An ex-vivo assessment of a new single probe triple modality (Trilogy) lithotripter.

INTRODUCTION AND OBJECTIVES: This Swiss LithoClast® Trilogy lithotrite is a new lithotrite for percutaneous nephrolithotomy (PCNL). It has four modifiable settings; impact, frequency, ultrasound and suction. We aim to determine the optimal device settings for the fastest stone clearance. MATERIALS AND METHODS: Kidney stone phantoms were made with Begostone in a powder to water ratio (15:3-15:6). Complete stone clearance (seconds) was calculated and impact and frequency were adjusted and repeated N = 3. Intra renal pressure (IRP) was then measured in a porcine kidney model. RESULTS: Stone phantoms with physical properties similar to struvite were cleared best with 100% impact and frequency of 12 Hz. Both uric acid stone phantoms and calcium phosphate stone phantoms were cleared most efficiently with an impact of 30% and a frequency of 4 Hz. The mean time to clear uric acid stone phantoms was 83 s versus 217 s for calcium phosphate stone phantoms. Similarly, for calcium oxalate stone phantoms, an impact of 30% and a frequency of 4 Hz was associated with the fastest clearance time, mean 204 s. However, the differences between 4, 8 and 12 Hz were not statistically significant. At a suction level of 60% or higher, IRP became negative. CONCLUSION: These results indicate that stone phantoms of hard kidney stones are cleared more efficiently at lower impact and frequency settings. With regard to suction, a setting of ≤ 50% appears to be the optimal setting.

Intrarenal pressures during percutaneous nephrolithotomy: a porcine kidney model.

BACKGROUND: Increased intrarenal pressure during endoscopic lithotripsy is associated with increased adverse outcomes. The objective of this study was to evaluate the effect of various devices on IRP during percutaneous intrarenal surgery in ex vivo porcine kidney models. METHODS: Whole intact porcine urinary tracts were harvested. Intrarenal pressure was measured using cystometrometry software. Intrarenal pressure during PCNL was recorded using variations of percutaneous access sheath size, irrigation height of 100 cm and 60 cm, use of a ureteric catheter and use of suction. The primary outcome was absolute IRP measurements. Secondary outcomes were comparisons of IRP between techniques. RESULTS: Using a 30 Fr vs 26 Fr access sheath and 26 Fr nephroscope the mean pressure at an irrigation height of 60 cm was significantly lower than 100 cm (p = 0.0013 vs p < 0.0001, respectively). Pressure's during mini-PCNL were significantly higher than conventional PCNL in all variations. Using the 16.5 Fr access sheath and 12 Fr nephroscope produced a significantly lower pressure at a 60 cm irrigation height than 100 cm (p = 0.0010). IRP was significantly lower with a ureteric catheter in place vs no ureteric catheter at 100 cm (p = 0.0015) and at 60 cm (p = 0.0040). CONCLUSIONS: Using standard PCNL tract sizes intrarenal pressure varied significantly depending on the height of the irrigation fluid. Mini-PCNL is at higher risk of pathological pressure, however, the use of a ureteric catheter significantly decreased pressure. To maintain safe IRP during PCNL urologists should be aware of these significant variations.

The Carbon Footprint of Single-Use Flexible Cystoscopes Compared with Reusable Cystoscopes.

Introduction: Single-use devices for endourologic procedures are becoming more popular. The environmental impact of single-use instruments is relatively unknown. This study aimed to compare the carbon footprint of single-use vs reusable flexible cystoscopes based on waste production and estimated carbon emissions. Methods: An analysis of the solid waste produced when using the aScope™ 4 Cysto (Ambu®) single-use flexible cystoscope compared with the reusable Cysto-Nephro Videoscope CYF-VA2 (Olympus®) was performed. The solid waste generated was measured (grams) and recorded as either recyclable, landfill, or contaminated, and carbon dioxide (CO2) produced by disposal, manufacture, and cleaning was calculated. Results: A total of 40 flexible cystoscopies (20 single-use and 20 reusable) were analyzed. Median total weight of waste produced was 622 g (interquartile range [IQR] 621-651) for the single-use cystoscope compared with 671.5 g (IQR 659-677.5) for the reusable cystoscope (p < 0.0001). More waste was disposed of by incineration after single-use than reusable cystoscopy (496 g [IQR 495-525] vs 415 g [IQR 403-421.5], p < 0.0001). However, more waste went to landfill after reusable cystoscopy (256 g ± 0 vs 126 g ± 0, p < 0.0001). There was no difference in weight of waste produced based on the indication for cystoscopy (p = 0.1570). A total of 2.41 kg of CO2 (IQR 2.40-2.44) was produced per case for the single-use flexible cystoscope compared with 4.23 kg of CO2 (IQR 4.22-4.24) for the reusable cystoscope (p < 0.0001). Conclusion: Environmental accountability is essential in modern health care. This study highlights that disposable flexible cystoscopes have a significantly lower impact on the environment in terms of carbon footprint and landfill. We propose that environmental impact studies should be a routine part of device development for a sustainable future.

Renal lobar dysmorphism: a potential mimic of renal malignancy.

A renal pseudotumour is any apparent renal mass that simulates a tumour on radiological imaging but is composed of normal tissue. Renal pseudotumours may be inflammatory, vascular, postsurgical or congenital. We report a case of renal lobar dysmorphism (RLD) of the kidney, a congenital renal pseudotumour. A 45-year-old man presented with scrotal swelling. Testicular ultrasound showed an epididymal cyst. Renal ultrasound showed a right solid renal apparent mass of 2.4 cm in diameter. Triphasic renal CT showed this was consistent with RLD. Intravenous urography confirmed a central calyx within the dysmorphic lobe. RLD is a rare congenital normal anatomical variant, which can appear as a renal pseudotumour. No further investigation or intervention is necessary. We present the radiological findings of RLD and review the literature.

Rapid development and recurrence of translocation renal cell carcinoma.

Translocation renal cell carcinoma (RCC) is a rare aggressive malignancy in adults. A 40-year-old man presented with painless macroscopic haematuria. Initial investigations of renal ultrasound, CT scan, urine culture and urine cytology were normal. On rigid cystoscopy and pyelo-ureteroscopy, bleeding was seen from a normal-appearing right renal upper pole. An arteriovenous malformation was suspected, and laser cautery was performed. Left renal biopsy was performed due to proteinuria and suggested IgA nephropathy. The patient represented with haematuria and repeat imaging only 17 months after first presentation displayed a 9.8 cm right renal tumour with renal vein thrombus. An upper tract urothelial cancer was suspected, and the patient underwent right nephroureterectomy. Histopathology revealed translocation RCC, completely excised. Ten months postoperatively, metastasis was seen on surveillance imaging and subsequently confirmed on biopsy. The patient was referred for systemic therapy and remains alive 19 months postprocedure.

Saksenaea vasiformis infection in an immunocompetent patient in rural Australia.

An 81-year-old man from rural Australia presented with right pretibial cellulitis 7 days after minor trauma against furniture. He failed to improve despite antibiotics and surgical debridement. Subsequent cultures grew the rare fungus Saksenaea vasiformis, which was treated with further surgical debridement, amphotericin B and posaconazole. This was successful and the patient made a full recovery. We present the case and discuss lessons learnt.

Haemorrhagic cholecystitis in a newly anticoagulated patient.

A 74-year-old man undergoing rehabilitation after pneumonia developed right upper quadrant abdominal pain. Five days earlier he had been commenced on apixaban for a new diagnosis of atrial fibrillation. Ultrasound and CT scans revealed an acalculous grossly thickened gallbladder, with high attenuation non-echogenic material both within and surrounding the structure. Active contrast extravasation was seen at the neck. On laparotomy, a perforated internally bleeding gallbladder containing a single calculus was found, with significant free blood within the abdomen. After cholecystectomy, the patient recovered slowly in hospital before nursing home placement.

Spontaneous renal calyceal and ureteric rupture secondary to intravenous contrast during computed tomography intravenous pyelogram.

Upper urinary tract rupture in the absence of trauma is typically related to ureteric calculi causing obstructive nephropathy. Spontaneous extravasation of contrast during CT intravenous pyelography (CT IVP) is infrequently reported. Two cases, who underwent CT IVP to further investigate positive urine cytology and microscopic haematuria, respectively, are described here. In both cases, there was spontaneous extravasation of contrast seen in the postcontrast scans in the absence of ureteric calculi or hydronephrosis which is very unusual.

Colovesical fistula presenting with epididymitis.

This article reports a case of colovesical fistula presenting with epididymitis. A 75-year-old man with a recent conservatively managed localised diverticular perforation presented to hospital with acute pain and swelling of his left testicle and epididymis. On further questioning, the patient reported passing air in his urine. Urine cultures grew Enterococcus faecalis. Ultrasound scan confirmed a diagnosis of bacterial epididymitis and the patient was treated with intravenous antibiotics. Subsequent CT imaging revealed air in the bladder and a colovesical fistula. The patient went on to have Hartmann's procedure with repair of the bladder defect. This case highlights that: (1) Colovesical fistulae may rarely present with epididymitis. (2) Colovesical fistulae are the most common cause of pneumaturia.

Vesicocutaneous fistula following adjuvant radiotherapy for prostate cancer.

Vesicocutaneous fistulas (VCF) are a rare complication of radical radiotherapy to the pelvis. Timely diagnosis and management are often difficult and complex. We report the unusual case of a 64-year-old gentleman who presented to the emergency department with worsening sepsis and profuse discharge from a cutaneous opening in the left groin. This presentation was 6 weeks following the completion of external beam radiotherapy for apical margin-positive prostate cancer (pT3a). A diagnosis of a VCF was confirmed after CT scanning of the abdomen and pelvis with contrast. Urinary diversion was achieved by a temporary urethral catheter insertion. Full resolution of this gentleman's symptoms was accomplished. In this article, we present a non-invasive approach to the management of VCF. This case raises intricate management issues in the atypical development of an early urinary tract fistula postradiotherapy.