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Redefining Clinically Significant Hematuria After Holmium Enucleation of the Prostate.

Introduction and Objective: Holmium laser enucleation of the prostate (HoLEP) is often offered for symptomatic prostatic enlargement at high risk for bleeding. However, prior studies define clinically significant hematuria (CSH) narrowly as the need for blood transfusion or significant decrease in hemoglobin. We sought to evaluate risk factors contributing to a broader definition of CSH, which may contribute to alteration of clinical course. Methods: We analyzed 164 patients in a prospectively maintained database who underwent HoLEP at a single institution across two surgeons from November 2020 to April 2023. HoLEP was performed using Moses 2.0 (Boston Scientific) laser and the Piranha enucleation system (Richard Wolf). We defined CSH broadly as follows: clot retention, return to operating room, perioperative management variation due to hematuria, or continued gross hematuria past 1 month postoperatively. Univariable and multivariable ANOVAs were used. Multivariable analysis of CSH risk based on the use of antiplatelet (AP) agents or anticoagulants included correction for age, enucleation time (surrogate for case difficulty), and prostate volume. Results: 17.7% (29/164) of our patients developed CSH after HoLEP. Longer enucleation time was a mild risk factor for developing CSH (multivariate odds ratio [OR] 1.01, p = 0.02). The strongest predictor of CSH was the use of anticoagulation or AP agents (OR 2.71 p < 0.02 on univariable analysis, OR 2.34 p < 0.02 on multivariable analysis), even when aspirin 81 mg was excluded. Conclusion: With a broadened definition, 18% of patients developed CSH following HoLEP, which impacted the clinical course. Our data suggest that the current definition of significant hematuria is too narrow and does not capture many patients whose clinical course is affected by hematuria. While safe, anticoagulants and APs significantly predicted an increased CSH risk, and patients should be counseled accordingly.

Routine Urinary Biochemistry Does Not Accurately Predict Stone Type Nor Recurrence in Kidney Stone Formers: A Multi-Centre, Multi-Model, Externally Validated Machine-Learning Study.

Urinary biochemistry is used to detect and monitor conditions associated with recurrent kidney stones. There are no predictive machine learning (ML) tools for kidney stone type or recurrence. We therefore aimed to build and validate ML models for these outcomes using age, gender, 24-hour urine biochemistry and stone composition. Data from 3 cohorts were used, Southampton, UK (n=3013), Newcastle, UK (n=5984) and Bern, Switzerland (n=794). Of these 3130 had available 24-hour urine biochemistry measurements (calcium, oxalate, urate, pH, volume), and 1684 had clinical data on kidney stone recurrence. Predictive machine learning models were built for stone type (n=5 models) and recurrence (n=7 models) using the UK data, and externally validated with the Swiss data. Three sets of models were built using complete cases, multiple imputation and oversampling techniques. For kidney stone type one model (XGBoost built using oversampled data) was able to effectively discriminate between calcium oxalate, calcium phosphate and urate on both internal and external validation. For stone recurrence, none of the models were able to discriminate between recurrent and non recurrent stone formers. Kidney stone recurrence cannot be accurately predicted using modelling tools built using specific 24-hour urinary biochemistry values alone. A single model was able to differentiate between stone types. Further studies to delineate accurate predictive tools should be undertaken using both known and novel risk factors, including radiomics and genomics. .

Open Access
Antimicrobial Prophylaxis for Percutaneous Nephrolithotomy: Contemporary Practice Patterns.

Updated in 2019, the American Urological Association's (AUA) Best Practice Statement on Urologic Procedures and Antimicrobial Prophylaxis outlines prophylaxis for percutaneous nephrolithotomy (PCNL). Recent studies have challenged these recommendations. We hypothesized endourologists do not routinely follow the AUA's statement on antibiotic use during PCNL and assessed their prescribing patterns. A 24-question survey was distributed to members of the Endourological Society. The primary outcome was adherence to the AUA's recommendations. Two multiple logistic regression analyses were performed with demographics and antibiotic preference as predictors of following the AUA. A total of 51.4% of endourologists follow the AUA Best Practice Statement for antimicrobial prophylaxis of uncomplicated PCNL. No demographic data was predictive of following the AUA. 90.9% and 83.6% reported they have "never" used the first-line recommendation options of metronidazole and aztreonam, respectively. Preferred antibiotics were cephalosporins (uncomplicated 60%, complicated 52.6%), fluoroquinolones (13.3%, 7.2%), aminoglycosides (12.7%, 17.8%), penicillins (7.9%, 11.2%), carbapenems (0.6%, 0.7%), trimethoprim-sulfamethoxazole (2.4%, 5.9%), fosfomycin (0.6%, 0.7%), nitrofurantoin (2.4%, 2.6%), aztreonam (0%, 0.7%), and clindamycin (0%, 0.7%). For uncomplicated PCNL, 63.1% prescribe ≤ 24 hours of perioperative antibiotics. For complicated PCNL, 16.2% prescribe ≤ 24 hours of perioperative antibiotics while 20.4% begin antibiotics 7 or more days prior. Nearly half of respondents do not follow the AUA's recommendations for antibiotic choice for PCNL. Few endourologists prescribe 7 days of preoperative antibiotics for complicated PCNL despite supporting data. Metronidazole and aztreonam are rarely used as a first line antibiotic choice for PCNL and their roles needs to be further evaluated as first line prophylaxis recommendations. Updates on antibiotic recommendations for PCNL are needed based on current literature, antimicrobial stewardship, and contemporary practice patterns.

Comparison of a Valveless Trocar System and Conventional Insufflation in Pediatric Urologic Surgery.

Background Conventional operative insufflation uses a one-way trocar to handle instruments while maintaining pneumoperitoneum. In 2007, the AirSeal® valveless trocar insufflation system was introduced, which maintains stable pneumoperitoneum while continuously evacuating smoke. Although this device has been validated in adult patients, it has not been extensively validated in the pediatric population. Materials and Methods A retrospective cohort study of pediatric urology patients aged 0 to 21 who underwent laparoscopic pyeloplasty between March 2016 and October 2021 was performed. Intraoperative physiologic parameters, procedure characteristics, postoperative outcomes, and demographics of each patient in whom either AirSeal® insufflation systems (AIS) or conventional insufflation systems (CIS) was utilized were obtained from hospital records. Data was compared across the AIS and CIS cohorts. The primary outcomes were intraoperative anesthetic and physiologic parameters, including end tidal CO2 (ETCO2), oxygen saturation (SaO2), body temperature, positive inspiratory pressure (PIP), systolic blood pressure (SBP), and heart rate (HR). Results There were no significant differences in the anesthetic and physiologic parameters in the AIS and CIS groups. In addition, no differences in demographics, procedural characteristics, or complication rates were found between the cohorts. Conclusion The AirSeal® valveless trocar insufflation system demonstrates comparable intraoperative anesthetic and physiologic outcomes compared to conventional one-way valve insufflation in pediatric laparoscopic pyeloplasty. Certain surgeon-related qualitative metrics are underappreciated in this study however, including improved visualization with vigorous suctioning and pressure maintenance with frequent instrument exchanges. Surgeon experience may mask the benefits of these characteristics as it pertains to quantitative surgical outcomes such as estimated blood loss (EBL), operative time, and perioperative complications.

An Updated Systematic Review and Meta-Analysis on the Technical, Oncologic, and Safety Outcomes of Microwave Ablation in Patients with Renal Cell Carcinoma.

Percutaneous microwave ablation (MWA) has emerged as a new energy modality for percutaneous renal tumour ablation with potential advantages over radiofrequency and cryoablation. The goal of our study was to determine MWA outcomes for suspicious renal masses, with a subset analysis for biopsy-proven renal cell carcinoma (RCC) and larger (T1b) tumours. Studies reporting outcomes of MWA for RCC were identified. Random effects models with inverse-variance weighting were used to pool outcomes, including technical success rate (TSR), technical efficacy rate (TER), local recurrence rate (LRR), cancer-specific survival rate (CSSR), overall survival rate (OSR), and complications. Among 914 studies captured, 27 studies with 1584 patients (1683 malignant renal tumours) were included. The pooled TSR and TER were 99.6% (95% CI, 98.0-100%) and 96.2% (93.8-98.2%). The pooled LRR was 3.2% (1.9-4.7%). At 1, 3, and 5-years, the pooled CSSRs were 100% (99.4-100%), 100% (98.4-100%), and 97.7% (94.5-99.7%), while pooled OSRs were 99.0% (97.5-99.9%), 96.0% (93.1-98.3%), and 88.1% (80.3-94.2%). The pooled minor and major complication rates were 10.3% (7.1-13.9%) and 1.0% (0.3-2.1%). In 204 patients with 208 T1b tumours, the pooled TSR and TER were 100% (96.6-100%) and 85.2% (71.0-95.8%). The pooled LRR was 4.2% (0.9-8.9%). At 1, 3, and 5-years, the pooled CSSRs were 98.2% (88.7-100%), 97.2% (78.5-100%), and 98.1% (72.3-100%). At 1 and 3-years, the pooled OSRs were 94.3% (85.7-99.6%) and 89.3% (68.7-100%). The pooled minor and major complication rates were 14.8% (7.4-23.8%) and 2.6% (0-7.8%). MWA demonstrated favorable short- to intermediate-term oncologic outcomes with low complication rates, including in the T1b subset, with moderate quality of data and heterogeneity of assessed outcomes. This supports MWA as a safe and effective treatment for RCC and a potential viable option for larger tumours.

Time Efficiency and Performance of Single-Use Versus Reusable Cystoscopes: A Randomized Benchtop and Simulated Clinical Assessment.

Introduction A flexible cystoscope is an indispensable tool for urologists, facilitating a variety of procedures in both the operating room and at bedside. Single-use cystoscopes offer benefits including accessibility and decreased burden for reprocessing. The aims of this study were to compare time efficiency and performance of single-use and reusable cystoscopes. Methods Ten new AmbuⓇ aScopeTM 4 Cysto single-use and two Olympus CYF-5 reusable cystoscopes were compared in simulated bedside cystoscopy and benchtop testing. Ten urologists performed simulated cystoscopy using both cystoscopes in a randomized order. Times for supply-gathering, setup, cystoscopy, cleanup, and cumulative time were recorded, followed by a Likert feedback survey. For benchtop assessment, physical, optical, and functional specifications were assessed and compared between cystoscopes. Results The single-use cystoscope demonstrated shorter supply-gathering, setup, cleanup, and cumulative times (824 vs 1231s; p<0.05) but a comparable cystoscopy time to the reusable cystoscope (202 vs 212s; p=0.322). The single-use cystoscope had a higher image resolution but a narrower field of view. Upward deflection was greater for the single-use cystoscope (214.50° vs 199.45°; p<0.001) but required greater force (2.5x). Working channel diameter and irrigation rate were greater in the reusable cystoscope. While the single-use cystoscope lacked tumor enhancing optical features, it had higher Likert scale scores for Time Efficiency and Overall Satisfaction. Conclusion The single-use cystoscope demonstrates comparable benchtop performance and superior time efficiency compared to reusable cystoscopes. However, the reusable cystoscope has superior optical versatility and flow rate. Knowledge of these differences allow for optimal cystoscope selection based on procedure indication.

Does Resectoscope Sheath Size Influence Holmium Laser Enucleation of the Prostate (HoLEP) Outcomes? A Prospective Randomized, Controlled Trial.

Holmium laser enucleation of the prostate (HoLEP) is routinely performed with a 24, 26, or a 28 French (F) scope. Proponents of the larger scopes propose that a bigger sheath size allows for superior flow and visibility leading to a more efficient operation and better hemostasis. Those utilizing the smaller scopes suggest the lower profile is less traumatic, resulting in lower stricture rates and temporary incontinence. We sought to compare outcomes of ambulatory HoLEP using the 24F and 28F laser scope. From May 2022 to March 2023, we randomized patients undergoing HoLEP (<200 cm3 in size) 1:1 to either a 24F or 28F scope. The primary outcome was differences in surgical duration between groups (mins). Secondary outcomes included surgeon scope evaluation and post-operative patient results. There was no difference in patient characteristics in those randomized to 28F (n=76) versus 24F (n=76) (p>0.05) scopes. Procedural duration and efficiencies were not different between groups (all p>0.05). The 28F scope was associated with improved surgeon-graded irrigation flow and visibility (p<0.001). Patients treated with the 28F scope were more likely to achieve successful same-day trial of void (28F 94.3% vs. 24F 82.1%, p=0.048) and have a shorter length of stay (28F 7.0 vs. 24F 11.9 hours, p=0.014), however rates of same-day discharge were not statistically different (28F 87.8% vs. 24F 78.4%, p=0.126). There was no difference between the cohorts in rates of 90-day emergency room presentations, re-admissions, complications, or functional ouctomes (p>0.05). We identified no clear advantage of scope size with regards to intra-operative or post-operative outcomes at 3-month follow up due to scope size. However, if same-day discharge is part of your postoperative pathway, the 28F scope may shorten length of stay and increase rates of successful same-day trial of void.

Preoperative Frailty Scores Predict the Early Postoperative Complications of Holmium Laser Enucleation of Prostate.

Frailty is a recent multidimensional concept of a contemporary growing interest for understanding the complex health status of elderly population. We aimed to assess the impact of frailty scores on the outcome and complication rate of holmium laser enucleation of prostate (HoLEP). A seven-year data of HoLEP patients in a single tertiary referral center was reviewed. The preoperative, operative, early, and late postoperative outcome data was collected and compared according to the preoperative frailty scores. Frailty was assessed preoperatively using the Modified Hopkins frailty score. The study included 837 patients categorized into 2 groups; G I included 533 non-frail patients (frailty score =0) while G II included 304 frail patients (frailty score ≥1). The median (IQR) age was 70 (11) and 75 (11) for G I and G II respectively (<0.001). The 30-day perioperative complication rate (p= 0.005), blood transfusion (P= 0.013), failed voiding trial (P= 0.0015) and 30-day postoperative readmission (P= 0.0363) rates were significantly higher in frail patients of G II. The 2 groups were statistically comparable regarding postoperative international prostate symptom score (IPSS) (p= 0.6886, 0.6308, 0.9781), incontinence rate (p= 0.475, 0.592, 0.1546), postvoid residual (PVR) (0.5801, 0.1819, 0.593) at 6 weeks and 3-month, and 1-year follow up intervals respectively. Multivariate regression analysis showed that higher frailty scores (HR= 2.14, 95% CI= 1.63-2.96, P =0.005), larger preoperative prostate volume (HR= 1.34, 95% CI= 1.23-1.65, P =0.023), and positive preoperative urine culture (HR= 1.24, 95% CI= 1.13-1.54, P =0.037) significantly correlated to the incidence of perioperative complications. In elderly patients undergoing HoLEP, the preoperative frailty scores strongly correlate to the risk of perioperative complications. Frail patients should be counselled regarding their relative higher risk of early perioperative complications although they gain the same functional profit of HoLEP as non-frail patients.