Retrograde intrarenal surgery of renal stones: a critical multi-aspect evaluation of the outcomes by the Turkish Academy of Urology Prospective Study Group (ACUP Study)

AIMS

To outline and evaluate the incidence, management and follow-up of the residual fragments (RFs) following retrograde intrarenal surgery (RIRS) of renal stones by the Turkish Academy of Urology Prospective Study Group (ACUP Study).

METHODS

Following the ethical committee approval, 15 centers providing data regarding the incidence, management, and follow-up of RFs after RIRS were included and all relevant information was recorded into the same electronic database program ( https://acup.uroturk.org.tr/ ) created by Turkish Urology Academy for Residual Stone Study.

RESULTS

A total of 1112 cases underwent RIRS for renal calculi and RFs were observed in 276 cases (24.8%). Of all the parameters evaluated, our results demonstrated no statistically significant relation between preoperative DJ stenting and the presence of RFs (χ2 (1) = 158.418; p = 0.099). RFs were significantly higher in patients treated with UAS (82 patients, 29.3%) during the procedure compared to the cases who did not receive UAS (194 patients, 23.3%) (χ2 (1) = 3.999; p = 0.046). The mean period for a secondary intervention after RIRS was 28.39 (± 12.52) days. Regarding the procedures applied for RF removal, re-RIRS was the most commonly performed approach (56%).

CONCLUSIONS

Despite the reported safe and successful outcomes, the incidence of RFs is higher, after the RIRS procedure particularly in cases with relatively larger calculi. Such cases need to be followed in a close manner and although a second flexible ureteroscopy is the treatment of choice for fragment removal in the majority of these patients, shock wave lithotripsy and percutaneous nephrolithotomy may also be preferred in selected cases.

Is fluoroscopy necessary during flexible ureteroscopy for the treatment of renal stones?

Objective

To investigate the feasibility and effectiveness of flexible ureteroscopy (fURS) without fluoroscopy during the treatment of renal stones.

Patients and methods

Between April 2013 and August 2018, 744 patients’ data were evaluated retrospectively. Of these, 576 patients were included in the study. All fURS were performed by experienced surgeons. All procedures were planned with zero-dose fluoroscopy. But, if fluoroscopy was necessary for any reasons, these patients were excluded from the study. Demographic data, perioperative parameters, stone-free rate (SFR), and complication rates were recorded.

Results

Of the patients planned for fluoroless fURS (ffURS), the procedure was successfully achieved in 96.7% (557/576 patients), as 19 patients required fluoroscopy during the procedure for various reasons. In the patients included in the study, the mean (SD) stone size was 11.6 (5.2) mm and the mean (SD) operating time was 39.4 (8.2) min. After the first session of ffURS, the SFR was 83.3% (achieved in 464 patients). Second and third sessions of ffURS were performed in 32 (5.7%) and seven (1.2%) patients, respectively. Overall, the complication rate was 11.8% and all complications were minor (Clavien–Dindo Grade I or II).

Conclusions

The ffURS technique seems to be a safe and effective treatment compared to conventional fURS in patients with renal stones. This procedure should be performed in experienced centers, where fluoroscopy can be considered not to be mandatory during fURS.

Abbreviations CIRF

clinically insignificant residual fragment; CT: computed tomography; EAU: European Association of Urology; (f)fURS: (fluoroless) flexible ureteroscopy; FT: fluoroscopy time; KUB: plain abdominal radiograph of the kidneys, ureters and bladder; mSv: millisievert; PCNL: percutaneous nephrolithotomy; pps: pulse-per-second; rem: roentgen equivalent man; PUJ: pelvi-ureteric junction; SFR: stone-free rate

Unusual intrascrotal lesions in adults in urological practice

OBJECTIVE

Unusual intrascrotal lesions in adults generally have been described as case reports in the medical literature. We present two lesions observed in two clinics over more than 28 years, with their radiological, pathological and clinical characteristics.

METHODS

Retrospective study preformed between 1989 and 2017 in 446 patients undergoing inguinal orchiectomy. Clinical data were obtained reviewing patient` s tables. All patients were evaluated with physical examination, medical history, serum tumor markers (alpha fetoprotein, beta human chorionic gonadotropin, LDH), and scrotal ultrasound in the perioperative period.

RESULTS

In 396 cases (88,78%) the diagnosis was germ cell or non-germ cell tumor and the remainder 50 patients (11.2%) presented 15 different intrascrotal lesions. These lesions were rhabdomyosarcoma (1 patient), intrascrotal cavernous hemangioma (1 patient), dermoid cyst (2 cases), epidermoid cyst (4 patients), paratesticular mesothelioma (1 case), parietal testicular tunica vaginalis cyst (2 patients), spermatic granuloma (3 cases). The number of patients with tuberculosis orchitis was 6 and granulomatous orchitis 8. There were 8 patients with fibrous pseudotumor. 1 patient presented testicular plasmocytoma. Metastatic involvement secondary to lymphoma and leukemia appeared in 4 cases. Brucella epididymitis-orchitis 7 cases. 2 cases of adult pure yolk sac testicular tumors. Additional evaluations and treatments were performed depending on histologic diagnosis.

CONCLUSIONS

The exact diagnosis of these lesions is difficult due to their rarity and they must always be considered for differential diagnosis.

Flexible Ureterorenoscopy versus Mini-Percutaneous Nephrolithotomy for the Treatment of Renal Stones

PURPOSE

To compare the pain status and stone free rates of flexible ureterorenoscopy (F-URS) versus mini-percutaneousnephrolithotomy (mini-PNL) for the treatment of 1-to 2-cm renal stones.

MATERIALS AND METHODS

This study was retrospectively designed with match paired method. Between January 2013 and December 2016, 387 patients underwent stone surgery for renal stones, 45 patients underwent FURS and 45 patients underwent mini-PNL. 90 patients were divided into two groups according to the surgical procedures. Group 1 patients underwent F-URS, and Group 2 patients underwent mini-PNL. During the intraoperative andpostoperative periods, pain management for all patients was standardized. Pain scores were determined using a visual analogue scale (VAS) completed at 2, 6, 12 and 24 hours postoperatively. The stone free status, hemoglobin levels, fluoroscopy time (FT), operation time (OT), hospitalization time (HT), return to work time (RWT), and complications were noted for each patient.

RESULTS

Of all patients, the mean age was 41.1 ± 12.1 years and the mean stone size was 13.9 ± 2.9 mm. The VAS scores were significantly higher in the mini-PNL group at 2, 6, 12 and 24 hours (P < .05). The stone-free status and complication rates were similar between the two groups (P > .05); however, the hemoglobin decreases and the fluoroscopy, operation, hospitalization and return to work times were higher in the mini-PNL group than in the F-URS group (P < .05).

CONCLUSION

F-URS is less painful than mini-PNL for the treatment of 1- to 2-cm renal stones. However, the stone free rate is similar between the two procedures while mini-PNL is superior in terms of fluoroscopy, operation, hospitalization and return to work duration. We think that F-URS is more comfortable and less painful than mini-PNL and achieves a similar stone free rate for the treatment of 1- to 2-cm renal stones.

Shock wave lithotripsy or retrograde intrarenal surgery: which one is more effective for 10-20-mm renal stones in children

OBJECTIVES

To compare shock wave lithotripsy and flexible ureteroscopy in children with renal stone's diameter of 10 to 20 mm.

MATERIALS AND METHODS

This is a retrospective study including 79 children, who had renal stone and underwent either shock wave lithotripsy or flexible ureteroscopy between January 2007 and June 2017. Of those, 38 patients underwent shock wave lithotripsy assigned as group 1 and 41 patients underwent flexible ureteroscopy assigned as group 2. Stone-free rate, fluoroscopy time, procedure time, complication rates, hospitalization time, and cost-effectiveness were monitored and included in the analyses.

RESULTS

The mean patient age was 4.4 ± 3.5 in group 1 and 4.9 ± 4.1 in group 2. Stone-free rate was not different in both groups in the first and third months of follow-up. The mean fluoroscopy time was statistically significantly longer in group 1 compared to group 2. Procedure and hospitalization times were longer in group 2 compared to group 1. No complications were seen in either groups. The expenditure was calculated as 135.23 and 869.41 Euro per patient for groups 1 and 2, respectively, which shows significant higher cost in group 2.

CONCLUSIONS

In this present study, we have shown that shock wave lithotripsy is cheaper, has short hospitalization time and long fluoroscopy time and similar stone-free rate, and has the same efficiency compared to flexible ureteroscopy regarding pediatric renal stones with the diameter between 10 and 20 mm.

Surgical treatment of an acquired posterior urethral diverticulum with cystoscopy assisted robotic technique

A 42-year-old man with a history of recurrent urethral stenosis, recurrent urinary tract infection and macroscopic hematuria has referred to our clinic. He underwent several internal urethrotomies and currently using clean intermittent self-catheterization. During the internal urethrotomy, we noted a large posterior urethral diverticulum (UD) between verumontanum and bladder neck. His obstructive symptoms were resolved after the catheter removal. But perineal discomfort, urgency and dysuria were prolonged about 3-4 weeks. Urinalysis and urine culture confirmed recurrent urinary tract infections. Due to this conditions and symptoms, we planned a surgical approach which was planned as transperitoneal robotic-assisted laparoscopic approach. This technique is still applied for the diverticulectomy of the bladder. In addition to this we utilized the cystoscopy equipments for assistance. During this process, cystoscope was placed in the UD to help the identification of UD from adjacent tissues like seminal vesicles by its movement and translumination. Operating time was 185 min. On the post-operative third day he was discharged. Foley catheter was removed after 2 weeks. Urination was quite satisfactory. His perineal discomfort was resolved. The pathology report confirmed epidermoid (tailgut) cyst of the prostate. Urethrogram showed no radiologic signs of UD after 4 weeks. Irritative and obstructive symptoms were completely resolved after 3 months. No urinary incontinence, erectile dysfunction or retrograde ejaculation was noted. While posterior UD is an extremely rare situation, surgical treatment of posterior UD remains uncertain. To our knowledge, no above-mentioned cystoscopy assisted robotic technique for the treatment was described in the literature.

Does the Intensity of Cutting Power Affect Postoperative Symptoms During Transurethral Resection with a Monopolar System?

The aim of this study was to investigate the effect of intensity of cutting power on postoperative symptoms after transurethral resection (TURP) with a monopolar system for benign prostatic hyperplasia. One hundred thirty-six men with benign prostatic obstructions undergoing elective transurethral prostatectomy were enrolled in the study. Patients were divided into three groups according to the intensity of cutting power. The cutting power intensities were 80-119 W for group 1, 120-159 W for group 2, and 160-200 W for group 3, respectively. In the postoperative period, patients were evaluated with International Prostate Symptom Score (IPSS) and quality-of-life (QoL) questionnaires. In the postoperative period, maximal flow rate (Q max), and post-voiding residue (PVR) were significantly improved in patients who had monopolar TURP performed. When compared to the other groups, the IPSS score was found to be significantly higher in group 3 at 3, 4, and 8 weeks. In addition, the QoL assessment scores for group 3 were superior at 3 weeks. The improvements of Q max and PVR were similar among the three groups (p < 0.0001). At the end of 3 months, IPSS and QoL were significantly improved in all groups. The intensity of cutting power during prostate resection with a monopolar system may affect the postoperative improvements and symptoms.

CD3G gene defects in familial autoimmune thyroiditis

The patients with CD3γ deficiency can present with different clinical findings despite having the same homozygous mutation. We report three new CD3gamma-deficient siblings from a consanguineous family with a combined T-B+NK+ immunodeficiency and their variable clinical and cellular phenotypes despite the same homozygous mutation of the CD3G gene (c.80-1G>C). We also re-evaluate a previously reported non-consanguineous family with two CD3gamma-deficient siblings with the same mutation. The median age at diagnosis was 11 years (14 months-20 years). We found all five patients to display autoimmunity: autoimmune thyroiditis (n = 5), autoimmune haemolytic anaemia (n = 2), immune thrombocytopenia (n = 1), autoimmune hepatitis (n = 1), minimal change nephrotic syndrome (n = 1), vitiligo (n = 1) and positive antinuclear antibodies (n = 3) as well as high IgE (n = 2) and atopic eczema (n = 2). While CD3(+) TCRαβ+T cell percentages were low in all patients, only one had lymphopenia and 3 had CD3(+) T cell lymphopenia. Strikingly, we report frequent and multiple autoimmunity in tested heterozygous carriers in both families (n = 6; in 67%), and frequent autoimmunity in family members not available for testing (n = 5, in 80%). The results suggest that CD3G should be studied as a candidate gene for autoimmunity and that CD3gamma deficiency should be considered among other primary immunodeficiencies with predominantly autoimmune manifestations.

Reduced radiation fluoroscopy protocol during retrograde intrarenal surgery for the treatment of kidney stones

PURPOSE

To discuss whether fluoroscopic imaging is essential during the ureteroscopic treatment of kidney stones in an effort to diminish radiation exposure.

MATERIALS AND METHODS

Seventy-six patients with kidney stones were treated with retrograde intrarenal surgery (RIRS). In the operation room, a mobile C-arm fluoroscopy system was ready to use in case fluoroscopic imaging was needed. The manipulations were performed with tactile and visual cues. The perioperative and postoperative parameters were retrospectively evaluated.

RESULTS

The mean age of the patients was 39.9 ± 13.8 years. The mean stone size was 14.1 ± 4.1 mm. The insertion of the access sheath was performed over the guidewire under single shoot fluoroscopic imaging in all patients. Additional fluoroscopic imaging was required to localize the stone (n = 2) and to determine the collecting system anatomy (n = 2) for 4 (5.2%) patients with previous renal surgery and severe hydronephrosis. Stone-free status was accomplished in 63 (82.9%) patients.

CONCLUSION

The RIRS with low-dose fluoroscopy protocol for kidney stones can be safely and effectively performed in patients with no special circumstances such as anatomical abnormalities or calyceal diverticular stones.

The efficacy of bupivacaine infiltration on the nephrostomy tract in tubeless and standard percutaneous nephrolithotomy: a prospective, randomized, multicenter study

OBJECTIVE

To assess the analgesic efficacy of bupivacaine infiltrations into the nephrostomy tract in tubeless and standard percutaneous nephrolithotomy (PCNL).

METHODS

This prospective, randomized controlled study enrolled 121 patients. Patients were randomized to receive a 20-mL infiltration of 0.25% bupivacaine into the nephrostomy tract after PCNL. Patients were divided into 2 groups. The group 1 patients received bupivacaine infiltrations, whereas group 2 did not. Patients' visual analog scale (VAS) pain scores were evaluated at 6, 12, and 24 hours postoperatively. Pain in the postoperative period was managed with intramuscular diclofenac sodium (75 mg) or meperidine (pethidine) hydrochloride (50 mg), as requested by the patients.

RESULTS

The patients were a mean age of 43.2 ± 12.7 years (range, 18-74 years). The VAS pain scores at 6, 12, and 24 hours postoperatively and the amount of diclofenac sodium needed were significantly less in the group with bupivacaine infiltration than in those that did not receive the infiltration (P <.05). The VAS pain scores in patients with tubeless PCNL were significantly lower than those in patients with standard PCNL (P <.05).

CONCLUSION

The pain after tubeless and standard PCNL may be decreased by bupivacaine infiltration into the nephrostomy tract. The findings of the present study reveal that a tubeless procedure and local analgesic infiltration into the nephrostomy tract after the PCNL is the more comfortable procedure for the patients.

PathCase: pathways database system

MOTIVATION

As the blueprints of cellular actions, biological pathways characterize the roles of genomic entities in various cellular mechanisms, and as such, their availability, manipulation and queriability over the web is important to facilitate ongoing biological research.

RESULTS

In this article, we present the new features of PathCase, a system to store, query, visualize and analyze metabolic pathways at different levels of genetic, molecular, biochemical and organismal detail. The new features include: (i) a web-based system with a new architecture, containing a server-side and a client-side, and promoting scalability, and flexible and easy adaptation of different pathway databases, (ii) an interactive client-side visualization tool for metabolic pathways, with powerful visualization capabilities, and with integrated gene and organism viewers, (iii) two distinct querying capabilities: an advanced querying interface for computer savvy users, and built-in queries for ease of use, that can be issued directly from pathway visualizations and (iv) a pathway functionality analysis tool. PathCase is now available for three different datasets, namely, KEGG pathways data, sample pathways from the literature and BioCyc pathways for humans.

AVAILABILITY

Available online at http://nashua.case.edu/pathways

Repair of hypospadiac urethral duplication with dismembered urethroplasty

Urethral duplication is a complex and rarely seen anomaly with three anatomic variants: epispadiac (dorsal), hypospadiac (ventral) and Y-type. Here we report an 11-year-old male patient with hypospadiac urethral duplication who presented with daytime urinary incontinence and dribbling, urethral stricture and possible obstructive uropathy. After endoscopic treatment of the stricture in the ventral (dominant) urethra, urethral reconstruction was done anastomosing the ventral (dominant) and dorsal (non-dominant atretic urethra) in a dismembered fashion.

Can serum Inhibin B and FSH levels, testicular histology and volume predict the outcome of testicular sperm extraction in patients with non-obstructive azoospermia?

INTRODUCTION

In our study, we evaluated the diagnostic accuracy of serum follicle stimulating hormone (FSH), Inhibin B, testicular volumes and distribution of testicular sperm extraction (TESE) outcome according to the histological diagnosis in men with non-obstructive azoospermia.

MATERIALS AND METHODS

Between February 2001 and April 2002, 66 men presenting with infertility of at least 1 year were found to have non-obstructive azoospermia. Serum FSH and Inhibin B levels, testicular volumes and pathological analysis were reviewed retrospectively using medical records of these patients.

RESULTS

Of 66 patients, 52 were enrolled into the study and sperm extraction was successful in 31 of 52 patients (59.6%). There was no statistically significant difference between the patients who had successful and unsuccessful TESE in terms of mean serum Inhibin B, FSH levels and testicular volumes (P>0.05). The area under ROC analysis for serum Inhibin, serum FSH and testicular volume was 0.557, 0.523 and 0.479, respectively. For Inhibin B, the best cut-off value for discriminating between successful and failed TESE at 90% sensitivity was 6.25 with a very low level of specificity (14%) and diagnostic accuracy that was 53.8.

CONCLUSION

Besides the controversies about the direct marker role of serum Inhibin B in determination of spermatogenesis, it does not seem to give a clue about the prediction of sperm presence before TESE. Because of the conflicting results in the literature, the potential role of serum Inhibin B as a marker for prediction of sperm presence in testis is yet to be determined.

Annotating proteins by mining protein interaction networks

MOTIVATION

In general, most accurate gene/protein annotations are provided by curators. Despite having lesser evidence strengths, it is inevitable to use computational methods for fast and a priori discovery of protein function annotations. This paper considers the problem of assigning Gene Ontology (GO) annotations to partially annotated or newly discovered proteins.

RESULTS

We present a data mining technique that computes the probabilistic relationships between GO annotations of proteins on protein-protein interaction data, and assigns highly correlated GO terms of annotated proteins to non-annotated proteins in the target set. In comparison with other techniques, probabilistic suffix tree and correlation mining techniques produce the highest prediction accuracy of 81% precision with the recall at 45%.

AVAILABILITY

Code is available upon request. Results and used materials are available online at http://kirac.case.edu/PROTAN.

Factors affecting the success rate of extracorporeal shock wave lithotripsy for renal calculi in children

The aim of the study was to analyse factors affecting the success rate of extracorporeal shock wave lithotripsy (ESWL) in children with renal calculi. We performed a retrospective analysis reviewing records of 85 (40 female, 45 male) children (89 renal units) subjected to ESWL for treatment of renal calculi during 1990-2005 in our department. As 4 patients had bilateral calculi and 19 children (21 renal units) had renal stones at more than one different site, each location was analysed separately for convenience. The mean age of the patients was 10.3+/-4.6 (2-16) years. The stone-free rates for renal pelvis, lower, middle and upper caliceal calculi were 70, 62, 50 and 73%, respectively. A higher rate (33%) of insignificant fragments (< or = 4 mm) was noted for lower pole calculi. Increased stone diameter (P=0.0001) and burden (P=0.04) were found as the most significant factors that adversely affect the stone-free rate for pelvis renalis calculi, whereas an acutely oriented infundibulum and/or a long lower infundibulum (P=0.005) were unfavourable factors for clearance of lower caliceal stones. The stone-free rate in children with multiple calculi was 48%, while 29% of the renal units had retained fragments. ESWL is a good initial option for treatment of most of the renal calculi < 2 cm except in the presence of unfavourable lower caliceal anatomy. Increased stone burden, multiple stones, staghorn calculi, narrow lower infundibulopelvic angle and long lower infundibulum are factors that adversely affect the clearance rate.