Reverse Trendelenburg Positioning Minimizes Stone Retropulsion During Ureteroscopic Laser Lithotripsy: A Prospective Randomized Study
Comparative proteomic profiling of uric acid, ammonium acid urate, and calcium-based kidney stones
INTRODUCTION/BACKGROUND:Kidney stone matrix proteins may help explain cellular mechanisms of stone genesis. However, most existing proteomic studies have focused on calcium oxalate stones. Here, we present a comparative proteomic analysis of different kidney stone types. METHODS:Proteins were extracted from the stones of patients undergoing percutaneous nephrolithotomy (PCNL). Approximately 20 μg of protein was digested into tryptic peptides using filter aided sample preparation, followed by liquid chromatography tandem-mass-spectrometry using an EASY-nLC 1200 and Orbitrap Fusion Lumos mass spectrometer. A standard false discovery rate cutoff of 1% was used for protein identification. Stone analysis was used to organize stone samples into similar groups. We selected the top 5% of proteins based on total ion intensities and used DAVID and Ingenuity Pathway Analysis to identify and compare significantly enriched gene ontologies and pathways between groups. RESULTS:Six specimens were included and organized into the following four groups: 1) mixed uric acid (UA) and calcium-based, 2) pure UA, 3) pure ammonium acid urate (AAU), and 4) pure calcium-based. We identified 2,426 unique proteins (1,310-1,699 per sample), with 11-16 significantly enriched KEGG pathways identified per group and compared via heatmap. Based on number of unique proteins identified, this is the deepest proteomic study of kidney stones to date and the first such study of an AAU stone. CONCLUSIONS:The results indicate that mixed UA and calcium-based kidney stones are more similar to pure UA stones than pure calcium-based stones. AAU stones appear more similar to pure calcium-based stones than UA containing stones and may be related to parasitic infections. Further research with larger cohorts and histopathologic correlation is warranted.
Endoscopic Incisional Uses of Thulium Laser Fiber in Upper Urinary Tract Strictures [Meeting Abstract]
Introduction &Objective: Endoscopic laser incision of upper tract strictures is a minimally invasive option usually utilizing the Holmium:YAG laser. The thulium fiber laser (TFL) has an effective ablation and coagulation profile that has been successfully applied for prostate enucleation and en bloc bladder tumor excision, and may make it a new option for laser incision of strictures. We review our experience and outcomes using the TFL for treatment of upper tract strictures.
Method(s): Our prospectively maintained Endourology database was queried and 15 patients with mean age of 56 underwent endoscopic stricture incision with TFL from February 2020 to January 2021. Preoperative imaging consisted of CT scans, renal scans, and ultrasonography. The procedure was performed ureteroscopically using a 200u fiber with settings of 1J and 20 Hz. Only patients with a short (< 2cm stricture) were considered candidates. Post-operative imaging was then compared to assess radiologic resolution, improvement, or worsening.
Result(s): Of the cohort, 3 had calyceal diverticula and 12 had ureteral/ureteropelvic junction (UPJ) strictures. Of these, 8 (53%) had a prior history of ureteroscopy or percutaneous nephrolithotomy, 2 (13%) had robotic reconstruction, and 2 (13%) had open reconstruction. The most common indications for surgery were stones (87%), hydronephrosis (80%), and pain (66%). Ureteral strictures were encountered at the UPJ (9), ureterovesicular junction (1), mid ureter (1), and ileal ureteral anastomosis (1). Of 12 patients with ureteral/UPJ strictures, 10 had a ten-week post op CTU/ultrasound; 6 (60%) had resolution and 4 (40%) had improved hydronephrosis. Of 3 patients with calyceal diverticulum, all had resolution of symptoms with ten-week post op ultrasound with no evidence of stone or diverticulum reformation. Of the entire cohort, 3 patients had six month post op imaging; all demonstrated maintained resolution of hydronephrosis. Every patient was discharged same day with no reported post-operative complications.
Conclusion(s): Endoscopic laser incision of ureteral strictures using TFL may be a feasible method of managing strictures requiring a minimally invasive approach. It is versatile and can be applied to treating many areas of the upper tract including calyceal diverticula, UPJ obstruction, and strictures at ureteroenteric anastomosis. Preliminary results on short term outcomes are encouraging and more long term follow up will be required to better define the TFL's potential
The Surgical Technique of Mini Percutaneous Nephrolithotomy
The mini percutaneous nephrolithotomy (mini-PCNL) has become a versatile tool to remove kidney stones >2â€‰cm, lower pole stones >1â€‰cm, renal stones previously unresponsive to shockwave therapy or inaccessible by ureteroscopy (within a caliceal diverticulum), stones within complex urinary tracts (urinary diversions, transplanted kidney, and horseshoe kidneys), and large impacted proximal ureteral stones. After positioning in either the supine or prone position, a cystoscopy is performed to place an open-ended catheter, occlusion balloon, or Accordian device into the collecting system. A foley catheter is placed in the bladder. An ultrasound with a curvilinear probe is used to survey the kidney and guide access into the collecting system with an 18â€‰g percutaneous needle. Once access is obtained, a small 0.5â€‰cm skin incision is made and the percutaneous tract is dilated over a wire. A 16.5F metallic or self-dilating suctioning access sheath is positioned with fluoroscopic guidance. A 12F rigid mini-PCNL nephroscope is used to evaluate the collecting system. Once a calculus is observed, options for stone fragmentation include a lithotripter with ultrasonic and ballistic energy, or laser lithotripsy using holmium or thulium laser fibers. Flexible ureteroscopy can be considered to ensure clearance of the collecting system. A 6F ureteral stent can be placed in either a retrograde or antegrade approach for drainage. The tract is sealed using Surgiflo hemostatic matrix with thrombin. Guidelines for postoperative care and troubleshooting techniques for mini-PCNL are reviewed along with the surgical steps in the accompanying video (Supplementary Video S1). There are few randomized trials comparing mini-PCNL with standard PCNL and ureteroscopy. There is some evidence to suggest a difference in transfusion rates comparing mini- and standard PCNL, as well as differences in stone-free rates when comparing mini-PCNL with ureteroscopy for the treatment of lower pole stones.
Barriers experienced by patients with multiple sclerosis in seeking care for lower urinary tract symptoms
AIM: The Actionable Bladder Symptom and Screening Tool (ABSST) is used to identify multiple sclerosis (MS) patients in possible need of evaluation for urinary symptoms. The primary objective of this study was to identify barriers experienced by MS patients in seeking evaluation for urinary symptoms. We also assessed the utility of ABSST tool in identifying patients that will follow up with urologic evaluation. METHODS: This was a prospective observational study where 100 patients with MS were enrolled from an MS center. Patients completed demographic information, questions to assess barriers to care, a short form of the ABSST, and incontinence questionnaires. An ABSST score >3 met criteria for referral and evaluation. One year after enrollment, follow up calls assessed whether patients had seen a urinary specialist. RESULTS: The most common barriers to seeking care included "Doctor never referred" (16%) and "Doctor never asked" (13%). Thirty-eight percent (n = 8/21) of men stated "Doctor never referred" compared to 10% (n = 8/79) of women (P = 0.002). Twenty-seven patients had an ABSST Score >/=3 and were more interested in seeing a specialist compared to those scoring <3 (88.9%, n = 24/27 vs. 26%, n = 19/73; P = <0.001). After 1 year, 70 patients were reached for follow up. A total of 57.9% (n = 11/19) patients who followed up for evaluation screened positive on the ABSST. CONCLUSIONS: The ABSST is a valuable tool to identify MS patients with urinary symptoms who will likely follow up for genitourinary evaluation. However, other barriers beyond awareness exist and prevent patients from being evaluated.
Management of neurogenic lower urinary tract dysfunction in multiple sclerosis patients
Multiple sclerosis (MS) can be a debilitating neurological condition that attributes significant morbidity to bladder dysfunction. Although many effective treatment options exist, symptomatic patients are often underdiagnosed and undertreated. The purpose of this article is to give an overview of the current literature including new screening tools to identify symptomatic patients and updates on treatment options including medications, botulinum toxin, and neuromodulation.
Factors that are barriers to care in patients with multiple sclerosis complaining of urinary symptoms; based on the actionable bladder symptom and screening tool (ABSST) [Meeting Abstract]
Objective: To identify barriers multiple sclerosis (MS) patients experience in seeking evaluation for urinary symptoms and its relationship to the Actionable Bladder Symptom and Screening Tool (ABSST). Background: The ABSST is used to identify urinary symptoms in patients with MS and may identify patients in need of referral and evaluation for neurogenic overactive bladder symptoms (NDO). Although up to 80% of MS patients may experience urinary symptoms, evaluation by a specialist and treatment are under-utilized in this population. Methods: This was a prospective observational study. 100 patients with MS, but currently not seeing a genitourinary specialist were enrolled from an MS comprehensive center with a Female Pelvic Medicine and Reconstructive Surgery (FPMRS) physician on staff. Patients completed demographic information, a short form of the ABSST and questions to assess barriers to seeking a specialist for bladder problems. An ABSST score >3 met criteria for referral and evaluation. In addition they were asked a single item question about their desire to be evaluated by a specialist for bladder problems. Two-month after enrollment, follow up calls assessed whether patients had seen a specialist to assess their urinary complaints. X2 tests were used to compare categorical variables. Results: Of the 100 patients, there were 79 women and 21 men, mean age was 44.5 years and average time since diagnosis of MS was 10.4 years. Ethnicities included 45% Caucasian, 21% African American, 21% Hispanic, 2% Asian, and 11% Other/Multiracial. Overall, 40% of patients indicated that they would want to see a specialist to evaluate their bladder symptoms and 33% of patients had already seen one in the past. Most frequent reasons for seeking prior care were incontinence (46%) and recurrent UTIs (24%). Overall, the most common barriers to seeking care included "Doctor never referred" (18%), "Doctor never asked" (15%), "Had enough problems to deal with" (15%), "Thought there were no treatments available" (12.5%) and "Felt embarrassed" (10%). 40% of men stated "Doctor had never referred or asked" compared to 10% of women (p=0.002). 27 patients had an ABSST Score>3 and were more interested in seeing a specialist compared to those scoring <3 (91% vs. 40%; p= .000). When compared to patients with an ABSST<3, those with an ABSST>3 had a significant difference in level of education (p<0.05), type of mobility used (p<0.05), and employment status (p=0.005). Patients with an ABSST >3 cited limitations associated with insurance, cost, transportation, or inaccessibility more often than those with an ABSST <3 (9% vs. 3%, p=0.009). After 2 months, 49 patients were reached for follow up. Despite persistent or worsening urinary symptoms in some patients, only 1 participant had followed up. Conclusions: The ABSST is a valuable tool to identify MS patients with urinary symptoms and willingness to seek evaluation. Identification of this need alone unfortunately did not result in a significant increase in evaluation, despite ongoing symptoms. This underscores that other barriers, beyond awareness such as communication, costs and logistics, play a tremendous role preventing patients getting the evaluation that is needed. Further work is required to elucidate these factors
The actionable bladder symptom and screening tool (ABSST): A simple and useful way of assessing lower urinary tract dysfunction in patients with multiple sclerosis [Meeting Abstract]
Objective: s To characterize a sample of patients with multiple sclerosis (MS) that would be recommended for evaluation by an expert in bladder dysfunction based on the Actionable Bladder Symptom and Screening Tool (ABSST), and to correlate the ABSST with several commonly used questionnaires including the Overactive Bladder Questionnaire (OABq), Patient Global Impression of Severity (PGI-S), International Consultation on Incontinence Questionnaire (ICIQ), and Medical Epidemiology and Social Aspects of Aging (MESA). Background: Although up to 80% of patients diagnosed with multiple sclerosis (MS) experience lower urinary tract symptoms, evaluation and treatments are significantly under accessed. The (ABSST) is a newly validated tool that can be used in patients with MS to screen for neurogenic overactive bladder symptoms (NDO). It is a simple 8-item questionnaire that aids in identifying patients that need a referral for evaluation. Methods: This was a prospective observational study. 100 patients diagnosed with MS, not currently seeing a bladder dysfunction specialist, were enrolled from an MS center. After obtaining consent, patients were asked to fill out a validated short form of the ABSST, the OABq short form, the PGI-S, the ICIQ and the MESA. An ABSST score >3 is considered a positive screening test and met criteria for referral to a specialist. OAB subscale scores grouped responses related to symptom bother and Quality of life (HRQL), which was further subdivided into HRQL-Coping, HRQL-Sleep, or HRQL-Emotions. A high score for the symptoms subscale indicated worse symptoms and a low score of the quality of life subscales indicated worse quality of life. The MESA scores grouped responses that characterized either urgency or stress incontinence. There were no subscales for PGIS or ICIQ. Mean questionnaire scores were compared between patients who screened positive or negative for the ABSST using one-way ANOVA and X2 tests. Results: Patient's mean age was 44.5 years and average time since diagnosis was 10.4 years. There were 79 women and 21 men. Ethnicities included 45% Caucasian, 21% African American, 21% Hispanic, 2% Asian, and 11% Other/Multiracial. 27 patients had an ABSST Score >3. When compared to patients with an ABSST<3, those with an ABSST>3 had a significant difference in level of education (p<0.05), level of mobility (p<0.05), and employment status (p=0.005). See figure 1. Patients with an ABSST>3 were more likely to have seen a doctor in the past for bladder problems (52% vs. 27%; p=0.019), more frequently for urinary incontinence (19%) and urinary tract infections (13%). They were also more likely to be using medications for bladder symptoms (23% vs. 4%; p=0.004) or to have used them in the past (42% vs. 15%; p=0.004). Patients with a positive ABSST had a significant difference in the mean scores of the following subscales: OABq Symptoms (57.4 vs. 15.0; p=0.000); OAB-Total HRQL (50.4 vs. 89.9;p=0.000); OABHRQL Cope (43.4 vs. 89.4;p=0.000); OAB-HRQL Sleep (42.5 vs. 84.2; p=0.000); OAB-HRQL Emotion (62.1 vs. 93.7; p=0.000); MESA-Urgency Incontinence (40.4 vs. 12.3; p=0.000); MESA-Stress Incontinence (33.8 vs.15.0; p=0.000); and ICIQ-SF (8.2 vs. 2.3; p=0.000). There was a significant correlation between PGIS Score and a positive ABSST (p=0.000). Conclusions: The differences observed in MS patients who score positive on the ABSST may represent the progressive nature of some cases of MS and its association with NDO. A positive screening response correlates and captures the severity of symptoms, impact on quality of life and classifications of both urinary incontinence across several overactive bladder and urinary incontinence questionnaires. These findings highlight the importance of continued screening in MS patients for NDO, even when patients have been evaluated or treated in the past. This need makes the ABSST a valuable simple tool for providers to efficiently identify and refer MS patients for further evaluation and treatment. (Figure presented)
Youtube as source for vaginal mesh information [Meeting Abstract]
Introduction: Social media networks and websites are an important source of healthcare information exchange. Despite the quantity of information, there is growing evidence for poor quality medical information that may be misleading and biased. Some studies suggest information available online on controversial topics may disperse inaccurate information and contribute to public confusion. Objective: The goal of this study is to examine information available in YouTube videos on a controversial urologic topic, pelvic organ prolapse (POP) repairs with mesh. Methods: A keyword search of ''vaginal POP repair with mesh'' was performed and the first 100 search results examined on 7/29/13. Videos not in English, lacking spoken words, or duration 910 minutes were excluded. Video characteristics including source (legal, medical, other), number of views, time online and duration were recorded. The content of each video was assessed in the following domains: description of POP, management of POP, explanation of the 2011 FDA Safety Communication, and balanced presentation of information. Scores were assigned based on whether the video made a series of objective statements pertaining to each domain, The proportion of statements made in the video per domain was calculated and videos of different sources were compared. Significance was assessed by t test. Results: 51 videos were excluded, and the remaining 49 were viewed. The sources were 69% legal firm, 24% medical institution, and 7% other. The former 2 groups were compared. Videos from medical institutions were older (online for 31.6 vs. 14.2 months, p lt; 0.01), longer (249 vs 99 seconds, p lt; 0.01), and had more views per month (784 vs. 140 , p lt; 0.01) when compared to legal videos. Legal videos explained more aspects of the 2011 FDA Safety Communication (0.22 vs. 0.07; p<0.01). Medical videos did not show a significant difference in addressing aspects of other domains including description of POP (0.25 vs. 0.12, p=0.087, management of POP (0.2 vs. 0.14, p=0.086), or presentation of balanced information (0.10 vs. 0.06; p=.528). Conclusions: The majority of information available in YouTube videos on the topic of vaginal POP repair with mesh is recent, short, and published through legal services that outline the 2011 FDA Safety communication but contain less comprehensive descriptions of POP compared to other videos. However, low overall scores in all domains studied, regardless of source, demonstrate lack of content. This raises questions about the utility of YouTube as a source of information for patients
ACTIONABLE: A SIMPLE AND EFFECTIVE WAY OF ASSESSING LOWER URINARY TRACT DYSFUNCTION IN PATIENTS WITH MULTIPLE SCLEROSIS [Meeting Abstract]