Concerns about stone free rate and procedure events of percutaneous nephrolithotripsy (PCNL) for 2-4 cm kidney stones by standard-PCNL vs mini-PCNL- comparative randomised study.

BACKGROUND: To compare the efficacy and safety of standard percutaneous nephrolithotomy (PCNL) with mini- PCNL for kidney stones 2-4 cm. METHODS: Eighty patients were enrolled in a comparative study, they were randomly divided into mini-PCNL group (n = 40) and standard-PCNL (n = 40). Demographic characteristics, perioperative events, complications, stone free rate (SFR) were reported. RESULTS: Both groups showed no significant difference in clinical data about age, stone location, back pressure changes, and body mass index. The mean operative time was (95 ± 17.9 min) in mini-PCNL, and (72.1 ± 14.9 min). Stone free rate were 80% and 85% in mini-PCNL and standard-PCNL respectively. Intra-operative complications, post-operative need for analgesia, hospital stay were significantly higher in standard-PCNL compared to mini-PCNL (85% vs. 80%). The study followed CONSORT 2010 guidelines for reporting parallel group randomization. CONCLUSION: Mini-PCNL is an effective and safe treatment of kidney stones 2-4 cm, it has the advantage over standard-PCNL being has less intra-operative events, less post-operative analgesia, shorter hospital stay, while operative time and stone free rate are comparable when considering multiplicity, hardness, and site of stones.

Holmium Laser Enucleation vs Bipolar Plasmakinetic Enucleation of a Large Volume Benign Prostatic Hyperplasia: A Randomized Controlled Trial.

Objectives: To compare safety and efficacy of bipolar plasmakinetic enucleation of prostate (BPEP) vs holmium laser enucleation of prostate (HoLEP) for management of large benign prostatic hyperplasia (BPH) (>80 g). Patients and Methods: Patients with failed medical treatment, International Prostate Symptom Score (IPSS) >13, peak urinary flow rate (Qmax)<15 mL/s and prostate size ≥80 g were enrolled in this randomized controlled trial from November 2016 to February 2018 and managed by HoLEP (Group A; 33 patients) or BPEP (Group B; 31 patients). Patients on anticoagulants (AC) were not excluded. Patients were followed up for 12 months. Perioperative data were compared between both groups using Student's-t, Mann-Whitney, Paired-t, Wilcoxon signed rank, chi-square, or Fisher-exact tests as appropriate. Results: There was no significant difference between both groups in age, rate of presentation with urinary retention, recurrent hematuria, frequency of patients on ACs/antiplatelets, prostate size, prostate specific antigen (PSA), Qmax, IPSS, quality of life (QoL), and post-void residual urine (PVRU). Operative time was significantly longer in BPEP (p = 0.003) and catheterization duration (p = 0.019). Other perioperative parameters including level of Na+ and hemoglobin, resected tissue weight, hospital stay, and complications were not significantly different between both groups. There was no need for blood transfusion in all patients. There was significant postoperative improvement in IPSS, PVRU, QoL, PSA, and Qmax in each group. However, there was no significant difference between both groups in these parameters. Conclusion: HoLEP and BPEP are comparable regarding safety and efficacy for treatment of BPH (>80 g) including patients on ACs. However, BPEP required a longer catheterization duration and operative time. ClinicalTrials.gov Identifier: NCT03998150.

Internal versus external ureteric stents for uretero-ileal anastomosis after laparoscopic radical cystectomy with orthotopic neobladder: A prospective comparative study.

OBJECTIVE: To prospectively compare the use of external ureteric stents with internal JJ stenting of the uretero-ileal anastomosis in patients undergoing laparoscopic radical cystectomy (LRC) with a Y-shaped ileal orthotopic neobladder (ON). PATIENTS AND METHODS: The study included 69 patients undergoing LRC with ON. Patients were grouped according to the type of uretero-ileal stents used. An external ureteric stent was used in Group A (33 patients) and a JJ stent was used in Group B (36). We prospectively compared the duration of hospital stay, the incidence of short- and intermediate-term complications in the two study groups. RESULTS: The mean (SD) follow-up periods were 29.18 (3.94) and 28.19 (3.37) months for patients in Groups A and B, respectively. Perioperative patient characteristics were comparable in the two study groups. The use of JJ stenting was associated with a shorter hospital stay compared with external stenting, at a mean (SD) of 14.63 (3.74) and 6.8 (3.03) days in Groups A and B, respectively (P < 0.001). The incidence of urinary leakage was comparable in the two study groups, at 6.1% in Group A vs 8.3% in Group B (P = 1.0). Strictures of the uretero-ileal anastomosis occurred in two patients (6%) in Group A and confirmed by intravenous urography. All strictures were treated with antegrade JJ fixation. CONCLUSION: JJ stents could be used as an effective alternative to external ureteric stents to support the uretero-ileal anastomosis. JJ stenting is associated with a shorter hospital stay and similar complication rates compared with external stenting in patients undergoing LRC with ON.

Laparo-endoscopic single-site radical cystectomy with orthotopic urinary diversion: Technique, feasibility, and the 3-year follow-up.

OBJECTIVES: To assess the feasibility, operative morbidity and oncological outcome of laparoendoscopic single-site (LESS) radical cystectomy. PATIENTS AND METHODS: Ten patients with clinical stage T1-T2 bladder cancer underwent a LESS radical cystectomy. The mean (SD) age of the patients was 64.8 (8.6) years and their mean body mass index was 25.9 (2.7) kg/m(2). The procedure was done via a single-incision laparoscopic surgery port using a rigid 5-mm 30° long-shaft laparoscope in addition to the two working instruments. A 7-cm Pfannenstiel incision was made to remove the specimens and to allow the creation of an ileal neobladder with hand assistance. RESULTS: In eight patients the LESS radical cystectomy was completed as scheduled, with the other two requiring a conversion, one to an open procedure due to locally advanced disease, and the other to conventional laparoscopy due to gas leakage. The mean (SD) operative duration was 236 (49) min, with a mean estimated blood loss of 575 (113) mL, and a mean hospital stay of 5.5 (0.7) days. No postoperative analgesic medications were prescribed and patients returned to normal activity after a mean (SD) of 17.6 (2.6) days. The pathological examination showed negative surgical margins for the bladder specimens, with a mean (SD) of 14 (1.9) lymph nodes retrieved. Seven patients were cancer-free within a mean (SD, range) follow-up of 37 (6, 29-44) months. CONCLUSIONS: LESS radical cystectomy is technically feasible, with a favourable course and convalescence, and it has an acceptable oncological outcome.

Holmium laser enucleation of the prostate: initial report of the first 230 Egyptian cases performed in a single center.

OBJECTIVES: To report our experience with the first 230 cases of holmium laser enucleation of the prostate (HoLEP) performed in a single center. METHODS: A total of 230 cases of HoLEP were performed between June 2007 and June 2008. Mean age of patients was 69.8 +/- 10.3 years, and 21.3% of patients were either on anticoagulant or antiplatelet treatment. There was no limit for prostate size, with a mean prostate size of 86.5 +/- 65.4 g (range: 20-350 g). Follow-up was performed regularly at 1, 3, 6, and 12 months, assessing the Q(max), PVR, and International Prostate Symptom Score. RESULTS: Weight of prostate chips retrieved after morcellation was 78.6 +/- 61.3 g (range: 10-350), with enucleation time 102.2 +/- 55.4 minutes and morcellation time 19.3 +/- 10.1 minutes, leading an estimated efficiency rate of 0.64 g/min. The rate of decrease in prostate volume and prostate-specific antigen was 90.8% and 82.5%, respectively. At 1 month, mean Q(max) increased from 7.7 +/- 2.3 to 25.8 +/- 10.1 mL/s (P

Antegrade ureteral stenting during laparoscopic dismembered pyeloplasty: intraoperative findings and long-term outcome.

OBJECTIVE: The objective of this study was to compare the results of antegrade (AG) ureteral stenting with retrograde (RG) stenting during laparoscopic dismembered pyeloplasty. MATERIALS AND METHODS: Between October 2003 and April 2007, a case series of 47 laparoscopic dismembered pyeloplasties were done by three surgeons of equal expertise in laparoscopic surgery, where the Double-J ureteral stent was placed by the RG method (RG stenting group) in 15 cases and by the AG method (AG stenting group) in 32 patients. Intraoperative findings and operative data were recorded. Clinical and radiological outcomes were evaluated during the follow-up visits at 3, 6, 12 months and then annually. RESULTS: Differences in patient's age and body mass index were not statistically significant. Laparoscopic pyeloplasty was successfully completed in 45 patients, with two cases of conversion to open (one in each group). A crossing vessel was identified in 42% of RG stenting group versus 45% of AG stenting group. A state of high ureteral insertion was identified in 16% of AG stenting group, a finding that was never seen in RG stenting group. Mean operative time was 271 +/- 21 minutes for RG stenting group versus 199 +/- 34 minutes for AG stenting group, a difference that was statistically significant (p

Laparoscopic augmentation ileocystoplasty: results and outcome.

BACKGROUND: Routine use of laparoscopic augmentation ileocystoplasty has not yet been established. OBJECTIVES: To assess the outcome of laparoscopic augmentation ileocystoplasty. DESIGN, SETTING, AND PARTICIPANTS: Twenty-three patients underwent laparoscopic augmentation ileocystoplasty for hypocompliant bladder. INTERVENTION: Bladder dissection and reconstruction of the ileovesical anastomosis were performed laparoscopically, whereas the ileal pouch was prepared extracorporeally through a small 3- to 4-cm muscle-splitting incision. MEASUREMENTS: Patient data, operative details, and follow-up were recorded. Urodynamic evaluation was performed preoperatively and after 12 mo, taking the bladder capacity and the maximum detrusor pressure as a measure for the outcome of the procedure. RESULTS AND LIMITATIONS: All cases were completed laparoscopically, with a mean operative time 202 min; mean hospital stay 5 d, and mean urethral catheter duration 11 d. After 12 mo, the estimated bladder volume increased from a mean 111 ml to 788 ml (p<0.01), whereas the maximum detrusor pressure dropped from a mean 92 cm H(2)O to 15 cm H(2)O (p<0.01). During a mean follow-up of 39 mo, two long-term complications have been reported: bladder stone and spontaneous rupture of the augmented bladder due to neglected clean intermittent self-catheterization. CONCLUSIONS: Laparoscopic augmentation ileocystoplasty is a safe procedure, technically feasible and with favourable urodynamic outcome.

Laparoscopic transperitoneal ureterolithotomy.

PURPOSE: To present our experience with laparoscopic ureterolithotomy as a potential alternative to open ureterolithotomy. PATIENTS AND METHODS: Between October 2003 and October 2005, a total of 27 laparoscopic ureterolithotomies were performed in 25 patients. The mean age of the patients was 39.8 +/- 17.5 years, and the mean body mass index (BMI) was 28.7 +/- 3.9 kg/m2. The inclusion criteria were stone(s) in the middle or upper ureter not suitable for treatment with SWL or endoscopy. Bilateral stones, multiple stones at the same level, recurrent stones, or stones in duplex systems were not a contraindication. A transperitoneal approach was used. RESULTS: The mean operative time was 145 +/- 42 minutes. The mean blood loss was 62.5 +/- 23 mL with mean hemoglobin decline of 0.78 +/- 0.31 g/dL. Postoperative analgesia was a single dose of a non-steroidal anti-inflammatory drug on day 1. The mean postoperative hospital stay was 4.1 +/- 6.7 days. No evidence of backpressure changes or increase in the serum creatinine concentration was observed during the follow-up. Assessment of the BMI, level of the stone, and laterality showed no statistical impact on the mean operative time. CONCLUSIONS: Laparoscopic ureterolithotomy is technically feasible with the advantage of being minimally invasive and having lower postoperative morbidity.

Laparoscopic vesical diverticulectomy.

PURPOSE: We report our initial experience with 13 cases of laparoscopic vesical diverticulectomy done via an extravesical approach between November 2002 and October 2004. PATIENTS AND METHODS: All patients were male, with a mean age of 53 years and a mean body mass index of 26.2 kg/m2. A transperitoneal approach was preferred. The diverticulum was of the primary type in three patients and of the secondary type resulting from benign prostatic hyperplasia in seven patients and a longstanding urethral stricture in three patients. RESULTS: The mean operative time was 265 minutes with a mean blood loss of <100 mL and a mean postoperative hemoglobin decline of 1.1 g/dL. The urethral catheter was removed on day 7 postoperatively in the patients with a primary diverticulum, whereas it was left for 11 to 14 days in patients with secondary bladder diverticula. Postoperative complications occurred in only one patient with a primary diverticulum, taking the form of extravasation from the suture line in the control gravity-fill cystogram that was done routinely prior to urethral-catheter removal. Leakage resolved with urethral catheterization for 2 more weeks. The postoperative stay was 3 to 4 days. CONCLUSION: Laparoscopic diverticulectomy is technically feasible and safe and may represent an alternative to the standard open procedure.

Laparoscopic radical prostatectomy--an analysis of factors affecting operating time.

OBJECTIVES: Although laparoscopic radical prostatectomy (LRP) is accomplished within 2 to 3 hours by experienced surgeons, less is known about the operating times (OTs) for recently trained surgeons or the influence of additional factors. As of November 2001 at our institution, two senior surgeons had each performed more than 100 cases of LRP and two junior surgeons had each performed fewer than 30. We prospectively studied the next 100 consecutive LRPs to assess the factors influencing the OT. METHODS: Transperitoneal LRPs were performed by two senior (n = 62) and two junior surgeons (n = 38) with random case assignment. We assessed body mass index, prostate size, prior abdominal surgery, androgen deprivation, surgeon experience, procedures in addition to LRP, lymph node dissection, nerve sparing, and sural nerve grafting as potential predictors of the OT. RESULTS: Prostate weight, androgen deprivation, and prior abdominal surgery did not significantly affect the OT, but grade 1 obesity increased the OT by an average of 38 minutes. The mean OT by surgeon experience was 214 minutes for seniors and 347 minutes for juniors (P <0.001). By procedure type, the OT ranged from 180 minutes for LRP only by seniors to 459 minutes for LRP plus lymph node dissection plus sural nerve grafting by juniors. Lymph node dissection and sural nerve grafting significantly increased the OT by 46 and 101 minutes, respectively, and nerve sparing did not. For each combination of procedures, seniors averaged significantly shorter times than did juniors. A multiple regression model with stepwise selection showed that prostate weight, sural nerve grafting, pelvic lymph node dissection, use of a surgical robot, and surgeon experience significantly affected the OT. CONCLUSIONS: The results of this prospective study of 100 cases of LRP showed that the OT for senior surgeons averaged 2 to 3 hours, but less experienced surgeons, and additional procedures, add significantly to the OT.

Positive margins after laparoscopic radical prostatectomy: a prospective study of 100 cases performed by 4 different surgeons.

OBJECTIVE: Laparoscopic radical prostatectomy (LRP) has been refined by experienced surgeons into a competitive treatment alternative for localized prostate cancer. Less is known, however, about the outcomes of "learning curve" cases from newly trained surgeons. We prospectively studied 100 cases of LRP performed by 2 senior and 2 junior surgeons and addressed the rates of positive margins-an important early endpoint of oncologic efficacy. METHODS: 100 consecutive cases of LRP were performed by two senior (n=62) and two junior surgeons (n=38) by a 5-port transperitoneal route. Whole-mount step-section prostate specimens were examined by Stanford protocol. RESULTS: Positive margins occured in 25% of cases: 18% for pT2a (2/11), 18% for pT2b (11/61), 45% for pT3a (10/22), and 50% for pT3b (2/4) (p=0.002 pT2 vs. pT3). By surgeon experience, the rates were 19% (12/62) for senior and 34% (13/38) for junior (p=0.04). However, in a multiple logistic regression analysis, only pathologic stage (p=0.083) and Gleason sum (p=0.0133) reached statistical significance, while surgeon experience did not (p=0.0992). CONCLUSION: Positive margin rates after laparoscopic radical prostatectomy are significantly influenced by pathologic stage and Gleason score, and are within the range reported from open series. The higher positive margin rate from junior surgeons, although not statistically significant, suggests the need for further study and continued mentoring during surgery and/or video review of cases to improve oncologic results.