A single day fasting may increase emergency room visits due to renal colic.

We aimed to explore whether a single-day of fasting (SDF) increase emergency room (ER) visits due to renal colic (RC). We elected to concentrate on Yom-Kippur (i.e.: SDF), the holiest day in Judaism. Food and liquid consumption is prohibited during this day for 25 h, and an estimated 50-70% fasting rate is observed. SDF always takes place between mid-September and mid-October during which the temperature in the Middle-East ranges between 19 and 30 °C. ER visits for RC between 01/2012 and 11/2019 were reviewed, and the Gregorian days on which SDF occurred were retrieved. The number of ER visits for RC was compared between SDF and the surrounding days/months as well as to another single-day "standard" holiday (SDSH) that precedes SDF in 10 days and is not associated with fasting. Of 11,717 ER visits for RC, 8775 (74.9%) were males. Male:Female ratio was 3:1. The mean daily number of ER visits for RC during the 3 days following SDF was 6.66 ± 2.49, significantly higher compared with the mean annual daily visits (4.1 ± 2.27, p < 0.001), the mean daily visits during the week prior to SDF (5.27 ± 2.656, p = 0.032), and the mean daily visits during September (5.06 ± 2.659, p = 0.005), and October (4.78 ± 2.23, p < 0.001). The mean number of ER daily visits for RC during the 3 days following SDSH, 5.79 ± 2.84, did not differ compared with the mean daily visits during September and October (p = 0.207; p = 0.13, respectively). It was lower compared to SDF, however statistically insignificant (p = 0.285). A single-day fasting may increase ER visits for RC. The mechanism underlying this phenomenon is unknown.

The Impact of Dietary Modifications and Medical Management on 24-Hour Urinary Metabolic Profiles and the Status of Renal Stone Disease in Recurrent Stone Formers.

BACKGROUND: Dietary modifications and patient-tailored medical management are significant in controlling renal stone disease. Nevertheless, the literature regarding effectiveness is sparse. OBJECTIVES: To explore the impact of dietary modifications and medical management on 24-hour urinary metabolic profiles (UMP) and renal stone status in recurrent kidney stone formers. METHODS: We reviewed our prospective registry database of patients treated for nephrolithiasis. Data included age, sex, 24-hour UMP, and stone burden before treatment. Under individual treatment, patients were followed at 6-8 month intervals with repeat 24-hour UMP and radiographic images. Nephrolithiasis-related events (e.g., surgery, renal colic) were also recorded. We included patients with established long-term follow-up prior to the initiation of designated treatment, comparing individual nephrolithiasis status before and after treatment initiation. RESULTS: Inclusion criteria were met by 44 patients. Median age at treatment start was 60.5 (50.2-70.2) years. Male:Female ratio was 3.9:1. Median follow-up was 10 (6-25) years and 5 (3-6) years before and after initiation of medical and dietary treatment, respectively. Metabolic abnormalities detected included: hypocitraturia (95.5%), low urine volume (56.8%), hypercalciuria (45.5%), hyperoxaluria (40.9%), and hyperuricosuria (13.6%). Repeat 24-hour UMP under appropriate diet and medical treatment revealed a progressive increase in citrate levels compared to baseline and significantly decreased calcium levels (P = 0.001 and 0.03, respectively). A significant decrease was observed in stone burden (P = 0.001) and overall nephrolithiasis-related events. CONCLUSIONS: Dietary modifications and medical management significantly aid in correcting urinary metabolic abnormalities. Consequently, reduced nehprolithiasis-related events and better stone burden control is expected.

[THE EFFICACY OF ENDOSCOPIC DUAL LASER TREATMENT FOR LOW GRADE UPPER TRACT UROTHELIAL CARCINOMA].

INTRODUCTION: Until recently, radical nephroureterectomy was considered the gold standard treatment for upper tract urothelial carcinoma (UTUC). Post-operative complications, long-term adverse effects of nephrectomy as well as the risk of contralateral recurrence have led to the development of nephron-sparing techniques. OBJECTIVES: To evaluate the safety, complication rate, and oncologic outcomes of ureteroscopic nephron-sparing treatment for low-grade UTUC utilizing a hybrid laser system that incorporates two types of lasers: Nd:YAG and Ho:YAG. METHODS: We reviewed the files of patients who underwent ureteroscopic treatment for UTUC with the hybrid laser system between the years 2014-2018. Only cases of low-grade UTUC and follow-up time of at least 6 months were included in the present study. The following were analyzed: demographic data, tumor histologic characteristics, peri-operative complications, histologic upgrade, oncologic outcomes (i.e: local recurrence, local spread, metastatic progression). RESULTS: A total of 38 patients, who underwent 74 ureteroscopies, met inclusion criteria. Mean tumor size was 16.2 mm. No intra-operative complications were recorded. Two post-operative complications were recorded in one patient - hematuria and retroperitoneal bleeding - both had been treated conservatively. Mean follow-up time was 21.8 months. Local recurrence rate was 73%. Histologic upgrade has been observed in two patients. Four patients (10.5%) were referred to radical nephroureterectomy. There were no cases of local spread, distant metastases or death during the follow-up period. DISCUSSION: Endoscopic dual-laser treatment for low-grade UTUC is safe, surgically feasible and associated with good short-term oncologic outcome. Patient selection and strict follow-up are mandatory.

[A COMPARISON BETWEEN TWO POTASSIUM CITRATE REGIMENS FOR THE TREATMENT OF NEPHROLITHIASIS].

BACKGROUND: UROCIT-K is a potassium-citrate regimen prescribed for the prevention of kidney stone formation. In 2013, K-CITEK was introduced to the local market as a new potassium-citrate regimen that reduces kidney stone formation in a declared rate of 93. OBJECTIVES: We sought to explore the efficacy of K-CITEK versus UROCIT-K. METHODS: A prospective database of patients treated with potassium-citrate regimens for nephrolithiasis has been reviewed. Patients were divided into two groups: those who were treated with UROCIT-K only (Group 1) and those who were treated with K-CITEK only (Group 2). The two groups were compared as regards to demographics, length of follow-up, urinary citrate level and stone burden changes, as well as the number of stone events (i.e: colic, surgery) throughout the follow-up period. In a separate analysis another group (Group 3) was checked. This group consisted of patients who were initially treated with UROCIT-K and later on were switched to K-CITEK. RESULTS: The study group consisted of 104 patients: 54 patients in Group 1, 38 in group 2 and 12 in group 3. The latter was omitted from analysis due to the small size. Groups 1 and 2 resembled in their demographic data and medical comorbidities. No statistically significant differences were found in terms of change in urinary citrate levels, stone burden or recurrent stone events. CONCLUSIONS: K-CITEK for the treatment of kidney stone prevention was found to be as equally effective as UROCIT-K in terms of increasing urinary citrate levels, reducing stone burden and maintaining the intervals between kidney stone events.

24-h urine metabolic profile: is it necessary in all kidney stone formers?

PURPOSE: A 24-h urine metabolic profile (24-UMP) is an integral part of nephrolithiasis work-up. We aimed to explore whether it can be waived under certain circumstances. MATERIALS AND METHODS: We reviewed our prospective registry database of patients seen at our outpatient clinic for nephrolithiasis between the years 2010 and 2017. Data included: gender, age at first stone, body mass index (BMI), self-reported comorbidities and family history of nephrolithiasis. A 24-UMP was obtained from each patient under random diet. The following were recorded: urine volume, urinary levels of sodium, calcium, uric acid, oxalate and citrate. Presence of at least one comorbidity (i.e., hypertension/diabetes/hyperlipidemia) was defined as "associated comorbidities" (AC). Their absence was defined as "no comorbidities" (NC). Subjects were divided into two subgroups: first-time and recurrent stone formers, which were further divided into two subgroups: 1st + AC; 1st + NC; recurrent + AC; recurrent + NC. 24-UMPs have been compared between the four groups. RESULTS: Four hundred and fifty-seven patients were included in the study. In the AC groups, patients demonstrated higher BMI levels (p = 0.001), and were statistically significantly obese (BMI > 30, p = 0.001) and older at first stone event (p = 0.001). First formers, either with AC or NC were more likely to have low urine volume (LUV) compared with recurrent formers (72.5 vs. 59.5%, p = 0.005). In the remaining metabolic abnormalities, no such differences were observed. CONCLUSIONS: First-time stone formers, either with or without AC are likely to demonstrate LUV as their primary metabolic abnormality in 24-UMP. Therefore, 24-UMP may be postponed until recurrent stone event.

Nephrolithiasis in Israel: Epidemiological Characteristics of Return Patients in a Tertiary Care Center.

BACKGROUND: The prevalence and etiology of nephrolithiasis vary, depending on geography, gender and ethnicity. OBJECTIVES: To analyze the demographic data of return nephrolithiasis patients in a tertiary care center. METHODS: We retrospectively reviewed our prospective registry database of return patients seen at our outpatient clinic for nephrolithiasis. Data included gender, age at first visit, age at first stone event, body mass index (BMI), self-reported hypertension, diabetes mellitus (DM), and hyperlipidemia. All patients were seen at least twice and had undergone a metabolic workup. RESULTS: A total of 260 return patients were seen during the period 2010-2015. The male:female ratio was 3.1:1. Mean age at the first stone event was 44.1 years. Median time elapsed since the first stone event to medical evaluation was 5 years (interquartile range 1-12 years). Hypertension was reported by 33.1% of the patients, DM by 23.5% and hyperlipidemia by 30.4%. All three diseases were reported by 11.5% of patients. The metabolic abnormalities detected were hypocitraturia (60%), low urine volume (LUV) (60%), hypercalciuria (40.8%), hyperoxaluria (24.2%), hyperuricosuria (16.5%) and hyperuricemia (13.5%). Stone compositions from most to least frequent were calcium-oxalate (81%), calcium-phosphate (11.9%) and uric acid (7.1%). We also found that 24.6% were obese (BMI ≥ 30 kg/m2) and showed higher rates of hypertension, DM, hyperlipidemia, hyperuricemia and hyperuricosuria compared with non-obese patients. Significantly higher rates of obesity and LUV were detected in females compared with males. Patients over age 45 had lower rates of hyperuricemia compared with patients ≥ 45 years old (P = 0.038). CONCLUSIONS: Factors related to nephrolithiasis can potentially differ among populations and countries. Our findings emphasize the significance of individualized national health programs to address local issues.

Non-surgical treatment of latrogenic postoperatively diagnosed ureteral injuries.

BACKGROUND: latrogenic ureteral injury may be seen following abdominopelvic surgeries. While ureteral injuries identified during surgery should be immediately and surgically repaired, those that are postoperatively diagnosed may be treated non-surgically by draining the ipsilateral kidney. Data regarding the outcome of this approach are still missing. OBJECTIVES: To evaluate the success rates of non-surgical management of ureteral injuries diagnosed following abdominopelvic surgeries. METHODS: We retrospectively reviewed the files of all patients treated for iatrogenic ureteral injuries diagnosed following abdominopelvic surgeries. Patients' ipsilateral kidney was percutaneously drained following diagnosis of injury by either nephrostomy tube (NT)/nephro-ureteral stent (NUS) or double-J stent (DJS) inserted retrogradely. The tube was left in place until a pyelogram confirmed healing or a conservative approach was abandoned due to failure. RESULTS: Twenty-nine patients were identified as having ureteral injury following abdominopelvic surgery. Median time from injury to renal drainage was 9 days, interquartile range (IQR) 4-17 days. Seven cases (24%) had surgical repair. Among the other 22 patients, in 2 oncology patients the conservative approach was maintained although renal drainage failed to resolve the injury. In the remaining 20, median drainage length was 60 days (IQR 43.5-85). Calculated overall success rates following renal drainage was 69% (18/29), and with NUS approached 78.5%. CONCLUSIONS: Ureteral injuries diagnosed following abdominopelvic surgeries can be treated conservatively. Ipsilateral renal drainage should be the first line of treatment before surgical repair, and NUS may be the preferred drainage to obtain spontaneous ureteral healing.

Randomized trial of stone fragment active retrieval versus spontaneous passage during holmium laser lithotripsy for ureteral stones.

PURPOSE: We assessed whether allowing spontaneous passage of small fragments is different from complete intraoperative extraction during semirigid ureteroscopy for ureteral stones. MATERIALS AND METHODS: A total of 60 patients undergoing ureteroscopy and holmium laser lithotripsy were randomized to intraoperative fragment retrieval (group 1) or exhaustive lithotripsy and spontaneous fragment expulsion (group 2). The primary outcome was differences in unplanned medical and emergency room visits. Other outcomes were the rehospitalization, pain analgesia, time to complete recovery and 30-day stone-free rates. RESULTS: Patients in group 1 were younger (47 vs 54 years, p = 0.05). Other characteristics, including stone burden and site, presentation mode, and ureteral dilation and stent placement rates, did not differ between the groups. Group 2 patients had a higher rate of unplanned visits (3% vs 30%, OR 12.4, 95% CI 1.8-80.3, p = 0.01), a trend toward higher rates of rehospitalization (0% vs 10%, p = 0.24) and the need for ancillary treatment (0% vs 7%, p = 0.49), and a lower stone-free rate (100% vs 87%, p = 0.1). Complications developed in 1 group 1 patient and in 2 in group 2, including 2 with postoperative fever and 1 with mucosal undermining of the guidewire. CONCLUSIONS: Not actively retrieving fragments during semirigid ureteroscopy and holmium laser lithotripsy is associated with a higher risk of unplanned medical visits than complete intraoperative extraction. It also shows a tendency toward higher rates of rehospitalization, residual stones and the need for ancillary procedures.

Retrograde intra-renal surgery for stone extraction.

OBJECTIVE: To assess various clinical parameters affecting the efficacy and safety profile of retrograde intra-renal surgery (RIRS) for stone extraction. MATERIAL AND METHODS: Between the years 2001 and 2003, 63 patients underwent RIRS in our department for renal calculi, including 25 who had stones >/=20mm in size. RESULTS: Among the 63 patients who underwent the operation, 19 (30%) had infectious complications postoperatively. Although neither preoperative stenting nor stone burden were found to have any direct implication on postoperative course, a trend was seen as 64% of the infected patients had initially had large renal stones (>/=20mm in diameter) and 59% had been preoperatively drained. CONCLUSIONS: RIRS is currently considered to be a safe standard retrograde endoscopic procedure for treating renal calculi. However, patients with stones>20 mm in diameter or multiple small calculi, especially in the presence of pre-existing tubes or following prior urinary tract infections, represent a subgroup of patients that are, in general, at higher risk of remarkable infectious complication rates and are likely to experience less satisfying stone-free rates when RIRS surgery is performed.