Lower Pole Research Articles

Open distal ureteroureterostomy for non-refluxing duplicated collecting system in children: Multicentric study and mid-term outcomes

When indicated, ureteroceles and ectopic ureters in duplicated collecting systems can be managed via upper or lower urinary tract surgical approaches, or a combination of both. Open ureteroureterostomy (UU) has been described to address these conditions in the absence of lower pole (LP) vesicoureteral reflux (VUR). We report outcomes from multiple centers worldwide with mid-term follow-up. Our study consists of a retrospective review of records and imaging of children who underwent open distal UU via inguinal incision for duplicated collecting system without lower pole VUR in institutions from North America, South America, and the Caribbean. Descriptive statistics and univariate analysis were utilized. The records of 127 patients who underwent open distal UU for double collecting system between 2009 and 2022 were reviewed. Of those, 65% were female (n=82), with a mean age at operation of 18 months (range 3-180). Main presentation at surgery included prenatal hydronephrosis (64%, n=81), followed by febrile urinary tract infections (28%, n=36), and urinary incontinence or other (8%, n=10). The patients with antenatal or incidental diagnosis of hydronephrosis were classified as preoperative Society for Fetal Urology (SFU) grade 3 (n=64) and 4 (n=54) (96%). Those who were classified with SFU grade 0-2 (4%) had symptomatic clinical presentations including febrile urinary tract infections (UTIs) (n=3), urinary incontinence (n=3), and a 12-year-old patient with recurrent abdominal pain (n=1). Mean operative time from skin incision to skin closure was 86min (range 45-240). Mean hospital stay was estimated at 1.1 days (range 0.5-4). In our cohort of 127 patients, 3 (2%) developed Clavien-Dindo grade I (2 with ureteral stent displacement and 1 with a urine leak/managed conservatively), 6 (5%) with grade II (3 febrile and 3 non-febrile UTIs managed with oral antibiotics), and 2 (2%) with grade IIIb complications (urine leaks requiring surgical management), which were appropriately treated. None presented grade IV or V complications. A double J stent was used in 56 patients (44%), and a Penrose drain was left in 10 (8%). A total of 125 children (98%, n=125/127) showed sonographic improvement of hydronephrosis, or resolution of symptoms with stable ultrasound findings. Successful outcome was similar for both ureterocele and ectopic ureter subgroups: 49/49 patients with ureterocele showed 100% improvement, 76/78 children with ectopic ureter showed improvement in 97% of the cases. On univariate analysis, outcomes were similar regardless of the use of ureteral stents (p=0.11). Mean follow-up was 28.2 months (range 12-85). Open distal UU is a good alternative for the definitive surgical management of ectopic ureters and ureteroceles without LP VUR. This multicentric and mid-term follow-up study demonstrates that open distal UU offers high success rates, low morbidity, short operative times and hospital stays, and satisfactory aesthetic outcomes. Additionally, the surgery is performed extra-peritoneally and may not require the use of stents or drains, depending on surgeon preference. Further investigations are being conducted to determine the role of UU in the settings of double collecting systems associated with ipsilateral LP VUR.

Composite Sling: A Strategy for Enhancing Inferolateral Support in Mastopexy with Implant.

Augmentation mastopexy has attracted the attention of numerous authors seeking to improve surgical outcomes and ensure breast implant stability. The utilization of the dual plane technique with a lateral sling, pioneered by Ono and Karner, has demonstrated effectiveness in providing long-term implant support. However, challenges arise in cases of anatomical variations, such as a short pectoralis major (PM) muscle or chest, necessitating alternative approaches like the composite sling. This study presents a technique designed to elongate and broaden the lateral sling to enhance implant support. The composite sling incorporates components from the abdominal part of the PM muscle, the aponeurotic/muscular part of the external oblique muscle, and the cranial part of the rectus abdominis. Procedures were performed on 29 patients using the composite sling technique from July 2022 to October 2023. The follow-up period ranged from 6 to 18 months (average of 11.89 months). The lateral sling approach was successfully extended to cases with a short PM muscle or chest, previously managed using the dual plane technique without inferolateral support. No increase in complications or implant displacements was observed compared with the original lateral sling approach. However, four reoperations addressed issues such as dog ears, scarring, and minor asymmetries. Consistent results were observed throughout the follow-up period, particularly in maintaining upper pole fullness and preventing lower pole ptosis. The composite sling approach provides a viable solution for cases where the original sling technique is impractical. Its implementation could broaden surgical options and optimize results, particularly in cases of unfavorable anatomy.

A Rare Representation of Kidney Vasculature – Cadaveric Case Report

Understanding the nuances of renal vascular anatomy is paramount in the context of retroperitoneal surgeries and kidney transplant procedures. This case report describes the unique vascular variations observed in the right kidney of an adult male cadaver during dissection. The right kidney was supplied by three renal arteries: two through the hilum and an extra hilar superior polar branch, and one through the lower pole. Three renal veins emerged independently from the hilum, each opening separately into the inferior vena cava. Two of these veins emerged anterior to the renal pelvis, while the third emerged posterior to it. Notably, two veins terminated into the lateral aspect of the inferior vena cava, while one terminated into its posterior aspect.

Composite eosinophilic solid and cystic renal cell carcinoma and clear cell renal cell carcinoma: a rare case report and literature review

BackgroundEosinophilic solid and cystic renal cell carcinoma (ESC-RCC) is a novel subtype of renal cell carcinoma characterized by its relatively low incidence and indolent behavior. We report a rare case of ESC-RCC concurrent with clear cell renal cell carcinoma (ccRCC) in a single kidney.Case presentationA 48-year-old male, was found to have a mixed echogenic mass in the left kidney during a physical examination. He has no history of hematuria and flank pain. An abdominal CT scan revealed a 3.0 * 1.9 * 2.5 cm3 mass with unclearly bordered at the lower pole of the left kidney. Abdominal MRI showed two nodules of different sizes in the left kidney, suggesting the possibility of a tumor. The patient underwent a subtotal nephrectomy, and the postoperative pathological results indicated ESC-RCC combined with ccRCC. The patient recovered well without tumor recurrence during the 12-month follow-up.ConclusionWe reported a case of renal composite tumors, comprising the rare ESC-RCC and the more common ccRCC. Imaging combined with postoperative pathological examination is crucial for the definitive diagnosis of these rare tumors.

Comparative analysis of scoring systems for patients undergoing retrograde intrarenal surgery with isolated lower calyx stones.

It is critical to provide patients with accurate information on potential surgical outcomes during the preoperative phase. Several scoring systems have been developed for this specific purpose. This study aimed to examine the predicted efficacy of scoring systems in patients with isolated lower calyx stones who underwent retrograde intrarenal surgery (RIRS). We performed a retrospective analysis of 85 patients who underwent RIRS for lower calyx stones between 2016 and 2023. The study computed each participant's Resorlu-Unsal Stone score (RUSS), R.I.R.S. scoring system score, Modified Seoul National University Renal Stone Complexity (S-ReSC) score, S.T.O.N.E. score, Ito's nomogram, and T.O.HO score. Residual stones less than 4mm were classified as clinically insignificant residual fragments (CIRFs) and regarded as successful. Following that, we used receiver-operating characteristic (ROC) curves to compare various scoring systems' success predictions. The median scores for RUSS, R.I.R.S. scoring system, Modified S-ReSC, S.T.O.N.E., Ito's nomogram, and T.O.HO score were 1 (1), 7 (2), 2 (0), 11 (1), 18 (4), and 7 (1), respectively. When CIRF cases were included, the stone-free rate increased to 80%. Only Ito's nomogram from scoring systems has a statistically significant cut-off value for success in ROC analysis (p = 0.021). In multivariate analysis, stone volume and preoperative hydronephrosis were associated with success (p = 0.004 and p = 0.035, respectively). In the multivariate analysis, none of the scoring systems were significantly associated with success. Hence, a new scoring system must be developed exclusively for patients with isolated lower pole stones undergoing RIRS.

Tonsillar healing membrane characteristic for tonsillectomy using combined cold dissection and bipolar electrocautery

PurposeTo evaluate post-tonsillectomy healing process using combined cold dissection and bipolar cautery for hemostasis.MethodsThis case series included patients for whom tonsillectomy was done by cold dissection and limited the bipolar cautery for hemostasis and dealing with the lower pole only. Saline irrigation was used for the tonsillar bed after tonsillectomy and a wet saline-moistened pack was placed into the tonsil fossa. Intra-oral digital photographs were reviewed postoperative, at 3rd, 5th, 7th, 9th, 11th, 13th, 15th, and 21st day after surgery. Patients were asked to register their postoperative pain using a standardized visual analog scale. The time of separation of the healing membrane (HM) and any blood clot and/or bleeding surface were recorded.ResultsAmong included 114 patients, the HM color was white without odor in all cases. Extension of the HM was limited to the tonsillar bed in 112 patients (98%) and exceeded in 2 patients (2%). The mean time for HM separation was 8.8 ± 1.1 days (range = 7–14) with a significantly longer period of separation in females (p = 0.0008). There was no significant correlation between the time of the HM separation and the age of the patients (P = 0.9).ConclusionCold dissection tonsillectomy with limited hot tools usage for hemostasis by bipolar cautery with frequent saline wash leads to odorless HM and a good healing process with an average separation of the HM and so less pain and post-tonsillectomy bleeding.

Clinical comparative study of single-use and reusable digital flexible ureteroscopy for the treatment of lower pole stones: a retrospective case-controlled study

ObjectivesTo compare the clinical efficacy and safety of single-use and reusable digital flexible ureteroscopy for the treatment of lower pole stones.MethodsWe enrolled 135 patients underwent reusable flexible ureteroscopy (FURS) and 78 patients underwent single-use digital FURS. Demographic, clinical variables, anatomical parameters of the lower calyx and perioperative indicators were compared in the two groups.ResultsThirty-six patients in the infundibuloureter angle (IPA) < 45° subgroup had a mini-percutaneous nephrolithotomy (mini-PCNL), including 25 patients in the reusable FURS group and 11 patients in the single-use FURS group. The demographic and clinical variables in the two FURS groups were comparable. There was no statistical difference in the success rate of stone searching (P > 0.05). In terms of the success rate of lithotripsy, there was also no statistical difference in the IPA ≥ 45° subgroup (P > 0.05), whereas single-use FURS was superior in the IPA < 45° subgroup (χ2 = 6.513, P = 0.011). The length of the working fiber in the reusable FURS and single-use FURS groups was 3.20 ± 0.68 mm and 1.75 ± 0.47 mm, respectively (t = 18.297, P < 0.05). The use of a stone basket in the reusable FURS (31/135, 23.0%) was significantly higher than that in the single-use FURS (8/78, 10.3%) (χ2 = 5.336, P = 0.021). Compared with the reusable FURS group, the single-use FURS group had shorter operation times (P < 0.05) and higher stone-free rate (SFR) (χ2 = 4.230, P = 0.040). There was no statistical difference in the intraoperative transfer of mini-PCNL and postoperative complications between the two groups (P > 0.05).ConclusionsSingle-use and reusable FURS are alternative methods for removal of lower pole stones (i.e., 2 cm or less). Single-use FURS has a high success rate of lithotripsy, shorter operation time, and high stone-free rate.

Is Bigger Better? Comparison of 150 µm and 200 µm Thulium Fiber for In Situ Lower-Pole Lithotripsy.

Introduction: The thulium fiber laser (TFL) generates a focused beam, which can be transmitted to laser fibers with small core diameters and may facilitate in situ lower-pole lithotripsy. This study compares lithotripsy performance of the 150 and 200 µm TFL in a lower pole benchtop kidney model. Materials and Methods: Using a 3D model printed from an actual kidney, in situ laser lithotripsy was performed on 1 cm lower-pole BegoStones (calcium oxalate monohydrate consistency) using four different settings (all 20W) and two fiber sizes (150 and 200 µm). Procedure time, laser time, total pulse energy, and fiber stripping were compared between the two fibers using an ANOVA or independent t-test. Results: The 150 µm fiber at 0.2 J × 100 Hz had the shortest lasing and procedure time (17.3 and 18.5 minutes) and lowest total pulse energy (20.75 kJ) compared with other study arms (p < 0.001). Overall procedure time, lasing time, and total pulse energy were significantly different between the 8 settings (p < 0.001 for all). At higher frequency (100 and 200 Hz), lasing time was significantly faster compared with 20 and 50 Hz (19.9 vs 27.3 minutes; p < 0.001). Furthermore, the average total procedure time was shorter with 150 µm compared with 200 µm regardless of settings (23.2 vs 29.8 minutes; p < 0.001). Conclusion: The 150 µm fiber results in shorter procedure and lasing time at lower total energy levels during lower-pole in situ lithotripsy. Overall, the fastest setting was 0.2 J and 100 Hz with the 150 µm fiber. Smaller laser fibers can potentially allow more efficient in situ laser lithotripsy with better irrigation and visibility at higher deflection angles.

"Autologous Breast Dermal Filler": A Novel Technique for Breast Reconstruction After Nipple- or Skin-Sparing Mastectomy in Pubertal Gigantomastia.

For females in puberty, mastectomy caused by pathological gigantomastia usually brings significant psychological problems. Appropriate immediate breast reconstruction method is necessary. The aim of this study is to present a novel method of breast reconstruction that requires neither implants nor donor-site sacrifice. All patients who were diagnosed with pathological gigantomastia and indicated for nipple-sparing or skin-sparing mastectomy (NSM or SSM) were selected. All extra skin was de-epithelialized, followed by NSM or SSM through a vertical incision on the lower pole of the breast. Then, a skin and dermal envelope in all directions was formed. Whether to preserve the nipple-areolar complex depended on its perfusion. The dermal flap was folded inward to serve as the "autologous dermal filler" and reconstruct the breast. A second surgery of inframammary fold elevation for larger projection was performed at least 6 months. Follow up for at least 1 year and record complications as well as pre- and postoperative BREAST-Q Scores. A total of 11 breasts were included. Four (36.4%) were NSM and seven (63.6%) were SSM. Nipple to sternal notch distance in NSM and SSM was 32.3±9.1cm and 35.1±4.4cm, respectively. No complications occurred, while one breast with NSM showed nipple upward displacement. The BREAST-Q indicated significant postoperative improvements in breast satisfaction (20.5 ± 11.3 vs 80.2 ± 10.4) and psychosocial well-being (23.4 ± 8.9 vs. 81.4 ± 11.3). Preliminary study demonstrated the efficacy and long-term safety of "autologous breast dermal filler." For adolescents, it is a less invasive autologous breast reconstruction method, or transitional plan for further adjustment in adulthood. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Effect of infundibulopelvic angle on outcomes of ureteroscopy: a systematic review and meta-analysis

PurposeThe infundibulo-pelvic angle (IPA) is reportedly a predictor of successful ureteroscopy for lower pole renal stones, however there is uncertainty at which IPA success is likely. We therefore aimed to perform a meta-analysis and determine at which the angle of likely success and failure.MethodsWe performed a systematic review and meta-analysis as per Cochrane guidelines in accordance to the PRISMA statement. The review was registered with PROSPERO prior to commencement (ID: CRD42022296732). We included studies reporting on outcomes of ureteroscopy for lower pole stones, with IPA. We excluded patients undergoing alternative treatments for lower pole stones, anatomical abnormalities and studies with < 10 patients. We assessed bias with the Newcastle-Ottawa scale. We performed meta-analysis in R, and summarised the findings as per GRADE.ResultsOverall, there were 13 studies included, with 10 included for meta-analysis. These studies covered n = 1964 patients (71% stone free). Overall, the stone free patients had a significantly less acute mean IPA (52o ± 9o), compared to the non-stone free patients (39o ± 7o), on meta-analysis (REM MD = -13.0, 95% CI: -18.7 to -7.2, p < 0.001). On examination of forest plots, at IPA < 30o no patients were stone free, whilst > 50o all were stone free. Risk of bias was moderate, and certainty of evidence was ‘very low’.ConclusionWith a very low certainty of evidence, we demonstrate that at an IPA of < 30o no patient is stone free, whilst > 50o all patients (in this review) are stone free. More evidence is therefore needed.

Factors predicting stone-free rates after retrograde intrarenal surgery for lower pole kidney stones

Introduction: We aimed to investigate the factors impacting stone clearance following retrograde intrarenal surgery (RIRS) for lower pole kidney stones and to determine whether there is a significant relationship between the infundibular pelvic angle (IPA) of the kidney's lower pole and stone fragment clearance. Methods: We retrospectively reviewed patients who underwent flexible ureteroscopy (f-URS) for lower pole renal calculi between December 2020 and July 2023 at our institution. Patient demographics and stone parameters were recorded, including stone size, number, volume, density, and IPA. Intraoperative data, including total operative time, lasing time, type of laser used, and stone composition, were collected and analyzed. All patients underwent a computed tomography (CT) scan at three months followup. We recorded the presence of residual stones and the percentage of stone volume reduction. Patients with a stone size 3 mm were deemed stone-free. All patients were discharged home on the same operative day. Results: A total of 123 patients were included in the study: 71 in the stone-free group (group 1) and 52 in the residual stones group (group 2). On univariate analysis, there were significant differences between the two groups in terms of stone size, IPA, and the type of ureteroscopy used. At three months followup, 96% (24/25) of patients with an IPA &lt;30° had residual stones, compared to 28.6% (28/98) of patients with an IPA &gt;30° (p&lt;0.001). There was no significant difference in the intraoperative or postoperative complications between the two groups. On multivariate analysis, IPA and stone size were the only predictive factors for the presence of residual stones. Twelve patients (23.1%) from group 2 required retreatment. Conclusions: RIRS is an effective treatment option for the management of lower pole kidney stones. IPA, in conjunction with stone size, appears to dictate the stone clearance rates of RIRS for lower pole stones.

Experimental Investigation of a Digital Quadrupole Inductively Coupled Plasma Mass Spectrometer for Elemental Analysis.

We describe the development and initial characterization of a digital waveform scanning quadrupole mass filter (digital QMF) used for inductively coupled plasma mass spectrometry (ICP-MS). Unlike a conventional voltage scanning QMF, in the digital QMF, the frequency of the digital waveform is scanned to filter ions with different m/z through the quadrupole, and m/z is proportional to 1/f2. In digital QMF, the duty cycle of the digital waveform driving the quadrupole is modified such that stability regions of interest are accessible for mass analysis with no DC voltage applied. Here, we evaluate the performance of our digital ICP-QMS instrument at several duty cycles and corresponding stability zones: from zone 1 to zone 3,2. We demonstrate that, regardless of the stability zone used, frequency vs m/z calibration matches theory. For lower-order stability zones, the mass range of the analyzer is limited by the high-frequency waveform required; however, at zone 3,2, we demonstrate a mass range from at least 40 to 232 Th, which covers most of the elemental mass range. Similar to the conventional QMF, higher stability regions of the digital QMF can yield a higher resolution. We obtained the best resolution for our current instrument at zone 3,2 with a 62.50/37.50 duty cycle. The resolution at full-width at 10% peak height (R10%) was 1200 and 1100 for 115In+ and 232Th+, respectively. Lower pole bias yielded a R10% of 1400 for 40Ar+. Resolution and sensitivity comparisons indicate that higher q values and higher duty cycles lead to enhanced resolution, but lower sensitivity. Our results validate the operation of digital quadrupole ICP-MS and suggest that, with continuous improvement of electronics and instrumentation, a high resolution digital waveform scanning ICP-QMS for elemental analysis is possible.

Robot-assisted treatment of simple renal cysts

BACKGROUND: The gold standard in the surgical treatment of simple renal cysts is laparoscopic cyst fenestration. However, laparoscopic procedures have disadvantages which include poor ergonomics of the instruments hindering surgeon's work in children's small abdomen. Robot-assisted surgery has the potential to make surgeon's work easier and to improve surgical outcomes in patients with kidney cysts for the instruments have seven degrees of freedom, hand tremor is filtered. It also promotes comfortable console positioning for the surgeon, and three-dimensional wide-angle imaging of the surgical field. AIM: To present the first experience of applying robot-assisted surgery for fenestration (decortication) of the outer portion of the cyst and argon-plasma coagulation of its inner lining. METHODS: The author's present retrospective data of all patients with simple renal cysts operated on with robot-assisted approach at the Irkutsk State Regional Children's Clinical Hospital. The diagnosis was put after ultrasound examination of kidneys and after computed tomography with intravenous contrast agent. Surgery was performed using a new model of the Versius robotic system manufactured by Cambridge Medical Robotics (UK). RESULTS: Patients' mean age at the time of surgery was (13±5.3) years (median 15 [11; 16] years), mean weight — (46.7±17.2) kg (median 54 [40.5; 56.5] kg), smallest body weight — 27 kg, size of cysts — (1.8±2.4) cm (median 0.4 [0.4; 2.5] cm). Cystic formations in all patients were located on the left: in the upper pole in 2 patients, in the lower pole in 1 patient. During the surgical intervention, there were no complications in the form of bleeding from the kidney parenchyma or damage to neighbouring organs. Histological analysis revealed that the lining of the cyst wall contained transitional epithelium without signs of malignancy. Duration of surgery was (136.7±72.2) min (median 95 [95; 157] min), duration of patients' stay in the intensive care unit — (19.9±2.5) hours (median21.3 [19.1; 21.4] hours), duration of hospital stay — (9.3±2.3) days (median 8 [8; 10] days). Ultrasound examination made in 1, 3 and 6 months after the surgery revealed no signs of disease recurrence in the form of residual accumulation of fluid associated with kidney parenchyma. CONCLUSION: The experience described in the article is encouraging and confirms the reasonability and safety of robot-assisted procedures in pediatric urology.

Surgical outcomes of novel retroperitoneal low anterior vs posterior and transperitoneal access in single-port partial nephrectomy.

Single-Port Robot-Assisted Partial Nephrectomy (SP-RAPN) can be performed by transperitoneal and retroperitoneal approaches. However, there is a lack of surgical outcomes for novel Retroperitoneal Low Anterior Access (LAA) in SP-RAPN. The study compared outcomes of the standard approach (SA), considering transperitoneal (TP) and posterior retroperitoneal (RP) access vs LAA in SP-RAPN series. 102 consecutive patients underwent SP-RAPN between 2019 and 2023 at a tertiary referral robotic center were identified. Baseline characteristics, peri- and post-operative outcomes were collected. Patients were stratified according to surgical approach into standard (RP or TP) vs LAA and, subsequently, RP vs LAA. Multivariable logistic regression analysis was used to test the probability of the same-day discharge adjusting for comorbidity indexes. Overall, 102 consecutive patients were included in this study (68 SA - 26 TP and 42 posterior RP vs 34 LAA). Median age was 60 (IQR 51.5-66) years and median BMI was 31 (IQR 26.3-37.6). No baseline differences were observed. LAA exhibited significantly shorter length of stay (LOS) (median 10 [IQR 8-12] vs 24 [IQR 12-30.2.] hours, p < .0001), reduced post-operative pain (p < .0001) and decreased narcotic use on 0-1 PO Day (p < .001) compared to SA and RP only. Multivariate analysis, adjusting for comorbidities, identified LAA as a strong predictor for Same-Day Discharge. LAA is an effective approach as well as RP and TP, regardless of the renal mass location, whether it is anterior or posterior, upper/mid or lower pole, yielding favorable outcomes in LOS, post-operative pain and decreased narcotics use compared to SA in SP-RAPN.

Comparison Between the Efficacy &amp; the Safety of Single Use Flexible Ureteroscopy Lithotripsy and Miniaturized Percutaneous Nephrolithotomy (Mini PCNL) for the Management of Renal and Proximal Ureteral Calculi of ≤ 2CM

Abstract Background Urolithiasis has become a common medical problem with about 2- 3% prevalence rate and still increasing in the general population. Renal calculi represent about 80- 90% of all urinary calculi with high recurrence rate. Single Use Flexible Ureteroscopy Lithotripsy and Percutaneous Nephrolithotomy Lithotripsy are recommended in the 2013 European Association of Urology guidelines as the first line in management of lower pole calculi when renal anatomy is unfavorable for Extracorporeal Shock Wave Lithotripsy. Furthermore, Single Use Flexible Ureteroscopy Lithotripsy is extremely effective for management of calculi of ≤ 2 cm in diameter and complex renal calculi. Aim of the Work The aim of our study is to compare the outcome of using Single Use Flexible URS versus Mini-PCNL with ≤22 Fr tract accessin management of pelvic, lower calyceal and proximal ureteral calculi ≤ 2cm. It was conducted on 40 patients that were randomly divided into 2 groups. Group A were treated with Mini-PCNL (20cases), whereas group B were treated with Single Use Flexible URS (20 cases). Patients and Methods A clinical trial, it was carried out at Ain Shams University, Urology department from October 2020 to October 2021 and done over 40 patients complaining of single pelvic, lower calyceal or upper ureteric stone ≤ 2 cm. The patients underwent either Mini-PCNL or Single Use Flexible URS randomly according to simple randomization using Gpowa computer program with ratio 1:1. Results Our study showed that Single Use Flexible URS achieves a comparable stone free rates to Mini- PCNL as there is no statistically significant difference between group A and group B in the stone free rate.Flexible URS reduces the risks associated with Mini-PCNL.Blood loss is highly significant in Mini-PCNL group more than in Single Use Flexible URS group.The incidence of post-operative fever and infection is non- significant between 2 groups. It is (15%)3 cases from 20 cases in group A although, (5%)1case from 20 cases in group B. There is highly significant difference between group A and group B in both operation time and hospital stay. This means that the patients take more intra operative time in Flexible URS group than in Mini-PCNL group,but more hospitalization in Mini- PCNL group than Single Use Flexible URS group.There is no statistically significant difference between 2 groups in the need for double J stent or auxiliary procedure such as ESWL. Conclusion Single Use Flexible URS is widely used nowadays and the treatment of choice for management of renal calculi due to its high efficacy and low morbidity in management of renal stones up to 20 mm. This study indicated that Single Use Flexible URS is an effective technique for management of renal and proximal ureteric calculi ≤ 2cm. In comparison to Mini-PCNL, it not only has a similar stone free rate, but also is associated with lower complication rates, more favorable recovery time. But it has longer operative time.

Assessment of Factors Responsible for Stone-Free Status After Retrograde Intrarenal Surgery.

Aim The study aimed to evaluate the predictive factors that determined stone-free rate (SFR) after retrograde intrarenal surgery (RIRS). Materials and methods This prospective study was conducted on 183 patients undergoing RIRS for renal stones. Patients were categorized into two groups, depending on stone-free status one month following the procedure. SFRwas defined as the complete absence of stones or stones <4 mm. The parameters studied included patient demographics, presence of hydronephrosis, presence of preoperative double J-stent, abnormal renal anatomy, and stone characteristics (stone burden, stone number, stone density, stone location, lower pole infundibulopelvic angle, and lower pole renal infundibular length (RIL)). Univariate and multivariate analyses were performed to identify risk factors for residual stones. We assessed the predictive ability of the RIRS score and Resorlu-Unsal stone score (RUSS) for evaluating SFR utilizing receiver operating characteristic (ROC) analysis. Results 183 patients were included inthe study with a median age of 51 years. 131 (71.6%) patients were declared stone-free after the procedure. The mean stone size and density were 16.9 SD±7.5 mm and 1038 SD±342 Hounsfield units (HU) respectively. Stone-free patients had lower stone size (14.3 mm vs. 23.6 mm, p<0.01) and stone density (970 HU vs. 1211 HU, p<0.01) compared to non-stone-free patients. Patients with residual stones had steeper lower pole renal infundibulopelvic angle (RIPA) (31.3° vs. 40.7°, p<0.01) and longer RIL(26.6 mm vs. 21.1 mm, p<0.01). Stone multiplicity (p<0.01), lower pole stone location (p<0.01), and renal malformations (p<0.01)were significant influencing factors for residual renal stones after RIRS. Multivariate analysis revealed stone size, stone density (HU), and stone location as independent predictors for SFR after RIRS. Among the scoring systems, the RIRS score had the highest diagnostic accuracy for SFR (area under the curve (AUC): -0.882, 95% CI-0.828-0.936). Conclusion Stone size, stone density (HU), and stone number are important predictors of SFR after RIRS. Lower pole stone location and abnormal renal anatomy play a substantial role in determining SFR after RIRS. In lower pole stones, a long RIL and acute RIPA negatively influence SFR. Additionally, the RIRS score was found to be a better predictor for SFR than the RUSS score.

The pathogenic mechanism of monosodium urate crystal-induced kidney injury in a rat model.

(MSU) crystals usually in the kidney tubules especially collecting ducts in the medulla. Previous animal models have not fully reproduced the impact of MSU on kidneys under non-hyperuricemic conditions. In the group treated with MSU, the upper pole of the rat kidney was injected intrarenally with 50 mg/kg of MSU, while the lower pole was injected with an equivalent volume of PBS solution. The body weight and kidney mass of the rats were observed and counted. H&E staining was used to observe the pathological damage of the kidney and to count the number of inflammatory cells. Masoon staining was used to observe the interstitial fibrosis in the kidneys of the rat model. Flow cytometric analysis was used for counting inflammatory cells in rats. ElISA was used to measure the concentration of serum and urine uric acid, creatinine and urea nitrogen in rats. At the MSU injection site, a significantly higher infiltration of inflammatory cells and a substantial increase in the area of interstitial fibrosis compared to the control group and the site of PBS injection were observed. The serum creatinine level was significantly increased in the MSU group. However, there were no significant differences in the rats' general conditions or blood inflammatory cell counts when compared to the control group. The injection of urate crystals into the kidney compromised renal function, caused local pathological damage, and increased inflammatory cell infiltration and interstitial fibrosis. Intrarenal injection of MSU crystals may result in urate nephropathy. The method of intrarenal injection did not induce surgical infection or systemic inflammatory response.

Survival outcomes of billroth-I reconstruction following distal gastrectomy for gastric cancer patients in Vietnam: A 5-year follow-up

This study aims to describe the long-term survivorship of Billroth I (or Pean's) reconstruction technique in patients with distal gastric cancer. A single-arm longitudinal observational study was conducted at Viet Duc University Hospital, Hanoi, Vietnam, from 2018 to 2021. A total of 103 patients who were diagnosed with primary carcinoma in the lower third of the stomach and underwent lower pole gastrectomy with Péan anastomosis were recruited. The Kaplan–Meier analysis was used to estimate the survival outcome. A multivariate Cox proportional hazard regression model was used to measure the factors associated with survivorship. Results showed that 8.7% died during the study period. The Restricted Mean Survival Time (RMST) was 61.9 (95%CI=59.4-64.4) months. RMST was significantly different across the stages of cancer, T and N. Specifically, patients with advanced stage (III) had a substantially lower RMST (49.2 months) compared to those with early-stage (I&amp;II). Patients with T4 or N3 also had the lowest RMST compared to those with other characteristics (p&lt;0.05). Female patients had a lower risk of dying than their male counterparts (HR=0.092, 95%CI=0.013-0.661). Patients with a higher level of Node (N) had a significantly higher risk of dying than those with a lower level (HR=5.103; 95%CI=1.716-15.178). Having comorbidities was associated with a lower risk of dying (HR=0.066; 95%CI=0.008-0.531) than not having comorbidity. To conclude, the findings indicate favourable long-term results for patients with distal gastric cancer undergoing the Billroth I (or Pean's) reconstruction technique. The practice above may be the established protocol for managing these particular patients.

Resection of pleural solitary fibrous tumors with distinct feeding vessels arising from the descending aorta: a case report

BackgroundPleural solitary fibrous tumors (pSFTs) are rare mesenchymal pleural tumors with rich vascularity. Surgical resection is the cornerstone of pSFTs treatment, requiring careful preoperative imaging to delineate lesion extent and vascular supply including contrast-enhanced computed tomography and other examinations depending on its size and characteristics.Case presentationThe patient was a 34-year-old female with a mass measuring approximately 67 × 42 × 65 mm in the left posterior mediastinum. Intraoperatively, the mass demonstrated rich vascularity. Two veins originating from the abdominal cavity entered the lower pole, one converged from the superior pole, draining into the brachiocephalic vein. Additionally, two arteries arose directly from the descending aorta, while several veins drained into the intercostal veins. In response to unexpected intraoperative vascular findings, vascular clips and silk threads were used to ligate them. Subsequently, the tumor was successfully dissected, with approximately 600 ml of blood loss recorded during the 4-hour surgery. The patient exhibited a satisfactory postoperative recovery, and follow-up spanning over six months revealed no indications of recurrence or metastasis.ConclusionsWe firstly present a case of successful resection of a pSFT in a 34-year-old woman with a distinct feeding vessel arising from the descending aorta and describe the related surgical procedures. This case highlights preoperative evaluation of mass vascularity based on contrast-enhanced computed tomography. When blood supply is challenging to clarify, angiography can offer additional details, especially for giant pSFTs. Despite this, thorough intraoperative exploration remains essential to detect unexpected vessels. Appropriate interventions should be customized based on the vascular origins and the surrounding anatomical structures.

Exploring the Ideal of Breast Beauty: A Morphometric Analysis Based on the Opinions of the Brazilian Population.

Background The quest to identify parameters deemed optimal for breast aesthetics holds paramount significance in both aesthetic and reconstructive surgery. The definition of ideal breast beauty, however, is subject to cultural variations and diverse standards, necessitating a detailed understanding. Objective This study delves into the perspectives of the Brazilian population regarding the aesthetics of the female breast. Methods A selection of images portraying variations in the distribution of upper and lower pole ratios across four distinct proportion models (35:65, 45:55, 50:50, and 55:45) was presented to participants. Through a meticulously crafted questionnaire administered via Google Forms, respondents were tasked with identifying the images they deemed most beautiful and attractive. Comprehensive demographic data of the study participants were gathered and subsequently correlated with their group-specific opinions. Results A total of 3744 questionnaire responses were collected 228 of which were from plastic surgeons/residents. The average age was 35years, with 55.3% being women. Notably, breasts featuring a ratio of 45:55 emerged as the consensus choice for the epitome of beauty, garnering preference from 73% of the general population, 68% of women, 78% of men, and an equal 78% of plastic surgeons. This preference was consistent across all regions of the country. Conclusion Breasts with a ratio of 45:55 were universally deemed the most aesthetically pleasing. Similarly, breasts with a 50:50 ratio of breast tissue emerged as the next preferred choice. These insights contribute valuable perspectives on aesthetic considerations in breast surgery within the unique cultural context of Brazil.Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .