Ghani KR, Olumolade OO, Daignault-Newton S, et al. What is the optimal stenting duration after ureteroscopy and stone intervention? Impact of dwell time on postoperative emergency department visits. J Urol. 2023 Sep;210(3):472-480.

Special thanks to Drs Graham Hale and Daniel Garvey at the University of Illinois at Chicago.

“To string or not to string”: that is the question that inspires strong opinions among urologists doing ureteroscopy to treat stones. Unfortunately, a dearth of literature exists to adequately address this question even though it’s frequently encountered in clinical practice. Thankfully, researchers exploring the Michigan Urological Surgery Improvement Collaborative registry have provided some interesting data to consider.

The authors report the frequency and reasons for emergency department visits after ureteral stent removal in over 4000 patients after ureteroscopy for stone treatment. About 2/5 had a stent with an extraction string. A little under 1/3 of urologists never used a string. About 1/10 of patients presented to the emergency department within 30 days of ureteroscopy, with about 1/3 on the day of or the day after stent removal. Patients with a stent on string had almost a doubled emergency department visit rate and were more likely to present for flank pain, UTI, nausea, dysuria, and stent dislodgement. The predicted probability of an emergency department visit on the day of or after stent on string removal was significantly higher when dwell times were less than 5 days.

These results may incriminate stents on strings. However, the circumstances and advantages of using a stent on string should not be ignored. Quantifying the effects of an extra clinic visit to remove the stent could further contextualize these findings. In any case, this study gives us practical and fascinating data with which to continue the conversation of stent dwell time and “string or no string” after ureteroscopy for stone treatment.

Kaplan SA, Moss J, Freedman S, et al. The PINNACLE study: a double-blind, randomized, sham-controlled study evaluating the Optilume BPH Catheter System for the treatment of lower urinary tract symptoms secondary to benign prostatic hyperplasia. J Urol. 2023 Sep;210(3):500-509.

Special thanks to Drs Graham Hale and Omer Acar at the University of Illinois at Chicago.

A new minimally invasive surgical therapy to treat lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) adds another option for patients who don’t want a complete prostatic resection that often results in unwanted sexual function side effects. The Optilume BPH Catheter System involves a double-lobed paclitaxel-coated balloon that combines mechanical expansion with drug delivery at the level of prostatic urethra to create an anterior commissurotomy in 30 minutes or less. The PINNACLE study reports safety, efficacy, and outcomes at 1-year follow-up.

In this prospective, double-blind, controlled study, 148 men with BPH-LUTS were randomized 2:1 to Optilume or a sham procedure. Comparing outcomes at 12 months, the average improvements in International Prostate Symptom Score and uroflow Qmax from baseline were found to be significantly higher in the Optilume group. There was no reported difference between the study groups in terms of sexual side effects. Both arms observed mild improvement in average scores for erectile and ejaculatory function. In the Optilume group, a total of 5 serious adverse events were reported, including 4 with hematuria requiring endoscopic management and 1 with a false passage, as well as an array of relatively minor complications, including temporary urinary incontinence that resolved by conservative measures within a month.

The Optilume device is a welcome addition to the expanding armamentarium of treatment options for men with bothersome BPH-LUTS who wish to preserve sexual function. We look forward to future studies evaluating its performance under local anesthesia and the durability of its outcomes.

Schuler N, Shepard L, Saxton A, et al. Predicting surgical experience after robotic nerve-sparing radical prostatectomy simulation using a machine learning-based multimodal analysis of objective performance metrics. Urol Pract. 2023 Sep;10(5):447-455.

Special thanks to Drs Juan Torres-Anguiano and Simone Crivellaro at the University of Illinois at Chicago.

Surgical skills play a crucial role in a surgeon’s practice and directly impact patient outcomes. Prior methods of assessment of these skills were subject to many limitations, including a lack of objectivity, time consumption, and difficulty in incorporating different data sources.

These authors examined how machine learning could help judge urologists’ skills in performing a robotic-assisted radical prostatectomy by using a virtual platform to mimic the surgery. They gathered various surgical metrics from different sources, including videos of the surgery, movements of the robot, and how much traction force was applied at different steps of the procedure. Data were collected from 35 board-certified urologists with differing experiences. What’s interesting is that the authors innovated a new way to measure how well the surgeons performed, which they called “objective performance indicators,” derived from observing how the robot moved during the surgery and verified by a previously validated standardized test for surgical skills. With the multidata machine-learning algorithm, the method distinguished between low- and high-caseload surgeons with a 96% success rate in a simulation-based environment.

Unlike prior efforts, this study uniquely merges surgical factors like movement tracking and traction forces for skill assessment in robotic surgery. While conducted on simulations with a small surgeon sample, the algorithm lays groundwork for future skill assessment and learning models across different stages expertise during lifelong learning in surgery.