Comparison of retrograde ureterorenoscopy (URS) and percutaneous anterograde ureteroscopy for removal of impacted upper ureteral stones >10mm in the elderly population

ABSTRACT Purpose: We aimed to compare the success and complication rates of the anterograde and retrograde Ureterorenoscopy (URS) for impacted upper ureteral stones in patients > 65 years of age. Materials and Methods: Data of 146 patients >65 years of age and underwent anterograde URS (n=68) in supine position or retrograde URS (n=78) for upper ureteral impacted stones>10 mm between January 2014 and September 2018 were collected prospectively. The groups were compared for success and complication rates, duration of operation, hospital stay, and ancillary procedures. Results: Anterograde and retrograde URS groups were similar for demographic and stone related characteristics. The success rate of the anterograde URS group was significantly higher than the retrograde URS group (97.1% vs. 78.2%, p=0.0007). The complication rates were similar for the two groups (p=0.86). Clavien grade I and II complications were observed in 3 patients in each group. The mean hemoglobin drop was 0.5 g/dL in the anterograde URS group and blood transfusion was not performed in any of the patients. The mean duration of operation was 41.2±12.5 minutes in the mini-PNL group and 59.6±15.1 minutes in the RIRS group and the difference was statistically significant (p=0.02). The median duration of hospitalization was 1 day for both groups. Conclusions: Performing anterograde URS in supine position provided better success rates and similar complication rates compared to retrograde URS. Based on these results anterograde URS shall be considered as one of the primary treatment options for management of impacted upper ureteral stones in the elderly population.

The burden of chronic ureteral stenting in cervical cancer survivors

ABSTRACT Purpose Ureteral obstruction in cervical cancer occurs in up to 11% of patients, many of whom undergo ureteral stenting. Our aim was to describe the patient burden of chronic ureteral stenting in a population-based cohort by detailing two objectives: (1) the frequency of repeat procedures for ureteral obstruction; and, (2) the frequency of urinary adverse effects (UAEs) (e.g., lower urinary tract symptoms, flank pain). Materials and Methods From SEER-Medicare, we identified 202 women who underwent ureteral stent placement prior to or following cervical cancer treatment. The frequency of repeat procedures and rate ratios were compared between treatment modalities. The rates and rate ratios of UAEs were compared between our primary cohort (stent + cervical cancer) and the following groups: no stent + cervical cancer, stent + no cancer, and no stent + no cancer. The “no cancer” group was drawn from the 5% Medicare sample. Results 117/202 women (58%) underwent >1 stent procedure. The frequency of additional procedures was significantly higher in patients who received radiation as part of their treatment. UAEs were very common in women with stent + cancer. The rate of UTI was 190 (per 100 person-years), 67 for LUTS, 42 for stones, and 6 for flank pain. These rates were 3-10 fold higher than in the no stent + no cancer control group; rates were also higher than in the no stent + cancer and the stent + no cancer women. Conclusions The burden of disease associated with ureteral stents is higher than expected and urologists should be actively involved in stent management, screening for associated symptoms and offering definitive reconstruction when appropriate.

Cervical cancer: Renal complications and survival after percutaneous nephrostomy / Câncer de colo uterino: complicações renais e sobrevida após nefrostomia percutânea

SUMMARY Introduction: Obstructive nephropathy is a frequent complication in the course of advanced cervical cancer (CC), and ultrasonography-guided percutaneous nephrostomy (PCN) is a well established technique for fast ureteral desobstruction. Objective: To identify possible factors related to the survival and quality of life of patients with advanced CC presenting acute urinary obstructive complications that after desobstruction by PCN recovered urinary flux and renal function. Method: This is an analytical, descriptive, cross-sectional study that included 45 patients with CC who underwent PCN and were divided into 2 groups: “death” (DG) and “survival” (SG), in a public hospital that is reference for oncologic diseases in Northern Brazil. Results: The mean serum creatinine of the patients preceding PCN was >10 mg/dL, and after PCN <2 mg/dL. The cutoffs of 8.7 g/dL for Hb (p=0.0241) and 27% for Ht (p=0.0065) indicated the values that better discriminate the outcomes of the groups. The presence of low blood pressure was statistically correlated (p=0.0037) to the outcome “death”. Changes in glomerular filtration rate (already reduced in all cases) were not associated to the levels of Hb/Ht or to the outcome “death” during the nephrological follow-up. Conclusion: PCN was responsible for the recovery of renal function in 61.7% of the patients, leading to interruption of renal replacement therapy (RRT) in all of those patients. Hb levels >8.7g/dL and Ht >27% were associated to longer survival, and the presence of low blood pressure during follow-up was associated with progression to death.

RESUMO Introdução: a nefropatia obstrutiva é complicação frequente na evolução do câncer do colo uterino (CCU) avançado e a nefrostomia percutânea guiada por ultrassonografia (NFT) é uma técnica bem estabelecida para a rápida desobstrução ureteral. Objetivo: esclarecer os fatores relacionados à evolução ou não para óbito e qualidade de vida das pacientes com CCU avançado com complicações obstrutivas urinárias agudas e que, após desobstrução pela NFT, recuperaram fluxo urinário e função renal. Método: foi realizado estudo transversal analítico descritivo, que avaliou dois grupos de pacientes com CCU submetidas à NFT [óbito (GO) e sobrevida (GS)], em um hospital público, referência para doenças oncológicas da região Norte do país. Resultados: a creatinina sérica média inicial era >10 mg/dL pré-NFT e tornou-se <2 mg/dL após. Quanto à sobrevida, os pontos de corte de 8,7 g/dL de Hb e 27% de Ht melhor discriminaram a evolução dos grupos GO e GS (p=0,0241 e p=0,0065). Hipotensão se associou significantemente (p=0,0037) com a evolução para óbito. Variações na taxa de filtração glomerular, que já era reduzida em todos os casos, não se associaram aos níveis de Hb/Ht ou à evolução para óbito durante seguimento nefrológico. Conclusão: a NFT permitiu a recuperação da função renal em 61,7% das pacientes com CCU, dispensando terapia de substituição renal. Níveis de Hb >8,7 g/dL e Ht >27% estiveram associados a maior sobrevida, e a hipotensão durante o seguimento associou-se com evolução para óbito.

Incidence and clinical characteristics of lower urinary tract symptoms as a presenting symptom for patients with newly diagnosed bladder cancer

PurposeThe incidence of lower urinary tract symptoms (LUTS) as the sole presenting symptom for bladder cancer has traditionally been reported to be low. The objective of this study was to evaluate the prevalence and clinical characteristics of newly diagnosed bladder cancer patients who presented with LUTS in the absence of gross or microscopic hematuria.Materials and MethodsWe queried our database of bladder cancer patients at the Atlanta Veteran’s Affairs Medical Center (AVAMC) to identify patients who presented solely with LUTS and were subsequently diagnosed with bladder cancer. Demographic, clinical, and pathologic variables were examined.Results4.1% (14/340) of bladder cancer patients in our series presented solely with LUTS. Mean age and Charlson Co-morbidity Index of these patients was 66.4 years (range = 52-83) and 3 (range = 0-7), respectively. Of the 14 patients in our cohort presenting with LUTS, 9 (64.3%), 4 (28.6%), and 1 (7.1%) patients presented with clinical stage Ta, carcinoma in Situ (CIS), and T2 disease. At a median follow-up of 3.79 years, recurrence occurred in 7 (50.0%) patients with progression occurring in 1 (7.1%) patient. 11 (78.6%) patients were alive and currently disease free, and 3 (21.4%) patients had died, with only one (7.1%) death attributable to bladder cancer.ConclusionsOur database shows a 4.1% incidence of LUTS as the sole presenting symptom in patients with newly diagnosed bladder cancer. This study suggests that urologists should have a low threshold for evaluating patients with unexplained LUTS for underlying bladder cancer.

A Single-Institution Experience with Metallic Ureteral Stents: A Cost-Effective Method of Managing Deficiencies in Ureteral Drainage

IntroductionThe limitations of traditional ureteral stents in patients with deficiencies in ureteral drainage have resulted in frequent stent exchanges. The implementation of metallic stents was introduced to improve the patency rates of patients with chronic upper urinary tract obstruction, obviating the need for frequent stent exchanges. We report our clinical experiences with the use of metallic ureteral stents in the management of poor ureteral drainage.Materials and MethodsFifty patients underwent metallic ureteral stent placement from 2009 to 2012. Stent failure was defined as an unplanned stent exchange, need for nephrostomy tube placement, increasing hydronephrosis with stent in place, or an elevation in serum creatinine. Stent life was analyzed using the Kaplan-Meier methodology, as this was a time dependent continuous variable. A cost analysis was similarly conducted.ResultsA total of 97 metallic stents were placed among our cohort of patients: 63 in cases of malignant obstruction, 33 in the setting of cutaneous ureterostomies, and 1 in an ileal conduit urinary diversion. Overall, stent failure occurred in 8.2% of the stents placed. Median stent life was 288.4 days (95% CI: 277.4-321.2 days). The estimated annual cost for traditional polymer stents (exchanged every 90 days) was $9,648-$13,128, while the estimated cost for metallic stents was $4,211-$5,313.ConclusionOur results indicate that metallic ureteral stent placement is a technically feasible procedure with minimal complications and is well tolerated among patients. Metallic stents can be left in situ for longer durations and provide a significant financial benefit when compared to traditional polymer stents.

Steinstrasse predictive factors and outcomes after extracorporeal shockwave lithotripsy

PURPOSE: Urinary stone disease is a common medical problem. Extracorporeal shockwave lithotripsy (SWL) has been applied with high success and low complication rates. Steinstrasse (SS) is a possible complication after SWL. The aim of the present study was to prospectively evaluate the factors and outcomes associated with SS after SWL. MATERIALS AND METHODS: We have prospectively evaluated 265 SWL sessions (2005-2009). Two lithotriptors were used randomly: Siemens Lithostar and Dornier Compact S. All patients had imaging exams after 30 and 90 days or according to symptoms. RESULTS: SS was observed in 14 (5.3 percent) out of 265 SWL procedures (n = 175 patients, 51.5 percent women/48.5 percent men, mean ± SD age = 46.3 ± 15.5 years). SS was more common after SWL for pelviureteral calculi rather than caliceal stones (p = 0.036). There was a trend toward more occurrences of SS after SWL for larger stone area (> 200 mm², p = 0.072). Preoperative ureteral stent didn't prevent SS. SWL machine, intensity, number of pulses and frequency were not associated with SS formation. Post-SWL pain, fever and gravel elimination were factors associated with SS (p = 0.021; p = 0.011; p = 0.078). When SS occurred, treatment modalities included Medical Expulsive Therapy (MET), ureteroscopy and SWL. CONCLUSIONS: Steinstrasse is an uncommon event after SWL and seems to occur more frequently with larger pelviureteral stones. Impaction of stones is more frequent in the middle ureter. All patients should be followed after SWL, but SS should be specially suspected if there is macroscopic gravel elimination, flank pain and/or fever. When SS occurs, treatment should be promptly introduced, including medical expulsive therapy, surgical approach or SWL in selected cases. Further prospective studies are awaited to evaluated preventive measures for SS occurrence.

Fibrosis retroperitoneal idiopática: un enigma médico / Retroperitoneal fibrosis: a medical enigma

La fibrosis retroperitoneal es una enfermedad rara de causa desconocida. Fue descrita por primera vez en la literatura inglesa en 1948 por Ormond. Sin embargo, la primera descripción conocida de esta enfermedad fue realizada por el urólogo francés Albarran en 1905. Se caracteriza por una inflamación crónica e inespecífica del retroperitoneo, la cual puede atrapar y obstruir las estructuras que allí se encuentran, particularmente a los uréteres. Es frecuente que la enfermedad se detecte en etapas avanzadas, cuando se manifiesta por falla renal crónica. Los avances en las técnicas imaginológicas y el mayor conocimiento de la entidad han permitido que el diagnóstico se realice con mayor frecuencia en etapas más tempranas, cuando los pacientes aún no se encuentran obstruidos. Como resultado de las observaciones que muestran que los aneurismas inflamatorios de la aorta abdominal difieren de la enfermedad de Ormond sólo en el diámetro de la aorta inflamada, se ha sugerido que ambos síndromes representan variaciones de la misma patología, la cual se ha llamado "periaortitis crónica".

Retroperitoneal fibrosis is an uncommon disease of unclear cause. It was described for the first time in English literature by Ormond, in 1948. However, the first known description of this disease was done by the French urologist Albarran, around 1905. It is characterized by chronic nonspecific inflammation of the retroperitoneum that can entrap and obstruct retroperitoneal structures, notably the urethers. This disease frequently is detected only after severe renal failure is present. However, advances in imaging techniques and increased awareness of the disease have resulted in an earlier diagnosis in unobstructed patients. As a result of the observations that showed that the only difference between an inflammatory aneurysm of the abdominal aorta and Ormond's disease is the diameter of the vessel, it had been suggested that both syndromes represent variations of the same pathology, which has been named "chronic periaortitis".

Laparoscopic dismembered pyeloplasty in 47 cases

PURPOSE: To evaluate the results of a sequence of 47 laparoscopic Anderson-Hynes pyeloplasties for the treatment of patients with ureteropelvic junction obstruction, independently of the etiology. MATERIALS AND METHODS: Twenty male and 27 female patients diagnosed with ureteropelvic junction obstruction were treated by Anderson-Hynes transperitoneal laparoscopic dismembered pyeloplasty from April 2002 to January 2006. The age of the patients ranged from four to 75 years, with a mean age of 32.3 years. The follow-up ranged between six and 30 months, with a mean follow-up time of 24 months. The outcomes were evaluated through the assessment of symptoms and imaging studies. RESULTS: In 44 (93.6 percent) of the 47 patients, resolution of the pain and a reduction in ureteropelvic dilation were observed. The mean operative time was 157 minutes (ranging from 90 to 270 minutes). Neither blood transfusion nor conversion to open surgery was required. The mean hospital stay was 2.2 days. The presence of crossing vessels over the ureteropelvic junction was verified in 26 patients (55 percent), and vessel transposition in relation to the urinary tract was performed in 25 of these cases. In one patient, the crossing vessel was mobilized out of the ureteropelvic junction with a perivascular suture to the renal capsule associated with the pyeloplasty. CONCLUSIONS: The outcome of transperitoneal Anderson-Hynes laparoscopic pyeloplasty used for different causes of pyeloureteral obstruction presented a success rate similar to a previously-published open procedure, with the advantage of being less invasive. This procedure may be considered the first option for the treatment of ureteropelvic junction obstruction.