Effects of irrigation parameters and access sheath size on the intra-renal temperature during flexible ureteroscopy with a high-power laser.

OBJECTIVES: To investigate the effect of different laser power settings on intra-renal temperature (IRT) under different irrigation conditions during flexible ureteroscopy (FURS) in a live-anesthetized porcine model. METHODS: Following ethics approval, 2 female pigs weighing ~ 28 kg were used. Under general anesthesia, a percutaneous access was obtained to fix a K-type thermocouple inside the pelvi-calyceal system for real-time recording of IRT during FURS without UAS, UAS-10/12, UAS-12/14, and UAS-14/16F. A high-power holmium laser was used and the IRT was recorded during laser activation for up to 60 s at a laser power of 20 W, 40 W, and 60 W under gravity irrigation and manual pump irrigation. RESULTS: Under gravity irrigation, FURS without UAS was associated with hazardous IRT at a laser power as low as 20 W for as short as 20 s of laser activation. The IRT was rendered borderline when UAS was used. This UAS buffering effect disappeared with the use of higher laser-power settings (40 W and 60 W) with the maximal IRT exceeding 60 °C. Moreover, laser activation at 60 W was associated with very rapid increase in IRT within few seconds. Under pump irrigation, laser activation at the highest power setting (60 W) for 60 s was associated with a safe IRT, even without the use of UAS. The maximal IRT was below 45 °C. CONCLUSION: The use of high-power Ho:YAG laser carries potentially harmful thermal effect when used under gravity irrigation, even when large-diameter UAS is used. High-power settings (> 40 W) require high irrigation flow. The use of UAS is advisable to reduce the IRT and balance any intra-renal pressure increase.

Lasers for stone treatment: how safe are they?

PURPOSE OF REVIEW: To update laser lithotripsy advances in regard to new laser types and technologies as well as review contemporary laser safety concerns. RECENT FINDINGS: The high prevalence of urolithiasis and the continuing miniaturization of scopes has encouraged the growth of laser lithotripsy technology. The holmium:yttrium-aluminum-garnet (Ho:YAG) laser has been used for over 20 years in endourology and has been extensively studied. Holmium laser power output is affected by a number of factors, including pulse energy, pulse frequency, and pulse width. Several recent experimental studies suggest that the new dual-phase Moses 'pulse modulation' technology, introduced in high-power laser machines, carries a potential to increase stone ablation efficiency and decrease stone retropulsion. A newly introduced thulium fiber laser (TFL) has been adapted to a very small laser fiber size and is able to generate very low pulse energy and very high pulse frequency. Both of these technologies promise to play a larger role in laser lithotripsy in the near future. However, more experimental and clinical studies are needed to expand on these early experimental findings. Even though laser lithotripsy is considered safe, precautions should be taken to avoid harmful or even catastrophic adverse events to the patient or the operating room staff. SUMMARY: The Ho:YAG laser remains the clinical gold standard for laser lithotripsy for over the last two decades. High-power Ho:YAG laser machines with Moses technology have the potential to decrease stone retropulsion and enhance efficiency of laser ablation. The new TFL has a potential to compete with and perhaps even replace the Ho:YAG laser for laser lithotripsy. Safety precautions should be taken into consideration during laser lithotripsy.

Acute focal bacterial nephritis is associated with invasive diagnostic procedures - a cohort of 138 cases extracted through a systematic review.

BACKGROUND: Acute focal bacterial nephritis (AFBN) is a rare disease currently described only in case reports and small case series. In this study we summarize the clinical features of AFBN as has been documented in the literature and draw recommendations on the proper diagnosis and therapy. METHODS: A systematic literature review was undertaken in PUBMED, Web of Science and The Cochrane Library online databases for relevant literature on AFBN in adults. RESULTS: Literature review revealed a total of 38 articles according to our inclusion criteria, of which we could extract data from 138 cases of AFBN. Fever (98%) and flank pain (80%) were most commonly reported symptoms. E. coli was the most frequent pathogen. Diagnosis was set by CT and/or MRI (52%) with or without sonography or by sonography alone (20%) as well as by sonography combined with IVU. In total, sonography was applied in 83% of cases. All but one patient received antibiotic treatment. Kidney lesions were occasionally mistaken for neoplasms or renal abscesses and as a result, cases were subjected to percutaneous puncture (12.3%), surgical exploration (5.1%) and partial or radical nephrectomy (4.4%). Four cases (2.9%) developed a renal abscess. CONCLUSIONS: The diagnosis of AFBN is set by characteristic clinico-radiological findings. Differential diagnoses of this interstitial bacterial infection include renal abscess and tumor. Correct diagnosis is occasionally impeded by atypical symptoms. Invasive diagnostic and therapeutic procedures should be limited as the majority of cases respond well to conservative treatment.

Acute Focal Bacterial Nephritis Can Lead to Unnecessary Invasive Procedures: A Report of Three Cases.

Acute focal bacterial nephritis (AFBN) is a rarely diagnosed interstitial bacterial infection of the kidney. Due to the non-specific clinical presentation of this entity, correct diagnosis can be challenging. In this work, we present three cases of AFBN aiming to stress the diversity of clinical presentation associated with the disease and the fact that patients with AFBN are at risk of undergoing unnecessary invasive procedures. The employment of invasive diagnostic and therapeutic procedures on the management of AFBN should be limited, as the majority of patients respond well to conservative therapy.

The full metallic double-pigtail ureteral stent: Review of the clinical outcome and current status.

The full metallic double-J ureteral stent (MS) was introduced as a method for providing long-term drainage in malignant ureteral obstruction. Experimental evaluation of the MS revealed that its mechanical features allow efficient drainage in difficult cases, which could not be managed by the insertion of a standard polymeric double-J stent. Clinical experience with the MS showed controversial results. Careful patient selection results in efficient long-term management of malignant ureteral obstruction. The use of the MS should also be considered in selected benign cases. Major complications are uncommon and the minor complications should not hinder its use. Experience in pediatric patients is limited and warrants additional study. The cost-effectiveness of the MS seems to be appropriate for long-term treatment. Further investigation with comparative clinical trials would document the outcome more extensively and establish the indications as well as the selection criteria for the MS.

'Scarless' laparoscopic urologic surgery by the combination of mini-laparoscopic and laparoendoscopic single-site surgery equipment.

OBJECTIVE: We evaluated reconstructive and oncological laparoendoscopic single-site surgery (LESS) combined with mini-laparoscopic instruments as standard equipment. PATIENTS AND METHODS: 30 patients underwent reconstructive and oncological LESS: mini-laparoscopic-assisted LESS pyeloplasty (LESS-P, n = 18), mini-laparoscopic-assisted LESS partial nephrectomy (LESS-PN, n = 7) or mini-laparoscopic-assisted LESS radical prostatectomy (LESS-RP, n = 5). Perioperative data were prospectively collected. RESULTS: The 18 LESS-P cases had operative times ranging between 120 and 180 min (average 147.9 min). Estimated blood loss ranged between 100 and 300 ml (average 202.1 ml). Two patients required additional management for failed reconstruction. LESS-PN was performed in 7 patients with tumor size ranging between 2.5 and 3.8 cm (average 2.7 cm). Average operative time and blood loss were 155 (140-180) min and 321.4 (250-550) ml, respectively. Renal artery clamping took place in 1 case. LESS-RP was performed in 5 patients; average operative time was 156 (140-180) min and average blood loss 196 (100-400) ml. Functional and oncological outcome was directly comparable to laparoscopic radical prostatectomy. CONCLUSION: The combination of LESS and mini-laparoscopic instrumentation as routine equipment of reconstructive LESS reveals a different perspective for 'scarless' urologic surgery.

Drug-eluting metallic stents in urology.

Drugeluting metal stents (DESs) have been extensively used in coronary and vascular disease. This type of stents has been proven to provide significantly lower restenosis rates due to the reduction of neo-intimal hyperplasia in comparison to the traditionally used bare metal stents (BMSs). The latter stents have been evaluated for more than a decade in urological practice in an attempt to provide permanent relief of urethral or ureteral obstruction. Although the initial results were promising, long-term experience revealed significant complications, which are mainly attributed to stent-related hyperplastic reaction compromising stent patency. The favorable experience of vascular DESs led to the application of DESs in both the urethra and ureter of animal models. These experimental results demonstrated a reduction of hyperplastic reaction of DESs in comparison to BMSs. Nevertheless, clinical data are currently not available. Considering the fact that DESs are under continuous development, the use of DESs in urology holds promise for the future and seems to be an intriguing field.

Clinical outcomes of laparo-endoscopic single-site surgery radical nephrectomy.

INTRODUCTION: The conventional laparoscopic surgery is now paving way to the new technologies including robotic and laparoscopic single-site surgery (LESS). We present our updated experience on LESS radical nephrectomy (LESS-RN). PATIENTS AND METHODS: The data from patients undergoing LESS-RN in our two institutions were reviewed along with various clinical and pathological parameters. RESULTS: Between 2008 and 2011, 42 LESS-RN were performed (right = 22, left = 20) with mean (range) age and BMI of 63.7 (33-86) years and 25.1 (18-38.6) kg/m(2), respectively. In addition to the instruments in the single port, one extra 3-mm needlescopic instrument was required in 19 patients (right = 17, left = 2). In three patients, two additional 5-mm trocars and instruments were required. None required open conversion. The recorded adverse events include one bowel injury (intraoperative closure without the need for stoma), one postoperative bleeding requiring blood transfusion, one prolonged ileus, and one deep venous thrombosis. The resected specimens revealed pT1a (n = 3), pT1b (n = 33), pT2a (n = 4), and pT3b (n = 2) tumors. The finding of pT3b was incidental rather than planned procedure. None of the patients had positive margins. CONCLUSION: LESS-RN has proven to be feasible and safe. Beyond cosmesis, further advantages of this approach need to be addressed by randomized trials.

SDH-deficient renal cell carcinoma: A case report associated with a novel germline mutation.

The highly syndromic nature of succinate dehydrogenase-deficient RCCs constitutes their active surveillance and molecular profiling the alpha and omega.

Ureteral metal stents: 10-year experience with malignant ureteral obstruction treatment.

PURPOSE: Ureteral patency in malignant ureteral obstruction cases is a therapeutic challenge. We report our long-term experience with palliative treatment for extrinsic malignant ureteral obstruction with percutaneous placement of metal mesh stents. MATERIALS AND METHODS: From January 1996 to December 2005, 90 patients with a mean age of 59 years (range 35 to 80) with ureteral obstruction due to extrinsic ureteral compression and/or encasement by primary or metastatic tumors, or retroperitoneal lymphadenopathy underwent implantation of self-expandable metal mesh stents. A total of 119 ureters were managed. Followup included urinalysis, blood biochemistry tests and transabdominal ultrasound or intravenous urography. RESULTS: The technical success rate of percutaneous antegrade insertion of ureteral self-expandable metal mesh stents was 100%. Renal biochemistry normalized and hydronephrosis gradually resolved 1 to 2 weeks after stent insertion. Median followup was 15 months (range 8 to 38). Hyperplastic reaction and/or encrustation, or tumor ingrowth developed in 45 stents. Secondary intervention, such as repeat balloon dilation and coaxial stenting, was done to improve patency. Migration was observed in 13 metal stents. The primary and secondary patency rates during followup were 51.2% and 62.1%, respectively. A double pigtail or external-internal stent was inserted in 45 cases in which secondary interventions did not ensure patency. CONCLUSIONS: Internal drainage of extrinsic malignant ureteral obstruction with metal mesh stents provides long-term decompression of the upper urinary tract in select cases. Certain problems limit the application of metal mesh stents in the ureter. Further studies are warranted to identify independent predictors of ureteral patency after the application of metal stents for malignant obstruction.

Current status of laparoendoscopic single-site surgery in urology.

PURPOSE: Laparoendoscopic single-site surgery (LESS) uses single incisions for the introduction of instruments through a specially designed multi-lumen single port (multi-port) for the performance of several urologic procedures. METHODS: Literature review regarding the LESS approach took place on May 2009 and the experiences of our institutions were also included. RESULTS: Almost all urologic intra-abdominal and pelvic procedures have been successfully and safely performed with the LESS approach. Nevertheless, current experience is limited and there are significant technical challenges to the performance of LESS techniques. CONCLUSIONS: Wider adaptation of the approach requires refinement of LESS instrumentation to overcome the technical challenges of the approach. The improved outcome should also be documented with further clinical evaluation.

The use of a ureteral access sheath for the urethral dilatation and catheterization of difficult urethral strictures.

BACKGROUND: Urethral catheterization can often be technically demanding due to the presence of obstructing segments within the urethra. Conventional methods attempting to restore urethral patency often are unsuccessful and traumatize the urethral lumen. METHOD: We present an innovative technique by using a hydrophilic guidewire and a hydrophilic ureteral access sheath for the 'first-line' catheterization and management of 'difficult' urethral strictures. We used this technique in 10 extremely difficult cases of strictures present in all the urethral segments. RESULT: The dilation was successful and atraumatic in all the cases due to the hydrophilic nature of the access sheath. In all patients, larger sizes of urethral catheters were gradually inserted within the next couple of days. CONCLUSION: We propose 'access sheath'-assisted urethral dilatation as a safe and simple alternative for the 'first-line' catheterization and, possibly, management of 'difficult' urethral strictures.

The Effect of Irrigation Power and Ureteral Access Sheath Diameter on the Maximal Intra-Pelvic Pressure During Ureteroscopy: In Vivo Experimental Study in a Live Anesthetized Pig.

Objectives: To assess the effect of irrigation settings and the size of ureteral access sheath (UAS) on the maximal intra-pelvic pressure (IPPmax) during ureteroscopy (URS) in pigs. Materials and Methods: In supine position, three anesthetized female pigs underwent cystoscopy to insert a 6F ureteral catheter in each ureter. Pigs were then turned to prone position to establish a percutaneous access, insert a 10F nephrostomy tube in the kidney, and connect it to a urodynamic device. An 8F semi-rigid ureteroscope or the Flex-X2 Flexible Ureteroscope was used with two irrigation settings: gravity flow and manual pumping using a commercial pump. URS was performed without UAS and with the UAS 9.5/11, 12/14, 14/16 at the ureteropelvic junction and the IPPmax was recorded. Results: Under gravity irrigation, the recorded IPPmax during semi-rigid URS in the distal ureter and the renal pelvis was 0 and 30 cmH2O, respectively. Further, the IPPmax during flexible URS in the renal pelvis without UAS, with UAS 9.5/11.5, with UAS 12/14, and with UAS 14/16 was 23, 6, 2, and 1 cmH2O, respectively. Under manual pumping, the IPPmax during semi-rigid URS in the distal ureter and the renal pelvis was 84 and 105 cmH2O, respectively. Further, the IPPmax during flexible URS in the renal pelvis without UAS, with UAS 9.5/11.5, with UAS 12/14, and with UAS 14/16 was 45, 46, 18, and 1 cmH2O, respectively. Conclusion: Manual pumping can significantly increase the IPPmax to unsafe levels during URS. The UAS can significantly decrease the IPPmax, even under manual pumping. The larger the UAS, the lower the IPPmax. The use of UAS can render URS safer by acting as a safeguard against the consequences of increased IPP, even under forced irrigation.

Quality of life after radical prostatectomy.

INTRODUCTION: Radical prostatectomy is a standard approach to the management of prostate cancer. As the oncological outcome has improved, focus has drawn to the postoperative amelioration of health-related quality of life (HRQOL). MATERIALS AND METHODS: The instruments that have already been used, or may be used, in assessing the HRQOL postoperatively in men with prostate cancer are presented. RESULTS: Urinary and sexual dysfunction as well as fecal incontinence form the three possible major complications after surgery which affect the patient's quality of life. Meticulous counseling regarding the potential morbidity associated with the operation that may affect the patient's quality of life should be made before the patient gives his informed consent. CONCLUSIONS: Questionnaires only partially help to identify patients with dysfunction, especially sexual and bowel dysfunction, and careful patient counseling with their partners present is the best way to evaluate the presence of dysfunction pre- or postoperatively.

Robot-Assisted Simple Prostatectomy by an Extraperitoneal Approach.

The incidence of symptomatic benign prostate hyperplasia and bladder outlet obstruction has increased during the last two decades. Most of men are treated conservatively. When medical therapy is inadequate to relief symptoms, surgical treatment is necessary. Absolute indications for surgical treatment are gross hematuria, recurrent urinary infections and retentions as well as bladder stones. With advent of minimally invasive surgery, large prostates tend to be treated either endoscopically or laparoscopically (including robotic assistance). Herein, the robotic-assisted simple prostatectomy is described.

Application of paclitaxel-eluting metal stents in renal artery of pig model.

BACKGROUND AND PURPOSE: Recent reports concerning coronary, carotid, and femoral vasculature have proposed the use of drug-eluting metal stents (MS) to improve clinical and angiographic outcomes. Based on these reports, we used paclitaxel-eluting MS within an animal renal artery lumen and compared the results with those using a bare-metal stent. MATERIALS AND METHODS: The experimental model in this study was the female pig renal artery. Ten pigs with weights ranging from 25 to 30 kg were used. Twenty stents were placed, two in each animal. The MS placement was randomly performed in either the right or left renal artery of each animal. In 10 arteries, a 3.5 x 18 mm R-stent (group A) was placed; in the remaining 10 arteries, a 3 x 32 mm paclitaxel-eluting coronary stent (T-stent, group B) was inserted. Patency was estimated with the use of digital subtraction angiography, CT angiography, and virtual endoscopy at 24 hours and 1 month poststent placement. RESULTS: The positioning of the MS was successful in all cases. The initial angiographic result was maintained 24 hours after the intervention. No stent migration was seen, except for one paclitaxel stent that was acutely occluded. The one-month patency rate, as demonstrated by angiography, CT angiography, and virtual endoscopy, was 70% (8 arteries) in group A and 90% (9 arteries) in group B. The thickness of the endothelium and of the muscular coat was statistically significantly less in group B compared with group A (P = 0.0352 and P = 0.0046, respectively). CONCLUSION: These preliminary experimental study results suggest that the paclitaxel-eluting MS is more efficient than the bare-metal stent when used within the pig renal artery. Further experimental and clinical studies are necessary to validate our preliminary encouraging results.

The Decline of Laparoendoscopic Single-Site Surgery: A Survey of the Endourological Society to Identify Shortcomings and Guidance for Future Directions.

INTRODUCTION: To analyze the most recent temporal trends in the adoption of urologic laparoendoscopic single-site (LESS), to identify the perceived limitations associated with its decline, and to determine factors that might revive the role of LESS in the field of minimally invasive urologic surgery. MATERIALS AND METHODS: A 15 question survey was created and sent to members of the Endourological Society in September 2016. Only members who performed LESS procedures in practice were asked to respond. RESULTS: In total, 106 urologists responded to the survey. Most of the respondents were from the United States (35%) and worked in an academic hospital (84.9%). Standard LESS was the most popular approach (78.1%), while 14.3% used robotics, and 7.6% used both. 2009 marked the most popular year to perform the initial (27.6%) and the majority (20%) of LESS procedures. The most common LESS procedure was a radical/simple nephrectomy (51%) followed by pyeloplasty (17.3%). In the past 12 months, 60% of respondents had performed no LESS procedures. Compared to conventional laparoscopy, respondents only believed cosmesis to be better, however, this enthusiasm waned over time. Worsening shifts in enthusiasm for LESS also occurred with patient desire, marketability, cost, safety, and robotic adaptability. The highest rated factor to help LESS regain popularity was a new robotic platform. CONCLUSION: The decline of LESS is apparent, with few urologists continuing to perform procedures attributed to multiple factors. The availability of a purpose-built robotic platform and better instrumentation might translate into a renewed future interest of LESS.

Rigid-only versus combined rigid and flexible percutaneous nephrolithotomy: a systematic review.

INTRODUCTION: Percutaneous nephrolithotomy (PNL) is usually performed worldwide with a rigid-only antegrade approach. Daily practice suggests that adding flexible nephroscopy and/or ureteroscopy to conventional rigid PNL might improve its efficacy and safety, but available evidence is weak. Appraisal of reliable outcomes of such PNL techniques would better guide intraoperative choices and optimize surgical results. Therefore, our objective was to systematically review relevant literature comparing the outcomes of rigid-only PNL and combined flexible PNLs (adding flexible nephroscopy and/or flexible ureteroscopy) for the treatment of large and/or complex upper urinary tract calculi, with regard to efficacy and safety. EVIDENCE ACQUISITION: Ovid MedLine, PubMed, Scopus and Web of Science databases were searched in August 2016 to identify relevant studies. Article selection was performed according to the Preferred Reporting Items for Systematic Review and Meta-analysis criteria. EVIDENCE SYNTHESIS: Six articles reporting on 666 patients were included: two randomized controlled trials, two retrospective comparative studies and two case series ≥50 patients (one prospective and one retrospective). A narrative synthesis of minor evidences was also prepared. The adjunct of flexible nephroscopy and/or ureteroscopy provided better stone-free rates (range 86.7-96.97%), through a single percutaneous access most of the times and in any position, reducing the need for second-look procedures. Safety of the combined flexible procedures was improved to a variable degree, with a consensual reduction of the mean hospital stay (range 5.1-7 days). CONCLUSIONS: The current evidence suggests that patients with large and/or complex urolithiasis might benefit from the adjunct of flexible nephroscopy and/or ureteroscopy to rigid PNL.

Nerve-sparing endoscopic extraperitoneal radical prostatectomy: University of Leipzig technique.

PURPOSE: To describe the various operative steps as well as the functional and oncologic results of nerve-sparing endoscopic extraperitoneal radical prostatectomy (nsEERP). PATIENTS AND METHODS: One hundred twenty preoperatively potent patients have been treated with bilateral nsEERPE in our department. The average age of the patients was 60.3 years (range 41-74 years), and the mean prostate weight was 48.6 g (range 24-117 g). RESULTS: The mean operative time was 136 minutes (range 75-210 minutes). No conversions to open surgery were necessary. The mean catheterization time was 5.7 days (range 4-20 days). Lymphadenectomy was performed in 26 patients. The pathologic stages were pT2 in 78 and pT3 in 42 patients. Positive margins were detected in 7.7% (N = 6) and 19% (N = 8) of the patients with pT2 and pT3 disease, respectively. Erections sufficient for intercourse were reported in interviews with 58 patients (48.3%) during the 6-month follow-up period. Follow-up of at least 1 year is deemed necessary to draw more definite conclusions about erectile function. One week postoperatively, 32 patients (26.7%) required a maximum of 1 pad, 59 patients (49.2%) 2 or 3 pads, and 29 patients (24.2%) more than 3 pads per day because of incontinence, whereas 3 and 6 months after the procedure, 98 (82%) and 106 (88%) of the patients required a maximum of 1 pad, respectively. CONCLUSION: Our results demonstrate that nsEERPE can be performed with equal efficacy and preliminary results similar to those of standard open radical prostatectomy as well as transperitoneal laparoscopic prostatectomy while completely avoiding intraperitoneal complications.

Case report: laparoscopic adrenalectomy in a patient with primary adrenal malignant melanoma.

We report a case of laparoscopic management of a primary malignant melanoma of the left adrenal gland. A 42-year-old male presented a 55 x 60-mm round, inhomogeneous, noninvasive mass of the left adrenal gland. Hormone-activity values were within normal range. The mass was removed laparoscopically en bloc along with the left adrenal gland, and its histopathologic evaluation was consistent with the features of a malignant melanocytic tumor. Postoperatively, the patient presented no signs of fever or remarkable blood loss and was discharged on the third day in good clinical condition. He is free of disease 1 year later.