Simplified method using kidney / ureter / bladder x-ray to determine the appropriate length of ureteral stents

ABSTRACT Purpose: To investigate a method to determine the appropriate length of ureteral stents, given that the stent length may lead to exacerbation of urinary symptoms if the stent crosses the bladder midline. Materials and Methods: We retrospectively reviewed the position of the distal curl of the ureteral stent using kidney/ureter/bladder (KUB) radiographs after ureteroscopic lithotripsy in 165 patients who underwent placement of 24- or 26-cm ureteral stents. According to the KUB findings, we categorized the position of the distal curl of the ureteral stent into two groups. In Group 1, the stents did not cross the midline (appropriate length); in Group 2, the stents crossed the midline (inappropriate length). We assessed several patient parameters (sex, height, body mass index, and stone side) and the index of ureteral length using KUB radiographs ("C-P") and computed tomography (CT, "P-V"). Multivariate analysis was performed to identify the most significant factors affecting the position of ureteral stents. We also calculated the cutoff points of the receiver operating characteristic (ROC) curve of C-P and P-V for the position of ureteral stents. Results: The multivariate analysis showed that C-P was the most significant factor affecting the position of ureteral stents (p < 0.001) in patients with 24- and 26-cm ureteral stents. Comparison of the ROC curves of C-P and P-V showed that C-P was superior to P-V (p < 0.01) in patients with 24- and 26-cm stents. Conclusion: The use of KUB radiographs was effective and simple in determining the appropriate length of ureteral stents.

Ureteroscopy and stone treatment in the elderly (≥70 years): prospective outcomes over 5- years with a review of literature

ABSTRACT Objective: To assess outcomes of ureteroscopy for treatment of stone disease in the elderly. Ureteroscopy (URS) is an increasingly popular treatment modality for urolithiasis and its applications are ever expanding with the development of newer technologies. Its feasibility and outcomes within the elderly population to our knowledge remain under-reported. Materials and Methods: We examined the patient demographics and surgical outcomes from our prospective database for patients ≥70 years who underwent URS for urolithiasis, in a 5-year period between March 2012 and December 2016. Results: A total of 110 consecutive patients underwent 121 procedures (1.1 procedure/patient) with a mean age of 77.2 years (range: 70-91 years). Stone location was in the kidney/ pelviureteric junction (PUJ) in 29%, ureter in 37% and in multiple locations in 34%. The initial and final stone free rate (SFR) was 88% and 97% respectively. While 73% were done as true day case procedures, 89% patients were discharged within 24 hours. Eleven patients (9%) underwent complications of which 10 were Clavien I/II including acute urinary retention, urinary tract infection, stent symptoms and pneumonia. One patient underwent Clavien IV complication where they needed intensive care unit admission for urosepsis but fully recovered and were discharged home subsequently. Conclusion: Ureteroscopy is a safe and effective method of managing urolithiasis in elderly patients. Although most patients are discharged within 24-hours, consideration needs to be made for patients where social circumstances can impact their discharge planning.

Comparing the short - term outcomes and complications of monopolar and bipolar transurethral resection of bladder tumors in patients with coronary artery disese: a prospective, randomized, controlled study

ABSTRACT Introduction: To compare the perioperative outcomes and complications of monopolar and bipolar transurethral resection of bladder tumors (TURBT) in patients with coronary artery disease (CAD). Materials and Methods: A total of 90 CAD patients with newly diagnosed bladder cancer who underwent TURBT were randomized into monopolar TURBT (M-TURBT) and bipolar TURBT (B-TURBT) groups. Primary outcome was safety of the procedures including obturator jerk, bladder perforation, clot retention, febrile urinary tract infection and TUR syndrome. The secondary outcome was the efficacy of TURBT procedures, including complete tumor resection, sampling of the deep muscle tissue and sampling of the qualified tissues without any thermal damage. Results: Mean ages of the patients in M-TURBT and B-TURBT groups were 71.36±7.49 and 73.71±8.15 years, respectively (p=0.157). No significant differences were found between M-TURBT and B-TURBT groups regarding complete tumor resection (76.2% vs. 87.5%, p=0.162) and muscle tissue sampling rates (71.4% vs. 64.6%,p=0.252). Obturator jerk was detected in 16.7% of the patients in M-TURBT group and 2.1% in B-TURBT group (p=0.007). No statistically significant differences were found between the groups regarding intraoperative and postoperative complications. Conclusions: Both monopolar and bipolar systems can be used safely and effectively during TURBT procedure in CAD patients. Due to the more frequently seen obturator jerk in M-TURBT than B-TURBT, careful surgical approach is needed during M-TURBT.

Endourologic strategies for a minimally invasive management of urinary tract stones in patients with urinary diversion

ABSTRACT Objective To present our experience in minimally invasive management of urinary tract stones in patients with urinary diversion. Materials and Methods We retrospectively reviewed 26 patients with urinary tract stones after cystectomy and urinary diversion. The types of urinary diversion were ileal conduit, colon conduit, ileal orthotopic neobladder in 19, 4, and 3 patients, respectively. At postoperative days 2, a plain KUB and urinary ultrasonography were performed in order to assess stone fragmentation or hydronephrosis. According to postoperative imaging, stone free rate (SFR) was defined as complete absence of fragments or residual stones less than 4mm. Results 19 patients were treated with minimally invasive percutaneous lithotripsy (MPCNL) and 2 patients required second-look MPCNL. Anterograde flexible ureteroscopy was performed in 2 patients, while in 2 patients a combined anterograde and retrograde approach was required. Three reservoir stones were treated by transurethral neo-bladder lithotripsy. Postoperative significant complications occurred in 2 patients (7.7%). The highest percentage of stone composition was struvite, as a result of chronic urinary tract infection (UTI). SFR was 88.5% (23 of 26). Conclusions Our experience showed that MPCNL is a safe and effective treatment modality with little morbidity for renal and upper ureteral stones in patients with urinary diversion. For middle and lower ureteral stones, an anterograde approach could be also considered as a first line treatment, but a combined anterograde and retrograde approach was required when the anterograde access alone cannot provide acceptable results.

Use of the Uro Dyna-CT in endourology - the new frontier

ABSTRACT We describe the use of the Uro Dyna-CT, an imaging system used in the operating room that produces real-time three-dimensional (3D) imaging and cross-sectional image reconstructions similar to an intraoperative computerized tomography, during a percutaneous nephrolithotomy and a contralateral flexible ureteroscopy in a complete supine position. A 65 year-old female patient had an incomplete calyceal staghorn stone in the right kidney and a 10mm in the left one. The procedure was uneventful and the intraoperative use of the Uro Dyna-CT identified 2 residual stones that were not found by digital fluoroscopy and flexible nephroscopy at the end of surgery, helping us to render the patient stone-free in one procedure, which was confirmed by a postoperative CT scan. Prospective studies will define the real role of the Uro Dyna-CT for endourological procedures, but its use seems to be a very promising tool for improving stone free rates and decreasing auxiliary procedures, especially for complex cases.

A prospective multicenter European study on flexible ureterorenoscopy for the management of renal stone

ABSTRACT Purpose The aim of this study was to describe the outcomes and the complications of retrograde intrarenal surgery (RIRS) for renal stones in a multi-institutional working group. Materials and Methods From 2012 to 2014, we conducted a prospective study including all RIRS performed for kidney stones in 4 European centers. Demographic information, disease characteristics, and perioperative and postoperative data were gathered. Patients and stone data, procedure characteristics, results and safety outcomes were analyzed and compared by descriptive statistics. Complications were reported using the standardized Clavien system. Results Three hundred and fifty-six patients underwent 377 RIRS with holmium laser lithotripsy for renal stones. The RIRS was completed in all patients with a mean operative time of 63.5 min. The stone-free status was confirmed endoscopically and through fluoroscopic imaging after the first procedure in 73.6%. The second procedure was performed in twenty patients (5.6%) achieving an overall stone free rate of 78.9%. The overall complication rate was 15.1%. Intra-operative and post-operative complications were seen in 24 (6.7%) and 30 (8.4%) cases, respectively. Conclusions RIRS is a minimally invasive procedure with good results in terms of stone-free and complications rate.

Comparison of shock wave lithotripsy (SWL) and retrograde intrarenal surgery (RIRS) for treatment of stone disease in horseshoe kidney patients

ABSTRACT Objectives In this study it is aimed to compare the success and complication rates of SWL and RIRS in treatment of HSK stone disease. Materials and methods In this retrospective study data of 67 patients treated with either SWL (n=44) or RIRS (n=23) for stone disease in HSK between May 2003 to August 2014 was investigated. age, gender, stone size and multiplicity, stone free status, renal colic episodes and complication rates of the SWL and RIRS groups were compared. Results Mean age of the population was 42.5±8.2 (range: 16-78) years and mean stone size was 16.9±4.1 mm. SWL and RIRS groups were similar with regard to demographic characteristics and stone related characteristics. SFR of the SWL and RIRS groups were 47.7%(21/44 patients) and 73.9% (17/23 patients) respectively (p=0.039).Renal colic episodes were observed in 3 and 16 patients in the RIRS and SWL groups respectively (p=0.024). No statistically significant complications were observed between the SWL (8/44 patients) and RIRS (4/23) groups (p=0.936). Conclusions In HSK patients with stone disease, both SWL and RIRS are effective and safe treatment modalities. However RIRS seems to maintain higher SFRs with comparable complication rates.

Impact of retrograde flexible ureteroscopy and intracorporeal lithotripsy on kidney functional outcomes

ABSTRACT Objective: The aim of the study was to evaluate renal function and to identify factors associated with renal function deterioration after retrograde intrarenal surgery (RIRS) for kidney stones. Materials and Methods: We retrospectively analyzed patients with renal stones treated by RIRS between January 2010 and June 2013 at a single institute. We used the National Kidney Foundation classification of chronic kidney disease (CKD) to classify Glomerular Filtration Rate (GFR) in 5 groups. The baseline creatinine level was systematically pre-operatively and post-operatively evaluated. All patients had a creatinine blood measurement in June 2013. A change toward a less or a more favorable GFR group following RIRS was considered significant. Results: We included 163 patients. There were 86 males (52.8%) and 77 females (47.3%) with a mean age of 52.8±17 years. After a mean follow-up of 15.5±11.5 months, median GFR was not significantly changed from 84.3±26.2 to 84.9±24.5 mL/min (p=0.675). Significant renal function deterioration occurred in 8 cases (4.9%) and significant renal function amelioration occurred in 23 cases (14.1%). In univariate analysis, multiple procedures (p=0.023; HR: 5.4) and preoperative CKD (p=0.011; HR: 6.8) were associated with decreased renal function. In multivariate analysis these factors did not remain as predictive factors. Conclusion: Stone management with RIRS seems to have favorable outcomes on kidney function; however, special attention should be given to patients with multiple procedures and preoperative chronic kidney disease.

New head-mounted display system applied to endoscopic management of upper urinary tract carcinomas

Purpose We tested a new head-mounted display (HMD) system for surgery on the upper urinary tract. Surgical Technique Four women and one man with abnormal findings in the renal pelvis on computed tomography and magnetic resonance imaging underwent surgery using this new system. A high definition HMD (Sony, Tokyo, Japan) is connected to a flexible ureteroscope (Olympus, Tokyo, Japan) and the images from the ureteroscope are delivered simultaneously to various participants wearing HMDs. Furthermore, various information in addition to that available through the endoscope, such as the narrow band image, the fluoroscope, input from a video camera mounted on the lead surgeon’s HMD and the vital monitors can be viewed on each HMD. Results Median operative duration and anesthesia time were 53 and 111 minutes, respectively. The ureteroscopic procedures were successfully performed in all cases. There were no notable negative outcomes or incidents (Clavien-Dindo grade ≥1). Conclusion The HMD system offers simultaneous, high-quality magnified imagery in front of the eyes, regardless of head position, to those participating in the endoscopic procedures. This affordable display system also provides various forms of information related to examinations and operations while allowing direct vision and navigated vision. .

A novel endoscopic treatment for renal arteriopelvic fistula post-percutaneous nephrolithotomy (PCNL)

Main findings We describe the use of a novel endoscopic approach in the management of unremitting gross hematuria following post-percutaneous nephrolithotomy (PCNL) in a 65-years-old male. This approach proved successful and cost-effective in managing haemorrhage post-PCNL when renal angiography failed to localize the source of bleeding. Case hypothesis The recommended treatment modality for renal calculi ≥ 2cm is PCNL. It is essential that clinicians are aware of the various complications that can arise from PCNL, including arteriovenous fistula, which is typically managed with renal angio-embolization. The development of a renal arteriopelvic fistula (APF) is an extremely rare complication, and accounts of haemorrhage from renal APF and its treatment have not been well-described in the literature. We successfully hypothesized that the ureteroscopic localization, fulguration, and closure with a fibrin sealant at the site of the arterial bleed results in optimal treatment for this clinical presentation. We report this case in detail. Promising Future Implications The successful and cost-effective endoscopic approach described here for treatment of post-PCNL renal APF and unremitting gross hematuria ought to be considered as an adjunct to renal angiography and embolization when the source of bleeding cannot be accurately identified using traditional imaging modalities. .

Endoscopic treatment of vesicoureteral reflux with polyacrylate polyalcohol copolymer and dextranomer/hyaluronic acid in adults

Purpose Aim of this study is to examine the effectiveness of dextranomer/hyaluronic acid copolymer and polyacrylate polyalcohol copolymer in endoscopic treatment of vesicoureteral reflux disease in adult patients with and without chronic renal failure. Materials and Methods Thirty two patients (12 female, 20 male) with a total of 50 renal units were treated for vesicoureteral reflux. There were 26 (81%) chronic renal failure patients. The success of treatment was evaluated by voiding cystouretrography at 3rd and 12th months after subureteric injection. The persistence of reflux was considered as failure. Patients were divided into two groups according to injected material. Age, sex, grade of reflux and treatment results were recorded and evaluated. Results Reflux was scored as grade 1 in seven (14%), grade 2 in 16 (32%), grade 3 in 21 (42%) and grade 4 in six (12%) renal units. There was not patient with grade 5 reflux. Fourteen renal units (28%) were treated with dextranomer/hyaluronic acid copolymer (group 1) and 36 renal units (72%) were treated with polyacrylate polyalcohol copolymer (group 2). The overall treatment success was achieved at 40 renal units (80%). The treatment was successful at 11 renal units (79%) in group 1 and 29 renal units (81%) in group 2 (p = 0.71). There was not statistically significant difference between two groups with patients with chronic renal failure in terms of treatment success (p = 1.00). Conclusions The effectiveness of two bulking agents was similar in treatment of vesicoureteral reflux disease in adult patients and patients with chronic renal failure. .

Single-session ureteroscopic pneumatic lithotripsy for the management of bilateral ureteric stones

PURPOSE: In nowadays there is no consensus on single-session ureteroscopic lithotripsy (URSL) for the management of bilateral ureteric stones. The aim of this study was to evaluate efficacy and safety of single-session URSL in patients with bilateral ureteric stones. MATERIALS AND METHODS: 41 patients who have undergone bilateral single-session URSL were evaluted in this study. A 8/9.8 Fr Wolf semi-rigid ureteroscope was used for the procedures, and the stones were fragmented with pneumatic lithotripter. RESULTS: A high stone-free rate was achieved (90.2%) after single endoscopic procedure with a retreatment rate of 9.8%. The procedure was most successful for distal ureteric stones with a 96.2% stone-free rate followed by middle ureteric stones with a 81.8% stone-free rate while the least success was achieved for proximal ureteric stones with a 77.7% stone-free rate (p < 0.05). A greater stone-free rate was obtained in those with stones less than 10 mm (93.7%) than in those with stones larger than 10 mm (77.7%) (p < 0.05). Ureteral perforation occurred in only one patient (2.4 %). No long-term complication was observed in any patient. CONCLUSIONS: Bilateral single-session URSL can be performed effectively and safely with a low complication rate in patients with bilateral ureteric stones. It can reduce the need of anaesthetics and hospital stay.

Patient position and semi-rigid ureteroscopy outcomes

Introduction: Two positions have been reported for ureteroscopy (URS): dorsal lithotomy (DL) position and dorsal lithotomy position with same side leg slightly extended (DLEL). The aim of the present study was to compare the outcomes associated with URS performed with patients in DL vs. DLEL position. Material and Methods: A total of 98 patients treated for ureteral calculi were randomized to either DL or DLEL position during URS, and were prospectively followed. Patients, stone characteristics and operative outcomes were evaluated. Results: Of the 98 patients included in the study, 56.1 percent were men and 43.9 percent women with a mean age of 42.6 ± 16.8 years. Forty-eight patients underwent URS in DL position and 50 in DLEL position. Patients' age, mean stone size and location were similar between both groups. Operative time was longer for the DL vs. DLEL group (81.0 vs. 62.0 minutes, p = 0.045), mainly for men (95.2 vs. 63.9 minutes, p = 0.023). Mean fluoroscopy use, complications and success rates were similar between both groups. Conclusions: Most factors associated with operative outcomes during URS are inherent to patient's condition or devices available at each center, and therefore cannot be changed. However, leg position is a simple factor that can easily be changed, and directly affects operative time during URS. Even though success and complication rates are not related to position, placing the patient in dorsal lithotomy position with an extended leg seems to make the surgery easier and faster.

Ureteroscopic pneumatic lithotripsy of impacted ureteral calculi

INTRODUCTION: This work evaluates the results of ureteroscopic treatment of impacted ureteral stones with a pneumatic lithotripter. MATERIALS AND METHODS: From March 1997 to May 2002, 42 patients with impacted ureteral stones were treated by retrograde ureteroscopic pneumatic lithotripsy. Twenty-eight patients were female and 14 were male. The stone size ranged from 5 to 20 mm. The ureteral sites of the stones were distal in 21, middle in 12 and proximal in 9. RESULTS: Considering stones with distal location in the ureter, 1 patient had ureteral perforation and developed a stricture in the follow-up (4.7 percent). As for stones in the middle ureter, 2 perforations and 1 stricture were observed (8.3 percent) and regarding stones located in the proximal ureter, 5 perforations and 4 strictures occurred (44 percent). In the mid ureter, 1 ureteral avulsion was verified. In 34 patients without ureteral perforation, only 1 developed a stricture (2.9 percent). Of 8 patients who had perforation, 6 developed strictures. The overall incidence of stricture following treatment of impacted ureteral calculi was 14.2 percent. CONCLUSIONS: Ureteroscopy for impacted ureteral calculi is associated with a higher incidence of ureteral perforation and stricture. Ureteroscopy of proximal ureteral calculi is associated with a high risk of perforation, when compared to mid or distal ureteral calculi. Ureteral perforation at the site of the stone seems to be the primary risk factor for stricture formation in these cases.