Effectiveness of the Eutectic Mixture of Local Anaesthetics Cream in the Management of Arteriovenous Fistula Needle Insertion Pain in Patients Undergoing Haemodialysis.

This review aimed to assess the effectiveness of the eutectic mixture of local anaesthetics (EMLA) cream in the management of arteriovenous fistula (AVF) needle insertion pain in adult patients undergoing haemodialysis (HD) compared with other alternative interventions. The main search was conducted in November 2020 and updated in December 2021. In the search strategy, keywords and synonyms were used and multiple databases were searched with no date limitation to ensure a comprehensive search that would yield all studies relevant to the review and minimise location bias. A total of 209 studies were found in this search and filtered. After filtering through these studies, only five studies were finally included in the review. EMLA-cream was found to be effective in reducing AVF needle insertion pain among adult patients undergoing HD. Despite EMLA cream's effectiveness in reducing HD needle insertion pain and its fewer side effects, the findings of the included studies should be interpreted with caution, as there are some limitations, and further research is required.

Comparison of cytoreductive partial versus radical nephrectomy in metastatic renal cell carcinoma: To be on the horns of a dilemma.

BACKGROUND: Cytoreductive radical nephrectomy (cRN) with immunotherapy is the treatment of choice in patients with metastatic renal cell carcinoma (mRCC). Limited data are available on the role of cytoreductive partial nephrectomy (cPN) in mRCC. This study is a systematic review and meta-analysis of the evidence regarding survival rates comparing cPN versus cRN. METHODS: PubMed/Medline, Scopus, Google Scholar, EMBASE, and the Cochrane Library were reviewed in December 2021 according to PRISMA. Four articles including 2669 patients were selected to enroll in the study. The identified reports were reviewed and their methodological quality was subjected to total quality assessment. The outcomes were cancer specific survival (CSS) and overall survival rate (OS). RESULTS: Totally 2669 patients, 542 in cPN and 2127 in cRN groups enrolled in final analysis. Of the preoperative data, there were significant differences in preoperative size of tumor between cRN and cPN patients (p < 0.001), however Fuhrman grades were comparable between groups (low grade: p = 0.51, high grade: p = 0.76). There were comparable results in 1-year (p = 0.07), 2-year (p = 0.08), and 3-year (p = 0.71) CSS rates between cPN versus cRN. There was no significant difference between cPN versus cRN in OS rate (p = 0.61). CONCLUSION: There are comparable results between cPN and cRN in CSS and OS rate. However, due to a lack of data, future study will need to do more extensive studies using prospectively recorded patient features to evaluate the cPN and cRN in the metastatic setting.

Cytoreductive radical prostatectomy versus systemic therapy and radiation therapy in metastatic prostate cancer: A systematic review and meta-analysis.

Cytoreductive prostatectomy had gained a lot of interest in treatment of metastatic prostate cancer (mPCa) but this treatment approach is still in the experimental phase. This systematic review and meta-analysis was conducted to shed light on the merits of cytoreductive radical prostatectomy compared to systemic and radiation therapy in treatment of mPCa. In February 2021, summary data from 12 original research papers covering 100,973 patients is abstracted. PubMed/Medline, Scopus, Google Scholar, EMBASE, and the Cochrane Library were all reviewed and 12 publications were chosen for inclusion. The evaluated outcomes were 1-, 3-, and 5-year Cancer-Specific (CSS) and overall survival (OS) rates. Cytoreductive radical prostatectomy had significantly higher survival rate for 1-year (OR: 3.03; 95% CI: 2.30-3.98; p < 0.001), 3-year (OR: 2.47; 95% CI: 2.14-3.51; p < 0.001), and 5-year CSS rates (OR: 2.90; 95% CI: 2.10-4.01; p < 0.001) than systemic therapy in mPCa. Higher significant rates of 1-year (OR: 2.35; 95% CI: 1.65-3.36; p < 0.001), three-year (OR: 2.25; 95% CI: 1.96-2.60; p < 0.001), and 5-year OS rates (OR: 2.54; 95% CI: 2.10-3.08; p < 0.001) were also detected for cytoreductive radical prostatectomy compared to systemic therapy. There were no significant differences in 1-year (OR: 1.21; 95% CI: 0.88-1.66; p = 0.25), 3-year (OR: 1.21; 95% CI: 0.92-1.59; p = 0.18), and 5-year CSS rates (OR: 0.91; 95% CI: 0.58-1.42; p = 0.67) between cytoreductive radical prostatectomy and radiation in mPCa patients. Also, no significant differences in 1-year (OR: 1.06; 95% CI: 0.77-1.47; p = 0.71), 3-year (OR: 0.83; 95% CI: 0.60-1.14; p = 0.25), and 5-year OS rates (OR: 1.84; 95% CI: 0.76-4.45; p = 0.18) were detected between cytoreductive radical prostatectomy and radiation therapy. Cytoreductive radical prostatectomy had significantly higher 1-, 3-, and 5-year CSS and OS rates compared to systemic therapy. Comparable CSS and OS rates were found between cytoreductive radical prostatectomy and radiation therapy.

A study on comparative outcomes of totally ultrasonography-guided percutaneous nephrolithotomy in prone versus flank position: a randomized clinical trial.

PURPOSE: The percutaneous nephrolithotomy (PCNL) has become the gold-standard for treating patients with the larger renal stones and staghorn calculi. This study was designed to evaluate the outcomes of flank versus prone position in patients underwent ultrasonic-guided PCNL for treatment of large kidney stones. METHODS: This prospective randomized clinical trial was conducted from September 2017 to September 2019 in the department of Urology, Labbafinejad University hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Two hundred patients with kidney stones larger than 2 cm underwent PCNLs in prone (n = 100) or flank position (n = 100). Success rate, operative time, access time, hemoglobin and creatinine changes, hospital stay, auxiliary procedure and surgical complications were compared between the two groups. RESULTS: The two groups were similar in their baseline characteristics. The success rates in prone (87%) versus flank position (85%) were not significantly different at the first post-operative follow-up (p = 0.91). At the three-month follow-up, the overall stone free rates for the prone position PCNLs and flank position PCNLs were 94/100 (94%) and 90/100 (90%) (p = 0.96). There were no significant difference between the groups in operative time (p = 0.42), access time (p = 0.66), hemoglobin (p = 0.46) and creatinine (p = 0.22) changes, hospital stay (p = 0.05), auxiliary procedures (p = 0.75) and surgical complications. CONCLUSION: Overall, there is no significant difference between prone and flank positions in success rate and complications. More prospective studies must be carried out to identify patient populations who are most apt to benefit from one position over the other. TRIAL REGISTRATION NUMBER: IRCT20200902048597N1 DATE OF REGISTRATION: 2020-11-21, retrospectively registered.

Is a Safety Guide Wire Necessary for Transurethral Lithotripsy using Semi-Rigid Ureteroscope? Results from a Prospective Randomized Controlled Trial.

BACKGROUND: Experts recommend us to keep a safety guidewire during the process of upper urinary tract endoscopy, though there is a lack of high-level evidence to support  the efficacy and safety of  this opinion. This study conducted to compare the outcome of ureteral stone breakage in the presence or absence of safety guidewire. MATERIALS AND METHODS: Patients candidate for endoscopic breakage of ureteral stone using a semi-rigid ureteroscope, were randomly assigned in  two groups based on keeping a safety guidewire (group1)  or removing the guidewire (group2) before the process of breaking ureteral stone by lithoclast. Demographic factors, history of previous stone treatment, kidney function, stone location, symptoms duration and severity were recorded for each patient. Primary outcomes include success rate of stone treatment and secondary outcomes include number of attempts to enter to ureter, success rate of ureteral entry, success rate of stone achievement, stone migration rate and success rate of ureteral stent insertion. The recorded data were entered to the SPSS software and descriptive statistical analysis including power calculation and non-inferiority design for the primary and secondary outcomes, was performed. P-value less than 0.05 was considered significant. RESULTS: From January 2016 till May 2018, 320 patients were randomized with 160 patients in each arm. Considering the cases who were missed due to follow-up loss, there were 153 patients in group 1 and 147 patients in group 2 at the end of the study. Baseline data were equally distributed in both groups. Based on the initial analysis, the studied variables had no significant difference between two groups; though, according to the subgroup analysis of patients with proximal ureter stones, patients in Group 1 had higher rates of ureteral injury comparing to the patients in Group 2 (p=0.03). CONCLUSION: According to our findings, keeping the safety guidewire through the process of endoscopic stone breakage (stone size: less than 1.5Cm) seems to add no significant benefit to the procedure outcome, while it increases the ureteral injuries in the proximal ureter stones, but not in mid or distal ureter stones.

Symptom Resolution and Recurrence Outcomes after Partial Versus Total Laparoscopic Adrenalectomy: 13 years of Experience with Medium-Long Term Follow up.

PURPOSE: Partial adrenalectomy (PA) is an emerging modality typically performed for the treatment of hereditary and sporadic bilateral tumors, to reduce the risk of adrenal failure. In this study, we evaluated the recurrence and functional outcomes after partial and total adrenalectomy (TA). MATERIALS AND METHODS: From March 2005 to July 2018, 284 patients with functional tumor or > 5 cm adrenal mass underwent clipless and sutureless laparoscopic partial or total adrenalectomy (PLA and TLA). Patients with a pathological diagnosis of pheochromocytoma, Cushing or Conn's disease and more than two year follow up were included in this study. Pre-operative and operative variables were collected retrospectively and functional outcomes and recurrence were gathered prospectively. RESULTS: One hundred forty patients (mean age: 43±5.1years) were included in the study. PLA and TLA were performed for pheochromocytoma (total n=78; PLA=12 (15%), TLA=66 (85%)), Cushing syndrome (toal n=17; PLA = 4 (24%), TLA = 13 (76%)), and Conn's disease (total n=45; PLA=7 (16%), TLA=38 (84%)). In pheochromocytoma patients, improvement of hypertension, palpitation, and headache was not different between patients who underwent PLA versus TLA (all P > 0.05). Two recurrences were observed in patients with pheochromocytoma who had undergone TLA. In patients with Cushing disease, central obesity, fascial plethora, and hypertension were improved in all patients six months after treatment, muscle weakness was improved one year after surgery, and acne and hyperpigmentation only improved two years after surgery. The length of time for resolution of symptoms was not different in patients who underwent PLA versus TLA. In Conn's disease hypertension was resolved in all patients and no patient required potassium supplements post-operatively. In follow up no recurrence was observed in patients with a pathological diagnosis of Cushing or Conn's disease. CONCLUSION: In our experience, PLA can provide excellent control of the symptoms parallel with TLA and with no statistically significant difference in recurrence making PLA an attractive option in patients with an adrenal mass.

Mini-Laparoscopic Management of Ureteropelvic Junction Obstruction in Adults and Children: A High-Volume Case Series.

Purpose: We retrospectively reviewed the perioperative outcomes of mini-laparoscopic procedure in the treatment of ureteropelvic junction obstruction (UPJO) in children and adults. Methods: From August 2009 to March 2017, 229 patients referred to our center to repair UPJO by mini-laparoscopic operation. In 203 cases, dismembered pyeloplasty was accomplished, while in other 26 cases, crossing aberrant vein division and crossing artery upward transposition were performed. A follow-up renal ultrasound was done on the cases 3 and 6 months after surgery. During the follow up period, if the patients had persistent hydronephrosis or sustained clinical complaints, diethylenetriamine pentaacetic acid (DPTA) scan was done to rule out the stenosis. Results: Among 229 patients, 140 patients were younger than 18 years (Range: 2 months-18 years old, mean: 3.01 ± 1.2 year) and others were scheduled as Adult (Range: 18-57 years old, mean: 35.12 ± 7.54 year). Total clinical and radiological success rates were 99.5% (228/229) and 86.5% (198/229) respectively. Mean operative times were 127.4 ± 20.3 minutes in dismembered pyeloplasty and 110.6 ± 12.7 minutes in crossing vessel transposition surgery. Mean of hemoglobin decreasing in children and adults was 0.3 ± 0.1 mg/dL; P = .26, and 0.5 ± 1.5 mg/dL; P = .13, respectively. Length of hospital stay was 3.41 ± 0.6 days in dismembered pyeloplasty and 2.1 ± 0.6 days in patients with crossing vessel transposition surgery. We did not suture the skin incision in the entrance site of 3 mm ports and the surgical scar was hardly visible after 6 months. Conclusions: The results of our study suggest that mini-laparoscopic pyeloplasty in adults and particularly in children is feasible, and it seems to be safe and effective in the treatment of UPJO. Furthermore, the patients tolerated the surgery well and they appreciated its outstanding cosmetic outcomes.

Comparison of Open Versus Laparoscopic Versus Hand-Assisted Laparoscopic Nephroureterectomy: A Systematic Review and Meta-Analysis.

BACKGROUND: A systematic analysis of the evidence regarding oncological, perioperative and postoperative outcomes of open nephroureterectomy (ONU), laparoscopic nephroureterectomy (LNU), and hand-assisted laparoscopic nephroureterectomy (HALNU) was designed. METHODS: The summarized data were abstracted from 52 original research articles representing 19,195 patients. PubMed/Medline, Scopus, Google Scholar, EMBASE, and the Cochrane Library were reviewed in March 2017, following PRISMA framework. A total of 52 publications were selected for inclusion. The primary outcomes were 2- and 5-year cancer-specific survival (CSS) rate, overall survival (OS) rate, and recurrence-free survival (RFS) rate. The secondary outcomes were operative time, lengths of hospitalization period, estimated blood loss, transfusions, major Clavien complication rate, metastasis rate, bladder recurrence rate, and positive surgical margin. RESULTS: On comparing LNU versus ONU and HALNU versus ONU, no significant differences between the 5-year CSS rate (P = .25, P = .39), OS rate (P = .06, P = .46), and RFS rate (P = .85, P = .73) were found. On comparing LNU versus ONU and HALNU versus ONU during a 2-year follow-up period, the following were found: CSS rate (P = .61, P = .04) and OS rate (P = .33, P = .19). There were no significant differences between the LNU versus ONU and HALNU versus ONU rates, regarding bladder recurrence (P = .12, P = .85) and metastasis rate (P = .07, P = .27). Significant higher operative time (P = .01, P = .0004), lower length of hospitalization period (P < .001, P < .001), and estimated blood loss (P = .0004, P < .001) were found in comparison to that of LNU versus ONU and HALNU versus ONU. CONCLUSION: Both LNU and HALNU had comparable oncological and better perioperative and postoperative outcomes, when compared with ONU.

Comparison of retropubic, laparoscopic and robotic radical prostatectomy: who is the winner?

PURPOSE: This study is a systematic analysis of the evidence regarding oncological, perioperative and postoperative outcomes and the cost of open retropubic radical prostatectomy (ORP), laparoscopic radical prostatectomy (LRP) and robotic-assisted laparoscopic radical prostatectomy (RALP). METHODS: Summary data was abstracted from 104 original research articles representing 227,400 patients. PubMed/Medline, Scopus, Google Scholar, EMBASE and the Cochrane Library were reviewed in December 2016. A total of 104 publications were selected for inclusion. The primary outcomes were positive surgical margin (PSM) and major complication rate according to Clavien classifications. Secondary outcomes were operative time, length of hospital stay, estimated blood loss, transfusions, conversions, rate of post-operative erectile dysfunction and incontinence and total cost of procedure. RESULTS: ORP had a significantly higher rate than RALP for PSM (OR: 1.18; 95% CI 1.05-1.32; p = 0.004), but the rate of PSM was not significantly different between ORP versus LRP (OR: 1.37; 95% CI 0.88-2.14; p = 0.17) and RALP versus LRP (OR: 0.83; 95% CI 0.40-1.72; p = 0.62). The major Clavien complication rate was significantly different between ORP and RALP (OR: 2.14; 95% CI 1.24-3.68; p = 0.006). Estimated blood loss, transfusions and length of hospital stay were low for RALP, moderate for LRP and high for ORP. The rate of erectile dysfunction (OR: 2.58; 95% CI 1.77-3.75; p < 0.001) and incontinence (OR: 3.57; 95% CI 2.28-5.58; p < 0.001) were significantly lower after RALP than LRP and equivalent for other comparisons. Total cost was highest for RALP, followed by LRP and ORP. CONCLUSIONS: For PSM and peri- and post-operative complications, RALP showed better results than ORP and LRP. In the context of the biases between the studies, one should interpret the results with caution.

Tubeless versus standard percutaneous nephrolithotomy in pediatric patients: a systematic review and meta-analysis.

BACKGROUND: This systematic review and meta-analysis was designed to evaluate the post-operative outcomes between tubeless and standard percutaneous nephrolithotomy (PCNL) among children. METHODS: Literature searches were performed following the Cochrane guidelines. We conducted a systematic review and meta-analysis that included three trials investigating the outcomes including the length of hospital stay, operation time, hemoglobin decrease, blood transfusion rate, perirenal fluid presence, post-operative fever, stone clearance rate, and the need for a second operation. RESULTS: The patients who underwent tubeless PCNL had shorter length of hospitalization compared to standard PCNLs (mean difference -1.57, 95% confidence interval -3.2 to 0.07, p = 0.06). No significant decrease was detected in hemoglobin after tubeless PCNL compared to standard PCNL (mean difference 0.05, 95% confidence interval -0.03 to 0.13, p = 0.21). There were no significant differences in operation time (p = 0.7), perirenal fluid presence (p = 0.15), post-operative fever (p = 0.72), stone clearance (p = 0.68), and the need for a second operation (p = 0.90). CONCLUSIONS: This study showed no significant difference between tubeless and standard PCNLs in children. However, due to the lack of data, the results should be mentioned prudently. Future randomized trials with more sample sizes and longer follow-ups are warranted.

Staged Bilateral Laparoscopic Adrenalectomy for Infantile ACTH-independent Cushing's Syndrome (Bilateral Micronodular Non-pigmented Adrenal Hyperplasia): A Case Report.

ACTH-independent Cushing's syndrome is an uncommon disorder in children. While laparoscopic adrenalectomy is well-established in adults, it is rarely used in infants and is associated with some concerns. A seven-month infant was referred to our hospital due to progressive signs and symptoms of Cushing's syndrome. Laboratory data confirmed ACTH-independent hypercortisolism. No history of exogenous corticosteroid contact was observed. The patient underwent left transperitoneal laparoscopic adrenalectomy when she was 7 months old, nevertheless,complete response was not seen. The patient underwent right laparoscopic adrenalectomy (contra-lateral adrenal gland) when she was 20 months old. The signs and symptoms of Cushing's syndrome began to resolve and serum and urine cortisol levels became normal 3 months after the second surgery. laparoscopic adrenalectomy is safe and feasible in infants, and in this case, relieved patient of the symptoms and saved her life.

Comparing the Efficacy and Safety of Ultrasonic Versus Pneumatic Lithotripsy in Percutaneous Nephrolithotomy: A Randomized Clinical Trial.

BACKGROUND: Percutaneous nephrolitotomy (PCNL) is the preferred treatment for large renal stones. There is a need for more comparative data for different lithotripters used in PCNL. OBJECTIVE: To evaluate the comparative safety and efficacy of ultrasonic and pneumatic lithotripsy in patients undergoing PCNL. DESIGN, SETTING, AND PARTICIPANTS: This randomized clinical trial was conducted at Labbafinejad University Hospital, Tehran, Iran. A total of 180 patients were selected and divided randomly into two groups: 88 patients to pneumatic and 92 to ultrasonic lithotripsy. INTERVENTION: Standard fluoroscopy-guided PCNL was performed using pneumatic or ultrasonic lithotripsy. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary outcome was the procedure success rate. We also evaluated other outcome measures including operation time, stone fragmentation and removal time (SFRT), length of hospital stay, and postoperative complications. We used SPSS software version 18.0 for data analysis. RESULTS AND LIMITATIONS: The two groups were similar in baseline characteristics. There were no significant differences between the groups in stone fragmentation and removal time (p=0.63), stone free rate (p=0.44), and hospital stay (p=0.66). SFRT for hard stones was shorter using pneumatic lithotripsy (p<0.001). By contrast, ultrasonic lithotripsy was associated with a shorter SFRT for soft stones (p<0.001). Postoperative complications were similar in the two groups. A limitation of this study might be the 3-mo follow-up period. CONCLUSIONS: In general, there were no significant differences in the success rate and complications between pneumatic and ultrasonic lithotripsy. SFRT was significantly shorter using pneumatic lithotripsy for hard stones, and ultrasonic lithotripsy for soft stones. PATIENT SUMMARY: We found no significant differences in the success rate and complications of percutaneous nephrolitotomy using pneumatic and ultrasonic lithotripsy. Ultrasonic and pneumatic lithotripsy differed in the time for stone fragmentation and removal for hard and soft stones.

Stented Versus Stentless Laparoscopic Ureterolithotomy: A Systematic Review and Meta-Analysis.

INTRODUCTION: This systematic review and meta-analysis were designed to evaluated the efficacy and safety of stented versus stentless laparoscopic ureterolithotomy (LU). METHODS: We conducted a systematic review and meta-analysis that included six trials that investigated the outcomes, including the rate of prolonged urine leakage, operative time, time to drain removal, and estimated blood loss, between stented versus stentless LU. RESULTS: Four studies with 289 participants were included in the study. There was no significant difference between two groups in rate of prolonged urine leakage (odds ratios [OR] 0.35, 95% confidence intervals [CI] 0.09-1.46, p = 0.15). Significant longer operative time was detected in patients who underwent stented LU compared with stentless group (mean difference 11.36, 95% CI 7.53-15.20, P < .00001). There was no significant difference between two groups in day of drain removal (mean difference -1.09, 95% CI -2.33-0.15, P = .08). No significant difference in blood loss in patients who underwent stented LU compared with stentless group was detected (mean difference 7.67, 95% CI -0.29-15.64, P = .06). CONCLUSION: Our study demonstrated that the rate of prolonged urine leakage, time to drain removal, and estimated blood loss were not significantly different between stented and stentless LU.

Living related and living unrelated kidney transplantations: A systematic review and meta-analysis.

AIM: To compare the outcomes between related and unrelated kidney transplantations. METHODS: Literature searches were performed following the Cochrane guidelines. We conducted a systematic review and a meta-analysis, which included 12 trials that investigated outcomes including the long-term (ten years), mid-term (one to five years), and short-term (one year) graft survival rate as well as the acute rejection rate. Meta-analyses were performed using fixed and random-effects models, which included tests for publication bias and heterogeneity. RESULTS: No difference in graft survival rate was detected in patients who underwent living related kidney transplantations compared to unrelated (P = 0.44) transplantations after ten years. There were no significant differences between the graft survival rate in living related and unrelated kidney transplantations after a short- and mid-term follow-up (P = 0.35, P = 0.46). There were no significant differences between the acute rejection rate in living related and unrelated kidney transplantations (P = 0.06). CONCLUSION: The long, mid and short term follow-up of living related and unrelated kidney transplantation showed no significant difference in graft survival rate. Also, acute rejection rate was not significantly different between groups.

What is the impact of extracorporeal shock wave lithotripsy on semen parameters? A systematic review and meta-analysis.

BACKGROUND: Extracorporeal shock wave lithotripsy (ESWL) is an important tool for the management of urolithiasis. The effects of shockwaves on tissues are established. The aim of this meta-analysis is to evaluate the microscopic semen characteristics of young men before and after ESWL treatment for lower ureteral calculi. METHODS: Literature searches were performed following the Cochrane guidelines. We conducted a systematic review and meta-analysis that included six trials that investigated the effects of ESWL on semen parameters, including sperm concentration, motility, and hematospermia. Meta-analyses were performed using fixed and random-effects models with tests for publication bias and heterogeneity. RESULTS: Significant worsening was detected in sperm concentration and motility after ESWL between case and control groups (mean difference -17.23, 95% confidence interval -22.53 to -11.93, p<0.00001, mean difference -10.82, 95% confidence interval -18.56 to -3.07, p = 0.006). Rate of microscopic and macroscopic hematospermia was significantly higher after ESWL between case and control groups [risk ratio (RR) 40.00, 95% confidence interval 10.11-158.30, p<0.00001, RR 14.33, 95% confidence interval 2.82-72.90, p = 0.001]. All parameters recovered after 3 months. CONCLUSIONS: This study showed sperm concentration, motility, and rate of hematospermia (microscopic and macroscopic) were affected by ESWL that was used for the treatment of lower ureteral stone. Long-term studies with a focus on male fertility (i.e., pregnancy rates) after ESWL are warranted.

Efficacy and safety of percutaneous nephrolithotomy with adult standard size instruments in children under 3 years of age: a 10 years single-center experience.

BACKGROUND: Using percutaneous nephrolitotomy (PCNL) with large adult instruments in treatment of pediatricurolithiasis is still in debate. This study was conducted to evaluate the efficacy and safety of PCNL with adult's instrument in treatment of patients less than 3 years old. METHODS: Data on patient characteristics and outcomes for 261 consecutive children undergoing PCNL at a Labbafinejad University Hospital were collected prospectively from September 2006 to February 2016. Thirty-two children, with 34 renal units, who were treated with PCNL were enrolled in the study. All PCNL procedures were performed via subcostal approach with one access tract in all of them. Postoperative complications were evaluated according to the modified Clavien grading system. RESULTS: The mean age of patients was 19.4 ± 6.2 months. Two patients had bilateral stones; thus, PCNL was performed on 34 kidney units. The mean size of the largest stone diameter was 17.5 ± 7.8 mm. The mean duration of procedures was 121.52 ± 29.05 minutes, ranging from 60 to 180 minutes. The most common complication was fever (n = 9, 26.4%), and hemorrhage that needs transfusion was the second one (n = 4, 11.7%). Seventeen patients with complications were in the first degree of Clavien complication system and five of them were in the second degree. CONCLUSIONS: Due to our experience, utilizing PCNL with adult-sized instruments in management of urolithiasis in less than 3 years old children appeared to be effective and relatively safe.

The value of transcranial Doppler derived pulsatility index for diagnosing cerebral small-vessel disease.

BACKGROUND: The pulsatility index (PI), measured by transcranial Doppler (TCD) ultrasonography, can reflect vascular resistance induced by cerebral small-vessel disease (SVD). We evaluated the value of TCD-derived PI for diagnosing SVD as compared with magnetic resonance imaging (MRI). MATERIALS AND METHODS: Fifty-six consecutive cases with SVD (based on MRI) and 48 controls with normal MRI underwent TCD. Based on MRI findings, patients were categorized into five subgroups of preventricular hyperintensity (PVH), deep white matter hyperintensity (DWMH), lacunar, pontin hyperintensity (PH), and PVH+DWMH+lacunar. The sensitivity and specificity of TCD in best PI cut-off points were calculated in each group. RESULTS: The sensitivity and specificity of TCD in comparison with MRI with best PI cut-off points were as follows: In PVH with PI = 0.83, the sensitivity and specificity was 90% and 98%, respectively. In DWMH with PI = 0.79, the sensitivity and specificity was 75% and 87.5%, respectively. In lacunar with PI = 0.80, the sensitivity and specificity was 73% and 90%, respectively. In PH with PI = 0.69, the sensitivity and specificity was 92% and 87.5%, respectively. And, in PVH+DWMH+lacunar subgroup with PI = 0.83, the sensitivity and specificity was 90% and 96%, respectively. CONCLUSIONS: Increased TCD derived PI can accurately indicate the SVD. Hence, TCD can be used as a non-invasive and inexpensive method for diagnosing SVD, and TCD-derived PI can be considered as a physiologic index of the disease as well.

One step closer to sparing total blood loss and transfusion rate in total knee arthroplasty: a meta-analysis of different methods of tranexamic acid administration.

BACKGROUND: Tranexamic acid (TXA) in orthopedics has recently been gaining favor due to its efficacy and ease of use, both in intravenous (IV) and intraarticular (IA) usage. However, because of safety concerns with IV administration, there has been a growing interest in the IA use of TXA to prevent bleeding. MATERIALS AND METHODS: This study conducted a systematic review and meta-analysis that included 31 randomized, controlled trials in which the effect of systemic and topical TXA on total blood loss (TBL), rates of transfusion, and thromboembolic events was investigated. RESULTS: Compared to the control, the IA administration of TXA led to the significant reduction of mean TBL (p < 0.001), rate of transfusion (p < 0.001), and reduction of rate of thromboembolic events (p = 0.29). Compared to the control group, the IV administration of TXA resulted in significant reduction of mean TBL (p < 0.001), rate of transfusion (p < 0.001), and rate of thromboembolic events (p = 0.66). Although no significant differences in efficacy and safety between the IA and IV administration of TXA were found, the IA method was safer than the IV method in that it reduced rate of transfusion and thromboembolic events. CONCLUSION: This study showed that TXA leads to significant reductions in TBL and the rate of allogeneic transfusions. Generally, no significant difference was detected between IA and IV administration of TXA; however, more studies with focus on safety and efficacy are warranted.

Prevalence and clinical characteristics of headache among medical students, Isfahan, Iran.

BACKGROUND: Headache is one of the most common complaints during medical curriculum and it occurs due to numerous psychological and physical stressors, which are more common in medical students than general population. The purpose of this study was to evaluate the frequency of different types of headache and associated factors. MATERIALS AND METHODS: This cross-sectional study was conducted in Isfahan University of Medical Sciences, from September 2011 to January 2012. First- to seven-year medical students who have experienced some forms of headache in their life and had headache attacks during the past 6 months were included in this study. All medical students completed a structured check list, which consisted of demographics data, associated factors, and headache characteristics. RESULTS: A total of 480 (258 [53.8%] males and 222 [46.2%] females) students (93.7%) were evaluated. The prevalence of headache was 58.7%, the prevalence of migraine, and tension-type headache was 14.2% (10.5% in male vs. 18.5% in female, P = 0.08) and 44.2% (49.2% in male vs. 39.2% in female, P = 0.006), respectively. A family positive history was found in 9.5% of students with headache. The lower socio-economic status, year of study (3(rd) and 5(th) year students), was seemed to had higher prevalence in students with headache. There was no significant difference between headache and concomitant disease. CONCLUSION: The results demonstrate that prevalence of headache is high among medical student. Socio-economic and the year of study might be significant factors in the prevalence of headache. Further multicenter studies would be necessary to evaluate headache epidemiology among medical students in the whole country.