Proximal Ureteral Calculi Research Articles

Management of Incidentally Detected Urinary Tract Calculus in Patients Awaiting Living Donor Liver Transplantation: A Protocol-Based Approach

Urinary tract calculi (UTC) in patients awaiting living donor liver transplant (LDLT) requires proper management due to increased risk of infections in the post-liver transplant (LT) period. A retrospective analysis of records of LDLT recipients with UTC was conducted between July 2019 and July 2023. No prisoners or paid participants were included. Thirty patients (25 women and 5 men) with a mean age of 44.45 ± 9.67 years, model of end stage liver disease with sodium (MELD-Na) of 20.5 ± 12.2 were diagnosed to have a UTC during pre-LT evaluation. Twenty-five patients had renal stones, whereas five patients had ureteric calculus (22 were unilateral and 8 were bilateral calculi). Fifteen patients underwent double J (DJ)-stenting prior to LT. The mean stone size in patients who underwent DJ stenting was 13.6 (±9.83) mm vs 4.78 (±5.3) mm in whom stenting was not done. Patients with preoperative DJ stenting had a significantly reduced hospital stay (18.5 ± 2.1 days), lower mortality rates (0%), and lower rates of hematuria (6.66%) vs (23.4 ± 12.8 days, 13.33% and 13.3%, respectively). Patients with preoperative DJ stenting underwent post-transplant definitive procedure for UTC without any complications. Our Protocol for Incidentally Detected Ureteric Stones in LT Recipients: a. Proximal-ureteric calculi: Preoperative DJ stenting (2-3 days prior/ on day of LT) → LT → ESWL/URS 2-3 weeks later → DJ stent removal after 2-3 weeks. b. Distal-ureteric calculi: Preoperative DJ stenting ± URS (2-3 days prior/ day of LT) → LT → DJ stent removal after 2-3 weeks. Our protocol for incidentally detected renal stones in LT recipients: a. Stone size (< 5 mm) and nonobstructive calculi with no active UTI: No surgical intervention → Liver transplant under antibiotics cover → medical management of stone. b. Multiple calculi sized < 5 mm or single stone 5-10 mm: DJ stent placement → LT → ESWL/RIRS after 4-6 weeks → DJ stent removal after 3 weeks. c. Single stone size > 10 mm or multiple calculi > 5 mm: DJ stent placement → LT → RIRS/PCNL after 4-6 weeks→DJ stent removal after 3-4 weeks. A systemic minimally invasive approach is needed for pre-LT management of UTC for better patient outcomes.

Surgical Approaches to Proximal Ureteral Stones &gt;1 Cm: A Comparative Study of M-PCNL and Semirigid URSL

Background: For the management of proximal ureteric calculi modalities like Extracorporeal shockwave lithotripsy, mini-Percutaneous Nephrolithotomy, UreteroRenoscopic Lithotripsy, and Retrograde Intra-Renal Surgery have been commonly used. The objective of this study is to compare the efficacy and safety of mini-Percutaneous Nephrolithotomy and semirigid Ureterorenoscopic Lithotripsy in terms of the total operation time, stone clearance rate, duration of hospital stays, post-operative hemoglobin drop, and peri-operative complications. Methods: This study was a hospital-based, prospective, comparative study conducted in the Urology Unit of Nepalgunj Medical College (NGMC). Eighty patients were included in the study, divided into two groups: 40 patients in the m-PCNL group (Group A) and 40 patients in the URSL group (Group B). Results: The mean age of the total patients was 36.34 ± 12.68 years. The mean duration of surgical procedure in m-PCNL Group was 26.93±9.43 minutes and in URSL it was 20.88±7.06 minutes. The mean duration of hospital stay in m-PCNL Group was 3.63±1.10 days and in URSL group it was 2.70±1.24 days. In m-PCNL, 5 cases (12.5%) had fever, 2 cases (5%) had hematuria and in URSL, 10 cases (25%) had a fever, 7 cases (17.5%) had hematuria and 1 case (2.5%) had dyspnea because of pulmonary complication. Conclusion: Our findings demonstrate that both m-PCNL and URSL can be done for proximal ureteric calculi &gt;1cm but m-PCNL has significantly better stone clearance with no residual stone and thus concludes m-PCNL is better than semirigid URSL for the management of proximal ureteric calculi greater than 1cm.

Perioperative Prophylaxis of Upper Urinary Tract Infections in Percutaneous Nephrolithiasis Surgery

The objective: to compare the effectiveness and safety of using fosfomycin trometamol in perioperative prophylaxis with other standard antibiotics in patients performing mini percutaneous nephrolithotripsy (mPNL). Materials and methods. The study was conducted in the period from May 2020 to May 2023 in the urology department of the Kyiv Clinical Regional Hospital (base of the Department of Urology of the P. L. Shupyk National Institute of Health of Ukraine). The study inclusion criteria were patients with renal or proximal ureteral calculi with indications for mPNL, with a total size of renal calculi from 1.0 to 4.0 cm. Two hundred patients were randomly divided into 2 groups, depending on the drug taken for perioperative prophylaxis. 95 patients took fosfomycin trometamol (group A), while the other 105 patients took the second-generation cephalosporin cefuroxime (control group B). Patients in the fosfomycin group took a single oral dose of 3,0 g, which was taken 12 hours before mPNL. Control group B took a dose of 1.5 g of cefuroxime intravenously 12 hours before surgery. An analysis of the frequency of infectious complications and side effects between the two groups, as well as the postoperative length of stay in the hospital, was conducted. Results. Postoperative infection complications were observed in 15 patients of both groups, which was 7.5% of all 200 studied patients: 3.2% (n=3) in the group А and 11.4% (n=12) in the group В (p&lt;0,05). Lower rates of postoperative fever were observed in the fosfomycin group - 2.1% versus 9.5% in the cefuroxime group (p&lt;0,05) with an increase in the ratio of preoperative and postoperative leukocytes (more than 1.5) in the fosfomycin group in 3.2% of patients versus 10.5% in the cefuroxime group (p&lt;0,05) and an increase of C-reactive protein in the fosfomycin group 45±15 mg/l versus 165±45 mg/l, respectively (p&lt;0.0001). In patients in the fosfomycin group with nephrostomy drainage, itwas removed on the next postoperative day in 75 (97,7%) vs 72 (87,8%) patients in the control group (p&lt;0,05). There were statistical differences between the groups in terms of the average length of stay in the hospital – 1.9 in the fosfomycin group versus 2.3 days in control group (p&lt;0,05); and the mean time of ureteral stent removal after the procedure was 10.5±3.5 days in the fosfomycin group and 14.5±4.5 days in the control group (p&lt;0,05). Conclusions. One preoperative oral dose of 3,0 g of fosfomycin trometamol in combination with standard perioperative infection prophylaxis in percutaneous surgery of upper urinary tract stones showed good efficacy and safety with reducing of average length of hospitalization of patients. Fosfomycin tromethamol can be used as a mainstream option for therapeutic and prophylactic purposes in the treatment of urinary tract infections, which will help prevent further increases in resistance to commonly used antibiotics. However, further research is needed to draw definitive conclusions and recommendations.

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.

Predictors for emergency readmission in patients with ureteral calculi: a focus on pain management and stone location.

The management of patients with ureteral calculi in the emergency department (ED) remains challenging due to high revisit rates. To identify predictors of revisits among patients with ureteral calculi in the ED. Data from patients who presented at a tertiary academic hospital in Seoul, Republic of Korea, between February 2018 and December 2019, were analyzed retrospectively. Variables, including the respiratory rate (RR), estimated glomerular filtration rate (eGFR), duration of pain, number of analgesic doses, location of ureteral calculi, and ED length of stay (LOS) were examined using logistic regression. We also examined some additional variables included in the STONE and CHOKAI scoring systems to examine their association with revisit. Significant predictors of revisits included the number of analgesic doses and the location of ureteral calculi. Patients who required multiple analgesic doses or those with proximal or mid-ureteral calculi were more likely to revisit the ED. Although the STONE and CHOKAI scores could predict uncomplicated ureteral calculi, we found that the CHOKAI score is a valuable tool for predicting the likelihood of patient revisits (p = 0.021). Effective pain management and consideration of calculi location are important for predicting patient revisits. More research is required to validate findings, develop precise predictive models, and empower tailored care for high-risk patients. In patients with ureteral calculi in the ED, the number of analgesics given and stone location predict return visits. Proximal ureteral calculi on CT may require early urologic intervention to prevent pain-related revisits.

Ureteral stricture formation after endoscopic removal of obstructing stones: could it be predicted with well-assessed radiological parameters?

The possible role of well-assessed radiological parameters in the prediction of ureteral stricture formation in cases with impacted obstructive ureteral calculi has been evaluated. 46 adult patients with or without ureteral stricture formation after ureteroscopic stone management were included. In addition to stone size and some certain radiological parameters including ureteral wall thickness (UWT) of the involved ureter at the impacted stone site was also measured and noted on computed tomography (CT) images. Parameters were evaluated in two subgroups of cases, namely: Group 1: patients in whom a ureteral stricture formed after endoscopic stone removal and Group 2: patients normal ureteral anatomy without any stricture formation. The possible relationship between the UWT values and degree of hydronephrosis (HN) with subsequent stricture formation was comparatively evaluated. All of the stones were proximal ureteral calculi in both groups. Both the degree of HN and proximal ureteral diameter (PUD) parenchymal was higher in cases with stricture formation. In addition, mean parenchymal thickness was lower and mean values of UWT measurements at the stone site were 3.70 ± 0.97mm and 2.17 ± 0.26mm in Groups 1 and 2, respectively. A cutoff value 2.49mm for UWT was found to be highly predictive for stricture formation. UWT value calculated at the obstructing stone site was found to be predictive enough for the likelihood of ureteral stricture formation with high sensitivity and specificity . This evaluation along with some other radiological parameters may enable the urologists to follow such cases on this aspect with necessary measures taken.

Safety and Efficacy of Bilateral Tubeless Supine Mini-Percutaneous Nephrolithotomy for the Management of Bilateral Renal Calculi in Renal Failure Patients

Background: To evaluate the safety, efficacy, feasibility, stone-free rate, and complications of bilateral tubeless supine mini-percutaneous nephrolithotomy (M-PCNL) for bilateral multiple renal calculi with renal failure as a single-stage procedure. Materials and Methods: We conducted aretrospective study from January 2020 to March 2022 in adult patients with bilateral renal or proximal ureteric calculi with renal failure who were subjected to bilateral supine tubeless M-PCNL. Patients on regular hemodialysis before the procedure were excluded. Data regarding the demographic profile, stone characteristics on non-contrast computed tomography (NCCT), duration of surgery, complications, and auxiliary procedures were retrieved from clinical records. Residual stone fragments of≤4mm in NCCT were considered clinically insignificant. The Clinical Research Office of the Endourological Society validation ofClavien score for PCNL complications was used. Results: A total of twenty-seven patients with a mean age of 45.9years were included in this study. The mean size of stone diameter per renal unit was 2.4 ± 0.4 cm. The mean preoperative serum creatinine was 2.8 mg/dL. A total of 62 tracts and 27 sessions were required for complete treatment of all 54 renal units in the 27 successfully treated patients. The average operating time was 75 (52–122) min on both sides. Serum creatinine drop at onemonth postsurgery was statistically significant (p &lt; 0.0001). Mean hospitalization time was 3.6 days [3–6 days]. The primary stone-free rate was 92.5%. Grade I, II, and IVA complications were recorded in three (11.1%), eight (29.6%), and two (7.4%) patients, respectively. Conclusion: Bilateral tubeless supine M-PCNL for bilateral renal calculi in selective patients with renal failure in a single session is a safe, feasible, and effective option which can be carried out without increased morbidity and can be attempted if the first-side M-PCNL has gone smoothly within a reasonable amount of time.

Vacuum-assisted dedusting lithotripsy in the treatment of kidney and proximal ureteral stones less than 3cm in size.

This study aimed to compare the outcomes of vacuum-assisted dedusting lithotripsy (VADL) using flexible vacuum-assisted ureteral access sheath (FV-UAS) versus traditional flexible ureteroscopic lithotripsy (fURL) in patients with kidney or proximal ureteral calculi less than 3cm in size. A total of 371 patients who successfully underwent fURL treatment were enrolled. These patients were divided into traditional fURL group and VADL group. Outcomes of both groups were compared using 1:1 propensity score-matched analysis. Stratified analyses based on stone size and location were also conducted. Finally, 103 well-matched patients in each group were identified. No septic shock or death occurred. The immediate stone-free rate (SFR) and follow-up SFR of VADL group were significantly higher (78.6% vs. 50.5%, p < 0.001; 94.2%% vs. 75.7%, p < 0.001). No difference was observed in postoperative fever rate (2.9% vs. 3.9%, p = 1.000) and duration of lithotripsy (37.7 ± 20.1min vs. 40.3 ± 18.9min, p = 0.235). For patients with stones ≤ 2cm in size, the immediate SFR and follow-up SFR in VADL group were higher (86.7% vs. 60.6%, p < 0.001; 96.0% vs. 83.1%, p = 0.010). The same trend was observed in the 2-3cm subgroup (57.1% vs. 28.1%, p = 0.023; 89.3% vs. 59.4%, p = 0.009). Although the in situ fragmentation strategy was employed more frequently in VADL group for lower pole stones, the SFR was still higher. Subgroup analyses did not reveal any significant differences in either infectious complications or duration of lithotripsy. VADL technique can significantly improve the postoperative SFR for the patients with kidney or proximal ureteral stones less than 3cm in size treated by flexible ureteroscope.

Comparison between tubeless mini-percutaneous nephrolithotomy versus flexible ureterorenoscopic lithotripsy for the treatment of upper ureteral calculi larger than 1 cm

Abstract Background This study aimed to assess the outcome and safety of tubeless mini-percutaneous nephrolithotomy (mPCNL) and flexible ureterorenoscopic lithotripsy (fURSL) in treating upper ureteral stones larger than 1 cm. Materials and Methods Between July 2017 and June 2020, 218 patients who underwent tubeless mPCNL and fURSL for upper ureteral calculi larger than 1 cm were enrolled in this study. Patient characteristics and perioperative outcomes and complications were evaluated by retrospective chart review. Results Immediate stone-free rates after the procedure were 100% of patients for the tubeless mPCNL and 71.0% of patients for the fURSL group (P = 0.004). The mean ± SD operative time per patient was 79.8 ± 21.8 minutes in the tubeless mPCNL group, and it was 99.7 ± 33.8 minutes in the fURSL groups (P = 0.009). The average hospital stay was 2.7 ± 1.9 days in the tubeless mPCNL group and 1.5 ± 1.2 days in the fURSL group (P &lt; 0.001). The rates of febrile episode for the tubeless mPCNL and fURSL groups were 14.3% and 2.3%, respectively (P = 0.028) Conclusions Tubeless mPCNL and fURSL are safe and feasible treatment options for proximal ureteral calculi larger than 1 cm. Tubeless mPCNL offers better outcome of higher stone-free rate and shorter operation time compared with fURSL but with a higher rate of febrile complications and longer hospital stay.

Efficacy of emergency extracorporeal shock wave lithotripsy in the treatment of ureteral stones: a meta-analysis

ObjectiveTo compare the clinical efficiency and safety of emergency extracorporeal shock wave lithotripsy (eESWL) and delayed extracorporeal shock wave lithotripsy (dESWL) in the treatment of ureteral stones.MethodsCochrane Library, PubMed, Google Scholar, and Web of Science were searched from January 1, 1992 to September 30, 2022, and all comparative studies involving eESWL and dESWL for ureteral calculi were included. Statistical analysis was performed using Review Manager 5.3 software. Funnel plot was used to evaluated publication bias.ResultsA total of 9 articles involving 976 patients diagnosed with ureteral stones were included. The results showed that the stone-free rate (SFR) after four weeks was significantly higher in the eESWL group than in the dESWL group [relative risk (RR) = 1.22, 95% confidence interval (CI): 1.13–1.32, P < 0.01]. In subgroup analysis of different stone locations, proximal ureteral calculi [RR = 1.25, 95% CI: 1.14–1.38, P < 0.01] and mid-to-distal ureteral calculi [RR = 1.18, 95% CI: 1.03–1.34, P < 0.05] all showed a higher SFR in the eESWL group. eESWL significantly shortened the stone-free time(SFT) [mean difference (MD) = -5.75, 95% CI: -9.33 to -2.17, P < 0.01]. In addition, eESWL significantly reduced auxiliary procedures [RR = 0.53, 95% CI: 0.40–0.70, P < 0.01]. No significant difference in complications was found between the two groups [RR = 0.90, 95% CI: 0.69–1.16, P > 0.05].ConclusioneESWL can significantly improve SFR, shorten SFT, and reduce auxiliary procedures.

Efficacy of ultrasound monitoring during extracorporeal shock wave lithotripsy: A multi-institutional propensity score-matched study.

To evaluate the efficacy of ultrasound-assisted monitoring during shock wave lithotripsy for kidney and proximal ureteral calculi. We retrospectively reviewed 535 patients who initially underwent shock wave lithotripsy for renal or proximal ureteral calculi between January 2012 and December 2021. The patients were divided into the X-ray group (n = 294) and ultrasound plus X-ray group (n = 241) based on the methods of targeting and monitoring calculi during shock wave lithotripsy. Because of differences in patient backgrounds, 1:1 propensity score-based matching was performed. The primary endpoint was the stone-free rate. In the final 1:1 matched cohort, 192 kidney stone cases and 162 proximal ureteral stone cases were analyzed. For patients with kidney calculi, the stone-free rate of the ultrasound plus X-ray group was significantly higher than that of the X-ray group (66.7% vs. 47.9%; P = 0.013). In the multivariate analysis, a large stone area (odds ratio 2.37), lower caliceal stones (odds ratio 3.37), and X-ray monitoring alone (odds ratio 0.49) were independently associated with shock wave lithotripsy failure. For patients with proximal ureteral stones, there was no significant difference in the stone-free rate between the ultrasound plus X-ray group and X-ray group (71.6% and 58.0%, respectively; P = 0.100). During the multivariate analysis, high computed tomography attenuation (odds ratio 2.31) and large stone area (odds ratio 2.18) were independent factors associated with residual stones after shock wave lithotripsy. Ultrasound-assisted monitoring may contribute to a higher stone-free rate for patients with kidney calculi, but not for those with proximal ureteral calculi.

Ureteral calculi lithotripsy for single ureteral calculi: can DNN-assisted model help preoperatively predict risk factors for sepsis?

To explore the utility of radiomics and deep learning model in assessing the risk factors for sepsis after flexible ureteroscopy lithotripsy (FURL) or percutaneous nephrolithotomy (PCNL) in patients with ureteral calculi. This retrospective analysis included 847 patients with treatment-naive proximal ureteral calculi who received FURL or PCNL. All participants werepreoperatively conducted non-contrast computed tomography scans, and relevant clinical information was meanwhile collected. After propensity score matching, the radiomics model was established to predict the onset of sepsis. A deep learning model was also adapted to further improve the prediction accuracy. Performance of these trained models was verified in another independent external validation set including 40 cases of ureteral calculi patients. The overall incidence of sepsis after FURL or PCNL was 5.9%. The least absolute shrinkage and selection operator (LASSO) regression analysis revealed 26 predictive variables, with an overall AUC of 0.881 (95% CI, 0.813-0.931) and an AUC of 0.783 (95% CI, 0.766-0.801) in external validation cohort. Judicious adaption of a deep neural network (DNN) model to our dataset improved the AUC to 0.920 (95% CI, 0.906-0.933) in the internal validation. To eliminate the overfitting, external validation was carried out for DNN model (AUC = 0.874 (95% CI, 0.858-0.891)). The DNN was more effective than the LASSO model in revealing risk factors for sepsis after FURL or PCNL in single ureteral calculi patients, and females are more susceptible to sepsis than males. Deep learning models have the potential to act as gatekeepers to facilitate patient stratification. • Both the least absolute shrinkage and selection operator (LASSO) and deep neural network (DNN) models were shown to be effective in sepsis prediction. • The DNN model achieved superior prediction capability, with an AUC of 0.920 (95% CI, 0.906-0.933). • DNN-assisted model has potential to serve as a gatekeeper to facilitate patient stratification.

MP027 - Holmium-YAG laser lithotripsy versus ballistic lithotripsy for treatment of proximal ureteral calculi: A prospective, randomized, bicentric and comparative study

MP027 - Holmium-YAG laser lithotripsy versus ballistic lithotripsy for treatment of proximal ureteral calculi: A prospective, randomized, bicentric and comparative study

Choice of access for endoscopic treatment of patients with proximal ureter calculi. Our experience

BACKGROUND: Urolithiasis is an actual problem of urology. Over the past 20 years, the tactics of treating patients with urolithiasis has changed significantly. However, there are currently no standardized algorithms for choosing the most effective treatment for a particular patient.&#x0D; AIM: To evaluate the efficacy and safety of using a mininephroscope in comparison with the use of a flexible ureterorenoscope when performing percutaneous antegrade ureterolithotripsy in the treatment of patients with proximal ureteral calculi.&#x0D; MATERIALS AND METHODS: A retrospective analysis of case histories of 61 patients with calculi in the proximal ureter was performed. All patients for surgical treatment were hospitalized in a planned manner with a previously installed nephrostomy drain 12Ch. All patients underwent percutaneous antegrade ureterolithotripsy 15 using a mininephroscope (Group 1) and 46 using a flexible ureterorenoscope (Group 2).&#x0D; RESULTS: The clinical performance of the mininephroscope and the flexible ureterorenoscope for ureterolithotripsy is similar. In patients of the 1st and 2nd groups, the average duration of the operation (59 10 min and 63 9 min, respectively, p 0.1) and the Stone Free Rate (SFR) on the first day after surgery (respectively 93.3% and 95.7%) did not significantly differ. There were no intraoperative complications in any of the patients. The frequency of postoperative complications in patients of the 1st and 2nd groups was low, all complications corresponded to the 1st degree according to the ClavienDindo classification. The duration of postoperative hospital stay in patients of the 1st and 2nd groups was the same and averaged 3 days.&#x0D; CONCLUSIONS: Performing percutaneous antegrade ureterolithotripsy using a nephroscope and a flexible ureterorenoscope ensures the achievement of SFR in the same short time, the minimum duration of surgery and the duration of the postoperative bed-day, as well as a low incidence of postoperative complications.

Cost-effectiveness of anti-retropulsive devices varies according to the locations of proximal ureteral stones: a retrospective cohort study

BackgroundAnti-retropulsive devices are often used to prevent stone migration in the treatment of proximal ureteral calculi. They are helpful. However, in the meantime, they also add extra expenses. This study was carried out to investigate the best criteria for treating proximal ureteral stones with anti-retropulsive devices.MethodsData from all patients who underwent ureteroscopic holmium: YAG laser lithotripsy for solitary upper ureteral stones in 2018 were collected. Patients who encountered stone retropulsion during the process of inserting the ureteroscope were excluded. Patients were divided into either group URS or group URS + ARD depending on whether the anti-retropulsive device was used. Then, the stone-free rate, expenses and other criteria were compared between groups according to stone location. Stone-free was defined as no stones present.ResultsFor stones located ≤ 30 mm from the ureteropelvic junction (UPJ), the stone-free rates for the URS group were 80% and 80% at one day and one month after the operation, respectively. Those for the URS + ARD group were 71.4% and 78.6% at one day and one month, respectively. For stones located 31–90 mm from the UPJ, the stone-free rates were 84.7% and 84.7% for the URS group and 89.6% and 95.5% for the URS + ARD group at one day and one month, respectively. A statistically significant difference occurred at one month. For stones located > 90 mm from the UPJ, the two groups were both stone free. In the URS + ARD group, expenses were higher. In addition, the mean diameter of residual stones derived from stones located at 31–90 mm from the UPJ was statistically smaller, and 4 of 7 residual stones passed spontaneously within one month, which was obviously more than that in other locations and the URS group. Other outcomes, including operation time and postoperative stay, showed no significant difference between the groups.ConclusionAnti-retropulsive devices are indeed helpful, but they might be cost-effective for stones located solely in the middle part of the upper ureter, not for those too close to or far from the ureteropelvic junction.

Laparoscopic management of ureter stones, comparison of two techniques

Aim: With the improvement of minimally invasive urology procedures, open surgical interventions are less common to treat ureteralcalculus. Laparoscopic ureterolithotomy (LU) indications are large multiple and/or impacted ureteral calculus that may not be treatedwith shock-wave lithotripsy or ureterorenoscopy approaches. In this study, we aimed to compare laparoscopic retroperitoneal andtransperitoneal ureterolithotomy techniques in terms of perioperative-postoperative results.Materials and Methods: We reviewed 45 patients with large and impacted upper ureter calculus who underwent transperitonealor retroperitoneal LU between January 2012 and December 2017. The transperitoneal and retroperitoneal routes were grouped asgroup 1 and 2, respectively. Groups were crosschecked according to preoperative, intraoperative, and postoperative clinical datum.Results: We did not find statistically meaningful disparity between groups with regards to age, gender, stone size, blood loss andbody mass index. The stone free accomplishment ratio was 100% in group 1 and 2. Visual analogue scale scores were higher andstatistically meaningful in group 1 (p<0.05). The mean operative time was statistically shorter in group 2 (p:0.022). No double J stentinserted routinely intraoperatively.Conclusion: Compared to those obtained with the transperitoneal technique, the retroperitoneal technique has a significantly shorteroperating time and less postoperative pain for large and impacted proximal ureteral calculus. More randomized, controlled andprospective studies on large samples are needed.

Laser lithotripsy for proximal ureteral calculi in adults: can 3D CT texture analysis help predict treatment success?

To explore whether multiple 3D computed tomography texture analysis (3D-CTTA) parameters can predict the therapeutic effects of holmium: YAG laser lithotripsy (LL) on ureteral calculi. The files from 94 patients (102 stones) with proximal ureteral calculi treated only by LL at a single institution were retrospectively retrieved from January 2016 to March 2019. According to intra-operative observations and postoperative reexamination, samples were divided into a completely crushed and a non-crushed group. Preoperative non-contrast-enhanced computed tomography (NCCT) images obtained by multiple CT scanners were imported to MaZda software for 3D texture analysis (TA). The CT-derived value of each target stone was measured, and 15 TA parameters were extracted by delineating volumes of interest (VOIs). Receiver operating characteristic (ROC) curves were drawn to determine the optimal critical value of each parameter based on the Youden index, and univariable and multivariable logistic regression analyses determined the significant factors for LL success. In univariable analysis, significant differences (p < 0.05) were observed among 7 parameters. In multivariable analysis, Perc.01 3D > 2062 (p = 0.03) and Z-fraction of image in runs (Z-Fraction) > 0.45570 (p = 0.009) were significant independent predictors, with odds ratios (ORs) of 24.204 and 60.329, respectively. In subgroup analysis based on the cutoff value of the CT-derived value (HU = 960), Perc.01 3D (OR = 44.154, 95% CI (2.379, 819.618), p = 0.011) and Z-Fraction (OR = 14.519, 95% CI (2.088, 100.953), p = 0.007) remained statistically significant. The combination of 3D-CTTA parameters and the CT-derived value can be used as a quantitative reference to predict whether a target stone could be completely crushed by LL. • Computed tomography texture analysis (CTTA) may be helpful in selecting suitable laser lithotripsy (LL) patients. • 3D-CTTA better predicts stone fragility than commonly used methods (such as the CT-derived value). • The combination of CTTA and the CT-derived value can be used as a preoperative quantitative reference.

Miniaturization of PCNL; Necessity or What?

Objective: Now a days, percutaneous nephrolithotomy (PCNL) is the treatment of choice for retrieval of renal and proximal ureteral calculi. The primary goal of PCNL is to achieve stone free status while minimizing morbidity and complications. In recent years, the instruments used have been miniaturized in an effort to decrease morbidity associated with standard PCNL as well as increase the efficacy of stone removal. The aim of this study was to compare the safety and efficacy of PCNL using different tract size. Patients and Methods: This hospital based prospective interventional study was conducted on patients with 1 to 4 cm renal stones who underwent PCNL either by Mini or by Standard PCNL technique in Chattogram Medical College Hospital and different private hospitals in Chattogram from July 2016 to October 2018. Patients aged above 12 years of age, irrespective of gender with normal renal function were evaluated to compare stone clearance, access time, fluoroscopy time for access, total operative time, need for blood transfusion, postoperative hospital stay, postoperative pain, fever, urinary leakage and other complications between two groups. Those who had previous history of open renal surgery, active urinary tract infection, renal malformation, uncorrected coagulopathy and morbid obesity were excluded. Results: A total of 78 patients were enrolled consecutively for PCNL who were divided equally into two groups randomly for minimally invasive PCNL (Mini-PCNL) and Standard PCNL. The average stone size in mini-PCNL group was 2.59±0.89 cm, and 2.66±0.97 cm in standard-PCNL group (p=0.7). Mean tract size was 18.53 ± 1.29 F (16-20) and 26.11 ± 4.61 F (24-30) respectively with P value &amp;lt;0.001. In mini-PCNL operative time was significantly longer than that of standard PCNL with 112.11 ± 20.29 vs. 98.68± 19.75 minutes respectively with p=.004. Conversely, there was an advantage of mini-PCNL over the standard one in terms of a significantly reduced hemoglobin drop (0.5 ± 0.26 vs. 0.83 ± 0.32 gm%, p value 0.001) and hospital stay (2.18 ± 0.77 vs. 3.39 ± 1.10 days, p value= 0.001), respectively though there was no statistical difference in terms of stone clearance rates between two groups (86.84% vs. 92.11%, p=0.45). There was no statistical difference in terms of visual analogue scale (VAS) score (5.55±1.54 vs. 6.24±1.6) for pain perception. The complication rate of mini-PCNL had no significant difference with that of standard PCNL (10.52% vs 12.50%, p=0.72). No statistical difference was recorded in terms of postoperative fever (eŠ38C) between two groups (2 in each group, 5.2%, p=1 Blood transfusion requirement was much less in mini PCNL group (10.52% vs. 34.2%, p=0.01). Conclusion: In addition to minimal bleeding and excellent stone clearance, mini- PCNL has several features for which it should be considered as an alternative or adjunct tostandard PCNL, URS, and ESWL. These include safe supra-costal puncture, excellent access to nearly all calyces and upper ureter, less hospital stay and suitable for large stones also. Future studies should continue to refine methods to assess complexity and safety and to determine consensus on the use of mini- PCNL. Bangladesh Journal of Urology, Vol. 23, No. 1, January 2020 p.11-16

Efficacy and Safety of Semi-rigid Ureteroscopic Lithotripsy (URS) for Proximal Ureteral Stone ≥10 mm

To evaluate the efficacy and safety of the semi-rigid URS with pneumatic lithotripsy for the treatment of large (>10 mm) proximal ureteral calculi. Cohort study. Section of Urology, Department of Surgery, The Aga Khan University Hospital, Karachi, Pakistan, from January 2010 to December 2018. All patients with single, radio-opaque unilateral proximal ureteral stones >10 mm were included in the study. Patients with urosepsis, pregnancy, solitary kidney, and indwelling JJ stent or prior percutaneous nephrostomy drainage were excluded. Patients without any visualisation of stone on abdominal X-Ray done at 4 weeks of the procedure were labelled as stone-free. One hundred and three cases with stones >10 mm and fulfilling the selection criteria were included. The mean age was 40.83 + 14.92 years. The mean stones size was 13.33 + 4.64 mm. The mean procedure time was 41.50 + 15.60 minutes. Indwelling JJ stents were placed in 49 (47.6 %) cases. The stone-free rate was 83.5% at four weeks with calculated efficiency quotient (EQ) of 0.72, using a standard equation. The overall complication rate was 27% with the majority being minor (Clavian-Dindo grade 1). Only one patient had urosepsis (MCG IV). Ancillary procedures were performed in 17 (16.5%) cases, most commonly the extracorporeal shock wave lithotripsy (ESWL) in 14 (13.5%) cases, followed by the secondary URS in 3 (2.9%) cases. Semi-rigid URS is an effective and safe procedure for the large proximal ureteral stones, with limited access to flexible instruments. Key Words: Ureteroscopy, Semi-rigid, Stone, Proximal, Clearance, Safety.

Outcome of Semi-rigid Ureteroscopy with LASER Lithotripsy for Management of Upper Ureteric Calculi

Background: Proximal ureteral calculi are common with multi-modalities of treatment, with continuous invention of new modalities. Aim of the work: To present the early experience with LASER lithotripsy using semi-rigid ureteroscopy for treatment of upper ureteral calculi, regarding safety and efficacy. Patients and Methods:Eighty patients with upper ureteral stones managed by LASER lithotripsy using semi-rigid ureteroscopy were included [30 prospective and 50 retrospective]. Patient evaluation included medical history, clinical examination with preoperative laboratory and radiological investigations. The outcome measure was stone free rate, Intra operative and Postoperative complications, operative time, hospitalization time, and post-operative analgesia. Results: During the period from January 2018 through February 2020 in 30 prospective cases but retrospectively in 50 cases done in the last two years, 68.8% of patients were males and 31.2% of them were females, mean of age was 43.70 with range from 20 to 66 years, and mean of BMI was 19.75 with range from 18 to 23 with laterality of 60% of patients was right but of 40% was left and stone opacity of 96.25% of patients was radio opaque, while, 3.75% was radio lucent stones the mean operative time was 50.78 minutes and mean duration of hospital stay was 1.3 days. In addition, 66.2% of patient needed JJ, 32.5% required ureteric catheter and 15% failed ESWL. The mean ureteral stone diameter was 10.81. The clearance rate 97.5%; two cases had migrated stone. Conclusion: Semirigid ureteroscope with LASER lithotripsy is an effective and safe procedure for management of large proximal ureteral stones with a lesser rate of stone migration needs use of flexible ureterorenoscopy.