An international delphi survey and consensus meeting to define the risk factors for ureteral stricture after endoscopic treatment for urolithiasis.

PURPOSE: Iatrogenic ureteral strictures (US) after endoscopic treatment for urolithiasis represent a significant healthcare concern. However, high-quality evidence on the risk factors associated with US is currently lacking. We aimed to develop a consensus statement addressing the definition, risk factors, and follow-up management of iatrogenic US after endoscopic treatment for urolithiasis. METHODS: Utilizing a modified Delphi method, a steering committee developed survey statements based on a systematic literature review. Then, a two-round online survey was submitted to 25 experts, offering voting options to assess agreement levels. A consensus panel meeting was held for unresolved statements. The predetermined consensus threshold was set at 70%. RESULTS: The steering committee formulated 73 statements. In the initial survey, consensus was reached on 56 (77%) statements. Following in-depth discussions and refinement of 17 (23%) statements in a consensus meeting, the second survey achieved consensus on 63 (86%) statements. This process underscored agreement on pivotal factors influencing US in endoscopic urolithiasis treatments. CONCLUSIONS: This study provides a comprehensive list of categorized risk factors for US following endoscopic urolithiasis treatments. The objectives include enhancing uniformity in research, minimizing redundancy in outcome assessments, and effectively addressing risk factors associated with US. These findings are crucial for designing future clinical trials and guiding endoscopic surgeons in mitigating the risk of US.

Ureteral stricture rate after endoscopic treatments for urolithiasis and related risk factors: systematic review and meta-analysis.

PURPOSE: We aimed to accurately determine ureteral stricture (US) rates following urolithiasis treatments and their related risk factors. METHODS: We conducted a systematic review and meta-analysis following the PRISMA guidelines using databases from inception to November 2023. Studies were deemed eligible for analysis if they included ≥ 18 years old patients with urinary lithiasis (Patients) who were subjected to endoscopic treatment (Intervention) with ureteroscopy (URS), percutaneous nephrolithotomy (PCNL), or shock wave lithotripsy (SWL) (Comparator) to assess the incidence of US (Outcome) in prospective and retrospective studies (Study design). RESULTS: A total of 43 studies were included. The pooled US rate was 1.3% post-SWL and 2.1% post-PCNL. The pooled rate of US post-URS was 1.9% but raised to 2.7% considering the last five years' studies and 4.9% if the stone was impacted. Moreover, the pooled US rate differed if follow-ups were under or over six months. Patients with proximal ureteral stone, preoperative hydronephrosis, intraoperative ureteral perforation, and impacted stones showed higher US risk post-endoscopic intervention with odds ratio of 1.6 (P = 0.05), 2.6 (P = 0.009), 7.1 (P < 0.001), and 7.47 (P = 0.003), respectively. CONCLUSIONS: The overall US rate ranges from 0.3 to 4.9%, with an increasing trend in the last few years. It is influenced by type of treatment, stone location and impaction, preoperative hydronephrosis and intraoperative perforation. Future standardized reporting and prospective and more extended follow-up studies might contribute to a better understanding of US risks related to calculi treatment.

Efficacy and safety of the EMS Swiss LithoClast® Trilogy for PCNL: results of the European multicentre prospective study on behalf of European Section of UroTechnology.

PURPOSE: PCNL requires a lithotrite to efficiently break stones, and some devices include active suction to remove the fragments. We set out to determine the efficacy and safety of the Swiss LithoClast® Trilogy, in a prospective European multicentre evaluation and compared it to published stone clearance rates for Trilogy based on surface area (68.9 mm2/min) and using the 3D calculated stone volume (526.7 mm3/min). METHODS: Ten European centres participated in this prospective non-randomized study of Trilogy for PCNL. Objective measures of stone clearance rate, device malfunction, complications and stone-free rates were assessed. Each surgeon subjectively evaluated ergonomic and device effectiveness, on a 1-10 scale (10 = extremely ergonomic/effective) and compared to their usual lithotrite on a 1-10 scale (10 = extremely effective). RESULTS: One hundred and fifty seven PCNLs using Trilogy were included (53% male, 47% female; mean age 55 years, range 13-84 years). Mean stone clearance rate was 65.55 mm2/min or 945 mm3/min based on calculated 3D volume. Stone-free rate on fluoroscopy screening at the end of the procedure was 83%. Feedback for suction effectiveness was 9.0 with 9.1 for combination and 9.0 for overall effectiveness compared to lithotrite used previously. Ergonomic score was 8.1, the least satisfactory element. Complications included 13 (8.2%) Clavien-Dindo Grade II and 2 (1.3%) Grade III. Probe breakage was seen in 9 (5.7%), none required using a different lithotrite. CONCLUSIONS: We have demonstrated that Trilogy is highly effective at stone removal. From a user perspective, the device was perceived by surgeons to be highly effective overall and compared to the most commonly used previous lithotrite, with an excellent safety profile.

Complications associated with ureterorenoscopy (URS) related to treatment of urolithiasis: the Clinical Research Office of Endourological Society URS Global study.

INTRODUCTION: Ureterorenoscopy (URS) is a popular and growing option for management of ureteric and renal stones. The CROES URS Global Study was set up to assess the outcomes of URS in a large worldwide cohort of patients involving multiple centres. In this paper, we analysed the database for intra-operative and post-operative complications associated with ureterorenoscopy. METHODS: The CROES database was established via collaboration between 114 centres in 32 countries worldwide, and information on both intra-operative and post-operative complications was collected electronically between January 2010 and October 2012. RESULT: On analysis of a total of 11,885 patients, the overall complication and stone-free rates were found to be 7.4 and 85.6 %, respectively. The intra-operative and post-operative complication rates were 4.2 and 2.6 %, respectively, and in total 5 deaths were reported in the study period. Taking into account different world economies, there were no differences in the complication rates between the developing and developed nations or between different centres from different continents. CONCLUSION: Ureterorenoscopy is a safe and effective procedure for treatment of stones, the outcomes of which are broadly comparable in different parts of the world for similar patient and stone demographics.

Targeted prostate cancer screening in men with mutations in BRCA1 and BRCA2 detects aggressive prostate cancer: preliminary analysis of the results of the IMPACT study.

OBJECTIVE: To evaluate the role of targeted prostate cancer screening in men with BRCA1 or BRCA2 mutations, an international study, IMPACT (Identification of Men with a genetic predisposition to ProstAte Cancer: Targeted screening in BRCA1/2 mutation carriers and controls), was established. This is the first multicentre screening study targeted at men with a known genetic predisposition to prostate cancer. A preliminary analysis of the data is reported. PATIENTS AND METHODS: Men aged 40-69 years from families with BRCA1 or BRCA2 mutations were offered annual prostate specific antigen (PSA) testing, and those with PSA > 3 ng/mL, were offered a prostate biopsy. Controls were men age-matched (± 5 years) who were negative for the familial mutation. RESULTS: In total, 300 men were recruited (205 mutation carriers; 89 BRCA1, 116 BRCA2 and 95 controls) over 33 months. At the baseline screen (year 1), 7.0% (21/300) underwent a prostate biopsy. Prostate cancer was diagnosed in ten individuals, a prevalence of 3.3%. The positive predictive value of PSA screening in this cohort was 47·6% (10/21). One prostate cancer was diagnosed at year 2. Of the 11 prostate cancers diagnosed, nine were in mutation carriers, two in controls, and eight were clinically significant. CONCLUSIONS: The present study shows that the positive predictive value of PSA screening in BRCA mutation carriers is high and that screening detects clinically significant prostate cancer. These results support the rationale for continued screening in such men.

Circulating miR-141 and miR-375 are associated with treatment outcome in metastatic castration resistant prostate cancer.

Metastatic castration resistant prostate cancer (mCRPC) is associated with high mortality, where monitoring of disease activity is still a major clinical challenge. The role of microRNAs (miRs) has been widely investigated in prostate cancer with both diagnostic and prognostic potential. The aim of this study was to investigate the relationship between circulating miRs and treatment outcome in mCRPC patients. The relative expression of five miRs (miR-93-5p, -125b-1-5p, -141-3p, -221-3p, and miR-375-3p) was investigated in plasma samples from 84 mCRPC patients; 40 patients were treated with docetaxel (DOC cohort) and 44 patients with abiraterone (ABI cohort). Blood was sampled at baseline before treatment start and at radiological progression. The plasma levels of four miRs; miR-93-5p, -141-3p, -221-3p, and miR-375-3p decreased significantly after treatment initiation in patients receiving docetaxel, and for miR-141-3p and miR-375-3p the level increased again at the time of radiological progression. In the patients treated with abiraterone, the plasma level of miR-221-3p likewise decreased significantly after the first treatment cycle. High baseline levels of both miR-141-3p and miR-375-3p were significantly associated with a shorter time to radiological progression in both cohorts. Additionally, high baseline levels of miR-141-3p and miR-221-3p were significantly associated with a shorter overall survival (OS) in the ABI cohort, while high levels of miR-141-3p and miR-375-3p were significantly associated with shorter OS in the DOC cohort. Plasma levels of miR-141-3p and miR-375-3p may predict time to progression in mCRPC patients treated with docetaxel or abiraterone. The clinical impact of these findings is dependent on validation in larger cohorts.

Characteristics of symptomatic men with testicular microlithiasis - A Danish cross-sectional questionnaire study.

Testicular microlithiasis (TML) is an incidental finding at ultrasonography of the scrotum. A link between testicular microlithiasis and testicular cancer has been suggested. However, the majority of studies are retrospective using ultrasonography with minor data on health status and life style characteristics. Our objective was to investigate if lifestyle and health are associated with TML. In 2014, we conducted a self-administered questionnaire survey including 1538 men, who all due to testicular/scrotal symptoms had an ultrasound investigation of the scrotum during 2004-2013. The men were divided into men with TML and men without. The 23-items questionnaire included items on age, height, weight, lifestyle (alcohol consumptions, smoking habits, workload, exercise and food), previous diseases in the testicles, pain and consumption of analgesics. The prevalence of TML was 12.8%. Overall, lifestyle factors did not vary between men with or without TML. However, men with TML did consume more crisp than men without. Development of TML was not associated to classic life style factors such as alcohol consumption, smoking habits, or mothers smoking during pregnancy. Also, age and height could not be linked to presence of TML. We did find, however, that men with TML experienced less physical activity and consumed more crisp than men without TML. Since ingestion of crisps has potential carcinogenic effect (acrylamide), this finding needs confirmation in a separate study.

Testicular Microlithiasis: Patient Compliance in a Two-Year Follow-Up Program.

Introduction: We present a retrospective 2-year follow-up cohort of 103 men with testicular microlithiasis (TML) and discuss patient compliance and the value of surveillance. Methods: A retrospective analysis of patients examined with scrotal ultrasonography (US) in the period from 2008 through 2010 was performed. A total of 103 men with TML were diagnosed and offered US follow-up every 6 months for 2 years. They were retrospectively analyzed regarding demographics and follow-up details, including the development of any kind of malignancy until March 2015, using the Danish Electronic Pathology Registry. Results: The prevalence of TML was 10.3%. Of the 103 men with TML, 23 (22.3%) had TML in the left testicle, 38 (36.9%) in the right (p=0.002), and 42 (40.8%) had bilateral TML. Patient compliance was low with 11.7% participating in all US follow-up examinations. 5 men presented risk factors (testicular atrophy (N=1) and previous testicular cancer (N=4)), but no cases of testicular malignancy were found in the follow-up period. Conclusion: The low patient compliance conflicts with the ESUR Scrotal Imaging Subcommittee guidelines that recommend scrotal US follow-up annually for TML until the age of 55 years. The fact that no cancers were found during follow-up using the pathology registry calls the value of follow-up into question.

An electron microscopic study of clinical Paget's disease of the nipple.

An ultrastructural study of the epidermis from eight patients with clinical Paget's disease of the nipple supports the epidermotropic theory. There was no evidence that the Paget's cells originated from keratinocytes. We propose the hypothesis that Paget's cells represent transformed ductal cells, from the subjacent lactiferous ducts of the nipple, which have migrated into the epidermis, either as neoplastic cells or as normal ductal cells with secondary in situ transformation in the epidermis.

Ureteropelvic junction obstruction and ureteral strictures treated by simple high-pressure balloon dilation.

The long-term results of simple high-pressure balloon dilation in the treatment of ureteropelvic junction obstruction (UPJO) and ureteral strictures were evaluated. A total of 77 consecutive patients were treated: 40 had UPJO and 37 ureteral strictures. The etiology of the obstruction included congenital UPJO, previous stones, sequelae of endoscopic and open surgery, radiotherapy, and urinary tract reconstruction. A retrograde ureteroscopic approach was used. Evaluation included clinical and radiographic examinations and renal scintigraphy with diuretic wash-out. The procedure was repeated in 21 cases. The median follow-up was 29 months. The procedure was considered successful if it left the patient asymptomatic and with improved renographic function and drainage. The overall success rate was 70%. The best results were obtained in strictures secondary to stones, with a success rate of 94%, and in strictures secondary to reconstructive and ureteroscopic surgery, with a success rate of 91%. In congenital UPJO, the results were less encouraging: in patients with a symptom debut after the age of 18 years, balloon dilation was successful in 57% of cases; in patients with symptom debut before the age of 18 years, success was achieved in only 25% of cases. There were no major complications. It was concluded that simple high-pressure balloon dilation is a safe and reasonably effective technique for the management of most ureteral strictures and congenital UPJO with symptom debut in adult life. Balloon dilation seems to have no place in the treatment of primary congenital UPJO in children.

Metastasis to the penis. Case reports and review of the literature.

Metastasis to the penis is rare, despite rich vascularization and complex circulation. Less than 200 cases have been reported. Three new cases of penis metastasis from primary tumours in the bladder and prostate, respectively, are described. The most common symptoms are penile induration and swelling. Treatments, all of which must be considered merely palliative, consist of local tumour excision, radiation therapy, cytostatic and hormone therapy, possibly with partial or total penis amputation. The prognosis is poor, irrespective of the therapy and site of the primary tumour. More than 80% of the patients die within six months after the occurrence of penis metastasis, as a result of disseminated cancer disease.

A double-blind placebo-controlled trial of omeprazole on urinary pH in healthy subjects.

Urinary pH is related to urinary calculus formation as well as urinary infection. Omeprazole is an effective inhibitor of gastric acid secretion through inhibition of the parietal cell H+K+ATPase. In this study we have evaluated a possible effect of omeprazole on urine acidification. Ten healthy male subjects took placebo and omeprazole, 40 mg o.m., for 10 days in a double-blind placebo-controlled trial. Morning fasting urinary pH was measured on day 10 of each treatment course using a pH meter. No effect of omeprazole on urinary pH could be demonstrated. It is thus unlikely that it is necessary to take omeprazole treatment into consideration in stone screening. As omeprazole did not affect urinary pH, no urological side effects related to changes in urinary pH can be expected.

[Citrate and kidney stones]. / Citrat og nyresten.

Citrate is an important naturally occurring inhibitor of calcium stone formation in urine. Urinary citrate excretion was examined in 43 consecutive patients with recurrent idiopathic calcium nephrolithiasis and in 50 normal controls by a specific enzymatic technique. Hypocitraturia (< 1.6 mmol/24h) was found in 14 (33%) stone formers compared to 6 (12%) normal controls (p = 0.03). Citrate excretion expressed as citrate-creatinine ratio in 24 hour urine samples was significantly lower in the stone formers than in the healthy controls (p = 0.03), and significantly lower in healthy men, compared to healthy females (p = 0.006). There was a great variability in urinary citrate levels in both groups, and a considerable overlap in the urinary citrate excretion between normal subjects and stone formers. Factors other than urinary citrate excretion must therefore be of importance in the pathophysiology of calcium stone formation. Citrate-calcium ratio in urine proved to be a reliable index in discriminating stone formers from healthy subjects.

[Proximal bilateral humeral fractures with posterior dislocation of the head of the humerus]. / Proksimal bilateral humerusfraktur med posterior luksation af caput.

Seizures as the cause of skeletal fractures are well recognized. The commonest is fracture of the humerus. Bilateral fractures are rare and extremely rare in combination with posterior dislocation of the shoulder joint. Two cases of this condition with very unusual etiology are described here. The mechanism of the injury is described and the treatment discussed. Regardless of the method of primary reposition employed, no difference in the subsequent joint function appears to be observed. Nevertheless, recognition of the condition and early reduction are of importance for the result.

[Fetal hydronephrosis]. / Føtal hydronefrose.

Antental intervention in cases where the foetus was suspected of having hydronephrosis has been the subject of intense discussion in recent years where the diagnosis was technically possible. The object of this investigation was to assess the end result in foetuses with hydronephrosis diagnosed prenatally and who were treated expectantly without intervention in utero. Fourteen consecutive cases of suspected foetal hydronephrosis are described. In four of the cases the hydronephrosis was transient without consequences for subsequent renal function. Three infants died, however, immediately after birth. All three were shown to have multiple malformations and/or chromosome anomalies. Unilateral dilatation of the upper urinary tract (seven cases) was by and large, associated with a good prognosis. Foetuses with bilateral dilatation of the upper urinary tract (seven cases) had poorer prognoses but this might also be related to other serious malformations. If this is compared with the disappointing result obtained by prenatal intervention in the form of foetal surgery or introduction of vesico-amniotic stents, very little evidence is found in favour of in utero intervention. In the great majority of cases, conservative prenatal regime is preferable.

[Urine cytology as a supplement to cystoscopy and biopsy in the control of bladder tumors]. / Urincytologi som supplement til cystoskopi og biopsi ved kontrol af blaeretumorer.

Throughout the years several investigations have either recommended or discredited exfoliative urine cytology because of high incidence of false negative or false positive results. Most authors agree that high grade bladder tumors are diagnosed with fairly high certainty (80-87%) by using exfoliative urine cytology whereas the value of urine cytology of low grade bladder tumors is uncertain. This investigation, including 200 patients who came for cystoscopic control of bladder tumors, revealed 87% accordance between cystoscopic biopsy and exfoliative urine cytology of high grade tumors while there were 47% false negative and no false positive of low grade tumors. On this background, it must be concluded that exfoliative urine cytology is an important investigation in diagnosing and controlling patients with bladder tumors, but the method can not always stand alone.

[Polyglyconate or polyglycolic acid suture in patients with suspected impaired wound healing]. / Polyglykonat- eller polyglykolsyresutur hos patienter med forventet haemmet sårheling.

A randomized study of abdominal fascial closure using interrupted polyglyconate and polyglycolic acid sutures after laparotomy was carried out in 204 consecutive patients with suspected impaired wound healing. There were no statistically significant differences between the two sutures with regard to development of fascial disruption and incisional hernia. Wound infection demanding surgical intervention was found in 7% of patients with polyglyconate sutures and in 16% of those with polyglycolic acid sutures (p = 0.04). Monofilament polyglyconate suture does not reduce the incidence of fascial disruption and incisional hernia after laparotomy in patients with suspected impaired wound healing but the incidence of wound infection may be reduced compared with that of multifilament polyglycolic acid suture.

Renal acidification defects in patients with their first renal stone episode.

To rule out renal acidification defects, 40 consecutive patients with their first renal stone episode were evaluated by measurement of fasting morning urine pH levels followed by a short ammonium chloride loading test in cases with high levels. Two patients (5%) exhibited incomplete distal renal tubular acidosis, the rest had normal urinary acidification. In view of the short duration of stone disease in the patients studied, the acidification defects were considered to be primary, and the stone formation secondary. The results justify extension of these simple screening procedures for unmasking renal acidification defects to include all patients with renal stone disease.