What Is the Ideal Treatment for 20-30 mm Kidney Stones? Comparative Outcomes of 1197 Patients.

Background: The purpose of this study is to compare the efficacy and safety of extracorporeal shockwave lithotripsy (SWL), retrograde intrarenal surgery (RIRS), mini-percutaneous nephrolithotomy (mPNL), and standard-percutaneous nephrolithotomy (stPNL) for the treatment of 20-30 mm kidney stones. Methods: The records of 1197 patients (SWL = 149, RIRS = 205, mPNL = 525, and stPNL = 318) from 8 centers were reviewed retrospectively. Four procedures were compared for stone-free rates (SFRs), auxiliary treatment, and associated complications. Results: Initial SFRs were 43.6%, 54.6%, 86.7%, and 87.7% in SWL, RIRS, mPNL, and stPNL, respectively (P < .001), whereas the final SFRs were 71.8%, 80%, 90.5%, and 89.6% (P < .001). The rate of auxiliary treatment in the groups was 38.3%, 26.8%, 5%, and 4.4%, respectively (P < .001). The initial and final SFRs in the mPNL and stPNL groups were higher than those in SWL and RIRS groups (P < .001). The rate for auxiliary treatment was lower in the mPNL and stPNL groups (P < .001). The operation time was longer in the RIRS group (P = .005). According to the Clavien-Dindo classification, the complication rate in the SWL group was lower than that in the surgical approaches (P < .001); however, no statistical difference was detected between RIRS, mPNL, and stPNL groups. mPNL and stPNL had a higher success rate than RIRS or SWL for treating 20-30 mm kidney stones. Conclusion: In the treatment of 2-3 cm renal stones, RIRS and PNL were more effective than SWL to obtain a better SFR and less auxiliary treatment rate. Compared with RIRS, mPNL and stPNL provided a higher SFR with similar complication rates.

Fluid intake recommendations in urolithiasis and general advice to patients without metabolic risk factors.

Urolithiasis is a highly prevalent global disease with substantially increasing incidence in the last two decades. Data from the literature suggests that 26%-50% of patients will have a recurrence within 10 years after an initial symptomatic stone episode. Therefore, interest has been raised in preventive strategies, aiming to modify the risk factors of stone recurrence by implementing dietary and lifestyle changes and specific medical treatments for stone formers, depending on their recurrence risk factors. Certain dietary factors are thought to contribute significantly to the increased incidence of urolithiasis, particularly a diet low in fiber and high in animal protein, fat, and sodium. Fluid intake is perhaps the most important and modifiable step in the prevention of urolithiasis, irrespective of stone composition. However, the amount of fluid to be consumed and the implications of various fluid types on stone formation are still controversial. In this article, the relationship between fluid intake, beverage types and stone formation-prevention will be discussed. Moreover, general dietary recommendations for patients without metabolic risk factors will be reviewed based on the current literature.

Lower Urinary Tract Reconstruction for Ectopic Ureterocele: What Happens in the Long-term Follow-up?

BACKGROUND: We aimed to analyze the long-term clinical and lower urinary tract function outcomes in children with duplex system ectopic ureterocele who underwent ureteroneocystostomy and ureterocelectomy. METHODS: Fifty-one patients (28 females, 23 males) who underwent a series of surgical interventions including lower urinary tract reconstruction in childhood for duplex system ectopic ureterocele in our center between 1998 and 2019, were retrospectively reviewed. The demographic and clinical data, surgical history, and the indication for ureterocelectomy were noted. Lower urinary tract dysfunction (LUTD) status was assessed through dysfunctional voiding symptom scores (DVSS) and uroflowmetry in all patients at the last follow-up. The clinical outcomes, and LUTD were evaluated. RESULTS: At the last visit at a mean follow-up of 117.18 ± 57.87 months after ureterocelectomy, ipsilateral persistent lower pole VUR was detected in 5.6% (3/54 renal units, 2 females and 1 male) of the cases, who were treated using the subureteric injection. Abnormal DVSS (median 11, range 9-15) was detected in 27.4% (14/51 pts) of the patients. Out of these, 57.1% (8/14 pts) had storage symptoms, 35.7% (5/14 pts) had voiding symptoms, and 7.1% (1/14 pts) had both storage and voiding symptoms while 71.4%(10/14 pts) had abnormal uroflowmetry findings (plateau shaped flow curve in 2, staccato shaped curve with sustained EMG activity in 3, tower shaped curve in 2, interrupted shaped curve in 3 patients). Five patients had elevated residual volume. Anticholinergics were administered to six patients who had overactive bladder symptoms. In addition, two girls required open bladder neck reconstruction due to stress incontinence caused by bladder neck insufficiency. CONCLUSIONS: Our findings showed that clinical success was achieved using the lower urinary tract reconstruction with no need for re-operation in 90.2% of patients with duplex system ectopic ureterocele. However, LUTD was present in 27.4% of our patients in the long-term follow-up. Therefore, LUTD should be carefully assessed in the long-term follow-up of these patients.

Attitudes of urologists on metabolic evaluation for urolithiasis: outcomes of a global survey from 57 countries.

Although stone disease is an important health problem with high incidence and recurrence rates, it is a preventable disease. Attitudes and practices of urologists regarding the prevention of recurrence continue to be a subject of debate. In this context, an online survey study was conducted involving 305 urologists from 57 different countries. The first 7 questions collected demographic data about the urologists and the remaining 23 questions were about the recurrence and metabolic evaluation, medical treatment, and follow-up of urinary stone disease. Most urologists (85.2%) thought that metabolic examination was important. Approximately one-third of the participants (34.1%) performed 24-hour urine analysis and stone analysis was ordered by 87.5% of the urologists. Metabolic analysis was performed for all patients by 14.7% of the participants. For pediatric patients this rate was 68.5%, and for adults with recurrence the rate was 81.6%. Reasons cited by the urologists for not performing metabolic analysis included not feeling confident doing so (18.3%), having limited facilities in their hospital (26.5%), having an excessive daily workload (31.8%), patient-related factors (27.5%), and referring patients to other departments for metabolic evaluation (20.9%). Although majority of the responding urologists do consider the metabolic analysis as vital important, they seemed not to be willing to perform these tests with the same degree of enthusiasm in their daily practice. Our results show that urologists need support in performing and interpreting 24-hour urine analysis, improving their knowledge levels, and communicating with patients. Urology residency training should focus more on the prevention of urinary stone recurrence in addition to the surgical training.

Could retrograde intrarenal surgery be a safe and effective alternative to mini-percutaneous nephrolithotomy in the management of relatively large (20-30 mm) stones? A critical evaluation.

PURPOSE: To compare the outcomes of mini-percutaneous nephrolithotomy (mPCNL) and retrograde intrarenal surgery (RIRS) in patients with renal stones sizing 2-3 cm. METHODS: A total of 566 patients from 6 institutions who underwent mPCNL (n = 440) and RIRS (n = 126) procedures were enrolled in our study. The retrospective patient cohort was reviewed and compared. Binary logistic regression analysis was performed to determine factors predicting success in the RIRS group. RESULTS: The stone-free rates were 91.1 and 77% for the mPCNL and RIRS groups, respectively (p < 0.001). The auxiliary procedure rates were 4.5 and 39.7% in the mPCNL and RIRS groups, respectively (p < 0.001). Mean values of hemoglobin decrease, fluoroscopy time, and hospitalization time were significantly higher in the mPCNL group (p < 0.001). While the Clavien grade 1-2 complication rates were 10.9 and 34.1% (p < 0.001) in two groups, these values were 2.7 and 1.6% (p = 0.539), respectively, for Clavien grade 3-4 complication rates. Although three patients in the mPCNL group received blood transfusions, none of the patients in the RIRS groups were transfused. The stone location and stone density parameters were found to be the independent predictive factors for RIRS success. CONCLUSIONS: mPCNL provided a higher stone-free rate, less need for the auxiliary procedure, and lower complication rates compared to RIRS in patients with 2-3 cm stones. Blood loss, radiation exposure, and a hospital stay of mPCNL can be significantly reduced with the RIRS technique in selected patients.

Evaluation of the optimal duration for retrograde intrarenal stone surgery to prevent postoperative complications.

OBJECTIVE: To evaluate retrograde intrarenal surgery (RIRS) outcomes and to determine the effect of operative time on complications of RIRS. METHODS: Patients undergoing RIRS for renal stones were evaluated. These patients were divided into two groups according to the operation time (Group 1<60 minutes and Group 2>60 minutes). Peroperative outcomes such as fluoroscopy time, stone-free rates, complications and duration of hospitalization were compared. RESULTS: Group 1 consisted of 264 patients and Group 2 consisted of 297 patients. SFR rates, duration of hospitalization, and postoperative urinary tract infection rates were similar in both groups. Fluoroscopy time was 7.8±7.3 (0-49) sec in group 1 and 13.1±9.8 (0-81) sec in group 2. Complications according to modified Clavien-Dindo classification system (MCDCS) were 13 and 32 patients (Grade 1), 31 and 63 patients (Grade 2), 1 and 1 patient (Grade 3) in group 1 and 2, respectively. There was statistical difference between the two groups in terms of duration of fluoroscopy time and the MCDCS. Although duration of hospitalization and UTI rates were higher in group 2, no statistical significance was observed among groups. CONCLUSION: Limiting the operation time to 60 minutes in RIRS seems to be important in reducing postoperative complications.

Diabetes mellitus is the only independent predictor of both postoperative and long term renal functions in elective laparoscopic partial nephrectomy with limited or overextended warm ischemia.

OBJECTIVE: To investigate the predictive factors of renal functional change at postoperative period and at last follow-up in patients undergoing elective and clamped laparoscopic partial nephrectomy (LPN) with limited (≤20 minutes) and overextended (≥40 minutes) warm ischemia time (WIT). MATERIAL AND METHODS: From our prospectively collected LPN database, elective and warm ischemia-applied LPNs were retrospectively analyzed in two groups: limited (n=55, Group 1, WIT≤20 minutes) and overextended (n=28, Group 2, WIT≥40 minutes) WITs. Preoperatively, estimated glomerular filtration rate (eGFR) was ≥60 mL/min/1.73 m2 in all patients. Demographic, clinical, perioperative and renal functional parameters were compared between two groups. Age, diabetes mellitus (DM), pathological tumor size, preoperative eGFR and WIT were used in multivariable analyses to investigate the independent predictors of de novo Stage 3 or greater chronic kidney disease (CKD) (eGFR<60 mL/min/1.73m2) at postoperative period and at the last follow-up. RESULTS: Preoperative (p=0.009) and pathological (p=0.011) tumor size, PADUA (p=0.001) and R.E.N.A.L. Nephrometry (p=0.006) scores and operative time (p<0.001) were significantly higher in Group 2. Preoperative eGFR (86 vs. 88 mL/min/1.73 m2, p=0.328) was similar between two groups. In postoperative period, compared to Group 1, decreased eGFR (86 vs. 62.5 mL/min/1.73 m2, p<0.001) and percent preserved eGFR (97.2 vs. 77.2%, p<0.001) were found in Group 2. After median follow-up of 33 and 30 months (p=0.732) for Groups 1 and 2, respectively, eGFR at the last follow-up (84 vs. 80.0 mL/min/1.73 m2, p=0.347) and percentage preserved eGFR at last follow-up (97.7 vs. 92.5%, p=0.806) were similar between two groups. Overextended WIT (≥40 minutes), preoperative decreased eGFR (<77.5 mL/min/1.73m2) and DM were the independent predictors of de novo Stage 3 or greater CKD at postoperative period, while DM and age were the predictors of de novo Stage 3 or greater CKD at the last follow-up. CONCLUSION: Overextended WIT (≥40 minutes) caused significant postoperative renal functional loss in elective LPN but this functional loss recovers at long term follow-up. However, diabetes mellitus is the only predictor of renal functional loss both in the postoperative period and at the last follow-up.

Evaluation of gonadotropin-replacement therapy in male patients with hypogonadotropic hypogonadism.

Hypogonadotropic hypogonadism (HH) is a rare disease in which medical treatment has a high success rate to achieve fertility. This study aimed to analyze the efficacy of hormone replacement therapy and determine predictive factors for successful spermatogenesis and spontaneous pregnancy in patients with idiopathic HH. A total of 112 patients with low testosterone (T), luteinizing hormone (LH) and follicle-stimulating hormone (FSH), and normal prolactin levels were diagnosed with HH and administered LH and FSH analogs as hormone replacement therapy. During treatment, 96 (85.7%) patients had sperm present in ejaculate samples. Among these patients, 72 were married and wanted a child. Of these 72 patients, 48 (66.7%) of couples had pregnancies from natural conception. After initiation of treatment, the mean time for the appearance of sperm in semen was 9.48 months. There were no significant differences between baseline FSH, T, and LH levels; however, older age, larger testicular size, and low rate of undescended testes were favorable factors for successful spermatogenesis. Larger testicular size and older age were also the main predictive factors for natural conception. We found that patients with undescended testes had a younger age, smaller testes, and lower T levels compared with patients exhibiting descended testes. The rate of sperm found in the ejaculate was not significantly decreased in patients with undescended compared with descended testis (73.7% vs 87.6%, P = 0.261). The medical approach for males with HH and azoospermia provides a successful treatment modality in regard to successful spermatogenesis and achievement of pregnancy.

The association between variant urothelial histologies, pathological stage and disease specific survival in patients with bladder cancer.

OBJECTIVE: We aimed to compare the oncological outcomes of patients with variant urothelial histologies (VH) with pure urothelial histology (PUH) in bladder cancer (BC) patients. MATERIAL AND METHODS: This study includes 223 patients who underwent radical cystectomies (RCs) between September 2006 and July 2016 with complete follow-up data A retrospective screening was performed to identify the patients with PUH and VH. The primary outcomes of interest were pathological stage of disease at RC and disease-specific survival (DSS). For comparison of categorical variables, Fisher's exact test and Pearson chi- square and for continuous variables Wilcoxon rank-sum and Mann-Whitney U tests were used. Kaplan-Meier (KM) method was used for survival analysis and log-rank test was used for comparison of survival rates. Predictors of survival were detected with mulitivariable Cox-proportional hazards model including the variables such as gender, age, existence of VH, lymph node dissection (LND) type and pathological stage of the disease. RESULTS: A moderate-degree correlation was detected between VH and pathological stages of RC (r=0.45, p<0.001). In PUH group, 39 (25.8%) of 151 patients died after a median follow-up of 20 (0-107) months; whereas 37 (51.4%) of 72 patients with VH died after a median follow-up of 16.5 (0-104) months (p<0.001). In terms of pathological stage, the number of patients with PUH and VH were at stages pT0-2 (n=100; 66.2% vs. n=19; 26.4%), pT3-4 (n=35; 23.2% vs. 38; 52.8%, and in 16 (10.6%) and 15 (20.8%) patients with LN positivity, respectively (p<0.001). KM survival analysis revealed a significantly decreased DSS in patients with VH compared to PUH (p<0.001). Meanwhile, pathological disease stage and existence of VH were found to be associated with decreased DSS in the multivariate model. CONCLUSION: The present study revealed that VH is associated with advanced pathological tumor stage at RC and decreased DSS compared to patients with PUH in patients with BC.

Prospective evaluation of complications in laparoscopic urology at a mid-volume institution using standardized criteria: Experience of 1023 cases including learning curve in 9 years.

AIM: To evaluate the laparoscopic operations performed in our department according to the modified Clavien classification system of complications. MATERIALS AND METHODS: Between September, 2005 and February, 2014, a total of 1023 laparoscopic cases were performed. This period was divided into three terms (Terms 1, 2 and 3 consisting of 38, 32 and 32 months, respectively). According to the European Scoring System (ESS), easy (E), slightly difficult (SD), fairly difficult (FD), difficult (D), very difficult (VD) and extremely difficult (ED) cases were 35, 88, 170, 390, 203 and 137, respectively. The perioperative complications were evaluated based on the 3 time periods, with a specific emphasis on determining the learning curve according to the modified Clavien classification system of complications. RESULTS: A total of 236 (23.1%) complications were observed according to the modified Clavien classification. The minor (Clavien I-II) and major (Clavien III, IV and V) complication rates were 20.5% (n = 210) and 2.4% (n = 26), respectively. Clavien I was the most frequently encountered type of complication (n = 120, %11.7). No significant difference was observed among all 3 time periods regarding total complication rates. The D cases had the highest complication rate compared to E, SD, FD, VD and ED cases among all three terms. The total number of complications increased significantly with increasing grade of technical difficulty according to the ESS. CONCLUSION: Complications encountered in our laparoscopic surgery experience were predominantly minor, and the rate of complications was not significantly increased during the learning curve. The present data can provide guidance and manage expectations for surgeons introducing laparoscopy into their practice.

Warm Ischemia-Related Postoperative Renal Dysfunction in Elective Laparoscopic Partial Nephrectomy Recovers During Intermediate-Term Follow-Up.

PURPOSE: To analyze the impact of warm ischemia time (WIT) on early postoperative and ultimate renal function after elective laparoscopic partial nephrectomy (LPN). PATIENTS AND METHODS: One hundred and twenty-seven patients who underwent elective, ischemia-applied LPN were investigated in this study. The study patients were without stage 3 or greater chronic kidney disease (CKD) (estimated glomerular filtration rate [eGFR] <60 mL/min/1.73 m(2)) before LPN. Initially, the patients were grouped using the criteria of postoperative de novo stage 3 or greater CKD: Group A (n=104, eGFR ≥60 mL/min/1.73 m(2)) and group B (n=23, eGFR <60 mL/min/1.73 m(2)). The patients were also divided into two groups using 27.75 minute cutoff value obtained by receiver operating curve (ROC) analysis for WIT: Group 1 (n=69, WIT <27.75 min) and group 2 (n=58, WIT ≥27.75 min). The groups were compared with regard to demographic, perioperative, histopathologic, and renal functional outcomes. RESULTS: The decreased preoperative eGFR (P<0.001) and increased WIT (P=0.007), operative time (P=0.015), diabetes mellitus (DM) rate (P=0.019) and pathologic tumor size (P=0.031) were significantly different in group B. Multivariate analysis determined that independent predictors of de novo stage 3 or greater CKD in the early postoperative period were preoperative eGFR (P<0.001), WIT (P=0.014), and DM (P=0.030); meanwhile, preoperative eGFR (P=0.006) was the only independent predictor at last follow-up. Decreased median postoperative eGFR (P=0.018) and percent preserved postoperative eGFR (P=0.001) were significantly different in the increased WIT group, as well as elevated median postoperative eGFR loss (P=0.001). After similar follow-up (26 vs 23.5 months, P=0.913), the increased and limited WIT groups were not significantly different with regard to final eGFR (P=0.936), final eGFR loss (P=0.749) and percent preserved final eGFR (P=0.690). CONCLUSIONS: In elective LPN, increased WIT plays an important role in renal functional loss in the early postoperative period. This functional loss, however, recovered after an intermediate term follow-up period, similar to that of patients undergoing limited WIT.