Piruz Motamedinia

The Expanded Use of Percutaneous Resection for Upper Tract Urothelial Carcinoma: A 30-Year Comprehensive Experience

INTRODUCTION The gold standard treatment for upper tract urothelial carcinoma (UTUC) is radical nephroureterectomy (RNU). The role of endoscopic resection is limited to low-risk patients. In this study, we present our 30-year experience in the endoscopic management of UTUC. METHODS In this retrospective study, we identified 141 patients who underwent percutaneous UTUC resection. Demographic and clinical data were collected, including tumor characteristics, bacillus Calmette-Guérin (BCG) and mitomycin use, tumor recurrence, progression to RNU, and overall survival (OS), and compared in univariate and multivariate analyses. RESULTS Median follow-up was 66 months. Recurrence occurred in 37% of low-grade patients and 63% of high-grade (HG) patients, with a median time to recurrence of 71.4 vs 36.4 months, respectively. Grade was the only predictor of recurrence (HR 2.12, p = 0.018). The latest time to recurrence occurred after 116 months of surveillance. RNU was avoided by 87% of patients. Age, imperative indications for endoscopy, a history of bladder cancer, and tumor stage and grade were predictors of OS; however, in multivariate analysis, grade and stage lost significance. BCG and mitomycin did not protect against recurrence, progression to RNU, or death over resection alone. CONCLUSION Percutaneous management of UTUC allows for renal preservation in the majority of patients with resectable disease. Patients with HG tumors are more likely to experience recurrence, but are not at an increased risk of death. Intraluminal BCG and mitomycin continue to have a limited adjuvant role to resection. Recurrence may occur many years following initial resection and therefore prolonged surveillance is advised.

The effect of intraluminal content on the bursting strength of vessels ligated with the harmonic ACE and LigaSure V.

PURPOSE Energy-based surgical devices (ESDs) are critical for maintaining hemostasis during laparoscopy; however, there are no studies that have evaluated the function of ESDs under different physiologic conditions. We evaluated the effect of intraluminal vessel content on bursting pressure (BP) after ligation with two ESDs: the Harmonic ACE and the LigaSure V. MATERIALS AND METHODS Bursting trials were performed on the vasculature of 24 pigs. Blood vessels were distended with blood of different hematocrit concentrations or an albumin solution of varying protein content. The vessel size and BP of each vessel was recorded after ligation with each ESD. RESULTS In arteries 0 to 3 mm and veins 0 to 3 mm in size ligated with the Harmonic ACE or the LigaSure V, there were significantly elevated vessel BPs with supraphysiologic intraluminal hematocrits. In arteries and veins ligated with the Harmonic ACE, increasing albumin concentrations also led to increasing BPs, though these maximal BPs were lower than those obtained with supraphysiologic hematocrit levels. Increasing albumin concentrations did not increase the BP of the LigaSure V. Within the ranges tested, there was no decrease in vessel BP associated with anemia. CONCLUSION In small vessels, a supraphysiologic hematocrit increased the BP of both arteries and veins when using the Harmonic ACE or the LigaSure V. With the devices tested, anemia did not seem to affect BP. While factors such as intraluminal protein concentration may play a role with ultrasonic energy devices, the mechanism of the increased BP remains unclear. Better understanding of ESDs will help in the design of future devices.

Erythropoietin-induced optimization of renal function after warm ischemia.

BACKGROUND AND PURPOSE Recent preclinical data have indicated that erythropoietin (Epo) can protect organs from ischemic damage. We evaluated the ability of Epo to protect the kidney from the effects of ischemia. METHODS Thirty dogs underwent a laparoscopic nephrectomy and were allowed to recover for 2 weeks. The dogs were then divided into five groups. Animals in groups 1 and 2 underwent 1.5 hours of abdominal insufflation with placebo (saline) injection (group 1) or Epo injection (group 2) before; groups 3 to 5 underwent 1 hour of laparoscopic renal artery clamping after placebo injection (group 3), Epo injection (group 4), or mannitol injection (group 5). Serum evaluations and 24-hour urine collections were performed weekly. After 28 days, the animals were sacrificed. Statistical analysis was performed with the Kruskal-Wallis test. RESULTS After recovery from the initial nephrectomy, all dogs had similar serum hematocrit and creatinine levels. Hematocrit was not significantly affected by Epo administration at any time point. Immediately after the second surgery, dogs that underwent renal artery clamping (groups 3-5) had significantly lower 24-hour urine creatinine levels than those that were not clamped (groups 1-2). After 4 weeks of recovery, the dogs that had received Epo before ischemia (group 4) had recovered significantly more renal function than the dogs that received placebo or mannitol before ischemia (urine creatinine level = Epo 149.1 mg/dL v placebo 70.7 mg/dL v mannitol 80.7 mg/dL). At sacrifice, microalbuminuria was also significantly less in dogs receiving Epo before ischemia than their mannitol or placebo counterparts. CONCLUSION The current study demonstrates that administering Epo before warm ischemia can improve the recovery of renal function after ischemia better than placebo or mannitol.

Update on technological and selection factors influencing shockwave lithotripsy of renal stones in adults and children.

Purpose of review The aim of this review is to evaluate recently published peer reviewed literature on the subject of shockwave lithotripsy. Recent findings Based on in-vitro animal studies, escalating voltage results in better stone comminution and ultimately applies less total voltage to the surrounding tissue, theoretically causing less harm. Several studies have also shown that a slower shockwave rate improves stone fragmentation for intrarenal stones. Stones measuring greater than 1000 HU require a significantly greater number of shocks to destroy. The current literature continues to support shockwave lithotripsy as both a safe and effective means for managing stone disease in pediatric patients. Medical expulsive therapy with alpha-blockers appears to be efficacious, shortening the time to stone and fragment expulsion as well as minimizing pain. Skin-to-stone distance, Hounsfield units, stone size, and location are the best studied and most validated parameters that correlate with shockwave lithotripsy success. Summary Shockwave lithotripsy continues to evolve with the advent of better technology, improved imaging, and the development of several parameters that can be used to predict success, to counsel our patients, and improve stone-free rates.

Can Activities of Daily Living Predict Complications following Percutaneous Nephrolithotomy

PURPOSE Activities of daily living provide information about the functional status of an individual and can predict postoperative complications after general and oncological surgery. However, they have rarely been applied to urology. We evaluated whether deficits in activities of daily living could predict complications after percutaneous nephrolithotomy and how this compares with the Charlson comorbidity index and the ASA(®) (American Society of Anesthesiologists(®)) classification. MATERIALS AND METHODS We retrospectively reviewed the records of all patients who underwent percutaneous nephrolithotomy between March 2013 and March 2014. Those with complete assessment of activities of daily living were included in analysis. Perioperative outcomes, complications and hospital length of stay were examined according to the degree of deficits in daily living activities. RESULTS Overall 176 patients underwent a total of 192 percutaneous nephrolithotomies. Deficits in activities of daily living were seen in 16% of patients, including minor in 9% and major in 7%. Complications developed more frequently in those with vs without deficits in daily living activities (53% vs 31%, p = 0.029) and length of stay was longer (2.0 vs 4.5 days, p = 0.005). On multivariate logistic regression activities of daily living were an independent predictor of complications (OR 1.11, p = 0.01) but ASA classification and Charlson comorbidity index were not. CONCLUSIONS Activities of daily living are easily evaluated prior to surgery. They independently predict complications following percutaneous nephrolithotomy better than the Charlson comorbidity index or the ASA classification. Preoperative assessment of daily living activities can help risk stratify patients and may inform treatment decisions.

A Case for Nephron Sparing Surgery in the Management of Upper Tract Urothelial Carcinoma

Upper tract urothelial carcinoma (UTUC) is rare and its management presents many challenges. Outside of distal ureterectomy for select cases, management has been primarily radical nephroureterectomy. Endoscopic nephron sparing management (NSM) is recognized to have some role in UTUC treatment; however, it is yet to gain firm footing in the treatment algorithm. In this review, we discuss the benefits of NSM with regards to oncologic outcomes, renal function preservation, and cost savings. Finally, we propose recognition of endoscopic NSM as a first-line treatment in selected patients with low risk disease.

Perioperative cultures and the role of antibiotics during stone surgery

Urinary tract infection and urosepsis are the most common complications associated with the procedures urologists employ to manage stone disease. Recommendations regarding antibiotic prophylaxis and utilization of perioperative urine and stone culture prior to shockwave lithotripsy (SWL) or endoscopic intervention have evolved overtime. We sought to provide readers with a comprehensive consensus regarding these most recent recommendations.

Variation in National Opioid Prescribing Patterns Following Surgery for Kidney Stones

Background Opioid misuse is a significant public health problem. As initial exposures to opioids are frequently encountered through the management of postoperative pain, we examined patterns of opioid prescribing following surgical treatment for nephrolithiasis. Methods We identified patients with nephrolithiasis in the national Women Veterans Cohort Study (WVCS) who were treated surgically by diagnosis and procedure codes. Using standard conversion factors, we calculated the morphine milligram equivalent (MME) dose prescribed. We used descriptive statistics to characterize opioid prescription across management strategy and multivariable regression to examine clinical and demographic characteristics associated with dispensed dose. Results We identified 22,609 patients diagnosed with kidney stones during 1999-2014, 1,976 of whom were treated surgically and 1,582 (80.1%) of whom received an opioid prescription. The median age was 39 years, and 1,366 (90%) were male; 1,314 (86.3%) were treated with ureteroscopy, 172 (11.3%) with extracorporeal shockwave lithotripsy, and 36 (2.4%) with percutaneous nephrolithotomy. The median number of days supplied per opioid prescription (interquartile range) was 10 (5-14), and patients were dispensed a median of 180 (140-300) MME. A total of 6.4% of patients received ≥50 MME/d. On multivariable analysis, comorbid diagnosis of post-traumatic stress disorder (PTSD) was associated with higher total dispensed dose, whereas surgery type was not. Conclusions We observed substantial variation in opioid prescribing following surgical treatment of nephrolithiasis. Although type of surgical intervention did not impact opioid dosing, patients with a diagnosis of PTSD were more likely to receive higher doses. This work can inform efforts to improve the safety and efficacy of postoperative opioid prescribing.

PD35-04 PROSPECTIVE RANDOMIZED TRIAL OF ANTIBIOTIC PROPHYLAXIS DURATION FOR PERCUTANEOUS NEPHROLITHOTOMY: PRELIMINARY RESULTS

INTRODUCTION AND OBJECTIVES: Single institution studies have suggested possible benefit of a week of preoperative antibiotics prior to percutaneous nephrolithotomy (PNL). Yet prior studies are limited by lower methodology (Level IIa)1, including heterogeneous populations2, or utilizing quasi-sepsis definitions2. Other than the recommended peri-operative dose of IV antibiotics <24 hours per AUA Best Practice Statement, the duration/benefit of preoperative antibiotics remains unclear. We sought to perform a rigorous (adhering to CONSORT guidelines) multi-institutional trial assessing utility of preoperative PNL antibiotics for patients at low risk of infectious complications. METHODS: We performed a randomized controlled trial (RCT) coordinated across 7 academic stone centers for low risk PNL patients. Low risk patients were defined as those with negative urine cultures and under no antibiotic treatment course within 14 days of procedure, and without any urinary drains (catheters, stents, nephrostomy tubes). Patients randomized to the intervention arm received nitrofurantoin 100 mg twice daily for 7 days preceding surgery. All enrolled patients received standard preoperative dose of ampicillin (vancomycin if allergic) and gentamicin (ceftriaxone if eGFR<60 or allergic). PNL was performed per the usual practice of each treating surgeon. Baseline patient and stone characteristics were recorded. Perioperative infection related adverse events within the first 30 days were compared in both groups. RESULTS: Thirty-four patients were randomized to each arm. Adverse events occurring within the first 30 days of procedure are reported in Table 1. The infection rate after PNL in the intervention arm was 17.6% (6/34) versus 11.8% (4/34), p1⁄40.49. Two of the patients in the intervention arm with infectious complications needed readmission and two others required admission to the intensive care unit. Total length of hospital stay demonstrated no difference between the two groups (1.09 versus 1.47, p1⁄40.2). There was no mortality reported during this study period. CONCLUSIONS: There appears to be no advantage to providing one week of preoperative oral antibiotics in patients at low risk for infectious complications. Less than 24 hours peri-operative antibiotics as per AUA Best Practice Statement appears sufficient. We continue to analyze this low risk group with a more robust data set, as well as analyze preoperative antibiotic benefit in other stratified risk groups. 1. Mariappan et al. BJU Int 2006 2. Kumar et al. Urol Res 2012

Unsuspected Malignancy During Percutaneous Nephrolithotomy: The Snake in the Grass.

Abstract Squamous cell carcinoma of the upper tract (SCC-UT) is a rare neoplasm that disproportionately affects patients with longstanding nephrolithiasis. Diagnosis is challenging and typically comes at late stages; as such, the prognosis is poor. The absence of a reliable diagnostic predictor for SCC highlights the need to keep the diagnosis in mind for at-risk patient populations. In this study, we describe a small case series of rapidly progressive SCC-UT incidentally discovered during percutaneous nephrolithotomy.