Patients' Radiation Exposure During Endovascular Abdominal Aortic Aneurysm Repair.

BACKGROUND: To investigate associations between patient characteristics, intraprocedural complexity factors, and radiation exposure to patients during endovascular abdominal aortic aneurysm repair (EVAR). METHODS: Elective standard EVAR procedures between January 2015 and December 2020 were retrospectively analyzed. Patient characteristics and intraprocedural data (i.e., type of device, endograft configuration, additional procedures, and contralateral gate cannulation time [CGCT]) were collected. Dose area product (DAP) and fluoroscopy time were considered as measurements of radiation exposure. Furthermore, effective dose (ED) and doses to internal organs were calculated using PCXMC 2.0 software. Descriptive statistics, univariable, and multivariable linear regression were applied to investigate predictors of increased radiation exposure. RESULTS: The 99 patients were mostly male (90.9%) with a mean age of 74 ± 7 years. EVAR indications were most frequently abdominal aortic aneurysm (93.9%), penetrating aortic ulceration (2.0%), focal dissection (2.0%), or subacute rupture of infrarenal abdominal aortic aneurysm (2.0%). Median fluoroscopy time was 19.6 minutes (interquartile range [IQR], 14.1-29.4) and median DAP was 86,311 mGy cm2 (IQR, 60,160-130,385). Median ED was 23.2 mSv (IQR, 17.0-34.8) for 93 patients (93.9%). DAP and ED were positively correlated with body mass index (BMI) and CGCT. Kidneys, small intestine, active bone marrow, colon, and stomach were the organs that received the highest equivalent doses during EVAR. Higher DAP and ED values were observed using the Excluder endograft, other bi- and tri-modular endografts, and EVAR with ≥2 additional procedures. Multivariable linear regression analysis revealed that BMI, ≥2 additional procedures during EVAR, and CGCT were independent positive predictors of DAP and ED levels after accounting for endograft type. CONCLUSIONS: Patient-related and procedure-related factors such as BMI, ≥2 additional procedures during EVAR, and CGCT resulted predictors of radiation exposure for patients undergoing EVAR, as quantified by higher DAP and ED levels. The main intraprocedural factor that increased radiation exposure was CGCT. These data can be of importance for better managing radiation exposure during EVAR.

Radiation Exposure and Surgical Outcomes after Antegrade Sclerotherapy for the Treatment of Varicocele in the Paediatric Population: A Single Centre Experience.

INTRODUCTION: Antegrade sclerotherapy (Tauber) effectively treats varicocele. However, fluoroscopy exposes young males to ionizing radiation. We aimed to evaluate radiation exposure and surgical outcomes after the Tauber procedure. MATERIALS AND METHODS: We retrospectively analysed data from 251 patients. Dose area product (DAP) and fluoroscopy time were recorded. The effective dose was calculated with the PCXMC software. Descriptive statistics and linear regression tested the association between clinical predictors and radiation exposure. RESULTS: Median (IQR) age and body mass index (BMI) were 14 (13-16) years and 20.1 (17.9-21.6) kg/m². Five (2.1%) patients developed clinical recurrence and two (0.81%) developed complications. Median fluoroscopy time and DAP were 38.5 (27.7-54.0) s and 89.6 (62.5-143.9) cGy*cm2. The effective dose was 0.19 (0.14-0.31) mSv. Fluoroscopy time was higher in patients with collateral veins (41 (26-49) s vs. 36 (31-61) s, p = 0.02). The median amount of sclerosing agent (SA) used was 3 (3-4) ml. DAP was higher when SA > 3 mL was used (101.4 (65-183) cGy*cm2 vs. 80.5 (59-119) cGy*cm2; p < 0.01). At univariable linear regression, age, BMI, operative time and SA > 3 mL were associated with higher DAP (all p < 0.01). At multivariable linear regression, only BMI (beta 12.9, p < 0.001) and operative time (beta 1.9, p < 0.01) emerged as predictors of higher DAP, after accounting for age and SA > 3 mL. CONCLUSIONS: The Tauber procedure is safe and associated with low effective doses. Operative time and the patient's BMI independently predict a higher radiation dose.

Coenzyme Q10 and Melatonin for the Treatment of Male Infertility: A Narrative Review.

BACKGROUND: Lifestyle and environmental factors can negatively impact fertility by means of oxidative stress. In this context, antioxidant supplementation therapy has gained much interest in recent years, and different molecules, alone or in combination, have been studied. OBJECTIVE: The purpose of the present review is to investigate the evidence regarding the efficacy of coenzyme Q10 (CoQ10) and melatonin on male infertility. METHODS: A literature search using PUBMED database from 2000 to October 2022 was performed to explore the role of CoQ10 and melatonin on male reproductive function. CONCLUSIONS: The analysis involved a narrative synthesis. CoQ10, alone or in combination, appears to reduce testicular oxidative stress and sperm DNA fragmentation and to improve sperm parameters; particularly sperm motility. Moreover, CoQ10 treatment is associated with higher pregnancy rates, both naturally and through assisted reproductive technology (ART). Larger studies are needed to precisely determine its clinical efficacy. Melatonin is a known antioxidant and preclinical studies have shown its ability to modulate reproductive function through hormonal and immune system regulation and sperm cell proliferation. Regardless, clinical studies are necessary to assess its potential in male infertility.

Clinically Meaningful Improvements in Sperm DNA Fragmentation Severity in Infertile Men Treated with Superoxide Dismutase Supplementation: A Single-Center Experience.

Background. Antioxidants are commonly used for the treatment of idiopathic male infertility. Previous studies have shown that antioxidants are able to improve sperm quality, but little is known about their impact on sperm DNA fragmentation (SDF). Preliminary findings showed that superoxide-dismutase (SOD)-based antioxidant plus hydroxytyrosol and carnosol (FertiPlus® SOD) therapy was associated with SDF improvement in a small cohort of infertile men. Therefore, we aimed to assess rates of and predictors of semen parameters and SDF improvements in infertile men treated with FertiPlus® SOD therapy (SOD+) or with other antioxidants without SOD (SOD−) in the real-life setting. Methods. Data from 60 consecutive infertile men with baseline SDF ≥ 30% and treated with SOD+ or SOD− for at least three months were analyzed. Clinical parameters and serum hormones were collected. Sperm parameters and SDF were requested at baseline and after SOD+ or SOD− treatment. Clinically meaningful SDF change after treatment was defined as SDF improvement >20% compared to baseline. Propensity score matching was performed to adjust for baseline differences between groups. Descriptive statistics were used to compare clinical and hormonal characteristics between SOD+ and SOD− groups. Semen characteristics were compared before and after treatment. Logistic regression models investigated the association between clinical variables and SDF improvement. Results. Groups were similar in terms of clinical, serum hormones and semen parameters at baseline after matching. Compared to baseline, sperm progressive motility (17 (10−36)% vs. 27 (12−41)%) and normal morphology (2 (1−6)% vs. 4 (2−6)%) significantly improved after SOD+ treatment (all p < 0.01), but not after SOD−. SDF values significantly improved after treatment in both groups, compared to the baseline evaluation (all p < 0.01). However, SDF values were lower after SOD+ than SOD− treatment (30 (22−36)% vs. 37 (31−42)%, p = 0.01). Similarly, a clinically meaningful improvement in SDF at follow-up was more frequently found after SOD+ than SOD− treatment (76.7% vs. 20.0%, p = 0.001). Multivariable logistic regression analysis showed that SOD+ treatment (OR 5.4, p < 0.001) was an independent predictor of clinically meaningful SDF improvement, after accounting for age and baseline FSH values. Conclusions. This cross-sectional study showed that, in a cohort of primary infertile men with SDF ≥ 30%, SOD-based treatment was significantly effective in improving SDF compared to antioxidants without SOD. Approximately 80% of men treated with SOD+ achieved clinically meaningful improvement in SDF after three months of treatment. Sperm progressive motility and normal morphology also improved after SOD+ therapy but not after SOD−. These results suggest that SOD+ treatment could be considered an effective option for the management of idiopathic infertile men with elevated SDF.

The comprehensive complication index as a tool for reporting the burden of complications after mini-percutaneous nephrolithotomy: is it time to leave the Clavien-Dindo classification behind?

PURPOSE: To validate the comprehensive complication index (CCI) for mini-percutaneous nephrolithotomy (mPCNL). METHODS: Data from 287 patients who underwent mPCNL were analyzed. Complications after mPCNL were classified using both the CCI and the Clavien-Dindo classification (CDC). Descriptive statistics and linear/logistic regression analyses detailed the association between clinical predictors and mPCNL outcomes. RESULTS: After mPCNL, 83 (28.9%) patients had complications, of which 12 (4.2%) patients with multiple complications had a higher CCI score compared to the traditional CDC system accounting only for the highest grade. The CCI enabled a more accurate prediction of length of stay (LOS) than CDC (CCI: r = 0.32; p < 0.01 vs. CDC: r = 0.26; p = 0.01). Patients with multiple complications had higher stone volume (p = 0.02), longer operative time and LOS (all p < 0.01). A higher rate of post-operative hospital readmission (33.3% vs. 9.9%, p = 0.02) and lower rate of stone free (33.3% vs. 64.7%, p = 0.04) were found in patients with multiple complications than in those with single complication. Linear regression analysis revealed that multiple complications were associated with longer LOS (p < 0.001) after accounting for BMI and stone volume. Similarly, having multiple complications was associated with fivefold higher risk of readmission (p = 0.02). CONCLUSION: The CCI is a valuable metric for assessing post-operative complications after mPCNL. The cumulative CCI is a better predictor of LOS than the CDC for mPCNL. Minor complications not captured by the highest CDC score are relevant since patients with multiple complications have longer LOS and higher rate of readmission than those with single ones.

Varicocoele embolization with sclerosing agents leads to lower radiation exposure and procedural costs than coils: Data from a real-life before and after study.

OBJECTIVES: To investigate clinical outcomes, radiation exposure and procedural costs associated with percutaneous varicocoele embolization using coils and sclerosing agents (SAs) in a cohort of young-adult men. MATERIALS AND METHODS: Data from consecutive men treated with percutaneous varicocoele embolization using coils and SA between 2017 and 2021 were analyzed. The allocation was based on a change of policy occurred in June 2020 with the substitution of coils with SA (before and after study). Semen analysis values were based on 2010 WHO reference criteria. Anatomic variants of gonadal veins were categorized according to Jargiello et al. Intraoperative radiation dose and procedural costs were collected for each patient. Descriptive statistics and linear regression models were used to describe the association between clinical parameters with procedural costs and radiation exposure. RESULTS: One hundred sixteen men were included, of whom 76 (65.5%) received coils, and 40 (34.5%) received SA. Baseline characteristics of the two study groups did not differ. A type 3 Jargiello anatomic variation of left gonadal vein was found in 45.7% of cases. Radiation dose was lower in the SA group as compared to the coils one (13.2 [7-43] vs. 19.8 [12-57] Gy/cm2 ; p < 0.001). Similarly, procedural costs were lower for the SA group (169.6 [169-199] € vs. 642.5 [561-775] €; p < 0.001). At follow-up, pain and sperm variables significantly improved in both groups (p < 0.01), without differences among the embolic materials. Linear regression model revealed that coils use was associated with higher radiation exposure (beta 8.8, p = 0.02) than SA after accounting for anatomic variation of gonadal vein, body mass index, and vascular access. CONCLUSIONS: SA and coils for varicocoele embolization are equally safe and effective. The use of SA was associated with lower radiation exposure and procedural costs than coils. These results should be considered in terms of public health cost and patient's safety.

Development of a Novel Clinical and Radiologic Risk Score to Predict Septic Complications After Urinary Decompression in Patients with Obstructive Uropathy.

Background: Well-defined clinical predictors of sepsis after upper tract drainage for obstructive uropathy are lacking. The study aim is to develop a data-driven score to predict risk of sepsis after decompression of the upper urinary tract. Materials and Methods: Complete clinical and radiologic data from 271 patients entering the emergency department for obstructive uropathy and submitted to stent/nephrostomy tube decompression were evaluated. The Charlson Comorbidity Index (CCI) was used to score comorbidities. The definition of sepsis was an increase in ≥2 Sequential Organ Failure Assessment points (or a postoperative persistently elevated score +1 additional increase) and documented blood or urine cultures. Descriptive statistics and stepwise multivariable logistic regression modeling with receiver operating characteristic analysis were performed to obtain a composite risk score to predict the risk of sepsis after surgery. This study was approved by our local Ethics Commitee (Prot. 25508). Results: Fifty-five (20.3%) patients developed sepsis. At multivariable analysis, CCI ≥2 (odds ratio [OR] 3.10; 95% confidence interval [CI] 1.36-7.04), maximum body temperature ≥38°C (OR 4.35; 95% CI 1.89-9.44), grade III-IV hydronephrosis (OR 2.37; 95% CI 1.10-4.98), HU of the dilated collecting system ≥7.0 (OR 4.47; 95% CI 2.03-9.81), white blood cells ≥15 × 103/mmc (OR 2.77; 95% CI 1.24-6.19), and C-reactive protein ≥10 (OR 3.27; 95% CI 1.41-7.56) were independently associated with sepsis. The positive predictive value of a true sepsis increased incrementally as a function of number of positive variables, ranging from 1.6% to 100.0% among patients with 1 and 6 positive variables, respectively. Conclusion: Our risk score identifies accurately patients with an increased risk of sepsis after urinary decompression for obstructive uropathy, hence improving clinical management.

Cost analysis between mini-percutaneous nephrolithotomy with and without vacuum-assisted access sheath.

PURPOSE: To perform a cost analysis between vacuum-assisted percutaneous nephrolithotomy (vmPCNL) and minimally invasive PCNL (MIP) and explore potential predictors of costs associated with the procedures. METHODS: We analyzed data from 225 patients who underwent vmPCNL or MIP at a single tertiary referral academic center between January 2016 and December 2020. We collected patients' demographics, peri-and postoperative data and detailed expense records. After propensity score matching, 108 (66.7%) vmPCNL and 54 (33.3%) MIP procedures were analyzed. Descriptive statistics assessed differences in clinical and operative parameters. Univariable and multivariable linear regression models tested the association between clinical variables and costs. RESULTS: Operative time (OT) was shorter for vmPCNL, and the use of additional instruments to complete litholapaxy was more frequent in MIP (all p ≤ 0.01). Length of stay (LOS) was longer for MIP patients (p = 0.03) and the stone-free (SF) rate was higher after vmPCNL (p = 0.04). The overall instrumentation cost was higher for vmPCNL (p < 0.001), but total procedural costs were equivalent (p = 0.9). However, the overall cost for the hospitalization was higher for MIP than vmPCNL (p = 0.01). Univariable linear regression revealed that patient's comorbidities, OT, any postoperative complication and LOS were associated with hospitalization costs (all p < 0.001). Multivariable linear regression analysis revealed that LOS and OT were associated with hospitalization costs (all p < 0.001), after accounting for vmPCNL procedure, patients' comorbidities, and complications. CONCLUSION: vmPCNL may represent a valid option due to clinical and economic benefits. Shorter OT, the lower need for disposable equipment and the lower complication rate reduced procedural and hospitalization costs.

Spontaneous Upper Urinary Tract Rupture Caused by Ureteric Stones: Clinical Characteristics and Validation of a Radiological Classification System.

BACKGROUND: This study seeks to validate a radiological classification system of spontaneous upper urinary tract rupture (sUUTR) and to analyse its relationship with clinical, laboratory and radiological characteristics of sUUTR. METHODS: We analysed data from 66 patients with a computerised tomography (CT)-proven sUUTR treated with ureteral or nephrostomy catheter positioning. Comorbidities were scored with the Charlson Comorbidity Index (CCI). All CT scans were reviewed by two experienced radiologists and one urologist, who classified sUUTR in (a) local spread, (b) free fluid and (c) urinoma. Interobserver agreement for radiological score was evaluated with the Intraclass Correlation Coefficient (ICC) and Cohen's Kappa analyses. Descriptive statistics and logistic regression models verified the association between clinical variables and sUUTR severity. RESULTS: The interobserver agreement for sUUTR classification was high among radiologists and between the radiologists and the urologist (all Kappa > 0.7), with an overall high interrater reliability (ICC 0.82). Local spread, free fluid and urinoma were found in 24 (36.4%), 39 (59.1%) and 3 (4.5%) cases, respectively. Patients with free fluid/urinoma had higher rate of CCI ≥ 1 than those with local spread (40.5% vs. 16.7%, p = 0.04). Intraoperative absence of urine extravasation was more frequently found in patients with local spread than those with free fluid/urinoma (66.7% vs. 28.6%, p < 0.01). Multivariable logistic regression analysis revealed that local spread (OR 4.5, p < 0.01) was associated with absence of contrast medium extravasation during pyelography, after accounting for stone size, fever and CCI. CONCLUSIONS: The analysed sUUTR classification score had good inter/intra-reader reliability among radiologists and urologists. Absence of urine extravasation was five times more frequent in patients with local spread, making conservative treatment feasible in these cases.

Nomenclature in thulium laser treatment of benign prostatic hyperplasia: it's time to pull the rabbit out of the hat.

We performed a narrative review with the focus on laser settings and surgical procedure with thulium laser. Our primary goal was to define the most valid settings of each surgical procedure to overcome the inconsistency about nomenclature of thulium surgery and to ensure comparability of future publications. A literature search of articles on thulium laser treatment of benign prostatic hyperplasia (BPH) was conducted between 2009 and 2019. We proposed a new classification standard for laser settings and associated surgical procedure. Each article was analyzed and categorized as concordant or discordant referring to the new classification. In total, 74 papers were included in this narrative review. Overall, 43% and 42% of included studies reported discordant laser parameters and surgical description, respectively. Most of the studies on vaporization were categorized as discordant because they reported a medium/low laser setting instead of high power. Conversely, 93.3% of studies on enucleation were deemed as discordant for laser setting because they reported high power parameters instead of medium-low power setting. Most of the studies on laser enucleation and vapo/enucleation were considered discordant for surgical procedure since authors did not mention the use of mechanical vs. laser method for enucleation. The current literature lacks a uniform definition and standardization of the terminology of thulium laser settings and surgical techniques to guarantee comparability between different approaches. We found a huge heterogeneity in 10 years of surgery with thulium laser. We proposed a new classification of laser setting and procedural description for categorization of thulium laser surgery for BPH.

Clinical Comparison of Mini-Percutaneous Nephrolithotomy with Vacuum Cleaner Effect or with a Vacuum-Assisted Access Sheath: A Single-Center Experience.

Purpose: To compare outcomes of two different miniaturized percutaneous nephrolithotomy (PCNL) techniques: minimally invasive PCNL (MIP) with the vacuum cleaner effect and vacuum-assisted mini-PCNL (vmPCNL). Materials and Methods: Data from 104 (66.7%) patients who underwent vmPCNL and 52 (33.3%) patients who underwent MIP at a single tertiary referral academic center between January 2016 and December 2019 were analyzed. Patient demographics and peri- and postoperative data were recorded, and propensity score matching was performed. Descriptive statistics and linear regression models were used to identify variables associated with operative time (OT) and patient effective dose. Logistic regression analyses were used to identify factors associated with infectious complications and stone-free (SF) status. Results: Patient demographics and stone characteristics were comparable between groups. vmPCNL was associated with shorter OT (p < 0.001), fluoroscopy time, and patient effective dose (4.2 mSv vs 7.9 mSv; p < 0.001). A higher rate of infectious complications was found in the MIP group (25.0% vs 7.7%, p < 0.01). Linear regression analysis showed that stone volume, multiple stones, and MIP procedure (all p values ≤0.02) were associated with longer OT. Similarly, OT and the MIP procedure (p ≤ 0.02) were associated with higher patient effective dose. Logistic regression analysis revealed that the stone volume, positive preoperative bladder urine culture, and MIP procedure (all p values ≤0.02) were associated with postoperative infectious complications. vmPCNL was not associated with the SF rate. Conclusions: Mini-PCNL performed with continuous active suction is associated with lower rates of infectious complications, shorter OT, and lower patient effective dose than MIP.

Hounsfield unit attenuation value can differentiate pyonephrosis from hydronephrosis and predict septic complications in patients with obstructive uropathy.

We aimed to assess the role of computerized tomography attenuation values (Hounsfield unit-HU) for differentiating pyonephrosis from hydronephrosis and for predicting postoperative infectious complications in patients with obstructive uropathy. We analysed data from 122 patients who underwent nephrostomy tube or ureteral catheter placement for obstructive uropathy. A radiologist drew the region of interest for quantitative measurement of the HU values in the hydronephrotic region of the affected kidney. Descriptive statistics and logistic regression models tested the predictive value of HU determination in differentiating pyonephrosis from hydronephrosis and in predicting postoperative sepsis. A HU cut-off value of 6.3 could diagnose the presence of pyonephrosis with 71.6% sensitivity and 71.5% specificity (AUC 0.76; 95%CI: 0.66-0.85). At multivariable logistic regression analysis HU ≥ 6.3 (p ≤ 0.001) was independently associated with pyonephrosis. Patients who developed sepsis had higher HU values (p ≤ 0.001) than those without sepsis. A HU cut-off value of 7.3 could diagnose the presence of sepsis with 76.5% sensitivity and 74.3% specificity (AUC 0.79; 95%CI: 0.71-0.90). At multivariable logistic regression analysis, HU ≥ 7.3 (p ≤ 0.001) was independently associated with sepsis, after accounting for clinical and laboratory parameters. Measuring HU values of the fluid of the dilated collecting system may be useful to differentiate pyonephrosis from hydronephrosis and to predict septic complications in patients with obstructive uropathy.

Impact of Surgical Experience on Radiation Exposure during Retrograde Intrarenal Surgery: A Propensity-Score Matching Analysis.

BACKGROUND: The impact of surgical experience on radiation exposure (RE) during endourological procedures has been poorly investigated. OBJECTIVE: To assess the impact of surgical experience on fluoroscopy time (FT) and RE during retrograde intrarenal surgery (RIRS). DESIGN, SETTING, AND PARTICIPANTS: The study included 140 patients who underwent RIRS performed either by a senior surgeon (expertise of >100 RIRSs) (group A) or by two junior residents (expertise of <15 RIRSs) (group B) between January 2016 and May 2018. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: We tested the hypothesis that surgical experience had a limited impact on RE during RIRS. To adjust for potential baseline confounders, propensity-score matching was performed. Descriptive statistics and linear regression models tested the association between clinical variables and FT and patients' effective doses. RESULTS AND LIMITATIONS: There was no significant difference between the two groups for baseline, intraoperative, and postoperative characteristics. Overall FT (p=0.97) and effective dose (p=0.79) did not differ between groups. A statistically significant association was found between male sex (all p<0.03), stone burden (all p<0.001), operative time (all p<0.003), and postoperative double-J placement (all p<0.02) with both FT and effective dose. Linear multivariable analysis revealed that body mass index was significantly associated with effective dose (p=0.002). Similarly, longer operative time (all p<0.03) and double-J placement (all p<0.04) were significantly associated with increased FT and effective dose. CONCLUSIONS: Surgical experience has a limited impact on FT and RE during RIRS. Longer operative time and double-J placement were associated with increased FT and effective dose. PATIENT SUMMARY: In this study, we assessed whether surgical experience affects fluoroscopy time and patient's effective dose during retrograde intrarenal surgery (RIRS). We found that radiation exposure (RE) was not affected by surgeon's experience and that the standardisation of the surgical technique at the beginning of the learning curve of young surgeons may represent the key factor in reducing RE during RIRS.