Supine mini percutaneous nephrolithotomy in horseshoe kidney.

OBJECTIVE: The percutaneous nephrolithotomy (PCNL) in Horseshoe kidneys (HSK) is usually performed in the prone position, allowing entry through the upper pole and providing good access to the collecting system. However, in patients with normal kidney anatomy, the supine position is reliable and safe in most cases, but it is unknown whether the supine position is adequate in patients with HSK. The purpose of this study was to describe the results of PCNL in HSK in three different surgical institutions and to evaluate the impact of supine position during surgery, comparing pre-operative and post-operative data, complications, and stone status after surgery. MATERIAL AND METHODS: Between 2017 and 2022, a total of 10 patients underwent percutaneous renal surgery for stone disease in HSK. All patients were evaluated pre- and post- operatively with non-contrast CT. we evaluated patients (age and gender), stones characteristics (size, number, side, site and density ), and outcomes. The change in haemoglobin, hematocrit, creatinine and eGFr were assessed between the most recent preoperative period and the first postoperative day. Procedure success was defined as stone-free or presence of ≤4 mm fragments (Clinically Insignificant residual Fragments - CIrF). Complications were registered and classified according to Clavien-dindo Grading System, during the 30 - day postoperative period and Clavien scores ≥ 3 were considered as major complications. Statistical analysis was performed using "r 4.2.1" software, with a 5% significance level. we also compared pre-operative and post-operative data using "wilcoxon signedrank test". RESULTS: No statistical difference was observed between preoperative and post-operative renal function data. At one post operative day CT scan, an overall success rate of 100% was registered. 9/10 patients were completely free from urolithiasis (stone-free rate: 90%), while 1/10 patients had ≤4 mm residual stone fragments (CIrF rate: 10%). No cases of intraoperative complications were registered. Post-operative complications were reported in 1/10 patients. A patient developed urosepsis (defined as SIrS with clinical signs of bacterial infections involving urogenital organs - Clavien-dindo Grade II) after procedure, and was treated with intravenous antibiotic therapy successfully.  Conclusions: This study shows that in patients with HSK mini- PCNL in supine position allows to achieve good stone free rate with a very low morbidity. According to our series, the described technique for PCNL in HSK should be an option. Nevertheless these results must be confirmed by further studies.

Complications of endourological procedures and their treatment.

Endourological treatment for urinary stones and other obstructive urinary tract diseases is minimally invasive but in some cases it involves serious complications. This collection of cases describes some complications of endourological procedures and how they were treated. Case 1: A case of right ultrasound-guided percutaneous nephrostomy found to be misplaced in the inferior vena cava. The case was safely managed, but it showed that ultrasound guidance alone may be insufficient so it is recommended that percutaneous nephrostomy should be always placed under fluoroscopic control, either alone or in combination with ultrasound guidance. Case 2: A case of renal subcapsular hematoma occurring on retrograde intrarenal surgery at high perfusion pressure. The hematoma was drained under combined ultrasonic and radiological guidance. Post treatment recovery was uneventful. Large stone size, severe ipsilateral hydronephrosis, long operation time, higher hydrostatic pressure of the irrigating solution and low ureteral wall compliance are supposed to be risks factors associated with renal subcapsular formation. Management strategy should be tailored to patient's clinical conditions. In hemodynamically stable patients, large hematoma drainage is recommended to prevent further complications and favours early recovery. Case 3: A case of double J stent fracture discovered one month after the insertion to relieve obstruction from a 1 cm stone in the right proximal ureter. The distal fragment of the stent was removed by cystoscopy while the proximal fragment was removed by semirigid ureteroscopy in two sessions due to fever and extensive calcification. Case 4: A mini-invasive technique for transurethral replacement of completely encrusted urinary stents in female patients. This technique allows the interventional radiologist to replace obstructed urinary stents by avoiding more invasive and traumatic urological procedures with sedation.

Ureteral iliac artery fistula in idiopathic retroperitoneal fibrosis: A case report.

Ureter-arterial fistula (UAF) is an uncommon condition. The presentation is usually a life-threatening intermittent massive gross hematuria and the diagnosis is still a challenge for urologist. Idiopathic Retroperitoneal fibrosis (IRF) is a condition of unknown etiology characterized by a highly fibrotic retroperitoneal mass that frequently causes ureteral obstruction. To our knowledge we report the first case describing the UAF in a patient suffering from IRF. We hypothesize that inflammation and fibrosis resulted in fixation of the ureter to the adjacent artery causing a fistulous path. UAF was managed by deploying a 10 x 59 mm endo-graft at the intersection of common iliac artery bifurcation with the right ureter. Post treatment course was uneventful.

Clinical and psychological outcomes of patients undergoing Retrograde Intrarenal Surgery and Miniaturised Percutaneous Nephrolithotomy for kidney stones. A preliminary study.

PURPOSE: To assess disease-specific and health-related QoL, anxiety and depression as well as satisfaction regarding retrograde intrarenal surgery (RIRS) and miniaturized percutaneous nephrolithotomy (mPCNL) intervention for kidney stones up to 2.5 cm. Secondarily, pain as well as perioperative and postoperative patient outcomes were evaluated. METHODS: 60 consecutive patients with kidney stones of dimensions not exceeding 2.5 cm were enrolled in the study of which 30 underwent RIRS and 30 mPCNL. Perioperative characteristics (age, gender, body mass index (BMI), stone side and size, previous interventions for kidney stones and duration of hospitalization) and surgical outcomes (hemoglobin drop, stone-free rate, visual analogue scale (VAS), stenting time, size of ureteral access sheath (UAS) deployment, and postoperative complications) of patients were collected. Quality of life and psychological outcomes were evaluated using validated questionnaires. RESULTS: No significant differences were found between the two groups in terms of age, gender, BMI, stone side and size (p > 0.05). Significant differences between the mPCNL and the RIRS groups were found regarding stenting time (p = 0.032) and duration of hospital stay (p < 0.001). The stone-free rates of mPCNL vs RIRS were not significantly different between the two groups (73.3% vs 66.7%, p > 0.05). Peri- and postoperative complications were not statistically different between the two groups (p > 0.05). RIRS group reported higher anxiety and depression scores compared with the mPCNL group (3 [range 0-15] vs 15 [range 6-24], p < 0.01). We found significant differences between the two groups in social (p < 0.05) and vitality (p < 0.01) scores. VAS pain score was significantly lower in the mPCNL group than in the RIRS one (p < 0.05). CONCLUSIONS: These results open new scenarios in the treatment of kidney stones up to 2.5 cm when RIRS and mPCNL have interchangeable indications. Since in our experience complications and success rate are similar, the surgical choice of switching from RIRS to mPCNL in real-time and viceversa may be proposed to the patient in the preoperative counseling.

Subcapsular Kidney Urinoma After Percutaneous Nephrolithotomy.

Background: A rare percutaneous nephrolithotomy (PCNL) complication and its management is reported. Case Presentation: A male patient, 43 years of age, underwent PCNL for a large left pyelocaliceal stone. Surgery was performed in the Valdivia-Galdakao supine position. The percutaneous tract was established by combined radiologic and sonographic guidance. The tract was dilated by balloon and a 24F Amplatz sheath was located. As complete clearance was not achieved because of a residual lower pole caliceal stone, a ureteral Double-J and a 20F nephrostomy were located for a second-look PCNL through the same tract after 7 days. After second-look PCNL residual stone was still not cleared because it was unreachable through the tract established and the patient was discharged without nephrostomy and with the ureteral stent, retrograde intrarenal surgery (RIRS) was planned in 3 to 4 weeks. Hemoglobin, hematocrit, and the renal function were normal. On the seventh day after PCNL, no leakage was detected from the percutaneous tract, but the patient started to complain about flank discomfort and fever. Imaging showed a 6 cm lower pole subcapsular collection. After 3 days of conservative management with antibiotics, the subcapsular collection did not resolve and a percutaneous 6F mono-J drainage in the collection was placed. Drain output was at first purulent and evolved into urine throughout the following days. Drain urine culture was positive for Escherichia coli infection and carbapenemic-targeted antibiotic was offered to the patient. Collection drained about 400 cc in 7 days and the drain was removed when the output was less than 10 cc per day. No late complications were reported and RIRS was scheduled in 1 month to clear the residual stone. Conclusion: Subcapsular urinoma post-PCNL is an uncommon but severe complication. Prompt and correct drainage may solve it.

Split-leg percutaneous nephrolithotomy: a safe and versatile technique.

OBJECTIVES: Percutaneos nephrolithotomy (PCNL) is the gold standard for treatment of urinary stones larger than 2 cm and refractory to ESWL. Nowadays most debate about surgical technique is related to the positioning of patients. We report our expe- rience on prone PCNL with split-leg variant (SL-PCNL) MATERIALS AND METHODS: 30 consecutive patients underwent prone SL-PCNL. Preoperative stone size was deter- mined by measuring stones longest diameter on CT scan. In cases with multiple stones, stone size was determined by the sum of each stone diameter on CT scan. Patients evaluated con- sisted of 20 females and 10 males and median age was 55 (20-72). The average BMI was 27 (24-35). 15 patients had multiple stones, 10 pyelocalicial, 10 pelvic larger than 2 cm, 2 in horseshoe kidneys and 3 staghorn stones. RESULTS: Stone free rate was 87% after first look and 97% after second look. In 2 cases, we used a flexible ureteroscopy 7.5 Fr (Flex 2 - Storz) to treat a calculus in ureter or for a contemporary double access (Endoscopic combined Retrograde Intrarenal Surgery ECIRS). In 28 cases we placed a 20 fr nephrostomy while in two cases procedure was tubeless. In 20 cases we placed a double-J catheter. In 2 cases we performed two tract and in 2 horseshoe kidneys access was close to spine. The average surgical time was about 90 minutes (range 30-120 minutes). Hemoglobin drop was about 1.5 mg/dl (range 1-3 .4 mg/dl) and no major complications were reported. CONCLUSIONS: In our experience PCNL in prone with spread-legs variant is a versatile technique and allows to match the advantages you have with same technique in supine, providing at the same time benefits in cases of anatomical abnormalities, challenging cases, or when multi-tract accesses are required.

NOTES hybrid transvaginal radical nephrectomy for tumor: stepwise progression toward a first successful clinical case.

BACKGROUND: Natural orifice translumenal endoscopic surgery (NOTES) has been used to perform nephrectomy in the laboratory; however, clinical reports to date have used multiple abdominal trocars to assist the transvaginal procedure. OBJECTIVE: To present our stepwise technique development and the first successful clinical case of NOTES transvaginal radical nephrectomy for tumor with umbilical assistance without extraumbilical skin incisions. DESIGN, SETTING, AND PARTICIPANTS: The four transvaginal NOTES procedures were performed at two institutions after obtaining institutional review board approval. Various operative steps were developed experimentally in three clinical cases, and on March 7, 2009, we performed the first successful case of NOTES hybrid transvaginal radical nephrectomy without any extraumbilical skin incisions. Using one multichannel access port in the vagina and one in the umbilicus, laparoscopic visualization, intraoperative tissue dissection, and hilar control were performed transvaginally and transumbilically. The intact specimen was extracted transvaginally. MEASUREMENTS: All perioperative data were accrued prospectively. A stepwise progression to the successful completion of the fourth case is systematically presented. RESULTS AND LIMITATIONS: Intraoperatively, at incrementally more advanced stages of the procedure, the first three NOTES clinical cases were electively converted to standard laparoscopy because of rectal injury during vaginal entry, of failure to progress, and of gradual bleeding during upper-pole dissection after transvaginal hilar control, respectively. The fourth case was successfully completed via transvaginal and umbilical access without conversion to standard laparoscopy. Operative time was 3.7 h, estimated blood loss was 150 cm(3), and hospital stay was 1 d. Final pathology confirmed a 220-g, pT1b, 7-cm, grade 2, clear-cell renal cell carcinoma with negative margins. The patient was readmitted for an intraabdominal collection that responded to drainage and antibiotics. CONCLUSIONS: We report our stepwise progression and the initial successful clinical case of NOTES hybrid transvaginal radical nephrectomy for tumor, assisted with only one umbilical trocar. Although transvaginal nephrectomy is feasible in the highly selected patient with favorable intraoperative circumstances, considerable refinements in technique and technology are necessary if this approach is to advance beyond mere anecdote.

Ureteroscopic laser endopyelotomy in secondary UPJ obstruction after pyeloplasty failure.

OBJECTIVES: Secondary ureteropelvic junction (UPJ) obstruction after failure of open and laparoscopic repair may be challenging to resolve due to possible extensive fibrosis and the increased invasiveness of this procedure. Alternatively, ureteroscopic laser endopyelotomy may be a more acceptable procedure for patients and surgeons. We report our preliminary experience with ureteroscopic holmium laser endopyelotomy after open pyeloplasty failure and define the complications that arose and the results. MATERIALS AND METHODS: We performed 6 retrograde endopyelotomies with a holmium laser for failed UPJ repairs following the Anderson-Hynes procedures. Patient follow-up was carried out every 3 months using sonography and renal scan, and again after 1 year using renal scan and urography. RESULTS: Mean hospitalization was 2.1 days. Ureteroscopic laser endopyelotomy was successful in 4 cases (66.6%). In 2 patients, failure occurred at the third month of follow-up. Complications included 1 case of slight bleeding, which was resolved conservatively without the need for blood transfusion, and 2 cases of guidewire rupture. CONCLUSIONS: Secondary UPJ obstruction is more challenging to resolve by open or laparoscopic approach. Retrograde endopyelotomy gives a valid alternative thanks to its success rate and its better acceptance by patients. We consider retrograde laser endopyelotomy the approach to choose when faced with secondary UPJ obstruction after open or laparoscopic failures.

Proposed urodynamic pressure-flow nomogram to diagnose female bladder outlet obstruction.

OBJECTIVE: To investigate female bladder outlet obstruction by urodynamics and create a nomogram to propose in clinical applications. PATIENTS AND METHODS: We investigated by urodynamic studies 200 women referred for lower urinary tract symptoms. A total of 179 patients were available for analysis: 136 served as control and 43 as obstructed. The following urodynamic variables were studied and compared in both groups: Free peak urinary flow (Free Qmax), intubated peak urinary flow (Qmax P/F), Free voiding time, pressure-flow voiding time, Detrusor pressure at peak flow rate (PdetQmax), Maximum detrusor pressure (PdetMax), Free postvoiding residual, Pressure-flow postvoiding residual. All data are presented according to descriptive statistics as mean and standard deviation (SD). Comparisons between the control and between the obstructed group were performed by means of Student's t test for equality of means, p<0.01 were considered significant. By creating ROC curves we calculated sensitivity, specificity, and positive and negative predictive values in all the patients data to derive the optimal combination of Maximum flow together with detrusor pressure at maxflow, and Maximum flow together with Maximum detrusor pressure. RESULTS: Free peak urinary flow (Free Qmax) was 26.6+/-11 ml/seconds for the control and 10.9+/-3.6 ml/seconds for the obstructed group (p<0.001). Qmax P/F were 22+/-8.7 cm water in the control group and 10+/-3.9 cm water in the obstructed group (p<0.001). Free voiding time were in both 28.2+/-15 seconds and 48+/-24 seconds (p<0.001) respectively; P/F voiding time were 41.4+/-21 seconds and 78.2+/-52 seconds (p<0.001) respectively. PdetQmax in control and obstructed group were 17.2+/-11.3 and 27.6+/-12.5 cm water (p<0.001) respectively. PdetMax were 25.2+/-14.0 and 39.4+/-18.9 cm water (p<0.001) respectively. Free postvoiding residual 25.1+/-37.4 and 74.6+/-79.3 cc (P<0.001). P/F postvoiding residual were respectively 24.9+/-44.7 and 96.0+/-102.6 cc (p<0.001). All the differences among the variables investigated in both groups were statistically significant. We calculated sensitivity, specificity, and positive and negative predictive values. According to receiver operating characteristics (ROC) curve analysis, the overall combining values of free max flow rate of 13 ml/sec or less and detrusor pressure at max flow rate of 22 cm water or greater we obtained a sensitivity of 55.8%, a specificity of 96.3%, a positive predictive value of 82.8% and a negative predictive value of 87.3%. Moreover we combined Max flow rate of 13 ml/sec and Maximum detrusor pressure of 38 cm water to obtain a sensibility of 48.8%, a specificity of 99.3%, a positive predictive value of 95.5% and a negative predictive values of 86%. CONCLUSIONS: Diagnosing female BOO is a challenge condition and an accepted pressure-flow nomograms are still missing. We propose our nomogram as a valid and reliable tool to investigate female bladder outlet obstruction.

Out-of-focus shockwaves: a new tissue-protecting therapy?

INTRODUCTION: It seems that vasoconstriction induced by 12 Kv shock waves reduces kidney lesions caused by subsequent application of 24 Kv shock waves. The lowest shock wave voltage to induce this protective effect is not known yet and may be lower than the common energy setting of commercial lithotripters. Because of this we propose the application of shock waves as a tissue protecting method. MATERIALS AND METHODS: Preliminary pressure measurements were performed on an experimental unmodified HM3 lithotripter (at 12 and 24 Kv), using a 20 ns rise time needle hydrophone connected to a 100 MHz digital oscilloscope. Ten pressure records were obtained at different aging of the spark plug. A new spark plug was used for each voltage. Pressure measurement were also performed on a Tripter compact lithotripter at 6 positions along the focal axis, starting at F2 and moving away from the reflector, using maximum voltage and capacitance (22 Kv, HI-2). The position on the focal axis of the Tripter Compact with the same pressure as measured at 12 Kv on the HM3 at F2 was chosen as the prophylactic treatment spot (PTS). In vivo pressure measurement were done on the Tripter Compact placing the needle hydrophone inside the lower pole of the right kidney of an anesthetized healthy 25 kg female pig. Measurements were done at the same positions mentioned above, without moving the hydrophone, inside the pig. For both in vitro and in vivo measurements, the radiopaque hydrophone was aligned with the focal axis, using the fluoroscopy system of the lithotripter. RESULTS: The mean positive pressure peak at the second focus of the HM3 lithotripter was 64 and 153 mV at 12 Kv, respectively. Coefficients of variations were 0.28 and 0.13. No significant pressure differences were detected below 700 and 2220 discharges with the HM3 and the Tripter compact, respectively. The difference peak amplitudes are all significant (p<0.01 in a one tailed test) with the exception of F2 and F2+1 Ohm. CONCLUSIONS: Prophylactic administrations of out-of-focus shock waves may reduce tissue damage during SWL. Experiments in vivo are underway in order to prove this hypothesis.

Detrusor pressure uroflowmetry studies in women: effect of 4 Fr transurethral.

PURPOSE: Pressure flow technique on males is considered a standard diagnostic procedure to investigate the voiding process, while on female this is still under investigation. Many studies have been conducted in order to establish a female bladder outlet obstruction nomograms using a 7 Fr catheter, but recently a report showed that 7 Fr catheter may adversely affect the voiding process on women. We studied the effect of 4 Fr urethral catheter in women undergoing pressure flow evaluation in order to assess any detrimental effect in the voiding process. MATERIALS: We evaluated a database of 85 patients referred for lower urinary tract symptoms. First, all patients had free uroflowmetry and then underwent pressure flow studies utilizing two catheters: a 12 Fr for filling and a 4 Fr mono J for measuring detrusor pressure. After filling we removed the 12 Fr catheter and pressure flow was performed leaving the 4 Fr only in the urethra. As positive correlation of flow rate with voided volume is well established, we selected only 33 patients who had similar prevoided volumes varying by less than 30% and free and intubated flow parameters were compared according to volume categories in order to strengthen the statistic analysis. RESULTS: In each group all the free and pressure flow parameters were not statistically different. Only in the group who voided within 250 and 500 ml we found the pressure flow voiding time to be almost longer than the free flow equivalent, but not statistically different (31.1 +/- 15 versus 56.7 +/- 49.3; p = 0.05). Furthermore we did not find any difference in free and intubated morphology of curves. CONCLUSIONS: A 4 Fr transurethral catheter does not affect adversely the voiding process in women undergoing pressure flow studies for lower urinary tract symptoms. This finding has very important clinical implications for interpreting female voiding patterns and may be considered the best tool to define bladder outlet obstruction on women.