Harefuah最新文献

Aims: To evaluate the multi-institutional experience of performing robotic-assisted laparoscopic pyeloplasty (RALP) for ureteropelvic junction obstruction (UPJO) in the pediatric population.

Methods: Beginning in 2016, all children with UPJO, including complex cases, uniformly underwent RALP instead of the previously used laparoscopic or open surgical approaches. This study is a multicenter retrospective chart review. It includes an analysis of demographic data, preoperative, intraoperative, and postoperative parameters, complications, and outcomes.

Results: During an 8-year period, 199 children (76% boys and 24% girls) underwent RALP. This group constitutes the study cohort. Challenging cases included: 24 cases with a weight less than 6 kg, 21 redo RALP procedures following previous open surgery failures, 7 cases of UPJO in the lower pole of a double collecting system, 7 children who underwent simultaneous nephrolithotomy, 7 cases of bilateral UPJO, 3 horseshoe kidneys, 3 single kidneys, and one case of giant hydronephrosis crossing the midline. The median age was 15 months (IQR, 5-43 months) and the median weight was 8.3 kg (IQR, 7-17 kg). The median operative time was 80 minutes (IQR, 64-107 minutes). No significant intraoperative complications were reported, although there was one case of conversion to open surgery due to lack of progress. The median length of hospitalization was 1.4 days (IQR, 1-4 days), with one-third of the children being discharged within 24 hours of the operation. In 18 cases, Clavien-Dindo grade II complications were noted, predominantly postoperative urinary tract infections. At a median follow-up of 20 months (IQR, 15.5-32.5 months), the success rate was 98%, with 4 patients requiring additional procedures due to persistent obstruction.

Conclusions: Robotic-assisted pyeloplasty in children is a safe and effective procedure with a high success rate. RALP can be performed at all ages, including in complex cases. It has become the gold standard at our institutions.

Introduction: Pelvic kidney is a congenital anomaly whereby the kidney fails to ascend to its normal anatomical location during early embryonic development. This, in turn, makes traditional surgical approaches for renal calculi challenging.

Aims: To summarize our experience with robotic-assisted pyelolithotomy (RPPK) for pelvic kidney stones.

Methods: A retrospective review of patients who underwent RPPK between 2014 and 2023 was conducted. Demographic data, stone characteristics (size and density), operative details, and postoperative outcomes were collected and analyzed.

Results: Four patients underwent RPPK between 2014 and 2023, three of whom were male. The mean age was 51.2 years (range: 45-54), BMI was 26.6 (22.3-32.2). All patients had a right-sided pelvic kidney. Two patients had previously undergone a failed attempt for ureteroscopy and laser lithotripsy. Stone diameter was 27.7 mm (17-35 mm) and estimated density was 1207.5 HU (905-1500 HU). Mean operative time was 265 minutes (200-323 minutes), while time from incision to closure was 142.2 minutes (95-225 minutes). No ureteral stent or surgical drain were left at the conclusion of the procedures. Upper urinary tract correction was not involved in any of the cases. Blood loss was negligible. The length of hospital stay was 2.2 days. No immediate complications were recorded within one week and one-month post-surgery. Mean follow-up length was 7.5 months (3-13 months).

Conclusions: RPPK is safe and effective in the management of pelvic kidney stones. The challenging renal anatomy, as well as stone size and density are not obstacles when it comes to the robotic approach in comparison to other fragmentation methods.

Introduction: This special issue of 'Harefuah' presents original research papers and review articles that reflect recent developments and innovations in urological care in Israel and worldwide. The expanding urological challenges today relate to establishing innovative and evidence-based treatment approaches tailored to the unique needs of patients and the risk factors in the development of urological diseases. These enable proper explanation and acquisition of accurate knowledge by patients and their families regarding the disease, risk, treatment, and recommended follow-up. Promoting shared decision-making models regarding treatment course and planning personalized surgical interventions improves treatment outcomes and patient and family experience. The issue covers a wide range of urological topics, from treating benign prostatic hyperplasia, through innovations in the diagnosis and treatment of urological tumors, developments in endourology, to innovative solutions in urinary tract reconstruction. These articles reflect the extensive clinical and research activity in the field of urology in Israel and provide an up-to-date picture of future trends and technological developments expected to influence urological care in the coming years.

Introduction: Sinonasal mycetoma (fungus ball) is a non-invasive, typically unilateral fungal infection affecting one of the paranasal sinuses. It presents with variable clinical symptoms such as facial pain and unilateral nasal discharge or may be discovered incidentally on imaging. Fungus ball, or Mycetoma, is a saprophytic infection of the paranasal sinuses. Usually, it is an isolated disease of one paranasal sinus, most commonly the maxillary sinus. The sinus obstruction and accumulation of fungi, typically Aspergillus Fumigatus causes a chronic infection which can be asymptomatic or associated with headache/ facial pain, unilateral rhinorrhea, and nasal obstruction. Ocular symptoms can also occur. Clinical diagnosis is confirmed by imaging, mostly computed tomography (CT). CT will show sinus opacification with or without associated calcifications and hyperostosis. Treatment is surgical, with Functional Endoscopic Sinus Surgery as the gold standard. The typical finding is a mucopurulent cheesy material within the sinus. The surgery consists of complete fungal debridement and lavage while creating the optimal ventilation of the sinus involved. A definite diagnosis can be made with histopathological and microbiologic testing of samples. Antibiotic therapy before or after surgery is not required, according to the literature.

Introduction: Kidney stone disease is very common in the western world and combined with the aging of the population, it brings about the need to treat older patients with numerous comorbidities. Percutaneous nephrolithotomy (PCNL) is the standard of care for patients with stones 2 cm and above but is more invasive. Thus, with the elderly patient comes the dilemma: whether to choose the percutaneous path or to proceed with ureteroscopy even at the cost of several procedures in order to complete the task at hand. Recent developments also added the choice of smaller working channels and the options of choosing a standard channel (30f) and faster surgery or using a miniaturized one perhaps with slower surgery with possible side effects.

Aims: To estimate the efficacy and safety of a standardized PCNL in the elderly population in comparison to younger patients undergoing the same procedure.

Methods: A single center retrospective study was conducted of all the patients who underwent a standardized PCNL for kidney stones during the years 2019-2023. All demographical and clinical data were gathered.

Results: The study population included 81 patients, of whom 18 (22%) were in their seventies and 63 (78%) were under 70 years of age. As expected, the older group had a higher Charlson Comorbidity Index and a higher ASA score (p=0.003, p<0.001 respectively). The diameter of the largest stone was 2.2 cm with no differences between the two groups (p=0.995), nor in stone number, location volume or density. Procedure time, hemoglobin level and kidney function after surgery were similar. Residual stone fragments per non-contrast CT a day after the procedure did not differ between the groups (a median size of 2 mm in the younger group vs. 1.5 mm). The elderly group spent more time in the hospital (5 days vs. 4, p=0.023), but there were no differences in complications.

Conclusions: A standardized PCNL can be performed safely and effectively in the elderly without significant differences in comparison to younger patients. Chronological age alone should not take the percutaneous option off the table for an elder with a large kidney stone.

Introduction: This article reports the case of a 72-year-old patient who presented to the emergency department with a prolonged complaint of worsening back pain lasting approximately five weeks. He was diagnosed with discitis combined with osteomyelitis, which required surgical intervention due to clinical deterioration despite antibiotic treatment.

Introduction: Benign prostatic hyperplasia (BPH) is common in men over 50 years of age and often causes urinary tract obstruction, which can lead to urinary retention and reliance on a permanent catheter. In cases where medical treatment fails or it is contraindicated, surgical treatment is recommended. This study explored an alternative: prostatic artery embolization (PAE), evaluating its effectiveness in weaning patients off a catheter.

Methods: In this retrospective study, data was collected on patients who underwent PAE at our institution, by the same physician, from August 2018 to November 2023, to treat persistent urinary retention or had contraindications to catheter weaning. A statistical analysis was conducted.

Results: A total of 115 patients underwent PAE, 29 patients for weaning off a catheter. Their average age was 73.4 years (SD - 10.19). The average prostate volume was 167.44 grams (SD - 85.4). The majority, 62%, had significant comorbidities (ASA of 3-4). After PAE, 28 patients (97%) weaned off the catheter. The side effects were mostly mild (17%) with a Clavien-Dindo score of 1 to 2 and resolved spontaneously. More serious side effects were observed in two patients and included partial necrosis of the glans penis and renal failure. Both side effects resolved completely during follow-up.

Conclusions: PAE is a good solution for weaning off a urethral catheter in patients with significant comorbidities. This procedure has a high success rate in catheter weaning and mostly mild and transient side effects.

Introduction: Urolithiasis imposes a significant financial burden on healthcare systems.

Aims: To investigate the factors influencing the treatment costs of ureteral stones.

Methods: A cross-sectional study was performed based on a retrospective cohort of Emergency Department (ED) patients with CT proven ureteric stone. Clinical, laboratory and imaging data were collected, including data on hospital admissions, ED readmissions, procedures, and total treatment cost.

Results: During the period 2018 - 2020, 805 ED patients were identified on CT with ureteral stone, of whom 773 met the inclusion criteria. Treatment costs were directly related to the patient's age: NIS 15,125 for 18-30 year olds, NIS 19,225 for 31-50 year old patients, NIS 22,866 for patients aged 51-70 years, and NIS 34,665 for patients over 70 years (p<0.001). Female patients incurred NIS 5,190 higher costs than male patients (p=0.03). Stone size and location were also associated with increased costs: <5mm (NIS 11,773), 5-10mm (NIS 34,500), and >10mm (NIS 58,340) (p<0.001); NIS 37,067 vs NIS 14,764 for proximal and distal stones respectively (p<0.001). Positive urine culture (p<0.001), elevated CRP (p<0.001), lower GFR (p=0.002) and concomitant renal stones (p<0.001) were associated with higher treatment costs. Prior renal drainage increased costs by NIS 7,450 (p<0.001). Stone composition also affected costs, with struvite stones being the most expensive to treat (NIS 53,552) (p<0.001).

Conclusions: Treatment costs are primarily influenced by patient age, stone size, location and composition. Additionally, the presence of an infectious state increases the overall treatment costs.

Introduction: MASSIVE TUMOR INSIDE A GIANT BLADDER DIVERTICULUM.

Introduction: In recent decades, with improvement in therapy, men born with spina bifida (myelomeningocele) live longer and reach adulthood. This raises the question whether they develop age-related benign prostatic hyperplasia (BPH). We recently found that low spinal cord injuries reverse age-related prostatic growth, suggesting that continuous nervous system support is essential for sustaining BPH.

Objectives: This study aimed to examine if patients born with spina bifida develop BPH as they age.

Methods: This was a multi-center study. The prostate volume (PV) of 24 spina bifida patients older than 35 years were documented from recent available imaging, or from ultrasound testing conducted as part of the research. Each patient's measured volume was compared to expected age-adjusted average volumes of healthy men. Additional clinical variables were collected.

Results: Patients' median age was 46 years, with a range of 35-61 years. The prostate volume of spina bifida patients was on average 18% smaller than age-expected volume (P<0.005). The most common level of injury was lumbar; however, no significant correlation was found between the level of injury and PV. Non-parametric statistical tests did not show a significant correlation between PV and other clinical variables, probably due to the small sample size.

Conclusions: Spina bifida patients have smaller PV than age expected, and do not commonly develop BPH. This information is beneficial for clinicians counselling spina bifida patients. Moreover, it provides additional evidence of the nervous system's role in developing BPH and raises the possibility of finding a non-hormonal pharmacological intervention for reversing BPH.