Outcomes of a non-randomised audit of single pigtail suture stents in urolithiasis management of Asian patients in Singapore.

Objective: Double-J (DJ) ureteric stents are commonly placed perioperatively for semirigid or flexible ureteroscopic renal surgery. It is believed that lesser stent material within the bladder mitigates stent-related symptoms. This study aimed to evaluate the J-Fil ureteral stent, a single pigtail suture stent compared with conventional DJ stent in relation to stent symptoms in an Asian population undergoing ureterorenal intervention. Methods: Based on internal audit committee recommendation approval, the records of 50 patients retrieved, available data of 41 patients who were prospectively enrolled into two groups (Group 1 [J-Fil stent group], n=21 and Group 2 [DJ stent group], n=20) between August 2020 to January 2021, were analysed. Parameters compared were nature of procedure, stone location and size, ease of deployment or removal, and complications. A modified universal stent symptom questionnaire was used to assess morbidity of stent symptoms within 48 h of insertion and at removal. Results: Both groups had similar median age, distribution in male to female ratio, and stone size. The overall median universal stent symptom questionnaire score at insertion was similar for bladder pain, flank or loin pain, and quality of life between Group 1 and 2; however, at removal Group 1 fared significantly better than Group 2, especially for flank or loin pain and pain at voiding. Both groups had similar ease in insertion with no hospital readmissions. Conclusion: Our audit favoured the single pigtail suture stent in Asian ureters in mitigating stent-related issues. It showed a good safety profile with easy deployment and removal. It promises a new standard in stenting.

Antibiotic treatment failure of uncomplicated urinary tract infections in primary care.

BACKGROUND: Higher resistance rates of > 20% have been noted in Enterobacteriaceae urinary isolates towards ciprofloxacin and co-trimoxazole (C + C) in Singapore, compared with amoxicillin-clavulanate and nitrofurantoin (AC + N). This study examined if treatment failure varied between different antibiotics, given different resistant rates, for uncomplicated urinary tract infections (UTIs) managed in primary care. We also aimed to identify gaps for improvement in diagnosis, investigations, and management. METHODS: A retrospective cohort study was conducted from 2019 to 2021 on female patients aged 18-50 with uncomplicated UTIs at 6 primary care clinics in Singapore. ORENUC classification was used to exclude complicated UTIs. Patients with uncomplicated UTIs empirically treated with amoxicillin-clavulanate, nitrofurantoin, ciprofloxacin or co-trimoxazole were followed-up for 28 days. Treatment failure was defined as re-attendance for symptoms and antibiotic re-prescription, or hospitalisation for UTI complications. After 2:1 propensity score matching in each group, modified Poisson regression and Cox proportional hazard regression accounting for matched data were used to determine risk and time to treatment failure. RESULTS: 3194 of 4253 (75.1%) UTIs seen were uncomplicated, of which only 26% were diagnosed clinically. Urine cultures were conducted for 1094 (34.3%) uncomplicated UTIs, of which only 410 (37.5%) had bacterial growth. The most common organism found to cause uncomplicated UTIs was Escherichia coli (64.6%), with 92.6% and 99.4% of isolates sensitive to amoxicillin-clavulanate and nitrofurantoin respectively. Treatment failure occurred in 146 patients (4.57%). Among 1894 patients treated with AC + N matched to 947 patients treated with C + C, patients treated with C + C were 50% more likely to fail treatment (RR 1.49, 95% CI 1.10-2.01), with significantly higher risk of experiencing shorter time to failure (HR 1.61, 95% CI 1.12-2.33), compared to patients treated with AC + N. CONCLUSION: Treatment failure rate was lower for antibiotics with lower reported resistance rates (AC + N). We recommend treating uncomplicated UTIs in Singapore with amoxicillin-clavulanate or nitrofurantoin, based on current local antibiograms. Diagnosis, investigations and management of UTIs remained sub-optimal. Future studies should be based on updating antibiograms, highlighting its importance in guideline development.

Influence of pre-stenting on RIRS outcomes. Inferences from patients of the Global Multicentre Flexible Ureteroscopy Outcome Registry (FLEXOR).

BACKGROUND: Retrograde Intrarenal Surgery (RIRS) is recommended as an alternative to percutaneous nephrolithotomy for stones up to 2 cm. Pre-stenting before RIRS remains controversial with various studies differing in outcomes and recommendations. We aim to understand how pre-stenting influences surgical outcomes. METHODS: A number of 6579 patients from the TOWER group registry were divided into pre-stented (group 1) and non-pre-stented groups (group 2). Patients aged ≥18 years old, with normal calyceal anatomy were enrolled. Patients with ureteric stones, anomalous kidneys, bilateral stones, planned for ECIRS were excluded. RESULTS: Patients are homogeneously distributed in both groups (3112 vs. 3467). The predominant indication for pre-stenting was symptom relief. Overall stone size was comparable, whilst group 1 had a significantly more multiple (1419 vs. 1283, P<0.001) and lower-pole (LP) stones (1503 vs. 1411, P<0.001). The mean operative time for group 2 was significantly longer (68.17 vs. 58.92, P<0.001). Stone size, LP stones, age, recurrence and multiple stones are contributing factors for residual fragments at the multivariable analysis. The incidence of postoperative day 1 fever and sepsis was significantly higher in group 2, indicating that pre-stenting is associated with a lower risk of post-RIRS infection and a lower overall complications rate (13.62% vs. 15.89%) (P<0.001). CONCLUSIONS: RIRS without pre-stenting can be considered safe without significant morbidity. Multiple, lower-pole and large stone is a significant contributor towards residual fragments. Patients who were not pre-stented had significantly higher but low-grade complications, especially for lower pole and large volume stones. While we do not advocate routine pre-stenting, a tailored approach for these patients should include proper counselling regarding pre-stenting.

Choosing the best way for urinary decompression and developing a novel predictive model for septic shock using SOFA in these patients.

OBJECTIVES: To identify predictive factors for the development of sepsis/septic shock postdecompression of calculi-related ureteric obstruction using the Sequential Organ Failure Assessment (SOFA) score and to compare clinical outcomes and odd risk ratios of patients developing sepsis/septic shock following the insertion of percutaneous nephrostomy (PCN) versus insertion of retrograde ureteral stenting (RUS). METHODS: Clinico-epidemiological data of patients who underwent PCN and/or RUS in two institutions for calculi-related ureteric obstruction were retrospectively collected from January 2014 to December 2020. RESULTS: 537 patients (244 patients in PCN group, 293 patients in RUS group) from both institutions were eligible for analysis based on inclusion and exclusion criteria. Patients with PCN were generally older, had poorer Eastern Cooperative Oncology Group status, and larger obstructive ureteral calculi compared to patients with RUS. Patients with PCN had longer durations of fever, the persistence of elevated total white cell and creatinine, and longer hospitalization stays compared with patients who had undergone RUS. RUS up-front has more unsuccessful interventions compared with PCN. There were no significant differences in the change in SOFA score postintervention between the two interventions. In multivariate analysis, the higher temperature just prior to the intervention (adjusted odds ratio [OR]: 2.039, p = 0.003) and Cardiovascular SOFA score of 1 (adjusted OR:4.037, p = 0.012) were significant independent prognostic factors for the development of septic shock postdecompression of ureteral obstruction. CONCLUSIONS: Our study reveals that both interventions have similar overall risk of urosepsis, septic shock and mortality rate. Despite a marginally higher risk of failure, RUS should be considered in patients with lower procedural risk. Patients going for PCN should be counseled for a longer stay. Post-HDU/-ICU monitoring, inotrope support postdecompression should be considered for patients with elevated temperature within 1 h preintervention and cardiovascular SOFA score of 1.

Role and Importance of Ergonomics in Retrograde Intrarenal Surgery: Outcomes of a Narrative Review.

Background: With recent technological advancement, new and improved endoscopic instruments and laser devices have catapulted flexible ureteroscopy to the forefront, hence making retrograde intrarenal surgery (RIRS) a popular choice for the management of renal stones. However, RIRS has also resulted in an increasing number of work-related musculoskeletal disorders, which can have a detrimental impact on surgeons' physical health and operative lifespan. The aim of our review is to examine the impact and feasibility of ergonomic adjustments and outline future directions and recommendations to improve the awareness of and reduce the prevalence of musculoskeletal injuries among urologists. Methods: This study was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A thorough literature review was conducted of several databases using the following keywords and Medical Subject Headings (MeSH) terms to generate a search strategy: nephrolithiasis, kidney calculus, renal calculus, staghorn calculus, ergonomics, position, fatigue, comfort, tire, physical strain, visual strain, muscle, ureteroscopy, RIRS, laser, and lithotripsy. Studies were chosen for inclusion by reviewers independently, and the data were consolidated for analysis. Results: A total of 1446 articles were identified on initial literature search; 23 were included in the final analysis. The impact of various ergonomic modifications on operative outcomes, surgeons, surgical equipment, and patients, was analyzed. In addition, we summarized all the improvements that resulted in better ergonomics in RIRS. Conclusion: Ergonomics in RIRS is poorly understood and there are currently no formal guidelines for this aspect. While modern endourology armamentarium seems to help with procedural ergonomics, more needs to be done to enhance surgeon comfort, protect surgeon longevity, and prioritize the health and safety of endourologists.

Expanded criteria donors in deceased donor kidney transplantation - An Asian perspective.

There is an increasing gulf between demand and supply for kidneys in end-stage renal failure patients worldwide, especially Asia. Renal transplantation is often the treatment of choice for long-suffering patients who have to undergo dialysis on a regular basis. The utilization of expanded criteria donors (ECDs) to address the donor pool shortage has been proven to be a legitimate solution. Metzger first described the classification of standard criteria donor and ECD in 2002. Since then, the criterion has undergone various modifications, with the key aims of optimizing organ procurement rate while minimizing discard and rejection rates. We review the methods to improve selection, characterization of risks, and surgical techniques. Although the ECD kidneys have a higher risk of impaired donor and recipient outcome than the "standard criteria" transplants, it may be justified by the improved overall survival of these patients compared to those who remained on dialysis. It is, therefore, crucial that we perform meticulous selection, along with state of the art surgical techniques to maximize the use of this scarce resource. In this article, we review the pre-procurement and post-procurement processes implemented to preserve outcomes.

Detection of Clinical Mesenchymal Cancer Cells from Bladder Wash Urine for Real-Time Detection and Prognosis.

Bladder cancer (BC) is a disease that requires lifelong surveillance due to its high recurrence rate. An efficient method for the non-invasive rapid monitoring of patient prognosis and downstream phenotype characterization is warranted. Here, we develop an integrated procedure to detect aggressive mesenchymal exfoliated bladder cancer cells (EBCCs) from patients in a label-free manner. Using a combination of filtration and inertial focusing principles, the procedure allowed the focusing of EBCCs in a single stream-line for high-throughput separation from other urine components such as large squamous cells and blood cells using a microfluidic sorting device. Characterization of enriched cells can be completed within hours, suggesting a potential utility for real-time detection. We also demonstrate high efficiency of cancer cell recovery (93.3 ± 4.8%) and specific retrieval of various epithelial to mesenchymal transition (EMT) phenotype cell fractions from respective outlets of the microfluidic device. EMT is closely associated with metastasis, drug resistance and tumor-initiating potential. This procedure is validated with clinical samples, and further demonstrate the efficacy of bladder wash procedure to reduce EBCCs counts over time. Overall, the uniqueness of a rapid and non-invasive method permitting the separation of different EMT phenotypes shows high potential for clinical utility. We expect this approach will better facilitate the routine screening procedure in BC and greatly enhance personalized treatment.

Enterotomy closure using knotless and barbed suture in laparoscopic upper gastrointestinal surgeries.

BACKGROUND: Barbed sutures are recently being employed in intracorporeal suturing in various laparoscopic digestive surgeries. The purpose of this paper was to present our initial experience of enterotomy closure with barbed sutures in upper gastrointestinal and bariatric surgeries, and share optimal technique of using such sutures for enterotomy closure. METHODS: Fifty patients who underwent laparoscopic closure of enterotomies using barbed sutures were identified in two institutions in Singapore from January 2012 to December 2013. Patient demographics, short-term operative outcomes including anastomotic time, onset of diet, hospital stay, and early post-operative complications are reported. RESULTS: In 50 patients a total of 62 anastomotic sites were closed with barbed sutures. The barbed sutures appear to reduce mean anastomotic suturing time of the Roux-en-Y gastrojejunal closure (17.34 vs 44.55 min, p value 0.0001) and jejunojejunal closure (19.46 vs 31.01 min, p value 0.0013) when compared to a subgroup of patients with the same anastomotic sites closed using the standard non-barbed suture. The mean onset to start on diet was 2 ± 1.5 days and mean duration of hospital stay is 7 + 5.3 days. One (1.6%) anastomotic leak was observed day 3 after a gastric bypass in the series. This leak was the result of a technical error due to inappropriate suturing technique. There were no mortalities, other complications or readmission. While applying traction on the suture brings two tissue edges closer, we observed that pushing the tissues toward each other provided more apposition and prevented unnecessary tearing of tissues that could potentially result in complications CONCLUSIONS: Barbed closure sutures appear to be safe and effective in laparoscopic upper gastrointestinal procedures for closing enterotomies provided appropriate technique is used. The potential benefit is simplifying intracorporeal enterotomy closure.