Dynamic renal scans as a modality for follow-up of flexible ureteroscopy.

OBJECTIVE: To determine whether dynamic renal scans - DTPA or MAG3 - routinely performed after flexible ureteroscopies (f-URS) could detect the development of an obstruction and thus promote prompt early intervention for kidney preservation. PATIENTS AND METHODS: In this retrospective study, with all the data recorded prospectively between April 2010 and October 2023, 250 renal units in 242 patients with upper urinary tract stones (UUTS) who underwent ureterorenoscopy by one surgeon in the same medical center were evaluated. Stone-free rate (SFR) was defined as no residual fragments at all using an intraoperative "triple test". The following characteristics were examined: gender, BMI, age, Hounsfield unit, stone diameter, laterality, renal/ureteral stones, stone-free rate, and auxiliary procedures per renal unit. The Clavien-Dindo classification was used to report complications. Renal units with residual stones were scheduled for a 2nd f-URS. Post- flexible ureteroscopy ureteral obstruction and renal function were detected using renal scan DTPA or MAG-3. The primary outcome was renal/ ureteral obstruction. RESULTS: The mean patient age was 53 years. The mean stone size was 12.3 mm. Stones in renal pelvis, upper, middle and lower calyces were treated in 9.2% (23), 27.6% (69), and 30.8% (77) of cases, respectively; 44% (110) ureteral stones were also treated. The single- and second-session SFRs were 94.8% and 99.7%, respectively. A third auxiliary procedure was needed in one renal unit (0.4%). The mean number of procedures per renal unit was 1.06 (264/250). Ureteral double-J stents were inserted in 53.6% (134) of the cases. In 37 (14.8%) cases, a stent was placed before surgery. Post-operative complications were minor, with readmission and pain control needed in only two patients (0.8%). No avulsion or perforation of the ureters was observed. In six patients with t1/2 between 10-20 minutes, a second renal scan revealed spontaneous improvement and no obstruction in five patients. One patient with large stones and a history of prior ureteroscopy developed a ureteral stricture (0.4%) and needed treatment with laser endoureterotomy. CONCLUSIONS: Post-flexible ureteroscopy obstruction due to ureteral stricture is very rare. A routine renal scan post-operatively may be used in potentially high-risk patients.

Goldfinger bypassing and en bloc stapling without dissection of renal vessels during laparoscopic nephrectomy.

OBJECTIVE: To test the employment of the Goldfinger Dissector (GD) to bypass and en bloc stapling of renal hilus without vascular dissection. Thus far no study has experimented the use of this integrated technique. PATIENTS AND METHODS: From July 2002 to October 2020, clinical data were collected from 288 patients who underwent transperitoneal laparoscopic nephrectomies. They were divided into two groups: using GD with en bloc stapling (n = 174, group I) or the separation and ligation method (n = 114, group II) using the same Endo GIA Universal (Vascular) Stapler. Comparative analysis was carried out between the two groups, examining blood loss, operative time, intra and postoperative complications and hospital stay. RESULTS: The mean age was 58.3 and 55.1 years in group I and II, respectively. Ratio of 90/84 and 55/59 males/females was found in group I and II, respectively.Blood loss was 65.5 ml and 188.9 ml, operative time was 156.5 and 189.2 minutes, wound infection occurred in three patients in each group (1.7% and 2.6%), ileus in 4 (2.3%) and 1 (0.87%), atrial fibrillation in 1 (0.57%) and 0%, incisional hernia in 0 (0%) and 2 (1.75%), deep vein thrombosis (DVT) in 0 (0%) and 1 (0.87%), conversion to open surgery in 2 (1.15%) and 5 (4.39%), mean hospital stay 3.5 days and 4 days in group I and II, respectively. CONCLUSIONS: Routine use of the GD and en bloc stapling of the renal pedicle in laparoscopic nephrectomy is safe and useful. This technique can decrease blood loss, operative time, and have some benefit in conversion to open surgery.

Sheathed flexible retrograde intrarenal surgery without safety guide wire for upper urinary tract stones.

OBJECTIVES: To assess the success rate and intraoperative complications of flexible ureterorenoscopy (f-URS) in patients with upper urinary tract (UUT) stones using a ureteral access sheath (UAS) without a safety guide wire (SGW). PATIENTS AND METHODS: Between April 2010 and March 2022, 464 renal units in patients with renal stones with and without concomitant ureteral stones (UUT), underwent ureterorenoscopy by one surgeon, and UAS was used in all of them. The primary endpoint was the stone-free rate (SFR). SFR was defined as no residual fragments at all. The following characteristics were examined: age, sex, laterality, renal/ureteral stones, stone diameter, SFR, Hounsfield unit, auxiliary procedures, double-J stent insertion, and intraoperative complications. This study was retrospective, with all the data recorded prospectively. Patients with residual stones were scheduled for the 2nd RIRS. The Clavien-Dindo classification was used to report complications. RESULTS: The mean patient age was 52.9 years. The mean stone size was 13.1 mm. Lower pole, upper and middle calyces, renal pelvis and ureteral stones were found in 51.5% (239), 34.9% (162), 18.3% (85) and 46.9% (218) of cases, respectively. The mean diameter was 8.1 mm, 8 mm, 12.5 mm and 8.1 mm for the lower pole, upper and middle calyces, renal pelvis and ureteral stones, respectively. The single- and second-session SFRs were 90% and 100%, respectively. The mean number of procedures per renal unit was 1.1. Ureteral double-J stents were inserted in 45.7% (212) of patients. In 96 cases, a stent was placed before surgery. Postoperative complications were minor, with no avulsion or perforation of the ureters; readmission and insertion of a DJ stent occurred in one patient. Ureteral stricture developed in one patient (0.2%) and needed treatment with laser ureterotomy. CONCLUSIONS: f-URS is a safe and effective mode of surgical management of renal and simultaneous renal and ureteral calculi using the ureteral access sheath without a safety guide wire. A guide wire should not be routinely used in these cases.

Intralesional injection of the calcium channel blocker Verapamil in Peyronie's disease: A critical review.

OBJECTIVE: To assess the effectiveness of an intralesional injection of verapamil in men with Peyronie's disease (PD). MATERIALS AND METHODS: The data provided in the current review are based on a thorough review of the available original articles on PD retrieved with a systematic literature search using PubMed- Medline, and the Cochrane Central Register of Controlled Trials, up to December 2019, to identify studies dealing with Peyronie's disease and its treatment. Included were only original articles, that we thoroughly evaluated. We searched for the primary and secondary terms of: "Peyronie's disease," "Penile curvature," "Erectile dysfunction," "Verapamil and Peyronie's disease," "Calcium channel blocker," and "Intralesional injection." RESULTS: The initial search of the databases yielded a total of 1240 studies (PubMed: 1058; Cochrane: 182), as of December 2019. Seventy studies were removed due to duplication. Further 986 studies were removed due to not being in English (except for one study by Arena F. for which we got a translation form Italian), being about animal experimentations, not being full-text, and not being clinical trials. Likewise, studies not referring at all to verapamil were excluded (148). From the remaining 36 full-text articles we focused on 13 studies which met the inclusion criteria, mainly being deemed relevant to the context of this study. CONCLUSIONS: Calcium channel blockers have been shown in both in vitro and in vivo studies to inhibit the synthesis and secretion of extracellular matrix molecules, as well as to increase collagenase activity. Patients with localised plaque are the best candidates for intralesional injections of verapamil. The beneficial effects of intralesional verapamil are apparent within the first three months. For patients who respond to treatment, the injections should be continued for six months. Patients who fail to respond to intralesional verapamil or whose angulation is greater than 30° at presentation should be considered candidates for surgery. Injection of verapamil is clinically safe for patients with Peyronie's disease, and it appears to induce a rapid, beneficial effect in patients for the reduction of plaque size. Intralesional verapamil injection for Peyronie's disease could reduce pain, decrease penile curvature, and improve sexual function.

Laparoscopic nephrectomy in xanthogranulomatous pyelonephritis.

INTRODUCTION: The aim of this article was to report our experience with laparoscopic and retroperitoneoscopic nephrectomy in patients with xanthogranulomatous (XPG) pyelonephritis. MATERIAL AND METHODS: Between November 2002 and September 2010, 27 patients, with a mean age of 61.1 years (range 43-85), underwent laparoscopic nephrectomy for a unilateral nonfunctioning kidney, because of xanthogranulomatous pyelonephritis. Patient's data was collected retrospectively and included patient age, gender, intraoperative conversion rate, operative time, estimated blood loss, length of hospital stay, perioperative transfusion rate, renal function pre- and postoperatively and postoperative complications. RESULTS: Laparoscopic nephrectomy was successful in 26 patients. It was transperitoneal in 15 patients, retroperitoneal in 11 patients and in one patient the operation was initiated as retroperitoneal and converted to transperitoneal. One conversion to open surgery was needed. The mean operative time was 193.6 minutes (range 123-340). The mean estimated blood loss was 223.5 ml (range 30-1000). The mean hospital stay was 4.8 days (range 3-12). The transfusion rate was 29.6%. Serum creatinine was 1.3 mg/dl the day before and the day after the operation. Major complications occurred in patients (11.1%). CONCLUSIONS: Laparoscopic nephrectomy should be considered as an initial approach for XGP. The indications for laparoscopic nephrectomy should be extended to these patients.

Testicular Metastasis from Renal Cell Carcinoma: A Case Report and Review of the Literature.

Testicular metastases from renal cell carcinoma (RCC) are extremely rare. To the best of our knowledge, only 33 cases have been described in the literature. Most of the reported cases are of unilateral testicular metastasis from RCC. We report a case of metachronous ipsilateral testicular metastasis from RCC in a 78-year-old man 6 years after nephrectomy. Scrotal ultrasonography showed a 4 × 5 cm mass in the right testis. Right inguinal orchiectomy was performed for diagnosis. Computed tomography revealed liver and lung metastases. First-line therapy with sunitinib was started in November 2016 for metastatic RCC.

Ureteral injury concomitant with kidney injury due to blunt trauma: case report.

A 27- year old man fell from seven meters high. A CT of abdomen and pelvis with contrast injection showed injury of right kidney, perirenal hematoma, and periureteral extravasation of contrast. Retrograde pyelography confirmed the diagnosis of partial transection of the right upper ureter. Conservative management of the case is discussed. A JJ internal ureteral stent was inserted successfully.

Percutaneous nephrolithotomy for pediatric renal calculus disease: 5 years of local experience.

INTRODUCTION: Pediatric renal calculus disease has been considered a management dilemma. The various treatment modalities have different effects on the growing kidney, with concern to the significant recurrence rate, and the long-term outcome. We report our experience with performing percutaneous nephrolithotomy (PCNL) monotherapy in staghorn or complex pediatric renal calculi. PATIENTS AND METHODS: We retrospectively analyzed the results of PCNL in 9 children treated at our institute between 2001 and 2006. A total of 9 children (10 renal units) with a mean age of 10.1 years underwent 10 percutaneous nephrolithotomies (PCNLs). One patient underwent bilateral percutaneous nephrolithotomy at the initial presentation. The average calculus size was 45.9 mm (range 15-65 mm). Of the patients, 7 had complete or partial staghorn, 1 was a shock wave lithotripsy (SWL) failure, and 1 had a stone located in a lower calyx with a narrowed infundibulum; 7 from the 9 patients turned out to have some kind of a metabolic disorder--cystinuria in 6 patients and hyperoxaluria in one patient. The operations were performed under the guidance of monoplane fluoroscopy--standard PCNL in 3 cases and percutaneous nephrolithotomy with minimal access (mini-perc) in 7 cases. A rigid nephroscope was used in all of the cases. The stones were fragmented with pneumatic or ultrasonic devices and extracted with forceps. RESULTS: Stone-free status was achieved in 8 renal units (80%) after a single stage PCNL. With subsequent shock wave lithotripsy (SWL), the clearance rate had increased to 100%. The mean operating time was 88 minutes (range, 35 to 180 minutes) and no intraoperative or postoperative major complications were observed and no blood transfusions were required. One patient had suffered from intraoperative hypothermia, which had responded to conservative treatment. CONCLUSIONS: PCNL is an effective and safe form of therapy in pediatric stone disease. Since two-thirds of pediatric stone patients have an underlying metabolic disorder, a close cooperation of adult and pediatric urologists, nephrologists and radiologists is necessary in order to achieve good results in the treatment of pediatric nephrolithiasis.

[External ureteral injuries].

INTRODUCTION: Traumatic ureteral injuries are quite uncommon. Penetrating and non-blunt trauma are the most common cause of ureteral injuries. Most of the blunt ureteral injuries described in the literature are case reports. Simultaneous bilateral ureteral injury is extremely rare. DIAGNOSIS: In homodynamic stable patients imaging studies should be conducted when there is suspicion of urinary tract injury. Abdominal computerized tomography with contrast injection and delayed scans are the gold standard for staging such injuries. Excretory urography may be used when computerized tomography is not feasible. When both of these imaging studies are not diagnostic and there is still a high suspicion of injury, a retrograde pyelography would be the next imaging study option. MANAGEMENT: Partial ureteral transection can be managed with ureteral stent placement. Complete ureteral transection and some grade III injuries should be explored and repaired with debridement, placement of ureteral stent and tension-free anastomosis of healthy ureteral ends with absorbable stitches and omental or peritoneal wrap. The type of anastomosis depends on the height of the ureteral injury and whether the contralateral ureter is existent and with no diseases. CONCLUSIONS: A high index of suspicion is needed in diagnosing ureteral injury in patients with blunt or penetrating trauma. Delay in diagnosis or inappropriate treatment would lead to serious immediate and delayed complications, from mild hematoma to abscess, sepsis, strictures, obstructive nephropathy, and renal unit loss.

Three cases of penile paraffinoma: a conservative approach.

Injection of foreign materials into different body parts has long been performed to change the body contour. The treatment of choice should be radical excision, otherwise recurrence of the symptoms can occur. However, in selected patients, conservative treatment should be considered. We report the cases of 3 Thai foreign workers, with a history of penile oil injections.

[Numerical aberrations of chromosomes 11 and 17 detected by fish--fluorescence in situ hybridization combined with cytology in exfoliated cells from voided urine in patients with urothelial carcinoma of the bladder].

OBJECTIVES: To study the use of FISH analysis for detecting the presence of numerical alterations of chromosomes 11 and 17 combined with cytology in exfoliated cells from voided urine as a method for diagnosis and follow-up in patients with urothelial carcinoma (UC) of the bladder. MATERIALS AND METHODS: During the period April 2005 till June 2006, three groups were studied. The first group included 15 patients without UC. The second group included 25 patients undergoing evaluation for suspected UC. The third group included 25 patients enrolled in cystoscopy follow-up for previous UC. All the patients underwent cystoscopy, cytologic examination and FISH analysis for centromeric probes 11 and 17 performed on voided urine. After diagnosing the bladder UC, the tumor was staged and graded according to the pathologic findings. The sensitivity and specificity of FISH and Cytology were assessed. Data were analyzed with t-test when comparing two groups, and using ANOVA test when comparing more than two groups. These statistical analyses were executed with statistical software PRISM version 4.03. RESULTS: The sensitivity of FISH when using the centromeric probes of chromosomes 11 and 17 was 95.2%. The specificity was approximately 94.4%. The monosomy, trisomy, and polysomy in the patients with UC were 95.2%, 78.6% and 35.7% (p < 0.05) respectively. FISH was positive in 92.3% (24/26) in low grade tumors and in 100% (16/16) in high grade tumors (p > 0.05). The sensitivity of cytology was 31%. The cytology was positive in 23% (6/26) in low grade tumors and in 43.8% (7/16) in high grade tumors (p < 0.05). CONCLUSIONS: FISH analysis using centromeric probes of chromosomes 11 and 17 is an effective noninvasive method for the detection of altered chromosome numbers in bladder cancer cells in urine exfoliated cells. The sensitivity of FISH is higher than that of cytology in detecting UC. The combined analysis of FISH and cytology, does improve the accuracy of cytology but does not improve the specificity. Monosomy is the most prevalent numerical aberration found in patients with UC of the bladder. FISH analysis might give better results especially when cytology is negative. This method may help to decrease the frequency of cystoscopies in the follow-up of patients with confirmed bladder UC. Using multi-probe FISH test may improve the sensitivity. However, further studies are needed to confirm our results and conclusions.

[Biochemical failure after radical prostatectomy].

An elevated or detectable serum PSA after radical prostatectomy for prostate cancer is significant in the great majority of the cases with recurrent or persistent disease. Elevation of serum PSA causes concern for the patient and his physician since the best way to treat these patients is yet unknown. Analysis of large series of patients who underwent radical prostatectomy demonstrates that as many as 30% of patients will experience biochemical relapse represented by elevation of serum PSA. Most of the relapses occur in the first 5 years. However, 10 to 15 years are necessary to ascertain the true clinical progression rate of prostate cancer after radical prostatectomy. The time lag between the biochemical and clinical manifestation of metastatic disease may extend for up to 8 years, followed by an additional 5-year median time until cancer specific death. Radiation therapy may be beneficial as an adjuvant or early salvage if PSA < 1.5 ng/ml and for patients with high probability of local recurrence. Early salvage radiation therapy is a more acceptable option than adjuvant radiation therapy, saving 70% of patients with adverse pathology unnecessary treatment. Hormonal treatment at the time of biochemical relapse is justified in selected patients.