Current Urology

Chan, Kimberley; Shakir, Taner; El-Taji, Omar; Patel, Amit; Bycroft, John; Lim, Chou Phay; Vasdev, Nikhil

2023 Current Urology

doi: 10.1097/cu9.0000000000000181pmid: 37692143

Abstract Urolithiasis is the most common cause of nonobstetric abdominal pain, resulting in 1.7 admissions per 1000 deliveries. Urolithiasis most commonly occurs in the second and third trimesters, with an incidence between 1:125 and 1:2000. Acute urinary system obstructions are challenging to manage in obstetric patients because they contribute to physiological and anatomical changes that result in pathological outcomes. The restricted use of computed tomography in diagnosing and managing urolithiasis is particularly challenging. In addition, a prompt diagnosis is required because the presence of renal calculi during pregnancy increases the risk of fulminating sepsis and preterm delivery. Affected pregnancies are conservatively managed; however, 1 in 4 requires surgical intervention. Indications for surgical interventions are complex and range from nephrostomy insertion to empirical stent placement or ureteroscopy. Therefore, a multidisciplinary approach is required to optimize patient care. The diagnosis and management of urolithiasis in pregnancy are complex. We reviewed the role, safety, advantages and disadvantages of diagnostic tests and treatment used to manage acute urinary obstructions in pregnancy.

Juliebø-Jones, Patrick; Beisland, Christian; Gjengstø, Peder; Baug, Stephen; Ulvik, Øyvind

2023 Current Urology

doi: 10.1097/cu9.0000000000000157pmid: 37692136

Abstract Background The management of suspected kidney stone disease in pregnancy is challenging. In cases of persistent flank pain and where investigations may have rendered equivocal results, ureteroscopy (URS) is a recognized diagnostic and therapeutic intervention. This study aimed to investigate the safety and outcomes associated with performing URS during pregnancy, as the technique has evolved over the past 4 decades at our center. Materials and Methods We performed a retrospective analysis of pregnant patients who underwent URS at our tertiary center between 1984 and 2022. Outcomes of interest included anesthetic approach, operative time, hospital stay, and complications. Results Eighty-seven pregnant patients underwent 96 URS procedures, and 60% (n = 57) of these procedures were performed during the third trimester. Overall, 58% (n = 56) of the procedures were achieved with local anesthesia and light sedation. During the most recent decade, the latter was successfully carried out in 97% of the procedures, with the remainder occurring under spinal anesthesia as per patient choice. Overall, 57% (n = 50) of the whole study group had ureteral calculi found at the time of surgery and in 88% (n = 44) of these cases, fragmentation/extraction was performed. The remainder had insertion of ureteral stent with definitive clearance deferred until postpartum. Mean operative time and postprocedure hospital stay was 33 minutes (range, 7–100 minutes) and 2.2 days (range, 0–16 days), respectively. The overall intraoperative and postoperative complication rates were 2% and 11%, respectively. During the final decade, the latter improved to 6% and all adverse events were minor (Clavien I/II), with the exception of a single case. Regarding exit strategy, ureteral stent was placed in 42% (n = 40) of the procedures, 23% (n = 22) had ureteral catheter inserted, and the remainder (35%, n = 34) had none. Conclusions Ureteroscopy can be safely performed during pregnancy using anesthetic approach with local anesthesia and light sedation. Development of a local protocol and multidisciplinary management algorithm are instrumental in enabling the delivery of such a service.

Yu, Kai; Du, Zhebin; Xuan, Hanqing; Cao, Yang; Zhong, Hai; Li, Fangzhou; Chen, Qi

2023 Current Urology

doi: 10.1097/cu9.0000000000000148pmid: 37692135

Abstract Background The goal of this study was to determine the safety and efficacy of endoscopic combined intrarenal surgery (ECIRS) performed in the prone split-leg position for the treatment of complex renal stones. Materials and methods A mature ECIRS protocol was designed. Retrospective analysis was conducted of medical records between January 2020 and December 2021 of patients with complex renal stones at one center who underwent ECIRS by 2 skilled surgeons using retrograde flexible ureteroscopy and mini-percutaneous nephrolithotomy in the prone split-leg position. Results A total of 44 patients were included in this study. Mean stone size was 26.1 ± 12.7 mm, and the number of calyces involved was 4.36 ± 2.09. Mean operative time was 71.1 ± 21.8 minutes. Postoperative decline in hemoglobin was 15.8 ± 9.8 g/L. Seventy-five percent of patients achieved stone-free status. The mean number of residual stones was 2.8 ± 2.3, and the mean residual stone size was 10.30 ± 4.76 mm. Six patients (13.6%) developed postoperative complications, including 4 with fever during the first 2 days postoperatively and 2 patients with transient postoperative pain. No patients developed severe complications. Conclusions Endoscopic combined intrarenal surgery in the prone split-leg position can be performed safely by experienced surgeons using retrograde flexible ureteroscopy in conjunction with mini-percutaneous nephrolithotomy as a successful technique for the treatment of complex renal stones.

Aggarwal, Gaurav; Adhikary, Samiran Das

2023 Current Urology

doi: 10.1097/cu9.0000000000000162pmid: 37692141

Abstract Background Noncontrast computed tomography (CT) scan of the kidneys, ureter and bladder is the standard investigative modality for diagnosing and following up patients with urolithiasis. With each scan, a patient receives radiation of 18–34 mGy. Dose considerations become pertinent because of a 10% lifetime incidence rate and higher than 50% risk of recurrence, necessitating repeated imaging in the lifetime of a stone former. Hence, this study aimed to assess the sensitivity of “reduced-radiation” CT imaging by altering scan settings to lower than the “standard” norms. Materials and methods Altogether, 222 patients (255 “kidney-ureter” stone-bearing units or “renal units”) with urolithiasis and patients undergoing CT for other reasons with incidental findings of renal/ureteric calculi between 2017 and 2019 were included. All patients were subjected to 3 sequential scans at tube current settings of 250 mA (CT-N/Standard), 100 mA (CT-100), and 50 mA (CT-50) at a constant voltage of 120 kV. Their clinicodemographic and radiological findings were recorded and assessed for significance. Results Of the 255 renal units, 117 were between 30 and 44 years of age, 75% were men. Of the 255 patients, 178 (70.1%) reported a first stone episode and 77 had recurrence. Lower ureteric calculi were predominant (40.4%). All calculi were identified on CT-N; CT-100 failed to detect calculi in 1 patient, and CT-50 failed in 3 patients, where all calculi were <3 mm in size. Meanwhile, none were undetected among patients with obesity. The sensitivity was 99.61% for the CT-100 and 98.82% for the CT-50, which indicated a 2.5 and 5 times lower radiation and dose/length, respectively, than CT-N. Conclusions The reduced-radiation CT scan is safe, sensitive, and accurate for the diagnosis and follow-up of patients with urolithiasis with significantly lower radiation exposures. Our study lays the foundation to accept low-dose CT in general and CT-50 in particular, as the new “standard of care,” and attempt further dose reduction without loss of diagnostic efficacy.

Gopala, Sathish K.; Joe, Jim; Chandran, Jithesh

2023 Current Urology

doi: 10.1097/cu9.0000000000000178pmid: 37692132

Abstract Background Dietary supplementation with citrate-containing juices may serve as an effective alternative to potassium citrate therapy for preventing calcium oxalate stone recurrence. This study was performed to evaluate whether consumption of lemon–tomato juice can decrease the tendency for stone formation in the urine of calcium oxalate stone formers. Materials and methods The study was conducted as a prospective interventional randomized crossover clinical trial with a repeated-measures design. Twenty-two patients with calcium oxalate stones and no metabolic abnormalities in the urine treated with lithotripsy at a tertiary care center from August 2017 to July 2018 were recruited. After a 14-hour overnight fasting, urine samples were collected after the patients consumed either milk only or milk and lemon–tomato juice. Their urine was tested for multiple parameters, including urine pH, specific gravity, calcium–creatinine ratio, and supersaturation with sodium oxalate, followed by optical density measurement via spectrophotometry. Results There were no significant differences in the background characteristics between the 2 groups. The optical density of the urine samples obtained after consumption of milk only was significantly higher than that after consumption of milk and lemon–tomato juice (mean = 0.131 for milk only vs. 0.053 for milk and lemon–tomato juice, p < 0.001). The urine calcium–creatinine ratio was similar between the groups (mean = 0.141 for milk only vs. 0.076 for milk and lemon–tomato juice, p = 0.019). Conclusions The addition of lemon–tomato juice as a source of citrate in the diet significantly decreases the established risk factors for calcium oxalate stone formation in patients. This study was prospectively registered at CTRI under number CTRI/2017/04/008312 on April 7, 2017.

Faddan, Amr A.; Najieb, Osama; Gadelkareem, Rabea A.

2023 Current Urology

doi: 10.1097/cu9.0000000000000152pmid: 37692133

Abstract Background Despite the continuous update of guidelines for the management of kidney stones, the ability to predict a successful response to extracorporeal shockwave lithotripsy (SWL) remains a topic of research. This is due to the need to refine the decision making in the context of technological advancements and current pandemics. This study aimed to determine the predictors of stone-free rate (SFR) after single-session SWL in adult patients with a single kidney stone 10 to 20 mm in diameter. Materials and methods A retrospective review of the records of patients with a single kidney stone 10 to 20 mm in diameter was performed at a private SWL center from December 2019 to February 2021. Univariate and multivariate analyses were performed for stone- and patient-related factors, using the Student t and Mann-Whitney U tests for the quantitative variables and the Fisher exact and Pearson correlation tests for the qualitative variables. Results A total of 138 patients were eligible for this study, including 92 men and 46 women. The mean age was 38.6 ± 12.4 years, and the mean body mass index (BMI) was 25.9 ± 3.4 kg/m2. Four weeks after SWL, 120 patients (87%) were free of stones, and 18 (13%) needed further treatment. Univariate analyses showed that SFR was negatively correlated with increased BMI (p = 0.0001), maximum stone length (p = 0.0001), transverse diameter of the stone (p = 0.0001), number of shocks per session (p = 0.052), and Hounsfield unit (HU) (p = 0.0001). Multivariate analysis revealed that HU (p = 0.009), maximum stone length (p = 0.01), BMI (p = 0.000), and presence of double-J stent (p = 0.034) were independent risk factors for failure of single-session SWL in the treatment of kidney stones 10 to 20 mm in diameter. The estimated average cost per case was USD 450.5. Conclusions Increased HU, maximum stone length, BMI, and presence of double-J stents were independent risk factors for low SFR after single-session SWL for a kidney stone 10 to 20 mm in diameter. The cost of SWL remains an advantage in the private sector.

Ranjan, Satish Kumar; Mittal, Ankur; Mirza, Anissa Atif; Kumar, Sunil; Panwar, Vikas Kumar; Navriya, Shivcharan; Mandal, Arup Kumar; Mammen, Kim Jacob

2023 Current Urology

doi: 10.1097/cu9.0000000000000169pmid: 37692144

Abstract Background Nephrolithiasis is a global health problem. The recurrence rate after the first stone clearance is approximately 50% at 5 years. Metabolic abnormalities are an important factor responsible for stone recurrence. Our prevalidated study aimed to evaluate metabolic abnormalities associated with first-time uncomplicated renal stone formers (FTURSF). Materials and methods In this prospective, exploratory, time-bound, descriptive study, 30 first-time renal stone formers were evaluated for metabolic abnormalities. High-risk stone formers were excluded from the study. Data were collected in a predefined proforma, transferred to an Excel sheet, and analyzed using the Statistical Package for Social Sciences 20 and Epi Info 7. Fisher exact test, Mann-Whitney U test, paired t test, and Pearson correlation coefficient were used for statistical analyses. Results The mean age of the participants was 35.57 ± 11.07 years, with a male-to-female ratio of 1.72. The most common abnormality was a 24-hour urine volume of <2.5 L in 73.33% of the participants. One or more metabolic abnormalities were detected in 76.67% of the participants. Other common metabolic abnormalities detected were hypocitraturia (60%), hypercalciuria (16.67%), hyperoxaluria (13.33%), and hyperuricosuria (3.33%). Parathyroid adenoma was detected in one participant (3.33%). Conclusions Our study documented significant metabolic abnormalities in FTURSF. Therefore, a simplified metabolic evaluation protocol should be adopted while evaluating FTURSF. Detection of an underlying metabolic abnormality would enable the early institution of preventive measures to reduce stone recurrence and related complications.

Munien, Kale; Winston, Joshua; Davies, Nicholas

2023 Current Urology

doi: 10.1097/cu9.0000000000000179pmid: 37692139

Abstract Horseshoe kidney is a rare anatomical variant with low clinical morbidity. However, the characteristic shape of horseshoe kidney causes significant anomalies within the vascular and collecting systems. This complicates the diagnosis and management of coexisting pathologies within the kidneys. Here, we report a rare case of concurrent diagnoses of ipsilateral ureteric calculus and renal cell carcinoma within a horseshoe kidney and describe the subsequent management rationale based on the current literature.

Wu, Yaohai; Zhang, Shiqiang; Chen, Chujie; Pang, Jun

2023 Current Urology

doi: 10.1097/cu9.0000000000000135pmid: 37692138

Abstract Increasing evidence indicates that N6-methyladenosine (m6A) methylation modification serves important functions in biological metabolism. Dysregulation of m6A regulators is related to the progression of different malignancies, including renal cell carcinoma (RCC). Recent studies have reported preliminary findings on the influence of m6A regulator dysregulation on RCC tumorigenesis and development. However, no comprehensive review that integrates and analyzes the roles of m6A modification in RCC has been published to date. In this review, we focus on the dysregulation of m6A regulators as it relates to RCC tumorigenesis and development, as well as possible applications of m6A modification in RCC diagnosis and therapeutics.

Teishima, Jun; Murata, Daiki; Yukihiro, Kazuma; Sekino, Yohei; Inoue, Shogo; Hayashi, Tetsutaro; Mita, Koji; Hasegawa, Yasuhisa; Kato, Masao; Kajiwara, Mitsuru; Shigeta, Masanobu; Maruyama, Satoshi; Moriyama, Hiroyuki; Fujiwara, Seiji; Matsubara, Akio

2023 Current Urology

doi: 10.1097/cu9.0000000000000105pmid: 37692134

Abstract Objectives This study aimed to clarify the significance of therapeutic timing on the effectiveness of nivolumab for treating metastatic renal cell carcinoma. Marterials and methods Fifty-eight patients with metastatic renal cell carcinoma treated with nivolumab monotherapy were retrospectively studied. Patients who were treated with nivolumab as second-line therapy were included in the second-line group, while the others were included in the later-line group. The clinicopathological characteristics, effects of nivolumab, and prognoses of these groups were compared. Results Twenty and thirty-eight patients were included in the second-line and later-line groups, respectively. There were no significant differences in the distribution of International Metastatic Renal Cell Carcinoma Database Consotium risk and other clinicopathological characteristics between the 2 groups. The proportion of patients whose objective best response was progressive disease in the second-line group was significantly lower than that in the later-line group (15% vs. 50%, p = 0.0090). The 50% progression-free survival with nivolumab in the second-line group was significantly better than that in the later-line group (not reached and 5 months, p = 0.0018). Multivariate analysis showed that the second-line setting was an independent predictive factor for better progression-free survival (p = 0.0028, hazard ratio = 0.108). The 50% overall survival after starting nivolumab in the second-line and later-line groups was not reached and 27.8 months, respectively (p = 0.2652). Conclusions The therapeutic efficacy of nivolumab as second-line therapy is expected to be better than that of later therapy.

Mukendi, Alain Mwamba; Mataruka, Gerald Tatenda; Nadimpalli, Ramesh; Kasapato, Tshisola Miji

2023 Current Urology

doi: 10.1097/cu9.0000000000000108pmid: 37692137

Abstract Microphthalmia-associated transcription factor family (transcription factor E3 or transcription factor EB) translocation renal cell carcinomas (RCCs) are rare neoplasms. These renal neoplasms can be either asymptomatic and incidentally discovered on imaging or symptomatic, with the most common presenting symptoms being hematuria, pain, and abdominal mass, or paraneoplastic event. In conventional RCCs, hypertension is considered a risk factor and a possible paraneoplastic event, whereas, in translocation RCCs, prior exposure to cytotoxic chemotherapy is the only known risk factor, and hypertension as an isolated associated paraneoplastic event has never been reported. Interestingly, hypertension as the only presenting symptom in RCC is extremely rare. We report a case of transcription factor E3 positive RCC in a young adult presenting only with hypertension that normalized after radical nephrectomy. To the best of our knowledge, this is the first reported case of hypertension secondary to microphthalmia-associated transcription translocation RCC.

Zollinger, Benjamin W.; Shoen, Ezra J.; Gresham, Charles F.; Whalen, Michael J.

2023 Current Urology

doi: 10.1097/cu9.0000000000000158pmid: 37692140

Abstract Endoscopic management via retrograde ureteroscopic laser ablation of upper tract urothelial carcinoma (UTUC) has become the preferred treatment modality for low-risk tumors. The most popular ablative lasers over the past 15–20 years have been the holmium:yttrium-aluminum-garnet (Ho:YAG) and neodymium (Nd:YAG) lasers, but recently the thulium (Th:YAG) laser has emerged as a potential alternative. This review compares the mechanism of action, physiological properties and effects, and oncologic outcomes of Ho:YAG/Nd:YAG lasers versus the Th:YAG laser for UTUC treatment. Potential advantages of the Th:YAG laser over existing technologies are outlined, followed by a discussion of emerging laser technologies in UTUC management.

Chen, David C.; Qu, Liang; Webb, Howard; Qin, Kirby; Chislett, Bodie; Xue, Alan; Khaleel, Sari; De Jesus Escano, Manuel; Chung, Eric; Adam, Ahmed; Bolton, Damien; Perera, Marlon

2023 Current Urology

doi: 10.1097/cu9.0000000000000122pmid: 37692142

Abstract Objective The aim of the study is to investigate improvements in lower urinary tract symptoms in men with benign prostatic hyperplasia (BPH) treated with prostatic Aquablation. Materials and methods We performed a literature search of clinical trials using the MEDLINE, Embase, and Cochrane Library databases and retrieved published works on Aquablation for the treatment of BPH up to August 2021. Unpublished works, case reports, conference proceedings, editorial comments, and letters were excluded. Risk of bias was assessed using the ROBINS-I tool. Raw means and mean differences were meta-analyzed to produce summary estimates for pre- versus post-International Prostate Symptom Scores, maximum flow rate, and male sexual health questionnaire value changes. An inverse-variance weighted random effects model was used. Results Seven studies were included in this review (n = 551 patients) that evaluated various urological parameters. At 3 months, the International Prostate Symptom Scores raw mean difference from baseline was −16.475 (95% confidence interval [CI], −15.264 to −17.686; p < 0.001), with improvements sustained for 12 months. Similarly, maximum flow rate improved by +1.96 (95% CI, 10.015 to 11.878; p < 0.001) from pre to 3 months postoperatively. In addition, the male sexual health questionnaire change pooled effect size was −0.55 (95% CI, −1.621 to 0.531; p = 0.321) from preintervention to postintervention at 3 months. Meta-analyses of some outcomes showed large statistical heterogeneity or evidence of publication bias. Conclusions Aquablation seems to improve lower urinary tract symptoms in men with BPH while providing relatively preserved sexual function. Further research is required to confirm these preliminary results.