Necole M. Streeper

The significance of lymphovascular invasion in transurethral resection of bladder tumour and cystectomy specimens on the survival of patients with urothelial bladder cancer

To test the hypothesis that patients with bladder cancer who had evidence of lymphovascular invasion (LVI) in their transurethral resection of bladder tumour (TURBT) and radical cystectomy (RC) specimens would have a worse prognosis and higher likelihood of clinical understaging, and to assess the effect of LVI discovered at RC on subsequent disease‐related mortality, as the prognostic significance of LVI in TURBT or RC specimens of patients treated for urothelial carcinoma of the bladder is not completely established.

Thermoregulatory behavior in infant Norway rats (Rattus norvegicus) and Syrian golden hamsters (Mesocricetus auratus): arousal, orientation, and locomotion.

The responses of 2- and 8-day-old rats (Rattus norvegicus) and hamsters (Mesocricetus auratus) to thermal stimulation were assessed in 4 experiments. In Experiment 1, the surface underlying the pup was cooled, and the latency to escape to a region of warmth was measured. Experiment 2 required pups to locomote farther to gain access to warmth. Experiment 3 was similar to Experiment 1 except the underlying surface was heated. Finally, in Experiment 4, locomotor behavior was assessed during isothermal cooling in which there was no possibility for escape. In general, hamsters exhibited more rapid and robust responses to thermal stimulation than rats. A framework for interpreting these results is presented emphasizing how differences in locomotor and thermogenic capabilities influence thermoregulatory behavior under different task conditions.

Microscopic haematuria at time of diagnosis is associated with lower disease stage in patients with newly diagnosed bladder cancer

To determine whether the severity of haematuria (microscopic or gross) at diagnosis influences the disease stage at presentation in patients diagnosed with bladder cancer.

Percutaneous Nephrolithotomy in Patients With BMI >50: Single Surgeon Outcomes and Feasibility

OBJECTIVE To evaluate the use of percutaneous nephrolithotomy (PNL) and technical approach in the super obese population (body mass index [BMI] ≥ 50). MATERIALS AND METHODS We performed a retrospective review of 31 consecutive PNL cases with a BMI > 50 from a single surgeon (SYN) from 1995 to 2013. Procedures were performed in the prone position, and upper pole access was used. Operative time, length of hospital stay, stone burden, complication rates, and stone-free rates were measured. RESULTS Of the 31 patients who underwent PNL (age 51.2 ± 12; 71% female), the mean BMI was 59.1 ± 6 kg/m(2) (range 50.4-71.7 kg/m(2)). Mean stone burden was 3.8 cm ± 2. The majority of patients (90.3%) had an upper pole puncture site for access with an operative time of 122.1 ± 75 minutes. The technique was similar to non-obese patients; however, there was a need for extra-long instrumentation. The overall stone-free rate was 71%, with utilization of a second-look PNL in 11 cases. The complication rate, Clavien grade 3 or higher, was 9.7% (3 of 31). CONCLUSION PNL is technically feasible, safe, and effective in patients with a BMI ≥ 50. The complication rate, length of hospital stay, and stone-free rate with use of second-look PNL in super obese patients are comparable to severely obese patients. Intervention should not be automatically ruled out or delayed based on the patients BMI alone.

Using Behavior Change Techniques to Guide Selections of Mobile Applications to Promote Fluid Consumption

OBJECTIVE To determine the extent to which validated techniques for behavior change have been infused in commercially available fluid consumption applications (apps). MATERIALS AND METHODS Coders evaluated behavior change techniques represented in online descriptions for 50 fluid consumption apps and the latest version of each app. RESULTS Apps incorporated a limited range of behavior change techniques (<20% of taxonomy). The number of techniques varied by operating system but not as a function of whether apps were free or paid. Limitations include the lack of experimental evidence establishing the efficacy of these apps. CONCLUSION Patients with urolithiasis can choose from many apps to support the recommended increase in fluid intake. Apps for iOS devices incorporate more behavior change techniques compared to apps for the Android operating system. Free apps are likely to expose patients to a similar number of techniques as paid apps. Physicians and patients should screen app descriptions for features to promote self-monitoring and provide feedback on discrepancies between behavior and a fluid consumption goal.

Preliminary Evidence Suggests Periureteral Botulinum Toxin Type A Injection Improves Ureteral Stone Passage in the Porcine Model.

PURPOSE We evaluated the use of periureteral injection of botulinum toxin type A (Botox(®), BTX-A) to facilitate passage of ureteral stones in a porcine model. We believe that reducing detrusor muscle tone around the intramural ureter may facilitate passage of ureteral stones through the ureterovesical junction. MATERIALS AND METHODS With complete Institutional Animal Care and Use Committee approval, artificial stones (BegoStone plus) were placed by retrograde ureteroscopy into the proximal ureter using fluoroscopic guidance using an in-vivo porcine model. Six animals underwent periureteral BTX-A injection 30 U/mL to three locations around the ureteral orifice, and six animals were in the control group undergoing periureteral injection of physiologic saline. RESULTS There was a significant decrease in time to stone passage in the BTX-A group compared with the control group, 2.6 ± 1.3 vs 6.8 ± 2.9 days, respectively (p = 0.018). None of the animals had evidence of vesicoureteral reflux postprocedure (N = 0/12). CONCLUSIONS Preliminary results suggest that periureteral injection of BTX-A facilitates ureteral stone passage in this model. BTX-A may provide a simple, office-based endoscopic treatment option for ureteral stones. Further studies would be necessary to evaluate its efficacy in humans compared with traditional medical expulsive therapy.

PD37-12 PATIENTS PREFER THE USE OF A PATIENT DECISION-MAKING AID WHEN DISCUSSING SURGICAL OPTIONS FOR NEPHROLITHIASIS

METHODS: The magnetic Blackstar DJ is a 7 french ureteral stent with a small magnet fixed with a string at the distal DJ loop. To remove the DJ a customized catheter with a magnetic Tiemann tip is used. The catheter is inserted after transurethral application of a standard lubricant and removed with the DJ after getting in contact with the DJ’s magnet. The study was approved by local ethics committee. We placed the magnetic DJ in 20 consecutive patients after ureteroscopy for stone removal. No additional foley catheter was placed. The DJ was removed the next day with the magnetic retrieval catheter either by a physician or a nurse. Retrieval time, patient comfort and feasibility of the retrieval device were assessed. RESULTS: The DJ could be removed with the retrieval device within less than 30 seconds in 19 out of 20 patients. In the first patient the removal was not successful due to an enlarged prostate middle lobe. For this patient a cystoscopical removal was needed. In the second patient the removal was performed under fluoroscopic control to ensure save handling of the retrieval device by the surgeon. In all other patients the removal of the catheter was performed in the patients room on the ward. CONCLUSIONS: The removal of the magnetic DJ using the retrieval device is fast and easy and can be performed by physicians as well as nurses. The patients didn’t complain about a lot of discomfort during the removal. This technique might lead to significant cost reduction compared to the standard cystoscopical removal of ureter stents with sterile instruments in the endourological operation room. Our feasibility study indicates this magnetic DJ to significantly reduce patient’s discomfort by DJ removal and therefore seems to be a promising new device for endourologists.

Shared Decision Making for Urolithiasis: The Use of a Patient Decision Making Aid

Introduction: Patients desire an active role in health care decisions. We evaluated whether a patient decision making aid is useful when considering surgical treatment for urolithiasis. Methods: Patients with a history of urolithiasis were recruited for study. They were asked to consider a hypothetical case of an asymptomatic 10 mm proximal ureteral stone for which elective surgical intervention was recommended. Shock wave lithotripsy and ureteroscopy were presented as potential options. A patient decision making aid was developed to explain and compare the options. A urologist presented the information to the patients, once using the patient decision making aid and then without the aid. We assessed participant satisfaction with each format, and invited comments about the aid and its content, design and clarity. Results: Mean ± SD age of the 4 male and 10 female participants was 61 ± 9 years. Of the participants 86% found the patient decision making aid helpful but identified areas for improvement. Specifically, patients wanted more information on stent placement, stent discomfort, long‐term effects and cost. Of the participants 79% reported that the aid improved their understanding of the treatment options compared to the session without the aid. While 8 of 14 participants preferred hearing surgeon recommendations, most still reported value in the patient decision making aid. Conclusions: Patient decision making aids are increasingly used in the management of several diseases and they require patient input into development. In our study the aid improved patient self‐reported understanding of surgical options for ureteral stone removal. Notably, most participants still preferred to make decisions based on the surgeon recommendation. Modification of the patient decision making aid based on patient suggestions will enhance its usefulness and applicability in the clinical setting.

Difficult Case: Ureteral Stricture Distal to a Stone

Ureteral stricture is a late complication of ureteroscopy (URS) and can be challenging to treat stones when present concomitantly. Ureteral stones may fail to spontaneously pass secondary to a distally located ureteral stricture. Retrograde access may be difficult or unable to be obtained depending on the degree of the stricture and presence of stone impaction. This chapter will focus on the treatment options for a ureteral stone with a distal ureteral stricture.

Ureteroscopy for Treatment of Calculi

The focus of this chapter is on the indications, technical considerations, and complications of ureteroscopy for both renal and ureteral calculi. When making decisions about treatment of both renal and ureteral calculi, it is important to take the following into consideration: probability of stone-free rate, need for additional procedures, and morbidity related to the treatment modality. We will discuss in detail the indications for each of the treatment modalities that are considered for both renal and ureteral calculi including: ureteroscopy (URS) with intracorporeal lithotripsy, extracorporeal shock wave lithotripsy (ESWL), and percutaneous nephrolithotomy (PCNL). Discussion will include treatment decisions based on the following stone characteristics: size, location, and Hounsfield unit (HU) density to suggest potential stone composition. During surgical planning, it is also important to consider the following patient characteristics: children, pregnancy, coagulopathies or bleeding disorders, and patient body habitus. In addition, we will discuss technical considerations including specifications of current available flexible ureteroscopes and lithotripters. The last section of the chapter will review the possible complications from ureteroscopy including: bleeding, infection, ureteral stent discomfort, ureteral injury, need for secondary treatment, renal damage, and ureteral stricture.