Are Nephrostomy and Ureteral Stent Necessary after Multi-Access Percutaneous Nephrolithotomy?

INTRODUCTION: Totally tubeless percutaneous nephrolithotomy (PCNL) is a well-established technique used in single -access procedure nevertheless these results challenge the multi-access PCNL as a contra-indication to application of this technique. AIMS: To compare complication rates and safety of use of this technique after multi-access PCNL. METHODS: A Total of 130 patients with renal stones were enrolled in this cohort study. Totally tubeless PCNL with single access (Group A, n = 70) and multi-access (Group B, n = 60) were done and bleedings were assessed by measuring hemoglobin (Hb) drop, blood transfusion rate and need for angioembolization besides leakage rates which were also recorded. RESULTS: In the 130 patients who underwent totally tubeless PCNL, no leakage from puncture site nor angioembolization cases were identified. There was no significant statistical differences between 2 groups regarding Hb drop (1.91 in single access versus 2.20 in multi-access), transfusion rate and length of hospital stay (p > 0.05). Stone-free rate was increased from 91% in single access to 97% in multi access by adding percutaneous access sites (from 91% in single access to 97% in multi-access). CONCLUSIONS: Multi-access totally tubeless PCNL seems feasible and has comparable complication rates including Hb drop besides providing the advantage of higher stone-free rates using multi-access tracts.

Endovisually guided zero radiation ureteral access sheath placement during ureterorenoscopy.

BACKGROUND: Almost all endourologic procedures use fluoroscopic imaging in some steps, which exposes both the patient and the surgical team to considerable amounts of radiation. Primary reports on results of a simple direct visual endoscopic access sheath placement technique which does not use fluoroscopy at all are presented. MATERIAL AND METHODS: First a semi-rigid ureteroscopy was carried out up to the renal pelvis, then the access sheath (36 cm, 11/13 Fr) without the obturator was placed over a 7.5 Fr semi-rigid ureteroscope and ureteroscopy was repeated over the guide wire to the point where the sheath could be inserted without force as if the ureteroscope would act as the guide wire (rod), which is controlled under direct endoscopic vision. RESULTS: Eighty-eight cases out of 106 procedures were successful regarding the insertion of the ureteral access sheath (UAS) under direct vision using a 36 cm 13/11 Fr sheath. Fourteen ureters had non-negotiable strictures needing stenting for passive dilation. The mean time for UAS insertion was 19 s. The stone free-rate was 78.12%. Among our 106 cases, there were six cases of the upper tract urothelial cancers. CONCLUSION: Ureteral access sheath placement could be safely performed using a semi-rigid ureteroscope under direct visual control and resulted in shorter operative time, without radiation exposure during the RIRS procedure of both the patient and the surgery team.

Trainee-Associated Factors and Proficiency at Percutaneous Nephrolithotomy.

Percutaneous nephrolithotomy (PNL) is a complicated procedure for urology trainees. This study was designed to investigate the effect of trainees' ages and previous experience, as well as the number of operated cases, on proficiency at PNL by using patient outcomes. A cross sectional observational study was designed during a five-year period. Trainees in PNL fellowship programs were included. At the end of the program, the trainees' performance in PNL was assessed regarding five competencies and scored 1-5. If the overall score was 4 or above, the trainee was considered as proficient. The trainees' age at the beginning of the program and the years passed from their residency graduation were asked and recorded. Also, the number of PNL cases operated by each trainee was obtained via their logbooks. The age, years passed from graduation, and number of operated cases were compared between two groups of proficient and non-proficient trainees. Univariate and multivariate binary logistic regression analysis was applied to estimate the effect of aforementioned variables on the occurrence of the proficiency. Forty-two trainees were included in the study. The mean and standard deviation for the overall score were 3.40 (out of 5) and 0.67, respectively. Eleven trainees (26.2%) recognized as proficient in performing PNL. Univariate regression analysis indicated that each of three variables (age, years passed from graduation and number of operated cases) had statistically significant effect on proficiency. However, the multivariate regression analysis revealed that just the number of cases had significant effect on achieving proficiency. Although it might be assumed that trainees' age negatively correlates with their scores, in fact, it is their amount of practice that makes a difference. A certain number of cases is required to be operated by a trainee in order to reach the desired competency in PNL.

Primary Report of Totally Tubeless Percutaneous Nephrolithotomy Despite Pelvi-calyceal Perforations.

PURPOSE: Nephrostomy tube insertion and/or a ureteral stent placement is advised when pelvi-calyceal perforations are encountered during percutaneous nephrolithotomy (PNL) nevertheless totally tubeless PNL is a possible exit strategy in percutaneous renal surgery therefore case series on the short term clinical outcomes of noninvasive management of iatrogenic pelvicalyceal perforations encountered during PNL is presented. PATIENTS AND METHODS: During retrospective analysis of 1271 PNL procedures, 25 incidents of accidental ureteral catheter/ jj stent dislodgement during first 24 post-operative hours were identified in patient who had pelvi calyceal perforations and had no nephrostomy tube (tubeless). Thirteen patients could not be re-stented nor a nephrostomytube could have been placed for them mainly due to patient refusal or comorbid conditions. The main outcome was rate of successful noninvasive management. RESULTS: Eighteen Patients bearing mucosal tears (grade I trauma) or visible peri-pelvic fat (grade II) successfully recovered without need for ureteral stenting or nephrostomy (72.0%). In seven (28.0%) cases of extension of the perforation into the peri-pelvic fat (grade III), either nephrostomy insertion or JJ stenting was needed for resolution of fever and urinoma. The major limitation was the necessity to exclude patients and manage them in the standard fashion according to clinical guidelines. CONCLUSION: Iatrogenic perforations of the collecting system are quite diverse in terms of severity that result in different natural histories and not all might need urinary diversion via nephrostomy or ureteral stenting.Low grade perforations may be successfully managed in totally tubeless fashion nevertheless further prospective investigations seem warranted.

Totally tubeless percutaneous nephrolithotomy is feasible in morbidly obese patients.

OBJECTIVE: Regarding technical difficulties that obese body habitus might impose to percutaneous nephrolithotomy (PNL) success and higher risk of peri-operative complications in this group of patients, we decided to retrospectively gather data from our patients during past 8 years to determine the stone free and complication rates. MATERIAL AND METHODS: Between January 2007-December 2015, seventy-eight obese patients with body mass index over 35 who had indication for PNL including stones larger than 2 cm in pelvi-calyceal system or smaller extracorporeal shock wave lithotripsy (ESWL) resistant stones or who were not a fit candidate for ESWL due to increased skin to target distance, with no contraindication of PNL (including bleeding diathesis, inability to be positioned in prone) were enrolled. They were randomly assigned to group 1 (standard PNL with nephrostomy and ureteral stent) or group 2 (totally tubeless PNL with no ureteral stent and no nephrostomy). The outcomes were compared. RESULTS: The transfusion rate, operation time, and the hemoglobin drop were same across the groups (p>0.05). Total analgesic use was equivalent of 33.8 vs. 14.7 mgs of morphine sulfate (18-77 mg) and was significantly lower in total tubeless group (p=0.001). Return to normal activity was described as total number of in-patient and outpatient days from time of admission to the point which the patients returns to normal life activity such as going to job or school and was 19.4 vs. 9.3 days (6-30 days, p=0.001). CONCLUSION: Totally tubeless PNL in obese subjects would have lower analgesic use and return to normal activity versus standard PNL. Totally tubeless PNL is recommended for obese patients.

A pilot randomized study on use of oral acetazolamide in patients with refractory dysuria.

PURPOSE: Assessment of daily oral acetazolamide in treatment of refractory dysuria. METHODS: Forty-one patients were randomly allocated to either be treated with acetazolamide (250 mg twice daily) or to receive placebo. The irritative voiding symptoms and urinary pH were recorded before and after treatment. The quality of life indices including the impact of voiding symptoms on daily and social activities, mood disturbance and sleep disorders were also measured by a questionnaire. RESULTS: Urinary pH was increased in the group taking acetazolamide (P < 0.001). They also reported alleviation of dysuria (P < 0.001), frequency (P = 0.039) and urgency (P = 0.016). However, nocturia was not improved in the study group. No change was observed in the aforementioned parameters in the placebo group. Daily personal life, social activities and the quality of sleep were improved by 52, 38 and 33%, respectively. CONCLUSION: Oral acetazolamide can reduce the irritative voiding symptoms and improve the quality of life which is concomitant with an increase in urinary pH.

Is Serum Uric Acid Level Correlated with Erectile Dysfunction in Coronary Artery Disease Patients?

Coronary artery disease (CAD) and vascular insufficiency are consequences of modern lifestyle, and vasogenic erectile dysfunction (ED) is one of the leading causes of sexual dysfunction which could be prevented like ischemic heart disease if the risk factors are discovered and managed. Seventy-five men scheduled for coronary angiography were asked to fill out the IIEF5 questionnaire and underwent serum lipoprotein-a, uric acid, lipid profile, testosterone, Sex Hormone Binding Globulin (SHBG), dehyderoepiandrostendion sulfate (DHEAS) tests; and the results were compared with those of erectile dysfunction patients with and without coronary artery disease. Ten out of 32 CAD patients (30%) and 6 of 43 normal coronary men had ED Prevalence (P=0.04). The average serum uric acid in ED patients with normal coronary was 5.6 (± 0.68) 6.5 ±078 mg/dl in ED patients of CAD group P=0.034. Men with both ED and CAD had significantly higher levels of lipoprotein-a compared to those CAD patients with normal sexual function. Higher uric acid and lipoprotein-a levels are correlated with the presence of ED in patients with CAD.

Comparing Bleeding Complications of Double and Single Access Totally Tubeless PCNL: Is It Safe to Obtain More Accesses?

PURPOSE: To assess bleeding complications in totally tubeless double-access percutaneous nephrolithotomy (PCNL) and compare it with the single-access method. METHODS: One hundred and seven patients with large or scattered renal stones were enrolled in this cohort study. Totally tubeless PCNL with one access (group A, 70 cases) or two accesses (group B, 37 cases) was done and bleeding was assessed by measuring the hemoglobin drop of the patients, blood transfusion rate and need for performing angioembolization. RESULTS: The mean (SD) hemoglobin drops in groups A and B were 1.97 (1.24) and 2.31 (1.24), respectively; p = 0.176. Blood transfusion rates in two groups were 7.1 and 10.8% (p = 0.716), respectively. None of our patients required angioembolization. The average hemoglobin drop and blood transfusion rate with double tracts were approximately near to those in single tract group and in acceptable ranges. The average hospital stay in groups A and B were 3.1 and 3.2 days (p = 0.074), respectively. There was no leakage from puncture site/s and stone free rates in the two groups were 85.7 and 97.3% (p = 0.093). CONCLUSION: Totally tubeless double-access PCNL is feasible and bleeding complications are comparable to single access totally tubeless PCNL making it an effective strategy to achieve more stone free rates.

Concomitant anterior and posterior urethral valves in pediatrics: A single center experience over 12 years and long-term follow up after endoscopic treatment.

OBJECTIVE: To report our 12-year experience with endoscopic management of patients with concomitant anterior and posterior urethral valves. METHODS: We retrospectively reviewed the charts of patients referred to us for management of urethral valves from 2000 to 2012 to find cases with concomitant anterior and posterior valves. The diagnosis of valves was first suspected on voiding cystourethrography and confirmed by urethrocystoscopy. We collected available data on patients' age at diagnosis, clinical presentations, ultrasound and urodynamic findings, and surgical treatments. The final outcome at last follow up was also recorded. RESULTS: From 38 cases with anterior urethral valve, six (15.8%) presented concomitant anterior and posterior valves. The age at diagnosis in these patients ranged from antenatal diagnosis to 13 years. Initial presenting symptoms were recurrent urinary tract infection, incontinence, urosepsis and poor urinary stream. All valves were ablated by transurethral fulguration/resection using small-sized urethrocystoscopes. Among those with concomitant anterior and posterior valves, four patients had vesicoureteral reflux at presentation that resolved in two patients after valve ablation. One patient progressed to renal failure and required dialysis. Bladder hypercontractility and detrusor overactivity were the main urodynamic patterns in these patients. CONCLUSIONS: Concomitant anterior and posterior valves seem to be more prevalent than previously assumed, and might be missed on initial assessment. Oblique view voiding cystourethrography with full-length delineation of the urethra is of paramount diagnostic importance when obstruction is suspected. A meticulous urethrocystoscopy should follow for confirming the diagnosis and endoscopic ablation/resection of the valves.

Does bone marrow-derived mesenchymal stem cell transfusion prevent antisperm antibody production after traumatic testis rupture?

OBJECTIVE: To determine whether transfusion of mesenchymal stem cells (MSCs) could prevent humoral immune response and autoimmunization against sperms after traumatic testis rupture. METHODS: Immunomodulatory properties of MSCs have been evaluated by a prospective cohort on 50 adult BALB/c mice. In each interventional arms of study, controlled testis rupture and surgical repair were exerted. In addition to tissue repair, single dose of 5×10(5) MSCs labeled by green fluorescent protein was delivered intravenously to 20 cases (cell therapy group). After euthanizing, seroconversion of antisperm antibody (ASA) was compared between 2 interventional groups as response of humoral immune system. Lung and testis tissues were examined for green fluorescent protein-positive cells to assess whether presence of stem cells is correlated with seroconversion rates. RESULTS: Six cases had been lost during the study. Fourteen of 16 mice in cell therapy control group formed ASA (87.5%) but 6 of 18 mice (33.3%) in cell therapy group were immunized and formed ASA (P=.002). Transplanted cells were traced in lungs of 55% (n=10) of cell therapy group and none were found in trauma site. Small volume of mice blood was our main limitation to trace seroconversion or quantitative measurement of ASA in each case. CONCLUSION: In this in vivo model of autoimmune infertility, bone marrow-derived MSC transfusion showed immunosuppressive effects on antibody production. Considering immunomodulatory properties of MSCs even in allogeneic settings, novel clinical application should be investigated further.

Surgically treated bladder hemangiopericytoma/solitary fibrous tumor: report of a 12-year asymptomatic follow-up.

Hemangiopericytoma (HPC)/solitary fibrous tumor (SFT) is an uncommon vascular tumor suggested to be originating from pericytes. There are few reports on bladder HPC/SFT. We present a case of huge bladder HPC/SFT measuring 13.9 × 12.2 × 11.1 cm with invasion to right iliac vein in a 54-year-old man. The patient underwent radical surgical tumor excision without chemotherapy or radiotherapy. The patient is symptom-free without recurrence or metastasis during the 12-year follow-up period. This case is the longest follow-up reported to date for bladder HPC/SFT.

Is intravenous urography required when ultrasonography and KUB evidence a ureteroscopy plan?

PURPOSE: To determine whether pre-ureteroscopic stone extraction (USE) evaluation by intravenous urography (IVU) can change the clinical decision made on the basis of a plain X-ray of the kidneys, ureters, and bladder (KUB) plus an ultrasonography in the case of ureteral calculi. MATERIALS AND METHODS: From October 2005 to November 2007, 139 USE candidates were selected based on ultrasonography and KUB, and were randomly divided into two groups. Each group was assessed by an expert urologist to decide about the treatment plans. Thereafter, all the patients underwent an IVU pre-operatively and were evaluated for the second time by the other urologist considering IVU. Presence of a hydronephrotic kidney on the ultrasonography, existence of a density in the probable tract of the ureter on KUB, and previous episodes of renal colic were considered as inclusion criteria. Exclusion criteria were non-opaque stones on KUB, hypersensitivity to contrast media, and serum creatinine > 1.5 mg/dL. RESULTS: On the basis of ultrasonography and KUB assessment, all of the patients were identified candidate for USE. According to secondary IVU-based planning, of 139 patients, 127 (91.3%) required USE, 10 (7.1%) ureteroscopy, and 2 (1.4%) non-operative treatment. About 8.7% of treatment plans was changed by IVU, which was not statistically significant (P = .35). Positive predictive value of ultrasonography plus KUB to diagnose a ureteral stone which needed USE was 92.8% while IVU is the gold standard (95% confidence interval: 92.38 to 93.22). CONCLUSION: Intravenous urography is not useful enough to be performed routinely before entire USEs.

Feasibility of totally tubeless percutaneous nephrolithotomy under the age of 14 years: a randomized clinical trial.

OBJECTIVE: To assess the outcome and safety of the totally tubeless percutaneous nephrolithotomy (PCNL) in comparison with standard PCNL in the children under the age of 14 years. PATIENTS AND METHODS: Twenty-three patients under the age of 14 with renal stones were enrolled in a prospective randomized clinical trial during March 2010 to June 2011. The inclusion criteria were existence of renal stone larger than 2.5 cm in diameter or extracorporeal shockwave lithotripsy-resistant kidney stone; furthermore, exclusion criteria were kidney anomalies, renal failure on admission, and serious bleeding or perforation in the collecting system during the operation. The patients were divided into two groups according to block randomization. Group A comprised of 13 children with mean age 10.31 (4-14) years, were rendered totally tubeless at the end of surgery, while 10 patients in group B with mean age 11.1 (9-14) years underwent standard PCNL. The incidence of complications, transfusion rate, analgesic use, hemoglobin drop, operation time, and hospital stay were compared between the two groups during a one-month study period. RESULTS: The mean stone burden was 29.23 mm (SD=4.85) in group A versus 31.4 mm (SD=5.19) in group B. Hospitalization averaged 39.54 (SD=11.39) hours versus 58.7 (SD=10.37) (p<0.001) and the average analgesics use was 0.07 (SD=0.03) mg/kg of morphine versus 0.15 (SD=0.04) (p<0.001), respectively. Operation time, transfusion rate, complications, retreatment, and hemoglobin drop were not different, significantly. CONCLUSION: Totally tubeless PCNL for pediatric population yields decreased hospital stay and analgesic use with no more complications. So, it can be considered as a standard and cost-beneficial procedure in appropriately selected group of patients.

Ureterocele associated with renal agenesia presented as a pelvic mass in an adult.

Adult ureteroceles are generally known as simple ureteroceles with minimal obstructive effects 1 that can usually be managed endoscopically. Such pathology presented with acute abdominal pain and fever in a 32-year-old man with left renal agenesia, a cranial blind left ureter and left obstructed ureterocele. The retained secretions were suppurative.

Role of frenular web preservation on ejaculation latency time.

Premature ejaculation (PE) is one of prevalent male sexual dysfunctions worldwide. Despite many psychiatric backgrounds, yet there are speculations about organic etiologies considering both anatomic and physiologic points of view. This survey assesses effect of frenular web preservation on premature ejaculation. One thousand and forty otherwise healthy men being visited for urolithiasis (asymptomatic patients) were asked for PE according to the International Society of Sexual Medicine definition criteria as intravaginal ejaculation latency time (IELT) less than a minute according to stop watch checked by patients' partner and were examined for presence of frenular web. Frenular web defined as a residual of frenulum after a circumcision. Overall prevalence of PE was 18.2% (n=102). We found the presence of frenulum at physical examination in 255 out of 560 (45.5%). Prevalence of PE was 20.7% (n=53) and 16% (n=49) in patients with frenular web preserved and without it, respectively. PE was higher among the men with frenulum preserved; but no statistically significant differences were seen (P=0.70). We did not find any relationship between frenular web and PE, and concerns about this, during circumcision, may not be justified. PE is a not only a problem of local anatomical condition but many psychological and neurological factors could interact with it.

A 75-year old man complaining of flank pain and obstructive urinary symptoms: a case report.

Benign renal cystic adenoma with out malignant features is a very rare entity. A 75 year old male with obstructive Lower tract symptoms and vague flank pain was admitted and planned for nephrectomy of non functional kidney -due to long term nephrolithiasis- intra operative finding was a cystic hydronephrotic kidney filled by thick mucous secretions which turned out to be a cyst adenoma of kidney with no malignant features.

Is antibiotic prophylaxis necessary in patients undergoing ureterolithotripsy?

Transurethral Ureterolithotripsy (TUL) is a frequently used procedure in urology departments. Many urologists perform TUL without antibiotic prophylaxis; however the use of chemoprophylaxis before TUL remains a controversial issue in urology. This study was carried out to assess the safety of omitting antibiotic prophylaxis prior to TUL. In a prospective randomized clinical trial from January 2005 to December 2007, 114 patients with ureteral stones were enrolled; Fifty seven had preoperative antibiotic prophylaxis administered before TUL and fifty seven patients underwent TUL without antibiotic prophylaxis. The rate of postoperative infectious complications (fever, positive blood culture, significant bactriuria), the length of hospital stay and overall stone free rate were compared between the two groups. There was no statistically significant difference between two groups in the operation time, length of hospital stay, postoperative bacteriuria, positive urine culture, postoperative fever and overall success rate of TUL. It appears that the incidence of infectious complications does not increase in patients undergoing TUL without antibiotic prophylaxis if they have negative pre-operative urine culture and antiseptic technique have been performed thorough the procedure.

Prevalence of selected sexually and blood-borne infections in Injecting drug abuser inmates of bandar abbas and roodan correction facilities, Iran, 2002

Human Immunodeficiency Virus (HIV) and other blood borne viral infections like hepatitis B virus (HBV) and hepatitis C virus (HCV) are major health issues especially in young and growing population of developing countries. All around the globe correctional facilities are known as potential source of spreading such disease. During summer 2002, HIV, HCV antibodies, hepatitis B surface (HBs) antigen and rapid plasma reagin (RPR) test were checked in venous blood samples of 252 injecting drug abuser prisoners from correctional facilities in southern Iran. Overall HIV, HCV and HBV infection rate was 15.1 percent (38/249), 64.8 percent (163/249), and 4.7 percent (12/249), respectively. HCV infection rate of HIV positive cases was 94 percent (35/38). All RPR results were negative. Duration of previous drug abuse and imprisonment were correlated with HIV and HCV infection (p value = 0.0003 and 0.015 & p value =0.02 and 0.02). Considering the higher prevalence of HIV and HCV infection in correctional facilities compared to general population of Iran, warrants immediate multidisciplinary approaches targeted at controlling further spread of these infections primarily among prisoners and secondarily preventing them to act as carrier to general population.

Prevalence of selected sexually and blood-borne infections in Injecting drug abuser inmates of bandar abbas and roodan correction facilities, Iran, 2002.

Human Immunodeficiency Virus (HIV) and other blood borne viral infections like hepatitis B virus (HBV) and hepatitis C virus (HCV) are major health issues especially in young and growing population of developing countries. All around the globe correctional facilities are known as potential source of spreading such disease. During summer 2002, HIV, HCV antibodies, hepatitis B surface (HBs) antigen and rapid plasma reagin (RPR) test were checked in venous blood samples of 252 injecting drug abuser prisoners from correctional facilities in southern Iran. Overall HIV, HCV and HBV infection rate was 15.1% (38/249), 64.8% (163/249), and 4.7% (12/249), respectively. HCV infection rate of HIV positive cases was 94% (35/38). All RPR results were negative. Duration of previous drug abuse and imprisonment were correlated with HIV and HCV infection (p value = 0.0003 and 0.015 & p value =0.02 and 0.02). Considering the higher prevalence of HIV and HCV infection in correctional facilities compared to general population of Iran, warrants immediate multidisciplinary approaches targeted at controlling further spread of these infections primarily among prisoners and secondarily preventing them to act as carrier to general population.