ROLE OF ALPHA BLOCKER IN URETERORENOSCOPY.

Objective: To determine the efficacy of alpha blockers in successful management of lower and mid ureteral stones by ureterorenoscopy. Study Design: Comparative prospective study. Place and Duration of Study: Department of Urology, Combined Military Hospital Quetta Pakistan, from Jul 2018 to Dec 2019. Methodology: Total of 150 patients having mid and lower ureteric calculi requiring ureterorenoscopy were divided into two groups. Group A included patients without pre-treatment with alpha blocker was administered before they were subjected to ureterorenoscopy. Study group B included patients who received daily oral dose of alpha blocker, Tamsulosin 0.4 mg twice daily, for 1 week before ureterorenoscopy. Per-operative findings in both the groups were recorded. Results were analyzed by comparing the outcome between both groups in terms of ease of performing procedure, duration of procedure, complications, duration of hospital stay and need for stent placement. Results: Mean operative time was significantly shorter in group B as compared to group A, (15.9 ± 3.81 min vs. 21.9 ± 3.63 min; p≤0.001). Demographic and stone characteristics were comparable between the both groups. Success rate was 74 (98.7%), in group B as compared to 68 (90.7%) in group A, with statistically significant difference (p=0.020). Complications in group B were less frequent 1 (1.3%) vs 7 (9.3%) in group A (p-value=0.027). Conclusion: Use of alpha blockers for one week before performing ureterorenoscopy resulted in fewer complications and made the procedure easier to perform as well.

Prediction of the ureteric stone outcome by CT scan

Background and objective: Urolithiasis is prevalent in both developed and developing countries, which is attributed to changes in lifestyles. Management of ureteric stones is highly dependent on their characteristics such as volume, size, and density which can be determined based on the images obtained from CT scan. The present study was carried out to examine the association between the final outcomes of the stones and different stone parameters specified by CT scan. Methods: The present prospective cross-sectional study consisted of 100 patients who had been referred to the Radiology Department of Rizgary and Erbil Teaching Hospitals in Erbil, Kurdistan Region, Iraq, over six months in 2019 to undergo abdominal CT scan with clinical suspicion of ureteric stones. All patients underwent non-contrast MDCT scan, and the CT images were evaluated for the presence of ureteric stone, site of the stone, side, diameter in three planes, volume, and density. The outcome of the stone was correlated with each above variables. Results: Ureteric stones were more prevalent among the young and middle age group (25-64 years) with an approximate male-to-female ratio of 3.34:1. There were significant associations between stone outcomes (i.e. spontaneous passage or need for intervention) and the stone characteristics including volume (P <0.001), density (P <0.001)site (upper, mid and lower ureter) (P = 0.02), anteroposterior diameter (P <0.001), transverse diameter (P = 0.006), and superior inferior diameter (P <0.001). Conclusion: Upon the significant correlation between the spontaneous passage of ureteric stones and their characteristics (i.e., volume, density, site, anteroposterior diameter, transverse diameter, and superior inferior diameter), it is highly recommended that all patients with urolithiasis undergo CT scan examination in order to make the proper decision regarding stone management. Keywords: Ureteric stones; CT scan; Stone characteristics; Spontaneous passage.

The Matryoshka technique in percutaneous nephrolithotomy

Objective: Miniaturized percutaneous nephrolithotomy (PCNL) reduces the risk of haemorrhagic complications, but the limited field of work represents a drawback. To obtain the best outcomes, the percutaneous access size should be intraoperatively tailored. Our purpose is to describe the indications and the procedural steps of the Matryoshka technique and to report its clinical outcomes. Materials and methods: We performed a retrospective analysis of the data from consecutive Matryoshka PCNL procedures from October 2016 to January 2018. Collected data included patients’ history, stone characteristics, intra- and post-operative items, stone clearance and need for retreatment. The main indication to the Matryoshka technique is the inability to securely position a guidewire due to an obstruction or narrowness in the pyelocalyceal system. This technique begins by puncturing the calyx hosting the stone and advancing a hydrophilic guidewire through the needle. If the guidewire cannot proceed beyond the stone, the Matryoshka technique is employed for tract stabilization. The tract is carefully dilated with small-bore instruments and a cautious lithotripsy is performed to create enough space to introduce the guidewire beyond the stone under visual control. Once the access has been stabilized the surgeon can upsize the tract to the optimum to complete the procedure. Additionally, the technique can be employed when an intraoperative reassessment induces the surgeon to further dilate the tract to quicken the procedure. Results: Sixteen patients were included, with a median stone volume of 3.49 cm3. Median operative time was 112 minutes. Three Clavien I-II (postoperative fever) and one Clavien IIIB (colon perforation) complications were reported. No blood transfusions were recorded. Three patients underwent scheduled retreatment as part of a multistep procedure. Out of the remaining 13 patients, 10 (76.9%) obtained a complete stone clearance.Conclusions: The Matryoshka technique helps the urologist to obtain a secure percutaneous access and makes PCNL flexible and progressive, potentially minimizing the risk of access-related complications.

Comparison of balloon dilation tract real-time monitored by ultrasound combined with endoscopic versus unitary ultrasound guided in percutaneous nephrolithotomy: a retrospective study

Background: The establishment of tract is very important in percutaneous nephrolithotomy. At present, balloon dilatation is widely used, but ultrasound or fluoroscopy guided balloon dilatation tract can not achieve real-time monitoring of the whole process, which easily leads to failure of tract establishment. we use ultrasound combined with endoscopic technology to realize the whole process monitoring of tract establishment. The purpose is to evaluate the safety and effectiveness of the technology.Methods: Patients who underwent PCNL with only using the balloon dilator from January 2019 to April 2021 in the Second Affiliated Hospital of Anhui Medical University were retrospectively reviewed. They were divided into ultrasound combined with endoscopic guidance group and ultrasound-guided group. The demographic and renal stone characteristics, intraoperative and postoperative data were analyzed.Results: A total of 72 patients were included in the study, including 35 patients in the ultrasound combined with endoscopic guidance group and 37 patients in the ultrasound-guided group. There was no difference in demographic and stone characteristics between the two groups.There were no significant differences between the two groups in surgical time, number of tract, hemoglobin decreased, stone free rate, ancillary treatment and postoperative complication rate. The tract establishment time of the ultrasound combined with endoscopic guidance group was significantly less than that of the ultrasound-guided group (P<0.05). There was no tract establishment failure in the ultrasound combined with endoscopic guidance group, while there were 7 cases in the ultrasound-guided group.Conclusions: Ultrasound combined with endoscopic guidance can monitor the establishment of working tract of PCNL in real time. Compared with unitary ultrasonic guidance, the time of tract establishment can be shortened and the failure of tract establishment can be avoided.

External validation of the T.O.HO. score and derivation of the modified T.O.HO. score for predicting stone-free status after flexible ureteroscopy in ureteral and renal stones

The T.O.HO. scoring system was developed to predict stone-free status after flexible ureterenoscopy (fURS) lithotripsy applied for ureter and renal stones. This study aimed to perform the external validation of the T.O.HO. score in the Turkish population and propose a modification for this system. Material Methods Patients who underwent fURS for kidney and ureteral stones between January 2017 and January 2020 were retrospectively analyzed. The patient and stone characteristics and perioperative findings were noted. The T.O.HO. score was externally validated and compared with the STONE score. Stone-free parameters were evaluated with the multivariate analysis. Based on the results of this analysis, the T.O.HO. score was modified and internally validated. Results A total of 621 patients were included in the study. The stone-free rate was determined as 79.8% (496/621) after fURS. The regression analysis showed that stone area had better predictive power than stone diameter (p=0.025). Lower pole (reference), middle pole [odds ratio (OR)=0.492 p=0.016] and middle ureteral (OR=0.227, p=0.024) localizations, stone density (OR=1.001, p<0.001), and stone volume (OR = 1.008, p <0.001) were determined as independent predictive markers for stone-free status. Based on the effect size of the stone surface area in the nomogram, stone volume was divided into five categories, at 1-point intervals. The AUC values of the T.O.HO., STONE, and modified T.O.HO. score in predicting stone-free status were calculated as 0.758, 0.634, and 0.821, respectively. The modified T.O.HO. created by adding stone volume was statistically significantly superior to the original version (ROC curve comparison, p < 0.001). Conclusion The T.O.HO. score effectively predicted stone-free status after fURS. However, Modified T.O.HO. SS showed the best predictive performance compared with original T.O.HO. SS.

The relationship between the stone-free status after extracorporeal shockwave lithotripsy (ESWL) treatment in different patient and kidney stone characteristics: A single center experience in Saudi Arabia

Purpose: The objective was to unveil the relationship between different relevant patient and kidney stone characteristics and the stone-free status post extracorporeal shockwave lithotripsy (ESWL) treatment. Materials and methods: Kidney stones cases referred for ESWL from October 2019 to January 2020 were collected. A total of 225 adult patients who met the criteria of being new cases of single radio-opaque kidney stones measuring 5 to 20 mm were included. We were looking for disintegrated stones down to 4 mm or less as a marker for stone-free (SF) status. The studied parameters were gender, laterality (right or left kidney), location of the stone within the kidney, stone’s density measured in Hounsfield units (HU), stone’s size, and stone-to-skin distance (SSD). Results: Out of the 225 cases treated, only 175 (77.8%) became SF after or during the study timeframe. SF status was achieved after the first session in 131 cases (58.2%). The bivariate analysis of the factors associated with higher SF rates found to be statistically significant were left kidney ( p-value of < 0.01), low stone density ( p-value of < 0.01), short stone–skin distance ( p-value of < 0.01), and small stone size ( p-value of < 0.01). On the other hand, gender and stone location within the kidney showed no association with ESWL outcomes. Conclusion: Kidney laterality, SSD, stone density, and size are influencing parameters on ESWL outcomes and achievement of stone-free status.

Striking a balance: outcomes of short-term Mono-J placement following ureterorenoscopy

To evaluate factors affecting the outcomes of short-term Mono-J insertion for 6 h following ureteroscopic stone removal. Patients treated with a Mono-J for 6 h after ureterorenoscopy and stone removal were analysed. FaST 1 and 2 (Fast Track Stent Studies), two consecutive single academic centre studies, were conducted between August 2014 and April 2018. In each study, we randomized patients with renal or ureteral calculi to two groups before ureterorenoscopy. FaST 1 compared a Mono-J insertion for 6 h versus Double-J insertion for 3–5 days after ureterorenoscopy. FaST 2 compared a Mono-J insertion to a tubeless procedure in the same clinical setting. All patients were pre-stented for 3–5 days before URS. The study endpoint was stent-related symptoms as assessed by a validated questionnaire (USSQ). Results were stratified by clinical parameters, stone characteristics and operation details. 108 of 156 initially randomized patients undergoing ureterorenoscopy were included. USSQ scores covering the time 3–5 weeks after stone removal showed a significantly reduced urinary symptoms and pain index compared to the scores before ureterorenoscopy. USSQ results before and after stone removal did not correlate with stone size or operation time and did not differ significantly depending on stone localization, the treating endourologist, or ureterorenoscopic device used (p > 0.05). Six patients (5%) required reintervention. Following secondary ureterorenoscopy and ureteral drainage with a Mono-J for 6 h, quality of life is independent of stone size and localization, operation time, the treating endourologist, and the URS device used.

Retrograde intrarenal surgery or percutaneous nephrolithotomy in the treatment of impacted proximal ureteric calculi

The objective of this study was to compare the clinical efficacy of retrograde intrarenal surgery (RIRS) and percutaneous nephrolithotomy (PCNL) in the treatment of impacted proximal ureteric calculi. This was a retrospective study on surgical outcomes of 202 patients with impacted proximal ureteric calculi. Overall, 140 and 62 were treated with RIRS and PCNL, respectively. The effects of the choice of the surgical method on the surgical outcomes were evaluated by preoperatively scoring patients with high-risk factors related to stone characteristics and analyzing these scores. Compared to the RIRS group, the surgical duration of the PCNL group was significantly shorter (51.69 ± 25.07 min vs. 67.46 ± 27.12 min, p < 0.05), stone-free rate (SFR) was significantly increased (98.4% vs. 72.10%, p < 0.05), and total treatment cost was lower (US $1678.61 ± 714.86 vs. US $3901.45 ± 1069.46, p < 0.05). Preoperatively, the efficacy of PCNL was higher than that of RIRS based on the higher scores observed. The results indicated PCNL had a better SFR and higher surgical efficacy, whereas RIRS had higher surgical safety parameters, a shorter perioperative period, but a lower initial SFR. PCNL is often more advantageous for complicated impacted proximal ureter stone.