The experience of a tertiary referral center with laparoscopic pyelolithotomy for large renal stones during 18 years.

This study aimed to evaluate the outcomes of laparoscopic pyelolithotomy, including its efficacy and feasibility in treatment of large renal stones. All patients who underwent laparoscopic pyelolithotomy operations in a referral center were enrolled from 2003 to 2020. The final analysis included 436 patients. The total stone free rate was 88.3% and the stone-free rate for staghorn/multiple stones versus other types of stones was 81% vs. 91% (P = 0.002). Likewise, the total operation duration was 158 ± 50 and the operation duration for staghorn/multiple stones versus other types of stones was 171 ± 51 min vs. 153 ± 49 min (P < 0.001). The operation duration (169 ± 51 vs. 155 ± 58 vs. 155 ± 42 min) and hospitalization (4.5 ± 2.3 vs. 4.0 ± 2.2 vs. 3.6 ± 1.8) decreased with increasing the surgeons' experience over time. The outcomes of laparoscopic pyelolithotomy for children versus adults versus geriatric patients and in patients with normal versus abnormal kidney anatomy did not reveal statistically significant differences. Laparoscopic pyelolithotomy could be employed as an alternative surgical approach for patients with large kidney stones of any age or with kidney abnormalities provided that appropriate expertise is available to carry out the procedure.

Our Experience with Totally Ultrasonography-Guided Percutaneous Nephrolithotomy in Children.

Purpose: To present the safety and efficacy of totally ultrasonography-guided percutaneous nephrolithotomy (PCNL) for managing urinary stones in pediatric patients. Patients and Methods: Ten children with a mean age of 5.4 (3-11) years underwent totally ultrasonography-guided PCNL from March 2013 to November 2013. The pyelocaliceal system was punctured with the patient in the prone position by using ultrasonographic guidance, and the tract was dilated using a single-shot dilation technique. All steps of renal access were performed by using ultrasonography; no fluoroscopy was used. PCNL in all cases was performed by using adult instruments. Results: The mean stone size was 28.9±6.7 mm (range 17-35 mm). The mean access time to stone was 4.45±2.25 minutes (range 3-10 min). The mean nephroscopic time was 45.9±17 minutes (range 20-80 min). The stone-free rate was 83%. Mean hospital stay of patients was 3 days (range 2-5 days). No major complications were happened. Only one patient needed ureteral stent insertion because of urinary leakage from the nephrostomy tract. Conclusion: Our experience with totally ultrasonography-guided PCNL using adult size instruments in children revealed proper results and acceptable complications compared with the standard technique of PCNL. Likewise, this alternative method has the advantage of preventing radiation hazard.

Laparoscopic pyelolithotomy in patients with previous ipsilateral renal stone surgery.

OBJECTIVES: To evaluate the safety and efficacy of transperitoneal laparoscopic pyelolithotomy in renal stone cases with previous renal surgeries. PATIENTS AND METHODS: In this prospective study, 190 consecutive patients with renal stones, who were candidates for transperitoneal laparoscopic pyelolithotomy, were enrolled. The patients were divided into two groups. In group A, 163 patients without a history of renal surgery underwent standard laparoscopic pyelolithotomy, whereas in group B laparoscopic pyelolithotomy was performed in 27 patients with a history of kidney stone surgery including percutaneous nephrolithotomy or open stone surgery. All intraoperative data including the operating time and complications such as bleeding requiring transfusion were recorded. Postoperative data such as length of hospitalization, hemoglobin level alteration, and other complications were also recorded. RESULTS: There was no significant difference in the preoperative data such as stone size, stone site, age, sex, and stone side between the two groups. There was no significant difference in the stone-free rate between the two groups (p = 0.4). There was no significant difference between the two study groups regarding the operating time, hospital stay, stone-free rate, complications, and transfusion rate. CONCLUSION: Laparoscopic pyelolithotomy can be used as a safe and feasible treatment modality in the setting of previous renal surgery. The complications and stone-free rate of laparoscopic pyelolithotomy in patients with history of renal surgery are acceptable.

Percutaneous Nephrolithotomy Versus Laparoscopy in the Management of Large Proximal Ureteral Stones: The Experience of Two Different Settings.

PURPOSE: This study was conducted to compare the success rate and complications of percutaneous nephrolithoto-my (PCNL) and laparoscopic ureterolithotomy for the treatment of large proximal ureteral stones. MATERIALS AND METHODS: In this prospective cohort study, the success rate and complications in 52 patients under-going PCNL in Hamadan's Shahid Beheshti Hospital and 55 patients undergoing laparoscopic ureterolithotomy in Tehran's Shahid Labbafinejad Hospital were compared. All patients had large proximal ureteral stones. RESULTS: In the PCNL group, the mean age was 47.78 ±16.72 years, 75% were male, and 50% of calculi were on the upper right side and the rest on upper left side. The mean duration of surgery was 32 ± 9.4 minutes and success rate 100%. The mean stone size was 18.33 ± 2.63 mm in PCNL group and 21.29 ± 2.18 mm in laparoscopy group which was significantly different (P <.001). In the laparoscopy group, the mean age of patients was 42.92 ± 16.10 years and 83.6% were male. In this group, 46.6% of calculi were on the right side and the rest were on the left side. The mean duration of surgery was 107.43 ± 22.86 minutes and success rate was 100%. There was not a statistically significant association between surgical technique and age, gender, stone location, mean hospital stay length after surgery, degree of hydronephrosis and success rate (P >.05). However, surgery duration was significantly shorter in the PCNL group compared to the laparoscopy group (P <.001) and the decrease in hemoglobin, hematocrit and serum urea level was more pronounced in the PCNL group than in the laparoscopy group. CONCLUSION: PCNL and laparoscopic ureterolithotomy met with the same success rate in the treatment of upper large ureteral stones. However, the two methods should be utilized depending on the hospital facilities and equip-ment, surgical team qualifications, and patient conditions.

Comparison of Open Versus Laparoscopic Versus Hand-Assisted Laparoscopic Nephroureterectomy: A Systematic Review and Meta-Analysis.

BACKGROUND: A systematic analysis of the evidence regarding oncological, perioperative and postoperative outcomes of open nephroureterectomy (ONU), laparoscopic nephroureterectomy (LNU), and hand-assisted laparoscopic nephroureterectomy (HALNU) was designed. METHODS: The summarized data were abstracted from 52 original research articles representing 19,195 patients. PubMed/Medline, Scopus, Google Scholar, EMBASE, and the Cochrane Library were reviewed in March 2017, following PRISMA framework. A total of 52 publications were selected for inclusion. The primary outcomes were 2- and 5-year cancer-specific survival (CSS) rate, overall survival (OS) rate, and recurrence-free survival (RFS) rate. The secondary outcomes were operative time, lengths of hospitalization period, estimated blood loss, transfusions, major Clavien complication rate, metastasis rate, bladder recurrence rate, and positive surgical margin. RESULTS: On comparing LNU versus ONU and HALNU versus ONU, no significant differences between the 5-year CSS rate (P = .25, P = .39), OS rate (P = .06, P = .46), and RFS rate (P = .85, P = .73) were found. On comparing LNU versus ONU and HALNU versus ONU during a 2-year follow-up period, the following were found: CSS rate (P = .61, P = .04) and OS rate (P = .33, P = .19). There were no significant differences between the LNU versus ONU and HALNU versus ONU rates, regarding bladder recurrence (P = .12, P = .85) and metastasis rate (P = .07, P = .27). Significant higher operative time (P = .01, P = .0004), lower length of hospitalization period (P < .001, P < .001), and estimated blood loss (P = .0004, P < .001) were found in comparison to that of LNU versus ONU and HALNU versus ONU. CONCLUSION: Both LNU and HALNU had comparable oncological and better perioperative and postoperative outcomes, when compared with ONU.

Association between single nucleotide polymorphisms in the PI3K/AKT/mTOR pathway and bladder cancer risk in a sample of Iranian population.

In the past few years several investigations have focused on the role of PI3K/AKT/mTOR pathway and its deregulations in different cancers. This study aimed to examine genetic polymorphisms of this pathway in bladder cancer (BC). In this case-control study, 235 patients with pathologically confirmed bladder cancer and 254 control subjects were examined. PIK3CA, AKT1 and mTOR variants were analyzed using polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP). The findings proposed that the PIK3CA rs6443624 SNP significantly decreased the risk of BC (OR=0.44, 95 % CI=0.30-0.65, p<0.0001 CA vs CC; OR=0.35, 95 % CI=0.16-0.78, p=0.0107, AA vs CC; OR=0.60, 95 % CI=0.46-0.79, p=0.0002, A vs T). The AKT1 rs2498801 variant is associated with a decreased risk of BC (OR=0.57, 95 % CI=0.39-0.82, p=0.003, AG vs AA; OR=0.74, 95 % CI=0.56-0.97, p=0.032, G vs A) while, AKT1 rs1130233 polymorphism considerably increased the risk of BC (OR=3.70, 95 % CI=2.52-5.43, p<0.0001, GA vs GG; OR=5.81, 95 % CI=1.53-21.97, p=0.010, AA vs GG; OR=2.71, 95 % CI=1.98-3.70, p<0.0001, A vs G). Additionally, mTOR rs2295080 variant notably increased the risk of BC (OR=2.25, 95 % CI=1.50-3.38, p<0.0001, GT vs GG; OR=4.75, 95 % CI=2.80-8.06, p<0.0001, TT vs GG; OR=3.10, 95 % CI=2.34-4.10, p<0.0001, T vs G). None of the other examined polymorphisms (AKT1 rs1130214, AKT1 rs3730358, mTOR rs1883965) revealed significant association with BC. In conclusion, our findings suggest that PIK3CA rs6443624, AKT1 rs2498801, AKT1 rs1130233, as well mTOR rs2295080 polymorphism may be related to bladder cancer development in a sample of Iranian population. Validation of our findings in larger sample sizes of different ethnicities would provide evidence on the role of variants of PI3K/AKT/mTOR pathway in developing BC.

Fluoroscopy-free ultrasonography-guided percutaneous nephrolithotomy in pediatric patients: a single-center experience.

OBJECTIVES: To present the safety and efficacy of fluoroscopy-free ultrasound-guided PCNL for the treatment of renal calculi in pediatric patients of all ages. METHODS: 30 children with mean age of 5 years (6 months-12 years) underwent totally ultrasound-guided PCNL from March 2013 to August 2016. The pyelocalyceal system was punctured in prone position using only ultrasonography guidance, and the tract was dilated using a single shot dilation technique. No fluoroscopy was used during any of the stages of renal access. The procedure was performed using adult-sized instruments. RESULTS: The mean stone size was 27.1 ± 8.7 mm. Mean access time was 4.3 ± 2 min. Mean nephroscopic time was 34.6 ± 15.2 min. Mean hospital stay of patients was 3 days (range 2-5). 21 patients were stone-free after the procedure (70% success rate). Only four patients out of 30 experienced postoperative complications. CONCLUSIONS: The results of this study showed that fluoroscopic-free ultrasound-guided PCNL in pediatric patients of all ages is safe, highly efficient, and minimizes potential radiation exposure risks associated with the procedure.

Tubeless versus standard percutaneous nephrolithotomy in pediatric patients: a systematic review and meta-analysis.

BACKGROUND: This systematic review and meta-analysis was designed to evaluate the post-operative outcomes between tubeless and standard percutaneous nephrolithotomy (PCNL) among children. METHODS: Literature searches were performed following the Cochrane guidelines. We conducted a systematic review and meta-analysis that included three trials investigating the outcomes including the length of hospital stay, operation time, hemoglobin decrease, blood transfusion rate, perirenal fluid presence, post-operative fever, stone clearance rate, and the need for a second operation. RESULTS: The patients who underwent tubeless PCNL had shorter length of hospitalization compared to standard PCNLs (mean difference -1.57, 95% confidence interval -3.2 to 0.07, p = 0.06). No significant decrease was detected in hemoglobin after tubeless PCNL compared to standard PCNL (mean difference 0.05, 95% confidence interval -0.03 to 0.13, p = 0.21). There were no significant differences in operation time (p = 0.7), perirenal fluid presence (p = 0.15), post-operative fever (p = 0.72), stone clearance (p = 0.68), and the need for a second operation (p = 0.90). CONCLUSIONS: This study showed no significant difference between tubeless and standard PCNLs in children. However, due to the lack of data, the results should be mentioned prudently. Future randomized trials with more sample sizes and longer follow-ups are warranted.

Simultaneous Bilateral Laparoscopic Adrenalectomy for Adrenal Metastases of Renal Cell Carcinoma: A Case Report.

The possibility of bilateral adrenal gland metastasis from renal cell carcinoma (RCC) has been extremely rarely reported. Surgery may be the preferred treatment strategy for adrenal metastasis from RCC. In this article, we present a patient with bilateral large adrenal metastases from the left RCC, which was managed with simultaneous bilateral laparoscopic excision. A 64-year-old woman had undergone left adrenal sparing radical nephrectomy for a left RCC 7 years ago. Her abdominal CT scan revealed bilateral large adrenal metastasis. She underwent bilateral laparoscopic adrenalectomy. The operation was uneventful and the patient was discharged after 4 days with no complications. Bilateral laparoscopic adrenalectomy for adrenal metastasis seems to be a feasible and safe procedure in such cases, but this needs to be confirmed by further studies with a larger sample size.

Bilateral Laparoscopic Stone Surgery for Renal Stones- A Case Series.

PURPOSE: To present our experience with synchronous or metachronous laparoscopic pyelolithotomy and ureterolithotomy for patients with bilateral urolithiasis. MATERIALS AND METHODS: The data of all patients who underwent laparoscopic pyelolithotomy (± ureterolithotomy) for bilateral renal and/or ureteral stones from November 2009 to July 2014 were included. Laparoscopic operations were performed through a transperitoneal approach. RESULTS: 10 patients underwent laparoscopic operations for renal stones (19 kidney stones) and ureteral stones (1 ureteral stone). 4 patients underwent synchronous operations and 6 patients underwent metachronous operations. The mean ± SD of operation duration were 212 ± 51 minutes for synchronous operations and 166 ± 41 minutes for metachronous operations. Residual stone was observed 5 patients. No patient developed urinary leakage. CONCLUSION: Laparoscopic pyelolithotomy and/or ureterolithotomy for bilateral stones is a feasible option in centers with experience in laparoscopy.

Comparing the Efficacy and Safety of Ultrasonic Versus Pneumatic Lithotripsy in Percutaneous Nephrolithotomy: A Randomized Clinical Trial.

BACKGROUND: Percutaneous nephrolitotomy (PCNL) is the preferred treatment for large renal stones. There is a need for more comparative data for different lithotripters used in PCNL. OBJECTIVE: To evaluate the comparative safety and efficacy of ultrasonic and pneumatic lithotripsy in patients undergoing PCNL. DESIGN, SETTING, AND PARTICIPANTS: This randomized clinical trial was conducted at Labbafinejad University Hospital, Tehran, Iran. A total of 180 patients were selected and divided randomly into two groups: 88 patients to pneumatic and 92 to ultrasonic lithotripsy. INTERVENTION: Standard fluoroscopy-guided PCNL was performed using pneumatic or ultrasonic lithotripsy. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary outcome was the procedure success rate. We also evaluated other outcome measures including operation time, stone fragmentation and removal time (SFRT), length of hospital stay, and postoperative complications. We used SPSS software version 18.0 for data analysis. RESULTS AND LIMITATIONS: The two groups were similar in baseline characteristics. There were no significant differences between the groups in stone fragmentation and removal time (p=0.63), stone free rate (p=0.44), and hospital stay (p=0.66). SFRT for hard stones was shorter using pneumatic lithotripsy (p<0.001). By contrast, ultrasonic lithotripsy was associated with a shorter SFRT for soft stones (p<0.001). Postoperative complications were similar in the two groups. A limitation of this study might be the 3-mo follow-up period. CONCLUSIONS: In general, there were no significant differences in the success rate and complications between pneumatic and ultrasonic lithotripsy. SFRT was significantly shorter using pneumatic lithotripsy for hard stones, and ultrasonic lithotripsy for soft stones. PATIENT SUMMARY: We found no significant differences in the success rate and complications of percutaneous nephrolitotomy using pneumatic and ultrasonic lithotripsy. Ultrasonic and pneumatic lithotripsy differed in the time for stone fragmentation and removal for hard and soft stones.

Pri-miR-34b/c rs4938723 polymorphism increased the risk of prostate cancer.

The association studies between miR-34b/c rs4938723 polymorphism and cancer risk showed conflicting results. This study aimed to assess the impact of rs4938723 polymorphism on prostate cancer risk. This case-control study was done on 151 prostate cancer (PCa) patients and 152 benign prostate hyperplasia to examine whether rs4938723 polymorphism in the promoter of pri-miR-34b/c was linked to the carcinogenesis of PCa in a sample of Iranian population. Genotyping of Pri-miR-34 b/c rs4938723 polymorphism was performed by using polymerase chain reaction restriction fragment length polymorphism (PCR-RFLP) method. The results showed that rs4938723 variant significantly increased the risk of PCa in codominant (OR = 1.92, 95% CI = 1.15 - 3.18, p= 0.012, TC vs TT), dominant (OR = 1.99, 95% CI = 1.23 - 3.24, p= 0.005, TC + CC vs TT), and allelic (OR = 1.79, 95% CI = 1.20 - 2.68, p= 0.005, C vs T) inheritance model. Our findings propose that Pri-miR-34 b/c rs4938723 variant may be a risk factor for the development of PCa in a sample of Iranian population. Larger sample sizes with different ethnicities are required to validate our findings.

Laparoscopic Pyelolithotomy in Children Less Than Two Years Old with Large Renal Stones: Initial Series.

PURPOSE: Treatment of pediatric urolithiasis is still on debate. This study was designed to evaluate the safety and efficacy of laparoscopic pyelolithotomy in five children less than two years old. MATERIALS AND METHODS: Five children (less than two years old) with large kidney stones underwent laparoscopic pyelolithotomy. All patients underwent laparoscopic pyelolithotomy via a transperitoneal approach. After medial mobilization of colon and once renal pelvis and ureteropelvic junction were exposed, a longitudinal or circular incision was made on the renal pelvis, depending on the location and shape of the stone. Stones were extracted using an Endobag. Demographic data, size of stones, operation time, duration of hospital stay and stone free rate were assessed. RESULTS: Four boys and a one girl were included in this study. The mean age of patients was 17.6 (range: 13-22) months and the mean duration of operation was 130 (range: 115-145) minutes. The mean size of stone was 24.6 (range: 22-27) mm and the mean duration of hospital stay was 4.4 (range: 4-5) days. Stone free rate was 100%. There was no major complication. CONCLUSION: Even with a small number of patients, our results seem to show that laparoscopic pyelolithotomy could be a treatment option for selected cases of young pediatric cases with large renal stones. We believe that transperitoneal laparoscopic pyelolithotomy is feasible and it introduces a novel approach for managing kidney stones in pediatric population. .

Solo Sonographically Guided PCNL under Spinal Anesthesia: Defining Predictors of Success.

Aim. Sonography has been brought in percutaneous nephrolithotripsy (PCNL) as an adjunct to or substitute for X-ray to restrict radiation exposure. This study was designed to investigate the possible predictors for the success of the solo sonographically guided PCNL. Methods. 148 consecutive cases were prospectively enrolled. All steps of PCNL were performed solely with sonography guidance under spinal anesthesia. Residual stones were evaluated the day after surgery using sonography and plain radiography. Results. The mean age was 46 ± 15 years; 40% of kidneys had hydronephrosis. The mean stone burden was 504 ± 350 mm(2). The mean duration of surgery was 43 ± 21 minutes. The early stone-free rate was 92% in inferior or middle calyceal stones, 89.5% in single pelvic stones, 81.5% in partial staghorn stones, and 61.9% in staghorn stones. The mean residual stone size was 13 ± 8 mm. Logistic regression showed that a lower age and a larger stone burden significantly predicted positive residual stones. Fifteen percent of patients presented with grade I or II and six percent showed grade III complication based on Clavien classification. There was no cases of organ injury or death. Conclusion. Solo ultrasonographically guided PCNL under spinal anesthesia is feasible with an acceptable stone-free rate and complication rate.

X-Ray Free Minimally Invasive Surgery for Urolithiasis in Pregnancy.

PURPOSE: Our goal was to present our experience with ultrasound guided supine or prone percutaneous nephrolithotomy in three pregnant women under spinal anesthesia. MATERIALS AND METHODS: Three pregnant women in the 16th, 20th and 28th weeks of pregnancy presented with symptomatic large renal stone in the first patient and multiple renal stones in the second and third patients which were unresponsive to conventional medical therapy. They requested a definitive stone treatment. The operations were done in November 2012, June 2014 and February 2015. Data was gathered prospectively. All steps of gaining access to the pyelocalyceal system including needle insertion, tract dilation, and Amplatz sheath placement were performed under ultrasonography guidance. Tract was dilated with a single shot technique. The first two procedures were performed in supine position and the third procedure was performed in lateral flank position. RESULTS: Two patients were stone-free postoperatively and one patient had only an asymptomatic 4 mm residual stone. They were discharged on the 2nd postoperative day and had an uneventful postoperative course. No fever, bleeding or renal colic was noticed during postoperative hospitalization. All patients delivered their fetuses at term without any abnormality reported by the examining pediatric specialist after their birth. CONCLUSION: Ultrasonography can be used as an imaging modality guiding all steps of obtaining percutaneous access in pregnant women. Supine or flank ultrasound guided percutaneous nephrolithotomy can be offered to pregnant women in whom conservative measures fail to the patients' wellbeing.

Comparison of safety and efficacy of laparoscopic pyelolithotomy versus percutaneous nephrolithotomy in patients with renal pelvic stones: a randomized clinical trial.

PURPOSE: A randomized clinical trial was designed to compare the efficacy, success rate and surgical complications of percutaneous nephrolithotomy (PCNL) and laparoscopic pyelolithotomy (LP). MATERIALS AND METHODS: Sixty patients with renal pelvic stones larger than 2 cm were randomly divided into two groups of LP and PCNL. All patients were followed up to three months after surgery using renal diethylenetriamine­pentaaceticacid (DTPA) scan and determining the glomerular filtration rate (GFR). RESULTS: Mean operation time (149 ± 31 vs. 107 ± 26 min) and mean hospital stay (3.4 vs. 2.16 days) were significantly higher in LP, but mean hemoglobin drop (0.85 vs. 1.88 g/dL) and the rate of blood transfusion were significantly lower. Stone free rate was 90% and 86.6% for LP and PCNL, respectively (P =.59), while the changes in GFR were not statistically significant 3 days after surgery between two groups. Those in LP group showed better improvement in GFR at three months postoperatively. Improvement of the affected split kidney function was significantly higher in LP group (P =.04). No major complications were observed in both groups according to Clavien grading system. CONCLUSION: PCNL remains the gold standard treatment for most large kidney stones, nevertheless, laparoscopic pyelolithotomy can be considered for selected cases especially in whom maximal preservation of renal function is  necessary. 

Major vascular injury in laparoscopic urology.

BACKGROUND AND OBJECTIVES: Major vascular injury is the most devastating complication of laparoscopy, occurring most commonly during the laparoscopic entry phase. Our goal is to report our experience with major vascular injury during laparoscopic entry with closed- and open-access techniques in urologic procedures. METHODS: All 5347 patients who underwent laparoscopic urologic procedures from 1996 to 2011 at our hospital were included in the study. Laparoscopic entry was carried out by either the closed Veress needle technique or the modified open Hasson technique. Patients' charts were reviewed retrospectively to investigate for access-related major vascular injuries. RESULTS: The closed technique was used in the first 474 operations and the open technique in the remaining 4873 cases. Three cases of major vascular injury were identified among our patients. They were 3 men scheduled for nephrectomy without any history of surgery. All injuries occurred in the closed-access group during the setup phase with insertion of the first trocar. The injury location was the abdominal aorta in 2 patients and the external iliac vein in 1 patient. Management was performed after conversion to open surgery, control of bleeding, and repair of the injured vessel. CONCLUSIONS: Given the high morbidity and mortality rates associated with major vascular injury, its clinically higher incidence in laparoscopic urologic procedures with the closed-access technique leads us to suggest using the open technique for the entry phase of laparoscopy. Using the open-access technique may decrease laparophobia and encourage a higher number of urologists to enter the laparoscopy field.

Delayed postpercutaneous nephrolithotomy hemorrhage: prevalence, predictive factors and management.

OBJECTIVE: The aim of this study was to assess the prevalence, potential risk factors and management of delayed post-percutaneous nephrolithotomy (PCNL) bleeding. MATERIAL AND METHODS: Records of 2512 patients who had undergone PCNL from April 2008 to April 2011 were reviewed retrospectively. The prevalence of delayed post-PCNL hemorrhage and correlation of different variables such as age, body mass index, stone location and burden, surgical approach, type and number of access ports, type of drainage, comorbidities and previous history of stone surgery with postoperative bleeding were assessed. The efficacy of conservative management and need for angioembolization were analyzed. RESULTS: In total, 2304 patients [1562 men (67.8%) and 742 women (32.2%)], with a mean age of 46.4 ± 13.6 years (range 17-86 years), were enrolled in the study. The prevalence of delayed hemorrhage was 2.6% (61 patients) and the mean time to the onset of hemorrhage after PCNL was 5.8 days (range 3-11 days). Of 61 patients presenting with delayed hemorrhage, only 16 patients received a blood transfusion. Eight patients underwent angiography because of uncontrolled bleeding and only three underwent embolization. No significant association was found between other variables and post-PCNL hemorrhage, except for type of drainage, in that tubeless surgery increased the rate of postoperative bleeding. CONCLUSION: Delayed hemorrhage is an uncommon complication following PCNL that can be successfully managed with conservative management; only a few patients will require angiography and then embolization. Tubeless PCNL significantly predicted the occurrence of severe postoperative bleeding.

Is modified retroperitoneal lymph node dissection alive for clinical stage I non-seminomatous germ cell testicular tumor?

PURPOSE: To evaluate efficacy of modified retroperitoneal lymph node dissection (RPLND) in the management of patients with pathological stage (PS) I non-seminomatous germ cell testicular tumor (NSGCT) in a retrospective study. MATERIALS AND METHODS: Between April 2002 and April 2012, 55 patients with clinical stage (CS) I NSGCT had undergone modified RPLND according to Sloan-Kettering modified RPLND template. Clinicopathological parameters, retroperitoneal relapse, and antegrade ejaculation rate were evaluated in patients with PS I. RESULTS: Of 55 patients, 41 (74.5%) and 14 (25.5%) subjects were in PS I and II, respectively. In PS I group, the mean patients' age was 32.8 years (range, 19 to 51 years) at the end of the follow-up period. Three patients missed the follow-up; hence, were excluded from the study. Mean follow-up duration was 56 months (range, 6 to 120 months). Tumor recurrence was identified in no subjects at the end of the follow-up period. Overall peri and postoperative complication rate was 18% (7 patients). Out of 38 patients, 23 (61%) had post RPLND antegrade ejaculation at the end of the study. CONCLUSION: Modified template RPLND is a safe, effective, and sufficient treatment for patients with no retroperitoneal micrometastasis after the procedure. Furthermore, this strategy may obviate the need for close, expensive, and potentially harmful follow-up protocol in patients with PS I NSGCT.