A multicenter-based critical analysis of laser settings during intrarenal laser lithotripsy by the Turkish academy of urology prospective study group (ACUP study).

OBJECTIVE: In this multicenter prospective study, we aimed to evaluate the use of holmium:yttrium-- aluminum-garnet laser during retrograde intrarenal surgery for kidney stones and the relationship between laser-related parameters and procedure-related perioperative parameters. MATERIAL AND METHODS: The 769 patients whose laser setting parameters (fiber thickness, number of shots, frequency (max.), laser power (max.), and total energy) were completely registered were included in this study program. The intraoperative ureteral lesions were evaluated using postureteroscopic lesion scale (PULS) scores and the postoperative complications with the modified Clavien-Dindo classification system. RESULTS: The maximum levels of laser power and the frequency were used in the middle calyceal stones; the value of total energy consumed was found to be higher gain in cases with multiple stones (all parameters P < .05). There was a significant positive correlation among (mean number of shots [P < .001, r » 0.46], frequency [P » .009, r » 0.1], maximum power [P < .001, r » 0.11], total energy [P < .001, r » 0.25]), anesthesia time (P < .001, r » 0.42), surgery time (P < .001, r » 0.47), and stone size. The mean number of shots increased (P < .001, r » 0.25), and the frequency level decreased (P < .001, r » -0.17) significantly with increasing Hounsfield unit (HU) values. Again, the mean number of shots and maximum laser power increased in correlation with the increasing hospitalization time (P » .004, r » 0.09 and P » .02, r » 0.07, respectively). In addition, it was observed that higher laser subparameter values and thicker fibers were used in PULS grade 2. CONCLUSION: As the stone size and HU values increased, laser-setting parameters were found to show significant variability. The increase in different parameters of the laser setting was found to be associated with longer anesthesia time, surgery time, and hospitalization period and increased risk of local trauma with PULS grade.

Retrograde intrarenal surgery of renal stones: a critical multi-aspect evaluation of the outcomes by the Turkish Academy of Urology Prospective Study Group (ACUP Study).

AIMS: To outline and evaluate the incidence, management and follow-up of the residual fragments (RFs) following retrograde intrarenal surgery (RIRS) of renal stones by the Turkish Academy of Urology Prospective Study Group (ACUP Study). METHODS: Following the ethical committee approval, 15 centers providing data regarding the incidence, management, and follow-up of RFs after RIRS were included and all relevant information was recorded into the same electronic database program ( https://acup.uroturk.org.tr/ ) created by Turkish Urology Academy for Residual Stone Study. RESULTS: A total of 1112 cases underwent RIRS for renal calculi and RFs were observed in 276 cases (24.8%). Of all the parameters evaluated, our results demonstrated no statistically significant relation between preoperative DJ stenting and the presence of RFs (χ2 (1) = 158.418; p = 0.099). RFs were significantly higher in patients treated with UAS (82 patients, 29.3%) during the procedure compared to the cases who did not receive UAS (194 patients, 23.3%) (χ2 (1) = 3.999; p = 0.046). The mean period for a secondary intervention after RIRS was 28.39 (± 12.52) days. Regarding the procedures applied for RF removal, re-RIRS was the most commonly performed approach (56%). CONCLUSIONS: Despite the reported safe and successful outcomes, the incidence of RFs is higher, after the RIRS procedure particularly in cases with relatively larger calculi. Such cases need to be followed in a close manner and although a second flexible ureteroscopy is the treatment of choice for fragment removal in the majority of these patients, shock wave lithotripsy and percutaneous nephrolithotomy may also be preferred in selected cases.

A review study to evaluate holmium:YAG laser lithotripsy with flexible ureteroscopy in patients on ongoing oral anticoagulant therapy.

The objective of this study was to evaluate the safety and efficacy of flexible ureteroscopy (FURS) and holmium:YAG laser lithotripsy for the treatment of upper urinary tract stones in patients on active oral anticoagulants. The records of 1081 patients who underwent flexible ureteroscopic holmium:YAG (Ho:YAG) laser lithotripsy for upper ureteral and renal calculi from 1999 to 2015 were retrospectively reviewed. A total of 84 patients on continuous oral anticoagulation or antiplatelet therapy (warfarin, aspirin, or clopidogrel) were identified. Of these patients, 40 were on warfarin, 25 on aspirin, 11 on clopidogrel, and 8 on both aspirin and clopidogrel. The drugs were not discontinued. The baseline characteristics, indications for anticoagulation therapy, perioperative data, stone-free rate, and complications were documented. Evaluation of outcomes was assessed at 1-, 3-, and 6-month follow-up postoperatively. Mean stone size was 19.7 ± 9.4 (range 8 to 31 mm). Twenty patients had upper ureteral and 64 patients had intrarenal calculi. Two patients had bilateral renal calculi. Mean operation time was 78.2 ± 23.8 min (range 17 to 144 min). Two procedures (2.3%) in warfarin group were terminated due to persistent bleeding causing visual impairment. No transfusions were required. The mean serum hemoglobin levels did not change significantly (12.9 ± 3.7 to 12.2 ± 3.3 g/dL). No thromboembolic or cardiac adverse events were observed perioperatively. The double-j (DJ) ureteral catheterization time was 29.6 ± 9.3 days (range 14 to 68 days) and the hospital stay was 1.6 ± 0.6 days (range 1 to 4). The stone-free rate was 95.2% (80 patients) at 6 months. Flexible ureteroscopic Ho:YAG laser lithotripsy in patients requiring long-term anticoagulation therapy seems to be a safe and effective procedure and should be considered as a first-line treatment option in such patients for the surgical management of upper urinary tract stones.

Comparison of absorbed irrigation fluid volumes during retrograde intrarenal surgery and percutaneous nephrolithotomy for the treatment of kidney stones larger than 2 cm.

PURPOSE: Irrigation-induced increase in intrarenal pressure is of concern because it may cause infection due to increased pyelovenous and pyelolymphatic absorption. This study is the first to compare prospectively the absorbed fluid volumes during percutaneous nephrolithotomy (PCNL) and retrograde intrarenal surgery (RIRS) for stones larger than 2 cm. MATERIALS AND METHODS: General anesthesia was applied to all patients. Isotonic solution containing 1 % ethanol was used as irrigation fluid. Venous blood ethanol concentration was first measured with the start of irrigation and thereafter every 15 min until the patients left the recovery room. Absorbed fluid volumes were measured using the blood ethanol concentrations. Duration of irrigation, irrigated fluid volume, stone size and grade of hydronephrosis were also recorded. RESULTS: A total of 60 patients were included the study. Fluid absorption occurred in all patients. Minimum and maximum ranges of fluid absorption were 20-573 mL for RIRS and 13-364 mL for PCNL. The increase in fluid absorbed volume was observed as a result of the given amount of irrigating fluid used in the PCNL group. Also prolongation of operation led to a significant increase in absorption in the PCNL group. Increase in body mass index, stone size, and hydronephrosis did not affect fluid absorption significantly in either of the two operation techniques in correlation analyzes. CONCLUSION: Both RIRS and PCNL are conducted under high pressure and can be accompanied potential complications such as SIRS. The fluid absorption confirmed in our study should be taken into consideration during RIRS and PCNL.

Intraoperative Evaluation of Ureteral Access Sheath-Related Injuries Using Post-Ureteroscopic Lesion Scale.

OBJECTIVE: In the present study, intraoperative ureteral injuries inflicted during retrograde intrarenal surgery (RIRS) with ureteral access sheath (UAS) use were evaluated using the Post- Ureteroscopic Lesion Scale (PULS). MATERIALS AND METHODS: Patients in whom a UAS was used during RIRS and for whom ureter images were video recorded during the procedure were included in the study. PULS grading was performed after UAS removal, and video sequences of all patients were viewed by a junior resident, a senior resident, and four experienced urologists and assessed according to the PULS. Ureteral lesions in distal, middle, proximal, and multiple locations were evaluated and compared according to the PULS scale. The inter-rater reliability of PULS grading among various urologists was also evaluated. RESULTS: The evaluation comprised 101 patients. In 77 patients, 9.5/11.5 French UAS devices were used, and in 24 patients, 12/14 French UAS devices were used. The stone-free rate, clinical insignificant residual fragments, and final stone-free rate were 41.6%, 53.5%, and 98%, respectively. In 58.4% of the patients, no lesions were present according to PULS grading. No lesions of Grade 3 and above were found; however, there were lesions of Grade 1 and 2 in 38.6% and 2.9% of the patients, respectively. Injuries were found in the proximal ureter only and distal ureter only in 45.23% and 40.47% of the patients, respectively. Multiple injuries occurred in 5.94% of the patients (in 3.96% in the proximal and distal ureter, in 0.99% in the mid- and distal ureter, and in 0,99% in the proximal, mid-, and distal ureter). In the grading performed according to the PULS classification, there was a high accuracy among the residents and specialists. CONCLUSIONS: The assessment of UAS-induced injuries using standardized intraoperative methods will help to evaluate the procedure more objectively and will guide the postoperative follow-up of patients.

Impact of obesity on functional and oncological outcomes in radical perineal prostatectomy.

INTRODUCTION: We evaluated the impact of obesity on perioperative morbidity, functional, and oncological outcomes after radical perineal prostatectomy (RPP). METHODS: A total of 298 consecutive patients underwent RPP at our institution. Patients were categorized into 3 groups based on their body mass index (BMI): Normal weight <25 kg/m(2) (Group 1), overweight 25 to <30 kg/m(2) (Group 2), and obese ≥30 kg/m(2) (Group 3). We compared the groups with respect to perioperative data, postoperative oncologic, and functional outcomes. Evaluation of urinary continence and erectile function was performed using a patient-reported questionnaire and the International Index of Erectile Function-5 questionnaire, respectively, administered preoperatively and at 3, 6, and 12 months. Limitations included short follow-up time, retrospective design and lack of a morbidly obese group. RESULTS: No significant differences were found among the 3 groups with regard to operative time, estimated blood loss, length of hospital stay, catheter removal time, positive surgical margin, and complication rates. At 12 months, 94.7%, 95% and 95% of normal, overweight and obese patients, respectively, were continent (free of pad use) (p = 0.81). At 12 months, 30.6%, 29.8% and 30.4% of patients had spontaneous erections and were able to penetrate and complete intercourse in Group 1, Group 2, and Group 3, respectively (p = 0.63). CONCLUSIONS: In this cohort of patients, no clinically relevant risks were associated with increasing BMI.

Subepithelial pelvic hematoma of the kidney (Antopol-Goldman Lesion).

Renal pelvic hematoma (Antopol Goldman lesion) is a rare but significant condition that may clinically mimick a renal or a pelvic neoplasm. Differential diagnosis and optimal treatment are still not known certainly. A 80-year-old male patient admitted to the emergency department with gross hematuria/clot retention and right flank pain. Magnetic resonance imaging (MRI) imaging revealed a filling defect in the right renal pelvis. Diagnostic flexible uretrorenoscopy was performed and a renal pelvic tumor was excluded. A 6 Fr double J (DJ) ureteral catheter was placed for 4 weeks while the patient was under an antifibrinolytic therapy. Filling defect was not detected at 3(rd) month control MRI. During 6 months of the follow-up period, gross hematuria or any abnormal radiological finding was not encountered.

A rare complication of ureteral double-J stenting after flexible ureteroscopy: renal parenchymal perforation.

Double-j (DJ) ureteral stenting is a very common procedure performed after various endourological procedures. Although several complications due to DJ stent insertion were revealed, only three cases of renal parenchymal perforation have been reported to date. We present a case of a 35-year-old woman who had perforation of renal parenchyma without perirenal hematoma following insertion of DJ ureteral stent after flexible ureteroscopy for the treatment of an upper ureteral calculi. Non-contrast computed tomography was used for diagnosis. Patient was successfully managed with repositioning of the stent under fluoroscopic guidance on postoperative second day postoperatively.

The bladder carcinoma secondary to schistosoma mansoni infection: A case report with review of the literature.

INTRODUCTION: Schistosomiasis is a rare condition in Turkey but remains second most prevelant parasitic infestation worldwide. PRESENTATION OF CASE: A 67-years old male patient admitted to a hospital with macroscopic hematuria. Bladder tumor was diagnosed and referred to our department for the treatment. Transurethral resection of bladder tumor was performed and pathological examination revealed high-grade papillary urothelial carcinoma and Schistosoma mansoni eggs. The patient used praziquantel 40mg orally for the treatment of Schistosomiasis and intravesical immunotherapy was applied 6 weeks along per week. Neither recurrence of tumor nor S. mansoni eggs in the urine were detected at the 18th month. DISCUSSION: In spite of well-known etiological relationships between Schistosoma haematobium and bladder cancer, there is very limited number of cases of bladder carcinoma secondary to S. mansoni infestation in the literature. All of the reported 5 cases were from the rural regions of Brazil. On the other hand, it was noticed that pathological examination had been reported in only one of these cases, and the diagnosis was leiomyoma. Therefore, to the best of our knowledge, there is no data in the literature regarding the clinical course of the transitional cell carcinoma secondary to S. mansoni. CONCLUSION: Regarding the increasing travels all around the world, clinicians should remember that Schistosoma infection is certainly a part of the differential diagnosis of bladder carcinoma, even if the patients are not from endemic regions.

An unusual long-term survey of a patient with widespread malignant urachal tumor, not given chemotherapy or radiotherapy.

The urachus establishes a connection between the dome of the bladder and the umbilicus throughout fetal life. If the urachus does not close completely, malignancy is a potential complication. The primary treatment for malignant urachal tumor is surgical excision. A 61-year-old male patient diagnosed with urachal carcinoma had undergone partial cystectomy 25 years previously. Twenty years later, local recurrence was treated with another partial cystectomy without umbilical remnant excision. Recurrence at the umbilical site was excised 2 years later, but intraperitoneal invasion had occurred, and the patient underwent a total colectomy at that time. Local disease and disseminated metastases in the thorax and intra- and extraperitoneal areas were noted upon admission to our hospital. Urachal carcinomas are usually aggressive tumors, and surgical treatment should include partial or radical cystectomy and excision of the urachus and umbilicus, to prevent local recurrence and distant metastasis.

A comparison of 120 W laser photoselective vaporization versus transurethral resection of the prostate for bladder outlet obstruction by prostate cancer.

OBJECTIVE: To compare the mid-term outcomes of photoselective vaporization of prostate (PVP) with GreenLight HPS 120 W laser and transurethral resection of the prostate (TURP) for obstructive lower urinary tract symptoms (LUTS) in men with prostate cancer (CaP). PATIENTS AND METHODS: Seventy four patients with locally advanced (T3/T4) CaP with severe LUTS or acute urinary retention (AUR) were allocated to TURP (n = 36) or PVP (n = 38). International Prostate Symptom Scores (IPSS), maximum flow rates (Qmax) and post-void residual volumes (Vres), PSA levels, prostate volumes, complications, catheter removal and hospitalization periods were recorded. Patients were reassessed at 3, 6, and 12 months. RESULTS: The catheter removal time was significantly longer in the TURP group (3.8 ± 1.1 vs. 1.2 ± 0.7 days, p = 0.02), whereas failure of initial voiding trial was higher in PVP (2.7 vs. 13.1%, p = 0.01). No significant difference in IPSS, Qmax and Vres values was observed within the follow-up period between two groups. A significant difference in urethral stricture rate (8.3 vs. 0%), catheter removal time (3.8 ± 11 vs. 1.2 ± 0.7 days) and hospital stay (2.9 ± 0.6 vs. 1.1 ± 0.5 days) was observed in favor of PVP. CONCLUSIONS: Palliative PVP is very safe and effective by means of symptomatic relief in patients with locally advanced CaP.

180-W XPS GreenLight laser vaporization for benign prostate hyperplasia: 12-month safety and efficacy results for glands larger than 80 mL.

The purpose of the current study was to evaluate the efficacy and safety of laser prostatectomy by using the latest 180-W XPS GreenLight laser with the new MoXy fiber in the surgical treatment of glands larger than 80 mL in a prospective study. From December 2011 to May 2013, 68 consecutive patients with a mean age of 71.1 ± 9.8 years (range 49 to 85) underwent 180-W XPS laser prostatectomy at our institution. The baseline characteristics, perioperative data, and complications were recorded. Evaluation of outcomes was assessed at 3, 6, and 12 months postoperatively comparing subjective (International Prostate Symptom Score [IPSS], International Index of Erectile Function-5 [IIEF-5]) and objective (Maximal flow rate [Qmax], postvoid residual urine [PVR], transrectal ultrasound [TRUS] volume) parameters to the preoperative data. Mean preoperative prostate volume was 104.3 ± 29.7 mL (range 81 to 185). Mean operation time was 65.5 ± 29.6 min (range 38 to 124), with a mean energy delivery of 398 ± 169 kJ (range 39 to 523). The catheterization time was 20.8 ± 1.9 h (range 6 to 92) and the hospital stay was 27.3 ± 8.7 h (range 12 to 80). No major intraoperative complications were observed. Improvement in IPSS, Qmax, and PVR was statistically significant (p < 0.001) at 3, 6, and 12 months. Urethral strictures were observed in two patients (2.9%). No patients required reintervention due to residual adenoma. The average volume reduction was 40.5% at 12 months. Photoselective vaporization of the prostate (PVP) using the new 180-W XPS GreenLight laser system seems to be a safe and effective procedure and could play an important role in the surgical treatment of symptomatic benign prostatic hyperplasia (BPH) patients with larger prostate volumes.

A new robot for flexible ureteroscopy: development and early clinical results (IDEAL stage 1-2b).

BACKGROUND: An improved armamentarium has had a significant impact on the emerging role of flexible ureteroscopy (FURS) for the management of nephrolithiasis; however, FURS still represents a challenging technique. OBJECTIVE: To examine a robotic device designed for FURS for its impact on ergonomics and outcome of the procedure based on the IDEAL (idea, development, evaluation, assessment, long-term study) framework. DESIGN, SETTING, AND PARTICIPANTS: Roboflex Avicenna consists of a surgeon's console and a manipulator for the flexible ureterorenoscope. Following experimental evaluation of the prototype (IDEAL stage 1) and receipt of ethical approval, seven surgeons treated 81 patients (mean age: 42 yr [range: 6-68]) with renal calculi (mean volume: 1296±544 mm(3) [range: 432-3100 mm3]) in an observational study (IDEAL stage 2). SURGICAL PROCEDURE: Robotic FURS was performed with the Roboflex Avicenna robotic device. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Numerical data were analysed with the Mann-Whitney test, and categorical variables were analysed using the chi-square test or Fisher exact test. P values <0.05 were considered statistically significant. RESULTS AND LIMITATIONS: Mean robot docking time was 59.6±45 s. Mean operative time was 74min (range: 40-182). Mean fragmentation speed was 29.1±6.1 mm3/min. Ergonomics based on a validated questionnaire showed significant advantage for robotic FURS (total score: 5.6 vs 31.3; p<0.01). A 10/12F-access sheath was used in 72 patients. Two cases required secondary FURS, one because of malfunction of the flexible digital ureteroscope and another because of larger residual fragments. In the remaining 79 cases, complete stone disintegration was accomplished. CONCLUSIONS: Roboflex Avicenna provides a suitable and safe platform for robotic FURS with significant improvement of ergonomics. Future studies should evaluate its impact on the clinical outcome of FURS. PATIENT SUMMARY: Robotic flexible ureteroscopy (FURS) was performed with the Roboflex Avicenna robotic device. Results showed that Roboflex Avicenna provides a suitable and safe platform for robotic FURS with significant improvement of ergonomics.

Is retrograde flexible nephrolithotripsy feasible for calyceal diverticular stone?

The aim of this study is to manage the calyceal diverticular (CD) stone, several treatment options were applied but it is still a challenging condition of endourology. In this retrospective study, we aim to report the results of our patients with CD stones treated with retrograde flexible nephrolithotripsy (RFNL). A total of 47 patients (55 procedures) who underwent RFNL by a single surgeon for CD stones from January 2004 to March 2013 were evaluated retrospectively. The demographic properties and initial complaints of those patients have been recorded along with their comorbidities and previous history of stone management. Moreover, the size and number of the stones, the duration of the surgery, fluoroscopy time, stone-free rate (SFR) and postoperative complications of the patients have been evaluated. The mean age was 41.8 years (range 16-71). Of the study population, 31 (65.9%) were male. Mean stone size was 21.1 (7-52) mm whereas in 3 (6.4%) of the cases the stones could not be reached. Mean duration of the surgery was 92.8 (57-163) min whereas mean fluoroscopy time was 35.9 (14-103) s. After 3 months of follow-up period, the SFR was 85.1%. No major complications occurred. RFNL with holmium laser and nitinol basket catheter application is a feasible and successful procedure in the management of CD stones. With its high success rates, low incidence of complications and minimal morbidity when compared with other treatment options, RFNL has the potential of becoming the preferred treatment option in the minimally invasive management of patients with CD stones.

Treatment of renal stones with flexible ureteroscopy in preschool age children.

The aim of the study is to evaluate the efficacy and safety of retrograde intrarenal surgery (RIRS) to treat renal stones in preschool age (<7 years) children. From September 2005 to May 2013, a total of 65 children (31 boys and 34 girls) with 72 renal stones were treated using RIRS. Patients were considered stone-free when the absence of residual fragments was observed on imaging studies. In the presence of residual calculi >4 mm, a second-stage RIRS was performed. The pre-operative, operative and post-operative data of the patients were retrospectively analyzed. A total of 65 patients with a mean age of 4.31 ± 1.99 years (6 months-7 years) were included in the present study. The mean stone size was 14.66 ± 6.12 mm (7-30 mm). The mean operative time was 46.47 ± 18.27 min. In 5 (7.69%) patients, the initial procedure failed to reach the renal collecting system and ended with the insertion of a pigtail stent. The stone-free rates were 83.07 and 92.3% after the first and second procedures, respectively. Complications were observed in 18 (27.7%) patients and classified according to the Clavien system. Post-operative hematuria (Clavien I) occurred in 6 (9.2%) patients, post-operative urinary tract infection with fever (Clavien II) was observed in 10 (15.4%) patients, and ureteral wall injury (Clavien III) was noted in 2 (3%) patients. RIRS is an effective and safe procedure that can be used to manage renal stones in preschool age children.