Obstructive Urosepsis: Is It Possible to Personalize the Ureteral Endoscopic Treatment?

INTRODUCTION: Urinary tract infection involves mortality rate when combined with ureteral obstruction. Lithotripsy has been contraindicated; however, it has been shown to be safe in selected situations. No specific criteria have been widely accepted to indicate which patients are suitable for definitive treatment. The objective of this study was to identify prognostic factors associated with poor outcome but also those patients whose definitive treatment can be performed. METHODS: Observational cohort study from a prospectively maintained database of septic patients defined by the Sequential Organ Failure Assessment (SOFA). Univariate analysis was used to compare prognostic factors with Δ-SOFA score <2 (group 1) and those with a Δ-SOFA ≥2 (group 2) obtained on day 3 and on admission. Different combinations of neutrophils, lymphocytes and platelets were tested as prognostic factors. Time to decompression calculated from the CT scan report to the end of surgery. RESULTS: A total of 229 patients were enrolled during 11 years. Two patients died. Time from CT scan to urinary tract decompression was higher in the Δ-SOFA≥2 (p = 0.04). Thrombocytopenia and the platelet-to-lymphocyte ratio were associated with Δ-SOFA≥2. Stones were disintegrated in 33.48% in group 1 and 48.84% in group 2. Platelet count and time to decompression were associated with a worse prognosis (p = 0.0008 and 0.0017). On receiver operator curve analysis, platelets count <105,056 and time to decompression >4.72 hours were linked to poorer outcomes. CONCLUSIONS: Personalized treatment, based on accessible biomarkers, can be achieved in most patients. Early surgical decompression was associated with better prognosis and definitive treatment can be performed in selected patients.

Modified biplanar (0-90°) endoscopic-guided puncture technique for percutaneous nephrolithtomy: refinement with endoscopic combined intrarrenal surgery to reduce fluoroscopy and operative time.

INTRODUCTION: We aim to publish our innovative modified biplanar 0-90 endoscopic guided puncture technique for percutaneous nephrolithotomy in supine recorded with a GoPro® camera for standardization of the technique. It solves drawbacks of the fluoroscopic technique, i.e., in kidneys with complex anatomy, it may be challenging to distinguish calyces as they are often superposed, and it does not allow for all benefits of a combined endoscopic approach (1, 2). Our technique shortens puncture and fluoroscopic time and is easy to teach and reproduce. METHODS: A 77-year-old female patient had previous double J insertion due to an obstructing stone in the right distal ureter. She managed to pass the distal stone but remained with the double J and a 20mm stone (1300HU) in the right renal pelvis. The shared decision was for the actual standard of care (3, 4) endoscopic combined intrarenal surgery (ECIRS). The MiniECIRS started with flexible ureteroscopy and a posterior calix which gave direct access to the stone was chosen. The tip of the flexible scope was used to mark point A with the C-arm in the 0-degree position and line B in the 90-degree position. Puncture was fast and the MiniECIRS was uneventful with a single mid-pole access guided by the flexible scope. The surgeon had a Full-HD GoPro® camera mounted on his head, controlled by the surgical staff. All essential surgical steps were recorded. RESULTS: The quality of the recorded movie was graded as excellent, and the camera did not cause any discomfort to the surgeon. Operative and X-Ray time were 120minutes and 2minutes (7.64mGy). Hemoglobin drop was 0.8g/dL. The post-operative day-1 computed tomography scan was stone-free. The patient was discharged 24h after surgery. Kidney stent was left with a string and removed after 5days. The patient remained asymptomatic and metabolic evaluation revealed a calcium oxalate stone, low urinary volume and hypocitraturia which were treated with potassium citrate and hydration. CONCLUSION: The Modified Biplanar (0-90 degree) Endoscopic-Guided Puncture Technique for Percutaneous Nephrolithotomy joins the reproducibility of the same technique under fluoroscopy with advantages regarding safety and efficiency of ECIRS.

Current scenario of endourological treatment of kidney stones in brazil: results of a national survey.

OBJECTIVE: To elucidate the current scenario of endourology in Brazil for the treatment of urinary lithiasis, with an emphasis on regional differences and the reasons why certain techniques are still underutilized. MATERIALS AND METHODS: An electronic questionnaire was sent by email to the 4,745 members of the Brazilian Urological Society (BSU) in 2016 to collect information on the 3 main endourological procedures used in the treatment of nephrolithiasis: Semi-rigid ureteroscopy (URS), Flexible ureteroscopy (F-URS) and percutaneous nephrolithotripsy (PCNL). RESULTS: A total of 1,267 urologists answered the questionnaire. It was observed that the vast majority perform URS (95.6%), while 80.2% perform F-URS and only 72.1% perform PCNL. Regarding the surgical volume, most perform up to 10 procedures per month (73.4% to 88.2%) and the main impediment was the lack of patients with the pathology (42.1% to 67.7%). The lack of equipment or hospital infrastructure was one of the main limiting factors for rigid (23%) and flexible (38.1%) URS, mainly in the North and Northeast regions of the country. Regarding PCNL, most of them reported lack of practical experience in the method (29.9%). Finally, most urologists expressed interest in taking courses in endourology. CONCLUSION: Ureteroscopy, rigid or flexible, is already well established in the country, requiring the direction of more resources for its practice, especially in less developed regions. Regarding PCNL a significant part of Brazilian urologists still lack practical experience in this procedure, emphasizing the need for greater investment in teaching this technique.

Delayed Bleeding After Retrograde Intrarenal Surgery: A Rare Complication in Ectopic Pelvic Kidney.

Anatomical variations in the pelvic ectopic kidney (PEK) present many challenges to stone treatment. Retrograde intrarenal surgery (RIRS) has emerged as the treatment of choice for small to medium stones. We present a case of delayed hemorrhage due to an arteriocaliceal fistula. A 57-year-old man with a 12 mm middle calyx stone was subjected to uneventful RIRS, despite a high grade of scope deflection. Recovery was unremarkable until 37 days after surgery when the patient started recurrent hematuria and clot retention. Renal angiography revealed a bleeding vessel from an arteriocaliceal fistula. Superselective arterial embolization was successfully performed. Anomalous collecting system and vasculature can increase the risk of complications in PEKs. Massive bleeding from unusual arterial blood supply was effectively treated by angioembolization.

Urinary lithiasis - conventional open surgery.

The Guidelines Project, an initiative of the Brazilian Medical Association, aims to combine information from the medical field in order to standardize producers to assist the reasoning and decision-making of doctors. The information provided through this project must be assessed and criticized by the physician responsible for the conduct that will be adopted, depending on the conditions and the clinical status of each patient.

Urinary lithiasis: evaluation of the use of laser vs. Pneumatic ureteral lithotripsy.

The Guidelines Project, an initiative of the Brazilian Medical Association, aims to combine information from the medical field in order to standardize producers to assist the reasoning and decision-making of doctors. The information provided through this project must be assessed and criticized by the physician responsible for the conduct that will be adopted, depending on the conditions and the clinical status of each patient.

Prostate cryoablation: prospective analysis comparing high- and low-risk prostate cancer outcomes.

AIM: To evaluate percutaneous cryotherapy as a primary treatment option for prostate cancer, comparing different risk groups. PATIENTS AND METHODS: Forty-seven prostate cryoablation procedures were performed on 44 patients. Patients median age was 70.9, and average pretreatment PSA of 13.8 ng/dl. Patients were divided into low-risk (13 patients), high-risk (24 patients) and radiation failure patients (7 patients). The follow-up period ranged from 18 to 60 months (median 41 months). RESULTS: In the low-risk group, we found after 12 and 24 months of follow-up, 92 and 86% of patients free of PSA relapse (PSA <1 ng/ml), respectively. In the high-risk group, the PSA failure was 39 and 52.9%. For the radiation failure group, 86 and 71.4% of patients had PSA below 1 ng/dl. At 48 months of follow-up, 80% of the low-risk patients, 42.8% of the high-risk group and 71.4% of the radiation failure group were free of PSA relapse. The complication rates were low, with 13% of urinary incontinence and no cases of rectal injury. CONCLUSION: Prostate cryoablation is a viable and promising minimally invasive alternative for localized or locally advanced prostate cancer patients.

Modified biplanar (0-90o) endoscopic-guided puncture technique for percutaneous nephrolithtomy: refinement with endoscopic combined intrarrenal surgery to reduce fluoroscopy and operative time

ABSTRACT Introduction: We aim to publish our innovative modified biplanar 0-90 endoscopic guided puncture technique for percutaneous nephrolithotomy in supine recorded with a GoPro® camera for standardization of the technique. It solves drawbacks of the fluoroscopic technique, i.e., in kidneys with complex anatomy, it may be challenging to distinguish calyces as they are often superposed, and it does not allow for all benefits of a combined endoscopic approach (1, 2). Our technique shortens puncture and fluoroscopic time and is easy to teach and reproduce. Methods: A 77-year-old female patient had previous double J insertion due to an obstructing stone in the right distal ureter. She managed to pass the distal stone but remained with the double J and a 20mm stone (1300HU) in the right renal pelvis. The shared decision was for the actual standard of care (3, 4) endoscopic combined intrarenal surgery (ECIRS). The MiniECIRS started with flexible ureteroscopy and a posterior calix which gave direct access to the stone was chosen. The tip of the flexible scope was used to mark point A with the C-arm in the 0-degree position and line B in the 90-degree position. Puncture was fast and the MiniECIRS was uneventful with a single mid-pole access guided by the flexible scope. The surgeon had a Full-HD GoPro® camera mounted on his head, controlled by the surgical staff. All essential surgical steps were recorded. Results: The quality of the recorded movie was graded as excellent, and the camera did not cause any discomfort to the surgeon. Operative and X-Ray time were 120minutes and 2minutes (7.64mGy). Hemoglobin drop was 0.8g/dL. The post-operative day-1 computed tomography scan was stone-free. The patient was discharged 24h after surgery. Kidney stent was left with a string and removed after 5days. The patient remained asymptomatic and metabolic evaluation revealed a calcium oxalate stone, low urinary volume and hypocitraturia which were treated with potassium citrate and hydration. Conclusion: The Modified Biplanar (0-90 degree) Endoscopic-Guided Puncture Technique for Percutaneous Nephrolithotomy joins the reproducibility of the same technique under fluoroscopy with advantages regarding safety and efficiency of ECIRS.

Percutaneous prostate cryoablation as treatment for high-risk prostate cancer.

PURPOSE: To evaluate percutaneous cryotherapy as a primary treatment option for high-risk prostate cancer patients. PATIENTS AND METHODS: From October 2000 to February 2005, 21 high-risk (Gleason e.8 and/or PSA > 10 and/or stage > T2a) prostate cancer patients underwent 24 percutaneous prostate cryoablation procedures. Patients' median age was 70.9, and the average pretreatment PSA was 19.5 ng/dL. The follow-up period ranged from 6 to 60 months (median, 41 months). RESULTS: The PSA failure rate was 39%, 52.9%, and 42.8% at 12, 24, and 60 months of follow-up, respectively. Overall complication rates were low, with 8% of urinary incontinence and no cases of rectal injury; however, 96% of erectile dysfunction occurred. The cryoablation procedure failed in 12 patients (57.2%); 7 (58.3%) of these were local failures (positive prostate biopsies). CONCLUSION: Percutaneous cryoablation of the prostate is a safe minimally invasive treatment, but it has poor PSA-free survival outcomes in high-risk prostate cancer patients.

Urinary lithiasis - conventional open surgery

The Guidelines Project, an initiative of the Brazilian Medical Association, aims to combine information from the medical field in order to standardize producers to assist the reasoning and decision-making of doctors. The information provided through this project must be assessed and criticized by the physician responsible for the conduct that will be adopted, depending on the conditions and the clinical status of each patient.

How are we protecting ourselves from radiation exposure? A nationwide survey.

PURPOSE: We performed a nationwide survey of Brazilian urologists to study behaviors toward radiation exposure and the use of protective and monitoring equipment. METHODS: A 13-question e-mail questionnaire was sent to 4,526 Brazilian urologists; the questions addressed demographic characteristics, radiation exposure, and the utilization of shielding devices and dosimeters. The reasons why these devices were not used were also investigated. RESULTS: A total of 332 completed questionnaires were analyzed (7.3 %); the median age of the respondents was 43.3 ± 10.8 years. Lead aprons and thyroid protection are utilized in every procedure by 84.4 and 53.89 % of respondents, respectively. Protective eyeglasses are never used by 72.12 % of the respondents. Older urologists were more likely not to use adequate protection. Of the urologists who responded, 76.42 % never use dosimeters. CONCLUSION: This study shows an unsatisfactory utilization of radiation-shielding devices and dosimeters, revealing a low compliance to the as low as reasonably achievable principle among Brazilian urologists.

Current scenario of endourological treatment of kidney stones in brazil: results of a national survey

ABSTRACT Objective: To elucidate the current scenario of endourology in Brazil for the treatment of urinary lithiasis, with an emphasis on regional differences and the reasons why certain techniques are still underutilized. Materials and Methods: An electronic questionnaire was sent by email to the 4,745 members of the Brazilian Urological Society (BSU) in 2016 to collect information on the 3 main endourological procedures used in the treatment of nephrolithiasis: Semi-rigid ureteroscopy (URS), Flexible ureteroscopy (F-URS) and percutaneous nephrolithotripsy (PCNL). Results: A total of 1,267 urologists answered the questionnaire. It was observed that the vast majority perform URS (95.6%), while 80.2% perform F-URS and only 72.1% perform PCNL. Regarding the surgical volume, most perform up to 10 procedures per month (73.4% to 88.2%) and the main impediment was the lack of patients with the pathology (42.1% to 67.7%). The lack of equipment or hospital infrastructure was one of the main limiting factors for rigid (23%) and flexible (38.1%) URS, mainly in the North and Northeast regions of the country. Regarding PCNL, most of them reported lack of practical experience in the method (29.9%). Finally, most urologists expressed interest in taking courses in endourology. Conclusion: Ureteroscopy, rigid or flexible, is already well established in the country, requiring the direction of more resources for its practice, especially in less developed regions. Regarding PCNL a significant part of Brazilian urologists still lack practical experience in this procedure, emphasizing the need for greater investment in teaching this technique.

Urinary lithiasis: evaluation of the use of laser vs. Pneumatic ureteral lithotripsy

The Guidelines Project, an initiative of the Brazilian Medical Association, aims to combine information from the medical field in order to standardize producers to assist the reasoning and decision-making of doctors. The information provided through this project must be assessed and criticized by the physician responsible for the conduct that will be adopted, depending on the conditions and the clinical status of each patient.

Predictors of hemorrhage after laparoscopic partial nephrectomy.

OBJECTIVES: To identify risk factors associated with hemorrhage during laparoscopic partial nephrectomy (LPN), and to determine the impact of hemorrhage on hospital course. METHODS: We retrospectively analyzed prospective data from 335 LPNs to identify clinicopathologic factors associated with hemorrhagic complications (blood loss requiring ≥ 1 U transfusion) and extended length of hospitalization (≥ 3 days). We excluded patients with a coagulopathy or perioperative vascular injuries. RESULTS: We identified 23 patients (7%) undergoing LPN with hemorrhagic complications (group 1 and 312 patients (93%) without complications (group 2). Mean age was 64.1 ± 14.4 vs 57.6 ± 12.7(P = .006), American Society of Anesthesiologists (ASA) score ≥ 3 seen in 61% vs 37% (P = .02), mean tumor size (cm) was 2.90 ± 2.02 vs 2.59 ± 1.15 (P = .93), mean total operative time (min) was 250.1 ± 116.1 vs 191.8 ± 69.2 (P = 0.006), and mean hospital stay (days) was 4.7 ± 3.4 vs 3.1 ± 3.0 (P = .0002), for groups 1 and 2, respectively. Hypertension, diabetes mellitus, chronic renal insufficiency, obesity, smoking, and coronary artery disease-congestive heart failure were present in group 1 vs group 2: 39.1% vs 31.4% (P = .4), 17.4% vs 8% (P = .12), 8.7% vs 1.9% (P = .09), 4.3% vs 3.5% (P = .57), 17.4% vs 5.4% (P = .04), and 8.7% vs 2.2% (P = .11), respectively. On multivariate analysis, smoking (P < .0437) and ASA score ≥ 3 (P < .0233) were associated with hemorrhagic complications. Hemorrhagic complications were 3.5 times more likely in smokers than nonsmokers (95% confidence interval, 1.0-11.7), and 2.9 times more likely with an ASA class ≥ 3. Only age (P < .0002) and operative time (P < .0001) were associated with longer hospitalization. CONCLUSIONS: High ASA scores and smoking are risk factors for hemorrhagic complications during LPN. Hemorrhagic complications did not significantly affect hospitalization length.

Laparoscopic ureteroplasty using on-lay appendix graft.

Complex ureteral reconstruction has been performed with ileum, appendix, or other intestinal segments for the treatment of long ureteral strictures. In the past decade, challenging ureteral reconstruction has been approached using laparoscopic urology. We report the case of a 6-cm iatrogenic stricture after treatment of stone disease. The stricture was treated using a laparoscopic on-lay appendix graft. This laparoscopic technique used the on-lay concept, which, in addition to minimizing postoperative pain and the length of hospitalization, allowed a tension-free watertight anastomosis and preserved the ureteral vascular supply. This approach should be considered a viable minimally invasive alternative for ureteral reconstruction when endoscopic treatment has failed.

Pathologic findings in patients with ureteropelvic junction obstruction and crossing vessels.

OBJECTIVES: To define the role of crossing vessels in the pathophysiology of ureteropelvic junction (UPJ) obstruction, we analyzed the relationship between the presence of crossing vessels and UPJ pathologic findings in patients undergoing laparoscopic pyeloplasty. The significance of crossing renal vessels in patients with UPJ obstruction is unclear. METHODS: We performed a retrospective analysis of 155 consecutive patients undergoing laparoscopic pyeloplasty. Pathologic specimens from the UPJ were evaluated in 95 patients. The presence or absence of crossing vessels was documented intraoperatively. The histopathologic findings allowed for categorization into 5 groups: group 1, normal ureteral tissue; group 2, chronic inflammation; group 3, smooth muscle hypertrophy, group 4, fibrosis; and group 5, smooth muscle atrophy. The pathologic findings between patients with and without crossing vessels were compared. RESULTS: Overall, crossing vessels were identified in 98 patients (63.2%). Of the 95 cases with specimens retrieved for histologic analysis, 65 had crossing vessels and 30 did not. The most common UPJ histologic finding in patients with crossing vessels was no intrinsic abnormality (43%). In contrast, this was seen in only 10% of patients without a crossing vessel. In the group without crossing vessels, chronic inflammation (40%) was the predominant histologic findings. Patients with a crossing vessel were less likely to have intrinsic histologic pathologic findings (P < .0003). CONCLUSIONS: Patients with crossing vessels and UPJ obstruction had no histologic abnormalities identified in 43% of cases. This finding implicates crossing vessels in the pathogenesis of select cases of UPJ obstruction and direct mechanical compression as the etiology of obstruction in these individuals.