Publications by authors named "Tim Large"

35 Publications

Multi-institutional Prospective Randomized Control Trial of Novel Intracorporeal Lithotripters: ShockPulse-SE vs TrilogyTM Trial.

J Endourol 2021 Apr 11. Epub 2021 Apr 11.

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

Introduction: Currently, there are multiple intracorporeal lithotripters available for use in percutaneous nephrolithotomy (PCNL). This study aimed to evaluate the efficiency of two novel lithotripters; TrilogyTM and ShockPulse-SE.

Methods: This is a prospective, multi-institutional, randomized trial comparing outcomes of PCNL using two novel lithotripters between February 2019 and June 2020. The study assessed objective measures of stone clearance time, stone clearance rate, device malfunction, stone-free rates, and complications. Device assessment was provided via immediate postoperative survey by primary surgeons.

Results: There were 100 standard PCNLs completed using either a TrilogyTM or ShockPulse-SE lithotrite. Using quantitative Stone Analysis Software to estimate stone volume, the mean stone volume was calculated at 4.18 ± 4.79 cm3 and 3.86 ± 3.43 cm3 for the Trilogy and ShockPulse-SE groups respectively . Stone clearance rates were found to be 1.22 ± 1.67 and 0.77 ± 0.68 cm3/min for TrilogyTM versus ShockPulse-SE (p=0.0542). When comparing TrilogyTM to ShockPulse-SE in a multivariate analysis, total OR time (104.4 ± 48.2 vs 121.1 ± 59.2 min p=0.126), rates of secondary procedures (17.65% vs 40.81% p=0.005), and device malfunctions (1.96% vs 34.69% p<0.001), were less, respectively. There was no difference in final stone free rates between devices.

Conclusion: The TrilogyTM lithotripter removed stones significantly faster than previous generations of intracorporeal lithotripters. In the case of large stones the efficiency of the TrilogyTM device optimizes clearance and operating times.
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http://dx.doi.org/10.1089/end.2020.1097DOI Listing
April 2021

Comparison of Newly-Optimized Moses Technology Versus Standard Holmium:YAG for Endoscopic Laser Enucleation of the Prostate.

J Endourol 2021 Apr 3. Epub 2021 Apr 3.

Northwestern University Feinberg School of Medicine, 12244, Urology, Chicago, Illinois, United States;

Introduction: The purpose of this study was to describe our initial experience of using a newly-optimized Moses technology that is part of the second generation Moses platform specifically designed for holmium laser enucleation of the prostate M2-HoLEP, and compare it to patients undergoing holmium laser enucleation of the prostate (HoLEP) using standard holmium:YAG technology (S-HoLEP).

Methods: We retrospectively collected data on patients who underwent M2-HoLEP and compared it to the last 50 patients in whom we performed S-HoLEP. Specifically, we compared preoperative symptom scores for lower urinary tract symptoms (LUTS) and erectile dysfunction (ED), preoperative objective voiding metrics, as well as intraoperative characteristics, perioperative characteristics, postoperative complications, postoperative symptom scores for LUTS and ED, and postoperative objective voiding metrics. Additionally we evaluated the ability for same day discharge following surgery in the M2-HoLEP group.

Results: We included 104 total patients for analysis. We compared the first 54 patients undergoing M2-HoLEP to 50 patients undergoing S-HoLEP. Both groups had similar age, BMI, use of anticoagulation medication, LUTS and ED scores, and objective voiding metrics. Operations performed with M2-HoLEP had faster mean hemostasis time (8.7 vs 10.6 ± 6 minutes, p=0.03) as well as hemostasis rate (0.13 vs 0.30 grams/minute, p=0.01). Same day discharge was successful in 69.4% of patients in the M2-HoLEP group. Postoperatively, both groups also had similar and low rates of urinary retention and complications. At follow-up, both groups had similar symptom scores for LUTS and ED, as well as similar objective voiding metrics.

Conclusion: The newly optimized Moses pulse modulation technology is safe and efficient for the treatment of BPH. Such technologic improvements in the laser have greatly enhanced the feasibility of same day discharge of patients undergoing HoLEP.
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http://dx.doi.org/10.1089/end.2020.0996DOI Listing
April 2021

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

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 Multi-institutional Review of Single-access Percutaneous Nephrolithotomy for Complex Staghorn Stones.

Eur Urol Focus 2020 Dec 28. Epub 2020 Dec 28.

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

Background: With the heterogeneous distribution of novel surgical technologies and variable physician training, there is a need to re-evaluate contemporary outcomes of percutaneous nephrolithotomy (PCNL) for complex staghorn stones.

Objective: To evaluate contemporary outcomes of guideline-supported treatment for patients with staghorn kidney stones using single-access PCNL in multiple North American centers.

Design, Setting And Participants: We performed a multi-institutional retrospective review of staghorn stones managed from January 1, 2017 to January 1, 2019, inclusive. We excluded patients with more than a single percutaneous access per renal unit and those who underwent a concomitant contralateral procedure.

Outcome Measurements And Statistical Analysis: Safety (Clavien-Dindo complications) and efficacy in terms of a strictly defined stone-free rate were examined for single-access PCNL performed on staghorn stones with a Guy's stone score of 3-4.

Results And Limitations: We evaluated 301 patients meeting the inclusion criteria with an average age of 57 yr (range 18-87). All stones had a Guy's stone score of 3 (36.2%) or 4 (63.8%). The mean (± standard deviation) stone burden was 191.4 ± 49.8 mm. Of the 297 patients (98.6%) who underwent computed tomography on postoperative day 1, 132 (44.4%) showed no residual stone, 111 (37.3%) had a largest fragment <4 mm, and 54 (18.2%) had a fragment ≥4 mm after primary single-access PCNL. Secondary procedures were performed in 117 patients (38.9%). Imaging at 3 mo demonstrated that 210/257 patients (82%) were stone-free. The overall complication rate was 17.9%, with 11 patients (3.7%) experiencing Clavien-Dindo grade ≥3 complications.

Conclusions: Single-access PCNL for complex staghorn stones is safe and effective. High stone-free rates with minimal morbidity are achievable with current techniques.

Patient Summary: This study confirms that single-access percutaneous nephrolithotomy provides excellent outcomes in the treatment of complex kidney stones. This surgical technique has both safe and effective outcomes that are reproducible across multiple centers in North America.
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http://dx.doi.org/10.1016/j.euf.2020.11.005DOI Listing
December 2020

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

AUTHORS REPLY.

Urology 2020 Dec;146:65-66

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

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http://dx.doi.org/10.1016/j.urology.2020.08.065DOI Listing
December 2020

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

Early Surgical Intervention for Symptomatic Renal and Ureteral Stones is Associated With Reduced Narcotic Requirement Relative to Trial of Passage.

Urology 2020 Dec 29;146:59-66. Epub 2020 Sep 29.

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

Objectives: To evaluate if trial of passage (TOP) or initial surgical intervention resulted in less narcotic analgesia utilization in patients with acute renal colic due to stone disease.

Methods: We retrospectively evaluated 135 patients with acute renal colic due to nephroureterolithiasis managed by a single surgeon. Patients were standardly offered TOP or surgical intervention with ureteroscopy (URS). A subset of patients were stented with delayed URS due to presence of infection, pain, or a nonaccommodating ureter. Our standard practice is narcotic-free URS, prescribing a stent cocktail including non-steroidal anti-inflammatories. We compared rates of narcotic prescription over the entire treatment course for patients electing TOP vs surgery (primary or delayed URS). We secondarily analyzed rates of surgical intervention among initial TOP.

Results: We included 135 patients, with 69 (51.1%) TOP as initial treatment, 39 (28.9%) stent with delayed URS, and 27 (20.0%) primary URS. Thirty-nine (56.5%) TOP patients underwent URS at a median time of 18 days (IQR 6-31 days) from diagnosis. More TOP patients required a narcotic prescription (60.9% vs 35.9% vs 33.3%, respectively; P = .010) compared to patients undergoing initial stent or URS. However, when an opioid prescription was provided, the total morphine milligram equivalents prescribed among each group was not statistically significant.

Conclusion: Patients electing initial treatment with TOP for renal colic due to stone disease were more likely to require narcotic prescriptions than patients electing initial surgical intervention.
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http://dx.doi.org/10.1016/j.urology.2020.08.063DOI 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

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

Using Low-Calorie Orange Juice as a Dietary Alternative to Alkali Therapy.

J Endourol 2020 10 4;34(10):1082-1087. Epub 2020 Aug 4.

From Indiana University Department of Urology and Litholink Corporation, Laboratory Corporation of America Holdings, Indianapolis, Indiana, USA.

The pursuit of a dietary source to increase urine pH and citrate in stone formers has been ongoing for >30 years. Early evidence showed that orange juice (OJ) contains alkali and citrate, but high sugar and ascorbic acid content limited the use of OJ as a viable daily source of alkali. Recently, novel low-calorie OJs have emerged and could potentially be a better option. Beverages with high concentrations of alkali citrate and malate were identified using ion chromatography. Two low-calorie OJ beverages, in addition to crystal light lemonade beverage (CLLB), were chosen. Healthy volunteers (5 men, 5 women) drank 1 L of OJ or CLLB with 1 L water daily for 7 days, and then completed a 24-hour urinalysis. A washout week was instituted between trial weeks. The study design is a prospective randomized crossover control trial. A paired analysis using comparison of means was used to evaluate low-calorie OJ and CLLB. Volunteers had no prior history of kidney stones and maintained a journal with beverage compliance, side effect (SE), and dietary consumption data. Tropicana 50 (TRP50), Kroger low-calorie OJ (KLCO), and CLLB were found to have a total alkali content of 56.60, 47.9, and 17.3 mEq/L, respectively, based on ion chromatography. Consumption of all three beverages raised urinary citrate (116.6 [-118 to 373, 177.9 [-3 to 359], 155.6 [-4 to 237] ▵mg/day 95% confidence interval) and urinary pH (0.25 [0.08-0.53], 0.74 [0.41-1.07  < 0.05], 0.25 [0.25-0.64]), respectively, compared with water phase. Based on journal entries by volunteers, TRP50 had the most SEs (90% participants) felt to be a result of the artificial sweetener (Stevia). Low-calorie OJs, and to a lesser extent CLLB, have alkali and citrate based on ion chromatography. Daily consumption by healthy volunteers of KLCO can raise urinary pH.
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http://dx.doi.org/10.1089/end.2020.0031DOI Listing
October 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

Comparative Study of Percutaneous Tic Technique Vs Standard Percutaneous Nephrolithotomy.

Urology 2020 Jun 17;140:27-33. Epub 2020 Feb 17.

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

Objective: To compare the PERC-tic technique, described as placement of dual wires under fluoroscopic guidance adjacent to the stone within the obstructed calyx, to standard percutaneous nephrolithotomy (PCNL) with working wires secured down the ureter.

Materials And Methods: This is a retrospective cohort study of patients who underwent a PCNL procedure between October 2016 and November 2018. Patients undergoing the PERC-tic technique were compared to patients undergoing standard PCNL. Regression models evaluated if PERC-tic PCNL was associated with equivalent stone-free rates to standard PCNL at 90 days, need for secondary procedures, and 90-day hospital readmission.

Results: This study involved 126 PCNL cases of which 63 were done using the PERC-tic technique and 63 with standard PCNL. In multivariate analysis, there was no statistical difference in 90-day stone-free rate between standard PCNL and PERC-tic cohorts (P = .08). We did note a 6 times higher likelihood of needing secondary procedures for residual stones in the PERC-tic vs standard PCNL groups (71% vs 30% P <.0001). There was no statistical significance in 90-day hospital readmission rates between groups (P = .47).

Conclusion: Our findings suggest similar stone-free rate at 90 days and higher rates of secondary procedures after PERC-tic PCNL compared to the standard approach; however, there was no difference in complications. These findings may reflect decreased visualization with the PERC-tic technique or simply be reflective of the case difficulty requiring the use of the PERC-tic technique. These findings can be used for patient counseling when considering this technique for complex stone disease.
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http://dx.doi.org/10.1016/j.urology.2019.12.040DOI Listing
June 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

Robot-Assisted Radical Prostatectomy in Patients with a History of Holmium Laser Enucleation of the Prostate: The Indiana University Experience.

J Endourol 2020 02;34(2):163-168

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

We sought to update our experience of oncologic and functional outcomes of robot-assisted radical prostatectomy (RARP) for prostate cancer in patients with history of holmium laser enucleation of the prostate (HoLEP). Twenty-seven patients with previous HoLEP who underwent RARP were matched 1:1 with RARP patients with no history of transurethral surgery. Demographic, operative, oncologic, continence, and erectile function outcomes were analyzed. Median time between HoLEP and RARP was 31 months with a mean prostate-specific antigen doubling time of 4.28 ng/mL/year. Operative times were significantly longer with higher bladder neck reconstruction rates and similarly low complication rates. Biochemical recurrence was relatively low (7%) in the HoLEP group, identical to the comparative group. Continence at last follow-up was not statistically significant between groups, although time to continence favored the non-HoLEP cohort. Erectile function recovery was generally poor in the post-HoLEP cohort (11%), although bilateral nerve sparing was rarely performed (11%). Compared with our initial experience, there were significant improvements in time to continence (16 36 weeks). No T2 post-HoLEP RARP since 2010 has had a positive surgical margin. Post-HoLEP prostatectomy remains feasible with similar perioperative and oncologic outcomes compared with matched cohorts. Functional recovery remains slowed yet may continue to improve with technical familiarity.
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http://dx.doi.org/10.1089/end.2019.0436DOI Listing
February 2020

Comparative Study of Holmium Laser Enucleation of the Prostate With MOSES Enabled Pulsed Laser Modulation.

Urology 2020 Feb 30;136:196-201. Epub 2019 Nov 30.

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

Objective: To compare outcomes for patients undergoing holmium laser enucleation of the prostate (HoLEP) for lower urinary tract symptoms secondary to benign prostate hyperplasia using 3 different laser fibers and 2 different laser energy modes.

Materials And Methods: This is a review of a clinic registry of men with lower urinary tract symptoms secondary to benign prostate hyperplasia who underwent HoLEP between August 2018 and January 2019. Patients were assigned to group 1 (50 patients), group 2 (50 patients), and group 3 (50 patients) based on the HoLEP being completed with either a Slimline 550µm, Slimline 1000µm, or MOSES 550 µm laser, respectively. The groups were compared using SSPS for ANOVA comparison of means and multivariate logistic regression.

Results: Ten patients who underwent concomitant stone surgery (2 PCNL, 8 ureteroscopy , 3 bilateral cases) and 11 patients had bladder stones removed; ancillary procedures did not significantly differ between groups(P = .2). Prostate enucleation times differed significantly (22.5 + 7.3, 16.4 + 6.9, 18.1 + 8.6 minutes P ≤.001) between groups. However, statistical significance was lost once enucleation time was indexed against enucleated tissue weight. Time to achieve hemostasis (minutes) was statistically different between groups (10.6 + 6.1, 7.7 + 5.2, 6.3 + 4.8 P <.001). This difference in hemostatic time was maintained on multilogistic regression demonstrating that MOSES laser enucleation was associated with a 3.9-minute decrease time to achieve hemostasis after enucleation compared to Slimline 550 HoLEP (P <.001).

Conclusion: Our findings suggest that modulated pulsed laser energy can improve hemostasis during the enucleation phase of a HoLEP resulting in shorter Operating Room times.
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http://dx.doi.org/10.1016/j.urology.2019.11.029DOI Listing
February 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

The Role of Prostate Specific Antigen Monitoring after Holmium Laser Enucleation of the Prostate.

J Urol 2020 02 6;203(2):304-310. Epub 2019 Sep 6.

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

Purpose: Prostate specific antigen screening for prostate cancer has recently been challenged due to poor sensitivity. In addition to prostate cancer, a number of conditions elevate prostate specific antigen, of which benign prostatic hyperplasia is most common. The objective of this study was to assess the positive predictive value of prostate specific antigen and prostate specific antigen density for prostate cancer risk following holmium laser enucleation of the prostate.

Materials And Methods: We queried an institutional review board approved database of holmium laser enucleation of the prostate performed at Indiana University from 1999 to 2018 to identify 1,147 patients with prostate specific antigen data available after holmium laser enucleation. A total of 55 biopsies after enucleation were recorded. Demographics, prostate specific antigen, prostate volume and oncologic details were analyzed. The primary outcome was biopsy proven prostate cancer.

Results: A total of 55 patients underwent transrectal ultrasound prostate biopsy for cause after holmium laser enucleation of the prostate. Cancer was identified in more than 90% of biopsied cases. Men with prostate specific antigen above 1 ng/ml at biopsy had a 94% probability of cancer detection and an 80% risk of clinically significant disease. Prostate specific antigen density above 0.1 ng/ml was associated with a 95% risk of cancer and an 88% risk of clinically significant cancer. Prostate specific antigen greater than 5.8 ng/ml or prostate specific antigen density greater than 0.17 ng/ml was universally associated with biopsy proven cancer.

Conclusions: Prostate specific antigen and prostate specific antigen density have high positive predictive value for prostate cancer risk after holmium laser enucleation of the prostate. Thresholds for biopsy should be lower than in patients who do not undergo holmium laser enucleation. Those who undergo that procedure and have prostate specific antigen above 1 ng/ml or prostate specific antigen density above 0.1 ng/ml are at higher risk for harboring clinically significant disease and should undergo biopsy. Referring physicians should be aware of these significant risk shifts.
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http://dx.doi.org/10.1097/JU.0000000000000530DOI Listing
February 2020

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

Use of the Quick Sequential Organ Failure Assessment Score for Prediction of Intensive Care Unit Admission Due to Septic Shock after Percutaneous Nephrolithotomy: A Multicenter Study.

J Urol 2019 08 8;202(2):314-318. Epub 2019 Jul 8.

Departments of Urology, Massachusetts General Hospital , Boston , Massachusetts.

Purpose: Recent studies have demonstrated that quick sequential organ failure assessment criteria may be more accurate than systemic inflammatory response syndrome criteria to predict postoperative sepsis. In this study we evaluated the ability of these 2 criteria to predict septic shock after percutaneous nephrolithotomy.

Materials And Methods: We performed a retrospective multicenter study in 320 patients who underwent percutaneous nephrolithotomy at a total of 8 institutions. The criteria for quick sequential organ failure assessment and systemic inflammatory response syndrome were collected 24 hours postoperatively. The study primary outcome was postoperative septic shock. Secondary outcomes included 30 and 90-day emergency department visits, and the hospital readmission rate.

Results: Three of the 320 patients (0.9%) met the criteria for postoperative septic shock. These 3 patients had positive criteria for quick sequential organ failure assessment and systemic inflammatory response syndrome. Of the entire cohort 23 patients (7%) met quick sequential organ failure assessment criteria and 103 (32%) met systemic inflammatory response syndrome criteria. Specificity for postoperative sepsis was significantly higher for quick sequential organ failure assessment than for systemic inflammatory response syndrome (93.3% vs 68.4%, McNemar test p <0.001). The positive predictive value was 13% for quick sequential organ failure assessment criteria and 2.9% for systemic inflammatory response syndrome criteria. On multivariate logistic regression systemic inflammatory response syndrome criteria significantly predicted an increased probability of the patient receiving a transfusion (β = 1.234, p <0.001). Positive quick sequential organ failure assessment criteria significantly predicted an increased probability of an emergency department visit within 30 days (β = 1.495, p <0.05), operative complications (β = 1.811, p <0.001) and transfusions (p <0.001). The main limitation of the study is that it was retrospective.

Conclusions: Quick sequential organ failure assessment criteria were superior to systemic inflammatory response syndrome criteria to predict infectious complications after percutaneous nephrolithotomy.
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http://dx.doi.org/10.1097/JU.0000000000000195DOI Listing
August 2019

Best practice in the management of benign prostatic hyperplasia in the patients requiring anticoagulation.

Ther Adv Urol 2018 Dec 29;10(12):431-436. Epub 2018 Oct 29.

Indiana University School of Medicine, IU Health Physicians Urology, 1801 N. Senate Blvd., Indianapolis, IN 46202-5114, USA.

In today's aging population, urologists are often treating older patients with multiple comorbidities. Lower urinary tract symptoms from benign prostate hyperplasia (LUTS/BPH) is a common condition that affects men, with increasing prevalence as men age. In a subset of patients, the symptoms are too severe or refractory to medical therapy and, therefore, surgical therapy is required to improve their LUTS. The use of medical therapy often delays the need to intervene surgically in men with LUTS/BPH and with advances in the management of cardiovascular disease, urologists are increasingly encountering more men requiring BPH surgery on chronic anticoagulation therapy. The decision of when to offer surgical intervention and how to manage anticoagulation medication in the perioperative setting is a dilemma with which surgeons are dealing with increasing frequency. The purpose of this review is to clarify the optimal approach to the surgical patient with LUTS/ BPH requiring anticoagulation therapy.
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http://dx.doi.org/10.1177/1756287218807591DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6295789PMC
December 2018

Trends and Perioperative Outcomes Across Major Benign Prostatic Hyperplasia Procedures from the ACS-NSQIP 2011-2015.

J Endourol 2019 01;33(1):62-68

2 Department of Urology, IU Health Methodist Hospital, Indiana University School of Medicine, Indianapolis, Indiana.

Background And Purpose: There are currently several different surgical options for patients with benign prostatic hyperplasia (BPH). The literature has demonstrated equivalent or superior results for holmium laser enucleation of prostate (HoLEP) but with exceptional long-term durability compared to other minimally invasive options. Despite this, HoLEP is not widely practiced. Herein, we investigate trends and outcomes from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) to support a need for further adoption of HoLEP.

Methods: Using ACS-NSQIP data from 2011 to 2015, trends, baseline characteristics, and perioperative outcomes were collected for major BPH procedures: transurethral resection of prostate (TURP), TURP for regrowth, photovaporization of prostate (PVP), HoLEP, and simple prostatectomy.

Results: The most common procedure performed every year was TURP with PVP performed about half as often, while HoLEP (4%-5%) was performed about as infrequently as simple prostatectomy (3%). More African American men underwent simple prostatectomy except in 2011. International normalized ratio (INR) was highest every year for PVP. Hospital stay and transfusion rates were lowest with PVP and HoLEP. Transfusion rates for simple prostatectomy were high (16.0%-25.4%). Lower rates of readmission, reoperation, and urinary tract infection were seen in some years with HoLEP.

Conclusions: Given the previously reported favorable outcomes and long-term durability of HoLEP, these ACS-NSQIP data further support that HoLEP should be more often practiced for patients undergoing surgery for BPH.
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http://dx.doi.org/10.1089/end.2018.0266DOI Listing
January 2019

Initial Experience with Narcotic-Free Ureteroscopy: A Feasibility Analysis.

J Endourol 2018 10 12;32(10):907-911. Epub 2018 Sep 12.

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

Background And Purpose: In the United States, there is an opioid abuse epidemic fueled by prescription medications. Concerns that uncontrolled pain after surgical procedures will result in poor patient satisfaction and increased workload for ancillary staff are potential factors that influence provider prescription habits. Currently, there is a paucity of literature on analgesic requirements after ureteroscopy (URS) for nephrolithiasis. Our study objective was to evaluate the safety of narcotic-free ureteroscopy (nf-URS) and assess its impact on provider workload.

Methods: We performed a retrospective chart review of 104 patients, between October 2017 and May 2018, who underwent URS and who required a stent postprocedure. Starting February 2018, patients without absolute contraindication or allergies to nonsteroidal anti-inflammatory drugs received a prescription for diclofenac instead of hydrocodone or oxycodone. Postoperative phone calls to nurses and residents, emergency room visits, and prescription monitoring reports were evaluated for all patients, and compared between the nf-URS and the standard ureteroscopy (s-URS).

Results: There were 52 nf-URS and 52 s-URS procedures. In the postoperative period, 9 (17%) nf-URS and 10 (19%) s-URS patients called with postoperative pain issues. Five (10%) nf-URS vs 9 (17%) s-URS patients obtained narcotics after seeking additional medical care after URS because of inadequate pain control. There were no postoperative complications in our cohort. Compared with s-URS, 6871.5 mg less of morphine equivalent dosage (1375 hydrocodone tablets) was administered to nf-URS patients immediately after surgery.

Conclusions: Attempts to reduce the number of narcotic prescriptions are paramount in the fight against narcotic addiction in the United States. Although our initial cohort is small, this feasibility study provides compelling evidence that nf-URS is a safe and effective practice. Furthermore, nf-URS resulted in a dramatic decrease in the number of narcotics circulating in the community.
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http://dx.doi.org/10.1089/end.2018.0459DOI Listing
October 2018