Xanthogranulomatous Pyelonephritis: A pooled quantitative analysis of published cases.

Xanthogranulomatous Pyelonephritis (XGP) is a serious and rare inflammatory disease of unknown etiology. This systematic review analyzes XGP cases. We performed a literature search for "Pyelonephritis, Xanthogranulomatous." The primary composite outcome was recovery with post-surgery complications, partial recovery, death, or chronic kidney disease. The secondary outcome was any presentation or treatment complication. Predictor variables consisted of demographics, history, symptoms, and diagnosis/management. Among the 251 patients, the mean age was 36.1 years, and 57.4% were female. The most common symptom and finding were fever (55.0%) and renal stones (53.8%), respectively. There were 15.5% with the composite outcome. There were 51.0% with any presentation or treatment complication. Multivariate logistic regression analysis for the composite outcome showed that kidney of both/horseshoe (OR:3.86, 95% CI:1.01, 14.73, p = 0.048), dialysis required (OR:8.64, 95% CI:2.27, 32.94, p = 0.002), and operative treatment of nephrostomy or nephrostomy followed by nephrectomy (OR:4.57, 95% CI:1.58, 13.17, p = 0.01) were each significantly associated with increased odds. Fever (OR:3.04, 95% CI:1.63, 5.67, p <0.001) and renal stones (OR:2.55, 95% CI:1.35, 4.81, p = 0.004) were each significantly associated with increased odds for any presentation/treatment complication. In conclusion, XGP patients with involvement of both or horseshoe kidneys, dialysis requirements, or treatment of nephrostomy or nephrostomy followed by nephrectomy may require aggressive treatment to mitigate poor patient outcomes.

Effect of nephrostomy sheath size on renal pelvic pressure during endoscopic combined intrarenal surgery: artificial kidney model study.

BACKGROUND: This study aimed to evaluate the intrarenal pelvic pressure in endoscopic combined intrarenal surgery using an artificial kidney model. METHODS: An artificial kidney model was created using the Urovac evacuator™. Four sizes of nephrostomy sheaths (MIP-L: 25/26 Fr, MIP-M: 16.5/17.5 Fr, MIP-S: 11/12 Fr, MIP-XS: 8.5/9.5 Fr) and two sizes of ureteral access sheaths (12/14 Fr and 10/12 Fr) were installed into the model. For each combination of nephrostomy and ureteral access sheath, renal pelvic pressure was measured with and without insertion of the retrograde flexible ureteroscope. Irrigation from the nephroscope was adjusted to 40-160 mmHg using an automatic irrigation device, and the irrigation of the ureteroscope was by spontaneous dripping at 80 cmH2O. Conditions were measured six times, and the renal pelvic pressure was compared in different conditions. RESULTS: Without ureteroscope insertion through the ureteral access sheath, the renal pelvic pressure never exceeded 30 mmHg. Meanwhile, when the ureteroscope was inserted, the renal pelvic pressure increased as the nephrostomy sheath and ureteral access sheath became narrower and as the irrigation pressure increased. Intrarenal pelvic pressure exceeded 30 mmHg when the irrigation pressure was increased in 12/14 Fr ureteral access sheath when MIP-XS was used, and in 10/12 Fr ureteral access sheath when MIP-XS and MIP-S were used. CONCLUSIONS: The use of a thin nephrostomy sheath in endoscopic combined intrarenal surgery can lead to increased intrarenal pelvic pressure. Although our results are from an artificial kidney model, special care is suggested to be required when using a retrograde flexible ureteroscope simultaneously in treatment of patients.

The Whitaker test: a predictive tool for evaluating the surgical efficacy of upper urinary tract reconstruction in patients carrying a nephrostomy tube after surgery.

PURPOSE: To explore the role of the Whitaker test in evaluating the postoperative outcome of upper urinary tract reconstruction surgery in patients carrying a nephrostomy tube after surgery. PATIENTS AND METHODS: This was a prospective observational study performed in 42 patients with nephrostomy tube undergoing the Whitaker test after upper urinary tract reconstruction surgery between January 2020 and December 2021. Data on clinical information, the Whitaker test and surgical procedure were collected prospectively, and the long-term follow-up results were analysed retrospectively. RESULTS: The 46 ureters of 42 patients (right 16, left 22, bilateral 4) underwent six common upper urinary tract surgical reconstruction procedures and one combined procedure, including pyeloplasty, ureteroureterostomy, lingual mucosal onlay graft, appendiceal onlay flap, ureteral reimplantation, Boari flap, and ipsilateral lingual mucosal onlay graft combined ureteral reimplantation. All patients underwent the Whitaker test successfully without any discomfort after examination. The postoperative Whitaker test showed 43 kidneys without obstruction and 3 kidneys with obstruction. At a median follow-up of 18 months (range 13-31), the follow-up results showed that the overall success rate of the surgery was 100% (46/46). Concerning the concordance Whitaker test and follow-up results, the observed proportion of agreement was 93.5% (43/46). CONCLUSION: The Whitaker test can achieve similar consistency with the long-term follow-up results after upper urinary tract reconstruction surgery and can be used as a tool to evaluate the surgical efficacy of upper urinary tract reconstruction surgery, which can provide a prognostic efficacy evaluation for patients carrying a nephrostomy tube after surgery.

Laparoscopic pyelotomy combined with ultrasonic lithotripsy via a nephroscope for the treatment of complex renal stones.

The purpose of the study was to introduce a novel surgical approach of combining laparoscopic pyelotomy with ultrasonic lithotripsy via a nephroscope for the treatment of complex renal stones. Between May 2021 and April 2023, 32 patients underwent laparoscopic pyelotomy combined with ultrasonic lithotripsy via a nephroscope and their perioperative variables were retrospectively collected and outcomes were assessed. Dissection and incision of the anterior renal pelvis wall was performed via a laparoscope. A 19.5 F nephroscope was introduced into the renal pelvis through a laparoscopic trocar from the incision. Stones were fragmented and sucked out using a 3.3 mm ultrasonic probe placed through the nephroscope. All operations were completed successfully and the stone-free rate at 3 days after operation was 87.5% (28/32). Four (12.5%, 4/32) patients with staghorn stones had a small residual stone in the lower calyx after operation and did not require reintervention. No patient required perioperative transfusion and four (12.5%, 4/32) patients with struvite stones developed postoperative fever, which was successfully treated with intravenous antibiotics. The mean follow-up time was 14.0 ± 7.2 months, with no patient developing long-term complications. This approach offers a safe and effective treatment option for complex renal stones, as the method exhibits a high clearance rate with few complications.

Double J stent combined with pyelostomy tube in pediatric laparoscopic pyeloplasty: a 5-year clinical experience in a single center.

OBJECTIVE: To compare the outcome of using a double J (DJ) stent combined with pyelostomy tube with a DJ stent alone in laparoscopic pyeloplasty (LP) for pediatric ureteropelvic junction obstruction (UPJO). METHODS: A retrospective review of all patients with UPJO treated with LP between January 2017 and November 2021 was conducted in our center. According to different postoperative drainage methods patients were divided into a DJ stent group (52 cases) and a DJ stent combined with pyelostomy tube group (combination group, 41 cases). Operative time, bleeding volume, perirenal drainage stent removal time, postoperative hospital stay, postoperative complications, and renal function recovery were compared between the two groups. Renal ultrasound and diuretic renogram (DR) were used for preoperative and postoperative follow-up. RESULTS: A total of 52 patients were in the DJ stent group and 41 patients in the combination group. The mean hospital stay was 6.46 ± 2.66 days in the DJ stent group and 5.22 ± 1.63 days in the combination group (p < 0.05). Postoperative complications developed in 14 out of 52 patients in the DJ stent group (26.9%), while complications developed in 8 out of 41 patients in the combination group (19.5%) (p > 0.05). Non-catheter-related complications developed in 10/52 patients in the DJ stent group (19.2%) and only 1/41 patients in the combination group (2.4%) (p < 0.05). The renal function and renal cortex thickness in both groups were improved. CONCLUSION: Both the DJ stent drainage and the DJ stent combined with pyelostomy drainage are safe and effective. We should fully consider the patient's preoperative and intraoperative conditions and choose appropriate drainage methods. A DJ stent combined with pyelostomy tube can reduce non-catheter related complications, facilitate postoperative recovery, and the hospital stay was significantly shorter than the DJ stent group. However, it is necessary to pay attention to the nursing treatment of the pyelostomy tube and guard against the occurrence of pyelostomy tube shedding.

Laparoscopic Pyelolithotomy for treating urolithiasis in ectopic pelvic kidneys.

INTRODUCTION: The management of urolithiasis ectopic pelvic kidneys (EPK) can be challenging because of the aberrant anatomy (1-4). We demonstrate the step-by-step technique of the laparoscopic approach for treating urolithiasis in EPK. PATIENTS AND METHODS: Three men with EPK (2 left, 1 right) underwent laparoscopic pyelolithotomy through a transperitoneal approach. After establishing the pneumoperitoneum, the parietal peritoneum was opened at the parietal colic sulcus and the bowel displaced medially. The kidney was identified in the retroperitoneum and the renal pelvis exposed after removal of the perirenal adipose tissue. The renal pelvis was opened, and the stones were identified and retrieved with forceps in 2 cases and with a flexible nephroscope in 1 case. The renal pelvis was closed with a 3/0 running barbed suture. A DJ stent was placed in all patients. RESULTS: For the first time, a laparoscopic technique for treating stones in the ectopic kidney is demonstrated in detail. Mean patient age was 52.6 years (44-58). The mean stone size was 22.3 mm (20-24 mm). Stones were in the renal pelvis in 2 cases and in the inferior calyx in 1 case. Mean operative time was 146 minutes (135-155 min). Mean estimated blood loss was 116 ml (60-140 ml). No complications were observed. The mean hospital stay was 3 days. The DJ stents were removed after 3 weeks. All patients were stone free at the postoperative CT scan with a mean follow-up of 3.3 months (1-6 months). CONCLUSIONS: Laparoscopic pyelolithotomy can be an effective and reproducible minimally invasive technique for treating urolithiasis in EPK.

The efficacy of bupivacaine infiltration along nephrostomy tract on postoperative pain control and opioid consumption after PCNL: a prospective randomized controlled trial.

OBJECTIVE: Percutaneous nephrolithotomy (PCNL) is a common endourological procedure for patients with large kidney stones, but the management of postoperative pain is still a major challenge. The aim of this clinical trial was to evaluate the efficacy of 0.25% bupivacaine infiltration along the nephrostomy tract on postoperative pain scores and analgesia consumption in patients who underwent PCNL. PATIENTS AND METHODS: A total of 50 patients who underwent PCNL were enrolled in this prospective, randomized controlled trial (NCT04160936). Patients were prospectively randomized into two equal groups: the study group (n=25) received 20 mL of 0.25% bupivacaine infiltration along the nephrostomy tract, whereas patients in the control group (n=25) did not. Postoperative pain as the primary outcome was assessed by using a visual analogue scale (VAS) and a dynamic visual analogue scale (DVAS) at different time points. The secondary outcomes were the time for first opioid demands, the number of opioid demands, and the total opioid consumption over the 48 h postoperatively. RESULTS: There were no significant differences between the two groups regarding demographics, surgery, and stone characteristics. Patients in the study group had significantly less VAS and DVAS pain scores compared to the control group. The mean time of the first opioid demand in the study group was significantly longer as compared to the control group (7.1 ± 2.5h vs. 3.2 ± 1.8 h, p<0.001). The mean number of doses and total consumption of opioids were significantly less in the study group compared to the control group over 48 h (1.5 ± 0.8 vs. 2.9 ± 0.7 and 122.82 ± 62.5 mg vs. 223 ± 70 mg, respectively) (p<0.0001). CONCLUSIONS: Local anesthetic infiltration of 0.25% bupivacaine along the nephrostomy tract is efficient in alleviating post-operative pain and reducing opioid consumption after PCNL.

Comparison of safety and efficacy of one shot dilation vs. gradual dilation technique in supine percutaneous nephrolithotomy.

PURPOSE: To compare the efficacy and safety of gradual dilation (GD) and one-shot dilation (OSD) techniques in patients who underwent supine percutaneous nephrolithotomy (PCNL). METHODS: The data of 176 patients who underwent supine PCNL were reviewed. Eighty-seven patients who underwent OSD were defined as group 1, and 89 patients who underwent GD were defined as group 2. Both surgical techniques were compared with each other in terms of various parameters. Then, regression analysis of factors predicting stone-free status and complications in patients who underwent supine PNL were performed. Then, regression analysis of factors predicting success rate and complications in patients who underwent supine PNL were performed. RESULTS: No statistical difference was found in terms of stone-free rate, Clavien-Dindo complication grade and operation time. No statistical difference was found in terms of success rate, Clavien-Dindo complication grade and operation time. However, the fluoroscopy time was found to be significantly shorter in group 1 (p < 0.001). In the analysis of factors predicting stone-free status, the presence of calyceal stones, increased stone size and number were associated with a decrease in stone-free rate. In the analysis of factors predicting success, the presence of calyceal stones, increased stone size and number were associated with a decrease in success rate. Increased fluoroscopy and operation time, increased complication rates were found to be significantly associated with residual stone. Analysis of factors predicting complications found a higher complication rate in patients with low BMI and severe hydronephrosis. Increased complication was associated with increased time to nephrostomy removal and hospital stay, decrease in stone-free rate, decrease in Hb and increase in Cre value at the postoperative 24th hour. CONCLUSION: When comparing OSD and GD in patients undergoing supine PCNL, both techniques have similar stone-free and complication rates. When comparing OSD and GD in patients undergoing supine PCNL, both techniques have similar success and complication rates. Compared to GD, the OSD technique can be preferred primarily due to its shorter fluoroscopy time.

Minimally invasive nephrolithotomy versus retrograde intrarenal surgery in surgical management of Lower calyceal stones: a systematic review with meta-analysis.

OBJECTIVE: The efficacy and safety of minimally invasive nephrolithotomy (MPCNL) versus retrograde intrarenal surgery (RIRS) was assessed for lower calyceal (LC) stones. METHODS: Our team conducted a systematic literature search up to December, 2022, using PUBMED, EMBASE and the Cochrane Library. The study was registered in PROSPERO, CRD 42021247197. Randomized controlled trials evaluating the efficacy and safety of MPCNL versus RIRS for LC stones were collected. Heterogeneity among the studies was assessed using the χ 2 test based on the Q and I2 tests. Pooled effect sizes were calculated using a fixed model if I2 is less than 50%; otherwise, a random-effects model was chosen. The primary outcomes were the 3-month stone-free rate (3SFR) and total complications, while the secondary outcomes were the operating time, hospital stay, haemoglobin reduction, bleeding, postoperative fever and complications with the Clavien-Dindo system. A subgroup analysis of 10-20 mm LC stones was also designed. RESULTS: A total of 7 peer-reviewed trials comprising 711 patients were identified. No statistical differences were observed in the heterogeneity results of the 3SFR or total complications ( P >0.1, I2 < 50%). Compared with RIRS, MPCNL had an unfavourable safety profile, resulting in total complications [odds ratio (OR): 1.87 (95% CI: 1.05, 3.33); P =0.03], haemoglobin reduction [OR: 0.81 (95% CI: 0.15, 1.47); P =0.02] and complications with Grade I [OR: 5.52 (95% CI: 1.34, 22.83); P =0.02] but an improved efficacy and 3SFR [OR: 2.43 (95% CI: 1.48, 3.97); P =0.0004]. As for the 10-20 mm LC stones, compared with RIRS, MPCNL also had an unfavourable safety profile, resulting in total complications [OR: 2.47 (95% CI: 1.20, 5.07); P =0.01], complications with Grade I [OR: 4.97 (95% CI: 0.99, 25.01); P =0.05] and an increased hospital stay [OR: 2.46 (95% CI: 2.26, 2.66); P =0.00001] but an improved efficacy and 3SFR {OR: 3.10 (95% CI: 1.61, 5.99); P =0.0008]. The efficacy effect of MPCNL and safety effect of RIRS were nearly equal for both stones sized less than 20 mm (number needed to treat = 17, number needed to harm = 20) and stones sized 10-20 mm (number needed to treat = 20, number needed to harm = 13). No statistical difference was found between the MPCNL and RIRS groups for the rest of outcomes. CONCLUSION: Both MPCNL and RIRS are safe and effective management methods. Moreover, compared with RIRS, MPCNL had an unfavourable safety profile but improved efficacy for LC stones of ≤20 mm or 10-20 mm, and the differences were statistically significant. The relative profit of efficacy of MPCNL was similar to the relative profit of safety of RIRS.

Near-infrared ray catheter and indocyanine green via nephrostomy in delayed robotic reconstruction of injured ureter: A case report.

Delayed surgical reconstruction of iatrogenic ureteral injuries is often a challenging procedure because spreading scar tissue impedes accurate identification and dissection of the injured ureter. We report a novel real-time navigation system using a ureteral near-infrared ray catheter (NIRC) and indocyanine green (ICG) via nephrostomy in delayed robot-assisted ureteral reconstruction. A female patient presented with complete obstruction of the right upper ureter after gynecological surgery with extensive lymphadenectomy. A nephrostomy tube was urgently placed, and surgical repair was performed. A straight NIRC was placed in the right ureter up to the obstruction point. ICG was administered via nephrostomy. Near-infrared light could clearly visualize the ureter and renal pelvis encased in scar tissue. The ureter and renal pelvis were dissected and successfully anastomosed. We found that near-infrared navigation using ureteral NIRC and ICG via nephrostomy was valuable for delayed laparoscopic reconstruction of the injured ureter.

The use of endoscopy-assisted nephrolithotomy for unilateral nephrolith removal in a rabbit (Oryctolagus cuniculus).

A 3-year-old spayed female rabbit (Oryctolagus cuniculus) was referred with mineralizations in the left kidney. Despite medical management, 8 months after the initial examination, a 5.3-mm obstructive nephrolith with dilatation of the renal diverticuli was observed with abdominal ultrasonography. Surgical removal by endoscopy-assisted nephrolithotomy was completed. A flexible endoscope was introduced into the renal pelvis through a puncture incision in the lateral aspect of the kidney. The nephrolith was removed with endoscopic grasping forceps through the same orifice and the renal pelvis and diverticula were flushed to extract the smaller mineralized particles. The nephrotomy site was closed and the kidney was sutured to the abdominal wall. The rabbit recovered uneventfully. Six months after surgery, a non-obstructive stone was identified; however, 2 years later the rabbit remains asymptomatic. To the authors' knowledge, this is the first report on the use of endoscopy-assisted nephrolithotomy to extract a complicated nephrolith in a rabbit.

L'utilisation de la néphrolithotomie assistée par endoscopie pour l'élimination unilatérale des néphrolithes chez un lapin ( Oryctolagus cuniculus ). Une lapine stérilisée de 3 ans (Oryctolagus cuniculus) a été référée avec des minéralisations dans le rein gauche. Malgré la prise en charge médicale, 8 mois après l'examen initial, un néphrolithe obstructif de 5,3 mm avec dilatation des diverticules rénaux a été observé à l'échographie abdominale. L'ablation chirurgicale par néphrolithotomie assistée par endoscopie a été réalisée. Un endoscope flexible a été introduit dans le pelvis rénal par une incision de ponction dans la face latérale du rein. Le néphrolithe a été retiré avec une pince à préhension endoscopique par le même orifice et le bassinet et les diverticules rénaux ont été rincés pour extraire les plus petites particules minéralisées. Le site de néphrotomie a été fermé et le rein a été suturé à la paroi abdominale. Le lapin a récupéré sans incident. Six mois après la chirurgie, une pierre non obstructive a été identifiée; cependant, 2 ans plus tard, le lapin reste asymptomatique. À la connaissance des auteurs, il s'agit du premier rapport sur l'utilisation de la néphrolithotomie assistée par endoscopie pour extraire un néphrolithe compliqué chez un lapin.(Traduit par Dr Serge Messier).

Comparison between prone and supine nephrolithotomy in pediatric population: a double center experience.

PURPOSE: Stone disease in the pediatric age is an increasing issue. Percutaneous Nephrolithotomy (PNL) can be used for larger and complex stones. As in adults it can be performed in the supine or prone position. METHODS: We retrospectively reviewed two centers' experience in prone and supine PNL in children to analyze its results and complications. RESULTS: 33 patients underwent prone and 19 supine procedures. Patients in the prone group were younger than in the supine, while no significant differences were found in stone burden, access size, operative time or complications. Complications were: 8 and 4 Clavien 1 for the prone and supine group, respectively, one case of urosepsis (4b) in the prone and 2 cases of Clavien 3 in the supine group (double J stent placement for renal colic and ureteroscopy for steinstrasse). Tubeless procedures and mean nephrostomy time were in favor of the supine group, whereas fluoroscopy time and ureteral drainage stay were in support of the prone group. Stone free rate was better in the supine group (83.3 vs 66.6%), possibly reflecting the capability to perform a combined approach in 12 patients (allowing to reach all the calyx with simultaneous anterograde and retrograde access) or younger age in the prone group (13 vs 2 patients ≤5 years), with no differences in stone burden. CONCLUSIONS: Supine approach seems to guarantee higher stone-free rates. Larger series are necessary to determine what the best technique is in terms of X-ray exposure, operative time and complications.

Robot-Assisted Laparoscopic Calyceo-Pyelostomy for Vascular Compression of the Upper Calyx (Fraley Syndrome).

Fraley's Syndrome is a rare anatomic vascular malformation described in 1966 where an aberrant crossing vessel compresses the upper infundibulum and leads to upper calyx massive dilation. It is mostly asymptomatic and the diagnosis often missed; however, surgery is usually required for symptomatic cases. Open surgery is still frequently used while minimally invasive management is anecdotal in the literature. We report the first robot-assisted calyceo-pyelostomy. An 18-year-old female patient presented with intermittent, recurring, severe left flank pain leading to insomnia, evolving in the last 3 months. A 3-phases computerized tomography scan (CT-scan) showed a rotated left kidney, with upper calyx massive dilation and thinning of the upper renal parenchyma without any evident obstacle. Cystocopy and retrograde pyelography were performed. It confirmed a single ureteral meatus, a single ureter, and a narrowed upper calyx with upper calyx dilation. An ureteral catheter (JJ stent) was inserted in the upper calyx and the patient was planned for surgical exploration. During robotic surgery, an abnormal crossing vessel was identified and the diagnosis of Fraley's syndrome was made intraoperatively. According to previous literature, a calyceo-pyelostomy with uncrossing of the upper major calyx and resection of the narrowed upper infundibulum was performed. Total operative time was 114 min, pneumoperitoneum time was 96 min, blood loss less than 10 ml, and patient was released on post-operative day 2. The ureteral stent was removed 4 weeks after the intervention. At 12 postoperative weeks, the patient had complete regression of pain and the 12 postoperative week CT-scan showed a reduction of the dilation and a patent anastomosis. Fraley's syndrome is a rare entity. In our case, the diagnosis of Fraley syndrome was made intraoperatively after an extensive previous workup, underlining the difficulty to make this diagnosis. We report and provide a video of the first robot-assisted procedure for Fraley's syndrome in a nephron-sparing technique. Patient was pain-free at the 3-month.

Robotic pyelolithotomy in a solitary pelvic kidney complicated with fulminant Clostridium difficile: a case report.

BACKGROUND: Robotic-assisted surgeries have gradually become the standard of care for many procedures, especially in the field of urology. Despite the widespread use of robotic assistance in surgeries, data on its postoperative complications are extremely limited. We detail a rare presentation of fulminant Clostridium difficile colitis requiring surgical intervention in a patient with a solitary ectopic pelvic kidney who underwent a robotic-assisted pyelolithotomy. Highlights of the most recent management recommendations for C. difficile infection are also presented. CASE PRESENTATION: A 26-year-old Caucasian woman who underwent a robot-assisted pyelolithotomy of a pelvic kidney developed tachycardia, leukocytosis, and severe diarrhea 2 days following surgery. Because of her long history of antibiotic use, her severe symptoms were concerning for C. difficile colitis. This was confirmed by a C. difficile toxin test and a computed tomography scan. She was given recommended antibiotics, but her condition progressively deteriorated. The patient developed fulminant colitis and toxic megacolon, for which she underwent an exploratory laparotomy with subtotal abdominal colectomy and ileostomy creation on the twelfth day of her hospitalization. She fully recovered and was discharged 3 weeks after her subtotal colectomy. CONCLUSION: Although robotic surgeries have been shown to have several advantages, risk of postsurgical complications remains. We present a rare case of fulminant C. difficile colitis that complicated a robotic-assisted pyelolithotomy. Active prevention, early detection, and optimization of management are essential to preventing unfavorable outcomes.

Nephrostomy Balloon and Sheath Suprapubic Tube Placement-A Minimally Invasive Approach to Large Caliber Suprapubic Tube Placement.

Suprapubic tubes (SPT) are a vital tool in the management of complex urologic voiding conditions. There are numerous methods of SPT placement, each with pros/cons: peel-away kits are easy to place, but often have small caliber SPTs, that is, 12 or 14 Fr, prone to kinking, that require serial upsizing to achieve the desired caliber; open SPT placements permit an initial large caliber SPT but are more invasive, particularly in obese patients. This video demonstrates a minimally invasive technique for SPT placement in patients with preserved urethral access to the bladder that safely allows for initial, precise placement of large caliber (>20F) catheters using the Nephromax nephrostomy balloon/sheath (NBS-SPT). Technique: A 6″ 17G Tuohy spinal needle is placed percutaneously 3 cm above the pubis (generally in the abdominal crease), 1-2 cm off midline towards the side the patient prefers to keep the drainage bag. The needle is angled to enter the bladder dome in the midline, which is visualized cystoscopically with a full bladder. The angling will allow the catheter to lie flat and decrease kinking. The stylette is removed and a stiff wire is advanced. A 2 cm horizontal skin incision is made. A 24 Fr NBS is advanced into the bladder under vision and inflated to 18 ATM. The balloon is then deflated/removed and the SPT is passed through the sheath into the bladder. Once inflated, the sheath removed and the SPT is secured to the skin. Study: A 10-year retrospective review of NBS-SPT placements at a single institution was performed, analyzing patient characteristics, surgical details, and surgical outcomes. NBS-SPT was attempted 65 times over the study period. The most common indications included acquired/congenital neurogenic bladder (48%) and urinary retention (25%). A simultaneous additional procedure (eg, cytolitholapaxy, bladder neck incision) was performed in 31% of NBS-SPTs. Median body mass index was 29.5 (interquartile range: 25-33.9) and 34% had prior abdominal procedures. Median operative time (NBS-SPT only) was 16 minutes (interquartile range: 14-20). All procedures were successful in placing a catheter 20F. Thirty-day Clavien I/II complication rate was 18% (hematuria n = 3; cellulitis n = 4; early SPT exchange for clogging n = 5); A Clavien IIIb complication occurred in one patient with hematuria requiring fulguration. First SPT exchange in clinic was successful in 95%, with 2 patients requiring replacement under anesthesia. NBS-SPT is a safe and efficient minimally invasive technique for initial, precise placement of large caliber SPT in patients with urethral bladder access.

Simplified PADUA renal (SPARE) nephrometry score validation and long-term outcomes after robot-assisted partial nephrectomy.

BACKGROUND: International guidelines suggest the use of anatomic scores to predict surgical outcomes after partial nephrectomy (PN). We aimed at validating the use of Simplified PADUA Renal (SPARE) nephrometry score in robot-assisted PN (RAPN). MATERIALS AND METHODS: Three hundred and sixty-eight consecutive RAPN patients were included. Primary endpoints were overall complications, postoperative acute kidney injury (AKI) and TRIFECTA achievement. Secondary endpoint was estimated glomerular filtration rate (eGFR) decrease at last follow-up. Multivariable logistic and linear regression models were used. RESULTS: Of 368 patients, 229 (62%) vs. 116 (31%) vs. 23 (6.2%) harboured low- vs. intermediate- vs. high-risk renal mass, according to SPARE classification. SPARE score predicted higher risk of overall complications (Odds ratio [OR]: 1.23, 95%CI 1.09-1.39; P < 0.001), and postoperative AKI (OR: 1.20, 95%CI 1.08-1.35; P < 0.01). Moreover, SPARE score was associated with lower TRIFECTA achievement (OR: 0.89, 95%CI 0.81-0.98; P = 0.02). Predicted accuracy was 0.643, 0.614 and 0.613, respectively. After a median follow-up of 40 (IQR: 21-66) months, eGFR decrease ranged from -7% in low-risk to -17% in high-risk SPARE. CONCLUSIONS: SPARE scoring system predicts surgical success in RAPN patients. Moreover, SPARE score is associated with eGFR decrease at long-term follow-up. Thus, the adoption of SPARE score to objectively assess tumor complexity prior to RAPN may be preferable.