The relationship between the force applied and perceived by the surgeon during ureteral access sheath placement: ex-vivo experimental model.

PURPOSE: To define a peak force of insertion (PFOI) threshold for ureteral damage during ureteral access sheath (UAS) placement on an experimental ureteral orifice model. METHODS: A specially designed water tank using 2 laparoscopic 5 mm ports and 2 different size (10 Fr and 8 Fr) sealing cap adaptors (SCA) as ureteral orifices was used to perform the test. A 10-12 Fr UAS was fixed to a load cell and the force of insertion (FOI) was continuously recorded with a digital force gauge.13 experts in the field of endourology who participated performed 3 UAS insertions. The FOI was recorded initially with 10 Fr followed by 8 Fr SCA. On the final insertion, the orifice was obstructed, leaving a 5 cm length to insert the UAS. The experts were asked to "Stop at the point they anticipate ureteral damage, and they would not proceed in real life". RESULTS: Using 10 Fr SCA the PFOI was 2.12 ± 0.58 Newton (N) (range:1.48-3.48) while 8 Fr SCA showed a PFOI 5.76 ± 0.96 N (range:4.05-7.35). Six of the experts, said they would stop proceeding when they reached above 5.1 N. Three experts had PFOI < 5.1 N and the other 4 stated they would go with PFOIs of 5.88, 6.16, 6.69 and 7.35 N when using SCA of 8 Fr.The highest load they would stop proceeding had a PFOI of 6.09 ± 1.87 N (range: 2.53-10.74). CONCLUSION: The PFOI threshold for ureteral damage inserting UAS of the experts is variable. Although FOI is a subjective perception, experience suggests that ureteral injury may occur at an average of 6.05 N perceived by surgeons' tactile feedback. In-vivo measurement of UAS PFOI may confirm a threshold.

International Alliance of Urolithiasis (IAU) guideline on staghorn calculi management.

BACKGROUND: The stone burden based management strategy reported in the guidelines published by different associations is well known for a long time. Staghorn calculi, representing the largest burden and most complex stones, is one of the most challenging cases to practicing urologists in clinical practice. The International Alliance of Urolithiasis (IAU) has released a series of guidelines on the management of urolithiasis. PURPOSE: To develop a series of recommendations for the contemporary management management of staghorn calculi and to provide a clinical framework for urologists treating patients with these complex stones. METHODS: A comprehensive literature search for articles published in English between 01/01/1976 and 31/12/2022 in the PubMed, OVID, Embase and Medline database is performed. A series of recommendations are developed and individually graded following the review of literature and panel discussion. RESULTS: The definition, pathogenesis, pathophysiology, preoperative evaluation, intraoperative treatment strategies and procedural advice, early postoperative management, follow up and prevention of stone recurrence are summarized in the present document. CONCLUSION: A series of recommendations regarding the management of staghorn calculi, along with related commentary and supporting documentation offered in the present guideline is intended to provide a clinical framework for the practicing urologists in the management of staghorn calculi.

Consultation on UTUC II Stockholm 2022: diagnostic and prognostic methods-what's around the corner?

PURPOSE: To map current literature and provide an overview of upcoming future diagnostic and prognostic methods for upper tract urothelial carcinoma (UTUC), including translational medical science. METHODS: A scoping review approach was applied to search the literature. Based on the published literature, and the experts own experience and opinions consensus was reached through discussions at the meeting Consultation on UTUC II in Stockholm, September 2022. RESULTS: The gene mutational profile of UTUC correlates with stage, grade, prognosis, and response to different therapeutic strategies. Analysis of pathway proteins downstream of known pathogenic mutations might be an alternative approach. Liquid biopsies of cell-free DNA may detect UTUC with a higher sensitivity and specificity than urinary cytology. Extracellular vesicles from tumour cells can be detected in urine and may be used to identify the location of the urothelial carcinoma in the urinary tract. 3D microscopy of UTUC samples may add information in the analysis of tumour stage. Chemokines and chemokine receptors were linked to overall survival and responsiveness to neoadjuvant chemotherapy in muscle-invasive bladder cancer, which is potentially also of interest in UTUC. CONCLUSION: Current diagnostic methods for UTUC have shortcomings, especially concerning prognostication, which is important for personalized treatment decisions. There are several upcoming methods that may be of interest for UTUC. Most have been studied for urothelial carcinoma of the bladder, and it is important to keep in mind that UTUC is a different entity and not all methods are adaptable or applicable to UTUC.

Consultation on UTUC II Stockholm 2022: diagnostics, prognostication, and follow-up-where are we today?

PURPOSE: To summarise the current knowledge regarding diagnostics, prognostication and follow-up in upper tract urothelial carcinoma (UTUC). METHODS: A scoping review combined with expert opinion was applied to provide an overview of the current research field. Based on the published literature and the experts' own experience and opinions, consensus was reached through presentations and discussions at the meeting Consultation on UTUC II in Stockholm 2022. RESULTS: The strongest prognostic factors in UTUC are tumour grade and stage. They are correlated, and grade is used for indirect staging. The diagnostic examinations should include multiphase computed tomography urography (CTU) with corticomedullary phase, and urethrocystoscopy with cytology. If there is no clear diagnosis for clinical decision-making, ureterorenoscopy (URS) with focal cytology and biopsies should be performed. Both WHO classification systems (1973/1999 and 2004/2016) should be used. Novel biomarker tests are not yet widespread nor recommended for the detection of UTUC. Long-term, regular follow-up, including URS in patients who have had organ-sparing treatment, is important to check for tumour recurrences, intravesical recurrences, metastases and progression of the tumour. CONCLUSION: Proper diagnostics with correct grading of UTUC are necessary for appropriate treatment decisions. The diagnostics should include CTU with corticomedullary phase, urine or bladder cytology, URS with focal barbotage cytology, and biopsies when needed for proper diagnosis and risk stratification. Regular, long-term follow-ups are fundamental, due to the high rate of recurrence and risk of progression.

Identification of early stage and metastatic prostate cancer using electrochemical detection of beta-2-microglobulin in urine samples from patients.

To improve prostate cancer (PCa) diagnosis, it is imperative to identify novel biomarkers and establish effective screening techniques. Here, we introduce electrochemical biosensing of ß-2-Microglobulin (ß2M) in urine as a potential diagnostic tool for PCa. The immunosensor is composed of a screen-printed graphene electrode coated with anti ß2M antibodies. The sensor is capable of detecting the protein directly in urine without any sample pretreatment within 45 min including sample incubation and a lower limit of detection of 204 µg/L. The sensor demonstrated a significant difference in the ß2M-creatinine ratio in urine between control and both local- and metastatic PCa (mPCa) (P = 0.0302 and P = 0.0078 respectively), and between local- and mPCa (P = 0.0302). This first example of electrochemical sensing of ß2M for the diagnosis of PCa may set the stage for an affordable, on-site screening technique for PCa.

Kidney stone disease.

Kidney stone disease is rapidly increasing with a strong relationship to metabolic syndrome. This review gives a brief overview of the current state and current treatment modalities. Increasing use of CT and ultrasound scans leads to increased diagnosis of asymptomatic kidney stones, which rarely require treatment. The trend in stone treatment goes towards endoscopic lithotripsy which together with ESWL enables a personalised approach. Obstructive stones with infection require urgent intervention to reduce mortality. Increased fluid intake, dietary changes as well as potassium citrate supplements are the most important elements in stone prevention in the common idiopathic stone disease.

Gadolinium-enhanced MRI visualizing backflow at increasing intra-renal pressure in a porcine model.

INTRODUCTION: Intrarenal backflow (IRB) is known to occur at increased intrarenal pressure (IRP). Irrigation during ureteroscopy increases IRP. Complications such as sepsis is more frequent after prolonged high-pressure ureteroscopy. We evaluated a new method to document and visualize intrarenal backflow as a function of IRP and time in a pig model. METHODS: Studies were performed on five female pigs. A ureteral catheter was placed in the renal pelvis and connected to a Gadolinium/ saline solution 3 ml/L for irrigation. An occlusion balloon-catheter was left inflated at the uretero-pelvic junction and connected to a pressure monitor. Irrigation was successively regulated to maintain steady IRP levels at 10, 20, 30, 40 and 50 mmHg. MRI of the kidneys was performed at 5-minute intervals. PCR and immunoassay analyses were executed on the harvested kidneys to detect potential changes in inflammatory markers. RESULTS: MRI showed backflow of Gadolinium into the kidney cortex in all cases. The mean time to first visual damage was 15 minutes and the mean registered pressure at first visual damage was 21 mmHg. On the final MRI the mean percentage of IRB affected kidney was 66% after irrigation with a mean maximum pressure of 43 mmHg for a mean duration of 70 minutes. Immunoassay analyses showed increased MCP-1 mRNA expression in the treated kidneys compared to contralateral control kidneys. CONCLUSIONS: Gadolinium enhanced MRI provided detailed information about IRB that has not previously been documented. IRB occurs at even very low pressures, and these findings are in conflict with the general consensus that keeping IRP below 30-35 mmHg eliminates the risk of post-operative infection and sepsis. Moreover, the level of IRB was documented to be a function of both IRP and time. The results of this study emphasize the importance of keeping IRP and OR time low during ureteroscopy.

International Alliance of Urolithiasis guideline on retrograde intrarenal surgery.

OBJECTIVES: To set out the second in a series of guidelines on the treatment of urolithiasis by the International Alliance of Urolithiasis that concerns retrograde intrarenal surgery (RIRS), with the aim of providing a clinical framework for urologists performing RIRS. MATERIALS AND METHODS: After a comprehensive search of RIRS-related literature published between 1 January 1964 and 1 October 2021 from the PubMed database, systematic review and assessment were performed to inform a series of recommendations, which were graded using modified GRADE methodology. Additionally, quality of evidence was classified using a modification of the Oxford Centre for Evidence-Based Medicine Levels of Evidence system. Finally, related comments were provided. RESULTS: A total of 36 recommendations were developed and graded that covered the following topics: indications and contraindications; preoperative imaging; preoperative ureteric stenting; preoperative medications; peri-operative antibiotics; management of antithrombotic therapy; anaesthesia; patient positioning; equipment; lithotripsy; exit strategy; and complications. CONCLUSION: The series of recommendations regarding RIRS, along with the related commentary and supporting documentation, offered here should help provide safe and effective performance of RIRS.

Bladder diverticulum in Ehlers-Danlos syndrome.

Ehlers-Danlos syndrome (EDS) is a group of hereditary connective tissue disorders which are clinically characterized by hypermobility of joints, hyperelasticity of skin and tissue insufficiency, sometimes leading to herniation, bleeding, and organ rupture. This is a case report of a 55-year-old man with EDS and a big bladder diverticulum in which we discuss treatment strategy in patients with EDS and bladder diverticula. Initially, treatment approach should be conservative due to high recurrence rates and potential complications following surgical procedures. Invasive procedures - preferably minimally invasive - may be indicated, based on an individual risk evaluation.

An Intervention Offering Self-management Support Through mHealth and Health Coaching to Patients With Prostate Cancer: Interpretive Description of Patients' Experiences and Perspectives.

BACKGROUND: Observational management strategies such as active surveillance and watchful waiting are considered to be acceptable approaches in patients with low-risk localized prostate cancer and a safe alternative to aggressive treatment. During observational management, treatment is postponed until the disease progresses, which often never occurs. However, approximately 90% of patients with a low-risk disease choose aggressive treatment owing to anxiety. Strategies to address anxiety are needed for optimal management of this population and to improve the quality of life of patients with low-risk localized prostate cancer. A review highlighted that mobile health (mHealth) in tandem with health coaching can support patients' self-management of health behaviors and improve well-being. OBJECTIVE: This study aims to explore patients' experiences with and perspectives on an intervention offering self-management support through the use of mHealth devices and health coaching to identify supportive features that enable patients to perform sustainable changes that improve well-being. METHODS: We used an interpretive description approach, combining semistructured interviews with 13 purposively selected patients with prostate cancer and participant observations of patient-coach interactions in coaching sessions. The interviews were transcribed and analyzed. The self-determination theory was used as a theoretical lens. Field notes and coaching notes from each session were used to orient data generation and confirm or challenge the analysis. RESULTS: Our analysis suggested that patients' self-awareness and psychological identity influenced their experiences with and perspectives on the self-management support offered by mHealth and health coaching in clinical practice. The patients' individual experiences and perspectives indicated that they placed themselves in a dynamic continuum of sustaining or repressing their identity, self-awareness, and individual qualities. Our analysis revealed 4 interacting themes, all related to the psychological identity of the patients. CONCLUSIONS: For the group of patients with prostate cancer to experience well-being, we found it important for them to sustain their self-image when offered a self-management intervention. Motivation and autonomy were important aspects for the individual patients to sustain their self-image throughout the intervention. In contrast, demotivation and a sense of paternalism could result in fostering an experience of having to repress self-awareness.

The Danish linguistic validation of the Ureteral Stent Symptoms Questionnaire.

INTRODUCTION: The aim of the study was to validate the Ureteral Stent Symptom Questionnaire (USSQ) in Danish for patients with indwelling ureteral stents. METHODS: The linguistic validation of the original USSQ was performed following standardised multi-step translation procedures. Seventy patients with indwelling ureteral stents were asked to complete the Danish USSQ one and two weeks after stent placement and four weeks after stent removal. RESULTS: A total of 65 patients (92.9%) completed the USSQ. Statistical evaluation revealed good internal consistency in all domains except work performance. Satisfactory convergent validity (less-than -0.4 or greater-than 0.4) was demonstrated for urinary symptoms, body pain and global quality of life. The test-retest reliability-coefficient was statistically significant for urinary symptoms, general health, pain and sexual matters. Inter-domain associations were positive and monotone for all subscales. All sub-scores, except sexual matters, significantly decreased from one week after stent insertion to four weeks after stent removal (p less-than 0.001). CONCLUSION: The Danish USSQ is a reliable and valid instrument with which to evaluate urinary symptoms and general health in patients with indwelling ureteral stents. FUNDING: Ideforum, Vejle Hospital, University Hospital of Southern Denmark, granted 80,000 DKK to support this work. TRIAL REGISTRATION: The Danish National Ethics Committee and Region Syddanmark approved the study (Study approval number 20192000-168 and journal number 19-52219, respectively).

Correlation between stage of prostate cancer and tyrosine and tryptophan in urine samples measured electrochemically.

Prostate cancer (PCa) is the second most common cancer in men and one of the leading causes of cancer-related deaths. Early detection is the key to successful treatment and provides the greatest chance to cure the patient. Currently, early detection involves screening for prostate-specific antigen levels in blood, which is not a tumor-specific biomarker. There is a critical need to develop clinically useful methods for screening for more reliable biomarkers. Here, we introduce an electrochemical biosensor that measures the concentrations of the amino acids tyrosine and tryptophan, and propose it as a possible diagnostic and prognostic tool for PCa. The limits of detection of tyrosine and tryptophan using the electrochemical sensors were 1.15 and 1.13 µmol/L in 1:10 urine: PBS, respectively. This study is the first to present electrochemical measurements of tyrosine and tryptophan directly in patient urine samples. We demonstrated an inverse correlation between the measured electrochemical signals and the severity of PCa. The most notable observation was a significant difference between controls and metastatic PCa patients (P ≤ 0.001). This observation was further validated using Liquid-Chromatography-Mass Spectrometry. Our data provides the basis for further research with electrochemical measurements of tyrosine and tryptophan as potential biomarkers for PCa.

Healthcare Professionals' Experiences and Perspectives of Facilitating Self-Management Support for Patients with Low-Risk Localized Prostate Cancer via mHealth and Health Coaching.

Introduction: Self-monitoring of self-management interventions with the use of mobile health (mHealth) can enhance patients' well-being. Research indicates that mHealth and health coaching act symbiotically to providing a more constructive outcome. Nurse coaches seem to have a significant role in translating the patients' tracked data. Objective: The objective was to explore healthcare professionals' experiences of an intervention offering self-management support through mHealth and health coaching for patients with prostate cancer. Methods: We used the interpretive description methodology, combining semi-structured individual and focus group interviews and participant observations of patient-coach interactions and use of mHealth in coaching sessions. The study was conducted between June 2017 and August 2020. Results: The nurse coaches experienced motivation and autonomy when possessing the right competences for coaching. Furthermore, the nurse coaches experienced conflicting expectations of their roles when having to integrate mHealth. Conclusion: The experience of being competent, autonomous, and confident is important for the nurse coaches to be mentally present during the coaching sessions. On the other hand, the findings indicate that having the sense of not being confident in one's own ability to perform leads to reduced motivation.

Renal stone detection using a low kilo-voltage paediatric CT protocol - a porcine phantom study.

INTRODUCTION: Reducing tube voltage is an effective dose saving method in computed tomography (CT) assuming tube current is not concurrently increased. Recent innovations in scanner technology now enable CT tube voltage reduction to 70 kV thereby increasing opportunities for dose reduction in paediatric patients, but it is unclear if the increased image noise associated with 70 kV impacts on ability to visualise renal stones accurately. The purpose was to assess detectability of nephrolithiasis using a bespoke paediatric phantom and low kV, non-contrast CT and to assess inter-observer agreement. METHODS: Forty-two renal stones of different size and chemical composition were inserted into porcine kidneys and positioned in a bespoke, water-filled phantom mimicking a 9-year-old child weighing approximately 33kg. The phantom was scanned using 120 and 70 kV CT protocols, and the detectability of the stones was assessed by three radiologists. Absolute agreement and Fleiss' kappa regarding detectability were assessed. RESULTS: The mean diameter of renal stones as measured physically was 4.24 mm ranging from 1 to 11 mm. Four stones were missed by at least one observer. One observer had a sensitivity of 93 and 95% at 70 and 120 kV, respectively, while the sensitivity for observers 2 and 3 was 98% at both kV levels. Specificity was 100% across readers and kV levels. Absolute agreement between the readers at 70 kV was 92% (kappa = 0.86) and 98% (kappa = 0.96) at 120 kV indicating a strong agreement at both kV levels. CONCLUSIONS: The results suggest that lowering the kV does not affect the detection rate of renal stones and may be a useful dose reduction strategy for assessment of nephrolithiasis in children.