Experts' recommendations in laser use for the treatment of urolithiasis: a comprehensive guide by the European Section of Uro-Technology (ESUT) and Training-Research in Urological Surgery and Technology (T.R.U.S.T.)-Group.

PURPOSE: To identify laser lithotripsy settings used by experts for specific clinical scenarios and to identify preventive measures to reduce complications. METHODS: After literature research to identify relevant questions, a survey was conducted and sent to laser experts. Participants were asked for preferred laser settings during specific clinical lithotripsy scenarios. Different settings were compared for the reported laser types, and common settings and preventive measures were identified. RESULTS: Twenty-six laser experts fully returned the survey. Holmium-yttrium-aluminum-garnet (Ho:YAG) was the primary laser used (88%), followed by thulium fiber laser (TFL) (42%) and pulsed thulium-yttrium-aluminum-garnet (Tm:YAG) (23%). For most scenarios, we could not identify relevant differences among laser settings. However, the laser power was significantly different for middle-ureteral (p = 0.027), pelvic (p = 0.047), and lower pole stone (p = 0.018) lithotripsy. Fragmentation or a combined fragmentation with dusting was more common for Ho:YAG and pulsed Tm:YAG lasers, whereas dusting or a combination of dusting and fragmentation was more common for TFL lasers. Experts prefer long pulse modes for Ho:YAG lasers to short pulse modes for TFL lasers. Thermal injury due to temperature development during lithotripsy is seriously considered by experts, with preventive measures applied routinely. CONCLUSIONS: Laser settings do not vary significantly between commonly used lasers for lithotripsy. Lithotripsy techniques and settings mainly depend on the generated laser pulse's and generator settings' physical characteristics. Preventive measures such as maximum power limits, intermittent laser activation, and ureteral access sheaths are commonly used by experts to decrease thermal injury-caused complications.

Experts' recommendations in laser use for the treatment of upper tract urothelial carcinoma: a comprehensive guide by the European Section of Uro-Technology (ESUT) and Training Research in Urological Surgery and Technology (T.R.U.S.T.) group.

PURPOSE: To highlight and compare experts' laser settings during endoscopic laser treatment of upper tract urothelial carcinoma (UTUC), to identify measures to reduce complications, and to propose guidance for endourologists. METHODS: Following a focused literature search to identify relevant questions, a survey was sent to laser experts. We asked participants for typical settings during specific scenarios (ureteroscopy (URS), retrograde intrarenal surgery (RIRS), and percutaneous treatment). These settings were compared among the reported laser types to find common settings and limits. Additionally, we identified preventive measures commonly applied during surgery. RESULTS: Twenty experts completed the survey, needing a mean time of 12.7 min. Overall, most common laser type was Holmium-Yttrium-Aluminum-Garnet (Ho:YAG) (70%, 14/20) followed by Thulium fiber laser (TFL) (45%, 9/20), pulsed Thulium-Yttrium-Aluminum-Garnet (Tm:YAG) (3/20, 15%), and continuous wave (cw)Tm:YAG (1/20, 5%). Pulse energy for the treatment of distal ureteral tumors was significantly different with median settings of 0.9 J, 1 J and 0.45 J for Ho:YAG, TFL and pulsed Tm:YAG, respectively (p = 0.048). During URS and RIRS, pulse shapes were significantly different, with Ho:YAG being used in long pulse and TFL in short pulse mode (all p < 0.05). We did not find further disparities. CONCLUSION: Ho:YAG is used by most experts, while TFL is the most promising alternative. Laser settings largely do not vary significantly. However, further research with novel lasers is necessary to define the optimal approach. With the recent introduction of small caliber and more flexible scopes, minimal-invasive UTUC treatment is further undergoing an extension of applicability in appropriately selected patients.

Predicting urine culture results in candidates for lithotripsy.

Background: Urological guidelines assert that "urine culture should be obtained" before surgical management of ureteral or kidney stones. Thus, many surgeries are delayed by 1-3 days until the results of urine culture are available. During this time, the patient frequently experience pain and possible kidney damage. We investigated the hypothesis that it is possible to predict the results of urine culture in candidates for surgical intervention using parameters that are accessible immediately upon admission. Materials and methods: A database of 1000 patients who underwent either percutaneous nephrolithotomy (PCNL) or ureteroscopy/retrograde intrarenal surgery was analyzed. Eleven parameters potentially related to urinary infections and accessible to the clinician at the emergency department were correlated with the preoperative urine culture results. Results: Of the patients, 234 (23.4 %) had positive cultures. On multivariate analysis, only sex, hydronephrosis grade, and history of previous nephrolithotomy were significantly associated with a positive preoperative urine culture. The risk of a positive culture can be easily determined from a simple table or an Excel-based calculator. This risk could be as low as 0.45% for a man without a history of PCNL and no hydronephrosis (4% in a woman with similar parameters) or as high as 79.5% in a man with a history of PCNL and hydronephrosis (85% in a woman with similar parameters). Conclusions: The risk of preoperative positive urine culture can be predicted using 3 parameters that are accessible upon admission. In low-risk cases, prompt surgical treatment can be provided, eliminating the anticipation time for urine culture results.

Timing of midstream urine culture before endourological procedure-can we do better?-A comparative study.

Endourological procedures are the mainstay of treatment for stone disease in the upper urinary system. Infection is a common complication, and urine cultures (UC) are often obtained preoperatively. In this study, we sought to investigate the role of positive UC in the 90 days prior to surgery (90PreOp) in predicting postoperative infectious complications in comparison to a single positive preoperative UC (PreOP). We compared the correlation between positive PreOp UCs and positive 90PreOp UCs with postoperative urosepsis, and a positive UC obtain proximal to obstruction (Prox UC) during percutaneous nephrolithotomy, ureteroscopy and a placement of nephrostomy tube or ureteral stent. Data from 140 consecutive patients were collected. PreOp UCs were positive in 15 (11%) of patients versus 31 of 140 (22%) positive 90PreOp UCs. All six sepsis events had a positive 90PreOp UC, and five had a positive PreOp UC. Fourteen (93.3%) out of 15 positive Prox UC had a positive 90PreOp UC, whereas only 7 (38.9%) had a positive 90PreOp UC. Positive 90PreOp UC outperformed PreOp UC in predicting positive Prox UC, OR = 12.8 (95% CI 3.70-44.30, p < 0.001), versus OR of 88.9 (95% CI 11.0-720.7, p < 0.001); sensitivity 93%(95% CI 68-100%) versus 47%(95% CI 21-73%); as well as area under the ROC curve(AUC), 0.90 (CI 0.80-0.95) for 90PreOp versus 0.70 (CI 0.56-0.82) for positive Prox UC. Uropathogen persistence was better identified when using 90PreOp UC (27%) than using PreOp UC (12%). We suggest reviewing UCs taken within 90 days preoperatively as this was found superior to a single preoperative midstream UCs in predicting postoperative infectious sequela after stone procedure.

Is there a correlation between meatal stenosis severity, lower urinary tract symptoms and uroflowmetry?

INTRODUCTION: We have recently validated a meatal Stenosis (MS) severity grading system that is based on physical examination. OBJECTIVES: The study objective was to examine the correlation between this grading system, patients' urinary symptoms, uroflowmetry and postvoid residual parameters. STUDY DESIGN: Patients referred for our clinic for urinary and non-urinary complaints, were prospectively enrolled. Urinary symptoms questionnaire, uroflowmetry parameters and post-voiding residuals (PVR) were assessed, and photographs of the urethral meatus were taken for each patient. The photographs were graded blindly according to the previously validated grading system and correlated with urinary symptoms, uroflowmetry parameters and PVR. RESULTS: Overall, 75 patients were assessed (20 grade 0, 23 grade 1 and 32 grade 2). When using grade 0 as a reference, the odds ratio (OR) for reporting narrow stream was 6.4 (95%CI 1.65-24.77) and 4 (95%CI 1.18-14.16) for grade 1 and 2 respectively. OR for prolonged urination was 6 (95% CI 1.47-24.89) for Grade 1 and 2; OR for upward stream deviation was10.08 (95%CI -2.43-41.82) for grade 1 and 15.12 (95%CI - 3.74-61.17) for grade 2. Uroflowmetry results showed lower Qmax from 16.8(SD ± 8.0) ml/sec in grade 0-9.6 ml/s on grade 1 and 2 (p < 0.001) (Figure 1). PVR was not statistically different in the three groups. DISCUSSION: Our main findings were that meatal stenosis severity grade is associated with narrow stream as reported by parent, prolonged urination, and upward deviation of urinary stream, with increasing severity with worsening stenosis. MS grade was also associated with significant worsening of uroflow measures: a lower Qmax, Qmean and a longer time-to-Qmax. Post-void residual volume was not significantly different between the different severity grades. This study showed the clinical significance of the grading system. With subjective and objective measures. The implementation of this grading system in clinics, may aid in decision making regarding surgical intervention in the appropriate patients, and avoid unnecessary procedures. CONCLUSION: The Severity of MS seen on physical examination correlates well with obstructive symptoms and decrease of urine stream seen on uroflowmetry. These findings confirm the importance of the grading system in the evaluation of patients with MS and may be additional measure that assist in consulting parents on the indications to meatotomy.

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.

[NEOADJUVANT CHEMOTHERAPY BEFORE RADICAL CYSTECTOMY - MIGHT IT BE OFFERED SELECTIVELY?]

INTRODUCTION: Neoadjuvant cisplatin-based chemotherapy prior radical cystectomy is the standard of care in patients with a muscle invasive bladder cancer. It is intended to treat micro-metastases. However, most patients do not develop metastases even without chemotherapy and are receiving this treatment in vain. In this study, we looked for pre-operative risk factors for developing metastases that can triage the patients that really need neoadjuvant therapy. METHODS: From 1998 to 2018, 285 patients underwent radical cystectomy without neoadjuvant chemotherapy. During a median follow-up of 42.5 months, 99 patients (34%) developed recurrent disease after a median duration of 12 months. The study compared 10 different preoperative parameters of patients who developed or did not develop recurrence. RESULTS: An increased risk of metastases was found in older patients (39.8% in older than 69 years vs. 33.3% in younger patients, p=0.045), in patients with a high Charlson Comorbidity index (46.2% in 5 and above vs. 28.2% when lower than 4, p=0.003), and in patients with large tumor diameter (p=0.01). No difference was found in the other variables examined including: gender, primary versus secondary tumor, tumor stage, presence of histological variant, hydronephrosis, carcinoma in situ (CIS) or sarcomatoid differentiation. CONCLUSIONS: Older age, comorbidity, and large tumor diameter predict the risk of recurrence after radical cystectomy. However, overlap between the groups precludes the use of these parameters for clinical decisions. Therefore, neoadjuvant chemotherapy treatment should currently be offered to all candidates for radical cystectomy. Hopefully, future molecular markers will be able to predict the risk of metastases.

[DOES CHOOSING BETWEEN DUSTING OR FRAGMENTATION DURING LASER LITHOTRIPSY OF URINARY STONES CHANGE THE LONG TERM RESULTS?]

INTRODUCTION: Variations in laser pulse energy and it's frequency during lithotripsy, affect the rate and the method of stone breaking. The main modes of lithotripsy are dusting and fragmentation. AIMS: Comparison between long term results of dusting versus fragmentation, by defining the stone free rate (SFR) for each method and the time period until re-treatment need. METHODS: Clinical and radiological follow-up of 43 patients who underwent laser intervention using dusting or fragmentation. Both groups shared similar demographic features, stone sizes and locations. For each group, the percentage of patients without stones requiring intervention during the follow-up period of 36 months was defined as a success parameter. The incidence of emergency department (ED) admissions and auxiliary interventions were assessed. RESULTS: Thirty-eight patients were included in the study. No difference in the median period of time to clinically significant stone was seen (p=0.213). No difference was found in SFR between the dusting (83.3%) and the fragmentation (84.6%) groups respectively (p=1.000). No statistically significant difference was shown in ED admissions due to renal colic occurring in 31.6% and 10.5% within dusting and fragmentation groups respectively (p=0.116). CONCLUSIONS: No difference in time period until clinically significant stone appearance was seen. No significant difference in SFR was found between the groups at the long term follow-up. DISCUSSION: It seems that within the dusting group, the ED admission rate could be somewhat higher. However, this impression lacks statistical significance. A long term prospective study with a larger population is needed to confirm these results.

Transurethral Prostatectomy Before or After External Beam Radiotherapy: Complications and Reoperation Rates.

PURPOSE: Patients treated by external beam radiotherapy (EBRT) for localized carcinoma of the prostate (CAP) often suffer from urinary obstruction. While most patients can be treated medically, some require transurethral prostatectomy (TURP) for alleviation of obstruction. The consequences of combing EBRT and TURP are controversial. The objective of this study was to evaluate the success and complication rates of TURP combined with EBRT. PATIENTS AND METHODS: Between 2001 and 2017, 3501 patients underwent TURP. Sixty-six of them were treated with EBRT for CAP. Surgical complications according to the Clavien-Dindo (CD) scale and the need for secondary interventions were compared to 66 randomly selected patients operated on for benign prostatic hyperplasia (BPH). RESULTS: Patients who underwent TURP for BPH were significantly older compared to the patients with CAP with an average of 76.4 (SD 4.3) vs 71 (SD 8.2) years, p<0.0001. Substantial post-operative complications were rare in both groups with only a single case of CD grade 3 in each group. However, patients with CAP required significantly more secondary surgeries (21% vs 6%, p=0.02) and significantly more additional interventions (37.9% vs 13.6%, p=0.0025). There was no difference in complication rate, in the need for additional interventions or in the oncological outcome when comparing patients operated before or after EBRT. CONCLUSION: The complication rate of TURP done before or after EBRT is low and comparable to surgery for BPH. However, the rates of secondary surgeries and additional interventions in these patients are high (40%). TURP before or after EBRT provides similar results.

Trimodal therapy in T2-4aN0M0 bladder cancer--How to select the best candidate?

The reported results of trimodal treatment (TMT) in muscle-invasive bladder cancer vary widely. We attempted to characterize the profile of ideal candidates for this approach. Between 2000 and 2019, 105 patients (median age 78 years) with T2-4aN0M0 bladder cancer were treated with TMT and analyzed retrospectively. Mean radiotherapy dose was 62 Gy (SD 8.4). Ten pretreatment prognostic parameters were evaluated including tumor diameter on pre-TURBT CT. Multivariate analyses was performed and combination of parameters was studied. After a median follow-up of 29 months, 53 patients (50.5%) developed recurrence and 70 patients (67.7%) died. Death was disease-specific in 46 patients (65.7%). Tumor diameter was the most significant prognostic parameter with p < 0.0001 for overall, disease-specific and recurrence-free survivals. For every 1 cm increase in tumor diameter, the risk of disease-specific mortality increased by 1.57. Age, cisplatin eligibility and the Charlson Comorbidity Index were significant predictors of overall survival but not of disease-specific or recurrence-free survival. Patients who were cisplatin-eligible with a tumor diameter ≤3 cm had a 5-year disease-specific survival rate of 79.2% as opposed to 33.9% in patients without one of these features (p < 0.001). When tumor diameter exceeded 5 cm (irrelevant of all other parameters), 5-year disease-specific survival rate was only 28.2%. Patient profiles can accurately predict response to TMT. In cisplatin-eligible patients with a tumor diameter ≤3 cm, TMT provides an excellent disease-specific survival rate. In patients with a tumor diameter >5 cm TMT renders unacceptably poor treatment outcomes.

Formulation and validation of meatal stenosis grading system.

INTRODUCTION: Meatal stenosis (MS) is a common finding in circumcised children. Indication for surgical correction is based on urinary symptoms such as strength and direction of urine stream as well as physical examination, including direction and caliber of the urinary stream. There is no objective grading of MS severity, and therefore indications for surgery and management protocols are vague. OBJECTIVE: We aimed to formulate a standardized, validated, and reliable grading system for MS severity based on the physical examination finding. STUDY DESIGN: Photographs of the urethral meatus were taken in patients scheduled for meatotomy due to MS, whereas patients without this condition served as control. The photographs were rated by three experienced fellowship trained pediatric urologists. The study was conducted in two phases: 1) development of a grading system by the expert panel and 2) testing of the proposed grading system for inter- and intra-rater reliability. To estimate the correlation between different rates, the intra-class correlation coefficient (ICC) was calculated. RESULTS: Three grades were generated: Grade 0 (wide open meatus, visible mucosa), Grade 1 (minimal mucosa/fibrotic tissue visible), and Grade 2 (pinpoint meatus/no mucosa visible/large fibrotic layer). A panel of 51 raters (pediatric urologist, community urologist, pediatricians) participated in the survey evaluating the representative photos from 86 patients. Inter-rater reliability was high ICC = 0.99 (95% confidence interval [CI] of 0.983-0.996, P < 0.0001) Cronbach's alpha = 0.992. In total, 18 raters participated in the same survey two weeks later for intra-rater reliability. An identical grading was obtained in 83.3% of photographs (kappa = 0.455 [P < 0.05]). CONCLUSION: We propose a grading system that is a valid, reliable, and reproducible method to classify the severity of MS on physical exam. This grading system could improve the healthcare provider's and parent's communication and can be a building block for further research in this field. A further research should assess the correlation with clinical signs and symptoms.

Factors Predicting Operating Room Time in Ureteroscopy and Ureterorenoscopy.

BACKGROUNDS/AIMS: Operation room (OR) time is of great value affecting surgical outcome, complications and the daily surgical program with financial implications. METHODS: We retrospectively evaluated 570 consecutive patients submitted to ureteroscopy or ureterorenoscopy for the treatment of ureteral or renal stones. Demographic parameters, patient's stones characteristics, type of ureteroscope, surgeon experience and surgical theater characteristics were analyzed. OR time was calculated from the initiation of anesthesia to patient extubation. Multivariate analysis was conducted using a linear regression test with multiple parameters to identify predictors of OR time. RESULTS: Eight factors were identified as significant. These include total stones volume, ureteroscope used, stone number, nurses experience, radio-opacity of the stone on kidney-ureter-bladder X-ray, main surgeon experience, operating room type, and having a nephrostomy tube prior to surgery. CONCLUSIONS: The surgical team experience and familiarity with endourological procedure, and the surgical room characteristics has a crucial impact on OR time and effectiveness.

Door To Detorsion Time Determines Testicular Survival.

OBJECTIVE: To determine the importance of the duration of in-hospital management of patients with testicular torsion for testes survival. The time from onset of symptoms until surgery is a well-known factor determining testicular survival but there is no data regarding the contribution of in-hospital management duration to testicular survival. Unlike the time from onset of symptoms until seeking medical attention, the time from registration to the emergency department (ED) to the time of detorsion-"Door To Detorsion time" (DTD) is dependent on medical providers and should be minimized. MATERIALS AND METHODS: Data was retrieved on all patients who underwent surgery for testicular torsion in 1994-2014 (N = 219). We used multivariable logistic regression analysis to examine independent association between DTD time or duration of symptoms to testicular survival. RESULTS: Median DTD time was 135 minutes (range 23-546). Among patients with a viable testis, median DTD time was 107 minutes (range 35-381) compared to 160 minutes (range 23-546) among patients with a nonviable testis (P <.001). Logistic regression models showed that both DTD time (P = .04) and duration of symptoms (P <.001) are independent factors associated with testicular survival. Adjusted odds ratio was 1.0048 for a nonviable testis for every minute of delayed management in the ED (P = .04). Results suggest that every 10 minutes of delay in the ED increases the chance of having a nonviable testis in exploration by 4.8%. CONCLUSION: DTD is an independent factor predicting testicular survival. Institutional efforts should be made to decrease duration of DTD. DTD should be considered as a measure for quality of care.

Will Stone Density Stop Being a Key Factor in Endourology? The Impact of Stone Density on Laser Time Using Lumenis Laser p120w and Standard 20 W Laser: A Comparative Study.

Introduction and Objectives: Ureteroscopy is the gold standard for most urinary tract calculi. Our institute recently incorporated a powerful 120 W holmium laser machine integrating innovative technology (Lumenis® MOSES PulseTM120H Holmium:YAG laser; Lumenis Ltd.). In this retrospective comparative study, we evaluated the influence of stone density on laser dusting time in a high-power 120 W laser machine vs a standard 20 W machine (Dornier Medilas® H20 Holmium:YAG laser; Dornier Ltd.) Methods: We conducted a retrospective review of medical records of patients who underwent ureteroscopy during the years 2013-2018 for a solitary stone. Stone and clinical characteristics, among other parameters, have been evaluated, including the total laser time until complete stone dusting. Results: Among 631 eligible patients, 462 were treated with a 20 W standard laser and 169 patients with a p120w laser machine. Overall laser time was less than half with p120w laser vs d20w (195 seconds vs 397.14 seconds, p-value <0.001). Multivariate regression demonstrated 234.91 seconds shorter laser time with a p120w laser while controlling confounders such as stone volume, hydronephrosis, and location (p value <0.0001). This pattern was demonstrated in all stone densities. The association between laser dusting time per stone volume and stone density demonstrated relatively constant laser time when using p120w laser, even for hard stones. When the standard 20 W laser was used, laser time was longer in each stone density. Moreover, a stone density of 1164 HU and more demonstrated an upward shift of laser time to stone density curve in standard d20w laser group only. Conclusions: Time to complete stone dusting using p120w laser is extremely shorter, approximately half, comparing with the standard 20 W laser. This pattern is robust and even exponential when evaluating laser time per stone density, especially in hard stones. A new horizon of powerful innovative laser technology will enable to improve endourology practice and patients' care.

Is emergency percutaneous antegrade drainage of the upper urinary tract useful for future percutaneous nephrolithotomy access?

PURPOSE: To compare percutaneous nephrolithotomy (PCNL) operations between patients with a preoperative nephrostomy tube and patients that the renal access was obtained at the time of the surgery. MATERIALS AND METHODS: We retrospectively evaluated PCNL cases. Patients were divided into two groups. Group 1 - a non-nephrostomy tube (percutaneous nephrostomy, PCN) group and Group 2 - patients with a PCN placed before the procedure. All preoperatively placed PCN's were performed in emergency situations by interventional radiologists (IR). Complications were classified according to the Clavien-Dindo classification. We compared stone characteristics, operation time, complications, efficacy and PCN usability at surgery. RESULTS: Five hundred twenty-seven patients who were submitted to PCNL for renal stones were included in the study. In 73 patients (13.9%) the PCNs were placed before the surgery. Patients and stone characteristics, mean operative time (p=0.830), complications (p=0.859) and stone-free rates (93.0%) were similar between the groups. There was a trend toward higher complication rates in Group 1, but the difference was not statistically significant. Only 21 (29.0%) of preoperatively placed PCNs were used during PCNL for establishing a tract. The reasons for not using PCN tract were: pelvic or infundibular insertion (30.0%) and suboptimal anatomic location (70.0%). CONCLUSIONS: Preoperative emergency inserted PCNs by IR usage rates were low during PCNL. Its placement neither affects the incidence of complications nor affects the operation time and outcomes. As such, when emergency renal drainage is indicated, the need for a future definitive PCNL should not influence the decision about the modality of renal drainage.

Postoperative Delirium after Urological Surgery: A Literature Review.

PURPOSE: We aimed to thoroughly search and identify studies referring to risk factors associated with postoperative delirium (POD) in patients undergoing open as well as en-doscopic urological surgery. METHODS: The review after a systematic literature search included 5 studies. RESULTS: The incidence of POD was reported to be between 7.8 and 30% depending on the type of the urologic surgery, while in the majority of the studies the onset happened on the first postoperative day and the symptoms lasted 3 ± 0.8 days. Seventeen different risk factors for POD were identified and presented in detail. CONCLUSION: The Mini-Mental State Examination score and older age were significantly associated with the development of POD. However, the Confusion Assessment Method is very well validated against the diagnosis of delirium from the specialists.

A study of prostate volumes in patients with spinal cord injury.

AIMS: To evaluate the development of benign prostatic hyperplasia (BPH) in patients with spinal cord injury (SCI) and to deduce the role of the nervous system in this process. METHODS: Prostate volumes (PVs) of 65 men older than 30 years of age who sustained SCI were determined from CT scans. Correlations of PVs with SCI level, age, age during SCI and duration of paralysis were calculated. RESULTS: Average patient's age during SCI was 37.7 (±19) years and during measurement of PV 54.8 (±15.3) years. PVs of patients with SCI were similar to expected age-adjusted volumes (29.7 ± 24 mL vs 29.9 ± 5.7 mL, P = 0.95). We dichotomized the cohort into two groups: High SCI (T5 and above) and low SCI (T6 and below) with almost identical: number of patients, age of SCI and duration of paralysis. Patients with lower injuries, had significantly smaller PVs when compared both to patients with higher injuries (19.4 ± 6.3 and 39.8 ± 30, P = 0.0006) and to age-adjusted normal PVs (19.4 ± 6.3 and 29.2 ± 5.8, P = 0.0005). Correlation of PV with age was found in patients higher injuries (R2 = 0.26, p = 0.003) but not in patients with lower (R2 = 0.08, P = 0.11). Moreover, patients with lower SCI had significantly smaller prostate even compared to expected PVs during SCI (18.7 ± 4.6 cc vs 27.8 ± 6.9 cc, P = 0.00006). CONCLUSIONS: Low SCI stops and reverses age related increase in PV. This phenomenon does not occur in high SCIs. This suggests that continuous support of the nervous system is essential for sustaining BPH and raises the possibility of finding a non-hormonal pharmacological intervention for reversing BPH.

Detecting Novel Urine Biomarkers for the Early Diagnosis of Prostate Cancer: Platelet Derived Growth Factor-BB as a Possible New Target.

INTRODUCTION: Although the prostate specific antigen revolutionized the diagnosis of prostate cancer (PCa), it has its limitations. We prospectively examined the potential use of the platelet-derived growth factor-BB (PDGF-BB) as a urine biomarker for the early diagnosis of PCa. MATERIALS AND METHODS: The urine samples of 118 patients were collected after a prostatic massage and all the patients subsequently underwent ultrasound-guided transrectal biopsy. PDGF-BB was detected in the urine by enzyme-linked immunosorbent assay. RESULTS: Patients with PCa had greater levels of prostate specific antigen and PDGF-BB. Receiver operating characteristic curve analysis showed that the optimal cut-of of PDGF-BB for the prediction of PCa was 1,504.9 with a sensitivity of 60% and a specificity of 51.3%. For a 100 unit increase in PDGF-BB, the likelihood for PCa increased about 4%. CONCLUSION: PDGF-BB showed a significant predictive ability for PCa. Detection of PDGF-BB in urine with Elisa was easy and improved our diagnostic accuracy in the diagnosis of PCa.

[ACTIVE SURVEILLANCE IN RECURRENT LOW-RISK BLADDER TUMORS].

OBJECTIVES: To report our experience with the active surveillance policy in patients with recurrent low-risk bladder tumors. METHODS: The files of 52 patients who underwent active surveillance instead of immediate surgical resection were reviewed. Different variables concerning tumor growth rate were evaluated. RESULTS: A total of 75 surveillance periods were documented in 52 patients (mean age 75.6 years S.D. 10.45 years, 37 males and 14 females), Mean surveillance period length was 16.5 months (S.D. 16.1). All tumors resected after surveillance were found in stage Ta and in low-grade except one tumor which was high-grade; 70 active surveillance periods ended with tumor resection, and 5 patients were still under surveillance when the research ended; 27 surveillance periods (37.7%) ended because of the growth of additional tumors. Active surveillance therefore spared 27 surgeries. The rate of tumor growth during surveillance depended on the tumor's largest diameter at the beginning of surveillance. If initial tumor diameter was smaller than 5 mm (68 cases), the median tumor growth rate was 1.12 mm3/month (IRQ: 0-6.55). If the initial tumor diameter was ≥5 mm (7 cases), the median tumor growth rate was 137.14 mm3/month (IRQ: 2.21-1787.5, p < 0.05). CONCLUSIONS: Small, recurrent papillary bladder tumors pose minimal risk to the patient. An active surveillance policy, without immediate resection of the tumor is safe, can spare surgeries and can be considered in patients presenting with small papillary recurrence.

Abbreviated CT protocol for postoperative surveillance of renal cancer.

INTRODUCTION: Postoperative surveillance protocols after nephrectomy for kidney cancer include periodic computed tomography (CT) scans of the chest and abdomen. A single study exposes the patient to 21 mSv (equivalent to 7-year exposure to natural background radiation). The objective of this study was to evaluate the hypothesis that an abbreviated CT protocol restricted to the chest and upper abdomen (i.e., to the level of the intervertebral disk L3-L4) is sufficient for routine postnephrectomy follow-up as it detects most tumor recurrence with lower radiation exposure. METHODS: We identified 493 patients treated with radical or partial nephrectomy for localized kidney cancer and followed with periodic CT scans of the chest and abdomen for prolonged periods. The frequency and location of cancer recurrence were documented. The ratio of infield recurrence for the complete chest, and abdomen and for the abbreviated protocol was recorded. The decrease in radiation exposure was calculated. RESULTS: At a median follow up of 96 months, 82 patients (16.6%) developed recurrence. The frequent sites of recurrence were the lungs (53), the bones (9), and local recurrence (22). Complete chest and abdominal CT identified 78 of the recurrences (95%) and the abbreviated protocol identifying all but one of these (94%). The abbreviated protocol exposed the patient to 48% (standard deviation 4.3%) less radiation compared to the full protocol. CONCLUSIONS: Using an abbreviated CT protocol that includes the chest and upper abdomen for surveillance after surgery of localized kidney cancer decreases radiation exposure by half with only a minor decrease in the sensitivity of the examination.