David Sehrt

Early effectiveness of endoscopic posterior urethra primary alignment.

BACKGROUND Posterior urethra primary realignment (PUPR) after complete transection may decrease the gap between the ends of the transected urethra, tamponade the retropubic bleeding, and optimize urinary drainage without the need of suprapubic catheter facilitating concurrent pelvic orthopedic and trauma procedures. Historically, the distorted anatomy after pelvic trauma has been a major surgical challenge. The purpose of the study was to assess the relationship of the severity of the pelvic fracture to the success of endoscopic and immediate PUPR following complete posterior urethral disruption using the Young-Burgess classification system. METHODS A review of our Level I trauma center database for patients diagnosed with pelvic fracture and complete posterior urethral disruption from January 2005 to April 2012 was performed. Pelvic fracture severity was categorized according to the Young-Burgees classification system. Management consisted of suprapubic catheter insertion at diagnosis followed by early urethral realignment when the patient was clinically stable. Failure of realignment was defined as inability to achieve urethral continuity with Foley catheterization. Clinical follow-up consisted of radiologic, pressure studies and cystoscopic evaluation. RESULTS A total of 481 patients with pelvic trauma from our trauma registry were screened initially, and 18 (3.7%) were diagnosed with a complete posterior urethral disruption. A total of 15 primary realignments (83.3%) were performed all within 5 days of trauma. The success rate of early realignment was 100%. There was no correlation between the type of pelvic ring fracture and the success of PUPR. Postoperatively, 8 patients (53.3%) developed urethral strictures, 3 patients (20.0%) developed incontinence, and 7 patients (46.7%) reported erectile dysfunction after the trauma. The mean follow-up of these patients was 31.8 months. CONCLUSION Endoscopic PUPR may be an effective option for the treatment of complete posterior urethral disruption and enables urinary drainage to best suit the multispecialty surgical team. The success rate of achieving primary realignment did not appear to be related to the complexity and type of pelvic ring fracture. LEVEL OF EVIDENCE Epidemiologic study, level III; therapeutic study, level V.

The S.T.O.N.E. Score: A new assessment tool to predict stone free rates in ureteroscopy from pre-operative radiological features

OBJECTIVE To develop a user friendly system (S.T.O.N.E. Score) to quantify and describe stone characteristics provided by computed axial tomography scan to predict ureteroscopy outcomes and to evaluate the characteristics that are thought to affect stone free rates. MATERIALS AND METHODS The S.T.O.N.E. score consists of 5 stone characteristics: (S) ize, (T)opography (location of stone), (O)bstruction, (N)umber of stones present, and (E)valuation of Hounsfield Units. Each component is scored on a 1-3 point scale. The S.T.O.N.E. Score was applied to 200 rigid and flexible ureteroscopies performed at our institution. A logistic model was applied to evaluate our data for stone free rates (SFR). RESULTS SFR were found to be correlated to S.T.O.N.E. Score. As S.T.O.N.E. Score increased, the SFR decreased with a logical regression trend (p < 0.001). The logistic model found was SFR=1/(1+e^(-z)), where z=7.02-0.57•Score with an area under the curve of 0.764. A S.T.O.N.E. Score ≤ 9 points obtains stone free rates > 90% and typically falls off by 10% per point thereafter. CONCLUSIONS The S.T.O.N.E. Score is a novel assessment tool to predict SFR in patients who require URS for the surgical therapy of ureteral and renal stone disease. The features of S.T.O.N.E. are relevant in predicting SFR with URS. Size, location, and degree of hydronephrosis were statistically significant factors in multivariate analysis. The S.T.O.N.E. Score establishes the framework for future analysis of the treatment of urolithiasis.

Initial experience of a novel ergonomic surgical chair for laparoscopic pelvic surgery

INTRODUCTION We present the initial experience of a novel surgical chair for laparoscopic pelvic surgery, the ETHOS™ (Bridge City Surgical, Portland, OR). MATERIALS AND METHODS The ETHOS chair has an adjustable saddle height that ranges from 0.89 to 1.22 m high, an overall width of 0.89 m, and a depth of 0.97 m. The open straddle is 0.53 m and fits most OR tables. We performed 7 pelvic laparoscopy cases with the 1st generation ETHOS™ platform including 2 laparoscopic ureteral reimplantations, 5 laparoscopic pelvic lymphadenectomies for staging prostate cancer in which one case involved a laparoscopic radical retropubic prostatectomy, performed by 2 different surgeons. RESULTS All 7 pelvic laparoscopic procedures were successful with the ETHOS™ chair. No conversion to open surgery was necessary. Survey done by surgeons after the procedures revealed minimal stress on back or upper extremities by the surgeons from these operations even when surgery was longer than 120 minutes. Conversely, the surgical assistants still had issues with their positions since they were on either sides of the patient stressing their positions during the procedure. CONCLUSION The ETHOS chair system allows the surgeon to operate seated in comfortable position with ergonomic chest, arms, and back supports. These supports minimize surgeon fatigue and discomfort during pelvic laparoscopic procedures even when these procedures are longer than 120 minutes without consequence to the patient safety or detrimental effects to the surgical team.

Significance of surgical plume obstruction during laparoscopy.

With the advent of laparoscopic surgery, the need of optimal visualization and efficient instrumentation has created a need for better understanding of the characteristics of the surgical plume. Despite the technological advances of digital imaging and dissector technology (ultrasonic, radiofrequency electrical, and bipolar), the inconvenient and sometimes harmful generation of a surgical plume decreases visualization, often requiring the surgeon to remove the scope from the surgical field and remove the obstructing particles. If visualization is suboptimal or lost during bleeding, the outcome can be deadly. Therefore, we reviewed the available reports in the literature focused on the quantification of surgical plumes.

1539 THE S.T.O.N.E. SCORE: A NOVEL INSTRUMENT TO PREDICT STONE FREE RATES IN URETEROSCOPY FROM PRE-OPERATIVE FEATURES

INTRODUCTION AND OBJECTIVES: Success of treatment for renal and ureteral stones depends on qualitative data such as stone size and location. Surgical decision making and data set comparisons would be significantly enhanced by a consistent, reproducible system that quantitates the pertinent characteristics of renal and ureteral stones. We have developed and propose a standardized lithometric scoring system (S.T.O.N.E Score) to quantify the anatomical characteristics of stones on computerized tomography. METHODS: The STONE score consists of 5 features known to effect the stone free rates of nephrolithiasis with ureteroscopy. The features examined include (S)ize, (T)opography (location), (O)bstruction, (N)umber of stones, and (E)valuation of Hounsfield Units. Each component is scored on a 1-3 point scale as shown in Table 1. We applied the STONE score to 186 consecutive ureteroscopy at Denver Health Medical Center. A logistic model was formed to our data for stone free rates. Stone free was considered the absence of stones or residual stone fragments less than 2 mm on visual inspection or by KUB. RESULTS: Stone free rates were found to be related to STONE Sum. As STONE Sum increased, the stone free rates decreased with a logical regression trend. The logistic model found was Stone Free 1 1/[1 Exp(5.5246 0.3669 * Score)] with an ROC 0.7. The comparison between our data and the model is shown in Table 2. In the STONE model, a score less than 9 has a stone free rate of more than 90% while a stone score greater than 14 has a rate less than 60%. Sum scores of 5, 6 and 14 did not fit with the model, likely because of too few cases. None of the patients in our series had a sum of 15. CONCLUSIONS: Our model correlated with our stone free rate data; however, Our model was limited by our small sample size. A model with individual weights to each feature from a multi-institutional study would more accurately predict stone free rates. This is a pragmatic model to implement in a clinical setting and is the first model to predict stone free rates from ureteroscopy.