Bricker versus Wallace ureteroileal anastomosis: A multi-institutional propensity score-matched analysis.

AIM OF THE STUDY: The aim of our study is to evaluate the difference in stricture rate between matched groups of Bricker and Wallace techniques for ureteroileal anastomosis. PATIENTS AND METHODS: A retrospective analysis of patients undergoing urinary diversion (UD) with Bricker and Wallace ureteroileal anastomosis at two university hospitals. Two groups of Bricker and Wallace patients were matched in a 1:1 ratio based on the age, sex, body mass index (BMI), Charlson comorbidity index (CCI), preoperative hydronephrosis, prior radiation therapy or abdominal surgery, pathologic T and N stages and 30-days-Clavien grade complications≥III. A multivariable Cox regression analysis was conducted to identify predictors of ureteroenteric stricture (UES) in all patients. RESULTS: Overall, 740 patients met the inclusion criteria and 209 patients in each group were propensity matched. At a similar median follow-up of 25 months, UES was detected in 25 (12%) and 30 (14.4%) patients in Bricker and Wallace groups, respectively (p = 0.56). However, only one patient in the Bricker group developed a bilateral stricture compared to 15 patients in the Wallace group, resulting in a significantly higher number of affected renal units in the Wallace group: 45 (10.7%) versus only 26 (6.2%) in the Bricker group (p = 0.00). On multivariable extended Cox analysis, prior radiotherapy, presence of T4 pelvic malignancy and nodal positive disease were independent predictor of UES formation. CONCLUSION: The technique of ureteroileal anastomosis itself does not increase the rate of stricture; however, conversion of two renal units into one is associated with a higher incidence of bilateral upper tract involvement.

Risk factors for ureteroenteric stricture after radical cystectomy and urinary diversion: A systematic review.

Introduction: Ureteroenteric stricture (UES) is the leading cause of renal function deterioration after radical cystectomy (RC) and urinary diversion (UD). The aim of the present review is to summarize studies that discussed the risk factors associated with UES development. Identifying the responsible factors is of importance to help surgeons to modify their treatment or follow-up strategies to reduce this serious complication. Materials and Methods: A comprehensive search of the literature using the PubMed database was conducted. The target of the search was only studies that primarily aimed to identify risk factors of UES after RC and UD. References of searched papers were also checked for potential inclusion. Results: The search originally yielded a total of 1357 articles, of which only 15 met our inclusion criteria, comprising 13, 481 patients. All the studies were observational, and retrospective published between 2013 and 2022. The natural history of UES and the reported risk factors varied widely across the studies. In 13 studies, a significant association between some risk factors and UES development was demonstrated. High body mass index (BMI) was the most frequently reported stricture risk factor, followed by perioperative urinary tract infection (UTI), robotic-assisted radical cystectomy (RARC), occurrence of post-operative Clavian grade ≥ 3 complications and urinary leakage. Otherwise, many other risk factors were reported only once. Conclusion: The literature is still lacking well-designed prospective studies investigating predisposing factors of UES. The available data suggest that the high BMI, RARC and complicated postoperative course are the main risk factors for stricture formation.

Effect of co-trimoxazole and N-acetylcysteine alone and in combination on bacterial adherence on ureteral stent surface.

To assess the effect of co-trimoxazole and N-acetylcysteine (NAC), alone and in combination, on bacterial adherence to biofilm formed on ureteral stent surfaces. This prospective randomized study was conducted on 636 patients who underwent double J ureteral stent insertion after variable urological procedures. Patients were randomized into four groups: A (n = 165), no antibiotics or mucolytics during stent indwelling; B (n = 153), oral NAC (200 mg/day for children aged < 12 years old and 600 mg/day for adults) during stent indwelling; C (n = 162), oral co-trimoxazole (2 mg TMP/kg/day) during stent indwelling; and D (n = 156), both oral NAC and co-trimoxazole during stent indwelling. Two weeks following double J stent (JJ stent) insertion, urinalysis was performed on all patients and urine culture was done for all the patients at the day of double J stent removal. The stent was removed 2 weeks postoperatively, and a stent segment sized 3-5 cm from the bladder segment of the stent was sent for culture. Positive stent cultures were found in 63.6% (105/165), 43.1% (66/153), 37% (60/162), and 19.2% (30/156) patients of groups A, B, C, and D, respectively. E. coli was the organism most commonly isolated from the stent culture in all groups. The combination of co-trimoxazole and NAC was more effective in reducing bacterial adherence on ureteral stent surfaces than either alone.

Primary versus deferred ureteroscopy for the management of obstructive anuria secondary to ureteric urolithiasis in children: a prospective randomized study.

To compare the role of primary and deferred ureteroscopy (URS) in the management of obstructive anuria secondary to ureteric urolithiasis in pediatric patients. This prospective randomized study included 120 children aged ≤ 12 years who presented with obstructive anuria secondary to ureteric urolithiasis between March 2019 and January 2021. The children were subdivided into group A, which included children who had undergone primary URS without pre-stenting, and group B, which included children who had undergone URS after ureteric stenting. All children were clinically compensated and sepsis-free. Patients with underlying urological structural abnormalities were excluded. The operative time, improvement of renal functions, stone-free rate, and complications were compared between the two groups. At the 1-month follow-up, urine analysis; kidney, ureter, and bladder radiography; and ultrasonography were performed. The patient characteristics of both groups did not show any significant difference. Primary URS had failed in ten children (16.6%) in group A. Moreover, failure of stenting was noted in six patients (11%) in group B. The mean operative time for group B was significantly lower than that for group A (p ≤ 0.001). The stone-free rate was significantly higher in group B (p ≤ 0.001). The rate of overall complications was higher in group A. Deferred URS is preferable over primary URS in the management of obstructive anuria secondary to ureteric urolithiasis". In children because of the lower need for ureteric dilatation, higher stone- free rate, shorter procedure time, and lower complication rate.

Risk factors for postoperative Clostridium difficile infection after radical cystectomy for bladder cancer: a NSQIP database analysis.

INTRODUCTION: Patients undergoing cystectomy for bladder cancer are at an increased risk for Clostridium difficile infection (CDI) due to prolonged antibiotics and underlying comorbidities. We aim to evaluate CDI risk factors in cystectomy patients. MATERIALS AND METHODS: Utilizing National Surgical Quality Improvement Program (NSQIP), patients undergoing cystectomy with diagnosis of bladder cancer between 2015-2017 were included. Baseline demographics including age, sex, comorbidities, and preoperative labs were collected. Univariate and multivariable logistic regression were used to evaluate risk factors for and complications of CDI during the index hospitalization. RESULTS: There were a total of 6,432 patients included in the analysis, with 6,242 (96%) and 190 (4%) in the non-CDI vs. CDI groups, respectively. Patients with a diagnosis of postoperative CDI were more likely to be female [4.09% vs. 2.71%, p = 0.001] and have lower preoperative albumin [3.78 g/dL (0.52) vs. 3.92 g/dL (0.48), p = 0.003]. Patients with a history of female sex (OR 1.46, p = 0.03), neobladder (OR 1.57, p = 0.01), and low preoperative albumin (OR 1.45, p = 0.04) were at the highest risk for development of CDI postoperatively. Patients with a diagnosis of CDI were more likely to experience readmission within 30 days (31.1% vs. 19.2%, p < 0.001). CONCLUSION: Utilizing the NSQIP database, we identified predictors for development of CDI in cystectomy patients. Female sex, continent diversion, and low preoperative albumin all significantly increased the rate of CDI. While our findings are retrospective, they are compelling enough to warrant further prospective investigation.

Prospective comparison of tadalafil 5 mg alone, silodosin 8 mg alone, and the combination of both in treatment of lower urinary tract symptoms related to benign prostatic hyperplasia.

BACKGROUND: Men with lower urinary tract symptoms (LUTS) associated with benign prostatic hyperplasia (BPH), will have deterioration in the quality of life. Likewise, BPH can be complicated by damage to bladder function, bladder stones formation, hematuria, and impaired kidney function. The goal of treatment is to avoid all those effects caused by BPH. OBJECTIVE: To evaluate the efficacy of tadalafil alone, silodosin alone, and the combination of both in the treatment of LUTS associated with BPH. PATIENTS AND METHODS: Patients in our department with BPH who had LUTS were assigned randomly to three groups: A (101 patients) received tadalafil, 5 mg; B (102 patients) received silodosin, 8 mg; and group C (105 patients) received the combination of tadalafil, 5 mg, and silodosin, 8 mg. For all participants, we asses changes in the maximum urinary flow rate (Qmax), International Prostate Symptom Score (IPSS), International Index of Erectile Function (IIEF) score, Post-voiding urine (PVR) and all results were recorded and analyzed with the (SPSS) and Microsoft Excel 2010. RESULTS: Qmax, IPSS, PVR and IIEF score improved significantly more with the combination of tadalafil and silodosin than with either drug alone (p < 0.001). Three months after treatment, the mean Qmax values were 14.4 ml/sec in group A, 15.2 ml/sec in group B, and 15.8 ml/sec in group C; and the mean IPSSs were 17.6 in group A, 16.7 in group B, and 15.6 in group C (p < 0.001). CONCLUSION: Tadalafil and silodosin are effective treatment options in men with BPH who have LUTS, but the combination of both is more effective and feasible in treating LUTS of BPH.

Lichen sclerosis-induced long segment anterior urethral stricture: The early outcome of one-stage repair using dorsolateral onlay buccal mucosa graft.

BACKGROUND: Substitution urethroplasty using buccal mucosal grafts can be performed by several approaches including ventral onlay graft, dorsal onlay graft, or ventral urethrotomy with dorsal inlay graft. Our study aims to evaluate the surgical outcome of dorsolateral buccal mucosal graft for long segment anterior urethral stricture >6 cm in patients with Lichen sclerosus (LS). METHODS: A retrospective study included patients who underwent repair for long segment anterior urethral stricture >6 cm due to LS between January 2013 and April 2019. All patients were followed-up at 3, 6, 9, and 12 months postoperatively and then yearly by clinical symptoms, uroflowmetry, and calculation of post-void residual urine volume. Retrograde urethrogram was requested for patients with voiding symptoms or decreased maximum flow rate. Stricture recurrence that required subsequent urethrotomy or urethroplasty was considered failure. The success rate and surgical complications were collected and analyzed. RESULTS: Thirty patients were identified. The median age (range) was 39 (25-61) years and a median (range) stricture length was 8 (6-14) cm. Most of postoperative complications were of minor degree. The success rate at median follow-up of 15 (12-24) months was 86.5%. The median maximum flow rate increased significantly from 6 (2-11) ml/s preoperatively to 18 (range: 6-23) ml/s at the 6th month (p value < 0.001). CONCLUSION: Dorsolateral buccal mucosal grafts urethroplasty for long anterior urethral stricture caused by LS has a high success rate and low risk of complications including stricture recurrence.

Synchronous transurethral cystolitholapaxy and TURP reveals better results than transurethral cystolitholapaxy plus medical therapy for BPH: a randomized prospective study on 100 patients with concomitant urinary bladder stone(s) and BPH.

OBJECTIVE: This report presents the results of a randomized prospective study comparing synchronous transurethral cystolitholapaxy and transurethral resection of the prostate (TURP) with transurethral cystolitholapaxy plus medical treatment for benign prostatic hyperplasia (BPH) in patients with concomitant vesical stone(s) and BPH. PATIENTS AND METHODS: The study included 100 patients with bladder stone(s) < 2.5 cm associated with BPH. Eligible patients were divided randomly into two groups: group I (n = 50 patients) underwent simultaneous transurethral cystolitholapaxy and TURP, and group II (n = 50 patients) underwent transurethral cystolitholapaxy and received postoperative tamsulosin plus finasteride. RESULTS: The mean follow-up was 20.1 ± 5.3 months. No statistically significant differences were found between the 2 groups regarding the preoperative parameters (age, prostatic volume, bladder stone characteristics, prostate-specific antigen level, International Prostate Symptom Score, peak urinary flow rate, and post-void residual urine volume). Both groups experienced statistically significant postoperative improvement in IPSS, post-void residual (PVR) urine volume, and peak flow rate compared with the preoperative parameters (P < 0.001 for all parameters). However, patients in group 1 had a more pronounced improvement (P < 0.001 for all parameters). Thus, 15 patients in group 2 underwent TURP during follow-up. PVR urine and prostate volume predicted the failure of medical therapy and the need for TURP. CONCLUSION: Synchronous transurethral cystolitholapaxy and TURP revealed better results than transurethral cytolitholapaxy plus medical therapy. Cystolitholapaxy without TURP should not be indicated especially in patients with significant PVR urine volumes and larger prostates.

Percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy for renal insufficiency.

OBJECTIVE: To assess the effect and outcome of percutaneous nephrolithotomy (PNL) versus extracorporeal shock wave lithotripsy (SWL) in patients with renal insufficiency. PATIENTS AND METHODS: A prospective randomized clinical study of 104 renal insufficiency patients with renal stones (serum creatinine 2-4 mg/dl and eGFR < 60 ml/min/1.73 m2 more than 3 months) randomized into two groups: Group A underwent PNL; Group B underwent shock wave lithotripsy (SWL). Treatment effects and outcomes compared between the two groups. RESULTS: Between Group A of 50 patients and Group B of 54 cases, demographic data showed no statistically significant differences. The stone-free rate was 84% in Group A versus 26.6% in Group B after the first SWL session. After completion of all SWL sessions, the rate was 88.9% for Group B. Comparing pre and postoperative results of Group A, there is significant improvement of serum creatinine concentrations by 9.1% (p = 0.001), significant improvement of creatinine clearance (p = 0.000) and eGFR (p = 0.003). Although regarding Group B preoperatively and 3 months after SWL there is significant improvement by 8.7% (p = 0.0001), which is less than that of Group A, there is also, improvement of eGFR by 6.7% (p = 0.001), which is less than the eGFR improvement in Group A (12.3%). But there is no statistically significant difference is noted for creatinine clearance in Group B (p = 0.09). CONCLUSION: The outcomes for PNL and SWL in patients with renal insufficiency and renal stones are encouraging as minimally invasive procedures with no negative effects on kidney function.

LigaSure versus the standard technique (Hem-o-lok clips) for robot-assisted radical prostatectomy: a propensity score-matched study.

The aim of the study is to compare the utility and efficacy of the LigaSure system and standard surgical clips for robot-assisted radical prostatectomy. The medical records of 473 patients who underwent robot-assisted radical prostatectomy between May 2011 and 2018 were retrospectively reviewed and analyzed. The patients were divided into the LigaSure (n = 125) and Hem-o-lok (n = 348) groups, based on the device used to ligate the vascular pedicle. Owing to differences in the patient characteristics, a 1:2 propensity score matching was performed. In the final matched cohort, 375 patients were included for analysis. The median initial prostate-specific antigen level was not significantly different between the two groups. The median surgical and console times were significantly shorter for the LigaSure group than for the Hem-o-lok group (p < 0.001 and 0.003, respectively). The number of specimens with positive surgical margins was significantly lower in the LigaSure group than in the Hem-o-lok group (24.8 vs 40.8%, p = 0.002). The number of specimens with positive surgical margins for pathological stage T2 cases was also significantly lower in the LigaSure group than in the Hem-o-lok group (17.0 vs 37.5%, p < 0.001). However, non-focal positive surgical margins and biochemical recurrence-free survival rates at 1 year postoperatively were not significantly different (11.2 vs 18.4%, p = 0.075 and 91.2 vs 92.8%, p = 0.565, respectively). The LigaSure system was associated with fewer positive surgical margins and shorter operation time, indicating that it could be a useful alternative to Hem-o-lok clips for controlling the prostatic pedicle in robot-assisted radical prostatectomy, despite its high costs.

Peri-operative outcomes between primary and replacement artificial urinary sphincter surgery: An ACS-NSQIP analysis.

OBJECTIVE: To evaluate differences in perioperative clinical outcomes in men undergoing artificial urinary sphincter (AUS) implantation in primary versus replacement settings. Secondarily, we aimed to identify patient-related factors contributing to complications associated with AUS placement. MATERIALS AND METHODS: A review of the American College of Surgeons-National Surgical Quality Improvement Program was performed between 2010 and 2018 identifying males undergoing AUS implantation. Subjects were further subdivided into primary implantation or removal/replacement of AUS simultaneously via current procedural terminology codes 53445 and 53447, respectively. 30-Day postoperative outcomes were compared between cohorts using t-test and Fisher's exact test. The relationship between patient factors and complications was evaluated using logistic regression. RESULTS: A total of 1,892 patients were identified: 1,445 primary AUS placement and 447 AUS replacement procedures. Patients undergoing AUS replacement were statistically older than those undergoing primary implantation (71.4 vs 69.7 years, P < .001). AUS replacement procedures were associated with an increased rate of superficial surgical site infection (SSI) compared to primary procedures (1.3% vs 0.4%, P » .042). There were no differences identified between cohorts for deep SSI, cardiopulmonary complications, reoperation, operative time, or length of stay. Logistic regression demonstrated that higher body mass index was found to be independent risk factors for any complications, and diabetes mellitus was associated with increased risk of AUS-related readmission. CONCLUSION: Within the perioperative period, patients undergoing replacement AUS have an increased risk of superficial SSI compared to primary AUS implantation. These findings can assist with appropriate perioperative counseling of patients undergoing primary and replacement AUS implantations.

Cholecalciferol for the prophylaxis against recurrent urinary tract infection among patients with benign prostatic hyperplasia: a randomized, comparative study.

PURPOSE: To explore the role of cholecalciferol for the prophylaxis against recurrent urinary tract infection (UTI) in patients with benign prostatic hyperplasia (BPH). METHODS: Our randomized, uncontrolled prospective study included 389 naïve BPH patients with moderate/severe symptoms, consecutively. The patients were randomly allocated to two groups; group-A included 193 patients who received tamsulosin, while group-B included another 196 patients who received tamsulosin with cholecalciferol. The study population was followed up for 2 years after the start of the treatment. For all the patients enrolled, clinical evaluation, imaging studies (abdominal and trans-rectal ultrasonography), and laboratory investigations [including urinalysis, urine culture with antibiotic susceptibility testing for positive cultures and estimation of prostate-specific antigen (PSA) level] were provided. RESULTS: The incidence rate of recurrent UTI was 9% among the study population; it was significantly higher among group-A patients compared to those of group-B (13.5% vs. 4.6%, p 0.003, OR 2.7, 95% CI 1.5-4.3). Compared to patients of group-A, those of group-B developed a significantly lower level of PSA at the end of treatment period (0.16 ± 0.03 ng/mL vs. 0.27 ± 0.08 ng/mL, p 0.043, OR 1.9, 95% CI 1.2-6.8). CONCLUSIONS: Adjuvant cholecalciferol supplementation may be protective against recurrent UTI among patients with BPH receiving tamsulosin therapy without extra adverse effects.

Determinants of health-related quality of life for patients after urinary lithotripsy: ureteroscopic vs. shock wave lithotripsy.

PURPOSE: To compare the longitudinal health-related quality of life (HRQoL) after surgical intervention with ureteroscopic lithotripsy (URSL) and shock wave lithotripsy (SWL) and to evaluate the factors affecting HRQoL in urolithiasis patients. METHODS: A total of 262 patients who underwent lithotripsy (SWL, n = 61; URSL, n = 201) for upper urinary tract calculi treatment between June 2012 and January 2015 were evaluated. All patients were administered the Short-Form 36-item survey (SF-36) to assess HRQoL at four timepoints: before surgery, on the day of discharge, and 1 and 6 months after lithotripsy. Stone-free rates, complications, and analgesic requirements were evaluated to compare the effects of the two procedures on HRQoL. RESULTS: At the day of discharge, patients in the URSL group had significantly lower mean scores on five different subscales of the SF-36 questionnaire, namely, physical functioning, role-physical, social functioning, role-emotional, and mental health. The stone-free rate at 3 months after lithotripsy was significantly lower in the SWL group (72.1% vs. URSL, 93.0%; p < 0.001). The hospital stay was shorter in the SWL group (2.1 ± 0.07 vs. URSL, 4.1 ± 0.13 days; p < 0.001), and the analgesia requirements were also lower in the SWL group (0.3 ± 0.08 vs. URSL, 0.9 ± 0.20; p < 0.001). CONCLUSIONS: The post-lithotripsy HRQoL was superior for SWL compared to URSL on the discharge date despite the lower stone-free rate of the former. The longer hospital stay and higher postoperative pain appeared to be the determinants of the lower HRQoL in the URSL group.