The experience of a tertiary referral center with laparoscopic pyelolithotomy for large renal stones during 18 years.

This study aimed to evaluate the outcomes of laparoscopic pyelolithotomy, including its efficacy and feasibility in treatment of large renal stones. All patients who underwent laparoscopic pyelolithotomy operations in a referral center were enrolled from 2003 to 2020. The final analysis included 436 patients. The total stone free rate was 88.3% and the stone-free rate for staghorn/multiple stones versus other types of stones was 81% vs. 91% (P = 0.002). Likewise, the total operation duration was 158 ± 50 and the operation duration for staghorn/multiple stones versus other types of stones was 171 ± 51 min vs. 153 ± 49 min (P < 0.001). The operation duration (169 ± 51 vs. 155 ± 58 vs. 155 ± 42 min) and hospitalization (4.5 ± 2.3 vs. 4.0 ± 2.2 vs. 3.6 ± 1.8) decreased with increasing the surgeons' experience over time. The outcomes of laparoscopic pyelolithotomy for children versus adults versus geriatric patients and in patients with normal versus abnormal kidney anatomy did not reveal statistically significant differences. Laparoscopic pyelolithotomy could be employed as an alternative surgical approach for patients with large kidney stones of any age or with kidney abnormalities provided that appropriate expertise is available to carry out the procedure.

Antegrade Percutaneous Retrieval of Upward Migrated Double-J Stent in Very Small Size Pediatric Patients Under Ultrasonic Guide.

Purpose: To evaluate the safety of antegrade percutaneous retrieval migrated ureteral stent in very small size pediatric patients with ultramini instruments under ultrasonography guide. Materials and Methods: A total number of 10 out of 115 patients who were referred to our center with upward migrated Double-J (DJ) were candidates for antegrade approach from 2017 to 2020. The pyelocalyceal system was punctured in a prone position by using an 18-gauge disposable needle with Chiba tip and visualization of the upper tract by 3.5 MHz ultrasonic guidance. Then 0.038-inch J tipped guide wire was passed through the needle and the tract was dilated up to 6F under ultrasonographic guide. The 8F access sheath was positioned over the 6F dilator. The semirigid 6F ureteroscope was introduced through the sheath and DJ was removed with a grasper. Results: The mean age was 11.4 ± 5.48 months. The mean time from the previous surgery to DJ removal procedure was 6.4 ± 0.84 weeks. The mean operation time was 11.7 ± 1.76 minutes. All the patients were discharged from the hospital within the 1st day. There were no serious complications (grade 3, 4, or 5) according to Clavien-Dindo classification. Conclusion: The antegrade retrieval of upward migrated DJ with ultramini instrument under ultrasonographic guidance in failed cases of retrograde approach is a safe and effective approach in very small size pediatric patients.

A Case Report of COVID-19 in a Living Kidney Transplant Recipient: A Challenging Case with Complete Rehabilitation.

Adjustment of immunosuppressive and COVID-19 treatment in terms of drug interactions is still challenging. Herein, we report a 45-year-old woman with end-stage renal disease due to autosomal dominant polycystic diseases (ADPKD) with COVID-19 and pulmonary involvement following kidney transplantation. The patient was properly treated by discontinuation of immunosuppressive drugs, bronchoscopy, and high volume of blood transfusions. The fact that we quickly used early intubation and a new treatment regimen that suppressed immune systems may help physicians develop optimal treatment strategies for similar severe cases. However, this treatment method requires more detailed evaluations due to the contradictory results in reviewing other studies.

Benign prostatic hyperplasia: Who will benefit from surgical intervention? A single center experience.

BACKGROUND: To evaluate the pre-operative factors affecting clinical response to prostate surgery in men with benign prostatic hyperplasia (BPH). MATERIALS AND METHODS: In this prospective cohort study, 172 patients who underwent surgical intervention for BPH (either as open prostatectomy (n = 78) or monopolar-trans-urethral resection of prostate (n = 94) from February 2017 to October 2019 were consecutively enrolled. Pre-operative conventional three-lumen urodynamic study and transabdominal sonography were performed for all patients to determine peak flow rate (Qmax), detrusor pressure at the peak flow rate (PdetQmax), post-void residual volume (PVR), presence of detrusor overactivity (DO), prostate volume and median lobe size, and bladder wall thickness with empty and full bladder. Uroflowmetry and cystoscopy were performed during follow-up, whenever indicated. Successful surgical outcome was defined as subjective satisfaction of the patient and a Qmax of more than 15 ml/s on post-operative uroflowmetry. RESULTS: At 1-year follow-up, complete resolution of lower urinary tract syndrome (LUTS) was detected in 138 (80.2%) patients; however, 21 (12.2%) still had pure obstructive LUTS, 9 (5.2%) had pure storage LUTS, and 4 (2.3%) were still suffering from both storage and obstructive LUTS. After performing multivariable analysis, shorter duration of pre-operative medical treatment and higher pre-operative bladder contractility index (BCI) were found to be independent predictors of successful surgery (p = 0.012 and p < 0.001, respectively). Results of the ROC curve analysis showed that a preoperative BCI level more than 90.95 and pre-surgical medical treatment duration less than 14.45 months have the most specificity and sensitivity to predict the success of surgical outcome. We also observed that the probability of recovery decreased considerably over time following surgery. CONCLUSION: Shorter duration of pre-operative medical treatment and increased pre-operative BCI can independently predict favorable outcome of BPH surgery. These factors could be used for better patient management and appropriate planning and consultation before BPH surgery.

Single Umbilical Stoma for Bilateral Ureterostomy after Radical Cystectomy.

PURPOSE: Cutaneous ureterostomy after radical cystectomy is less preferred compared with other permanent urinary diversions due to bilateral stomas. Single umbilical stoma for bilateral ureterostomy (SUSBU) may be a choice, in this study we reviewed the outcomes of SUSBU in seventeen patients who underwent radical cystectomy. METHODS AND MATERIALS: This was a case-series study conducted from April 2016 to Dec 2017. Seventeen male patients with confirmed PT2 bladder urothelial carcinoma who were not suitable for performing conduit or orthotopic urinary diversion, including those with high-risk patients underwent single umbilical stoma for bilateral ureterostomy after radical cystectomy. All patients were prospectively followed up for 24 months ± 2 months, this study was done in a teaching center mainly by senior residents. RESULTS: The mean age of patients was 68.6 ± 6.41 years. The mean length of operation time was 176.7 ± 15.1 minutes (from intubation to extubation from anesthesia). Sixteen patients were diagnosed with PT2 and one patient had a PT4 diagnosis. The decrease in hemoglobin level after surgery was 1.72 mg/dl ± 0.35 and creatinine increased by 0.15 ± 0.05 mg/dl. None of our patients had oliguria. One case developed constipation and no gas passing, with the suspicion of obstruction, underwent abdominal exploration, however, no obstruction or urine leakage was found and the patient was treated conservatively. One patient developed a fever during admission, in which atelectasis was identified as the cause. One patient underwent a second operation because of fascia dehiscence. CONCLUSION: It seems that this technique is suitable for high-risk patients with acceptable operating time, surgical complications, and fast recovery after the operation and one ureterostomy bag instead of two one's comparing to bilateral cutaneous ureterostomy.

Off Clamping Laparoscopic Resection of An Extreme Rare Renal Mesenchymal Tumor: An Angiomyolipoma of Renal Capsule.

Renal mesenchymal tumors are described as neoplasms with vascular, fibrous, and adipose tissues. The renal lipoma is an extremely rare renal mesenchymal tumor, typically originating from renal capsule and it is usually presented as well circumscribed homogenous fat containing mass. Angiomyolipoma (AML) is the most common benign mesenchymal renal tumor which is composed of mature epithelioid cells. The renal AML usually presented as exophytic, non-infiltrative, and fat contain tumor. The well differentiated renal retroperitoneal liposarcoma and lipoma seem to be misdiagnosed by exophytic renal angiomyolipoma but the renal AML usually arises from renal parenchyma with characteristic images. A 37-year-old woman came to our clinic with rapid growth renal mass and pain. The spiral abdominopelvic computed tomography scan (CT-scan) showed well-circumscribed hypoheterodense fat-containing mass near to middle pole of the right kidney with minimal fat stranding without neovascularity and cortical defect. The Patient underwent off-clamping laparoscopic resection of renal mass with pre-operative impression: liposarcoma versus lipoma of the kidney. The cross-section of the surgical specimen revealed irregular lobulated fatty tissue with hemorrhagic streaks. Definite diagnosis was made by immunohistochemistry study. Spindle cells and epithelioid cells are diffusely and strongly positive for α-smooth muscle actin. The perivascular cells and epithelioid cells are positive for HMB-45 and Melanin. The immunostaining pattern was compatible with angiomyolipoma that originated from renal capsule. In our experience, a rapid growing mass that is accompanied by pain draws the attention to malignant process. The renal AML rarely arises from renal capsule without characteristic images so having high doubt may lead to proper pre-operative diagnosis.

Is a Safety Guide Wire Necessary for Transurethral Lithotripsy using Semi-Rigid Ureteroscope? Results from a Prospective Randomized Controlled Trial.

BACKGROUND: Experts recommend us to keep a safety guidewire during the process of upper urinary tract endoscopy, though there is a lack of high-level evidence to support  the efficacy and safety of  this opinion. This study conducted to compare the outcome of ureteral stone breakage in the presence or absence of safety guidewire. MATERIALS AND METHODS: Patients candidate for endoscopic breakage of ureteral stone using a semi-rigid ureteroscope, were randomly assigned in  two groups based on keeping a safety guidewire (group1)  or removing the guidewire (group2) before the process of breaking ureteral stone by lithoclast. Demographic factors, history of previous stone treatment, kidney function, stone location, symptoms duration and severity were recorded for each patient. Primary outcomes include success rate of stone treatment and secondary outcomes include number of attempts to enter to ureter, success rate of ureteral entry, success rate of stone achievement, stone migration rate and success rate of ureteral stent insertion. The recorded data were entered to the SPSS software and descriptive statistical analysis including power calculation and non-inferiority design for the primary and secondary outcomes, was performed. P-value less than 0.05 was considered significant. RESULTS: From January 2016 till May 2018, 320 patients were randomized with 160 patients in each arm. Considering the cases who were missed due to follow-up loss, there were 153 patients in group 1 and 147 patients in group 2 at the end of the study. Baseline data were equally distributed in both groups. Based on the initial analysis, the studied variables had no significant difference between two groups; though, according to the subgroup analysis of patients with proximal ureter stones, patients in Group 1 had higher rates of ureteral injury comparing to the patients in Group 2 (p=0.03). CONCLUSION: According to our findings, keeping the safety guidewire through the process of endoscopic stone breakage (stone size: less than 1.5Cm) seems to add no significant benefit to the procedure outcome, while it increases the ureteral injuries in the proximal ureter stones, but not in mid or distal ureter stones.

Laparoscopic Donor Nephrectomy Is a Safe Surgical Approach in Healthy Obese Kidney Donors: A 10-Year Single-Center Retrospective Study.

OBJECTIVES: A lack of donors continues to be a significant problem. Kidney donors with a body mass index ≥ 30 kg/m² are not suitable for laparoscopic donor nephrectomy; however, some studies have suggested that an obese donor could be an appropriate donor with similar surgical outcomes. Here, we report the results of our 10-year experience of laparoscopic donor nephrectomy, examining the effects of body mass index on the surgical results of laparoscopic donor nephrectomy. MATERIALS AND METHODS: We retrospectively reviewed medical records of patients who underwent laparoscopic donor nephrectomy at the Shahid Beheshti University Medical Science, Urology Center (Tehran, Iran) from 2005 to 2015. The collected information included pretransplant and posttransplant serum levels of hemoglobin and creatinine. We also collected data on surgical outcomes (operation time, cold and warm ischemia, need for blood transfusion, and conversion to open surgery, length of hospital stay, and complication rates) with respect to body mass index categories (≤ 24.9, 25-29.9, and ≥ 30 kg/m²). RESULTS: Of 1083 kidney donors, 732 donors had body mass index of ≤ 24.9 kg/m², 256 had body mass index between 25 and 29.9 kg/m², and 95 had body mass index of ≥ 30 kg/m². Differences among groups were not significant in terms of operation time (P = .558), warm or cold ischemic time (P = .829 and .951, respectively), blood transfusion (P = .873), and length of hospital stay (P = .850). CONCLUSIONS: The laparoscopic approach for donor nephrectomy is a safe and effective method in obese donors without significant postoperative complications.

Percutaneous Endoscopic Treatment of Complicated Delayed Bleeding Postpercutaneous Nephrolithotomy: A Novel Suggestion.

Background: Delayed bleeding after percutaneous nephrolithotomy (PCNL), which may occur within the first 3 weeks postoperatively, is a life-threatening complication that may result from arteriovenous fistula and arterial pseudoaneurysm. Angioembolization is the standard treatment when these patients develop hemodynamic instability despite conservative measures. Contrast hypersensitivity and renal insufficiency, however, contraindicate angiogram and subsequent embolization; in these patients, alternative methods such as the one described in this study may help in resolving the renal hemorrhage. Case Presentation: In this case series, we report the effective management of post-PCNL hemorrhage with nephroscopy and nephrostomy and drainage and tamponade because angioembolization was not feasible. Conclusion: Delayed bleeding after PCNL may be managed conservatively with nephrostomy drainage and tamponade when angioembolization is not feasible.

Symptom Resolution and Recurrence Outcomes after Partial Versus Total Laparoscopic Adrenalectomy: 13 years of Experience with Medium-Long Term Follow up.

PURPOSE: Partial adrenalectomy (PA) is an emerging modality typically performed for the treatment of hereditary and sporadic bilateral tumors, to reduce the risk of adrenal failure. In this study, we evaluated the recurrence and functional outcomes after partial and total adrenalectomy (TA). MATERIALS AND METHODS: From March 2005 to July 2018, 284 patients with functional tumor or > 5 cm adrenal mass underwent clipless and sutureless laparoscopic partial or total adrenalectomy (PLA and TLA). Patients with a pathological diagnosis of pheochromocytoma, Cushing or Conn's disease and more than two year follow up were included in this study. Pre-operative and operative variables were collected retrospectively and functional outcomes and recurrence were gathered prospectively. RESULTS: One hundred forty patients (mean age: 43±5.1years) were included in the study. PLA and TLA were performed for pheochromocytoma (total n=78; PLA=12 (15%), TLA=66 (85%)), Cushing syndrome (toal n=17; PLA = 4 (24%), TLA = 13 (76%)), and Conn's disease (total n=45; PLA=7 (16%), TLA=38 (84%)). In pheochromocytoma patients, improvement of hypertension, palpitation, and headache was not different between patients who underwent PLA versus TLA (all P > 0.05). Two recurrences were observed in patients with pheochromocytoma who had undergone TLA. In patients with Cushing disease, central obesity, fascial plethora, and hypertension were improved in all patients six months after treatment, muscle weakness was improved one year after surgery, and acne and hyperpigmentation only improved two years after surgery. The length of time for resolution of symptoms was not different in patients who underwent PLA versus TLA. In Conn's disease hypertension was resolved in all patients and no patient required potassium supplements post-operatively. In follow up no recurrence was observed in patients with a pathological diagnosis of Cushing or Conn's disease. CONCLUSION: In our experience, PLA can provide excellent control of the symptoms parallel with TLA and with no statistically significant difference in recurrence making PLA an attractive option in patients with an adrenal mass.

Iranian Urology Association Coronavirus Disease 2019 (COVID-19) Taskforce Pamphlet (IUA-CTP) Recommended Practice based on National Epidemiologic Analysis.

Since the emergence of Covid19 epidemics different guidelines and protocols have been published by Urology associations. Most of these recommendations have focused on the aptitude of any disease or condition for postponement. With the evolution of the outbreak, it is clear that postponement of procedures is not the policy we can rely on exclusively. We must know where do we stand? Where are we going in our country? How useful our recommendations have been for urology practitioners? We try to draw a clearer although-to some extent- conjectural picture and to adjust our protocols to this picture of outbreak evolution. Assuming that anything in this predicament is subject to unexpected changes. For these goals, we raise these arguments in three sections. First, where do we stand and where are we going? Explaining the present situation and best available statistics of the disease, the velocity the disease is spreading and our approximate predicted date its subsidence or partial remission. In a web form survey, we tried to evaluate that in the absence of a clear picture of outbreak progress in a specific area, how useful experts' points of view will be for the urologists working in non-referral centers especially in relevance to equivocal and challenging cases. Will there be any significant difference at all? In the third section, we try to give the plot to guide scheduling or postponing procedures in any given are according to the level of involvement. Here we considered both the characteristics of the special urology condition and also the situation and progress of the outbreak in that area.

Endoscopic Dilatation of Meatal Stenosis of Ureterocele in Adult Patients: An Easy and Innovative Technique with Literature Review.

This study presents initial experience in endoscopic meatal dilatation of obstructive ureterocele in adult patients. During cystourethroscopy, we tried to find the orifice of ureterocele, passed a guide wire and introduce an 8 Fr ureteroscope in to the ureterocele orifice, going up to the renal pelvis as under vision dilatation of ureterocele meatus. Two Double-J stent were inserted and remained for six weeks to keep the meatus dilated. Adverse effect of endoscopic management was decreased due to minimal anatomic changes. Patients' symptoms were relieved and no evidence of new onset vesico-ureteral reflux and obstruction were seen after up to one-year follow-up. Endoscopic meatal dilatation of stenotic ureterocele in adult patients is safe and effective thus, trying to find the orifice of ureterocele is suggested.

Factors Predicting Prostate Specific Antigen Failure Following Radical Prostatectomy: Experience with 961 Patients.

OBJECTIVE: To determine disease-related predictors for the occurrence of prostate specific antigen (PSA) failure in Iranian prostate cancer patients who underwent radical prostatectomy. METHODS: In this cohort study, we enrolled eligible patients with prostate cancer who underwent radical prostatectomy at our center between 2001 and 2018. The primary endpoint was the incidence of postoperative biochemical failure, defined as two consecutive PSA levels >= 0.2 ng/dl. Patients with TNM stage >= III, Gleason score >=8, or baseline PSA above our calculated cut-off level were considered as high risk. Kaplan-Meier survival method and Cox proportional hazards regression analysis were used for determining the biochemical relapse-free survival and its predictors. RESULTS: Data of 959 patients (age=61.2 ± 6.4 years) were analyzed with a median follow up of 36 months (range 6 months to 18 years). A total of 97 patients (10.1%) developed biochemical failure at the time of analysis who had a significantly older age and longer follow-up duration (P=0.024 and P<0.001, respectively). Preoperative PSA level of 8.85 mg/dl could predict the occurrence biochemical failure with a sensitivity of 83.2% and specificity of 39.2% (Area under the curve=0.601, 95% CI: 0.541-0.662; P=0.001). In the multivariate analysis, higher preoperative PSA, Gleason score?8, and high-risk TNM stage were independent predictors for biochemical relapse (P=0.029, P=0.001, and P=0.008, respectively). CONCLUSION: Preoperative PSA, Gleason score, and TNM stage were independent predictors for biochemical failure following radical prostatectomy in prostate cancer patients. We also determined a lower cut-point for PSA that could predict biochemical failure.