Humphreys, Mitchell R.

ABSTRACT Objectives Lasers are integral to contemporary endourologic stone surgery; however, reported institutional practices regarding laser access, personnel requirements, and safety protocols vary. We sought to characterize respondent‐reported laser access models, operational requirements, safety practices, and perceived barriers to care. Materials and Methods A cross‐sectional, web‐based 25‐item survey was distributed between October 2024 and March 2025 through social media, professional organizations, and departmental contacts. The survey assessed practice characteristics, laser access, physician and technician responsibilities, institutional safety requirements, and perceived barriers to care. Responses were self‐reported, collected anonymously, and summarized using descriptive statistics. Results A total of 187 respondents completed the survey; 85.6% identified as endourologists and 61.5% practiced in academic settings. Most respondents reported institution‐owned laser equipment (70.1%), while 9.6% reported contracted equipment and 20.3% combination models. Among respondents addressing contracted equipment availability ( n = 58), 55.2% reported ready access after regular business hours and 46.6% on weekends. Among 182 evaluable responses, 65.4% reported that physicians could operate lasers without a technician present. Fifty‐two respondents perceived that technician availability could affect patient care; among these, 40 reported potential delays in definitive treatment and 33 reported potential multiple or staged procedures. Staff laser safety goggles could be deferred according to 78.4% of evaluable responses, and 18.3% reported a prior institutional laser safety incident. Conclusion This survey identified substantial respondent‐reported variation in laser access, staffing requirements, and safety practices. The findings describe perceived institutional practices and barriers and do not establish effects on treatment delays, workflow efficiency, patient outcomes, or comparative safety. Future studies should directly compare institutional models using objective measures of access, workflow, treatment delays, and safety outcomes.

Objective To assess the effect of Moses™ 2.0 (Lumenis Be Ltd., Yokneam Illit, Israel; Boston Scientific, Marlborough, MA, USA) for lithotripsy of renal stones of 8–20 mm in diameter on operative time, surgeon workload, and retropulsion. Subjects/Patients and Methods In our multicentre, randomised, double‐blind clinical trial, patients were randomised 1:1 to standard or Moses 2.0 laser lithotripsy and stratified by stone size. Patients and surgeons were blinded to laser modality. Primary outcomes were total operative time as well as surgeon workload assessed by the National Aeronautics and Space Administration‐Task Load Index (NASA‐TLX). Secondary outcomes were stone retropulsion evaluated by blinded video review and postoperative clinical outcomes. Linear regression modelling was used for analysis. Results A total of 153 patients (79 Standard, 74 Moses 2.0) with similar clinical, stone, and operative characteristics were evaluated. There was no significant difference in operative times between the Standard and Moses 2.0 groups ( P = 0.73). Moses 2.0 was associated with lower effort, frustration, mental, physical, and temporal workload, as well as higher rated overall performance compared to the standard laser. Video review demonstrated no difference in rates of retropulsion ( P = 0.13). Complication rates (Standard: 13%; Moses 2.0: 10%) and stone‐free rates (Standard: 51%; Moses: 2.0 55%) were comparable. Conclusion Our study evaluated the impact of Moses 2.0 technology on high‐powered renal stone dusting, constituting the largest double‐blind trial of its kind to date. There was insufficient evidence to suggest any difference in operative times or clinical outcomes when using Moses 2.0 compared to standard laser lithotripsy. Moses 2.0 was associated with reduced surgeon workload, which has implicit impact on surgeon wellness.

Abstract Purpose The temporarily implanted nitinol device (TIND) is a minimally invasive surgical technique (MIST) for benign prostatic hyperplasia (BPH) that promises fewer unwanted side effects compared with traditional bladder outlet procedures for small glands with high-riding bladder necks, including transurethral incision of the prostate (TUIP). This study sought to compare the effect of TIND vs. TUIP on ejaculatory function in sexually active males using the Male Sexual Health Questionnaire Ejaculatory Function Short Form (MSHQ-EjD-SF). Methods A retrospective review of a prospectively maintained database of all patients who underwent TIND at our institution between 1/1/2022 and 10/1/2024. Patients were excluded if they reported no postoperative ejaculations. Patients who underwent TUIP during the same period were compared. Age, prostate volume, PSA, and urinary parameters were collected. MSHQ-EjD-SF scores were collected for all patients. Continuous variables were compared using Wilcoxon Rank sum test and categorical variables using Fisher’s exact test. Results A total of 27 patients underwent TIND, of which 17 reported postoperative ejaculations and were compared with 17 patients who underwent TUIP during the same period with similar baseline age, prostate volume, and urinary parameters. Median MSHQ-EjD-SF score was higher after TIND compared with TUIP (15.0 (14.0, 15.0) vs. 13.0 (11.0, 13.0), p < 0.01), while bother score was lower (0.0 (0.0, 0.0) vs. 1.0 (0.0, 2.0), p = 0.02). Conclusions Patients experienced negligible effect on ejaculatory function after TIND compared with TUIP. This may be an effective bladder outlet procedure for patients who prioritize their postoperative ejaculatory function.

Introduction: Adequate bladder distention is critical for safe and efficient transurethral morcellation during endoscopic prostate enucleation. Traditional assessment methods are subjective and may compromise safety and efficiency. We evaluated the feasibility and impact of continuous intravesical pressure (IVP) monitoring using a handheld pressure meter during morcellation compared with conventional manual bladder assessment. Material and Methods: In this prospective, randomized pilot study, 30 patients undergoing transurethral morcellation after bipolar prostate enucleation were randomized 1:1 to continuous IVP monitoring with a handheld pressure meter (Group A) or manual suprapubic bladder assessment by a urology fellow (Group B). In Group A, morcellation was performed while IVP remained within a predefined safe range (15–60 mmHg), with pauses for pressure correction as needed. The primary outcome was the number of morcellation pauses. Secondary outcomes included morcellation time, morcellation efficiency (g/min), total operative time, hemoglobin deficit, complications, and functional outcomes (International Prostate Symptom Score, maximum urinary flow rate, and post-void residual) at 3 and 6 months. Results: Baseline characteristics were comparable between groups. Morcellation time was significantly shorter in Group A (8.9 ± 3.7 vs 13.3 ± 2.1 minutes; p = 0.0008), with fewer morcellation pauses (3.3 ± 0.7 vs 5.7 ± 1.2; p < 0.0001) and higher morcellation efficiency (9.9 ± 2.0 vs 5.9 ± 0.6 g/min; p < 0.0001). Enucleation time, total operative time, tissue weight, and hemoglobin deficit were similar. No bladder injuries or postoperative fever occurred. Functional outcomes at 3 and 6 months were comparable. Conclusion: Continuous IVP monitoring using a handheld pressure meter during transurethral morcellation is feasible, reduces interruptions, and significantly improves morcellation efficiency without compromising safety or functional outcomes. This inexpensive technique may be a valuable safety adjunct, particularly for less experienced surgeons, and merits evaluation in larger randomized trials.

Introduction: Ureteroscopy (URS) is the most commonly performed surgery for the management of renal stones. Post-URS sepsis has been reported to be around 5%, but most studies rely on purchased datasets or electronic medical record (EMR) data that pull data based on billing codes of sepsis without clinical verifications. This study aims to evaluate the true incidence of sepsis using the Sepsis-3 criteria at a single tertiary care institution. Methods: A retrospective review was conducted on all URS procedures at a single tertiary care institution from 2021 to 2022, including both Medicare and private insurance patients ≥18 years old. The EMR was queried for URS procedure codes and readmission within 30 days post-procedure with a sepsis diagnosis code. All other procedures, including URS during percutaneous nephrolithotomy, were excluded. Each identified case was evaluated for sepsis using the Sepsis-3 criteria, including sequential organ failure assessment (SOFA) and quick SOFA (qSOFA). Results: A total of 1316 patients underwent URS. Nineteen patients were identified with a sepsis diagnosis, giving an initial post-URS sepsis rate of 1.44%. After EMR verification, 5 patients were excluded, leaving 14 (1.06%) patients with a diagnosis code of sepsis. Using Sepsis-3 criteria, only 6 (0.44%) met the diagnosis. Conclusions: This retrospective review identified only 0.44% of patients with a true post-URS sepsis within 30 days using Sepsis-3 criteria. The difference in our rate from the initial query and current literature highlights the need for accurate clinical diagnosis and documentation of sepsis.

Purpose: To compare stone clearance, stone-free status, and complications between patients undergoing ureteroscopy for renal stones using either Flexible and Navigable Ureteral Access Sheath (FANS) or the CVAC 2.0 system. Materials and Methods: A prospective study was completed on patients undergoing flexible ureteroscopy for renal stones at a single institution from March 2024 to December 2024. Subject demographics, intra-op data, volumetric and single-dimension stone clearance on non-contrast CT, and complications were compared. Stone-free rates (SFRs) using standardized cutoffs were compared. Pearson correlation analysis was performed to assess the relationship between preoperative stone volume and postoperative stone burden. Subanalysis was performed for patients with preoperative stone burden >1.5 cm. Results: A total of 123 cases (CVAC 2.0-36, FANS-87) were included, with 64 eligible for volumetric analysis. Preoperative stone volume was larger in the CVAC group vs FANS (1075 mm 3 vs 397 mm 3 ; p < 0.001). Absolute stone clearance was greater in the CVAC group (1016 mm 3 vs 392 mm 3 ; p < 0.001), whereas residual stone volume (4.1 mm 3 vs 15.0 mm 3 ; p = 0.55) and SFRs (90% vs 81%; p = 0.48) were similar. In individuals with >1.5 cm preoperative stone burden, relative stone clearance was greater with CVAC 2.0 (98.9% vs 95.1%; p = 0.026). Pearson correlation analysis revealed positive linear relationship between preoperative stone volume and residual stone volume for FANS, but not for CVAC 2.0. Conclusions: In this comparative study of FANS and CVAC 2.0, over 95% stone clearance was observed in both groups despite large initial stone burdens. In contrast to FANS, residual stone volumes with CVAC 2.0 did not increase significantly with increasing preoperative stone volumes.

Introduction: Percutaneous nephrolithotomy (PCNL) has been a mainstay treatment for large stone burdens since the 1980s, historically offering improved stone-free rates over retrograde intrarenal surgery (RIRS). Gaining optimal access into the renal collecting system can be challenging, requiring advanced skills or interventional radiology assistance. The learning curve for fluoroscopic and ultrasonography access can be steep, with only a minority of PCNL access performed by urologists in the United States. This study compares robotic-assisted electromagnetic (EM) guidance to traditional fluoroscopy for obtaining percutaneous renal access between cohorts of novice and expert urologists. Methods: Ten novices and five expert urologists used robotic-assisted EM guidance to obtain access in a modified supine position compared with using fluoroscopy in a traditional prone position in human cadavers. Primary success was defined as papillary access. Performance metrics, including number of puncture attempts, time to access, radiation exposure, and participant confidence, were compared between novices and experts. Results: Robotic-assisted EM guidance improved success rates for both novices (100% vs 70%) and experts (93% vs 87%) compared with fluoroscopy. Novices showed greater accuracy using robotic assistance (97% vs 37%). The number of insertion attempts decreased with robotic guidance for both groups (novices: 3.42 ± 0.44 vs 1.47 ± 0.19; experts: 2.13 ± 0.36 vs 1.40 ± 0.24; p < 0.002). EM guidance ( p < 0.05) and experience ( p < 0.05) significantly reduced the time from needle insertion to access (novices: 12.86 ± 2.41 minutes vs 4.49 ± 0.96 minutes; experts: 4.90 ± 1.40 minutes vs 4.09 ± 1.12 minutes). Radiation exposure was notably lower with EM guidance (novices, 1.12 ± 0.17 mGy vs 4.86 ± 0.70 mGy; experts, 0.69 ± 0.12 mGy vs 4.11 ± 1.21 mGy; p < 0.001). Novices felt more confident (5[3–5] vs 2[1–4], p < 0.001) and at ease (5[3–5] vs 2.75[1–3], p < 0.001) with EM guidance. Conclusion: Robotic-assisted EM guidance improves percutaneous access success, reduces attempts and radiation exposure, and enhances novice confidence and accuracy. This technology could enable urologists to more effectively and safely perform PCNL, especially for less experienced practitioners.

Objectives To compare postoperative complication rates of patients with metabolic syndrome (MetS) with patients without MetS after holmium laser enucleation of the prostate (HoLEP) for management of benign prostatic hyperplasia (BPH). Patients and Methods We retrospectively reviewed patients aged >40 years who underwent HoLEP at our institution from 2007 to 2022. Criteria for MetS were diagnoses of at least three of the following: diabetes mellitus, hypertension, hyperlipidaemia, or obesity (body mass index ≥30 kg/m 2 ). Uni‐ and multivariable logistic regression were used to compare the likelihood of immediate, 30‐day, and 90‐day complications between groups. Results A total of 1500 patients were included with a median (interquartile range) age of 70 (65–76) years. Patients with MetS were more likely to develop complications at both 30 and 90 days, including urinary incontinence, irritative voiding symptoms, and bleeding ( P < 0.001). After adjusting for potential confounders, patients with MetS had a greater than three times odds of both 30‐ and 90‐day complications compared to patients without MetS (30‐day adjusted odds ratio [aOR] 3.32, 95% confidence interval [CI] 2.21–5.01, P < 0.001; and 90‐day aOR 3.64, 95% CI 2.49–5.31, P < 0.001). Conclusion Metabolic syndrome was associated with a three‐fold likelihood of 30‐ and 90‐day complications after HoLEP. This could be an important factor to consider in preoperative counselling and patient selection.

Objectives: The aims of the study are to develop a prostate cancer risk prediction model that combines clinical and magnetic resonance imaging (MRI)–related findings and to assess the impact of adding Prostate Imaging-Reporting and Data System (PI-RADS) ≥3 lesions-level findings on its diagnostic performance. Methods: This 3-center retrospective study included prostate MRI examinations performed with clinical suspicion of clinically significant prostate cancer (csPCa) between 2018 and 2022. Pathological diagnosis within 1 year after the MRI was used to diagnose csPCa. Seven clinical, 3 patient-level MRI-related, and 4 lesion-level MRI-related findings were extracted. After feature selection, 2 logistic regression models with and without lesions-level findings were created using data from facility I and II (development cohort). The area under the receiver operating characteristic curve (AUC) between the 2 models was compared in the PI-RADS ≥3 population in the development cohort and Facility III (validation cohort) using the Delong test. Interfacility differences of the selected predictive variables were evaluated using the Kruskal-Wallis test or chi-squared test. Results: Selected lesion-level features included the peripheral zone involvement and apparent diffusion coefficient (ADC) values. The model with lesions-level findings had significantly higher AUC than the model without in 655 examinations in the development cohort (0.81 vs 0.79, respectively, P = 0.005), but not in 553 examinations in the validation cohort (0.77 vs 0.76, respectively). Large interfacility differences were seen in the ADC distribution (P < 0.001) and csPCa proportion in PI-RADS 3–5 (P < 0.001). Conclusions: Adding lesions-level findings improved the csPCa discrimination in the development but not the validation cohort. Interfacility differences impeded model generalization, including the distribution of reported ADC values and PI-RADS score-level csPCa proportion.