Initial outcomes and surgical techniques of prostatic urethral lift for benign prostatic hyperplasia in Japan.

OBJECTIVES: The prostatic urethral lift (PUL) has been used as a minimally invasive surgery for benign prostatic hyperplasia (BPH) since April 2022 in Japan. This study evaluated the initial outcomes and surgical techniques of PUL for BPH. METHODS: In this prospective, single-center study, indications were based on the proper use guidelines for PUL in Japan. Preoperative patient status, postoperative progress at 1 and 3 months, and perioperative complications were evaluated. The surgical technique was changed twice, and the subgroup analysis and technique were evaluated. RESULTS: Of the 50 patients who underwent surgeries performed by a single surgeon, the median age and prostate volume were 71 years and 42.0 mL, respectively. Furthermore, the median operative time and number of implants used were 20 min and 5, respectively. No postoperative fever or severe hematuria requiring reoperation occurred. All patients were discharged from the hospital the day following the PUL, as scheduled. Postoperative International Prostate Symptom Score, quality of life score, maximum flow rate, and postvoid residual volume at 1 and 3 months were significantly improved compared with the preoperative values. A significant improvement in maximum flow rate was observed in the subgroup analysis from 1 month postoperatively in the group with an anterior channel creation focus. CONCLUSIONS: PUL is effective and safe in cases with prostate volumes of <100 mL. Lifting the bladder neck is important for opening an anterior prostatic urethral channel and improving urinary function during the early postoperative period.

Perioperative changes in ganglioside monosialodihexosylganglioside (GM3) molecular species for benign prostatic hyperplasia: a preliminary report.

Benign prostatic hyperplasia (BPH) progresses with age and is associated with chronic inflammation. We focused on the relationship between BPH and ganglioside monosialodihexosylganglioside (GM3), a sialic acid-containing glycosphingolipid that is involved in chronic inflammation. GM3 molecular species would have a significant role in regulating inflammatory processes. In this prospective study, preoperative and postoperative serum samples were obtained from patients who underwent holmium laser enucleation of the prostate (HoLEP) for BPH. Preoperative and postoperative measurements of serum GM3 species were performed one month before and three months after HoLEP. Twenty-three patients were included in the study. The average patient age was 75 years, and the average prostate volume was 66 mL. The average weight of the surgically resected prostate tissue was 42 g. At three months after HoLEP, the serum concentration of GM3 species was found to have decreased after HoLEP compared with the preoperative concentration of GM3 species. Six GM3 species such as d18:1-17:0 [C17 acyl chain (-17:0) linked to a C18 sphingosine base with a double bond (d18:1-) by an amide linkage], were significantly reduced. The sample size was small; therefore, this study showed only preliminary results and could not evaluate prostate tissue inflammation. This study showed that the serum concentrations of several GM3 species, which indicate chronic inflammation, may be significantly reduced after BPH surgery.

Sodium-glucose cotransporter-2 inhibitors increase urinary tract infections?-a cross sectional analysis of a nationwide Japanese claims database.

Sodium-glucose cotransporter-2 (SGLT2) inhibitors are a novel class of antidiabetic drugs. Guidelines for the proper use of SGLT2 inhibitors recommend caution regarding urinary tract infections (UTIs). However, little evidence has been reported on the relationship between SGLT2 inhibitors and UTIs in large epidemiological studies. We investigated (1) the relationship between diabetes mellitus (DM) and UTIs and (2) the relationship between SGLT2 inhibitor prescriptions and the likelihood of developing UTIs in patients with DM, using a nationwide Japanese health insurance claims database by MDV analyzer®. We found that the incidence of UTIs was significantly higher among patients with DM than among those without DM (odds ratio (OR), 1.71; 95% confidence interval (CI), 1.69-1.72, for male; OR, 1.90; 95% CI, 1.89-1.92 for female). In contrast, in male patients with DM, the prescription of SGLT2 inhibitors was negatively associated with the likelihood of developing UTIs (OR, 0.74; 95% CI, 0.72-0.75). Among female patients with DM, there was no significant difference in the incidence of UTIs with or without an SGLT2 inhibitor prescription (OR, 0.99; 95% CI, 0.96-1.01). Subgroup analyses by age confirmed similar relationships between SGLT2 inhibitor prescriptions and UTIs, except for female patients aged ≤39 years, in whom SGLT2 inhibitor prescription was negatively associated with the likelihood of developing UTIs. In conclusion, our analysis of a nationwide claims database found no evidence that SGLT2 inhibitors increase UTIs in Japanese patients with DM, regardless of sex or age.

Inhibition of sodium-glucose cotransporter 2 suppresses renal stone formation.

BACKGROUND AND AIMS: Nephrolithiasis is a common renal disease with no effective medication. Sodium-glucose cotransporter-2 (SGLT2) inhibitors, an anti-diabetic agent, have diuretic and anti-inflammatory properties and could prevent nephrolithiasis. Here, we investigated the potential of SGLT2 inhibition against nephrolithiasis using large-scale epidemiological data, animal models, and cell culture experiments. METHODS: This study included the data of diabetic patients (n = 1,538,198) available in the Japanese administrative database and divided them according to SGLT2 inhibitor prescription status. For animal experiments, renal calcium oxalate stones were induced by ethylene glycol in Sprague-Dawley rats, and phlorizin, an SGLT1/2 inhibitor, was used for the treatment. The effects of SGLT2-specific inhibition for renal stone formation were assessed in SGLT2-deficient mice and a human proximal tubular cell line, HK-2. RESULTS: Nephrolithiasis prevalence in diabetic men was significantly lower in the SGLT2 inhibitor prescription group than in the non-SGLT2 inhibitor prescription group. Phlorizin attenuated renal stone formation and downregulated the kidney injury molecule 1 (Kim1) and osteopontin (Opn) expression in rats, with unchanged water intake and urine volume. It suppressed inflammation and macrophage marker expression, suggesting the role of the SGLT2 inhibitor in reducing inflammation. SGLT2-deficient mice were resistant to glyoxylic acid-induced calcium oxalate stone formation with reduced Opn expression and renal damages. High glucose-induced upregulation of OPN and CD44 and cell surface adhesion of calcium oxalate reduced upon SGLT2-silencing in HK-2 cells. CONCLUSION: Overall, our findings identified that SGLT2 inhibition prevents renal stone formation and may be a promising therapeutic approach against nephrolithiasis.

Inhibition of platelet-derived growth factor pathway suppresses tubulointerstitial injury in renal congestion.

OBJECTIVE: Increased central venous pressure in congestive heart failure is responsible for renal dysfunction, which is mediated by renal venous congestion. Pericyte detachment from capillaries after renal congestion might trigger renal fibrogenesis via pericyte-myofibroblast transition (PMT). Platelet-derived growth factor receptors (PDGFRs), which are PMT indicators, were upregulated in our recently established renal congestion model. This study was designed to determine whether inhibition of the PDGFR pathway could suppress tubulointerstitial injury after renal congestion. METHODS: The inferior vena cava between the renal veins was ligated in male Sprague-Dawley rats, inducing congestion only in the left kidney. Imatinib mesylate or vehicle were injected intraperitoneally daily from 1 day before the operation. Three days after the surgery, the effect of imatinib was assessed by physiological, morphological and molecular methods. The inhibition of PDGFRs against transforming growth factor-ß1 (TGFB1)-induced fibrosis was also tested in human pericyte cell culture. RESULTS: Increased kidney weight and renal fibrosis were observed in the congested kidneys. Upstream inferior vena cava (IVC) pressure immediately increased to around 20 mmHg after IVC ligation in both the imatinib and saline groups. Although vasa recta dilatation and pericyte detachment under renal congestion were maintained, imatinib ameliorated the increased kidney weight and suppressed renal fibrosis around the vasa recta. TGFB1-induced elevation of fibrosis markers in human pericytes was suppressed by PDGFR inhibitors at the transcriptional level. CONCLUSION: The activation of the PDGFR pathway after renal congestion was responsible for renal congestion-induced fibrosis. This mechanism could be a candidate therapeutic target for renoprotection against renal congestion-induced tubulointerstitial injury.

Impact of preoperative factors on catheter position in peritoneal dialysis: a prospective cohort study.

BACKGROUND: Peritoneal dialysis (PD) catheter malposition is one of the complications of renal replacement therapy. This study aimed to determine the preoperative factors that cause PD catheter malposition. METHODS: The prospective cohort study included patients who underwent PD catheter insertion surgery and had preoperative and postoperative computed tomography scans. We compared preoperative and intraoperative factors between the lower depth catheter group (group L) and upper depth catheter group (group U), and preoperative and intraoperative factors between the posterior catheter group (group P) and anterior catheter group (group A). In addition, PD catheter obstruction requiring surgical intervention in each group was followed up for 1 year. RESULTS: A total of 150 patients were categorized into groups L (n = 77) and U (n = 73), or groups P (n = 107) and A (n = 43). Body mass index (BMI; P = 0.02), subcutaneous fat area (P = 0.02), and rate of previous abdominal surgery (P = 0.01) were significantly lower in group L than in group U. In terms of anterior catheter position, females had more-anterior catheter positions. The time to PD catheter obstruction requiring surgical intervention (P = 0.03) was significantly lower in group U than in group L. CONCLUSIONS: High BMI, high subcutaneous fat area, high subcutaneous fat thickness, and previous abdominal surgery were identified as preoperative factors that cause the PD catheter to have an upper depth. Female sex was a preoperative influencing factor for the anterior PD catheter position.

Safety of peritoneal dialysis catheter surgery under dexmedetomidine and local anesthesia for elderly patients in Japan: a single-center prospective cohort study.

BACKGROUND: The number of patients aged ≥ 75 years and who need renal replacement therapy is steadily increasing. The study aimed to determine the safety of open surgery for peritoneal dialysis (PD) catheter placement in such patients. METHODS: This prospective cohort study included patients who underwent PD catheter placement by open surgery under dexmedetomidine (DEX) and local anesthesia at our institution from January 2015 to February 2021. Patients were divided into the following two groups according to age at the time of surgery: ≥ 75 years (group A) and < 75 years (group B). We compared the perioperative and postoperative complications (i.e., time to the first PD-related peritonitis and catheter obstruction requiring surgical intervention within 1 year) between the groups. RESULTS: A total of 118 patients were categorized into groups A (n = 65) and B (n = 53). No significant intergroup differences were observed in the postoperative fever, total duration of surgery, perioperative hemoglobin decrease, changes in the white blood cell count and C-reactive protein, postoperative catheter leakage, postoperative hospital stay, time to the first PD-related peritonitis, and catheter obstruction requiring surgical intervention within 1 year. CONCLUSIONS: The surgery for PD catheter placement by open surgery under DEX and local anesthesia in elderly patients is safe and effective.

The Impact of Preoperative Risk Factors on Peritoneal Dialysis-Related Peritonitis: A Single-Center Prospective Study in Japan.

Background and Objectives: Peritoneal dialysis (PD)-related peritonitis is a critical problem. However, preoperative risk factors for PD-related peritonitis have not been established. Thus, we aimed to determine the preoperative risk factors for PD-related peritonitis. Materials and Methods: This is a single-center prospective observational study. All peritonitis episodes during the study period were recorded, and preoperative and intraoperative clinical parameters were compared between patients with and without peritonitis to examine risk factors for PD-related peritonitis. Furthermore, subcutaneous and abdominal fat volumes were evaluated using computed tomography. Results: Among a total of 118 patients, 24 patients developed peritonitis. The proportion of male patients (83% vs. 61%, p = 0.04), body mass index (25 vs. 22 kg/m2, p = 0.04), and subcutaneous fat area (120 vs. 102 cm2, p = 0.01) were significantly higher and the proportion of patients living with family members (75% vs. 94%, p = 0.02) was significantly lower in the peritonitis group than in the non-peritonitis group. There were no significant differences in age, operation method, surgeon experience, previous abdominal surgery, medical history of diabetic nephropathy, serum albumin level, and renal function between the two groups. Conclusions: Male patients with high subcutaneous fat who are living alone might be at higher risk of PD-related peritonitis. These characteristics might be useful in risk assessment and patient education before PD induction.

Efficacy of one-surgeon basketing technique for stone extraction during flexible ureteroscopy for urolithiasis.

Objective: To evaluate the safety and efficacy of using one-surgeon basketing technique by a solo surgeon for stone extraction during flexible ureteroscopy (f-URS) for urolithiasis. Patients and methods: This retrospective study enrolled patients with urinary calculus who underwent f-URS at two institutions in Japan between September 2014 and March 2020. A total of 100 patients were operated by one experienced surgeon using the one-surgeon basketing technique. With this approach, the f-URS apparatus was manipulated with the non-dominant hand and the basket catheter was manipulated with the dominant hand. We retrospectively examined the perioperative results, complications, and stone-free rate [with 'stone free' defined as ≤2 mm with kidney-ureter-bladder (KUB) at 1 month after f-URS] to estimate the safety and efficacy for comparison with the results of conventional retrieval basketing technique. Results: Among our study population, the median stone size was 14 mm and median operative time was 74 min. A stone-free status was achieved in 91 patients (91%). The median stone fragmentation time was 15 min and stone retrieval time was 30 min. All included patients were treated using the one-surgeon basketing technique. Complications related to stone retrieval were identified in two patients (2%); the degree of ureteral injury was classified as Clavien-Dindo Grade IIIa. Conclusion: The one-surgeon basketing technique is safe and effective for the extraction of stone fragments during f-URS for urolithiasis. This technique does not require assistance for basketing; therefore, f-URS with active retrieval basketing can be completed by a solo surgeon. Abbreviations: BMI: body mass index; KUB: kidney-ureter-bladder; SFR: stone-free rate; UAS: ureteral access sheath; f-URS: flexible ureteroscopy.

The impact of preoperative percutaneous nephrostomy as a treatment strategy before flexible ureteroscopy for impacted upper ureteral stones with hydronephrosis.

BACKGROUND: The treatment of impacted upper ureteral stones with hydronephrosis remains a challenge for urologists. The current study aimed to evaluate the impact of preoperative percutaneous nephrostomy (PNS) as a treatment strategy before flexible ureteroscopy (f-URS) of asymptomatic impacted upper ureteral stones with hydronephrosis. METHODS: This multicenter retrospective study included patients who underwent PNS (group A, n=61) and those who did not (group B, n=75) before f-URS for asymptomatic impacted upper ureteral stones with hydronephrosis. Impacted ureteral stones are defined as those that remain in one position for >2 months. Operative outcomes, including stone-free rate, operation time, postoperative hospital days, and complication rate, were evaluated. RESULTS: There were no significant differences in age, sex, and stone size between the two groups except in the grade of hydronephrosis, with group A having more cases of advanced hydronephrosis than group B. The stone-free rate was significantly higher in group A than in group B [95% vs. 77% (P=0.004)]. However, there were no significant differences between the groups in operation time [55 vs. 55 min (P=0.84)], postoperative fever [5% vs. 5% (P=1.00)], and postoperative hospital days [2 vs. 2 days (P=0.44)]. In group A, preoperative PNS placement was performed 4 days before f-URS, and the PNS was removed postoperatively on the same day of the f-URS. Additionally, subgroup analysis was performed in cases of grade 2 and 3 hydronephrosis. A total of 110 patients, 60 who underwent f-URS with PNS and 50 who underwent f-URS without PNS, were included. The stone-free rate was significantly higher in f-URS with PNS than in f-URS without PNS [95% vs. 76% (P=0.005)]. However, no significant differences were found between the groups in operation time, ureteral injury, postoperative fever, and postoperative hospital days. CONCLUSIONS: At grade 2 or 3 hydronephrosis, preoperative PNS as a treatment strategy for a few days prior to f-URS for impacted upper ureteral stones improved the stone-free rate without increasing the operation time and postoperative length of hospital stay.