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OBJECTIVE: This study aimed to evaluate the pelvicalyceal anatomy on accessibility of reusable flexible ureteroscopy (fURS) to the lower pole calyx during retrograde intrarenal surgery (RIRS). METHODS: Here, 854 patients with ureteral or kidney stones with access to a renal collecting system using reusable fURS were classified into either the accessible group, in whom the deepest lower pole calyces could be touched; and the inaccessible group, in whom the deepest lower calyces could not be touched. We measured the infundibulopelvic angle (IPA), infundibular width (IW), infundibular length (IL), and calyceal pelvic height (CPH) using retrograde pyelograms and performed intergroup comparisons. RESULTS: The median IPA, IW, IL, and CPH in the accessible and inaccessible group were 60.5° and 45.6° (p < 0.001), 10.8 and 9.4 mm (p < 0.001), 33.2 and 36.4 mm (p < 0.001), and 25.9 and 30.9 mm (p < 0.001), respectively. IPA (OR 0.963, 95% CI 0.952-0.974, p < 0.001) and IW (OR 0.519, 95% CI 0.331-0.816, p = 0.004) were significant risk factors of renal pelvicalyceal anatomy related to the accessibility of the lower pole calyces. The cut-off value for IPA and IW was 45.8°(p < 0.001) and 7.8 mm (p < 0.001), respectively. CONCLUSIONS: IPA < 45.8° and IW <7.8 mm were negative predictors to access the lower pole calyces when using reusable fURS during RIRS.
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Cálculos Renais , Ureter , Humanos , Ureteroscopia , Rim/diagnóstico por imagem , Rim/cirurgia , Cálices Renais/cirurgia , Cálices Renais/anatomia & histologia , Cálculos Renais/cirurgia , Ureter/cirurgia , Resultado do TratamentoRESUMO
OBJECTIVES: This study aimed to compare the simultaneous use of two devices versus a single device through a single working channel in flexible ureteroscopy using a ureteral access sheath for single ureteral stones. METHODS: In a bench study, the time to (i) set laser fiber, (ii) exchange laser fiber and nitinol basket through working channel, and (iii) pull out the device from working channel were measured 10 times in each step. In a clinical study, 156 patients who underwent flexible ureteroscopy with a ureteral access sheath for a ureteral stone in middle and upper ureter between April 2019 and November 2021 were assessed. One device was used at a time for 79 patients (S-Group) and two were simultaneously used for 77 (D-Group). Surgical outcomes and complications were compared. RESULTS: In the bench study, the mean time to change from laser fiber to basket and from basket to laser fiber through the working channel were 26.1 ± 3.7 s and 23.6 ± 2.0 s (p = 0.084), respectively, which were significantly longer than the laser setup time (p < 0.001). In the clinical study, although the stone-free rate was not significantly different between the groups (S-Group 89.8%, D-Group 93.5%; p = 0.412), the median operation time was significantly shorter (p < 0.001) and the rate of postoperative stenting was significantly lower (p = 0.002) in the D-Group. There were no significant between-group differences in intra- and post-operative complications. CONCLUSION: The simultaneous use of two devices through a single working channel is safe and could help save the time needed to exchange the laser fiber and nitinol basket.
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Ureter , Cálculos Ureterais , Ligas , Humanos , Masculino , Estudos Retrospectivos , Ureter/cirurgia , Cálculos Ureterais/cirurgia , Ureteroscópios , Ureteroscopia/efeitos adversosRESUMO
INTRODUCTION: A prolonged operative time of lithotripsy with ureteroscopy for urolithiasis increases the risk of infectious complications; however, few reports have investigated the factors prolonging the operative time for ureteral stones. We investigated the factors associated with longer operative time in ureteroscopy for ureteral stones. METHODS: This retrospective cohort study analyzed patients who underwent retrograde ureteroscopic lithotripsy for ureteral stones and achieved an endoscopic stone-free status between April 2019 and July 2022. Patients were classified into two groups based on an operative time of ≥90 minutes or <90 minutes. We compared the patient and stone characteristics and surgical outcomes, and investigated the factors associated with a prolonged operative time. RESULTS: The cohort comprised 519 patients, with 58 patients in the group with an operative time of ≥90 minutes. Compared to the shorter operative time group, the longer operative time group had a significantly greater proportion of males, stone diameter, stone volume, and Hounsfield units of stone; additionally, the longer operative time group had higher prevalences of endoscopic findings of edema, polyps, and mucosa-stone adherence. Multivariable analysis showed that stone size >10 mm (odds ratio 4.05), polyps (odds ratio 2.40), and mucosal adherence (odds ratio 3.51) were significantly associated with an operative time exceeding 90 minutes. There were no significant differences between the two groups in the incidences of postoperative fever and systemic inflammatory response syndrome. CONCLUSIONS: Stone size, endoscopic findings of polyps, and mucosa-stone adherence were independent factors associated with a longer operative time.
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Introduction: Prostatic urethral lift is a treatment option for benign prostatic hyperplasia, yet information on surgeries following this procedure is scarce. Case presentation: A 71-year-old man with persistent urinary retention following prostatic urethral lift underwent a secondary holmium laser enucleation of the prostate. The morcellation procedure, complicated by the presence of implants from the previous surgery, broke the morcellator blade. The fragmented blade was successfully retrieved without any organ damage. Postoperatively, the patient encountered no complications and showed improvement in his urinary symptoms. Conclusion: This case highlights the potential risk of device breakage when a secondary surgery, specifically the morcellation process, is performed following prostatic urethral lift. Care must be taken to prevent interaction between the implants and the morcellator. Our case demonstrates the efficacy of holmium laser enucleation of the prostate as a salvage surgical intervention for patients in whom prostatic urethral lift has failed.
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Background and Objective: This retrospective cohort study aimed to evaluate the clinical outcomes of vacuum-assisted mini-endoscopic combined intrarenal surgery (vmECIRS) for staghorn stones. Patients and Methods: We analyzed a total of 61 cases treated with initial vmECIRS using 14F/16F ClearPetra® percutaneous sheaths for staghorn stones. We primarily measured complications and stone-free rates (SFRs) to evaluate the safety and efficiency of vmECIRS. In addition, pre- and intraoperative factors in patients who experienced postoperative fever >38°C and achieved an initial stone-free status were evaluated. Results: The percentages of staghorn stones were 36.1% and 63.9% for complete and partial stones, respectively. The median stone volume was 8.48 cm3. The median operation time was 117 minutes, and the mean number of procedures was 1.54. Regarding postoperative complications, postoperative fever >38°C was reported in 18 patients (29.5%). The initial and final SFRs were 50.8% and 91.8%, respectively. Among patients with emerging fever >38°C, positive urine culture was the only significant risk factor in the multivariate analysis (odds ratio [OR], 7.500; 95% confidence interval [CI], 1.772-31.751; p = 0.006). Moreover, for achieving initial stone-free status, body mass index and stone volume were significant risk factors in the multivariate analysis (OR, 0.872; 95% CI, 0.776-0.980; p = 0.021; and OR, 0.882; 95% CI, 0.784-0.994; p = 0.039, respectively). Conclusions: These findings suggest that vmECIRS is safe and effective for treatment of staghorn stones. Although current guidelines suggest that percutaneous nephrolithotomy is the gold standard surgical technique for staghorn stones, vmECIRS could also be a treatment strategy. The Clinical Trial Registration number (ID: 2022-05-17-1).
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Cálculos Renais , Nefrolitotomia Percutânea , Nefrostomia Percutânea , Cálculos Coraliformes , Humanos , Estudos Retrospectivos , Nefrostomia Percutânea/métodos , Cálculos Coraliformes/cirurgia , Endoscopia , Cálculos Renais/cirurgia , Cálculos Renais/etiologia , Resultado do TratamentoRESUMO
Background and Objective: This retrospective cohort study aimed to evaluate the safety of stentless flexible ureteroscopy (fURS) using a ureteral access sheath (UAS) for stone management. Patients and Methods: A total of 270 ureteral stentless postoperative patients were analyzed. Stentless indication was characterized by having no ureteral wall or mucosa injury with only slight erosion, <1 hour operative time, and no endoscopic stone fragments with or without stone dust. Postoperative complications and pain were analyzed for safety measurements. In addition, preoperative and intraoperative risk factors associated with the incidence of systemic inflammatory response syndrome (SIRS) and postoperative pain were evaluated. Results: The most common UAS sizes were 10/12F (69.6%) and 9.5/11.5F (28.1%). The rate of patients who were stone free was 95.9%. The median operation time was 34 minutes. Only three grade 1 ureteral injuries occurred intraoperatively. Postoperative SIRS occurred in 8.8% of patients, and postoperative use of analgesics was 35.9%. Only four patients were required to undergo eventual ureteral stenting. Less than 10/12F UAS was the only factor positively associated with preventing postoperative SIRS (odds ratio [OR], 4.733; 95% confidence interval [CI], 1.085-20.644). Older age and preoperative ureteral stenting were positively associated with preventing postoperative pain (OR, 0.970; 95% CI, 0.951-0.990 and OR, 0.427; 95% CI, 0.232-0.786; respectively). Conclusion: Stentless fURS with UAS in stone management was feasible for selected patients. UAS size of <10/12F, older age, and preoperative stenting are possible keystones to achieving stentless fURS with UAS postoperatively. IRB approval number; 20216101.
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Cálculos Ureterais , Ureteroscopia , Humanos , Dor Pós-Operatória/etiologia , Estudos Retrospectivos , Stents/efeitos adversos , Síndrome de Resposta Inflamatória Sistêmica/epidemiologia , Cálculos Ureterais/complicações , Ureteroscopia/efeitos adversosRESUMO
Background: This study aimed to evaluate the efficacy of a high-power holmium laser with Moses technology (MT) for the treatment of lower pole stones during retrograde intrarenal surgery (RIRS). Methods: Herein, 305 patients with lower pole stones who underwent RIRS using a high-power holmium laser with MT were retrospectively classified into the stone-free (SF) and non-SF groups. We measured the stone burden, stone volume, stone hardness, pre- or post-operative stent placement, infundibulopelvic angle (IPA), infundibular width (IW), infundibular length (IL), and calyceal pelvic height in terms of pelvicalyceal anatomy using retrograde pyelograms and evaluated the predictive factors of postoperative SF. Results: A total of 173 (56.7%) and 229 (75.1%) patients achieved a SF status on postoperative day one and at one month, respectively. Operation time in the SF group was shorter than that in the non-SF group (51.0 vs. 74.5 min). There were no significant differences in postoperative complications between the SF and non-SF groups. Significantly predictive risk factors in postoperative SF included total stone volume (odds ratio (OR), 1.056; 95% CI, 1.015-1.099; p = 0.007), IPA (OR, 0.970; 95% CI, 0.956-0.993; p = 0.009), and IW (OR, 0.295; 95% CI, 0.121-0.718; p = 0.007). The cut-off values of stone volume, IPA, and IW were 515.2 mm3, 46.8°, and 7.75 mm, respectively. Conclusions: A high-power holmium laser with MT in lower pole stones is a valuable option for positive outcomes and patient's safety. Larger stone volume, acute IPA, and narrow IW were negative predictors related to postoperative SF status.
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INTRODUCTION: Large adrenal adenomas are clinically rare. We report a case of a large adrenal adenoma with a renal arteriovenous malformation, mimicking a malignant adrenal tumor in preoperative imaging. CASE PRESENTATION: A 66-year-old woman presented to a local hospital with abdominal pain. A right adrenal tumor was detected, 66 mm in diameter and surrounded by thick and tortuous vessels. Based on the imaging findings, pheochromocytoma was suspected. However, clinical symptoms and endocrine abnormalities were absent, and radionuclide accumulation in scintigraphy was negative. Laparoscopic right adrenalectomy was performed. Intraoperatively, a notable growth of vessels forming a nidus surrounding the tumor was observed. Pathologically, this was diagnosed as an adrenocortical adenoma in conjunction with a renal arteriovenous malformation. CONCLUSION: We report a case of a large adrenal tumor surrounded with an arteriovenous malformation. To the best of our knowledge, this is the first reported case of this combination.
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OBJECTIVES: A pre-equipped metal trocar is required to use as a camera trocar due to a specification change in the da Vinci X/Xi system (Intuitive Surgical). We observed slight slippage of a trocar placed by the open method. With optical trocar access (OTA), the initial trocar is viewed directly with a laparoscope during placement. Reports regarding OTA for robotic surgery are limited, particularly for robot-assisted radical prostatectomy (RARP). We modified the OTA procedure such that it was appropriate for RARP. PATIENTS AND METHODS: A total of 158 patients were enrolled in this study. The first trocar placement time (FTPT) was compared between the open and OTA groups. In the OTA group, the trocar was mainly placed through the upper abdominal quadrant. We also analyzed the differences between the conventional and modified OTA procedures using the Kii Fios First Entry trocar (Applied Medical). We examined the factors affecting the FTPT using linear regression models. A P value <.05 was considered significant. RESULTS: The FTPT was significantly shorter in the OTA group than the open group (P < .0001). The modified method was associated with a shorter FTPT (P = .0001). None of the patient characteristics affected the FTPT in either group. No major complications were observed. CONCLUSIONS: OTA was applied successfully during RARP. Use of the Kii Fios First Entry trocar with upper abdominal quadrant placement was suitable for RARP.