Browsing by Author "Assmus, Mark A."

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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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    Ex Vivo Comparison of Efficiency, Safety, and Surgeon Satisfaction in Four Commercial Morcellators
    (Mary Ann Liebert, 2021) Lee, Matthew S.; Assmus, Mark A.; Cooley, Lauren; Li, Eric; Large, Tim; Krambeck, Amy; Urology, School of Medicine
    Introduction Holmium Laser Enucleation of the Prostate (HoLEP) is a size-independent treatment option for the management of benign prostatic hypertrophy. While advancements in laser technology have led to clinical improvements in the enucleation portion of HoLEP, the morcellation aspect of HoLEP is often the rate-limiting step. We sought to compare efficiency and surgeon satisfaction in four commercial morcellators. Methods This was an ex vivo study comparing four commercial morcellators: the Wolf Piranha, the Lumenis VersaCut, the JenaSurgical MultiCut Solo, and the Hawk Morcellator. Four surgeons with significant experience performing HoLEPs participated. Surgeons tested each device to morcellate two different prostate models 1) morcellating as much microwave-cooked chicken breast in 10 minutes and 2) timed morcellation of bull testicles. Surgeons completed subjective surveys after each morcellator trial. Objective outcomes included: morcellation efficiency (g/min morcellated) and aspiration power (time to aspirate 1 L of saline). Means of continuous variables were compared using ANOVA. Categorical variables were compared using chi-square tests. Statistical analyses were performed using SAS 9.4 (2019). Results Comparing subjective outcomes, the Piranha was chosen as the safest morcellator (p=0.0058). The least safe morcellator was thought to be the MultiCut by 75% of surgeons (p=0.046). The Piranha was chosen as the most effective morcellator by 75% of surgeons (p=0.046). Comparing objective parameters between the morcellators, the Piranha had the fastest aspiration time (43.50±10.34 s, p=0.0116). There were no significant differences in morcellation efficiency when using chicken breast (p=0.3096). However, when comparing the morcellation efficiency using bull testicles, the Piranha had the highest efficiency at 39.68±3.57 g/min (p=0.0268). Conclusion In this ex-vivo study comparing four different commercially available morcellators, the Piranha had the highest aspiration power. No significant differences were found in morcellation efficiency using microwave-cooked chicken breast. The Piranha was felt to be the safest and most effective morcellator.
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    Next generation sequencing in patients with nephrolithiasis: how does it perform compared with standard urine and stone cultures?
    (Sage, 2021-02-22) Nottingham, Charles U.; Assmus, Mark A.; Peters, Alexander W.; Large, Tim; Agarwal, Deepak K.; Rivera, Marcelino E.; Krambeck, Amy E.; Urology, School of Medicine
    Background: Our aim was to compare microorganism detection between standard culture (Ctx) and next generation sequencing (NGS) in patients undergoing surgery for nephrolithiasis; we prospectively compared both urine and stone culture results using these two techniques. Methods: We prospectively compared microorganism detection of urine and stone cultures using Ctx versus NGS in patients undergoing surgery for nephrolithiasis. We analyzed preoperative voided urine (Voided) using both Ctx and NGS. Intraoperatively, renal stone (Stone) cultures were analyzed with Ctx and NGS. The primary outcome was concordance in microorganism detection between Voided Ctx and Stone NGS, as well as between Stone Ctx and Stone NGS. Results: We prospectively evaluated 84 patients. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of Voided Ctx predicting Stone Ctx were 66.7%, 73.7%, 54.5%, and 82.4%, respectively. Concordance of Voided Ctx microorganisms to Stone microorganisms decreased when NGS was used for the Stone compared with Ctx. The sensitivity, specificity, PPV, and NPV of Voided NGS to predict Stone Ctx microorganisms were 85.2%, 24.6%, 34.8%, and 77.8%, respectively. The concordance of Voided NGS to Stone microorganisms improved when the Stone was analyzed via NGS compared with Ctx. Conclusion: NGS has a higher detection rate of microorganisms than standard culture for both preoperative urine and stone cultures. Voided NGS was the most sensitive in predicting a positive Stone sample, but the specificity and PPV were, overall, low. Further correlation of NGS microorganism detection with patient outcomes will determine which clinical situations may benefit most from NGS versus standard culture in patients with urinary-tract stones.
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    Same Day Discharge Following Holmium Laser Enucleation in Patients Assessed to have Large Gland Prostates (≥175mL)
    (Liebert, 2021) Assmus, Mark A.; Large, Tim; Lee, Matthew S.; Agarwal, Deepak K.; Rivera, Marcelino E.; Krambeck, Amy E.; Urology, School of Medicine
    Background: Holmium laser enucleation of the prostate (HoLEP) is a highly effective and durable minimally invasive surgery for benign prostatic hyperplasia. Historically, alternative treatments for large glands (≥175mL) are associated with prolonged length of stay (LOS) and postoperative catheterization. However, advances in laser technology combined with surgical technique optimization have early evidence supporting same day discharge. We look to examine contemporary same day discharge outcomes for large glands. Materials & Methods: With IRB approval we queried our EMR and retrospective clinical registry to examine perioperative outcomes of large gland (≥175mL) prostates that underwent HoLEP with consideration for same day discharge. Results: From 12/10/2019 to 09/29/2020 we identified 55 patients with a preoperative prostate size ≥175mL (39 CT, 12 MRI, 4 TRUS), of which 45 were scheduled for same day discharge and 10 for admission. Mean preop prostate size was 229.9mL (range 175-535mL) and 36 (65.5%) were in urinary retention. Mean preop PSA was 8.58ng/mL, AUA Symptom Score 22.3, and Qmax 8.8mL/s. At 3 months postop follow up mean AUASS was 6.7, PSA 0.87ng/mL and Qmax 20.4mL/s. All comer same day discharge rate was 70% (38/55). Of patients planned for same day discharge 38/45 (84%) were successful. Average LOS for all patients was 11.8h with catheterization of 21.2h. When compared to 2010 published large gland outcomes, our current LOS represents a 220% reduction. Looking specifically at patients planned for same day discharge, average LOS and catheter duration was 8.8h and 17.0h, while LOS and catheter duration for patients planned for admission was 25.7h and 39.4h, respectively. Conclusions: We report the first outcomes of preoperatively planned same day discharge for HoLEP in large glands (≥175mL). A combination of technologic advances and optimization of technique have allowed for a safe adoption of same day discharge, providing additional advantages over alternative large gland treatments.
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    Understanding holmium laser enucleation of the prostate (HoLEP) recovery: Assessing patient expectations and understanding
    (Canadian Urological Association, 2022) Assmus, Mark A.; Lee, Matthew S.; Large, Tim; Krambeck, Amy E.; Urology, School of Medicine
    Introduction: Although holmium laser enucleation of the prostate (HoLEP) is a highly effective surgery, there is a variable recovery period where patients may experience hematuria, dysuria, or urinary incontinence (UI). Despite preoperative consultation, there is a paucity of literature examining the effectiveness of physician-patient communication in preparing the patient for the postoperative recovery period. We sought to examine recovery expectations as a patient-reported outcome (PRO) metric for HoLEP. Methods: With institutional review board approval, we queried our electronic medical record and retrospective clinical registry to identify 50 consecutive patients that underwent HoLEP from November 2019 to March 2020 by two endourologists. Patients were provided questionnaires via Twistle© ≥6 months postoperatively. Patient demographics and perioperative course was examined in the context of responses. Our primary objective was determining whether patients felt they had a reasonable understanding of the recovery process. Results: We observed a 92% (46/50) response rate, with an average patient age of 69.4 years (range 55-88). Overall, 91.3% (42/46) felt they had a reasonable understanding of the recovery. Additionally, 97.8% (45/46) were aware of temporary UI, with 87% having ≥1 episodes of UI after catheter removal. We found 47.8% (22/46) of patients expected UI to resolve within 30 days, while 8.6% expected >90 days of UI. All patients were aware of the risk of hematuria, with 93.5% (43/46) expecting resolution within 30 days (<7 days: 47.8%; 7-14 days: 28.3%; 15-30 days: 17.4%). Conclusions: Although surgical technique continues to improve HoLEP, ensuring adequate physician-patient communication to optimize expectations is crucial. We report patient understanding of HoLEP recovery and areas for future improvement.