Consultation on kidney stones, Copenhagen 2019: lithotripsy in percutaneous nephrolithotomy.

PURPOSE: To evaluate the balance between existing evidence and expert opinions on the safety and efficacy of new technological improvements in lithotripsy techniques for percutaneous nephrolithotomy (PCNL). METHODS: A scoping review approach was applied to search literature in Pubmed, Embase, and Web of Science. Consensus by key opinion leaders was reached at a 2-day meeting entitled "Consultation on Kidney Stones: Aspects of Intracorporeal Lithotripsy" held in Copenhagen, Denmark, in September 2019. RESULTS: New-generation dual-mode single-probe lithotripsy devices have shown favourable results compared with use of ballistic or ultrasonic lithotripters only. However, ballistic and ultrasonic lithotripters are also highly effective and safe and have been the backbone of PCNL for many years. Compared with standard PCNL, it seems that mini PCNL is associated with fewer bleeding complications and shorter hospital admissions, but also with longer operating room (OR) time and higher intrarenal pressure. Use of laser lithotripsy combined with suction in mini PCNL is a promising alternative that may improve such PCNL by shortening OR times. Furthermore, supine PCNL is a good alternative, especially in cases with complex renal stones and large proximal ureteric stones; in addition, it facilitates endoscopic combined intrarenal surgery (ECIRS). CONCLUSION: Recent technological improvements in PCNL techniques are promising, but there is a lack of high-level evidence on safety and efficacy. Different techniques suit different types of stones and patients. The evolution of diverse methods has given urologists the possibility of a personalized stone approach, in other words, the right approach for the right patient.

Comparative assessment of biodegradable-antireflux heparine coated ureteral stent: animal model study.

BACKGROUND: Double J ureteral stents are widely used on urological patients to provide drainage of the upper urinary tract. Unfourtunately, ureteral stents are not free from complications, as bacterial colonization and require a second procedure for removal. The purpose of the current comparative experimental study is to evaluate a new heparin-coated biodegradable antireflux ureteral stent (BraidStent®-H) to prevent urinary bacterial colonization. METHODS: A total of 24 female pigs were underwent determination of bacteriuria and nephrosonographic, endoscopic and contrast fluoroscopy assessment of the urinary tract. Afterward, were randomly assigned animals to Group-I, in which a 5Fr double-pigtail ureteral stent was placed for 6 weeks, or Group-II, in which a BraidStent®-H was placed. Follow-up assessments were performed at 1, 3, 6, 8, 12 weeks. The final follow-up includes the above methods and an exhaustive pathological study of the urinary tract was accomplished after 20 weeks. RESULTS: Bacteriuria findings in the first 48 h were significant between groups at 6 h and 12 h. Asymptomatic bacteriuria does not reach 100% of the animals in Group-II until 48 h versus Group-I where it appears at 6 h. The weekly bacteriuria mean rate was 27.7% and 44.4% in Group I and II respectively, without statistical significance. In Group II there were no animals with vesicoureteral reflux, with statistical significance at 3 and 6 weeks with Group-I. The 91.2% of stents in Group-II were degraded between 3 and 6 weeks, without obstructive fragments. Distal ureteral peristalsis was maintained in 66.6-75% in Group-II at 1-6 weeks. CONCLUSIONS: The heparin coating of BraidStent® allows an early decrease of bacterial colonization, but its effectiveness is low at the long term. Heparin coating did not affect scheduled degradation rate or size of stents fragments. BraidStent®-H avoids the side effects associated with current ureteral stents, thus should cause less discomfort to patients.

Reduction of ureteral stent encrustation by modulating the urine pH and inhibiting the crystal film with a new oral composition: a multicenter, placebo controlled, double blind, randomized clinical trial.

BACKGROUND: Encrustation of ureteral double J stents is a common complication that may affect its removal. The aim of the proposed study is to evaluate the efficacy and safety of a new oral composition to prevent double J stent encrustation in indwelling times up to 8 weeks. METHODS: A double-blinded, multicenter, placebo-controlled trial was conducted with 105 patients with indwelling double J stents enrolled across 9 public hospitals in Spain. The patients were randomly assigned (1:1) into intervention (53 patients) or placebo (52 patients) groups for 3 to 8 weeks and both groups self-monitored daily their morning urine pH levels. The primary outcome of analysis was the degree of stent ends encrustation, defined by a 4-point score (0 - none; 3 - global encrustation) using macroscopic and electron microscopy analysis of crystals, after 3 to 8-w indwelling period. Score was exponentially transformed according to calcium levels. Secondary endpoints included urine pH decrease, stent removal, and incidence of adverse events. RESULTS: The intervention group benefits from a lower global encrustation rate of stent ends than placebo group (1% vs 8.2%; p < 0.018). Mean encrustation score was 85.12 (274.5) in the placebo group and 18.91 (102.27) in the intervention group (p < 0.025). Considering the secondary end points, treated patients reported greater urine pH decreases (p = 0.002). No differences in the incidence of adverse events were identified between the groups. CONCLUSIONS: Our data suggest that the use of this new oral composition is beneficial in the context of ureteral double J indwelling by decreasing mean, as well as global encrustation. TRIAL REGISTRATION: This trial was registered at www.clinicaltrials.gov under the name "Combined Use of a Medical Device and a Dietary Complement in Patient Urinary pH Control in Patients With an Implanted Double J Stent" with date 2nd November 2017, code NCT03343275, and URL.

First clinical evaluation of a new single-use flexible ureteroscope (LithoVue™): a European prospective multicentric feasibility study.

INTRODUCTION: We evaluated a new digital single-use flexible ureteroscope, LithoVue™ with respect to deflection, image quality and maneuverability. METHODS: A prospective cohort study was conducted in eight tertiary reference centers in Europe in December 2015 and January 2016. All consecutive patients included underwent flexible ureteroscopy and were 18 years or older. Deflection and image quality pre- and post-use and maneuverability were rated with a Likert scale. RESULTS: A total of 40 procedures were performed (five per institution). The indication for FURS was treatment of renal stones in 92.5 % of the cases. Before LithoVue™ usage, the median measured upward and downward deflections were both 270°. Image quality was rated as "very good" in 65 % of cases and "good" in 30 %. Maneuverability was "very good" in 77.5 % and "good" in 17.5 %. At the final evaluation, median upward and downward deflections were both 270°. Image quality was still "very good" in 65 % of cases and "good" in 30 % with no significant difference compared with preoperative data (p = 1). Maneuverability was "very good" in 72.5 % and "good" in 17.5 %, with no significant difference compared with preoperative data (p = 0.92). Two LithoVue™ broke during surgery (5 %): one occurring in extreme deflection with acute infundibulopelvic angle and spontaneous loss of vision for the second one. CONCLUSION: The LithoVue™ displayed good image quality, active deflection and maneuverability. Further evaluation of surgical outcomes and cost analysis will help to present the best utility of this single-use FURS in current practice.

Characterising endourologist learning curve during percutaneous nephrolithotomy: implications on occupational dose and patients.

In this study we have characterised the learning curve for percutaneous nephrolithotomy procedures over 301 cases for six years. Different surrogate parameters of clinical expertise have been used, such as dose area product, total procedure time, fluoroscopy time and personal equivalent doses. In addition, two different endourologists have been monitored; one of whom had specific Radiation Protection training (ICRP 85). Eye lens dose was estimated from thermoluminescent dosimeters. Significant differences were observed between both endourologists, especially in the fluoroscopy time. Finally, both entrance skin dose and effective doses of patients have been determined.

Characterizing endourologist learning curve during percutaneous nephrolithotomy: implications on occupational dose and patients.

In this study we have characterized the learning curve of percutaneous nephrolithotomy procedures over 301 cases for six years. Different surrogate parameters of clinical expertise have been used, such as dose area product, total procedure time, fluoroscopy time and personal equivalent doses. In addition, two different endourologists have been monitored; one of whom was subjected to a specific Radiation Protection training (ICRP 85). Eye lens dose is estimated from thermoluminescent dosimeters. Significant differences are observed between both endourologists, especially in the fluoroscopy time. Finally, both entrance skin dose and effective doses of patients have been determined.

A method for estimating DMSA SPECT renal function for assessing the effect of percutaneous nephrolithotripsy on the treated pole.

BACKGROUND: The aim of this study was to develop a method for estimating DMSA SPECT renal function on each renal pole in order to evaluate the effect of percutaneous nephrolithotripsy by focusing the measurements on the region through which the percutaneous approach is performed. METHODS: Twenty patients undergoing percutaneous nephrolithotripsy between November 2010 and June 2012 were included in this study. Both Planar and SPECT-DMSA studies were carried out before and after nephrolithotripsy. The effect of percutaneous nephrolithotripsy was evaluated by estimating the total renal function and the regional renal function of each renal pole. Despite PCNL has been previously reported as a minimally invasive technique, our results showed regional renal function decreases in the treated pole in most patients, affecting the total renal function in a few of them. RESULTS: A quantification method was used for estimating the SPECT DMSA renal function of the upper, interpolar and lower renal poles. Our results confirmed that total renal function was preserved after nephrolithotripsy. Nevertheless, the proposed method showed that the regional renal function of the treated pole decreased in most patients (15 of 20 patients), allowing us to find differences in patients who had not shown changes in the total renal function obtained from conventional quantification methods. CONCLUSION: A method for estimating the SPECT DMSA renal function focused on the treated pole enabled us to show for the first time that nephrolithotripsy can lead to a renal parenchymal damage restricted to the treated pole.

Adenomatoid paratesticular tumor: report of 5 new cases and literature review.

OBJECTIVE: To report 5 cases of adenomatoid tumor of the epididymis that have been diagnosed in the last 11 years at our hospital. We performed a bibliographic review with discussion of diagnosis, differential diagnosis and treatment of this rare type of lesion. METHOD: We have performed a retrospective analysis of epididymal adenomatoid tumors diagnosed during the last 11 years in our hospital, from January 2001 to June 2012. RESULTS: The average age of the series was 44 years. The predominant reason for consultation was long duration painless scrotal mass, with palpable nodule, usually dependent of the epididymis. 60% of the patients have been studied with abdominal ultrasound, which showed a nodular paratesticular lesion, with an echogenicity compatible with solid tissue. Tumor markers associated with testicular tumors (alpha-fetoprotein (AFP)), beta-human chorionic gonadotropin (b-HCG) and lactate dehydrogenase (LDH) were analyzed in 60% of the cases, being normal in all patients. 3 lumpectomies, 1 epididymectomy and 1 radical orchiectomy have been performed. CONCLUSIONS: The discovery of a solid epididymal mass is uncommon in clinical practice. Physical examination and imaging tests should confirm the paratesticular origin of the lesion, being then trans-scrotal epididymectomy the treatment of choice. If diagnosis is uncertain, inguinal approach and intraoperative biopsy are mandatory.

Outcomes and patterns of use of Radium-223 in metastatic castration-resistant prostate cancer.

Introduction: Radium-223 dichloride (Ra-223) is recommended as a treatment option for metastatic castration-resistant prostate cancer (mCRPC) patients with symptomatic bone metastases and no visceral disease, after docetaxel failure, or in patients who are not candidates to receive it. In this study, we aimed to ambispectively analyze overall survival (OS) and prognostic features in mCRPC in patients receiving Ra-223 as per clinical routine practice and identify the most suitable treatment sequence. Patients and methods: This study is observational, multicentric, and ambispective. Eligibility criteria included mCRPC patients treated with Ra-223, with an Eastern Cooperative Oncology Group (ECOG) performance status of 0-2, without visceral metastases, and no more than three cm involved lymph nodes. Results: A total of 145 patients were included; the median age was 73.97 years, and a Gleason score of more than or equal to 7 in 61 (48%) patients; 73 (81%) had previously received docetaxel. The most important benefit was reached by those patients who received Ra-223 in the second-line setting, with a median OS of 17 months (95% CI, 12-21), and by patients who received six cycles of treatment, with a median OS of 19 months (95% CI, 14-21). An alkaline phosphatase (ALP) decrease was also identified as a prognosis marker. When performing the multivariate analysis, the time to develop castration-resistant disease longer than 24 months was the most important prognostic factor to predict the evolution of the patients receiving Ra-223. Ra-223 was well tolerated, with thrombocytopenia, anemia, and diarrhea being the main adverse events. Conclusion: There is a benefit for those patients who received Ra-223 in the second-line setting, regardless of prior use of docetaxel. In addition, a survival benefit for patients presenting with a decline in ALP was observed.

Criteria and indicators to evaluate quality of care in genitourinary tumour boards.

PURPOSE: Genitourinary (GU) multidisciplinary tumour boards (GUMTBs) are key components of patient care, as they might lead to changes in treatment plan, improved survival, and increased adherence to guidelines. However, there are no guidelines on how GUMTBs should operate or how to assess their quality of performance. METHODS: A systematic literature review was conducted to identify criteria and indicators to evaluate quality in GUMTBs. A scientific committee-comprising 12 GU cancer specialists from seven disciplines-proposed a list of criteria and developed indicators, evaluated in two rounds of Delphi method. Appropriateness and utility of indicators were scored using a 9-point Likert scale. Consensus was defined as at least two-thirds of Delphi respondents selecting a score sub-category that encompassed the median score of the group. RESULTS: Forty-five criteria were selected to evaluate the quality of GUMTBs covering five dimensions: organisation, personnel, protocol and documentation, resources, and interaction with patients. Then, 33 indicators were developed and evaluated in the first round of Delphi, leading to a selection of 26 indicators in two dimensions: function, governance and resources, and GUMTB sessions. In the second round, consensus was reached on the appropriateness of all 26 indicators and on the utility of 24 of them. Index cards for criteria and indicators were developed to be used in clinical practice. CONCLUSIONS: Criteria and indicators were developed to evaluate the quality of GUMTBs, aiming to serve as a guide to improve quality of care and health outcomes in patients with GU cancer.

Predictive analysis of factors associated with percutaneous stone surgery outcomes.

INTRODUCTION: The aim of this study is to identify surgical, patient- and stone-related factors predictive of clinical success and complications after percutaneous nephrolithotomy (PCNL). MATERIALS AND METHODS: We prospectively studied 100 consecutive PCNL procedures. Univariate and multiple regression models were used in order to identify which variables could act as independent predictors of PCNL outcomes. Success was defined as complete absence of fragments in a non-contrast CT. The Clavien-modified grading system was used to classify the complications. RESULTS: Univariate analysis showed that patients rendered stone-free had a significantly lower stone burden, shorter operating times, single stones and non-struvite composed calculi. Patient age, nephrostomy tract dilation with high pressure balloon and a stone composition different to struvite behaved as significant protective factors for complications. Logistic regression models revealed that the main independent prognostic factor for success was stone surface (OR = 0.997 per mm2, p = 0.000), followed by multiple stones (OR = 0.203, p = 0.050). On the other hand, struvite composition (OR = 5.911, p = 0.028) was an independent predictor for the development of complications, whilst age (OR = 0.936, p = 0.012) and high pressure balloon dilation (OR = 0.041, p = 0.007) were rendered independent protective variables. CONCLUSIONS: Stone burden and multiple calculi in the kidney affect the immediate stone-free rate, whilst Amplatz dilation, struvite stones and young patients lead to a higher incidence of postoperative complications. This information can be very useful for patient counseling, regarding percutaneous kidney stone management.

Extracellular Vesicles' Genetic Cargo as Noninvasive Biomarkers in Cancer: A Pilot Study Using ExoGAG Technology.

The two most developed biomarkers in liquid biopsy (LB)-circulating tumor cells and circulating tumor DNA-have been joined by the analysis of extracellular vesicles (EVs). EVs are lipid-bilayer enclosed structures released by all cell types containing a variety of molecules, including DNA, mRNA and miRNA. However, fast, efficient and a high degree of purity isolation technologies are necessary for their clinical routine implementation. In this work, the use of ExoGAG, a new easy-to-use EV isolation technology, was validated for the isolation of EVs from plasma and urine samples. After demonstrating its efficiency, an analysis of the genetic material contained in the EVs was carried out. Firstly, the sensitivity of the detection of point mutations in DNA from plasma EVs isolated by ExoGAG was analyzed. Then, a pilot study of mRNA expression using the nCounter NanoString platform in EV-mRNA from a healthy donor, a benign prostate hyperplasia patient and metastatic prostate cancer patient plasma and urine samples was performed, identifying the prostate cancer pathway as one of the main ones. This work provides evidence for the value of using ExoGAG for the isolation of EVs from plasma and urine samples, enabling downstream applications of the analysis of their genetic cargo.

Cytotoxicity Assessment of a New Design for a Biodegradable Ureteral Mitomycin Drug-Eluting Stent in Urothelial Carcinoma Cell Culture.

Urothelial tumour of the upper urinary tract is a rare neoplasm, but unfortunately, it has a high recurrence rate. The reduction of these tumour recurrences could be achieved by the intracavitary instillation of adjuvant chemotherapy after nephron-sparing treatment in selected patients, but current instillation methods are ineffective. Therefore, the aim of this in vitro study is to evaluate the cytotoxic capacity of a new instillation technology through a biodegradable ureteral stent/scaffold coated with a silk fibroin matrix for the controlled release of mitomycin C as an anti-cancer drug. Through a comparative study, we assessed, in urothelial carcinoma cells in a human cancer T24 cell culture for 3 and 6 h, the cytotoxic capacity of mitomycin C by viability assay using the CCK-8 test (Cell counting Kit-8). Cell viability studies in the urothelial carcinoma cell line confirm that mitomycin C embedded in the polymeric matrix does not alter its cytotoxic properties and causes a significant decrease in cell viability at 6 h versus in the control groups. These findings have a clear biomedical application and could be of great use to decrease the recurrence rate in patients with upper tract urothelial carcinomas by increasing the dwell time of anti-cancer drugs.

European Association of Urology Section of Urolithiasis and International Alliance of Urolithiasis Joint Consensus on Retrograde Intrarenal Surgery for the Management of Renal Stones.

BACKGROUND: Retrograde intrarenal surgery (RIRS) has become the preferred treatment modality for nephrolithiasis. However, because of ongoing uncertainties regarding the optimal perioperative management, operative technique, and postoperative follow-up, as well as a lack of standardization for outcome reporting, consensus is needed to achieve more uniform clinical practice worldwide. OBJECTIVE: To develop recommendations for RIRS on the basis of existing data and expert consensus. DESIGN, SETTING, AND PARTICIPANTS: A protocol-driven, three-phase study was conducted by the European Association of Urology Section of Urolithiasis (EULIS) and the International Alliance of Urolithiasis (IAU). The process included: (1) a nonsystematic review of the literature to define domains for discussion; (2) a two-round modified Delphi survey involving experts in this field; and (3) an additional group meeting and third-round survey involving 64 senior representative members to formulate the final conclusions. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The results from each previous round were returned to the participants for re-evaluation of their decisions during the next round. The agreement threshold was set at 70%. RESULTS AND LIMITATIONS: The panel included 209 participants who developed 29 consensus statements on the following topics of interest: (1) perioperative infection management; (2) perioperative antithrombotic therapy; (3) fundamentals of the operative technique; and (4) standardized outcome reporting. Although this consensus can be considered as a useful reference for more clinically oriented daily practice, we also acknowledge that a higher level of evidence from further clinical trials is needed. CONCLUSIONS: The consensus statements aim to guide and standardize clinical practice and research on RIRS and to recommend standardized outcome reporting. PATIENT SUMMARY: An international consensus on the best practice for minimally invasive surgery for kidney stones was organized and developed by two international societies. It is anticipated that this consensus will provide further guidance to urologists and may help to improve clinical outcomes for patients.

Blood-based protein biomarkers in bladder urothelial tumors.

Bladder cancer (BC) is the fifth most common cancer with a high prevalence rate. It is classically classified in two groups, namely non-muscle invasive (NMIBC) and muscle invasive (MIBC). NMIBC accounts for 75% of cases and has a better prognosis than MIBC. However, 30-50% of the NMIBC patients will show recurrences throughout their lives, and about 10-20% of them will progress to MIBC, with frequent metastasis and a reduced survival rate. The diagnosis of bladder cancer is confirmed by direct visualization of the tumour and other mucosal abnormalities with endoscopic excision using cystoscopy and transurethral resection of the bladder (TURBT). An adequate TURBT requires complete resection of all visible tumour with appropriate sampling of the bladder to assess the depth of invasion. However, for many years, researchers have attempted to identify and utilise urinary markers for bladder cancer detection. Voided urine cytology has been the mainstay of urine-based diagnosis of bladder cancer since originally described by Papanicolau and Marshall. Nonetheless, urine cytology has several drawbacks, including a poor sensitivity for low-grade/stage tumours, a lack of interobserver consistency and a variable range of readings (e.g., atypical, atypical-suspicious, non-diagnostic). These shortcomings have inspired the search for more sensitive bladder cancer biomarkers. To bring precision medicine to genitourinary oncology, the analysis of the plasma/serum wide genome and proteome offers promising possibilities.

Detection of Circulating Serum Protein Biomarkers of Non-Muscle Invasive Bladder Cancer after Protein Corona-Silver Nanoparticles Analysis by SWATH-MS.

Because cystoscopy is expensive and invasive, a new method of detecting non-invasive muscular bladder cancer (NMIBC) is needed. This study aims to identify potential serum protein markers for NMIBC to improve diagnosis and to find treatment approaches that avoid disease progression to a life-threatening phenotype (muscle-invasive bladder cancer, MIBC). Here, silver nanoparticles (AgNPs, 9.73 ± 1.70 nm) as a scavenging device together with sequential window acquisition of all theoretical mass spectra (SWATH-MS) were used to quantitatively analyze the blood serum protein alterations in two NMIBC subtypes, T1 and Ta, and they were compared to normal samples (HC). NMIBC's analysis of serum samples identified three major groups of proteins, the relative content of which is different from the HC content: proteins implicated in the complement and coagulation cascade pathways and apolipoproteins. In conclusion, many biomarker proteins were identified that merit further examination to validate their useful significance and utility within the clinical management of NMIBC patients.

The SCQ-SCORE: initial validation of a new scoring system for elective stone surgery prioritization in the COVID-19 era.

INTRODUCTION: Endourology waiting lists have increased during the COVID-19 pandemic and prioritization strategies are needed. Some tiered classifications have been put forward aimed at prioritizing patients by using criteria related with clinical severity or social impact of stone disease, yet no quantitative system has been published to date. The objective of this study is to present a new quantitative scoring system for elective stone surgery prioritization and show its intra- and inter-rater reliability. MATERIAL AND METHODS: A scoring system coined 'SCQ-score' was set up, which consists of 9 variables: infection (ranges 0-3), obstruction (0-3), indwelling time (0-3), admissions (0-3), symptoms (0-2), ureteral location (0-1), solitary or suboptimal kidney (0-1), chronic kidney disease (0-1) and presence of percutaneous nephrostomy (0-1).The intra- and inter-rater reliability of the SCQ-score was prospectively validated in 60 consecutive patients on the waiting list, by calculating the intraclass correlation coefficient (ICC). RESULTS: The SCQ-score demonstrated having an excellent interobserver agreement (ICC >0.75) for the final score and its different domains. After 4 weeks, a second analysis was carried out to measure its intra-rater reliability, which was also excellent. On average, 134.9 ±50 seconds were required to complete the SCQ-score. CONCLUSIONS: The SCQ-score is a new quantitative system to help prioritize elective stone surgeries, which has been shown to be user-friendly and to have an excellent intra- and inter-rater reliability. Initially developed to help during the COVID-19 pandemic, its utility will probably remain of interest in the post-COVID-19 era to ensure a fairer access to stone surgery.

Rupture of the superficial vein of penis: therapeutic options.

OBJECTIVE: To report an uncommon clinical case of spontaneous rupture of the superficial dorsal vein of penis. METHOD: A 27-year-old male patient attended the emergency room following spontaneous occurrence of a large hematoma and deformity in the penis. Rupture of cavernous bodies was initially suspected. RESULTS: Surgical examination revealed rupture of the superficial dorsal vein of penis, which was ligated. The patient was admitted to hospital for 24 hours, and showed total cosmetic and functional recovery at 2 weeks. CONCLUSIONS: Rupture of the superficial dorsal vein of penis is an uncommon condition considered in differential diagnosis of penile hematoma. Doppler ultrasound of the penis may allow for its diagnosis and for excluding rupture of corpora cavernosa. Although conservative management appears to be of choice, surgical examination, providing good cosmetic and functional postoperative results, is indicated when a reasonable doubt exists about diagnosis.