Sodium Bicarbonate Prescription and Extracellular Volume Increase: Real-world Data Results from the AlcalUN Study

Oral alkalization with sodium bicarbonate (NaHCO₃ ) or citrate is prescribed for conditions ranging from metabolic acidosis to nephrolithiasis. Although most nephrologists/urologists use this method routinely, extracellular volume (ECV) increase is the main feared adverse event reported for NaHCO₃ . Thus far, no trial has specifically studied this issue in a real-world setting. AlcalUN (NCT03035812) is a multicentric, prospective, open-label cohort study with nationwide (France) enrollment in 18 (public and private) nephrology/urology units. Participants were adult outpatients requiring chronic (>1 month) oral alkalization by either NaHCO₃ -containing or no-NaHCO₃ -containing agents. The ECV increase (primary outcome) was judged based on body weight increase (ΔBW), blood pressure increase (ΔBP), and/or new-onset edema at the first follow-up visit (V1). From February 2017 to February 2020, 156 patients were enrolled. After a median 106 days of treatment, 91 (72%) patients reached the primary outcome. They had lower systolic (135 (125, 141) vs. 141 (130, 150), P = 0.02) and diastolic (77 (67, 85) vs. 85 (73, 90), P = 0.03) BP values, a higher plasma chloride (106.0 (105.0, 109.0) vs. 105.0 (102.0, 107.0), P = 0.02) at baseline, and a less frequent history of nephrolithiasis (32 vs. 56%, P = 0.02). Patients experienced mainly slight ΔBP (< 10 mmHg). The primary outcome was not associated (P = 0.79) with the study treatment (129 received NaHCO₃ and 27 received citrate). We subsequently developed three different models of propensity score matching; each confirmed our results. Chronic oral alkalization with NaHCO₃ is no longer associated with an ECV increase compared to citrate in real-life settings.

Miniaturized percutaneous nephrolithotomy versus retrograde intrarenal surgery in the treatment of lower pole renal stones

OBJECTIVES

Miniaturization of percutaneous nephrolithotomy techniques have led to their increased consideration for lower pole renal stones that can prove more challenging to reach using retrograde intrarenal surgery. The objectives of the present study were to evaluate and compare the outcomes of miniaturized percutaneous nephrolithotomy (miniPCNL) and retrograde intrarenal surgery (RIRS) for the treatment of lower pole renal stones.

MATERIALS AND METHODS

A retrospective study was performed in two academic urology departments between January 2016 and June 2019. Patients presenting with one or multiple stones of the lower calyx and/or renal pelvis, between 10 and 40mm based on CT-scan treated by miniPCNL or RIRS were included.

RESULTS

In all, 115 miniPCNL and 118 RIRS procedures were included. The rate of patients with no significant residual fragment (stone free rate) after the first procedure was higher in the miniPCNL group (69% vs. 52% P=0.01), especially for stones>20mm (63% vs. 24% respectively, P<0.001) and stones with a density≥1000HU (69% vs. 42% respectively, P=0.009). The higher stone free rate of miniPCNL was confirmed in multivariate analysis, adjusting for stone size and number of stones, OR 4.02 (95% CI 2.08-8.11, P<0.0001). The overall postoperative complication rate was higher in the miniPCNL group than in the RIRS group (23% vs. 11%, P=0.01). A second intervention for the treatment of residual fragments was necessary for 9.6% of patients in the miniPCNL group versus 30.5% of patients in the RIRS group (P<0.001). Pre-stenting rate and duration of ureteral drainage (2 [1-8] vs. 25 days [7-37], P<0.001) were lower in the miniPCNL group.

CONCLUSIONS

The stone free rate was higher after miniPCNL, especially for stones>20mm and with a density>1000 HU, but was associated with a higher risk of postoperative complications and a longer hospital stay. RIRS resulted in fewer complications at the cost of a higher retreatment rate and longer ureteral stenting.

LEVEL OF EVIDENCE

3.

Superselective Ischemia in Robotic Partial Nephrectomy Does Not Provide Better Long-term Renal Function than Renal Artery Clamping in a Randomized Controlled Trial (EMERALD): Should We Take the Risk?

BACKGROUND

Superselective clamping of tumor-targeted arteries aims to eliminate ischemia of the remnant kidney while keeping tumor bed bloodless during excision.

OBJECTIVE

To evaluate the impact of superselective clamping on long-term renal function, compared with renal artery early unclamping.

DESIGN, SETTING, AND PARTICIPANTS

A randomized monocentric single-blind trial (1:1) was conducted from February 2018 to August 2019. Patients with a single renal tumor were candidates for a robot-assisted partial nephrectomy (RAPN) in a referral center. EMERALD (NCT03679572) was powered to include 50 patients with an interim analysis after 30 cases.

INTERVENTION

Superselective RAPN (SS-RAPN) with near-infrared fluorescence (NIRF) or conventional RAPN with renal artery early unclamping.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary endpoint was the percent change of estimated glomerular filtration rate (eGFR) in the operated kidney after 6 mo (combination of eGFR and relative function on ^99mTc-DMSA scintigraphy). Secondary endpoints assessed feasibility and safety of the technique.

RESULTS AND LIMITATIONS

Relative eGFR reduction in the operated kidney at 6 mo did not differ significantly (-21.4% vs -23.4%, p=0.66). This absence of difference remained after adjusting on percentage of kidney volume preserved, which was an independent predictor of functional preservation. There were no significant differences in terms of blood loss, change in hemoglobin, postoperative complications, transfusion, and conversion to radical nephrectomy (two vs zero) or to open surgery (one vs zero). Despite a good accrual, the steering committee interrupted the trial after the interim analysis for futility given the absence of trend in favor of SS-RAPN.

CONCLUSIONS

SS-RAPN using NIRF does not provide better renal function preservation than renal artery clamping, questioning the interest of this technique at a higher risk of bleeding.

PATIENT SUMMARY

In this randomized controlled trial, superselective clamping of tumor feeding arteries did not show any advantage in terms of long-term renal function compared with conventional artery clamping.

Endoscopic management of primary obstructive megaureter in pediatrics

AIMS

The aims of this study were to evaluate the efficacy and safety of endoscopic treatment of primary obstructive megaureter in children, and to assess its long-term outcome.

METHODS

Case files of 35 children who had endoscopic treatment of symptomatic primary obstructive megaureter between 2006 and 2016 were retrospectively analyzed. All children had ureterovesical junction dilatation with one or more ureteral dilators, and insertion of a JJ stent. An analysis of the case files and a comparison between pre- and postoperative ultrasound and scintigraphy findings were performed.

RESULTS

The study population consisted of 22 boys and 13 girls aged between 2 months and 16 years. The follow-up period ranged from 8 months to 10 years. Twenty-one children (60%) were under 2 years at the time of treatment. The average duration of JJ stenting was 7 weeks (3-16 weeks). Thirty-four of 35 children (97%) were considered definitively cured, that is, asymptomatic with preserved renal function. Two children required open surgery for a failed endoscopic treatment procedure. Secondary reimplantation surgery was only necessary in one case (1/35) after technically satisfactory endoscopic treatment. Twelve of 35 children had a complication, including two Clavien III complications. Comparison of pre- and postoperative ultrasonography showed a significant decrease in ureteral diameter in 31 cases. Postoperative scintigraphy showed a significant improvement in the ureteral leaking curve in 20 children.

CONCLUSION

In our experience, endoscopic treatment of congenital obstructive megaureter in pediatrics seems to be safe and effective. It is proposed as a first-line treatment for children requiring an intervention, even for young children under 2 years.

Super-selective robot-assisted partial nephrectomy using near-infrared flurorescence versus early-unclamping of the renal artery: results of a prospective matched-pair analysis

Introduction

Super-selective clamping of tumor-specific segmental arteries was developed to eliminate ischemia of the remnant kidney while limiting hemorrhage during partial nephrectomy. The objective is to evaluate the benefice of super-selective clamping on renal functional outcome, compared to early-unclamping of the renal artery.

Materials and Methods

From March 2015 to July 2016, data from 30 patients undergoing super-selective robot-assisted PN (RAPN) for a solitary tumor by a single surgeon were prospectively collected. Tumor devascularization was assessed using indocyanine green near-infrared fluorescence. A matched-pair analysis with a retrospective cohort undergoing early-unclamping was conducted, adjusting on tumor complexity and preoperative eGFR. Perioperative, oncologic and functional outcomes using DMSA-renal scintigraphy were assessed. Multivariate analysis was performed to identify predictors of postoperative renal function and de novo chronic kidney disease (CKD).

Results

Super-selective RAPN was successful in 23/30 patients (76.7%), 5 requiring secondary main artery clamping due to persistent tumor fluorescence. Matched-pair analysis showed similar operating time, blood loss, positives margins and complication rates. Super-selective clamping was associated with an improved eGFR variation at discharge (p=0.002), 1-month (p=0.01) and 6-month post-op (-2%vs-16% p=0.001). It also led to a better relative function on scintigraphy (46%vs40% p=0.04) and homolateral eGFR (p=0.04), and fewer upstaging to CKD stage ≥3 (p=0.03). On multivariate analysis, super-selective clamping was a predictor of postoperative renal function.

Conclusion

Super-selective RAPN leads to an improved preservation of renal function and a reduced risk of de novo CKD stage≥3, while keeping the benefit of main artery clamping on perioperative outcomes.

[Congenital undescended testis: Should open processus vaginalis have any impact on the elected surgical approach?]

PURPOSE

Compare the position of the undescended testis at clinical examination and under general anesthesia with the patency of an open processus vaginalis.

PATIENTS AND METHODS

We included children from 2 to 18 years of age operated for a unilateral or bilateral undescended testis between January 2006 and April 2014 at the Annecy Genevois hospital, France. The analysis was conducted considering that the individual was the testis. Testicular position before surgery, under general anesthesia and patency of open processus vaginalis as a surgical finding were prospectively recorded.

RESULTS

Three hundred and six children were included. The analysis was conducted over 401 testes. The position at clinical examination was significantly linked to a persistent open processus vaginalis (P=0.0045). Over the 282 testes considered as candidate for Bianchi's procedure, as to say intra- or supra-scrotal under general anesthesia, 154 had a persistent processus vaginalis (55%).

CONCLUSION

There is a link between a persistent processus vaginalis and the location of the undescended testis which should encourage us not to neglect the inguinal approach, and eventually to question the relevance of Bianchi's procedure.

LEVEL OF EVIDENCE

4.

Putting sexuality (back) into HIV/AIDS: issues, theory and practice

After more than twenty years of programming and activism aimed at stemming the sexual transmission of HIV (and addressing the needs of those most vulnerable to infection) the HIV/AIDS epidemic continues to grow worldwide. Taking up this concern, this paper argues that one of the reasons why HIV prevention has had limited success is because of inadequate conceptualization of human sexuality in such work. Giving sexuality a more prominent position in responses to the epidemic raises a range of issues, including theorization of gender, understanding of sexual subjectivity, the significance of pleasure (or lack of pleasure) in sexual decision-making, and conceptualization of sexual behaviour and culture. Taking these themes forward entails asking significant questions about the underlying paradigmatic and methodological commitments of mainstream HIV/AIDS research, especially the tendency to reproduce accounts of human sexuality as if it were a measurable form of conduct only. Advocating new approaches that take the meaning and symbolic value of sexualities into account complicates established orthodoxies in the field whilst offering potential for more effective HIV prevention strategies.

U.N. guidance note on HIV and sex work "reworked" by activists

In 2007, UNAIDS issued a guidance note on HIV and sex work, the tone and contents of which angered sex workers, activists and public health workers worldwide. In this article, based on presentations at the conference, M. Seshu et al describe the problems with the guidance note, discuss the reaction to its publication, and explain how a group of activists got together to develop a reworked version of the guidance note.