In vivo ureteroscopic intrarenal pressures and clinical outcomes: a multi-institutional analysis of 120 consecutive patients.

OBJECTIVES: To evaluate the pressure range generated in the human renal collecting system during ureteroscopy (URS), in a large patient sample, and to investigate a relationship between intrarenal pressure (IRP) and outcome. PATIENTS AND METHODS: A prospective multi-institutional study was conducted, with ethics board approval; February 2022-March 2023. Recruitment was of 120 consecutive consenting adult patients undergoing semi-rigid URS and/or flexible ureterorenoscopy (FURS) for urolithiasis or diagnostic purposes. Retrograde, fluoroscopy-guided insertion of a 0.036-cm (0.014″) pressure guidewire (COMET™ II, Boston Scientific, Marlborough, MA, USA) to the renal pelvis was performed. Baseline and continuous ureteroscopic IRP was recorded, alongside relevant operative variables. A 30-day follow-up was completed. Descriptive statistics were applied to IRP traces, with mean (sd) and maximum values and variance reported. Relationships between IRP and technical variables, and IRP and clinical outcome were interrogated using the chi-square test and independent samples t-test. RESULTS: A total of 430 pressure traces were analysed from 120 patient episodes. The mean (sd) baseline IRP was 16.45 (5.99) mmHg and the intraoperative IRP varied by technique. The mean (sd) IRP during semi-rigid URS with gravity irrigation was 34.93 (11.66) mmHg. FURS resulted in variable IRP values: from a mean (sd) of 26.78 (5.84) mmHg (gravity irrigation; 12/14-F ureteric access sheath [UAS]) to 87.27 (66.85) mmHg (200 mmHg pressurised-bag irrigation; 11/13-F UAS). The highest single pressure peak was 334.2 mmHg, during retrograde pyelography. Six patients (5%) developed postoperative urosepsis; these patients had significantly higher IRPs during FURS (mean [sd] 81.7 [49.52] mmHg) than controls (38.53 [22.6] mmHg; P < 0.001). CONCLUSIONS: A dynamic IRP profile is observed during human in vivo URS, with IRP frequently exceeding expected thresholds. A relationship appears to exist between elevated IRP and postoperative urosepsis.

Nutcracker syndrome, conservative approach: a case report.

The nutcracker phenomenon (NCP) refers to the compression of the left renal vein, most commonly between the aorta and the superior mesenteric artery (SMA). Nutcracker syndrome (NCS) should be limited to patients who present with the characteristic clinical signs and symptoms alongside diagnostic imaging of the anatomy associated with the syndrome. We report a case of NCS presenting with painless visible hematuria and left flank pain. Imaging showed a left renal vein stenosis at the origin of the SMA with collateralization. Diagnosis of NCP is made by a variety of imaging techniques; approaches to the treatment of NCS include conservative methods, open surgical, laparoscopic or endovascular techniques. Correlation with symptoms, laboratory results and excluding other causes continues to be important in the workup of NCS. Collaboration with the establishment of an International Consortium database will aid in the understanding of this rare disease.

Penile calciphylaxis-a complicated case managed with circumcision and glansectomy.

Penile calciphylaxis is a serious manifestation of calcifying uremic arteriolopathy, with only a small number of cases reported in the literature. It is rare, characterized by calcification within the walls of small vessels, resulting in ischaemic changes to the skin, and is mainly seen in patients with end-stage renal failure (ESRF). Management of penile calciphylaxis is difficult, with both conservative and surgical approaches advocated for. Due to their comorbidity profile, patients with penile calciphylaxis can present multiple management challenges. We present a case of penile calciphylaxis in a patient with ESRF who was initially managed conservatively, and then underwent circumcision and glansectomy due to a necrotic glans penis and non-resolving penile pain. The patient was spared a partial penectomy and went on to make a full recovery.

Evaluation of a new disposable flexible ureterorenoscope and comparison to an established disposable flexible ureterorenoscope: a prospective, observational study.

PURPOSE: To objectively and subjectively assess the performance and surgical outcomes of the new Innovex EU-scope™ single-use digital flexible ureteroscope (fURS). METHODS: A prospective cohort study was carried out (August 2019 to May 2020). The new single-use fURS (Innovex Medical Devices Co. Shanghai, China) was analysed with regard to visibility, manoeuvrability, laser interference and overall performance using a validated Likert scale. Outcomes are compared to the LithoVue™ (Boston Scientific, Marlborough, MA). RESULTS: One hundred patients were included in this study. 50 cases underwent retrograde fURS using the Innovex EU-scope™ and 50 with the LithoVue™. There were no differences in the patient demographics data, or operative data between the two groups. The Innovex EU-scope™ scored higher visibility scores compared to the LithoVue™, median 4, interquartile range (IQR) (4-4), vs. 3.5, IQR (3-5), p = 0.5086. Both scopes had similar manoeuvrability scores. The Innovex EU-scope™ scored significantly lower with regard to comfort compared to the LithoVue, median 4 IQR (3-4) vs. 4.5 IQR (4-5), p = 0.0445. Whereas, laser interference, affected the Innovex much less than the LithoVue™. Both scopes scored well for overall performance. The median overall performance score for the Innovex was 4 IQR (4-4) vs. 4 IQR (4-5). CONCLUSIONS: This Innovex EU-scope™ has good objective and subjective visibility and manoeuvrability profiles. This single-use flexible ureteroscope may achieve similar clinical outcomes to an established single use instrument.

Objective and subjective improvement in children with idiopathic detrusor overactivity after intravesical botulinum toxin injection: A preliminary report.

OBJECTIVE: The purpose of this study is to evaluate the effect of Intravesical Botulinum toxin injection on the symptoms and urodynamic parameters in pediatric patients with idiopathic overactive bladder (iOAB) refractory to medical treatment. MATERIALS AND METHODS: The study was designed as an open-label uncontrolled therapeutic clinical trial. The eligible patients who underwent Intravesical botulinum toxin injection were evaluated before treatment. The evaluation included a 7-day paper bladder diary to assess OAB symptoms (frequency, urgency urinary incontinence (UUI) and nocturnal enuresis (NE)), filling the Arabic International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI short form), and conducting urodynamic study. The Urodynamic parameters obtained were the maximum filling detrusor pressure, cystometric bladder capacity, and compliance. After 12 weeks of the intravesical injection, the patients were revaluated and the results were compared using paired samples t-test. RESULTS: The study enrolled 75 patients. And of those, statistical analysis was done on 46 patients who did follow the study protocols. The mean age was 8.9 years and male to female ratio was 1:4. There was a statistically significant improvement in overactive bladder symptoms and urodynamic parameters in the patient injected with botulinum toxin with minimal side effects. CONCLUSION: The evidence in this study would support the safety and efficacy of Intravesical botulinum toxin injection in children with refractory idiopathic OAB with significant improvement of symptoms, quality of life, as well as urodynamic parameters. TYPE OF STUDY: Open-label uncontrolled therapeutic clinical trial. LEVEL OF EVIDENCE: III.

Leydig cell tumor in grey zone: A case report.

INTRODUCTION: Leydig cell tumor constitutes only about 1-3% of testicular neoplasms. There is apparently increased incidence in the last few years; one possible explanation for this phenomenon is the widespread use of ultrasound technology and the subsequent increased early detection of smaller lesions that have not been found in historical series. CASE PRESENTATION: We report a case of Leydig cell tumor of testis in a patient presenting with painless long standing slowly growing left scrotal mass who found to have intrapulmonary nodule and multiple enlarged retroperitoneal lymph nodes on staging work up. The mass was managed by radical orchiectomy. Pathological diagnosis was Leydig cell tumor. DISCUSSION: Orchiectomy is the accepted mode of treatment but follow-up every 3-6 months with physical examination, hormone assays, scrotal and abdominal ultrasonography, chest radiography, and CT scans is essential in such a case with a potential for malignant behavior. CONCLUSION: Inguinal orchiectomy is the therapeutic decision of choice and long-term follow-up is necessary to exclude recurrence or metastasis. Cases which fall in the grey zone like ours need to be followed up carefully for metastasis instead of rushing into an early retroperitoneal lymph node dissection, with its potential risks and complications.

Long term efficacy of extracorporeal shock wave therapy [ESWT] for treatment of refractory chronic abacterial prostatitis.

OBJECTIVE: To evaluate the effect and safety of extracorporeal shockwave therapy (ESWT) on chronic pelvic pain syndrome (CPPS)/chronic abacterial prostatitis after failure of most other modalities of treatment, the maintenance of the treatment effect for up to one year post treatment and whether the patients are in need for further sessions. MATERIALS AND METHODS: In a follow-up survey of 41 patients, the study inclusion criteria were CPPS patients who failed at least previously 3 modalities of treatment other than ESWT, who were treated by ESWT once a week for one month with a protocol of 2500 pulses at 1 bar over 13 min, Nonaddiction to drugs and narcotics. The exclusion criteria included being under treatment by another method another diagnosis such as prostate cancer, therapy plan alteration, and noninclination to continue this treatment. Then the patients were followed up at 2 weeks, 6 months and 12 months after finishing the course of ESWT. The study was designed as an open-label uncontrolled therapeutic clinical trial which was conducted in Jordan university hospital through the period 2015-2016. Data were compared using paired samples t-test. RESULTS: Of our total 55 patients 8 of them did not complete the study protocol, 6 of them had missed follow up over the whole follow up period and 41 patients were evaluated. The patient's age group ranged between 18 and 78 years with a mean age of 42 and a median age of 43. The mean of National Institutes of Health -Chronic Prostatitis Symptom Index (NIH-CPSI), the International Prostate Symptom Score (IPSS), American Urological Association Quality of Life Due to Urinary Symptoms (AUA QOL_US) and International Index of Erectile Function (IIEF) were evaluated pre and post ESWT at 2 weeks, 6 months and 12 months and it showed statistically significant improvement in all parameters with maintenance of the effect without any significant side-effect of the treatment over the 12 months. CONCLUSIONS: The evidence in this study would support the safety and efficacy of ESWT in refractory cases of CPPS at least for one year post treatment.