[DOES CHOOSING BETWEEN DUSTING OR FRAGMENTATION DURING LASER LITHOTRIPSY OF URINARY STONES CHANGE THE LONG TERM RESULTS?]

INTRODUCTION: Variations in laser pulse energy and it's frequency during lithotripsy, affect the rate and the method of stone breaking. The main modes of lithotripsy are dusting and fragmentation. AIMS: Comparison between long term results of dusting versus fragmentation, by defining the stone free rate (SFR) for each method and the time period until re-treatment need. METHODS: Clinical and radiological follow-up of 43 patients who underwent laser intervention using dusting or fragmentation. Both groups shared similar demographic features, stone sizes and locations. For each group, the percentage of patients without stones requiring intervention during the follow-up period of 36 months was defined as a success parameter. The incidence of emergency department (ED) admissions and auxiliary interventions were assessed. RESULTS: Thirty-eight patients were included in the study. No difference in the median period of time to clinically significant stone was seen (p=0.213). No difference was found in SFR between the dusting (83.3%) and the fragmentation (84.6%) groups respectively (p=1.000). No statistically significant difference was shown in ED admissions due to renal colic occurring in 31.6% and 10.5% within dusting and fragmentation groups respectively (p=0.116). CONCLUSIONS: No difference in time period until clinically significant stone appearance was seen. No significant difference in SFR was found between the groups at the long term follow-up. DISCUSSION: It seems that within the dusting group, the ED admission rate could be somewhat higher. However, this impression lacks statistical significance. A long term prospective study with a larger population is needed to confirm these results.

Comparison of Partial and Radical Laparascopic Nephrectomy: Perioperative and Oncologic Outcomes for Clinical T2 Renal Cell Carcinoma.

INTRODUCTION: Nephron-sparing surgery has emerged as the treatment of choice for small renal masses. However, its role in larger tumors remains controversial. In this study, we compare the outcomes of laparoscopic partial nephrectomy (LPN) vs those of laparoscopic radical nephrectomy (LRN) for T2 renal tumors. MATERIALS AND METHODS: Thirteen patients who had LPN and 16 patients who had LRN for T2 renal tumors were retrospectively analyzed for preoperative factors (age, gender, comorbidities, hemoglobin, and creatinine levels and estimated glomerular filtration rate [eGFR]), operative and perioperative characteristics (tumor characteristics, operative time [OT], warm ischemia time [WIT], estimated blood loss [EBL], length of stay [LOS], and postoperative complications), histopathologic results, and follow-up data (eGFR and recurrences). RESULTS: Tumor size was comparable between groups; however, tumors in the LRN group were more endophytic, central, and closer to the collecting system. There were no cases of positive surgical margins. Median OT was 160 minutes vs 230 minutes (p = 0.0029) and EBL was 25 mL vs 100 mL ([p = 0.0027], LRN vs LPN). Median WIT in the LPN group was 27 minutes, with three zero ischemias. Minor postoperative complications (≤Clavien-Dindo III) were noted in 6.25% and 23% (LRN vs LPN). Median LOS was 4.56 and 5.77 days (LRN vs LPN), respectively. Mean postsurgery eGFR was significantly lower for the LRN group (54.5 cc/[min ·1.73 m2] vs 76.3 cc/[min ·1.73 m2], p = 0.019). Within mean follow-up of 44.5 months, one tumor recurrence in the contra lateral kidney was observed in the LPN group and two cases of metastasis in the LRN group. CONCLUSIONS: We show that LPN is technically feasible for T2 tumors, with acceptable intra- and perioperative outcomes. Furthermore, our results show a significant advantage in preservation of renal function for LPN without compromising oncologic results. Taken together, we believe that LPN should be considered for larger tumors based on technical feasibility rather than only tumor size.

Retrospective Analysis of Laparoscopic Partial Nephrectomies Using the Zero Ischemia Technique.

PURPOSE: To report a series of 89 off-clamp laparoscopic partial nephrectomies (LPN) performed without using any additional "nephron sparing" manipulations. METHODS: Retrospective analysis of surgical characteristics, complications, postoperative results, and renal function changes. RESULTS: Between March 2008 and May 2014, 89 LPN using zero ischemia technique were performed. Most of the patients (61.8%) were male. The median age was 62 years (23-88). The mean BMI was 27.5 kg/m2 (20.8-54.2). The median tumor size was 3.0 cm (1.0-8.0). Tumor location was upper, middle, and lower part of the kidney in 33 (37.0%), 42 (47.2%), and 14 (15.7%) of patients, respectively. The median operative time was 154 min (58-289). The median hemoglobin change was -1.6 g/dL (0.5-5.5). The transfusion rate was 7.9%. The mean preoperative glomerular filtration rate was 96.6 mL/min (21.5-180.0) with a mean postoperative decline of 6.52 mL/min. The mean creatinine elevation after LPN was 0.09 mg/dL. The median hospital stay was 6 days (2-24). The intraoperative complications rate was 2.3%. Early postoperative complication rate was 33.7%. Late complications occurred in 6.7%. In 7 cases (7.9%), the surgical margins were microscopically involved by tumor cells. Conversion rate was 3.4%. CONCLUSION: Data obtained in the current series show that laparoscopic partial nephrectomy can be successfully performed without hilar clamping. Our results are comparable with contemporary data. Larger prospective studies would be helpful in assessing the evidence-based advantages of the "zero ischemia" technique.

Does the use of ureteral stents with extraction strings increase urinary infection rates?

PURPOSE: To assess the effect of ureteral stents with extraction string on the rate of postoperative UTI after ureteroscopies. METHODS: Retrospective analysis of patient records who underwent ureteroscopy from January 2011 to August 2014 was performed. Patients were grouped into three groups according to postoperative stent status: non-stented or ureteral catheter for up to 24 h (NS), ureteral stent without extraction string (US) and ureteral stent with an extraction string (US-E). RESULTS: There were 144, 133 and 282 cases in the NS, US and US-E groups, respectively. Overall infection rate was 4.7%; NS-2.1%, US-3.0% and US-E-6.7% (p = 0.057). Four percentage of men and 6.6% of women had postoperative UTI (p = 0.22). Within the group of men infection rates were 0, 2.4 and 6.4% for the NS, US and US-E groups, respectively (p = 0.01). For women, UTI rates were 7.5, 4.0 and 8.5% in the NS, US and US-E groups, respectively (p = 0.6). Infection rates were 20 and 3.9% (p = 0.001) for patients with extraction strings for >8 and <8 days. In multivariate analysis the presence of an extraction string was found to be a risk factor for infection OR 7.7 (1.01-58.9, 95% CI, p = 0.049) along with renal stone location OR 5.09 (2.1-12.05, 95% CI, p < 0.001). CONCLUSIONS: No statistically significant difference was found between overall infections rates for patients with and without extraction strings, and such difference was found within the male group, suggesting extraction strings in men may increase the risk of infection.

Limited field noncontrast computerized tomography for followup of ureteral stones: initial results.

PURPOSE: Due to high specificity and sensitivity noncontrast computerized tomography is increasingly used to diagnose and follow patients with ureteral stones. We evaluated the feasibility of limited field noncontrast computerized tomography to follow patients with ureteral stones. MATERIALS AND METHODS: Included in the study were 71 patients who underwent diagnostic and followup noncontrast computerized tomography due to ureteral stones. According to stone position on the first diagnostic scan a limited field batch from the followup scan was formed and examined by an independent radiologist. Radiation doses and rates of potentially missed findings in the batch were compared to those of the full followup noncontrast scan. RESULTS: Average full followup noncontrast computerized tomography length was 46.5 cm and average batch length was 20.7 and 13.8 cm for proximal and distal stones, respectively. The average full followup noncontrast scan radiation dose was 12.2 mSv. Average batch doses were 6.1 and 4.1 mSv for proximal and distal stones, respectively (p = 0.002), resulting in a radiation exposure reduction of 48.8% for proximal stones and 66% for distal stones. In 3 cases additional clinical information (not including hydronephrosis) was missed when relying only on batch images. This additional information did not impact further urological treatment. CONCLUSIONS: Limited field noncontrast computerized tomography is a feasible option for following patients diagnosed with ureteral stones. It may lead to significantly lower radiation exposure.