- Email: [email protected]
MP50-10 PREDICTING POSTOPERATIVE FEVER AND SYSTEMIC INFLAMMATORY RESPONSE SYNDROME AFTER URETEROSCOPY
THE JOURNAL OF UROLOGYâ
Vol. 197, No. 4S, Supplement, Sunday, May 14, 2017
METHODS: We retrospectively reviewed our first 75 cases with the 7.7Fr disposable flexible digital ureteroscope and identified any problems, difficulties, or complications related to the scope itself. RESULTS: Of the 75 patients, 47 were female 28 were male; 39 cases were left sided, 30 were right sided, and 6 were bilateral. The reasons for ureteroscopy include stone disease in 60 pts, ureteral stricture disease in 5 patients, and upper tract transitional cell carcinoma (TCC) in 10 patients. There was difficulty in getting up the ureter (ureterovesical junction) in 3 patients; one due to distal ureteral narrowing requiring balloon dilation, the other 2 due to proximal ureter narrowing requiring stenting. Passage of the scope was relatively effortless in the remaining retrograde URS patients. Two patients underwent antegrade ureteroscopy through an established nephrostomy tract to treat ureteroenteric anastomotic strictures. There was mild interference in the video system during laser lithotripsy of hard stones (calcium oxalate monohydrate but did not prevent treatment. But the system was incompatible with the use of electrocautery. During fulguration of upper tract TCC, the system continually shut down during the use of a 3Fr electrode. Another difficulty with visualization occurred during antegrade ureteroscopy for 2 ureteroileal anastomotic strictures. Due to problems with distant focusing, there was difficulty identifying the true lumen past the stricture, which lead to inaccurate incision of the soft tissue resulting in extravasation in both cases. CONCLUSIONS: This new disposable ureteroscope works well for routine ureteroscopy with laserlithotripsy but should not be used with electrocautery and avoided for antegrade incision of ureteroenteric anastomotic strictures. Its strength is in near focusing rather than distant focusing which is fine for stones but not for the latter situation. Source of Funding: None
MP50-09 ROBOTIC FLEXIBLE URETEROSCOPIC TREATMENT OF RENAL AND URETERAL CALCULI: FIRST-IN-MAN EXPERIENCE WITH A NOVEL ROBOTIC SYSTEM Mihir Desai*, Los Angeles, CA; Shashikant Mishra, Abhishek Singh, Ravindra Sabnis, Arvind Ganpule, Mahesh Desai, Nadiad, India INTRODUCTION AND OBJECTIVES: To present the first in man experience with the Robotic Endoscopy System (RES) for the treatment of renal and ureteral calculi. METHODS: The RES is a novel system comprised of a remotedriven robotic flexible ureteroscope and robotic access sheath. The robotic ureteroscope incorporates digital optics and the system has the ability to control the laser fiber and irrigation inflow-outflow remotely. The system has a stroke length to navigate the collecting system from the urethra to the kidney. The primary performance endpoint was completion of the intended procedure; the primary safety endpoint was incidence of perioperative complication. The RES performance was graded on a visual analog scale of 1 (worst) to 10 (best) for stability, ease of locating stones, ability to fragment, control and visualization. P values were calculated using the Mann-Whitney U test or Fisher’s exact test. RESULTS: Of 18 screened adult patients, 16 underwent flexible robotic ureteroscopy (11 with 1; 4 with 2 and 1 with 3 stones). Two patients were excluded intraoperatively due to ureteral strictures. The twenty-two treated stones were distributed throughout the collecting system (n ¼ 7 lower pole, n ¼ 5 renal pelvis, n ¼ 5 interpolar, n ¼ 3 upper ureter, n ¼ 1 upper pole and n ¼ 1 distal ureter). Median stone size was 10 (6 to 20) mm. All procedures were completed successfully using robotic control. One patient experienced fever (101 F) that resolved without intervention. Overall, median total procedure time (TPT) was 73.5 (range ¼ 21 to 131) minutes; median total robot time (TRT) was 42 (6 to 99) minutes. In patients with a single stone only, median TPT decreased from 98 (50 to 131) minutes (first 5 cases) to 40 (21 to 77) minutes (last 6 cases), P ¼ 0.036; median TRT also decreased from 44 (20 to 89) minutes (first 5 cases) to 19.5 (6 to 43) minutes (last 6 cases), P ¼ 0.055. In 5 patients with lower pole stones, median TPT was 50 (21 to 131) minutes; median TRT was 20 (16 to 76) minutes. Stability, ease of locating stone and control, as evaluated by number of scores greater than 9, improved significantly in the last 6 cases(P ¼ 0.035).
e687
CONCLUSIONS: The robotic ureteroscopy with calculi lithotripsy is safe and feasible using the RES. Future comparative studies to manual ureteroscopy are warranted. Source of Funding: The study was funded by Auris Surgical Robotics.
MP50-10 PREDICTING POSTOPERATIVE FEVER AND SYSTEMIC INFLAMMATORY RESPONSE SYNDROME AFTER URETEROSCOPY Andrew Higgins, Amanda Young, Korey Kost, Brielle Schreiter, Marisa Clifton, Brant Fulmer, Tullika Garg*, Danville, PA INTRODUCTION AND OBJECTIVES: Ureteroscopy (URS) is the standard of care for surgical management of small upper urinary tract stones. A common and life-treating complication of URS is postoperative infection. The objective was to identify risk factors for postoperative fever (POF) and systemic inflammatory response syndrome (SIRS) after URS. METHODS: We identified 2375 URS performed for stone disease in an integrated healthcare delivery system from 2008-2014. The primary outcome was POF (temperature greater than 100.4F) or SIRS (yes/no). The study team selected preoperative and intraoperative risk factors for data collection a priori. Univariate comparisons were performed between those who had POF/SIRS and those who did not. Variables with a p value <0.1 were entered into a stepwise logistic regression model. RESULTS: A total of 179 out of 2375 patients had POF/SIRS (7.5%). Subjects with POF/SIRS were older, female, had higher body mass index (BMI) and Charlson comorbidity index (CCI), bilateral stones, stone size >¼ 1cm, renal location, pre-stenting, positive preoperative urine culture, and post-operative antibiotics. Table 1 demonstrates the univariate analysis of candidate predictors and POF/SIRS. Sex, CCI, laterality (unilateral or bilateral), stone location (renal, ureteral, or both), and type of ureteroscope comprised the final model (Table 2). CONCLUSIONS: Female sex, higher CCI, using both flexible and semi-rigid ureteroscopes, renal stones, and bilateral stones are associated with POF/SIRS after URS. This data may be used to identify and counsel high-risk individuals for surgical planning.
THE JOURNAL OF UROLOGYâ
e688
Source of Funding: None.
MP50-11 THE SURGICAL EXPERIENCE INFLUENCES THE SAFETY BUT NOT EFFICACY OF RIRS FOR KIDNEY STONES: A PROPENSITY SCORE ANALYSIS Francesco Berardinelli*, Piergustavo De Francesco, Luca Cindolo, Vasto, Italy; Silvia Proietti, Milano, Italy; Orietta Dalpiaz, Graz, Austria; Derek Hennessey, Melbourne, Australia; Cecilia Cracco, Cesare Scoffone, Torino, Italy; Luigi Schips, Vasto, Italy; Guido Giusti, Milano, Italy INTRODUCTION AND OBJECTIVES: The safety and the efficacy of Retrograde IntraRenal Surgery (RIRS) is influenced by many factors such as stone burden and location but also by technical skills of the operating surgeon . The aim of this study is to evaluate if the surgeon experience could influence the outcomes of RIRS in terms of stone clearance and complication rate. METHODS: Data of patients who underwent RIRS for kidney stones were prospectively collected. Cases were divided in 2 groups. Group 1: cases operated by 3 surgeons in the early phase of learning curve (surgical experience less than 100 RIRS); Group 2: cases operated by two surgeons with a great experience in endourology (>400 RIRS). Patients and stone data, results and safety outcomes were analyzed. Multivariable regression model was used. Differences between groups was estimated using propensity scores to adjust for the bias inherent to the different patient characteristics RESULTS: 381 RIRS were analyzed (Group 1: 150 RIRS; Group 2: 231 RIRS). The clinical data and stone parameters were comparable between 2 groups (Table1). The SFR was 70% in Group 1 and 77.9% in Group 2 (p¼0.082). Operative time was significantly shorter in the Group 2 (76.3 vs. 53.1min, p¼0.001). The overall complication rate was significantly lower in Group 2 (20.7 vs. 8.7 p¼0.001) (Table 2). At unadjusted analysis, a non significant difference was found between centers on SFR (OR 1.51 95%CI 0.95 to 2.41). Conversely, a significant difference was found on overall complications at unadjusted analysis (OR 0.36 95%CI 0.20 to 0.67) with lower overall complication in Group 2. Both results were confirmed by propensity score analysis (Fig.1 and Fig.2). CONCLUSIONS: This study shows that surgeon experience influences the outcomes of RIRS mainly in terms of safety. Further studies will be needed to assess the exact number of procedures necessary to obtain a plateau in the rate of complications and success
Vol. 197, No. 4S, Supplement, Sunday, May 14, 2017
Source of Funding: none
MP50-12 PERCUTANEOUS NEPHROLITHOTOMY IN LOW BODY MASS INDEX PATIENTS: CAN THINNESS INFLUENCE PERIOPERATIVE OUTCOMES AND COMPLICATIONS? Jose Agudelo*, Euro Arias, Jhonan Chirinos, Nasser Ktech, Luis Urdaneta, Juan Bustamante, Manuel Riveros, Maracaibo, Venezuela INTRODUCTION AND OBJECTIVES: Despite a considerable increase in obese and overweight population, there is also a significant portion of underweight people worldwide. There are plenty of papers about the relationship of the different BMI indexes on PCNL outcomes and morbidities. However, there is no literature about the correlation between underweight and PCNL results. The aim of the study was to compare perioperative variables of PCNL in patients with BMI scores, and to explore whether they have an effect on the outcomes of this surgery. METHODS: We conducted a single-center retrospective evaluation of perioperative outcomes and complications in 182 patients who underwent PCNL surgery between 2010 and 2012. Patients were stratified as underweight BMI less than 18.5 kg/m2, normal weight BMI 18.5 to 24.99 kg/m2, overweight 25 to 29.99 kg/ m2, and obese more than 30 kg/m2. The groups were assessed in terms of baseline characteristics, intraoperative and postoperative variables, including minor and majors complications. One-way ANOVA and univariate logistic regression analysis were used to assess the association between BMI (classified into 4 levels) and variables mentioned. RESULTS: The distributions of the 182 patients in each BMI category were underweight 21 (12%), normal body weight 38 (21%), overweight 72 (39%), and obese 51 (28%). Most of the patients (91.2%) underwent previous unenhanced computed tomography scan in which 38% showed large pelvic stones, 41% staghorn and 2% of anomalous kidneys. There was no difference in the baseline characteristics of groups with respect to age, sex, or stone size. Stone free rates showed no significant differences between groups (p¼0.76). Operative time was significantly longer in obese patients (p¼0.001). On the other hand, postoperative leakage in days, and the presence of postoperative fever, was significantly higher in the underweight group (p¼0.001). There was also one colonic perforation reported in the low BMI group. CONCLUSIONS: PCNL has demonstrated to be an efficacious and safe procedure in patients with different BMI scores. Our findings suggest that low BMI patients could be at higher risk of perioperative morbidities. Further investigation with a larger series of patients is needed to confirm this observation.
Vol. 197, No. 4S, Supplement, Sunday, May 14, 2017
METHODS: We retrospectively reviewed our first 75 cases with the 7.7Fr disposable flexible digital ureteroscope and identified any problems, difficulties, or complications related to the scope itself. RESULTS: Of the 75 patients, 47 were female 28 were male; 39 cases were left sided, 30 were right sided, and 6 were bilateral. The reasons for ureteroscopy include stone disease in 60 pts, ureteral stricture disease in 5 patients, and upper tract transitional cell carcinoma (TCC) in 10 patients. There was difficulty in getting up the ureter (ureterovesical junction) in 3 patients; one due to distal ureteral narrowing requiring balloon dilation, the other 2 due to proximal ureter narrowing requiring stenting. Passage of the scope was relatively effortless in the remaining retrograde URS patients. Two patients underwent antegrade ureteroscopy through an established nephrostomy tract to treat ureteroenteric anastomotic strictures. There was mild interference in the video system during laser lithotripsy of hard stones (calcium oxalate monohydrate but did not prevent treatment. But the system was incompatible with the use of electrocautery. During fulguration of upper tract TCC, the system continually shut down during the use of a 3Fr electrode. Another difficulty with visualization occurred during antegrade ureteroscopy for 2 ureteroileal anastomotic strictures. Due to problems with distant focusing, there was difficulty identifying the true lumen past the stricture, which lead to inaccurate incision of the soft tissue resulting in extravasation in both cases. CONCLUSIONS: This new disposable ureteroscope works well for routine ureteroscopy with laserlithotripsy but should not be used with electrocautery and avoided for antegrade incision of ureteroenteric anastomotic strictures. Its strength is in near focusing rather than distant focusing which is fine for stones but not for the latter situation. Source of Funding: None
MP50-09 ROBOTIC FLEXIBLE URETEROSCOPIC TREATMENT OF RENAL AND URETERAL CALCULI: FIRST-IN-MAN EXPERIENCE WITH A NOVEL ROBOTIC SYSTEM Mihir Desai*, Los Angeles, CA; Shashikant Mishra, Abhishek Singh, Ravindra Sabnis, Arvind Ganpule, Mahesh Desai, Nadiad, India INTRODUCTION AND OBJECTIVES: To present the first in man experience with the Robotic Endoscopy System (RES) for the treatment of renal and ureteral calculi. METHODS: The RES is a novel system comprised of a remotedriven robotic flexible ureteroscope and robotic access sheath. The robotic ureteroscope incorporates digital optics and the system has the ability to control the laser fiber and irrigation inflow-outflow remotely. The system has a stroke length to navigate the collecting system from the urethra to the kidney. The primary performance endpoint was completion of the intended procedure; the primary safety endpoint was incidence of perioperative complication. The RES performance was graded on a visual analog scale of 1 (worst) to 10 (best) for stability, ease of locating stones, ability to fragment, control and visualization. P values were calculated using the Mann-Whitney U test or Fisher’s exact test. RESULTS: Of 18 screened adult patients, 16 underwent flexible robotic ureteroscopy (11 with 1; 4 with 2 and 1 with 3 stones). Two patients were excluded intraoperatively due to ureteral strictures. The twenty-two treated stones were distributed throughout the collecting system (n ¼ 7 lower pole, n ¼ 5 renal pelvis, n ¼ 5 interpolar, n ¼ 3 upper ureter, n ¼ 1 upper pole and n ¼ 1 distal ureter). Median stone size was 10 (6 to 20) mm. All procedures were completed successfully using robotic control. One patient experienced fever (101 F) that resolved without intervention. Overall, median total procedure time (TPT) was 73.5 (range ¼ 21 to 131) minutes; median total robot time (TRT) was 42 (6 to 99) minutes. In patients with a single stone only, median TPT decreased from 98 (50 to 131) minutes (first 5 cases) to 40 (21 to 77) minutes (last 6 cases), P ¼ 0.036; median TRT also decreased from 44 (20 to 89) minutes (first 5 cases) to 19.5 (6 to 43) minutes (last 6 cases), P ¼ 0.055. In 5 patients with lower pole stones, median TPT was 50 (21 to 131) minutes; median TRT was 20 (16 to 76) minutes. Stability, ease of locating stone and control, as evaluated by number of scores greater than 9, improved significantly in the last 6 cases(P ¼ 0.035).
e687
CONCLUSIONS: The robotic ureteroscopy with calculi lithotripsy is safe and feasible using the RES. Future comparative studies to manual ureteroscopy are warranted. Source of Funding: The study was funded by Auris Surgical Robotics.
MP50-10 PREDICTING POSTOPERATIVE FEVER AND SYSTEMIC INFLAMMATORY RESPONSE SYNDROME AFTER URETEROSCOPY Andrew Higgins, Amanda Young, Korey Kost, Brielle Schreiter, Marisa Clifton, Brant Fulmer, Tullika Garg*, Danville, PA INTRODUCTION AND OBJECTIVES: Ureteroscopy (URS) is the standard of care for surgical management of small upper urinary tract stones. A common and life-treating complication of URS is postoperative infection. The objective was to identify risk factors for postoperative fever (POF) and systemic inflammatory response syndrome (SIRS) after URS. METHODS: We identified 2375 URS performed for stone disease in an integrated healthcare delivery system from 2008-2014. The primary outcome was POF (temperature greater than 100.4F) or SIRS (yes/no). The study team selected preoperative and intraoperative risk factors for data collection a priori. Univariate comparisons were performed between those who had POF/SIRS and those who did not. Variables with a p value <0.1 were entered into a stepwise logistic regression model. RESULTS: A total of 179 out of 2375 patients had POF/SIRS (7.5%). Subjects with POF/SIRS were older, female, had higher body mass index (BMI) and Charlson comorbidity index (CCI), bilateral stones, stone size >¼ 1cm, renal location, pre-stenting, positive preoperative urine culture, and post-operative antibiotics. Table 1 demonstrates the univariate analysis of candidate predictors and POF/SIRS. Sex, CCI, laterality (unilateral or bilateral), stone location (renal, ureteral, or both), and type of ureteroscope comprised the final model (Table 2). CONCLUSIONS: Female sex, higher CCI, using both flexible and semi-rigid ureteroscopes, renal stones, and bilateral stones are associated with POF/SIRS after URS. This data may be used to identify and counsel high-risk individuals for surgical planning.
THE JOURNAL OF UROLOGYâ
e688
Source of Funding: None.
MP50-11 THE SURGICAL EXPERIENCE INFLUENCES THE SAFETY BUT NOT EFFICACY OF RIRS FOR KIDNEY STONES: A PROPENSITY SCORE ANALYSIS Francesco Berardinelli*, Piergustavo De Francesco, Luca Cindolo, Vasto, Italy; Silvia Proietti, Milano, Italy; Orietta Dalpiaz, Graz, Austria; Derek Hennessey, Melbourne, Australia; Cecilia Cracco, Cesare Scoffone, Torino, Italy; Luigi Schips, Vasto, Italy; Guido Giusti, Milano, Italy INTRODUCTION AND OBJECTIVES: The safety and the efficacy of Retrograde IntraRenal Surgery (RIRS) is influenced by many factors such as stone burden and location but also by technical skills of the operating surgeon . The aim of this study is to evaluate if the surgeon experience could influence the outcomes of RIRS in terms of stone clearance and complication rate. METHODS: Data of patients who underwent RIRS for kidney stones were prospectively collected. Cases were divided in 2 groups. Group 1: cases operated by 3 surgeons in the early phase of learning curve (surgical experience less than 100 RIRS); Group 2: cases operated by two surgeons with a great experience in endourology (>400 RIRS). Patients and stone data, results and safety outcomes were analyzed. Multivariable regression model was used. Differences between groups was estimated using propensity scores to adjust for the bias inherent to the different patient characteristics RESULTS: 381 RIRS were analyzed (Group 1: 150 RIRS; Group 2: 231 RIRS). The clinical data and stone parameters were comparable between 2 groups (Table1). The SFR was 70% in Group 1 and 77.9% in Group 2 (p¼0.082). Operative time was significantly shorter in the Group 2 (76.3 vs. 53.1min, p¼0.001). The overall complication rate was significantly lower in Group 2 (20.7 vs. 8.7 p¼0.001) (Table 2). At unadjusted analysis, a non significant difference was found between centers on SFR (OR 1.51 95%CI 0.95 to 2.41). Conversely, a significant difference was found on overall complications at unadjusted analysis (OR 0.36 95%CI 0.20 to 0.67) with lower overall complication in Group 2. Both results were confirmed by propensity score analysis (Fig.1 and Fig.2). CONCLUSIONS: This study shows that surgeon experience influences the outcomes of RIRS mainly in terms of safety. Further studies will be needed to assess the exact number of procedures necessary to obtain a plateau in the rate of complications and success
Vol. 197, No. 4S, Supplement, Sunday, May 14, 2017
Source of Funding: none
MP50-12 PERCUTANEOUS NEPHROLITHOTOMY IN LOW BODY MASS INDEX PATIENTS: CAN THINNESS INFLUENCE PERIOPERATIVE OUTCOMES AND COMPLICATIONS? Jose Agudelo*, Euro Arias, Jhonan Chirinos, Nasser Ktech, Luis Urdaneta, Juan Bustamante, Manuel Riveros, Maracaibo, Venezuela INTRODUCTION AND OBJECTIVES: Despite a considerable increase in obese and overweight population, there is also a significant portion of underweight people worldwide. There are plenty of papers about the relationship of the different BMI indexes on PCNL outcomes and morbidities. However, there is no literature about the correlation between underweight and PCNL results. The aim of the study was to compare perioperative variables of PCNL in patients with BMI scores, and to explore whether they have an effect on the outcomes of this surgery. METHODS: We conducted a single-center retrospective evaluation of perioperative outcomes and complications in 182 patients who underwent PCNL surgery between 2010 and 2012. Patients were stratified as underweight BMI less than 18.5 kg/m2, normal weight BMI 18.5 to 24.99 kg/m2, overweight 25 to 29.99 kg/ m2, and obese more than 30 kg/m2. The groups were assessed in terms of baseline characteristics, intraoperative and postoperative variables, including minor and majors complications. One-way ANOVA and univariate logistic regression analysis were used to assess the association between BMI (classified into 4 levels) and variables mentioned. RESULTS: The distributions of the 182 patients in each BMI category were underweight 21 (12%), normal body weight 38 (21%), overweight 72 (39%), and obese 51 (28%). Most of the patients (91.2%) underwent previous unenhanced computed tomography scan in which 38% showed large pelvic stones, 41% staghorn and 2% of anomalous kidneys. There was no difference in the baseline characteristics of groups with respect to age, sex, or stone size. Stone free rates showed no significant differences between groups (p¼0.76). Operative time was significantly longer in obese patients (p¼0.001). On the other hand, postoperative leakage in days, and the presence of postoperative fever, was significantly higher in the underweight group (p¼0.001). There was also one colonic perforation reported in the low BMI group. CONCLUSIONS: PCNL has demonstrated to be an efficacious and safe procedure in patients with different BMI scores. Our findings suggest that low BMI patients could be at higher risk of perioperative morbidities. Further investigation with a larger series of patients is needed to confirm this observation.