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

PURPOSE

We aimed to accurately determine ureteral stricture (US) rates following urolithiasis treatments and their related risk factors.

METHODS

We conducted a systematic review and meta-analysis following the PRISMA guidelines using databases from inception to November 2023. Studies were deemed eligible for analysis if they included ≥ 18 years old patients with urinary lithiasis (Patients) who were subjected to endoscopic treatment (Intervention) with ureteroscopy (URS), percutaneous nephrolithotomy (PCNL), or shock wave lithotripsy (SWL) (Comparator) to assess the incidence of US (Outcome) in prospective and retrospective studies (Study design).

RESULTS

A total of 43 studies were included. The pooled US rate was 1.3% post-SWL and 2.1% post-PCNL. The pooled rate of US post-URS was 1.9% but raised to 2.7% considering the last five years' studies and 4.9% if the stone was impacted. Moreover, the pooled US rate differed if follow-ups were under or over six months. Patients with proximal ureteral stone, preoperative hydronephrosis, intraoperative ureteral perforation, and impacted stones showed higher US risk post-endoscopic intervention with odds ratio of 1.6 (P = 0.05), 2.6 (P = 0.009), 7.1 (P < 0.001), and 7.47 (P = 0.003), respectively.

CONCLUSIONS

The overall US rate ranges from 0.3 to 4.9%, with an increasing trend in the last few years. It is influenced by type of treatment, stone location and impaction, preoperative hydronephrosis and intraoperative perforation. Future standardized reporting and prospective and more extended follow-up studies might contribute to a better understanding of US risks related to calculi treatment.

Does obesity really affect renal transplantation outcomes?

INTRODUCTION

Kidney transplantation is the treatment of choice for patients with stage 5 chronic kidney disease (CKD). About 60% of CKD patients are overweight or obese at the time of kidney transplantation, and post-transplant obesity occurs in 50% of patients, with a weight gain of 10% in the first year and high risk of cardiovascular mortality. Obesity is associated with an increased risk of delayed graft function (DGF), acute rejection, surgical complications, graft loss and mortality. The aim of this study is to assess the clinical evolution of obese and overweight patients that have received a kidney transplant, based on short- and long-term complications associated with a higher BMI.

MATERIAL AND METHODS

A descriptive, observational, cross-sectional study was conducted with 104 kidney or pancreas-kidney transplant patients between March 2017 and December 2020, with a follow-up until April 2021. For comparative analysis, patients were grouped according to BMI.

RESULTS

Mean age was of 56.65 years, 60.6% male and 39.4 % female. Overweight patients experienced prolonged surgeries, more surgical wound dehiscence, delayed graft function, hernias, proteinuria and more indications for renal biopsies. Additionally, obese patients displayed more DGF, indications for renal biopsies, proteinuria, development of diabetes mellitus, atrial fibrillation and needed prolonged hospital stays.

CONCLUSIONS

Despite a high prevalence of comorbidity in the overweight and/or obese population, we found no reduction in patient and/or graft survival. However, longer follow-up is needed.

Has fluoroless endourology (URS and PCNL) come of age? Evidence from a comprehensive literature review

INTRODUCTION

Radiation via the use of imaging is a key tool in management of kidney stones. Simple measures are largely taken by the endourologists to implement the 'As Low As Reasonably Achievable' (ALARA) principle, including the use of fluoroless technique. We performed a scoping literature review to investigate the success and safety of fluoroless ureteroscopy (URS) or percutaneous nephrolithotomy (PCNL) procedures for the treatment of KSD.

METHODS

A literature review was performed searching bibliographic databases PubMed, EMBASE and Cochrane library, and 14 full papers were included in the review in accordance with the PRISMA guidelines.

RESULTS

Of the 2535 total procedures analysed, 823 were fluoroless URS vs. 556 fluoroscopic URS; and 734 fluoroless PCNL vs. 277 fluoroscopic PCNL. The SFR for fluoroless vs. fluoroscopic guided URS was 85.3% and 77%, respectively (p=0.2), while for fluoroless PCNL vs. fluoroscopic group was 83.8% and 84.6%, respectively (p=0.9). The overall Clavien-Dindo I/II and III/IV complications for fluoroless and fluoroscopic guided procedures were 3.1% (n=71) and 8.5% (n=131), and 1.7% (n=23) and 3% (n=47) respectively. Only 5 studies reported a failure of the fluoroscopic approach with a total of 30 (1.3%) failed procedures.

CONCLUSION

The ALARA protocol has been implemented in endourology in numerous ways to protect both patients and healthcare workers during recent years. Fluoroless procedures for treatment of KSD are safe and effective with outcomes comparable to standard procedures and could become the new frontier of endourology in selected cases.

Factors associated with ureteral strictures following ureteroscopy for impacted ureteral stones? A multicenter study by EAU-YAU endourology and urolithiasis working party

OBJECTIVE

To determine the relation between ureteral stone impaction and ureteral stricture formation and associated factors.

MATERIAL AND METHODS

We retrospectively analyzed the medical records of all patients who underwent endoscopic ureteral stone surgery for impacted ureteral stone at three academic institutions in Turkey, United Kingdom and Spain between June 2019 and January 2022. Examined parameters included patient demographics, stone side, size and localization, time between initiation of symptoms and surgery, type of ureteroscopy (rigid/flexible), presence of nephrostomy or double-J stent prior to URS, intraoperative complications (avulsion/perforation, stone-free status, number of procedures required for stone-free status, postoperative imaging results.

RESULTS

A total of 41 patients whom 25 were male and 16 were female, from 3 institutions were included the study. The mean age of the patients was 48.2 ± 13.5 years. The median largest diameter of the stones was 9 mm (IQR: 8 mm). Total 14 (34.1%) patients developed ureteral strictures following ureteroscopy. There was no difference between patients who developed ureteral strictures and patients who did not developed strictures in terms of stone laterality, stone location, hydronephrosis and multiplicity, p = 0.58, p = 0.14, p = 0.79 and p = 0.31. Patients who developed ureteral strictures had a higher rate of preoperative urinary diversion such as nephrostomy or DJS, p = 0.000.

CONCLUSION

Interruption of urine passage through ureter via urinary diversion such as nephrostomy or DJS stent prior to ureteral stone surgery might lead ureteral stricture formation in the postoperative period.

SORGENTINA-RF FUSION NEUTRON PLANT: PRELIMINARY DESIGN OF THE BIOSHIELDING IN COMPLIANCE WITH DOSE CONSTRAINTS FOR WORKERS EXPOSURE

An accelerator-driven 14 MeV neutron source of new concept, denominated SORGENTINA-RF, will be installed in ENEA Brasimone Research Centre, to test the feasibility of producing radionuclides of medical relevance using fusion neutrons. The main goal of the facility is generating 99Mo as precursor of 99mTc, a radionuclide widely used in nuclear medicine diagnostic procedures, using the 14 MeV fusion neutrons produced by the plant. This work describes the study performed for the design of a proper shielding structure that aims at fulfilling the requirement of 0.01 mSv/h dose rate limit on the external surface of the shielding during beam-on operations. The proposed shielding consists of a layered structure composed of 2 m standard concrete and 1 m baritic concrete. The design is still in the preliminary phase to assess the feasibility and the economic issues as well as structural impact of the shielding structure.

Safety and Outcomes of using ureteric access sheath (UAS) for treatment of Pediatric renal stones: Outcomes from 2 tertiary endourology centers

OBJECTIVE

To look at the safety and outcomes of using ureteral access sheath (UAS) for pediatric renal stones. The use of UAS is variable in urological practice with very little clinical work on their use in pediatric kidney stone disease.

PATIENTS AND METHODS

Data was retrospectively collected from 2 large European tertiary endourology centers for all pediatric patients (≤16 years) with renal stones who underwent flexible ureteroscopy and lasertripsy (FURSL) via UAS. Data was collected on patient details, stone demographics and clinical outcomes of the FURSL procedure.

RESULTS

Forty-eight patients with a mean age of 10.7 years were treated with FURSL for a mean single and cumulative stone size of 10.4 mm and 15 mm respectively, with two-third having multiple stones and stones in the lower pole. The initial and final stone free rate (SFR) was 66.7% and 100% respectively with 1.3 procedures/patient. One patient each had intra-operative grade 1 ureteric injury and post-operative UTI, with no other injuries or complications noted. Over a mean follow-up of 17 months, no other complications were noted.

CONCLUSION

Ureteral access sheath is safe for treatment of pediatric renal stones with excellent outcomes and are especially useful for larger or multiple stones. While there does not seem to be any medium-term sequalae, to avoid risk of ureteral injury, we would suggest using the smallest size sheath possible. We would argue these procedures are best done in specialist high-volume endourology units for optimal results.

µRANIA-V: an innovative solution for neutron detection in homeland security

Detection of neutrons is becoming of the utmost importance, especially in the studies of radioactive waste and in homeland security applications. The crisis of 3He availability has required the development of innovative techniques. One solution is to develop light gas detectors for neutron counting to be used as portals for ports and airports. The neutron is converted on the Boron-coated cathode, releasing a charged particle, whose passage can be identified by the gas detector. While several technologies have been deployed in the past, the project μRANIA-V (μRwell Advanced Neutron Identification Apparatus) aims to detect thermal neutrons by means of the μRwell technology, an innovative gas detector. The goal is to produce tiles to operate as portals in homeland security or for radioactive waste management. The technological transfer towards the industry has started, thus the production can be cost-effective also owing to a construction process relatively easier compared to similar apparatus. By reading directly the signals from the amplification stage, the neutrons can be counted with simplified electronics further reducing the total cost. In this paper, the project will be described, with details on the μRwell technology and on the neutron counting, on the test beam performed, and on the future plans.

64Cu production by 14 MeV neutron beam

64Cu is an emerging radionuclide of great interest in personalized nuclear medicine. It is produced by a cyclotron via the reaction 64Ni(p,n)64Cu. This production method increased during the last decades, because small biomedical cyclotrons can be easily installed close to the nuclear medicine department of a hospital. As a matter of fact, 64Ni is a very expensive target material. For this reason, an alternative 64Cu production method was investigated at ENEA by using the quasi-monochromatic 14 MeV fusion neutron beam made available at the Frascati Neutron Generator (FNG) located at the ENEA – Frascati Research Center. In particular, two nuclear reactions were studied: 65Cu(n,2n)64Cu and 64Zn(n,p)64Cu. The radiochemical analysis of the activated samples was performed at the ENEA-NMLNWM laboratory located in ENEA-Casaccia Research Center. The activity measurements were carried out at the ENEA-INMRI, located in the ENEA-Casaccia Research Center, with high metrological level conditions and by assuring their traceability to the 64Cu primary activity standard here developed and maintained. A prediction of the 64Cu production by means of the high-brilliance 14 MeV neutron source named Sorgentina is also discussed.

On the slowing down of 14 MeV neutrons

An experimental procedure is assessed to obtain moderated neutron fields starting from almost monochromatic 14 MeV neutrons generated by means of an accelerator-driven D-T source. The use of a metallic pre-moderator and a standard hydrogen-containing moderator is effective in producing neutron spectra featuring a thermal peak and an epithermal slowing down tail extending up to 14 MeV. The performance of proposed moderation system was investigated by means of MCNP Monte Carlo calculations, benchmarked against experimental measurements using an explorative set up, assembled at the Frascati Neutron Generator. The benchmarked calculations allow at making predictions about the brilliance of a 14 MeV neutron moderator in view of possible applications in neutron science.

Comparison between measurement and calculations for a 14 MeV neutron water activation experiment

The nuclear heat loads due to gamma rays emitted from the decay of 16N and delayed neutrons from17N, generated by the activation of water in cooling circuits, are critical for ITER design. The assessment of nuclear heating from activated water is complex; it requires temporal and spatial dependent transport and activation calculations taking into account variation of irradiation, water flow conditions and cooling circuits’ parameters. A water activation experiment has been recently conducted at the14 MeV Frascati Neutron Generator (FNG) in order to validate the methodology for water activation assessment used for ITER and to reduce the safety factors applied to the calculation results, which have a large impact on the schedule, commissioning and licensing. Water circulating inside an ITER First Wall (FW) mock-up was irradiated with 14 MeV neutrons and then measured using a large CsI scintillator detector. The system consists of a closed water loop where the cooling water, transiting through an ITER FW mock-up, is irradiated by FNG. The induced 16N activity via 14 MeV neutrons interactions with 16O via the 16O(n,p)16N reaction is measured in a dedicated counting station via an expansion volume. The water then passes to a much larger holding delay tank, and after several 16N half-lives decay time, it is then recirculated and exposed again to neutrons in the ITER First Wall (FW) mock-up. The measured 16N activity is obtained measuring the emitted characteristic 6.13 and 7.12 MeV gamma-rays. Calculations were performed in an accurate model of the FW mock-up using the MCNP Monte Carlo code and FENDL-3.1 nuclear data library to obtain the predicted flux impinging on the water. The EASY-2007 inventory code was used to predict the 16N activity. In this work, a comparison between measurements and calculations is reported together with associated uncertainty analysis.

Treatment of isolated small renal stones leads to resolution of symptoms and should be routinely offered to patients: retrospective outcomes from a university hospital

INTRODUCTION

Treatment of smaller renal stones and the symptomatic value it offers to patients is often debated. We wanted to analyse surgical outcomes for treatment of small renal stones and whether treatment resulted in symptom resolution.

MATERIALS AND METHODS

All patients who underwent ureterorenoscopy (URS) for isolated symptomatic small renal stones ≤10 mm over a 7-year period were retrospectively included and subdivided into those with stones of ≤7 mm (Group A) and stones of 8-10 mm (Group B). Patients with multiple renal stones, ureteric stones, or combined renal and ureteric stones were excluded. Based on the symptoms, the patient groups were those with pain, urinary tract infection (UTI) and haematuria. Resolution of symptoms was defined as no symptoms during the follow-up period.

RESULTS

A total of 109 patients with a single small renal stone ≤10 mm underwent URS and stone treatment, with mean age of 50 years and a male:female ratio of 1:1.2. The mean operative time was significantly longer in Group B (55.9 min vs 33.07 min, p = 0.001). In total, 97.2% (n = 70) of patients in Group A and 83.7% (n = 31) of patients in Group B were stone free (p = 0.017). Complete resolution of symptoms was seen in 63 (92.6%), 24 (85.7%) and 13 (100%) patients with pain, UTI and haematuria, respectively. There were no statistically significant differences in symptom resolution between patients with stones ≤7 mm and those with stones 8-10 mm in size.

CONCLUSION

Ureteroscopic treatment is a feasible option for small symptomatic stones, since it may lead to symptom resolution. Based on our study we would recommend that patients with symptomatic small renal stones are offered endoscopic treatment.

Role of Complementary Medicine (Music, Acupuncture, Acupressure, TENS and Audio-Visual Distraction) in Shockwave Lithotripsy (SWL): A Systematic Review From EAU Sections of Urolithiasis (EULIS) and Uro-Technology (ESUT)

We performed a systematic review to look at the role of alternative or complementary medicine such as music, acupressure, acupuncture, transcutaneous electrical nerve stimulation (TENS) and audiovisual distractions to decrease analgesia requirement and alleviate anxiety during SWL. Twenty-three papers(2439 participants) were included: Music (n = 1056.6%), Acupuncture (n = 517.7%), Acupressure (n = 13.8%), TENS (n = 617.2%), and audiovisual distraction (n = 14.6%). Most of the studies showed that complementary therapy, lowered pain, and anxiety with higher patient satisfaction and willingness to undergo the procedure. With its feasibility and convenience, urological guidelines need to endorse it, and more should be done to promote its use in outpatient urological procedures.

Ubiquitin binds the amyloid β peptide and interferes with its clearance pathways

Several lines of evidence point to a compromised proteostasis associated with a reduction of the Ubiquitin Proteasome System (UPS) activity in patients affected by Alzheimer's Disease (AD) and suggest that the amyloid β peptide (Aβ) is an important player in the game. Inspired also by many reports, underlining the presence of ubiquitin (Ub) in the amyloid plaques of AD brains, here we set out to test whether Ub may bind the Aβ peptide and have any effect on its clearance pathways. By using an integrated array of MALDI-TOF/UPLC-HRMS, fluorescence, NMR, SPR, Microscale Thermophoresis (MST) and molecular dynamics studies, we consistently demonstrated that Aβ40 binds Ub with a 1 : 1 stoichiometry and K d in the high micromolar range. In particular, we show that the N-terminal domain of the Aβ peptide (through residues D1, E3 and R5) interacts with the C-terminal tail of Ub (involving residues K63 and E64), inducing the central region of Aβ (14HQKLVFFAEDVGSNK28) to adopt a mixed α-helix/β-turn structure. ELISA assays, carried out in neuroblastoma cell lysates, suggest that Aβ competitively binds Ub also in the presence of the entire pool of cytosolic Ub binding proteins. Ub-bound Aβ has a lower tendency to aggregate into amyloid-like fibrils and is more slowly degraded by the Insulin Degrading Enzyme (IDE). Finally, we observe that the water soluble fragment Aβ1-16 significantly inhibits Ub chain growth reactions. These results evidence how the non-covalent interaction between Aβ peptides and Ub may have relevant effects on the regulation of the upstream events of the UPS and pave the way to future in vivo studies addressing the role played by Aβ peptide in the malfunction of proteome maintenance occurring in AD.

99mTc by 99Mo produced at the ENEA-FNG facility of 14MeV neutrons

A severe supply crisis of ⁹⁹Mo, precursor of ^99mTc a diagnostic radionuclide largely used in Nuclear Medicine, occurred in 2008-2009 due to repeated shut-down of the two main (aged) fission reactors. An alternative route for producing ⁹⁹Mo by ¹⁰⁰Mo(n,2n)⁹⁹Mo reaction was investigated at ENEA. The experiment, designed according to Monte Carlo simulations performed with the Fluka code, produced ⁹⁹Mo by irradiating a natural Molybdenum powdered target with 14MeV neutrons produced at the Frascati Neutron Generator. The ⁹⁹Mo specific activity was measured at metrological level by γ-ray spectrometry.

Thermal neutron radiative capture on cadmium as a counting technique at the INES beam line at ISIS: A preliminary investigation of detector cross-talk

Experimental tests are presented that assess the cross-talk level among three scintillation detectors used as neutron counters exploiting the thermal neutron radiative capture on Cd. The measurements were done at the INES diffractometer operating at the ISIS spallation neutron source (Rutherford Appleton Laboratory, UK). These tests follow a preliminary set of measurements performed on the same instrument to study the effectiveness of this thermal neutron counting strategy in neutron diffraction measurements, typically performed on INES using squashed ³He filled gas tubes. The experimental data were collected in two different geometrical configurations of the detectors and compared to results of Monte Carlo simulations, performed using the MCNP code.

A possible approach to 14MeV neutron moderation: A preliminary study case

Deuterium-Tritium (D-T) interactions produce almost monochromatic neutrons with about 14MeV energy. These neutrons are used in benchmark experiments as well as for neutron cross sections assessment in fusion reactors technology. The possibility to moderate 14MeV neutrons for purposes beyond fusion is worth to be studied in relation to projects of intense D-T sources. In this preliminary study, carried out using the MCNP Monte Carlo code, the moderation of 14MeV neutrons is approached foreseeing the use of combination of metallic materials as pre-moderator and reflectors coupled to standard water moderators.

Radiative neutron capture as a counting technique at pulsed spallation neutron sources: a review of current progress

Neutron scattering techniques are attracting an increasing interest from scientists in various research fields, ranging from physics and chemistry to biology and archaeometry. The success of these neutron scattering applications is stimulated by the development of higher performance instrumentation. The development of new techniques and concepts, including radiative capture based neutron detection, is therefore a key issue to be addressed. Radiative capture based neutron detectors utilize the emission of prompt gamma rays after neutron absorption in a suitable isotope and the detection of those gammas by a photon counter. They can be used as simple counters in the thermal region and (simultaneously) as energy selector and counters for neutrons in the eV energy region. Several years of extensive development have made eV neutron spectrometers operating in the so-called resonance detector spectrometer (RDS) configuration outperform their conventional counterparts. In fact, the VESUVIO spectrometer, a flagship instrument at ISIS serving a continuous user programme for eV inelastic neutron spectroscopy measurements, is operating in the RDS configuration since 2007. In this review, we discuss the physical mechanism underlying the RDS configuration and the development of associated instrumentation. A few successful neutron scattering experiments that utilize the radiative capture counting techniques will be presented together with the potential of this technique for thermal neutron diffraction measurements. We also outline possible improvements and future perspectives for radiative capture based neutron detectors in neutron scattering application at pulsed neutron sources.

The insulin degrading enzyme activates ubiquitin and promotes the formation of K48 and K63 diubiquitin

We report an ATP-dependent ubiquitin conjugation with IDE which, in turn, promotes Ub-Ub linkages in tube tests. We propose a novel function for IDE as a non-canonical ubiquitin activating enzyme.

Morphological Changes of Bladder Mucosa in Patients Who Underwent Instillation with Combined Sodium Hyaluronic Acid-Chondroitin Sulphate (Ialuril®)

<b><i>Objective:</i></b> To investigate what changes are endoscopically evident after glycosaminoglycans (GAGs) therapy by hyaluronic acid (HA) and chondroitin sulphate (CS) (Ialuril®) in female patients affected by bladder pain syndrome(BPS)/ interstitial cystitis (IC) or recurrent urinary tract infections (rUTIs). <b><i>Patients and Methods:</i></b> 21 female patients over 18 years affected by rUTIs or BPS/IC received intravesical instillation of HA and CS (4 weekly instillations followed by 2 instillations every 2 weeks and 2 instillation monthly). Post-treatment evaluation included cystoscopy and patient assessment of improvement in symptoms and satisfaction on a visual analogue scale (VAS) from 0 to 10. <b><i>Results:</i></b> The post-treatment endoscopy showed a positive effect on bladder mucosa morphology. In 2 cases, treatment did not change endoscopic findings and clinical symptoms. In the other patients, when macroscopic features of the bladder mucosa normalized, the clinical picture improved. <b><i>Conclusions:</i></b> GAGs therapy by HA and CS (Ialuril) improves the morphology of bladder mucosa in patients with rUTI or BPS/IC.

Proton vibrational dynamics in lithium imide investigated through incoherent inelastic and Compton neutron scattering

In the present study we report neutron spectroscopic measurements on polycrystalline lithium imide, namely, incoherent inelastic neutron scattering at 20 K, and neutron Compton scattering from 10 K up to room temperature. From the former technique the H-projected density of phonon states up to 100 meV is derived, while the latter works out the spherically averaged single-particle (i.e., H, Li, and N) momentum distributions and, from this, the mean kinetic energies. Only for H at the lowest investigated temperature, non-gaussian components of its momentum distribution are detected. However, these components do not seem directly connected to the system anharmonicity, being fully compatible with the simple N-H bond anisotropy. Neutron data are also complemented by ab initio lattice dynamics simulations, both harmonic and, at room temperature, carried out in the framework of the so-called "quantum colored noise thermostat" method. The single-particle mean kinetic energies in lithium imide as a function of temperature show a quite peculiar behavior at the moment not reproduced by ab initio lattice dynamics methods, at least as far as H and Li are concerned. As matter of fact, neither their low temperature values nor their temperature trends can be precisely explained in terms of standard phonon calculations.

Spectral broadening of characteristic γ-ray emission peaks from 12C(3He,pγ)14N reactions in fusion plasmas

The spectral broadening of characteristic γ-ray emission peaks from the reaction (12)C((3)He,pγ)(14)N was measured in D((3)He) plasmas of the JET tokamak with ion cyclotron resonance heating tuned to the fundamental harmonic of (3)He. Intensities and detailed spectral shapes of γ-ray emission peaks were successfully reproduced using a physics model combining the kinetics of the reacting ions with a detailed description of the nuclear reaction differential cross sections for populating the L1-L8 (14)N excitation levels yielding the observed γ-ray emission. The results provide a paradigm, which leverages knowledge from areas of physics outside traditional plasma physics, for the development of nuclear radiation based methods for understanding and controlling fusion burning plasmas.