Transformations in BPH Surgical Practices: A Longitudinal Study of Trends and Predictions.

INTRODUCTION: The workload for BPH surgery is expected to rise with an increase in life expectancy and a growing population. Surgical modalities for BPH have evolved, shifting towards minimally invasive transurethral procedures. This study aims to investigate the trends in BPH surgical procedures across medical centers in Israel. METHODS: Data from seven academic medical centers in Israel from 2010 to 2022 were analyzed. Procedures included open prostatectomy, transurethral prostatectomy (TURP), laser enucleation of the prostate (HoLEP), and photovaporization of the prostate (PVP). Statistical analyses were employed, including t-tests, ANOVA, and ARIMA models. RESULTS: Over 12 years, 13,478 BPH procedures were performed. TURP was the most common (72%), followed by open surgery (12%), HoLEP (12%), and PVP (3%). Annual procedures increased by approximately 5% each year, with a cumulative surge of 63% cases by 2022. The average patient's age remained stable. TURP and HoLEP showed continual growth, while open surgery declined. HoLEP exhibited a shorter length of hospital stay compared to other modalities. Predictive models suggest open prostatectomy will cease within two years, while TURP and HoLEP will continue to rise. CONCLUSION: This study highlights a significant increase in BPH surgical procedures over time, with a notable preference for TURP and HoLEP. The findings emphasize the importance of size-independent techniques like HoLEP for optimal healthcare management in the future.

Characterization of the histological response to the Butterfly Prostatic Retraction Device in patients with benign prostatic hyperplasia.

PURPOSE: The Butterfly Prostatic Retraction Device ("Butterfly") is a permanent nitinol implant for benign prostatic hyperplasia. This study examines the chronic response of prostate tissue to the Butterfly in histological specimens from patients in the Butterfly pilot clinical study. METHODS: Retrospective qualitative and semi-quantitative review of histological specimens of seven (7) patients who participated in the Butterfly pilot clinical study. Patients had at least 1-month implantation with the Butterfly prior to implant removal and TURP. Tissue samples were graded by two pathologists. RESULTS: Four out of six patients had IPSS decreased from baseline. All seven patients' samples had signs of chronic inflammation; one demonstrated acute inflammation and one demonstrated fibrosis. In three cases, intraglandular calcification was identified. There was no ischemic necrosis induced by the implant, and no encrustation, urethral edema, or cellular atypia was noted. CONCLUSION: The Butterfly demonstrated an overall favorable safety profile in terms of tissue response. This study demonstrates that there is no significant tissue reaction in the prostatic urethra due to presence of Butterfly device.

The Butterfly: A Novel Minimally Invasive Transurethral Retraction Device for Benign Hypertrophy of the Prostate.

INTRODUCTION: The Butterfly Prostatic Retraction device is a novel transurethral implant designed to dilate the prostatic urethra and treat lower urinary tract symptoms. We assessed its safety, efficacy and impact on urinary flow, ejaculation, and quality of life. MATERIALS AND METHODS: We included 64 men, treated for benign prostate hyperplasia for at least 1 year. All patients had Qmax≤ 13 mL/s and IPSS >12. Insertion of the device was performed via cystoscopy. Follow-up visits were performed at 2 weeks, 1, 3, 6, and 12 months and included uroflowmetry, IPSS, QoL, and sexual function questionnaires. Cystoscopy was performed on 3 and 12 months. RESULTS: Patients age was 50-83 years. 28 patients completed a 1-year follow-up with an intact device. Mean Qmax improved by 2 mL/s (25%), IPSS median drop was 10 points (40%), and QoL score was 1.5 points (38%). Sexually active patients reported antegrade ejaculation. On cystoscopy, gradual coverage of the devices with urethral mucosa was observed. In 1 patient, the device was repositioned. In 19 patients, the device was removed. 12 patients returned to alpha-blocker therapy and 7 patients underwent TURP. One patient developed a bulbar urethral stricture. CONCLUSIONS: We demonstrated feasibility and good tolerability of the Butterfly device.

Fluoroless Ureteroscopy: Experience in More Than 100 Patients.

BACKGROUND: Ureteroscopy is becoming the primary treatment for ureteral stones. As a standard of care, ureteroscopy is performed under the supervision of fluoroscopy. Recent advances in endourological technology make the need for fluoroscopy questionable. OBJECTIVES: To summarize our experience with a no-fluoroscopy technique for selected cases of ureteral stones. METHODS: Patients were considered suitable for fluoroless ureteroscopy if they had one or two non-impacted stones, in any location in the ureter, 5-10 mm size, with a normal contralateral renal unit and no urinary tract infection. Procedures were performed using rigid scopes, nitinol baskets/forceps for stone retrieval, and Holmium:YAG laser for lithotripsy. Stents were placed per surgeon's decision. RESULTS: During an 18-month period, 103 patients underwent fluoroless ureteroscopy. In 94 patients stones were removed successfully. In six, the stones were pushed to the kidney and treated successfully on a separate session by shock wave lithotripsy. In three patients no stone was found in the ureter. In five patients, miniature perforations in the ureter were noted and an indwelling double J stent was placed. CONCLUSIONS: Fluoroless ureteroscopy resulted in a high rate of success. We believe that in selected cases it can be used with minimal adverse events.

The Importance of Cystoscopy in Diagnosis and Treatment of Urethral Stricture Following Transurethral Prostatectomy.

BACKGROUND: Transurethral prostatectomy is the gold standard surgical treatment of bladder outlet obstruction due to benign enlargement of the prostate, with more than 30,000 procedures performed annually in the United States alone. The success rate of this minimally invasive procedure is high and the results are durable. The development of urethral stricture is a long-term complication of the procedure and is noted in about 2% of patients. The stricture narrows the urethral lumen, leading to re-appearance of obstructive urinary symptoms. Traditionally, the evaluation of the stricture was performed by retrograde urethrography. Advancements in the fields of flexible endoscopy allowed rapid inspection of the urethra and immediate dilatation of the stricture in selected cases. OBJECTIVES: To compare the efficacy of urethrography versus cystoscopy in the evaluation of urethral strictures following transurethral prostatectomy. METHODS: A retrospective review was conducted of a series of 32 consecutive patients treated due to post-transurethral resection of prostate (TURP) urethral stricture. RESULTS: Twenty patients underwent both tests. In 16 there was concordance between the two tests. Four patients had no pathological findings in urethrography but had strictures in cystoscopy. All strictures were short (up to 10 mm) and were easily treated during cystoscopy, with no complaints or re-surgery needed in 24 months follow-up. CONCLUSIONS: Cystoscopy was superior to urethrography in the evaluation of post-TURP strictures. Strictures where often short and treated during the same procedure. We recommend that cystoscopy be the procedure of choice in evaluating obstructive urinary symptoms after TURP, and retrograde urethrography be preserved for selected cases.

The natural history of secondary muscle-invasive bladder cancer.

BACKGROUND: The management of patients with high-grade non muscle invasive bladder cancer (NMIBC) brings diagnostic and therapeutic challenges. In the current study, we sought to study the natural history of progression to "secondary" muscle-invasive bladder cancer (MIBC)-cancer that developed during follow up of patients presenting with non-muscle invasive bladder cancer (NMIBC). METHODS: Between 1998 and 2008, 760 patients were treated for bladder cancer. Primary MIBC (>=T2) tumors (present upon presentation) were diagnosed in 114 patients. All patients with high-grade NMIBC were treated with intravesical BCG. Mean follow-up was 44 months. RESULTS: Forty patients (6.1%) developed secondary MIBC after a mean period of 21 months from initial diagnosis of bladder cancer. The 2- and 5-year disease-specific survival rates were better for patients with secondary MIBC (90% and 56% compared to 69% and 42% for patients with primary disease, p=0.03). The Kaplan-Meier curves of the two groups were parallel but displaced by approximately 2 years. CONCLUSION: In the current series, MIBC progression occurred among initially presenting patients with NMIBC in 6.1%. In most patients, the initial diagnosis of NMIBC is correct and muscle invasion occurs after a mean period of about 2 years. This supports a non-radical approach in patients with high-grade T1, Ta or Tis. Meticulous follow-up with liberal biopsy of any suspicious lesion may provide early diagnosis of invasive disease.

Characterization of fecal microbiome in biopsy positive prostate cancer patients.

Objectives: To characterize the fecal microbiome in newly diagnosed prostate cancer patients. Patients and methods: Forty-nine consecutive patients who were referred for trans rectal prostate biopsy were tested. Patients who received antibiotics 3 months prior to the biopsy, patients with history of pelvic irradiation, prostate or colon cancer, inflammatory bowel disease and urinary tract infection were excluded. A rectal swab was obtained just prior to the biopsy, immediately placed in a sterile tube and kept in -80°C. Sequencing was performed for the 16S rRNA 515F + 806R gene fragment using the QIIME2 software. Analytic tests included Beta diversity (Weighted Unifrac, Unweighted Unifrac, Bray-Curtis), Alpha diversity (Faith, Evenness), Taxa bar plots and PCoA plots. Results: Forty-five samples were suitable for analysis with at least 8000 readings per sample. All patients were Caucasian. Twenty patients had prostate cancer and 25 had benign prostates (BPH). Among prostate cancer patients, Gleason Score was 3 + 3 in 11 patients, 3 + 4 in 5, 4 + 3 in 3, and 4 + 4 in 2. There was no statistical difference in demographic parameters between the groups. We identified over 1000 bacterial species, typical for the colonic microbiome. No significant differences in bacterial populations were found between prostate cancer versus benign prostate patients nor between age groups or between subgroups of Gleason or International Society of Uro-pathology (ISUP) scores. Conclusions: Although the microbiome has previously been shown to have an impact on the human microenvironment and cancer risk, we could not demonstrate a significant difference between the flora diversity of newly diagnosed prostate cancer patients and BPH patients. Further research into distinct bacterial metabolic pathways may reveal unique risk factors for prostate cancer.

Predicting the risk of high-grade bladder cancer using noninvasive data.

AIM: To examine the hypothesis that the risk of high-grade bladder cancer can be predicted using noninvasively obtained data. PATIENTS AND METHODS: We retrospectively analyzed the database of 431 patients that had transurethral resection of first-time bladder tumors between June 1998 and December 2009. Pre-operative parameters evaluated were: patients' age; gender; sonographic tumor diameter, number and location of tumor inside the bladder; presence of hydronephrosis, and results of urinary cytology. Parameters that showed significance in multivariate analysis were incorporated into the nomogram. RESULTS: Multivariate analysis of the data showed that patient's age, the presence of hydronephrosis, sonographic tumor diameter (risk of a high-grade tumor: 14, 29, 43.3, 55.7 and 69.4% at diameters: 0.5-1.5, 1.6-2, 2.1-2.5, 2.6-3 and >3 cm, respectively), location of tumor in the bladder (risk of high-grade tumor: 28.8, 47, 67.5 and 90.5% in the lateral walls, posterior/base, anterior and dome, respectively), and urinary cytology were all highly significant and independent predictors of high-grade tumors. A nomogram constructed using these variables scored an area of 0.853 in the ROC curve. CONCLUSIONS: The risk of high-grade bladder tumor can be accurately predicted using non-invasively obtained information. This prediction can help to triage patients with newly detected bladder cancer for biopsy.

Coronal reconstruction of unenhanced abdominal CT for correct ureteral stone size classification.

PURPOSE: To determine whether size measurement of a urinary calculus in coronal reconstruction of computed tomography (CT) differs from stone size measured in the axial plane, and whether the difference alters clinical decision making. METHODS: We retrospectively reviewed unenhanced CT examinations of 150 patients admitted to the emergency room (ER) with acute renal colic. Maximal ureteral calculus size was measured on axial slices and coronal reconstructions. Clinical significance was defined as an upgrading or downgrading of stone size according to accepted thresholds of treatment: < or =5 mm, 6-9 mm and > or =10 mm. RESULTS: There were 151 stones in 150 patients (male:female 115:34, mean age 41 years). Transverse stone diameters ranged from 1 to 11 mm (mean 4 mm). On coronal images, 56 (37%) stones were upgraded in severity; 46 (30%) from below 5 mm to 6 mm or more, and ten (7%) from 6-9 mm to 10 mm or more. Transverse measurement on the axial slices enabled correct categorization of 95 stones (63%). CONCLUSION: Transverse calculus measurement on axial slices often underestimates stone size and provides incorrect clinical classification of the true maximal stone diameter. Coronal reconstruction provides additional information in patients with renal colic that may alter treatment strategy.

Extracorporeal shock wave lithotripsy in prepubertal children: 22-year experience at a single institution with a single lithotriptor.

PURPOSE: The sophistication of percutaneous nephrolithotomy and ureteroscopy challenges the efficacy of ESWL for urolithiasis in prepubertal patients. We evaluated our long-term experience with ESWL in these patients and determined its efficiency. MATERIALS AND METHODS: We retrospectively reviewed the charts of all prepubertal patients who underwent ESWL. We evaluated the need for tubing, the 3-month stone-free rate, the need for additional ESWL, and the effect of stone size and location, and cystinuria on the 3-month stone-free rate. RESULTS: Between 1986 and 2008, 119 males and 97 females with a mean age of 6.6 years who had urolithiasis underwent ESWL using the Dornier HM3 lithotriptor. We treated 157 children with renal calculi with an average +/- SD diameter of 14.9 +/- 8.9 mm, of whom 66 (42%) required a tube in the urinary system. The 3-month stone-free rate was 80% and 31 patients (19.7%) needed an additional procedure. Stone location did not affect the stone-free rate but stone size did. We treated 59 patients for ureteral stones with an average stone length of 9.5 +/- 4.8 mm, of whom 41 (69%) required tube insertion. The 3-month stone-free rate was 78% and 13 patients (22%) needed an additional procedure. The 3-month stone-free rate did not depend on stone location or size. The rate was 37.5% in patients with cystinuria and 82.5% in all others (p <0.0001). Six patients (2.8%) had complications. CONCLUSIONS: The 3-month stone-free rate after ESWL in prepubertal patients is 80% and 20% of patients require additional procedures. ESWL is most effective for kidney stones less than 11 mm. ESWL has inferior results for cystine stones compared to other calculi. Complications are rare.

Bladder neck closure in children: a decade of followup.

PURPOSE: Bladder neck closure necessitates lifelong clean intermittent catheterization. Concerns have been raised regarding well-being and compliance in patients on long-term clean intermittent catheterization. Noncompliance may result in subsequent hydronephrosis, incontinence, infection, cystolithiasis and perforation. We analyzed our long-term results with bladder neck closure followed at least 10 years for patient compliance with clean intermittent catheterization, upper tract preservation, continence, complications and subsequent procedures. MATERIALS AND METHODS: All patients followed at least 10 years after bladder neck closure were included in this study. RESULTS: Seven boys and 5 girls with a mean age of 7.0 years and urinary incontinence underwent bladder neck closure and continent urinary diversion between 1993 and 1998. The primary diagnosis was exstrophy in 5 patients, spinal dysraphism in 3, trauma in 2, sacral agenesis in 1 and a duplicated hindgut in 1. Mean followup was 12.4 years (range 10 to 14). All patients performed clean intermittent catheterization 4 to 6 times daily. Hydronephrosis improved or remained stable in the 11 patients who underwent bladder augmentation. Mild new hydronephrosis developed in 1 patient and resolved after increasing clean intermittent catheterization frequency. Bladder neck closure successfully cured incontinence in all of the last 6 patients who underwent modified bladder neck closure with a posterior bladder neck flap, while 2 of the earlier 6 bladder neck closures required revision for a subsequent 100% success rate. Additional operations were required in 6 patients. To our knowledge this is the longest followup after bladder neck closure reported in the literature. CONCLUSIONS: Patient compliance with long-term clean intermittent catheterization is good after bladder neck closure. Bladder neck closure provides excellent long-term safety for the upper urinary tract and continence. It is associated with relatively low morbidity, which is correctible.

Prostatic urothelial carcinoma: is transurethral prostatectomy necessary before bacillus Calmette-Guérin immunotherapy?

OBJECTIVE: To evaluate the efficacy of transurethral prostatectomy (TURP) followed by bacillus Calmette-Guérin (BCG) immunotherapy in patients with prostatic urothelial carcinoma (PUC) and compare the results of studies using combined TURP and BCG with studies in which TURP was not performed. PATIENTS AND METHODS: Patients with bladder cancer and PUC were treated with TURP followed by six weekly intravesical instillations of BCG. Response was determined and monitored by periodic bladder and prostatic urethra biopsies and urinary cytology. Also, the outcome of previous series using similar methodology was compared with the outcome of studies in which TURP was not performed. RESULTS: In all, 20 patients with PUC were treated with TURP followed by intravesical instillations of BCG. The median follow-up was 52.5 months. All patients had an initial complete response (CR). The prostatic urethra 5-year recurrence-free survival rate was 90%. However, bladder and prostatic urethra 5-year recurrence-free survival rate was only 30%. Five patients (25%) died from urothelial carcinoma (UC) after a median period of 58.5 months (two from bladder cancer metastases and three from upper tract metastases). The long-term prostatic urethra CR rate in studies using TURP before immunotherapy was significantly higher than the CR rate in studies using immunotherapy alone (P < 0.001). However, there was no difference when bladder and prostatic urethra CR rates were considered together (P = 0.54). CONCLUSION: In patients with PUC, TURP before BCG immunotherapy eliminates PUC in most cases, and is probably the preferred treatment for this disease. The risk of UC-specific mortality in these patients is high.

The natural history of bladder carcinoma in situ after initial response to bacillus Calmette-Gúerin immunotherapy.

OBJECTIVES: To explore patterns of recurrence, muscle invasion, and disease specific mortality in patients with bladder carcinoma in situ (CIS) who responded to an induction course with intravesical bacillus Calmette-Gúerin (BCG) immunotherapy. METHODS: Between June 1985 and December 2003, 104 patients (mean age 67 years) were diagnosed with either pure (38 patients) or concomitant (66 patients) CIS. Patients who responded to one (92 patients) or two (12 patients) induction courses of intravesical BCG instillation were included in the study. Response was determined and monitored by routine periodic bladder biopsies. Outcome of patients and the effect of various prognostic parameters were assessed after a median follow-up of 75 months. RESULTS: The 5- and 10-year recurrence-free survival rates were 63% and 54%, respectively. The 5- and 10-year muscle-invasive-free survival rates were 79% and 77%, and the 5- and 10-year disease-specific survival rates were 90.5 and 85.8%, respectively. Median time to recurrence, muscle invasion, and disease-specific mortality was 18, 19, and 40 months, respectively. Pure and concomitant CIS were associated with a similar outcome. The recurrence of nonmuscle-invasive tumor did not increase the risk for muscle invasion or mortality. CONCLUSIONS: Pure and concomitant bladder CIS share similar biologic behavior. Muscle-invasive disease is expected in about 25% of the BCG responders followed for long time periods and disease-specific mortality in 15%. Tumor recurrence, whether nonmuscle-invasive or muscle-invasive, follows a similar time table suggesting that these are not sequential but parallel and independent processes.

Vesical vs. extra-vesical patterns of recurrence after the treatment of urothelial upper tract tumors.

OBJECTIVE: The objective of this study was to define recurrence patterns after nephro-ureterectomy (NU) for urothelial upper tract tumor (UUTT), and to suggest guidelines for follow-up. METHODS: The effects of age, gender, UUTT grade, stage, size, location in the urinary system, and the administration of adjuvant chemotherapy on disease-free survival were assessed retrospectively. RESULTS: Fifty-three patients (mean age 62.7 years) underwent NU for UUTT and were followed with periodic cystoscopy, urinary cytology, and CT of the chest and abdomen. During a median follow-up period of 72 months, 26 patients (49%) developed tumor recurrence. Almost 95% of the recurrences occurred within the first 48 months following surgery. Two distinct patterns of recurrence were identified: vesical and extra-vesical recurrences. Vesical recurrence occurred in 19 patients (35.8%) and did not impair survival. The risk of vesical recurrence was independent of UUTT grade or stage. Patients who had Grades 1 or 2 UUTT developed only low-grade vesical recurrence, while patients with Grade 3 UUTT developed either high- or low-grade vesical recurrences. Extra-vesical recurrence occurred in 8 patients (15.1%); all had an initial Grade 3 UUTT, and were associated with short median survival. CONCLUSIONS: Patients presenting with Grades 1 or 2 UUTT are at risk of developing low-grade bladder tumors. Therefore, cystoscopic surveillance is recommended. Patients presenting with Grade 3 UUTT are at risk of developing both high- and low-grade bladder tumors as well as extra-vesical recurrence. An aggressive multimodality program including cystoscopy, urinary cytology, and CT of the chest and abdomen is advisable.

Cutaneous tube ureterostomy: a fast and effective method of urinary diversion in emergency situations.

AIM: To report on a simple and rapid method of urinary diversion. This method was applied successfully in different clinical scenarios when primary reconstruction of the ureters was not possible. MATERIALS AND METHODS: The disconnected ureter is catheterized by a feeding tube. The tube is secured with sutures and brought out to the lateral abdominal wall as cutaneous tube ureterostomy (CTU). RESULTS: This method was applied in three different clinical scenarios: a 40-year-old man who sustained multiple high-velocity gunshots to the pelvis with combined rectal and bladder trigone injuries and massive bleeding from a comminuted pubic fracture. Damage control included colostomy and bilateral CTUs. A 26-year-old woman had transection of the right lower ureter during abdominal hysterectomy. Diagnosis was delayed for 3 weeks when the patient developed sepsis. The right kidney was diverted with a CTU. A 37-year-old male suffered from bladder perforation and hemorrhagic shock. Emergency cystectomy was done and urinary diversion was accomplished with bilateral CTUs. In all cases, effective drainage of the urinary system was achieved with normalization of kidney function. CONCLUSION: When local or systemic conditions preclude definitive repair and damage control surgery is needed, CTU provides fast and effective urinary diversion.

Radical cystectomy vs. chemoradiation in T2-4aN0M0 bladder cancer: a case-control study.

BACKGROUND: Muscle-invasive bladder cancer is most commonly treated by radical cystectomy. Patients who are too sick to go through this surgery or who are unwilling to accept the mutilation associated with it are referred to chemoradiation. We compared the results of these 2 modalities using age-matched populations. PARTICIPANTS AND METHODS: Between 1998 and 2008, 33 patients were treated with chemoradiation for biopsy-proven T2-4aN0M0 urothelial bladder cancer. For every patient treated with chemoradiation, an age-matched patient who underwent radical cystectomy on the same year was selected for comparison. Mean radiotherapy dose was 62 Gy (standard deviation = 8.4) and median follow-up of both groups was approximately 36 months. RESULTS: The groups were similar in age, proportion of men, and length of follow-up. However, the Charlson comorbidity index was significantly lower for operated patients (3.45 vs. 4.36, P = 0.01). Furthermore, 2 patients (6%) in the chemoradiation group had salvage cystectomy (one for disease recurrence and another for bladder shrinkage). The 2- and 5-year overall survival rates after surgery were 74.4% and 54.8%, respectively, and after chemoradiation were 70.2% and 56.6% (P = 0.8), respectively. The 2- and 5-year disease-free survival rates after surgery were 67.8% and 63.2%, respectively, and after chemoradiation were 63% and 54.3% (P = 0.89), respectively. Side effects were mild in both groups, with grade 3+toxicity seen in only 2 operated and 4 irradiated patients. CONCLUSIONS: Despite having a significantly higher comorbidity index, patients treated with chemoradiation had similar overall and disease-free survival rates with low toxicity. Treatment with chemoradiation should be considered in patients with T2-4aN0M0 bladder cancer.

Cystine stones: a single tertiary center experience.

OBJECTIVE: To analyze the epidemiological and clinical characteristics and therapeutic outcomes of patients with cystine stones and to compare them with the characteristics of patients with calcium oxalate stones. PATIENTS AND METHODS: We identified 30 patients with cystine stones who were consulted in our department from January 1972 until December 2013. These patients were matched and paired, based on age and gender, to 30 calcium oxalate stone formers who were diagnosed and treated in our department from January 2011 until December 2013. RESULTS: Cystine stones were significantly large in size (p<0.001) and most of them were found in the kidney (p=0.002). Patients with cystinuria had their first stone episode at an early age (p<0.001) compared with patients with calcium oxalate stones. No significant differences were observed regarding the frequency and the severity of symptoms. Both groups had similar visits per year in outpatient clinics, emergency room admissions, and episodes of febrile urinary tract infections. Cystine stone formers had undergone significantly higher number of procedures for stone removal (p<0.001). No statistical differences were found in the compliance rates between the groups. Patients with cystine stones had significantly higher serum creatinine levels (p=0.005). CONCLUSIONS: Cystine stones present in an earlier age and have the likelihood to be large in size. Patients with cystine stones undergo a greater number of procedures, and they have a greater risk to develop chronic renal impairment.

Unique features of laparoscopic cholecystectomy in Beta thalassemia patients.

Beta Thalassemia patients suffer from a high incidence of gallstones as well as systemic complications of iron overload. We performed laparoscopic cholecystectomy in 8 beta thalassemia patients and describe their specific features. Diagnosis was based on patients' clinical presentation and sonography. Trocars were readjusted due to the hepatomegaly. No intraoperative cholangiograms were performed. Follow-up included clinical assessment and abdominal sonography. All procedures were completed laparoscopically. Pigment cirrhosis and fibrosis around the cystic duct were noted in all patients. No biliary injury occurred. Post operatively, 4 patients suffered fluid leakage through the trocar site, treated conservatively. No major cardiopulmonary complications occurred. During a mean follow-up time of 65 months, all patients are symptom free and without evidence of biliary lithiasis. Thalassemia patients are difficult and often high-risk patients. Improvement in anesthesia and monitoring enables better management of these patients. Laparoscopic cholecystectomy should be advised in carefully selected thalassemia patients.

Laparoscopic nephrectomy for infected, obstructed and non-functioning kidneys.

Since laparoscopic nephrectomy was introduced by Clayman et al, it has been doubted whether it should be employed in patients with extensive perirenal fibrosis. In this series, 20 consecutive patients underwent laparoscopic nephrectomy for obstructed, infected, non-functioning kidneys. Preoperative assessment included urine cultures, abdominal sonography, intravenous pyelography, computerized tomography and a renal scan. Laparoscopic nephrectomies were performed using either the transperitoneal or the retroperitoneal approach.Patients' mean age was 52 years (range 20-77, SD = 15.2). Three patients underwent previous open surgery on the same kidney and 15 had percutaneous nephrostomies. The etiology of obstruction was stone disease in 15 cases, uretero-pelvic junction obstruction (3), iatrogenic ureteral injury (1), and infected multicystic kidney (1). Mean operative time was 224 minutes (range 140-325, SD = 57). Conversion to open surgery was necessary in one patient due to splenic injury. Mean hospital stay was 3 days (range 2-6, SD = 1). Laparoscopic nephrectomy was feasible in cases of severe perirenal fibrosis, with an acceptable rate of complications, and may be considered in patients with obstructed, infected, and non-functioning kidneys.

A predictive model for stone radiopacity in kidney-ureter-bladder film based on computed tomography parameters.

OBJECTIVE: To create a model for prediction of stone radiopacity based on computed tomography (CT) parameters. METHODS: We reviewed the medical records of 513 patients referred to our department for consultation for urolithiasis between March 2011 and December 2012. CT scan and kidney-ureter-bladder (KUB) film were reviewed to identify the value of scout film in revealing radiopaque stones and to identify parameters predicting radiopacity in scout-negative stones. RESULTS: Of 375 patients who met inclusion criteria and were finally analyzed, all 206 visible stones in scout film were KUB radiopaque. Analyzing scout-negative stones, we found that 92 stones (54.4%) were radiopaque in KUB. Multivariate analysis showed that stone size >9.7 mm, non-midureteral stone location, anterior abdominal wall fat thickness ≤23.9 mm, and Hounsfield units >772 are all independent predictors of stone radiopacity in stones that were not visible in scout film, and the aforementioned parameters were used for the creation of a Web-based calculator. CONCLUSION: Scout film can identify radiopaque stones in KUB with high specificity, and thus, KUB can be used for following-up stones which are visible in CT scout film. For stones that are not visible in scout film, the probability of a stone to be radiopaque in KUB can be calculated trough our predictive model.