Tumour size in adrenal tumours: its importance in the indication of adrenalectomy and in surgical outcomes-a single-centre experience.

OBJECTIVE: To evaluate the relevance of tumour size in adrenal tumours in the estimation of malignancy risk and in the outcomes of adrenalectomy. METHODS: We evaluate the histological results and surgical outcomes (intraoperative and postsurgical complications) in a retrospective single-centre cohort of patients without history of active extraadrenal malignancy with adrenal tumours consecutively operated in our centre during January 2010 and December 2020. We compared these results in lesions smaller and larger than 40, 50, and 60 mm. RESULTS: Of 131 patients with adrenal tumours who underwent adrenalectomy, 76 (58.0%) had adrenal masses measuring ≥ 40 mm; 47 were > 50 mm and 28 > 60 mm. The final diagnosis was adrenocortical carcinoma (ACC) in 7 patients, pheochromocytoma in 35, and benign lesions in the remaining. All patients with ACC had adrenal masses > 50 mm, with Hounsfield units > 40 and low lipidic content in the CT. The risk of ACC and pheochromocytoma increased as tumour size did. The diagnostic accuracy of tumour size was quite good for the prediction of ACC (AUC-ROC 0.883). Nevertheless, when only adrenal tumours with HU < 40 were considered, the risk of ACC was 0% independent of tumour size. For pheochromocytomas, the risk was of 8.6% independent of tumour size for lesions with < 20HU. The risk of intraoperative and postoperative complications was independent of tumour size. CONCLUSION: Risk of malignancy and of pheochromocytoma increased as tumour size increased, but, in the presurgical estimation of malignancy risk and of pheochromocytoma, not only tumour size, also lipidic content and other radiological features, should be considered. The risk of complications was independent of tumour size, but hospital stay was longer in patients with complication or open approach.

Xanthogranulomatous pyelonephritis: a focus on microbiological and antibiotic resistance profiles.

BACKGROUND: Xanthogranulomatous pyelonephritis (XGP) is an inflammatory condition of the kidney and its treatment most often involves a combination of antibiotics and nephrectomy. This study aimed to define the clinical features and management of XGP, focusing on microbiological aspects and antibiotic therapy. METHODS: We performed a retrospective study of 27 cases of XGP diagnosed between January 2001 and January 2020 to analyse their clinical and management characteristics. In addition, a literature review was conducted of XGP case series covering the period from 2000-2020. We searched PubMed for case series through April 2020 without language restrictions. Studies reporting case series of XGP (more than ten cases) were included if they were relevant to this study. RESULTS: Twenty-seven patients were diagnosed with XGP, and 26 of them were histologically proven to have XGP. A total of 81.5% of the patients were female and the mean age was 59.6 years (SD 19.2). The most frequent symptoms were flank pain (70.4%) and fever (59.3%), while 77.8% of patients had renal stones. Proteus mirabilis was detected in the urine culture in 18.5% of patients, followed by detection of Escherichia coli in 14.8% of patients. The computed tomography (CT) findings included perirenal (29.6%) or pararenal (29.6%) involvement in the majority of patients. Twenty-six patients underwent nephrectomy. Piperacillin/tazobactam and ceftriaxone were the most commonly prescribed antibiotics for treatment. The reported piperacillin/tazobactam and ceftriaxone resistance rates were 14.3% and 16.6%, respectively. Twenty-six case series were included in the literature review, reporting 693 cases in total. CONCLUSION: We found well-established characteristics of XGP patients among series in terms of previous history, clinical, laboratory and imaging findings, and operative and postoperative outcomes. It is important to know the clinical presentation and potential severity of XGP, as well as the most frequently involved microorganisms and their antibiotic resistance profiles, to select the most appropriate antibiotic therapy.

Spanish consensus document for acceptance and rejection of kidneys from expanded criteria donors.

In the recent years, more than 60% of available deceased donors are either older than 50 yr or have significant vascular comorbidities. This makes the acceptance and rejection criteria of renal allografts very rigorous, especially in cases of younger recipients, and at the same time encourages live donations. In our country, there is a lack of homogeneity in the percentages of use of expanded criteria donor (ECD) allografts between the different autonomous communities. Furthermore, the criteria vary greatly, and in some cases, great importance is given to the biopsy while in others very little. In this study, we present a unified and homogenous criteria agreed upon by consensus of a 10-member Panel representing major scientific societies related to renal transplantation in Spain. The criteria are to be used in accepting and/or rejecting kidneys from the so-called ECDs. The goal was to standardize the use of these organs, to optimize the results, and most importantly to provide for the maximum well being of our patients. Finally, we believe that after taking into account the Panel's thorough review of specific scientific literature, this document will be adaptable to other national renal transplant programmes.

Is extracorporeal lithotripsy a first-line treatment for urinary stones today?

OBJECTIVE: To evaluate the efficacy and complications of extracorporeal lithotripsy (SWL) as a first-line treatment for renal and ureteral stones METHODS: Retrospective and observational study of all the patients treated with lithotripsy in a third level center between January 2014 and January 2021; characteristics of the patients, the stones, complications and results of SWL is recollected. Multivariate logistic regression of the factors associated with stone size reduction was performed. A statistical analysis of the factors associated with additional treatment after SWL and factors associated with complications is also executed. RESULTS: 1727 patients are included. Stone mean size was 9,5mm. 1540 (89.4%) patients presented reduction in stone size. In multivariate analysis, stone size (OR=1.13; p=0.00), ureteral location of the lithiasis (OR=1.15; p=0.052) and number of waves (p=0.002; OR=1.00) used in SWL are the factors associated with reduction of stone size. Additional treatment after lithotripsy was needed in 665 patients (38.5%). The factors associated with the need for retreatment were stone size (OR=1.131; p=0.000), number of waves (OR=1.000; p=0.000), energy (OR=1.005; p=0.000). 153 patients (8.8%) suffered complications after SWL. A statistically significant association was found between the size of the lithiasis (p=0.024, OR=1.054) and the previous urinary diversion (P=0.004, OR=0.571). CONCLUSION: Lithotripsy remains an effective treatment as the first line of therapy for reno-ureteral lithiasis with a low percentage of complications.

[Lessons learned after the disruption caused by COVID-19 in the management of urolithiasis: An example of adaptation in a high-volume center]. / Lecciones aprendidas sobre el manejo de la urolitiasis tras los perjuicios causados por la COVID-19: un ejemplo de adaptación en un centro de alto volumen.

Introduction: The aim was to determine the impact of COVID-19 pandemic on urolithiasis presentation and management. Methods: In this retrospective study, we comparatively evaluated urgent and elective procedures due to urolithiasis during the early 8 months of the COVID-19 pandemic (March 1, 2020, to October 31, 2020) compared to the same period a year before, and between waves. Fisher's exact test, Student's t-test, chi-square test and Mann-Whitney U test were used to compare the patients' characteristics and outcomes between the 2 periods and waves. Results: Five hundred and thirty procedures were included. The overall numbers of surgical procedures due to urolithiasis were similar between pre-pandemic and pandemic periods. Regarding elective surgery, our data draw attention to the increased complication rate in the pandemic times, but no statistically significant differences in terms of types of procedures and need for complementary treatments were observed. We noted that patterns of presentation of complicated renal colic were different during COVID-19 pandemic, with a higher number of days after the onset of symptoms and a higher proportion of patients presenting acute kidney injury. Furthermore, a significant increase of creatinine levels at presentation in first wave was detected, and a growth in the number of urgent procedures after the first wave was noted, owing to the delay in urolithiasis treatment and diagnosis. Conclusions: The COVID-19 pandemic has negatively affected both urgent and elective management of urolithiasis. Lessons about the management of urolithiasis in this context should be learned to avoid fatal complications and improve standards of care.

Lessons learned after the disruption caused by COVID-19 in the management of urolithiasis: An example of adaptation in a high-volume center.

BACKGROUND: The aim was to determine the impact of COVID-19 pandemic on urolithiasis presentation and management. METHODS: In this retrospective study, we comparatively evaluated urgent and elective procedures due to urolithiasis during the early eight months of the COVID-19 pandemic (March 1, 2020, to October 31, 2020) compared to the same period a year before, and between waves. The student's t-test, chi-square test, Mann-Whitney U test and Fisher's exact test were used to compare the patients' characteristics and outcomes between the two periods and waves. RESULTS: Five hundred and thirty procedures were included. The overall numbers of surgical procedures due to urolithiasis were similar between pre-pandemic and pandemic periods. Regarding elective surgery, our data draw attention to the increased complication rate in the pandemic times, but no statistically significant differences in terms of types of procedures and need for complementary treatments were observed. We noted that patterns of presentation of complicated renal colic were different during COVID-19 pandemic, with a higher number of days after the onset of symptoms and a higher proportion of patients presenting acute kidney injury. Furthermore, a significant increase of creatinine levels at presentation in first wave was detected, and a growth in the number of urgent procedures after the first wave was noted, owing to the delay in urolithiasis treatment and diagnosis. CONCLUSION: The COVID-19 pandemic has negatively affected both urgent and elective management of urolithiasis. Lessons about the management of urolithiasis in this context should be learned to avoid fatal complications and improve standards of care.

Extracorporeal shock wave lithotripsy for lower calyx stones: predicting treatment success.

INTRODUCTION: The use of extracorporeal shock wave lithotripsy (ESWL) for lower calyx stones is associated with a high rate of residual fragments. Our aim is to analyse the effectiveness and complications of ESWL for lower calyx stones. METHODS: Retrospective review of patients with lower renal calyx stones treated with ESWL between January-2014 and December-2020. Measurement of infundibular length, infundibular width and infundibulopelvic angle in lower renal pole to determine favourable anatomy. ESWL failure: fragments >3 mm detected in plain abdominal film, CT scan and/or renal ultrasound 3 months after treatment. Complications after ESWL, auxiliary procedures along with risk factors associated with perirenal haematoma were analysed. SPSS statistical software was used. RESULTS: 512 patients with lower calyx stones were treated with ESWL. 80.3% of patients had a favourable anatomy. Overall stone-free rate was 70.5%. Regarding main complications after ESWL, stainstrasse was described in 5 patients and urinary tract infection in 3 patients. 10 perirenal haematomas (2%) were reported. Statistical association was found between antiplatelet treatment and the risk of perirenal haematoma (p = 0.004). Logistic binary regression proved the association between unfavourable anatomy of the lower renal pole (p = 0.000), size of the stone (p = 0.001), number of shock waves (p = 0.003), energy applied (p = 0.038) and the need for additional treatment after ESWL. CONCLUSIONS: ESWL can still be considered as the initial treatment option for lower renal pole stones. The size of the stone, an unfavourable anatomy of the lower renal calyx, number of shock waves and energy applied can help predict the need for additional treatment.

Clinical Usefulness of Prostate-specific Membrane Antigen-ligand Positron Emission Tomography/Computed Tomography for the Detection of Prostate Cancer Biochemical Recurrence after Primary Radiation Therapy in Patients with Prostate-specific Antigen Below the Phoenix Threshold: Systematic Review and Meta-analysis.

AIMS: After primary radiotherapy, biochemical recurrence is defined according to the Phoenix criteria as a prostate-specific antigen (PSA) value >2 ng/ml relative to the nadir. Several studies have shown that prostate-specific membrane antigen (PSMA)-ligand positron emission tomography/computed tomography (PET/CT) can help in detecting recurrence in patients with low PSA values. This study aimed to assess the detection rate and patterns of PSMA-ligand PET/CT uptake in patients with suspected biochemical recurrence after primary radiotherapy and with PSA levels below the Phoenix threshold. MATERIALS AND METHODS: The meta-analysis was carried out in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Articles providing data on patients with suspected prostate cancer recurrence after primary radiotherapy with a PSA value below the Phoenix threshold and who underwent PSMA-ligand PET/CT were included. Quality assessment was carried out using the Quality Assessment of Diagnostic Accuracy Studies-2 tool (QUADAS-2). RESULTS: In total, five studies were included, recruiting 909 patients (202 with PSA ≤2 ng/ml). The PSMA-ligand detection rate in the patients with ≤2 ng/ml ranged from 66 to 83%. The most frequent source of PSMA-ligand PET/CT uptake was local recurrence, followed by lymph node metastasis and bone metastasis. PSMA-ligand PET/CT uptake due to local-only recurrence was more likely in patients with PSA ≤2 ng/ml compared with PSA > 2 ng/ml: risk ratio 0.72 (95% confidence interval 0.58-0.89), P = 0.003. No significant differences were observed in the detection of PSMA-ligand uptake in other areas. Limitations include a lack of biopsy confirmation, cohort reports with small sample sizes and a potentially high risk of bias. CONCLUSION: A significant detection of PSMA-ligand-avid disease was observed in patients with PSA levels below the Phoenix threshold. There was a higher likelihood of detecting local-only uptake when the PSA value was ≤2 ng/ml. The findings suggest that a critical review of the Phoenix criteria may be warranted in the era of PSMA-ligand PET/CT and highlight the need for further prospective trials.

Metabolic syndrome in calcium oxalate stones: Is it so important in this type of lithiasis?

INTRODUCTION AND OBJECTIVE: The association of the metabolic syndrome with lithogenesis has been described, especially in uric acid stones. The aim of the work was to analyze the role of the metabolic syndrome in oxalocalcic lithogenesis. MATERIALS AND METHODS: Metabolic evaluation of 151 patients including biochemical, hormonal and 24-urine urine parameters, as well as characteristics associated with metabolic syndrome. The relationship between the characteristics associated with the metabolic syndrome and those related to lithogenesis was evaluated using Spearman's correlation coefficient (SCC), Student's t test and Fisher's exact test. RESULTS: The average body mass index (BMI) was 25.9 (SD 3.7). The median age was 51 years (18.6-84.8) and 64.9% were men. There were no statistically significant differences between hypertension and estradiol, testosterone, triglycerides or cholesterol (P=.191, .969, .454, .345, respectively). Regarding glucose, the mean was 114.5 and 93.5mg/dl in patients with and without hypertension (P=.000). The levels of glucose, estradiol, testosterone or cholesterol did not vary with proteinuria (P=.518, P=.227, P=.095, P=.218, respectively). The mean triglycerides were 185.6 and 108.2mg/dl in patients with and without proteinuria (P=.001). Hypertension and proteinuria were not associated (P=.586). BMI correlated with serum and urinary uric acid and urinary creatinine. CONCLUSIONS: There are few associations between the characteristics of the metabolic syndrome and the anomalies related to lithogenesis. Metabolic syndrome does not seem to have a relevant role in the development of oxalocalcic stones.

Effects of deep brain stimulation of dorsal versus ventral subthalamic nucleus regions on gait and balance in Parkinson's disease.

OBJECTIVE: Deep brain stimulation (DBS) of the subthalamic nucleus (STN) improves motor function, including gait and stability, in people with Parkinson's disease (PD) but differences in DBS contact locations within the STN may contribute to variability in the degree of improvement. Based on anatomical connectivity, dorsal STN may be preferentially involved in motor function and ventral STN in cognitive function. METHODS: To determine whether dorsal DBS affects gait and balance more than ventral DBS, a double blind evaluation of 23 PD patients with bilateral STN DBS was conducted. Each participant underwent gait analysis and balance testing off Parkinson's medication under three DBS conditions (unilateral DBS in the dorsal STN region, unilateral DBS in the ventral STN region and both stimulators off) on 1 day. RESULTS: Improvements were seen in Unified Parkinson's Disease Rating Scale (UPDRS)-III scores and velocity in walking trials as fast as possible (Fast gait) and preferred pace (Pref gait), as well as stride length for Fast and Pref gait, with dorsal and ventral stimulation compared with the off condition (post hoc tests, p<0.05). However, there were no differences with dorsal compared to ventral stimulation. Balance, assessed using the multi-item mini-Balance Evaluation Systems Test (mini-BESTest), was similar across conditions. CONCLUSIONS: Absence of differences in gait and balance between the dorsal and ventral conditions suggests motor connections involved in gait and balance may be more diffusely distributed in STN than previously thought, as opposed to neural connections involved in cognitive processes, such as response inhibition, which are more affected by ventral stimulation.

Dystonia in neurodegeneration with brain iron accumulation: outcome of bilateral pallidal stimulation.

Neurodegeneration with brain iron accumulation encompasses a heterogeneous group of rare neurodegenerative disorders that are characterized by iron accumulation in the brain. Severe generalized dystonia is frequently a prominent symptom and can be very disabling, causing gait impairment, difficulty with speech and swallowing, pain and respiratory distress. Several case reports and one case series have been published concerning therapeutic outcome of pallidal deep brain stimulation in dystonia caused by neurodegeneration with brain iron degeneration, reporting mostly favourable outcomes. However, with case studies, there may be a reporting bias towards favourable outcome. Thus, we undertook this multi-centre retrospective study to gather worldwide experiences with bilateral pallidal deep brain stimulation in patients with neurodegeneration with brain iron accumulation. A total of 16 centres contributed 23 patients with confirmed neurodegeneration with brain iron accumulation and bilateral pallidal deep brain stimulation. Patient details including gender, age at onset, age at operation, genetic status, magnetic resonance imaging status, history and clinical findings were requested. Data on severity of dystonia (Burke Fahn Marsden Dystonia Rating Scale-Motor Scale, Barry Albright Dystonia Scale), disability (Burke Fahn Marsden Dystonia Rating Scale-Disability Scale), quality of life (subjective global rating from 1 to 10 obtained retrospectively from patient and caregiver) as well as data on supportive therapy, concurrent pharmacotherapy, stimulation settings, adverse events and side effects were collected. Data were collected once preoperatively and at 2-6 and 9-15 months postoperatively. The primary outcome measure was change in severity of dystonia. The mean improvement in severity of dystonia was 28.5% at 2-6 months and 25.7% at 9-15 months. At 9-15 months postoperatively, 66.7% of patients showed an improvement of 20% or more in severity of dystonia, and 31.3% showed an improvement of 20% or more in disability. Global quality of life ratings showed a median improvement of 83.3% at 9-15 months. Severity of dystonia preoperatively and disease duration predicted improvement in severity of dystonia at 2-6 months; this failed to reach significance at 9-15 months. The study confirms that dystonia in neurodegeneration with brain iron accumulation improves with bilateral pallidal deep brain stimulation, although this improvement is not as great as the benefit reported in patients with primary generalized dystonias or some other secondary dystonias. The patients with more severe dystonia seem to benefit more. A well-controlled, multi-centre prospective study is necessary to enable evidence-based therapeutic decisions and better predict therapeutic outcomes.

Intraparenchymal renal artery pseudoaneurysm following nephrostomy tube insertion in a patient with a solitary kidney: A case report.

Intraparenchymal renal artery aneurysms are uncommon and represent less than 10% of all renal artery aneurysms. They are caused by trauma or iatrogenic injury, and their rupture can lead to life-threatening hemorrhage. We report the case of a 48-year-old male with history of left solitary kidney and orthotopic neobladder, who presented with massive hematuria 7 days after nephrostomy tube placement because of obstructive uropathy and acute renal failure due to ureteroileal stricture. An abdominal CT angiography revealed an intraparenchymal renal artery aneurysm, and it was successfully treated with superselective endovascular embolization, achieving maximal parenchymal preservation.

Combined laparoscopic surgery for the treatment of pelvic organ prolapse and recurrent urinary incontinence. / Técnica quirúrgica para la corrección simultánea del prolapso de órganos pélvicos y la incontinencia urinaria recidivada mediante laparoscopia.

INTRODUCTION: Laparoscopic sacral colpopexy (LSC) is the gold standard treatment for apical pelvic organ prolapse (POP). Artificial urinary sphincter (AUS) has a high success rate in treating recurrent stress urinary incontinence (SUI). OBJECTIVE: To describe the first simultaneous LSC and AUS implantation through a vesicovaginal approach to the bladder neck. MATERIAL AND METHODS: Operation is performed through a transperitoneal approach. The rectovaginal space is created and the posterior mesh is fixed. The vesicovaginal and both laterovesical spaces are dissected. The vesicovaginal space is connected to both lateral spaces. This is main step of the procedure because it let us place the cuff around the bladder neck in a non-blind fashion. The anterior mesh is fixed to the vagina. The anterior side of the bladder neck is dissected and the cuff implanted. Both meshes are fixed to the promontory. Pressure-regulating balloon is inserted, the pump is placed in the labia majora and the components are connected. Peritoneum is closed. RESULTS: Surgical time was 180 minutes, bladder catheter was removed at 5th postoperative day, hospital stay was 5 days. The AUS was activated 6 weeks after surgery. No perioperative complications occurred. After 12 months the patient is pad-free and prolapse was objectively and subjectively cured. CONCLUSIONS: Vesicovaginal dissection is a shared step in this technique of LSC and AUS implantation. This approach could minimize the risk of bladder neck injury. We propose this technique in selected cases of prolapse and recurrent SUI.

Analysis of preoperative and postoperative expectations of penile implant candidates. / Evaluación de las expectativas preoperatorias y postoperatorias del candidato a prótesis peneana. Estudios de satisfacción.

Penile prosthesis implantation is a good option for the treatment of refractory erectile dysfunction. However, the patient's expectations, among other factors, condition his satisfaction after surgery. This review article aims to present the scientific evidence available concerning patient satisfaction with penile prosthesis surgery.

Subthalamic nucleus stimulation-induced regional blood flow responses correlate with improvement of motor signs in Parkinson disease.

Deep brain stimulation of the subthalamic nucleus (STN DBS) improves motor symptoms in idiopathic Parkinson's disease, yet the mechanism of action remains unclear. Previous studies indicate that STN DBS increases regional cerebral blood flow (rCBF) in immediate downstream targets but does not reveal which brain regions may have functional changes associated with improved motor manifestations. We studied 48 patients with STN DBS who withheld medication overnight and underwent PET scans to measure rCBF responses to bilateral STN DBS. PET scans were performed with bilateral DBS OFF and ON in a counterbalanced order followed by clinical ratings of motor manifestations using Unified Parkinson Disease Rating Scale 3 (UPDRS 3). We investigated whether improvement in UPDRS 3 scores in rigidity, bradykinesia, postural stability and gait correlate with rCBF responses in a priori determined regions. These regions were selected based on a previous study showing significant STN DBS-induced rCBF change in the thalamus, midbrain and supplementary motor area (SMA). We also chose the pedunculopontine nucleus region (PPN) due to mounting evidence of its involvement in locomotion. In the current study, bilateral STN DBS improved rigidity (62%), bradykinesia (44%), gait (49%) and postural stability (56%) (paired t-tests: P < 0.001). As expected, bilateral STN DBS also increased rCBF in the bilateral thalami, right midbrain, and decreased rCBF in the right premotor cortex (P < 0.05, corrected). There were significant correlations between improvement of rigidity and decreased rCBF in the SMA (r(s) = -0.4, P < 0.02) and between improvement in bradykinesia and increased rCBF in the thalamus (r(s) = 0.31, P < 0.05). In addition, improved postural reflexes correlated with decreased rCBF in the PPN (r(s) = -0.38, P < 0.03). These modest correlations between selective motor manifestations and rCBF in specific regions suggest possible regional selectivity for improvement of different motor signs of Parkinson's disease.

Urinary sepsis after endourological ureterorenoscopy for the treatment of lithiasis. / Sepsis urinaria tras tratamiento endourológico de la litiasis por ureterorrenoscopia.

OBJECTIVE: To evaluate the incidence, clinical presentation and factors associated with the development of urinary sepsis after performing ureterorenoscopy. MATERIAL AND METHODS: Retrospective study of patients undergoing ureterorenoscopy for the treatment of lithiasis between July 2015 and October 2017. Patients who developed urinary sepsis during the 30 days following the intervention were identified. Personal, clinical, surgical and microbiological backgrounds were collected. Statistical analysis was performed with the Chi squared test (or Fisher's exact test), Student's t (or U Mann-Whitney) or logistic regression as appropriate. RESULTS: 246 ureterorenoscopies were performed, 184 (74.8%) on ureteral stones and 62 (25.2%) on kidney stones, with a mean age of 52 (44.5-59.5) years. After procedure, 18 (7.3%) patients developed urinary sepsis, 10 of them (55.5%) occurred in the first 24h. The urine culture showed enterobacteria (61.1%) and enterococci (38.9%). The antibiogram showed greater sensitivity to nitrofurantoins (100%) and quinolones (72%). The statistical analysis showed that female sex, the clinical debut of urolithiasis as urinary sepsis, having received antibiotic or having required urinary diversion by a double J during debut, positive presurgical uroculture and the persistence of residual lithiasis after surgery were significantly associated (P<.05) with the development of urinary sepsis after ureterorenoscopy. CONCLUSION: Urinary sepsis is a complication that appears after performing ureterorenoscopy, especially in female patients with a history of urinary sepsis, antibiotic therapy, double J, previous positive urine culture or residual lithiasis after the procedure.

Comparison between percutaneous nephrolithotomy and flexible ureteroscopy for the treatment of 2 and 3cm renal lithiasis. / Comparación entre nefrolitotomía percutánea y ureteroscopia flexible para el tratamiento de litiasis renales de entre 2 y 3cm.

CONTEXT AND OBJECTIVES: The first-line treatment for >2cm lithiasis is percutaneous nephrolithotomy (PNL), leaving flexible ureteroscopy (fURS) as a second option. In the present review, the stone-free rate and the complications of both techniques were evaluated in the treatment of 2-3cm stones. MATERIAL AND METHODS: Systematic review of studies that compared both techniques. Studies that were not comparative, as well as those carried out in the pediatric population or with <2cm or>3cm stones, were excluded. Two researchers independently performed the investigation, obtaining 5 studies that made up a total of 815 patients: 252 belonged to the fURS group and 563 to the PNL group. Four studies were retrospective, and one was non-randomized prospective. RESULTS: Stone-free rate ranged between 47.0% and 95.0% for the fURS and between 87.0% and 100% for the PNL. The complication rate was 8.8-29.0% in the fURS and 11.9-27.0% in the PNL. fURS required a greater number of procedures, and had a lower decrease in haemoglobin and creatinine rise compared to PNL. CONCLUSIONS: The stone-free rate was higher for PNL, although the fURS could reach comparable results at the expense of performing several procedures. Both techniques have a similar frequency of complications, but the PNL has more postsurgical analytical alterations.

Experience With Hypothermic Machine Perfusion in Expanded Criteria Donors: Functional Outcomes.

Hypothermic machine perfusion (HMP) decreases delayed graft function (DGF) and improves 1-year graft survival in expanded criteria donors (ECDs). Time of HMP could be associated with incidence of DGF. OBJECTIVE: To analyze functional outcomes of ECD grafts preserved totally (local grafts) or partially (imported grafts) with HMP. MATERIALS AND METHODS: We analyzed prospectively collected data from a cohort of first ECD graft receptors, with a minimum follow-up of 6 months. A total of 119 imported and 74 local grafts were included. Local ECD kidneys were preserved with HMP after retrieval. Imported ECD kidneys were preserved with simple cold storage and HMP. Vascular thrombosis, acute rejection, DGF, 1-year glomerular filtration rate, and 1-year graft survival were assessed. Univariate and estimative multivariate logistic regression was applied for analysis of DGF. A Cox proportional hazards model was applied to estimate graft survival. RESULTS: DGF occurred in 14 recipients of local grafts and in 33 recipients of imported grafts (28.0 vs 18.1%, P = .13); 1-year graft survival was better in the group of local grafts (80.3 vs 91.9%, P = .03). No differences in vascular thrombosis (5.9 vs 5.4%, P = .88), acute rejection (12.3 vs 9.8%, P = .91), or 1-year glomerular filtration rate (41.2 vs 40.5 mL/m/1.73m2, P = .87) were observed. In multivariate analysis, adjusted odds ratio for DGF was 1.20 (P = .79) and adjusted hazard ratio for graft survival was 1.93 (P = .31). CONCLUSIONS: There is a trend that complete HMP reduces the risk of DGF and improves 1-year graft survival in ECD kidneys.

MicroRNAs in Kidney Machine Perfusion Fluid as Novel Biomarkers for Graft Function. Normalization Methods for miRNAs Profile Analysis.

MicroRNAs (miRNAs) are post-transcriptional regulators that have emerged as promising biomarkers in kidney transplantation. Quantification of miRNAs can be analyzed by means of biological normalization. The purpose of normalization is to remove technical variation in data, which is not related to the biological changes under investigation. Proper normalization is critical for the correct analysis and interpretation of results. MATERIAL AND METHODS: A prospective cohort study was conducted on graft dysfunction in kidney transplantation from expanded criteria donors. After RNA extraction quantitative real-time polymerase chain reaction was performed. The exogenous spike-in normalization was used as technical normalization. Relative expression was calculated using the 2-ΔΔCt method and UniSp2 spike-in was used as reference for normalization. Results obtained were further analyzed by the application of the mean expression value that uses the calculated mean of all miRNAs in a given sample. RESULTS: The mean expression value approach confirmed the significance of a subset of the miRNAs previously identified for delayed graft function development and composed by miRNAs miR-486-5p, miR-144-3p, miR-142-5p, and miR-144-5p. CONCLUSIONS: MicroRNAs are becoming increasingly important as biomarkers in multiple disease processes including kidney transplantation. Perfusion fluid, particularly during hypothermic machine perfusion, provides a valuable pretransplantation source for identification of organ viability biomarkers. Although there is no clear consensus concerning the normalization technique, the mean expression value method shows the better normalization strategy.

A new approach to laparoscopic implantation of the artificial urinary sphincter: Vesicovaginal approach to the bladder neck. / Nueva aproximación al implante laparoscópico del esfínter urinario artificial: abordaje vesicovaginal al cuello vesical.

INTRODUCTION: The artificial urinary sphincter (AUS) is not used extensively in the treatment of female urinary stress incontinence (USI) due to the poor reproducibility of the techniques used. We describe a new approach to laparascopic implantation, of which dissection of the vesicovaginal space is an essential step. This enables an approach under direct vision to the posterior surface of the bladder neck. MATERIAL AND METHODS: We present two cases where this approach was used. A transperitoneal approach was made in the Trendelenburg position. The main steps were: creating the vesicovaginal space until identifying the bladder neck, creating two laterovesical spaces, communicating these with the vesicovaginal space, and dissecting the anterior surface of the bladder neck, attempting to preserve the pubovesical ligament. The cuff and reservoir were inserted through the 12mm infraumbilical trocar. The connections were externalised through a left suprapubic incision and a subcutaneous tunnel created up to the labia majora where the activation pump was placed. The procedure was completed with closure of the peritoneum. It is essential to use a vaginal valve to facilitate dissection. RESULTS: Surgery time: 140 and 135minutes, with no intraoperative complications. After removing the urinary catheter, one patient had elevated postvoid residual urine volume, which was managed conservatively. Hospital stay: 72h. At 3 and 9 months the patients were fully continent. CONCLUSIONS: We present the preliminary results of laparoscopic implantation of an AUS through a vesicovaginal approach to the posterior surface of the bladder neck, which might reduce potential complications that have been observed after the routine techniques.