Current Urology最新文献

With advancements in laser technology and urological techniques, flexible ureterorenoscopy has emerged as a vital surgical approach for managing stone disease. Various techniques can be employed to customize endourological stone treatments. Despite the continuous evolution of equipment, it remains crucial to comprehend the fundamental steps of the procedure. This paper offers a comprehensive step-by-step guide that integrates the latest advancements in both scopes and lasers. Additionally, it outlines potential pitfalls and strategies to circumvent them, aiming to achieve optimal stone clearance and deliver individualized patient care safely and efficiently.

[This corrects the article DOI: 10.1097/CU9.0000000000000224.].

Background: The lifetime occurrence of urinary stones is approximately 1%-15%, and the peak age of occurrence is 30 years. Approximately one fifths of urinary tract stones are found in the ureter, of which two thirds are in the distal ureter. Many drugs, including phosphodiesterase-5 inhibitors (PDE5Is) and α-blockers, are used to relax the smooth muscles in medical expulsive therapy (MET). We aimed to compare the combination of tadalafil and tamsulosin versus tadalafil alone as MET for stones in the L1/3 ureter of 10 mm or less.

Materials and methods: A total of 150 patients with L1/3 ureteric stones measuring 10 mm or less were enrolled in the study and randomly assigned to one of 3 equal groups using a computer-generated random number. Patients in group A prescribed tadalafil 10 mg/d. However, those in group B were prescribed tamsulosin 0.4 mg and tadalafil 10 mg/d, whereas those in group C received a placebo once daily. Stone expulsion rate and pain recurrence were evaluated after 14 days.

Results: The stone expulsion rate was significantly higher in the tadalafil and tamsulosin groups and the tamsulosin group than in the placebo group in the current study by 68% in the combination group, 64% in the tadalafil alone group, and 42% in the placebo group (p = 0.019). In the current study, a combination was associated with lower pain recurrence than tadalafil alone or placebo, with means of 1.06, 1.9, 2.98 (with a p value of 0.001). Stone size was not effective in any group.

Conclusions: The combination of PDE5Is and α-blockers effectively increases the expulsion of lower ureteric stones (5-10 mm), but with the same effect as PDE5Is alone, with the advantage of decreasing pain recurrence. Stone size did not affect the expulsion rate in patients who received MET for stones less than 1 cm in size.

Ureterosigmoidostomy was commonly utilized as a procedure for continent urinary diversion. However, ureterosigmoidostomy is associated with complications such as infection, electrolyte disturbances, and neoplasia development. A 40-year-old Caucasian male presented with acute left flank pain. Past medical history was significant for bladder exstrophy for which ureterosigmoidostomy urinary diversion was performed during childhood. On physical exam, multiple circular erythematous patches were scattered across the forearms that had been presented for 2 years. Cross-sectional imaging demonnttated an ill-defined mass at the site of ureteral implantation with associated severe left hydroureteronephrosis. Endoscopy revealed a mass at the site of ureteral implantation and biopsy demonstrated invasive, poorly differentiated adenocarcinoma. The dermatosis was diagnosed as interstitial granulomatous dermatitis, a rare inflammatory skin condition associated with underlying autoimmune disease or malignancy. Patient elected operative management with left nephrectomy, sigmoidectomy, and ileal conduit diversion. Ihis case demonnttates a rare presentation of cutaneous paraneoplastic syndrome after development of colon cancer after ureterosigmoidostomy. Ureterooolonic urinary diversion has a demonnttaaie risk of neoplasia development at the anastomotic site, requiring routine endoscopic surveillance.

Objectives: This study aimed to ascertain the relevance of the Guy's stone score in the evaluation and outcome of percutaneous nephrolithotomy (PCNL).

Materials and methods: This 2-year hospital-based, prospective clinical study enrolled 100 patients who were indicated for PCNL. All patients were allocated into groups according to the Guy's stone score and were compared for factors associated with stone-free rate (SFR) and complication risk. The data were statistically analyzed using SPSS version 20.

Results: The median patient age was 40 years (range, 5-70 years). A greater portion of the patients were aged 31-40 years. A majority of the stones were solitary, found in 83% of the kidneys. Overall, 49% were grouped as Guy's stone score 1, 26% as 2, 11% as 3, and 14% as 4. The overall SFR was 97%. Furthermore, SFR was found to be 100% for Guy's stone score 1, 100% for 2, 90.91% for 3, and 85.7% for 4. Intraoperative and postoperative complication rates were found in 6% and 38% of the patients, respectively. Among postoperative complications, pain (26%) was the most frequent, followed by fever (8%), bleeding (3%), and puncture site abscess (1%).

Conclusions: Based on the study findings, Guy's stone score was efficient in predicting PCNL outcomes.

Background: Partial nephrectomy (PN) is considered the gold standard surgical treatment for renal masses < 7cm in size (T1 tumors). Since the introduction of the robotic-assisted laparoscopic PN (raPN) in high-volume centers, it has been increasingly adapted and standardized by urologists worldwide. There is growing evidence that the robot-assisted laparoscopic technique is associated with superior outcomes compared to those of open and conventional laparoscopic techniques. This study aimed to summarize the contemporary outcome data of raPN for renal tumors with varying degrees of complexity and to assess whether the outcomes reported from high-volume centers are reproducible in a limited caseload setting.

Materials and methods: This was a retrospective study of a single surgeon's experience, including 123 consecutive patients undergoing raPN at our institution. Ultimately, 110 patients were included in the analysis. Basic characteristics, tumor complexity as described by the RENAL score, complications described by the Clavien-Dindo classification system, and functional and oncological outcomes were assessed and analyzed statistically.

Results: Of the 110 patients, 27 (24%), 61 (55%), and 23 (21%) had low, intermediate, and high degrees of complexity, respectively, according to the RENAL score. A cancer-negative surgical margin was achieved in 108 (97%) patients. A total of 70 (64%) patients had no loss of renal function, while 20 (27%) had minimal loss of renal function. Complications of > 3 Clavien-Dindo classification during the first 30 postoperative days occurred in 5 (5%) patients. The 3 complexity groups were found to have significantly different ischemia time: Low, 8 minutes (interquartile range [IQR], 8-9.5); Intermediate, 12 minutes (IQR, 10-13); and High, 15.5 minutes (IQR, 11.25-18.75) (p < 0.001). There were no significant differences between the groups.

Conclusions: Contemporary standards for raPN are safe and reproducible. Adherence to the technique reported by centers of excellence yielded comparable results with regard to tumor control, preservation of renal function, and complication rates in lower-volume settings.

Background: The use of visual aids to enhance patient learning is becoming increasingly common in medicine. Patients with a better understanding of surgical procedures tend to have better long-term outcomes due to the active seeking of help when complications occur postsurgery. We hypothesized that showing patients an animation of ureteroscopy with instructions on how to address potential complications would increase their understanding of the perioperative nature of ureteroscopy.

Methods and materials: Fifty patients were selected between May and August 2019. The group consisted of patients who had recently undergone ureteroscopy for nephrolithiasis or who would undergo ureteroscopy in the near future. Patients were given a prevideo assessment, followed by video and postvideo assessments. The prevideo and postvideo assessments were multiple choice and identical, except for 3 additional questions at the end of the postvideo assessment asking about patient opinions regarding the video. Patients were unaware that they would be completing a postvideo assessment until they had finished watching the video.

Results: When asked about the symptoms of a urinary tract infection postprocedure, 72% of patients answered incorrectly, with 58% choosing "go to the emergency department immediately," in the prevideo assessment versus 6% in the postvideo assessment (p < 0.05). If bleeding was a possible side effect of the procedure, 20% versus 0% answered incorrectly (p < 0.05). When asked about stent placement after surgery, 6% versus 0% answered incorrectly. One hundred percent of patients in both assessments answered correctly that stones would be removed and a scope was inserted into the urethra. Ninety-four percent of patients noted the video was presented in a very clear way, 80% noted that the video increased their understanding of the procedure "a lot," and 82% noted the video increased the quality of their visit "a lot."

Conclusions: Using an animated video to explain ureteroscopy and laser lithotripsy is beneficial.

Background: Sacral neuromodulation (SNM) treatment of refractory urinary symptoms is associated with quality of life improvements using disease-specific instruments. There is a paucity of information relating universal health outcomes to effective treatment of urinary symptoms. The objective was to analyze changes in Patient-Reported Outcomes Measurement Information System (PROMIS) item-bank scores following SNM for treating refractory lower urinary tract symptoms (LUTS).

Materials and methods: This is a sub-analysis collected from an institutional review board approved, retrospective chart review evaluating changes between pre- and post-procedure PROMIS scores in subjects undergoing successful SNM implantation for refractory LUTS at a multidisciplinary adult continence clinic. The difference between pre- and post-procedure PROMIS scores was compared via two-sided Wilcoxon signed-rank test, with p <0.05 considered statistically significant.

Results: Of the 29 subjects, most were female (89.66%), Caucasian (68.97%), nonsmokers (89.66%) with public insurance (62.07%). The median age was 63years and body mass index was 33.2kg/m². Procedure indications included urinary urge incontinence (83%), mixed urinary incontinence (10%), retention (17.24%), and overactive bladder (3%). Pain Interference and Depression scores had a nonsignificant improvement from 64.2 (ranging 58.9-67.5) to 60.75 (ranging 55.2-67.2), p = 0.21, and 55.2 (ranging 51.5-59.9) to 53.4 (ranging 49.5-61.1), p = 0.33, respectively. Median Physical Function scores demonstrated nonsignificant worsening following implantation from 38.0 (ranging 34.7-40.9) to 36.1 (ranging 33.1-40.8) (p = 0.25). Twenty-one subjects (72%) reported an improvement in at least 1 PROMIS item-bank with 6 subjects (21%) reporting no improvement in any of the item-banks.

Conclusions: Treatment of refractory LUTS with SNM resulted in no statistically significant changes in the PROMIS item-banks of Physical Function, Pain Interference, or Depression. Further prospective investigation is necessary to delineate the relationship of the self-reported universal-health outcomes in the treatment of LUTS.

Background: There is limited published evidence regarding the incidence of intraoperative and postoperative events and the effect of percutaneous nephrolithotomy (PCNL) in supine and prone positions and laparoscopic pyelolithotomy on kidney function in patients with large and complex calculi.

Materials and methods: We evaluated the surgical outcomes of 97 patients with large and complex kidney stones. The patients were divided into 3 groups: those who underwent PCNL in the prone position, PCNL in the supine position, and pyelolithotomy by laparoscopy and retroperitoneoscopy. General surgical outcomes, size of residual stones, stone-free rate, glomerular filtration rate (GFR), and split GFR obtained from Tc-99m renal dynamic scintigrams were analyzed.

Results: Percutaneous nephrolithotomy in the prone position was correlated with improved function of the affected kidney. In the supine PCNL group, none of the analyzed indicators demonstrated a significant difference. Dynamic nephroscintigrams revealed negative changes in terms of accumulation and secretion of the affected kidney. A slight decrease in creatinine clearance was noted. However, positive dynamics in split GFR and secretory index were seen in this group. The laparoscopic group showed positive results in all analyzed parameters. However, full assessment of the function of the affected kidney in this group was limited due to restricted use of laparoscopic pyelolithotomy for complex stones.

Conclusions: Percutaneous nephrolithotomy in the prone position resulted in the most favorable renal functional outcomes for patients with high-grade renal calculi, whereas a laparoscopic approach may be preferred for patients with stones of lower grades. The most significant factors that adversely affected renal function were intraoperative bleeding volume, kidney stone size and density, and body mass index.

The disorder of sex development is a rare disorder that usually occurs in early childhood. As adults, those with disorder of sexual development present with gynecomastia, primary amenorrhea, and primary infertility, which often causes great psychological impact. We report a unique case of a male adult hermaphrodite presenting with hematometra and hematosalpinx. Early management including psychiatry counseling, gender reassignment, and surgery is essential. Our patient underwent müllerian tissue removal with phallus reconstruction.