Jessica Kreshover

Is a Safety Wire Necessary During Routine Flexible Ureteroscopy

BACKGROUND AND PURPOSE The 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. METHODS A 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. RESULTS Flexible 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. CONCLUSIONS This 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.

Predictors for Negative Ureteroscopy in the Management of Upper Urinary Tract Stone Disease

OBJECTIVE To identify factors predictive of negative ureteroscopy (URS). Although computed tomography (CT) scans are sensitive in assessing upper tract calculi, there is increased effort to limit CT radiation exposure. On occasion, patients undergo URS and it is discovered that the stone has already passed. METHODS Retrospective chart review was conducted on all URS cases for renal and ureteral stones performed by a single surgeon from August 2003 to May 2008. Renal units were examined separately and excluded for stone size >10 mm, staged procedures, and previously placed ureteral stents. Negative URS cases were compared with those where stones were identified for differences in stone size, location, presence of preoperative pain, time interval since CT, presence of hydronephrosis, and use of medical expulsive therapy (MET). RESULTS Two-hundred fifty-six cases were identified. Twenty-five of 256 renal units (9.8%) did not have stones upon direct visualization. Stone size (P < .001) and stone location (P = .043) were significantly associated with outcome on univariate analysis. On multivariate analysis, only stone size was significant (P < .001). CONCLUSION Negative URS occurred in almost 10% of cases, with reasonable chance of spontaneous stone passage. Our data support smaller stone size and distal location as predictive of negative URS as opposed to preoperative pain, presence of hydronephrosis, and use of MET. Time interval since CT was not predictive. Rate of negative ureteroscopy is not insignificant, thus patients with small, distal stones who elect to undergo URS should be counseled regarding negative URS with an alternative being repeat imaging.

Open, Laparoscopic, and Robotic Ureteroneocystotomy for Benign and Malignant Ureteral Lesions: A Comparison of Over 100 Minimally Invasive Cases

INTRODUCTION Laparoscopic (LAP) and robot-assisted laparoscopic (RAL) approaches have been applied to ureteroneocystostomies (UNC) although such experience has been limited to a small number of patients and limited follow-up. Herein, we detail our experience with over 100 minimally invasive UNC, the largest such series to date. METHODS All minimally invasive UNC performed at our institution between 1997 and 2013 and all open UNC performed between 2008 and 2013 were identified. Perioperative parameters of relevance were identified and recorded. Chi-squared and ANOVA with post hoc Tukey analysis were performed for all categorical and continuous variables, respectively. RESULTS A total of 130 patients met our study criteria. One hundred five underwent the minimally invasive approach (20 RAL and 85 LAP). Mean follow-up duration was 504 days. Patients in the RAL, LAP, and open cohorts were of similar age, gender and laterality distribution, American Society of Anesthesiologists (ASA) score, body-mass index, history of previous abdominal surgery, history of prior treatment for the ureteral lesion, and surgical indication ( Table 1 ). Operative time was similar across all cohorts (235-257 minutes, p=0.123). Estimated blood loss (EBL) was significantly lower in the RAL and LAP cohorts (100 and 150 mL) compared to their open counterparts (300 mL, p=0.001) although a decrease in hematocrit was similar across all groups. Only four intraoperative complications (4.7%) and two (2.4%) conversions to open were identified in the LAP group, without statistical significance. No intraoperative complications or conversions were identified in the RAL or open cohorts. Median length of stay (LOS) was significantly shorter in the minimally invasive cohorts compared to open (p<0.002). Ninety-day readmission rates (18.8-20%), major complications (10-20%), and failure rates (5.9-16%) were highest in the open cohort although without statistical significance. CONCLUSION RAL or LAP UNC is feasible, safe, and comparable to the open technique with some perioperative benefit in EBL, LOS, and stent duration.

PD17-02 THE USE OF CYTOLOGY DURING THE WORKUP OF PATIENTS WITH PRIMARY MICROSCOPIC HEMATURIA: GUIDELINE COMPLIANCE PATTERNS AMONG A COHORT OF ACADEMIC UROLOGISTS

INTRODUCTION AND OBJECTIVES: In an effort to improve patient autonomy, several organizations publish online data on surgeon performance. One such organization is Pro-Publica, an independent nonprofit newsroom that publishes an online 0surgeon scorecard.0 This scorecard reports calculated death and complication rates for surgeons performing elective procedures including radical prostatectomy in Medicare patients. We wanted to understand how the general public would interpret this data and how it would impact patients’ selection of surgeon. METHODS: 265 adults at the Minnesota State Fair were asked to interpret a representative image from the Pro-Publica surgeon scorecard. Participants were told that a loved one had already scheduled cancer surgery with a surgeon they trusted. They were then shown a graphic with a dot representing the point estimate complication rate and a bar representing the 95% confidence interval (CI) of their surgeon. They were also shown a graphic with 13 other surgeons’ point estimate complication rates, all of which fell within the CI of the index surgeon’s complication rate. Another surgeon with a 0.5% lower point estimate but statistically equivalent complication rate to the first surgeon was indicated on the graphic. Participants were then asked if they would recommend switching surgeons after seeing this graphic. RESULTS: The surveyed population was educated with 89% having attended or graduated from college (n1⁄4235). Median age of participants was 50 years (range 20-74) with 68% females (n1⁄4179). Participants were from 136 different zip codes predominantly in the upper Midwest. When presented with the graphic representing two surgeons with different point estimate complication rates falling within the same confidence interval, 124 or 46.8% (95% CI 41-53) of respondents would recommend switching surgeons based on this single graphic. CONCLUSIONS: Nearly half of adults surveyed would recommend switching cancer surgeons for genitourinary malignancies based on a graphical representation of surgeons’ complication rates even though there was no statistically significant difference between the two surgeons. This suggests that simplistic displays of complicated statistical data may lead to changes in medical decision-making based on random error of measurement instead of true differences in surgeon quality.

1710 ASSESSMENT OF RADIATION EXPOSURE FROM DIAGNOSTIC IMAGING IN PATIENTS UNDERGOING URETEROSCOPY WITH LASER LITHOTRIPSY FOR UPPER TRACT STONES

and 5 to 10 dB less from the flow channel relative to power measured by AC. The relative difference between the AR and AC powers was able to differentiate stone twinkling and flow with a sensitivity of 0.94 and a specificity of 0.89. CONCLUSIONS: Twinkling is a potentially useful method of imaging kidney stones with ultrasound but its value will remain limited without an imaging mode optimized for the unique ultrasound signals that typify stones. Autoregression is a simple, computationally efficient alternative signal processing method to conventional autocorrelation processing that addresses the limitation of ambiguity between kidney stone twinkling and true blood flow.