Outcomes of retrograde intrarenal surgery compared with ultra-mini percutaneous nephrolithotomy in the management of renal calculi.

INTRODUCTION: To evaluate the outcomes of retrograde intrarenal surgery (RIRS) and ultra-mini percutaneous nephrolithotomy (umPCNL) in the management of renal calculi. MATERIAL AND METHODS: Between March 2015 and January 2018, a total of 44 patients were treated with umPCNL. The outcomes of these patients were compared with 75 patients who underwent RIRS for renal calculi during the same time period. RESULTS: Median stone size was 9 mm in the umPCNL group and 7 mm in the RIRS group. Stone-free rates after a single procedure were achieved in 85% of patients for the RIRS group and 98% for the umPCNL group. 16% of RIRS patients were left with a ureteric stent, whilst 7% of patients (n = 5) needed a second RIRS. One patient in the umPCNL group was left with a percutaneous nephrostomy; all other patients were left totally tubeless. The mean operative time was 66 minutes in the RIRS group and 55 minutes in the umPCNL group (p = 0.04). The minor complication rates for the RIRS and umPCNL groups were 17% and 15%, respectively. One patient in the RIRS group required postoperative nephrostomy insertion; there were no major complications in the umPCNL group. The median length of stay was 0 days in the RIRS group and 1 day in the umPCNL group. CONCLUSIONS: The overall study showed that umPCNL has low complication rates and good stone-free rates, with a lower requirement for ancilliary procedures. UmPCNL is an acceptable alternative in selected patients with small- to moderate-sized renal calculi.

Local Anesthetic Flexible Ureterorenoscopy in the Management of Urolithiasis.

Introduction: Patients unfit for general anesthesia who present with renal tract pathology currently have limited options. Many of these patients present in the emergency setting with imperative reasons for intervention, including sepsis, renal failure, and pain. Conservative management and temporizing measures, such as percutaneous nephrostomy, are associated with significant morbidity. Ureterorenoscopy (URS) is a central component of the management of upper tract disease and is routinely performed under general anesthesia. We describe our institution's experience of URS using only local anesthetic (LA) lubricating gel per urethra. Methods: A single centre, retrospective analysis of 78 patients was performed for an 11 year period. Demographic data and Charlson comorbidity index scoring were collected for all patients. Outcomes, including stone-free rates, tolerability, and complications, were analyzed. Results: In total 58% of patients were men. Mean age was 68 and Charlson comorbidity index was 5.2. Indications for URS included pain (68%) and renal failure (15%). Totally 10% of patients previously had retrograde stenting because of sepsis. Median stone size was 8 mm. All patients were able to tolerate the procedure and none were abandoned because of pain. The overall stone-free rate was 82% after one procedure. The stone-free rate for mid and distal ureteral stones was 97%. Nineteen percent of patients were left with a ureteral stent after the procedure, with the remaining patients left totally tubeless. Median length of stay was 1 day. There were no complications above Clavien Grade 2. Conclusion: Urologists are increasingly faced with unfit patients presenting with urolithiasis. In the appropriately selected patient, LA flexible ureterorenoscopy is a feasible option with good outcomes. This approach is a useful addition to the armamentarium available to patients deemed unsuitable for general or regional anesthesia.

Long-Term Outcomes of Laparoscopic Nephroureterectomy with Transurethral Circumferential Excision of the Ureteral Orifice for Urothelial Carcinoma.

INTRODUCTION: When performing open or laparoscopic nephroureterectomy (LNU), the optimal way to excise the distal ureter remains controversial. There are concerns that primary endoscopic detachment of the intramural ureter is associated with adverse outcomes. Existing studies have limited number of patients and inadequate oncologic follow-up. We provide our institutions experience of this technique. MATERIALS AND METHODS: Data were collected prospectively on 59 patients (37 men) who underwent LNU for a 10-year period at a single center using a standardized technique: initial endoscopic circumferential release of the distal ureter and bladder cuff followed by retroperitoneal en bloc LNU. RESULTS: Patients had a mean age of 67 years and Charlson score of 2. One case was converted to open surgery. Mean operative time was 194 minutes with estimated blood loss of 125 mL. Three patients (5%) required a blood transfusion. Mean in-patient stay was 3 days. Forty-six patients had urothelial carcinoma. Seventy-one percent of patients had high-grade disease (n = 33) and 21% had distal ureteral disease (n = 10). One patient required open excision of recurrence at the site of the excised ureteral orifice and remains disease free 5 years later. Five-year cancer-specific survival was 100% for patients with stages pTa (n = 7) and pT1 (n = 14), 93% for stage pT2 (n = 7) disease, and 49% for patients with stage pT3 (n = 18) disease. CONCLUSIONS: Transurethral resection of the ureteral orifice during LNU achieves acceptable long-term oncologic outcomes while minimizing perioperative morbidity and in-patient stay. This represents the largest single-center study of this technique to date.

Predictive Factors for Time to Progression after Hyperthermic Mitomycin C Treatment for High-Risk Non-Muscle Invasive Urothelial Carcinoma of the Bladder: An Observational Cohort Study of 97 Patients.

INTRODUCTION: Hyperthermic mitomycin (HM) is a novel treatment modality for selected patients with high-risk non-muscle invasive bladder cancer (NMIBC). We sought to determine predictors of response to this therapy. PATIENTS AND METHODS: A longitudinal, cohort study of 97 patients with high-risk NMIBC treated with ≥4 HM instillations on a prophylactic schedule was conducted. The primary outcome was time-to-progression survival; secondary outcomes were overall survival, cancer-specific survival, and adverse events. Descriptive statistics, Kaplan-Meier survival analyses, Cox proportional hazards modelling, and univariate and multivariable regression were performed. RESULTS: The presence of initial complete response (CR; no evidence of disease at first check video-cystoscopy and urine cytology) post-HM treatment was an independent predictor of good response to HM. Female patients and those without carcinoma in situ (CIS) also appeared to respond better to the intervention. The overall bladder preservation rate at a median of 27 months was 81.4%; 17/97 (17.5%) patients died during the course of the study. CONCLUSIONS: High-risk NMIBC patients can be safely treated with HM and have good oncological outcome. However, those without an initial CR have a poor prognosis and should be counselled towards adopting other treatment methodologies such as cystectomy. Female gender and lack of CIS may be good prognostic indicators for response to HM.

Durability, safety and efficacy of polyacrylamide hydrogel (Bulkamid(®)) in the management of stress and mixed urinary incontinence: three year follow up outcomes.

INTRODUCTION: There are a myriad of treatment options available for patients suffering with the increasingly prevalent condition of stress urinary incontinence (SUI). The minimally invasive nature of periurethral bulking agents makes them an attractive proposition in the correctly selected patient. There is, however, limited data available on the medium to long term safety and efficacy of this procedure. The aim of our study is to evaluate the outcomes of Polyacrylamide Hydrogel (PAHG) (Bulkamid(®)) as a periurethral bulking agent at our institution. MATERIAL AND METHODS: From 2006 to 2011, two hundred and fifty six women underwent periurethral bulking with PAHG in the management of SUI or mixed urinary incontinence (MUI). Women were assessed with at least yearly quality of life and ICIQ questionnaires. RESULTS: The majority of patients had the procedure under a local anaesthetic, with a median operative time of 9 minutes. Median follow up was 38 months. 82% of patients reported cure/significant improvement at 3 months. Importantly, this high satisfaction rate was maintained at final follow up and was reflected in both VAS and ICIQ scores. There were no reported adverse reactions and no significant safety concerns. CONCLUSIONS: We conclude that Bulkamid(®) injection is an efficacious, minimally invasive, and safe procedure for a selected group of patients with stress incontinence. In our study, PAHG has been shown to be durable and safe.

Splenic abscess rupture postappendicectomy.

The authors present a case of splenic abscess rupture postappendicectomy. Splenic abscess is rare with a reported incidence of 0.05%-0.7%. It is extremely unusual for a splenic abscess to result in splenic rupture. Contiguous spread, in this case from postappendix perforation, can cause splenic abscess formation. Postemergency splenectomy, the patient required admission to intensive therapy unit for 5 days but made a good postoperative recovery. This case is important to report as this is a rare postoperative complication of generalised peritonitis and this case highlights that astute diagnosis and management of the deteriorating surgical patient and rapid mobilisation of theatre are lifesaving.

Probabilistic diffusion tractography of the optic radiations and visual function in preterm infants at term equivalent age.

Children born prematurely have a high incidence of visual disorders which cannot always be explained by focal retinal or brain lesions. The aim of this study was to test the hypothesis that visual function in preterm infants is related to the microstructural development of white matter in the optic radiations. We used diffusion tensor imaging (DTI) with probabilistic diffusion tractography to delineate the optic radiations at term equivalent age and compared the fractional anisotropy (FA) to a contemporaneous evaluation of visual function. Thirty-seven preterm infants (19 male) born at median (range) 28(+4) (24(+1)-32(+3)) weeks gestational age, were examined at a post-menstrual age of 42 (39(+6)-43) weeks. MRI and DTI were acquired on a 3 Tesla MR system with DTI obtained in 15 non-collinear directions with a b value of 750 s/mm(2). Tracts were generated from a seed mask placed in the white matter lateral to the lateral geniculate nucleus and mean FA values of these tracts were determined. Visual assessment was performed using a battery of nine items assessing different aspects of visual abilities. Ten infants had evidence of cerebral lesions on conventional MRI. Multiple regression analysis demonstrated that the visual assessment score was independently correlated with FA values, but not gestational age at birth, post-menstrual age at scan or the presence of lesions on conventional MRI. The occurrence of mild retinopathy of prematurity did not affect the FA measures or visual scores. We then performed a secondary analysis using tract-based spatial statistics to determine whether global brain white matter development was related to visual function and found that only FA in the optic radiations was correlated with visual assessment score. Our results suggest that in preterm infants at term equivalent age visual function is directly related to the development of white matter in the optic radiations.