Comparing Same-Sitting Bilateral vs Unilateral Retrograde Intrarenal Surgery in the Elderly

OBJECTIVE

To compare same-sitting bilateral vs unilateral retrograde intrarenal surgery (RIRS) in elderly patients, focusing on postoperative complications and stone-free rates (SFR).

METHODS

Data from 2 multicenter databases, FLEXible ureteroscopy Outcomes Registry (FLEXOR) (unilateral RIRS) and same sitting bilateral-retrograde intrarenal surgery (SSB-RIRS) (bilateral RIRS), were analyzed, considering only patients aged 70+ with preoperative computed tomography. Patients were categorized into Group 1 (bilateral RIRS) and Group 2 (unilateral RIRS). Follow-up included imaging assessments and secondary treatments as needed.

RESULTS

Group 1 included 146 patients, while group 2 had 495. Group 1's patients were slightly older and had a higher prevalence of recurrent stone formation. Group 2 often underwent RIRS for incidental stones. Group 1 had larger and more pelvic stones. Laser lithotripsy and total operation times were significantly longer in Group 1. Group 2 had significantly higher overall stone-free rates, although there were no significant differences in ancillary procedures for residual fragments. Group 1 experienced more pelvicalyceal injuries needing stenting, postoperative fever, and post-op hematuria not requiring transfusion.

CONCLUSION

In conclusion, bilateral RIRS can be carefully considered in elderly patients. Preoperative counseling is essential for both primary and repeat RIRS procedures, and further research is needed to optimize instrument and laser strategies for better outcomes in elderly RIRS patients.

A novel mortality risk score for emphysematous pyelonephritis: A multicenter study of the Global Research in the Emphysematous Pyelonephritis group

Background

Emphysematous pyelonephritis (EPN) is a necrotizing infection of the kidney and the surrounding tissues associated with considerable mortality. We aimed to formulate a score that classifies the risk of mortality in patients with EPN at hospital admission.

Materials and methods

Patients diagnosed with EPN between 2013 and 2020 were retrospectively included. Data from 15 centers (70%) were used to develop the scoring system, and data from 7 centers (30%) were used to validate it. Univariable and multivariable logistic regression analyses were performed to identify independent factors related to mortality. Receiver operating characteristic curve analysis was performed to construct the scoring system and calculate the risk of mortality. A standardized regression coefficient was used to quantify the discriminating power of each factor to convert the individual coefficients into points. The area under the curve was used to quantify the scoring system performance. An 8-point scoring system for the mortality risk was created (range, 0-7).

Results

In total, 570 patients were included (400 in the test group and 170 in the validation group). Independent predictors of mortality in the multivariable logistic regression were included in the scoring system: quick Sepsis-related Organ Failure Assessment score ≥2 (2 points), anemia, paranephric gas extension, leukocyte count >22,000/μL, thrombocytopenia, and hyperglycemia (1 point each). The mortality rate was <5% for scores ≤3, 83.3% for scores 6, and 100% for scores 7. The area under the curve was 0.90 (95% confidence interval, 0.84-0.95) for test and 0.91 (95% confidence interval, 0.84-0.97) for the validation group.

Conclusions

Our score predicts the risk of mortality in patients with EPN at presentation and may help clinicians identify patients at a higher risk of death.

Improving Outcomes of Same-sitting Bilateral Flexible Ureteroscopy for Renal Stones in Real-world Practice-Lessons Learnt from Global Multicenter Experience of 1250 Patients

Background

Bilateral kidney stones are commonly treated in staged procedures.

Objective

To evaluate outcomes after same-sitting bilateral retrograde intrarenal surgery (SSB-RIRS) for renal stones.

Design setting and participants

Data from adults who underwent bilateral RIRS in 21 centers were retrospectively reviewed (from January 2015 to June 2022). The inclusion criteria were unilateral/bilateral symptomatic bilateral stone(s) of any size/location in both kidneys and bilateral stones on follow-up with symptom/stone progression. Stone-free rate (SFR) was defined as absence of any fragment >3 mm at 3 mo.

Outcome measurements and statistical analysis

Continuous variables are presented as medians and 25-75th percentiles. A multivariable logistic regression analysis was performed to evaluate independent predictors of sepsis and bilateral SFR.

Results and limitations

A total of 1250 patients were included. The median age was 48.0 (36-61) yr. Of the patients, 58.2% were prestented. The median stone diameter was 10 mm on both sides. Multiple stones were present in 45.3% and 47.9% of the left and right kidneys, respectively. Surgery was stopped in 6.8% of cases. The median surgical time was 75.0 (55-90) min. Complications were transient fever (10.7%), fever/infection needing prolonged stay (5.5%), sepsis (2%), and blood transfusion (1.3%). Bilateral and unilateral SFRs were 73.0% and 17.4%, respectively. Female (odds ratio [OR] 2.97, 95% confidence interval [CI] 1.18-7.49, p = 0.02), no antibiotic prophylaxis (OR 5.99, 95% CI 2.28-15.73, p < 0.001), kidney anomalies (OR 5.91, 95% CI 1.96-17.94, p < 0.001), surgical time ≥100 min (OR 2.86, 95% CI 1.12-7.31, p = 0.03) were factors associated with sepsis. Female (OR 1.88, 95% CI 1.35-2.62, p < 0.001), bilateral prestenting (OR 2.16, 95% CI 1.16-7.66, p = 0.04), and the use of high-power holmium:YAG laser (OR 1.63, 95% CI 1.14-2.34, p < 0.01) and thulium fiber laser (OR 2.50, 95% CI 1.32-4.74, p < 0.01) were predictors of bilateral SFR. Limitations were retrospective study and no cost analysis.

Conclusions

SSB-RIRS is an effective treatment with an acceptable complication rate in selected patients with kidney stones.

Patient summary

In this large multicenter study, we looked at outcomes after same-sitting bilateral retrograde intrarenal surgery (SSB-RIRS) for renal stones in a large cohort. We found that SSB-RIRS was associated with acceptable morbidity and good stone clearance after a single session.

Indications, preferences, global practice patterns and outcomes in retrograde intrarenal surgery (RIRS) for renal stones in adults: results from a multicenter database of 6669 patients of the global FLEXible ureteroscopy Outcomes Registry (FLEXOR)

PURPOSE

To collect a multicentric database on behalf of TOWER research group to assess practice patterns and outcomes of retrograde intrarenal surgery (RIRS) for kidney stones.

METHODS

Inclusion criteria: age ≥ 18 years, normal renal/calyceal system anatomy, calculi of any size, number, and position.

STUDY PERIOD

January 2018 and August 2021. Stone-free status: absence of fragments > 2 mm, assessed post procedure according to the local protocol (KUB X-Ray and/or ultrasound or non-contrast CT scan).

RESULTS

Twenty centers from fifteen countries enrolled 6669 patients. There were 4407 (66.2%) men. Mean age was 49.3 ± 15.59 years. Pain was the most frequent symptom indication for intervention (62.6%). 679 (10.2%) patients underwent RIRS for an incidental finding of stones. 2732 (41.0%) patients had multiple stones. Mean stone size was 10.04 ± 6.84 mm. A reusable flexible ureteroscope was used in 4803 (72.0%) procedures. A sheath-less RIRS was performed in 454 (6.8%) cases. Holmium:YAG laser was used in 4878 (73.1%) cases. A combination of dusting and fragmentation was the most common lithotripsy mode performed (64.3%). Mean operation time was 62.40 ± 17.76 min. 119 (1.8%) patients had an intraoperative injury of the ureter due to UAS insertion. Mean postoperative stay was 3.62 ± 3.47 days. At least one postoperative complication occurred in 535 (8.0%) patients. Sepsis requiring intensive care admission occurred in 84 (1.3%) patients. Residual fragments were detected in 1445 (21.7%) patients. Among the latter, 744 (51.5%) patients required a further intervention.

CONCLUSION

Our database contributes real-world data to support to a better understanding of modern RIRS practice and outcomes.

RIRS with disposable or reusable scopes: does it make a difference? Results from the multicenter FLEXOR study

Introduction

With several single-use ureteroscopes now available, our aim was to analyze and compare data obtained globally from high-volume centers using both disposable and reusable flexible ureteroscopes and see if indeed in real-world practice either scope has a distinct advantage.

Methods

Retrospective analysis was performed on the FLEXOR registry, which was created as a TOWER group (Team of Worldwide Endourological Researchers, research wing of the Endourological Society) endeavor. Patients who underwent retrograde intrarenal surgery (RIRS) for renal stones from January 2018 to August 2021 were enrolled from 20 centers globally. A total of 6663 patients whose data were available for analysis were divided into Group 1 (Reusable scopes, 4808 patients) versus Group 2 (Disposable scopes, 1855 patients).

Results

The age and gender distribution were similar in both groups. The mean stone size was 11.8 mm and 9.6 mm in Groups 2 and 1, respectively (p < 0.001). Group 2 had more patients with >2 cm stones, lower pole stones and of higher Hounsfield unit. Thulium fiber laser (TFL) was used more in Group 2 (p < 0.001). Patients in Group 2 had a slightly higher stone-free rate (SFR) (78.22%) and a lower number of residual fragments (RFs) compared with Group 1 (p < 0.001). The need for further treatments for RF and overall complications was comparable between groups. On multivariate analysis, overall complications were more likely to occur in elderly patients, larger stone size, lower pole stones, and were also more when using disposable scopes with longer operative time. RFs were significantly higher (p < 0.001) for lower pole, larger, harder, multiple stones and in elderly.

Conclusion

Our real-world practice observations suggest that urologists choose disposable scopes for bigger, lower pole, and harder stones, and it does indeed help in improving the single-stage SFR if used correctly, with the appropriate lasers and lasing techniques in expert hands.

Real-world Global Outcomes of Retrograde Intrarenal Surgery in Anomalous Kidneys: A High Volume International Multicenter Study

OBJECTIVE

To analyze the trends and outcomes of retrograde intrarenal surgery for treatment of urolithiasis in anomalous kidneys in a large international multicenter series.

MATERIALS AND METHODS

We designed a multicentric retrospective study. Nineteen high-volume centers worldwide were included. Pre-, peri- and postoperative data were collected, and a subgroup analysis was performed according to renal anomaly.

RESULTS

We analyzed 414 procedures: 119 (28.7%) were horseshoe kidneys, 102 (24.6%) pelvic ectopic kidneys, 69 (16.7%) malrotated kidneys and 50 (12.1%) diverticular calculus. The average size (SD) of the stone was 13.9 (±6) millimeters and 193 (46.6%) patients had a pre-operative stent. In 249 cases (60.1%) a disposable scope was used. A UAS (ureteral access sheath) was used in 373 (90%) patients. A Holmium laser was used in 391 (94.4%) patients. The average (SD) operating time was 65.3 (±24.2) minutes. Hematuria, caliceal perforation and difficulty in stone localisation were mostly seen in diverticular stones and difficulty in UAS placement and lithotripsy in the cases of renal malrotation. The overall complication rate was 12%. Global stone-free rate was 79.2%. Residual fragments (RF) were significantly lesser in the pre-stented group (P <.05). Diverticular calculi was the group with more RF and needed ancillary procedures (P <.05).

CONCLUSION

Retrograde intrarenal surgery in patients with anomalous kidneys is safe and effective with a high single-stage stone-free rate and low complication rate. There is a trend toward using smaller and disposable scopes and smaller UAS. Diverticular stones can still be challenging with higher rates of intraoperative hematuria, caliceal perforation and RF.

[Factors predicting of failure after conservative treatment in III-V grade renal trauma]

INTRODUCTION AND OBJECTIVES

Surgical exploration of renal injury secondary to major trauma often leads to nephrectomy. The aim of this work was to identify the factors associated with the need for surgery in patients with III-V grade renal trauma who were initially managed conservatively.

MATERIALS AND METHODS

We retrospectively reviewed data from patients with Grade III-V kidney injury between June 2005 and June 2015. Demographic, clinical and bio-radiological characteristics at admission and follow-up, as well as management and complications, were recorded. Patient data, including conservative treatment, was a success without recourse to nephrectomy, and those patients who needed surgery were analyzed.

RESULTS

Seventy three patients were included in this study. Grade III accounted for 45%, Grade IV: 49% and Grade V: 5%. The success rate for conservative treatment was 79%: 31 patients grade III (94%), 26 grade IV (72%) and no grade V patients. hypotension at admission (P=0.04), hematoma size greater than 3.5 centimeters (P=0.002), grade V (P=0.003), anemia (P=0.04), blood transfusion (P=0.01) and worsening of lesions of the control CT lesions (P=0.001), are the factors considered as predictive of failure of conservative treatment.

CONCLUSION

Conservative management is the treatment of choice in III-V grade renal trauma, and the prognostic factors found in this study make it possible to better select patients.

LEVEL OF EVIDENCE

4.

[Oncological results of a series of 93 laparoscopic radical cystectomies: 5 years of follow-up]

OBJECTIVE

To report oncological results at 5 years after laparoscopic radical cystectomy (LRC) with lymph node dissection for bladder cancer (BC).

PATIENTS AND METHODS

This is a retrospective single-center study of all patients who underwent LRC for BC by the same surgeon from February 2007 to March 2016. Demographic, perioperative and oncologic data were collected. We reported overall survival rate (OS), cancer specific (CSS) and recurrence-free survival (SSR), as primary indicators of oncologycal outcomes. These survival rates were estimated according to the Kaplan-Meier method. Log-rank tests were used to explore overall survival according tumor stage, lymph node involvement and surgical margins status.

RESULTS

In all, 93 patients (82 men and 11 women) underwent LRC. Mean age was 59 years. Minor complications (Clavien I-II) occurred in 24.7%. Major complications (Clavien IIIa-V) were observed in 8.6%. No patients received neoadjuvant chemotherapy. Median lymph node (LN) yield was 15 and 26.5% patients had positive LN. The positive surgical margins (SMs) rate was 5.3%. Median follow-up for the entire patients was 50 months (19-84 months). Forty-three patients (46.2%) were followed for at least 71 months. Five year RFS, CSS and OS were 67%, 85% and 79%, respectively. Non organ confined desease, positive LN and positive SMs were associated with poorer OS (P<0.039, P<0.016 and P<0.001).

CONCLUSION

LRC was associated with acceptable long-term oncologic outcomes, similar to those currently reported after open cystectomy for BC.

LEVEL OF EVIDENCE

3.

[Evaluation of the learning curve of laparoscopic radical cystectomy for cancer: Morbidity and oncological results]

INTRODUCTION

The objective of this work was to evaluate the impact of the laparoscopic radical cystectomy learning curve on perioperative and oncological outcomes.

PATIENT AND METHODS

This is a retrospective and single-center study of all patients who underwent laparoscopic radical cystectomy for bladder cancer from February 2007 to March 2016, (93 patients) Perioperative and oncological data were collected. We used mixed statistical models to predict the number of patients needed in the learning phase. We compared the perioperative parameters of the patients in the learning phase with those of the rest of the patients. Overall survival was estimated using the Kaplan-Meier method.

RESULTS

Thirty-six patients are required for the learning phase (P1). The expertise phase begins after the 36th LRC (P2). In both phases, there was no significant difference in age, ASA score, and tumor stage (P=0.237, P=0.577, P=0.998). Mean operative time was 328.3min and 262.4min in P1 and P2 (P=0.0001), mean blood loss was 333.7mL and 194.3mL in P1 and P2 respectively (P=0.0003). The rate of major complications was high in the learning phase (P=0.042). There was no significant difference in lymph node yield, positive surgical margins and overall survival (P=0.068, P=0.194, P=0.703).

CONCLUSION

This learning experience was evaluated without compromising oncological results, but with a significantly higher rate of major complications.

LEVEL OF EVIDENCE

3.

[Leiomyosarcoma of the urinary bladder treated using laparoscopic cystectomy and bladder replacement by enterocystoplasty: about a case]

Our study aims to report a new case of leiomyosarcoma of the urinary bladder, a rare tumor, and to propose a new therapeutic approach, given the non-consensual nature of its treatment. A 31-year old patient, with no particular previous history, presented with total haematuria with clot formation. The clinical and paraclinical assessment showed a voluminous solid tumor mass occupying the apex of urinary bladder and extending to the right lateral wall, with infiltrating appearance, without lymph node involvement or invasion of local or distal organs. Surgical management was based on total laparoscopic cystectomy and bladder replacement by enterocystoplasty. The postoperative course was uneventful. Radiological examinations at 3, 6, 12 and 24 months showed no recurrence. Thus, adaptive surgery should be proposed on a case-by-case basis, to improve the quality of life of patients suffering from this condition.

[The local anesthesia for the prostatic biopsies echo-guided: forward-looking randomized study comparing two methods]

INTRODUCTION

The realization of the prostatic biopsies is a painful act. The objective of our work was to compare the analgesic efficiency of the injection of the lidocaine at the level of periprostatics laterals and apical areas compared with the use of gel of lidocaine intrarectal associated with the taking of oral tramadol.

PATIENTS AND METHODS

Between November 2007 and December 2009, 60 patients admitted in the service of urology of the university hospital Mohammed VI of Marrakesh for prostatic biopsies were randomized in two groups. The group 1 (30 patients) received two tablets from tramadol 50mg with 10 mL of gel of lidocaine 2% intrarectal while 30 patients of the group 2 received 10 mL from lidocaine 2% injected at the level of periprostatics laterals and apicales. The pain was estimated by a visual analog scale (AVS) at the introduction of the probe of echography (AVS 1), at the time of the biopsy (AVS 2) and 20 minutes later (AVS 3).

RESULTS

There was no significant difference between both groups concerning AVS 1 means. The average score of the pain was significantly lower in the group 2 for the AVS 2 and AVS 3.

CONCLUSION

The periprostatics anesthesia assured a better control of the pain at the time of the prostatic biopsy and 20 minutes later, without increase of the complications. We recommend it to decrease the pain and the discomfort related to this technique.

Bladder cancer in the second trimester of pregnancy: tough decisions. A case report with review of the literature

We report a rare case of a patient presenting with a nonmuscle invasive papillomatosis transitional cell carcinoma of the bladder in the second trimester of pregnancy. We describe the management dilemmas encountered and the challenging treatment option selected to optimize outcome for the patient and infant. Close collaboration between urologists, obstetricians and medical colleagues is needed for optimal, safe and effective management of bladder tumours during pregnancy.

Sciatica leading to the discovery of a renal cell carcinoma

Metastatic renal cell cancer is not exceptional in kidney cancer (30% of patients with kidneyl cancer). Its prognosis is particularly severe. However, sciatic neuralgia (sciatica) remains an exceptional revealing clinical sign of this disease. The authors report the case of a patient admitted with right sciatica as chief complain, leading to the discovery of a renal cell carcinoma. Although uncommon, renal cell carcinoma spine metastasis should be included in the differential diagnosis of back pain and sciatica.

[Perineal-scrotal gangrene: epidemiological and therapeutic aspects. About 45 cases]

Perineoscrotal gangrene is an acute disease, a rare and severe affection of the perineum, whose evolution is unpredictable and rapidly extensive. The diagnosis is clinical. The paraclinical examinations allow early diagnosis and assessment of anatomical and biological repercussions. We conducted a retrospective study of 45 patients spread over six years, involving a multidisciplinary team consisting of three specialists (urologists, visceral, plastic surgeons). The average age was 52 years. The largely male dominated our series. Fournier gangrene was the most common etiology. We noted five cases of death (11%) in the acute phase, secondary to septic shock (four patients) or multiple organ failure (one patient). The evolution was favorable in 40 other patients in the series, requiring an initial management in intensive care unit, and surgical treatment. The average hospital stay was 17 days. After the acute phase, all patients underwent a surgery for skin coverage, ranging from guided healing (two patients) to musculocutaneous flap of the gracilis (six patients) via the secondary suture (four patients), the burying the testes (18 patients) and half thick skin graft, with a functional and aesthetic result was acceptable, and minimal sequelae. In our series, the most predictive prognostic factors would be the delay of care, sepsis on admission and associated diseases.

An unusual presentation of primary male genital tuberculosis

Urogenital tuberculosis is a rare disease; however, it is the second most common location for tuberculosis after the lung. Currently, incidence of urogenital tuberculosis is increasing due to factors such as a higher prevalence of immunosuppression (especially that caused by human immunodeficiency virus infection) and drug abuse. Herein a new case of male genital primary tuberculosis is reported presenting as a scrotal tumor; the originality of this observation lies in its unusual pseudotumor form.

[Infertility and testicular seminoma]

INTRODUCTION

Infertility in men may be associated with an elevated risk of testicular cancer. The authors report a case of testicular seminoma discovered fortuitously during a workup for infertility.

CASE

A 30 year-old male was seen for infertility. Physical examination and testicular ultrasonography were normal. The sperm count found oligoasthenospermia related to the excretory ducts. The patient underwent testicular biopsies for infertility, which showed an intratubular germ cell tumor. Tumor markers (beta HCG, alpha FP, LDH) were normal. Computed tomography was normal for the thorax, abdomen, and pelvis. We performed an inguinal orchiectomy. The pathology examination found seminoma, at a pT1 stage. One course of chemotherapy followed.

DISCUSSION

The incidence of testicular cancer is increasing throughout the world. Recent studies show a strong relation between infertility and an increased risk of testicular cancer, and some authors even suggest a causal relation.

[Study of the safety of double J ureteric stents]

INTRODUCTION

Endoscopic placement of ureteric stents was first described in 1967 by Zimskind. Few studies have evaluated the impact of double J ureteric stents on the patient's quality of life. This prospective study was designed to evaluate the safety and morbidity associated with ureteric stents.

PATIENTS AND METHODS

From February 2001 to June 2003, 115 patients (64 men and 51 women; mean age: 49.5 years [range: 19-90]) were included in this study. Ureteric stents were placed under general anaesthesia for urolithiasis (80 cases), ureteroplasty (25 cases) and extrinsic ureteric compression (10 cases). 28 cm 7F polyurethane stents were used in every case. Patients with double J stent for renal transplantation or pregnancy were excluded. The safety of stents was evaluated on the day of removal by a questionnaire based on a 100 mm visual analogue scale (VAS).

RESULTS

The mean duration of stenting was 91.8 days (range: 10-287). Macroscopic haematuria was reported in 56% of cases, dysuria was reported in 36% of cases and urgency was reported in 78% of cases. The mean score on the VAS was 44 (0-100) for global impression, 41 (0-100) for bladder pain, 41 (0100) for low back pain, 62 (2-100) for low back pain during micturition and 32 (0-100) for straining on the stent.

CONCLUSIONS

Double J stents are associated with high morbidity, which is sometimes underestimated by operators. Our study confirms that the duration of stenting must be as short as possible in order to improve patient comfort, which implies rapid organization of the aetiological management of these patients.

[Inferior calyx stone and flexible ureterorenoscopy to mobilize the stone before fragmentation]

Flexible ureterorenoscopy is recommended for the treatment of inferior calyx stones, 10 to 15 mm in diameter, particularly after failure of extracorporeal lithotripsy. It is recommended to mobilize an inferior calyx stone towards the renal pelvis or superior calyx before starting fragmentation. This manoeuvre is essential to preserve the ureterorenoscope. The objective of this technical note is to explain the stone "relocalization" manoeuvre and describe how in situ treatment of an inferior calyx stone can be dangerous for the flexible ureterorenoscope.