Ureteroscopy in the elderly: safety and functional results.

PURPOSE: To evaluate the effectiveness and safety of ureteroscopy (URS) for urinary stones treatment in patients ≥ 80 years of age. METHODS: From 2012 to 2021, 96 patients ≥ 80 years underwent URS for urinary stone disease. Patients' demographics and surgical outcomes were examined. RESULTS: The median length of follow-up was 25 months. Median age was 84 years. Half of the patients (53%) were ASA score 3 and 16% ASA 4. Mean stone diameter (SD) was 10.6 mm, and mean procedure time was 78 min. Eighty-three patients underwent follow-up imaging (ultrasonography or computed tomography) with a median time of 31 days. Stone-free rate was 73.9%. Twenty patients (20.7%) experienced a minor complication [Clavien-Dindo (CD) I-II] whereas five (5.7%) experienced a major complication (CD III-V). SD ≥ 10 mm predicted CD III-V complications (OR 1.25, 95% CI 1.01-1.55, p = 0.03). Urinary drainage prior the procedure with double J stent, nephroureteral stent or percutaneous nephrostomy tube had no impact on patients' SFR [74.6% in the drained group versus 64.0% in the undrained group (p = 0.44)] nor on major complications (OR 4.68, 95% CI 0.25-87.77, p = 0.30). CONCLUSION: In elderly patients, URS for treatment of renal and ureteral stones is a relatively efficient and safe procedure. The risk of major complications is low, and the only associated risk factor found was SD ≥ 10 mm. Urinary drainage prior the procedure did not affect patients' outcomes.

The relationship between patients' kidney stone type and demographics in Israel: analysis of 10 K patients.

PURPOSE: To analyze urinary stone composition in Israel and assess the effects of key demographic parameters (gender, age, socioeconomic status, ethnicity, medical history and geographic region) on stone composition. METHODS: A retrospective review was conducted of stone analysis of 10,633 patients from an HMO Israeli database analyzed by a central laboratory from 2014 to 2019 and subjected to Fourier-transform infrared spectroscopy. Associations between stone composition and different demographic parameters were determined using the Chi-square test. RESULTS: Calcium oxalate (CaOx) monohydrate accounted for 51.9% of the stones. Of the total sample, 5776 stones had one single component (54%), whereas 4857 (46%) had mixed components. Men had a higher frequency of CaOx stones (89.6% vs. 85.6%), whereas women had a higher frequency of calcium phosphate, infection, and cystine stones (27.2%, 17.7%, and 0.9% vs. 17.2%, 7.5%, and 0.5%, respectively). Cystine stones were more abundant in Arabs (1.2% vs. 0.5% in the Jewish population). Lower socioeconomic status was associated with a higher prevalence of calcium phosphate, uric acid, and infection stones and a lower prevalence of CaOx stones. Uric acid stones were associated with medical conditions such as diabetes, hypertension, ischemic heart disease, and obesity (28.3%, 24.9%, 25.7%, and 22.6% vs. 9.6%, 8.4%, 12.3%, and 10.3%, respectively). CONCLUSIONS: Stone types were highly influenced by patients' demographics. COM was the most common stone component in either pure or complex form. UA stone prevalence was found to increase with age and was associated with medical conditions such as diabetes, hypertension, ischemic heart disease, and obesity.

The Butterfly: A Novel Minimally Invasive Transurethral Retraction Device for Benign Hypertrophy of the Prostate.

INTRODUCTION: The Butterfly Prostatic Retraction device is a novel transurethral implant designed to dilate the prostatic urethra and treat lower urinary tract symptoms. We assessed its safety, efficacy and impact on urinary flow, ejaculation, and quality of life. MATERIALS AND METHODS: We included 64 men, treated for benign prostate hyperplasia for at least 1 year. All patients had Qmax≤ 13 mL/s and IPSS >12. Insertion of the device was performed via cystoscopy. Follow-up visits were performed at 2 weeks, 1, 3, 6, and 12 months and included uroflowmetry, IPSS, QoL, and sexual function questionnaires. Cystoscopy was performed on 3 and 12 months. RESULTS: Patients age was 50-83 years. 28 patients completed a 1-year follow-up with an intact device. Mean Qmax improved by 2 mL/s (25%), IPSS median drop was 10 points (40%), and QoL score was 1.5 points (38%). Sexually active patients reported antegrade ejaculation. On cystoscopy, gradual coverage of the devices with urethral mucosa was observed. In 1 patient, the device was repositioned. In 19 patients, the device was removed. 12 patients returned to alpha-blocker therapy and 7 patients underwent TURP. One patient developed a bulbar urethral stricture. CONCLUSIONS: We demonstrated feasibility and good tolerability of the Butterfly device.

Obstruction of the ureter by neurofibroma of the urinary bladder treated endoscopically.

We present a case of a 23-year-old male with NF-1 diagnosed with bladder neurofibroma at childhood with regular ultrasound (US) follow-up since then, who presented with an obstructed left kidney. A detailed evaluation including blood tests and advanced imaging revealed left hydroureteronephrosis associated with a large bladder mass. The patient underwent cystoscopy and resection of the left ureteral orifice that was covered by the mass, and an indwelling ureteral stent was left in place. A follow-up US was performed one month after stent removal showing resolution of the hydronephrosis.

Association between early change in neutrophil-to-lymphocyte ratio after radical cystectomy and treatment outcomes.

OBJECTIVES: To evaluate the associations of peri-operative neutrophil-to-lymphocyte ratio (NLR) and change in NLR with survival after radical cystectomy. PATIENTS AND METHODS: We retrospectively reviewed a multicentre cohort of patients with bladder cancer who underwent radical cystectomy between 2010 and 2020. Preoperative NLR, postoperative NLR, delta-NLR (postoperative minus preoperative NLR) and NLR change (postoperative divided by preoperative NLR) were calculated. Patients were stratified based on elevation of preoperative and/ or postoperative NLR above the median values. Multivariable Cox regression models were used to evaluate the associations of peri-operative NLR and NLR change with survival. RESULTS: The study cohort included 346 patients with a median age of 69 years. The median (interquartile range) preoperative NLR, postoperative NLR, delta-NLR and NLR change were 2.55 (1.83, 3.90), 3.33 (2.21, 5.20), 0.43 (-0.50, 2.08) and 1.2 (0.82, 1.96), respectively. Both preoperative and postoperative NLR were elevated in 110 patients (32%), 126 patients (36%) had an elevated preoperative or postoperative NLR, and 110 patients (32%) did not have an elevated NLR. On multivariable analysis, increased preoperative and postoperative NLR were significantly associated with decreased survival. While delta-NLR and NLR change were not associated with outcome, patients with elevations in both preoperative and postoperative NLR had the worst overall (hazard ratio [HR] 2.97, 95% confidence interval [CI] 1.78, 4.95; P < 0.001) and cancer-specific survival rates (HR 2.41, 95% CI 1.3, 4.4; P = 0.004). CONCLUSIONS: Preoperative and postoperative NLR are significant predictors of survival after radical cystectomy; patients in whom both NLR measures were elevated had the worst outcomes. Future studies should evaluate whether an increase in NLR during long-term follow-up may precede disease recurrence.

Urosepsis and abscess in an adult with a triplicated renal collecting system treated percutaneously and endoscopically.

Ureteral triplication is an extremely rare congenital disorder of the urinary tract. A review of the literature has shown that only about 100 cases have been reported worldwide. We present a case of a 50-year-old female with a known complete ureteral duplication on the right side and incomplete ureteral triplication on the left side that presented with signs of sepsis accompanied by a tender left flank mass. A detailed evaluation including imaging studies and endoscopy revealed a middle moiety obstruction causing abscess formation in the collecting system. A connection between the mid and lower moieties was demonstrated through an upper calyx of the lower moiety. The abscess was drained, and the patient further underwent ureteral stents placement to both the mid and lower ureters. Following antimicrobial treatment and several weeks of maximal drainage, the connection between the moieties was obviated, with no further episodes of urinary tract infection documented in follow up.

Nutritional Status Impairment Due to Neoadjuvant Chemotherapy Predicts Post-Radical Cystectomy Complications.

BACKGROUND: Radical cystectomy (RC) is the standard treatment for muscle invasive bladder cancer (MIBC). Neoadjuvant chemotherapy (NAC) is associated with improved patient survival. The impact of NAC on nutritional status is understudied, while the association between malnutrition and poor surgical outcomes is well known. This study aims to examine the association between NAC, nutritional status impairment, and post-operative morbidity. MATERIALS AND METHODS: We included MIBC patients who underwent RC and received NAC from multiple academic centers in Israel. Cross-sectional imaging was used to measure the psoas muscle area and normalized it by height (smooth muscle index, SMI). Pre- and post-NAC SMI difference was calculated (represents nutritional status change). The primary outcomes were post-RC ileus, infection, and a composite outcome of any complication. Logistic regression models were fit to identify independent predictors of the outcomes. RESULTS: Ninety-one patients were included in the study. The median SMI change was -0.71 (-1.58, -0.06) cm2/m2. SMI decline was significantly higher in patients with post-RC complications (-18 vs. -203, p < 0.001). SMI change was an independent predictor of all complications, ileus, infection, and other complications. The accuracy of SMI change for predicting all complications, ileus, infection, and other complications was 0.85, 0.87, 0.75, and 0.86, respectively. CONCLUSIONS: NAC-related nutritional deterioration is associated with increased risk of complications after RC. Our results hint towards the need for nutritional intervention during NAC prior to RC.

Trajectory of inhaled cadmium ultrafine particles in smokers.

INTRODUCTION: Tobacco smoking is a significant source of cadmium exposure among smokers. Most of inhaled heavy metals, including cadmium, are attached to ultrafine particles (UFPs) surface. A low inhaled UFP content in exhaled breath condensate reflects a high inflammatory status of airways. Increased respiratory epithelial permeability and translocation to the circulation is the proposed mechanism. UFP recovered from smokers' airways have high levels of cadmium compared with the airways of non-smokers. METHODS: Urine was collected from 22 smokers subjects and 43 non-smokers. Samples were analysed for UFP and cadmium content. UFP were measured in urine samples by means of the NanoSight LM20 system (NanoSight, UK). A Niton XL3 X-ray fluorescence spectrometer analyzer (Thermo Fischer Scientific, Germany) quantified heavy metal contents in the urine samples. RESULTS: Smokers had elevated UFP and cadmium content in urine compared with non-smokers (4.6 E8/mL and 20.6 ppm vs 3.4 E8/mL and 18.5 ppm, p=0.05 and p=0.05, respectively). Smokers had elevated levels of lead and rubidium compared with non-smokers (8.9 ppm and 27 ppm vs 7.8 ppm and 2 ppm, p=0.05 and p=0.04, respectively) DISCUSSION: We suggest that the trajectory of cadmium-related UFP in smokers begins by its inhalation into the airways. The UFPs induce inflammation and oxidative stress in the small airways, are subsequently translocated from the interstitium to the circulation and are finally detected and secreted in urine.

[DOES CHOOSING BETWEEN DUSTING OR FRAGMENTATION DURING LASER LITHOTRIPSY OF URINARY STONES CHANGE THE LONG TERM RESULTS?]

INTRODUCTION: Variations in laser pulse energy and it's frequency during lithotripsy, affect the rate and the method of stone breaking. The main modes of lithotripsy are dusting and fragmentation. AIMS: Comparison between long term results of dusting versus fragmentation, by defining the stone free rate (SFR) for each method and the time period until re-treatment need. METHODS: Clinical and radiological follow-up of 43 patients who underwent laser intervention using dusting or fragmentation. Both groups shared similar demographic features, stone sizes and locations. For each group, the percentage of patients without stones requiring intervention during the follow-up period of 36 months was defined as a success parameter. The incidence of emergency department (ED) admissions and auxiliary interventions were assessed. RESULTS: Thirty-eight patients were included in the study. No difference in the median period of time to clinically significant stone was seen (p=0.213). No difference was found in SFR between the dusting (83.3%) and the fragmentation (84.6%) groups respectively (p=1.000). No statistically significant difference was shown in ED admissions due to renal colic occurring in 31.6% and 10.5% within dusting and fragmentation groups respectively (p=0.116). CONCLUSIONS: No difference in time period until clinically significant stone appearance was seen. No significant difference in SFR was found between the groups at the long term follow-up. DISCUSSION: It seems that within the dusting group, the ED admission rate could be somewhat higher. However, this impression lacks statistical significance. A long term prospective study with a larger population is needed to confirm these results.

A comparison between 68Ga-labeled prostate-specific membrane antigen-PET/CT and multiparametric MRI for excluding regional metastases prior to radical prostatectomy.

OBJECTIVES: To compare the ability of 68Ga -PSMA PET/CT (PSMA PET/CT) and multiparametric MRI (mpMRI) to exclude lymph node invasion (LNI) in patients who undergo radical prostatectomy (RP). MATERIALS AND METHODS: A multicenter cohort of patients who underwent PSMA PET/CT and pelvic mpMRI prior to RP with pelvic lymph node dissection (PLND) was analyzed. Increased Ga68-PSMA uptake on PET/CT and enlarged (> 10 mm) or abnormal lymph nodes on mpMRI were considered positive findings. The final surgical pathology served as the standard of reference. The negative predictive value (NPV) was calculated for each modality separately, as well as the combined value. RESULTS: Included were 89 patients with D'Amico intermediate (45%) or high-risk (55%) prostate cancer. The median number of extracted LN was 9 (IQR 6-14). LNI was found in 12 (13.5%) patients. The NPV of mpMRI, PSMA PET/CT, and the two tests combined were 87%, 89%, and 90%, in the entire cohort, 95%, 97%, and 97% in patients with intermediate-risk disease, and 80%, 82%, and 83% in patients with high-risk disease, respectively. The median diameter of LN missed by both imaging and the median intranodal tumor diameter was 5.5 (IQR 3-10) mm and 1 (IQR 1-3) mm, respectively. CONCLUSIONS: PSMA PET/CT and mpMRI demonstrated similar performance in excluding pelvic LNI with NPV of approximately 90%. The combination of both tests does not improve NPV significantly. Therefore, even in the era of advanced imaging, PLND is still recommended for accurate staging, especially in the high-risk population.

Retrospective Analysis of Laparoscopic Partial Nephrectomies Using the Zero Ischemia Technique.

PURPOSE: To report a series of 89 off-clamp laparoscopic partial nephrectomies (LPN) performed without using any additional "nephron sparing" manipulations. METHODS: Retrospective analysis of surgical characteristics, complications, postoperative results, and renal function changes. RESULTS: Between March 2008 and May 2014, 89 LPN using zero ischemia technique were performed. Most of the patients (61.8%) were male. The median age was 62 years (23-88). The mean BMI was 27.5 kg/m2 (20.8-54.2). The median tumor size was 3.0 cm (1.0-8.0). Tumor location was upper, middle, and lower part of the kidney in 33 (37.0%), 42 (47.2%), and 14 (15.7%) of patients, respectively. The median operative time was 154 min (58-289). The median hemoglobin change was -1.6 g/dL (0.5-5.5). The transfusion rate was 7.9%. The mean preoperative glomerular filtration rate was 96.6 mL/min (21.5-180.0) with a mean postoperative decline of 6.52 mL/min. The mean creatinine elevation after LPN was 0.09 mg/dL. The median hospital stay was 6 days (2-24). The intraoperative complications rate was 2.3%. Early postoperative complication rate was 33.7%. Late complications occurred in 6.7%. In 7 cases (7.9%), the surgical margins were microscopically involved by tumor cells. Conversion rate was 3.4%. CONCLUSION: Data obtained in the current series show that laparoscopic partial nephrectomy can be successfully performed without hilar clamping. Our results are comparable with contemporary data. Larger prospective studies would be helpful in assessing the evidence-based advantages of the "zero ischemia" technique.

Does the use of ureteral stents with extraction strings increase urinary infection rates?

PURPOSE: To assess the effect of ureteral stents with extraction string on the rate of postoperative UTI after ureteroscopies. METHODS: Retrospective analysis of patient records who underwent ureteroscopy from January 2011 to August 2014 was performed. Patients were grouped into three groups according to postoperative stent status: non-stented or ureteral catheter for up to 24 h (NS), ureteral stent without extraction string (US) and ureteral stent with an extraction string (US-E). RESULTS: There were 144, 133 and 282 cases in the NS, US and US-E groups, respectively. Overall infection rate was 4.7%; NS-2.1%, US-3.0% and US-E-6.7% (p = 0.057). Four percentage of men and 6.6% of women had postoperative UTI (p = 0.22). Within the group of men infection rates were 0, 2.4 and 6.4% for the NS, US and US-E groups, respectively (p = 0.01). For women, UTI rates were 7.5, 4.0 and 8.5% in the NS, US and US-E groups, respectively (p = 0.6). Infection rates were 20 and 3.9% (p = 0.001) for patients with extraction strings for >8 and <8 days. In multivariate analysis the presence of an extraction string was found to be a risk factor for infection OR 7.7 (1.01-58.9, 95% CI, p = 0.049) along with renal stone location OR 5.09 (2.1-12.05, 95% CI, p < 0.001). CONCLUSIONS: No statistically significant difference was found between overall infections rates for patients with and without extraction strings, and such difference was found within the male group, suggesting extraction strings in men may increase the risk of infection.

Demonstrative Imaging of Emphysematous Cystitis.

This case report presents an incidental finding of emphysematous cystitis on computed tomography (CT) scan done as part of evaluating abdominal pain in a 78 years old man with a history of metastatic thymus carcinoma.

Chronic pelvic pain syndrome: a clinical enigma.

Chronic nonbacterial prostatitis is an ill-defined, painful clinical condition that is characterized by various nonspecific symptoms, some of which are related to urination or the male reproductive organs. Urologists diagnose this particular condition when the symptoms are not associated with urinary bacterial growth before and after transrectal prostate massage. In this review, we describe the recommended and optional tests that can be performed in these cases. There is significant overlap between chronic nonbacterial prostatitis and other unexplained pain conditions, raising the question as to whether the prostate is the culprit. The sources and mediators of pain and the psychological aspects of this complex condition are discussed. Treatments consist of traditional antibiotics and α-blockers. Because the pain relief is often temporary, patients seek other solutions. Various therapeutics have been introduced to satisfy the expectations of patients and physicians. We discuss other pain medications, as well as intraprostatic drug injections and shockwave therapy. Importantly, however, not all of these suggestions have been widely accepted by urologists or pain clinics.

Limited field noncontrast computerized tomography for followup of ureteral stones: initial results.

PURPOSE: Due to high specificity and sensitivity noncontrast computerized tomography is increasingly used to diagnose and follow patients with ureteral stones. We evaluated the feasibility of limited field noncontrast computerized tomography to follow patients with ureteral stones. MATERIALS AND METHODS: Included in the study were 71 patients who underwent diagnostic and followup noncontrast computerized tomography due to ureteral stones. According to stone position on the first diagnostic scan a limited field batch from the followup scan was formed and examined by an independent radiologist. Radiation doses and rates of potentially missed findings in the batch were compared to those of the full followup noncontrast scan. RESULTS: Average full followup noncontrast computerized tomography length was 46.5 cm and average batch length was 20.7 and 13.8 cm for proximal and distal stones, respectively. The average full followup noncontrast scan radiation dose was 12.2 mSv. Average batch doses were 6.1 and 4.1 mSv for proximal and distal stones, respectively (p = 0.002), resulting in a radiation exposure reduction of 48.8% for proximal stones and 66% for distal stones. In 3 cases additional clinical information (not including hydronephrosis) was missed when relying only on batch images. This additional information did not impact further urological treatment. CONCLUSIONS: Limited field noncontrast computerized tomography is a feasible option for following patients diagnosed with ureteral stones. It may lead to significantly lower radiation exposure.

A simple method to inject dense plaques of Peyronie's disease.

OBJECTIVE: To present a novel method to increase injection force of medication into very fibrotic and sometimes calcified plaques in patients with Peyronie's disease and try to improve infiltration of the drug inside the plaque. METHODS: We adapted a simple commercial inflation device, commonly used in other surgical fields, to improve injection force. RESULTS: The device was easily used in 8 patients, enabling injections into hard, most resistant plaques, without local or systemic complications. CONCLUSION: A simple technical method to improve the force of an intralesional injection is introduced.

Adjuvant methods to improve results of local bladder irrigations by chemotherapy for NMIBC.

Non-muscle-invasive bladder cancer is characterized by frequent recurrences requiring repeated transurethral resections and carries a risk of progression to muscle-invasive disease. The routinely used, passive diffusion irrigation of the bladder with mitomycin C has achieved limited success in avoiding these events. We review two methods that may improve penetration of mitomycin C into the bladder wall, thus leading to better results in terms of recurrence rate and bladder preservation.