Partial nephrectomy series using Versius robotic surgical system: technique and outcomes of an initial experience

Partial nephrectomy (PN) represents a procedure where the use of a robot has further enabled successful completion of this complex surgery. The results of this procedure using Versius Robotic Surgical System (VRSS) still need to be evaluated. Our working group described the technique and reported the initial results of a series of PN using VRSS. We presented our setting, surgical technique and outcomes for PN, using VRSS. Between 2022 and 2023, 15 patients underwent PN performed by two surgeons in two different centers. Fifteen patients underwent PN. The median lesion size identified on preoperative imaging was 4 (IQR 2.3-5) cm. Median PADUA score was 8 (IQR 7-9). Two procedures were converted to radical nephrectomy for enhanced oncological disease control. Of the 13 nephrectomies that were completed as partial, 7 were performed clampless and 6 with warm ischemia clamping. Median clamping time was 10 (IQR 9-11) minutes. No procedure was converted to open. Median blood loss was 200 (IQR 100-250) mL. Median total operative time was 105 (IQR 100-110) minutes. Median console time was 75 (IQR 66-80) minutes. Median set-up time was 13 (IQR 12-14) minutes. No intraoperative complications were reported. The median hospitalization time was 4 (IQR 3.5-4) days. None of the patients were transfused and none of the patients required readmission. In a pathology report, one patient had a positive surgical margin. Our initial experience suggests that performing PN using VRSS is feasible with good short-term outcomes.

An original mininvasive corporoplasty technique for penile curvature without circumcision

Objective: We describe an original minimally invasive penile plication technique with scrotal or infrapubic access, not requiring circumcision, for penile curvature of different severity and types. This technique can be used to correct both congenital and acquired curvatures, mono or bidirectional deformities. Materials and methods: Between 2012 and 2018 we treated 134 patients suffering from congenital curvature (33) and acquired curvature from Peyronie's disease (101). The average curvature was 62.2° (± 30.4°). Preoperative evaluation included prostaglandin E1 injection with photographic documentation and measurement of penile angulation, administration of IIEF- 15, vasoactive penile Doppler ultrasound, analysis of thermal and vibratory sensitivity with Genito-Sensory-Analyzer (GSA) and assessment of nocturnal penile stiffness with Rigiscan, performed twice, for a detailed evaluation of patient’s erectile function. Scrotal access was performed in patients with dorsal and/or lateral penile curvature; the infrapubic access was performed in patients with ventral curvature. After preparation and incision of Colles’ fascia, penis was partially degloved and an original plication technique called "binary corporoplasty" was performed at the site or sites established at preoperative assessment, with non-resorbable synthetic multifilament (Premicron®) suture. Results: Complete correction of penile curvature was achieved in 96.8 % of patients. No major complications were reported, and no patients suffered worsening in erectile function or in penile sensitivity. The average shortening of convex side was 1.65 cm (± 0.7 cm) and all patients report easy intercourse after correction. The average time of surgery was 46 minutes (± 11 min) and all procedures were performed as a day-hospital or ambulatory settings, with local anesthesia and light sedation. Overall satisfaction rate is 96%. Conclusions: This is a simple and rapid technique that perfectly corrects even the most severe and complex penile curvatures. In comparison to traditional techniques, such as Nesbit procedure, this technique is associated with low morbidity, a very low recurrence rate and a great aesthetic results. Aesthetic and functional patients’ satisfaction was excellent.

Influence of operative time and blood loss on surgical margins and functional outcomes for laparoscopic versus robotic-assisted radical prostatectomy: a prospective analysis

Introduction

The aim of this article was to analyze whether operative time and blood loss during radical prostatectomy (RP) can significantly influence surgical margins (SM) status and post-operative functional outcomes.

Material and methods

We prospectively analyzed prostate cancer (PC) patients undergoing RP, using robot-assisted (RARP) or laparoscopic (LRP) procedures. Blood loss was defined using the variation in hemoglobin (Hb, g/dl) values from the day before surgery and no later than 4 hours after surgery.

Results

From a whole population of 413 cases considered for RP, 67% underwent LRP and 33.0% RARP. Positive SM (SM+) were found in 33.9% of cases. Mean surgical operative time was 172.3 ±76 min (range 49–485), whereas blood loss was 2.3 ±1.2 g/dl (range 0.3–7.6). Operative time and blood loss at RP were not significantly correlated (r = -0.028275; p = 0.684). SM+ rates significantly (p = 0.002) varied by operative time; a higher SM+ rate was found in cases with an operative time <120 min (41.2%) and >240 min (53.4%). The risk of SM+ significantly increased 1.70 and 1.94 times in cases with an operative time <120 min and >240 min, respectively, independently to the surgical approach. The rate of erectile disfunction (ED) varied from 22.4% to 60.3% between <120 min and >240 min procedures (p = 0.001). According to blood loss, SM+ rates slightly but significantly (p = 0.032) varied; a higher rate of SM+ was found in cases with a Hb variation between 2–4 g/dl (35.9%).

Conclusions

Independently to the surgical approach, operative time, more than blood loss at RP, represents a significant variable able to influence SM status and post-operative ED.

Phytotherapy as ancillary treatment after urinary stone lithotripsy in pediatric age

AIM

Small stone fragments (NSRF) may be observed after mini-invasive lithotripsy. A 3-components herbal extract drug was tested in young patients presenting NSRF to assess efficacy, safety and tolerability.

MATERIAL AND METHODS

Patients aged 6-18 years, treated by endo-urological procedures in 5-year period, were randomly divided in 2 groups. Group A received a 3-components phytotherapic composed of Herniaria hirsuta and Peumus boldus plus water oral intake for 12 days/month in 3 months. Group B had no adjuvant phytotherapy. Group A and B were divided in 2 subgroups, according to persistence of NSRF. Patients were evaluated after the endo-urological procedure (Time 0), at 3-months therapy (Time 1) and after 3-months follow-up (Time 2). Persistence or development of new micro-lithiasis, adverse effects and urological check were registered.

RESULTS

Thirty-four patients were enrolled (Group A=15, Group B=19). Two patients were excluded. In Group A, 6 patients were stone free at Time 0 and had no recurrence, while 7 patients (53.8%) had NSRF at Time 0, reduced to 3 (23.0%) and to 2 (15.4%) at Time 1 and 2 respectively. In Group B, 11 patients (57.9%) presented NSRF at Time 0, reduced to 8 (42.1%) and 7 (36.8%) at Time 1 and 2. The difference was significant (Time 1 p=0.006, Time 2 p=0.009). No adverse effects were reported.

DISCUSSION AND CONCLUSIONS

The drug was effective in preventing new stones development and reducing significantly stone fragments persisting after endo-urological lithotripsy in children, with optimal tolerability and no adverse effects.

KEY WORDS

Arbutin, Boldine, Phytotherapy, Pediatrics, Umbelliferone, Urinary tract stones.

An Italian multicenter analysis of emergency admissions and treatment of upper tract urolithiasis during the lockdown and reopening phases of the COVID-19 pandemic: Are we ready for a second wave of the outbreak?

OBJECTIVES

To assess if the lockdown period (March-April 2020) during the coronavirus disease-19 outbreak in Italy influenced the number, presentation, and treatment of urgent admissions to the emergency department for ureteral lithiasis, and to evaluate the same variables during the reopening phase (May-June 2020).

METHODS

We performed a retrospective analysis of patients admitted to the emergency department of three different hospitals (two coronavirus disease-19 hubs). Demographics and data on acute pyelonephritis, acute kidney injury, urinoma, hematuria, inpatient admission/discharge home, and type of treatment were gathered and compared with the same periods in 2019.

RESULTS

A total of 516 patients were admitted during the study period, of whom 62.4% were male. Their mean age was 58.86 ± 16.24 years. The number of admissions decreased significantly, by 51.25% (P = 0.003), during lockdown compared to 2019 (78 vs 160 admissions). The number of admissions in the reopening phase (May-June 2020) was in line with that in 2019 (n = 138). The number of hospitalizations (P = 0.005), acute obstructive pyelonephritis (P = 0.019), and complications (P = 0.02) was statistically significantly higher during lockdown compared to 2019. The increase in the rate of surgical procedures nearly reached significance (P = 0.059). The odds of having complications and being hospitalized were almost fivefold (odds ratio 4.68, 95% confidence interval 1.98-11.07) and twofold greater (odds ratio 2.39, 95% confidence interval 1.29-4.43) compared to the same period in 2019. No difference was noted between May-June 2020 and 2019.

CONCLUSION

The coronavirus disease-19 lockdown period provoked a meaningful reduction in symptomatic ureteral lithiasis admission. Most patients presented with complicated disease, which required an increased rate of interventional procedures compared to the equivalent period in 2019. Admissions reverted to normal levels during the reopening phase.

The impact of COVID-19 outbreak on urolithiasis emergency department admissions, hospitalizations and clinical management in central Italy: a multicentric analysis

Introduction and objectives

Patients and methods

Results

Conclusions

Patient-reported outcomes for typical single cheek harvesting vs atypical lingual, labial or bilateral cheeks harvesting: a single-center analysis of more than 800 patients

PURPOSE

The optimal harvesting site for oral grafting in patients with urethral strictures remain controversial, with no study investigating morbidity on large scale. We aimed to compare typical single cheek harvesting vs atypical lingual, labial or bilateral cheeks harvesting in terms of complications and patient-reported outcomes.

METHODS

Within 827 patients treated at our referral center with oral graft urethroplasty, we compared typical vs atypical harvesting techniques. A self-administered, semiquantitative, non-validated questionnaire assessed early (10 days) and late (4 months) postoperative complications and patient-reported outcomes. A semiquantitative score was calculated according to patient responses, and it was used to assess early (6 questions) and late (13 questions) patient dissatisfaction status. Patients were defined early and/or late dissatisfied when they scored ≥ 7 and ≥ 10 at the early or late questionnaires, respectively.

RESULTS

Between 1998 and 2019, our patients predominantly received typical single cheek harvesting (89% vs 11%), with + 1.5% increase rate per year (p < 0.001). Early and late dissatisfied patients were, respectively, 170 (23%) vs 39 (44%) and 59 (8%) vs 16 (18%) in the typical vs atypical groups. Atypical harvesting was associated with higher rates of early (Odds ratio [OR]: 2.34; 95% Confidence interval [CI] 1.44-3.75; p = 0.001) and late (OR: 2.37; 95%CI 1.22-4.42; p = 0.008) postoperative dissatisfaction.

CONCLUSIONS

Typical single cheek harvesting was the preferred surgical option at our center and it was associated with negligible early and late rates of complications and patient's dissatisfaction. Conversely, atypical lingual, labial or bilateral cheeks harvesting was associated with higher complications and frequent patient dissatisfaction.

Utility of Preoperative Neutrophil/Lymphocyte Ratio as a New Objective Prognostic Tool in Endoscopically Treated Upper Tract Urothelial Carcinoma: A Retrospective Evaluation

Introduction: This exploratory retrospective analysis examined any potential prognostic role of preoperative neutrophil lymphocyte ratio (NLR) for progression-free survival (PFS) and time to endoscopically verified upper tract or bladder recurrence-free survival (RFS) in upper tract urothelial cancer (UTUC) patients selected for endoscopic treatment with subsequent endosurveillance. Patients and Methods: Eligibility criteria were natural orifice endoscopically retrogradely treated low-risk and imperative UTUC patients treated between 2005 and 2019, with biopsy confirmed diagnosis and 12 months minimum follow-up. For PFS, optimal NLR cutoff value was derived by log-rank test. Subsequently, both PFS and RFS were assessed for differences using Kaplan-Meier survival curves and log-rank test. Multivariate proportional Cox regression analysis adjusted for clinicopathologic variables was performed to examine end points for NLR-independent prognostic significance. Results: There were 100 eligible patients (63 truly low risk and 37 imperative cases). The optimal PFS log-rank test NLR cutoff value was 2.7. NLR ≥2.7 was significantly associated with shorter PFS (p = 0.01), and shorter upper tract RFS (p = 0.03), but not with bladder RFS (p = 0.90). Only positive high-grade cytology (hazard ratio [HR] 5.92, 95% confidence interval [CI] 2.140-16.35, p = 0.002) and NLR ≥2.7 (HR 4.28, 95% CI 1.34-13.72, p = 0.014) independently predicted PFS in multivariate analysis. Recurrence and progression were not significantly linked in the low-risk subset. Conclusions: This exploratory analysis showed that baseline NLR evaluation before first endoscopic UTUC treatment may be a valuable predictor and prognosticator of defined disease progression and of upper tract recurrence risk. In conjunction with high-grade urine cytology, NLR may improve risk stratification to optimize future individualized management.

Thulium-Holmium:YAG Duo Laser in Conservative Upper Tract Urothelial Cancer Treatment: 13 Years Experience from a Tertiary National Referral Center

Introduction and Objectives: To evaluate ablative safety and efficacy of thulium-holmium:YAG (TL-HL:YAG) duo laser in renal conserving retrograde intrarenal surgery (RC-RIRS) in upper tract urothelial carcinoma (UTUC). Materials and Methods: A retrospective study was performed on 178 consecutive patients referred for consideration of RC-RIRS UTUC-eLA (endoscopic laser ablation) in a tertiary center (January 2005 to December 2018). Key data were recorded using a standardized study proforma. Results: After endodiagnostic procedure, 42 declined rigorous endosurveillance protocol and went elsewhere for alternative treatment, leaving 136 patients, of whom 35 patients dropped out (25.7%) after undergoing primary radical nephroureterectomy (RNU) (unsuitable for renal preservation). This was left with 101 candidates who continued UTUC conservative management (intention-to-treat [ITT] population). Mean follow-up (FU) for these 101 patients was 28.7 months. At last FU (range 3-144 months), 70 patients (69.3%) were recurrence free, 22 (21.8%) had endoscopically treated recurrences, and a further 9 (8.9%) had undergone RNU. In the ITT population, kidney-preserving rate was 91%, whereas in imperative indications, it was 87.5%. Clavien-Dindo grade I complications only (self-limiting hematuria) were reported in 10%. Conclusions: Over a 13-year period, RC-RIRS UTUC treatment with the TL-HL:YAG duo laser was safe and oncologically noninferior to alternative combination laser energy technologies used for this indication.

Semirigid ureteroscopy prior retrograde intrarenal surgery (RIRS) helps to select the right ureteral access sheath

Objective: To evaluate ureteral compliance through semirigid ureteroscopy (sURS) in order to select the proper ureteral access sheath (UAS) size for retrograde intrarenal surgery (RIRS). Patients and methods: In a prospective study, 100 consecutive patients selected for elective sURS or RIRS were recruited. Each patient, initially underwent 9.5 Fr sURS with a safety guidewire 3Fr, in order to estimate ureteral compliance. If the ureter was compliant, a gently passage of a 12/14Fr UAS was attempted. If the ureter was not deemed compliant, passage of either a smaller UAS or a smaller semirigid 7Fr or a flexible 7.5Fr or a digital 8.5Fr scope with and without safety guidewire, was attempted. Age, gender, disease location, prestenting, previous RIRS and/or stone elimination, hydronephrosis, ureteral strictures, unsuccessful procedures, and complications, were analyzed as possible correlated factors of ureteral compliance. Results: In 77 patients the ureter was deemed compliant ≥ 14Fr. Of the preoperative factors that were examined, stent placement before RIRS (P < 0.002), previous RIRS (P = 0.000) and previous stone elimination (P = 0.004), correlated with ureter ≥ 14Fr. Ureteral lithiasis (P < 0.001), ureteral strictures (P < 0.05), unsuccessful procedures (P < 0.005) and complications (P = 0.01) correlated with ureter < 14Fr. The complication rate was 10% (10 patients) with ureteral injuries grade I in 9 patients and grade III in 1 patient according to the endoscopic grading system. Age, gender, hydronephrosis and urothelial carcinoma (UC) had no influence. Conclusions: sURS performed before RIRS allows selection of the right ureteral access sheath (UAS) and avoidance of major complications. Pre-stenting, previous RIRS and stone elimination history are all factors correlating with a compliant ureter.

Percutaneous endoscopic treatment for urinary stones in pediatric patients: where we are now

BACKGROUND

Percutaneous nephrolithotomy (PCNL) has been adopted for pyelo-calyceal stones treatment in pediatric patients, starting from the 90's. Very recently, miniaturization of endoscopic instruments allowed less invasive procedures with low complication rate. We reviewed our experience on upper tract stone treatment utilizing two different percutaneous accesses, focusing on the recent new miniaturized devices offered for pediatric renal stones.

METHODS

Patients presenting upper tract urinary stones observed from January 2011 to December 2015 and treated by percutaneous renal access were prospectively evaluated: age, sex, metabolic issues, associated abnormalities, treatment modalities, hospital stay and complication rate were recorded in a specific database. Two different endourological percutaneous modalities were adopted, depending to the stone size and position. PCNL was performed through a direct calyceal puncture under ultrasonographic and fluoroscopic guidance and Amplatz access dilatation till 24 Fr. Ballistic energy was used for fragmentation. Micropercutaneous (Microperc) procedure was recently offered utilizing a 4.85 Fr metallic needle and Holmium:YAG laser lithotripsy under direct vision through a 0.9 mm high resolution optic flexible wire connected with a telescope.

RESULTS

Thirty-eight percutaneous access to pyelo-calyceal renal stones were performed on a total of 108 children treated for upper tract stones, aged 4 to 18 years (mean age 7.5 years). The overall number of procedures was 144 (36 repeated procedures). Cystinuria was diagnosed in 5 patients. PCNL was adopted in 28 patients, Microperc was utilized in 8 patients. Hemoglobin dropdown was limited to 1.20±0.80 mg% in PCNL and was not significant in Microperc. No blood transfusion was needed. No significant complications were observed. Stone free rate or minimal not significant residuals were achieved in 82% of PCNL and in 87.5% of Microperc, after a single procedure.

CONCLUSIONS

Percutaneous endoscopic treatment of renal calculi is feasible in pediatric age, with high success rate in a single step. Advanced miniaturized endoscopic devices as Microperc guarantee high efficacy and reduced complication rate, but endo-urological experience and adequate learning curve are required, especially in small body weight children. Centralization of these patients in Pediatric Stone Centers is welcomed to optimize results and reduce risks.

Microperc for pediatric nephrolithiasis: technique in valdivia-modified position

INTRODUCTION

Micropercutaneous nephrolithotomy (microperc) has been recently proposed in adult patients. We present our initial experience in children using a modified technical approach.

METHODS

After the retrograde positioning of a 5F catheter, a 4.85F metallic needle (1.9 mm) was used for direct percutaneous calyceal access under ultrasonographic and fluoroscopic guidance with the patient in supine Valdivia-modified position. Once a three-way connector was inserted to the needle, stone fragmentation was performed under direct vision using a 200 μm holmium:YAG laser fiber and a 0.9-mm high-resolution (10,000 pixels) optic flexible wire connected with the telescope, with intermittent saline infusion. The transureteral catheter was removed within 18 to 24 hours.

RESULTS

A total of five patients aged 18 months to 11 years (mean, 5.8 years) received microperc lithotripsy in a 6-month period. The mean stone size was 15.0 mm (± 2.5 mm). Conversion to retrograde intrarenal surgery was necessary in one case, due to stone migration and poor visibility. Moderate hydronephrosis was present in one kidney. The mean operative time was 56 minutes (± 23 minutes). The blood loss was insignificant (< 0.6 Hbg/dL) and postoperative discomfort was minimal. The mean hospital stay was 2.4 ± 0.6 days for four patients after the removal of ureteral catheter. The JJ stent was removed after 15 days in the last patient. The overall stone-free rate at 1 month was 100% and no ancillary procedures were required. Conclusions Microperc is a new cost-effective and time-saving technique that we demonstrated as safe and effective in minimally invasive procedure for lower pole and pelvic renal stones of small size. Indications and limits should be defined by multicenter randomized studies, comparing the former procedures.

Treatment of pediatric renal stones in a Western country: a changing pattern

BACKGROUND

Over the last 10years the miniaturization of endoscopic instruments made minimally invasive procedures for kidney stones feasible even in children. The evolution in management of kidney stones in a tertiary care center in Europe is reported.

METHODS

Patients treated in our hospital for kidney stones from 2002 to 2011 were reviewed and group A (2002 to 2006) was compared with group B (2007 to 2011). The therapeutic options offered were Extracorporeal Shock Waves Lithotripsy (ESWL), Retrograde Intrarenal Surgery (RIRS), Percutaneous Lithotripsy (PCNL) and open surgery. Outcome measures were: first treatment chosen, stone free rate after a single procedure, and retreatment. Results were compared by chi-square test, with p <0.05 considered statistically significant.

RESULTS

333 patients, mean age 9.7years, were treated, 161 in group A and 172 in group B. ESWL was the first option in both groups, but decreased by 34% in group B vs A. In contrast, RIRS and PCNL increased by 17% and 16%, respectively, in group B vs group A. Open surgery was never required in primary lithiasis cases without associated malformations.

CONCLUSION

The advent of PCNL and RIRS has significantly changed the pattern of renal stone treatment in the pediatric age group. A progressive increase of endourologic minimally invasive procedures was recorded. Open surgery should be a very rare option.

Improving flexible ureterorenoscope durability up to 100 procedures

BACKGROUND AND PURPOSE

Controversy exists in the literature regarding flexible ureterorenoscopy (F-URS) durability, with a variable expected number of uses from a new F-URS. In this study, a tertiary center experience with the use of two consecutive F-URS is reported and suggestions as to how to improve durability further are made.

MATERIALS AND METHODS

All F-URS performed in the same tertiary care center between July 2009 and February 2011, with two new instruments Flex-X, were reviewed retrospectively. All renal pathology were included. Ureteral cases were excluded. A 9.5F semirigid ureteroscope was always used at the start for a ureteral optical predilation and to explore the upper urinary tract for possible lithotripsy/laser ablation/biopsy. The F-URS was introduced sequentially to explore the remaining calices. Data pertaining to the procedure were collected. The method of sterilization was complete immersion with Cidex®.

RESULTS

The instruments were substituted after 113 and 102 procedures, respectively. The first F-URS was used for a total operative time of 79 hours and 10 minutes while the second one was used for 71 hours and 25 minutes (mean 75 hours and 15 min). Procedure duration was 15 to 175 minutes (mean 58 min). The flexible instruments were used for a mean of 42 minutes per procedure (range 13-153 min). The indications for F-URS were therapeutic in 75.4% and diagnostic in 22.8% of the cases. For lower pole calculi, the stone was relocated in 65.2% and managed with the nonflexed flexible instrument 90% of the time. The most common causes of damage of F-URS were: Deflection mechanism impairment, inner sheath damage, and fiberoptic bundle breaks.

CONCLUSIONS

Increased durability of F-URS was from a variety of factors, a key element of which was the method of sterilization, while routine use of the semirigid instrument initially further contributed significantly to increase the number of F-URS procedures, saving overall costs.

First collaborative experience with thulium laser ablation of localized upper urinary tract urothelial tumors using retrograde intra-renal surgery

PURPOSE

Thulium laser ablation (TLA) outcomes with blinded performance evaluation after retrograde intra-renal surgical (RIRS) treatment of upper urinary tract transitional cell carcinomas (UUT-TCC).

MATERIALS AND METHODS

A UUT-TCC patient cohort undergoing RIRS-TLA by an international endoscopic surgical collaboration in a European center (April 2005-July 2009), underwent outcomes evaluation. All 4 surgeons were blinded and independently scored both TLA and Holmium:YAG laser ablation performance aspects annually using a Likert scoring system (0-10).

RESULTS

All patients (n = 59, median age 66 years, 9 with solitary kidney) had complete UUT inspection. Presenting lesion(s) were intra-renal (n = 30, 51%), ureteral (n = 13, 22%), and combined (n = 16, 27%). Single-stage TLA sufficed in 81.4% (tumors < 1.5 cm). Significant recurrence free survival differences occurred according to primary tumor size >/< 1.5 cm and multi-focality, but location made no difference. Median Likert scores were i) fiber-tip stability --5.5/8.75, p = 0.016; ii) reduced bleeding--5/8.5, p = 0.004; iii)fiber-tip precision--5.5/8.5, p = 0.003; iv) mucosal perforation reduction--3.5/7.5, p = 0.001; v) ablation efficiency tumors < 1.5 cm--6/9, p = 0.017; tumors > 1.5 cm--6.75/6.75, p = 1, and vi) overall efficiency--6/7.5, p = 0.09, for Holmium:YAG and TLA, respectively.

CONCLUSIONS

The Thulium laser delivered non-inferior recurrence free survival to RIRS-UUT-TCC Holmium:YAG laser ablation, but better median parameter performance scores in fiber-tip stability, precision, reduced bleeding and mucosal perforation reduction in expert ratings. Despite improved photothermal coagulation, and endo-visualization for tumors < 1.5 cm, both ablation and overall efficiency remained challenging for larger tumors with both existing laser technologies.

Flexible ureteroscopy for kidney stones in children

Endoscopic evaluation and management of different pathological conditions involving the upper urinary tract using rigid or flexible endoscopes, is now readily feasible and has been shown to be safe and efficacious even in the smallest children. Paediatric ureteroscopic procedures are similar to their adult counterparts, so that basic endoscopic principles should be observed. Aims of the management should be complete clearance of stones, preservation of renal function and prevention of stone recurrence. In order to select the most appropriate surgical treatment, location, composition, and size of the stone(s), the anatomy of the collecting system, and the presence of obstruction along with the presence of infection of the urinary tract should be considered. Although extracorporeal shockwave lithotripsy (ESWL) is still the most important procedure for treating urinary stones, advances in flexible endoscopes, intracorporeal lithotripsy, and extraction instruments have led to a shift in the range of indications. According to the location of the stone the treatment can be done with the rigid or flexible ureteroscope. To obtain stone fragments is essentialfor biochemical analysis. The stone composition may give significant information to prevent the high rate of recurrence, with dietary modification and specific therapy. Successful outcomes for the retrograde treatment of renal calculi are similar to the ones obtained in the adult population (stone free rate 91-98%). The retrograde semirigid and flexible ureteropyeloscopy, using a small calibre ureteroscope, are a valuable technique for kidney stones treatment in children. With excellent technique and meticulous attention to details, the significant complications are rare.

Anterior Perineal Reconstruction in Exstrophy-epispadias Complex

OBJECTIVES

To assess the role of correct anatomical reconfiguration of the anterior perineal musculature in exstrophy-epispadias (E-E) patients. To stress the use of a bipolar stimulator to detect the perineal muscular complex intraoperatively, and to increase the functional results of reconstruction in E-E patients.

METHODS

A total of 22 patients with E-E complex were treated in a 7-year period: 17 patients presenting classic bladder extrophy (aged 3 days to 6 years) and 5 incontinent male epispadias (aged 9 months to 16 years). An electric bipolar stimulator was used to identify and reapproximate at the midline the muscular fibers that constitute the periurethral muscular complex, as a part of the anterior perineal membrane. Outcome was evaluated at 24 months from surgery, considering bladder capacity, dry intervals, urinary infections (UTI's), upper tract deterioration and surgical complications (fistula, obstruction, dehiscence). Results were compared with a matched group of 19 E-E patients treated in the previous 5-year period, without the presented technique (control group). Student T-test was used for statistical analysis, considering p<or=0.05 as significant.

RESULTS

No bladder neck or urethral dehiscence was observed. Mean bladder capacity at 2-year follow-up was 80 cc in the exstrophic patients and 120 cc in the male epispadias. Mean dry interval increased to 75 minutes in the exstrophy patients and to 130 minutes in the male epispadias. Full daytime continence was achieved in 3 exstrophic and in all the epispadic patients. The difference with the control group of patients was significant (p<0.05).

CONCLUSIONS

Proper identification of the anterior perineal muscular complex, using a bipolar stimulator, and its reapproximation at the posterior urethra on the midline was demonstrated to be effective in increasing bladder cycling and in developing adequate bladder volume, anticipating coordinated micturition.

Retrograde ureteroscopy for distal ureteric stone removal in children

OBJECTIVE

To compare the efficacy and safety of ureteroscopy plus intracorporeal lithotripsy (ULT) with extracorporeal shock wave lithotripsy (ESWL) for treating distal ureteric calculi in childhood, as such stones are commonly treated by ESWL as the first option in adults but there is no agreement on the method of treating them in children.

PATIENTS AND METHODS

From July 2002 to July 2003, children presenting with ureteric stones were consecutively randomized for treatment using ULT or ESWL. The two groups were matched for age, sex and stone position in the distal ureter. A 7.5 F ureteroscope combined with a ballistic lithotripter or holmium-YAG laser was used for ULT. ESWL was administered using a second-generation lithotripter. The success rate, effectiveness quotient, complication rate and hospitalization were evaluated and compared using Student's t-test (chi-square) and Fisher's exact test as appropriate. In all, 31 patients (21 girls and 10 boys, mean age 7.2 years, range 2-17) were treated, by ULT in 17 (12 girls and five boys) and ESWL as a primary procedure in 14 (five boys and nine girls).

RESULTS

After one ULT, all the girls and four boys, and after ESWL, four girls and two boys, were rendered stone-free at the first treatment. The total stone-free rate was 16 of 17 for ULT and six of 14 for ESWL (P = 0.004). Eight patients had a second ESWL and three then became stone-free. The five patients in whom both ESWL treatments failed had a successful ULT. There was no significant difference between the groups in complication rate and hospitalization. General anaesthesia was required in all patients <12 years old treated by ULT or ESWL. The calculated efficiency quotient for treating distal ureteric calculi was significantly lower for ESWL than ULT (P < 0.05).

CONCLUSIONS

ULT should be recommended as the treatment of choice for distal ureteric calculi in children; using small ureteroscopes the target stone was treated safely and effectively.