Experimental and clinical applications and outcomes of using different forms of suction in retrograde intrarenal surgery. Results from a systematic review

OBJECTIVE

To identify the latest advances in suction devices and evaluate their effect in Retrograde intrarenal surgery (RIRS) and ureteroscopy for stones.

BASIC PROCEDURES

A systematic literature search was performed on 4th January 2023 using Scopus, PubMed, and EMBASE. Only English papers were included; both pediatric and adult studies were accepted. Duplicate studies, case reports, letters to the editor, and meeting abstracts were excluded.

MAIN FINDINGS

Twenty-one papers were selected. Several methods have been proposed for suction use in RIRS, such as through the ureteral access sheath or directly to the scope. Artificial intelligence can also regulate this system, monitoring pressure and perfusion flow values. All the proposed techniques showed satisfactory perioperative results for operative time, stone-free rate (SFR), and residual fragments. Moreover, the reduction of intrarenal pressure (induced by aspiration) was also associated with a lower infection rate. Even the studies that considered kidney stones with a diameter of 20 mm or higher reported higher SFR and reduced postoperative complications. However, the lack of well-defined settings for suction pressure and fluid flow prevents the standardization of the procedure.

CONCLUSION

Aspiration device in the surgical treatment of urinary stones favours a higher SFR, reducing infectious complications, as supported by the included studies. RIRS with a suction system provided to be a natural successor to the traditional technique, regulating intrarenal pressure and aspirating fine dust.

Evolution of hepatic encephalopathy over time: ecological data from a tertiary referral centre for hepatology

OBJECTIVES

Few data on hepatic encephalopathy (HE) over time are available, thus our aim was to study its evolution in patients with varying degree of HE on first assessment.

METHODS

Eighty-six patients with cirrhosis (age = 58 ± 11 years; males = 72) were evaluated 2-10 times for liver transplantation selection purposes, differential diagnosis or treatment optimization. The presence/severity of HE was assessed by clinical and neuropsychiatric indices [ Psychometric Hepatic Encephalopathy Score (PHES) and electroencephalography (EEG)] and the severity of liver disease by the Model for End-Stage Liver Disease (MELD) score. Treatment was instituted/modified after each evaluation.

RESULTS

Amongst 23 unimpaired patients, 56/6% remained unimpaired, 35/3% developed covert HE, 9/0% developed overt HE on second/third evaluation. Amongst 32 patients with covert HE, 25/10% became unimpaired, 44/19% remained covert, 31/13% developed overt HE. Finally, amongst 32 patients with overt HE, 19/16% became unimpaired, 25/13 % became covert and 56/25% remained overt. PHES results improved in patients with overt HE and EEG worsened over time (despite remaining normal) in unimpaired patients. In patients with multiple evaluations, HE evolution was manifold and difficult to predict.

CONCLUSIONS

HE evolution over time is variable and largely dependent on HE history/management. These data support the concept that HE is an essentially reversible condition.

Phytotherapy for male luts: What happens then? 10-year research

INTRODUCTION AND OBJECTIVES

Our objective is to assess the long-term results of phytotherapy, focusing on the interval between phytotherapy and pharmacological treatment and the predisposing risk factors to such switch on a 10-year follow-up.

MATERIAL AND METHODS

The data of patients taking phytotherapy for mild to moderate male lower urinary tract symptoms (LUTS) from January to December 2010 were retrospectively reviewed from a prospectively maintained database. Patients were followed for 10 years through medical visits and telephone consultations.

RESULTS

102 patients underwent at least one cycle of phytotherapy for LUTS. Twenty (19.6%) patients resolved their symptoms after one phytotherapy cycle and stopped any treatment, 27 (26.4%) continued phytotherapy, and 52 (51%) switched to alpha-blockers and/or 5a-reductase inhibitors after a median interval of 24 months. The reasons for treatment switch were symptoms (n = 45) or clinical progression (increased residual volume n = 15; urinary retention, n = 5). Patients switching to synthetic drugs had median higher age (60 vs 49), prostate volume (40 vs 26 cc), prostate specific antigen (PSA) (1.9 vs 0.9 ng/ml), residual volume (40 vs 0 cc), and a lower maximum flow rate (Qmax) (12 vs 15 ml/s) at presentation.

CONCLUSIONS

46% patients with mild to moderate LUTS undergoing phytotherapy will be either free of treatment or still on phytotherapy at 10 years from disease presentation. Older patients with larger prostates, increased residual volume and PSA, should be informed regarding their higher risk of symptomatic or clinical progression: the risk of a treatment switch to alpha-blockers or 5a-reductase inhibitors becomes an actual fact after an average span of 2 years.

1163 Diagnostic performance of a new echocardiographic method for coronary arteries abnormalities assessment

Background

The echocardiographic assessment of coronary arteries abnormalities (CCA) has always been challenging. In this view, we aimed to assess the performance of a new echocardiographic-based diagnostic method for CAA in pediatric and young adults’ population.

Methods

over 5 years, we examined all the outpatients undergoing routine echocardiography in our department. Our method consisted of 4-focused specific view scan: parasternal short-axis, parasternal long-axis, both left and right outflow tract, and apical 5-chamber view. Coronary-CT confirmed the CAA diagnosis. Two independent physicians retrospective reviewed the echocardiographic images, in a double-blinded fashion (coronary-CT and diagnosis), for performance analysis.

Results

in 2014-18, 5,998 outpatients underwent echocardiography (median age 14 years [6, 21 - IQR]). A total of 27 CAA were diagnosed: overall prevalence 0.0045%, 0.022% of incidence. N = 17/27 were anomalous aortic origin of coronary arteries (AAOCA), N = 3/27 anomalous coronary arteries from the pulmonary artery (ACAPA), and 7/27 fistulas. After the implementation, we found a progressive increment of CAA diagnosis (P for Trend = 0.038), in particular of AAOCA: both left and right coronaries (P-trend = 0.021 and P = trend 0.010, respectively). Our method showed better sensitivity than traditional CAA echocardiographic evaluation: 85% vs 55%, P = 0.032 [AUC 0.77, 95% CI (0.68, 0.87) and AUC 0.92, 95% CI (0.85, 0.99), respectively], with a good interobserver agreement for the adjudicated double-blinded retrospective diagnosis (99.75%, K = 0.73, P < 0.001).

Conclusions

the application of a new echocardiographic-based method for CAA-detection led to a significantly increased rate of identified anomalies. This approach demonstrated better sensitivity than traditional echocardiographic assessment. Implementing this protocol in clinical practice may improve the CAA diagnosis, and probably reduce the occurrence of CAA-related sudden cardiac death.

RIRS in the elderly: Is it feasible and safe?

BACKGROUND

The aim of this study was to compare the safety and efficacy of RIRS in men ≥65 years to those <65 years.

MATERIALS AND METHODS

Patients who underwent RIRS were prospectively collected from March 2013 to March 2014 in 5 European centers. Perioperative outcomes and complications in elderly men were compared with men <65 years. Univariable and multivariable analyses were performed for factors predicting overall complications. The groups were compared using Mann-Whitney U test. Categorical variables were compared using chi-squared test and the Yates correction or the Fisher's exact test.

RESULTS

A total of 399 patients with renal stones were included, 308 (77.19%) were aged <65 years, 91 (22.8%) were aged ≥65 years. Elderly patients were more likely to have higher ASA scores (35.7% vs 92.3%; p < 001), Charlson Comorbidity Index (1.8 vs. 5.2, p < 0.001), hyperlipidemia (10.06% vs. 30.76%; p = 0,0005) and coronary heart disease (5.51% vs. 17.58; p = 0.005) compared to younger cohort. Perioperative outcomes (stone free rate, operative time and re-intervention rate) did not show differences between the two groups (p > 0.05). Surgical and medical complication rates were similar between the cohorts (14.28% vs 9.89%; p = 0.38). Multivariate analysis did not identify any predictive factors of complications among the two groups (p > 0.05).

CONCLUSIONS

In this study, elderly RIRS patients had comparable short term efficacy and perioperative complications to younger patients, despite a higher prevalence of comorbidity. Age itself should not be considered as a risk factor for the development of complications in patients undergoing RIRS for renal stone.

Complications associated with ureterorenoscopy (URS) related to treatment of urolithiasis: the Clinical Research Office of Endourological Society URS Global study

INTRODUCTION

Ureterorenoscopy (URS) is a popular and growing option for management of ureteric and renal stones. The CROES URS Global Study was set up to assess the outcomes of URS in a large worldwide cohort of patients involving multiple centres. In this paper, we analysed the database for intra-operative and post-operative complications associated with ureterorenoscopy.

METHODS

The CROES database was established via collaboration between 114 centres in 32 countries worldwide, and information on both intra-operative and post-operative complications was collected electronically between January 2010 and October 2012.

RESULT

On analysis of a total of 11,885 patients, the overall complication and stone-free rates were found to be 7.4 and 85.6 %, respectively. The intra-operative and post-operative complication rates were 4.2 and 2.6 %, respectively, and in total 5 deaths were reported in the study period. Taking into account different world economies, there were no differences in the complication rates between the developing and developed nations or between different centres from different continents.

CONCLUSION

Ureterorenoscopy is a safe and effective procedure for treatment of stones, the outcomes of which are broadly comparable in different parts of the world for similar patient and stone demographics.

The surgical experience influences the safety of retrograde intrarenal surgery for kidney stones: a propensity score analysis

The aim of this study is to evaluate if surgical experience could influence the outcomes of retrograde intrarenal surgery (RIRS) in terms of stone clearance and complication rate. Patients from five institutions were included in this study. Patients were divided into two groups. Group 1: patients treated by three surgeons in the early phase of learning curve (surgical experience <100 procedures); Group 2: cases operated by two surgeons with great endourological experience (>400 procedures). Patients and stone characteristics, outcome and complications were analyzed. Multivariable regression model was used. Differences between groups were estimated using propensity scores to adjust for the bias inherent to the different characteristics. 381 RIRS were analyzed (Group 1: 150 RIRS; Group 2: 231 RIRS). Clinical data and stone parameters were comparable. The SFR was 70 % in Group 1 and 77.9 % in Group 2 (p = 0.082). Operative time was significantly shorter in the Group 2 (76.3 vs. 53.1 min, p = 0.001). The overall complication rate was significantly lower in Group 2 (20.7 vs. 8.7, p = 0.001). At unadjusted analysis, a non-significant difference was found between centers on SFR (OR 1.51 95 % CI 0.95-2.41). Conversely, a significant difference was found on overall complications (OR 0.36 95 %CI 0.20-0.67) with lower overall complication in Group 2. This study shows that surgeon experience influences the outcomes of RIRS mainly in terms of safety. Further studies will be needed to assess the exact number of procedures necessary to obtain a plateau in the rate of complications and success.

Optimization of silver nanowire-based transparent electrodes: effects of density, size and thermal annealing

Silver nanowire (AgNW) networks are efficient as flexible transparent electrodes, and are cheaper to fabricate than ITO (Indium Tin Oxide). Hence they are a serious competitor as an alternative to ITO in many applications such as solar cells, OLEDs, transparent heaters. Electrical and optical properties of AgNW networks deposited on glass are investigated in this study and an efficient method to optimize them is proposed. This paper relates network density, nanowire dimensions and thermal annealing directly to the physical properties of the nanowire networksusing original physical models. A fair agreement is found between experimental data and the proposed models. Moreover thermal stability of the nanowires is a key issue in thermal optimization of such networks and needs to be studied. In this work the impact of these four parameters on the networks physical properties are thoroughly investigated via in situ measurements and modelling, such a method being also applicable to other metallic nanowire networks. We demonstrate that this approach enables the optimization of both optical and electrical properties through modification of the junction resistance by thermal annealing, and a suitable choice of nanowire dimensions and network density. This work reports excellent optical and electrical properties of electrodes fabricated from AgNW networks with a transmittance T = 89.2% (at 550 nm) and a sheet resistance of Rs = 2.9 Ω □(-1), leading to the highest reported figure of merit.

Metallic nanowire networks: effects of thermal annealing on electrical resistance

Metallic nanowire networks have huge potential in devices requiring transparent electrodes. This article describes how the electrical resistance of metal nanowire networks evolve under thermal annealing. Understanding the behavior of such films is crucial for the optimization of transparent electrodes which find many applications. An in-depth investigation of silver nanowire networks under different annealing conditions provides a case study demonstrating that several mechanisms, namely local sintering and desorption of organic residues, are responsible for the reduction of the systems electrical resistance. Optimization of the annealing led to specimens with transmittance of 90% (at 550 nm) and sheet resistance of 9.5 Ω sq(-1). Quantized steps in resistance were observed and a model is proposed which provides good agreement with the experimental results. In terms of thermal behavior, we demonstrate that there is a maximum thermal budget that these electrodes can tolerate due to spheroidization of the nanowires. This budget is determined by two main factors: the thermal loading and the wire diameter. This result enables the fabrication and optimization of transparent metal nanowire electrodes for solar cells, organic electronics and flexible displays.

Is retrograde intrarenal surgery a viable treatment option for renal stones in patients with solitary kidney?

PURPOSE

To evaluate the effectiveness and safety of retrograde intrarenal surgery (RIRS) for stones up to 2 cm in diameter in patients with solitary kidney.

METHODS

From January 2008 to January 2013, we prospectively enrolled all consecutive patients with solitary kidney and renal stones. Plain abdominal computed tomography scan was performed preoperatively and 1 month after the procedure to assess the stone-free rates (SFR). Serum creatinine levels were detected preoperatively, at day 1 postoperatively, at 1 month postoperatively, and then every 6 months postoperatively.

RESULTS

During the study period, we prospectively enrolled a total of 29 patients. The mean age was 55.7 ± 12.3 years; the mean stone size was 1.3 ± 0.4 cm. The primary SFR was 72.4 %; the secondary SFR was 93.1 %. The mean number of procedures per patient was 1.24. The mean serum creatinine levels were 1.5 ± 0.6, 1.6 ± 0.7, 1.6 ± 0.6, and 1.7 ± 0.7 mg/dl preoperatively, at 1 day after RIRS, at 1 month after RIRS, and at 1 year after RIRS, respectively, without detection of any statistical difference (p = 0.76). Median follow-up time was 35.7 ± 19.3 (12-72) months, but that was available for only 18 patients. The mean serum creatinine level at the last follow-up was 1.7 ± 0.9 mg/dl. No major complications were recorded. Grade I complications occurred in eight patients (27.4 %).

CONCLUSIONS

RIRS is safe and effective in the treatment of renal stones in patients with solitary kidney, without worsening renal function.

Macrophage Activation Syndrome in a Child Affected by Malaria: The Choice of Steroid

Macrophage activation syndrome is a potentially fatal clinical syndrome caused by an excessive activation and proliferation of macrophages and T cells, leading to an exaggerated inflammatory reaction. It is well known that it can complicate the course of different conditions, especially autoimmune, lympho-proliferative, infectious diseases and drugs. Many infective pathogens can trigger the syndrome but the association with malaria has rarely been described, especially in children. We report a child with severe malaria complicated by MAS, in whom the clinical appearance of this syndrome could be considered as worsening of malaria itself. Furthermore, the use of steroids as first choice drugs in this complication, but arguable in malaria, has been highlighted. Clinicians should be aware of this syndrome when malaria does not respond to conventional therapy, since early diagnosis and prompt treatment may dramatically reduce the mortality associated with this condition.

[Recovery of urinary incontinence after retropubic radical prostatectomy. Results in 100 patients]

AIM OF THE STUDY

To shorten the time to recovery of full urinary continence after radical retropubic prostatectomy and to increase the postoperative continence rate.

MATERIALS AND METHODS

One hundred and five consecutive patients were submitted to radical retropubic prostatectomy for prostate cancer, with curative intent, focusing our attention on three steps of the operation. First, to achieve a complete control of bleeding from the dorsal vein complex and to perform a minimal touch dissection of the urethral stump; second, to perform a conservative dissection of the bladder neck, and, third, to implement a vascular type, watertight, vesico urethral anastomosis. Continence was assessed 24 hours after catheter removal and at monthly follow up visits until full recovery and graded as dry if no dropping was visible and the patient was able to interrupt the urinary stream during micturition; stress incontinence, if any dropping was observed during abdominal strain between micturitions; and wet, if uncontrollable dropping occurred, and the number of pads needed per day recorded.

RESULTS

At a median follow-up time of 18 months, range 6 to 30, a total of 87 of 100 evaluable patients (87%) resulted as dry; 10 patients (10%) resulted as having a variable degree of stress incontinence needing one to three pads per day, and 3 patients (3%) resulted as wet. In 41 of the 87 dry patients (47.1%) continence was achieved within the first day from catheter removal, and in a median time of 4 weeks, range 2 to 16 in the remaining 46 patients (52.9%).

CONCLUSIONS

The results of total continence rate of the present study seem to compare to the recent literature except for the time to full recovery which is shorter; it is difficult to identify the contribution of each single surgical step.

Quantitative viremia test for early prediction of a biochemical response in patients with chronic hepatitis C treated with interferon

To evaluate the importance of the changes in viremia as an early predictor of the outcome of interferon (IFN) therapy, we assayed the levels of hepatitis C virus (HCV)-RNA in stored serum samples obtained from 34 patients with chronic hepatitis C who showed different biochemical responses to therapy. Serum samples obtained before the start of therapy and after 1 and 3 months were used, and viremia levels were determined by "branched DNA (bDNA)" technique. Viremia levels at 1 month of therapy were lower than pre-therapy levels in all 19 patients who had shown a persistent normalization of ALT during therapy (responder patients). The bDNA test was negative, i.e. the levels of viremia were below the sensitivity threshold of the method, in 12 (63.1%) patients at 1 month and in 13 (68.4%) at the 3rd month of therapy, whereas the bDNA test was negative in none of the 15 non-responder patients at the 1st month and in only 2 (13.3%) of them at the 3rd month of therapy. The bDNA test was superior to the ALT test both in predicting the non-response and the biochemical response to IFN after 1 month of therapy. The bDNA test results, instead, were not predictive of the duration of the response to IFN, either at the 1st or 3rd months of therapy. These results seem to indicate the usefulness of measuring the HCV-RNA levels at the beginning and after 1 month of IFN therapy in order to envisage or exclude a possible biochemical response early on in treatment.

[Infectious diseases in the short stories written by Verga and Pirandello]

The author invites to appreciate some short stories by Giovanni Verga and Luigi Pirandello, Italian writers who lived at the turn of the last century. These tales give an interesting description of two infectious diseases (malaria and cholera), and analyze their relationship with the conditions of poverty and ignorance spread across rural areas in Sicily--a region in the South of Italy--at that times.

Thickness and echogenicity of the skin in children as assessed by 20-MHz ultrasound

BACKGROUND

Skin anatomy and physiology undergo modifications throughout the whole lifespan. In children the skin appears with structural characteristics, as evaluated by histology, which differ from those of adults, especially in the first years of life.

OBJECTIVE

The aim of our study was to evaluate skin thickness and echogenicity at different sites in children by 20-MHz ultrasound.

METHODS

Eight skin sites of 42 children and 30 young adults were studied with a 20-MHz B scanner. Skin thickness and mean echogenicity were evaluated. The echographic images were processed and segmented by a dedicated program: the 0-30 amplitude interval, which marks the hypoechogenic parts of the tissue, and the 201-255 range, highlighting the hyperreflecting areas, have been selected.

RESULTS AND CONCLUSION

Whereas skin thickness shows a gradual increase from birth to adulthood, maturation of the skin leads to variations in the intensity of its echogenicity, depending on the different skin areas. Whereas on the face and the trunk it appears lower in adults with respect to children, a gradual increase can be observed on the limbs with growing age. The distribution of skin reflectivity also greatly varies in different phases of life.

Unilateral laparoscopic retroperitoneal lymph node dissection for clinical stage I nonseminomatous germ cell testicular neoplasm

OBJECTIVE

The aim of this study is to evaluate the reliability of laparoscopic retroperitoneal lymph node dissection (LRPLND) in the management of clinical stage I nonseminomatous germ cell tumors (NSGCT).

METHODS

Since June 1993, unilateral LRPLND was performed in 6 patients diagnosed with clinical stage I NSGCT. All patients had undergone prior radical orchiectomy. The testicular cancer was left-sided in 3 cases and right-sided in the other 3 cases. Preoperative staging by means of tumor marker assessment, computerized tomography scan of the chest and abdomen and chest X-ray was unremarkable for metastatic disease.

RESULTS

All procedures were accomplished without any complications in a mean time of 325 min (275-420 min). The estimated perioperative blood loss was minimal (< 50 ml), and none of the patients required blood transfusion. In the case of the first patient, the hospital stay was 18 days due to a widespread subcutaneous emphysema. In the remaining 5 cases, the average hospitalization was 4.8 days, ranging from 4 to 6 days. The patients resumed normal activities within 12-27 days (mean 16.16 days) postoperatively. The mean number of lymph nodes removed was 6.8, ranging from 5 to 9. Histologic examination of the dissected lymph nodes revealed microscopic metastases from embryonal carcinoma in 2 patients. Both of these patients received adjuvant chemotherapy. The mean follow-up period is 21.3 months, ranging from 6 to 36 months. To date, no relapses have been observed.

CONCLUSION

In accordance with other reports, we believe that LRPLND is both feasible and effective. However, the definitive assessment of the efficacy and morbidity of this diagnostic procedure requires a larger and more comprehensive series as well as longer follow-up.

Search for a W' boson via the decay mode W'-->munumu in 1.8 TeV pp collisions

We report the results of a search for a W' boson produced in pp collisions at a center-of-mass energy of 1.8 TeV using a 107 pb-1 data sample recorded by the Collider Detector at Fermilab. We consider the decay channel W'-->&munumu and search for anomalous production of high transverse mass munumu lepton pairs. We observe no excess of events above background and set limits on the rate of W' boson production and decay relative to standard model W boson production and decay using a fit of the transverse mass distribution observed. If we assume standard model strength couplings of the W' boson to quark and lepton pairs, we exclude a W' boson with invariant mass less than 660 GeV/c2 at 95% confidence level.

Surgical procedures as a major risk factor for chronic hepatitis C virus infection in Italy: evidence from a case-control study

OBJECTIVES

The study was carried out to evaluate the risk factors associated with chronic hepatitis C virus (HCV) infection.

METHODS

This case-control study used multiple logistic regression analysis to determine risk factors associated with HCV infection. Study participants were followed at 10 liver or gastroenterologic units and included 294 subjects with chronic HCV infection and 295 age and sex matched anti-HCV-negative controls.

RESULTS

The use of glass syringes and surgical procedures was reported by as many as 77.6% and 73.8% of cases, respectively; blood transfusion was recorded in nearly a quarter of cases; 10.2% of cases, but none of the controls, reported past or current intravenous drug use. Multiple logistic regression analysis showed that blood transfusion, being the sexual partner of an intravenous drug user, and surgery all were independent predictors of the likelihood of HCV infection.

CONCLUSIONS

These findings indicate that, besides the well-known sources of infection, such as blood transfusion and intravenous drug use, surgical procedures may play an important role in the spread of HCV infection in Italy. Given that a large proportion of the general population undergoes surgery, a rational and relatively inexpensive policy for the prevention of HCV infection must focus on implementing efficient procedures for the sterilization of instruments and the use of disposable materials in surgical units.

Unilateral laparoscopic retroperitoneal lymphadenectomy for clinical stage I nonseminomatous testicular cancer

Since June 1993, unilateral laparoscopic retroperitoneal lymph-node dissection (LRPLND) has been performed in six patients with clinical Stage I nonseminomatous germ-cell tumors (NSGCT). All of the patients had undergone prior radical orchiectomy. The testicular cancer was left-sided in three cases and right-sided in three cases. Preoperative staging by means of tumor marker assessment, CT scan of the chest and abdomen, and chest radiography was unremarkable for metastatic disease. All procedures were accomplished without any complications in a mean time of 325 minutes (275-420 minutes). The estimated perioperative and postoperative blood loss was minimal, and none of the patients required blood transfusion. In the case of the first patient, the hospital stay was 18 days because of a widespread subcutaneous emphysema. In the remaining five cases, the average hospitalization was 4.8 days (range 4-6 days). The patients resumed normal activities within 12 to 27 days (mean 16.16 days) postoperatively. The mean number of lymph nodes removed was 6.8 (range 5-9). Histologic examination of these nodes revealed microscopic metastases from embryonal carcinoma in two patients, both of whom were subjected to adjuvant chemotherapy. The mean follow-up period is 27.1 months (range 12-42 months). To date, no relapses have been observed. In accordance with other reports, we believe that LRPLND is both feasible and effective. However, larger and more comprehensive studies with long-term follow-up are required to determine whether this approach is reliable and definitely superior to standard open surgery in the management of clinical Stage I NSGCT.

Adult endopyelotomy: impact of etiology and antegrade versus retrograde approach on outcome

PURPOSE

We evaluate our experience with endopyelotomy for ureteropelvic junction obstruction by stratifying the results of an antegrade versus a retrograde approach for primary, secondary, calculi related, high insertion and impaired renal function related obstruction, individually.

MATERIALS AND METHODS

We retrospectively reviewed results of 149 nonrandomized patients treated for ureteropelvic junction obstruction, of whom 83 underwent antegrade percutaneous endopyelotomy using a right angle Greenwald electrode and 66 underwent retrograde endopyelotomy using a cutting balloon device. Subjective results were based on an analog pain scale, objective results on renal scan, excretory urography or Whitaker test and cost-effectiveness analysis on total treatment cost.

RESULTS

In both primary and secondary ureteropelvic junction obstruction, retrograde endopyelotomy was related to a significantly shorter operating room time and hospital stay (p < 0.05). When treating noncalculous primary ureteropelvic junction obstruction (92 patients) there was a better objective, albeit not statistically significant, success rate with antegrade endopyelotomy (89 versus 71%) but retrograde endopyelotomy was 20% more cost-effective. When treating secondary ureteropelvic junction obstruction (37 patients) there was a better objective, albeit not statistically significant, success rate (83 versus 77%) with retrograde endopyelotomy, which was 37% more cost-effective. Complication rates were higher with antegrade compared to retrograde endopyelotomy for primary and secondary ureteropelvic junction obstruction (25 versus 14% and 26 versus 0%). In 20 patients with concomitant stones endopyelotomy results were better (93 to 100% success) than for any other categories of ureteropelvic junction obstruction. Of note, endopyelotomy also provided a reasonable outcome among patients with a high insertion primary ureteropelvic junction obstruction (70% success).

CONCLUSIONS

Antegrade endopyelotomy is the preferred approach in patients with primary ureteropelvic junction obstruction and concomitant renal calculi (13.4% of cases), and may also be preferable in patients with high insertion obstruction (6.7%). For all other primary and all secondary ureteropelvic junction obstruction, antegrade and retrograde endopyelotomy is effective therapy yet retrograde endopyelotomy results in less operating room time, shorter hospital stay, fewer complications and significantly less expense to achieve the desired outcome.