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We prospectively assessed the efficacy and the predictors of the success of oral dissolution therapy by alkalization for lucent renal calculi.Patients with radiolucent renal stones were counseled to undergo oral dissolution therapy, which entails oral potassium citrate 20 mEq 3 times daily, 3 L daily fluid intake and a dietary regimen. The study primary end point was the achievement of a 6-month stone-free rate with oral dissolution therapy. The other end point was a change in stone surface area as measured by noncontrast computerized tomography at 3 and 6 months.Between February 2015 and January 2016 only 182 of the 212 eligible patients who agreed to participate were compliant with oral dissolution therapy and included in the final analysis. Mean stone surface area at enrollment was 1.3 cm (range 0.16 to 11.84). At 3 months 97 (53.2%), 65 (35.7%) and 20 (11.1%) patients were oral dissolution therapy responders (stone-free), partial responders and nonresponders, respectively. Oral dissolution therapy achieved a 6-month stone-free rate of 83%, including 97 and 54 patients after 3 and 6 months of oral dissolution therapy, respectively. On regression analysis the initial 3-month response to oral dissolution therapy (p = 0.001), lower stone density (p = 0.03) and higher urine pH 12 weeks after treatment (p = 0.01) independently predicted the oral dissolution therapy response at 6 months.Regardless of stone size, oral dissolution therapy was an effective treatment approach for lucent renal stones. The initial response to oral dissolution therapy after 3 months was the key factor in determining the potential oral dissolution therapy response after 6 months. In addition, treatment compliance in achieving the targeted urine pH and low stone density has an independent role in the oral dissolution therapy response.

Despite being endorsed in most guidelines, wide adoption of holmium laser enucleation of the prostate is hindered by learning difficulties. We prospectively assessed the learning curve using a multidimensional approach.We prospectively report all perioperative safety and efficacy outcome measures as well as the need for reoperation and continence status. Case difficulty and learning curve characterization variables were considered, looking for predictors of different outcome measures. Our analysis included the first 313 procedures done by a total of 3 surgeons.Prostate volume and the number of previously performed cases independently predicted operative and enucleation efficiency (mean ± SD 0.76 ± 0.36 and 1.2 ± 0.6 gm per minute, respectively). Both measures plateaued only after the first 40 procedures. The mean percent reduction in postoperative prostate specific antigen was 80% ± 19%. A significantly lower decrease was independently predicted by the transrectal ultrasound depiction of a grossly multinodular prostate (p = 0.000, RPlateauing through the learning curve of holmium laser enucleation of the prostate is a moving target. Looking at different outcome measures, different levels of experience are needed to reach the plateau. Preoperative prostate volume, the number of previously performed cases and case density are the main influential factors in the curve. Urinary incontinence is the most relevant clinical outcome that was significantly affected by learning, although its transient nature is assuring.

We compared outcomes of percutaneous nephrolithotomy and retrograde intrarenal surgery in the treatment of children with renal calculi larger than 2 cm.A total of 38 patients younger than 16 years with renal calculi larger than 2 cm were randomized to undergo percutaneous nephrolithotomy or retrograde intrarenal surgery between May 2011 and February 2014. Demographic data, stone criteria, operative technique, radiation time, complications, blood transfusion, hemoglobin decrease, stone-free rate and length of hospital stay were compared between the groups. Stone-free status was documented if there were no residual stones after 1 month.The study included 43 renal units, of which 21 were subjected to retrograde intrarenal surgery and 22 to percutaneous nephrolithotomy. Operative time was comparable for both groups. Mean radiation time and hospital stay were longer after percutaneous nephrolithotomy (p0.001). Stone-free rate was significantly lower after retrograde intrarenal surgery monotherapy vs percutaneous nephrolithotomy monotherapy (71% vs 95.5%, p=0.046). Patients in the percutaneous nephrolithotomy group had significantly more complications compared to the retrograde intrarenal surgery group (p=0.018). Three patients in the percutaneous nephrolithotomy group received blood transfusions, compared to none in the retrograde intrarenal surgery group (p=0.015).For treatment of large or complex renal stones in pediatric patients percutaneous nephrolithotomy monotherapy has the advantage of better stone-free rates, while retrograde intrarenal surgery has the advantages of decreased radiation exposure, fewer complications and shorter hospital stay.

We determined the factors predicting unfavorable results of semirigid ureteroscopy for ureteral calculi.We reviewed the computerized files of 841 patients who underwent a total of 908 ureteroscopic procedures for ureteral stones from January 2003 through December 2006. A semirigid 6/7.5Fr ureteroscope was used in pediatric patients and an 8/10Fr or 8.5/11.5Fr ureteroscope was used in adults. Patients with favorable results were those who became stone-free after a single ureteroscopic procedure without any complications. They were compared with patients who had unfavorable results using univariate (chi-square and t tests) and multivariate (logistic regression) statistical tests to identify risk factors for unfavorable results.The study included 567 males and 274 females with a mean age of 48.5 years (range 2 to 81). The complication rate was 6.7% (61 procedures). The stone-free rate after a single ureteroscopic intervention was 87% (791 procedures). Favorable results were documented in 751 procedures (82.7%). Significant factors for unfavorable results were proximal ureteral stones, ureteroscopy done by surgeons other than experienced endourologists, stone impaction and stone width (relative risk 4, 2.5, 1.8 and 1.2, respectively).Semirigid ureteroscopy is a safe and highly effective treatment modality for ureteral stones.

This study was conducted to evaluate the safety and efficacy of the supracostal approach for percutaneous nephrolithotomy in pediatric patients.We retrospectively reviewed 60 percutaneous nephrolithotomy procedures done in 50 children (32 boys and 18 girls) between 2000 and 2007. Mean patient age was 7 +/- 4 years (range 9 months to 14 years). Noncontrast computerized tomography was the primary radiological investigation for most of the cases. The subcostal approach was used in 40 procedures, and the supracostal approach (above the 12th rib) was required in 20. We compared both approaches regarding preoperative characteristics, stone-free and complication rates, and the need for auxiliary procedures.The preoperative characteristics of the patients, urinary tracts and stones were comparable for both treatment groups. There were no major complications. Significant bleeding requiring blood transfusion was observed in 3 patients (5%), transient fever in 3 (5%) and urinary leakage through the nephrostomy site in 3 (5%). The distribution of complications among subcostal and supracostal approaches was comparable. Of the 60 renal units 46 (77%) were stone-free after percutaneous nephrolithotomy at discharge from the hospital. Of the remaining 14 units 9 (15%) were stone-free after shock wave lithotripsy and 5 (8%) had insignificant residual stones. Therefore, the overall stone-free rate at 3 months was 92.5%. Comparing the subcostal and supracostal approaches, there were no significant differences between hospital stays, complication rates, unplanned auxiliary procedures, and stone-free rates at discharge home and at 3-month followup.Percutaneous nephrolithotomy for treating renal stones in children provides a high degree of safety and efficacy whether a supracostal or subcostal approach is used.

A prospective randomized study was performed to compare the results of laparoscopic dismembered pyeloplasty using transperitoneal and retroperitoneal approaches.A total of 40 patients with primary ureteropelvic junction obstruction were included in the study. The patients were prospectively randomized between transperitoneal (20 patients, group 1) and retroperitoneal (20 patients, group 2) laparoscopic Anderson-Hynes pyeloplasty. All the patients were assessed preoperatively by excretory urography, diuretic isotope renography and computerized tomography angiography. The patients were followed at 3 and 6 months postoperatively, and then every 6 months. Evaluation was performed by excretory urography and diuretic renography. Both approaches were compared regarding operative time, morbidity, hospital stay, convalescence and functional outcome. The preoperative demographic data of the patients and radiological and operative findings were statistically correlated to the operative time.The preoperative data of both groups were comparable. All the procedures were successfully completed with laparoscopy. Mean operative times were 149 and 189 minutes for the transperitoneal approach and retroperitoneoscopy, respectively (p = 0.02). In groups 1 and 2 there were complications in 3 and 5 patients, respectively. Morbidity, hospital stay, convalescence and success rate had no significant differences between the groups. None of the patient parameters apart from the approach had a significant impact on operative time.Laparoscopic dismembered Anderson-Hynes pyeloplasty has a satisfactory functional outcome and low morbidity regardless of the approach. Nevertheless, with early experience retroperitoneoscopy is associated with a longer operative time.

Despite evidence that urologists can safely acquire percutaneous renal access for percutaneous nephrolithotomy, many centers still rely on interventional radiologists to obtain renal access. In this study we evaluated percutaneous access for percutaneous nephrolithotomy obtained by interventional radiologists or urologists, and compared access outcomes and complications.The surgical records of 1,121 patients with 1,155 stone bearing kidneys treated with percutaneous nephrolithotomy between 1999 and 2003 were reviewed. Patients were stratified according to percutaneous renal access into 509 patients with 661 access procedures performed by urologists and 612 patients with 612 access procedures performed by interventional radiologists.Both groups were comparable except there was a higher incidence of multiple stones in the urologist access group. Urologists had a significantly greater rate of using multiple and supracostal tracts compared to radiologists. The stone-free rates were 83.4% and 86.1% for urologist and radiologist access groups, respectively (p = 0.1). Major complications were seen in 74 patients (6.6%). Both groups had similar complication rates except for significant bleeding in the urology group (4.3%) compared with 2.1% in the radiology cohort (p = 0.02). Further multivariate analysis showed that bleeding was not related to the type of access whether performed by urologist or radiologist.The urologist is able to safely and effectively obtain percutaneous renal access for percutaneous nephrolithotomy as a single stage procedure. Despite more complex stones and higher access difficulty in the urology access group, access related complications and stone-free rates were comparable. We recommend percutaneous access training in urology training programs.

We identified risk factors predicting severe bleeding due to percutaneous nephrolithotomy.Computerized data on 2,909 patients who underwent a total of 3,878 percutaneous nephrolithotomy procedures between January 1995 and December 2005 were retrospectively reviewed. Data on patients who experienced severe bleeding requiring angiographic renal embolization were compared with those on other patients using univariate and multivariate analyses. We tested the characteristics of patients, kidneys and stones together with details of the operative procedure and surgeon experience.Severe bleeding complicated a total of 39 procedures (1%) in 25 males and 14 females with a mean age of 50.7 +/- 12.6 years. Associated morbidity included shock in 6 patients and perirenal hematoma in 4. Renal angiography revealed pseudoaneurysm in 20 patients, arteriovenous fistula in 9, the 2 lesions in 8 and arterial laceration in 2. Bleeding could be controlled with superselective embolization in 36 patients (92.3%). Followup was available on 33 patients (mean 21 +/- 15 months). Renal function was stable in all patients except 3 who had a post-embolization increase in serum creatinine, of whom all had a solitary kidney and none required renal replacement therapy. Significant risk factors for severe bleeding were upper caliceal puncture, solitary kidney, staghorn stone, multiple punctures and inexperienced surgeon.Percutaneous nephrolithotomy should be performed by an experienced endourologist in patients at risk for severe bleeding, such as those with a solitary kidney or staghorn stones.

INTRODUCTION AND OBJECTIVES: To prospectively assess the change and predictors of sexual function after different transurethral surgery for Benign Prostate Hyperplasia (BPH). METHODS: Patients presented for BPH surgery in a tertiary referral center between August 2012 and May 2014 were consented and prospectively enrolled in this trial. Inclusion criteria were sexually interested patients with interested partner. Exclusion criteria were patients with indwelling catheter for more than 1 month, patients who required re-intervention and patients with unreliable answers. Eligible patients were asked to fill the International Index of Erectile Function15 (IIEF-15) and ejaculatory subdomain of male sexual health (MSHQ) questionnaires preoperatively, 3 months and 6 months postoperatively. Studied interventions were Holmium laser enucleation of the prostate (HoLEP), Monopolar, Bipolar transurethral resection of the prostate (TURP) and diagnostic (OPC) outpatient cystoscopy (Sham procedure) ClinicalTrials.gov ID: NCT01810068 RESULTS: Out of 444 BPH patients, 245 were included. HoLEP, monopolar TURP and bipolar TURP were performed in 81, 112 and 52 procedures respectively. Sham group includes 35 sexually active men with free OPC who filled the questionnaire before and after OPC at the scheduled intervals. There were no significant changes in mean erectile function/IIEF (EF) score between baseline and 6-months visit in any of the study groups. Normal EF 26, has been reported in 48.6, 29.6, 29.5 and 23.1% of Sham, HoLEP, Monopolar and Bipolar groups respectively (P1⁄40.079). Regardless the study group lower morbidity score, BMI and higher baseline EF score are the only predictors of postoperative normal EF. There were no significant changes in mean orgasm/IIEF score between baseline and 6-months visit in Sham and HoLEP groups with statistically significant score reduction Monopolar and bipolar groups. However when compared to the Sham, changes were not statistically different from changes in Sham group. There were no significant changes in mean desire/IIEF, intercourse satisfaction/IIEF nor overall satisfaction score between baseline and 6-months visit in any of the study groups. There were significant reduction of mean ejaculatory/MSHQ score between baseline and 6-months visit in all study groups in comparison to Sham CONCLUSIONS: Sham controlled short term assessment of different BPH treating procedures denied the their impact on erectile function. However, all procedures significantly affect ejaculatory function with subsequent minimal effect on orgasm perception

We performed a prospective, randomized clinical trial to evaluate the outcome of ureteral stents for solitary ureteral stones 2 cm or less in moderately or severely obstructed systems using shock wave lithotripsy.Between 2001 and 2004, 186 patients who met study criteria were randomized into 2 groups. Group 1 received a pre-shock wave lithotripsy 6Fr Double-J stent and group 2 had no stent. Patients were treated with a Dornier MFL 5000 lithotripter. Results were compared in terms of clearance rates, number of shock waves and sessions, irritative voiding symptoms, incidence of complications and secondary interventions. Failure was defined as the need for additional procedure(s) for stone extraction.Overall 164 patients (88.2%) became stone-free after shock wave lithotripsy. Complete stone fragmentation was achieved after 1 to 3 and more than 3 session in 108 (58.1%), 30 (16.1%), 13 (7%) and 14 patients (7.5%), respectively. Ureteral stent insertion did not affect the stone-free rate, which was 84.9% and 91.4% in groups 1 and 2, respectively (p = 0.25). There was no statistical difference in the re-treatment rate, flank pain or temperature in the 2 groups. However, all patients in the stented group significantly complained of side effects attributable to the stent, including dysuria, suprapubic pain, hematuria, pyuria and positive urinary culture.Pretreatment stenting provides no advantage over in situ shock wave lithotripsy for significantly obstructing ureteral calculi. Shock wave lithotripsy is reasonable initial therapy for ureteral stones 2 cm or less that cause moderate or severe hydronephrosis.

INTRODUCTION AND OBJECTIVES: To study acute renal anatomical and functional changes after SWL of renal stones using electromagnetic Dornier Lithotripter S (DoLi S) (Dornier Med Tech Germering, Germany). METHODS: Between August 2012 and August 2013, 60 adult patients who were eligible for SWL were prospectively included in the study. Inclusion criteria were normotensive non-diabetic patients with single renal stone < 25 mm in a radiologically normal urinary tract with no previous surgical treatment and no other contraindications for SWL. Renal damage was evaluated by estimation of renal perfusion and anatomical changes using dynamic MRI before SWL, 2 hours and one week post-SWL. RESULTS: For all cases there was statistically significant decrease of the renal perfusion one week post-SWL (66% of aorta) in comparison to pre-SWL (71%) and 2 hours post-SWL (71%) (p < 0.05). On stratification of cases according to obstruction of renal units at one week follow-up there were 39 non-obstructed and 21obstructed renal units. There was no significant difference in renal perfusion for non obstructed cases at any time while for obstructed cases there was significant decrease of renal perfusion at one week post-SWL (62%) in comparison to pre (76%) and 2 hours post-SWL (75%) (p 1⁄4 0.003 and 0.005 respectively). Hematoma was observed in 7 cases (12%) 2 hours post-SWL of which 5 were subcapsular and 2 were intrarenal, 3 of the subcapsular hematomas were resolved on one week MRI. Generalized or localized loss of corticomedullary differentiation was observed in 2 patients (3.3%) on 2 hours post-SWL MRI increased to 7 cases (12%) at one week. CONCLUSIONS: SWL does not induce any deleterious acute renal anatomical or functional changes. Post-SWL obstruction has a major effect on the renal function on the treated side and must be managed urgently.

ASA score 1.34 0.64 PSA (ng/dl) 6.8 9.9 IPSS 18.5 7.9 QoL 3.7 1.5 Q-max (mL/sec) 6.5 5.6 PVR (mL) 348 280 IIEF-score 3.9 14.7 Prostate size by TRUS (CC) 94.8 52.7 Concomitant cystolithotripsy 98 (8.1%) Perioperative Data Energy utilized (KJ) 193.7 54.6 Operating time (min) 108 57 Enucleation time (min) 90.8 51.6 Morcellation time (min) 18.3 11.2 Haemoglobin deficit* (g/dl) 2.2 1.8 Hematocrit value deficit* (%) 3.4 6.2 Blood sodium deficit* (mmol/l) 2.6 1.7 Catheterization time (days) 1.4 1.9 Hospital stay (days) 1.3 1.6 Short-term Complications Failed trial of voiding 17 (1.4 %)

INTRODUCTION AND OBJECTIVES: To compare the results of percutaneous nephrolithotomy (PNL) and open surgery for treatment of staghorn stones in children. METHODS: The electronic records of children who underwent treatment of renal stones between September 2000 and 2009 were retrospectively reviewed. Exact matching criteria were used to compare PNL and open surgery in treatment of staghorn stones. The patients were matched for sex, stone burden (partial or complete staghorn) and laterality (unilateral or bilateral). Success, retreatment rates, need for auxiliary procedures, and complications were compared for both groups. RESULTS: We identified 13 matched pairs of renal units in 11 patients as 2 patients in each group had bilateral staghorn stones. Each group comprised 9 males and 2 females. All PNL procedures were completed successfully without intraoperative complication. Postoperative complications included hematuria in 2 patients and urinary leakage in one. Secondary procedures were needed after 7 PNL (53.8%). They included second look PNL in 3 units, SWL in 3 units and ureteroscopy for retrieval of a ureteral stone causing urinary leakage in one unit. Stone-free rate at three months was 77% as 10 renal units were free of stones and 3 had insignificant residual fragments 4mm. For open surgery, complications included; pleural injury, renal bleeding and postoperative fever in one patient for each complication. Secondary procedures were needed in 4 cases (30.8%) in the form of SWL for residual stones. Stone-free rate at 3 months was 84.6% because 11 renal units were free of stones and 2 had insignificant residuals. Table 1 summarizes the comparison between both treatment groups. The only significant difference was shorter hospital stay after PNL (P 0.008). CONCLUSIONS: For treatment of staghorn stones in children, percutaneous nephrolithotomy was comparable to open surgery with regard to complication and stone-free rates. However, PNL posed the advantage of shorter hospital stay and the disadvantage of more secondary procedures. Source of Funding: None