Continuous monitoring of intrapelvic pressure during flexible ureteroscopy using a sensor wire: a pilot study.

PURPOSE: To evaluate the feasibility of measuring the intrapelvic pressure (IPP) during f-URS with a wire including a pressure sensor and to assess IPP profiles during the procedure. METHODS: Patients undergoing f-URS for stone disease were recruited. A wire with pressure sensor was placed in the renal cavities to measure IPP. For these cases, either no ureteral access sheath (UAS) or 10/12 or 12/14-Fr UASs were used according to surgeon discretion. Irrigation was ensured by a combination of a continuous pressure generator set at 80 cmH2O and a hand-assisted irrigation system providing on-demand forced irrigation to provide proper visibility. Pressures were monitored in real time and recorded for analysis. RESULTS: Four patients undergoing five f-URS were included. IPP monitoring was successful in all patients. Mean baseline IPP was 6 cmH2O. During f-URS with only the endoscope in the renal cavities and irrigation pressure set at 80 cmH2O without any forced irrigation, the mean IPP was 63 cmH2O. Mean IPP during laser lithotripsy with the use of on-demand forced irrigation was 115.3 cmH2O. The maximum pressure peaks recorded during this therapeutic period using forced irrigation ranged from 289.3 to 436.9 cmH2O. CONCLUSION: High IPP levels may be achieved during f-URS with on-demand irrigation systems. The impact of these high pressures on the risk of complications and long-term consequences still need to be evaluated adequately. But, in this preliminary pilot study, IPP could be reliably and conveniently monitored and recorded using a wire with a digital pressure sensor.

Effects of Silicone Hydrocoated Double Loop Ureteral Stent on Symptoms and Quality of Life in Patients Undergoing Flexible Ureteroscopy for Kidney Stone: A Randomized Multicenter Clinical Study.

PURPOSE: We compared the hydrocoated silicone stent (Coloplast Imajin® hydro) to Percuflex™ Plus stent (Boston Scientific) in terms of patient comfort and quality of life after flexible ureteroscopy for stone disease over a 5-week prospective followup. MATERIALS AND METHODS: This is a multicenter, single-blind, prospective, randomized trial of 141 patients treated with flexible ureteroscopy for renal stones. Primary outcome was Ureteral Stent Symptom Questionnaire (USSQ) Body Pain Index recorded before Double-J® stent removal at day (D) 20. Secondary endpoints were USSQ scores at intermediate dates (D2, D7, D20) and 2 weeks after stent withdrawal (D35), occurrence of adverse events and stent encrustation. RESULTS: The trial was completed by 113 (80.1%) patients. Mean (SD) USSQ body pain scores were 25% lower at D20 for the silicone stent at 18.7 (11.4) vs 25.1 (14.2) (p=0.015). No difference in terms of adverse events and safety profile was observed. USSQ urinary symptoms scores at D2, D7 and D20 were lower in the silicone stent group at 26.4 (7.7) vs 31.8 (8.1) at D20 (p <0.001). The use of USSQ self-questionnaires was associated with a limited number of missing or incomplete answers. CONCLUSIONS: The primary results of this large sample prospective randomized controlled study comparing the silicone Imajin hydro stents to the Percuflex Plus stent show that silicone stents are associated with significantly less patient discomfort. We would recommend their use in patients who require stenting for stone disease.

Prospective Analysis of a Complete Retrograde Ureteroscopic Technique with Holmium Laser Stent Cutting for Management of Encrusted Ureteral Stents.

Purpose: To propose and evaluate a new endoscopic technique using only a retrograde ureteroscopic approach for the removal of heavily encrusted ureteral stents. Methods: Data from 51 consecutive patients with encrusted and retained ureteral stents were prospectively collected. Description of the successive steps of surgery is detailed. The holmium yttrium aluminum garnet (Ho:YAG) laser properties offer the opportunity for fragmentation of stent-attached encrustation and the ability to cut the stent itself. Reducing the length of the stent is critical to creating space in the ureter and to allow free access for ureteroscopes or ureteral access sheath placement. The primary outcome of this study was the feasibility and the safety of this retrograde intrarenal approach. Some factors of encrustation and outcomes are also discussed in comparison with lithotripsy, percutaneous, laparoscopic, open surgery, or a combination of these techniques. Results: The removal of the encrusted stent was possible with only this retrograde technique in 98% of patients. The transection of the encrusted stent with the Ho:YAG laser was useful in 71% of the patients. Mean operative time was 110 minutes and mean hospital stay was 2.33 days. Postoperative complications were mainly nonobstructive pyelonephritis (10%). The most significant predictor of this life-threatening complication was the presence of struvite stones with the encrusted stent (p = 0.018). Contrariwise, operative time, body mass index, gender, and encrustation rate were not associated with postoperative pyelonephritis. Both cystine stone disease and pregnancy led to faster stent encrustation. Conclusions: Retrograde ureteroscopic surgery is efficient and safe for removing retained stents and associated stone burdens. The Ho:YAG laser is essential to perform the encrustation removal and sectioning of the stent.

Early repeated ureteroscopy within 6-8 weeks after a primary endoscopic treatment in patients with upper tract urothelial cell carcinoma: preliminary findings.

OBJECTIVES: To evaluate the cancer detection rate (CDR) of an early repeated flexible ureteroscopy (2nd-look-URS) and its impact on the conservative management of patients affected with upper urinary tract urothelial carcinoma (UTUC). MATERIALS AND METHODS: Clinical and surgical data from 41 patients with UTUC who underwent 2nd-look-URS within 60 days of their first URS with concomitant laser tumour photoablation at a single tertiary care referral centre from 2009 to 2013 were retrospectively analyzed. Radical nephroureterectomy was offered during follow-up in case of massive tumour recurrence (defined as a tumour not completely removable only with a conservative approach). Descriptive statistics tested the impact of 2nd-look-URS outcomes on subsequent endoscopic evaluation. Kaplan-Meier curves assessed massive tumour recurrence-free survival (mRFS) rates according to the presence of a tumour at 2nd-look-URS. Cox regression analyses identified predictors of mRFS. RESULTS: CDR at 2nd-look-URS was 51.2 %. CDRs at third URS were 81.3 and 41.2 % in patients with a positive and a negative 2nd-look-URS, respectively (p = 0.02). At a mean (median) follow-up of 34.6 (27.6) months, mRFS rates were 88 and 48 % in patients with negative and positive 2nd-look-URS, respectively (log rank = 0.015). Tumour grade at first URS and 2nd-look-URS outcomes achieved predictor status for mRFS (HR 6.1, 95 % CI 1.42-26.27 and HR 5.39, 95 % CI 1.18-24.66, respectively, all p ≤ 0.03). CONCLUSIONS: 2nd-look-URS-related CDR in conservatively treated UTUC patients was 51.2 %. 2nd-look-URS outcomes affected the findings of both subsequent endoscopic evaluation and mRFS. Further studies are needed to confirm the benefits of this approach in terms of patient outcomes.

Urolithiasis and urinary tract infection among patients with inflammatory bowel disease: a review of US emergency department visits between 2006 and 2009.

OBJECTIVE: To compare patients with inflammatory bowel disease (IBD) to a general population of urinary stone formers who present to US emergency departments with infected urolithiasis. Patients with IBD are at risk for both infection and stone formation, however studies investigating emergent urolithiasis presentations for this population are limited. METHODS: Using the Nationwide Emergency Department Sample (2006-2009) we identified all patients presenting to the US emergency departments with a diagnosis of upper tract urolithiasis. We then described a subgroup with the concomitant diagnosis of IBD. We compared rates of urinary tract infection (UTI), sepsis, organ failure, admission, and mortality between the 2 groups. Using multivariate analysis, we determined whether or not IBD was a predictor of UTI, sepsis, and hospitalization. RESULTS: Overall, 14,352 patients had concomitant IBD and urolithiasis. IBD patients with urolithiasis presented with infections (10.4% vs 9.1%; P <.001), sepsis (0.6% vs 0.2%; P <.001), and end-organ failure (6.3% vs 1.6%; P <.001) more frequently than non-IBD patients. They were also more likely to have characteristics independently associated with infection and sepsis, such as older age and female gender. In adjusted analyses, IBD was an independent predictor of infection (odds ratio [OR] = 1.3 [1.14-1.46]; P <.0001), sepsis (OR = 1.8 [1.09-2.92]; P <.0001), and admission (OR = 3.3 [3.04-3.64]; P <.0001). CONCLUSION: IBD patients with urinary calculi have greater odds of UTI, renal failure, and sepsis compared to the general stone-forming population. The increased occurrence and severity of infected urolithiasis in this select group of patients warrants screening for stone disease, improved outpatient medical management, and early elective surgery for detected stones.

Comparative study of the treatment of renal stones with flexible ureterorenoscopy in normal weight, obese, and morbidly obese patients.

OBJECTIVE: To compare the efficacy and the safety of flexible ureterorenoscopy (f-URS) in the treatment of kidney stones according to the body mass index (BMI), which seems to be less influenced by weight compared with shock wave lithotripsy and percutaneous nephrolithotomy. METHODS: We conducted a retrospective monocentric study in patients with a known BMI who underwent an f-URS for kidney stones between 2006 and 2008. Success rates in the obese patients (OP) group (BMI ≥30 kg/m(2)) were compared with success rates in the normal weight patients (NWP) control group (BMI <25 kg/m(2)). Patients with a BMI ≥40 kg/m(2) were defined as morbidly obese patients (MOP), a subgroup of the OP group. The success was defined as a stone-free status (no or ≤2 mm residual stone) at the time of control, 3 months after the procedure assessed by kidneys-ureters-bladder radiography coupled with ultrasound (only in NWP with radiopaque stones), or computed tomography-scan. RESULTS: A total of 327 procedures were performed, including 97 f-URS in 87 OP (including 14 procedures in 13 MOP) and 230 procedures for 188 NWP. The overall success rate was 67.4% and 68% in the NWP and OP, respectively; P = .91 (71.4% in the MOP subgroup). Success rates decreased with an increasing stone size without any differences between the groups. Regardless of location and stone size (<10, 10-20, >20 mm), there was no statistical difference in the success rate. Postoperative morbidity was similar in both groups and occurred in 2.44% of cases. CONCLUSION: f-URS for kidney stones resulted in similar outcomes in NWP and OP, and even MOP, regardless of stone size and location and with equivalent morbidity.

The Role of Virtual Cystoscopy, after Multidetector Computed Tomography Imaging Reconstruction without the Use of Contrast Medium, in the Diagnosis and Evaluations of Bladder Tumors: Preliminary Study.

Introduction. Although conventional cystoscopy is considered to be the gold standard for diagnosis and follow-up of bladder tumors, it remains an invasive and costly procedure. With the advent of the multidetector CT (MDCT) scanners supported by specialized software virtual cystoscopy (VC) is possible. We assess the role of VC in diagnosing and evaluating bladder lesions. Materials and Methods. Between September 2010 and October 2011, 25 consecutive patients with cystoscopically confirmed bladder tumor underwent VC. The radiologists involved in this prospective study were blinded to the exact findings. After draining any residual urine with a catheter, the bladder was retrogradely insufflated with 200-600 cc of air. No intravenous or intravesical contrast was used. MDCT scan was performed in supine and prone positions and three-dimensional reconstruction of the urinary bladder was performed. Results. The examination was well tolerated by all patients with no complications. In total, 43 lesions were detected both with conventional cystoscopy and VC. Tumor size measured by CT ranged from 3 to 80 mm in diameter. The pathological report revealed noninvasive transitional cell carcinomas in all cases. Conclusion. VC has promising results in detecting exophytic bladder lesions. In the future it could be part of the diagnostic algorithm for bladder tumors.

Which ureteral access sheath is compatible with your flexible ureteroscope?

PURPOSE: Our aim is to evaluate different ureteral access sheaths (UASs), which are available in the international market and their compatibility with different available flexible ureteroscopes (F-URSs) to help the urologist choose the proper ureteral access sheath for his or her endoscope before commencing the procedure. MATERIALS AND METHODS: A total of 21 UASs and 12 F-URSs were evaluated. Measurements were obtained in French (F) units considering different characteristics for each UAS and each F-URS. Insertion test without friction between F-URS and UAS was considered as a successful test and was referred as (YES). RESULTS: All UASs and F-URSs were successfully submitted to the insertion test. All F-URSs that were inserted into UASs without friction had an internal diameter of at least 12F. Different lengths of UAS did not influence the test outcome. CONCLUSION: This study was able to establish a correlation table between different UASs and different flexible ureteroscopes. As of now, the 12/14F UAS is considered the universal UAS that accepts all F-URSs that are available in the endourology field. Nevertheless, we are expecting a significant change with the new standard size 10/12F UAS as well as huge advances in minimizing the size of different endoscopes.

Extracorporeal lithotripsy endoscopically controlled by ureterorenoscopy (LECURS): a new concept for the treatment of kidney stones-first clinical experience using digital ureterorenoscopes.

PURPOSE: To evaluate the feasibility and usefulness of extracorporeal lithotripsy endoscopically controlled by simultaneous flexible ureterorenoscopy (LECURS) and combined with Holmium laser lithotripsy for kidney stones surgery. METHODS: Retrograde flexible ureteroscopy allowed stone visualization and intrarenal relocation when possible. Extracorporeal schock wave lithotripsy (ESWL) was performed under direct vision allowing constant focal zone adjustment for optimal stone fragmentation. Holmium laser lithotripsy was used simultaneously when necessary. Post-operative assessment included ultrasound at day one and abdominal CT scan 3 weeks later to evaluate for residual fragments. RESULTS: Six patients with kidney stones were recruited including 3 with relative contraindication to ESWL. One patient had a stone beyond an infundibular stenosis and 2 had multiple stones in a horseshoe kidney with an uretero-pelvic junction (UPJ) stricture. A 100 % stone fragmentation rate was obtained. Post-operative ultrasound was normal in 5 patients and showed slight peri-renal infiltration in the other. One patient developed an obstructive pyelonephritis requiring antibiotics and changing a double J to a ureteral catheter. No other complications were noted. Three patients (50 %) were stone free after LECURS. Three patients underwent a second-look procedure for small (<3 mm) retained residual fragments. No damage was seen with the digital ureteroscopes, laser fibers or stone baskets. CONCLUSIONS: This initial experience with LECURS has shown to be feasible and safe. This opens the opportunity for further evaluation of this approach in order to improve outcomes of both approaches.

Penile cancer: what's new?

PURPOSE OF REVIEW: This article reviews the epidemiology, diagnostic modalities and treatment of localized and advanced penile cancer, with special emphasis on most recent findings from the literature. RECENT FINDINGS: Penile cancer is a rare disease and its treatment suffers from a paucity of evidence in the literature. Risk factors include phimosis with poor hygiene, human papilloma virus infections, chronic balanitis xerotica obliterans and smoking, among others. Surgical treatment for local disease remains the best option, but organ-preserving procedures provide good aesthetic and functional results with acceptable oncologic control. Regional disease, when present in the form of adenopathy, is best diagnosed with fine-needle aspiration, and treated with radical inguinal lymphadenectomy if resectable. Occult metastatic disease constitutes a challenge and is managed according to primary tumour risk factors. For nonresectable regional disease and metastases, neoadjuvant cisplatinum-based regimens are the best option, and provide a selection of patients who will be optimal candidates to consolidative surgical therapies. SUMMARY: Penile cancer at its various stages constitutes a therapeutic challenge. Management should be increasingly confined to high volumes centres of excellence, allowing for clinical trials, which will hopefully provide a better understanding of the disease and the best treatment approach.

RET Gly691Ser mutation is associated with primary vesicoureteral reflux in the French-Canadian population from Quebec.

Primary vesicoureteral reflux (pVUR) is a common, genetically heterogeneous congenital urinary tract abnormality in children. It causes urine to flow backward from the bladder to the ureter due to a developmental defect at the vesicoureteral junction, whose formation requires rearrangement during transformation (Ret)-mediated signaling pathways. To study the genetic causes of pVUR in Quebec patients, we used a sequencing-based candidate gene approach to screen the RET gene and found that 83 out of 118 pVUR patients are carriers of the rare A allele of single nucleotide polymorphism (SNP) rs1799939:G>A that results in a Gly691Ser mutation, a statistically significant increase in allelic frequency, that is absent at six flanking RET SNPs tested. Ser691 is a predicted phosphorylation site and our analysis of transfected cells showed that the Gly691Ser Ret mutant can efficiently interact and associate with a 75-80-kD tyrosine phosphorylated cellular protein, an event not seen with wild-type Ret. This interaction and/or the steric or electric hindrance created by phospho-Ser691 may interfere with the known regulatory functions of the normally phosphorylated phospho-Tyr687 and phospho-Ser696 on the cytoskeleton actin reorganization that are responsible for cell motility and morphology, which consequently may lead to the deficiency in ureteral development observed in pVUR. Our study demonstrates that the Ret Gly691Ser mutation is associated with pVUR and may be one of the genetic causes of this condition in the French-Canadian population in Quebec.