Double J Stents and Reno-Ureteral Lithiasis: Dynamic Changes in Management during the COVID-19 Pandemic.

PURPOSE: To provide an evidence-based review of the use of ureteral stents in managing reno-ureteral lithiasis during the COVID-19 pandemic. MATERIALS AND METHODS: A literature search was conducted between 2020 and 2023 using the PubMed and SCOPUS databases. As a part of the search query, we entered "ureteral stents" OR "double J stent" AND "renal colic" OR "ureteral obstruction" OR "reno-ureteral lithiasis" AND "COVID-19 Pandemic" OR "SARS-CoV-2 infection". RESULTS: Patients with lithiasis should be categorized into low priority, intermediate priority, high priority, and emergency under the COVID-19 pandemic scenario to manage their delay and save resources, including healthcare professionals, beds, and ventilators. However, immediate interventions are necessary for individuals at risk of life-threatening septic complications. During the COVID-19 pandemic, the feasibility of conducting or resuming elective activity depended on local circumstances, the accessibility of beds and ventilators, and the execution of screening protocols. If lithiasis surgery is delayed, consequences and increased effort will be inevitable. It is possible that teleconsultation could help guide these patients and cut down on unnecessary visits and exposure. CONCLUSIONS: COVID-19 has shifted treatment options for urinary stones, with ureteral stents being a safe, efficient, and cost-effective option for managing urolithiasis. Decompression is essential in emergency situations, while ureteral stents reduce the risk of infection and hospital visits.

Comparison between Retrograde Flexible Ureteroscopy and Percutaneous Nephrolithotomy for the Treatment of Renal Stones of 2-4 cm.

Background and objectives: Renal stones are widespread, with a lifetime prevalence of 10% in adults. Flexible ureteroscopy enables urologists to treat lower calyx stones or even complex renal stones through the natural orifice and achieve an acceptable stone-free rate. Hence, we analyzed the effectiveness and safety of FURS versus PCNL in treating renal stones between 20 and 40 mm in diameter. Materials and methods: We retrospectively analyzed 250 consecutive patients with large renal solitary stones (stone burden between 2 and 4 cm) from 1 January 2019 to 31 December 2020. The patients were divided into two groups: group 1 (125 patients), in which the patients were treated by a retrograde flexible ureteroscopic approach, and group 2 (125 patients), in which we used percutaneous nephrolithotomy. Stone characteristics and anatomical data were observed based on the computed tomography (CT) and/or KUB (Kidney-ureter-Bladder) radiography imaging archive. Results: The mean stone burden was 26.38 ± 4.453 mm in group 1 and 29.44 ± 4.817 mm in group 2. The stone-free rate after the first ureteroscopy was higher for the PNL(percutaneous nephrolithotomy) group (90.4%) than the F-URS group (68%). After two sessions of ureteroscopy, the SFR was 88.8% in the first group, and after three procedures, the SFR rose to 95.2%. The overall complication rate was higher in group 1 than in group 2 (18.4% vs. 16.8%), but without statistical relevance (p > 0.5). Furthermore, we encountered more grade III and IV complications in the PNL group (8.8% vs. 4.8%, p < 0.05). Conclusion: Flexible ureteroscopy proves to be efficient in treating renal stones over 2 cm. However, the patients must be informed that more than one procedure might be necessary to overcome the entire stone burden.

Bipolar en Bloc Resection - Is it the Future in Non-Muscle Invasive Bladder Cancer?

Bladder cancer is among the most common urological malignancies. In this context, despite of all the technological advancements, transurethral resection of bladder tumour (TURBT) continues to represent the gold-standard diagnostic and treatment in non-muscle invasive bladder tumours (NMIBTs). The surgical technique of en bloc bipolar tumour resection could be performed using the hemispherical shape plasma-button electrode and saline irrigation fluid or using the laser fiber. The malignant formation is gradually pushed up and separated from the bladder wall. The final aspect of the bladder wall reveals the clean muscular fibers of the detrusor layer, free of malignant tissue, irregularities or debris. Concerning the outcomes, the operative parameters are heterogenous in the literature, because of the different resection devices utilized. However, there are few main points where all the studies agreed, concerning the lower recurrence rates comparing with classical resection and also the good quality resection samples. In conclusion, even if the general outcomes are favourable for the en bloc resection, there is still a lack of large multicentric comparative trials which establish the right place of the method in the urological armamentarium.

Bipolar en bloc tumor resection versus standard monopolar TURBT - which is the best way to go in non-invasive bladder cancer?

The aim of the study was to observe similarities and differences regarding surgical safety and prognosis between en bloc bipolar resection and monopolar transurethral resection of bladder tumors (TURBTs) in medium size papillary non-muscle invasive bladder tumors (NMIBTs). A total of 90 patients with papillary bladder tumors presenting a diameter between 1 and 3 cm were equally divided and alternatively assigned for en bloc bipolar ablation (the study group) and conventional TURBT (the control group). During one year, every three months, the follow-up was performed and the protocol included urinary cytology and cystoscopy. Similar mean patients' age and tumor diameter were determined in both groups. In the study group, it was noticed an important reduced rate of obturator nerve reflex adverse event that caused bladder wall perforation. In addition, comparing the results between the two groups, the following aspects were observed in the study arm: decreased mean operation time (13.4 versus 19.7 minutes), hemoglobin level drop (0.28 versus 0.76 g∕dL), catheterization period (1.9 versus 2.8 days) and hospital stay (2.3 versus 3.1 days). A total of 41 and respectively 40 patients completed the 12 months follow-up protocol. After one year, the en bloc group presented a significantly lower recurrence rate, superior surgical safety, decreased perioperative morbidity and faster recovery. Therefore, the en bloc surgery approach presented a better oncological prognosis due to the reduced heterotopic NMIBT recurrences up to one year.

NBI-assisted digital flexible ureteroscopy in transitional renal cell carcinoma - an evidence-based assessment "through the looking glass" of the pathological analysis.

INTRODUCTION: Digital flexible ureteroscopy (FURS) increasingly became a routine diagnostic procedure in upper urinary tract transitional cell carcinoma (UUT-TCC). Identifying elements that may suggest the malignant nature of a lesion and obtaining biopsy specimens sufficient for a reliable pathological analysis remain difficult challenges. Narrow-band imaging (NBI) technology appears to provide a more accurate observation of the upper tract urothelium. PATIENTS, MATERIALS AND METHODS: During this prospective analysis, white light (WL) and NBI-assisted digital FURS were performed in 87 consecutive patients admitted for primary suspicion of UUT-TCC. The endoscopic technique comprised digital WL FURS, followed by the NBI assessment of the renal collecting system' mucosa. All suspicious areas of the pyelocaliceal urothelium were biopsied using the grasping forceps, separately for WL and NBI findings. RESULTS: A total of 113 UUT-TCC tumors (104 pTa and nine carcinoma in situ - CIS) were confirmed by pathology in 62 patients. The patients' detection rate was significantly improved in NBI mode when compared to standard FURS (98.4% versus 91.9%, respectively), due to cases either exclusively diagnosed with UUT-TCC (8.1%) or presenting additional urothelial tumors (12.9%). Overall, 13 pTa and two CIS lesions were solely observed in NBI, which was on the other hand characterized by a significantly increased proportion of unnecessary biopsies (NBI versus WL rate of false-positive results - 17.5% versus 10.1%, respectively). CONCLUSIONS: As additional tool for the standard WL evaluation of the pyelocaliceal system' urothelium, NBI-guided biopsies were emphasized as providing a significant diagnostic improvement during digital FURS.

Carcinoma in situ of the urinary bladder - from pathology to narrow band imaging.

OBJECTIVES: A retrospective clinical analysis was performed over a time period of 10 months while aiming to establish the impact of narrow band imaging (NBI) cystoscopy and transurethral resection of bladder tumors (TURBT) in cases of carcinoma in situ (CIS). MATERIALS AND METHODS: CIS tumor cells are characterized by a high cytological grade, a certain degree of cyto-nuclear pleomorphism, large, irregular, hyperchromatic nuclei, high nuclear/cytoplasmatic ratio and mitotic figures. One hundred thirty-nine patients were consecutively diagnosed with non-muscle invasive bladder cancer (NMIBC) based on standard white light cystoscopy (WLC) and NBI vision. Urinary cytology was performed in cases of flat lesions suspected by either type of cystoscopy before the TURBT staging. Conventional endoscopic resection was performed for all white light (WL) visible lesions and NBI-guided TURBT exclusively for the observed tumors. RESULTS: At subsequent pathological analysis, 13 CIS patients were confirmed. NBI cystoscopy emphasized a superior diagnostic accuracy as compared to WLC concerning the cases' (92.3% versus 69.2%) as well as lesions' (93.75% versus 71.9%) detection rates. NBI-TURBT provided a higher proportion of additional tumors' cases (53.8% versus 15.4%) when compared to classical resection but was marked by an increased frequency of false-positive results (18.9% versus 11.5%). Urinary cytology displayed an 84.6% sensitivity rate. CONCLUSIONS: NBI cystoscopy and resection substantially ameliorated the CIS-related diagnostic accuracy within a parallel to the standard endoscopic approach at the cost of a reduced specificity. NBI-TURBT was able to find more CIS patients as well as lesions, thus improving the sensitivity of standard resection and urinary cytology.