To Evaluate the Impact of Ho:YAG Laser Lithotripsy for Ureteroscopic Removal of Proximal and Distal Ureter Calculi.

Background Urinary calculus illness is a prevalent clinical issue encountered by the medical community, particularly urologists, in contemporary society. Laser technologies have been widely accepted as standard modalities for lithotripsy applications. Using the Ho:YAG laser has expanded the range of applications for ureteroscopic stone management (URS), enabling the treatment of bigger stones in all regions of the upper urinary tract. It is noteworthy that ureteroscopy (URS) demonstrates superior rates of stone clearance for distal stones, regardless of their size, with a success rate of 94.5% compared to 74% for other treatment modalities. Significant variation exists in the reported results and problems associated with Ho:YAG laser lithotripsy across different trials, as documented in the literature. The procedure's outcome might vary based on factors such as the size of the stone, the length of impaction, the presence of ureteral damage and granulation, the kind and size of endoscopes used, and the specific energy settings employed by various operators. The present study aimed to evaluate the impact of Ho:YAG laser lithotripsy for ureteroscopic removal of proximal and distal ureter calculi. Methods This prospective observational study was carried out in the Department of Urology at DY Patil Medical College and Hospital, Pune, from March 2021 to March 2023. Patients diagnosed with a case of ureteric stone who opted for URSL during the study period were included. A total of 50 patients who underwent URSL in the urology department were included in this study. These were then grouped into those with proximal ureteral stones and distal ureteral stones. (25 each) Results The study observed that patients diagnosed with proximal ureteral stones had bigger calculi, with a mean stone size of 15mm, in comparison to patients with distal ureteral stones, with a mean stone size of 10mm (P=0.010). The stone burden was significantly higher for proximal ureteral stone patients than those with distal ureteric stones (P=0.010). The average duration of the operating procedure for upper ureter stones was 70 minutes, but for lower stones, the mean operative time was 45 minutes (P<0.001). No statistical significance was seen in the median age of patients between the two groups (P=0.89). The maximum number of cases in the upper stone group were in the age group of 16-30 years, and in the lower stone group was in the age group of 31-45 years. The prevalence of DJ stents at the time of presentation was higher among patients diagnosed with proximal ureteric stones than those with distal ureteric stones, with rates of 28% and 20%, respectively (P=0.508). Full fragmentation was successfully accomplished in all patients within the distal calculus group, accounting for 100% of the cases. At the same time, for proximal ureteric stones, a single laser lithotripsy session resulted in 92% (23 patients) achieving a stone-free status after two weeks.  Conclusion The study observed that stone size, burden, and procedure duration were statistically significant among other criteria. Mean age, stone HU, prior DJ stent, and stone-free rate were statistically insignificant. The procedure indicated that Ho:YAG laser lithotripsy has efficacy in treating both proximal and distal ureteral stones, with minimal intraoperative and postoperative complications. None of the complications were due to laser energy.

Supine versus prone percutaneous nephrolithotomy for renal calculi: Our experience.

Objectives: To compare operative times, safety, and effectiveness of percutaneous nephrolithotomy in the supine versus the prone position. Materials and methods: An observational study of 100 patients was conducted in our institution for 2years from 2018 to 2020 divided into 2 groups: 50 patients underwent modified supine percutaneous nephrolithotomy (PCNL) and 50 patients underwent standard prone PCNL. The inclusion criteria included a renal calculus (calyx or pelvis) of any size for which PCNL was indicated and exclusion criteria were patients having contraindications for PCNL such as bleeding disorders, pregnancy, high risk, and co-morbid conditions. The measured data included operative time, number of punctures, stone-free rate, length of hospital stays, and rate of complications. Results: The 2 groups were comparable in mean age, male to female ratio, calculus size, number of punctures, residual calculi, and postoperative fever and pain. The mean difference of hemoglobin in the supine PCNL group was 0.37 g/dL whereas in the prone PCNL group it was 0.61 g/dL. The p value was significant at 0.043. The mean time to finish from initial postion was 72.24 minutes in supine PCNL and 88.12 minutes in prone PCNL. The p value was significant (p < 0.001). The mean time before puncture was 20.92 minutes in the supine position and 31.84 minutes in the prone position. The p value was significant (p < 0.001). The mean time from puncture to finish was 51.32 minutes in the supine position and 56.28 minutes in the prone position. The p value was significant (p < 0.001). Conclusions: As observed from this study, supine PCNL is associated with a significantly reduced operating time when compared to conventional prone position PCNL procedures. The postoperative complications such as pain and fever were not significantly different. Hence, the supine PCNL is an equally effective modality for treatment of a renal calculus with benefits of simultaneous retrograde access and less operative time compared to the prone PCNL.

Use of conventional DJ stent and single loop stent with string after ureterorenoscopic lithotripsy: Can we use? Can it be effective?

CONTEXT: Use of conventional double j stent with string and single loop stent with string after ureterorenoscopy. AIM: The aim of this study was to compare the use of both types of stents using the Ureteral Symptom Score Questionnaire (USSQ) and assess proximal migration. SETTINGS AND DESIGN: This was a single institute study. SUBJECTS AND METHODS: A total of 96 female patients with unilateral ureteric stones were enrolled. Patients underwent ureterorenoscopic lithotripsy, conventional double J (DJ) stent with string and single loop stent with string was placed. Before stent removal at 7-10 days, they were evaluated with X-ray kidney ureter bladder for proximal migration and USSQ for stent-related complaints. STATISTICAL ANALYSIS USED: Data were analyzed using Chi-square and Student's t-test. RESULTS: In our study, Group A (DJ loop with string) had 51 patients and Group B (single J loop with string) had 47 patients. The mean stone size in group A was 10.06 mm and Group B was 9.7 mm. Both groups had one case each of early stent expulsion and none had proximal migration of the stent. Group A had two cases of urinary tract infection and Group B had one case which resolved on antibiotics. Evaluating the USSQ questionnaire in both groups, urinary symptoms such as urgency (P = 0.03), dysuria (P = 0.02), interference with life (P = 0.01), and quality impact overall (P = 0.016) were statistically significant. Evaluating pain, sleep disturbance (P = 0.04), pain at voiding (P = 0.03), and flank pain during voiding (P = 0.018) was statistically significant. In general health, difficulty with heavyweight physical activity (P = 0.02), feeling calm (P = 0.16), social life enjoyment (P = 0.26), and need for extra help (P = 0.008) was significant. In sexual matters, 13 (28%) patients in Group B had no active sex (conscious) and 6 (12%) patients had stopped intercourse due to stent-related symptoms, whereas in Group A, it was 10 (20%) and 2 (4%) patients, respectively. CONCLUSIONS: The use of a single J stent with string is an effective method, has lesser complication, and is easier to remove.

Strategy to track double-J stents placed during COVID-19 using smartphone-based stent tracker application to prevent forgotten double-J stent in a high-volume centre: a smart solution.

BACKGROUND: Forgotten or retained (double-J) DJ stents may lead to several complications. Management of retained DJ stents poses a challenge for urologists not just surgically but also medicolegally and adds to the economic burden of the patient. Difficulty in follow-up for patients due to the contagious nature of COVID-19 and several restrictions posed in the form of lockdown. Smartphones today have become an integral part of our daily lives providing a convenient and reliable platform for data storage and access. METHODS: All patients requiring placement of DJ stents and agreeing to enrol in the study were registered on the application over the physicians smartphone. SMSs regarding dates for removal of stent and follow-up with the literature regarding stent care were sent to the patients in their regional language. RESULTS: A total of 100 patients were stented during this period of 3 months. Mean age was 42.61 years with three patients of paediatric age group. Mean duration of stent was 6 weeks. All patients received periodic messages (average 3) regarding follow-up and date for stent removal. 3%(n = 3) patients were delayed for follow-up; 2% (n = 2) patients lost to follow-up, compared to a 9% to 10% loss to follow-up in patients followed up only on paper discharges in our department previously. CONCLUSION: It significantly reduced the number of physical visits of the patient to the hospital and provided a more streamlined tracking of the indwelling stents for the user; patient compliance was found to be almost 98%; being cloud based (android/iOS), it was easily accessible to the user; and with the option of sharing the account details, the patient record could be accessed by several residents from their individual devices, which significantly reduced loss to follow-up rates from 9 to 2%.

Evaluation of stone volume and its relationship with surgical outcomes in patients with staghorn calculi.

INTRODUCTION: Urolithiasis is one of the most common renal diseases with a significant burden on health-care system worldwide. Here, we evaluated the stone volume and its relationship with duration of operation, blood loss, and total stone clearance in patients with staghorn calculi. MATERIALS AND METHODS: This was a prospective, single-center study conducted from October 2015 to September 2017. Patients of either sex aged more than 18 years of age with a confirmed diagnosis of staghorn calculus were eligible to participate in the study. Eligible patients were divided into three groups based on stone volume (assessed by three-dimensional computed tomography): Group 1 (≤5000 mm3), Group 2 (>5000 to ≤20,000 mm3), and Group 3 (>20,000 mm3). RESULTS: A total of 85 patients were enrolled in the study (Group 1, n = 9; Group 2, n = 66; and Group 3, n = 10). The mean age was 43.68 years, and 62.4% of patients were male. The mean operative time increased significantly from Groups 1-3, (31.67, 60.14, and 92.30 min, respectively). The mean pre- and postoperative hematocrit was highest in Group 3 (2.82%) (P < 0.0001). Overall, the correlation between stone volume and operative time and difference in hematocrit showed a positive relationship. A total of five patients had residual calculus, and only four patients reported complications. CONCLUSIONS: The results showed that patients with larger stone volume need more operative time and may have more blood loss.

Miniaturized percutaneous nephrolithotomy versus retrograde intrarenal surgery in the treatment of renal stones with a diameter <15 mm: A 3-year open-label prospective study.

AIM: The aim of this study is to compare the outcomes of miniaturized percutaneous nephrolithotomy (mini-perc) and retrograde intrarenal surgery (RIRS) in management of renal stones with a diameter <15 mm. MATERIALS AND METHODS: This was an open-label prospective study that included a total of 80 cases underwent mini-perc (n = 40) and RIRS (n = 40) between July 2014 and August 2017. The primary outcome objective was stone-free rate, retreatment rate, complications, hospital stay, operative time, and reduction in hemoglobin level. Data were analyzed using SPSS version 16.0 Software. RESULTS: Overall, 80 patients were enrolled in this study. The mean age was 40.12 and 38.20 years, and the mean stone size was 1.15 and 1.30 cm in mini-perc and RIRS group, respectively. Majority of the study participants were males. Overall, mini-perc and RIRS had stone clearance rates of 100% and 95.4%, respectively. Two patients required retreatment in RIRS group. The duration of hospital stay and the rate of complication was similar in both the groups. Operative duration was more in RIRS group. Decrease in hemoglobin level was more in mini-perc group. CONCLUSIONS: Results demonstrated that both modalities were associated with high stone clearance rates with minimal complications. RIRS was associated with less reduction in hemoglobin and could be used as standard treatment modality for small renal calculi.

Uroflow nomogram for healthy, 15-40 year old Indian men.

INTRODUCTION: Uroflowmetry is the objective method of measuring rate of urine flow. Nomograms are required to observe the change in flow rates at different voided volumes (VVs) and the use of which overcomes the limitation of referencing flow rates to any single VV. The purpose of the present study was to construct the Indian uroflow nomogram for adult healthy males between 15-40 years of age. METHODS: A total of 1000 healthy males between 15 and 40 years of age were included in the study. Exclusion criteria were any urinary symptoms or urological intervention. Parameters analyzed statistically were age, peak flow rate (Qmax), average flow rate (Qavg), and VV. A nomogram was drawn for the fitted regression model. RESULTS: The mean age was 27.26 ± 6.71 years. The mean Qmax, Qavg, and VV were 24.32 ± 3.50 ml/s, 9.45 ± 2.55 ml/s, and 420.93 ± 97.89 ml, respectively. The correlation between flow rates and VV was statistically significant, indicating that the higher the VV, the higher the flow rates. A negative significant correlation of Qmax with age was seen in our study. We observed a decline of Qmax by 1 ml/s/decade. The relationship of Qmax with VV is in linear progression up to 600 ml, and then it becomes a plateau and with higher VV it declined. CONCLUSION: Qmax exhibits significant correlation with VV and age. A nomogram was constructed to attain normal reference values of flow rate over different VVs.

Comparative evaluation of upper versus lower calyceal approach in percutaneous nephrolithotomy for managing complex renal calculi.

INTRODUCTION: Percutaneous nephrolithotomy (PCNL) is the treatment of choice for staghorn and large renal stones. The success of PCNL is highly related to optimal renal access. Upper calyceal puncture being more difficult and more demanding have relatively few studies presented. AIMS AND OBJECTIVES: This prospective study was carried out to evaluate the effectiveness and safety of upper calyceal versus lower calyceal puncture for the removal of complex renal stones through PCNL. MATERIALS AND METHODS: A total of 94 patients underwent PCNL for complex renal stone in our institute. Fifty-one of them underwent lower calyceal, while 43 underwent upper calyceal puncture. The two approaches are compared as per total duration of surgery, intraoperative blood loss, infundibular/pelvic tear, rate of complete clearance and rate of postoperative complications (pulmonary, bleeding, fever and sepsis, etc.). OBSERVATION AND RESULTS: In our study, the success rate was 76.47% for those in the lower, 90.70% for those in the upper calyceal access group. Thoracic complications (hydrothorax) occurred to 1 patient in upper calyceal supracostal access group. Bleeding requiring blood transfusion happened to 5 patients in lower calyceal access and 1 in upper calyceal group. CONCLUSION: In our study for the management of complex renal calculi, we conclude that in a previously unoperated kidney, upper calyceal puncture through subcostal or supra 12(th) rib is a feasible option minimizing lung/pleural rupture and gives a better clearance rate. We suggest that with due precautions, there should not be any hesitation for upper calyceal puncture in indicated patients.

Prospective randomised controlled trial comparing sub-epididymal orchiectomy versus conventional orchiectomy in metastatic carcinoma of prostate.

Androgen blockade (surgical or medical castration) is a standard procedure for patients with metastatic carcinoma prostate. Sub-epididymal orchiectomy involves removal of testis leaving behind epididymis. This epididymal stump over a period gives a pseudo testicular feel within the scrotum. We present a prospective randomized study to assess the functional utility of this procedure and compare it with total orchiectomy in terms of achieving castrate levels. From July 2005-Jan 2008, 60 patients with metastatic carcinoma prostate were alternately randomised and allotted to two groups, 30 underwent sub-epididymal orchiectomy (group A) and remaining 30 (group B) underwent total orchiectomy. Age: 56-80 years. Serum PSA: 55-268 ng/ml. Preoperative serum testosterone: Group A-300-650 ng/ml and group B-320-640 ng/ml. Postoperative serum testosterone: group A-2-18 ng\ml and group B-7-15 ng\ml on day 7 after surgery. Operating time-26-40 mins for group A and 20-34 mins for group B. Follow up-6 weeks and 3 months. At 3 months patients were asked to grade appearance of scrotum for asthetic value on a scale of 1-100 using visual analogue score. Postoperative serum testosterone reached castrate levels in seven days (both groups). Duration of surgery in both groups was comparable. Complications-wound infection in 1 patient (group A) & 1 scrotal hematoma (group B). Satisfaction score for group A (83.5 ± 9.7) was significantly (p < 0.05) better (95%CI-18.58-28.42), compared to that of group B (60 ± 9.4) by using't' test. Sub epididymal orchiectomy is comparable to total orchiectomy in terms of achieving castrate levels with similar operating time. It has significant advantage in terms of mental satisfaction to patients. It is a simple and safe procedure that can be conveniently performed in an outpatient clinic setting using pure local anaesthesia.