Infected hydronephrosis: can we reduce patient suffering and costs?

OBJECTIVE

To investigate the correlation among clinical parameters, risk factors, outcomes and costs in the context of patients with infected hydronephrosis.

METHODS

This retrospective, multi-centric study was conducted in three Romanian academic urology departments, and comprised data of patients with infected hydronephrosis treated between July 2013 and July 2014. Based on per-patient hospitalisation costs, the participants were divided into three groups: group A: cost less than 500 euros), group B: between 500 and 1,000 euros, and group C: over 1,000 euros). Differences between clinical parameters, comorbidities, type of procedure, admission to intensive care unit, length of hospital stay and costs were analysed.

RESULTS

Of the 175 patients, 49(28%) were in group A, 95(54.3%) in group B and 31(17.7%) in group C. The relevant parameters influencing outcomes and costs were age (p=0.001), neoplasical aetiology (p=0.001), leukocytosis (p=0.001), renal insufficiency (p=0.001), and moment of the intervention (p=0.005). Diabetes did not influence the costs (p=0.36). JJ stent insertion was tolerated at least the same as percutaneous nephrostomy, and with the same efficiency.

CONCLUSIONS

In order to avoid patient suffering and to reduce costs linked to the treatment of infected hydronephrosis, the patient-general practitioner-specialist collaboration is of the utmost importance. Symptoms, signs, paraclinical features and empirical use of antibiotics may all lead to a delay in proper management, thus making the hospitalisation longer and the costs significantly higher.

[Logistic regression analysis of risk factors of serious complications related with double-J ureteral stenting following percutaneous nephrolithotomy]

OBJECTIVE

To investigate the risk factors of the serious complications related with double-J ureteral stent placement following percutaneous nephrolithotomy (PCNL).

METHODS

Clinical data were reviewed for 272 patients treated with PCNL and indwelling double-J stents between January, 2014 and April, 2016. The risk factors of serious complications were identified using univariate and multivariate logistic regression analysis.

RESULTS

Serious complications of double-J ureteral stenting occurred in 63 patients (23.1%). Univariate and multivariate logistic regression analysis indicated that the ureter abnormalities (β=1.735, P=0.000, OR=5.670), stent indwelling duration (β=1.206, P=0.028, OR=3.340), gender (β=0.895, P=0.016, OR=2.446), preoperative urinary tract infection (β=0.849, P=0.020 , OR=2.338) and stent size (β=0.847, P=0.011, OR=2.333) were all risk factors of serious complications related with the procedure.

CONCLUSION

Male patients are exposed to a higher risk of serious complications following PCNL. Effective management of urinary tract infection and choice of appropriate stent size in cases of ureteral abnormalities help to reduce these complications. The double-J stent should be withdrawn as soon as possible in patients with good postoperative recovery.

[Flexible ureterorenoscopy vs percutaneous nephrolithotomy for renal stone management: Retrospective study]

PURPOSE

The aim of this study was to evaluate the efficacy and tolerance of renal stone fragmentation by flexible ureterorenoscopy (URS), compared to percutaneous nephrolithotomy (PCNL).

MATERIAL AND METHODS

Patients treated between 1998 and 2010 by URS and PCNL for intrarenal stone were reviewed. Patients' and stones' characteristics were analyzed. The preoperative parameters were reported as well as the procedure's efficiency and its complications. Success was defined by the absence of residual lithiasis visualized on renal imaging at 6 months of follow-up.

RESULTS

Among 531 patients included, there were 159 PCNL and 372 URS. The mean duration of hospitalization after PCNL was 8±4.6 days and 3±1.7 days after URS. The mean stones' size was higher in the PCNL group (19.9±7.5mm) than for the URS group (9.7±5.6mm; P<0.0001). The stone-free rate was significantly better in the PCNL group for stones measuring between 10 and 20mm (P<0.0001) and for stones of more than 20mm (P=0.017). Postoperative complications were significantly more frequent (27 %) and more severe (8.8 % vs Clavien III and IV) in the PCNL, than in the URS group, respectively (P=0.0001).

CONCLUSION

PCNL is a successful technique for renal stone fragmentation. However, URS seemed more tolerated despite a lower stone-free rate.

LEVEL OF EVIDENCE

4.

The evolution of urolithiasis assessment and management in the new millennium

INTRODUCTION

The aim of this review was to identify trends and developments in basic research, epidemiology, diagnosis, conservative and surgical management of urinary stone disease, and to demonstrate the evolution of urolithiasis management in the new millennium.

EVIDENCE ACQUISITION

We performed a literature search on Medline according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement up to December 2015 using the following key words: urolithiasis prevalence, recurrent urinary stone, metabolic syndrome and urolithiasis, urinary stone/urolithiasis metabolic evaluation, shockwave lithotripsy, ureterorenoscopy, percutaneous nephrolithotomy/nephrolitholapaxy. The key words were chosen following consensus as the single most appropriate and descriptive terms that would yield maximal relevant results in a single search for each section. We then segregated only relevant articles in the English language of the highest quality evidence (systematic review/meta-analysis, prospective cohorts and prospective randomized trials, levels of evidence: 1A and 1B, respectively) as well as experimental research. The initial relevance screening was based on title and abstract, whereas further filtering included full text screening. The evidence is subsequently presented and discussed on each relevant section, preceded by seminal references that are used as a basis for comparison to formulate our conclusions.

EVIDENCE SYNTHESIS

By using the key word "urolithiasis prevalence" we identified initially 1581 relevant articles. Following exclusion of duplicates and relevance screening, 154 articles were included for data extraction (9.77%). Of note, 31 articles focused on the pediatric population. By using the key words "metabolic syndrome and urolithiasis" we identified initially 127 relevant articles. Following exclusion of duplicates and relevance screening, 23 articles were included for data extraction (18.11%). It must be noted that the majority of studies are reviews, experimental models and prospective cohorts. By using the key words "urolithiasis metabolic evaluation" we identified initially 262 relevant articles. Following exclusion of duplicates and relevance screening, 179 articles were included for data extraction (68.32%). It must be noted that the majority of studies are reviews, experimental models and prospective cohorts. By using the key word "shockwave lithotripsy" we identified initially 695 relevant articles. Following exclusion of duplicates and relevance screening, 90 articles were included for data extraction (12.94%). By using the key word "ureterorenoscopy" we identified initially 2609 relevant articles. Following exclusion of duplicates and relevance screening, 186 articles were included for data extraction (7.12%). By using the key word "percutaneous nephrolithotomy" we identified initially 695 relevant articles. Following exclusion of duplicates and relevance screening, 381 articles were included for data extraction (10.42%).

CONCLUSIONS

The management of urolithiasis has evolved greatly and in multiple directions in the past fifteen years. There is a definite compartmentalization of basic research, innovation and development focusing on distinct stages of the disease, from epidemiologic features to pathophysiology, medical and surgical aspects. Patients enjoy better delivery of care, having ever more effective options to deal with their condition. The multidisciplinary approach provides more reliable solutions and will continue to drive the development of better preventative and treatment strategies in the future.

[Risk factor analysis of systemic inflammatory response syndrome in type 2 diabetics after percutaneous nephrolithotomy]

OBJECTIVE

To evaluate the risk factors of systemic inflammatory response syndrome (SIRS) in the patients with type 2 diabetes diagnosed with kidney stone after percutaneous nephrolithotomy (PCNL).

METHODS

In this study, 461 patients with type 2 diabetes who received PCNL in Peking University People's Hospital from June 2006 to December 2015 were reviewed. There were 281 males and 180 females with an average age of 57 years were included, of whom, 137 were diagnosed with SIRS after PCNL. The demographic data, clinical features, and test results were compared between the patients with SIRS and without SIRS, trying to identify the correlation between their clinical characters and the occurrence of SIRS.

RESULTS

The SIRS was significantly correlated with the patients' preoperative white blood cell counting (×10⁹/L) [7.76 (4.00-17.96) vs. 6.31 (2.00-17.40), P<0.001], preoperational blood glucose level (mmol/L) [7.30 (3.08-19.90) vs. 6.40 (3.42-16.78), P<0.001], operative time (min) [75 (20-270) vs. 60 (20-200), P<0.001], length of stay (d) [12 (2-46) vs. 11 (3-29), P=0.019], staghorn stones [38.8% (33/85) vs. 27.7% (104/376), P=0.042], and preoperational urinary tract infection [36.8% (50/136) vs. 26.6% (81/304), P=0.032]. There was no significant correlation between the SIRS and the patients' age, body mass index, preoperative hemoglobin level, preoperative serum creatinine, and transfusion. In multivariate analysis, abnormal preoperative white blood cell counting (OR=3.194, 95% CI: 1.531-6.666, P=0.002), operative time longer than 60 min (OR=1.635, 95% CI: 1.088-2.456, P=0.018), and preoperational blood glucose level higher than normal 7.1 mmol/L were significantly correlated with the presence of SIRS.

CONCLUSION

The high level of preoperational blood glucose, abnormal preoperative white blood cell counting, and long operative time were significantly correlated with the presence of SIRS in patients with type 2 diabetes after PCNL.

Paravertebral block for surgical anesthesia of percutaneous nephrolithotomy: Care-compliant 3 case reports

BACKGROUND

Paravertebral block is often used to provide postoperative analgesia after renal surgery. In this case-series report, we present our experience with 3 patients in whom percutaneous nephrolithotomy was performed successfully under ultrasound-guided 3-segment lumbar-thoracic paravertebral block.

CASE SUMMARY

Three patients were scheduled for percutaneous nephrolithotomy. All 3 patients were high-risk cases for both general and neuraxial anesthesia. After due deliberation and with the consent of patient and his family, ultrasound-guided paravertebral block was performed. Seven to 10 mL of 0.5% ropivacaine was injected at T10/T11, T11/T12, and T12/L1 paravertebral place, respectively. Sensory loss to pinprick from T8 to L2 was achieved in all 3 patients 20 min after administration of block. Surgical procedures for all 3 patients were successful, and none of the patients complained of pain during the operation.

CONCLUSIONS

Ultrasound-guided multilevel paravertebral block may be an attractive option for anesthetic management of percutaneous nephrolithotomy in clinical practice.

Outcome of Percutaneous Nephrolithotomy in Patients with Spinal Cord Neuropathy

PURPOSE

To investigate technical problems, complications and stone clearance rate in patients with spinal neuropathy who had undergone percutaneous nephrolithotomy.

MATERIALS AND METHODS

This cross-sectional study was done between 2004 and 2013 on 29 patients with both spinal cord neuropathy and kidney stones who were chosen for percutaneous nephrolithotomy in Sanandaj city, Iran. The data were obtained from patients' medical records and were documented in a researcher-made checklist. Absolute and relative frequency, mean and standard deviation were calculated.

RESULTS

A total of 43 percutaneous nephrolithotomies were performed on 32 kidneys. In 51.7% the right kidney, in 37.9% the left kidney and in three patients (10.3%) both kidneys were involved. There were 24 patients (82.8%) with spinal cord injury. Five patients (17.2%) had spina bifida. The mean of operation time was 129.7 minutes and the mean of hospital stay was 8.3 &plusmn; 3.1 days. The mean of kidney stone size was 35.7 &plusmn; 6.1 mm (25 to 45 mm). In 58.5% of the patients, surgery lasted more than two hours. Stone clearance rates were 53.1% and 78.1% after the first and second percutaneous nephrolithotomy.

CONCLUSION

Although patients with spinal cord injury have problems in terms of surgery and complications, percutaneous nephrolithotomy is an appropriate and safe treatment method for their kidney stones. Pre-operative counseling with a radiologist and an anesthesiologist is recommended.&nbsp.

A method for estimating DMSA SPECT renal function for assessing the effect of percutaneous nephrolithotripsy on the treated pole

BACKGROUND

The aim of this study was to develop a method for estimating DMSA SPECT renal function on each renal pole in order to evaluate the effect of percutaneous nephrolithotripsy by focusing the measurements on the region through which the percutaneous approach is performed.

METHODS

Twenty patients undergoing percutaneous nephrolithotripsy between November 2010 and June 2012 were included in this study. Both Planar and SPECT-DMSA studies were carried out before and after nephrolithotripsy. The effect of percutaneous nephrolithotripsy was evaluated by estimating the total renal function and the regional renal function of each renal pole. Despite PCNL has been previously reported as a minimally invasive technique, our results showed regional renal function decreases in the treated pole in most patients, affecting the total renal function in a few of them.

RESULTS

A quantification method was used for estimating the SPECT DMSA renal function of the upper, interpolar and lower renal poles. Our results confirmed that total renal function was preserved after nephrolithotripsy. Nevertheless, the proposed method showed that the regional renal function of the treated pole decreased in most patients (15 of 20 patients), allowing us to find differences in patients who had not shown changes in the total renal function obtained from conventional quantification methods.

CONCLUSION

A method for estimating the SPECT DMSA renal function focused on the treated pole enabled us to show for the first time that nephrolithotripsy can lead to a renal parenchymal damage restricted to the treated pole.

Salvage Percutaneous Nephrolithotomy: Analysis of Outcomes following Initial Treatment Failure

PURPOSE

Percutaneous nephrolithotomy has high potential for morbidity or failure. There are limited data regarding risk factors for failure and to our knowledge no published reports of surgical outcomes in patients with prior failed attempts at percutaneous stone removal.

MATERIALS AND METHODS

We identified patients referred to 3 medical centers after prior failed attempts at percutaneous nephrolithotomy. A retrospective chart review was performed to analyze reasons for initial failure and outcomes of salvage percutaneous nephrolithotomy. Outcomes were compared to those in a prospectively maintained database of more than 1,200 patients treated with a primary procedure.

RESULTS

Salvage percutaneous nephrolithotomy was performed in 31 patients. Unsuitable access to the stone was the reason for failure in 80% of cases. Other reasons included infection, bleeding and inadequate instrument availability in 6.5% of cases each. Compared to patients who underwent primary percutaneous nephrolithotomy those treated with salvage were more likely to have staghorn calculi (61.3% vs 31.4%, p <0.01) and a larger maximum stone diameter (3.7 vs 2.5 cm, p <0.01), and require a secondary procedure (65.5% vs 42.1%, p <0.01). There was no significant difference between the cohorts in the remaining demographics or perioperative outcomes. All patients were deemed completely stone free except one who elected observation for a 3 mm nonobstructing fragment.

CONCLUSIONS

Despite the more challenging nature and prior unsuccessful attempts at treatment, the outcomes of salvage percutaneous nephrolithotomy were no different from those of primary percutaneous nephrolithotomy when performed by experienced surgeons.

Comparison of laparoscopic stone surgery and percutaneous nephrolithotomy in the management of large upper urinary stones: a meta-analysis

For the treatment of large upper urinary stones percutaneous nephrolithotomy (PCNL) is generally considered the first choice, and Laparoscopic Stone Surgery (LSS) is an alternative. We aim to compare the efficiency and safety of PCNL with LSS, as far as the management of large upper urinary stones is concerned. A systematic search from Pubmed, Web of Science, Wiley Online Library and Elsevier was performed up to August 1, 2015 for the relevant published studies. After data extraction and quality assessment, meta-analysis was performed using the RevMan 5.3 software. 15 eligible trials evaluating LSS vs. PCNL were identified including 6 prospective and 9 retrospective studies with 473 patients undergoing LSS and 523 patients undergoing PCNL. Although LSS led to longer operative time (p = 0.01) and higher open conversion rate (p = 0.02), patients might benefit from significantly fewer overall complications (p = 0.03), especially lower bleeding rate (p = 0.02), smaller drop in hemoglobin level (p < 0.001), less need of blood transfusion (p = 0.01). The stone free rate was also higher for LSS compared with PCNL (p < 0.001) with less secondary/complementary procedure (p = 0.006). There was no significant difference in other demographic parameters between the two groups. Our data suggests that LSS turns out to be a safe and feasible alternative to PCNL for large upper urinary stones with less bleeding and higher stone free rate. Because of the inherent limitations of the included studies, further large sample prospective, multi-centric studies and randomized control trials should be undertaken to confirm our findings.

Staff lens doses in interventional urology. A comparison with interventional radiology, cardiology and vascular surgery values

The purpose of this work is to evaluate radiation doses to the lens of urologists during interventional procedures and to compare them with values measured during interventional radiology, cardiology and vascular surgery. The measurements were carried out in a surgical theatre using a mobile C-arm system and electronic occupational dosimeters (worn over the lead apron). Patient and staff dose measurements were collected in a sample of 34 urology interventions (nephrolithotomies). The same dosimetry system was used in other medical specialties for comparison purposes. Median and 3rd quartile values for urology procedures were: patient doses 30 and 40 Gy cm(2); personal dose equivalent Hp(10) over the apron (μSv/procedure): 393 and 848 (for urologists); 21 and 39 (for nurses). Median values of over apron dose per procedure for urologists resulted 18.7 times higher than those measured for radiologists and cardiologists working with proper protection (using ceiling suspended screens) in catheterisation laboratories, and 4.2 times higher than the values measured for vascular surgeons at the same hospital. Comparison with passive dosimeters worn near the eyes suggests that dosimeters worn over the apron could be a reasonable conservative estimate for ocular doses for interventional urology. Authors recommend that at least the main surgeon uses protective eyewear during interventional urology procedures.

Comparative study for the efficacy and safety of percutaneous nefhrolithotomy (PCNL) and retrograde intrarenal surgery (RIRS) for the treatment of 2-3,5 cm kidney stones

OBJECTIVES

Retrograde intrarenal surgery (RIRS) has become an important alternative for the treatment of kidney stones due to its increased safety and efficiency. The purpose of this study is to compare efficacy and safety features of RIRS against percutaneous nephrolithotomy (PCNL) for the treatment of 2 - 3.5 cm kidney stones.

METHODS

142 cases (106 RIRS and 36 PCNL) encompassing 2 - 3.5 cm kidney stones that have been treated in our center between December 2009 and December 2011 have been considered. Demographic variables, stone characteristics, surgical stay and surgical time have been evaluated. Additionally, the complication prerate and success rate after one and two procedures (retreatment) have also been assessed. Student's T, Mann-Whitney U y Chi² - V Cramer (p=0.05) tests were used for statistical analysis.

RESULTS

There are not statistically significant differences in demographic or stone variables. The calculated mean surgical time was lower for PCNL (85 min) than for RIRS (112 min). Mean hospital stay was statistically significantly shorter in RIRS (16 h vs. 98 h in RIRS, p=0.001). PCNL exhibited a higher global complication rate of 19.4% vs. 6.6% for RIRS (p=0.001). PCNL also showed a higher successful rate (80.6% vs. 73.6% for RIRS), although this difference was not statistically significant (p=0.40). When comparing the success rate after a second procedure, PCNL results in 94.3% vs. 93.5% for RIRS (p=0.88).

CONCLUSION

RIRS was found to be a safe and efficient procedure with a short hospital stay. Overall, RIRS can be considered as an alternative to PCNL for the treatment of renal stones smaller than 3.5 cm.

[Comparison of laparoscopic pyelolithotomy and percutaneous nephrolithotomy for renal pelvic stones larger than 2.5 cm]

OBJECTIVE

To compare the safety, efficacy and complications of laparoscopic pyelolithotomy (LPL) and percutaneous nephrolithotomy (PCNL) for treatment of renal pelvic stones larger than 2.5 cm.

METHODS

From 2011 to 2016, 32 patients underwent LPL and another 32 patients received PCNL for renal pelvic stones larger than 2.5 cm. The baseline characteristics of the patients, stone size, mean operative time, estimated blood loss, postoperative hospital stay, stone-free rate, postoperative analgesia, blood transfusion, and the intraoperative, early postoperative and long-term complications were compared between the two groups.

RESULTS

The baseline characteristics and stone size were comparable between the two groups. The mean operative time of LPL and PCNL was 117∓23.12 and 118.16∓25.45 min, respectively (P>0.05). The two groups showed significant differences in the mean estimated blood loss (63∓11.25 vs 122∓27.78 mL, P<0.01) and blood transfusion rate (0 vs 6.2%, P<0.01) but not in postoperative hospital stay (4.5∓1.34 vs 4.8∓2.2 days, P>0.05), stone-free rate (93.1% vs 87.5%, P>0.05) or the postoperative analgesia time (1.7∓0.5 and 1.9∓0.6 days, P>0.05). The incidence of intraoperative complications were significant lower in LPL group than in PCNL group (6.2% vs 25.0%, P<0.01), but the incidences of early postoperative complications (25.0% vs 34.4%, P>0.05) and long-term postoperative complications (9.4% vs 12.5%, P>0.05) were similar between them.

CONCLUSION

PCNL is the standard treatment for pelvic stones larger than 2.5 cm, but for urologists experienced with laparoscopic technique, LPL provides a feasible and safe option for management of such cases.

[Comparison of laparoscopic pyelolithotomy and percutaneous nephrolithotomy for renal pelvic stones larger than 2.5 cm]

OBJECTIVE

To compare the safety, efficacy and complications of laparoscopic pyelolithotomy (LPL) and percutaneous nephrolithotomy (PCNL) for treatment of renal pelvic stones larger than 2.5 cm.

METHODS

From 2011 to 2016, 32 patients underwent LPL and another 32 patients received PCNL for renal pelvic stones larger than 2.5 cm. The baseline characteristics of the patients, stone size, mean operative time, estimated blood loss, postoperative hospital stay, stone-free rate, postoperative analgesia, blood transfusion, and the intraoperative, early postoperative and long-term complications were compared between the two groups.

RESULTS

The baseline characteristics and stone size were comparable between the two groups. The mean operative time of LPL and PCNL was 117∓23.12 and 118.16∓25.45 min, respectively (P>0.05). The two groups showed significant differences in the mean estimated blood loss (63∓11.25 vs 122∓27.78 mL, P<0.01) and blood transfusion rate (0 vs 6.2%, P<0.01) but not in postoperative hospital stay (4.5∓1.34 vs 4.8∓2.2 days, P>0.05), stone-free rate (93.1% vs 87.5%, P>0.05) or the postoperative analgesia time (1.7∓0.5 and 1.9∓0.6 days, P>0.05). The incidence of intraoperative complications were significant lower in LPL group than in PCNL group (6.2% vs 25.0%, P<0.01), but the incidences of early postoperative complications (25.0% vs 34.4%, P>0.05) and long-term postoperative complications (9.4% vs 12.5%, P>0.05) were similar between them.

CONCLUSION

PCNL is the standard treatment for pelvic stones larger than 2.5 cm, but for urologists experienced with laparoscopic technique, LPL provides a feasible and safe option for management of such cases.

Endoscopic Management of Urolithiasis in the Horseshoe Kidney

OBJECTIVE

To assess the endourologic outcomes of patients diagnosed with a horseshoe kidney (HK) and symptomatic urolithiasis.

METHODS

A retrospective review was performed of patients diagnosed with an HK who underwent endoscopic management from 2002 to present.

RESULTS

We identified 45 patients with 64 stone-bearing moieties who underwent 56 procedures, of which 31 (69%) were male. Mean age was 49.4 years (23-78) and mean stone size was 1.6 cm (0.2-5.7). Of the 64 moieties, 37 (58%) underwent percutaneous nephrolithotomy (PCNL), 25 (39%) underwent ureteroscopy (URS), and 2 (3%) underwent extracorporal shockwave lithotripsy (SWL). More than one access was utilized in 2 (5.7%) moieties undergoing PCNL. Additional procedures were required in 10 (28.5%) PCNL patients, of which 7 were URS, 2 were secondary PCNL, and 1 sandwich therapy with SWL and PCNL. Stone-free rate by moiety was 81.1% for PCNL, 84% for URS, and 50% for SWL. Postoperative complications occurred in 3 patients in the PCNL group, including readmission for pain and complicated urinary tract infection. With a mean follow-up of 20.5 months (range 0-118 months), stone recurrence was noted in 7 (16%) patients with a total of 11 events. Calcium oxalate was the most common stone type and 20/24 (83%) of patients with metabolic evaluations were found to have at least one abnormality.

CONCLUSION

After careful consideration of the anatomy, individuals with HK and symptomatic urolithiasis can be managed safely by a variety of endoscopic approaches with excellent outcomes; however, secondary procedures and recurrence are common.

Iatrogenic ureteral injury during laparoscopic colectomy: incidence and prevention A current literature review

INTRODUCTION

Iatrogenic ureteral injury (IUI) is a serious complication that can occur during abdominal or pelvic operations with a reported frequency in literature of approximately 0.3-1.5%. Moreover, the number of iatrogenic ureteric injuries has increased markedly during the past two decades, partly because of the introduction of laparoscopy and the overall increase in surgical procedures.

MATERIAL AND METHOD

The present systematic review was set up to compare the incidence of IUI between laparoscopic and open colectomies. The study also assessed the features of the ureteric injuries and their prevention and management. We conducted a search of the literature for prospective and randomized clinical trials presenting a comparison between laparoscopic and open colorectal resections performed for any indication starting from 2003 to 2015.

RESULTS

After an initial moderate increase in incidence of IUIs, with growing experience in laparoscopic surgery, ureteral injuries not seem to be more in laparoscopic surgery than conventional surgery. Many surgeons and gynecologists agree that prophylactic ureteral catheterization may reduce the chance of IUIs.

CONCLUSIONS

Ureteral injury is especially difficult to detect during laparoscopic operations, and the symptoms of ureteric injury may develop either acutely or more insidiously, depending on the mechanism of injury. These injuries, if recognized late, can result in significant morbidity with loss of renal function. Early recognition and immediate repair of ureteral injuries during the same procedure is highly desirable. A ureteral injury not recognized and treated during the same procedure may require a temporary diverting nephrostomy and secondary surgery with increased morbidity.

KEY WORDS

Colectomy, Injury, Laparoscopy, Ureter.

Clearance of Stone Fragments and Stone Dust by Continuous Flow Hydrodynamics in Percutaneous Renal Surgery: An In Vitro Study

PURPOSE

To investigate the capacity of stone clearance in common percutaneous nephrolithotomy (PCNL) systems achieved solely by hydrodynamic effects in an in vitro setting.

METHODS

A watertight cylindrical cast with a caliceal void served as an in vitro model. Various instruments for percutaneous renal surgery working with both continuous flow (fCF) and open Rutner sidearm (fCO) were tested. The model was loaded with standardized artificial stone material (2 mm in diameter) to examine stone removal by the vacuum cleaner effect and with sand (0.1-0.5 mm in diameter) to measure the washout effect caused by irrigation backflow. The association between washout of gravel and irrigation pressure was analyzed using ANOVA. Regression analysis was performed to assess the influence of the instruments' hydrodynamic characteristics-effective cross section of the outflow and irrigation flow volume.

RESULTS

Provoking the vacuum cleaner effect removal of stones was only effective in fCF but not in fCO instruments. Depending on irrigation pressure, the volumetric flow rate and effective cross section of the outflow clearance of sand could be observed in various medium- and large-sized fCF and fCO instruments, whereas in small-sized systems, clearance effects were negligible. Regression analysis showed clearance of stone dust strongly associated with an instrument's volumetric flow rate.

CONCLUSIONS

This in vitro study demonstrated that the application of medium- and large-sized fCF PCNL systems removes both "insignificant" stones and dust solely by hydrodynamic effects. Further studies have to show if these effects also occur in the in vivo situation.

Management of anterior caliceal stones >15 mm

Anterior caliceal stones represent a challenge to endourologist to select the best modality of management with the least morbidity. To study different treatment modalities of management of anterior caliceal stones >15 mm. It is an observational prospective study of patients with anterior caliceal stones more than 15 mm. Inclusion criteria were patients with isolated anterior caliceal stones, or branched anterior caliceal stones with posterior caliceal extension. Patients were evaluated using non-contrast CT preoperatively. They were divided into three groups: group 1 underwent PCNL through posterior caliceal puncture in cases with wide anterior calyx infundibulum or obtuse infundibulopelvic pelvic, group 2 underwent PCNL through anterior caliceal access in cases with narrow infundibulum or acute infundibulopelvic angel and group 3 underwent flexible ureteroscopy and laser lithotripsy. Intraoperative and postoperative findings were recorded and compared. Eighty eight patients were included in this study, Group 1 (44 patients) group 2 (28 patients), and group 3 (16 patients). Operative time was not significantly different across the three groups (68 ± 11.5, 72 ± 9 and 74 ± 11 min in group 1, 2 and 3, respectively, P = 0.053). Fluoroscopy time was significantly shorter for group 3 (2 ± 0.5 m, P = 0.0001) compared to group 1 and 2 (5.6 ± 4.6 and 4.5 ± 1.4 min), respectively. There were no significant differences in stone-free rates after initial treatment between the three groups; 84, 82, and 69 %, in groups 1, 2 and 3, respectively (P = 0.4). Postoperative hemoglobin drop was noted to be highest for group 2 and lowest for group 3 which was significantly different (1.7 ± 0.8, 2.2 ± 1.1, and 0.3 ± 0.3 g/dl, for patients in groups 1, 2 and 3 respectively, P = 0.0001). Group 2 showed the highest post-operative complication rate (21 %) in comparison to group 1 (11 %) and group 3 (6 %), however, differences were not statistically significant (P = 0.3). PCNL through posterior or anterior caliceal puncture is an excellent modality to treat anterior caliceal stones with high stone clearance rate. Despite the higher chance of bleeding with anterior caliceal puncture, it is still inevitably needed in difficult anterior caliceal stones with unfavorable anatomy. RIRS is a good alternative to PCNL with the advantage of less radiation exposure and less bleeding.

[Factors affecting residual stones after percutaneous nephrolithotomy in patients with renal calculus]

OBJECTIVE

To explore the factors affecting the residual stones after percutaneous nephrolithotomy (PCNL) in patients with renal calculus.

METHODS

A retrospective analysis was performed for 1 200 patients who were affected by renal calculus and treated with PCNL between Jan 2008 and May 2014 in People's Hospital of Anyang City. Among those patients, 16 were diagnosed as bilateral renal stone and had two successive operations. The size, location and number of stones, previous history of surgery, the degree of hydronephrosis, urinary infection were included in the univariate analysis. Significant factors in univariate analysis were included in the multivariate analysis to determine factors affecting stone residual.

RESULTS

A total of 385 cases developed stone residual after surgery. The overall residual rate was 31.7%. In univariate analysis, renal pelvis combined with caliceal calculus (P=0.006), stone size larger than 4 cm (P=0.005), stone number more than 4 (P=0.002), the amount of bleeding more than 200 ml (P=0.025), operation time longer than 120 minutes (P=0.028) were associated with an increased rate of stone residual. When subjected to the Cox multivariate analysis, the independent risk factors for residual stones were renal pelvis combined with caliceal calculus (P=0.049), stone size larger than 4 cm (P=0.038) and stone number more than 4 (P=0.018).

CONCLUSIONS

Factors affecting the incidence of residual stones after PCNL are the size, location and number of stones. Larger size stone and the presence of renal pelvis combined with caliceal calculus are significantly associated with residual stones. Nevertheless, stone number less than 4 indicates an increased stone clearance rate.