A Proposal for Data Registry system for Urologic Cancers in Iran.

PURPOSE: Data registries are organized systems that facilitate collection, storage, and analysis of data related to a specific disease in a defined population. Here we introduce a data registry system which was designed to cover the four most common urologic cancers (prostate, bladder, renal and testis). MATERIALS AND METHODS: All contributing centers can enter data into the system after logging in with their unique usernames and passwords. In this system, the information of each individual patient will be entered in several structured forms covering various steps of management of the patients. RESULTS: Our proposed registry is an interactive, web-based database designed to collect complete data of patients with common urological cancers. We devised a council that functions as the central committee that will initiate, supervise, and monitor all steps of the projects including data collection, data audit, as well as data analysis and publication. To facilitate manuscript publication, the system will provide assistance and support throughout all the steps of statistical analysis and manuscript preparation. CONCLUSION: This proposed registry can have a national target and is designed to provide evidence-based information that could support strategic planning and national multi-centric studies.

Laparoscopic Donor Nephrectomy Is a Safe Surgical Approach in Healthy Obese Kidney Donors: A 10-Year Single-Center Retrospective Study.

OBJECTIVES: A lack of donors continues to be a significant problem. Kidney donors with a body mass index ≥ 30 kg/m² are not suitable for laparoscopic donor nephrectomy; however, some studies have suggested that an obese donor could be an appropriate donor with similar surgical outcomes. Here, we report the results of our 10-year experience of laparoscopic donor nephrectomy, examining the effects of body mass index on the surgical results of laparoscopic donor nephrectomy. MATERIALS AND METHODS: We retrospectively reviewed medical records of patients who underwent laparoscopic donor nephrectomy at the Shahid Beheshti University Medical Science, Urology Center (Tehran, Iran) from 2005 to 2015. The collected information included pretransplant and posttransplant serum levels of hemoglobin and creatinine. We also collected data on surgical outcomes (operation time, cold and warm ischemia, need for blood transfusion, and conversion to open surgery, length of hospital stay, and complication rates) with respect to body mass index categories (≤ 24.9, 25-29.9, and ≥ 30 kg/m²). RESULTS: Of 1083 kidney donors, 732 donors had body mass index of ≤ 24.9 kg/m², 256 had body mass index between 25 and 29.9 kg/m², and 95 had body mass index of ≥ 30 kg/m². Differences among groups were not significant in terms of operation time (P = .558), warm or cold ischemic time (P = .829 and .951, respectively), blood transfusion (P = .873), and length of hospital stay (P = .850). CONCLUSIONS: The laparoscopic approach for donor nephrectomy is a safe and effective method in obese donors without significant postoperative complications.

Laparoscopic pyelolithotomy in patients with previous ipsilateral renal stone surgery.

OBJECTIVES: To evaluate the safety and efficacy of transperitoneal laparoscopic pyelolithotomy in renal stone cases with previous renal surgeries. PATIENTS AND METHODS: In this prospective study, 190 consecutive patients with renal stones, who were candidates for transperitoneal laparoscopic pyelolithotomy, were enrolled. The patients were divided into two groups. In group A, 163 patients without a history of renal surgery underwent standard laparoscopic pyelolithotomy, whereas in group B laparoscopic pyelolithotomy was performed in 27 patients with a history of kidney stone surgery including percutaneous nephrolithotomy or open stone surgery. All intraoperative data including the operating time and complications such as bleeding requiring transfusion were recorded. Postoperative data such as length of hospitalization, hemoglobin level alteration, and other complications were also recorded. RESULTS: There was no significant difference in the preoperative data such as stone size, stone site, age, sex, and stone side between the two groups. There was no significant difference in the stone-free rate between the two groups (p = 0.4). There was no significant difference between the two study groups regarding the operating time, hospital stay, stone-free rate, complications, and transfusion rate. CONCLUSION: Laparoscopic pyelolithotomy can be used as a safe and feasible treatment modality in the setting of previous renal surgery. The complications and stone-free rate of laparoscopic pyelolithotomy in patients with history of renal surgery are acceptable.

Partial nephrectomy and positive surgical margin, oncologic outcomes and predictors: a 15-year single institution experience.

INTRODUCTION: The aim of this article was to compare oncological outcomes after partial nephrectomy between patients with positive (PSM) and negative (NSM) surgical margins. MATERIAL AND METHODS: In this retrospective study, the data of 733 patients who underwent partial nephrectomy with diagnosis of renal cell carcinoma (RCC) were analyzed. A total of 80 patients from the NSM group were matched to 42 PSM patients. The Kaplan-Meier method was used to estimate freedom from local disease recurrence and metastatic progression and overall survival. Cox proportional hazards models were used to assess the predictors for recurrence/metastasis. RESULTS: The mean age was 58.4 ±11.4 years (range: 29 to 82). Median follow-up was 24 months (IQ25-75: 15-36.2). A total of 5 patients from the PSM group (6.2%) developed local recurrence and metastasis was detected in 2 (2.5%) of them while no metastasis or recurrence was observed in the NSM group. In the multivariate analysis, positive surgical margin was the only independent predictor for recurrence/metastasis (HR[CI] = 0.19[0.04-0.75], p = 0.019). Recurrence-free survival was higher in the NSM group (100% for the NSM group vs 88.1%, p = 0.002) and recurrence/metastasis-free survival was also higher in the NSM group (100% for the NSM group vs 85.7%, p = 0.001), but there were no differences in overall survival between the two groups (96.3% for the NSM group vs 97.6% for the PSM group, p = 0.68). CONCLUSIONS: Although tumor recurrence was more prevalent in positive surgical margin patients who underwent partial nephrectomy, there were no differences in overall survival between the two groups. Therefore, active surveillance against further surgery would be a proper option after finding the tumor-involved margins.

Laparoscopic Pyelolithotomy for A Staghorn Stone in A Patient with History of Cystectomy and Ileal Conduit.

Laparoscopic pyelolithotomy has recently been introduced for renal stones. However, the use of this technique is limited in patients with history of extensive abdominal surgeries. We present a case of right side staghorn renal stone with history of abdominal open cystectomy who underwent laparoscopic pyelolithotomy with uneventful outcome.

Laparoscopic Pyelolithotomy for the Management of Large Renal Stones with Intrarenal Pelvis Anatomy.

PURPOSE: The role of laparoscopic pyelolithotomy (LPL) in the management of renal stones is evolving. One of the challenges in LPL for renal stones is patients with intrarenal pelvis. Here we present our experience with laparoscopic pyelolithotomy for the management of renal stones with intrarenal pelvis anatomy. MATERIALS AND METHODS: Patients candidate for laparoscopic pyelolithotomy from February 2014 to March 2015 were included. Intrarenal pelvis was defined as > 50% of the renal pelvis area contained inside renal parenchyma. Laparoscopic pyelolithotomy was done by transperitoneal approach. Residual stones were checked by computed tomography and/or intravenous pyelography and ultrasonography 6 weeks after the operation. RESULTS: 28 patients were included in this study. The mean±SD of patients' age was 45.8±12.5 years. 19 patients (68%) were male. Stone locations were pelvis, multiple, and staghorn in 22, 3, and 3 patients respectively. The mean±SD of operation duration was 160±48 minutes. Residual stones were observed in 3 patients with multiple (n=2) or staghorn (n=1) stones. Urinary leak was observed in 3 patients and was managed conservatively in 2 patients. In one patient ureteral stent was inserted by cystoscopy. No conversion to open surgery or re-operation occurred. CONCLUSION: Laparoscopic pyelolithotomy is a feasible operation for patients with renal stones and intrarenal pelvis in centers with adequate experience in laparoscopy. However, the success of LPL decreases in patients with multiple stones and intrarenal pelvis.

Percutaneous nephrolithotomy of staghorn renal stones in pediatric patients using adult-sized instrument.

INTRODUCTION: In this study, we aimed to evaluate the safety and efficacy of the percutaneous nephrolithotomy procedure performed with adult-sized instruments in pediatric cases with staghorn kidney stone. METHODS: We retrospectively evaluated the efficacy and safety of 94 percutaneous nephrolithotomy procedures performed during 15 years in a single center for 82 pediatric patients with staghorn calculi using adult-sized instruments (24-Fr nephroscope). Stone free status was defined as complete clearance of the stones or the presence of insignificant residual stones of <3 mm in diameter. RESULTS: The mean age was 108 ± 53 months (range, 14-180 months). There were 39 patients (48%) with complete staghorn stones and 43 cases (52%) with partial staghorn. We fulfilled 91.4% of operations through a single access. The stone free rate was 86.6% after one percutaneous nephrolithotomy session. In total, seven patients referred for shock wave lithotripsy and four cases were scheduled for the second percutaneous nephrolithotomy session. Fever occurred in 18 patients (21%) and bleeding requiring transfusion in four children (5%). Prolonged leakage from nephrostomy site requiring anesthesia for double J stent placement occurred in one patient. No grade IV or V Clavien complication occurred. CONCLUSION: The success rate and complications of percutaneous nephrolithotomy with adult-size instruments in pediatric patients are acceptable.

A New Touchless Technique for Suturing in Transperitoneal Laparoscopic Pyeloplasty.

BACKGROUND: The most difficult, time-consuming, and critical steps of laparoscopic pyeloplasty (LPP) are ureteral spatulation, apical ureteral stitch placement, and ureteropelvic anastomosis. To simplify these critical steps, avoid the risk of ureteral shortening, and also minimize ureteral manipulation, we present a modified dismembered technique for suturing with the outcome of patients who underwent LPP using this technique. MATERIALS AND METHODS: This study included 23 patients who were candidates for transperitoneal dismembered Anderson-Hynes LPP. The ureter was partially cut just below the ureteropelvic junction. The ureter was spatulated at its lateral aspect to cross the obstruction site and reach the normal ureter. The renal pelvis was obliquely cut equal to the size of ureteral spatulation. The ureter and pelvis were still connected partially. At this point, the first stitch was placed between the lower point of the spatulated ureter and the lowest corner of the renal pelvis. Anastomosis was performed by running sutures. RESULTS: No cases of internal organ injury and no cases of open surgery conversion were encountered. The radiologic success rate was 96%. After operation, in 1 patient, obstruction still existed and the patient underwent nephrectomy due to a nonfunctional obstructive kidney. CONCLUSIONS: This modification preserves total ureteral length and facilitates spatulation and suturing in transperitoneal laparoscopic dismembered pyeloplasty. The results showed that it is a useful method, especially for less-experienced surgeons.

Role of the gonadal vessels on the stone lodgment in the proximal ureter: Direct observation during laparoscopic ureterolithotomy.

INTRODUCTION: Previous radiological studies revealed that stones lodge more frequently in the ureterovesical junction (UVJ) as well as the proximal ureter. Factors that prevent stone passage from the proximal ureter are not well studied. AIM: To explore the site of the lodged stones in the proximal ureter with direct observation during laparoscopic ureterolithotomy. MATERIALS AND METHODS: Between November 2014 and February 2015, we included 26 patients including 18 men and 8 women with stones larger than 10 millimeters in the proximal ureter who were candidate for laparoscopic ureterolithotomy. We prospectively recorded the site of the lodged stones in the ureter during laparoscopic ureterolithotomy in relation with the sites of ureteral stenosis as well as the gonadal vessels. RESULTS: Among 26 patients with ureteral stone, in 19 cases stone was found close to the gonadal vein compared with seven cases that stone was in other locations of the ureter (p = 0.02). The characteristics of patients and stones were not different in cases that the stone was close to gonadal vessels compared with other locations. CONCLUSIONS: This study showed that most of the stones lodged in the proximal ureter were in close proximity with gonadal vessels. Gonadal vessels may be an extrinsic cause of ureteral narrowing.

Laparoscopic management of paraganglioma in a pregnant woman: a case report

ABSTRACT Introduction: Paraganglioma is an extremely rare catecholamine-producing tumor during pregnancy. Paraganglioma carries high risks of fetal and maternal mortality during pregnancy. We report a pregnant woman with paraganglioma in the second trimester. Case Description: A 24-year-old pregnant woman presented with severe hypertension in the 17th week of gestation. Hormonal examination and Magnetic Resonance Imaging (MRI) confirmed the diagnosis of extra adrenal pheochromocytoma (paraganglioma). She underwent laparoscopic tumor excision successfully. Conclusions: A high index of suspicion is needed to diagnose paraganglioma in a pregnant patient with hypertension. Laparoscopic tumor removal for paraganglioma seems to be a feasible and safe procedure during pregnancy.

Laparoscopic management of paraganglioma in a pregnant woman: a case report.

INTRODUCTION: Paraganglioma is an extremely rare catecholamine-producing tumor during pregnancy. Paraganglioma carries high risks of fetal and maternal mortality during pregnancy. We report a pregnant woman with paraganglioma in the second trimester. CASE DESCRIPTION: A 24-year-old pregnant woman presented with severe hypertension in the 17th week of gestation. Hormonal examination and Magnetic Resonance Imaging (MRI) confirmed the diagnosis of extra adrenal pheochromocytoma (paraganglioma). She underwent laparoscopic tumor excision successfully. CONCLUSIONS: A high index of suspicion is needed to diagnose paraganglioma in a pregnant patient with hypertension. Laparoscopic tumor removal for paraganglioma seems to be a feasible and safe procedure during pregnancy.

Fluoroscopy-free ultrasonography-guided percutaneous nephrolithotomy in pediatric patients: a single-center experience.

OBJECTIVES: To present the safety and efficacy of fluoroscopy-free ultrasound-guided PCNL for the treatment of renal calculi in pediatric patients of all ages. METHODS: 30 children with mean age of 5 years (6 months-12 years) underwent totally ultrasound-guided PCNL from March 2013 to August 2016. The pyelocalyceal system was punctured in prone position using only ultrasonography guidance, and the tract was dilated using a single shot dilation technique. No fluoroscopy was used during any of the stages of renal access. The procedure was performed using adult-sized instruments. RESULTS: The mean stone size was 27.1 ± 8.7 mm. Mean access time was 4.3 ± 2 min. Mean nephroscopic time was 34.6 ± 15.2 min. Mean hospital stay of patients was 3 days (range 2-5). 21 patients were stone-free after the procedure (70% success rate). Only four patients out of 30 experienced postoperative complications. CONCLUSIONS: The results of this study showed that fluoroscopic-free ultrasound-guided PCNL in pediatric patients of all ages is safe, highly efficient, and minimizes potential radiation exposure risks associated with the procedure.

Comparing the Efficacy and Safety of Ultrasonic Versus Pneumatic Lithotripsy in Percutaneous Nephrolithotomy: A Randomized Clinical Trial.

BACKGROUND: Percutaneous nephrolitotomy (PCNL) is the preferred treatment for large renal stones. There is a need for more comparative data for different lithotripters used in PCNL. OBJECTIVE: To evaluate the comparative safety and efficacy of ultrasonic and pneumatic lithotripsy in patients undergoing PCNL. DESIGN, SETTING, AND PARTICIPANTS: This randomized clinical trial was conducted at Labbafinejad University Hospital, Tehran, Iran. A total of 180 patients were selected and divided randomly into two groups: 88 patients to pneumatic and 92 to ultrasonic lithotripsy. INTERVENTION: Standard fluoroscopy-guided PCNL was performed using pneumatic or ultrasonic lithotripsy. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary outcome was the procedure success rate. We also evaluated other outcome measures including operation time, stone fragmentation and removal time (SFRT), length of hospital stay, and postoperative complications. We used SPSS software version 18.0 for data analysis. RESULTS AND LIMITATIONS: The two groups were similar in baseline characteristics. There were no significant differences between the groups in stone fragmentation and removal time (p=0.63), stone free rate (p=0.44), and hospital stay (p=0.66). SFRT for hard stones was shorter using pneumatic lithotripsy (p<0.001). By contrast, ultrasonic lithotripsy was associated with a shorter SFRT for soft stones (p<0.001). Postoperative complications were similar in the two groups. A limitation of this study might be the 3-mo follow-up period. CONCLUSIONS: In general, there were no significant differences in the success rate and complications between pneumatic and ultrasonic lithotripsy. SFRT was significantly shorter using pneumatic lithotripsy for hard stones, and ultrasonic lithotripsy for soft stones. PATIENT SUMMARY: We found no significant differences in the success rate and complications of percutaneous nephrolitotomy using pneumatic and ultrasonic lithotripsy. Ultrasonic and pneumatic lithotripsy differed in the time for stone fragmentation and removal for hard and soft stones.

Sleep Pattern, Duration and Quality in Relation with Glycemic Control in People with Type 2 Diabetes Mellitus.

Sleep disturbances have been shown to be associated with diabetes control, but the relation between planned wakings or napping with glycemic indices has not been evaluated yet. This study evaluated the relation between sleep quality, duration, and pattern, including daytime napping of people with diabetes and their glycemic control. A cross-sectional correlation research design was used for this study. We enrolled 118 people with type 2 diabetes receiving oral agents without major complications at the Shahid Bahonar Center, Kerman. The age, weight, height, serum HbA1c, as well as other glycemic indices and lipid profile were measured. BMI was also calculated. All participants were requested to fill in the Pittsburgh Sleep Quality Index (PSQI) questionnaire to evaluate their sleep quality. In addition, they were inquired about their sleep schedule during day and night. Pearson correlation and multiple regression analyses were conducted to examine the correlation between HbA1c and sleep pattern variables. The variables were also compared between participants with or without napping using t-test. All analyses were performed with the SPSS version 19 (SPSS, Chicago, IL, USA). The mean age was 58±11 years and mean HbA1c (%) was 7.8±11 (62±13 mmol/mol). Sleep duration and the number of sleep segments significantly predicted HbA1c (F (2,114)=5.232, P=0.007, R2=0.084). A one-hour increment in sleep duration was associated with a 0.174% (1.4 mmol/mol) decrement in HbA1c. PSQI score did not contribute to the regression model. Moreover, participants who napped (66%) had a lower HbA1c (7.6±1) compared to others (8.1±1.3) (P=0.04). We concluded that napping and segmented sleep are associated with a better glycemic control in type 2 diabetes and there is a linear correlation between sleep duration and better glycemic control.

Percutaneous Nephrolithotomy Using Split Amplatz Sheath: A Randomized Clinical Trial.

PURPOSE: To compare the outcome of percutaneous nephrolithotomy (PCNL) using split or intact Amplatz sheath. MATERIALS AND METHODS: Seventy two patients who underwent PCNL were randomly divided into two groups; PCNL using intact (group 1) and split (group 2) Amplatz sheath. Preoperative data, operative time, largest extracted stone size, fluoroscopy and lithotripsy time, and serum biochemistry tests before and after PCNL were evaluated. RESULTS: Preoperative features and stone size were not significantly different between the groups. There were no significant differences in complications and postoperative changes in hemoglobin and serum electrolytes. Stone free rate in group 2 (88.1%) was insignificantly higher than group 1 (83.3%) (p = .05), but in staghorn stones and stones larger than 1000 mm2, stone free rate in group 2 was significantly higher than group 1 (82% vs. 72%). The mean extracted stone size in group 2 (150 ± 49) was significantly larger than group 1 (40 ± 16 mm2) (p < .005). The mean operative, lithotripsy and fluoroscopy times were significantly longer in group 1. CONCLUSION: Using split Amplatz sheath in PCNL facilitates extraction of larger stone fragments which could contribute to shorter fluoroscopy, lithotripsy and operative times. .

Solo Sonographically Guided PCNL under Spinal Anesthesia: Defining Predictors of Success.

Aim. Sonography has been brought in percutaneous nephrolithotripsy (PCNL) as an adjunct to or substitute for X-ray to restrict radiation exposure. This study was designed to investigate the possible predictors for the success of the solo sonographically guided PCNL. Methods. 148 consecutive cases were prospectively enrolled. All steps of PCNL were performed solely with sonography guidance under spinal anesthesia. Residual stones were evaluated the day after surgery using sonography and plain radiography. Results. The mean age was 46 ± 15 years; 40% of kidneys had hydronephrosis. The mean stone burden was 504 ± 350 mm(2). The mean duration of surgery was 43 ± 21 minutes. The early stone-free rate was 92% in inferior or middle calyceal stones, 89.5% in single pelvic stones, 81.5% in partial staghorn stones, and 61.9% in staghorn stones. The mean residual stone size was 13 ± 8 mm. Logistic regression showed that a lower age and a larger stone burden significantly predicted positive residual stones. Fifteen percent of patients presented with grade I or II and six percent showed grade III complication based on Clavien classification. There was no cases of organ injury or death. Conclusion. Solo ultrasonographically guided PCNL under spinal anesthesia is feasible with an acceptable stone-free rate and complication rate.

When Health Diplomacy Serves Foreign Policy: Use of Soft Power to Quell Conflict and Crises.

OBJECTIVE: Health diplomacy has increasingly become a crucial element in forging political neutrality and conflict resolution and the World Health Organization has strongly encouraged its use. Global turmoil has heightened, especially in the Middle East, and with it, political, religious, and cultural differences have become major reasons to incite crises. METHODS: The authors cite the example of the human stampede and the deaths of over 2000 pilgrims during the 2015 annual Haj pilgrimage in Mecca. RESULTS: The resulting political conflict between Iran and Saudi Arabia had the potential to escalate into a more severe political and military crisis had it not been for the ministers of health from both countries successfully exercising "soft power" options. CONCLUSION: Global health security demands critical health diplomacy skills and training for all health providers. (Disaster Med Public Health Preparedness. 2016;page 1 of 4).

X-Ray Free Minimally Invasive Surgery for Urolithiasis in Pregnancy.

PURPOSE: Our goal was to present our experience with ultrasound guided supine or prone percutaneous nephrolithotomy in three pregnant women under spinal anesthesia. MATERIALS AND METHODS: Three pregnant women in the 16th, 20th and 28th weeks of pregnancy presented with symptomatic large renal stone in the first patient and multiple renal stones in the second and third patients which were unresponsive to conventional medical therapy. They requested a definitive stone treatment. The operations were done in November 2012, June 2014 and February 2015. Data was gathered prospectively. All steps of gaining access to the pyelocalyceal system including needle insertion, tract dilation, and Amplatz sheath placement were performed under ultrasonography guidance. Tract was dilated with a single shot technique. The first two procedures were performed in supine position and the third procedure was performed in lateral flank position. RESULTS: Two patients were stone-free postoperatively and one patient had only an asymptomatic 4 mm residual stone. They were discharged on the 2nd postoperative day and had an uneventful postoperative course. No fever, bleeding or renal colic was noticed during postoperative hospitalization. All patients delivered their fetuses at term without any abnormality reported by the examining pediatric specialist after their birth. CONCLUSION: Ultrasonography can be used as an imaging modality guiding all steps of obtaining percutaneous access in pregnant women. Supine or flank ultrasound guided percutaneous nephrolithotomy can be offered to pregnant women in whom conservative measures fail to the patients' wellbeing.

Castleman Disease Presenting as Renal Hilar Mass.

BACKGROUND: We report a case of unicentric Castleman disease, a rare type of benign proliferation of lymphoid tissue. We present an uncommon disease that was managed effectively using laparoscopy. CASE PRESENTATION: A 32-year-old woman presented with left-sided flank pain. A large retroperitoneal mass was detected in the left renal hilum close to the renal vessels. Laparoscopic removal of the mass was effectively performed. The pathologic examination was in favor of a rare type of benign proliferation of lymphoid tissue compatible with Castleman disease. The patient was cured with no evidence of recurrence in 1-year follow-up. CONCLUSION: Transperitoneal laparoscopic approach is feasible and effective in the management of this disease and is curative.