Faculty Bibliography

Objective: To assess the usefulness of incorporating the C-Arm Trainer (CAT) simulator into the annual American Urological Association (AUA) hands-on course for training of the percutaneous nephrolithotomy (PCNL) procedure. Methods: This prospective study was conducted during the annual meeting of the AUA in 2017. The course included four stations for training the 'bull's eye' technique for obtaining fluoroscopic-guided percutaneous renal access (PCA) using the CAT. After a didactic session, all participants were asked to complete a short questionnaire and undergo a pre-test to obtain a PCA in the posterior middle calyx. This was followed by 30-min practice on the simulator prior to undergoing a post-test. All participants were assessed during the pre-test and the post-test using a four-item checklist. Furthermore, all participants were asked to complete a qualitative analysis self-assessment questionnaire after the pre- and the post-test. Immediately after the course, all participants were invited to complete a course evaluation questionnaire. At 2 months after the course, all participants were asked to respond to a post-course survey to assess the usefulness and clinical impact of the course. Results: A total of 38 physicians, who attended the hands-on course, voluntarily participated in the study. Most of them were attending urologists (79%), with a mean of 9-years of independent practice. Only 21.1% had previous practice on PCNL simulators. Compared with the pre-test, there was significant improvement in the checklist total score (P < 0.001), temporal demands (P = 0.003), situational stress (P = 0.003), and performance (P=0.003) during the post-test. The participants considered the CAT very useful for training in PCA (score 5.3/6). A total of 14 (36%) participants responded to the course evaluation questionnaire, seven (50%) evaluated the course as excellent, four (28.6%) as very good, and three (21.4%) as good. Conclusion: The CAT simulator was considered useful for training in PCA. There was significant improvement in the qualitative and quantitative parameters during the post-test compared with the pre-test.

OBJECTIVES/OBJECTIVE:To assess for usefulness and validity evidence for incorporating the C-Arm Trainer (CAT) simulator into the annual AUA hands on course for training percutaneous nephrolithotomy (PCNL). MATERIALS AND METHODS/METHODS:The course started with a didactic session followed by four stations for training the "bull's eye" technique using the CAT simulator. Each station included a pre-test, 30-min practice on the simulator, and post-test. All participants were assessed using a 4-item checklist. All participants were asked to fill in a qualitative self-assessment questionnaire after the pre- and the post-test, and respond to a course evaluation questionnaire and post-course survey. RESULTS:A total of 38 physicians, who attended the hands on course, voluntarily participated in the study. Only 21.1% had previous practice on PCNL simulators. Compared with the results of the checklist total score and the qualitative self-assessment questionnaire scores after the pre-test, there was significant improvement in the checklist total score (p < 0.001), temporal demands (p = 0.003), situational stress (p = 0.003, and performance (0.003) after the post-test. A total of 14 (36%) participants responded to the course evaluation questionnaire, 50% evaluated the course as excellent, 28.6% as very good, and 21.4% as good. Unfortunately, only five (13%) participants responded to the post-course survey, 4/5 implemented the new competencies and knowledge into their practice, and 3/5 have attempted to obtain fluoroscopic guided PCA without assistance. CONCLUSION/CONCLUSIONS:The CAT simulator was considered useful for training the percutaneous renal access procedure. There was significant improvement in the qualitative and quantitative assessment parameters after the post-test compared with the pre-test.

Introduction & Objectives: To assess the usefulness of incorporating the C-Arm Trainer (CAT) simulator into the annual American Urological Association (AUA) hands on course for training percutaneous nephrolithotomy (PCNL) procedure. Materials & Methods: This prospective study was conducted during the annual AUA 2017 in Boston. The course included 4 stations for training the "bull's eye" technique for obtaining fluoroscopic-guided percutaneous renal access (PCA) using the fluoroless C-Arm Trainer (CAT). All participants received didactics in the form of presentations and videos about the PCNL procedure prior to the simulation session. All participants were then asked to fill in a short questionnaire and undergo a pre-test to obtain PCA using the bull's eye technique. This was followed by 30-minute practice on the simulator prior to undergo a post-test. All participants were assessed during the pre-test and the post-test using 4-item checklist. All participants were asked to fill in a qualitative self-assessment questionnaire after the pre- and the post-test. Immediately after the course, all participants were invited to fill in a course evaluation questionnaire. Two months after the course, all participants were asked to respond to a post course survey to assess the usefulness and the clinical impact of the course. Results: A total of 38 physicians, who attended the hands on course, voluntarily participated in the study. They came from 14 countries, 63% were from the US, Brazil and Mexico. Most of them (79%) were attending urologists with a mean of 9 years of independent practice. Only 21.1 % had previous practice on PCNL simulators. Compared with the results of the checklist total score and the qualitative self-assessment questionnaire scores after the pre-test, there was significant improvement in the checklist total score (P<0.001), temporal demands (p=0.003), situational stress (p=0.003, and performance (0.003) after the post-test. The participants considered the C-Arm Trainer simulator very useful for training the PCA (score 5.3/6). A total of 14 (36%) participants responded to the course evaluation questionnaire, 50% evaluated the course as excellent, 28.6% as very good, and 21.4% as good. None of them evaluated the course as fair or poor. Out of 13 participants responded to the question about the time adequacy, 8 (61.5%) described the time as adequate and 5 (38.5) described the time as inadequate. Unfortunately, only five (13%) participants; 3 urologists and 2 residents responded to the late post course survey. Interestingly, all of them described the fluoroscopic-guided percutaneous renal access as the preferred method. Conclusions: The CAT simulator was considered useful for training the percutaneous renal access procedure. There was significant improvement in the qualitative and quantitative assessment parameters after the post-test compared with the pre-test

Laparoscopic partial nephrectomy (LPN) compares favorably to traditional open nephron-sparing surgery (NSS) in terms of oncologic and surgical principles for kidney tumors. Studies have shown the modality to be feasible with similar oncologic efficacy and superior renal functional outcomes compared with laparoscopic radical nephrectomy (LRN) for tumors. The main advantages of LPN include marked improvements in estimated blood loss, decreased surgical site pain, shorter postoperative convalescence, better cosmesis, and nephron preservation. This review article evaluates the literature regarding LPN and discusses the main steps of the operation, the perioperative workup and management, surgical complications, and its role in the surgical management of kidney masses.

OBJECTIVE: We compared postoperative outcomes and quality of life (QoL) between patients who received a nephrostomy versus a ureteral stent following PCNL in a prospective double-blind randomized fashion. METHOD: Between September 2015 and March 2016, we randomized 30 patients undergoing PCNL to receive nephrostomy drainage (Group 1) or Double-J ureteral stent (Group 2) at conclusion of surgery. Nephrostomy tubes were removed within 48 hours and ureteral stents were removed at least 2 weeks after surgery. Patients' QoL was assessed with the Wisconsin StoneQOL questionnaire preoperatively and then 7-10 days and 30 days following surgery. We calculated the pre/post-PCNL QoL score difference between the two groups. We also evaluated perioperative characteristics, inpatient analgesic requirements, LOS, and complications. OUTCOME: Patient characteristics between Groups 1 and 2 were comparable with similar age (58.3 vs. 54.7, p = 0.534), gender ratio, stone burden (276.6 mm² vs. 259 mm², p = 0.84) and composition. There was no significant difference in stone-free rate (93.3% vs. 86.7%), operative times (125.7 mins vs. 115 mins, p = 0.29), EBL (103.3 mL vs. 100.7 mL, p = 0.9), LOS (3.2 vs. 1.9, p = 0.1), and complications (2 in each group). Inpatient analgesic requirements were also the same (both 21.1 mg, p = 1.0). Assessment of QoL showed significant differences in health-related QoL in 18 of the 28-question instrument at 7-10 days. Patients in Group 2 had significantly worse QoL change and responses on the StoneQOL assessment, not only those commonly associated with stent irritation. Both groups had similar QoL status at 30-days after surgery. CONCLUSION: Despite the literature advocating "tubeless" PCNL with ureteral stent placement at conclusion of surgery, our randomized prospective study shows that QoL is significantly worse with stent placement than with temporary nephrostomy drainage in the immediate aftermath following PCNL using a validated QoL assessment instrument specific for nephrolithiasis.

PURPOSE: Activities of daily living provide information about the functional status of an individual and can predict postoperative complications after general and oncological surgery. However, they have rarely been applied to urology. We evaluated whether deficits in activities of daily living could predict complications after percutaneous nephrolithotomy and how this compares with the Charlson comorbidity index and the ASA((R)) (American Society of Anesthesiologists((R))) classification. MATERIALS AND METHODS: We retrospectively reviewed the records of all patients who underwent percutaneous nephrolithotomy between March 2013 and March 2014. Those with complete assessment of activities of daily living were included in analysis. Perioperative outcomes, complications and hospital length of stay were examined according to the degree of deficits in daily living activities. RESULTS: Overall 176 patients underwent a total of 192 percutaneous nephrolithotomies. Deficits in activities of daily living were seen in 16% of patients, including minor in 9% and major in 7%. Complications developed more frequently in those with vs without deficits in daily living activities (53% vs 31%, p = 0.029) and length of stay was longer (2.0 vs 4.5 days, p = 0.005). On multivariate logistic regression activities of daily living were an independent predictor of complications (OR 1.11, p = 0.01) but ASA classification and Charlson comorbidity index were not. CONCLUSIONS: Activities of daily living are easily evaluated prior to surgery. They independently predict complications following percutaneous nephrolithotomy better than the Charlson comorbidity index or the ASA classification. Preoperative assessment of daily living activities can help risk stratify patients and may inform treatment decisions.

Introduction & Objective: Upper tract urothelial carcinoma (UTUC) accounts for less than 5% of urothelial malignancies. Despite radical nephroureterectomy remaining the gold standard. Less invasive endoscopic ablation or resection offers a reasonable strategy for those patients with an anatomic or functional solitary kidney, bilateral UTUC disease, poor renal function, or significant comorbidities. The Smith Institute has presented its 30-year comprehensive data for all patients, not only those where renal preservation was imperative, and its series has shown that 87% of both low-grade and high-grade tumor-resectable patients were able to avoid eventual nephroureterectomy. However, not all UTUC can be resected for curative intent and in some cases, palliative resection is needed to contain gross hematuria and improve quality of life. If the collecting system is obstructed, resection and debulking can help relieve obstruction and decrease the need for persistent external drainage. We present our data and a case presentation of percutaneous resection of UTUC with palliative intent. Materials and Methods: The Smith Institute has retrospectively reviewed its series on percutaneous resection vs nephroureterectomy and dialysis in 14 patientswith 7 in each group. These patients all had high-grade transitional cell carcinoma and anatomic or functional solitary kidneys. All patients were matched age, stage, and tumor grade. Results: The mean survival for percutaneous resection with palliative intent was 18 months while the survival for nephroureterectomy and dialysis was only 11 months. All patients in the dialysis group also required revision of their AV fistula graft. In essence, percutaneous management of UTUC provides at least equivalent survival without the adverse effects on quality of life of dialysis and increases survival by half a year. Conclusions: In summary, percutaneous resection of UTUC tumors offer minimal morbidity and serves as a viable palliative modality to patients to control gross hematuria or obstruction. We have shown a survival benefit vs nephroureterectomy with dialysis. It is also convenient to perform periodic surveillance with ureteroscopy and ablate any sizable tumor or bleeding lesions every 3 to 6 months as needed. The techniques seen in this video offer basic tenets of resection principles. The goals of palliative resection are to improve patients' quality of life by debulking obstructive tissue and preventing excessive or persistent bleeding with the intention of first doing no harm

Introduction & Objective: The Internet has become the weathervane for social attitudes and increasingly, healthcare topics are at the forefront of online discussion. The main three (Figure presented) search engines (Google, Microsoft's Bing, and Yahoo!) account for over 95% of all search queries in the US and over 95% of all website traffic from these engines originate on the first search results page. Essentially, search results on any topic from the first page of each engine dominate the information distributed to the American general public. With the 2012 US Preventive Services Task Force (USPSTF) recommendation against prostate cancer screening, we wanted to evaluate whether the online community agrees with this decision and determine what evidence was used in its formation. We also wanted to see the trend of online recommendations for the past three years to gauge public opinion. Materials and Methods: Using the query "prostate cancer screening" (as well as "PSA screening") on the three main search engines yielded a total of 28.59 million, 17.46 million, and 27.72 million results in November 2013, 2014, and 2015, respectively (Google 21m/7.3m/19.7m, Bing 3.82m/5.06m/4.01m, (Figure presented) Yahoo3.77m/5.07m/4.01m). We analyzed the first page of nonad results produced by each search engine looking at the source and type of website, its recommendations on screening, the number of references provided, and the level of evidence presented to determine information quality. Specifically we evaluated whether each website used the ERSPC and PLCO data (used by the USPSTF) in their recommendation. We excluded duplicate primary domain names on the same search results page but included them on different engines. Results: Our search queries provided a total of 29 distinct primary websites 2013, and 27 websites in 2014 and 2015. Most of the websites that appeared in the 2013 search also displayed prominently in subsequent years. The source and type of website and their recommendations can be seen in Figures 1 and 2. In general, the number of websites advocating discussion of the risks and benefits of screening with a physician and making an informed decision by the patient decreased slightly while sites that did not offer a definitive conclusion rose from over the past three years. Conclusions: Three years after the USPSTF presented its findings and recommendations against routine prostate cancer screening, the online community does not share the same disposition. However, the general consensus toward informed decision has slightly decreased suggesting the topic is still controversial andmost online sources will not point patients towards one way or the other