Browsing by Author "Agarwal, Deepak"

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    A Cost Comparison of Holmium Laser Enucleation of the Prostate with and without Moses
    (American Urological Association, 2021) Lee, Matthew S.; Assmus, Mark; Agarwal, Deepak; Large, Tim; Krambeck, Amy; Urology, School of Medicine
    Introduction: Holmium laser enucleation of the prostate (HoLEP) is a size-independent treatment option for the treatment of benign prostatic hyperplasia. HoLEP has been shown to have excellent improvements in prostate symptom scores and maximum flow rates that have been durable for 2 decades. However, the steep learning curve associated with HoLEP has prevented its widespread adoption. New advancements in lasers, specifically the Moses™ pulse-modulation technology, have resulted in improvements in hemostasis and achieving same-day discharges and catheter removals. We aimed to perform a cost-comparison to analyze if Moses-augmented HoLEP (m-HoLEP) resulted in cost-savings. Methods: A retrospective review was performed of a single expert surgeon's experience from May 2018 to November 2020, comparing m-HoLEP with HoLEP. Perioperative and postoperative variables were abstracted from the medical record. Univariate and multivariate analyses were performed using SAS® 9.4. Two-sided significance was set at p <0.05. Results: A total of 312 men underwent HoLEP during the study period (192 in m-HoLEP group and 120 in HoLEP group). The m-HoLEP group had more same-day discharges (p <0.001) and emergency department visits (6.3% vs 1.7%, p=0.0071). m-HoLEP resulted in hospital cost savings of $840 for the initial surgical episode (p=0.0297). When factoring in emergency department visits/readmissions, the cost savings decreased to $747 per case (p=0.0574). Conclusions: m-HoLEP was associated with same-day discharge and hospital cost savings of $840 for the initial surgical episode. Further study in other institutions with surgeons of varying experience levels will need to be performed to see if these findings can be replicated.
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    Ambulatory PCNL may be cost-effective compared to Standard PCNL
    (Mary Ann Liebert, 2021) Lee, Matthew S.; Assmus, Mark A.; Agarwal, Deepak; Rivera, Marcelino E.; Large, Tim; Krambeck, Amy; Urology, School of Medicine
    Abstract Background COVID-19 changed the practice of medicine in America. During the March 2020 lockdown, elective cases were cancelled to conserve hospital beds/resources resulting in financial losses for health systems and delayed surgical care. Ambulatory percutaneous nephrolithotomy (aPCNL) has been shown to be safe and could be a strategy to: ensure patients receive care that has been delayed, conserve hospital resources, and maximize cost-effectiveness. We aimed to compare the safety and cost-effectiveness of patients undergoing ambulatory percutaneous nephrolithotomy (aPCNL) against standard PCNL (sPCNL). Materials and Methods 98 patients underwent PCNL at Indiana University Methodist hospital, a tertiary referral center, by three expert surgeons from January 2020 to September 2020. The primary outcome of the study was to compare the 30-day rates of ED-visits, readmissions, and complications between sPCNL and aPCNL. Secondary outcomes included: cost analysis and stone free rates (SFRs). Prospensity-score matching was performed to ensure the groups were balanced. Statistical analyses were performed using SAS 9.4 using independent t-tests for continuous variables and chi-square analyses for categorical variables. Results 98 patients underwent PCNL during the study period (sPCNL=75 and aPCNL=23). After propensity-score matching, 42 patients were available for comparison (sPCNL=19 and aPCNL=23). We found no difference in 30-day ED-visits, readmissions, or complications between the two groups. aPCNL resulted in cost savings of $5327±442 per case. Stone free rates were higher for aPCNL compared to sPCNL. Conclusions aPCNL appears safe to perform and does not have a higher rate of ED-visits or readmissions compare to sPCNL. aPCNL may also be cost-effective compared to sPCNL.
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    A case of ureteral fungal mass removal in a patient taking empagliflozin
    (SpringerLink, 2021-11) Woloshuk, Andre; Lee, Matthew; Assmus, Mark; Agarwal, Deepak; Krambeck, Amy; Large, Tim; Urology, School of Medicine
    With increased use of sodium-glucose co-transporter 2 (SGLT2) inhibitors as antidiabetic agents, the risk of serious fungal urinary tract infection (UTI) may be increased. We present the case of a 67-year-old Caucasian female who was admitted for emphysematous pyelitis and found to have a fungal ball in the renal pelvis. Candida glabrata was cultured and the patient was managed with percutaneous nephrostomy tube placement and antifungal treatment. The fungal ball persisted and required surgical removal with ureteroscopy and basket extraction. Fungal balls can be a difficult sequelae of UTIs requiring a combination of antifungal and surgical intervention for definitive management.
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    Expanded Criteria Same Day Catheter Removal Following Holmium Laser Enucleation of the Prostate (HoLEP)
    (Liebert, 2022-07-05) Slade, Austen; Agarwal, Deepak; Large, Tim; Sahm, Erica; Schmidt, Jonathan; Rivera, Marcelino E; Urology, School of Medicine
    Introduction and Objectives Holmium laser enucleation of the prostate (HoLEP) is a highly effective treatment of benign prostatic hyperplasia (BPH). Technical advances and improved hemostatic properties of Holmium lasers have allowed for increased efficiency and outcomes. Same day catheter removal following HoLEP was described at our institution in 2020 following a 30-patient pilot trial. We now present an expanded update following widespread adoption at our facility. Methods We reviewed patients who underwent same day catheter removal after HoLEP between 1/1/2020 and 3/21/2021. Unlike previous trials, there were no limitations to prostate size. Other changes included catheter removal in phase two of recovery when nursing was available rather than the urology clinic. Descriptive statistics are presented of preoperative, operative, and postoperative data. Univariate and multivariate analysis was performed to assess associations with failure of same day void trial. Results The success rate of same-day catheter removal for the 114 identified patients was 87.7%. Mean age was 69.1  8.6 years and prostate volume was 109.2  61.5cc, 35% were dependent on catheterization for urinary retention preoperatively and 9% were on antiplatelet/anticoagulant therapy. A total of 26.5% of patients with ASA 3 or 4 failed catheter removal compared to 3.9% of patients with ASA 1 or 2 (Likelihood ratio 9.32, p=0.002), ASA status lost significance on multivariate analysis (p=0.076). Successful catheter removal was not significantly associated with age, BMI, prostate size, catheter dependency, anticoagulation/antiplatelet therapy, AUA symptom score, prior BPH surgery, or prostate cancer in final pathology. Conclusion Regardless of prostate size, same day catheter removal is a safe and reliable method of post-HoLEP patient management. Patients with an ASA 3 or 4 should be counseled regarding potential risks of temporary re-catheterization. Given ongoing nationwide shortages in hospital beds and staffing, same day discharge and catheter removal may allow for wider availability of surgical treatment for BPH.
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    Initial Experience with Novel Single-Use Disposable Ureteroscopy: A Prospective, Single Arm 90-Day Trial of the Axis Ureteroscope
    (AUA, 2021) Large, Tim; Rivera, Marcelino; Nottingham, Charles; Agarwal, Deepak; Mellon, Matthew; Krambeck, Amy; Urology, School of Medicine
    Introduction: Novel digital disposable ureteroscopes are becoming more commonplace in endourological practices. We trialed the Axis™ single-use ureteroscope, which is distributed within the United States by Dornier MedTech. Our goal was to demonstrate clinical equivalence to our reusable platform and to evaluate the cost-effectiveness of a single-use digital ureteroscope. Methods: We conducted a prospective 90-day trial where all flexible ureteroscopic procedures were completed using the single-use ureteroscope. The cases were monitored for scope failure, scope deficiencies and surgeon satisfaction scores via an immediate postoperative REDCap® survey. We also performed a cost analysis between reusable scopes and the single-use ureteroscope. The cost of the reusable platform included the amortized initial purchase, maintenance and clean processing. Results: Over a 90-day period, we performed 93 flexible ureteroscopy procedures with a single-use ureteroscope, of which 74 were completed using Axis. After controlling for operating room time and disposable items used, the utilization of Axis was associated with an average reduction of $140.31 per case. Extrapolating the per-case savings over an annual case volume, we estimate a total savings of $56,127.15. There were no disposable scope malfunctions. There were 4 (4.3%) cases converted to reusable scopes due to image quality (1), inadequate secondary deflection (2) and a tight ureter (1). Mean±SD score for image quality, mobility and ergonomics was 9.1±1.1, 8.9±1.1, 9.3±1.1, respectively. The 90-day complication rates were equal to our controls. Conclusions: We demonstrated that the Axis single-use digital ureteroscope is equivalent in function to our digital reusable scope and reduced the cost of flexible ureteroscopy.
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    Multi-Institutional Prospective Randomized Control Trial of Novel Intracorporeal Lithotripters: ShockPulse-SE vs Trilogy Trial
    (Mary Ann Liebert, 2021-11) Large, Tim; Nottingham, Charles; Brinkman, Ethan; Agarwal, Deepak; Ferrero, Andrea; Sourial, Michael; Stern, Karen; Rivera, Marcelino; Knudsen, Bodo; Humphreys, Mitchel; Krambeck, Amy; Urology, School of Medicine
    Introduction: Currently, there are multiple intracorporeal lithotripters available for use in percutaneous nephrolithotomy (PCNL). This study aimed to evaluate the efficiency of two novel lithotripters: Trilogy and ShockPulse-SE. Materials and Methods: This is a prospective multi-institutional randomized trial comparing outcomes of PCNL using two novel lithotripters between February 2019 and June 2020. The study assessed objective measures of stone clearance time, stone clearance rate, device malfunction, stone-free rates, and complications. Device assessment was provided through immediate postoperative survey by primary surgeons. Results: There were 100 standard PCNLs completed using either a Trilogy or ShockPulse-SE lithotrite. Using quantitative Stone Analysis Software to estimate stone volume, the mean stone volume was calculated at 4.18 ± 4.79 and 3.86 ± 3.43 cm3 for the Trilogy and ShockPulse-SE groups, respectively. Stone clearance rates were found to be 1.22 ± 1.67 and 0.77 ± 0.68 cm3/min for Trilogy vs ShockPulse-SE (p = 0.0542). When comparing Trilogy to ShockPulse-SE in a multivariate analysis, total operative room time (104.4 ± 48.2 minutes vs 121.1 ± 59.2 minutes p = 0.126), rates of secondary procedures (17.65% vs 40.81%, p = 0.005), and device malfunctions (1.96% vs 34.69%, p < 0.001) were less, respectively. There was no difference in final stone-free rates between devices. Conclusion: Both the Trilogy and ShockPulse-SE lithotripters are highly efficient at removing large renal stones. In this study, we noted differences between the two devices including fewer device malfunctions when Trilogy device was utilized.
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    Outcomes of octogenarians undergoing holmium laser enucleation of prostate
    (Springer, 2022-07) Heiman, Joshua; Agarwal, Deepak; Komanapalli, Sarah; Nottingham, Charles; Large, Tim; Krambeck, Amy; Rivera, Marcelino; Urology, School of Medicine
    Purpose Holmium laser enucleation of prostate (HoLEP) is an effective surgical procedure in men with BPH. Due to the increase in the use of medical therapy for BPH related lower urinary symptoms more octogenarians are presenting in a delayed fashion with significant symptoms and urinary retention. We evaluate the feasibility and safety of octogenarians undergoing HoLEP. Methods We performed a retrospective review of HoLEPs at our institution from July 2018 to December 2019. Patients were stratified into two groups based on age: < 80 and ≥ 80. Results A total of 458 patients were identified, with 74 (16.2%) ≥ 80. In patients ≥ 80, prostate volume was higher (p < 0.0005), there was a higher rate of antiplatelet/anticoagulation (p = 0.029) use, and a lower rate of alpha-blocker use (p = 0.0016). As expected, ASA scores which correlate with increasing number of concomitant diseases were greater in the ≥ 80 cohort (p = 0.016). There was no significant difference in intraoperative complications (p = 0.14), 90 day complication (p = 0.34), readmission rates (p = 0.425) or emergency room visits between groups (p = 0.15). Conclusions Despite higher medical comorbidities and increased rates of anticoagulation in octogenarians, there is no increase in operative or postoperative complication rates. Age alone should not be used as exclusion criteria for HoLEP.