Supine mini percutaneous nephrolithotomy in horseshoe kidney.

OBJECTIVE: The percutaneous nephrolithotomy (PCNL) in Horseshoe kidneys (HSK) is usually performed in the prone position, allowing entry through the upper pole and providing good access to the collecting system. However, in patients with normal kidney anatomy, the supine position is reliable and safe in most cases, but it is unknown whether the supine position is adequate in patients with HSK. The purpose of this study was to describe the results of PCNL in HSK in three different surgical institutions and to evaluate the impact of supine position during surgery, comparing pre-operative and post-operative data, complications, and stone status after surgery. MATERIAL AND METHODS: Between 2017 and 2022, a total of 10 patients underwent percutaneous renal surgery for stone disease in HSK. All patients were evaluated pre- and post- operatively with non-contrast CT. we evaluated patients (age and gender), stones characteristics (size, number, side, site and density ), and outcomes. The change in haemoglobin, hematocrit, creatinine and eGFr were assessed between the most recent preoperative period and the first postoperative day. Procedure success was defined as stone-free or presence of ≤4 mm fragments (Clinically Insignificant residual Fragments - CIrF). Complications were registered and classified according to Clavien-dindo Grading System, during the 30 - day postoperative period and Clavien scores ≥ 3 were considered as major complications. Statistical analysis was performed using "r 4.2.1" software, with a 5% significance level. we also compared pre-operative and post-operative data using "wilcoxon signedrank test". RESULTS: No statistical difference was observed between preoperative and post-operative renal function data. At one post operative day CT scan, an overall success rate of 100% was registered. 9/10 patients were completely free from urolithiasis (stone-free rate: 90%), while 1/10 patients had ≤4 mm residual stone fragments (CIrF rate: 10%). No cases of intraoperative complications were registered. Post-operative complications were reported in 1/10 patients. A patient developed urosepsis (defined as SIrS with clinical signs of bacterial infections involving urogenital organs - Clavien-dindo Grade II) after procedure, and was treated with intravenous antibiotic therapy successfully.  Conclusions: This study shows that in patients with HSK mini- PCNL in supine position allows to achieve good stone free rate with a very low morbidity. According to our series, the described technique for PCNL in HSK should be an option. Nevertheless these results must be confirmed by further studies.

Stone free rate and clinical complications in patients submitted to retrograde intrarenal surgery (RIRS): Our experience in 571 consecutive cases.

INTRODUCTION: The purpose of this study is to report the stone free rate (SFR) and clinical complications in patients submitted to retrograde intrarenal surgery (RIRS). MATERIALS AND METHODS: A total of 571 procedures of upper urinary stones treated using flexible ureteroscopy and holmium laser lithotripsy from January 2014 to February 2020 have been analyzed. Overall SFR was evaluated after 3 months following the procedure by means of a non-contrast computed tomography. Success was considered as stone-free status or ≤ 0.4 cm fragments. RESULTS: The overall SFR was 92.3% in group 1 (stone size: < 1 cm), 88.3% in group 2 (stone size: > 1 ≤ 2 cm), 56.7% in group 3 (stone size: 2-3 cm) and 69.6% in group 4 (multiple stones). Post-operative complications, according to the Clavien- Dindo (CD) classification system, were recorded in 32 (5.6%) procedures. The major complications recorded were: one case of subcapsular hematoma (SRH) associated with pulmonary embolism two days after the procedure (CD Grade IIIa) treated conservatively and one case of hemorrhagic shock 2 hour with multiple renal bleedings requiring urgent nephrectomy (CD Grade IVA). CONCLUSIONS: The RIRS is an effective and safe procedure with a high SFR significantly correlated with the stone size; at the same time, RIRS could be characterized by severe clinical complications that require rapid diagnosis and prompt treatment.

Asynchronous Bilateral Ureteric-Arterial Fistula: Diagnosis and Treatment.

A 48-year-old woman submitted to anterior exenteration plus ileal-cutaneous conduit for metastatic cervical cancer during the change of the ureteral stent showed massive bleeding in the left ureter. A selective intra-arterial angiography showed a fistula between the ureter and the left common iliac artery that the interventional radiologist quickly repaired by inserting a vascular endoprosthesis. Six months later, gross hematuria secondary to right ureter-iliac fistula occurred again and a second endoprosthesis was inserted. Asynchronous bilateral ureteric stent-related vascular fistula is an uncommon scenario, but it should be suspected in the presence of hematuria following ureteral stent replacement.

Subcapsular Kidney Urinoma After Percutaneous Nephrolithotomy.

Background: A rare percutaneous nephrolithotomy (PCNL) complication and its management is reported. Case Presentation: A male patient, 43 years of age, underwent PCNL for a large left pyelocaliceal stone. Surgery was performed in the Valdivia-Galdakao supine position. The percutaneous tract was established by combined radiologic and sonographic guidance. The tract was dilated by balloon and a 24F Amplatz sheath was located. As complete clearance was not achieved because of a residual lower pole caliceal stone, a ureteral Double-J and a 20F nephrostomy were located for a second-look PCNL through the same tract after 7 days. After second-look PCNL residual stone was still not cleared because it was unreachable through the tract established and the patient was discharged without nephrostomy and with the ureteral stent, retrograde intrarenal surgery (RIRS) was planned in 3 to 4 weeks. Hemoglobin, hematocrit, and the renal function were normal. On the seventh day after PCNL, no leakage was detected from the percutaneous tract, but the patient started to complain about flank discomfort and fever. Imaging showed a 6 cm lower pole subcapsular collection. After 3 days of conservative management with antibiotics, the subcapsular collection did not resolve and a percutaneous 6F mono-J drainage in the collection was placed. Drain output was at first purulent and evolved into urine throughout the following days. Drain urine culture was positive for Escherichia coli infection and carbapenemic-targeted antibiotic was offered to the patient. Collection drained about 400 cc in 7 days and the drain was removed when the output was less than 10 cc per day. No late complications were reported and RIRS was scheduled in 1 month to clear the residual stone. Conclusion: Subcapsular urinoma post-PCNL is an uncommon but severe complication. Prompt and correct drainage may solve it.

Primary carcinoid tumour of the testis: A case-report.

Testicular carcinoid tumours (TCT) account for less than 1% of all testicular neoplasms. A 17-year-old male underwent radical orchiectomy for a painful indurated and increased in size right testicle; a mixed echogenic mass, with a central homogeneous area surrounded by a hypoechoic edge with calcifications was found at ultreasound with increased vascularity at color Doppler examination. Biochemical markers were within normal limits. These symptoms are not specific and the majority of TCT are only diagnosed on histopathology. Patients should undergo long-term biochemical and radiological follow-up given potential for delayed metastases, in one case 17 years after primary treatment.

Management of severe blunt renal trauma in adult patients: a 10-year retrospective review from an emergency hospital.

UNLABELLED: What's known on the subject? and What does the study add? Immediate surgery for major renal truma has led to a high rate of nephrectomy in comparison with an expectant management. We reviewed our case material on the management of severe blunt renal trauma in adults with emphasis on conservative management. Only shattered kidneys and pedicle avulsion required immediate surgery. OBJECTIVE: To review retrospectively the management of major blunt renal truma in adult patients admitted to our level I trauma centre. PATIENTS AND METHODS: Among 1460 blunt abdominal trauma cases collected from January 2001 to December 2010, 221 (15%) affected the kidneys. All patients, except seven who needed immediate laparotomy, underwent a computed tomography scan to stage the injuries. Renal injuries were graded according to the American Association for the Surgery of Trauma Grading System; grade 4 and 5 injuries were subclassified based on vascular or parenchymal injury. RESULTS: Only 45/221 patients (20%) suffered major blunt renal trauma (21 grade 3, 18 grade 4 and six grade 5); 43% of the patients had associated lesions and 77% had gross haematuria. Nephrectomy rates were 9% for grade 3, 22% for grade 4 and 83% for grade 5 with an exploration rate of 26% for major renal trauma. CONCLUSIONS: Conservative management of grade 3-5 blunt renal trauma in haemodynamically stable patients yields more favourable results with high renal salvage rate. Grade 5 injuries still result in a nephrectomy rate of more than 80%. The absence of data on long-term outcomes and a potential inclusion bias due to the retrospective nature of the data represent major limitations of this review.

Prevalence and clinical significance of prostate cancer among 12,682 men with normal digital rectal examination, low PSA levels (< or =4 ng/ml) and percent free PSA cutoff values of 15 and 20%.

AIM: To report prevalence and clinical relevance of T1c prostate cancers (PCa) in a selected population of men with serum prostate-specific antigen (PSA) levels < or =4 ng/ml enrolled in a multicenter case-finding protocol. PATIENTS AND METHODS: A number of 16,298 men, aged 40-75 years, from the urology units they had been referred to, in most cases (81.6%) for lower urinary tract symptoms, were evaluated. Eighty percent of them had PSA < or =4 ng/ml and about 40% PSA < or =2.5 ng/ml. Patients with PSA < or =2.5 ng/ml and PSA between 2.6 and 4 ng/ml and with percent free PSA < or =15 and < or =20%, respectively, were eligible for biopsy; 28 patients refused it, and 11 patients were excluded from the study because of an abnormal digital rectal examination. Among 403 biopsied men, 82 had PSA < or =2.5 ng/ml (group A) and 321 PSA between 2.6 and 4 ng/ml (group B). RESULTS: A PCa was found in 109 cases (27.0%): 21 in group A and 88 in group B. 48 (44%) of the 109 patients with a PCa underwent radical prostatectomy: all cancers had a volume >0.5 cm(3), and 41% had a final Gleason sum > or =7; the PCa was organ confined in 34 patients (70.8%) and locally advanced in 14 patients (29.1%), and in 12 patients (25%) positive surgical margins were found. CONCLUSIONS: Using percent free PSA thresholds of 15 and 20%, 25.6% of the men with PSA < or =2.5 ng/ml and 27.4% of the men with PSA between 2.6 and 4 ng/ml were found to have a PCa, respectively. Most of these cancers, when submitted to radical prostatectomy, were found to be clinically significant. As these cancers are mostly organ confined, these patients are ideal candidates for curative nerve-sparing surgery.

Should men with serum prostate-specific antigen < or =4 ng/ml and normal digital rectal examination undergo a prostate biopsy? A literature review.

The clinical significance of a prostate cancer (PCa) cannot be determined solely by tumor volume (< or =0.5 cm(3)), as small tumors of higher Gleason grade and tumors occurring in younger men may become clinically significant even though the initial volume at diagnosis is small. A certain number of these minimal cancers are likely to remain clinically insignificant; however, it is unpredictable how many can progress beyond the curable stage by the time there is a rise in serum prostate-specific antigen (PSA) values. Compared to clinically detected PCa, PCa detected exclusively by PSA screening (clinical stage T1c) are less likely to be advanced but no more likely to be insignificant in terms of volume, pathologic stage, and Gleason pattern. Only 10-15% of PSA-detected cancers have the features of PCa found at autopsy or in cystoprostatectomy specimens. Actually, 25-30% of PCa are detected with PSA values between 2.5 and 4 ng/ml, and most of these cancers are clinically significant. Evidence from both retrospective and longitudinal studies has shown that the risk of a PCa is dependent on the patient's age and the initial serum PSA. This allows an individualized approach to PCa screening programs, and PSA cutoff values for biopsy indication may be lowered in selected patients.

End-to-end ureteral anastomosis: a simple alternative to cutaneous ureterostomy in selected patients.

UNLABELLED: End-to-end of terminal ureteral segments seems to be a good alternative to terminal cutaneous ureterostomy in very selected cases (patients with short life-expectancy or when it is impossible to utilize the bowel for urinary diversion). BACKGROUND: An end-to-end ureteral anastomosis (UA) drained by a single percutaneous nephrostomy is proposed as an alternative to permanent cutaneous ureterostomy. METHODS: In eight patients who underwent radical cystectomy, an end-to-end UA was realized. All patients had an advanced pelvic neoplasm and/or severe comorbidities with a short life-expectancy. RESULTS: End-to-end UA is a very simple intervention, well tolerated by the patient that requires only the periodic substitution of the nephrostomy. CONCLUSIONS: In very selected cases (patients with short life-expectancy, advanced disease) end-to-end UA is a quick and easy way to divert the urine after bladder removal.