Comparison Of Emergency And Elective Intervention With Semi-Rigid Ureteroscopic Lithotripsy For Patients With Ureteral Calculi

BACKGROUND

Ureteroscopy (URS) is a safe and highly effective treatment option for treatment of ureteral calculi. With the advancement of technology, there is also expansion of its indications including use in early or emergency setting. This study aims to compare safety and efficacy of emergency ureteroscopy (EmURS) versus elective ureteroscopy (ElURS) for ureteral stones.

METHODS

Patients with unilateral single radio-opaque ureteral stone who underwent semi-rigid URS from January 2008 till December 2019 were included. Patients with solitary kidney, uro-sepsis, pregnancy or pre-operative drainage with nephrostomy or JJ stent were excluded. EmURS was defined as URS being performed within 48 hours of presentation, while ElURS was defined as URS performed after failed medical expulsive therapy. Patient, stone and outcome related variables were compared in both groups. Stone free rate was defined as no evidence of stone on plain x-ray KUB after 1 week.

RESULTS

We compared 132 patients in EmURS group against 264 in ElURS group. Age, gender, comorbidities, stone location, laterality and mean stone size were comparable in both groups. EmURS had a less median operative time (p=0.05). Stone free rate achieved was 90.2% in EmURS and 87.1% in ElURS, respectively (p=0.38). Double J stent was placed in 44.7% and 46.2% of EmURS and ElURS respectively (p=0.89). Ancillary procedures were performed in 9.8% of EmURS and 11.7% of ElURS (p=0.57). Overall complication rates were reported in 7.6% in EmURS and 11.7% in ElURS (p=0.22) and most were Clavien grade 1.

CONCLUSIONS

Emergency URS for ureteral stones is a safe and effective one-stage definitive treatment option for patients with acute renal colic not responding to conservative management.

589 Role of Liver Support Systems in The Management of Post Hepatectomy Liver Failure: A Meta-Analysis and Systematic Review of Literature

Aim

Post hepatectomy liver failure (PHLF) is a rare but serious complication following liver resection. PHLF is associated with high mortality of up to 50% in severe cases. With limited treatment options available, there is a need to evaluate the role of systems that support the function of the liver as treatment modalities following PHLF development.

Method

The aim of this study was to review the literature and summarise the role of liver support systems (LSS) in the management of PHLF. Publications of interest were identified using systematically designed searches. Following screening, data from the relevant publications were extracted, pooled where possible, and analysed.

Results

Systematic review identified ten studies, which used either Plasma Exchange (PE) or Molecular Adsorbent Recirculating System (MARS) as LSS after PHLF development. The sample sizes of included studies were small, ranging from N = 2 to N = 13. Across all studies, the pooled 90-day mortality rate was 40% (95% CI: 15% - 68%). However, there was substantial heterogeneity (I2=64%), likely since the studies used a variety of definitions for PHLF and had different selection criteria for patient eligibility for LSS treatment.

Conclusions

Despite potential benefits, the current evidence is insufficient to recommend LSS for the routine management of severe PHLF, with the current literature consisting of only a limited number of studies. There is a definite need for larger, multicentre, prospective studies evaluating the conventional and newer modalities of support systems with a view to improve the outcomes in this group of patients.

Leiomyoma Urinary Bladder, Mimicking Urothelial Cancer

Leiomyoma of the urinary bladder is a rare bladder tumour, which is benign in nature. On presentation, it resembles urothelial cancer but it has an excellent prognosis. We reported two cases of urinary bladder leiomyoma. Both the patients presented with lower urinary tract symptoms (LUTS) and the patient in the second case also had painless haematuria. Bladder mass was detected initially on ultrasound and confirmed on contrast-enhanced computed tomography (CT). Transurethral resection of bladder tumour was performed in both cases and no recurrence was found on initial follow-up. But the second case had haematuria and recurrence on subsequent follow-up and managed by performing a partial cystectomy. Endoscopic management of bladder leiomyoma is a safe treatment option for bladder leiomyoma and if multiple recurrences noted with symptoms, then partial cystectomy can be considered. Histopathology is the only definitive way of establishing the diagnosis. These patients can be followed up initially with cystoscopy, and if no recurrence is detected, subsequent follow-up can be carried out with ultrasound.

Non-Invasive Predictors of Response to Tamsulosin for Benign Prostatic Obstruction

Objectives

To identify non-invasive predictors of response to tamsulosin 0.4 mg in patients with benign prostatic obstruction (BPO).

Methods

Males ≥ 50 years of age with lower urinary tract symptoms (LUTS) suggestive of BPO for over three months were included in the study. We assessed change in the mean International Prostate Symptom Score (IPSS) and maximum flow rate (Qmax) after six weeks of medical therapy. Clinical and uroflowmetry parameters were compared between two groups of patients with >25% vs. <25% change in the IPSS after treatment. Pre- and post-treatment post-void residue (PVR), Qmax, and IPSS were compared by independent t-test, univariate/multivariate regression analysis.

Results

A total of 121 patients were included. At presentation, the mean prostate size was 35.7±12.2 grams and the mean IPSS was 16.3 ± 4.8. Improvement in the mean IPSS was 7.83, with more marked improvement in storage compared to voiding LUTS (5.26 vs. 2.57). Majority (58%) had a quality of life (QoL) score of 4-5 at presentation whereas after 6-weeks of medication (83.5%) had a QoL score of 0-2. Treatment failure was noted in 11 (9.1%) patients. IPSS was higher and Qmax was lower at the time of presentation in patients who had <25% improvement. However, the two groups were identical on the basis of demographic and other factors (BMI, age, prostate size, PVR).

Conclusion

Moderate LUTS secondary to BPO responds favourably to alpha-blocker (tamsulosin 0.4 mg) treatment. Uroflowmetry (UFM) parameters, that is, Qmax and IPSS are important factors in predicting short-term response to medical therapy.

The Correlation Between STONE Nephrolithometry Score and Hemoglobin Drop in Patients Undergoing Percutaneous Nephrolithotomy

Objective

In this study, we aimed to determine the correlation between the STONE score [(S)ize of the stone, (T)opography or location, degree of (O)bstruction of the urinary system, (N)umber of stones, and (E)valuation of Hounsfield units] and postoperative hemoglobin drop in patients undergoing percutaneous nephrolithotomy (PCNL).

Methods

This was a prospective observational study and all adult patients aged 18-65 years undergoing unilateral, single-tract PCNL using 26 Ch. Amplatz sheath for renal calculi were included. The five variables of the STONE nephrolithometry score were calculated prior to the procedure. The stone-free rates were assessed on imaging at four weeks and complications were graded using the modified Clavien system.

Results

Of the 142 patients included, 75% were below 55 years of age. More than half of our patients were diabetic with more than 60% having a body mass index (BMI) above 25 kg/m². The mean STONE score was 7 with 33% having a high (>9) STONE score. The mean hemoglobin drop was 1.15 +0.92 g/dL with eight patients (5.63%) requiring transfusion and one (0.7%) requiring angioembolization; one patient required readmission for observation. Complete STONE clearance was achieved with PCNL alone in 78.2% of the patients. There was a significant correlation of hemoglobin drop with the STONE score, stone size, and preoperative creatinine clearance. Patients with a hemoglobin drop of >1 g/dL had a higher STONE score and mean stone size. The overall complication rate was significantly higher (10.5%) in patients with a hemoglobin drop of >1 g/dL as compared to those with a hemoglobin drop of <1 g/dL (2.8%).

Conclusion

Stone complexity as measured by the STONE score correlates with post-PCNL hemoglobin drop, stone clearance, and complication rates. The STONE score may be used for preoperative counseling and to evaluate the potential need for transfusion.

Efficacy and Safety of Semi-rigid Ureteroscopic Lithotripsy (URS) for Proximal Ureteral Stone ≥10 mm

OBJECTIVE

To evaluate the efficacy and safety of the semi-rigid URS with pneumatic lithotripsy for the treatment of large (>10 mm) proximal ureteral calculi.

STUDY DESIGN

Cohort study.

PLACE AND DURATION OF STUDY

Section of Urology, Department of Surgery, The Aga Khan University Hospital, Karachi, Pakistan, from January 2010 to December 2018.

METHODOLOGY

All patients with single, radio-opaque unilateral proximal ureteral stones >10 mm were included in the study. Patients with urosepsis, pregnancy, solitary kidney, and indwelling JJ stent or prior percutaneous nephrostomy drainage were excluded. Patients without any visualisation of stone on abdominal X-Ray done at 4 weeks of the procedure were labelled as stone-free.

RESULTS

One hundred and three cases with stones >10 mm and fulfilling the selection criteria were included. The mean age was 40.83 + 14.92 years. The mean stones size was 13.33 + 4.64 mm. The mean procedure time was 41.50 + 15.60 minutes. Indwelling JJ stents were placed in 49 (47.6 %) cases. The stone-free rate was 83.5% at four weeks with calculated efficiency quotient (EQ) of 0.72, using a standard equation. The overall complication rate was 27% with the majority being minor (Clavian-Dindo grade 1). Only one patient had urosepsis (MCG IV). Ancillary procedures were performed in 17 (16.5%) cases, most commonly the extracorporeal shock wave lithotripsy (ESWL) in 14 (13.5%) cases, followed by the secondary URS in 3 (2.9%) cases.

CONCLUSION

Semi-rigid URS is an effective and safe procedure for the large proximal ureteral stones, with limited access to flexible instruments. Key Words: Ureteroscopy, Semi-rigid, Stone, Proximal, Clearance, Safety.

Comparison Of Recurrence Rate Between "EN BLOC" Resection Of Bladder Tumour And Conventional Technique For Non-Muscle Invasive Bladder Cancer

BACKGROUND

Conventional transurethral resection of urinary bladder tumour (TURBT) using a wire loop diathermy violates the basic principle of oncological surgery, i.e. dissection through normal tissue. However, in the en bloc technique, the tumour is removed as a single specimen. We compared the quality of specimen and recurrence rate at three months (first check cystoscopy) in both the en bloc and conventional resection techniques.

METHODS

The subject accrual was done from June 1st, 2017 till June 30th, 2019 at a tertiary care hospital. Patients with newly diagnosed bladder tumour, solitary or multiple ≤3 cm were included in the study. Patients with carcinoma in situ, prior TURBT, or muscle-invasive bladder cancer were excluded. Eighty-two patients were available for final analysis, 41 in each group.

RESULTS

Mean age, gender ratio, tumour features (grade, stage, median number, and size) were comparable in the two groups. Median Operative time [interquartile range- (IQR)] was 30 (25-39.5) minutes in the en bloc group as compared to 45 (33-63.5) minutes in the conventional group (p < 0.001). The detrusor muscle was seen at the base of the primary tumour in all 41 (100%) en bloc cases as compared to 23 (56 %) cases in the conventional group (p<0.001). Overall recurrence at the first surveillance cystoscopy was 17%, with an insignificant difference between the groups. Recurrence at primary site was 19.5% in conventional TURBT compared to en bloc resection (n=1, 2.4%), (p = 0.013).

CONCLUSIONS

En bloc resection decreases the recurrence rate at the primary site. En bloc TURBT is a safe technique, providing high-quality specimens for histopathological evaluation and reducing the need for the second TURBT.

Urdu translation and validation of premature ejaculation diagnostic tool (PEDT)

Objective:

To validate an Urdu translation of premature ejaculation diagnostic tool (PEDT) by analyzing the association of this diagnostic tool with the clinical diagnosis of premature ejaculation (PE) and intravaginal ejaculatory latency time (IELT).

Methods:

This cross-sectional study was conducted at the urology section of the Aga Khan University Hospital, Karachi, for six months duration, from July 2018 to December 2018. In our study 108 subjects, aged 20 to 50 years, who were in a stable sexual relationship (heterosexual) for a minimum duration of six months, were asked to fill the Urdu version of PEDT, 61 with PE and 47 without PE.

Results:

The two groups matched for mean age, duration of relationship and education level. The duration of 1.2 (±0.5) minutes was the mean self-estimated IELT in the PE group and 3.7±0.9 minutes in patients without PE. There was a significant negative correlation of 0.6 (p-value <0.001) between the PEDT score and self-estimated IELT. The test-retest reliability for each item was found to be significant for each individual item (≥ 0.84, p-value <0.001) and 0.94 was the correlation coefficients of the total score, showing an excellent test-retest reliability. 0.93 was the Cronbach’s alpha score (95% Confidence interval = 0.905 - 0.948) indicating a significant internal consistency in the Urdu version of PEDT.

Conclusions:

The Urdu version of PEDT is a valid tool to define and quantify PE objectively, with adequate internal consistency. This version of PEDT has a good negative correlation with self-estimated IELT and excellent correlation with clinical PE.

Persistent fetal lobulation of kidney mimicking renal tumour

Renal pseudotumour is a term coined to describe conditions of renal anatomic variants that simulate focal renal pathology like a tumour on ultrasonography. These include persistent fetal lobulation, hypertrophy of Bertin columns and dromedary humps. We report a case of a 30-year-old nulliparous woman who was managed in gynaecology clinic for menorrhagia and was subsequently referred to us for management of recurrent urinary tract infections. The clinical examination was normal and on ultrasound scan, she was found to have multiple enlarged heterogeneous solid masses in both kidneys with significantly increased vascularity, suspicious for neoplastic lesions. She subsequently underwent a CT urogram and her case was discussed in uro-radiology meeting where a diagnosis of persistent fetal lobulation was made excluding other diagnoses. She was managed conservatively. We also present grey scale and Doppler ultrasound and CT urogram findings of this condition along with the literature review.

Spontaneous mediastinal hemorrhage secondary to oral anticoagulation

We report a rare case of spontaneous mediastinal hemorrhage secondary to appropriate oral anticoagulation in an otherwise healthy 35-year-old woman. This case was unique in view of the patient's age and the fact that she had no underlying pathologic condition. Although the literature describes only two other cases of spontaneous mediastinal hemorrhage secondary to oral anticoagulant therapy alone, such bleeding has also been observed in patients on combined oral anticoagulant and fibrinolytic therapy and on heparin therapy. Therefore, this kind of hemorrhage should be included in the differential diagnosis of chest pain in such patients. The diagnosis is confirmed by chest X-ray films, computer tomographic scanning, and digital angiography. Supportive treatment is usually sufficient, since tamponade tends to intervene before cardiac compromise can occur.

Symptomatic aneurysm of the abdominal aorta: successful surgery in elderly patients, one with a massive aneurysm

Three cases of symptomatic aneurysm of the abdominal aorta are presented. One patient age 96, described with this condition, is perhaps the oldest patient in the literature. In another patient the aneurysm measured two feet in length, extending from the diaphragm to the pelvic outlet. This was perhaps the biggest aneurysm yet recorded. All three patients presented difficult medical problems, withstood the operaion, and were discharged from the hospitals with successful results. Aneurysm of the abdominal aorta is a serious condition. It is commonly found in patients in their seventh decade. The condition carries a high mortality with advancing age, especially when associated with other diseases. In symptomatic aneurysms where expansion, dissection or frank hemorrhage is suspected, emergency resection and replacement with dacron graft is carried out.