Browsing by Author "Large, Tim"

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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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    Best practice in the management of benign prostatic hyperplasia in the patients requiring anticoagulation
    (Sage, 2018-10-29) Heiman, Joshua; Large, Tim; Krambeck, Amy; Graduate Medical Education, IU School of Medicine
    In today's aging population, urologists are often treating older patients with multiple comorbidities. Lower urinary tract symptoms from benign prostate hyperplasia (LUTS/BPH) is a common condition that affects men, with increasing prevalence as men age. In a subset of patients, the symptoms are too severe or refractory to medical therapy and, therefore, surgical therapy is required to improve their LUTS. The use of medical therapy often delays the need to intervene surgically in men with LUTS/BPH and with advances in the management of cardiovascular disease, urologists are increasingly encountering more men requiring BPH surgery on chronic anticoagulation therapy. The decision of when to offer surgical intervention and how to manage anticoagulation medication in the perioperative setting is a dilemma with which surgeons are dealing with increasing frequency. The purpose of this review is to clarify the optimal approach to the surgical patient with LUTS/ BPH requiring anticoagulation therapy.
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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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    Catheter Removal on the Same Day of Holmium Laser Enucleation of the Prostate: Outcomes of a Pilot Study
    (Elsevier, 2020-10-09) Agarwal, Deepak K.; Rivera, Marcelino E.; Nottingham, Charles U.; Large, Tim; Krambeck, Amy E.; Urology, School of Medicine
    Objectives: To determine if same day catheter removal is feasible in select population after holmium laser enucleation of the prostate (HoLEP). Methods: We performed an analysis of patients undergoing HoLEP at our institution who underwent same-day catheter removal after HoLEP. All HoLEPs were performed with Moses Optimized for BPH. Patients were dismissed from postoperative recovery unit (POCU) to the clinic for catheter removal and voiding trial. Results: To date, 30 patients have undergone same day catheter removal. Median age is 68.6 years (IQR 61.8-73.3) and preoperative prostate volume 81 ml (IQR 53-114.8). Median enucleation time was 39.5 min (IQR 30.5-53), morcellation time was 5 min (IQR 4-12 min) and enucleated specimen weight was 52.5 g (IQR 33-81). 27 (90%) patients successfully voided on the same day without requiring catheter replacement. All patients were catheter free by POD1. For patients who successfully passed their voiding trial, the median time from the end of the procedure to hospital discharge was 2.6 hours (IQR (2.1-2.9) and from the end of the HoLEP to catheter removal was 4.9 hours (IQR 3.5-6.0). Conclusions: We present for the first time that same day catheter removal is a feasible option in a select population of patients undergoing HoLEP. With more study, this has the potential for transforming the management of BPH, especially larger glands.
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    Clinical and Metabolic Correlates of Pure Stone Subtypes
    (Liebert, 2021) Brinkman, John E.; Large, Tim; Nottingham, Charles U.; Stoughton, Christa; Krambeck, Amy E.; Urology, School of Medicine
    Background: There are multiple stone types, each forming under different urinary conditions. We compared clinical and metabolic findings in pure stone formers to understand if there are consistent factors that differentiate these groups in terms of underlying etiology and potential for empiric treatment. Materials and Methods: Pure SFs based on infrared spectroscopic analysis of stones obtained at our institution between 01/2002 and 07/2018 with a corresponding 24-hour urinalysis were retrospectively evaluated. Results: 121 apatite, 54 brushite, 50 calcium oxalate dihydrate, 104 calcium oxalate monohydrate, and 82 uric acid patients were analyzed. Apatite, brushite, and calcium oxalate dihydrate patients were younger than calcium oxalate monohydrate and uric acid patients. Uric acid patients had the highest male predominance (76.8%), while apatite patients were predominantly female (80.2%). Uric acid was most associated with diabetes mellitus (45.3%), and calcium oxalate monohydrate with cardiovascular disease (27.2%) and malabsorptive gastrointestinal conditions (19.2%). Brushite patients had the highest prevalence of primary hyperparathyroidism (17%). Apatite, brushite, and calcium oxalate dihydrate patients demonstrated high rates of hypercalciuria (66.1%, 79.6%, 82%). Apatite and brushite patients had the highest urinary pH. Apatite patients exhibited the highest rate of hypocitraturia while calcium oxalate dihydrate patients exhibited the lowest (55.4%, 30%). Calcium oxalate monohydrate patients had the highest rate of hyperoxaluria (51.9%). Uric acid patients had the lowest urinary pH. There were no observable differences in the rates of hyperuricosuria or hypernatriuria. Conclusions: These results demonstrate that pure stone composition correlates with certain urinary and clinical characteristics. This data can help guide empiric clinical decision-making.
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    Comparative Study of Holmium Laser Enucleation of the Prostate With MOSES Enabled Pulsed Laser Modulation
    (Elsevier, 2020-02) Large, Tim; Nottingham, Charles; Stoughton, Christa; Williams, James, Jr.; Krambeck, Amy; Urology, School of Medicine
    Objective To compare outcomes for patients undergoing holmium laser enucleation of the prostate (HoLEP) for lower urinary tract symptoms secondary to benign prostate hyperplasia using 3 different laser fibers and 2 different laser energy modes. Materials and Methods This is a review of a clinic registry of men with lower urinary tract symptoms secondary to benign prostate hyperplasia who underwent HoLEP between August 2018 and January 2019. Patients were assigned to group 1 (50 patients), group 2 (50 patients), and group 3 (50 patients) based on the HoLEP being completed with either a Slimline 550µm, Slimline 1000µm, or MOSES 550 µm laser, respectively. The groups were compared using SSPS for ANOVA comparison of means and multivariate logistic regression. Results Ten patients who underwent concomitant stone surgery (2 PCNL, 8 ureteroscopy , 3 bilateral cases) and 11 patients had bladder stones removed; ancillary procedures did not significantly differ between groups(P = .2). Prostate enucleation times differed significantly (22.5 + 7.3, 16.4 + 6.9, 18.1 + 8.6 minutes P ≤.001) between groups. However, statistical significance was lost once enucleation time was indexed against enucleated tissue weight. Time to achieve hemostasis (minutes) was statistically different between groups (10.6 + 6.1, 7.7 + 5.2, 6.3 + 4.8 P <.001). This difference in hemostatic time was maintained on multilogistic regression demonstrating that MOSES laser enucleation was associated with a 3.9-minute decrease time to achieve hemostasis after enucleation compared to Slimline 550 HoLEP (P <.001). Conclusion Our findings suggest that modulated pulsed laser energy can improve hemostasis during the enucleation phase of a HoLEP resulting in shorter Operating Room times.
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    Comparison of cost-effectiveness and postoperative outcomes following integration of a stiff shaft glidewire into percutaneous nephrolithotripsy
    (Sage, 2021-08-22) Valadon, Crystal; Abedali, Zain A.; Nottingham, Charles U.; Large, Tim; Krambeck, Amy E.; Urology, School of Medicine
    Aims: To analyze the cost effectiveness of integrating a stiff shaft glidewire (SSGW) in percutaneous nephrolithotripsy (PCNL) relative to standard technique (ST). This is prudent because healthcare providers are experiencing increased pressure to improve procedure-related cost containment. Methods: ST for PCNL at our institution involves a hydrophilic glidewire during initial percutaneous access and then two new stiff shaft wires. The SSGW is a hydrophilic wire used for initial access and the remainder of the procedure. We collected operating room (OR) costs for all primary, unilateral PCNL cases over a 5-month period during which ST for PCNL was used at a single institution with a single surgeon and compared with a 6-month period during which a SSGW was used. Mean costs for each period were then compared along with stone-free rates and complications. Results: We included 17 total cases in the ST group and 22 in the SSGW group. The average operating room supply cost for the ST group was $1937.32 and $1559.39 in the SSGW group. The net difference of $377.93 represents a nearly 20% decrease in cost. This difference was statistically significant (p = 0.031). There was no difference in postoperative stone-free rates (82.4% versus 86.4%, p = 1.0, respectively) or complications (23.5% versus 13.6%, p = 0.677, respectively) between ST and SSGW groups. Conclusion: Transitioning to a SSGW has reduced OR supply cost by reducing the number of supplies required. The change in wire did not affect stone-free rates or complications.
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    Comparison of Newly Optimized Moses Technology vs Standard Holmium: YAG for Endoscopic Laser Enucleation of the Prostate
    (Liebert, 2021-12) Nottingham, Charles U.; Large, Tim; Agarwal, Deepak K.; Rivera, Marcelino E.; Krambeck, Amy E.; Urology, School of Medicine
    Introduction: The purpose of this study was to describe our initial experience of using a newly optimized Moses technology that is part of the second-generation Moses platform specifically designed for holmium laser enucleation of the prostate (M2-HoLEP) and compare it with patients undergoing HoLEP using standard holmium:YAG technology (S-HoLEP). Materials and Methods: We retrospectively collected data on patients who underwent M2-HoLEP and compared it with the last 50 patients in whom we performed S-HoLEP. Specifically, we compared preoperative symptom scores for lower urinary tract symptoms (LUTS) and erectile dysfunction (ED), preoperative objective voiding metrics, as well as intraoperative characteristics, perioperative characteristics, postoperative complications, postoperative symptom scores for LUTS and ED, and postoperative objective voiding metrics. Additionally, we evaluated the ability for same-day discharge following surgery in the M2-HoLEP group. Results: We included 104 total patients for analysis. We compared the first 54 patients undergoing M2-HoLEP with 50 patients undergoing S-HoLEP. Both groups had similar age, body mass index, use of anticoagulation medication, LUTS and ED scores, and objective voiding metrics. Operations performed with M2-HoLEP had faster mean hemostasis time (8.7 vs 10.6 ± 6 minutes, p = 0.03) as well as hemostasis rate (0.13 vs 0.30 min/g, p = 0.01). Same-day discharge was achieved in 69.4% of patients in the M2-HoLEP group. Postoperatively, both groups also had similar and low rates of urinary retention and complications. At follow-up, both groups had similar symptom scores for LUTS and ED, as well as similar objective voiding metrics. Conclusions: The newly optimized Moses pulse modulation technology is safe and efficient for the treatment of benign prostate hyperplasia. Such technologic improvements in the laser have greatly enhanced the feasibility of same-day discharge of patients undergoing HoLEP.
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    Correlating Patient Anxiety with Urinary Symptoms Before and After Holmium Laser Enucleation of the Prostate
    (Liebert, 2020) Nottingham, Charles U.; Agarwal, Deepak K.; Valadon, Crystal; Large, Tim; Rivera, Marcelino E.; Krambeck, Amy E.; Urology, School of Medicine
    Introduction and Objective: Preoperative anxiety has been shown to correlate with certain urinary symptoms in patients with certain types of voiding dysfunction, particularly overactive bladder. The purpose of this study was to evaluate if patient-reported anxiety correlates with pathologic characteristics, voiding symptoms, and objective metrics of bladder emptying in male patients undergoing holmium laser enucleation of the prostate (HoLEP). Patients and Methods: We began collecting patient-reported anxiety scores (generalized anxiety disorder 7-item or GAD-7) in addition to patient-reported scores of lower urinary tract symptoms (LUTS) and erectile dysfunction (ED) starting in November 2018 for men with LUTS due to benign prostate hyperplasia (BPH). We retrospectively evaluated the relationship between preoperative GAD-7 score with preoperative age, body mass index (BMI), preoperative urine flow metrics, preoperative postvoid residual (PVR), and preoperative symptom scores for LUTS (American Urological Association, BPH impact index [BII], and Michigan incontinence symptom index [MISI]) and ED (sexual health inventory for men and male sexual health questionnaire for ejaculatory dysfunction [MSHQ-EjD]). We then compared preoperative GAD-7 score with enucleated prostate weight, postoperative GAD-7 scores, postoperative urine flow metrics, postoperative PVR, and postoperative symptom scores for LUTS and ED. Results: We included 139 patients for analysis. The preoperative GAD-7 score positively correlated with preoperative BII scores (rs = 0.202, p = 0.019), MISI total (rs = 0.260, p = 0.002), and MISI bother (rs = 0.345, p < 0.001) scores. Preoperative GAD-7 negatively correlated with preoperative MSHQ-EjD (rs = −0.191, p = 0.031). Following HoLEP, all four of these correlations disappear. The GAD-7 score did not correlate with age, BMI, preoperative urine flow metrics, preoperative PVR, or other preoperative LUTS and ED symptom scores. In addition, preoperative GAD-7 score showed no correlation with enucleated prostate weight, postoperative urine flow metrics, postoperative PVR, and postoperative LUTS and ED symptom scores. Conclusions: Higher preoperative anxiety correlated with more severe preoperative urinary LUTS, particularly incontinence symptoms, in patients undergoing HoLEP. Following HoLEP, these symptoms improve regardless of patient anxiety level.