Evan Carlos

Wilms Tumor after Orthotopic Liver Transplant in a Patient with Alagille Syndrome .

We present a case of Wilms Tumor in a patient with Alagille syndrome 10 months after liver transplant. We explore a suggested genetic connection between these 2 diseases. In children with Wilms Tumor, we propose a pathoembryologic explanation for not just the tumor, but also for the cause of associated benign ureteral and renal parenchymal aberrancies that are commonly seen in the Alagille population. We also discuss the diagnostic and therapeutic challenges that can arise in a liver transplant patient with Alagille syndrome who subsequently develops a renal mass.

Psychiatric Diagnoses and Other Factors Associated with Emergency Department Return within 30 Days of Ureteroscopy

Purpose: Emergency department visits after ureteroscopy are costly and inconvenient. To better understand those at risk we aimed to identify patient demographic, medical and surgical factors associated with 30-day emergency department presentation following ureteroscopy for urolithiasis with particular attention to those with a history of a psychiatric diagnosis. Materials and Methods: We retrospectively reviewed 1,576 cases (1,395 adults) who underwent stone related ureteroscopy during 3 years at a total of 2 hospitals. We collected patient demographics, medical history and operative details. The primary outcome was return to the emergency department within 30 days of ureteroscopy. Logistic regression was performed to examine factors associated with emergency department presentation. Results: Of the patients 613 (43.9%) had a history of psychiatric diagnosis. Of those with ureteroscopy encounters 12.6% returned to the emergency department within 30 days of ureteroscopy, including 58.8% with a history of psychiatric diagnosis. On multivariable analysis variables associated with emergency department return included a history of psychiatric diagnosis (OR 1.57, p = 0.012), uninsured status (OR 2.46, p = 0.001) and a stone only in the kidney (OR 1.76, p = 0.022). Patients who returned to the emergency department had had more emergency department visits in the year prior to surgery (OR 1.40, p <0.001). On univariable analysis older patients and those with longer operative time were more frequently admitted from the emergency department (OR 1.03, p = 0.002 and OR 1.96, p = 0.03. respectively) while uninsured patients were admitted less frequently (OR 0.19, p = 0.013). No difference was noted in admissions between those with a psychiatric diagnosis and all others (60.7% vs 55.8%, p = 0.48). Conclusions: We identified factors associated with emergency department return after ureteroscopy, including a history of psychiatric diagnosis, uninsured status and emergency department visits in the year before surgery. These patients may benefit from targeted interventions to help avoid unnecessary emergency department visits.

Urethral Injury and the Penile Prosthesis

INTRODUCTIONnThe relative infrequency of urethral injuries during penile prosthesis implantation has caused the event to be understudied relative to the morbidity and cost associated with their management.nnnAIMnTo draw attention to both acute intraoperative and delayed urethral injuries via cylinder erosion by compiling and evaluating the available literature on their cause, diagnosis, and management.nnnMETHODSnA literature review was performed through PubMed from 1985 to 2018 regarding urethral injuries in the setting of penile prosthesis implantation. Comorbidities and anatomic factors that predispose a patient to a urethral injury were also queried.nnnMAIN OUTCOME MEASURESnThe goal is to identify at-risk populations and assess options for managing distal, mid-pendulous, and proximal acute urethral injuries that occur in the setting of penile prosthesis implantation. We also examine strategies to manage prosthesis erosion into the urethra.nnnRESULTSnAlthough urethral injuries are rare, certain patient populations are at higher risk for the event. Injuries at various locations along the urethra present unique challenging and morbid clinical scenarios. However, there are a variety of management options available that allow a patient to ultimately void normally and have a successfully implanted penile prosthesis.nnnCONCLUSIONnOverall, penile prostheses offer many patients an improved sexual quality of life. In the setting of prosthesis implantation both acute and delayed urethral injuries are rare, but their associated morbidity can undercut the benefits of the device. Our understanding of these injuries has matured, and we now possess management strategies that can mitigate the morbidity and frustration that accompany this complication. Carlos EC, Sexton SJ, Lentz AC. Urethral injury and the penile prosthesis. Sex Med Rev 2019;7:360-368.

In Vitro Comparison of a Novel Single Probe Dual-Energy Lithotripter to Current Devices

PURPOSEnThe LithoClast Trilogy is a novel single probe, dual-energy lithotripter with ultrasonic (US) vibration and electromagnetic impact forces. ShockPulse and LithoClast Select are existing lithotripters that also use a combination of US and mechanical impact energies. We compared the efficacy and tip motion of these devices in an in vitro setting.nnnMATERIALS AND METHODSnBegostones, in the ratio 15:3, were used in all trials. Test groups were Trilogy, ShockPulse, Select ultrasound (US) only, and Select ultrasound with pneumatic (USP). For clearance testing, a single investigator facile with each lithotripter fragmented 10 stones per device. For drill testing, a hands-free apparatus with a submerged balance was used to apply 1 or 2u2009lbs of pressure on a stone in contact with the device tip. High-speed photography was used to assess Trilogy and ShockPulses probe tip motion.nnnRESULTSnSelect-USP was slowest and Trilogy fastest on clearance testing (pu2009<u20090.01). On 1u2009lbs drill testing, Select-US was slowest (pu2009=u20090.001). At 2u2009lbs, ShockPulse was faster than Select US (pu2009=u20090.027), but did not significantly outpace Trilogy nor Select-USP. At either weight, there was no significant difference between Trilogy and ShockPulse. During its US function, Trilogys maximum downward tip displacement was 0.041u2009mm relative to 0.0025u2009mm with ShockPulse. Trilogy had 0.25u2009mm of maximum downward displacement during its impactor function while ShockPulse had 0.01u2009mm.nnnCONCLUSIONSnSingle probe dual-energy devices, such as Trilogy and ShockPulse, represent the next generation of lithotripters. Trilogy more efficiently cleared stone than currently available devices, which could be explained by its larger probe diameter and greater downward tip displacement during both US and impactor functions.

Antibiotic Utilization Before Endourological Surgery for Urolithiasis: Endourological Society Survey Results

INTRODUCTIONnUreteroscopy (URS) and percutaneous nephrolithotomy (PCNL) are common procedures performed to treat kidney stones. Despite advances in technology/technique, serious infectious complications can occur. To better understand the preoperative antibiotic administration patterns and adherence to guidelines from the American Urological Association (AUA) and the European Association of Urology (EAU), members of the Endourological Society were sent a clinical vignette-based survey to assess the antibiotic use in a variety of pre-URS and pre-PCNL scenarios.nnnMETHODSnEndourological Society members were e-mailed a survey that queried antibiotic therapy duration before uncomplicated URS and PCNL with negative and asymptomatic positive preoperative urine cultures (PUCs). For negative PUC questions, selecting more perioperative antibiotics was considered a prolonged course as it extends past the maximum of 24-hour perioperative prophylaxis recommended by both the AUA and EAU.nnnRESULTSnThe response rate was 16.3% for a total of 326 responders. Twenty-one percent to 39% of respondents reported giving prolonged courses of preoperative antibiotics before a URS or PCNL with a negative PUC (pu2009<u20090.0001). When presented with a negative PUC, more prolonged antibiotic courses were reported with the following hierarchy: PCNL for 2u2009cm intrarenal stones (39%) > URS for 12u2009mm renal pelvis stone (28%) > URS for 7u2009mm distal ureteral stones (21%) (pu2009<u20090.0001). In both negative and positive PUC questions, differences were noted in preoperative antibiotic prescribing patterns among site of practice (United States, Canada, Europe, Asia, South America, and Others), type of practice (academic vs all others), years in practice (<10 or ≥10 years), and surgical volume (URS and PCNL >100 or ≤100 annual cases).nnnCONCLUSIONSnAdherence to guidelines on antibiotic administration before PCNL and URS with a negative PUC varies by scenario and provider. In 21% to 39% of negative PUC cases, reported antibiotic use before a URS or PCNL is not consistent with recommendations from the AUA and EAU. Before a positive PUC URS or PCNL, nearly all surveyed provide preoperative antibiotics; however, the regimen length is variable.

Dusting Efficiency of the Moses Holmium Laser: an Automated in vitro Assessment

INTRODUCTIONnMoses technology is a novel Holmium:YAG laser system designed to minimize stone retropulsion and improve stone ablation when the laser is not in direct contact with the stone. Our aim was to assess the efficiency of Moses technology relative to short- and long-pulse lithotripsy using an automated in vitro dusting model of stone comminution.nnnMETHODSnAll tests were conducted using a Lumenis Pulse 120H Holmium:YAG laser with a 365u2009μm Moses D/F/L fiber. Hard (15:3) and soft (15:6) Begostones mimicking calcium oxalate monohydrate and uric acid stones, respectively, were used. To assess ablation efficiency and fiber tip degradation, a dusting model was employed: the laser was moved by a three-dimensional positioning system in a spiral motion across a flat Begostone surface submerged in water. Ablation efficiency was measured as stone mass loss after 4u2009kJ of energy delivery. Fiber tip degradation was measured at 1u2009kJ intervals. Comparative trials with short pulse, long pulse, Moses contact, and Moses distance settings were completed with the laser tip positioned at 0, 1, and 2u2009mm distances from the stone at energy settings of 0.4u2009J delivered at 70u2009Hz.nnnRESULTSnIn our dusting model, stone ablation was significantly greater the closer the laser was to the stone. On hard stones, pulse type did not have a significant impact on ablation at any distance. On soft stones at 0u2009mm, Moses contact produced the greatest ablation, significantly greater than long pulse (pu2009<u20090.05). At 1u2009mm, Moses distance produced significantly greater ablation than all other settings (pu2009=u20090.025) and was as effective as long or short pulse at 0u2009mm. At 2u2009mm distance, no pulse type demonstrated significantly different ablation. Fiber tip degradation was minimal and not significant between settings.nnnCONCLUSIONSnMoses technology delivers greater ablation of soft stones when in contact and 1mm from the stone surface.

Let’s get to the point: Comparing Insertion Characteristics and Scope Damage of Flat-tip and Ball-tip Holmium Laser Fibers

INTRODUCTIONnA ball-tip holmium laser fiber (TracTip; Boston Scientific) has been developed to theoretically reduce damaging friction forces generated within a ureteroscope working channel. We compared the insertional forces and damage with a ureteroscope inner lining when inserting standard flat-tip and ball-tip laser fibers.nnnMATERIALS AND METHODSnA standard ureteroscope channel liner was placed in a 3D-printed plastic mold. Molds were created at four angles of deflection (30°, 45°, 90°, and 180°) with a 1u2009cm radius of curvature. New 200u2009μm ball-tip (TracTip; Boston Scientific) and 200u2009μm flat-tip (Flexiva; Boston Scientific) laser fibers were advanced through the liner using a stage controller. A strain gauge was used to measure force required for insertion. Each fiber was passed 600 times at each angle of deflection. The ureteroscope liner was changed every 150 passes. Leak testing was performed every 50 passes or when the insertional force increased significantly to assess damage to the liner.nnnRESULTSnAt all deflection angles, the average insertional force was significantly lower with the ball-tip laser fibers compared with flat-tip laser fibers (pu2009<u20090.001). All trials with the ball-tip lasers were completed at each angle without any leaks. Two of four trials using flat-tip fibers at 45° deflection caused liner leaks (at 91 and 114 passes). At 90° deflection, all flat-tip trials caused liner leaks on first pass. The 180° trials could not physically be completed with the flat-tip laser fiber. Within the flat- and ball-tip groups, an increasing amount of force was needed to pass the fiber as the degree of deflection increased (pu2009<u20090.001).nnnCONCLUSIONSnThe ball-tip holmium laser fiber can be safely passed through a deflected ureteroscope without causing liner perforation. The standard flat-tip fiber requires greater insertion force at all angles and can cause the ureteroscope liner to leak if it is deflected 45° or more.

MP64-09 DECREASE IN LONG-TERM DISEASE-SPECIFIC SURVIVAL WITH PERIOPERATIVE BLOOD TRANSFUSION FOLLOWING RADICAL CYSTECTOMY

INTRODUCTION AND OBJECTIVES: Radical cystectomy (RC) is a morbid procedure, which can be associated with substantial blood loss and need for perioperative blood transfusion (PBT). PBT has been associated with a decrease in disease-specific survival for patients undergoing surgery for other malignancies. We hypothesize that receipt of PBT may have an immunosuppressive effect that can impact the natural course of bladder cancer after definitive surgical treatment. We evaluate the effects of blood transfusion on overall (OS), disease-specific (DSS), and recurrence-free survival(RFS)in patients who underwent RC for bladder carcinoma. METHODS: A retrospective review was performed of 521 patients who underwent RC at Loyola University Medical Center from 1996 to 2014. Patients were categorized into two cohorts; those who did and did not receive PBT. Student’s T-test was used to assess continuous variables, and Pearson’s Chi-squared test to assess categorical variables. The effect of PBT on OS, DSS, and RFS were estimated using the Kaplan-Meier method and compared with the log-rank test. RESULTS: Blood transfusion data was available for 487 patients (93.5%), with an overall mean follow up of 30 months. Of these patients, 243 (49.8%) received PBT. Cohorts were well-matched with regards to cancer-specific variables, with no differences between pathologic tumor stage, nodal stage, presence of lymphovascular invasion, primary histology, or presence of positive margins. PBT patients were older than control patients (mean age 69.1 vs 66.7, p<0.05). DSS and OS were found to be significantly decreased in PBT patients compared to controls, at median 77.8 months vs. 111.1 months (p1⁄40.002) and 54.5 months vs. 80.3 months (p1⁄40.002), respectively. Figures A and B. RFS approaches significance favoring improved freedom from recurrence in control patients, at median 64.4 months vs. 100.4 months respectively (p1⁄40.059). CONCLUSIONS: RC patients who received PBT had a decreased OS and DSS. Coupled with a trend toward a higher rate of cancer recurrence in the PBT group, these results suggest that receipt of blood products may have an immunosuppressive effect that impairs the body’s ability to fight microscopic residual disease, contributing to poorer survival in this cohort.