David S. Wang

Is a Safety Wire Necessary During Routine Flexible Ureteroscopy

BACKGROUND AND PURPOSEnThe use of flexible ureteroscopy (URS) for nephrolithiasis has been rapidly expanding. Initially, safety guidewires were maintained alongside the ureteroscope during stone manipulation to prevent loss of access and allow stent insertion in the event of perforation. We intend to determine the safety of flexible URS without a separate safety guidewire in a large series of patients.nnnMETHODSnA retrospective chart review was performed on all cases of flexible URS with laser lithotripsy performed by a single surgeon from August 2003 to May 2008. Preoperative patient characteristics, radiographic stone sizes, operative findings, and postoperative outcomes were recorded. Patients with renal or ureteropelvic junction (UPJ) stones were isolated for a qualitative data analysis.nnnRESULTSnFlexible URS was performed on 305 kidneys in 246 consecutive patients, of which 59 cases were bilateral. Cases were subdivided into complicated and uncomplicated. Two hundred seventy cases were uncomplicated and performed without a safety guidewire. No intraoperative complications resulted from the lack of a safety guidewire, including no cases of lost access, ureteral perforation/avulsion, or need for percutaneous nephrostomy tube. Thirty-five cases were complicated, necessitating a safety guidewire. Of these, 16 had concomitant obstructing ureteral stones, 5 had encrusted ureteral stents, and 14 had difficult access because of large stone burden or aberrant anatomy.nnnCONCLUSIONSnThis study demonstrates that, in a large series of patients, a safety guidewire was not necessary for routine cases of flexible URS with laser lithotripsy on renal or UPJ stones. Particular cases with complicated anatomy, difficult access, concomitant ureteral stones, simultaneous stone basketing, or bulky stone burden still necessitate use of a safety guidewire because of increased risk of adverse outcomes.

Loss of heterozygosity and microsatellite instability at chromosomal sites 1Q and 10Q in morphologically Distinct Regions of late stage prostate lesions

PURPOSEnWe investigated the incidence of loss of heterozygosity (LOH) and microsatellite instability in sporadic prostate cancer and surrounding tissue at loci encompassing the HPC1 and PTEN genes.nnnMATERIALS AND METHODSnSurgical specimens from 63 patients with sporadic stage T3 or T4 prostatic adenocarcinoma were analyzed for LOH and microsatellite instability. Microdissected tissue included morphologically normal foci, benign prostatic hyperplasia (BPH) and prostatic adenocarcinoma. LOH analysis was performed using 4 microsatellite markers that map in the region of the 1q24 to 25 locus of the putative prostate cancer susceptibility gene HPC1 and 4 that map in the region of the 10q23 locus of the PTEN gene.nnnRESULTSnThe incidence of LOH on 10q was consistent with that previously reported in prostatic tumors. LOH associated with the PTEN locus was recorded in morphologically normal foci, BPH and adenocarcinoma. Sequence analysis of PTEN in a limited number of lesions revealed mutations in nontumor and tumor tissue. Analysis of the DS10215 locus showed significant LOH in tumor but not in benign tissue, suggestive of a tumor suppressor gene in this region associated with prostatic neoplastic progression. In contrast, no significant LOH was observed in the same tissues at 4 loci on chromosome 1q. In this study we recorded elevated levels of microsatellite instability in benign prostatic tissue with an additional increase associated with prostatic adenocarcinoma.nnnCONCLUSIONSnThe low incidence of LOH in the region of the HPC1 locus in all prostate lesions studied suggests that this putative hereditary prostate cancer susceptibility locus does not appear to have a role in sporadic prostate cancer, at least not in the context of LOH. In contrast, analysis of the same tissues for LOH at chromosome 10q confirmed frequent alterations in this region linked to late stage prostate cancer. PTEN mutations in microdissected morphologically normal and BPH tissue showed alterations in nontumor tissue surrounding adenocarcinoma. Microsatellite instability was increased in adenocarcinomas over an elevated background recorded in surrounding tissues.

TUBERCULOSIS OF THE PENIS AFTER INTRAVESICAL BACILLUS CALMETTE-GUERIN TREATMENT

Infectious complications associated with intravesical bacillus Calmette-Guerin (BCG) are rare. We report on a patient with culture proved, BCG related penile infection with Mycobacterium bovis following intravesical therapy for superficial transitional cell carcinoma of the bladder. To our knowledge only 4 reports of BCG related penile or urethral infection have been previously published in the literature.

Re: Pregnancy after Urinary Diversion at Young Ages—Risks and Outcome

available at http://www.ncbi.nlm.nih.gov/pubmed/28209547 Editorial Comment: The authors studied 25 pregnant women who had previously undergone urinary diversion, with continent cutaneous diversion performed in 17, continent anal diversion in 4 and colonic conduit in 4. A total of 37 pregnancies were reported and 32 healthy children were born. There were 5 instances of spontaneous abortion during the first trimester. The most common urological complications were urinary tract infections (33%), although 12 patients had dilatation of the upper tract, with 3 requiring a temporary nephrostomy tube. In 28 of 32 cases cesarean delivery was performed. There were no urological complications during the cesarean sections. Thus, it seems that successful pregnancy with healthy delivery following urinary diversion is possible. The upper urinary tracts should be monitored for dilatation, and the majority of cases are delivered by cesarean section, with urological expertise available on standby. 87 88 David S. Wang, MD 89 90 91 92 93 94 95 96 97 98 99 100 101 102

Re: A Prospective Randomized Trial of the Effects of Early Enteral Feeding after Radical Cystectomy

available at http://www.ncbi.nlm.nih.gov/pubmed/27681493 Editorial Comment: Rates of symptomatic benign prostatic hyperplasia (BPH) increase with advancing patient age. Given the rapidly expanding geriatric population, clinicians will be faced with increased numbers of elderly men suffering from BPH who may require medical or surgical therapy. All forms of treatment have potential benefits and risks associated with use, which may have specific unique outcomes in older adults. These authors report a systematic review of published data that can help inform how clinicians approach patients with BPH. Unfortunately geriatric patients and particularly more frail or vulnerable older men are often excluded from clinical trials. This study summarizes the available

Re: Prevalence of Proteinuria and Other Abnormalities in Urinalysis Performed in the Urology Clinic

available at http://www.ncbi.nlm.nih.gov/pubmed/28212852 Editorial Comment: Urinalysis is perhaps the most common test performed in a typical urology office. Most urologists are vigilant about detecting microscopic hematuria or pyuria but frequently proteinuria is not as vigorously evaluated. In this large study of more than 26,000 patients 3 populations were evaluated, including general outpatients, urology outpatients and patients with kidney cancer. Significant proteinuria was identified in 8.6% of general outpatients, 18.6% of urology outpatients and 17.9% of patients with kidney cancer. It is noteworthy that a significant portion of urology outpatients and also patients with kidney cancer have significant proteinuria on office urinalysis. The urologist should be aware of this fact and consider referral to a nephrologist when necessary. Furthermore, when a patient has a diagnosis of kidney cancer, the urinalysis must screen for hematuria when determining treatment options. The urologist should look for proteinuria and consider obtaining a urinalysis in most patients.

Re: Quality Improvement in Cystectomy Care with Enhanced Recovery (QUICCER) Study

available at http://www.ncbi.nlm.nih.gov/pubmed/27128851 Editorial Comment: Enhanced recovery after surgery protocols are becoming prevalent. Most hospitals, including ours, have adopted such protocols after major surgery. In this study patients were nonrandomized to either to a cystectomy enhanced recovery pathway (CERP) or a standard nonenhanced recovery pathway. Data analyzed included hospital length of stay, complication rates and readmission rates. There were 79 patients who underwent the CERP protocol and 75 in the nonCERP group. Median length of stay was 5 days in the CERP group and 8 days in the nonCERP group. Also, there was no increase in complications or readmissions in the CERP patients who were discharged earlier. Thus, it seems the enhanced recovery protocol for radical cystectomy decreases hospital stay without compromising care and will likely be standard practice in the future.

Re: Do we Really Need to Wear Proper Eye Protection When Using Holmium:YAG Laser during Endourologic Procedures? Results from an Ex Vivo Animal Model on Pig Eyes

available at http://www.ncbi.nlm.nih.gov/pubmed/26472513 Editorial Comment: At most institutions, including our own, protective laser safety goggles are mandated for the patient, operating room personnel and surgeon during lithotripsy with holmium:YAG laser. However, there are times when the laser glasses interfere with vision, particularly when there is fogging of the lens, sweating of the surgeon or excessive bleeding during surgery. In this instance the surgeon will frequently remove the safety glasses. There are also urologists who do not routinely wear safety goggles during laser lithotripsy. In addition, there are urologists who believe that wearing laser safety goggles on top of conventional eyeglasses is cumbersome. In this ex vivo study the holmium laser was activated at different settings in the pupil of a pig eye at distances of 0, 3, 5, 8, 10 and 20 cm at various settings. The investigators used either no glasses, laser safety glasses or conventional eyeglasses for 1 to 5 seconds. The laser fibers were also fired onto conventional thermal paper. Histopathological evaluation was performed in all eyes to determine extent of corneal and retinal damage. Holmium laser induced corneal lesions were observed in unprotected eyes, ranging from superficial damage to full thickness necrotic areas, and were worse with closer distances, higher energy and longer duration of exposure. However, when the distance of the laser was 5 cm or more, there was no damage to the cornea in the unprotected eye. Also there was no damage to the retina in the unprotected eye, even at close distance. In pig eyes tested using conventional eyeglasses or laser protection goggles there was no damage to any eye regardless of distance. Similar findings were observed on thermal paper. It is somewhat reassuring that the risk of eye injury to the urologist using holmium:YAG laser seems to be extremely low. In cases where laser safety goggles are not used or are removed because of fogging the risk of significant damage to the surgeon seems extremely low, particularly if the surgeon already uses conventional eyeglasses. 101 102 David S. Wang, MD

Re: Pressure Makes Pleasure: A Preliminary Study of Increasing Irrigation Pressure of Flexible Cystoscopy Improves Male Patient Comfort by an Easy Way

available at http://www.ncbi.nlm.nih.gov/pubmed/25603481 Editorial Comment: It has always been my observation that increasing the irrigation pressure during office flexible cystoscopy facilitates male flexible cystoscopy, as the irrigation fluid may distend the urethra and/or sphincter to allow for easier passage of the flexible cystoscope. I will routinely ask my medical assistant to manually squeeze the saline bag during cystoscopy. In this nice randomized study the authors examined whether increasing the irrigation pressure during flexible cystoscopy resulted in decreased discomfort for male patients undergoing flexible cystoscopy. The height of the saline bag was randomized to 80, 100 and 150 cm above the examination table, and visual analogue scales were recorded. The group with the highest irrigation pressure (150 cm) had significantly less discomfort during cystoscopy. Thus, this simple modification seems to decrease discomfort for males undergoing office flexible cystoscopy.

Re: Scheduling Anesthesia Time Reduces Case Cancellations and Improves Operating Room Workflow in a University Hospital Setting

BACKGROUND: A new method of scheduling anesthesia-controlled time (ACT) was implemented on July 1, 2012 in an academic inpatient operating room (OR) department. This study examined the relationship between this new scheduling method and OR performance. The new method comprised the development of predetermined time frames per anesthetic technique based on historical data of the actual time needed for anesthesia induction and emergence. Seven “anesthesia scheduling packages” (0 to 6) were established. Several options based on the quantity of anesthesia monitoring and the complexity of the patient were differentiated in time within each package. STUDY DESIGN: This was a quasi-experimental time-series design. Relevant data were divided into 4 equal periods of time. These time periods were compared with ANOVA with contrast analysis: an intervention, pre-intervention, and post-intervention contrast were tested. All emergency cases were excluded. A total of 34,976 inpatient elective cases performed from January 1, 2010 to December 31, 2014 were included for statistical analyses. RESULTS: The intervention contrast showed a significant decrease (p < 0.001) of 4.5% in the prediction error. The total number of cancellations decreased to 19.9%. The ANOVA with contrast analyses showed no significant differences with respect to underand over-used OR time and raw use. Unanticipated results derived from this study, allowing for a smoother workflow: eg anesthesia nurses know exactly which medical equipment and devices need to be assembled and tested beforehand, based on the scheduled anesthesia package. CONCLUSIONS: Scheduling the 2 major components of a procedure (anesthesiaand surgeon-controlled time) more accurately leads to fewer case cancellations, lower prediction errors, and smoother OR workflow in a university hospital setting. (J Am Coll Surg 2016;-:1e9. 2016 by the American College of Surgeons. Published by Elsevier Inc. All rights reserved.)