Efficacy and safety of the EMS Swiss LithoClast® Trilogy for PCNL: results of the European multicentre prospective study on behalf of European Section of UroTechnology.

PURPOSE: PCNL requires a lithotrite to efficiently break stones, and some devices include active suction to remove the fragments. We set out to determine the efficacy and safety of the Swiss LithoClast® Trilogy, in a prospective European multicentre evaluation and compared it to published stone clearance rates for Trilogy based on surface area (68.9 mm2/min) and using the 3D calculated stone volume (526.7 mm3/min). METHODS: Ten European centres participated in this prospective non-randomized study of Trilogy for PCNL. Objective measures of stone clearance rate, device malfunction, complications and stone-free rates were assessed. Each surgeon subjectively evaluated ergonomic and device effectiveness, on a 1-10 scale (10 = extremely ergonomic/effective) and compared to their usual lithotrite on a 1-10 scale (10 = extremely effective). RESULTS: One hundred and fifty seven PCNLs using Trilogy were included (53% male, 47% female; mean age 55 years, range 13-84 years). Mean stone clearance rate was 65.55 mm2/min or 945 mm3/min based on calculated 3D volume. Stone-free rate on fluoroscopy screening at the end of the procedure was 83%. Feedback for suction effectiveness was 9.0 with 9.1 for combination and 9.0 for overall effectiveness compared to lithotrite used previously. Ergonomic score was 8.1, the least satisfactory element. Complications included 13 (8.2%) Clavien-Dindo Grade II and 2 (1.3%) Grade III. Probe breakage was seen in 9 (5.7%), none required using a different lithotrite. CONCLUSIONS: We have demonstrated that Trilogy is highly effective at stone removal. From a user perspective, the device was perceived by surgeons to be highly effective overall and compared to the most commonly used previous lithotrite, with an excellent safety profile.

Primary penile melanoma.

Primary penile melanomas are exceedingly rare (less than 1% of primary penile cancers), 221 cases being reported to date in PubMed indexed medical literature. More than half of the cases occur on the gland, usually in older people than on cutaneous counterpart and have unfavourable prognosis mainly due to the belated diagnosis. We report the case of a 77 years old male diagnosed with a pigmented ulcerated nodular melanoma of the gland with maximal thickness of 4.5 mm, mitotic index 8 mitoses/mm2 and vascular emboli. No lymph node enlargements or distant metastases were identified at presentation. Six months after the diagnosis the patient was well, free of disease. Clinically, penile melanomas may be mistaken for several lesions such as squamous carcinoma, penile nevi, pyogenic granuloma, Kaposi sarcoma. Histopathologic diagnosis is usually straight forward except for highly pleomorphic tumors; discrimination between primary penile tumor and penile metastatic melanoma is the most delicate problem of differential diagnosis. The treatment is not standardized; surgical wide excision or partial/total penectomy completed with sentinel lymph node biopsy are the most frequent methods of treatment; multi-agent chemotherapy and/or high-dose interferon alpha 2b therapy are recommended for patients with locally un-controllable disease and/or metastases.

Pelvic Organ Prolapse Quantification System (POP-Q) - a new era in pelvic prolapse staging.

The prolapse of one or several pelvic organs is a condition that has been known by medicine since its early days, and different therapeutic approaches have been proposed and accepted. But one of the main problems concerning the prolapse of pelvic organs is the need for a universal, clear and reliable staging method.Because the prolapse has been known and recognized as a disease for more than one hundred years, so are different systems proposed for its staging. But none has proved itself to respond to all the requirements of the medical community, so the vast majority were seen coming and going, failing to become the single most useful system for staging in pelvic organ prolapse (POP).The latest addition to the group of staging systems is the POP-Q system, which is becoming increasingly popular with specialists all over the world, because, although is not very simple as a concept, it helps defining the features of a prolapse at a level of completeness not reached by any other system to date. In this vision, the POP-Q system may reach the importance and recognition of the TNM system use in oncology.This paper briefly describes the POP-Q system, by comparison with other staging systems, analyzing its main features and the concept behind it.

From interstitial cystitis to chronic pelvic pain.

There are still many things to be found out about interstitial cystitis/painful bladder syndrome (IC/PBS) because the pathological processes underlying the condition are not yet elucidated, biological markers of the condition are not yet available, and the type and severity of symptoms can vary, so, clearly defining the condition is not yet possible. For example, it is not clearly understood whether IC/PBS represents a systemic disease, if it is localized in the bladder, or if it was initially localized in the bladder and it later evolved into a systemic disease. This condition is best managed by using a multidisciplinary approach. Management requires a good integration and knowledge of all pelvic organ systems and other systems including musculoskeletal, neurologic, and psychiatric systems.

TURP for BPH. How large is too large?

BPH remains one of the most common diseases that the urologist has to manage. The last decade brought numerous new techniques, aiming to improve the minimally invasive approach to BPH, but, for the moment, none had changed the place of TURP as the gold standard treatment for medium sized prostates. Based on a large personal experience, the authors present a study in which TURP is used for prostates over 80 ml, the cutoff point set by the guidelines of the European Association of Urology. The rationale for this study is that many situations require minimally invasive treatment, based on the express request of the patient, other conditions that makes open surgery very difficult or impossible, or the need for a quick discharge in an overcrowded service. The aim of the study was to prove that TURP is safe and effective even in larger prostates. The technique used is basically the classic one, with minor tactical alterations in some cases. Some cases required a two-stage approach, but offered good functional results after the first stage. The results proved that, with a good technique, a skilled urologist might achieve the same results by using TURP or open surgery for large sized prostates.

Diagnosis and treatment of erectile dysfunction--a practical update.

During the last decades, erectile dysfunction was considered a direct consequence of aging and, although of a great concern for the affected patient, little was available to evaluate and treat this problem. If aging could not be invoked in all cases, than the psychogenic etiology was the only explanation. Over the coming years, a better understanding of the physiology involved in the penile process of tumescence and detumescence has allowed for better approach of each disease asociated with erectile dysfunction so that adequate treatment modalities can be applied to the pacient. As we all know, every pacient is a particular case. The development of modern PDE-5 inhibiters, along with other more or less invasive therapies, puts a new light on the medical approach of ED.

[The importance of Doppler ultrasonographic evaluation of the ureteral jets in patients with obstructive upper urinary tract lithiasis]. / Importanta evaluarii jeturilor ureterale prin ecografie Doppler la pacientii cu obstructie litiazica a cailor urinare superioare.

INTRODUCTION: The practical significance of ureteral jets variance still remains a controversial issue. The aim of this study was to determine the place of this parameter in upper urinary tract pathology diagnosis. MATERIAL AND METHODS: Between January 2003 and January 2008, we evaluated 431 patients with upper urinary lithiasis and 79 healthy volunteers. Ureteral jets and renal resistive index were evaluated by Doppler color, Doppler pulse and 3D ultrasonographic modules. RESULTS: 280 patients presented Ist to IIIrd degree hydronephrosis. 76.1% of them didn't present ipsilateral ureteral jets at Doppler ultrasonography and 91% had a resistive index higher than 0.7. In patients without hydronephrosis, the ureteral jets were present in 78.8% of the cases, their velocity being reduced by 30-50% by comparison to the contralateral part. In this group, the resistive index was smaller than 0.7 in 81.4% of the cases. CONCLUSIONS: Ureteral jets analysis (morphology, velocity) may be useful as part of the diagnosis protocol of upper urinary tract lithiasis.

[Role of Doppler ultrasonography in the diagnosis and treatment of varicocele]. / Rolul ecografiei Doppler in evaluarea pacientilor cu varicocel.

Varicocele is a frequent condition in male population. Our objectives were to asses the role of Doppler ultrasonography in varicocele diagnosis, evaluation of surgical outcome and identify predictive factors for infertility. We studied 45 patients (21-46 years old), Doppler ultrasonography being used to determine the stage and reflux grade. In all patients presence of anti-spermatic antibodies was assessed. 27 patients were surgical treated. Postoperatively, presence or absence of reflux was assessed by Doppler ultrasonography. Spermogram was repeated in infertile patients. Our patients presented stage I (12 cases), stage II (18 cases) or stage III varicocele (15 cases). 16 patients (35%) were infertile (12 with grade III and 4 with grade II reflux), in 10 of these patients high levels of anti-spermatic antibodies being detected. Postoperatively, venous reflux was absent in all 27 patients. Among infertile patients, 80% of those younger than 25 years, 42% of those with ages between 25-30 years and none of those over 30 presented postoperative improvements of spermogram. Doppler ultrasonography is a non-invasive investigation for diagnosis, evaluation of venous reflux and detection of intratesticular varicocele. Opportunity of surgical treatment and evaluation of operative outcome can be determined using Doppler ultrasonography.

[Hynes-Andersen pyeloplasty by mini-laparoscopy transperitoneal approach]. / Pieloplastie Hynes-Andersen pe cale minilaparoscopica transperitoneala.

Laparoscopy had significantly gained in the field of urologic surgery, almost all the surgical procedures in the retroperitoneal space being made, from the simple ones (renal cystectomy, varicocelectomy) to the ones requiring higher expertise (nephrectomy, adrenalectomy) by retro-peritoneoscopy and also transperitoneal. At the Surgery Department of "Sf. Ioan" Hospital, Bucharest, we approached initially the retroperitoneal pathology by lomboscopy, but afterwards we choose the transperitoneal approach because of the generous workspace and the clearer anatomical landmarks, regardless of the procedures (renal cystectomy, varicocelectomy, adrenalectomy, nephrectomy, pyelo-lithotomy, ureterolithotomy). In association with the Urology Department of "Sf. Ioan" Hospital we practiced two Hynes Andersen pyeloplasty for pyelo-ureteral junction stenosis by transperitoneal approach, using mini-laparoscopy tools. In one of the cases we also perform a basinetal lithotomy.

[Doppler ultrasonography in the function assessment of double J ureteral endoprosthesis in patients with extrinsic ureteral obstruction]. / L'évaluation par l'écho-doppler de la fonctionnalité de l'endoprothèse urétérale par sondes JJ chez les patients avec obstruction urétérale extrinsèque.

OBJECTIVES: The efficacy of internal urinary drainage by double J stent is relatively difficult to evaluate by classical methods. This prospective study evaluated variations of the resistance index (RI) in patients with unilateral extrinsic ureteric obstruction, requiring internal drainage by double J stent. MATERIAL AND METHODS: Variations of the resistance index (RI) and the correlations between RI and the results of other investigations were determined in a group of 48 patients with unilateral extrinsic ureteric obstruction, treated by ureteric stent. The presence of urine from the stented ureteric meatus was also assessed. RESULTS: The preoperative assessment demonstrated a sensitivity of 73% for RI (> 0.7) and 84.5% for DRI for the demonstration of obstruction. Following stenting, RI decreased by 11%, with a mean index of 0.66; the RI was less than 0.07 in 62.5% of cases. The mean index was 0.68 one month later and 0.71 three months later (an increase of 0.05 compared to the post-stent evaluation). CONCLUSIONS: The resistance index may represent a useful element in the assessment of the efficacy of internal drainage by double J stent, while the presence of urine in the ureteric orifice may not be helpful.

[Duplex Doppler ultrasound value in upper urinary tract obstruction ]. / Rolul ecografiei duplex Doppler în evaluarea uropatiei obstructive.

UNLABELLED: Our prospective study aimed to establish the duplex Doppler ultrasonography (DDU) value in patient's investigative protocol with acute or chronic ureteral obstruction. A. DDU IN ACUTE URETERAL STONE OBSTRUCTION: Between October 1988 and January 2001 we applied DDU evaluation for 177 cases with ureteral lithiasis in which we also studied gray scale echography, resistive index (RI), the difference between affected kidney and contralateral kidney (delta RI) and the characteristics features (amplitude, velocity and frequency) of the ureteral jets (intravesical evaluation in color Doppler mode). a. For 65 cases with RI < 0.70, delta RI < or = 0.06 we didn't find obstruction and 95.4% of the patients had spontaneous passage of the stones. b. For 109 cases with RI > 0.70, delta RI > or = 0.06 the spontaneous passage of the stone was found in 40 cases (36.7%). DDU associated with ureteral jet evaluation increased the predictive value of this method. So, the presence of the ureteral jet on the obstructed side of the upper urinary tract was associated with 63% of spontaneous passage of the stone while the absence of the jet was followed by 5% of spontaneous passage of the stone. The RI was sensitive in 74% and specific in 81% and delta RI was sensitive in 85% and specific in 91%. B. DDU IN CHRONIC URETERAL OBSTRUCTION: Between October 1988 and January 2001 we evaluated the DDU value in chronical ureteral obstruction on 78 cases with operated and/or irradiated genital neoplasm's and retroperitoneal involvement. Our results found RI sensitive in 63% and specific in 70% and delta RI was sensitive in 72% and specific in 78%. After double J stenting (indwelling) RI varied from 0.74 to 0.66 (0.08), with a significative decrease (over 10%) in 61.5% of the cases in which preoperator RI was greater than 0.70. After 1 month we found an increase of RI with 0.02 and after 3 months with 0.05. IN CONCLUSION: We consider DDU a functional imagistic method with an important place in the investigative protocol of the obstructive uropathy.

[New criteria for the diagnosis and endourological treatment of urethral strictures]. / Noi criterii de diagnostic si tratament endourologic minim invaziv în strictura uretrala.

Between January 1994 and January 2000 we analyzed a series of 440 cases with urethral structures (US) in which we performed internal urethrotomy (IU). Bulbous site (76%), inflammatory etiology (84%) and primary disease (74%) were the characteristics of our series of patients. The diagnosis protocol was based on classical evaluation, urethral echography (7-10 MHz and endorectal Multiplan) and, in 37 cases, histopathological analysis of urethral callus. Based upon echographic description of the structural zone, the endo-incision was performed only at 12 o'clock position in 205 cases (46.8%), at 6 and 12 o'clock positions in 71 cases (16%), "star incision" in 141 cases (32%) and only at 6 o'clock position in 23 cases (5.2%). The recurrence rate was 15.7% (69 cases) after a follow-up period of 2 to 36 months. In 37 cases with urethral biopsy from structural zone, we described a high recurrence rate (62.5%) with "local active inflammation". Complementary treatment with anti-inflammatory drugs reduced this rate to 10% of cases. Our significative study revealed that echographic and histopathological evaluation of US could increase the efficiency of endourological treatment in this pathology; urethral ultrasound could be the first choice in the diagnostic of US and could establish the "perfect" site of endo-incision.

[An endoscopic treatment alternative in vesico-ureteral reflux (VUR)]. / Alternativa endoscopica de tratament a refluxului vezico-ureteral (RVU).

Vesicoureteral reflux (VUR) represent an important pathology (surgical treatment was until recently the "gold standard" therapy) in urology. Between September 1995 and October 1997 we used endoscopic Romanian collagen injection in 21 cases with VUR (3 cases grade II, 14 cases grade III, 4 cases grade IV). The collagen solution (1/1 with distilled water) was injected at the 6 hour of the ureteral large ostium (15/35 ml). In some cases we obtained the perfect occlusion of the incompetent ureteral ostium by complementary injections at 3 and 9 hours. It was necessary to reinject collagen twice in 8 cases and three times in 3 cases. Success rate appeared in 66.66% cases. We did not confront ourselves with postoperative complications. Hospitalization period was 3.2 days. The mean follow-up period was 12 months (range 6 to 28). Our results prove that endoscopic collagen injection applied in VUR is a simple, efficient, without complications method, minimally invasive.