Vascular calcification in kidney stone formers: the impact of age and stone composition.

An increased prevalence of vascular calcification (VC) has been reported in kidney stone formers (KSFs), along with an elevated cardiovascular risk. The aim of the current study is to assess whether VC in these patients develops at a younger age and is influenced by stone composition. This single-center, matched case-control study included KSFs with uric acid or calcium oxalate stones (diagnosed based on stone analysis) and age- and sex-matched controls without a history of nephrolithiasis. The prevalence and severity of abdominal aortic calcification (AAC) and bone mineral density (BMD) were compared between KSFs and non-KSFs. In total, 335 patients were investigated: 134 with calcium oxalate stones, 67 with uric acid stones, and 134 controls. Overall, the prevalence of AAC was significantly higher among calcium stone formers than among the controls (67.9% vs. 47%, p = 0.002). In patients under 60 years of age, those with calcium oxalate stones exhibited both a significantly elevated AAC prevalence (61.9% vs. 31.3%, p = 0.016) and severity (94.8 ± 15.4 vs. 30.3 ± 15.95, p = 0.001) compared to the controls. Within the age group of 40-49, osteoporosis was identified only in the KSFs. Multivariate analysis identified age, smoking, and the presence of calcium stones as independent predictors of AAC. This study highlights that VC and osteoporosis occur in KSFs at a younger age than in non-stone-formers, suggesting potential premature VC. Its pathogenesis is intriguing and needs to be elucidated. Early evaluation and intervention may be crucial for mitigating the cardiovascular risk in this population.

Trends in Emergency Department Admissions Due to Renal Colic in the Pediatric Population: A Multicenter Study.

BACKGROUND: Pediatric urolithiasis is relatively uncommon and is generally associated with predisposing anatomic or metabolic abnormalities. In the adult population, emergency department (ED) admissions have been associated with an increase in ambient temperature. The same association has not been evaluated in the pediatric population. OBJECTIVES: To analyze trends in ED admissions due to renal colic in a pediatric population (≤ 18 years old) and to assess the possible effect of climate on ED admissions. METHODS: We conducted a retrospective, multicenter cohort study, based on a computerized database of all ED visits due to renal colic in pediatric patients. The study cohort presented with urolithiasis on imaging during their ED admission. Exact climate data was acquired through the Israeli Meteorological Service (IMS). RESULTS: Between January 2010 and December 2020, 609 patients, ≤ 18 years, were admitted to EDs in five medical centers with renal colic: 318 males (52%), 291 females (48%). The median age was 17 years (IQR 9-16). ED visits oscillated through the years, peaking in 2012 and 2018. A 6% downward trend in ED admissions was noted between 2010 and 2020. The number of ED admissions in the different seasons was 179 in autumn (30%), 134 in winter (22%), 152 in spring (25%), and 144 in summer (23%) (P = 0.8). Logistic regression multivariable analysis associated with ED visits did not find any correlation between climate parameters and ED admissions due to renal colic in the pediatric population. CONCLUSIONS: ED admissions oscillated during the period investigated and had a downward trend. Unlike in the adult population, rates of renal colic ED admissions in the pediatric population were not affected by seasonal changes or rise in maximum ambient temperature.

Our experience with management of congenital urological pathologies in adulthood: What pediatric urologists should know and adult urologists adopt in pediatric practice experience.

Purpose: To summarize our experience in the management of congenital anomalies in the kidney and urinary tract (CAKUT) in adults. Materials and methods: We conducted a retrospective chart review of all adult patients who underwent primary surgical intervention for CAKUT between 1998 and 2021. Results: The study included 102 patients with a median age of 25 (interquartile range, 23-36.5). Of these, 85 (83.3%) patients reported normal prenatal ultrasound, and the remaining 17 (16.7%) patients were diagnosed with antenatal hydronephrosis. These patients were followed-up conservatively postnatally and were discharged from follow-up because of the absence of indications for surgical intervention or because they decided to leave medical care. All studied adult patients presented with the following pathologies: 67 ureteropelvic junction obstructions, 14 ectopic ureters, 9 ureteroceles, and 6 primary obstructive megaureters, and the remaining 6 patients were diagnosed with vesicoureteral reflux. Forty-three percent of the patients had poorly functioning moieties associated with ectopic ureters or ureteroceles. Notably, 67% of patients underwent pyeloplasty, 9% underwent endoscopic puncture of ureterocele, 3% underwent ureteral reimplantation, 6% underwent endoscopic correction of reflux, 7% underwent partial nephrectomy of non-functioning moiety, and the remaining 9% underwent robotic-assisted laparoscopic ureteroureterostomy. The median follow-up period after surgery was 33 months (interquartile range, 12-54). Post-operative complications occurred in 5 patients (Clavien-Dindo 1-2). Conclusions: Patients with CAKUT present clinical symptoms later in life. Parents of patients diagnosed during fetal screening and treated conservatively should be aware of this possibility, and children should be appropriately counseled when they enter adolescence. Similar surgical skills and operative techniques used in the pediatric population may be applied to adults.

Adopting ultrasound guided PCNL in nephrolithiasis management.

INTRODUCTION: This study aimed to evaluate the learning curve associated with the adoption of US guided PCNL and demonstrate that it can be carried out safely with results comparable to those obtained using standard PCNL. METHODS: Prospective study with 65 patients who underwent PCNL between 2019 and 2020. all procedures were performed in supine position and an initial attempt to gain access to the kidney using US was made. RESULTS: Mean procedure duration was 69.5 ± 27.8 min. Fluoroscopy was used with a mean dose of 276.68 ± 560.71 (cGycm3) and mean fluoroscopy time 40.25 ± 77.69 (s). Throughout the study there was a steady decrease in the use of fluoroscopy and amount of radiation to gain access to the kidney to only 25% at the study end. 76.5% of the patients were stone free at follow-up. Complication rate was 9.2%. CONCLUSIONS: Fluoroless US guided PCNL is safe, feasible and reproducible procedure.

Ultrasound-guided percutaneous nephrolithotomy (PCNL) success rates in patients with elevated body mass index: a comparative study.

Percutaneous nephrolithotomy (PCNL) is considered gold standard treatment of renal stones larger than 20 mm. Several studies have shown that ultrasound guidance during this procedure is more effective and safer than fluoroscopy. A higher body mass index (BMI) can make ultrasound-guided renal access more difficult and unsuccessful. We present a prospective analysis and comparison of ultrasound-guided PCNL in patients with normal and increased body mass index. We performed a prospective comparison of patients who underwent ultrasound-guided PCNL to remove renal stones by a single surgeon between 2020 and 2022. Patients with BMIs greater than 30 (mean 33.87-obese) were compared to those with BMIs less than 30 (mean 25.69-non-obese). Demographic, perioperative, and follow-up data were collected, analyzed, and included in this study. Total of 98 consecutive patients, with 49 patients in each group were analyzed. No statistically significant differences were observed in terms of stone volume (P = 0.085), stone density (P = 0.5590), location of renal access (P = 0.108), surgery duration (P = 0.38), blood loss (P = 0.54), or laboratory changes after surgery (P = 0.60). 87.76% of obese patients were stone free per CT scan at follow-up, compared to 73.47% of normal-weight patients (P = 0.1238). According to Clavien-Dindo classification, six patients in the non-obese group experienced grade II (10%) and grade III (2%) complications, as opposed to six patients in the obese group with grade I (2%), grade II (6%), and grade III (2%) complications. There was no significant correlation between body mass index and the success or safety of ultrasound-guided PCNL. Although more challenging, a higher BMI should not be an impediment to performing this approach. This method is safe, with no increased incidence of postoperative complications or compromise in stone-free status postoperatively and can diminish or avoid both patient's and medical team's exposure to ionizing radiation.

Open Label, Pilot Evaluation of the Safety and Efficacy of Intravesical Sustained Release System of Lidocaine and Oxybutynin (TRG-100) for Patients With Interstitial Cystitis/Bladder Pain Syndrome, Overactive Bladder and Patients With Retained Ureteral Stents Following Endourological Interventions.

BACKGROUND: Intravesical instillation of analgesic and anticholinergic drugs have shown efficacy in the treatment of pain and voiding symptoms. Unfortunately, drug loss with urination and dilution in the bladder limit their durability and clinical usefulness. We have recently developed and tested in vitro, a sustained delivery system (TRG-100) of fixed-dose combination of lidocaine and oxybutynin designed to allow for a longer exposure of the urinary bladder to the drugs. OBJECTIVE: To asses the safety and efficacy of TRG-100 in Interstitial Cystitis/Bladder Pain Syndrome (IC/BPS), overactive bladder (OAB), and endourological intervention stented (EUI) patients in an open-label, prospective study. METHODS: Thirty-six patients were enrolled: 10 IC/BPS, 10 OAB, and 16 EUI. EUI patients received a once-weekly installation until stent removal, OAB and IC/BPS patient received weekly installations for 4 consecutive weeks. Treatment effect was assessed by visual analog scale (VAS) score for the EUI group, voiding diaries for OAB group and VAS score, voiding diaries and O'Leary Sant Questionnaires for the IC/BPS group. RESULTS: The EUI group showed a mean 4-point improvement in their VAS score. The OAB group showed 33.54% reduction in frequency of urination and IC/PBS group showed a mean of 3.2-point improvement in their VAS score, 25.43% reduction in frequency of urination, and a mean 8.1-point reduction in O'Leary Sant Questionnaires score. All changes were statistically significant. CONCLUSION: Intravesical instillation of TRG-100 was found to be safe and efficient in reducing pain and irritative bladder symptoms in our study population. TRG-100 efficacy and safety should be further assessed in a large, randomized control trial.

[OBTAINING A PROSTATE MPMRI BEFORE THE FIRST PROSTATE BIOPSY - IS IT THE TIME TO CHANGE THE INDICATIONS IN ISRAEL?]

INTRODUCTION: Transrectal ultrasound is utilized as an auxiliary tool when performing a prostate biopsy, but its sensitivity and specificity are low. Performing prostate multiparametric magnetic resonance imaging (mp-MRI) before prostate biopsy can increase the probability to detect aggressive prostate cancer while decreasing the probability to detect indolent prostate cancer, thereby assisting in the selection of patients before the biopsy. The Israel Basket of Health Services does not include prostate mpMRI prior to the first prostate biopsy. Our objective was to examine the significance of performing mpMRI before prostate biopsy. METHODS: We retrospectively evaluated the demographic, clinical, and pathological data from men who underwent transrectal biopsy of the prostate in the last 30 months in our institute. In all men with suspicious findings on mpMRI, targeted biopsies were taken in addition to systematic biopsies. We considered cancer as clinically significant if the Gleason sum was 7 or above. Fisher's Exact test was performed for categorical variables and student t-test for continuous variables. RESULTS: Five hundred and sixteen men underwent prostate biopsy; 163(32%) performed prostate mpMRI before the biopsy; 101(25%) performed mpMRI before the first prostate biopsy and 62(59%) before the second or more prostate biopsies. Prostate cancer was detected in 46% of all men (61% in men after mpMRI versus 38% in men without, p<0.0001). In men for whom this was the first prostate biopsy, prostate cancer was detected in 47% (73% in men after mpMRI versus 39% in men without, p<0.0001); and after second or more biopsies 38% (42% in men after mpMRI versus 33% in men without, p=0.4147). Also, there was a statistically significant difference in the detection of clinically significant prostate cancer with mpMRI versus without. CONCLUSIONS: Performing prostate mpMRI before prostate biopsy significantly increases the detection rate of prostate cancer and clinically significant prostate cancer. It should be recommended to perform mpMRI before any prostate biopsy in accordance with the European and American Urology Association, and NCCN guidelines.

A Novel Surgical Technique for Obstructed Megaureter: Robot-Assisted Laparoscopic Dismembered Extravesical Cross-Trigonal Ureteral Reimplantation-Short-Term Assessment.

Purpose: To describe our experience with robot-assisted laparoscopic dismembered extravesical cross-trigonal ureteral reimplantation (RADECUR)-a novel minimally invasive surgical technique for treatment of obstructed megaureter. Materials and Methods: A retrospective review of our prospectively collected data, of all pediatric patients who underwent unilateral RADECUR for the treatment of primary or secondary obstructed megaureter at two medical centers during a 3-year period. Patient demographics, perioperative data, surgical technique, complications, and results are described. Results: Thirty-five pediatric patients underwent RADECUR between January 2016 and May 2019. Median age and weight at surgery were 28 months (interquartile range [IQR]: 20-58) and 20 kg (IQR: 13-27), respectively. There were no conversions to an open procedure. Median console time was 100 minutes (IQR: 90-125). Ten patients underwent intracorporeal excisional tapering of the obstructed ureter. Mean pre- and postoperative ureteral diameters were 14.5 mm (IQR: 12-18) and 7 mm (IQR: 0-10), respectively (p < 0.0001). All but one patient demonstrated a reduction in hydronephrosis and ureteral diameter on follow-up ultrasonography. Grade 1-2 Clavien-Dindo complications occurred in five patients (14%) and another patient developed a grade 3 complication. Three patients developed postoperative febrile urinary tract infection, one of them was found to have high-grade reflux and subsequently underwent open ureteral reimplantation. Conclusions: Unilateral robotic extravesical cross-trigonal ureteral reimplantation for treatment of obstructed megaureter in the pediatric population is safe and effective. Further larger scale comparative studies with other surgical techniques are needed to determine the role of RADECUR in the armamentarium of treatment for distal ureteral obstruction.

Trends in renal calculus composition and 24-hour urine analyses in patients with neurologically derived musculoskeletal deficiencies

ABSTRACT Purpose: To better characterize metabolic stone risk in patients with neurologically derived musculoskeletal deficiencies (NDMD) by determining how patient characteristics relate to renal calculus composition and 24-hour urine parameters. Materials and Methods: We performed a retrospective cohort study of adult patients with neurologically derived musculoskeletal deficiencies presenting to our multidisciplinary Kidney Stone Clinic. Patients with a diagnosis of NDMD, at least one 24-hour urine collection, and one chemical stone analysis were included in the analysis. Calculi were classified as primarily metabolic or elevated pH. We assessed in clinical factors, demographics, and urine metabolites for differences between patients who formed primarily metabolic or elevated pH stones. Results: Over a 16-year period, 100 patients with NDMD and nephrolithiasis were identified and 41 met inclusion criteria. Thirty percent (12 / 41) of patients had purely metabolic calculi. Patients with metabolic calculi were significantly more likely to be obese (median body mass index 30.3kg / m2 versus 25.9kg / m2), void spontaneously (75% vs. 6.9%), and have low urine volumes (100% vs. 69%). Patients who formed elevated pH stones were more likely to have positive preoperative urine cultures with urease splitting organisms (58.6% vs. 16.7%) and be hyperoxaluric and hypocitraturic on 24-hour urine analysis (37mg / day and 265mg / day versus 29mg / day and 523mg / day). Conclusions: Among patients with NDMD, metabolic factors may play a more significant role in renal calculus formation than previously believed. There is still a high incidence of carbonate apatite calculi, which could be attributed to bacteriuria. However, obesity, low urine volumes, hypocitraturia, and hyperoxaluria suggest an underrecognized metabolic contribution to stone formation in this population.

Trends in renal calculus composition and 24-hour urine analyses in patients with neurologically derived musculoskeletal deficiencies.

PURPOSE: To better characterize metabolic stone risk in patients with neurologically derived musculoskeletal deficiencies (NDMD) by determining how patient characteristics relate to renal calculus composition and 24-hour urine parameters. MATERIALS AND METHODS: We performed a retrospective cohort study of adult patients with neurologically derived musculoskeletal deficiencies presenting to our multidisciplinary Kidney Stone Clinic. Patients with a diagnosis of NDMD, at least one 24-hour urine collection, and one chemical stone analysis were included in the analysis. Calculi were classified as primarily metabolic or elevated pH. We assessed in clinical factors, demographics, and urine metabolites for differences between patients who formed primarily metabolic or elevated pH stones. RESULTS: Over a 16-year period, 100 patients with NDMD and nephrolithiasis were identified and 41 met inclusion criteria. Thirty percent (12 / 41) of patients had purely metabolic calculi. Patients with metabolic calculi were significantly more likely to be obese (median body mass index 30.3kg / m2 versus 25.9kg / m2), void spontaneously (75% vs. 6.9%), and have low urine volumes (100% vs. 69%). Patients who formed elevated pH stones were more likely to have positive preoperative urine cultures with urease splitting organisms (58.6% vs. 16.7%) and be hyperoxaluric and hypocitraturic on 24-hour urine analysis (37mg / day and 265mg / day versus 29mg / day and 523mg / day). CONCLUSIONS: Among patients with NDMD, metabolic factors may play a more significant role in renal calculus formation than previously believed. There is still a high incidence of carbonate apatite calculi, which could be attributed to bacteriuria. However, obesity, low urine volumes, hypocitraturia, and hyperoxaluria suggest an underrecognized metabolic contribution to stone formation in this population.

Pediatric robotic-assisted laparoscopic pyeloplasty (RALP): does weight matter?

PURPOSE: RALP is rapidly becoming the new gold standard treatment for UPJO in children, who suffer from uretero-pelvic obstruction (UPJO). However, presently there is a lack of data regarding the outcomes of RALP in young infants and smaller children. This study aims to compare the outcomes of RALP in children weighing less than 10 kg and matched with an analogous cohort who underwent open pyeloplasty (OP). METHODS: We prospectively compared patients who underwent RALP to a matched cohort of patients who underwent OP from our retrospectively acquired data registry. Comparative outcomes included: Demographics, success rate, complications, and length of hospital stay, postoperative pain score and failure rate. Failure was defined as the need for a secondary intervention for UPJO, or worsening hydronephrosis during follow-up. RESULTS: A total of 15 patients with a median age of 8 months (range 5-11 months) and median weight 7 kg (range 5.6-9.8 kg) underwent RALP between 2016 and 2018, a matched cohort of 15 children who underwent OP similar in terms of age, weight, gender and affected side between 2014 and 2016. All children had prenatal diagnosis of hydronephrosis and underwent surgery utilizing combined general and regional (Caudal MO) anesthesia. Intrinsic obstruction was present in 13 of RALP group (86.7%) and in 14 in OP group (93.3%). Mean operative time was 67.8 + 13.4 min in RALP group, while 66.5 + 9.5 min in OP group. (p = 0.76) All but two patients in RALP group had stent inserted and required subsequent anesthesia for stent removal, while all OP children had a Salle Pyeloplasty stent inserted during the procedure and underwent removal in an ambulatory setting without the need for anesthesia. There were no failures recorded in the RALP group, while one patient in OP required a secondary intervention. Mean hospital stay was 1 day (1-2 days) for RALP and 2 days (2-3 days) for OP. There was no difference in FLACC Pain Scale in both groups. Clavien-Dindo grade I-II complications occurred in one patient from each group. Two patients from RALP underwent subsequent ureteral reimplantation due to accompanying uretero-vescical junction obstruction. CONCLUSIONS: Our data suggest that RALP can be performed safely in pediatric patients weighing less than 10 kg. with similar outcomes when compared to patients undergoing an open procedure for the same pathology.

Attenuation of encrustation by self-assembled inorganic fullerene-like nanoparticles.

Ureteral stents and urethral catheters are commonly used medical devices for maintaining urinary flow. However, long-term placement (>30 days) of these devices in the urinary tracts is limited by the development of encrustation, a phenomenon that holds a prevalence of 50% within this patient population, resulting in a great deal of morbidity to the patients. Here we report the influence of surface coating of an all-silicone catheter with rhenium-doped fullerene-like molybdenum disulfide (Re:IF-MoS2) nanoparticles on the growth and attachment of in vitro encrustation stones. Scanning electron microscopy (SEM), energy dispersive X-ray spectroscopy (EDS), X-ray photoelectron spectroscopy (XPS) and X-ray powder diffraction (XRD) analyses indicated a remarkable attenuation in encrustation occupation on the Re:IF-MoS2-coated catheter surfaces compared to neat catheters. The doped nanoparticles displayed a unique tendency to self-assemble into mosaic-like arrangements, modifying the surface to be encrustation-repellent. The mechanism of encrustation retardation on the surface coated catheters is discussed in some detail. The ramification of these results for the clogging of other body indwelling devices is briefly discussed.