Suction in Percutaneous Nephrolithotripsy: Evolution, Development, and Outcomes from Experimental and Clinical studies. Results from a Systematic Review.

CONTEXT: Controversy exists regarding the therapeutic benefit of suction use during percutaneous nephrolithotripsy (PCNL). OBJECTIVE: To review and highlight the options available in the use of suction for PCNL, and to discuss their strengths and limitations. EVIDENCE ACQUISITION: A systematic literature search was performed using Scopus, EMBASE, and PubMed. Thirty four studies were included. There was one ex vivo study. Among clinical studies, 24 used a vacuum/suctioning sheath and nine a handpiece suction device/direct-in-scope suction. The suction technique was employed in standard, mini-PCNL, supermini-PCNL, and enhanced supermini­PCNL techniques. EVIDENCE SYNTHESIS: Handpiece suction devices demonstrated better safety and efficiency in treating large stones than nonsuction PCNL and in a much shorter time. Trilogy and ShockPulse-SE were equally effective, safe, and versatile for standard PCNL and mini-PCNL. The heavier handpiece makes Trilogy less ergonomically friendly. Laser suction handpiece devices can potentiate laser lithotripsy by allowing for better laser control with simultaneous suction of small fragments and dust. Integrated suction-based sheaths are available in reusable and disposable forms for mini-PCNL only. Mini-PCNL with suction reported superior outcomes for operative time and stone-free rate to mini-PCNL. This also helped minimize infectious complications by a combination of intrarenal pressure reduction and faster aspiration of irrigation fluid reducing the risk of sepsis, enhance intraoperative vision, and improve lithotripsy efficiency, which makes it a very attractive evolution for PCNL. CONCLUSIONS: Suction devices in PCNL are reforming the way PCNL is being done. Adding suction to mini-PCNL reduces infectious complications and improves the stone-free rate. Our review shows that despite the limited evidence, suction techniques appear to improve PCNL outcomes. PATIENT SUMMARY: In this review, we looked at the intra- and perioperative outcomes of percutaneous nephrolithotripsy (PCNL) with the addition of suction. With better stone fragmentation and fewer postoperative infections, this technology is very useful particularly for mini-PCNL.

Near-Infrared Fluorescence Imaging with Indocyanine Green for Robot-Assisted Partial Nephrectomy: A Systematic Review and Meta-Analysis.

BACKGROUND: We aimed to analyze the influence of near-infrared fluorescence (NIRF) using indocyanine green (ICG) with standard robot-assisted partial nephrectomy (RAPN) in patients with a kidney tumor (KT). METHODS: We performed a literature search on 12 September 2023 through PubMed, EMBASE, and Scopus. The analysis included observational studies that examined the perioperative and long-term outcomes of patients with a KT who underwent RAPN with NIRF. RESULTS: Overall, eight prospective studies, involving 535 patients, were eligible for this meta-analysis, with 212 participants in the ICG group and 323 in the No ICG group. For warm ischemia time, the ICG group showed a lower duration (weighted Mean difference (WMD) = -2.05, 95% confidence interval (CI) = -3.30--0.80, p = 0.011). The postoperative eGFR also favored the ICG group (WMD = 7.67, 95% CI = 2.88-12.46, p = 0.002). No difference emerged for the other perioperative outcomes between the two groups. In terms of oncological radicality, the positive surgical margins and tumor recurrence rates were similar among the two groups. CONCLUSIONS: Our meta-analysis showed that NIRF with ICG during RAPN yields a favorable impact on functional outcomes, whereas it exerts no such influence on oncological aspects. Therefore, NIRF should be adopted when preserving nephron function is a paramount concern.

Can a prostate biopsy be safely deferred on PI-RADS 1,2 or 3 lesions seen on pre-biopsy mp-MRI?

Introduction: Multi-parametric magnetic resonance imaging (mp-MRI) is currently used to triage patients with suspected prostate cancer, before deciding on prostate biopsies. In our study, we evaluated normal and equivocal pre-biopsy mp-MRIs to see whether it is safe to avoid biopsy with such findings. Methods: A retrospective study was conducted at a district general hospital in the UK between August 2017 and July 2018. Patients with negative and equivocal prebiopsy mp-MRI with high clinical suspicion of cancer had proceeded to biopsy. MRI reports with prostate imaging reporting and data system (PI-RADS) scores 1, 2, 3 and normal MRI were evaluated against the transrectal ultrasound-guided prostate biopsy (TRUS-PB) outcomes to demonstrate benign pathology, clinically insignificant or clinically significant cancer (csCa). CsCa was defined as Gleason score (GS) ≥3 + 4. Results: Out of 265 mp-MRIs studied, five (1.9%) were PI-RADS 1, 109 (41.1%) and 84 (31.7%) were PI-RADS 2 and 3 lesions respectively; 67 (25.3%) were reported as normal. Seventy-five (27.3%) patients did not have biopsies following their MRI and 73.3% (51/75) of them had benign feeling prostate. Negative MRIs (PI-RADS 1, 2 and normal MRI) showed 8.8% and PI-RADS 3 lesions demonstrated 11.9% csCa. Negative predictive value for normal MRI was 91.2%. Mean PSA density (PSAD) among the benign, GS 3 + 3 and csCa was 0.14, 0.16 and 0.27 ng/ml/ml respectively and this was statistically significant (p < 0.001). The average percentage of cancer found in GS 3 + 3 and csCa was 3.2% and 20.1%, respectively. Conclusion: Avoiding TRUS-PB following normal or equivocal mp-MRI should carefully be decided as 18.5% of cancer was demonstrated in this group and 9.8% of those who were diagnosed with cancer were csCa. PSAD and DRE findings provide additional information to help with this decision.

Use of Anabolic-Androgenic Steroids and Male Fertility: A Systematic Review and Meta-analysis.

Background: Anabolic-androgenic steroids (AASs) are often used by men for bodybuilding and to improve sports performance. The use is not limited to professional competitive athletes, but many amateur men. Objective: The objective of this study was to assess and systematically review the effects of AAS on male fertility parameters, spermiogram, testosterone, follicle-stimulating hormone (FSH) and luteinising hormone (LH) and to review reversibility and other morbidity impacting fertility. Methods: Eligibility criteria - We included studies mentioning data about adult males using supraphysiologic doses of AAS for sports performance or appearance enhancement, with comparison data from general population or matched controls if available reporting fertility parameters and sexual performance. Information sources - A systematic literature search was performed using PubMed, MEDLINE, EMBASE, Google Scholar and World of Science. Controlled clinical trials randomised or nonrandomised (if available), case series with or without matched controls, case reports, cross-sectional surveys, reports on follow-up of subjects caught in doping test and their fertility parameters when reported. Risk of bias/quality assessment - The quality assessment of the included studies was performed using the Newcastle-Ottawa Scale. Results: Included studies - Thirty-two studies were included. There were 12 cohort studies, 5 case-control studies, 9 cross-sectional surveys and 6 case reports. The study population comprised 9371 individuals, of which 2671 were AAS users. Synthesis of results - AAS users had reduced levels of FSH and LH than the naïve population. These levels remained low for 3-6 months after stopping AAS. One year after stopping AAS, the users and naïve population had insignificant differences in FSH and LH values. The total testosterone (TT) levels were comparable in users and naïve populations at baseline, 3 months and 6 months after stopping, but at 1 year, TT values were lower in AAS users. Sperm concentration in AAS users and naïve population was similar, but sperm motility was lower in AAS users. The testicular size was lower in AAS users. The erectile function improved with AAS use, but on withdrawal, there was decreased libido and erectile dysfunction. Most AAS users need additional medications to mitigate detrimental effects on fertility. Description of the effect - AAS use negatively impacted the gonadotrophin levels and had lower sperm motility and testicular size. Strength - Comprehensive review of 32 publications, study population of 9371 individuals, of which 2671 were AAS users, meta-analysis of reproductive hormones, semen parameters and testis size. Limitations: The limitations are small sample size of most of the studies, polypharmacy, lack of information on dosing and high heterogeneity. Interpretation: AAS use is detrimental for sperm motility and has a partially reversible negative impact on male fertility. Users must be cautioned about its negative impact on libido and erectile function.Registration: PROSPERO Registration No. CRD42023411294.

Bilateral Single-System Ectopic Ureter: When Can We Avoid Bladder Neck Reconstruction?

Bilateral single-system ectopic ureter (BSSEU) is often associated with underdeveloped incompetent bladder neck; hence, to achieve continence, bladder neck reconstruction (BNR) is usually advocated with ureteric reimplantation. Presented here is a 14-year-old girl with BSSEU who achieved continence without BNR. An attempt is made to look at factors that could identify patients in whom BNR could be avoided.

Comparison and outcomes of dusting versus stone fragmentation and extraction in retrograde intrarenal surgery: results of a systematic review and meta-analysis.

Introduction: Lithotripsy during retrograde intrarenal surgery (RIRS) can be achieved either by fragmentation and extraction or dusting with spontaneous passage. We aimed to perform a systematic review on the safety and stone-free rate after RIRS by comparing the techniques of dusting vs fragmentation/extraction. Material and methods: This review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. The inverse variance of the mean difference and 95% Confidence Interval (CI), Categorical variables were assessed using Cochran-Mantel-Haenszel Method with the random effect model and reported as Odds Ratio (OR) and 95% CI. Statistical significance was set at p <0.05. Results: There were 1141 patients included in 10 studies. Stone size was up to 2.5 cm All studies used holmium laser for lithotripsy. Meta-analysis showed no significant difference in surgical time (MD -5.39 minutes 95% CI -13.92-2.31, p = 0.16), postoperative length of stay (MD -0.19 days 95% CI -0.60 - -0.22, p=0.36), overall complications (OR 0.98 95% CI 0.58-1.66, p = 0.95), hematuria (OR 1.01 95% CI 0.30-3.42, p = 0.99), postoperative fever (OR 0.70 95% CI 0.41-1.19, p = 0.19) and sepsis (OR 1.03 95% CI 0.10-10.35, p = 0.98), immediate (OR 0.40 95% CI 0.13-1.24, p = 0.11) and overall stone-free rate (OR 0.76 95% CI 0.43-1.32, p = 0.33), and retreatment rate (OR 1.35 95% CI 0.57-3.20, p = 0.49) between the groups. Conclusions: This systematic review infers that urologists can safely use either option of fragmentation and basket extraction or dusting without extraction to achieve similar outcomes as both techniques are similar for efficacy and safety.

Role of Macroscopic Image Enhancement in Diagnosis of Non-Muscle-Invasive Bladder Cancer: An Analytical Review.

Early diagnosis of non-muscle-invasive bladder cancer (NMIBC) is of paramount importance to prevent morbidity and mortality due to bladder cancer. Although white light imaging (WLI) cystoscopy has long been considered the gold standard in the diagnosis of bladder cancer, it can miss lesions in a substantial percentage of patients and is very likely to miss carcinoma in situ and dysplasia. Tumor margin detection by WLI can be inaccurate. Moreover, WLI could, sometimes, be inadequate in distinguishing inflammation and malignancy. To improve the diagnostic efficacy of cystoscopy, various optical image enhancement modalities have been studied. These image enhancement modalities have been classified as macroscopic, microscopic, or molecular. Photodynamic diagnosis (PDD), narrow band imaging (NBI), and Storz image 1 S enhancement (formerly known as SPIES) are macroscopic image enhancement modalities. A relevant search was performed for literature describing macroscopic image enhancement modalities like PDD, NBI, and image 1 S enhancement. The advantages, limitations, and usefulness of each of these in the diagnosis of bladder cancer were studied. Photodynamic diagnosis requires intravesical instillation of a photosensitizing agent and a special blue light cystoscope system. PDD has been shown to be more sensitive than WLI in the detection of bladder cancer. It is superior to WLI in the detection of flat lesions. Bladder tumor resection (TURBT) by PDD results in more complete resection and reduced recurrence rates. PDD-guided TURBT may have some role in reducing the risk of progression. Narrow band imaging provides increased contrast between normal and abnormal tissues based on neovascularization, thereby augmenting WLI. NBI requires a special light source. There is no need for intravesical contrast instillation. NBI is superior to WLI in the detection of bladder cancer. The addition of NBI to WLI improves the detection of flat lesions like carcinoma in situ. NBI is not useful in predicting invasive tumors or grades of tumors. NBI-directed TURBT reduces recurrence rates and recurrence free survival. But its efficacy in retarding progression is unproven. Image 1 S-enhancement utilizes software-based image enhancement modes without the need for a special light source or intravesical contrast instillation. This system provides high-quality images and identifies additional abnormal-looking areas. Another advantage of this system is simultaneous side-by-side visualization of WLI and enhanced image, providing WLI images as the control for comparison. As with PDD, S-enhancement produces a lower rate of a missed bladder cancer diagnosis. The system significantly improves the diagnosis of NMIBC. The sensitivity and negative predictive value of image 1 S enhancement increase with the increase in cancer grade. A negative test by S-enhancement effectively rules out NMIBC. All the image enhancement modalities have proven their utility in improving detection and short-term cancer control. But none of these modalities have proven their utility in delaying progression, or in long-term cancer control. Cancer progression and long-term control are governed by the biological nature of cancer cells. Early detection by optical enhancement may not be of utility in this regard. Well-designed studies are needed to establish the efficacy of these modalities in the evaluation of patients with bladder cancer. The last word, in this regard, is yet to be written.

Myiasis (maggots) around nephrostomy tube.

Myiasis is caused by the presence of dipterous larvae in humans and animals. It is usually associated with poor hygienic conditions. A urologist rarely comes across myiasis. We report a case of myiasis around a recently placed nephrostomy tube. A 55-year-old male farmer from a rural area underwent right percutaneous nephrolithotomy. The procedure was terminated because of bradycardia and arrhythmia. There were residual calculi. A nephrostomy was kept. His relook nephroscopy was planned, but he was not willing. Hence, he was discharged with an indwelling nephrostomy tube. Two weeks later, he presented with severe pain around the right nephrostomy tube with surrounding pruritus. The wound hygiene was poor. He was found to have maggots around the nephrostomy tube. These were treated by local instillation of turpentine oil and oral and topical ivermectin, followed by manual removal of the maggots.

Clinical Andrologists: Do We Really Need Them in the Era of ART?

Infertility is on a rise, and so is the availability of assisted reproductive technique (ART) centres. The sole aim of these centers is to help these unfortunate couples achieve pregnancy. Hence, the concentration of the treatment is on the female partner, while the male is relegated to just being a source for sperm. In the era of intracytoplasmic sperm injection, when pregnancy is possible even with a single mature sperm, evaluation and management of male factor infertility (MFI) is often neglected. MFI and poor semen parameters are markers of male health. He could be suffering from erectile or ejaculatory issues or with correctable obstructive azoospermia. A simple timely varicocele correction may help resolve the issue. It is important to understand that MFI is not a disease but may be a symptom of major underlying clinical condition like testicular or brain tumors. Infertility treatment could be the only occasion when a male seeks health-care evaluation. India has a large pool of qualified urologists trained in andrological care. In contrast, gynecologists may not be trained in the management of male patients, hence there is an important place for andrological services to be an integral part of ART centers. Andrologists would offer minimal andrological evaluation and condition-specific treatment. This could avoid or reduce the need for invasive and expensive ART. Andrologists could also choose the most appropriate mode of sperm retrieval. Undoubtedly, availability of andrological services would improve the overall quality of care, reduce the costs and complications, and would also be medicolegally safe.

Evaluation of Spectra A and B Modes in Diagnosis of Suspicious Bladder Lesions.

Background: White light imaging (WLI) cystoscopy, a "gold standard" for diagnosis of nonmuscle invasive bladder cancer (NMIBC), can miss ∼25% of bladder cancers. Spectra A (SA) and Spectra B (SB) are virtual optical chromoendoscopy modes introduced by Storz. Objective: To evaluate whether SA and SB improve over WLI in diagnosis of NMIBC. Design, Setting, and Participants: Storz Professional Image Enhancement System (SPIES) modes allow side-by-side viewing of WLI and spectra images. Cystoscopy images of some patients with suspected NMIBC and some normal cystoscopy findings were cut in two parts: one WLI and the other SA or SB. Each individual image was sent to the 3721 members of Urological Society of India separately through online survey. Histologic diagnosis was considered final diagnosis. Intervention: The observers were asked whether they considered the image to be cancer; yes, no, or cannot say were the three response options. Outcome Measures and Statistical Analysis: Primary outcome measure was improved diagnosis of NMIBC. Diagnostic efficacy was analyzed through 2 × 2 tables, McNemar test, and Fleiss Kappa. Results and Limitations: A total of 273 observers participated in the study. The sensitivities of WLI, SA, and SB were 89.81, 91.15, and 88.81, respectively. The specificities were 73.18, 66.17, and 68.68, respectively. In patients with cancer, both SA and SB improved the diagnostic efficacy of WLI. SA added significantly to the diagnostic accuracy over WLI (χ2 = 12.23, p = 0.00046). SB also added significantly over WLI (χ2 = 11.76, p = 0.0006). With increasing cancer grade, the sensitivity and negative predictive value of all modes increased. The major limitation of this study is the online diagnosis based on still images. Conclusions: In patients with cancer, SA and SB significantly add to the diagnostic accuracy of WLI. As compared with the negative WLI, if SA and SB are negative, NMIBC would be less likely.

Acute Urinary Retention from Knotted Urethral Catheter Treated with Holmium Laser Ablation.

Background: Straight catheters are usually used for clean intermittent catheterization (CIC). Patients perform CIC without much difficulty. Spontaneous knotting of catheter is rare in large bore straight catheters and female patients. Case Presentation: A 50-year old lady, case of neurogenic bladder on CIC inserted a 14F straight catheter, drained some urine but was unable to remove the catheter. She presented in emergency with retention of urine. Her X-ray and ultrasound examination revealed a knotted catheter. Conservative measures to remove the catheter such as forceful injection of radio-opaque contrast and passage of hydrophilic guidewire did not work. She was taken in the operating room. The knot was ablated using holmium laser through transurethral passage of an 8F ureteroscope. Conclusions: Spontaneous knotting of urethral catheter is rare in adults. It should be suspected whenever a straight catheter cannot be removed. Inserting excessive length of catheter is an important risk factor. Holmium laser is an excellent tool to cut the catheter in a least invasive way when conservative measures have failed.