A study on comparative outcomes of totally ultrasonography-guided percutaneous nephrolithotomy in prone versus flank position: a randomized clinical trial.

PURPOSE: The percutaneous nephrolithotomy (PCNL) has become the gold-standard for treating patients with the larger renal stones and staghorn calculi. This study was designed to evaluate the outcomes of flank versus prone position in patients underwent ultrasonic-guided PCNL for treatment of large kidney stones. METHODS: This prospective randomized clinical trial was conducted from September 2017 to September 2019 in the department of Urology, Labbafinejad University hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Two hundred patients with kidney stones larger than 2 cm underwent PCNLs in prone (n = 100) or flank position (n = 100). Success rate, operative time, access time, hemoglobin and creatinine changes, hospital stay, auxiliary procedure and surgical complications were compared between the two groups. RESULTS: The two groups were similar in their baseline characteristics. The success rates in prone (87%) versus flank position (85%) were not significantly different at the first post-operative follow-up (p = 0.91). At the three-month follow-up, the overall stone free rates for the prone position PCNLs and flank position PCNLs were 94/100 (94%) and 90/100 (90%) (p = 0.96). There were no significant difference between the groups in operative time (p = 0.42), access time (p = 0.66), hemoglobin (p = 0.46) and creatinine (p = 0.22) changes, hospital stay (p = 0.05), auxiliary procedures (p = 0.75) and surgical complications. CONCLUSION: Overall, there is no significant difference between prone and flank positions in success rate and complications. More prospective studies must be carried out to identify patient populations who are most apt to benefit from one position over the other. TRIAL REGISTRATION NUMBER: IRCT20200902048597N1 DATE OF REGISTRATION: 2020-11-21, retrospectively registered.

Limitations of Spinal Anesthesia for Patient and Surgeon During Percutaneous Nephrolithotomy.

PURPOSE: To evaluate the intraoperative pain score of patients who undergo percutaneous nephrolithotomy under spinal anesthesia and to evaluate surgeons' and patients' convenience with this type of anesthesia. MATERIALS AND METHODS: PCNL cases who were performed by two endourology fellows under spinal anesthesia during June to July 2014 were included. Spinal anesthesia was performed using injection of 0.25mg/kg bupivacaine 0.5% in the intrathecal space. All procedures were performed with the patient in the prone position. Stone access was made by using ?uoroscopic guidance, and the tract was dilated using a single-stage technique. Visual analogue pain score was used to assess patients' pain during operation, immediately after, and 2 hours later. RESULTS: 50 patients were enrolled during the study period. Visual analogue pain score of 10 and 8 were observed in 5 and three patients respectively. In two patients the operation was terminated because of patient anxiety and pain. In another patient a second access was not obtained to remove a staghorn stone because of patient's agitation. Gross agitation was observed in six patients. Apart from flank pain, intraoperative pain was felt in the flank, scapula, abdomen and/or chest. CONCLUSION: Spinal anesthesia does not provide enough analgesia for the patient in a limited frequency of percutaneous nephrolithotomy operations. We could not find statistically significant predictors of insufficient analgesiabased on patients' demographics, stone characteristics or access location.

Bilateral Laparoscopic Stone Surgery for Renal Stones- A Case Series.

PURPOSE: To present our experience with synchronous or metachronous laparoscopic pyelolithotomy and ureterolithotomy for patients with bilateral urolithiasis. MATERIALS AND METHODS: The data of all patients who underwent laparoscopic pyelolithotomy (± ureterolithotomy) for bilateral renal and/or ureteral stones from November 2009 to July 2014 were included. Laparoscopic operations were performed through a transperitoneal approach. RESULTS: 10 patients underwent laparoscopic operations for renal stones (19 kidney stones) and ureteral stones (1 ureteral stone). 4 patients underwent synchronous operations and 6 patients underwent metachronous operations. The mean ± SD of operation duration were 212 ± 51 minutes for synchronous operations and 166 ± 41 minutes for metachronous operations. Residual stone was observed 5 patients. No patient developed urinary leakage. CONCLUSION: Laparoscopic pyelolithotomy and/or ureterolithotomy for bilateral stones is a feasible option in centers with experience in laparoscopy.

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.

Ultrasound - guided access during percutaneous nephrolithotomy: entering desired calyx with appropriate entry site and angle

ABSTRACT Objectives: To evaluate the success of ultrasonography directed renal access in entering the target calyx from proper entry site and in the direction of renal pelvis during percutaneous nephrolithotomy (PCNL). Materials and Methods: PCNL cases who were operated on by one fellow from May-June 2014 were included in this study. A vertically placed ultrasound probe on the patient flank in prone position was used to identify the preselected target calyx. Needle was advanced through needle holder and fluoroscopy was used to document the entered calyx, site and angle of entry. Results: Successful entering to the target calyx was achieved in 43 cases (91%). Successful entry with appropriate entry site and angle was observed in 34 cases (72%). Reasons for failure were minimal hydronephrosis, upper pole access and high lying kidneys. Conclusions: Although it is feasible to access a preselected calyx by ultrasonography guidance during PCNL, but entry to the calyx from the appropriate site and direction is another problem and needs more experience. In cases of minimal hydronephrosis, superior pole access or high lying kidneys, ultrasonography is less successful and should be used with care.

Efficacy and safety of percutaneous nephrolithotomy with adult standard size instruments in children under 3 years of age: a 10 years single-center experience.

BACKGROUND: Using percutaneous nephrolitotomy (PCNL) with large adult instruments in treatment of pediatricurolithiasis is still in debate. This study was conducted to evaluate the efficacy and safety of PCNL with adult's instrument in treatment of patients less than 3 years old. METHODS: Data on patient characteristics and outcomes for 261 consecutive children undergoing PCNL at a Labbafinejad University Hospital were collected prospectively from September 2006 to February 2016. Thirty-two children, with 34 renal units, who were treated with PCNL were enrolled in the study. All PCNL procedures were performed via subcostal approach with one access tract in all of them. Postoperative complications were evaluated according to the modified Clavien grading system. RESULTS: The mean age of patients was 19.4 ± 6.2 months. Two patients had bilateral stones; thus, PCNL was performed on 34 kidney units. The mean size of the largest stone diameter was 17.5 ± 7.8 mm. The mean duration of procedures was 121.52 ± 29.05 minutes, ranging from 60 to 180 minutes. The most common complication was fever (n = 9, 26.4%), and hemorrhage that needs transfusion was the second one (n = 4, 11.7%). Seventeen patients with complications were in the first degree of Clavien complication system and five of them were in the second degree. CONCLUSIONS: Due to our experience, utilizing PCNL with adult-sized instruments in management of urolithiasis in less than 3 years old children appeared to be effective and relatively safe.

Ultrasound - guided access during percutaneous nephrolithotomy: entering desired calyx with appropriate entry site and angle.

OBJECTIVES: To evaluate the success of ultrasonography directed renal access in entering the target calyx from proper entry site and in the direction of renal pelvis during percutaneous nephrolithotomy (PCNL). MATERIALS AND METHODS: PCNL cases who were operated on by one fellow from May-June 2014 were included in this study. A vertically placed ultrasound probe on the patient flank in prone position was used to identify the preselected target calyx. Needle was advanced through needle holder and fluoroscopy was used to document the entered calyx, site and angle of entry. RESULTS: Successful entering to the target calyx was achieved in 43 cases (91%). Successful entry with appropriate entry site and angle was observed in 34 cases (72%). Reasons for failure were minimal hydronephrosis, upper pole access and high lying kidneys. CONCLUSIONS: Although it is feasible to access a preselected calyx by ultrasonography guidance during PCNL, but entry to the calyx from the appropriate site and direction is another problem and needs more experience. In cases of minimal hydronephrosis, superior pole access or high lying kidneys, ultrasonography is less successful and should be used with care.

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.

Major vascular injury in laparoscopic urology.

BACKGROUND AND OBJECTIVES: Major vascular injury is the most devastating complication of laparoscopy, occurring most commonly during the laparoscopic entry phase. Our goal is to report our experience with major vascular injury during laparoscopic entry with closed- and open-access techniques in urologic procedures. METHODS: All 5347 patients who underwent laparoscopic urologic procedures from 1996 to 2011 at our hospital were included in the study. Laparoscopic entry was carried out by either the closed Veress needle technique or the modified open Hasson technique. Patients' charts were reviewed retrospectively to investigate for access-related major vascular injuries. RESULTS: The closed technique was used in the first 474 operations and the open technique in the remaining 4873 cases. Three cases of major vascular injury were identified among our patients. They were 3 men scheduled for nephrectomy without any history of surgery. All injuries occurred in the closed-access group during the setup phase with insertion of the first trocar. The injury location was the abdominal aorta in 2 patients and the external iliac vein in 1 patient. Management was performed after conversion to open surgery, control of bleeding, and repair of the injured vessel. CONCLUSIONS: Given the high morbidity and mortality rates associated with major vascular injury, its clinically higher incidence in laparoscopic urologic procedures with the closed-access technique leads us to suggest using the open technique for the entry phase of laparoscopy. Using the open-access technique may decrease laparophobia and encourage a higher number of urologists to enter the laparoscopy field.

Comparing supportive properties of poly lactic-co-glycolic acid (PLGA), PLGA/collagen and human amniotic membrane for human urothelial and smooth muscle cells engineering.

PURPOSE: To compare human urothelial and smooth muscle cells attachment and proliferation using three different matrices; poly lactic-co-glycolic acid (PLGA), PLGA/collagen and human amniotic membrane (hAM). MATERIALS AND METHODS: Human urothelial and smooth muscle cells were cultured and examined for expression of urothelium (pancytokeratin and uroplakin III) and smooth muscle cells [desmin and alpha smooth muscle actin (α-SMA)] markers. Cells were cultured on three scaffolds; PLGA, PLGA/collagen and hAM. Thereafter, they were analyzed for cell growth on days 1, 3, 7, 14 and 21 after seeding by 3-(4, 5-dimethylthiazole-2-yl)-2, 5-diphenyltetrazolium bromide (MTT) assay. Scaffolds were fixed and processed for hematoxylin and eosin (H&E) staining and immunohistochemistry against their cell specific markers after 7 and 14 days of culture. RESULTS: MTT assay results revealed that collagen has improved cell attachment features of PLGA and led to significant increase of MTT signal in PLGA/collagen compared to PLGA (P < .001) and hAM (P < .001). hAM was a weaker matrix for both cell types as demonstrated in MTT assay and scanning electron microscope (SEM) images. SEM micrographs showed normal phenotype and distribution on PLGA and PLGA/collagen. In the same line, cells formed a well-developed layer either on PLGA or PLGA/collagen, which maintained expression of their corresponding markers. CONCLUSION: Our findings demonstrated significant improvement of cell attachment and growth achieved by collagen coating (PLGA/collagen) compared to PLGA and hAM. hAM despite of its natural entity was a weaker matrix for bladder engineering purposes.

The mitochondrial C16069T polymorphism, not mitochondrial D310 (D-loop) mononucleotide sequence variations, is associated with bladder cancer.

BACKGROUND: Bladder cancer is a relatively common and potentially life-threatening neoplasm that ranks ninth in terms of worldwide cancer incidence. The aim of this study was to determine deletions and sequence variations in the mitochondrial displacement loop (D-loop) region from the blood specimens and tumoral tissues of patients with bladder cancer, compared to adjacent non-tumoral tissues. METHODS: The DNA from blood, tumoral tissues and adjacent non-tumoral tissues of twenty-six patients with bladder cancer and DNA from blood of 504 healthy controls from different ethnicities were investigated to determine sequence variation in the mitochondrial D-loop region using multiplex polymerase chain reaction (PCR), DNA sequencing and southern blotting analysis. RESULTS: From a total of 110 variations, 48 were reported as new mutations. No deletions were detected in tumoral tissues, adjacent non-tumoral tissues and blood samples from patients. Although the polymorphisms at loci 16189, 16261 and 16311 were not significantly correlated with bladder cancer, the C16069T variation was significantly present in patient samples compared to control samples (p < 0.05). Interestingly, there was no significant difference (p > 0.05) of C variations, including C7TC6, C8TC6, C9TC6 and C10TC6, in D310 mitochondrial DNA between patients and control samples. CONCLUSION: Our study suggests that 16069 mitochondrial DNA D-Loop mutations may play a significant role in the etiology of bladder cancer and facilitate the definition of carcinogenesis-related mutations in human cancer.

Autologous fibrin sealant in tubeless percutaneous nephrolithotomy; a prospective study.

PURPOSE: To evaluate the efficacy of autologous single-donor fibrin glue after tubeless percutaneous nephrolithotomy (PCNL). MATERIALS AND METHODS: Forty-three patients were planned for tubeless PCNL in a prospective cohort study and randomized in two groups with or without using fibrin glue. Randomization method was based on the computer-generated random numbers. RESULTS: Transfusion, urinary leakage, or major complications were found in neither of the groups. There was no difference between two groups in stone free rate (P = .53), and changes in hemoglobin (P = .61) and serum creatinine (P = .63) level. CONCLUSION: Although autologous fibrin glue did not play any significant role in improving results or decreasing complications after tubeless PCNL in our study, its use was safe and did not increase complications.

Laparoscopic anatrophic nephrolithotomy for management of staghorn renal calculi.

BACKGROUND: Management of staghorn renal stones is still challenging. We present our experience with laparoscopic anatrophic nephrolithotomy as an alternative option for management of staghorn renal calculi. PATIENTS AND METHODS: Twenty-four patients with staghorn renal calculi underwent 25 laparoscopic anatrophic nephrolithtomy procedures. Characteristics of patients and stones along with perioperative features such as operation time, transfusion, ischemic time, hospitalization, stone-free rate, and biochemical data were recorded prospectively. We applied the one-layer knotless technique for renorrhaphy repair. RESULTS: The mean age of the patients was 55.1 ± 10.9 years (range, 28-74 years). Eleven (44%) operations were done on the right side, and 14 (56%) were done on the left side. Complete and partial staghorn stones existed in 17 (68%) and 8 (32%) renal units, respectively. The mean stone size was 61.5 ± 11.5 mm. Ischemic time was 30.4 ± 7.55 minutes. The stone-free rate was 88% on discharge and 92% after one session of extracorporeal shockwave lithotripsy. CONCLUSIONS: Although percutaneous nephrolithotomy is the standard of care for treatment of staghorn stone, laparoscopic anatrophic nephrolithotomy seems to be a safe and feasible option in select patients.

Vascular clips are safe and a great cost-effective technique for arterial and venous control in laparoscopic nephrectomy: single-center experience with 1834 laparoscopic nephrectomies.

PURPOSE: To evaluate the safety and cost-effectiveness of Hem-o-lok and metallic titanium clips for both renal arterial and venous control in laparoscopic nephrectomies. PATIENTS AND METHODS: All patients who underwent laparoscopic nephrectomy from June 2000 to March 2011 in our center were included. Before July 2005, we used three medium-large titanium clips for safe control of renal vessels. After July 2005, we used two clips for renal artery control (one 10 mm Hem-o-lok clip and one medium-large titanium clip) and two clips for renal vein control (12 mm and 10 mm Hem-o-lok clips) in all cases. To prevent possible complications, we placed vascular clips 2 to 3 mm away from the aortic root of the renal artery underneath lumbar vessels. Episodes of clip failure were defined as intraoperative or postoperative hemorrhage or exploration because of clip failure. RESULTS: This study included 1834 laparoscopic nephrectomies (1423 donor nephrectomies, 214 simple nephrectomies, and 197 radical nephrectomies). All arteries and renal veins were controlled by titanium and Hem-o-lok clips. One complication that was probably related to vascular clips (titanium and Hem-o-lok), however, involved a delayed hemorrhage from a pseudoaneurysm at the aortic root of the renal artery, which was repaired at exploration. No complication was clearly related to vascular clips. Using Hem-o-lok and titanium clips instead of vascular staplers resulted in $670 savings per operation. CONCLUSIONS: Hem-o-lok and metallic vascular clips applied properly by trained surgeons according to published safety measures provide a safe and considerable cost-saving option for vascular control in laparoscopic nephrectomy.

Laparoscopic transperitoneal pyelolithotomy for management of staghorn renal calculi.

BACKGROUND: Recent developments in laparoscopic and retroperitoneoscopic techniques have modified the treatment of renal and ureteral stones. We present the efficacy and possible adverse complications of laparoscopic pyelolithotomy for the treatment of staghorn stones as an alternative to percutaneous nephrolithotomy (PCNL) in our single-surgeon series. PATIENTS AND METHODS: Thirteen patients (10 males and 3 females) underwent transperitoneal laparoscopic pyelolithotomy for removal of staghorn stones. Mean stone size was 5.1 cm (range, 4-6.5 cm). All patients had large stones in the renal pelvis and several (more than two) calices with extrarenal pelvis. RESULTS: Mean operative time was 177 minutes (range, 110-240 minutes), and the mean hospital stay was 4 days (range, 3-7 days). Transfusion was not required in any patient, and open conversion did not happen. Overall success rate was 84.6% (11/13), and 2 patients had residual stones that were managed with extracorporeal shockwave lithotripsy. There were no major complications (bleeding, sepsis, bowel injury, or urinary leakage). CONCLUSION: The role of laparoscopic kidney stone surgery has not been defined well, but laparoscopic transperitoneal pyelolithotomy may be performed with proper results and negligible complications in skillful hands. It could be a suitable alternative to PCNL for the treatment of staghorn stones in selected cases.

Comparing absorbable and nonabsorbable sutures in corporeal plication for treatment of congenital penile curvature.

PURPOSE: To compare the outcome of corporeal plication using absorbable versus nonabsorbable sutures for the treatment of congenital penile curvature. MATERIALS AND METHODS: Thirty-eight men older than 15 years old with congenital penile curvature were enrolled in the study. Patients were randomly divided into two equal groups based on the suture material (Nylon versus Vicryl) used in corporeal plication. Patients were followed up for a mean period of 8.1 ± 1.4 months (range, 6 to 9.1 months). A standardized questionnaire was used to evaluate long-term outcome and patient's satisfaction. RESULTS: Thirty-five patients (17 in Vicryl group and 18 in Nylon group) completed the study. Mean age of the patients and degree of penile curvature were not significantly different between the two groups (P = .74). Postoperatively, 15 (88.2%) and 16 (88.9%) patients in Vicryl and Nylon groups had 75% or greater correction in penile curvature, respectively (P = .61). Patient's satisfaction rate differed between two groups (82% in Vicryl group versus 66% in Nylon group), which did not reach statistical significance (P = .44). Palpable sutures were reported by 7 (39%) patients in Nylon group and only 1 (6%) in Vicryl group (P = .04). Shortening of penile length was reported by 3 (16.7%) patients in Nylon group and 4 (23.5%) in Vicryl group (P = .69). CONCLUSION: Corporeal plication technique using absorbable suture provides reasonable success rate with less frequent palpable suture knots.

The use of unaltered appendix transfer in ileal continent reservoir: 10 years experience, a novel technical modification.

INTRODUCTION: We report a new modified technique of unaltered appendix transfer to ileal pouch and preserving ileocecal segment. This modification enables us to use ileum as the popular type of enteric segment instead of ileocecal segment while using appendix as a catheterizable stoma. MATERIALS AND METHODS: Forty-five patients (30 men) who needed reconstruction of the lower urinary tract were enrolled for using appendix as a catheterizable stoma. Reservoir was reconstructed using ileal segment. The appendix was circumcised from its base over its pedicle. The spatulated appendix tip was exteriorized as a catheterizable stoma to the skin, preferably umbilicus, and its base was implanted to the ileal pouch. RESULTS: Follow-up records of 38 of 45 patients were available. The median follow-up period was 29 months. The mean intermittent catheterization interval was 4.19 +/- 1.6 hours. Urodynamic parameters were evaluated for 18 out of 38 patients. The median maximal pouch capacity determined as 380 mL. The median appendiceal closure pressure was 61 cm H2O. No pouch perforation occurred. Stomal stenosis occurred in 3 patients. They did not catheterize their appendiceal stoma because they restarted catheterization through the urethra. CONCLUSION: This novel approach enabled us to use ileum as today's more popular type of bowel segment to reconstruct enteric pouch rather than using ileocecal segment, while using appendix as a catheterizable stoma. One of the unique advantages of this technique is that the postponement of clean intermittent catheterization will not result in pouch perforation since the urine will leak when the pouch becomes overfill.

Acne and smoking: is there a relationship?

BACKGROUND: There are contradictory reports on the relationship between acne vulgaris and cigarette smoking. The objective of this study was to examine the relation between acne and cigarette smoking in a case-control study. METHODS: A questionnaire on smoking habits was offered to 350 patients with acne vulgaris and 350 patients suffering from skin diseases other than acne, aged 15-40 years, attending in a skin clinic in Tehran, Iran. The patients completed the questionnaires anonymously in the waiting room. RESULTS: Two hundred and ninety-three patients with acne (response rate 83.7 %) and 301 patients with other skin diseases (response rate 86.0 %) completed the questionnaires. Twelve acne patients (4.1 %) and 27 control patients (9.0 %) were current smokers (odds ratio = 0.43, 95% confidence limits 0.22 - 0.87, p < 0.05). But after adjustment for sex, this difference was not significant (odds ratio: 0.61, 95% CI: 0.30-1.26, p > 0.05, Mantel-Haenszel test). CONCLUSION: An association between acne and cigarette smoking was not found in this study.