The headache of the post transurethral prostate surgery pyuria: Pursuit for evidence.

• Objective To prospectively assess early post-TUPS (transurethral prostate surgery) urinalysis changes and bacteriuria with its clinical relevance. • Methods Patients with BPO enrolled for TUPS were prospectively assessed. Patients were assessed at 2, 4, 8, 12, and 24-weeks postoperatively by DVAS (dysuria-visual-analogue-scale), IPSS-QOL, uroflow, and PVR. Routine urinalysis was performed before discharge and at all visits. MSUC (midstream urine culture) was performed before discharge, 4 and 12-weeks postoperatively. • Results At final analysis 152 patients were evaluable. Significant pyuria was reported in 52%, 96.1%, 94.1%, 71.7%, 78.9% and 52.5% in before discharge, 2-, 4-, 8-, 12-, and 24-weeks urinalysis postoperative respectively. The mean time to non-significant-pyuria (95%CI) was 19.1(17.5-20.7), 20.1(17.3-22.9), 15.8(12.8-18.8) and 14(10.3-17.8) weeks after prostate resection, vaporization, enucleation, and incision respectively, (P0.03). Regardless of the TUPS technique, half of the patients had significant pyuria at 24-weeks postoperative. MSUC was positive in 37/152(24.3%), 3/152(2%), 23/152(15.1%), and 5/152(3.3%) preoperatively, before discharge, 4 and 12-weeks postoperative respectively. Only positive preoperative urine leucocyte esterase independently predicted positive 4-weeks MSUC (OR3.8, 95%CI1.3-11.1, P0.013). No significant correlation was found between IPSS or DVAS and positive MSUC nor between IPSS and postoperative pyuria at different follow-up points (P>0.05). However, the degree of postoperative dysuria was significantly correlated with postoperative pyuria count by urinalysis at 2-Weeks (r0.69, P0.03), 8-Weeks (r0.26, P0.001) and 12-Weeks (r0.23, P0.004). • Conclusion There is a persistent but gradually declining pyuria and microhematuria following TUPS up to 6 months postoperative. An earlier resolution was noted following prostate incision and enucleation. While routine urine analyses screening in these months would be of no clear clinical value, a routine urine culture would be of a reasonable significance at 1 month post-operatively.

Ureteral wall thickness as a predictor for non-invasive treatment success for steinstrasse. Can we save time?

PURPOSE: We aimed to define factors affecting the non-invasive overall treatment success (medical expulsive therapy (MET) ± shock wave lithotripsy (SWL)) for uncomplicated ureteral steinstrasse (SS) clearance. METHODS: We retrospectively evaluated consecutive patients who underwent SWL for renal stones between 2017 and 2021. Patients with uncomplicated SS were included. All patient's demographic and radiological data, e.g., age, gender, pre-SWL stenting, SS site, type, leading stone size in widest diameter (< 10 mm and ≥ 10 mm), ureteral wall thickness (UWT) in mm against the leading stone were collected. If SS was diagnosed, medical treatment was given for 4 weeks. In case of MET failure, either SWL for the leading stones + MET or direct URS was done. Non-invasive treatment success (SFR) was considered if complete clearance of SS occurred with no complications or the need for invasive intervention. RESULTS: A total of 145 patients were included with mean age of 45.9 ± 12.4 years. SFR in case of MET only occurred in 27.9%. Complications happened in 26 patients (17.9%). Non-invasive treatment SFR was achieved in 78 patients (53.8%) totally where SS type I, leading stone size ≤ 10 mm type and decreased UWT around the leading stone increased treatment success. CONCLUSION: Ureteral wall thickness is an important factor predicting SS management success. Besides the decreased UWT, non-invasive management should be offered for type I SS with leading stone ≤ 10 mm.

Randomized trial to assess the potential role of ascorbic acid and statin for post-contrast acute kidney injury prevention.

PURPOSE: To evaluate the effect of using statins and ascorbic acid for the prevention of post-contrast acute kidney injury (PC-AKI) in patients undergoing urologic diagnostic elective contrast-enhanced computed tomography (CECT). METHODS: This registered trial (NCT03391830) was for statin naïve patients underwent elective CECT. Patients were randomized allocated to two groups: the first group received atorvastatin 80-mg the day before the study and atorvastatin 40-mg two hours before the CECT and for continue on atorvastatin 40-mg two days after CECT; plus ascorbic acid 500 mg with atorvastatin. The other group received two tablets of placebo once/daily before the procedure and for another 3 days. The primary outcome was to assess the incidence PC-AKI. RESULTS: The baseline parameters were comparable between both groups. The final median (interquartile range "IQR") serum creatinine were 0.80 (0.60, 1.00) and 0.80 (0.60, 1.00), respectively, with insignificant p-value (p = 0.8). The median (IQR) final estimated GFR were 95.2 (72.8, 108.1) and 88.6 (71.9, 111.0) mL/min in placebo and statin plus ascorbic acid groups, respectively (p = 0.48). The eGFR difference median (IQR) were - 6.46 (- 11.72, - 4.18) and - 6.57 (- 13.38, - 3.82) ml/min in placebo and statin plus ascorbic acid groups, respectively (p = 0.58). PC-AKI occurred in 11 patients (9.8%) in placebo group and in 3 patients (3%) in statin plus ascorbic acid group (p = 0.04). CONCLUSIONS: Statin and ascorbic acid did not statistically improve neither serum creatinine nor eGFR values in patient underwent CECT. However, it can decrease the incidence of the clinically insignificant PC-AKI.

The efficacy of the new Bosniak classification v.2019 in benign lesions prediction within the higher Bosniak cysts classes.

INTRODUCTION: Identification of benign lesions among higher classes of renal Bosniak cysts who are vulnerable to active surveillance instead of surgical approach is still questionable. We aimed in this study to delineate the efficacy of the new Bosniak v2019 classification in benign lesions identification among those cases with higher Bosniak classes in comparison with the final histopathology. MATERIALS: In a retrospective review between 2010 and 2021 for patients diagnosed as higher classes Bosniak renal masses was done. Patients' demographics and radiological data i.e.,: age, gender, and final Bosniak v2019 categorization for class III: (1) Enhancing thick wall/septa >4 mm (III-WS) and (2) Enhancing irregular wall/septa or convex protrusion with obtuse margins <3 mm (III-OP) and for class IV as: (1) Enhancing nodule or convex protrusion with obtuse margins >4 mm (IV-OP) and (2) Enhancing nodule or convex protrusion with acute margins of any size (IV-AP). RESULTS: A total of 137 patients were included. Bosniak III was identified in 56 patients. Malignancy was detected in 74.5% of resected masses. Among resected Bosniak III cyst, 46.4% were benign histopathologically. Male gender and Bosniak III-OP were independent risks for malignancy among the resected Bosniak III cysts. Conversely, in resected Bosniak IV renal cysts, only 9 of resected masses were benign. In univariate analysis, male gender, absence of multilocular cyst and endophytic masses were predictors for malignancy in resected Bosniak IV cyst. None of the previous predictors was significant in multivariate analysis. CONCLUSION: The Bosniak subclassification v.2019 can define benign lesions. Bosniak III-OP was an independent risk for malignancy detection among the resected Bosniak III cysts.

Microscopic hematuria and pelvic ultrasonography could rule out flexible cystoscopy during surveillance for T1-low grade non-muscle invasive bladder cancer.

Purpose: Cystoscopy (rigid/flexible [FC]) is the standard surveillance tool for non-muscle invasive bladder cancer (NMIBC). Nevertheless, it has its drawbacks. The objective of this study is to evaluate the performance of microscopic hematuria (MH), abdominal ultrasonography (US), and urine cytology (UC) as potential substitutes for FC in patients with T1-low-grade (T1-LG) NMIBC. Methods: Over a 12-month period, patients attending our tertiary referral center for T1-LG NMIBC follow-up underwent urine analysis for MH and UC, and then US and FC were performed as outpatient surveillance procedures. Those with positive findings underwent inpatient rigid cystoscopy under anesthesia and biopsy. The negative predictive values (NPV) and sensitivity of different combinations of MH, UC, US, and FC were compared with the standard histopathology. Results: In 218 evaluated patients, FC had the highest NPV (97.9%). However, this figure showed no statistically significant difference if compared with the combination of negative MH and US (93.8%) (difference = 0.04, p = 0.1) or the combination of MH, US, and UC (94.9%) (difference = 0.03, p = 0.2). The reported sensitivity results were similarly comparable between FC (94.2%) and the aforementioned combinations (90.4% and 92.3%; differences: 0.038 and 0.019; p = 0.4 and 0.7, respectively). Conclusions: During the surveillance of NMIBC for patients diagnosed with T1-LG disease, the combination of MH/US has comparable sensitivity and NPV with FC. This non-invasive combination could be considered the first station that might preclude the need for FC in a considerable percentage of this group of patients.

Bladder perforation as a complication of transurethral resection of bladder tumors: the predictors, management, and its impact in a series of 1570 at a tertiary urology institute.

OBJECTIVES: To report the incidence, predictors, the impact of bladder perforation (BP), and our protocol of management in patients who underwent trans-urethral resection of bladder tumor (TURBT). METHODS: This is a retrospective study, between 2006 and 2020, on patients who underwent TURBT for non-muscle-invasive bladder cancer (NMIBC). Bladder perforation was defined as any full thickness resection of the bladder wall. Bladder perforations were managed based on their severity and type. Small BP with no or mild symptoms were managed with prolongation of urethral catheters. Those with significant extraperitoneal extravasations were managed by insertion of a tube drain (TD). Abdominal exploration was done for extensive BP and all intraperitoneal extravasations. RESULTS: Our study included 1,570 patients, the mean age was 58 ± 11 years and 86% were males. Bladder perforation was recorded in 10% (n = 158) of the patients. The perforation was extraperitoneal in 95%, and in 86%, the perforation was associated with no symptoms, mild symptoms, or mild fluid extravasation that required only prolongation of the urethral catheter. On the other hand, active intervention was required for the 21 remaining patients (14%) with TD being the most frequent management. History of previous TURBT (p = 0.001) and obturator jerk (p = 0.0001) were the only predictors for BP. CONCLUSIONS: The overall incidence of bladder perforation is 10%; however, 86% required only prolongation of urethral catheter. Bladder perforation did not affect the probability for tumor recurrence, tumor progression nor radical cystectomy.

Utility of Pre-Transplant Bladder Cycling for Patients With a Defunctionalized Bladder. A Randomized Controlled Trial.

OBJECTIVE: To study the necessity of pre-transplant programmed bladder cycling (PBC) in patients with defunctionalized bladder (DB). METHOD: This RCT included renal transplant (RT) candidates with DB. Eligible patients were assigned to 2 groups, group I underwent PBC before RT and group II underwent direct RT into the DB. The primary outcome was to assess the efficacy of PBC in improving post- RT bladder capacity. Secondly, to compare its impact on early urological complications and 3-month voiding function and 1-year graft function and survival. Graft function was evaluated using serum creatinine and eGFR using MDRD equation. RESULTS: Groups I included 23 patients and group II included 20 patients. The mean ±SD of bladder capacity was 88.7±11.7mL and 90.6 ±9.8mL in both groups, respectively (P = .5). In group I, PBC increased bladder capacity to 194.7 ±21.2 mL (P < .001). Targeted bladder capacity was achieved in 19 (82.6 %) patients and 2 patients developed UTI. At 3-months, bladder capacity, compliance and bladder contractility index improved significantly in both groups with a significant reduction in maximum detrusor pressure with no significant difference between both groups (P = .3,0.4, 0.2 and 0.8, respectively). Urinary leakage occurred in one (4.3%) and 3 patients (15%) in group 1 and 2, respectively (P = .2). At 1-year, no statistically significant differences in the median (IQR) serum creatinine (P = .05) and eGFR (P = .07) between both groups were noted. CONCLUSION: Pre-transplant PBC for DB-patients provided no clinical advantage concerning post-operative urological complication, urodynamic criteria and graft function and survival.

Study of Single Nucleotide Polymorphisms Associated with Breast Cancer Patients among Arab Ancestries.

The aim of this study is to investigate the single nucleotide polymorphisms (SNPs) associated with breast cancer in our population of Arab patients. We investigated 26 breast cancer patients and an equal number of healthy age- and sex-matched control volunteers. We examined the exome wide microarray-based biomarkers and screened 243,345 SNPs for their possible significant association with our breast cancer patients. Successfully, we identified the most significant (p value ≤9.14 × 10-09) four associated SNPs [SNRK and SNRK-AS1-rs202018563G; BRCA2-rs2227943C; ZNF484-rs199826847C; and DCPS-rs1695739G] among persons with breast cancer versus the healthy controls even after Bonferroni corrections (p value <2.05 × 10-07). Although our patients' numbers were limited, the identified SNPs might shed some light on certain breast cancer-associated functional multigenic variations in Arab patients. We assert on the importance of more extensive large-scale analysis to confirm the candidate biomarkers and possible target genes of breast cancer among Arab ancestries.

The Effect of Renal Transplantation on Female Sexual Function: An Age-Matched Pair Analysis.

OBJECTIVE: To evaluate female sexual function (FSF) after renal transplantation (RT) and compare it to an age-matched normal females (control). MATERIAL AND METHODS: The study included 100 sexually active RT females in child-bearing period. Sexual function was evaluated with Female Sexual Function Index (FSFI). We compared the mean scores of all domains of FSFI to an age-matched sexually active normal females. Also, we compared the current FSFI to the pre-transplant status in 54 married females before RT. Factors affecting the FSF after RT were assessed. RESULTS: In comparison to control group, RT group had statistically significant lower sexual desire (P <.001) with no significant differences as regard arousal, lubrication, orgasm, satisfaction, pain, and total FSFI score (P >.05). Among RT-females, 83% had normal sexual function, and 83.7% of the control had normal sexual function (P = .8). After RT, the FSFI score increased significantly from 20.7 ± 5.4 to 27.8 ± 3.1 (P <.001), and 85.2% had normal sexual function compared to 22.2% before RT (P <.001) with statistically significant improvement in all domains (P <.001) except for pain score (P = .8). Female circumcision was the only identified factor associated with FSD (P = .02). CONCLUSION: Successful RT significantly improves female sexual function of ESRD patients. The sexual function after RT is comparable to healthy control except for lower sexual desire.

Is JJ Ureteral Stenting Inferior to Percutaneous Nephrostomy as a Drainage Method in Emphysematous Pyelonephritis?

INTRODUCTION: The aim of the study was to examine the efficacy of JJ stenting in comparison with percutaneous nephrostomy (PCN) as a drainage method in patients with emphysematous pyelonephritis (EPN). METHODS: We retrospectively identified patients with EPN between January 2000 and January 2021. Platelet-to-leukocytic ratio (PLR) at the time of hospital admission and discharge, time taken to clear air locules and to normalize leukocytic count, and air locule volume in mm3 were identified. Renal drainage by either PCN or JJ stent was required if symptoms persist for ≥3 days or in obstructed renal units. Failure of drainage method was defined as conversion to another method of drainage, need for intensive care unit admission, salvage nephrectomy, and mortality. RESULTS: Twenty-nine patients were managed by JJ stent. Treatment success was identified in 20 patients and 19 patients who were managed by PCN and JJ stent, respectively. Higher air locule volume ≥16.7 mm3 and lower PLR ≤18.4 increased the risk of drainage failure (p = 0.009 and 0.001, respectively). CONCLUSION: Ureteral JJ stenting is an effective method for EPN drainage with a comparable overall success to the PCN use. Higher air locule volume and lower PLR increased the risk of drainage failure.

Optimization of shockwave lithotripsy use for single medium sized hard renal stone with stone density ≥ 1000 HU. A prospective study.

PURPOSE: To identify shock wave lithotripsy (SWL) success predictors in hard renal stones (average stone density ≥ 1000 HU). MATERIALS: We prospectively evaluated patients who underwent SWL for hard renal stones between April 2018 and December 2020. Radiological parameters were identified, e.g., stone site, size, the average density in addition to stone core and shell mean density, and renal cortical thickness (RKT). SWL sessions were performed using Doli-S lithotripter till a maximum of 3-4 sessions with 2-4 weeks interval. Initial response to SWL included stone fragmentation and decreased stone size after the first SWL. Treatment success was considered if complete clearance of renal stones occurred or in case of clinically insignificant residual fragments ≤ 4 mm after 12 weeks follow up by NCCT. RESULTS: Out of 1878 patients who underwent SWL, the study included 157 patients with hard renal stones. Treatment overall success was found in 92 patients (58.6%) where 69 patients (43.9%) had complete stone clearance. On multivariate analysis, stone shell density < 901 HU, maximum stone size < 1 cm, RKT > 1.95 cm and initial treatment response were associated with increased the success rate after SWL for hard renal stones (P = 0.0001, 0.009, < 0.0001 and < 0.0001, respectively). CONCLUSION: In hard renal stones, treatment overall success was found in 58.6% where complete stone clearance was found in 43.9%. Stone outer shell fragility, lower stone size, increased RKT and initial response to SWL were associated with a higher success rate at 12-week follow-up.

The accuracy of computed tomography in the diagnosis of upper urinary tract urothelial carcinoma in correlation with the final histopathology: A retrospective study in 275 patients at a Tertiary Urology Institute.

INTRODUCTION: Because the reports in the literature of radiologic investigations for upper tract urothelial cancer (UTUC) are limited by the number of patients, and included patients with different pathologies, we aimed to study the overall accuracy of computed tomography (CT) in the diagnosis of UTUC and their accuracy on predicting tumor location. METHODS: A retrospective review from 1990 to 2017 included patients who were treated for UTUC. Unenhanced CT scan was obtained first using Multi-Detector Computed Tomography (MDCT, Philips Medical Systems), then nonionic contrast medium, containing 350 mg iodine/ml was injected at 4 mL/s. Analysis was performed using SPSS®. RESULTS: Of 275 patients, complete data on CT was available on 270 (98%) patients. CT reported only two false positive and six false negative results and the overall accuracy was 96-97%. In comparison to the final pathological reports, CT/CTU detected 85% of the tumor location of in the renal pelvic and 50% of the calyceal tumors. In ureteric tumors, they detected distal (66/71= 93%) more than proximal ureteric tumors (60%). CONCLUSION: In our cohort, CT/ CTU has a high overall accuracy (97%) in diagnosing UTUC, capability to well visualize tumors of distal ureter and renal pelvis, but could miss calyceal tumors. The matter to rely only on CT without ureteroscopic biopsy in the diagnosis of UTUC especially if radical surgery is planned needs further prospective studies.

Functional multigenic variations associated with hodgkin lymphoma.

INTRODUCTION: The current study aimed to describe genotypes associated with Hodgkin lymphoma (HL) in a cohort of Saudi and non-Saudi patients and discuss their possible susceptibility to HL. METHODS: We studied clinical, histopathological, and laboratory findings of HL patients admitted over 12 years duration, at King Fahd University Hospital, KSA. The genomic DNAs of HL patients (n = 61) and normal control subjects (n = 36) were extracted, and genotyping was performed using the Illumina human exome bead chip. Set of HL patients and set of normal controls were included in this study. RESULTS: A total of 35 DNA variants were found to be highly significant with the P-value <9.90 × 10-11 among 243 345 exonic biomarkers and obeying the Hardy-Weinberg equilibrium. Nine, MEGF11-rs150945752 (P-value 1.20 × 10-12 ), CACNA1I- s58055559 (P-value 1.93 × 10-12 ), DECR2-rs146760080 (P-value 2.19 × 10-12 ), STAB1-rs143894786 (P-value 2.45 × 10-12 ), ZNF526-rs144433879 (P-value 2.76 × 10-12 ), CPLANE1-rs200612080 (P-value 3.77 × 10-12 ), DLK1-rs1058009 (P-value 5.95 × 10-12 ), RTN4RL2-rs61745214 (P-value 7.71 × 10-12 ), and PGRMC1-rs145582672 (P-value 8.56 × 10-12 ), exonic variants on chromosomes 15, 22, and 16 were highly associated with HL cases. THE HIGHLY SIGNIFICANT HAPLOTYPES AT CHROMOSOME 3: rs143894786G; rs149982219G with P-value = 3.43 × 10-14 was found to be the risk haplotype for the HL patients. The opposite alleles at chromosome 3: rs143894786A; rs149982219G is protective with P-value = 2.46 × 10-12 . Maximum number of SNPs at the chromosome 19: rs144433879C; rs181265966G; rs201144421C; rs145591797G; rs200560875G; rs77270337G (risk P-value = 2.24 × 10-12 ) and its opposite allele rs144433879A; rs181265966A; rs201144421T; rs145591797A; rs200560875A; rs77270337A (protective P-value = 2.60 × 10-9 ) were found to be associated haplotype with the HL and controls, respectively, in Saudi population. CONCLUSION: Our study concludes that the HL is genetically heterogeneous with multigene causation.

Critical analysis of pyeloplasty role in adults with late diagnosis of ureteropelvic junction obstruction-a comparative study.

PURPOSE: Due to the data paucity about the functional outcomes post pyeloplasty for patients diagnosed with ureteropelvic junction obstruction (UPJO) with a preoperative age above the age of 45 years and according to the elderly definition (age ≥ 65 years), we conducted this study to clarify the different outcomes in adults presented with late hydronephrosis. METHODS: We included patients who were managed by pyeloplasty with a preoperative age ≥ 45 years. We further subdivided those patients into; group (A) patient's age ≥ 65 years and group (B) patient's age ≥ 45 and < 65 years. Split renal function (SRF) difference was evaluated by the changes between the last follow-up and the baseline renogram, where 5% change was considered a significant change. Functional outcomes and factors predicting the functional recoverability post pyeloplasty were evaluated. RESULTS: A total of 119 patients were included. The mean age was 62.3 ± 16.4 years. Group (A) and group (B) included 47 and 72 patients, respectively. After 24 months, GFR and SRF were increased at the last follow-up (P = 0.32 and 0.57, respectively). No significant functional changes were noted between both groups. Sixty two, 7 and 13 patients showed static, decreased and improved renal function. Lower preoperative SRF was the only predictor for poor functional recoverability in patients with age ≥ 45 years who were managed by pyeloplasty. CONCLUSION: Elderly patients should not be excluded from the corrective surgery for UPJO. Lower preoperative SRF was the only predictor for renal function deterioration post pyeloplasty.

Initial radiological findings associated with active bleeding control necessity and long term functional outcomes after isolated high grade blunt renal trauma.

INTRODUCTION: To assess the predictors for conservative management failure and long term outcomes after isolated blunt high grade renal trauma (HGRT). METHODS:  A retrospective analysis of patients with isolated blunt HGRT (renal trauma grade ≥ IV) was conducted. Patients' demographics, clinical presentation, laboratory and radiological investigations, and different lines of treatment were retrieved. The primary outcome was to assess the predictors of conservative treatment failure (need for active bleeding control e.g.: transarterial angioembolization (TAE) and/or surgical exploration). The secondary outcome was to assess the renal parenchymal volume (RPV) changes post HGRT in correlation with the different lines of management using CT-measured RPV. The difference in RPV ≥ 5% at follow up was considered significant. RESULTS: The study included 63 patients, mean (SD) age was 35.1 (16.6) years. Conservative management was successful in 39 patients (62%), while the need for active bleeding control was required in 16 and 8 patients who underwent TAE and surgical exploration, respectively. Increased hematoma rim distance (HRD), laceration numbers > 3, parenchymal devascularization ≥ 25%, and presence of vascular contrast extravasation (VCE) were predictors for conservative treatment failure (P= 0.006, 0.02, 0.045 and 0.002, respectively). After a mean of 19 months follow up, patients were subclassified into 2 groups: patients with preserved RPV (28 patients) and patients with decreased RPV (29 patients). Renal parenchymal devascularization ≥ 25% was found a predictor for ipsilateral RPV decrease (P = 0.02). CONCLUSION: Increased HRD, laceration numbers > 3, parenchymal devascularization ≥ 25%, and presence of VCE are findings that reflect the necessity for active bleeding interventions after isolated blunt HGRT. Parenchymal devascularization ≥ 25% is an independent factor for RPV deterioration. Neither the grade of renal trauma nor the type of treatment is a predictor for such deterioration.

Enhanced recovery after surgery (ERAS) following radical cystectomy: is it worth implementing for all patients?

PURPOSE: To report the overall effect of ERAS protocol implementation in patients undergoing radical cystectomy and its impact on the length of hospital stay (LOS) and surgical outcomes considering their comorbid conditions. METHODS: Retrospective cohort study including 296 patients (146 non-ERAS patients vs. 150 ERAS patients) undergoing radical cystectomy and urinary diversion from 2010 to 2018. Age-adjusted Charlson Comorbidity Index (ACCI) score eight was set as cut off value between low-risk and high-risk patients. The primary outcome was LOS. Secondary outcomes were time to bowel movements, tolerance of regular diet, the incidence of postoperative ileus, postoperative complications, and 30- and 90-day readmission rates. RESULTS: A higher comorbidity burden was identified in the ERAS group compared to non-ERAS patients (p = 0.04). Median (IQR) LOS for non-ERAS was group 8(4) and 8(5) for ERAS group (p = 0.07). ERAS group demonstrated shorter time to resume bowel movements as well as time to tolerance of regular diet (p = 0.007, p = 0.023, respectively). Low-risk patients managed by the ERAS protocol demonstrated a significantly shortened gastrointestinal (GIT) recovery time (p = 0.001) as well as a reduction of LOS (p = 0.04). No significant reduction of LOS was identified for patients with higher comorbidity when placed on the ERAS protocol (p = 0.65). There were no significant differences in postoperative complications or readmission rates between groups. CONCLUSION: ERAS protocol implementation following radical cystectomy showed significant improvements in GIT recovery, nevertheless, it did not result in a decrease in LOS or readmission rates. Low-risk patients appeared to derive more benefit from ERAS protocol implementation than high-risk patients.

Development and validation of a simple stone score to estimate the probability of residual stones prior to percutaneous nephrolithotomy.

BACKGROUND: The aim of the present study was to develop and internally validate a simple stone score (SSS) to estimate the probability of clinically significant residual fragments (CSRF) prior to percutaneous nephrolithotomy (PNL). METHODS: The files of 1170 PNL procedures between January and December 2015 were evaluated. CT-derived stone characteristics were examined. Caliceal stone distribution (CSD) was assigned three grades based on the number of calices involved regardless of the renal pelvis (I = no or single calix; II = more than one calix; and III = more than 2 calices or complete staghorn stones). CSRF was defined as any residuals >4 mm in postoperative CT. A logistic regression model to predict the CSRF was fitted, and coefficients were used to develop the SSS. The SSS was validated by discrimination, calibration, and decision curve analysis (DCA). RESULTS: Patients' data were split into training (936, 80%) and validating (234, 20%) datasets. In the training partition, independent predictors of CSRF were CSD-grade II (OR: 4.2; 95%CI: 2.5-7; P<0.001), grade III (OR: 7.8; 95%CI: 4.2-14.4; P<0.001) and largest stone diameter (LSD) (OR:1.3; 95%CI: 1.1-1.6; P<0.001). Score points 0, 1, 2, and 0, 3, 9 were given to LSD<30, 30-40, >40 mm, and CSD grades I, II, III, respectively. Discrimination of the SSS was 0.79 and after 10-fold cross-validation and internal validation was 0.86. The calibration plot and DCA highlighted the validity and clinical significance of the SSS. CONCLUSIONS: The novel SSS could be used to describe the risk of CSRF prior to PNL. Further studies are invited for external validation.

Iatrogenic ureteral injuries: a case series analysis with an emphasis on the predictors of late ureteral strictures and unfavorable outcome in different surgical specialties.

INTRODUCTION AND HYPOTHESIS: We aimed to report the demographics and management of iatrogenic ureteral injuries (IUIs) with different surgical specialties. Moreover, our goal was to analyze the predictors of late ureteral strictures and secondary intervention after primary surgical management, and the final effect on the kidney. METHODS: A retrospective study, between 2006 and 2019, enrolled all patients undergoing urological, abdominal, and pelvic surgeries performed through open, laparoscopic, or endoscopic means. If IUIs were discovered intraoperatively, they were managed either by internal stent or surgical intervention following the standard procedure. For IUIs discovered postoperatively, either percutaneous nephrostomy (PCN) or double J (DJ) ureteral stents were inserted for later endoscopic or surgical management. The final outcomes were divided into two groups: patients with successful primary outcomes and those who required secondary intervention later. All predictors were compared between the two groups. RESULTS: Forty-eight patients were reviewed: 23 out of 48 (48%) from obstetrics and gynecology (ob/gyn) involving the lower ureter primarily with overall favorable outcomes (82%), 15 (31%) colorectal, and 10 (21%) urology with serious injuries affecting men in the upper ureter. The primary management included open surgery in 12 patients, and drainage (PCN or DJ) in 36 patients. Restoration of ureteral anatomy and kidney function was achieved in all, but 18 cases required a secondary correction, either endoscopically or surgically. Both early and late discovery resulted in the same outcome. On bivariate analysis, only the side of the injury (left side, p = 0.03), and the specialty (colorectal cancer surgeries, p = 0.01) were predictors for late ureteral strictures, and both sustained their significance in multivariate regression analysis. CONCLUSION: Iatrogenic ureteral injuries associated with ob/gyn surgeries involve the lower ureter, primarily with overall favorable outcomes (82%). Serious ureteroscopic IUIs affect men in the upper ureter with greater frequency. IUIs on the left side and colorectal cancer surgeries are the predictors for late strictures and secondary interventions.

5-Year Long-Term Outcome of Live-Donor Renal Transplant Recipients With Enterocystoplasty and Ureterocystoplasty: An Age- and Sex-Matched Pair Analysis.

OBJECTIVE: To assess surgical complications, febrile UTI, graft function and 5-year graft survival after renal transplantation (RT) in patients with augmentation cytsoplasty (AC) and to compare them to RT patients with normal lower urinary tract. MATERIALS AND METHODS: A case-control study of 34 RT patients with AC including 23 patients with enterocystoplasty (EC) and 11 patients with ureterocystoplasty (UC) was performed. The primary outcome was to determine the difference between both groups regarding postoperative surgical complications and febrile UTI episodes. Graft function was compared at 1, 3, and 5 years and 5-year graft survival was determined. The secondary outcome was to compare them to an age- and gender-matched control group (122 patients) with normal lower urinary tract. RESULTS: There was no significant difference regarding surgical complications or rates of hospital readmission between AC groups. Seventeen (73.9%) and 5 (45.5%) patients developed 33 and 14 episodes of febrile UTI in EC and UC groups, respectively (P= .5). Control group had shown lower incidence surgical complications (P = .001) and febrile UTIs (P = .02) compared to AC groups. At 3 and 5 years, UC had higher median eGFR than EC (P = .08, 0.008, respectively). The 5-year graft survival was 32 (94.1%) with no statistically significant difference between EC (95.7%) and UC (90.9%) (P = .5) or between AC and control (85.2%, P = .3). CONCLUSION: Although RT after AC was associated with higher surgical complications and UTI episodes, they had comparable 5-year graft survival to their control. When indicated, UC should be the preferred choice of AC whenever possible.

Preoperative risk factors for complications of percutaneous nephrolithotomy.

This study was conducted to evaluate preoperative risk factors for development of complications of percutaneous nephrolithotomy (PCNL). All consecutive patients aged ≥ 16 years who underwent PCNL during 2015 were retrospectively reviewed. Non-contrast CT (NCCT) was performed for all patients to evaluate stone complexity. The technique of PCNL was the same for all patients. Intra-operative and postoperative complications were recorded and classified based on modified Clavien system. The differences in preoperative data (patients, renal and stone characteristics including Guy's and STONE scores) between complicated and uncomplicated cases were compared using univariate and multivariate statistical analyses for detection of independent risk factors. The study included 1178 patients (61% were males). Mean age was 50 ± 12 years, and mean BMI was 30.7 ± 5.7 kg/m2. Complicated group included 166 patients (14.1%). Independent risk factors on multivariate analysis were infected preoperative urine culture (RR: 2.098, P 0.001, 95%CI: 1.380-3.189), largest stones diameter 30 mm or more (RR: 2.481, P > 0.001, 95%CI: 1.697-3.627) and number of calyces affected by the stones (RR: 2.431, P 0.002, 95%CI: 1.400-4.222 for affection of two calyces and RR: 2.778, P 0.005, 95%CI: 1.357-5.684 for affection of three calyces). While two scoring systems (Guy's and STONE) were not predictive of complications after PCNL, preoperative risk factors were infected preoperative urine culture, distribution of the stones or stone branches in two or three calyceal groups and stone size 30 mm or more.