Concurrent two surgeon approach for bilateral synchronous percutaneous nephrolithotomy: Initial experience at a University Teaching Hospital.

Percutaneous nephrolithotomy (PNL) has long been considered the bench-mark intervention for complicated urinary stones and has undergone important advancements since it was first described. Given the proven safety and efficacy of PNL, simultaneous bilateral PNL has been attempted for bilateral renal calculi to cut down on total procedure costs. To further cut down on operative time, concurrent bilateral synchronous PNL (BS-PNL) has been performed involving two surgeons, each operating concurrently on one renal unit. We performed a retrospective study to evaluate the safety and efficacy of BS-PNL in patients who consented for the procedure. Mean operative time taken from percutaneous access to skin closure was 78 min which was lower than that taken during the single surgeon approach for simultaneous bilateral PNL. Two (12%) out of 16 renal units required multiple punctures for stone clearance. Sheath size varied between 26Fr to 30Fr depending on the stone burden. Mean duration of hospital stay was 2 days. Fourteen (88%) out of 16 renal units had complete stone clearance. Fifteen (94%) out of 16 renal units had a double J stent placed for drainage. Only two patients had complications in the form of postoperative fever. In the background of already proven safety and efficacy of SB-PNL, the concurrent two surgeon approach appears to be feasible and safe with additional advantage of reduced operative time. However, the number of patients in this series were limited and a bigger and preferably multi-institutional study would be required before we can come to a definitive conclusion.

Outcomes and Complications from a Randomized Controlled Study Comparing Conventional Stent Placement Versus No Stent Placement after Ureteroscopy for Distal Ureteric Calculus < 1 cm

Ureteric stent insertion following ureteroscopic lithotripsy (URSL) is a common and widely accepted procedure. However, there is no agreement on whether a ureteric stent should be placed following an uncomplicated URSL. Furthermore, the definition of uncomplicated URSL remains debatable. To compare the efficacy, safety, and morbidity of no stent placement with the conventional stent placement after uncomplicated retrograde semirigid URS for a distal ureteric calculus of size ≤1 cm, we compared the corresponding complication rates, emergency visits, secondary interventions, and pain at follow-up. Following an uncomplicated ureteroscopic lithotripsy, 104 patients were randomized into the conventional stented group (CSG) and nonstented group (NSG). Lower urinary tract symptoms and sexual function were evaluated using validated questionnaires (IPSS + IIEF-5 + MSHQ-EjD/FSFI) preoperatively and at 4 weeks during follow-up. Pain scores at follow-up were recorded using a visual analogue scale (VAS). Patients who visited the emergency room or needed secondary interventions before the recommended follow-up time were noted. The Generalized Estimating Equations method was used to explore the difference in change in the domains of IPSS, IIEF-5, MSHQ-EjD, and FSFI between the two groups over time. A significant difference was noted in the following IPSS domains: Frequency, Urgency, Nocturia, Storage Symptoms, Total IPSS Score (p ≤ 0.001), and QoL (p = 0.002); IIEF-5 domains: Overall Score (p = 0.004); MSHQ-EjD domains: Ejaculation Bother/Satisfaction (p ≤ 0.001); and FSFI domains: Lubrication (p ≤ 0.001), Satisfaction (p = 0.006), and Overall Score (p = 0.004). There was no significant difference between the various groups in terms of distribution of emergency visits, readmission and secondary interventions, pain at follow-up (VAS), and need for long-term analgesia. Nonplacement of stents after uncomplicated URS decreases stent-related symptoms and preserves QoL without placing the patient under increased postoperative risk.

Telemedicine and Telehealth in Urology: Uptake, Impact and Barriers to Clinical Adoption.

Telemedicine has great potential in urology as a strong medium for providing patients with continuous high-quality urological care despite the hurdles involved in its implementation. Both clinicians and patients are crucial factors in determining the success of tele-consults in terms of simplicity of use and overall satisfaction. For it to be successfully incorporated into routine urological practice, rigorous training and evidence-based recommendations are lacking. If these issues are addressed, they can provide a significant impetus for future tele-consults in urology and their successful deployment, even beyond the pandemic, to assure safer and more environment-friendly patient management.

Neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR) and lymphocyte-monocyte ratio (LMR) in predicting systemic inflammatory response syndrome (SIRS) and sepsis after percutaneous nephrolithotomy (PNL).

The objective of this prospective observational study was to assess the clinical significance of neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR) and lymphocyte-monocyte ratio (LMR) as potential biomarkers to identify post-PNL SIRS or sepsis. Demographic data and laboratory data including hemoglobin (Hb), total leucocyte count (TLC), serum creatinine, urine microscopy and culture were collected. The NLR, LMR and PLR were calculated by the mathematical division of their absolute values derived from routine complete blood counts from peripheral blood samples. Stone factors were assessed by non-contrast computerized tomography of kidneys, ureter and bladder (NCCT KUB) and included stone burden (Volume = L × W × D × π × 0.167), location and Hounsfield value and laterality. Intraoperative factors assessed were puncture site, tract size, tract number, operative time, the need for blood transfusion and stone clearance. Of 517 patients evaluated, 56 (10.8%) developed SIRS and 8 (1.5%) developed sepsis. Patients developing SIRS had significantly higher TLC (10.4 ± 3.5 vs 8.6 ± 2.6, OR 1.19, 95% CI 1.09-1.3, p = 0.000002), higher NLR (3.6 ± 2.4 vs 2.5 ± 1.04, OR 1.3, 95% CI = 1.09-1.5, p = 0.0000001), higher PLR (129.3 ± 53.8 vs 115.4 ± 68.9, OR 1.005, 95% CI 1.001-1.008, p = 0.005) and lower LMR (2.5 ± 1.7 vs 3.2 ± 1.8, OR 1.18, 95% CI 1.04-1.34, p = 0.006). Staghorn stones (12.8 vs 3.24%, OR 4.361, 95% CI 1.605-11.846, p = 0.008) and long operative times (59.6 ± 14.01 vs 55.2 ± 16.02, OR 1.01, 95% CI 1.00-1.03, p = 0.05) had significant association with postoperative SIRS. In conclusion, NLR, PLR and LMR can be useful independent, easily accessible and cost-effective predictors for early identification of post-PNL SIRS/sepsis.

Super-mini percutaneous nephrolithotomy (SMP) vs retrograde intrarenal surgery (RIRS) in the management of renal calculi ≤ 2 cm: a propensity matched study.

OBJECTIVE: To compare the effectiveness and safety of Super-Mini PCNL (SMP) and Retrograde Intrarenal Surgery (RIRS) in the management of renal calculi ≤ 2 cm. PATIENTS AND METHODS: A prospective, inter-institutional, observational study of patients presenting with renal calculi ≤ 2 cm. Patients underwent either SMP (Group 1) or RIRS (Group 2) and were performed by 2 experienced high-volume surgeons. RESULTS: Between September 2018 and April 2019, 593 patients underwent PCNL and 239 patients had RIRS in two tertiary centers. Among them, 149 patients were included for the final analysis after propensity-score matching out of which 75 patients underwent SMP in one center and 74 patients underwent RIRS in the other. The stone-free rate (SFR) was statistically significantly higher in Group 1 on POD-1 (98.66% vs. 89.19%; p = 0.015), and was still higher in Group 1 on POD-30 (98.66% vs. 93.24%, p = 0.092) SFR on both POD-1 and POD-30 for lower pole calculi was higher in Group 1 (100 vs. 82.61%, p = 0.047 and 100 vs 92.61% p = 0.171). The mean (SD) operative time was significantly shorter in Group 1 at 36.43 min (14.07) vs 51.15 (17.95) mins (p < 0.0001). The mean hemoglobin drop was significantly less in Group 1 (0.31 vs 0.53 gm%; p = 0.020). There were more Clavien-Dindo complications in Group 2 (p = 0.021). The mean VAS pain score was significantly less in Group 2 at 6 and 12 h postoperatively (2.52 vs 3.67, 1.85 vs 2.40, respectively: p < 0.0001), whereas the mean VAS pain score was significantly less in Group 1 at 24 h postoperatively (0.31 vs 1.01, p < 0.0001). The mean hospital stay was significantly shorter in Group 1 (28.37 vs 45.70 h; p < 0.0001). CONCLUSION: SMP has significantly lower operative times, complication rates, shorter hospital stay, with higher stone-free rates compared to RIRS. SMP is associated with more early post-operative pain though.

A randomized trial investigating clinical outcomes and stent-related symptoms after placement of a complete intra-ureteric stent on a string versus conventional stent placement.

OBJECTIVE: To compare stent-related symptoms (SRS) associated with conventional ureteric JJ stent (CUS) placement and SRS associated with placement of a modified complete intra-ureteric stent (CIUS) with extraction suture, designed to minimize SRS, using the validated Ureteral Stent Symptom Questionnaire (USSQ). MATERIALS AND METHODS: We randomized 124 patients who had undergone uncomplicated ureteroscopic lithotripsy into a CIUS and a CUS placement group. USSQ scores were evaluated on postoperative days 1 and 7 (just before stent removal) and 4 weeks after stent removal (control values). Pain scores on a visual analogue scale (VAS) after stent removal were also recorded. Subdomain analysis of all SRS and stent-related complications were also compared. RESULTS: No significant intergroup differences were found in the domain scores for urinary symptoms (P = 0.74), pain (P = 0.32), general health (P = 0.27), work (P = 0.24), or additional problems (P = 0.29). However, a statistically significant difference was noted in VAS scores (P = 0.015). Analysis of subdomains of USSQ item scores showed the CIUS group had significantly better scores for urge incontinence (1.21 vs 1.00; P ≤ 0.001), discomfort on voiding (2.07 vs 1.50; P ≤ 0.001), difficulties with respect to light physical activity (1.131 vs 1.00; P ≤ 0.001), fatigue (1.84 vs 1.57; P = 0.002), feeling comfortable (3.68 vs 3.16; P = 0.003), need for extra help (1.96 vs 1.00; P ≤ 0.001), and change in duration of work (4.27 vs 1.86; P ≤ 0.001). However, the patients in the CIUS group were sexually inactive for the time during which the stent was indwelling (mean: 7.34 days). There was no difference in complication rates between the two groups. CONCLUSION: The use of a CIUS with strings after Ureteroscopy decreases SRS.

Use of ureteric stent related mobile phone application (UROSTENTZ App) in COVID-19 for improving patient communication and safety: a prospective pilot study from a university hospital.

INTRODUCTION: During the COVID-19 led lockdown, a reliable system to monitor ureteral stent insertion and timely removal became an important facet of their use. This study looks at the use of 'Urostentz' smartphone application (app) for stent procedures and whether it improved patient communication and safety during the lockdown. MATERIAL AND METHODS: The 'Urostentz' app was used for patients who underwent ureteric stent after ureteroscopy (URS) or percutaneous nephrolithotomy (PCNL) procedure. It is a smartphone app developed to improve patient safety, facilitate data collection, and provide an efficient interface to simplify ureteral stent tracking and patient communication. It also helps clinicians track stent-related symptoms (SRS) and provide digital remote assistance. RESULTS: A total of 33 patients registered with a mean age of 47.8 years (range:18-80) and a male: female ratio of 4.5:1. Of these, 29 (87.9%) used the Urostentz app, and 55.2% had SRS. The number of effective communication episodes ranged from 1-7/patient. Based on the symptoms and communication, stent was removed during lockdown (n = 2), within 1 week of lockdown lifted (n = 24) and within 2 weeks of lockdown lifted (n = 5). None of the patients suffered any stent-related complications and there were no cases of forgotten stents or readmissions despite the lockdown and lack of communication using standard practices. CONCLUSIONS: The Urostentz app proved to an effective medium of communication to provide guidance and personalized digital remote healthcare. It also allowed prompt removal of stents avoiding prolonged stent symptoms or forgotten stents. Such apps can have a much wider application in the post-COVID-19-era to reduce unnecessary post-procedural visits and reduce health care costs.

Fine-needle aspiration of fibrous dysplasia of bone: a worthwhile endeavor or not?

Fine-needle aspiration (FNA) is a minimally invasive technique which is enjoying ever-increasing popularity in the initial diagnosis of many pathologic processes. However, FNA diagnosis of neoplasms occurring within bones is less commonly employed and is not the preferred method in some types of bony lesions. Fibrous dysplasia is a primary neoplasm of bone for which it is not yet clear whether FNA can reliably yield adequate diagnostic material. Review of data from 82 cases of fibrous dysplasia diagnosed between 1990 and 2006 yielded six cases, in which diagnosis was initially attempted by FNA prior to open biopsy and surgical resection. Corresponding cytologic, histologic, and imaging characteristics of the cases were reviewed. Of the six cases in which initial diagnosis was attempted by FNA, only two of six (33%) yielded adequate diagnostic material. Smears of aspirated material in all cases contained nonspecific elements, including fragments of benign host bone and cartilage, bland stromal cells, adipocytes, blood, and debris. Importantly, the two positive FNA cases were dependent on the concurrent core needle biopsy (all smears of aspirate material were nondiagnostic). Even with image guidance, FNA is insufficient to obtain diagnostic material for cases of suspected fibrous dysplasia of bone. Core needle biopsy at least is recommended to obtain adequate material, and to reduce the risk of misdiagnosis due to sampling error.

Diagnosis of transmesocolic internal hernia as a complication of retrocolic gastric bypass: CT imaging criteria.

OBJECTIVE: The purpose of this study was to define the CT findings of surgically proven transmesocolic internal hernia after laparoscopic gastric bypass. CONCLUSION: Use of four CT signs should give radiologists a high degree of accuracy and confidence in recognizing internal hernia in patients who have undergone gastric bypass surgery.

Relapsing polychondritis in HIV-infected patients: a report of two cases.

Relapsing polychondritis is a rare autoimmune disease characterized by inflammation and degeneration of cartilaginous tissue. We describe the first reported cases of relapsing polychondritis in patients with human immunodeficiency virus (HIV) and no associated connective tissue diseases. The relationship between autoimmune and HIV diseases is complex and unclear. Treatment of HIV disease with antiretroviral therapy and subsequent immune restoration may lead to the development of autoimmune diseases in genetically susceptible individuals.

Internal hernias after laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Laparoscopic gastric bypass (Lap-RYGB) is an increasingly common procedure performed for severe obesity. Internal hernias are a potential problem associated with Lap-RYGB, and little is known about the clinical presentation and the diagnostic accuracy of this potentially serious complication. METHODS: A retrospective review of 1,000 retrocolic Lap-RYGB was performed to identify those who developed postoperative internal hernias. Clinical symptoms, radiologic characteristics, and operative outcomes were analyzed to determine clinical and radiologic diagnostic accuracy (including computed tomography [CT] scan and upper gastrointestinal imaging). Subsequent independent review was performed to match operative intervention with radiologic imaging and interpretation. Operative outcomes, including the hernia closure technique, hospital length of stay, and mortality were obtained. RESULTS: Of 1,000 Lap-RYGB procedures, 45 internal hernias were identified (4.5%) in 43 patients. Hernia location included transverse colon mesentery (n = 43, 95%) or Petersen's defect (n = 2, 5%). The most common clinical symptoms included intermittent, postprandial abdominal pain, and/or nausea vomiting (86%), although 20% had no abdominal tenderness. Initial radiologic imaging studies were diagnostic in 64%, although subsequent review of all imaging studies showed diagnostic abnormalities in 97%. CT findings suggestive of internal hernia include small bowel loops in the left upper quadrant and evidence of small bowel mesentery traversing the transverse colon mesentery. All patients with internal hernias underwent operative repair (98% performed laparoscopic). One patient had a negative laparoscopy, although the preoperative CT suggested an internal hernia was present. The mean time to intervention for an internal hernia repair was 225 days (range 2 to 490), whereas hospital length of stay was 1.2 days (range 1 to 4). No deaths were noted. CONCLUSIONS: Internal hernias after retrocolic lap-RYGB are associated with vague abdominal complaints and limited radiologic imaging results. A high index of clinical suspicion should be used in this patient population, and surgeon review of radiology imaging studies should be performed. Prompt surgical intervention is successful and can commonly be performed laparoscopically.

Multistranded hamstring tendon graft fixation with a central four-quadrant or a standard tibial interference screw for anterior cruciate ligament reconstruction.

BACKGROUND: Tibial fixation of hamstring tendon grafts has been the weak link in anterior cruciate ligament reconstruction. HYPOTHESIS: Use of a central four-quadrant sleeve and screw provides superior fixation when compared with standard interference screw fixation. STUDY DESIGN: Controlled laboratory study. METHODS: In eight pairs of cadaveric knees each anterior cruciate ligament was reconstructed using either an interference screw or a central sleeve and screw on the tibial side. The specimens were then subjected to cyclic loading followed by a load-to-failure test. RESULTS: The load required to cause 1 and 2 mm of graft laxity, defined as the separation of the femur and the tibia at the points of graft fixation, was significantly greater with the sleeve and screw than with the interference screw (at 2 mm: sleeve and screw, 216.1 +/- 30.1 N; interference screw, 167.0 +/- 33.2 N). The force at initial slippage for each of the graft strands was significantly higher with use of the central sleeve and screw. CONCLUSIONS: The four-quadrant sleeve and screw device may provide greater surface area for healing of hamstring tendon grafts and allow equal tensioning of graft strands before fixation. These factors are associated with increased strength of fixation and reduced laxity of the graft after cyclic loading. CLINICAL RELEVANCE: Use of the central four-quadrant sleeve and screw system offers increased strength of fixation in anterior cruciate ligament reconstruction with hamstring tendon graft.