupted aspirin therapy in high-cardiovascular risk patients: preliminary report.

OBJECTIVEnTo determine the feasibility and safety of performing percutaneous nephrolithotomy (PCNL) in high-cardiovascular risk patients remaining on aspirin therapy.nnnMETHODSnWe retrospectively reviewed all PCNLs performed by 3 fellowship-trained endourologists at a single institution between July 2012 and January 2014. All patients remaining on aspirin for imperative indications through the day of surgery were evaluated for surgical outcomes and thromboembolic events.nnnRESULTSnOf 281 PCNL procedures performed during the study period, 16 (5.7%) were performed in 14 patients taking aspirin, uninterrupted, through surgery. Mean surgery time was 66 minutes, mean estimated blood loss was 161 mL, and mean length of hospital stay was 2.8 days. All patients were stone free. There were no intraoperative complications. A total of 5 patients experienced a postoperative complication (n = 4, Clavien grade II; n = 1, Clavien grade IIIa). No patient experienced a perioperative thromboembolic or cardiac event. Three patients required a blood transfusion postoperatively, and none experienced delayed renal bleeding.nnnCONCLUSIONnPCNL can be performed safely and effectively in high-cardiovascular risk patients continuing aspirin perioperatively. Compared with the potential sequelae of a thromboembolic or cardiac event, PCNL is associated with an acceptably low transfusion rate, and should be considered a viable treatment option for large renal stones in this population.

Percutaneous nephrolithotomy in octogenarians and beyond: How old is too old?

Objective To specifically report perioperative characteristics and outcomes in patients 80 years and older undergoing percutaneous nephrolithotomy (PCNL). PCNL has been established as feasible in the elderly; however, to our knowledge no one has specifically reported feasibility in patients 80 years and older. Methods We retrospectively reviewed perioperative data of octogenarians who underwent PCNL at a high stone volume single institution, and matched them to patients <65 years of age by stone burden and sex. Patient demographics, perioperative outcomes and postoperative complications were compared. Results Thirty-three octogenarians (mean age 83.6 years) with 36 renal units were matched to 67 controls (mean age 48.6 years) with 72 renal units. Octogenarians had a higher mean American Society of Anesthesiologists (ASA) score, more comorbidities, and worse renal function. There were no differences in operative characteristics, length of hospital stay or stone free rates. Of the patients with preoperative urinary decompression (ureteral stent or nephrostomy tube) prior to PCNL, the elderly were more likely to have a history of urosepsis. Octogenarians did not experience more minor Clavien (I – II) or major Clavien (IIIa – IVb) complications. Conclusion Octogenarians who undergo PCNL were more likely to have cardiovascular comorbidities and a prior history of sepsis. Despite these risk factors, in appropriately selected patients PCNL can be safely and successfully performed in octogenarians without increased perioperative complications relative to a younger cohort.

Advances in percutaneous stone surgery

Treatment of large renal stones has changed considerably in recent years. The increasing prevalence of nephrolithiasis has mandated that urologists perform more surgeries for large renal calculi than before, and this has been met with improvements in percutaneous stone surgery. In this review paper, we examine recent developments in percutaneous stone surgery, including advances in diagnosis and preoperative planning, renal access, patient position, tract dilation, nephroscopes, lithotripsy, exit strategies, and post-operative antibiotic prophylaxis.

Robotic assisted laparoscopic simple suprapubic prostatectomy—The Smith Institute for urology experience with an evolving technique

Objective Despite a multitude of minimally invasive surgical options available for benign prostatic enlargement, open simple prostatectomy (OSP) remains the standard for large prostates (typically greater than 100 g). OSP, however, is associated with significant morbidity. Recently, a few reports touting robotic application to simple prostatectomy have been published. Herein, we reviewed our series of robotic assisted laparoscopic simple suprapubic prostatectomy (RALSSP) and detailed modifications in our technique as our experience increased. Methods All RALSSP cases performed between January 2013 and January 2014 were reviewed for demographics, pre-operative features, and perioperative outcomes. All parameters were tabulated and mean values were calculated. Students t-test was utilized with p < 0.05 deemed significant. Details regarding surgical technique were reviewed and highlighted. Results Fifteen patients underwent RALSSP during this period. Mean age of these men was 68.7 years. Mean body mass index (BMI) was 28.5 kg/m2. American Society of Anesthesiologists (ASA) score was on average 2.6. Average International Prostate Symptom Score (IPSS) was 16.2 with the majority of men experiencing some adverse clinical sequela of such benign prostatic hyperplasia (BPH). For those patients not in retention, preoperative post-void residual (PVR) was 428 mL. All patients underwent successful RALSSP without need for conversion or need for blood transfusion. Mean estimated blood loss (EBL) was 290 mL. Five patients underwent other concurrent procedures (e.g., cystolithotomy). Mean length of hospital stay (LOS) was 2.4 days and only five patients required continuous bladder irrigation (CBI) postoperatively. Postoperative PVR improved to a mean of 33 mL and IPSS improved to 4.5 (p < 0.001). No major complications were identified. Adaptation of low transverse cystotomy, utilization of a robotic tenaculum in the #3 arm with its control by a surgeon on a second console, and the utilization of mucosal advancement have all subjectively aided in performance of RALSSP and perioperative outcomes. Conclusion RALSSP allows for feasible performance of prostate adenoma enucleation with low risk of blood transfusion, short LOS, and significant improvement in IPSS and PVR; all while maintaining a minimally invasive approach. The use of a robotic tenaculum controlled by the secondary console and the mucosal advancement facilitate excellent outcomes and may play a role in minimizing hematuria and need for CBI.