Predictive Factors for the Peri-operative Outcome of Ureteroscopic Lithotripsy for Proximal Ureteric Stones.

BACKGROUND: Proximal ureteric stones are considered one of challenging location for lithotripsy using semirigid ureteroscopes. Aim of the study was to assess clinical and radiological characteristics associated with outcome of lithotripsy using semirigid ureteroscope for proximal ureteric stones. METHODS: Prospective observational study was done on patients who underwent semirigid ureteroscopic lithotripsy for proximal ureteric stone. Stone and ureteral mormphomeric parameters were documented from computed tomography urogram. Stone free status and complication rates were studied. To determine predictive factors for outcomes, multivariate regression analysis and receiver operative curve were used. RESULTS: One hundred patients were included in study. Demographic characteristics, stone size, density and mode of lithotripsy had no impact on stone free rate or complications. The mean ureteral wall thickness(p = 0.002), distance of stone from pelvi-ureteric junction(p = 0.005), degree of hydronephrosis(p = 0.0001) and peri-ureteric fat stranding (p = 0.038) were found to have significant association with stone free rate on univariate analysis. On multivariate analysis, mild hydronephrosis(p = 0.003) and distance of stone from pelvi-ureteric junction(p = 0.022) were significant for stone free rate. CONCLUSIONS: Mean ureteral wall thickness, stone distance from pelvi-ureteric junction, presence of peri-ureteric fat stranding and hydronephrosis affect stone free rate on univariate analysis. On multivariate analysis for stone free rate, stone distance from pelvi-ureteric junction and mild hydronephrosis were significant. There was no significant impact of any stone or ureteral morphometry on complication rate.

Prostatic Urethral Length as a Predictor for Surgery in Benign Prostatic Hyperplasia.

BACKGROUND: Benign prostatic hyperplasia is associated with structural and morphological changes including elongation of prostatic urethral length. The aim of our study was to assess whether prostatic urethral length could predict need of surgery in patients with benign prostatic hyperplasia. METHODS: This prospective observational study was conducted over a 12-months duration. All the patients who presented with lower urinary tract symptoms secondary to benign prostatic hyperplasia were evaluated with International Prostate Severity Score, serum Prostate Specific Antigen, Transrectal Ultrasound was done to measure prostatic urethral length, prostate volume, Intravesical prostatic protusion and Post-void Residual Urine. Patients not responding to medical treatment and complications secondary to benign prostatic hyperplasia underwent surgery. Logistic regression analysis was performed to identify risk factors associated with surgery. RESULTS: A total of 153 patients were included in the study. Eighty-three (54.2%) patients underwent surgery during the study period. Prostate volume, intravesical prostatic protrusion, post-void residual volume, serum prostate specific antigen, and prostatic urethral length were significantly higher in the surgical group. The mean prostatic urethral length in the surgical group was 39.47 + 10.2 mm and in the nonsurgical group was 26.20 + 6.72 mm (p <0.0001). According to the ROC curve-based prediction of surgery, the area under the curve for PUL was 0.866 and the best cutoff value was 31.5mm (81% sensitivity and 84.3% specificity). CONCLUSIONS: BPH patients with longer PUL may require surgical management. PUL measured by TRUS may be a predicting factor for the need of surgery in BPH Keywords: Benign prostatic hyperplasia; lower urinary tract symptoms; prostatic urethral length.

Comparative Study of Percutaneous Nephrolithotomy in Supine and Prone Positions.

BACKGROUND: The aim of the study is the compare efficacy and safety of percutaneous nephrolithotomy in supine and prone positions. Percutaneous nephrolithotomy is conventionally performed in prone position but in recent years numbers of supine percutaneous nephrolithotomies is increasing globally. METHODS: The hospital based cross-sectional observational study was conducted in the Department of Urology, Bir Hospital from July 2018 to January 2020. A total of 81 consecutive patients undergoing percutaneous nephrolithotomy were divided into two groups, with 38 patients in Supine (Group 1) and 43 patients in Prone (Group 2) positions, respectively. Patient's demographics, access time, operative duration, stone free rate, radiation dose and duration, irrigation fluid volume, post-operative hemoglobin drop and complications were compared. RESULTS: Demographic and stone characteristics were comparable in both groups. Supine Group (Group 1) had significantly shorter operative duration than Prone Group (Group 2), 44.63 ± 12.44minsvs 53.02 ±12.67mins (p< 0.04). The mean radiation duration was 99.11 ± 61.17secs in Group 1 and 108.40 ± 51.65 secs in Group 2 (p=0.46), respectively. Although the mean radiation dose was lower in Group 1 (375.1µGym2) than in Group 2 (465.7 µGym2), it was not statistically significant(p=0.24). The stone free rate at 1 month duration were comparable with 92.1% and 93.02% in Group 1 and Group 2 respectively (p=0.16). Overall complication rates were similar in both groups (15.7% in Group 1 vs 16.2% in Group 2), respectively. None of the patients in both groups had complications higher than Clavien IIIa. CONCLUSIONS: PCNL in supine position has significantly shorter operative time with similar complications and stone free rates as compared to prone position.

Comparison between shockpulse and pneumatic lithotripsy in percutaneous nephrolithotomy.

PURPOSE: To compare the effectiveness and safety of shockpulse with pneumatic lithotripsy in percutaneous nephrolithotomy. METHODS: A prospective randomized comparative study was performed in Department of Urology, Bir Hospital for 1-year duration with 61 patients in shockpulse (Group 1) and 58 patients in pneumatic lithoclast (Group 2) groups, respectively. Patient's demographics, stone characteristics, hemoglobin drop, hospital stay, operative duration, stone fragmentation time and postoperative complications were compared. RESULTS: The two groups did not differ significantly in terms of patient's demographic and stone characteristics. The mean hemoglobin drop was 1.96 ± 1.48 g/dl in Group 1 and 2.32 ± 1.38 g/dl in Group 2 (p = 0.16) and hospital stay was 3.14 ± 1.42 days in Group 1 and 3.29 ± 1.82 days in Group 2 (p = 0.62). The number of cases that required multiple tracts were six (9.8%) in Group 1 and 12 (20.68%) in Group 2 (p = 0.12). The stone-free rates were 78.69% in Group 1 and 74.13% in Group 2 (p = 0.66). Mean total operation time was 43.23 ± 18.49 min in Group 1 as compared to 51.53 ± 19.48 min in Group 2 (p = 0.0188). Mean stone fragmentation time was 17.95 ± 15.25 min in Group 1 and 24.37 ± 11.12 min in Group 2 (p = 0.0096). Overall complications were not significant between the two Groups (p = 0.58). On sub-analysis of the patients with single tracts in both groups the results were comparable to patients with single and multiple tracts combined. CONCLUSIONS: Despite similar stone-free rates and complications between the two Groups, shockpulse has significantly lower stone fragmentation time and total operation time as compared to pneumatic lithotripsy.

Stone Clearance by Computed Tomography after Percutaneous Nephrolithotomy: A Descriptive Cross-sectional Study.

INTRODUCTION: Percutaneous nephrolithotomy has the highest stone free rate among other procedures with relatively higher complication rate. Post-operative imaging after stone surgeries has not been uniform. This study was done to study about the stone clearance by computed tomography after percutaneous nephrolithotomy. METHODS: The descriptive cross-sectional study was conducted in the Department of Urology, Bir Hospital for six months duration. The patients undergoing percutaneous nephrolithotomy and those with intra-operative fluoroscopic clearance were evaluated with a low dose computed tomography after 48 hours to assess residual fragments its size and location. Patient's demographics, stone characteristics and complications were compared between the stone free and with residual stone patients. RESULTS: Out of 72 percutaneous nephrolithotomy performed, 40 patients were included in the study. Low dose computed tomography kidney, ureter and bladder after 48 hours of surgery detected residual fragments in 11 (27.5%) patients. The RFs size of <4mm were found in 7 (63.63%) of cases whereas RFs of >4mm were found in 4 (36.36%). The stone size was 352.47 ± 97.47 mm2 and 254.79 ± 172.68mm2 in group with residual fragments and stone free group respectively. CONCLUSIONS: Low dose computed tomography kidney, ureter and bladder done for assessment of stone clearance after 48 hours of percutaneous nephrolithomy detected residual in around one fourth of patients, however majority of them had residual fragments <4mm. Intra-operative fluoroscopic clearance may over estimate stone clearance after percutaneous nephrolithomy as about one third of patients still may have residual fragments of >4mm size.

Outcomes of Percutaneous Nephrolithotomy in Patients with Previous Ipsilateral Open Renal Stone Surgery.

BACKGROUND: Nephrolithiais is a recurrent disease. Recent advances have enabled stone surgeries to be performed by minimal invasive techniques; but still a large number of patients present with history of ipsilateral open renal stone surgery. Previous scar to the kidney and overlying muscles are fraught with possibility of increased complications. This study was conducted to evaluate the perioperative results of percutaneous nephrolithotomy in patients with a history of open stone surgery and to compare with those undergoing percutaneous nephrolithotomy for the first time. METHODS: A retrospective study of all the percutaneous nephrolithotomy performed by standard technique within four years at Bir Hospital was made. Patients were divided into those undergoing percutaneous nephrolithotomy for the first time and those who had undergone open renal stone surgery in the past. Preoperative and intraoperative variables were recorded and postoperative stone free status and complications were evaluated. RESULTS: Six hundred and twenty seven patients; out of 691, who had undergone percutaneous nephrolithotomy were included. Demographic variables and stone characteristics were similar in the two study groups. percutaneous nephrolithotomy was found to be statistically similar in the two groups in terms of the number of tracts made (p= 0.1642) and operative time (0.9197). Exit strategies were similar in both groups. Stone free rate was 83.33% in patients undergoing percutaneous nephrolithotomy for first time and 82.08% in those with history of open surgery. Average hospital stay was 3 days in both groups. Although the group with history of previous surgery had significantly more complications (p= 0.0207), Clavien grading was similar in the two groups. CONCLUSIONS: This study shows that the rate of complications is more in patients with history of open surgery, most complications are minor, not requiring intensive management. percutaneous nephrolithotomy is efficient and safe in patients with history of open renal stone surgery.

Urinary Stone Disease and Preventable Nephrectomies.

BACKGROUND: Urinary stone disease has high prevalence in our belt. The end stage complication of this disease turns out to be a non-functioning kidney, which in fact could be prevented by means of appropriate treatment and follow up. METHODS: This is retrospective study of the nephrectomy cases of last 8 years retrieved from the hospital database. Variables like age, sex, indications for nephrectomy, modalities of nephrectomy and morbidities among the primary and recurrent disease were taken into consideration. Analysis were done using Microsoft Excel 2016. RESULTS: Five hundred and twenty-nine nephrectomies were performed in last 8 years at our hospital. Female were more prone for nephrectomies. Age at third and fourth decade were most to be affected. Ninety percentage of nephrectomies were done for benign causes, 65% for the stone disease. The recurrent renal stone disease without any past surgical interventions were more prone to undergo nephrectomies. The conventional open technique of nephrectomy has largely been replaced by laparoscopic means in recent years. CONCLUSIONS: The main contributor for nephrectomy in our context is urinary stone disease, which is considered to be the preventable factor Keywords: Nephrectomy; renal stone; urinary stone disease.

Risk Factors for Postoperative Complications after Percutaneous Nephrolithotomy.

BACKGROUND: To identify the perioperative factors associated with complications after percutaneous nephrolithotomy by classification of complications according to the modified Clavien scoring system and evaluation of the minor and major complications related to the procedure. METHODS: A prospective study of all the percutaneous nephrolithotomy performed by standard technique within 1.5 years at Bir Hospital was made. Possible demographic, preoperative and intraoperative variables were included in the study and patients were followed up postoperatively for any complications. All complications were classified according to modified Clavien scoring system and analyzed to identify the prognostic variables. RESULTS: Two hundred and forty six percutaneous nephrolithotomy done within the study period were analyzed. Although 41.06 % of the study population developed complications, only 9.35 % had major complications. Age, body mass index, gender, clinical presentation, history of previous surgery and ASA score did not correlate with complications. Diabetes was the only comorbidity associated (p = 0.0482). Preoperatively estimated stone burden (p = 0.0023), number of calyces involved by the stones (p = 0.0002), and presence of staghorn calculi were significantly associated with development of postoperative complications. Multiple tracts were required (p = 0.0151) and operative time was longer (p < 0001) in the patients who developed complications. CONCLUSIONS: Percutaneous nephrolithotomy has lesser complications. Diabetic patients are more prone to develop complications. Larger stone burden, involvement of multiple calyces by stones and staghorn calculi are associated with need of multiple tracts and longer operative time, thus predisposing to higher incidence of complications.

Tamsulosin versus tadalafil as a medical expulsive therapy for distal ureteral stones: A prospective randomized study.

PURPOSE: This study aimed to compare the safety and efficacy of tamsulosin and tadalafil as medical expulsive therapy for distal ureteral stones. MATERIALS AND METHODS: This prospective randomized study was conducted at the Department of Urology of Bir Hospital over a period of 12 months in patients with distal ureteral stones sized 5 to 10 mm. Patients were randomly divided into 2 groups: group A received tamsulosin 0.4 mg and group B received tadalafil 10 mg at bedtime for 2 weeks. Stone expulsion rate, number of ureteric colic episodes and pain score, analgesic requirements, and adverse drug effects were noted in both groups. Statistical analyses were performed by using Student t-test and chi-square test. RESULTS: Altogether 85 patients, 41 in group A and 44 in group B, were enrolled in the study. The patients' average age was 31.72±12.63 years, and the male-to-female ratio was 1.5:1. Demographic profiles, stone size, and baseline investigations were comparable between the 2 groups. The stone expulsion rate was significantly higher in the tadalafil group than in the tamsulosin group (84.1% vs. 61.0%, p=0.017). Although the occurrence of side effects was higher with tadalafil, this difference was not significant (p=0.099). There were no serious adverse effects. CONCLUSIONS: Tadalafil has a significantly higher stone expulsion rate than tamsulosin when used as a medical expulsive therapy for distal ureteral stones sized 5-10 mm. Both drugs are safe, effective, and well tolerated with minor side effects.