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To evaluate the effectiveness of immersive VR distraction technology in alleviating anxiety and pain during flexible cystoscopy.We prospectively recruited 270 study participants who qualified for flexible cystoscopy and randomly assigned them to experimental and control groups. The experimental group consisted of 135 patients who employed a VR set during flexible cystoscopy, and the control group consisted of 135 patients who underwent the procedure without a VR set. Patient anxiety was determined quantitatively according to the State-Trait Anxiety Inventory. A visual analog scale for assessing pain intensity, satisfaction, and willingness to repeat the procedure was evaluated. In addition, difference in the hemodynamic parameter was also examined.The study findings demonstrated that the use of a VR set during flexible cystoscopy significantly improved the anxiety level over that of the control group (p = 0.001). Furthermore, this intervention led to a significantly increased level of satisfaction and willingness to repeat the procedure and a decrease in hemodynamic variables, specifically, systolic pressure, diastolic pressure, and heart rate (p = 0.001 in each case). Nonetheless, there were no significant differences between the groups with respect to the basic characteristic data, pain intensity, or oxygen saturation.Based on the present study, immersive VR can measurably decrease anxiety and increase satisfaction and willingness to repeat the procedure during flexible cystoscopy.14 September 2019; number: TCTR20190914002.

Background Double-J stents are favorably utilized after pyeloplasty. In rare situations, the stent may migrate upward. Here, we demonstrate the implementation and result of a supine percutaneous nephroscopic surgery (PNS) to retrieve a proximately migrated ureteral catheter in a pediatric patient. Patient and Methods A 1-year-old boy was suffering from an upward migration of a ureteric catheter into the right ureter after an open Anderson-Hynes pyeloplasty. The child was placed in the Galdakao-modified supine Valdivia (GMSV) position and a PNS procedure was performed. The calyceal access was carefully punctured by ultrasonographic guidance. The nephrostomy tract was dilated with a metal dilator using a one-step technique. An exploratory nephroscopy of the renal pelvis was conducted with a 12Fr miniature nephroscope and the migrated ureteral catheter was removed. A hybrid guidewire was retrogradely inserted into the ureteric orifice using a rigid ureteroscope. An antegrade double J stent was inserted in the proper position and a percutaneous nephrostomy was performed. Results and Conclusion This is the first report of a successfully removed upwardly migrated ureteral catheter with concurrent insertion of an antegrade double J stent by supine PNS in the GMSV position in an infant. The patient recovered well after surgery with no adverse event, demonstrating that this operation can be carried out safely on pediatric patients.

Large nephrolithiasis in a transplanted kidney is a rare situation and an associated risk from postoperative allograft dysfunction. We present our first experience with the implementation and successful result of an endoscopic combined intrakidney surgery (ECIKS) performed to remove a large donor-gifted stone after kidney transplant.A 47-year-old female recipient with end-stage kidney disease with no identifiable cause underwent deceased donor kidney transplant at our center. Immediately after the operation, her kidney function slowly improved, and noncontrast computed tomography illustrated a large nephrolithiasis without hydronephrosis. After 6 weeks, the patient was treated successfully by ECIKS, and the stone was totally removed. The patient recovered well after surgery without additional adverse events. There were no residual fragments assessed by computed tomography as of 3 months after the surgery.A large allograft nephrolithiasis can be successfully retrieved using ECIKS. This is technically feasible, safe, and associated with low morbidity.

Chinnakhet Ketsuwan, Charoen Leenanupunth, Yada Phengsalae, Premsant Sangkum, Wisoot Kongchareonsombat, Nongnart Kaewjai, Phanida Timjapoe Division of Urology, Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, 10400, ThailandCorrespondence: Phanida Timjapoe Tel +66-2-2011536Fax +66-2-2794704Email phanida.timj@gmail.comBackground: Extracorporeal shock wave lithotripsy (ESWL) is the only non-invasive treatment for urolithiasis; however, it can cause anxiety and pain for patients. Several new nonpharmacological adjuvant approaches have been developed to reduce adverse events.Objective: To analyze the efficacy of watching movies during ESWL to relieve anxiety and pain.Methods: A total of 84 patients were randomly divided into two groups. The experimental group consisted of 42 patients who watched their own selected movies during the ESWL session, while the control group included 42 patients who did not watch movies. Basic characteristics, hemodynamic parameters, State-Trait Anxiety Inventory, Visual Analog Scale for pain, willingness to repeat the procedure, and patient satisfaction rates were collected and analyzed.Results: After watching movies during ESWL, patients had a significantly lower anxiety level (p = 0.001) and a higher satisfaction rate (p = 0.021). No statistically significant differences were found in terms of demographic data, hemodynamic parameters, pain scores, or willingness to repeat the procedure.Conclusion: Watching self-selected movies during an ESWL can effectively reduce anxiety and improve satisfaction.Keywords: extracorporeal shock wave lithotripsy, movie, anxiety

Background Percutaneous nephrolithotomy (PCNL) is accepted as the gold standard of care for the treatment of large renal calculi. Kidney hemorrhage, which requires blood transfusion, is one of the most common complications after percutaneous kidney stone surgery. Objective To evaluate perioperative factors associated with transfusion requirements during PCNL. Materials and methods A total of 226 patients with kidney calculi undergoing PCNL between January 2011 and December 2019 were reviewed retrospectively. We analyzed the impact of perioperative clinical factors on the necessity of blood transfusion during PCNL. Results The overall blood transfusion rate was 9.29%. Multiple perioperative determinants were significantly correlated with the application of packed red blood cells (PRCs), including larger stone size (p = 0.006), multiple tract punctures (p = 0.029), presence of staghorn calculi (p = 0.026), and long operative time (OT; p = 0.017). Multivariate analysis demonstrated that only multiple tract punctures independently affected blood transfusion requirements during PCNL (p = 0.038). Conclusion In accordance with the present study, only the multiple tract punctures were associated with blood transfusion requirements in PCNL.

Introduction Phosphodiesterase 5 inhibitors are the predominant treatment option for erectile dysfunction. Aim This study evaluates the efficacy and safety of sildenafil orally disintegrating strips for the treatment of erectile dysfunction. Methods One hundred twenty erectile dysfunction patients were enrolled in a prospective, randomized, controlled crossover study and allocated into 2 groups of 60 participants. Patients were either treated with sildenafil strips or tablets for 8 weeks after which they crossed over into the alternate treatment formulation for another 8 weeks following a 4-week wash-out period. Each participant was assessed 8 times throughout the study period and their formulation preference registered at the end of the study. Main outcomes and measures Changes in the abridged International Index of Erectile Function (IIEF-5) score and Erection Hardness Score (EHS) resulting from sildenafil orally disintegrating strip or tablet treatments were the primary end points, with differences in onset of action, duration of action, and incidence of adverse events between the 2 formulations included as secondary end points. Results Both sildenafil formulations were effective in treating patients with erectile dysfunction. There was significant improvement of erectile function in term of IIEF-5 score and EHS from both formulations. The number and type of adverse events were also comparable. Likewise, there were no statistically significant differences between the earliest onset of action times and longest duration of action times. However, the results showed a 7.1-minute earlier onset of action time for orally disintegrating strips that may be considered as clinically meaningful by some patients. Conclusion Sildenafil orally disintegrating strips are a safe and effective alternative to the conventional tablet formulation for the treatment of erectile dysfunction.

Noppavut Sirirak, Premsant Sangkum, Yada Phengsalae, Wisoot Kongchareonsombat, Charoen Leenanupunth, Wattanachai Ratanapornsompong, Chinnakhet Ketsuwan Division of Urology, Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, 10400, ThailandCorrespondence: Chinnakhet Ketsuwan Tel +66-2-2011536Fax +66-2-2794704Email chinnakhet.ket@mahidol.ac.thBackground: The Size, Topography, Obstruction, Number, and Evaluation of Hounsfield units (S.T.O.N.E.) scoring system has been proposed as a novel prognostic surgical classification for urolithiasis in predicting success rate and complications.Objective: We carried out an externally validated S.T.O.N.E. score on rigid ureteroscopic lithotripsy (rURS).Materials and Methods: The data of patients who had undergone rURS between 2012 and 2019 at a tertiary referral center were audited retrospectively. The S.T.O.N.E. score was calculated based on factors determined through preoperative computed tomography images and was analyzed in association with stone-free rate (SFR), operating time, surgical complications, and length of stay (LOS).Results: A total of 155 patients were included in the study with a median stone size of 10 mm (7– 12) and a median S.T.O.N.E. score of 9 (8– 10). The overall SFR was 89.68%. SFRs were 100.0%, 97.83%, and 77.42% in low (5), moderate (6– 9), and high (10– 13) score groups, respectively. The S.T.O.N.E. score (p = 0.002) and stone size (p = 0.037) were predictive factors for SFR in multivariate analysis. Moreover, there was a significant correlation between the S.T.O.N.E. score and operative time, LOS, and presence of complications (r = 0.22, p = 0.006; r = 0.30, p < 0.001; and r = 0.27, p < 0.001, respectively). The area under the curve of the receiving operator characteristics’ curve for the S.T.O.N.E. score was 0.815.Conclusion: The S.T.O.N.E. scoring system is simple and effective in predicting postoperative outcomes; therefore, this score would be a valuable tool in clinical planning for every patient who undergoes rURS.Keywords: ureteroscopy, S.T.O.N.E. score, stone-free rate

Background Percutaneous nephrolithotomy (PCNL) is accepted as the gold standard of care for the treatment of large renal calculi. Kidney hemorrhage, which requires blood transfusion, is one of the most common complications after percutaneous kidney stone surgery. Objective To evaluate perioperative factors associated with transfusion requirements during PCNL. Materials and Methods A total of 226 patients with kidney calculi undergoing PCNL between January 2011 and December 2019 were reviewed retrospectively. We analyzed the impact of perioperative clinical factors on the necessity of blood transfusion during PCNL. Results The overall blood transfusion rate was 9.29%. Multiple perioperative determinants were significantly correlated with the application of packed red blood cells (PRCs), including larger stone size (p = 0.006), multiple tract punctures (p = 0.029), presence of staghorn calculi (p = 0.026), and long operative time (OT; p = 0.017). Multivariate analysis demonstrated that only multiple tract punctures independently affected blood transfusion requirements during PCNL (p = 0.038). Conclusion In accordance with the present study, only the multiple tract punctures were associated with blood transfusion requirements in PCNL.

Background Urothelial carcinoma of the transitional epithelium is the most common malignancy in the Thai kidney transplant population. Methods We report our experience in managing simultaneous upper and lower urinary tract urothelial cancer in a post–kidney transplant recipient through the use of laparoscopic bilateral nephron-ureterectomy and anterior pelvic exenteration with the use of a Studer orthotopic neobladder. A 35-year-old woman with end-stage renal disease underwent living related kidney transplantation in 2009. She presented with gross hematuria 5 years later. Enhanced computer tomography revealed diffuse bladder wall thickening with an intravesical polypoid soft tissue mass at the right ureterovesical junction extending to the right distal ureter. Hydronephrosis of the left native kidney without any demonstrable cause of obstruction was also noted. On trans-urethral resection, the pathological finding was high-grade, non-invasive urothelial cell carcinoma. Results The operation was successfully performed without intra- or post-operative complications. The patient could ambulate independently on post-operative day 2. The kidney graft function did not change from her pre-operative baseline. At 6 months' follow-up, the patient had no tumor recurrence, returned to normal activities, and was able to void spontaneously without any need of intermittent catheterization. Conclusions Laparoscopic bilateral nephron-ureterectomy for complete urinary tract extirpation is feasible, safe, and associated with low morbidity. This technique avoids a large abdominal midline incision or a bilateral flank incision for nephron-ureterectomy and is a good alternative surgical technique in post–kidney transplant patients who require complete urinary tract extirpation.