Influence of tract location on the outcomes of endoscopic combined intrarenal surgery: A retrospective analysis of 1000 cases.

OBJECTIVES: This study aimed to investigate the influence of tract location on surgical outcomes in endoscopic combined intrarenal surgery (ECIRS), considering the location of residual stones. METHODS: From January 2015 to December 2021, 1417 consecutive patients underwent ECIRS in three hospitals. After excluding patients with preoperative percutaneous nephrostomy, intended multi-stage procedures, those with a tract in the renal pelvis, and those with multiple tracts, 1000 patients were retrospectively analysed by comparing three groups based on tract location: group 1 (upper calyx), group 2 (middle calyx), and group 3 (lower calyx). A multivariate logistic regression model was implemented to assess whether the tract location independently affected the stone-free status. RESULTS: Patient characteristics were significantly different among the groups in terms of age, stone laterality, presence of calyceal stones, and hydronephrosis. There were no differences in stone-free rate (SFR) among the three groups. Multivariate analysis indicated that the tract location (group 1 or 2 compared with group 3) did not significantly affect the stone-free status (odds ratio = 1.4, 0.9-1.9, p = 0.066). Surgical duration significantly varied among the groups, with the shortest time observed in group 1. Organ injury was observed exclusively in group 1 (1.13%). Residual fragments were predominantly found in the lower calyx, with the calyx associated with the tract being the second most common location. CONCLUSIONS: Tract location does not significantly affect SFR. To improve the SFR, observation of the lower calyx and tract placement is important.

Models to predict the surgical outcome of mini-ECIRS (endoscopic combined intrarenal surgery) for renal and/or ureteral stones.

To establish a safer and more efficient treatment strategy with mini-endoscopic combined intrarenal surgery (ECIRS), the present study aimed to develop models to predict the outcomes of mini-ECIRS in patients with renal and/or ureteral stones. We retrospectively analysed consecutive patients with renal and/or ureteral stones who underwent mini-ECIRS at three Japanese tertiary institutions. Final treatment outcome was evaluated by CT imaging at 1 month postoperatively and stone free (SF) was defined as completely no residual stone or residual stone fragments ≤ 2 mm. Three prognostic models (multiple logistic regression, classification tree analysis, and machine learning-based random forest) were developed to predict surgical outcomes using preoperative clinical factors. Clinical data from 1432 ECIRS were pooled from a database registered at three institutions, and 996 single sessions of mini-ECIRS were analysed in this study. The overall SF rate was 62.3%. The multiple logistic regression model consisted of stone burden (P < 0.001), number of involved calyces (P < 0.001), nephrostomy prior to mini-ECIRS (P = 0.091), and ECOG-PS (P = 0.110), wherein the area under the curve (AUC) was 70.7%. The classification tree analysis consisted of the number of involved calyces with an AUC of 61.7%. The random forest model showed that the top predictive variable was the number of calyces involved, with an AUC of 91.9%. Internal validation revealed that the AUCs for the multiple logistic regression model, classification tree analysis and random forest models were 70.4, 69.6 and 85.9%, respectively. The number of involved calyces, and a smaller stone burden implied a SF outcome. The machine learning-based model showed remarkably high accuracy and may be a promising tool for physicians and patients to obtain proper consent, avoid inefficient surgery, and decide preoperatively on the most efficient treatment strategies, including staged mini-ECIRS.

Impact of Vacuum-Assisted Mini-Endoscopic Combined Intrarenal Surgery for Staghorn Stones: Analysis of Perioperative Factors of Postoperative Fever and Stone-Free Status.

Background and Objective: This retrospective cohort study aimed to evaluate the clinical outcomes of vacuum-assisted mini-endoscopic combined intrarenal surgery (vmECIRS) for staghorn stones. Patients and Methods: We analyzed a total of 61 cases treated with initial vmECIRS using 14F/16F ClearPetra® percutaneous sheaths for staghorn stones. We primarily measured complications and stone-free rates (SFRs) to evaluate the safety and efficiency of vmECIRS. In addition, pre- and intraoperative factors in patients who experienced postoperative fever >38°C and achieved an initial stone-free status were evaluated. Results: The percentages of staghorn stones were 36.1% and 63.9% for complete and partial stones, respectively. The median stone volume was 8.48 cm3. The median operation time was 117 minutes, and the mean number of procedures was 1.54. Regarding postoperative complications, postoperative fever >38°C was reported in 18 patients (29.5%). The initial and final SFRs were 50.8% and 91.8%, respectively. Among patients with emerging fever >38°C, positive urine culture was the only significant risk factor in the multivariate analysis (odds ratio [OR], 7.500; 95% confidence interval [CI], 1.772-31.751; p = 0.006). Moreover, for achieving initial stone-free status, body mass index and stone volume were significant risk factors in the multivariate analysis (OR, 0.872; 95% CI, 0.776-0.980; p = 0.021; and OR, 0.882; 95% CI, 0.784-0.994; p = 0.039, respectively). Conclusions: These findings suggest that vmECIRS is safe and effective for treatment of staghorn stones. Although current guidelines suggest that percutaneous nephrolithotomy is the gold standard surgical technique for staghorn stones, vmECIRS could also be a treatment strategy. The Clinical Trial Registration number (ID: 2022-05-17-1).

Pelvicalyceal anatomy on the accessibility of reusable flexible ureteroscopy to lower pole calyx during retrograde intrarenal surgery.

OBJECTIVE: This study aimed to evaluate the pelvicalyceal anatomy on accessibility of reusable flexible ureteroscopy (fURS) to the lower pole calyx during retrograde intrarenal surgery (RIRS). METHODS: Here, 854 patients with ureteral or kidney stones with access to a renal collecting system using reusable fURS were classified into either the accessible group, in whom the deepest lower pole calyces could be touched; and the inaccessible group, in whom the deepest lower calyces could not be touched. We measured the infundibulopelvic angle (IPA), infundibular width (IW), infundibular length (IL), and calyceal pelvic height (CPH) using retrograde pyelograms and performed intergroup comparisons. RESULTS: The median IPA, IW, IL, and CPH in the accessible and inaccessible group were 60.5° and 45.6° (p < 0.001), 10.8 and 9.4 mm (p < 0.001), 33.2 and 36.4 mm (p < 0.001), and 25.9 and 30.9 mm (p < 0.001), respectively. IPA (OR 0.963, 95% CI 0.952-0.974, p < 0.001) and IW (OR 0.519, 95% CI 0.331-0.816, p = 0.004) were significant risk factors of renal pelvicalyceal anatomy related to the accessibility of the lower pole calyces. The cut-off value for IPA and IW was 45.8°(p < 0.001) and 7.8 mm (p < 0.001), respectively. CONCLUSIONS: IPA < 45.8° and IW <7.8 mm were negative predictors to access the lower pole calyces when using reusable fURS during RIRS.

Primary impact of simultaneous use of double devices through one-working channel when performing flexible ureteroscope with ureteral access sheath for single ureteral stone: In bench and retrospective clinical study.

OBJECTIVES: This study aimed to compare the simultaneous use of two devices versus a single device through a single working channel in flexible ureteroscopy using a ureteral access sheath for single ureteral stones. METHODS: In a bench study, the time to (i) set laser fiber, (ii) exchange laser fiber and nitinol basket through working channel, and (iii) pull out the device from working channel were measured 10 times in each step. In a clinical study, 156 patients who underwent flexible ureteroscopy with a ureteral access sheath for a ureteral stone in middle and upper ureter between April 2019 and November 2021 were assessed. One device was used at a time for 79 patients (S-Group) and two were simultaneously used for 77 (D-Group). Surgical outcomes and complications were compared. RESULTS: In the bench study, the mean time to change from laser fiber to basket and from basket to laser fiber through the working channel were 26.1 ± 3.7 s and 23.6 ± 2.0 s (p = 0.084), respectively, which were significantly longer than the laser setup time (p < 0.001). In the clinical study, although the stone-free rate was not significantly different between the groups (S-Group 89.8%, D-Group 93.5%; p = 0.412), the median operation time was significantly shorter (p < 0.001) and the rate of postoperative stenting was significantly lower (p = 0.002) in the D-Group. There were no significant between-group differences in intra- and post-operative complications. CONCLUSION: The simultaneous use of two devices through a single working channel is safe and could help save the time needed to exchange the laser fiber and nitinol basket.

Efficiency of novel shielding curtains combined with pulsed irradiation for reducing radiation exposure in an operating room: Human renal collecting system phantom study.

OBJECTIVE: To evaluate the impact of novel shielding curtains combined with pulsed irradiation mode to protect medical radiation workers from radiation exposure during ureteroscopy. METHODS: 0.25 mm Pb equivalent novel shielding curtains were mounted to the caudal and bilateral sides of the operating table in the ureteroscopy setting. C-arm was positioned as per normal in the operating room with the X-ray tube under the patient table. A water-filled anthropomorphic renal collecting system phantom was positioned in the standard position on the operating table that was set at a height of 100 cm. The ionization chambers were also positioned at a height of 100 cm and set in eight positions. We took measurements at distances of 50, 100, 150, and 200 cm from the phantom with the focus directed toward the X-ray tube. We measured the spatial distribution of the scattered radiation dose in four combinations: (1) continuous irradiation mode without novel shielding curtains; (2) pulsed irradiation mode (11 films per second) without novel shielding curtains; (3) continuous irradiation mode with novel shielding curtains; and (4) pulsed irradiation mode with novel shielding curtains. Continuous or pulsed irradiation was activated for 30 s each time. RESULTS: Pulsed irradiation mode with novel shielding curtains was a significantly more efficient method than other combinations to reduce scattered radiation exposure in this study (P < 0.001). There was approximately a 95% reduction in scattered radiation exposure with the pulsed irradiation mode with novel shielding curtains set up as compared with continuous irradiation mode without novel shielding curtains. CONCLUSION: Combining a novel shielding curtain and using a low pulse radiation setting can greatly reduce radiation exposure during ureteroscopic procedures.

Evaluating Predictive Factor of Systemic Inflammatory Response Syndrome and Postoperative Pain in Patients Without Ureteral Stent Placement After Ureteral Access Sheath Use in Flexible Ureteroscopy for Stone Management.

Background and Objective: This retrospective cohort study aimed to evaluate the safety of stentless flexible ureteroscopy (fURS) using a ureteral access sheath (UAS) for stone management. Patients and Methods: A total of 270 ureteral stentless postoperative patients were analyzed. Stentless indication was characterized by having no ureteral wall or mucosa injury with only slight erosion, <1 hour operative time, and no endoscopic stone fragments with or without stone dust. Postoperative complications and pain were analyzed for safety measurements. In addition, preoperative and intraoperative risk factors associated with the incidence of systemic inflammatory response syndrome (SIRS) and postoperative pain were evaluated. Results: The most common UAS sizes were 10/12F (69.6%) and 9.5/11.5F (28.1%). The rate of patients who were stone free was 95.9%. The median operation time was 34 minutes. Only three grade 1 ureteral injuries occurred intraoperatively. Postoperative SIRS occurred in 8.8% of patients, and postoperative use of analgesics was 35.9%. Only four patients were required to undergo eventual ureteral stenting. Less than 10/12F UAS was the only factor positively associated with preventing postoperative SIRS (odds ratio [OR], 4.733; 95% confidence interval [CI], 1.085-20.644). Older age and preoperative ureteral stenting were positively associated with preventing postoperative pain (OR, 0.970; 95% CI, 0.951-0.990 and OR, 0.427; 95% CI, 0.232-0.786; respectively). Conclusion: Stentless fURS with UAS in stone management was feasible for selected patients. UAS size of <10/12F, older age, and preoperative stenting are possible keystones to achieving stentless fURS with UAS postoperatively. IRB approval number; 20216101.

Single-Session Impact of High-Power Laser with Moses Technology for Lower Pole Stones in Retrograde Intrarenal Surgery: Retrospective Study.

Background: This study aimed to evaluate the efficacy of a high-power holmium laser with Moses technology (MT) for the treatment of lower pole stones during retrograde intrarenal surgery (RIRS). Methods: Herein, 305 patients with lower pole stones who underwent RIRS using a high-power holmium laser with MT were retrospectively classified into the stone-free (SF) and non-SF groups. We measured the stone burden, stone volume, stone hardness, pre- or post-operative stent placement, infundibulopelvic angle (IPA), infundibular width (IW), infundibular length (IL), and calyceal pelvic height in terms of pelvicalyceal anatomy using retrograde pyelograms and evaluated the predictive factors of postoperative SF. Results: A total of 173 (56.7%) and 229 (75.1%) patients achieved a SF status on postoperative day one and at one month, respectively. Operation time in the SF group was shorter than that in the non-SF group (51.0 vs. 74.5 min). There were no significant differences in postoperative complications between the SF and non-SF groups. Significantly predictive risk factors in postoperative SF included total stone volume (odds ratio (OR), 1.056; 95% CI, 1.015-1.099; p = 0.007), IPA (OR, 0.970; 95% CI, 0.956-0.993; p = 0.009), and IW (OR, 0.295; 95% CI, 0.121-0.718; p = 0.007). The cut-off values of stone volume, IPA, and IW were 515.2 mm3, 46.8°, and 7.75 mm, respectively. Conclusions: A high-power holmium laser with MT in lower pole stones is a valuable option for positive outcomes and patient's safety. Larger stone volume, acute IPA, and narrow IW were negative predictors related to postoperative SF status.

Change in irrigation flow through a flexible ureteroscope with various devices in the working channel: Comparison between an automatic irrigation pump and gravity-based irrigation.

OBJECTIVES: To evaluate the change in the irrigation flow with various instruments in the working channel of a flexible ureteroscope by two automatic irrigation pumps and gravity-based irrigation in an ex vivo setting. METHODS: We used two automatic irrigation pumps: the Endoflow II and the UROMAT Endoscopic Automatic System for Irrigation and gravity-based irrigation. A flexible ureteroscope was connected to an irrigation tube with a working channel. The other side of the irrigation tube was attached to each automatic irrigation pump, which was connected with a 2-L saline bag or to a 2-L saline bag directly in case of gravity pressure. The flow volume from the working channel was measured three times for 30 s at various irrigation pressure settings, both when the working channel was unoccupied and occupied with various instruments. RESULTS: The irrigation flow steadily increased as the irrigation pressure in the automatic irrigation pumps increased and the saline position in gravity became higher (P < 0.05). However, the flow decreased as the size of the instrument in the working channel increased (P < 0.05). The efficiency of irrigation flow in gravity-based irrigation under the same pressure is significantly lower than one of two automatic irrigation pumps (P < 0.05). However, there was no significant difference in the efficiency of the irrigation flow between the Endoflow II and UROMAT Endoscopic Automatic System for Irrigation. The irrigation pressure setting needed to change to maintain adequate irrigation flow when using various working tools. CONCLUSIONS: The efficiency of irrigation flow in gravity-based irrigation is significantly lower than one of two automatic irrigation pumps. The irrigation flow decreases as the size of the instrument in the working channel increases.

Possible correlation of sonic hedgehog signaling with epithelial-mesenchymal transition in muscle-invasive bladder cancer progression.

PURPOSE: To investigate the role of sonic hedgehog (Shh) signaling and epithelial-mesenchymal transition (EMT) in bladder cancer progression and invasion. METHODS: We cultured three bladder cancer cell lines, muscle-invasive T24 and 5637, and non-muscle-invasive KK47, in the presence of a recombinant-Shh (r-Shh) protein or cyclopamine, a Shh signaling inhibitor, to investigate proliferation and expression of EMT markers. Wound-healing assays and transwell assay were performed to evaluate cell invasion and migration. Mice were then inoculated with bladder cancer cells and treated with cyclopamine. Mouse tumor samples were stained for Shh signaling and EMT markers. RESULTS: R-Shh protein enhanced cell proliferation, whereas cyclopamine significantly suppressed cell proliferation, especially in invasive cancer (5637 and T24) (p < 0.05). R-Shh protein promoted EMT, suppressed E-cadherin and enhanced N-cadherin and vimentin and Gli1, an Shh downstream molecule, while cyclopamine blocked EMT, especially in 5637 and T24. Cyclopamine also inhibited cell invasion and migration in vitro. In the animal study, intraperitoneal injection of cyclopamine significantly suppressed tumor growth in 5637 and T24 in mice (p = 0.01 and p = 0.004, respectively) and slightly suppressing KK47 tumor growth (p = 0.298). Significant cyclopamine-induced suppression of Gli1 in 5637 and T24 mouse tumors (both p = 0.03) was seen, suggesting that muscle-invasive bladder cancer may be more dependent on Shh signaling than non-muscle-invasive bladder cancer. CONCLUSIONS: Shh signaling and EMT were especially enhanced in muscle-invasive bladder cancer progression and invasion, and suppressed by the inhibition of Shh signaling.

Protocol for a comparison study of 1-day (single dose) versus 2-day prophylactic antibiotic administration in Holmium Laser enucleation of the prostate (HoLEP): a randomized controlled trial.

Background: The best method of antimicrobial prophylaxis administration for surgical site infection (SSI) in transurethral holmium laser resection and enucleation of the prostate (HoLEP)/bipolar transurethral enucleation (TUEB) remains controversial. The purpose of this study is to compare one-day and two-day cefazolin in a randomized 2 nd-phase study to help establish a protocol with a 95% confidence interval (CI) for SSI prevention. Methods: Patients undergoing HoLEP/TUEB for benign prostate hyperplasia without preoperative pyuria will be enrolled and randomized to receive prophylactic antibiotic administration for HoLEP/TUEB in two groups, 1-day cefazolin and 2-day cefazolin. The primary endpoint is the occurrence rate of postoperative urinary tract infection or urogenital infection within 30 days after HoLEP/TUEB with a statistical 95% CI in comparison between those groups. Secondary outcomes include the kind of infectious disease and evidence of diagnosis, day of diagnosis of infectious disease, performance of urine or blood culture, detection of bacteria, treatments, duration of treatments, AEs other than surgical site infection, and drug-induced AEs. Discussion: The results of this study will provide evidence for defining the optimal duration of cefazolin prophylactic antibiotic administration for SSI. Trial registration: This study was registered in the University Hospital Medical Information Network-Clinical Trial Registry ( UMIN000027955) based on recommendations from the International Committee of Medical Journal Editors (ICMJE) on July 1 st 2017.

Successful percutaneous flexible ureteroscopy for treatment of distal ureteral stones under modified Valdivia position after Cohen reimplantation.

INTRODUCTION: Endoscopic retrograde access to the upper urinary tract after Cohen reimplantation for the treatment of vesicoureteral reflux in children is usually difficult. CASE PRESENTATION: We experienced a case involving a few large ureteral stones in the right distal ureter after Cohen reimplantation. We initially failed retrograde access using flexible cystoscope. Therefore, we performed antegrade flexible ureteroscopy through the 10- to 12-Fr access sheath from the middle calyx to treat the few ureteral stones (>1.5 cm) in the right ureter with the patient in the modified Valdivia position. This one-stage procedure was successful. The patient achieved a stone-free status without major complications. CONCLUSION: The herein-described approach that was implemented after Cohen reimplantation was successful. We believe that recent endourologic developments contributed to the good outcome in this case.

Bacteremia complicating urinary tract infection by Pseudomonas aeruginosa: Mortality risk factors.

OBJECTIVES: To examine the clinical risk factors for death within 30 days of diagnosis of Pseudomonas aeruginosa-causing bacteremia after a urinary tract infection. METHODS: A total of 62 patients with Pseudomonas aeruginosa isolated from both urine and blood at the same episode from January 2009 to December 2016 were enrolled in the present study. We retrospectively investigated clinical risk factors for death by comparison between surviving patients and those who died within 30 days after diagnosis of P. aeruginosa bacteremia. The comparison for risk factors for bacteremia-related death included 31 categories, such as age, laboratory data, underlying diseases, clinical history, history of surgery, care in the intensive care unit, P. aeruginosa susceptibility to the antibiotics used at the time of bacteremia diagnosis and consultation with urological department. RESULTS: The study included 48 men and 14 women aged 71.3 ± 10.4 years. Nine patients (14.5%) died of P. aeruginosa bacteremia. Statistical analysis showed that non-survivors had significantly lower albumin levels than survivors (2.07 ± 0.62 vs 2.62 ± 0.65; P = 0.023). The non-survivors had significantly higher rates of ventilator use, history of heart disease, septic shock and lower rates of consultation with urological departments after diagnosis (P < 0.05). CONCLUSIONS: Patients with bacteremia complicating urinary infection by P. aeruginosa have a low death rate. Earlier intervention by urologists might improve patients' outcome. Lower albumin levels, ventilator use, history of heart disease and septic shock are factors associated with higher mortality rate.

Comparison between non-septic and septic cases in stone-related obstructive acute pyelonephritis and risk factors for septic shock: A multi-center retrospective study.

PURPOSE: This study assessed risk factors for septic shock in patients with obstructive acute pyelonephritis (APN) associated with upper urinary tract calculi in a multi-center retrospective study. METHODS: We studied 143 patients admitted to 4 hospitals in Japan with obstructive APN associated with upper urinary tract calculi. Data on gender, age, hypertension, diabetes, neurological disease or malignant disease, laboratory data (white blood cell (WBC) and C-reactive protein (CRP)), drainage, and bacterial strains including Escherichia coli in the non-septic and septic groups were collected. Risk factors for septic shock were analyzed by univariate and multivariate statistical analyses. RESULTS: There were a total of 107 non-septic cases (74.8%) and 36 septic cases (25.2%). The commonest strains of urinary tract infection-causative bacteria were E. coli in the non-septic group (23 cases, 21.5%) and septic group (13 cases, 36.1%) (p > 0.05). Emergency drainage was administered in 74.8% of the non-septic group and 97.2% of the septic group (p > 0.05). Meropenem was most often used as the initial treatment in the non-septic group (20 cases, 18.7%) and septic group (22 cases, 61.1%) (p < 0.0001). Risk factors for septic shock in multivariate analyses were diabetic mellitus (odds ratio (OR) = 3.591, p = 0.0098) and CRP ≥ 10 (OR = 1.057, p = 0.0119) as significant independent factors in this multicenter study. CONCLUSIONS: APN is a common infectious disease, especially in the cases with urinary tract obstruction where patients easily acquire bacteremia or sepsis. Stone-associated obstructed APN can cause fatal septic shock in cases with diabetes and CRP ≥ 10. Further prospective studies will be undertaken to draw definitive conclusions.

Reactive oxygen species-mediated switching expression of MMP-3 in stromal fibroblasts and cancer cells during prostate cancer progression.

Studies on the aberrant control of extracellular matrices (ECMs) have mainly focused on the role of malignant cells but less on that of stromal fibroblasts during cancer development. Herein, by using paired normal and prostate cancer-associated stromal fibroblasts (CAFs) derived from a coculture cell model and clinical patient samples, we demonstrated that although CAFs promoted prostate cancer growth, matrix metalloproteinase-3 (MMP-3) was lower in CAFs but elevated in prostate cancer cells relative to their normal counterparts. Furthermore, hydrogen peroxide was characterized as the central modulator for altered MMP-3 expression in prostate cancer cells and CAFs, but through different regulatory mechanisms. Treatment of CAFs but not prostate cancer cells with hydrogen peroxide directly inhibited mmp-3 promoter activity with concomitant nuclear translocation of nuclear factor-κB (NF-κB), indicating that NF-κB is the downstream pathway for the transcriptional repression of MMP-3 in CAFs. Hydrogen peroxide reduced thrombospondin 2 (an MMP-3 suppressor) expression in prostate cancer cells by upregulating microRNA-128. To the best of our knowledge, this is the first study to demonstrate the crucial role of reactive oxygen species in the switching expression of MMP-3 in stromal fibroblasts and prostate cancer cells during tumor progression, clarifying how the tumor microenvironment modulates ECM homeostasis control.

Does Surgeon Experience Affect Operative Time, Adverse Events and Continence Outcomes in Holmium Laser Enucleation of the Prostate? A Review of More Than 1,000 Cases.

PURPOSE: Holmium laser enucleation of the prostate has become an increasingly common surgical therapy for benign prostatic hyperplasia. However, the relationship between surgeon experience and surgical outcomes has not yet been fully investigated. In this study we investigated how surgeon experience with holmium laser enucleation of the prostate affected operative time, adverse events and outcomes related to urination. MATERIALS AND METHODS: We gathered a total of 1,113 cases of holmium laser enucleation of the prostate from 5 hospitals in Hyogo Prefecture, Japan. Included were data on surgeon experience with the procedure, operative time, enucleation time, morcellation time, patient age, perioperative and postoperative surgery related complications, and outcomes related to urination. RESULTS: A total of 39 surgeons were included in analysis. Statistical data showed that increasing surgical experience significantly contributed only to surgical time, enucleation time and urinary incontinence after holmium laser enucleation (p = 0.0146, 0.0216 and 0.0405, respectively). No significant changes were seen postoperatively in surgery related factors such as morcellation time, resected prostate volume, infectious or noninfectious surgery related complications, or urination related outcomes (p >0.05) Experience with at least 20 cases in particular affected surgical time (p = 0.0050), enucleation time (p = 0.0068) and urinary incontinence after holmium laser enucleation (p = 0.0021). CONCLUSIONS: Surgeon experience contributed to shortened operative time and enucleation time, and to decreased postoperative urinary incontinence but not to surgery related complications or urination related outcomes as shown by maximum urine flow and post-void residual urine volume. We also found that experienced surgeons with 31 to 50 cases might be associated with complications after holmium laser enucleation in larger prostate cases. Based on these data further prospective studies are scheduled to establish a program for training in holmium laser enucleation of the prostate.

Shock due to urosepsis: A multicentre study.

INTRODUCTION: Urosepsis is a severe infection that can cause shock afterwards. The purpose of this study is to investigate the clinical and bacterial risk factors for shock in those cases with urosepsis caused by urinary tract infection in a multicentre study. METHODS: Our study included 77 consecutive urosepsis cases from four hospitals. We examined factors such as patient characteristics, underlying disease, serum white blood cell (WBC) count, platelet count, C-reactive protein (CRP) level at the time of diagnosis of urosepsis, urinary tract occlusion, causative bacteria, and bacterial antibiotic susceptibilities. Statistical analyses were performed to assess the potential risk factors for shock during the clinical course of urosepsis by a multivariate analysis. RESULTS: We had 38 male and 39 female patients aged 25-104 (median 73). Underlying diseases included cancers (n=22, 28.6 %) and diabetes mellitus (n=17, 22.1 %). Positive blood culture was seen in 74 cases; these involved 88 bacterial strains, of which Escherichia coli was the most common (34 strains, 38.6 %). There were 31 cases with shock (40.3 %) and multivariate analyses demonstrated that serum CRP was the only clinical risk factor for shock due to urosepsis. CONCLUSIONS: Our study demonstrated that serum CRP was a risk factor for shock during urosepsis in a multicentre analysis. Further prospective studies with a greater number of patients are needed to draw more definitive conclusions.

Should We Change the Initial Treatment of Renal or Retroperitoneal Abscess in High Risk Patients?

INTRODUCTION: This study examined the risk factors for initial treatment failure in renal or retroperitoneal abscess as a multicenter study. MATERIALS AND METHODS: This retrospective analysis investigated consecutive patients with renal or retroperitoneal abscess who were hospitalized in Japan. The outcomes of these patients were classified into "cured" and "failure or recurrence." The potential clinical risk factors examined were abscess size, diabetes mellitus, major organ failure, laboratory data, fever, drainage, and causative organisms, for instance. RESULTS: Of the 74 patients, 40 (54.1%) were diagnosed with renal abscess and 34 (45.9%) with retroperitoneal abscess, 51 (68.9%) were cured by initial treatments, and 23 (31.1%) underwent failure or relapse; 33 (44.6%) were men and 41 (55.4%) were women. In detail, 36 patients were cured by conservative therapy only. Our multivariate analysis data showed that renal failure was the only significant factor for initial treatment failure (p = 0.0281). CONCLUSIONS: Our multivariate analysis showed that renal failure was a significant risk factor for initial treatment failure or recurrence.

Postoperative wound dealing and superficial surgical site infection in open radical prostatectomy.

The number of open radical prostatectomy (RP) surgeries has been decreasing owing to the spread of laparoscopic and robotic surgery, which has implications for postoperative wound healing. The purpose of this study was to investigate and document the current status of postoperative wound healing and superficial surgical site infection (SSI) in open RPs. One hundred and seventy-five antegrade RPs with the same or similar kinds of prophylactic antibiotic administration were divided into two groups: (i) 'no intervention' (wound covering group) and (ii) 'washing', using a washing solution from the second postoperative day to the day of skin staple removal (wound washing group). We compared these groups for the occurrence of superficial SSI. The wound covering group had three (3·03%) cases of superficial SSI, with one case caused by methicillin sensitive Staphylococcus aureus (MSSA). The wound washing group had nine (11·8%) cases of superficial SSI, with three cases caused by MSSA, two cases caused by methicillin resistant Staphylococcus aureus (MRSA) and one by Pseudomonas aeruginosa. The wound covering group showed a significantly lower ratio of superficial SSI (P = 0·0472). In conclusion, the postoperative wound status data in this study suggests that no wound intervention after RP resulted in a comparatively lower ratio of superficial SSI than in the wound washing group.