Initial Experience and Evaluation of a Nomogram for Outcome Prediction in Management of Medium-sized (1-2 cm) Kidney Stones.

BACKGROUND: The gold standard treatment for solitary medium-sized (1-2 cm) renal stones is not defined by recent guidelines, since management modalities including shockwave lithotripsy (SWL), retrograde intrarenal surgery (RIRS), and percutaneous nephrolithotomy (PNL) are recommended. Improved ability to predict patient outcomes would aid in patients' counseling and decision-making. OBJECTIVE: To develop a nomogram predicting treatment failure, based on preoperative clinical variables, to be used in the preplanning setting. DESIGN, SETTING, AND PARTICIPANTS: We recruited 2605 patients from 14 centers and carried out a multicenter retrospective analysis of 699 SWL, 1290 RIRS, and 616 PN L procedures performed as first-line treatment for 1-2-cm kidney stones. The variables evaluated included age, gender, previous renal surgery, body mass index, stone size, location, stone density, skin-to-stone distance, presence of urinary tract infections (UTIs), and hydronephrosis. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Multivariate logistic regression was fitted to predict treatment failure, defined as the presence of residual fragments >4 mm. A nomogram was developed based on the coefficients of the logit function. RESULTS AND LIMITATIONS: A total of 2431 (93.3%) patients were stone free; 174 (6.7%) treatment failures were recorded and considered the event to be predicted. On univariate analysis, type of procedure, preoperative hydronephrosis, stone density, stone location, and laterality turned out to be statistically significant. Skin-to-stone distance, UTIs, and previous renal surgery were predictors of failure on multivariate analysis. Each variable was given a score based on statistical relevance. The main limitation of the current study is its retrospective nature. CONCLUSIONS: This nomogram provides a prediction of treatment failure and need of reintervention for medium-sized kidney stones. External validation is needed to determine its reproducibility and validity. PATIENT SUMMARY: We developed a preoperative model of treatment outcomes for 1-2-cm kidney stones. Its application may assist urologists to counsel patients with regard to stone management modality.

Implicitly learning when to be ready: From instances to categories.

There is growing appreciation for the role of long-term memory in guiding temporal preparation in speeded reaction time tasks. In experiments with variable foreperiods between a warning stimulus (S1) and a target stimulus (S2), preparation is affected by foreperiod distributions experienced in the past, long after the distribution has changed. These effects from memory can shape preparation largely implicitly, outside of participants' awareness. Recent studies have demonstrated the associative nature of memory-guided preparation. When distinct S1s predict different foreperiods, they can trigger differential preparation accordingly. Here, we propose that memory-guided preparation allows for another key feature of learning: the ability to generalize across acquired associations and apply them to novel situations. Participants completed a variable foreperiod task where S1 was a unique image of either a face or a scene on each trial. Images of either category were paired with different distributions with predominantly shorter versus predominantly longer foreperiods. Participants displayed differential preparation to never-before seen images of either category, without being aware of the predictive nature of these categories. They continued doing so in a subsequent Transfer phase, after they had been informed that these contingencies no longer held. A novel rolling regression analysis revealed at a fine timescale how category-guided preparation gradually developed throughout the task, and that explicit information about these contingencies only briefly disrupted memory-guided preparation. These results offer new insights into temporal preparation as the product of a largely implicit process governed by associative learning from past experiences.

Cambridge Psycholinguistic Inventory of Christian Beliefs: A registered report of construct validity, internal consistency and test-retest reliability.

While religious beliefs are typically studied using questionnaires, there are no standardized tools available for cognitive psychology and neuroscience studies of religious cognition. Here we present the first such tool-the Cambridge Psycholinguistic Inventory of Christian Beliefs (CPICB)-which consists of audio-recorded items of religious beliefs as well as items of three control conditions: moral beliefs, abstract scientific knowledge and empirical everyday life knowledge. The CPICB is designed in such a way that the ultimate meaning of each sentence is revealed only by its final critical word, which enables the precise measurement of reaction times and/or latencies of neurophysiological responses. Each statement comes in a pair of Agree/Disagree versions of critical words, which allows for experimental contrasting between belief and disbelief conditions. Psycholinguistic and psychoacoustic matching between Agree/Disagree versions of sentences, as well as across different categories of the CPICB items (Religious, Moral, Scientific, Everyday), enables rigorous control of low-level psycholinguistic and psychoacoustic features while testing higher-level beliefs. In the exploratory Study 1 (N = 20), we developed and tested a preliminary version of the CPICB that had 480 items. After selecting 400 items that yielded the most consistent responses, we carried out a confirmatory test-retest Study 2 (N = 40). Preregistered data analyses confirmed excellent construct validity, internal consistency and test-retest reliability of the CPICB religious belief statements. We conclude that the CPICB is suitable for studying Christian beliefs in an experimental setting involving behavioural and neuroimaging paradigms, and provide Open Access to the inventory items, fostering further development of the experimental research of religiosity.

Advantages of the supine transgluteal approach for distal ureteral stone extracorporeal shock wave lithotripsy: outcomes based on CT characteristics.

BACKGROUND: Extracorporeal shock wave lithotripsy (ESWL) for distal ureteral stones can be performed in prone or supine position. The aim of this study was to investigate the advantages brought by the supine transgluteal ESWL approach for distal ureteral stones treatment using real-time ultrasound (US), and to show how computerized tomography (CT) scan parameters may be related to the outcomes. METHODS: Seventy consecutive supine transgluteal ESWL of distal ureteral stones were performed. All patients had a pre-treatment CT scan. The following parameter were evaluated: stone size, Hounsfield Units, skin-to-stone distance, sciaticum majus foramen width, stone to ureteral ostium distance, fragmentation and expulsion perception during the treatment, and the stone-free status. Stone focusing was obtained US, which allows a real-time visualization of stone location and fragmentation. Follow-up included a kidney ureter bladder (KUB) film and US examination at 2-3 weeks after treatment (median time: 18 days). Stone-free condition was defined as the complete absence of stone fragments. A linear regression analysis was used to assess the possible variables mostly related to stone-free status. P<0.05 was considered as significant. RESULTS: Median number of SWL sessions for patient was 1 (IQR: 1-1), mean 1.2±0.5. The re-treatment rate for stone-free patients was 18.3%. Stone-free rate was 85.7%. A clear and real time US stone fragmentation was perceived by the surgeon during the treatment in 42/70 (60%) of patients and correlated to the definitive stone-free status (P=0.04). Stone to ureteral ostium distance was the only variable affecting the stone-free condition (P=0.01). CONCLUSIONS: Supine transgluteal SWL of distal ureteral stones provide satisfactory outcomes in terms of stone-free rate. The distance of the stone to the ureteral ostium, measured by CT, appeared to be the only significant variable connected to SWL success.

Percutaneous nephrolithotomy in super obese patients (body mass index ≥ 50 kg/m²): overcoming the challenges.

OBJECTIVE: To analyse our experience with and the outcomes and lessons learned from percutaneous nephrolithotomy (PCNL) in the super obese (body mass index [BMI] ≥50 kg/m(2) ). PATIENTS AND METHODS: In this institutional review board approved study we retrospectively reviewed our PCNL database between July 2011 and September 2014 and identified all patients with a BMI ≥ 50 kg/m(2) . Patient demographics, peri-operative outcomes and complications were determined. Additionally, we identified a number of special PCNL considerations in the super obese that can maximize safe outcomes. RESULTS: A total of 21 PCNL procedures performed on 17 super obese patients were identified. The mean patient age was 54.8 years, the mean BMI was 57.2 kg/m(2) and the mean stone area was 1 037 mm(2) . Full staghorn stones were observed in six patients and partial staghorns in four patients. The mean operating time was 106 min and the mean haemoglobin decrease was 1.2 g/dL. The overall stone-free rate was 87%. There were four total complications: two Clavien grade II, one Clavien IIIb and one Clavien IVb. We identified several special considerations for safely preforming PCNL in the suber obese, including using extra-long nephroscopes and graspers, using custom-cut extra long access sheaths with suture 'tails' secured to easily retrieve the sheath, choosing the shortest possible access tract, readily employing flexible nephroscopes, placing nephroureteral tubes rather than nephrostomy tubes postoperatively, and meticulous patient positioning and padding. CONCLUSION: With appropriate peri-operative considerations and planning, PCNL is feasible and safe in the super obese. Stone clearance was similar to that reported in previous PCNL series in the morbidly obese, and is achievable with few complications.

Advantages of single-puncture transperineal saturation biopsy of prostate: analysis of outcomes in 125 patients using our scheme.

PURPOSE: Stereotactic biopsy has improved prostate cancer detection. Although the new approach is superior, standard procedure is still useful in a cohort of patients in whom MRI is not available. The standard saturation biopsy technique is still debatable. We describe our technique and analyze its outcomes. MATERIALS AND METHODS: One hundred twenty-five patients underwent saturation biopsy through a single transperineal access. Mean age was 64.73 year, mean PSA was 9.49 ng/ml, mean PSA density was 0.184, and mean prostate volume was 57.95 g. All patients underwent at least one previous prostatic biopsy: 24.8% of cases had diagnosis of atypical small acinar proliferation, 39.2% of cases had multifocal high-grade prostatic intraepithelial neoplasia, and 36% of cases had inflammation or benign prostatic hyperplasia. RESULTS: The detection rate was 38.4%. Prostate cancer occurred in 61.3% of patients with previous ASAP (p < 0.007). Cancer detection rate decreased with increasing number of previous biopsy and with increasing prostate volume (p < 0.001) and increased with increasing PSA density (p = 0.03). No major complications were reported. CONCLUSION: The traditional saturation biopsy may be useful when targeted biopsy cannot be used. Our technique is accurate for cancer detection. It can offer some advantages in comparison with other approaches.

Percutaneous nephrolithotomy in octogenarians and beyond: How old is too old?

OBJECTIVE: To specifically report perioperative characteristics and outcomes in patients 80 years and older undergoing percutaneous nephrolithotomy (PCNL). PCNL has been established as feasible in the elderly; however, to our knowledge no one has specifically reported feasibility in patients 80 years and older. METHODS: We retrospectively reviewed perioperative data of octogenarians who underwent PCNL at a high stone volume single institution, and matched them to patients <65 years of age by stone burden and sex. Patient demographics, perioperative outcomes and postoperative complications were compared. RESULTS: Thirty-three octogenarians (mean age 83.6 years) with 36 renal units were matched to 67 controls (mean age 48.6 years) with 72 renal units. Octogenarians had a higher mean American Society of Anesthesiologists (ASA) score, more comorbidities, and worse renal function. There were no differences in operative characteristics, length of hospital stay or stone free rates. Of the patients with preoperative urinary decompression (ureteral stent or nephrostomy tube) prior to PCNL, the elderly were more likely to have a history of urosepsis. Octogenarians did not experience more minor Clavien (I - II) or major Clavien (IIIa - IVb) complications. CONCLUSION: Octogenarians who undergo PCNL were more likely to have cardiovascular comorbidities and a prior history of sepsis. Despite these risk factors, in appropriately selected patients PCNL can be safely and successfully performed in octogenarians without increased perioperative complications relative to a younger cohort.

Retroperitoneoscopic single site renal biopsy surgery: right indications for the right technique.

BACKGROUND: Laparoendoscopic single-site surgery (LESS) has been developed in an attempt to further reduce the morbidity and scarring associated with laparoscopic surgery. In patients in whom there are indications to perform a laparoscopic renal biopsy, LESS surgery is a valid alternative to mini invasive surgery and is becoming more common. We report our experience on 14 renal biopsy procedures performed in a retroperitoneal LESS. METHODS: LESS renal biopsy was performed in 14 patients 18 to 80 years old (mean age 58.3 years) during a 36 month period. All procedures were performed by a single operator. The patient was in a standard flank position. The procedure was performed using a 2.5 cm, single incision via a retroperitoneal access at the Petit's triangle. A 5 mm biopsy forceps was used to collect the specimen under direct vision, and haemostasis was obtained with an Argon beam probe and the application of oxidized regenerated cellulose gauze. RESULTS: Biopsy was performed successfully in all cases. Mean operative time was 52.64 min, blood loss was minimal, and the hospital stay ranged from 12 to 24 hours. None of the patients required narcotics or additional analgesia in the postoperative period. No postoperative complications occurred. CONCLUSIONS: The LESS technique is safe, reliable (100% success), easy to learn, and offers subjective cosmetic benefits to the patient. Minimal hospitalization requirement following retroperitoneal LESS biopsy is an additional timely advantage over laparoscopic renal biopsy. We think that with the right indications (marked obesity, failure of previous percutaneous biopsy attempts, a solitary kidney and coagulopathy) LESS renal biopsy is a good alternative to laparoscopy. Our next step will be a randomized prospective study of LESS compared with laparoscopy for renal biopsy to support our findings.