IU Indianapolis ScholarWorks :: Browsing by Author "Rivera, Marcelino E."

Browsing by Author "Rivera, Marcelino E."

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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.
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.
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.
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.
Electromagnetic Guided Percutaneous Renal Access Outcomes Among Surgeons and Trainees of Different Experience Levels: A Pilot Study
(Elsevier, 2020-02) Borofsky, Michael S.; Rivera, Marcelino E.; Dauw, Casey A.; Krambeck, Amy E.; Lingeman, James E.; Urology, School of Medicine
Objective To determine feasibility of an electromagnetic (EM) guidance system (Auris Health, Redwood City, CA) in obtaining percutaneous renal access among urologists and trainees of different experience levels. EM-guidance is appealing for access as it allows real time, 3-dimensional targeting without radiation. Few studies have explored this for percutaneous nephrolithotomy (PCNL) and none have assessed its potential to decrease the learning curve in obtaining access using traditional techniques. Methods Institutional Animal Care and Use Committee approval was obtained to compare EM-guided percutaneous access to fluoroscopic guided access in a porcine model. Voluntary participants included urology trainees and faculty. They were categorized as beginner (no prior primary percutaneous nephrolithotomyexperience), intermediate (10-100 prior) and advanced (>100). Each participant attempted an EM and fluoroscopic guided puncture. Primary outcome was successful puncture. Secondary outcomes included access time, fluoroscopy time, and number of attempts. Participants were limited to 3 attempts and 10 minutes total to obtain access using each technique. Results Fourteen participants (6 beginners, 4 intermediates, and 4 experts) attempted 28 punctures. Overall success using EM-guidance was 93% compared to 71% using fluoroscopy ( P = .33). EM punctures had shorter access times (85 vs 255 seconds, P <.01) required fewer attempts (1 vs 2, P = .04) and had decreased associated fluoroscopy times (1 vs 96 seconds, P <.01) excluding the initial retrograde pyelogram and guidance of the ureteroscope to the desired calyx. Beginners showed comparable success rates and outcomes relative to experts despite higher access times. Conclusion EM-guidance is a promising new technique to decrease the learning curve of percutaneous access with high success rates and minimal radiation.
Holmium Laser Enucleation of the Prostate
(Liebert, 2018-05) Rivera, Marcelino E.; Lingeman, James E.; Krambeck, Amy E.; Urology, School of Medicine
Introduction: Holmium laser enucleation of the prostate (HoLEP) offers superior voiding outcomes to traditional transurethral resection and less morbidity than open simple prostatectomy. Likewise, HoLEP has been determined to result in excellent outcomes regardless of gland size. We present a step-by-step surgical approach to HoLEP describing both the traditional enucleation technique and a modified “top-down” surgical technique. Materials and Methods: In this video, two techniques are presented that were performed by two (A.E.K., J.E.L.) surgeons at our institution. Results: In the examples of the two enucleation techniques mentioned, outcomes are similar with regard to surgical and functional outcomes. Conclusions: HoLEP as a treatment for BPH with associated lower urinary tract symptoms (LUTS) results in excellent patient outcomes and can be offered to patients regardless of prostate volume.
In Vivo Entombment of Bacteria and Fungi during Calcium Oxalate, Brushite, and Struvite Urolithiasis
(Wolters Kluwer, 2020-12-23) Saw, Jessica J.; Sivaguru, Mayandi; Wilson, Elena M.; Dong, Yiran; Sanford, Robert A.; Fields, Chris J.; Cregger, Melissa A.; Merkel, Annette C.; Bruce, William J.; Weber, Joseph R.; Lieske, John C.; Krambeck, Amy E.; Rivera, Marcelino E.; Large, Timothy; Lange, Dirk; Bhattacharjee, Ananda S.; Romero, Michael F.; Chia, Nicholas; Fouke, Bruce W.; Urology, School of Medicine
Background: Human kidney stones form via repeated events of mineral precipitation, partial dissolution, and reprecipitation, which are directly analogous to similar processes in other natural and manmade environments, where resident microbiomes strongly influence biomineralization. High-resolution microscopy and high-fidelity metagenomic (microscopy-to-omics) analyses, applicable to all forms of biomineralization, have been applied to assemble definitive evidence of in vivo microbiome entombment during urolithiasis. Methods: Stone fragments were collected from a randomly chosen cohort of 20 patients using standard percutaneous nephrolithotomy (PCNL). Fourier transform infrared (FTIR) spectroscopy indicated that 18 of these patients were calcium oxalate (CaOx) stone formers, whereas one patient formed each formed brushite and struvite stones. This apportionment is consistent with global stone mineralogy distributions. Stone fragments from seven of these 20 patients (five CaOx, one brushite, and one struvite) were thin sectioned and analyzed using brightfield (BF), polarization (POL), confocal, super-resolution autofluorescence (SRAF), and Raman techniques. DNA from remaining fragments, grouped according to each of the 20 patients, were analyzed with amplicon sequencing of 16S rRNA gene sequences (V1-V3, V3-V5) and internal transcribed spacer (ITS1, ITS2) regions. Results: Bulk-entombed DNA was sequenced from stone fragments in 11 of the 18 patients who formed CaOx stones, and the patients who formed brushite and struvite stones. These analyses confirmed the presence of an entombed low-diversity community of bacteria and fungi, including Actinobacteria, Bacteroidetes, Firmicutes, Proteobacteria, and Aspergillus niger. Bacterial cells approximately 1 μm in diameter were also optically observed to be entombed and well preserved in amorphous hydroxyapatite spherules and fans of needle-like crystals of brushite and struvite. Conclusions: These results indicate a microbiome is entombed during in vivo CaOx stone formation. Similar processes are implied for brushite and struvite stones. This evidence lays the groundwork for future in vitro and in vivo experimentation to determine how the microbiome may actively and/or passively influence kidney stone biomineralization.
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.
Real-World Experience of Holmium Laser Enucleation of the Prostate with Patients on Anticoagulation Therapy
(Liebert, 2021) Agarwal, Deepak K.; Large, Tim; Stoughton, Christa L.; Heiman, Joshua M.; Nottingham, Charles U.; Rivera, Marcelino E.; Krambeck, Amy E.; Urology, School of Medicine
Background: Holmium laser enucleation of the prostate (HoLEP) is a highly effective procedure for benign prostatic hyperplasia that is size independent and has been recommended for patients necessitating antiplatelet (AP) and anticoagulant (AC) medications. Although HoLEP is feasible in AP/AC patients, there is a lack of published results on real-world outcomes of patients on AP/AC therapy undergoing HoLEP. Patients and Methods: We performed a retrospective review of our institutional HoLEP database of demographics, perioperative and postoperative data, and outcomes of patients on AP and AC therapy compared with none. We also further stratified patients on warfarin compared with direct oral anticoagulants (DOACs). Results: Of 472 patients who underwent HoLEP at our institution from July 2018 to December 2019 with data on AP/AC drugs, 30 (6.3%) were on AP and 65 (17.2%) were on AC. One patient continued AP (3.3%), six patients (9.2%) were bridged on AC, and one patient (1.5%) continued AC through the time of HoLEP at the discretion of the prescribing provider. Preoperatively, only age was significantly different among the three groups (p < 0.001). There were no intraoperative differences. Postoperatively, there was a higher 90-day complication rate in AP and AC groups (p = 0.035), but not an increase in emergency department (ED) visits (p = 0.557) or Clavien ≥3 complications (p = 0.16). In comparison of patients on warfarin with DOAC, there was a lower rate of successful voiding trial (p = 0.009), higher 90-day complications (p = 0.003), and more ED visits (p = 0.003) in the warfarin group. Conclusions: HoLEP is safe and effective for patients who require AP or AC therapy. There is no increase in serious complications or worsened postoperative voiding parameters. Of patients on AC, those on DOAC have better outcomes compared with warfarin.
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.

Browsing by Author "Rivera, Marcelino E."

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