Publications by authors named "Amy E Krambeck"

171 Publications

Opioid Free Ureteroscopy: what is the true failure rate?

Urology 2021 Mar 24. Epub 2021 Mar 24.

Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL. Electronic address:

Objective: To determine the true failure rate of opioid free ureteroscopy (OF-URS) and rates of new-persistent opioid use utilizing a national prescription drug monitoring program (PDMP).

Material And Methods: We identified 239 patients utilizing our retrospective stone database who underwent OF-URS from Februrary 2018-March 2020. In Feb 2018, we initiated a OF-URS pathway (diclofenac, tamsulosin, acetaminophen, pyridium and oxybutynin). Patients who had a contraindication to NSAIDs were excluded from primary analyses. A PDMP was then utilized to determine the number of patients who failed OF-URS (defined as receipt of an opioid within 31 days of surgery) as well as rates of new-persistent opioid use (defined as receipt of opioid 91-180 days after surgery). All statistical analyses were performed using SAS 9.4. Tests were two-sided and statistical significance was set at p<0.05.

Results: We found a OF-URS failure rate of 16.6% and 14.0% in the total and opioid naïve cohorts, respectively. Rates of new-persistent opioid use were 0.9% and 1.2%, respectively (lower than published expected rate of ∼6% after URS with postoperative opioids). 91% of patients obtained opioid from alternative sources. Uni/multivariate analyses were performed for both cohorts. In the total cohort, benzodiazepine users had a lower risk of OF-URS failure on multivariate analysis. No variables were associated with OF-URS failure in the opioid naïve cohort.

Conclusion: The true failure rate of OF-URS is higher than previously thought at 16.6% and 14.0%. However, efforts to reduce opioid prescriptions with OF-URS pathways have successfully reduced new-persistent opioid use.
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http://dx.doi.org/10.1016/j.urology.2021.03.011DOI Listing
March 2021

Next generation sequencing in patients with nephrolithiasis: how does it perform compared with standard urine and stone cultures?

Ther Adv Urol 2021 Jan-Dec;13:1756287221994972. Epub 2021 Feb 22.

Department of Urology, Indiana University School of Medicine, Indianapolis, IN, USA.

Background: Our aim was to compare microorganism detection between standard culture (Ctx) and next generation sequencing (NGS) in patients undergoing surgery for nephrolithiasis; we prospectively compared both urine and stone culture results using these two techniques.

Methods: We prospectively compared microorganism detection of urine and stone cultures using Ctx NGS in patients undergoing surgery for nephrolithiasis. We analyzed preoperative voided urine (Voided) using both Ctx and NGS. Intraoperatively, renal stone (Stone) cultures were analyzed with Ctx and NGS. The primary outcome was concordance in microorganism detection between Voided Ctx and Stone NGS, as well as between Stone Ctx and Stone NGS.

Results: We prospectively evaluated 84 patients. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of Voided Ctx predicting Stone Ctx were 66.7%, 73.7%, 54.5%, and 82.4%, respectively. Concordance of Voided Ctx microorganisms to Stone microorganisms decreased when NGS was used for the Stone compared with Ctx. The sensitivity, specificity, PPV, and NPV of Voided NGS to predict Stone Ctx microorganisms were 85.2%, 24.6%, 34.8%, and 77.8%, respectively. The concordance of Voided NGS to Stone microorganisms improved when the Stone was analyzed NGS compared with Ctx.

Conclusion: NGS has a higher detection rate of microorganisms than standard culture for both preoperative urine and stone cultures. Voided NGS was the most sensitive in predicting a positive Stone sample, but the specificity and PPV were, overall, low. Further correlation of NGS microorganism detection with patient outcomes will determine which clinical situations may benefit most from NGS standard culture in patients with urinary-tract stones.
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http://dx.doi.org/10.1177/1756287221994972DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7900788PMC
February 2021

Clinical and Metabolic Correlates of Pure Stone Subtypes.

J Endourol 2021 Feb 11. Epub 2021 Feb 11.

Indiana University School of Medicine, 12250, Urology, 1801 Senate Blvd. #220, Indianapolis, Indiana, United States, 46202;

: There are multiple stone types, each forming under different urinary conditions. We compared clinical and metabolic findings in pure stone formers to understand if there are consistent factors that differentiate these groups in terms of underlying etiology and potential for empiric treatment. : Pure SFs based on infrared spectroscopic analysis of stones obtained at our institution between 01/2002 and 07/2018 with a corresponding 24-hour urinalysis were retrospectively evaluated. : 121 apatite, 54 brushite, 50 calcium oxalate dihydrate, 104 calcium oxalate monohydrate, and 82 uric acid patients were analyzed. Apatite, brushite, and calcium oxalate dihydrate patients were younger than calcium oxalate monohydrate and uric acid patients. Uric acid patients had the highest male predominance (76.8%), while apatite patients were predominantly female (80.2%). Uric acid was most associated with diabetes mellitus (45.3%), and calcium oxalate monohydrate with cardiovascular disease (27.2%) and malabsorptive gastrointestinal conditions (19.2%). Brushite patients had the highest prevalence of primary hyperparathyroidism (17%). Apatite, brushite, and calcium oxalate dihydrate patients demonstrated high rates of hypercalciuria (66.1%, 79.6%, 82%). Apatite and brushite patients had the highest urinary pH. Apatite patients exhibited the highest rate of hypocitraturia while calcium oxalate dihydrate patients exhibited the lowest (55.4%, 30%). Calcium oxalate monohydrate patients had the highest rate of hyperoxaluria (51.9%). Uric acid patients had the lowest urinary pH. There were no observable differences in the rates of hyperuricosuria or hypernatriuria. : These results demonstrate that pure stone composition correlates with certain urinary and clinical characteristics. This data can help guide empiric clinical decision-making.
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http://dx.doi.org/10.1089/end.2020.1035DOI Listing
February 2021

Same-Day Discharge Following Holmium Laser Enucleation in Patients Assessed to Have Large Gland Prostates (≥175 cc).

J Endourol 2021 Mar 17. Epub 2021 Mar 17.

Department of Urology, Northwestern University, Chicago, Illinois, USA.

Holmium laser enucleation of the prostate (HoLEP) is a highly effective and durable minimally invasive surgery for benign prostatic hyperplasia. Historically, alternative treatments for large glands (≥175 cc) are associated with prolonged length of stay (LOS) and postoperative catheterization. However, advances in laser technology combined with surgical technique optimization have early evidence supporting same-day discharge. We look to examine contemporary same-day discharge outcomes for large glands. With Institutional Review Board (IRB) approval we queried our electronic medical record and retrospective clinical registry to examine perioperative outcomes of large gland (≥175 cc) prostates that underwent HoLEP with consideration for same-day discharge. From December 10, 2019 to September 29, 2020 we identified 55 patients with a preoperative prostate size ≥175 cc (39 CT, 12 MRI, 4 transrectal ultrasound), of which 45 were scheduled for same-day discharge and 10 for admission. Mean preoperative prostate size was 229.9 cc (range 175-535 cc) and 36 (65.5%) were in urinary retention. Mean preoperative prostate-specific antigen (PSA) was 8.58 ng/mL, American Urological Association Symptom Score (AUASS) 22.3, and Qmax 8.8 mL/second. At 3 months postoperative follow-up mean AUASS was 6.7, PSA 0.87 ng/mL and Qmax 20.4 mL/second. All comer same-day discharge rate was 70% (38/55). Of patients planned for same-day discharge 38/45 (84%) were effective. Average LOS for all patients was 11.8 hours with catheterization of 21.2 hours. When compared with 2010 published large gland outcomes, our current LOS represents a 220% reduction. Looking specifically at patients planned for same-day discharge, average LOS and catheter duration was 8.8 and 17.0 hours, whereas LOS and catheter duration for patients planned for admission was 25.7 and 39.4 hours, respectively. We report the first outcomes of preoperatively planned same-day discharge for HoLEP in large glands (≥175 cc). A combination of technologic advances and optimization of technique have allowed for a safe adoption of same-day discharge, providing additional advantages over alternative large gland treatments.
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http://dx.doi.org/10.1089/end.2020.1218DOI Listing
March 2021

Challenging Case of Holmium Laser Enucleation of the Prostate after Prior Prostatic Focal Laser Ablations and Rezum.

Urology 2021 Feb 6. Epub 2021 Feb 6.

Department of Urology, Indiana University School of Medicine, Indianapolis, IN. Electronic address:

Background: Holmium laser enucleation of the prostate (HoLEP) is an effective, size independent procedure for management of benign prostatic hyperplasia (BPH). Additionally, HoLEP is able to be performed successfully after prior surgical BPH treatments without complication and a low rate of long term retreatment. OBJECTIVES: To demonstrate challenging case of HoLEP in a patient with multiple, prior ablative BPH surgeries.

Material: A 63 year old male with refractory lower urinary tract symptoms after 2 focal laser ablations, one Rezum treatment, and medications (silodosin 8 mg and tadalfil 5 mg) presented to our clinic with obstructive lateral lobe BPH. The prostate was approximately 50 ml on digital rectal exam and preoperative cystoscopy demonstrated prostatic urethral calcifications and lateral lobe hypertrophy. Preoperative AUA symptom score (AUAss) was 12, peak urinary flow was 5.3 ml/s. A HoLEP was performed to alleviate the patients lower urinary tract symptoms and allow him to stop his medications.

Results: Total procedure time was 44 minutes, with enucleation time of 20 minutes and morcellation time of 1 minute. The HoLEP was started as a 2-cut technique, however due to poor surgical planes we changed to top-down technique. There was a small, posterior, nonclinically significant capsular perforation. Five grams of benign adenoma were removed. Patient was discharged on the day of surgery. Catheter was removed on postoperative day four due to patient desiring to return home (over 150 miles away) for catheter removal, instead of having it done in our clinic on postoperative day one. At most recent follow-up, AUAss was 5 and peak urinary flow was 13.2 ml/s.

Conclusion: HoLEP can be performed after prior, multiple BPH treatments successfully. These can prove to be more challenging cases. Prior ablative techniques can lead to fibrosis of transition zone tissue and distort the natural plane between adenoma and surgical capsule.
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http://dx.doi.org/10.1016/j.urology.2021.01.046DOI Listing
February 2021

Same Day Discharge is a Successful Approach for the Majority of Patients Undergoing Holmium Laser Enucleation of the Prostate.

Eur Urol Focus 2021 Jan 4. Epub 2021 Jan 4.

Department of Urology, Indiana University School of Medicine, Indianapolis, IN, USA. Electronic address:

Background: Limited research has focused on success with hospital discharge on the same day of surgery after holmium laser enucleation of the prostate (HoLEP).

Objective: To determine the success of same-day discharge in our HoLEP cohort and factors associated with this approach.

Design, Setting, And Participants: A retrospective review of our prospectively maintained HoLEP database demonstrated that 473 adult males underwent HoLEP from July 2018 to December 2019 at a tertiary referral center and high-volume HoLEP hospital. Patients were divided into groups according to planned inpatient admission (PIA), successful same-day discharge (SDD), or unplanned admission (UA).

Outcome Measurements And Statistical Analysis: The PIA, SDD, and UA groups were assessed for differences in preoperative demographic data, perioperative surgical data, and postoperative follow-up data. SDD and UA were then compared to determine if any specific factors predicted UA, including univariate and multivariate logistic regression analyses.

Results And Limitations: Age (p = 0.0049), use of anticoagulation (p = 0.037), American Society of Anesthesiologists score of 3-4 (p = 0.0017), and enucleation time (p=0.0178) were significantly higher in the PIA group. Morcellation time (p = 0.0059) and the rate of bedside catheter irrigation (p = 0.04) were higher in the UA group. The SDD group had the highest rate of successful voiding trial (p = 0.0001). Among the three groups, there was no difference in the rate of postoperative complications (p = 0.141). In a comparison of the SDD and UA groups, morcellation time (p = 0.041), the rate of bedside clot evacuation (p = 0.004), and successful voiding trial (p = 0.003) all favored SDD. There was no difference in 90-d complications (p = 0.536). A limitation is the retrospective nature of this study.

Conclusions: HoLEP can be successfully performed as day surgery without an increase in postoperative complications. HoLEP as day surgery is possible for any patient who does not require admission for medical comorbidities.

Patient Summary: Same-day discharge (SDD) after holmium laser enucleation of the prostate (HoLEP) is possible and is successful in 87.4% of patients. Patients with longer morcellation times and with post-procedure hematuria with clots are more likely to have an unplanned admission. Use of a 120-W modulated-pulse laser resulted in a higher rate of SDD success. The culture change to day surgery is time-intensive owing to education of the postsurgical care units and clinic staff, and in our experience took approximately 9 mo to seamlessly integrate SDD as our HoLEP standard of care.
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http://dx.doi.org/10.1016/j.euf.2020.12.018DOI Listing
January 2021

A Randomized Controlled Trial of Preoperative Prophylactic Antibiotics for Percutaneous Nephrolithotomy in Moderate to High Infectious Risk Population: A Report from the EDGE Consortium.

J Urol 2021 May 28;205(5):1379-1386. Epub 2020 Dec 28.

UC San Diego Health, San Diego, California.

Purpose: Postoperative infectious related complications are not uncommon after percutaneous nephrolithotomy. Previously, we noted that 7 days of antibiotics did not decrease sepsis rates compared to just perioperative antibiotics in a low risk percutaneous nephrolithotomy population. This study aimed to compare the same regimens in individuals at moderate to high risk for sepsis undergoing percutaneous nephrolithotomy.

Materials And Methods: Patients were prospectively randomized in this multi-institutional study to either 2 days or 7 days of preoperative antibiotics. Enrolled patients had stones requiring percutaneous nephrolithotomy and had either a positive preoperative urine culture or existing indwelling urinary drainage tube. Primary outcome was difference in sepsis rates between the groups. Secondary outcomes included rate of nonseptic bacteriuria, stone-free rate and length of stay.

Results: A total of 123 patients at 7 institutions were analyzed. There was no difference in sepsis rates between groups on univariate analysis. Similarly, there were no differences in nonseptic bacteriuria, stone-free rate and length of stay. On multivariate analysis, 2 days of antibiotics increased the risk of sepsis compared to 7 days of antibiotics (OR 3.1, 95% CI 1.1-8.9, p=0.031). Patients receiving antibiotics for 2 days had higher rates of staghorn calculus than the 7-day group (58% vs 32%, p=0.006) but post hoc subanalysis did not demonstrate increased sepsis in the staghorn only group.

Conclusions: Giving 7 days of preoperative antibiotics vs 2 days decreases the risk of sepsis in moderate to high risk percutaneous nephrolithotomy patients. Future guidelines should consider infectious risk stratification for percutaneous nephrolithotomy antibiotic recommendations.
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http://dx.doi.org/10.1097/JU.0000000000001582DOI Listing
May 2021

Real-World Experience of Holmium Laser Enucleation of the Prostate with Patients on Anticoagulation Therapy.

J Endourol 2021 Jan 6. Epub 2021 Jan 6.

Department of Urology, Indiana University School of Medicine, Indianapolis, Indiana, USA.

Holmium laser enucleation of the prostate (HoLEP) is a highly effective procedure for benign prostatic hyperplasia that is size independent and has been recommended for patients necessitating antiplatelet (AP) and anticoagulant (AC) medications. Although HoLEP is feasible in AP/AC patients, there is a lack of published results on real-world outcomes of patients on AP/AC therapy undergoing HoLEP. We performed a retrospective review of our institutional HoLEP database of demographics, perioperative and postoperative data, and outcomes of patients on AP and AC therapy compared with none. We also further stratified patients on warfarin compared with direct oral anticoagulants (DOACs). Of 472 patients who underwent HoLEP at our institution from July 2018 to December 2019 with data on AP/AC drugs, 30 (6.3%) were on AP and 65 (17.2%) were on AC. One patient continued AP (3.3%), six patients (9.2%) were bridged on AC, and one patient (1.5%) continued AC through the time of HoLEP at the discretion of the prescribing provider. Preoperatively, only age was significantly different among the three groups ( < 0.001). There were no intraoperative differences. Postoperatively, there was a higher 90-day complication rate in AP and AC groups ( = 0.035), but not an increase in emergency department (ED) visits ( = 0.557) or Clavien ≥3 complications ( = 0.16). In comparison of patients on warfarin with DOAC, there was a lower rate of successful voiding trial ( = 0.009), higher 90-day complications ( = 0.003), and more ED visits ( = 0.003) in the warfarin group. HoLEP is safe and effective for patients who require AP or AC therapy. There is no increase in serious complications or worsened postoperative voiding parameters. Of patients on AC, those on DOAC have better outcomes compared with warfarin.
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http://dx.doi.org/10.1089/end.2020.0886DOI Listing
January 2021

Catheter Removal on the Same Day of Holmium Laser Enucleation of the Prostate: Outcomes of a Pilot Study.

Urology 2020 Dec 10;146:225-229. Epub 2020 Oct 10.

Department of Urology, Indiana University School of Medicine, Indianapolis, IN. Electronic address:

Objective: To determine if same day catheter removal is feasible in a select population after holmium laser enucleation of the prostate (HoLEP).

Methods: We performed an analysis of patients undergoing HoLEP at our institution who underwent same-day catheter removal after HoLEP. All HoLEPs were performed with Moses 2.0 Optimized for BPH. Patients were dismissed from postoperative recovery unit to the clinic for catheter removal and voiding trial.

Results: To date, 30 patients have undergone same day catheter removal. Median age is 68.6 years (interquartile range [IQR] 61.8-73.3) and preoperative prostate volume 81 mL (IQR 53-114.8). Median enucleation time was 39.5 minutes (IQR 30.5-53), morcellation time was 5 minutes (IQR 4-12 minutes), and enucleated specimen weight was 52.5 g (IQR 33-81). Twenty-seven (90%) patients successfully voided on the same day without requiring catheter replacement. All patients were catheter free by POD1. For patients who successfully passed their voiding trial, the median time from the end of the procedure to hospital discharge was 2.6 hours (IQR [2.1-2.9]) and from the end of the HoLEP to catheter removal was 4.9 hours (IQR [3.5-6.0]).

Conclusion: We present for the first time that same day catheter removal is a feasible option in a select population of patients undergoing HoLEP. With more study, this has the potential for transforming the management of BPH, especially larger glands.
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http://dx.doi.org/10.1016/j.urology.2020.09.038DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7547315PMC
December 2020

Multimodal imaging reveals a unique autofluorescence signature of Randall's plaque.

Urolithiasis 2021 Apr 7;49(2):123-135. Epub 2020 Oct 7.

Department of Anatomy, Cell Biology and Physiology, Indiana University School of Medicine, Indianapolis, IN, USA.

Kidney stones frequently develop as an overgrowth on Randall's plaque (RP) which is formed in the papillary interstitium. The organic composition of RP is distinct from stone matrix in that RP contains fibrillar collagen; RP in tissue has also been shown to have two proteins that are also found in stones, but otherwise the molecular constituents of RP are unstudied. We hypothesized that RP contains unique organic molecules that can be differentiated from the stone overgrowth by fluorescence. To test this, we used micro-CT-guided polishing to expose the interior of kidney stones for multimodal imaging with multiphoton, confocal and infrared microscopy. We detected a blue autofluorescence signature unique to RP, the specificity of which was also confirmed in papillary tissue from patients with stone disease. High-resolution mineral mapping of the stone also showed a transition from the apatite within RP to the calcium oxalate in the overgrowth, demonstrating the molecular and spatial transition from the tissue to the urine. This work provides a systematic and practical approach to uncover specific fluorescence signatures which correlate with mineral type, verifies previous observations regarding mineral overgrowth onto RP and identifies a novel autofluorescence signature of RP demonstrating RP's unique molecular composition.
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http://dx.doi.org/10.1007/s00240-020-01216-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7965236PMC
April 2021

Determining the true burden of kidney stone disease.

Nat Rev Nephrol 2020 12 4;16(12):736-746. Epub 2020 Aug 4.

Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA.

The incidence and prevalence of kidney stones have increased over the past four decades. However, the diagnosis of 'kidney stone' can range from an incidental asymptomatic finding of limited clinical significance to multiple painful episodes of ureteral obstruction with eventual kidney failure. Some general strategies may be useful to prevent the recurrence of kidney stones. In particular, greater attention to kidney stone classification, approaches to assessing the risk of recurrence and individualized prevention strategies may improve the clinical care of stone formers. Although there have been some advances in approaches to predicting the recurrence of kidney stones, notable challenges remain. Studies of kidney stone prevalence, incidence and recurrence have reported inconsistent findings, in part because of the lack of a standardized stone classification system. A kidney stone classification system based on practical and clinically useful measures of stone disease may help to improve both the study and clinical care of stone formers. Any future kidney stone classification system should be aimed at distinguishing asymptomatic from symptomatic stones, clinically diagnosed symptomatic stone episodes from self-reported symptomatic stone episodes, symptomatic stone episodes that are confirmed from those that are suspected, symptomatic recurrence from radiographic recurrence (that is, with radiographic evidence of a new stone, stone growth or stone disappearance from presumed passage) and determine stone composition based on mutually exclusive categories.
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http://dx.doi.org/10.1038/s41581-020-0320-7DOI Listing
December 2020

Author Reply.

Urology 2020 Aug;142:75

Indiana University School of Medicine, Department of Urology, Indianapolis, IN.

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http://dx.doi.org/10.1016/j.urology.2020.02.037DOI Listing
August 2020

AUTHOR REPLY.

Authors:
Amy E Krambeck

Urology 2020 Jun;140:33

Indiana University, Department of Urology, Indianapolis, IN.

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http://dx.doi.org/10.1016/j.urology.2019.12.043DOI Listing
June 2020

A Precision Medicine Approach Uncovers a Unique Signature of Neutrophils in Patients With Brushite Kidney Stones.

Kidney Int Rep 2020 May 20;5(5):663-677. Epub 2020 Feb 20.

Department of Medicine, Division of Nephrology, Indiana University School of Medicine, Indianapolis, Indiana, USA.

Introduction: We have previously found that papillary histopathology differs greatly between calcium oxalate and brushite stone formers (SF); the latter have much more papillary mineral deposition, tubular cell injury, and tissue fibrosis.

Methods: In this study, we applied unbiased orthogonal approaches on biopsied renal papillae and extracted stones from patients with brushite or calcium oxalate (CaOx) stones. Our goal was to discover stone type-specific molecular signatures to advance our understanding of the underlying pathogenesis.

Results: Brushite SF did not differ from CaOx SF with respect to metabolic risk factors for stones but did exhibit increased tubule plugging in their papillae. Brushite SF had upregulation of inflammatory pathways in papillary tissue and increased neutrophil markers in stone matrix compared with those with CaOx stones. Large-scale 3-dimensional tissue cytometry on renal papillary biopsies showed an increase in the number and density of neutrophils in the papillae of patients with brushite versus CaOx, thereby linking the observed inflammatory signatures to the neutrophils in the tissue. To explain how neutrophil proteins appear in the stone matrix, we measured neutrophil extracellular trap (NET) formation-NETosis-and found it significantly increased in the papillae of patients with brushite stones compared with CaOx stones.

Conclusion: We show that increased neutrophil infiltration and NETosis is an unrecognized factor that differentiates brushite and CaOx SF and may explain the markedly increased scarring and inflammation seen in the papillae of patients with brushite stones. Given the increasing prevalence of brushite stones, the role of neutrophil activation in brushite stone formation requires further study.
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http://dx.doi.org/10.1016/j.ekir.2020.02.1025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7210605PMC
May 2020

Critical Assessment of Single-Use Ureteroscopes in an Porcine Model.

Adv Urol 2020 27;2020:3842680. Epub 2020 Apr 27.

Indiana University School of Medicine, Department of Urology, 1801 Senate Blvd. Suite 220, Indianapolis, IN 46202, USA.

Methods: A female pig was placed under general anesthesia and positioned supine, and retrograde access to the renal collecting system was obtained. The LithoVue (Boston Scientific) and Uscope (Pusen Medical) were evaluated by three experienced surgeons, and each surgeon started with a new scope. The following parameters were compared between each ureteroscope: time for navigation to upper and lower pole calyces with and without implements (1.9 F basket, 200 m laser fiber, and 365 m laser fiber for upper only) in the working channel and subjective evaluations of maneuverability, irrigant flow through the scope, lever force, ergonomics, and scope optics.

Results: Navigation to the lower pole calyx was significantly faster with LithoVue compared to Uscope when the working channel was empty (24.3 vs. 49.4 seconds, < 0.01) and with a 200 m fiber (63.6 vs. 94.4 seconds, =0.04), but not with the 1.9 F basket. Navigation to the upper pole calyx was similar for all categories except faster with LithoVue containing the 365 m fiber (67.1 vs. 99.7 seconds, =0.02). Subjective assessments of scope maneuverability to upper and lower pole calyces when the scope was empty and with implements favored LithoVue in all categories, as did assessments of irrigant flow, illumination, image quality, and field of view. Both scopes had similar scores of lever force and ergonomics.

Conclusions: In an porcine model, the type of single-use ureteroscope employed affected the navigation times and subjective assessments of maneuverability and visualization. In all cases, LithoVue provided either equivalent or superior metrics than Uscope. Further clinical studies are necessary to determine the implications of these findings.
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http://dx.doi.org/10.1155/2020/3842680DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7201811PMC
April 2020

Correlating Patient Anxiety with Urinary Symptoms Before and After Holmium Laser Enucleation of the Prostate.

J Endourol 2020 07 15;34(7):782-787. Epub 2020 Jun 15.

Department of Urology, Indiana University School of Medicine, Indianapolis, Indiana, USA.

Preoperative anxiety has been shown to correlate with certain urinary symptoms in patients with certain types of voiding dysfunction, particularly overactive bladder. The purpose of this study was to evaluate if patient-reported anxiety correlates with pathologic characteristics, voiding symptoms, and objective metrics of bladder emptying in male patients undergoing holmium laser enucleation of the prostate (HoLEP). We began collecting patient-reported anxiety scores (generalized anxiety disorder 7-item or GAD-7) in addition to patient-reported scores of lower urinary tract symptoms (LUTS) and erectile dysfunction (ED) starting in November 2018 for men with LUTS due to benign prostate hyperplasia (BPH). We retrospectively evaluated the relationship between preoperative GAD-7 score with preoperative age, body mass index (BMI), preoperative urine flow metrics, preoperative postvoid residual (PVR), and preoperative symptom scores for LUTS (American Urological Association, BPH impact index [BII], and Michigan incontinence symptom index [MISI]) and ED (sexual health inventory for men and male sexual health questionnaire for ejaculatory dysfunction [MSHQ-EjD]). We then compared preoperative GAD-7 score with enucleated prostate weight, postoperative GAD-7 scores, postoperative urine flow metrics, postoperative PVR, and postoperative symptom scores for LUTS and ED. We included 139 patients for analysis. The preoperative GAD-7 score positively correlated with preoperative BII scores ( = 0.202,  = 0.019), MISI total ( = 0.260,  = 0.002), and MISI bother ( = 0.345,  < 0.001) scores. Preoperative GAD-7 negatively correlated with preoperative MSHQ-EjD ( = -0.191,  = 0.031). Following HoLEP, all four of these correlations disappear. The GAD-7 score did not correlate with age, BMI, preoperative urine flow metrics, preoperative PVR, or other preoperative LUTS and ED symptom scores. In addition, preoperative GAD-7 score showed no correlation with enucleated prostate weight, postoperative urine flow metrics, postoperative PVR, and postoperative LUTS and ED symptom scores. Higher preoperative anxiety correlated with more severe preoperative urinary LUTS, particularly incontinence symptoms, in patients undergoing HoLEP. Following HoLEP, these symptoms improve regardless of patient anxiety level.
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http://dx.doi.org/10.1089/end.2020.0114DOI Listing
July 2020

A Comparison of Perioperative Stone-Free Rates and Complications Following Unilateral, Single-Access Percutaneous Nephrolithotomy by Access Location in 767 Patients.

Urology 2020 Aug 14;142:70-75. Epub 2020 Apr 14.

Indiana University School of Medicine, Department of Urology, Indianapolis, IN.

Objective: To compare perioperative outcomes between lower, mid, and upper pole access locations for patients undergoing single-access, unilateral percutaneous nephrolithotomy (PCNL).

Methods: We queried our institutional PCNL database to include patients who had unilateral, single access procedures. We excluded patients who had a contralateral procedure during the same admission or multiaccess procedures. Patients were grouped by the site of PCNL access (lower, mid, or upper pole). Among groups, we compared postoperative day 1 (POD1) stone-free rates as measured by abdominal CT scan or plain-film X-ray and consequent need for a secondary procedure. We further compared postoperative complication rates.

Results: We included 767 patients for analysis, with the majority of access locations being in the lower pole (80.2%). Patients across groups had similar age, body mass index, and stone laterality. Patients with horseshoe kidneys more commonly had mid or upper pole access compared to lower pole. The percentage of patients with no residual stone fragments seen on POD 1 imaging was similar for lower, mid, and upper pole groups (57.7% vs 65.0% vs 61.6%, respectively; P = .526). Additionally, we observed no difference in the percentage of patients requiring a secondary procedure among the above groups (33.5% vs 22.5% vs 31.3%, respectively; P = .337). Patients experienced no difference in complications among groups.

Conclusion: When performing unilateral PCNL using a single site of access, we observed no difference in stone-free rates or complications between lower, mid, and upper pole locations. Appropriate selection of access location in PCNL should be individualized to patient factors and surgeon experience.
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http://dx.doi.org/10.1016/j.urology.2020.02.031DOI Listing
August 2020

The use of outpatient opioid medication for acute renal colic and ureteral stents: Insights from a multi-institutional patient survey
.

Clin Nephrol 2020 Jun;93(6):269-274

Aims: To investigate the main reasons for use of opioids during acute episodes of renal colic and for ureteral stent symptoms post-operatively.

Material And Methods: A survey assessing the impact of decreased quality of life and use of opioid pain medication was distributed to patients with a history of ureteral stent at seven academic centers between July 2016 and June 2018.

Results: A total of 365 surveys were completed. Opioid use for stone (63.9%) and stent-related pain (39.0%) was common among respondents. When assessing whether patients used more opioids for stone or stent-related pain, 47.7% reported using more for stone pain while 15.0% reported using more for stent pain. 22.6% of patients required opioids for stent-related pain and not stone pain. Increasing patient age was found to be negatively associated with using opioids for stent-related pain (OR: 0.4, 95% CI: 0.3 - 0.6). Increasing age was also found to be negatively associated with opioid use for stone pain (OR: 0.6, 95% CI: 0.4 - 0.8). Patients with a greater number of prior stones had 3.2 times the odds of using opioids for stone pain, in our adjusted model (95% CI: 2.1 - 4.7).

Conclusion: Patients with more prior stone episodes are more likely to have used opioids for their most recent episode. Although ureteral stents have been shown to be associated with a decreased quality of life, we showed that the use of opioids for stent-related pain is less than that for stone pain. Younger patients are less likely to tolerate a stent without opioid analgesics.
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http://dx.doi.org/10.5414/CN109991DOI Listing
June 2020

AUTHOR REPLY.

Urology 2020 02;136:271

Indiana University, Indianapolis, IN.

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http://dx.doi.org/10.1016/j.urology.2019.08.063DOI Listing
February 2020

Endoscopic-assisted robotic pyelolithotomy: a viable treatment option for complex pediatric nephrolithiasis.

J Pediatr Urol 2020 Apr 19;16(2):192.e1-192.e5. Epub 2019 Dec 19.

Riley Hospital for Children at Indiana University Health, 705 Riley Hospital Drive, Suite 4230, Indianapolis, IN, 46202, USA.

Introduction And Objective: Endourological and percutaneous approaches are the standard of care for treatment of pediatric urolithiasis. However, in certain situations, an endoscopic-assisted robotic pyelolithotomy (EARP) can be an acceptable alternative. Limited data exist on pediatric EARP; thus, the authors describe their experience.

Methods: Patient selection: The authors retrospectively analyzed the records of all robotic procedures performed at five institutions from 7/09-10/17 to identify patients who underwent EARP. The authors collected demographics data, indications, operative time, and postoperative complications. Stone composition was reported as the majority composition (≥50%), unless any uric acid or struvite was noted, and those stones were classified as such.

Technique: Through a traditional or hidden incision endoscopic surgery (HIdES) robot pyeloplasty approach, the authors are able to easily pass a flexible endoscope through a robotic trocar and into the renal collecting system to perform pyeloscopy or ureteroscopy. Stones were primarily retrieved via the pyelolotomy and, if indicated, treated with laser lithotripsy.

Results: The authors identified 26 patients who underwent EARP in 27 renal units. Median patient age was 12.2 years (interquartile range [IQR] 6.1-14.5 years), and body mass index was 17.5 kg/m (IQR 16.5-25.4 kg/m). The median pre-operative dimension of the largest stone was 9.0 mm (IQR 5.8 mm-15.0 mm). Reasons for EARP: 21 (77.8%) concomitant pyeloplasty, four (14.8%) altered anatomy precluding other techniques, and two (7.4%) multiple large stones. Multiple stones were present in 20 renal units (74.1%). Stones were located in the renal pelvis in nine (33.3%), lower pole in 10 (37.0%), ureter in one (3.7%), and multiple locations in seven (25.9%). Hidden incision endoscopic surgery approach was used in 14 (51.9%), and the median operative time was 237.5 min (IQR 189.8-357.8 min) with a median length of stay 1.0 day (IQR 1.0-2.0 days). Stone composition included calcium oxalate in 14 (51.9%), calcium phosphate in five (18.5%), cysteine in two (7.4%), struvite in two (7.4%), and unknown in four (14.8%). Overall stone free status was 19 (70.4%); of the eight (29.6%) renal units with residual stones, four underwent ureteroscopy, two extracorporeal shockwave lithotripsy (ESWL), one spontaneously passed, and one underwent percutaneous nephrolithotomy (PCNL). After secondary treatment, final stone free rate was 96.3%. Complications included stent migration and admission for urosepsis. At a median follow-up of 12 months (IQR 6.2-19.2 months), five (18.5%) had stone recurrence.

Conclusions: Endoscopic-assisted robotic pyelolithotomy is a reasonable treatment option for select pediatric patients with concomitant ureteropelvic junction obstruction and nephrolithiasis or pediatric patients with stones inaccessible by standard methods.
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http://dx.doi.org/10.1016/j.jpurol.2019.12.007DOI Listing
April 2020

Variability in stone composition and metabolic correlation between kidneys in patients with bilateral nephrolithiasis.

Int Urol Nephrol 2020 May 20;52(5):829-834. Epub 2019 Dec 20.

Department of Urology, Indiana University Health At Methodist Hospital, 1801 Senate Blvd. Suite 220, Indianapolis, Indiana, USA.

Purpose: To evaluate the clinical significance of discordant stone analyses in patients undergoing bilateral ureteroscopy.

Materials And Methods: A retrospective chart review was performed for all patients undergoing stone extraction with bilateral ureteroscopy at our institution in an aim to identify patients who had bilateral stone analysis and 24-h urine chemistry data available. Stones were then classified based upon the dominant present (> 50%). Twenty-four hour urinalysis results were reviewed and statistical analysis performed comparing discordant and concordant patient populations, assessing significant differences that would potentially influence clinical management.

Results: We identified 79 patients (158 renal units) who had bilateral stones removed at the time of ureteroscopy. The majority of stones were classified as calcium oxalate (CaOx) (60.1%) followed by calcium phosphate (CaP) (27.8%), brushite (5.1%), uric acid (UA) (4.4%), and cystine (2.5%). Discrepancies in stone classifications were present 24% of the time. Evaluation of 24-h urinalysis results demonstrated that patients with CaOx:CaP stone discordance compared to CaOx:CaOx concordant stone formers were more likely to have an elevated pH (p = 0.02) and lower uric acid supersaturation (p = 0.01).

Conclusions: Discrepancies in stone mineral content are common in patients with bilateral stone disease. A single stone analysis from one side in the setting of bilateral stone disease is insufficient for management of patients with bilateral renal stones, and may lead to mismanagement when this misrepresented information is utilized in addition to 24-h urinalysis results. At least one stone analysis should be performed from both sides during a bilateral stone extraction procedure.
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http://dx.doi.org/10.1007/s11255-019-02360-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7457141PMC
May 2020

Comparison of laser fiber degradation and perioperative outcomes following holmium laser enucleation of the prostate using 550 and 1000 µm fiber diameters.

Int Urol Nephrol 2020 Apr 20;52(4):639-644. Epub 2019 Dec 20.

Department of Urology, Indiana University School of Medicine, 1801 Senate Blvd. Suite 220, Indianapolis, IN, 46202, USA.

Objective: To compare perioperative and post-operative outcomes for holmium laser enucleation of the prostate (HoLEP) between cases performed with a 550 µm or 1000 µm fiber.

Methods: We retrospectively reviewed the most recent 50 patients undergoing HoLEP with a 550 µm fiber and the most recent 50 patients with a 1000 µm fiber. The length of exposed laser fiber after stripping was measured pre- and post-enucleation, with the difference being our primary outcome of degradation length. We compared operative and clinical characteristics between patients undergoing HoLEP using 550 and 1000 µm laser fibers.

Results: All 100 patients met inclusion for analysis. Overall, the 550 µm fiber experienced more degradation than the 1000 µm fiber (2.9 vs 1.9 cm, respectively; p = 0.01). The 1000 µm fiber utilized significantly less energy compared to the 500 µm fiber (81 vs 109 kJ, respectively; p < 0.01). In addition, operations performed with the 1000 versus the 500 µm fiber were overall shorter (79 vs 88 min, respectively; p = 0.03), although both groups had statistically similar times for enucleation (45 vs 51 min, respectively; p = 0.42) and morcellation (10 vs 9 min, respectively; p = 0.50). These findings occurred in the context of statistically similar prostate weight enucleated and bladder stones treated between groups. Post-operatively patients experienced no difference in blood loss or dysuria.

Conclusions: Use of the 1000 µm fiber resulted in significantly less fiber degradation, energy requirement, and total operative time during HoLEP, in spite of similar prostate size and time required for enucleation and morcellation. Different fiber diameters do not appear to affect post-operative blood loss or dysuria.
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http://dx.doi.org/10.1007/s11255-019-02359-zDOI Listing
April 2020

Electromagnetic Guided Percutaneous Renal Access Outcomes Among Surgeons and Trainees of Different Experience Levels: A Pilot Study.

Urology 2020 02 14;136:266-271. Epub 2019 Nov 14.

Indiana University, Indianapolis, IN.

Objective: To determine feasibility of an electromagnetic (EM) guidance system (Auris Health, Redwood City, CA) in obtaining percutaneous renal access among urologists and trainees of different experience levels. EM-guidance is appealing for access as it allows real time, 3-dimensional targeting without radiation. Few studies have explored this for percutaneous nephrolithotomy (PCNL) and none have assessed its potential to decrease the learning curve in obtaining access using traditional techniques.

Methods: Institutional Animal Care and Use Committee approval was obtained to compare EM-guided percutaneous access to fluoroscopic guided access in a porcine model. Voluntary participants included urology trainees and faculty. They were categorized as beginner (no prior primary percutaneous nephrolithotomyexperience), intermediate (10-100 prior) and advanced (>100). Each participant attempted an EM and fluoroscopic guided puncture. Primary outcome was successful puncture. Secondary outcomes included access time, fluoroscopy time, and number of attempts. Participants were limited to 3 attempts and 10 minutes total to obtain access using each technique.

Results: Fourteen participants (6 beginners, 4 intermediates, and 4 experts) attempted 28 punctures. Overall success using EM-guidance was 93% compared to 71% using fluoroscopy (P = .33). EM punctures had shorter access times (85 vs 255 seconds, P <.01) required fewer attempts (1 vs 2, P = .04) and had decreased associated fluoroscopy times (1 vs 96 seconds, P <.01) excluding the initial retrograde pyelogram and guidance of the ureteroscope to the desired calyx. Beginners showed comparable success rates and outcomes relative to experts despite higher access times.

Conclusion: EM-guidance is a promising new technique to decrease the learning curve of percutaneous access with high success rates and minimal radiation.
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http://dx.doi.org/10.1016/j.urology.2019.08.060DOI Listing
February 2020

GeoBioMed sheds new light on human kidney stone crystallization and dissolution.

Nat Rev Urol 2020 Jan;17(1):1-2

Carl R. Woese Institute for Genomic Biology, University of Illinois at Urbana-Champaign, Urbana, IL, USA.

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http://dx.doi.org/10.1038/s41585-019-0256-5DOI Listing
January 2020

Treatment of non-obstructive, non-struvite urolithiasis is effective in treatment of recurrent urinary tract infections.

World J Urol 2020 Aug 23;38(8):2029-2033. Epub 2019 Oct 23.

Department of Urology, Mayo Clinic, Rochester, MN, USA.

Purpose: To determine if treatment of non-obstructing urolithiasis is effective in management of recurrent UTI.

Materials And Methods: A retrospective review was performed of patients undergoing elective management of non-struvite upper tract urinary calculi with recurrent UTI from 2009 to 2016. Recurrent UTI was defined at ≥ 3 UTI in 12 months, with symptoms and documented urine culture. Preoperative CT was performed in all patients to determine stone burden. All patients had postoperative imaging and ≥ 12 months of follow-up. Pre- and postoperative variables were between patients who had recurrent UTI after treatment versus those who did not.

Results: 46 patients met inclusion criteria. 42 (91.3%) were female. Median age was 63.7 years (IQR 49.1, 73.4) and median total stone burden was 20 mm (IQR 14-35). Within the cohort, 20 (43.5%) underwent ureteroscopy only, 26 (56.5%) underwent PCNL ± URS, and none underwent ESWL. Median postoperative follow-up was 2.9 years (IQR 2.0, 4.3). Only five patients (10.9%) had recurrent UTI after treatment. 80% were with the preoperative pathogen. The presence of residual stone was an independent risk factor for recurrent UTI after treatment (p < 0.046). Diabetes, hypertension, immunosuppression and chronic kidney disease were not.

Conclusions: Stone removal for patients with recurrent UTIs was associated with a high rate of success (89.1%) in elimination of further recurrent UTIs. Residual fragments are independently associated with persistent recurrent UTIs and thus, complete stone removal is of paramount importance in treatment of this patient population.
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http://dx.doi.org/10.1007/s00345-019-02977-3DOI Listing
August 2020

Initial Clinical Experience with Swiss LithoClast Trilogy During Percutaneous Nephrolithotomy.

J Endourol 2020 02 12;34(2):151-155. Epub 2019 Nov 12.

Department of Urology, Indiana University School of Medicine/IU Health Physicians, Indianapolis, Indiana.

Current available lithotrites have clinical stone clearance rates averaging 24 to 32 mm/minute. The objective of this study was to critically evaluate the initial experience with the Swiss LithoClast Trilogy lithotrite during percutaneous nephrolithotomy (PCNL). We prospectively enrolled patients with a minimum of 15 mm of stone in axial diameter at three locations (Indiana University, University of California Davis, and University of California San Diego) scheduled to undergo PCNL for nephrolithiasis over a 60-day trial period. We assessed objective measures of stone clearance time, stone clearance rate, device malfunction, stone-free rate, and complications. Each surgeon also evaluated subjective parameters from each case related to the use of Trilogy on a 1 to 10 scale (10 = extremely effective), and compared it with their usual lithotrite on a 1 to 5 scale (5 = much better). We included 43 patients and had 7 bilateral (16.3%) cases, for a total of 50 renal units. One case was a mini-PCNL. Two cases experienced device malfunctions requiring troubleshooting but no transition to another lithotrite. The mean stone clearance rate was 68.9 mm/minute. The stone-free rate on postoperative imaging was 67.6% (25 of 37 patients with available imaging). The lowest subjective rating was the ergonomic score of 6.7, and the highest subjective rating was the ease of managing settings score of 9.2. The surgeon impressions of ultrasound (7.3), ballistics (8.1), combination of ultrasound and ballistics (8.7), and suction (8.4) were high. One patient experienced an intraoperative renal pelvis perforation, one patient required a blood transfusion, one patient had a pneumothorax requiring chest tube placement, and one patient had a renal artery pseudoaneurysm requiring endovascular embolization. This multi-institutional study evaluated a new and efficient combination lithotrite that was perceived by surgeons to be highly satisfactory, with an excellent safety and durability profile.
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http://dx.doi.org/10.1089/end.2019.0561DOI Listing
February 2020

Percutaneous Nephrolithotomy in the 80 Years of Age and Older Population.

Urology 2019 Dec 16;134:62-65. Epub 2019 Sep 16.

Department of Urology, Indiana University/IU Health Physicians, Indianapolis, IN. Electronic address:

Objective: To evaluate feasibility of percutaneous nephrolithotomy (PCNL) for complex nephrolithiasis in patients 80 years of age and older compared to younger individuals.

Methods: From an institutional IRB-approved database, 1,647 patients were identified who underwent PCNL from 1999 to 2019. Patients were stratified by age: group 1 (20-59), group 2 (60-79), and group 3 (>80). Statistics were performed using chi-square and ANOVA to compare outcomes.

Results: Of the 1,647 patients, median age was 46, 66, and 83, respectively (P <0.0001). Three patients within group 3 were 90 or older. Females made up 54%, 46%, 56% of patients (P = 0.02). Average stone size with SD was 2.6 ± 2.2, 2.5 ± 2.3, 2.2± 1.9 cm for each group (P = 0.06). Mean preoperative hemoglobin (Hgb) was significantly lower in the 80+ group (13.8, 13.4, 13.1 g/dL, P <.0001). Change in Hgb was not significantly different. There were more Clavien II-IV complications (10.4, 14.4, 28.8%; P = 0.02) and transfusions (2.3, 4.7, 10.2%; P <0.001) in the elderly. The most common complications in the 80+ group were bleeding related (10.1%). No difference in readmission rates or ICU admissions was noted.

Conclusion: PCNL is feasible in the extremely elderly; however with a higher rate of complications and longer hospitalizations. No long-term sequelae or deaths in the 80 and older cohort were seen. This study allows us to appropriately counsel older patients on a realistic postoperative course and supports use of PCNL as the best means of long-term survival.
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http://dx.doi.org/10.1016/j.urology.2019.08.044DOI Listing
December 2019

Emerging Technologies in Lithotripsy.

Urol Clin North Am 2019 May 4;46(2):215-223. Epub 2019 Mar 4.

Department of Urology, Indiana University, Methodist Hospital, 1801 Senate Boulevard, Suite 220, Indianapolis, IN 46202, USA. Electronic address:

This comprehensive review updates the advances in extracorporeal lithotripsy, including improvements in external shockwave lithotripsy and innovations in ultrasound based lithotripsy, such as burst wave lithotripsy, ultrasonic propulsion, and histotripsy. Advances in endoscopic technology and training have changed the surgical approach to nephrolithiasis; however, improvements and innovations in extracorporeal lithotripsy maintain its status as an excellent option in appropriately selected patients.
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http://dx.doi.org/10.1016/j.ucl.2018.12.012DOI Listing
May 2019

Understanding, justifying, and optimizing radiation exposure for CT imaging in nephrourology.

Nat Rev Urol 2019 04;16(4):231-244

Department of Radiology, Mayo Clinic, Rochester, MN, USA.

An estimated 4-5 million CT scans are performed in the USA every year to investigate nephrourological diseases such as urinary stones and renal masses. Despite the clinical benefits of CT imaging, concerns remain regarding the potential risks associated with exposure to ionizing radiation. To assess the potential risk of harmful biological effects from exposure to ionizing radiation, understanding the mechanisms by which radiation damage and repair occur is essential. Although radiation level and cancer risk follow a linear association at high doses, no strong relationship is apparent below 100 mSv, the doses used in diagnostic imaging. Furthermore, the small theoretical increase in risk of cancer incidence must be considered in the context of the clinical benefit derived from a medically indicated CT and the likelihood of cancer occurrence in the general population. Elimination of unnecessary imaging is the most important method to reduce imaging-related radiation; however, technical aspects of medically justified imaging should also be optimized, such that the required diagnostic information is retained while minimizing the dose of radiation. Despite intensive study, evidence to prove an increased cancer risk associated with radiation doses below ~100 mSv is lacking; however, concerns about ionizing radiation in medical imaging remain and can affect patient care. Overall, the principles of justification and optimization must remain the basis of clinical decision-making regarding the use of ionizing radiation in medicine.
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http://dx.doi.org/10.1038/s41585-019-0148-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6447446PMC
April 2019

Stone-free Outcomes of Flexible Ureteroscopy for Renal Calculi Utilizing Computed Tomography Imaging.

Urology 2019 Feb 2;124:52-56. Epub 2018 Nov 2.

Indiana University School of Medicine, Department of Urology, Indianapolis, IN. Electronic address:

Objective: To assess stone-free rates following ureteroscopy (URS) for renal calculi at our institution using low-dose renal only computed tomography (CT).

Methods: A retrospective review of patients undergoing flexible URS for renal stones only with subsequent CT scan within 3 months. Meticulous basketing of all stone fragments was performed whenever possible. A "true" zero-fragment stone-free rate was determined by reviewing the CT scan and radiologist's report. Patients with nephrocalcinosis (as determined by visual inspection of papilla at the time of URS) were assigned the "stone-free" category.

Results: Flexible URS was performed in 288 renal units of 214 patients with renal calculi from 2013 to 2016. Median preoperative stone size was 6.2 mm with the average kidney containing 6.4 stones. An access sheath was used in 92% of cases. A total of 73% (209/288) renal units were completely stone free by CT assessment. Patients with residual fragments were as follows: 1 mm in 2% (7/288), 2-4 mm in 16% (46/288), and >4 mm in 9% of kidneys (26/288).

Conclusion: The true stone-free rate in patients undergoing flexible URS for renal calculi utilizing active basketing of fragments as determined by strict CT assessment was 73%. In patients with residual fragments, the majority are 2-4 mm in size making URS a treatment option for renal calculi with excellent stone-free results.
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http://dx.doi.org/10.1016/j.urology.2018.09.005DOI Listing
February 2019