Oral preparation of hyaluronic acid, chondroitin sulfate, N-acetylglucosamine, and vitamin C improves sexual and urinary symptoms in participants with recurrent urinary tract infections: a randomized crossover trial.

BACKGROUND: Intravesical instillation of hyaluronic acid (HA) has been associated with reduced sexual dysfunction in participants with recurrent urinary tract infections (rUTIs), but the efficacy of an oral treatment has never been investigated. AIM: To investigate the efficacy of an oral preparation of HA, chondroitin sulfate, N-acetylglucosamine, and vitamin C in improving sexual and urinary symptoms in a cohort of reproductive-age participants with rUTI. METHODS: In a monocentric randomized crossover pilot trial, participants with rUTI who were referred to our institute between March 2022 and April 2023 were randomized 1:1 in 2 groups: intervention vs control. All participants had an oral preparation of cranberry, D-mannose, propolis extract, turmeric, and Boswellia twice a day for 3 months. The intervention group also included an oral preparation of HA, chondroitin sulfate, N-acetylglucosamine, and vitamin C once a day for 3 months. Crossover of treatment occurred at 3 months for an additional 3 months. At baseline and 3 and 6 months, participants were evaluated clinically and with the International Prostate Symptom Score (IPSS) and Female Sexual Function Index (FSFI). Descriptive statistics and logistic regression models tested the impact of the intervention on urinary and sexual symptoms at each follow-up assessment. OUTCOMES: Improvement in sexual and urinary symptoms as measured by the FSFI and IPSS. RESULTS: Overall, 27 (54%) participants had an FSFI score <26.5 at enrollment. At 3 months, FSFI scores were higher in the intervention group vs control (P < .001), but IPSS scores were lower (P = .03). After crossover of treatment, FSFI and IPSS scores remained stable in the intervention group. However, after crossover, the control group showed a significant improvement in IPSS and FSFI scores (all P < .01) vs the 3-month assessment. At last follow-up, urinary and sexual symptoms were comparable between groups. In logistic regression analyses, the intervention group was associated with early improvement in sexual symptoms (odds ratio, 3.9; P = .04) and urinary symptoms (odds ratio, 5.1; P = .01) after accounting for clinical confounders. CLINICAL IMPLICATIONS: Combination treatment with HA, chondroitin sulfate, N-acetylglucosamine, and vitamin C is effective if started immediately or even after a few months from symptoms in participants with rUTI. STRENGTHS AND LIMITATIONS: The main limitation is the lack of long-term follow-up. CONCLUSION: The oral formulation of HA, chondroitin sulfate, N-acetylglucosamine, and vitamin C could be an effective therapy against urinary and sexual distress in participants with rUTI (NCT06268483; ClinicalTrials.gov).

Prevalence and predictors of stone passage after double J stenting for symptomatic ureteral stones: a cross-sectional, real-life study.

PURPOSE: To evaluate the rate of and predictors of stone passage (SP) after urgent retrograde stenting for symptomatic ureteral stones. METHODS: We retrospectively analysed data from 249 consecutive patients presenting to the emergency department for symptomatic ureteral stones and treated with retrograde stenting. Demographic, clinical and laboratory characteristics were collected. Stones parameters were collected before stenting and SP was evaluated at 1 month with computerized tomography. Descriptive statistics and logistic regression models tested the association between predictors and SP. RESULTS: Overall, median (IQR) age and stone diameter were 56 (45-68) years and 7.1 (4.4-9.8) mm, respectively. Stones were located in the proximal, mid and distal ureter in 102 (41.0%), 48 (19.3%) and 99 (39.8%) cases. SP was observed in 65 (26.2%) individuals. Stone diameter (3.2 vs. 7.7 mm, p < 0.001) and stone density (416 vs. 741, p < 0.001) were lower and a higher rate of distal stones (76.9% vs. 26.7%, p < 0.001) was found in the SP group compared to that with persistent stones. Multivariable logistic regression analysis showed that distal ureteral stone location (OR 7.9, p < 0.01) and lower HU (OR 0.9, p < 0.01) were associated with SP, after accounting for stone volume. Patients with a distal stone of 500 HU had a 75% probability of SP. CONCLUSION: Stone passage occurred in 26% of patients with indwelling stent due to symptomatic ureteral stones. Lower stone density and distal stone location were independent predictors of stone passage. Patients with these criteria should be managed with follow-up imaging and stent removal instead of ureteroscopy.

Transient ureteral obstruction after mini-percutaneous nephrolithotomy is associated with stone volume and location: results from a single-center, real-life study.

PURPOSE: To evaluate the rate of and predictors of ureteral obstruction after mini-percutaneous nephrolithotomy (mPCNL) for kidney stones. METHODS: We analyzed data from 263 consecutive patients who underwent mPCNL at a single tertiary referral academic between 01/2016 and 11/2022. Patient's demographics, stone characteristics, and operative data were collected. A nephrostomy tube was placed as the only exit strategy in each procedure. On postoperative day 2, an antegrade pyelography was performed to assess ureteral canalization. The nephrostomy tube was removed if ureteral canalization was successful. Descriptive statistics and logistic regression models were used to identify factors associated with a lack of ureteral canalization. RESULTS: Overall, median (IQR) age and stone volume were 56 (47-65) years and 1.7 (0.8-4.2) cm3, respectively. Of 263, 55 (20.9%) patients showed ureteral obstruction during pyelography. Patients without ureteral canalization had larger stone volume (p < 0.001), longer operative time (p < 0.01), and higher rate of stones in the renal pelvis (p < 0.01) than those with normal pyelography. Length of stay was longer (p < 0.01), and postoperative complications (p = 0.03) were more frequent in patients without ureteral canalization. Multivariable logistic regression analysis revealed that stone volume (OR 1.1, p = 0.02) and stone located in the renal pelvis (OR 2.2, p = 0.04) were independent predictors of transient ureteral obstruction, after accounting for operative time. CONCLUSION: One out of five patients showed transient ureteral obstruction after mPCNL. Patients with a higher stone burden and with stones in the renal pelvis are at higher risk of inadequate ureteral canalization. Internal drainage might be considered in these cases to avoid potential complications.

Vacuum-assisted mini-percutaneous nephrolithotomy is associated with lower rates of infectious complications compared to vacuum-cleaner procedure in patients at high risk for infections: a single-center experience.

PURPOSE: To evaluate the impact of vacuum-assisted mini-percutaneous nephrolithotomy (vamPCNL) vs. vacuum-cleaner mPCNL (vcmPCNL) on the rate of postoperative infectious complications in a cohort of patients with high risk factors for infections. METHODS: We retrospectively analysed data from 145 patients who underwent mPCNL between 01/2016 and 12/2022. Patient's demographics, stones characteristics and operative data were collected. vamPCNL and vcmPCNL were performed based on the surgeon's preference. High-risk patients were defied as having ≥ 2 predisposing factors for infections such as a history of previous urinary tract infections, positive urine culture before surgery, stone diameter ≥ 3 cm, diabetes mellitus and hydronephrosis. Complications were graded according to modified Clavien classification. Descriptive statistics and logistic regression models were used to identify factors associated with postoperative infectious complications. RESULTS: vamPCNL and vcmPCNL were performed in 94 (64.8%) and 51 (35.2%) cases, respectively. After surgery, infectious complications occurred in 43 (29.7%) participants. Patients who developed infectious complications had larger stone volume (p = 0.02) and higher rate of multiple stones (p = 0.01) than those who did not. Infectious complications occurred more frequently after vcmPCNL than vamPCNL (55.9% vs. 44.1%. p = 0.01) in high-risk patients. Longer operative time (p < 0.01) and length of stay (p < 0.01) were observed in cases with infectious complications. At multivariable logistic regression analysis, longer operative time (OR 1.1, p = 0.02) and vcmPCNL (OR 3.1, p = 0.03) procedures were independently associated with the risk of infectious complications post mPCNL, after accounting for stone volume. CONCLUSION: One out of three high-risk patients showed infectious complications after mPCNL. vamPCL and shorter operative time were independent protective factors for infections after surgery.

Extended pelvic lymph node dissection during robotic prostatectomy: antegrade versus retrograde technique.

BACKGROUND: Robot-assisted radical prostatectomy (RARP) with extended lymphadenectomy (ePLND) is the gold standard for surgical treatment of prostate cancer (PCa). Recently, the en-bloc ePLND has been proposed but no studies reported on the standardization of the technique. The aim of the study is to describe different standardized en-bloc ePLND, the antegrade and the retrograde ePLND, and to compare their surgical and oncological outcomes. MATERIALS & METHODS: From January 2018 to September 2019, all patients subjected to RARP plus ePLND by one single surgeon were enrolled. ePLND was performed in a retrograde fashion by starting laterally to the medial umbilical ligament from the internal inguinal ring proceeding towards the ureter, or in an antegrade way by starting from the ureter at its crossing with the common iliac artery and proceeding towards the femoral canal. Patients' demographic data, clinical and surgical data were collected. Each en-bloc ePLND was categorized as "efficient" or "inefficient" by the operator, as surrogate of surgeon's satisfaction. RESULTS: Antegrade and retrograde ePLND were performed in 41/105 (group A) and 64/105 (group R) patients, respectively. The two groups (A vs R) had similar median (IQR) number of lymph nodes retrieved [20 (16.25-31.5) vs 19 (15-26.25); p = 0.18], ePLND time [33.5 (29.5-38.5) min vs 33.5 (26.5-37.5) min; p = 0.4] and post-operative complications [8/41 (19.5%) vs 9/64 (14.1%); p = 0.61]. In group A, 3/41 (7.3%) clinically significant lymphoceles were reported, while 1/64 (1.6%) in group R (p = 0.3). 33/41 (80.5%) and 28/64 (44%) procedures were scored as efficient 59 in group A and R, respectively (p = 0.01). On multivariate regression, only BMI (B = 0.93; 95% CI 0.29-1.56; p = 0.005) was associated with a longer ePLND time. CONCLUSIONS: The study indicates that antegrade and retrograde en-bloc extended pelvic lymph node dissection (ePLND) have comparable surgical and oncologic outcomes, supporting the importance of standardizing the procedure rather than focusing on the direction. Although both techniques aligned with current evidence regarding lymph node invasion and complications, the antegrade approach was subjectively perceived as safer due to early isolation of critical anatomical landmarks. Encouragement for the use of en-bloc ePLND, regardless of direction, is emphasized to improve prostate cancer staging accuracy and procedural standardization.

Clinical and time-related predictors of sepsis in patients with obstructive uropathy due to ureteral stones in the emergency setting.

PURPOSE: Well-defined clinical predictors of sepsis after upper tract drainage for obstructive uropathy due to ureteral stones are needed. We aim to determine whether sepsis after decompression of the upper urinary tract may be predicted by clinical and time-related factors, specifically delay time from symptom onset to hospital presentation (StH) and from hospital presentation to surgical decompression (HtD). METHODS: In this single-center retrospective study, data from 196 consecutive patients presenting to the emergency department for obstructive uropathy due to ureteral stones and submitted to surgical decompression were evaluated. Postoperative sepsis was defined as an acute increase in ≥ 2 SOFA points and documented blood or urine cultures. RESULTS: Median StH and HtD were 24 (6-48) and 17 (10-30) hours, respectively. Thirty-three (16.8%) patients developed sepsis. Septic patients were more frequently female (75.8% vs. 37.4%, p < 0.001), had higher preoperative max body temperature (p < 0.001), white blood cells (WBC) count (p < 0.01), C-reactive protein (CRP) values (p < 0.001) and larger stone diameter (7.2 vs. 6 mm, p = 0.02). StH and HtD did not differ according to sepsis status. Time for WBC normalization and CRP halving were longer for septic patients (all p < 0.02). At multivariable logistic regression analysis, max body temperature ≥ 38 °C (OR 21.5; p < 0.001), female gender (OR 3.6; p = 0.02) and higher CRP (OR 1.1; p < 0.001) were independently associated with sepsis status. CONCLUSION: Clinical and laboratory parameters are associated with an increased risk of sepsis after decompression. StH and HtD timing are not associated with higher sepsis rates. In selected patients, urinary decompression could be delayed or primary ureteroscopy could be considered.

The clinical role of bacteremia and bacterial spread into the irrigation fluid during percutaneous nephrolithotomy: a prospective study.

PURPOSE: Backflow of pathogens and endotoxins from the renal pelvis to the bloodstream is one supposed mechanism for infectious complications development after endourological stones surgery. The aim of this study is detecting to prove bacterial spread into irrigation fluid and bloodstream during percutaneous nephrolithotomy (PCNL) and to correlate these findings with clinical and microbiological parameters and infectious complications (IC). METHODS: Bladder urine culture (BUC) was retrieved before PCNL; during the procedure, 2 blood samples (BC) and an irrigation fluid sample during fragmentation (SFUC) were collected for culture. Stone culture (SC) was also obtained. Patients were evaluated post-operatively for IC. RESULTS: Sixty-one patients were prospectively included. IC occurred in 15 patients (24.6%). SFUC was positive in 7/61 (11.5%); BC in 10/61 (16.4%). Among patients with positive BC; BUC, SFUC and SC were positive in 9 (90%), 6 (60%), and 8 (80%) cases, respectively. Out of 10 patients with positive BC, 4 developed post-operative IC. Pre-operative renal impairment (p = 0.04), intraoperative-evaluated stone residual (p = 0.02), BUC (p = 0.004), and SC (p = 0.008) were associated with IC. No correlation was found between bacterial spread in the irrigation fluid and blood and IC. CONCLUSION: We proved that bacteria can be detected into the irrigation fluid and blood during PCNL. This transient bacteremia appears to be unrelated to IC development.

Urologists are optimistic surgeons: prevalence and predictors of discordance between intraoperative stone-free rate and cross-sectional imaging evaluation after vacuum-assisted mini-percutaneous nephrolithotomy.

PURPOSE: To assess how accurate are urologists in predicting stone-free status (SFS) after vacuum-assisted mini-PCNL (vamPCNL) compared to computed tomography (CT) and clinical predictors of discordant SFS. METHODS: Data from 235 patients who underwent vamPCNL were analysed. Patient's demographics, stones' characteristics and operative data were recorded. SFS was evaluated intraoperatively by the treating urologist (iSFS) and with non-contrast CT 3 months after vamPCNL (ctSFS). SFS was defined as no residual stones. Stone complexity was scored with the Guy's score. Descriptive statistics and logistic regression models were used to identify clinical factors associated with discordant SFS (namely iSFS not confirmed at CT). RESULTS: iSFS and ctSFS were 88.5% and 65.5%, respectively, with 54 (23%) cases resulting in discordant evaluation of SFS between the surgeon and CT imaging. Patients with discordant SFS had larger stone volume (p < 0.001), higher rate of multiple stones (p = 0.03) and higher rate of multiple calyceal groups affected by stones (p < 0.001) than those with concordant SFS. The use of flexible ureteroscopes to look for residual stones after lithotripsy was more frequently reported in cases with concordant SFS (p = 0.001). Multivariable logistic regression analysis revealed that stones in > 2 calyceal groups (OR 10.2, p < 0.001), Guy's score II (OR 5.8, p < 0.01) and not using flexible ureteroscopes after lithotripsy (OR 2.9, p = 0.02) were independent predictors of discordant SFS. CONCLUSION: One out of five patients is erroneously considered SF after vamPCNL. Urologist should carefully evaluate patients with multiple calyceal stones and consider using flexible ureteroscopes to complete lapaxy of migrated fragments in order to improve their prediction of SFS.

The comprehensive complication index as a tool for reporting the burden of complications after mini-percutaneous nephrolithotomy: is it time to leave the Clavien-Dindo classification behind?

PURPOSE: To validate the comprehensive complication index (CCI) for mini-percutaneous nephrolithotomy (mPCNL). METHODS: Data from 287 patients who underwent mPCNL were analyzed. Complications after mPCNL were classified using both the CCI and the Clavien-Dindo classification (CDC). Descriptive statistics and linear/logistic regression analyses detailed the association between clinical predictors and mPCNL outcomes. RESULTS: After mPCNL, 83 (28.9%) patients had complications, of which 12 (4.2%) patients with multiple complications had a higher CCI score compared to the traditional CDC system accounting only for the highest grade. The CCI enabled a more accurate prediction of length of stay (LOS) than CDC (CCI: r = 0.32; p < 0.01 vs. CDC: r = 0.26; p = 0.01). Patients with multiple complications had higher stone volume (p = 0.02), longer operative time and LOS (all p < 0.01). A higher rate of post-operative hospital readmission (33.3% vs. 9.9%, p = 0.02) and lower rate of stone free (33.3% vs. 64.7%, p = 0.04) were found in patients with multiple complications than in those with single complication. Linear regression analysis revealed that multiple complications were associated with longer LOS (p < 0.001) after accounting for BMI and stone volume. Similarly, having multiple complications was associated with fivefold higher risk of readmission (p = 0.02). CONCLUSION: The CCI is a valuable metric for assessing post-operative complications after mPCNL. The cumulative CCI is a better predictor of LOS than the CDC for mPCNL. Minor complications not captured by the highest CDC score are relevant since patients with multiple complications have longer LOS and higher rate of readmission than those with single ones.

Cost analysis between mini-percutaneous nephrolithotomy with and without vacuum-assisted access sheath.

PURPOSE: To perform a cost analysis between vacuum-assisted percutaneous nephrolithotomy (vmPCNL) and minimally invasive PCNL (MIP) and explore potential predictors of costs associated with the procedures. METHODS: We analyzed data from 225 patients who underwent vmPCNL or MIP at a single tertiary referral academic center between January 2016 and December 2020. We collected patients' demographics, peri-and postoperative data and detailed expense records. After propensity score matching, 108 (66.7%) vmPCNL and 54 (33.3%) MIP procedures were analyzed. Descriptive statistics assessed differences in clinical and operative parameters. Univariable and multivariable linear regression models tested the association between clinical variables and costs. RESULTS: Operative time (OT) was shorter for vmPCNL, and the use of additional instruments to complete litholapaxy was more frequent in MIP (all p ≤ 0.01). Length of stay (LOS) was longer for MIP patients (p = 0.03) and the stone-free (SF) rate was higher after vmPCNL (p = 0.04). The overall instrumentation cost was higher for vmPCNL (p < 0.001), but total procedural costs were equivalent (p = 0.9). However, the overall cost for the hospitalization was higher for MIP than vmPCNL (p = 0.01). Univariable linear regression revealed that patient's comorbidities, OT, any postoperative complication and LOS were associated with hospitalization costs (all p < 0.001). Multivariable linear regression analysis revealed that LOS and OT were associated with hospitalization costs (all p < 0.001), after accounting for vmPCNL procedure, patients' comorbidities, and complications. CONCLUSION: vmPCNL may represent a valid option due to clinical and economic benefits. Shorter OT, the lower need for disposable equipment and the lower complication rate reduced procedural and hospitalization costs.

Comparison of the performances of the ADXBLADDER test and urinary cytology in the follow-up of non-muscle-invasive bladder cancer: a blinded prospective multicentric study.

OBJECTIVE: To compare directly the performance of the ADXBLADDER test with that of cytology in the detection of non-muscle-invasive bladder cancer (NMIBC) recurrences. BACKGROUND: ADXBLADDER is a urine test based on the detection of MCM5, a DNA licensing factor expressed in all cells capable of dividing. Expression is usually restricted to the basal stem cell compartment; however, in malignancy, MCM5-expressing cells can be found throughout the epithelium. Detection of MCM5 in urine sediment can be indicative of the presence of a bladder tumour. PATIENTS AND METHODS: A multicentre prospective, blinded study was carried out from August 2017 and July 2019 at 21 European Union centres, 14 of which collected matching cytology data. Urine was collected from patients prior to cystoscopy. Urine cytology and ADXBLADDER were performed and compared to the diagnosis obtained by cystoscopy. The performance of cytology and ADXBLADDER were then compared. RESULTS: The overall performance of ADXBLADDER demonstrated a sensitivity of 51.9%, a specificity of 66.4%, and a negative predictive value (NPV) of 92%. The sensitivity of ADXBLADDER for low- and high-grade recurrences was 44.1% and 58.8%, respectively. By contrast, cytology sensitivity was 16.7%, specificity was 98% and NPV was 90.7%. Cytology sensitivity for both low- and high-grade disease was 17.6%. CONCLUSIONS: ADXBLADDER detection of both low- and high-grade NMIBC recurrence is superior to that of cytology, with ADXBLADDER able to exclude the presence of high-grade recurrence in 97.8% of cases compared to 97.1% with cytology. These results show that ADXBLADDER has promise as a more reliable alternative to urine cytology in the follow-up of NMIBC.

Vacuum-assisted mini-percutaneous nephrolithotomy: a new perspective in fragments clearance and intrarenal pressure control.

PURPOSE: To describe the vacuum-assisted mini-percutaneous nephrolithotomy (vmPCNL) technique performed via the 16Ch ClearPetra sheath, to evaluate its outcomes and to analyze intrarenal pressure (IRP) fluctuations during surgery. METHODS: Data from all consecutive vmPCNL procedures from September 2017 to October 2019 were prospectively collected. Data included patients' and stones characteristics, intra and peri-operative items, post-operative complications and stone clearance. Patients undergoing vmPCNL from March to October 2019 were submitted to IRP measurement during surgery. RESULTS: A total of 122 vmPCNL procedures were performed. Median stone volume was 1.92 cm3. Median operative time was 90 min and median lithotripsy and lapaxy time was 28 min. Stone clearance rate was 71.3%. Thirty-one (25.2%) patients experienced post-operative complications, seven of which were Clavien 3. Postoperative fever occurred in nine (7.4%) patients and one (0.8%) needed a transfusion. No sepsis were observed. IRPs were measured in 22 procedures. Mean IRP was 15.3 cmH2O and median accumulative time with IRP > 40.78 cmH2O (pyelovenous backflow threshold) was 28.52 sec. Maximum IRP peaks were reached during the surgical steps when aspiration is closed (mainly pyelograms), whereas during lithotripsy and suction-mediated lapaxy, the threshold of 40.78 cmH2O was overcome in three procedures. CONCLUSIONS: vmPCNL is a safe procedure with satisfactory stone clearance rates. Mean IRP was always lower than the threshold of pyelo-venous backflow and the accumulative time with IRP over this limit was short in most of the procedures. During lithotripsy and vacuum-mediated lapaxy, IRP rarely raised over the threshold.

Diagnostic Accuracy of MCM5 for the Detection of Recurrence in Nonmuscle Invasive Bladder Cancer Followup: A Blinded, Prospective Cohort, Multicenter European Study.

PURPOSE: Detection of MCM5 containing cells in urine has been shown to be indicative of the presence of a bladder tumor on primary diagnosis. In this study we evaluate diagnostic performance of ADXBLADDER in patients undergoing cystoscopic surveillance in nonmuscle invasive bladder cancer followup. MATERIALS AND METHODS: A multicenter prospective blinded study was performed at 21 European centers with patients undergoing cystoscopy for nonmuscle invasive bladder cancer surveillance, diagnosed in the preceding 2 years. Urine was collected from all eligible patients and ADXBLADDER-MCM5 testing was performed. Performance characteristics were calculated by comparing MCM5 results to the outcome of cystoscopy plus pathological assessment. RESULTS: Of 1,431 eligible patients enrolled 127 were diagnosed with a bladder cancer recurrence. The overall sensitivity for the ADXBLADDER-MCM5 test in detecting bladder cancer recurrence was 44.9% (95% CI 36.1-54) with a 75.6% sensitivity for nonpTaLG tumors (95% CI 59.7-87.6). Specificity was 71.1% (95% CI 68.5-73.5). The overall negative predictive value was 93% (95% CI 91.2-94.5). However, ADXBLADDER was able to rule out the presence of a nonpTaLG recurrent tumor with a negative predictive value of 99.0% (95% CI 98.2-99.5). No statistically significant differences in the performance of ADXBLADDER were observed as a result of age or sex. CONCLUSIONS: This large blinded prospective study demonstrates that in the followup of patients with nonmuscle invasive bladder cancer ADXBLADDER is able to exclude the presence of the most aggressive tumors with a negative predictive value of 99%. These results indicate that ADXBLADDER could be incorporated in the followup strategy of nonmuscle invasive bladder cancer.

Medical Expulsive Therapy for Symptomatic Distal Ureter Stones: Is the Combination of Bromelain and Tamsulosin More Effective than Tamsulosin Alone? Preliminary Results of a Single-Center Study.

OBJECTIVES: To assess the safety and efficacy of bromelain plus tamsulosin versus tamsulosin alone as medical expulsive therapy (MET) for promoting spontaneous stone passage (SSP) of symptomatic distal ureter stones. PATIENTS AND METHODS: One-hundred-fourteen patients with a 4-10 mm distal ureteral stone were enrolled (Group A). Patients self-administered daily bromelain with tamsulosin for 30 days or until SSP or intervention was mandatory. Patients were compared to those from a control group taking tamsulosin as MET (Group B) and matched for the following factors: sex, age ±10%, stone diameter. A logistic regression model evaluated bromelain and the ureteral stone diameter as explanatory variables. RESULTS: SSP rates were 87.7 vs. 75.4% for group A vs. group B respectively (p = 0.016); with no difference observed for the time to self-reported stone expulsion (11.68 vs. 11.57 days; p = 0.91). Considering larger stones (> 5 mm), the SSP rate was 83.3% in group A and 61% in group B (p < 0.01). With each millimeter increment of stone diameter, the probability of SSP decreased by 59.1% (p < 0.0001), while it increased of 3.3 when bromelain was present. Only 3 cases of tamsulosin-related adverse events were recorded. CONCLUSION: The association of bromelain and tamsulosin as MET increases the probability of SSP of symptomatic distal ureteral stones, with no bromelain-related side effects recorded.

Clinical utility of computed tomography Hounsfield characterization for percutaneous nephrolithotomy: a cross-sectional study.

BACKGROUND: Computed Tomography (CT) is considered the gold-standard for the pre-operative evaluation of urolithiasis. However, no Hounsfield (HU) variable capable of differentiating stone types has been clearly identified. The aim of this study is to assess the predictive value of HU parameters on CT for determining stone composition and outcomes in percutaneous nephrolithotomy (PCNL). METHODS: Seventy seven consecutive cases of PCNL between 2011 and 2016 were divided into 4 groups: 40 (52%) calcium, 26 (34%) uric acid, 5 (6%) struvite and 6 (8%) cystine stones. All images were reviewed by a single urologist using abdomen/bone windows to evaluate: stone volume, core (HUC), periphery HU and their absolute difference. HU density (HUD) was defined as the ratio between mean HU and the stone's largest diameter. ROC curves assessed the predictive power of HU for determining stone composition/stone-free rate (SFR). RESULTS: No differences were found based on the viewing window (abdomen vs bone). Struvite stones had values halfway between hyperdense (calcium) and low-density (cystine/uric acid) calculi for all parameters except HUD, which was the lowest. All HU variables for medium-high density stones were greater than low-density stones (p < 0.001). HUC differentiated the two groups (cut-off 825 HU; specificity 90.6%, sensitivity 88.9%). HUD distinguished calcium from struvite (mean ± SD 51 ± 16 and 28 ± 12 respectively; p = 0.02) with high sensitivity (82.5%) and specificity (80%) at a cut-off of 35 HU/mm. Multivariate analysis revealed HUD ≥ 38.5 HU/mm to be an independent predictor of SFR (OR = 3.1, p = 0.03). No relationship was found between HU values and complication rate. CONCLUSIONS: HU parameters help predict stone composition to select patients for oral chemolysis. HUD is an independent predictor of residual fragments after PCNL and may be fundamental to categorize it, driving the imaging choice at follow-up.

Assessment of Effectiveness and Safety of Aspiration-Assisted Nephrostomic Access Sheaths in PCNL and Intrarenal Pressures Evaluation: A Systematic Review of the Literature.

Background: Different suction-assisted nephrostomic sheaths have been developed for percutaneous nephrolithotomy (PCNL). Objectives: (1) To examine PCNL techniques performed with different aspiration-assisted sheaths (Clear Petra® sheath, Superperc, SuperminiPCNL, and a miniPCNL patented sheath), with specific regard to effectiveness and safety outcomes in adult and paediatric patients; (2) to extrapolate intrarenal pressure (IRP) data during these procedures. Methods: A systematic literature search was performed in accordance with PRISMA guidelines. Relevant articles up to 8 February 2024 were included. Results: Twenty-five studies were selected, thirteen retrospective and twelve prospective. The use of four different aspirating sheaths for miniPCNL was reported: Clear Petra® sheath, Superperc, SuperminiPCNL, and a miniPCNL patented sheath. Stone free rates (SFRs) across techniques ranged from 71.3% to 100%, and complication rates from 1.5% to 38.9%. Infectious complication rates varied from 0 to 27.8% and bleeding complication rates from 0 to 8.9%. Most complications were low grade ones. The trend among studies comparing aspiration- and non-aspiration-assisted miniPCNL was towards equivalent or better SFRs and lower overall infectious and bleeding complication rates in suction techniques. Operation time was consistently lower in suction procedures, with a mean shortening of the procedural time of 19 min. Seven studies reported IRP values during suction miniPCNL. Two studies reported satisfactory SFRs and adequate safety profiles in paediatric patient cohorts. Conclusions: MiniPCNL with aspirating sheaths appears to be safe and effective in both adult and paediatric patients. A trend towards a reduction of overall infectious and bleeding complications with respect to non-suction procedures is evident, with comparable or better SFRs and consistently shorter operative times. The IRP profile seems to be safe with the aid of aspirating sheaths. However, high quality evidence on this topic is still lacking.

Narrow-band imaging (NBI) and white light (WLI) transurethral resection of the bladder in the treatment of non-muscle-invasive bladder cancer.

OBJECTIVE: Narrow-band imaging (NBI) is an optical image enhancement technology Summary that narrows the bandwidth of the light output from the endoscopy system to 415 nm and 540 nm. The aim of the present study is to evaluate the feasibility of NBI transurethral resection of the bladder (TURB NBI) compared to in White Light (TURB WLI) (Feasibility study) and the recurrence rate at the 1-year follow-up in patients treated for non-muscle-invasive bladder cancer (NMIBC) (recurrence study). METHODS: A total of 92 patients with a suspicion of primary or recurrent bladder cancer were prospectively enrolled in our study. Forty-five were consecutively enrolled to undergo WLI TURB and 47 consecutively to undergo NBI TURB. All patients underwent routine follow-up with flexible WLI cystoscopy every 3 months during the first year and every 6 months during the second year, supplemented by urine examination, urine culture, and bladder washout cytology. RESULTS: Type I-II complications were reported in 12 patients in the NBI group (25%) and in 10 patients in the WLI group (22%). Patients with High Grade NMIBC who underwent a second look WLI TURB had residual disease in 33% of NBI group and in 43% of WLI group.The recurrence rate at one year follow-up was 35% in NBI group and 50% in WLI group. No statistic significance can be issued for the clinical differences observed. CONCLUSIONS: TURB performed entirely by the NBI technique is feasible and safe. It guarantees a complete and rapid resection of good quality from a pathological point of view. Moreover, the technique is relatively inexpensive with respect to other methods proposed to enhance the detection rate, for which data on operative endoscopy are lacking. In our clinical experience, even if not statistically significant, NBI TURB reduces at one year follow up the recurrence rate of bladder NMI tumours when compared to WLI TURB (35% vs. 50%). Other larger, randomized, prospective trials with longer follow-up periods are required to confirm our outcomes.

Sexual and ejaculatory function after holmium laser enucleation of the prostate and bipolar transurethral enucleation of the prostate: a single-center experience.

Currently available surgical treatments for Lower Urinary Tract Symptoms (LUTS) due to Benign Prostatic Obstruction (BPO) are associated with an increased risk of sexual dysfunction. The aim of our study is to compare sexual and ejaculatory function after Holmium Laser Enucleation of the Prostate (HoLEP) and Bipolar Transurethral Enucleation of the Prostate (B-TUEP). We performed a retrospective analysis of data prospectively collected from 62 (44.9%) and 76 (55.1%) patients who underwent HoLEP and B-TUEP, respectively. Erectile function and ejaculation characteristics were assessed with the International Index of Erectile Function-Erectile Function (IIEF-EF) domain and the Male Sexual Health Questionnaire-Ejaculatory function (MSHQ-EJ) questionnaires. Our study recorded no change in erectile function and no significant difference in rates of preserved antegrade ejaculation after both surgeries. One month after surgery, rates of physical pain/discomfort and perceived decreased physical pleasure during ejaculation were higher in HoLEP than B-TUEP patients (all p < 0.03). Moreover, HoLEP patients were more bothered by their ejaculatory difficulties than B-TUEP men (p = 0.03). At 3- and 12-months follow-up, all ejaculation-related differences disappeared. In conclusion, both procedures are valid alternatives for BPO treatment as they offer comparable urinary and sexual outcomes in the long term. However, in the first month after surgery, HoLEP patients present with more ejaculatory difficulties.

Reducing the Frequency of Follow-up Cystoscopy in Low-grade pTa Non-muscle-invasive Bladder Cancer Using the ADXBLADDER Biomarker.

BACKGROUND: Non-muscle-invasive bladder cancer (NMIBC) is one of the most expensive cancers owing to frequent follow-up cystoscopies for detection of recurrence. OBJECTIVE: To assess if the noninvasive ADXBLADDER urine test could permit a less intensive surveillance schedule for patients with low-grade (LG) pTa tumor without carcinoma in situ (CIS) at the previous diagnosis. DESIGN, SETTING, AND PARTICIPANTS: In a prospective, double-blind, multicenter study, 629 patients underwent follow-up cystoscopy, transurethral resection of bladder tumor/biopsy of suspect lesions, and ADXBLADDER testing. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Diagnostic test accuracy and decision curve analysis were used to evaluate the impact of ADXBLADDER on decision-making on whether to perform follow-up cystoscopy. The primary endpoint was the negative predictive value (NPV) of ADXBLADDER for detection of high-grade and/or CIS (HG/CIS) recurrence and its impact on reducing unnecessary cystoscopies. RESULTS AND LIMITATIONS: ADXBLADDER had sensitivity of 66.7% (95% confidence interval [CI] 34.9-90.1%) and an NPV of 99.15% (95% CI 97.8-99.8%) for detection of HG/CIS recurrence. The probability of HG/CIS recurrence was 5.0% for ADXBLADDER-positive patients and 0.85% for ADXBLADDER-negative patients. For HG/CIS recurrence threshold probabilities between 0.85% and 5.0%, ADXBLADDER yields a net benefit with omission of cystoscopy for ADXBLADDER-negative patients. The corresponding net reduction in unnecessary cystoscopies ranges from 11 to 62 per 100 patients. CONCLUSIONS: Patients with LG pTa tumor at the previous diagnosis, for which the risk of HG/CIS recurrence is low and the ADXBLADDER NPV for ruling out HG/CIS recurrence is 99.15%, are ideally suited for a less intensive, personalized follow-up surveillance strategy using ADXBLADDER, with omission of cystoscopy for ADXBLADDER-negative patients. PATIENT SUMMARY: ADXBLADDER is a urine test that can predict the probability of recurrence of bladder cancer. Patients diagnosed with low-grade cancer confined to the bladder mucosa are ideally suited for less intensive follow-up using this test, which could reduce unnecessary cystoscopy procedures for those with a negative result, potentially improve quality of life, and reduce overall health care costs.