Patients undergoing double J substitution with a pigtail suture stent report a significant decrease of stent-related symptoms. Results from a prospective multicenter longitudinal trial.

PURPOSE: To compare stent-related symptoms (SRS) in patients with double J (DJ) undergoing substitution with a pigtail suture stent (PSS) after ureteroscopy (URS), through the Ureteral Stent Symptom Questionnaire (USSQ). MATERIALS AND METHODS: Patients with DJ undergoing URS for stone treatment were enrolled in this prospective multicenter longitudinal study. The USSQ was submitted thrice: 2 weeks after DJ, 2 weeks after PSS and 4 weeks after PSS removal (baseline). PRIMARY ENDPOINT: to compare Urinary Symptom Index Score and the rate of patients with pain 2 weeks after DJ and PSS. Secondary endpoints: to compare other USSQ scores and single answers 2 weeks after DJ and PSS, and DJ and PSS USSQ scores with baseline. RESULTS: 93 patients were enrolled. 2 weeks Urinary Symptom Index Score (p < 0.001) and the percentage of patients complaining of pain (60.2% vs 88.2%, p < 0.001) were significantly in favour of PSS compared to DJ. 2 weeks scores were significantly improved with PSS compared to DJ: Pain Index (p < 0.001), VAS (p < 0.001), General Health Index (p < 0.001) and Work Performance Index (p < 0.001). All urinary symptoms were significantly decreased with PSS, including renal pain during micturition and pain interfering with life. Pain Index Score (p = 0.622) and VAS (p = 0.169) were comparable to baseline with PSS, while differed with DJ. CONCLUSIONS: Patients undergoing DJ substitution with PSS after URS report a significant decrease of SRS. Urologists may consider positioning PSS after URS in pre-stented patients to reduce the impact of SRS.

Flexible Ureterorenoscopy Versus Shockwave Lithotripsy for Kidney Stones ≤2 cm: A Randomized Controlled Trial.

BACKGROUND: No clear recommendations are available on whether retrograde intrarenal surgery (RIRS) via flexible ureterorenoscopy or shockwave lithotripsy (SWL) should be preferred for kidney stones ≤2 cm, except for lower-pole stones. OBJECTIVE: To compare outcomes between RIRS and SWL. DESIGN, SETTING, AND PARTICIPANTS: This was a single-center randomized controlled trial from March 2015 to May 2018. Patients with a single 6-20-mm kidney stone were enrolled (NCT02645058). INTERVENTION: Patients were randomized to RIRS or SWL. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary endpoint was the single-procedure stone-free rate (SFR) at 1 mo. Two levels of success were set: fragments ≤4 mm (SFR-4) and no residual fragments (SFR-0). Secondary endpoints were the SFR at 6 mo and 1 yr and rates of complications and further treatments. RESULTS AND LIMITATIONS: A total of 138 patients underwent treatment (70 RIRS vs 68 SWL). In comparison to SWL, RIRS SFR results were higher at 1 mo (SFR-4 70.0% vs 45.6%; p = 0.004; SFR-0 50.0% vs 26.5%; p = 0.004) and 6 mo (SFR-4 79.7% vs 63.6%; p = 0.038; SFR-0 59.4% vs 40.9%; p = 0.032). There was no difference in SFR measures between the groups at 1 yr (SFR-4 p = 0.322; SFR-0 p = 0.392). Overall complications were comparable (p = 0.207), but the complication rate for stones >10 mm was higher for the SWL group (p = 0.021). The need for further treatment was comparable (p = 0.368). In terms of patient satisfaction, 86.8% and 77.1% of patients would choose SWL and RIRS again, respectively (p = 0.24). CONCLUSIONS: RIRS achieved better SFRs in comparison to SWL at 1 and 6 mo, but not at 1 yr. The RIRS complication rate was lower for stones >10 mm. SWL remains a viable alternative, especially for 6-10-mm stones, providing comparable results to RIRS in the long term. PATIENT SUMMARY: We compared outcomes for the treatment of kidney stones ≤2 cm with two techniques: flexible ureteroscopy, in which a flexible telescope is passed through the urethra and bladder to reach the ureter between the bladder and kidney; and shockwave lithotripsy, in which shockwaves are applied to the skin over the location of the kidney stone. Ureteroscopy achieved better stone-free results at 1 and 6 months, but not at 1 year.

Loop-tail stents fail in reducing stent-related symptoms: results of a prospective randomised controlled trial.

OBJECTIVE: To compare stent-related symptoms (SRS) of loop-tail (LT) and conventional double J (DJ) stents after uncomplicated flexible ureterorenoscopy (fURS), in a prospective randomised controlled single-blind parallel-group study. PATIENTS AND METHODS: Patients undergoing fURS were randomised into two groups: the LT Group received LT stents (Polaris™ Loop) and the DJ Group received conventional DJ stents (Vortek® ). The stent was removed after 4 weeks. The Ureteric Stent Symptom Questionnaire (USSQ) was administered at 2 days, 4 and 8 weeks (baseline evaluation) after stent insertion. The primary endpoint was to compare the Urinary Symptom Index Score of the LT vs DJ groups at 4 weeks after stent insertion. The secondary endpoints were to compare the USSQ domains' subscores at 2 days and 4 weeks after stent insertion, USSQ single answers at 4 weeks, and the 4-week USSQ domains' subscores adjusted for baseline. RESULTS: A total of 68 patients were randomised (34 LT and 34 DJ). The answers given at 4 weeks were not significantly different between the two groups for the Urinary Symptom Index Score (P = 0.982), Pain Index Score (P = 0.169), visual analogue scale (P = 0.276), and all the other domains of the USSQ. At 4 weeks, the single-answer analysis did not find any differences between the groups; the urinary symptoms were all comparable, as was the requirement for pain painkillers (P = 0.684) and pain during sex (P = 0.496). There were also no significant differences for every single domain score for the responses given at 2 days. The same applied to USSQ subscores at 4 weeks adjusted for the 8-week baseline results, which were also comparable. CONCLUSIONS: The study found no differences in terms of SRS between the LT and DJ groups, either at 2 days or 4 weeks after stent insertion, with or without baseline correction.

Pigtail Suture Stents Significantly Reduce Stent-related Symptoms Compared to Conventional Double J Stents: A Prospective Randomized Trial.

BACKGROUND: Double J (DJ) ureteral stents are commonly inserted after ureteroscopy (URS) procedures for stone treatment. However, stent-related symptoms are still a major issue. OBJECTIVE: To determine whether a commercially available pigtail suture stent (PSS) can reduce stent-related symptoms compared to a conventional DJ stent after uncomplicated URS. DESIGN SETTING AND PARTICIPANTS: We designed a randomized, single-blind, parallel-group trial from January to November 2020. The inclusion criteria were stone-free URS without intraprocedural complications. Patients with distal ureteral stones were excluded. INTERVENTION: Insertion of a PSS or DJ stent after URS. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary endpoint was the Urinary Symptom Index score on the Ureteral Stent Symptoms Questionnaire (USSQ) 2 wk after URS. Secondary endpoints were USSQ domain scores and responses to individual USSQ questions at 2 d and 2 wk after surgery. RESULTS AND LIMITATIONS: A total of 78 patients were randomized and treated according to protocol. The Urinary Symptom Index score (p = 0.004), overall Visual Analogue Scale (VAS) score (p = 0.022), and the percentage of patients complaining of pain (63.9% vs 86.1%, p = 0.029) were significantly in favor of PSS at both 2 d and 2 wk after URS. At 2 d, the VAS score among patients with pain (p = 0.025) and the General Health Index score (p = 0.036) were significantly better in the PSS group. No severe complications occurred in either group. Study limitations are the exclusion of patients with distal ureteral stones and the limited sample size. CONCLUSIONS: PSS significantly reduced stent-related symptoms after URS, in particular urinary symptoms and pain, compared to conventional DJ stents, and showed a good safety profile. PATIENT SUMMARY: Stents are hollow tubes placed in the passage between the kidney and the bladder (ureter). The standard stent has two coiled ends (double J stent) to keep it in place in both the kidney and the bladder. We tested a commercial stent with two strings at the bladder end (pigtail suture stent) after procedures to remove stones from the upper urinary tract and found that it caused less stent-related symptoms compared to a double J stent.This trial is registered at Clinicaltrials.gov as NCT03344120.

Ejaculation-sparing versus non-ejaculation-sparing anatomic GreenLight laser enucleo-vaporization of the prostate: first comparative study.

PURPOSE: To present the step-by-step description of an ejaculation-sparing anatomic photo-selective vaporization of the prostate (PVP) technique. To report the results of a series of ejaculation-sparing versus non-ejaculation-sparing anatomic PVPs. METHODS: Sexually active, benign prostatic hyperplasia (BPH) patients undergoing an anatomic PVP between 11/2018 and 2/2020 were included. Patients were divided into group A (ejaculation-sparing surgery) and group B (control group). Baseline, peri-operative and 6-months follow-up data were evaluated. Lower urinary tract symptoms (LUTS) and sexual function were assessed through internationally validated questionnaires. Groups were matched by an inverse probability of treatment weighting (IPTW) analysis. Logistic univariable regression analysis was performed to detect predictors of antegrade ejaculation preservation. RESULTS: Overall, 76 patients were included, among which 15 in group A and 61 in group B. Median (inter-quartile range, IQR) age was 72 (66.5-77) years, median (IQR) prostate volume 63.5 (54.5-98.5) cc. No differences about peri-operative outcomes were detected, included high-grade complications. At 6-months follow-up, no differences in urinary or erectile function were detected between groups, while ejaculation-sparing patients showed better Male Sexual Health Questionnaire (MSHQ) scores [7 (1-13) vs. 1 (1-1), p < 0.001] and higher rates of antegrade ejaculation (60% vs. 13.1%, p < 0.001). The ejaculation-sparing technique was identified as a predictor of post-operative antegrade ejaculation (OR 19.3, CI 95% 7.2-51.2, p < 0.001). CONCLUSION: The ejaculation-sparing anatomic PVP showed superiority over the control group in post-operative ejaculatory function scores and antegrade ejaculation rates. Besides, preliminary results suggested similar effectiveness in LUTS relief at a short-term follow-up.

How bothersome double-J ureteral stents are after semirigid and flexible ureteroscopy: a prospective single-institution observational study.

PURPOSE: To evaluate in details the actual extent of double-J stent-related symptoms after semirigid (URS) and flexible (RIRS) ureteroscopy using a validated questionnaire. METHODS: We asked to complete the Ureteric Stent Symptoms Questionnaire (USSQ) to all stone patients undergoing URS or RIRS with stent placement from 2010 to 2015. Stent-related symptoms' prevalence, severity, and impact on daily life were analyzed using descriptive statistics and five-order Likert scales. Subgroups analyses were performed. RESULTS: 232 patients completed the USSQ. Stents had a deep impact on urinary symptoms (daily frequency ≥ 1 per hour 59.1%, ≥ 1 nocturnal micturition 90.1%, urgency 86.6%, burning 82.3%) that represented a problem for 88.4% of patients. 83.2% complained of pain, mostly in the kidney (67.9%) or in the bladder area (31.3%), particularly during physical activity (72.9%) and micturition (77.0%). Pain interfered with everyday life in 92.2%. General health, working, and sexual activity were also affected. 62.0% of patients would be dissatisfied (51.6% unhappy or terrible) if further ureteral stenting was proposed in future. Younger patients and females were more affected. Limitations include observational design and lack of baseline evaluation. CONCLUSIONS: Ureteral stents are responsible for significant urinary symptoms and pain after semirigid and flexible ureteroscopy. They also considerably affect general health, working and sexual activity. Urologists should consider it carefully before stenting, inform patients about stent-related symptoms, and minimize stent indwelling time.

Retrograde intra-renal surgery under spinal anesthesia: the first large series.

BACKGROUND: Retrograde intra-renal surgery (RIRS) has become increasingly common and is mainly performed under general anesthesia (GA). There are no specific papers about RIRS performed under spinal anesthesia (SA). Our objective was to evaluate feasibility and results of RIRS performed under SA. METHODS: We analyzed all consecutive RIRS performed for stones in day surgery from March 2008 to September 2012. Single procedures outcomes of RIRS performed under SA were evaluated with US and KUB X-ray at 2 weeks. Further treatments, operative time and complications were also evaluated. Outcomes of RIRS performed under SA and GA were compared. Difference between groups was statistically analyzed. Significance level was set at P<0.05. RESULTS: One hundred thirty-nine RIRS under SA and 47 under GA were considered. Mean stone burden was 14±6 mm. No case of conversion from SA to GA occurred. Stone-free rate (SFR) level 4U of RIRS under SA and under GA were respectively 63.6% and 48.6%, SFR level 0U 24.5% and 25.7%, CIRF 39.1% and 22.9%. Further treatments were performed respectively in 20.8% and in 23.4%. No anesthesia-related and Clavien-Dindo grade ≥3 complications occurred. No statistically significant difference was found in stone-free rates, CIRF and significant residual fragments rates, need for further procedures, operative time and complications between the two groups. CONCLUSIONS: RIRS under SA seems feasible and effective for renal stones in day surgery. Results seem equivalent to RIRS under GA. SA can be considered for RIRS as an alternative to GA.

[Surgical resection of a massive residual retroperineal mass after chemotherapy in non-seminomatous germ cell tumor of the testis: a borderline case]. / Chirurgia su voluminosa massa residua retroperitoneale dopo chemioterapia per tumore non seminomatoso del testicolo: un caso limite.

BACKGROUND: According to the last EAU Guidelines about testicular cancer, surgical resection of residual masses after chemotherapy in NSGCT is indicated in the case of visible residual masses and when serum levels of tumor markers are normal or normalizing. If markers are not normalized and when several chemotherapeutic regimens have failed to cure metastatic disease, resection of residual tumors (so called "desperation surgery") should be offered to these patients. METHODS: We are going to present the case of a 30-year-old patient, affected by metastatic NSGCT. According to the prognostic-based staging system for metastatic germ cell cancer, our patient was in the poor prognosis group. The retroperitoneal mass involved all major vascular structures and still caused a bilateral obstruction of the upper urinary tract. Histological examination after radical orchiectomy revealed embryonal carcinoma and immature teratoma. The patient underwent a four-cycle VIP chemotherapy and then salvage chemotherapy with four cycles of TIP. After chemotherapy, the patient still presented large multiple metastatic localizations. Tumor markers were reduced but not normalized. The patient was then proposed for the resection of residual tumor. The residual mass could not be dissected from the left renal pedicle, so the left nephrectomy was unavoidable. The mass was hardly detached from vena cava and aorta. A bilateral iliac and retroperitoneal lymphadenectomy was performed. At the end of the procedure, the retroperitoneal space was completely free. RESULTS: Post-operative hospital stay was regular. A CT scan performed 3 months after the procedure did not show any residual lesion in the retroperitoneum. Three and six months later, the patient underwent the residual tumor resection of the right mediastinum and then of the left mediastinum and supraclavear metastases. Afterwards the patient underwent an EP consolidation chemotherapy. The patient is alive, 12 months after the retroperitoneal surgery. CONCLUSIONS: Our experience confirms that resection of residual tumors is safe and feasible also in cases of very large abdominal disease.

[Diagnosis and treatment of octogenarian neoplastic patients: bladder cancers]. / La diagnosi e il trattamento del paziente neoplastico ultra-ottantenne. Le neoplasie vescicali.

Age is a risk factor for the occurrence of bladder cancer and bladder cancer is a disease of the elderly. The choice of treatment relays on the staging into non-invasive and muscle-invasive bladder cancer. Non-invasive bladder cancer is usually treated with transurethral resection of the bladder (TURB) followed by intravesical therapy with BCG or chemotherapeutic agents. The gold standard in the treatment of muscle-invasive bladder cancer is radical cystectomy. The elderly and, in particular, the octogenarian have a worse tolerance for aggressive therapies, due to the higher incidence of side effects and complications. This problem could significantly occur for intravesical BCG therapy and for radical cystectomy. When the urologist faces the treatment of an octogenarian affected by bladder cancer, he should answer many questions: 1. In case of a non-invasive bladder cancer, is it possible to use the same drugs that we use for younger patients (BCG vs chemotherapeutic agents)? Should the timing and the kind of follow-up be the same? 2. Should the octogenarian affected by muscle-invasive bladder cancer undergo radical cystectomy or a less invasive treatment? What kind of diversion should be preferred? Is it possible to propose an orthotopic neobladder to an octogenarian patient? The choice of the treatment should be made on the basis of a careful evaluation of the patient, considering not only the patient's age but also comorbidities and life expectancy.