Manoj Monga

Objective: National guidelines recommend peri-procedural antibiotics prior to percutaneous nephrolithotomy (PCNL), yet it is not clear which is superior. We conducted a randomized trial to compare two guideline recommended antibiotics: ciprofloxacin (cipro) versus cefazolin, on PCNL outcomes, focusing on the development of systemic inflammatory response syndrome (SIRS) criteria. Methods: Adult patients who were not considered high risk for surgical or infectious complications undergoing PCNL were randomized to receive either cipro or cefazolin perioperatively. All had negative pre-operative urine cultures. Demographic and peri-operative data were collected, including SIRS criteria, intra-operative urine culture, duration of hospitalization, and need for intensive care. SIRS is defined by ≥2 of the following: body temperature < 96.8 °F or >100.4 °F, heart rate > 90 bpm, respiratory rate >20 per minute, WBC count 12,000 cells/mm³. Results: One hundred and forty seven patients were enrolled and randomized (79 cefazolin, 68 cipro). All pre-operative characteristics were similar (p>0.05), except for mean age, which was higher in the cipro group (64 vs. 57, p=0.03). Intra and post-operative findings were similar, with no difference between groups (p>0.05), except a longer mean hospital stay in the cefazolin group (2 hours longer, p=0.02). There was no difference between SIRS episodes on both univariate and multivariate analysis. Conclusions: Despite the relatively broader coverage for urinary tract pathogens with ciprofloxacin, this prospective randomized trial did not show superiority over cefazolin. Our findings therefore support two appropriate options for perioperative antibiotic prophylaxis in patients undergoing PCNL who are non-high risk for infectious complications.

Introduction: The objective of this process improvement project was to determine the effect of enhanced recovery after surgery (ERAS) protocol for percutaneous nephrolithotomy (PCNL) patients with respect to quality of life (QOL) and pain management in the postoperative recovery period. Methods: An electronic-based medical record ERAS orders protocol for PCNL was instituted at an academic medical center in July 2020. The protocol utilized a pain control regimen designed to minimize opioid medication use postoperatively. We prospectively evaluated PCNL patients' QOL through the Wisconsin Stone Quality of Life (WISQOL) survey and Patient-Reported Outcomes Measurement System (PROMIS) at routine perioperative visits. To assess any opioid reduction benefit of the ERAS protocol, we reviewed an age-matched historical cohort n = 66 (before ERAS implementation) to serve as a comparison cohort with respect to opioid usage. Results: After an inception cohort of 95 patients, 55 ERAS patients remained available for assessment with the WISQOL and PROMIS surveys. In comparison with the non-ERAS cohort, the ERAS cohort represented larger stones, more supine positioning, higher blood loss, shorter hospital stay, and more use of access sheath. ERAS patients received a significantly lower amount of opioids compared with non-ERAS patients upon discharge narcotic usage (116.13 morphine milliequivalent [MME] vs 39.57 MME, p = 0.0001). Compared with their preoperative evaluation, the ERAS cohort had significantly improved QOL scores at 1 week, which sustained through 8 weeks postoperatively. Moreover, pain intensity and pain interference scores were improved at 8 weeks postoperatively for ERAS patients compared with their preoperative time point. Conclusions: We demonstrate that standardizing medications in early efforts toward a PCNL ERAS protocol is feasible and allows for reduced opioid use by patients while achieving early and sustained postprocedure QOL.

Purpose: Retrograde intrarenal surgery (RIRS) requires urologists to adopt an awkward body posture for long durations. Few urologists receive training in ergonomics despite the availability of ergonomic best practices utilized by other surgical specialties. We characterize ergonomic practice patterns and rates of musculoskeletal (MSK) pain among urologists performing RIRS. Methods: A web-based survey was distributed through the Endourological Society, the European Association of Urology, and social media. Surgeon anthropometrics and ergonomic factors were compared with ergonomic best practices. Pain was assessed with the Nordic Musculoskeletal Questionnaire (NMQ). Results: Overall, 519 of 526 participants completed the survey (99% completion rate). Ninety-three percent of urologists consider ergonomic factors when performing RIRS to reduce fatigue (68%), increase performance (64%), improve efficiency (59%), and reduce pain (49%). Only 16% received training in ergonomics. Residents/fellows had significantly lower confidence in ergonomic techniques compared with attending surgeons with any career length. Adherence to proper ergonomic positioning for modifiable factors was highly variable. On the NMQ, 12-month rates of RIRS-associated pain in ≥1 body part, pain limiting activities of daily living (ADLs), and pain requiring medical evaluation were 81%, 51%, and 29%, respectively. Annual case volume >150 cases (odds ratio [OR] 0.55 [0.35–0.87]) and higher adherence to proper ergonomic techniques (OR 0.67 [0.46–0.97]) were independently associated with lower odds of pain. Limitations include a predominantly male cohort, which hindered the ability to assess gender disparities in pain and ergonomic preferences. Conclusions: Adherence to ergonomic best practices during RIRS is variable and may explain high rates of MSK pain among urologists. These results underscore the importance of utilizing proper ergonomic techniques and may serve as a framework for establishing ergonomic guidelines for RIRS.

In the process of urinary stone formation, several heavy metals and trace elements (HMTE) have been identified among the major constituents of the calculi. The micro-elements within the stones cannot be identified by ordinary laboratory analytical techniques, the latter can only detect the major crystalline component. The objective of the present study was to evaluate the different types of HMTE (no. 22) and their concentrations within the urinary stones. The stone samples were obtained from patients living in different geographical locations (10 countries: 5 Western and 5 non-Western). The number of retrieved stones after open or endoscopic procedures was 1177. The concentrations of the 22 HMTE in the stones were assessed by inductively coupled plasma optical emission spectrometry (ICP-OES). The statistical data were analyzed using Kruskal–Wallis, one-way ANOVA, and SPSS software (version 20). The biochemical stone analysis showed that calcium oxalate was present as a major component in 650 patients (55.2%), calcium phosphate in 317 (26.9%), and uric acid and cystine stones in 210 (17.8%). The analyzed stones showed the presence of HMTE in different concentrations. Significantly higher concentrations of 17 elements (Al, As, Ba, B, Ca, Cd, Co, Cr, Cu, Fe, Mn, Ni, Pb, S, Se, Sr, and Zn) were noted in all stones. Seven elements (Al, As, Se, Sr, Fe, Zn, and Ni) were present in higher concentrations in calcium-based stones. In comparison, eight elements (Mg, B, Ba, Cd, Se, Pb, Sr, and Zn) in higher concentrations were associated with phosphate-based stones. Both uric acid and cystine stones had a higher concentration of sulfur. The concentrations of HMTE in calcium phosphate stones were higher than in calcium oxalate and uric acid stones. Calculi obtained from patients living in western countries contained higher levels of 13 HMTE (B, Ba, Ca, Cd, Co, Cu, Fe, K, Mg, Mo, P, Pb, and Se) than those in non-western countries. The age of calculi-forming patients from non-western countries was younger than those living in western countries. These results may indicate the role of many significant heavy metals and trace elements in the pathogenesis of urinary stone formation. The types and contents of HMTE within urinary stones differ from one country to another. The conventional stone analysis techniques cannot either identify the stone micro-elements or the concentrations of HMTE, so a specific and additional instrument such as the ICP-OES is necessary. Further research work on the urinary stone micro-elemental structure could lead to a new strategy for the prevention of stone formation and recurrence.

Purpose:Pain is the leading cause for unplanned emergency department visits and readmissions after ureteroscopy (URS), making post-operative analgesic stewardship a priority given the current opioi...

Objective: To report the outcomes of percutaneous nephrolithotomy (PCNL) in horseshoe kidneys (HSK) in 12 institutions worldwide and evaluate the impact of patient position during operation. Methods: We carried out a retrospective analysis of PCNL procedures performed between 2008 and 2018 in patients with HSK. Pre-, peri-, and postoperative data were collected, and a subgroup analysis was performed according to patient position. Success was defined as an absence of >4-mm fragments. Values of p < 0.05 were considered significant. Results: We analyzed 106 procedures. The transfusion, complication, and immediate success rates (ISRs) were 3.8%, 17.5%, and 54.7%, respectively. The final success rate (FSR) increased to 72.4% after a mean of 0.24 secondary procedures. Logistic regression showed that higher body mass index (BMI) and stone size were significantly associated with residual fragments ≥4 mm. Sixty-seven patients (63.2%) were treated in prone and 39 (36.8%) in supine position. The prone group had a significantly higher BMI than the supine group (30.1 vs 27.7, p = 0.024). The transfusion, complication, and ISRs between the prone and supine groups were 4.5% vs 2.6% ( p = 0.99), 16.9% vs 18.4% ( p = 0.99), and 52.5% vs 69.2% ( p = 0.151), respectively. Surgical time was significantly longer in the prone group (126.5 vs 100 minutes, p = 0.04). Upper pole was the preferred access in 80.3% of the prone group and 43.6% of the supine group ( p < 0.001). The prone group had significantly more Clavien 2 complications than the supine ( p = 0.013). The FSR in the prone and supine groups increased to 66.1% and 82.1% after 0.26 and 0.21 secondary procedures, respectively. No complications higher than Clavien 3 occurred. Conclusion: PCNL in patients with HSK is safe and effective with a low complication rate. Higher BMI and stone size negatively impacted outcomes. Supine PCNL may be an option for treating kidney stones in patients with HSK.

Objectives To evaluate the safety and efficacy of combined top and down low power thulium laser enucleation of the prostate (ThuLEP). Patients and methods Between May 2017 and May 2019, after institutional board review approval, successfully consented patients underwent combined top and down low power ThuLEP. We used a 30 -W Thulium laser with a 550 μm laser fiber and a 26 Fr continuous flow resectoscope. We collected data related to prostate size, enucleation time, morcellation time, perioperative complications, and early outcomes. Results Sixty patients underwent combined Top and down low power ThuLEP with mean age 67 ± 8. Acute urine retention was the main indication for surgery in 22% of patients, while the remaining had mean IPPS score 26 ± 3. The mean prostate volume was 102 ± 25 ml and the mean Qmax was 6 ± 2 ml/sec. Mean operative time was 103 ± 25 min, while; mean enucleation time was 80 ± 12 min, and mean morcellation time was 17 ± 6 min. The mean enucleated prostate volume was 73 ± 16 g and the mean hemoglobin drop was 1 ± 0.2 mg/dl. There was no need for blood transfusion and the mean hospital stay was 18 ± 4 h and catheters were removed on discharge. The 1st visit was at one month, and we observed significant mean Qmax improvement18 ± 5 ml/s. Our results showed no significant change of IIEF-5 score at 12-month follow-up compared to baseline. Conclusion Low-power Thulium enucleation with a combined top and down technique provided a safe and efficacious outcome, that may reduce strenuous wrist flexion and eliminate the need for high-power Thulium laser device.

Purpose To evaluate the impact of extensive surgery on urine profile, serum exams and stone composition of complicated IBD patients. Methods Patients with IBD and a history of total proctocolectomy (TPC) with fecal diversion (end ileostomy or ileal pouch anal anastomosis—IPAA) were selected. Only patients with at least one complete 24-h urine profile were included. A case–control study was performed selecting patients with kidney stone disease in a random way who had also at least on complete 24-h urine profile. Case and controls were matched for age, gender, and body mass index (BMI). Groups were compared to urine profile, serum exams and stone composition. Results Sixty-eight patients were enrolled in this study, 34 patients with IBD who underwent TPC and had diagnosis of kidney stones and 34 matched patients with only kidney stones. IBD patients had a significantly lower urine volume, urine citrate and urine sodium. Regarding serum exams, only serum bicarbonate was statistically significant lower. In both groups, calcium oxalate stone was the most common. Conclusion Patients with IBD with TPC and kidney stones have a low urine volume and low urine citrate as main risk factors for kidney stone formation. As seen in the general population, calcium oxalate is the most common stone composition.