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Ali SN, Morgan K, Bhatt R, Jiang P, Patel RM, Landman J, Clayman R. Retrograde Cystonephroscopy for Complex Renal Calculi Using Novel Dual Action Aspiration, Irrigation Cystoscope: Initial Case Series. J Endourol 2022; 36:898-905. [PMID: 35045749 DOI: 10.1089/end.2021.0782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Introduction Percutaneous nephrolithotomy (PCNL) is the gold standard treatment for kidney stones ≥ 2 cm; however, it remains an invasive procedure with significant risks especially in individuals with severe medical co-morbidities. In contrast, while ureteroscopy is far less morbid, a major impediment to its use for larger calculi is the inability to evacuate the many fragments created during laser lithotripsy. Herein, we describe two patients with large volume calculi and a third high risk patient with a smaller stone that were treated with cystonephroscopy using a recently released, 16Fr flexible cystoscope equipped with dual aspiration and irrigation capabilities. Materials and Methods Three consecutive female patients underwent retrograde cystonephroscopy from June 2021 to July 2021 with a novel 16Fr aspiration enabled flexible cystoscope. Demographic data were collected. Pre-operative and post-operative CT-scan images were reviewed to determine linear stone dimensions and scalene ellipsoid volume. Results The three female patients had an average age of 72.3 years and an American Society of Anesthesiologists (ASA) physical status score of 3. The mean preoperative stone volume was 4950 mm3. The average post-cystonephroscopy stone volume was 217 mm3 resulting in a total stone clearance rate of 97%. No major complications occurred. Average procedure time was 176 minutes. Conclusions Among three high risk female patients, two with large volume calculi, retrograde cystonephroscopy with a novel aspiration-enabled cystoscope allowed for the procedure to be successfully completed solely via a retrograde approach.
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Jiang P, Afyouni AS, Brevik A, Peta A, King T, Dinh ST, Ayad M, Larson K, Limfueco L, Kosmala CM, Sharifi H, Patel RM, Landman J, Clayman R. The Impact of One Week of Pre-stenting on Porcine Ureteral Luminal Circumference. J Endourol 2022; 36:885-890. [PMID: 35044235 DOI: 10.1089/end.2021.0771] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVES Larger ureteral access sheaths (UAS) have the potential to improve ureteroscopic stone removal outcomes, but are often avoided by surgeons due to concerns of ureteral injury. Using our novel UAS force sensor and previously defined force thresholds for ureteral injury, we sought to evaluate the impact of one week of stenting on the maximum safe dilation of ureteral luminal circumference. METHODS Twelve juvenile female Yorkshire pigs (24 ureters) were evaluated. The inner (i.e. luminal) circumference of each ureter was determined using Cook urethral dilators ranging from 8-24Fr in 2Fr increments, 37cm in length. Each dilator was sequentially passed while applying the UAS force sensor to measure insertion force before and after one week of stent placement. Each ureter was randomized to receive either a 4.7Fr or 7.0Fr stent (20cm). Maximum ureteral luminal circumference was defined as successful passage of the dilator to the ureteropelvic junction with <6 newtons (N) of force (the force threshold previously defined by porcine and clinical studies to avoid ureteral damage). Following passage of the largest dilator at 6N, flexible ureteroscopy was performed and a post-ureteroscopic lesion score (PULS) was recorded. RESULTS After one week of stent placement, the median ureteral luminal circumference increased to 15Fr representing a mean increase of 3.8Fr + 2.8 (p<0.001). Twenty-one (88%) of the pre-stented ureters had an increase in luminal circumference, with 12 ureters (50%) dilated to >16Fr (p=0.032), six ureters (25%) dilated to >18Fr, and in two cases a maximum size of 24Fr was recorded. The PULS grade was < 2 in all cases, indicating no high grade ureteral injuries. Laterality and stent size did not impact ureteral luminal circumference after pre-stenting (p=0.232 and p=0.337, respectively). CONCLUSIONS One week of ureteral stenting resulted in nearly a 4Fr increase in the luminal circumference of porcine ureters.
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Jiang P, Arada RB, Okhunov Z, Afyouni AS, Peta A, Brevik A, Xie L, Ayad M, Xu P, Morgan K, Tapiero S, Patel RM, Nelson KJ, Lee JG, Clayman R, Landman J. Multidisciplinary Approach and Outcomes of Pretreatment Small (cT1a) Renal Mass Biopsy: Single-Center Experience. J Endourol 2022; 36:703-711. [PMID: 35018788 DOI: 10.1089/end.2021.0664] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE We evaluated our experience of a multidisciplinary approach to renal mass biopsy (RMB) for small renal masses (SRM) employing in-office ultrasound (US) guided biopsy by urology (24%), computed tomography (CT) or US biopsy by interventional radiology (IR) (79%), and endoscopic ultrasound-guided biopsy by gastroenterology (GI) (4%). METHODS A single-institution retrospective review of patients who underwent RMB for SRM from May 2013 to August 2019 was conducted. Data regarding patient demographics, tumor characteristics, biopsy technique, histopathology, and management were collected. Diagnostic rates, concordance with final pathology, complications, and outcomes were analyzed. RESULTS Of the 192 biopsies reviewed, 63% biopsies were malignant, 20% were benign, and 17% were non-diagnostic. Based on biopsy results, 71 patients (37%) elected active surveillance. Thirty-eight (20%) patients underwent cryoablation, 56 (29%) underwent partial nephrectomy (PN), 14 (7%) underwent radical nephrectomy (RN) and the remaining patients were treated elsewhere. The rate of surgery for benign pathology after pretreatment RMB was 3%. The concordance rate between biopsy and final pathology was 99% for malignancy, 96% for specific pathology subtype, and 85% for RCC grade. Median time from diagnosis to definitive treatment was 97 days (urology: 76, IR: 110 and GI: 54, p=0.002). Three (1.6%) Clavien I complications were reported. CONCLUSION Our multidisciplinary approach to renal mass biopsy for clinical stage T1a demonstrated favorable safety and diagnostic rates, which effectively directed management strategies and minimized surgery for benign disease. Urologist performed office-biopsies significantly shortened the time from diagnosis to definitive treatment. Our experience with GI EUS biopsy has demonstrated feasibility and safety for tumors that were otherwise not accessible percutaneously.
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Ali SN, Landman J. The Case for Laparoscopic Nephrectomy in Contemporary Practice. J Endourol 2021; 36:289-290. [PMID: 34877891 DOI: 10.1089/end.2021.0854] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The first laparoscopic nephrectomy performed in 1990 laid the foundation for the use of minimally invasive surgery in treatment all major urologic pathology. Compared to the open technique, laparoscopy promised equivalent oncologic outcomes, shorter operating room times, less blood loss and shorter convalescence times. However, with the introduction of the Da Vinci Surgical System in the early 2000's there was a push to replace all forms of laparoscopy with robotic technique. Unlike laparoscopy, the adoption of the robotics was driven by aggressive marketing rather than evidence of superior outcomes. Although the robotic technique has many benefits in pelvic and reconstructive surgery, the same benefits do not necessarily translate to the radical renal surgery such as radical nephrectomy. The robotic platform is costly to acquire and maintain. Multiple studies show no superiority in oncologic outcomes, operating room times, blood loss or complications rates when comparing robotic to laparoscopic nephrectomy. Conversely, laparoscopic radical nephrectomy is a well established technique that is backbone of training in most residency programs. The equipment is readily available in most hospitals and the availability of staplers and alternate energy devices makes it safe and effective, especially in radical nephrectomy due to the extirpative nature of the procedure. In the absence of any measurable benefit of robotics over laparoscopy, there remains a role for laparoscopic radical nephrectomy in contemporary practice.
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Karani R, Tapiero S, Jefferson FA, Vernez S, Xie L, Larson KN, Osann K, Okhunov Z, Patel RM, Landman J, Clayman RV, Stephany HA. Crowd-Sourced Assessment of Surgical Skills of Urology Resident Applicants: Four-Year Experience. JOURNAL OF SURGICAL EDUCATION 2021; 78:2030-2037. [PMID: 34147416 DOI: 10.1016/j.jsurg.2021.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 04/21/2021] [Accepted: 05/16/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To determine a) if surgical skills among urology resident applicants could be reliably assessed via crowdsourcing and b) to what extent surgical skills testing impacts resident selection. DESIGN Interviewees completed the following surgical skills tasks during their interview day: open knot tying (OKT), laparoscopic peg transfer (LPT), and robotic suturing (RS). Urology faculty and crowd-workers evaluated each applicant's video-recorded performance using validated scoring and were assessed for agreement using Cronbach's alpha. Applicants' USMLE scores, interview scores, and Jefferson Scale of Physician Empathy (JSPE-S) scores were assessed for correlation with skills testing scores and match rank. Additionally, a survey was distributed to interviewees assessing match outcomes. SETTING University of California Irvine Department of Urology, Surgical Skills Laboratory PARTICIPANTS: All 94 urology residency interviewees at the University of California Irvine Department of Urology from 2015-2018 were invited to complete the three surgical skills tasks on their interview day. RESULTS Survey responses were received from all 94 interviewees (100%). Crowd and expert agreement was good (α=0.88), fair (α=0.67), and poor (α=0.32) for LPT, RS, and OKT scores, respectively. The skills testing scores did not correlate with match rank, USMLE score, or JSPE-S score. On multivariate analysis, only interview score (r= -0.723; p<0.001) and faculty LPT score (r=-0.262; p=0.001) were significant predictors of match rank. Interviewees who reported matching into a top 3 residency choice had significantly higher faculty LPT scores than those who did not (11.9 vs. 9.7, p=0.03). CONCLUSIONS Surgical skills overall did not significantly impact match rank. Expert assessment of laparoscopic peg transfer skills and interview performance among urology resident applicants correlated with match rank.
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Jiang P, Peta A, Brevik A, Arada RB, Ayad M, Afyouni AS, Limfueco L, Nguyen N, Palma A, Patel RM, Landman J, Clayman R. Ex-vivo Renal Stone Dusting: Impact of Laser Modality, Ureteral Access Sheath, and Suction on Total Stone Clearance. J Endourol 2021; 36:499-507. [PMID: 34693735 DOI: 10.1089/end.2021.0544] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION AND OBJECTIVES Conventional renal stone dusting is challenging; the holmium laser (Ho:YAG) and holmium with MOSES Effect (Ho:YAG-MOSES) fail to uniformly produce fragments <100 microns (i.e. dust). The superpulse thulium fiber laser (sTFL) may more effectively render uroliths into "dust," and may thus improve stone free rates. Accordingly, we performed ex-vivo evaluations with all three laser modalities, assessing stone fragments and stone clearance. METHODS Seventy-two ex-vivo porcine kidney-ureter models were divided into 12 groups of six: laser type (Ho:YAG, Ho:YAG-MOSES, sTFL), ureteroscope (URS) with and without applied suction, and presence or absence of a 14Fr ureteral access sheath (UAS). Calcium oxalate stones were pre-weighed and implanted into each kidney via a pyelotomy. Stones were treated at 16 watts using dusting settings of 0.4Jx40Hz (Ho:YAG) 0.2Jx80Hz (Ho:YAG-MOSES), and 0.2Jx80Hz (sTFL) for up to 20 minutes. No stone basketing was performed. Kidneys were bi-valved and residual fragments were collected, dried, weighed, and sieved to determine fragment size and stone clearance. RESULTS Initial stone mass (mg), procedure time (sec), and laser energy expenditure (kJ) were similar in all 12 groups. The greatest stone clearance was seen with sTFL+suction+UAS (94%) compared to a conventional technique (Ho:YAG+no suction+no UAS) (65%, p<0.01). The use of sTFL provided greater stone clearance than Ho:YAG or Ho:YAG-MOSES. Aspiration improved stone clearance for sTFL (p=0.01) but not for Ho:YAG or Ho:YAG-MOSES, consistent with the creation of smaller fragments with sTFL. Presence of a 14F UAS improved stone clearance in all scenarios (p<0.01). CONCLUSIONS In this ex-vivo study, stone clearance was optimized under the following conditions: sTFL laser, 14F ureteral access sheath, and aspiration. This combination resulted in 94% of stone fragments cleared; the 6% remaining fragments were all <2 mm. In all scenarios, deployment of a 14Fr UAS improved stone clearance.
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Micali S, Calcagnile T, Sighinolfi M, Iseppi A, Morini E, Benedetti M, Oltolina P, Ragusa A, Kaleci S, Bevilacqua L, Puliatti S, De Nunzio C, Arada R, Chiancone F, Campobasso D, Eissa A, Bonfante G, Simonetti E, Cotugno M, Galli R, Curti P, Schips L, Ditonno P, Villa L, Ferretti S, Bergamaschi F, Bozzini G, Zoeir A, El Sherbiny A, Frattini A, Fedelini P, Okhunov Z, Tubaro A, Landman J, Bianchi G, Rocco B. Urinary tract infections in candidates to active treatment of renal stone: results from an international multicentric study on more than 2600 patients. EUR UROL SUPPL 2021. [DOI: 10.1016/s2666-1683(21)00867-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Karani R, Arada RB, Okhunov Z, Tapiero S, Landman J, Clayman RV. Endoscopic Guided Percutaneous Nephrolithotomy. J Endourol 2021; 35:S62-S67. [PMID: 34499544 DOI: 10.1089/end.2020.0556] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Percutaneous nephrolithotomy (PCNL) is the treatment of choice for kidney stones >2 cm in size. Obtaining a nephrostomy tract to access the kidney is a key step in this procedure that ultimately determines the patient's outcome. We describe each step of the endoscopic guided approach to PCNL as performed at the University of California, Irvine. Each step of the endoscopic guided PCNL is described and depicted in the video. Surgical steps depicted in the video are from various recorded PCNL procedures from our institution. This guide outlines the indications, preoperative preparation, patient positioning, surgical steps, and postoperative care for patients undergoing PCNL using the endoscopic guided approach. Direct observation of nephrostomy puncture, tract dilation using the balloon, and passing of the Amplatz sheath allow for proper access to the kidney and lower risk of injury. By following this systematic module of endoscopic guided PCNL, a nephrostomy tract can be created and accessed under direct observation, facilitating the routine steps of PCNL.
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Jiang P, Landman J. Re: Is Routine Renal Tumor Biopsy Associated with Lower Rates of Benign Histopathology following Nephrectomy for Small Renal Masses? Eur Urol 2021; 80:519. [PMID: 34373139 DOI: 10.1016/j.eururo.2021.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 07/19/2021] [Indexed: 11/17/2022]
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Patel RM, Okhunov Z, Jiang P, Tapiero S, Landman J. Office-Based Renal Tumor Biopsy: a Paradigm Change in the Management of a Small Renal Mass? Curr Urol Rep 2021; 22:43. [PMID: 34357476 DOI: 10.1007/s11934-021-01059-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/19/2021] [Indexed: 01/20/2023]
Abstract
PURPOSE OF REVIEW The goal of this paper is to evaluate the use of an office-based renal mass biopsy (RMB), whose feasibility could represent a paradigm shift in clinical practice. RECENT FINDINGS Despite the earlier diagnosis of patients with renal masses, the lack of evidence showing a reduction in cancer-specific mortality warrants an examination in treatment practices. RMB is underutilized when compared to biopsy practice for all other neoplasms in every other solid organ (except testis), and the majority of RMB performed are outsourced to interventional radiologists. Performing an ultrasound-guided, office-based RMB is safe, reproducible, and has a meaningful impact on management decisions. The use of percutaneous RMB in clinical practice is growing, and the use of RMB has meaningful impact on management decisions for renal masses. Incorporating ultrasound-guided biopsy of a renal mass into clinical practice is feasible, and in contemporary practice, the urologist has the skill set to perform the procedure reliably, with low morbidity, and with minimal patient discomfort.
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Okhunov Z, Gorin MA, Jefferson FA, Afyouni AS, Allaf ME, Pierorazio PM, Patel RM, Huynh LM, Tapiero S, Osann K, Kavoussi LR, Clayman RV, Landman J. Can preoperative renal mass biopsy change clinical practice and reduce surgical intervention for small renal masses? Urol Oncol 2021; 39:735.e17-735.e23. [PMID: 34364751 DOI: 10.1016/j.urolonc.2021.05.024] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 04/27/2021] [Accepted: 05/21/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION The role of renal biopsy prior to surgical intervention for a renal mass remains controversial despite the fact that for all other urological organs except the testicle, biopsy inevitably precedes treatment as is true for all other specialties dealing with solid masses (e.g. thyroid, breast, colon, liver, etc.). Accordingly, we sought to determine the impact of a routine biopsy regimen on the course of patients with cT1a lesions in comparison with a contemporary series of cT1a individuals who went directly to treatment without a preoperative biopsy. METHODS We analyzed a multi-institutional, prospectively maintained database of patients who underwent an office-based, ultrasound-guided, renal mass biopsy (RMB) for a cT1a renal mass (i.e. ≤4cm in largest dimension). Controls were selected from all patients in the database who had a cT1a renal lesion but did not undergo RMB. Both groups were analyzed for differences in treatment modality and surgical pathology results. RESULTS A total of 72 RMB and 73 control patients were analyzed. The groups were similar in regards to their baseline characteristics. Overall RMB diagnostic rate was 75%. Surgical pathology revealed that excision of benign tumors was eight-fold less in the RMB cohort compared to the control group (3% vs. 23%; P < 0.001). Additionally, the rate of active surveillance in the RMB cohort was nearly three times higher at 35% vs. 14% for the controls (P < 0.001). Biopsy was concordant with surgical pathology in 97% of cases for primary histology (i.e. benign vs. malignant), 97% for histologic subtype, and 46% for low (I or II) vs. high (III or IV) grade. On multivariate analysis patients who underwent surgical intervention without preoperative RMB were 6.7 times more likely to have benign histopathology compared to patients who underwent preoperative RMB (OR 6.7, 95% CI = 0.714 - 63.626, P = 0.096). There were no procedural or post-procedural RMB complications. CONCLUSIONS For patients with cT1a lesions, the implementation of routine office-based RMB led to a significant decrease in the rate of surgical intervention for benign tumors. This practice also resulted in a higher rate of active surveillance for the management of renal cortical neoplasms with benign histopathology compared to a control group.
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Afyouni AS, O'Leary M, Okhunov Z, Ayad M, Yoon R, Brevik A, Peta A, Patel RM, Dolan B, Landman J, Clayman R. Global Assessments of the Endockscope System: Long-Term Impact of Cyber Endoscopy. J Endourol 2021; 35:1684-1692. [PMID: 33926236 DOI: 10.1089/end.2020.1228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION The disproportionate costs of state-of-the-art endoscopic equipment prohibit urologists from performing endoscopy in underserved countries. Given the global prevalence of smartphones, we engineered a $45 alternative endoscope utilizing three-dimensional (3D) printed attachments, an 8x lens, and a 1,000-lumen light-emitting diode (LED) cordless flashlight (Endockscope System (ES)). MATERIALS AND METHODS At the 34th World Congress of Endourology in Cape Town, South Africa (WCE 2016; 4-year group) and at the 39th Congress of the Société Internationale d'Urologie in Athens, Greece (SIU 2019; 8-month group), a total of 40 ES kits were distributed free of charge to an international group of urologists. Participants were given instructions and a hands-on demonstration of the device. Urologists given an ES were subsequently asked to complete a survey between June and September 2020 which included questions regarding user satisfaction, comfort, and comparability of the ES to standard endoscopic systems. RESULTS Urologists from 23 countries received ES kits. Overall, 10 of 22 urologists (10/22; 45%) from the 4-year group and 18 of 18 urologists (18/18; 100%) from the 8-month group completed the survey. The ES device was used by 80% (8/10) and 83% (15/18) of urologists from the 4-year and the 8-month groups, respectively. Of note, the greatest impact of ES usage was among urologists from the most impoverished countries. Of those who used the ES, 44% (4/9) of urologists from the 4-year cohort and 47% (8/17) from the 8-month cohort reported they were able to perform more endoscopic procedures directly because of the ES. Moreover, 57% (4/7) of the 4-year participants and 67% (10/15) of the 8-month participants found the ES equal or superior in quality to their standard endoscopic equipment. CONCLUSION The ES provided an effective and inexpensive system that enabled urologists in resource-challenged countries to successfully perform and expand their use of urological endoscopy.
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Okhunov Z, Jiang P, Afyouni AS, Ayad M, Arada RB, Brevik A, Akopian G, Patel RM, Landman J, Clayman RV. Caveat Emptor: The Heat Is "ON": An In Vivo Evaluation of the Thulium Fiber Laser and Temperature Changes in the Porcine Kidney during Dusting and Fragmentation Modes. J Endourol 2021; 35:1716-1722. [PMID: 33906433 DOI: 10.1089/end.2021.0206] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION We sought to examine the intrarenal fluid and tissue temperature during dusting and fragmentation with the Thulium fiber laser (TFL) in an in vivo porcine kidney. METHODS In two pigs, temperature was continuously measured within the upper, middle, and lower calyces and at the tip of the ureteroscope. Four experimental protocols were performed: dual lumen ureteroscope with both warmed (37°C) and room temperature (20-22ºC) irrigation and single lumen ureteroscope with warmed and room temperature irrigation. In each pig, one kidney had a 14F ureteral access sheath (UAS), other kidney had no UAS. A 200µm TFL was fired at three settings: dusting (0.5J, 80Hz, 40W) with continuous activation for 5 minutes or until a temperature reached 44⁰C; low power (1J, 10Hz, 10W) and high-power fragmentation (1.5J, 20Hz, 30W). For fragmentation, the laser was activated for 10 seconds with a 2 second intermission for 1 minute. RESULTS In the absence of an UAS, in all but one circumstance, temperatures exceeded 44ºC at all settings with the use of either warm or room temperature irrigation, regardless of the type of ureteroscope. Temperatures recorded at the ureteroscope tip were 4ºC - 22ºC less than the temperatures recorded in the renal calyces. In contrast, with a 14F UAS in place, 6 distinct groups had temperatures that did not exceed 44ºC, specifically at low and high-power fragmentation settings with room temperature irrigation for both sets of ureteroscopes and at dusting and low-power fragmentation settings with warm temperature irrigation solely for the single lumen ureteroscope. Temperatures at the ureteroscope tip with an UAS yielded temperature differences from 17ºC less to 19ºC more than the renal calyces. CONCLUSIONS Thulium fiber laser is a novel technology for lithotripsy. In the absence of a UAS, high-power TFL fragmentation settings, may create temperatures that could result in urothelial tissue injury.
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Houshyar R, Glavis-Bloom J, Bui TL, Chahine C, Bardis MD, Ushinsky A, Liu H, Bhatter P, Lebby E, Fujimoto D, Grant W, Tran-Harding K, Landman J, Chow DS, Chang PD. Outcomes of Artificial Intelligence Volumetric Assessment of Kidneys and Renal Tumors for Preoperative Assessment of Nephron Sparing Interventions. J Endourol 2021; 35:1411-1418. [PMID: 33847156 DOI: 10.1089/end.2020.1125] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background Renal cell carcinoma is the most common kidney cancer and the 13th most common cause of cancer death worldwide. Partial nephrectomy and percutaneous ablation, increasingly utilized to treat small renal masses and preserve renal parenchyma, require precise preoperative imaging interpretation. We sought to develop and evaluate a convolutional neural network (CNN), a type of deep learning artificial intelligence, to act as a surgical planning aid by determining renal tumor and kidney volumes via segmentation on single-phase computed tomography (CT). Materials and Methods After institutional review board approval, the CT images of 319 patients were retrospectively analyzed. Two distinct CNNs were developed for (1) bounding cube localization of the right and left hemi-abdomen and (2) segmentation of the renal parenchyma and tumor within each bounding cube. Training was performed on a randomly selected cohort of 269 patients. CNN performance was evaluated on a separate cohort of 50 patients using Sorensen-Dice coefficients (which measures the spatial overlap between the manually segmented and neural network derived segmentations) and Pearson correlation coefficients. Experiments were run on a GPU-optimized workstation with a single NVIDIA GeForce GTX Titan X (12GB, Maxwell architecture). Results Median Dice coefficients for kidney and tumor segmentation were 0.970 and 0.816, respectively; Pearson correlation coefficients between CNN-generated and human-annotated estimates for kidney and tumor volume were 0.998 and 0.993 (p < 0.001), respectively. End-to-end trained CNNs were able to perform renal parenchyma and tumor segmentation on a new test case in an average of 5.6 seconds. Conclusions Initial experience with automated deep learning artificial intelligence demonstrates that it is capable of rapidly and accurately segmenting kidneys and renal tumors on single-phase contrast-enhanced CT scans and calculating tumor and renal volumes.
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Patel RM, Jiang P, Karani R, Phillips T, Arada RB, Xie L, Said H, Tapiero S, Landman J, Farzaneh T, Venkatesh R, Clayman RV. Analysis of Ureteral Diameter and Peristalsis in Response to Irrigant Fluid Temperature Changes in an In Vivo Porcine Model. J Endourol 2021; 35:1236-1243. [PMID: 33380276 DOI: 10.1089/end.2020.0849] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Objective: It has been previously reported that warming irrigation fluid higher than body temperature may decrease ureteral spasm and thereby facilitate ureteroscopic access to the proximal ureter. Our objective was to examine the effects on ureteral peristalsis and ureteral diameter if the irrigant was warmed to just under the biological threshold for injury. Materials and Methods: Two female adult Yorkshire pigs were studied in this pilot study. In the first pig, a dilute mixture of contrast and irrigation fluid at 37°C and then at 43°C was instilled for 30 minutes into each renal pelvis through a ureteral catheter at 40 mm Hg. Retrograde pyelogram images were captured for each trial and the caliber of the ureter was measured using Vitrea® software. In the second pig, a lumbotomy was performed, and a magnetic sensor was placed on the extraluminal surface of the ureter to monitor ureteral peristalsis while repeating the aforedescribed regimen. Thirty minutes after the first regimen, the force exerted during placement of a 16F ureteral access sheath (UAS) was recorded at both temperatures using the University of California, Irvine Ureteral Force Sensor. Results: There was no statistically significant difference in ureteral caliber along the length of the ureter at 43°C (p = 0.87, p = 0.32, p = 0.66 for proximal, middle, and distal ureter, respectively). Indeed, there was an increase in peristalsis from baseline with fluid irrigation at 37°C and at 43°C (59% and 65%, respectively). There was no significant difference in the force exerted for UAS placement at either temperature. On histologic analysis, there were no significant changes in ureteral histology or luminal diameter. Conclusions: In a porcine model, warming irrigation fluid to just under the biological threshold for injury did not increase ureteral caliber, decrease ureteral peristalsis, or facilitate UAS placement. As such, during ureteroscopy, we continue to warm our irrigation fluid just to body temperature.
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Xie L, O'Leary M, Jefferson FA, Karani R, Limfueco L, Parkhomenko E, Sung JM, Patel RM, Ichii H, Dafoe D, Clayman RV, Landman J. Interactive Virtual Reality Renal Models as an Educational and Preoperative Planning Tool for Laparoscopic Donor Nephrectomy. Urology 2021; 153:192-198. [PMID: 33556447 DOI: 10.1016/j.urology.2020.12.046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 12/13/2020] [Accepted: 12/20/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To evaluate the efficacy of interactive virtual reality (iVR) in providing a three-dimensional (3D) experience with the donor's anatomy for surgeons and patients, we present a retrospective, case-controlled study assessing the impact of iVR renal models prior to LDN on both surgical outcomes and patients' understanding of the procedure. MATERIALS AND METHODS Twenty patients undergoing LDN were prospectively recruited; their contrast-enhanced CT scans were transformed into iVR models. An iVR platform allowed the surgeons to rotate and deconstruct the renal anatomy; patients could also view their anatomy as the procedure was explained to them. Questionnaires assessed surgeons' understanding of renal anatomy after CT alone and after CT+iVR. Surgeons also commented on whether iVR impacted their preoperative plan. Patients assessed their anatomical understanding and anxiety level before and after iVR. Surgical outcomes for the iVR cohort were compared to a retrospectively matched, non-iVR cohort of LDN patients. RESULTS Surgeons altered their preoperative plan in 18 of 20 LDNs after viewing iVR models. Patients reported better understanding of their anatomy (5/5) and noted decreased preoperative anxiety (5/5) after viewing iVR. When compared to the non-iVR group, the iVR group had a 25% reduction in median operative time (P < .001). In terms of surgical outcomes, patients in the iVR group had a 40% lower median relative change in postoperative creatinine (P < .001). CONCLUSION Preoperative viewing of iVR models altered the operative approach, decreased the operative time, and improved donor patient outcomes. iVR models also reduced patients' preoperative anxiety.
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Karani R, Arada RB, Ayad M, Xie L, Brevik A, Peta A, Jiang P, Patel RM, Landman J, Clayman RV. Evaluation of a Novel Female Gender Flexible Ureteroscope: Comparison of Flow and Deflection to a Standard Flexible Ureteroscope. J Endourol 2021; 35:840-846. [PMID: 33439772 DOI: 10.1089/end.2020.0675] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Introduction: The advent of single-use disposable flexible ureteroscopes allows for rapid prototyping of novel endoscopes. In this regard, we sought to develop a female-specific ureteroscope, with a shorter working length, to account for the female anatomy. We hypothesized that the shorter, female-specific single-use flexible ureteroscope would engender higher irrigation flow at a given pressure than that of the standard-length ureteroscope. Methods: An in vitro analysis of a standard 65 cm Dornier Axis™ ureteroscope and a shorter, 45 cm female-specific Dornier Axis ureteroscope was performed. All other aspects of the endoscopes were identical. Each ureteroscope was oriented vertically and connected to a Thermedx® irrigation system to provide uniform pressurized flow. The average flow rate was computed over five, 2-minute periods at pressure settings of 50, 100, 150, and 200 mm Hg. Data were collected with the working channel unoccupied, after placement of a 200 μm (0.6F) holmium laser fiber and after passage of a 1.7F stone basket. The procedure was then repeated with the endoscopes at maximum deflection. Results: The female gender ureteroscope had significantly higher irrigation flow rates than the standard-length ureteroscope under all conditions by an average of 11% (p < 0.02). The highest average percent increase, 17% (p < 0.001), was seen with the 1.7F NGage® basket in the working channel with the endoscope straight. The maximum angle of deflection was not significantly different between the female gender and standard ureteroscopes with an open working channel (314° vs 315°, p = 0.86), with the 1.7F NGage basket in place (314° vs 315°, p = 0.15), and with the 200 μm holmium laser in place (316° vs 309°, p = 0.09). Conclusions: A 45 cm female gender ureteroscope allows for a higher irrigation flow rate than the standard-length ureteroscope under all test conditions. There is no added benefit with regard to deflection capabilities.
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Tapiero S, Limfuco L, Bechis SK, Sur RL, Penniston KL, Nakada SY, Antonelli JA, Streeper NM, Sivalingam S, Viprakasit DP, Averch TD, Okhunov Z, Patel RM, Chi T, Pais VM, Chew BH, Bird VG, Andonian S, Bhojani N, Canvasser NE, Landman J. The impact of the number of lifetime stone events on quality of life: results from the North American Stone Quality of Life Consortium. Urolithiasis 2021; 49:321-326. [PMID: 33409555 DOI: 10.1007/s00240-020-01238-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 12/17/2020] [Indexed: 11/28/2022]
Abstract
To evaluate the impact of chronic stone recurrence on an individual's quality of life using the validated Wisconsin Stone Quality of Life (WISQOL) questionnaire. We collected cross-sectional data on patients with kidney stones from 14 institutions in North America. A stone event was defined as renal colic, stone-related procedure or emergency department visit. The regression analyses using general linear models and pairwise comparison determined the impact of the number of stone events on quality of life. The median number of stone events among the 2205 patients who completed the questionnaire was 3 (IQR 1-6). The mean total score was 107.4 ± 28.7 (max 140 points). The number of lifetime stone events was an independent predictor of lower quality of life (p < 0.001), specifically, score declined significantly beyond five events. Compared with patients who experienced a single stone event, there was a 0.4, 2.5, and 6.9 point decline in the adjusted mean WISQOL score after 2-5, 6-10, or > 10 events, respectively. The cumulative number of lifetime stone events was associated with a lower quality of life when more than five stone events were occurred. These findings underscore the importance of efforts to determine the underlying metabolic etiology of urolithiasis in the recurrent stone former, and the institution of a regimen to place their stone disease in remission.
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Micali S, Sighinolfi MC, Iseppi A, Morini E, Calcagnile T, Benedetti M, Ticonosco M, Kaleci S, Bevilacqua L, Puliatti S, De Nunzio C, Arada R, Chiancone F, Campobasso D, Eissa A, Bonfante G, Simonetti E, Cotugno M, Galli R, Curti P, Schips L, Ditonno P, Villa L, Ferretti S, Bergamaschi F, Bozzini G, Zoeir A, Sherbiny AE, Frattini A, Fedelini P, Okhunov Z, Tubaro A, Landman J, Bianchi G, Rocco B. Initial Experience and Evaluation of a Nomogram for Outcome Prediction in Management of Medium-sized (1-2 cm) Kidney Stones. Eur Urol Focus 2021; 8:276-282. [PMID: 33419709 DOI: 10.1016/j.euf.2020.12.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 11/18/2020] [Accepted: 12/18/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND The gold standard treatment for solitary medium-sized (1-2 cm) renal stones is not defined by recent guidelines, since management modalities including shockwave lithotripsy (SWL), retrograde intrarenal surgery (RIRS), and percutaneous nephrolithotomy (PNL) are recommended. Improved ability to predict patient outcomes would aid in patients' counseling and decision-making. OBJECTIVE To develop a nomogram predicting treatment failure, based on preoperative clinical variables, to be used in the preplanning setting. DESIGN, SETTING, AND PARTICIPANTS We recruited 2605 patients from 14 centers and carried out a multicenter retrospective analysis of 699 SWL, 1290 RIRS, and 616 PN L procedures performed as first-line treatment for 1-2-cm kidney stones. The variables evaluated included age, gender, previous renal surgery, body mass index, stone size, location, stone density, skin-to-stone distance, presence of urinary tract infections (UTIs), and hydronephrosis. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Multivariate logistic regression was fitted to predict treatment failure, defined as the presence of residual fragments >4 mm. A nomogram was developed based on the coefficients of the logit function. RESULTS AND LIMITATIONS A total of 2431 (93.3%) patients were stone free; 174 (6.7%) treatment failures were recorded and considered the event to be predicted. On univariate analysis, type of procedure, preoperative hydronephrosis, stone density, stone location, and laterality turned out to be statistically significant. Skin-to-stone distance, UTIs, and previous renal surgery were predictors of failure on multivariate analysis. Each variable was given a score based on statistical relevance. The main limitation of the current study is its retrospective nature. CONCLUSIONS This nomogram provides a prediction of treatment failure and need of reintervention for medium-sized kidney stones. External validation is needed to determine its reproducibility and validity. PATIENT SUMMARY We developed a preoperative model of treatment outcomes for 1-2-cm kidney stones. Its application may assist urologists to counsel patients with regard to stone management modality.
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Nguyen DD, Luo JW, Lu XH, Bechis SK, Sur RL, Nakada SY, Antonelli JA, Streeper NM, Sivalingam S, Viprakasit DP, Averch TD, Landman J, Chi T, Pais VM, Chew BH, Bird VG, Andonian S, Canvasser NE, Harper JD, Penniston KL, Bhojani N. Estimating the health-related quality of life of kidney stone patients: initial results from the Wisconsin Stone Quality of Life Machine-Learning Algorithm (WISQOL-MLA). BJU Int 2020; 128:88-94. [PMID: 33205549 DOI: 10.1111/bju.15300] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 10/06/2020] [Accepted: 11/13/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To build the Wisconsin Stone Quality of Life Machine-Learning Algorithm (WISQOL-MLA) to predict urolithiasis patients' health-related quality of life (HRQoL) based on demographic, symptomatic and clinical data collected for the validation of the Wisconsin Stone Quality-of-Life (WISQOL) questionnaire, an HRQoL measurement tool designed specifically for patients with kidney stones. MATERIAL AND METHODS We used data from 3206 stone patients from 16 centres. We used gradient-boosting and deep-learning models to predict HRQoL scores. We also stratified HRQoL scores by quintile. The dataset was split using a standard 70%/10%/20% training/validation/testing ratio. Regression performance was evaluated using Pearson's correlation. Classification was evaluated with an area under the receiver-operating characteristic curve (AUROC). RESULTS Gradient boosting obtained a test correlation of 0.62. Deep learning obtained a correlation of 0.59. Multivariate regression achieved a correlation of 0.44. Quintile stratification of all patients in the WISQOL dataset obtained an average test AUROC of 0.70 for the five classes. The model performed best in identifying the lowest (0.79) and highest quintiles (0.83) of HRQoL. Feature importance analysis showed that the model weighs in clinically relevant factors to estimate HRQoL, such as symptomatic status, body mass index and age. CONCLUSIONS Harnessing the power of the WISQOL questionnaire, our initial results indicate that the WISQOL-MLA can adequately predict a stone patient's HRQoL from readily available clinical information. The algorithm adequately relies on relevant clinical factors to make its HRQoL predictions. Future improvements to the model are needed for direct clinical applications.
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Lim JRZ, Scotland KB, Bechis SK, Sur RL, Nakada SY, Antonelli JA, Streeper NM, Sivalingam S, Viprakasit DP, Averch TD, Landman J, Chi T, Pais VM, Bird VG, Andonian S, Bhojani N, Canvasser NE, Harper JD, Penniston KL, Chew BH. Response to: Khusid, Atallah, and Gupta re: "Metabolic Syndrome Negatively Impacts Stone-Specific Quality of Life" by Lim et al. J Endourol 2020; 34:1209-1210. [PMID: 33197227 DOI: 10.1089/end.2020.29102.jrl] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Lundeen C, Lim JRZ, Scotland KB, Ardekani RS, Penniston KL, Streeper NM, Chi T, Landman J, Viprakasit DP, Chew BH. What is the relationship of stress to patients' kidney stone-related quality of life? Can Urol Assoc J 2020; 15:E256-E260. [PMID: 33119497 DOI: 10.5489/cuaj.6652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Health-related quality of life (HRQOL) is decreased in patients with kidney stones at all stages of stone disease, even when asymptomatic. Stress is thought to contribute to HRQOL, although there has been minimal investigation into the effect of stress on stone-related quality of life (QOL). We used the Wisconsin Stone Quality of Life Questionnaire (WISQOL) to assess the relationship of stress to stone-related QOL in kidney stone patients. METHODS As part of the WISQOL Research Consortium, patients were approached in outpatient clinics and completed the WISQOL and the Perceived Stress Scale 10-item questionnaire (PSS-10). Patients with stones at enrollment were divided into those with symptoms and those without, while patients with no current stones formed another group. Questionnaire scores from each group were compared statistically and correlations between the groups were calculated. RESULTS Patients (n=704) were enrolled from six centers. The WISQOL successfully discriminated between patients with current stones and those without (p<0.0001), while the PSS-10 did not (p=0.0869). The PSS-10 revealed patients with symptomatic kidney stones experienced higher levels of general stress than asymptomatic subjects (p<0.0001). However, a Pearson correlation test comparing the responses from each instrument revealed no overall correlation between general stress and HRQOL (r=0.05). CONCLUSIONS Symptomatic kidney stones increase general stress, as these patients demonstrate higher PSS-10 scores. Despite this, no correlation exists between general stress and stone-related QOL in patients with stone disease regardless of their stone and symptom status. This implies the existence of other factors impacting QOL in these patients, which warrants further exploration.
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Schneider D, Abedi G, Larson K, Ayad M, Yoon R, Patel RM, Landman J, Clayman RV. In Vitro Evaluation of Stone Fragment Evacuation by Suction. J Endourol 2020; 35:187-191. [PMID: 32791862 DOI: 10.1089/end.2020.0517] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Introduction: Contemporary, flexible stone baskets are unable to extract submillimeter stone fragments at the time of ureteroscopic laser lithotripsy. In this in vitro study, the feasibility of suctioning submillimeter fragments with a standard Luer Lock syringe through the working channel of a flexible ureteroscope was assessed. Materials and Methods: Phantom stones made from industrial plaster were mechanically fragmented into ≤1 and ≤0.5-mm groups. Both stone groups were divided into five preweighed trial samples. Each stone group was then mixed in a beaker filled with normal saline. A standard 10-mL Luer Lock syringe was connected to a fiber-optic ureteroscope with a 1.2-mm working channel. The syringe was then used to suction stone fragments from the beaker. The suctioned stone fragments and the stone fragments remaining in the beaker after removing the overlying solution were separated, centrifuged with supernatant removed, and dried in an incubator set at 33°C for 1 week. Dried weights were recorded. Results: Mean total weights for ≤0.5 and ≤1.0-mm stone groups at baseline were 0.807 and 0.806 g, respectively. The mean percentages of stone fragments suctioned through the ureteroscope for ≤0.5 and ≤1.0-mm groups were 86% and 86%, respectively (p = 0.973). During suctioning, 64% of stones in the ≤0.5-mm group were trapped in either the working channel of the ureteroscope or within the Luer Lock syringe compared with 78% of stones in the ≤1-mm group (p = 0.001) requiring cessation of the procedure to clear the channel. Conclusions: It is feasible to suction submillimeter stone fragments by connecting a Luer Lock syringe to the working channel of a flexible ureteroscope. The limiting factor for removing stone fragments appears to be the small working channel of flexible ureteroscopes as trapping of fragments during suctioning is common and requires time-consuming removal of the endoscope and clearing of the channel.
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Lim JRZ, Scotland KB, Bechis SK, Sur RL, Nakada SY, Antonelli JA, Streeper NM, Sivalingam S, Viprakasit DP, Averch TD, Landman J, Chi T, Pais VM, Bird VG, Andonian S, Bhojani N, Canvasser NE, Harper JD, Penniston KL, Chew BH. Metabolic Syndrome Negatively Impacts Stone-Specific Quality of Life. J Endourol 2020; 34:1203-1208. [PMID: 32689819 DOI: 10.1089/end.2020.0247] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Purpose: Metabolic syndrome (MetS) is a cluster of metabolic diseases that is linked to atherosclerotic cardiovascular disease. MetS has also been linked to increased nephrolithiasis. However, limited research has been conducted on MetS and its impact on stone-specific health-related quality of life (HRQOL). This study aims to examine the hypothesis that the presence of MetS is associated with decreased HRQOL. Materials and Methods: The Wisconsin Stone Quality of Life Questionnaire, a stone-specific HRQOL questionnaire, was used to survey 3051 patients with kidney stones. Medical history was collected from patients. These data were used to distinguish MetS patients from non-MetS patients. Among patients with current stones, a Wilcoxon rank sum test was used to compare HRQOL scores from MetS patients and non-MetS patients. HRQOL from patients with and without individual MetS components were also compared, and a multivariate analysis was conducted. Results: Statistical comparison between MetS patients (median score 102/140) and non-MetS patients (median score 106/140) demonstrated a lower stone-specific HRQOL in patients with MetS (p = 0.049). Among individual MetS components, patients with diabetes mellitus (DM) or body mass index (BMI) >30 had significantly lower HRQOL than patients without DM or BMI <30 (p = 0.028 and p < 0.001, respectively). The multivariate analysis supported this trend as MetS remained a significant predictor of decreased HRQOL (p = 0.002) after controlling for other variables assessed. Conclusions: This study indicates an association between MetS and a lower stone-specific QOL. This has important implications for stone prevention strategies in patients with MetS. Clinical Trial Registration number: H14-01143.
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Nguyen DD, Luo J, Lim J, Scotland K, Bechis S, Sur R, Nakada S, Antonelli J, Streeper N, Sivalingam S, Viprakasit D, Averch T, Landman J, Chi T, Pais JV, Bird V, Andonian S, Canvasser N, Harper J, Chew B, Penniston K, Bhojani N. Wisconsin quality of life machine learning algorithm for predicting quality of life in kidney stone patients. EUR UROL SUPPL 2020. [DOI: 10.1016/s2666-1683(20)33385-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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