Faculty Bibliography

PURPOSE: We determined the optimal imaging study by which to diagnose and treat pregnant patients with suspected urolithiasis. MATERIALS AND METHODS: A retrospective, multicenter study was performed to determine the comparative accuracy of imaging modalities used before the surgical management of suspected urolithiasis in pregnant patients. Patients with a clinical suspicion of urolithiasis were evaluated with directed imaging including renal ultrasound alone, renal ultrasound and low dose computerized tomography, or renal ultrasound and magnetic resonance urography. When indicated, patients underwent therapeutic ureteroscopy. The rate of negative ureteroscopy was determined and the positive predictive values of the imaging modalities were calculated. RESULTS: A total of 51 pregnant patients underwent ureteroscopy. The mean age of the cohort was 27 years. Mean gestational age was 24.4 weeks. Of the women 24 (47%) underwent renal ultrasound and low dose computerized tomography, 22 (43%) underwent ultrasound alone, and 5 (10%) underwent renal ultrasound and magnetic resonance urography. Negative ureteroscopy occurred in 7 of the 51 patients (14%). The rate of negative ureteroscopy among patients who underwent renal ultrasound alone, renal ultrasound and low dose computerized tomography, and renal ultrasound and magnetic resonance urography was 23%, 4.2% and 20%, respectively. The positive predictive value of computerized tomography, magnetic resonance and ultrasound was 95.8%, 80% and 77%, respectively. CONCLUSIONS: The rate of negative ureteroscopy was 14% among pregnant women undergoing intervention in our series. Of the group treated surgically after imaging with ultrasound alone, 23% had no ureteral stone, resulting in the lowest positive predictive value of the modalities used. Alternative imaging techniques, particularly low dose computerized tomography, offer improved diagnostic information that can optimize management and obviate unnecessary intervention.

Recent innovations in imaging equipment and novel instrumentation have helped ureteroscopy evolve from a diagnostic to a therapeutic tool. In this review, the authors highlight several of the most recent advances in ureteroscopy that have helped allow unprecedented access, visualization, and treatment of upper urinary tract pathologic conditions.

Introduction: Management of renal colic and suspected urolithiasis in pregnancy remains a controversial topic. Competing concerns of operative fluoroscopy and prolonged duration of ureteral stent or nephrostomy tube fuel arguments for expectant management versus early surgical intervention. To address these concerns, we have offered ultrasound guided ureteroscopy for definitive management of suspected urolithiasis during pregnancy. We herein review our experience with this approach. Methods: We performed a multi-center retrospective review of all pregnant patients undergoing ureteroscopy for suspected urolithiasis between 2008 and 2010. All pregnant patients who had undergone ultrasound guided ureteroscopy were included in this study. We evaluated presence of stone, stone size, operative time, stent duration, and post-operative course. Results: Seven pregnant patients underwent ultrasound guided ureteroscopy. The mean age was 28 years, mean gestation 24 weeks, with stone sizes ranging from 5 to 22 mm. All patients had undergone preoperative stenting. Ureteral stones were identified and removed in four patients. Post-operative imaging confirmed that there was no residual hydronephrosis or significant ipsilateral renal stone burden. Average stent duration was 7.3 days. Preterm labor occurred in one case. Discussion: In our experience, ultrasound guided ureteroscopy is a viable option in pregnancy to manage patients with suspected urolithiasis after failed expectant therapy. This method avoids fetal exposure to ionizing radiation, yet allows intraoperative radiographic monitoring. With this approach it is possible to render the patient stone free, obviating the need for ureteral stents for the duration of the pregnancy.

PURPOSE OF REVIEW: To assess the safety and bleeding risk in men on chronic oral anticoagulation, including antiplatelet therapies, undergoing bladder outlet procedures for the treatment of benign prostatic hyperplasia (BPH). RECENT FINDINGS: There are conflicting findings; however, most recent series show that when treating bladder outlet obstruction from BPH in patients on chronic anticoagulants, there is an increased risk of hemorrhagic complications for these men. There is also an increased risk of cardiovascular and cerebrovascular complications, especially when antithrombotic therapy is used for secondary prevention and is withdrawn perioperatively. Some have found bipolar electrosurgical vaporization of the prostate, laser vaporization, and enucleation of the prostate to provide superior hemostatic outcomes compared to classic monopolar transurethral resection of the prostate. SUMMARY: Extra caution should always be given to patients on chronic anticoagulation undergoing surgical procedures, given increased risk of bleeding and cardiovascular and cerebrovascular complications. For men with BPH undergoing bladder outlet procedures, photoselective vaporization of the prostate, Holmium laser enucleation of the prostate, and vaporization of the prostate with bipolar electrosurgical instruments may result in less bleeding complications. Further prospective randomized studies are needed to elucidate which methods provide better hemostasis and lower postoperative bleeding to best manage men with BPH on chronic antithrombotic therapy, especially when the anticoagulation therapy cannot be discontinued prior to therapy.

PURPOSE: During pregnancy a ureteral stone and its management may pose risks for the mother and fetus. Definitive ureteroscopic management of an obstructing stone during pregnancy has been increasingly used without a reported increased incidence of urological complications. However, the rate of obstetric complications of ureteroscopy during pregnancy remains undefined. MATERIALS AND METHODS: Charts of pregnant women who had undergone ureteroscopy at 5 tertiary centers were reviewed. Patient and procedure characteristics were collected. Records were evaluated for the occurrence of obstetric complications in the postoperative period. RESULTS: A total of 46 procedures were performed in 45 patients at 5 institutions. There were 2 obstetric complications (4.3%), including 1 preterm labor managed conservatively and 1 preterm labor resulting in preterm delivery. There was no fetal loss. No statistically significant characteristics were identified differentiating those patients having obstetric complications. CONCLUSIONS: Ureteroscopy performed during pregnancy has been previously reported to be urologically safe and effective for addressing ureteral stones. In our multi-institutional series a 4% rate of obstetric complications was observed. Based on this risk a multidisciplinary approach is prudent for the pregnant patient undergoing ureteroscopy.