Jim Shen

Diagnosis of clinical and subclinical varicocele: how has it evolved?

In this review, we examine the evolution and application of various diagnostic modalities for varicoceles starting with venography, scintigraphy, and thermography and their role in the evaluation of a varicocele patient. Some of these methods have been supplanted by less invasive and more easily performed diagnostic modalities, especially ultrasound and Doppler examination of the scrotum. Advances in ultrasound and magnetic resonance imaging hold the potential to expand the role of imaging beyond that of visual confirmation and characterization of varicoceles. The ability to identify the early indicators of testicular dysfunction based on imaging findings may have implications for the management of varicoceles in the future.

Kidney, Ureter, and Bladder (KUB): A Novel Grading System for Encrusted Ureteral Stents

OBJECTIVE To introduce a grading system (kidney, ureter, and bladder [KUB]) to identify encrusted stents that may require multiple surgeries, multimodal surgery, and operative time > 180 minutes for successful removal. METHODS One hundred ten retained encrusted ureteral stents were retrospectively scored using the KUB grading system and this score was correlated with operative time, need for multiple surgeries or multimodal surgery, and stone-free rate. Data analysis was performed with t test, Mann-Whitney U test, and chi-square tests. A P value of <0.05 was considered statistically significant. RESULTS Average indwelling stent time was 17.2 months (0.7-139.0). There were 83.6% of stents removed in a single surgery, with 63.0% of these requiring multimodal surgery. K score ≥ 3 was associated with multiple surgeries (odds ratio [OR] 3.59, P = .006), multimodal surgery (OR 2.44, P = .04), operative time > 180 minutes (OR 3.80, P = .001), and lower stone-free rate (OR 0.23, P = .02). U score ≥ 3 was associated with operative time > 180 minutes (OR 3.28, P = .003). B score ≥ 3 was associated with lower stone-free rate (OR 0.23, P = .020). Total score ≥ 9 was associated with multiple surgeries (OR 4.19, P = .001), operative time > 180 minutes (OR 3.45, P = .002), and lower stone-free rate (OR 0.13, P = .001). CONCLUSION The KUB system identifies stents at risk for requiring multiple surgeries, multimodal surgery, and operative time > 180 minutes. It also correlates with stone-free rate. This grading system can help surgeons manage patient expectations and predict surgical complexity.

Controversies in varicocele repair--much ado about nothing?

and couples requiring assisted reproductive techniques (ARTs) as potential beneficiaries of varicocele repair. Esteves and Glina demonstrated the presence of sperm in the ejaculate of 8 out of 17 formerly azoospermic men after subinguinal microsurgical varicocele repair.8 Men who remain azoospermic after varicocele repair may have a higher rate of successful sperm retrieval during subsequent testicular microdissection sperm extraction.9 In a comparison of 80 men with clinically palpable varicoceles who underwent subinguinal microsurgical varicocelectomy versus 162 untreated men, the former group demonstrated higher pregnancy and live birth rates with lower miscarriage rates with the subsequent use of intracytoplasmic sperm injection.10 This evidence demonstrates a possible role for varicocelectomy to “downgrade” the type of ART required by an infertile couple or increase its success rate in a cost-effective manner. The role of varicocele repair may not necessarily be limited to the treatment of male factor infertility, as there is emerging evidence that varicocele repair can be of benefit in hypogonadal men. A series of 272 men with clinically palpable varicoceles undergoing subinguinal microsurgical varicocelectomy demonstrated a statistically significant increase in serum testosterone level for the subset of men with preoperative baseline testosterone ≤400 ng dl−1.11 One prospective study demonstrated an improvement in serum testosterone level for patients with preoperative baseline serum testosterone <300 ng dl−1 who underwent microsurgical varicocelectomy. In this study, the group undergoing microsurgical varicocelectomy also experienced improved erectile function as measured by International Index of Erectile Function-5 questionnaire.12 There remains the need for well-conducted prospective randomized controlled trials in order to provide higher-level evidence to support varicocele repair for the above-mentioned indications. The ideal trial would involve patients with palpable varicoceles and abnormal conventional semen parameters by World Health Organization criteria, well-documented preand post-treatment semen analyses, and preand post-treatment serum hormone profiles. There should be a robust mechanism for patient randomization into treatment and observation arms. Follow-up should occur for an appropriate timeframe with minimal patient attrition. Accruing patients for such studies may be difficult because of the fact that patients may not be willing to be randomized to an observation arm because of the potential delay in treatment. Assisted reproductive technologies as well as crossover to the treatment arm may aid in convincing patients to enroll. Contemporary studies with improved methodology and incorporating microsurgical techniques of varicocele repair have been increasingly optimistic regarding the benefits of varicocele repair in treating male factor infertility and hypogonadism. As prospective studies with improved methodology continue to be published and the body of literature accumulates, it is our opinion that varicocele repair will no longer remain “much ado about nothing.”

Applying translabial ultrasound to detect synthetic slings—You can do it too! A comparison of urology trainees to an attending radiologist

Translabial ultrasound (TUS) is a useful tool for identifying and assessing synthetic slings. This study evaluates the ability of urology trainees to learn basic pelvic anatomy and sling assessment on TUS.

Translabial ultrasound evaluation of pelvic floor structures and mesh in the urology office and intraoperative setting

BACKGROUND Translabial ultrasound (TUS) can provide an inexpensive alternative imaging modality for evaluating pelvic floor structures and synthetic slings as mesh can be difficult to identify on pelvic exam or cystoscopy, patients may be unable to provide an accurate history of previous pelvic surgery, and cross-sectional imaging with computed tomography and magnetic resonance imaging can be inadequate for evaluating synthetic slings. OBJECTIVE To demonstrate the use of TUS in the evaluation of female pelvic floor structures and mesh. METHODS Translabial ultrasound can be used in the Urology clinic or intraoperative setting using a curvilinear transducer. Following identification of anatomic landmarks in the various planes of the pelvic floor, TUS can evaluate for pelvic floor disorders and the type and location of synthetic mesh material. Artifacts, such as air pockets in the vagina or rectum and the hypoechoic pubic symphysis, are also considered. RESULTS Real-time imaging allows for dynamic examination of pelvic organ prolapse and urethral hypermobility that can contribute to pelvic exam findings. Bladder ultrasound can help evaluate for lesions, calculi, and even mesh erosion. Translabial ultrasound can also be used to differentiate hyperechoic retropubic and transobturator slings by identifying the position of sling arms and the appearance of the sling at different planes. Evaluation with TUS can demonstrate sling disruption, folding, urethral impingement, and erosion into pelvic floor structures. This can be particularly useful in patients presenting with pain, recurrent infections, or voiding dysfunction in which problems with mesh may not be easily identified on pelvic exam or cystoscopy. This imaging modality can complement a patients history, aid in preoperative planning, and enable intraoperative identification of mesh slings. CONCLUSION Translabial ultrasound provides a quick, readily available, and easy-to-learn imaging modality for evaluating pelvic floor structures and mesh in the office or intraoperative setting.

Do Illuminated Foot Pedals Improve the Speed and Accuracy of Pedal Activation During Endoscopic Procedures

PURPOSE Endourologic procedures such as percutaneous nephrolithotomy (PCNL) employ the use of foot pedals in low-light operating room (OR) settings. These pedals can be especially difficult to locate or distinguish when several pedals are present during a single operation. Improper instrument activation in the OR has led to serious complications ranging from unintentional electrocautery to patient burns and even an intraoperative explosion. This study evaluates the impact of color-coded illumination on speed and efficiency of foot pedal activation. MATERIALS AND METHODS During a simulated PCNL procedure, the foot pedals for a C-arm, laser, and ultrasonic lithotripter (USL) were placed in random positions. Ten participants performed pedal activation in a randomized sequence. Objective outcomes included time to instrument activation, number of attempted pedal presses, number of incomplete pedal presses, and number of incorrect pedal presses. Subjective preferences for pedal illumination were also determined. Data were analyzed using Mann-Whitney U, Wilcoxon signed-rank, and Chi-square tests with p < 0.05 indicating statistical significance. RESULTS Illuminated foot pedals were associated with decreases in the average activation time for all instruments collectively (3.95 seconds vs 6.49 seconds; p = 0.017) and individually (C-arm: 3.07 seconds vs 4.21 seconds; p = 0.006; laser: 13.04 seconds vs 15.18 seconds; p < 0.001; USL: 3.28 seconds vs 4.91 seconds; p < 0.001) compared with nonilluminated pedals. Illuminated pedals were associated with fewer attempted pedal presses (33.5 vs 39.5; p = 0.007) and incomplete pedal presses (1.5 vs 8.5; p = 0.002). The number of incorrect pedal presses decreased with illumination, but this did not reach statistical significance (0 vs 0.5; p = 0.08). Participants reported that illumination simplified pedal activation and recommended its use (p < 0.01). CONCLUSION Color-coded illumination improved the speed and efficiency of foot pedal activation during simulated PCNL. Participants subjectively preferred using illuminated foot pedals for endourologic procedures and felt that they improved safety and efficiency.

MP59-17 SUBCLINICAL RHABDOMYOLYSIS: AN UNDER-RECOGNIZED CONTRIBUTOR TO POSTOPERATIVE ACUTE KIDNEY INJURY IN PATIENTS UNDERGOING MINIMALLY INVASIVE UROLOGIC SURGERY

model (Spearman rho of 0.779) demonstrating preoperative GFR and GFR loss at 6 weeks post-op as the most important predictive factors. 10-year overall risk of NRCM was 29%. Significant predictors of NRCM were preoperative GFR, new baseline GFR, age, diabetes, and hypertension (all p<0.05). A predictive nomogram for 10-year NRCM was created with a c-index 0.71, demonstrating age and preoperative GFR as the most important predictive factors. GFR loss with surgery, as would be seen with typical PN vs. RN, only changed absolute mortality risk by 1-3% in nomogram-based examples (see Figure). CONCLUSIONS: GFR loss with RCS, which is directly related to choice of PN vs RN, strongly influences risk of developing CKD, but has much less impact on long-term survival. In contrast, age and preoperative GFR are much more robust predictors of 10year NRCM.

PD21-04 COMPARISON OF ULTRASOUND-GUIDED, CONVENTIONAL FLUOROSCOPIC, AND A NOVEL LASER DIRECT ALIGNMENT RADIATION REDUCTION TECHNIQUE FOR PERCUTANEOUS NEPHROLITHOTOMY

There was no association between patient0s CCI, age, race, insurance, hospital location (urban vs non-urban, and hospital type (teaching vs non-teaching) with regard to physician specialty obtaining RA. On multivariable analysis, RA by urologist was associated with lower rates of any complication (Clavien 1-5), shorter hospitalization (<2 days) and lower direct admission costs (<

V7-06 PERCUTANEOUS EXTERNALLY ASSEMBLED LAPAROSCOPIC (PEAL) SURGERY FOR FOWLER-STEPHENS ORCHIOPEXY: A VIDEO PRESENTATION

12,515) Figure 1. CONCLUSIONS: PCNL is performed with urologists obtaining percutaneous access the minority of the time in the United States. Highvolume urologists are more likely to obtain their own access. Access by urologist is associated with lower overall complications, shorter hospitalizations, and lower direct hospital costs.

MP40-13 THE IMPACT OF PERCEIVED STRESS AND HEALTH ON INSOMNIA IN WOMEN WITH OVERACTIVE BLADDER SYMPTOMS

METHODS: A collaborative team was formed and consisted of a pediatric urologist trained in minimally invasive and oncologic surgery as primary surgeon with an adult minimally invasive oncologic urologist as proctor. Key aspects for translation to the pediatric setting included: port placement, lower insufflation pressure, choice and size of instruments and supplies, and minimization of potential hemorrhage and ischemia with selective clamping/early unclamping technique. This approach was applied to a 14 kilogram, 3 year old female with a right lower pole lesion with cystic and solid components, concerning for malignancy. RESULTS: The mass was resected with negative margins and demonstrated benign pathology. Clamp time was 14 minutes, and EBL was minimal. There were no intraor post-operative complications. The patient’s creatinine was unchanged, and a follow-up ultrasound demonstrated no residual mass in a normal appearing right kidney. CONCLUSIONS: Collaboration of experienced pediatric and robotic teams allows for successful adaptation of adult techniques to pediatric patients. Specific considerations must be made in order to achieve safety and feasibility of RPN with selective clamping for renal preservation in cases of pediatric renal masses.