Malignant ureteral obstruction is an unfortunate finding that can be caused by a wide‐ranging number of malignancies with a prognosis of limited survival. Given its presentation and progression, it ...can be refractory to treatment by traditional single polymeric ureteral stents. With a higher failure rate than causes of benign ureteral obstruction, a number of other options are available for initial management, as well as in cases of first‐line therapy failure, including tandem stents, metallic stents, percutaneous nephrostomies and extra‐anatomic stents. We reviewed the literature and carried out a PubMed search including the following keywords and phrases: “malignant ureteral obstruction,” “tandem ureteral stents,” “metallic ureteral stents,” “resonance stent,” “metal mesh ureteral stents” and “extra‐anatomic stents.” The vast majority of studies were small and retrospective, with a large number of studies related to metallic stents. Given the heterogenous patient population and diversity of practice, it is difficult to truly assess the efficacy of each method. As there are no guidelines or major head‐to‐head prospective trials involving these techniques, it makes practicing up to the specific provider. However, this article attempts to provide a framework with which the urologist who is presented with malignant ureteral obstruction can plan in order to provide the individualized care on a case‐by‐case basis. What is clear is that prospective, randomized clinical trials are necessary to help bring evidence‐based medicine and guidelines for patients with malignant ureteral obstruction.
Objective To, first, propose a novel scoring system to standardize reporting for percutaneous nephrolithotomy because the instruments currently available to predict the percutaneous nephrolithotomy ...outcomes are cumbersome, not validated, and of limited clinical utility; and, second, assess and predict the stone-free rates and perioperative parameters applying S.T.O.N.E. nephrolithometry. Materials and Methods Five reproducible variables available from preoperative noncontrast-enhanced computed tomography were measured: stone size (S), tract length (T), obstruction (O), number of involved calices (N), and essence or stone density (E). Results A total of 117 patients were included. The mean score was 7.7 (range 4-11). The stone-free rate after the first procedure was 80%. There were 18 complications (21%). The most frequent complications were postoperative sepsis and bleeding. The S.T.O.N.E. score correlated with the postoperative stone-free status ( P = .001). The patients rendered stone free had statistically significant lower scores than the patients with residual stones (6.8 vs 9.7, P = .002). Additionally, the score correlated with the estimated blood loss ( P = .005), operative time ( P = .001), and length of hospital stay ( P = .001). Conclusion The novel scoring system we have presented was found to predict treatment success and the risk of perioperative complications after percutaneous nephrolithotomy. Reproducible, standardized parameters obtained from computed tomography imaging can be used for preoperative patient counseling, surgical planning, and evaluation of surgical outcomes across institutions and within medical studies.
Extrinsic malignant compression of the ureter is not uncommon, often refractory to decompression with conventional polymeric ureteral stents, and frequently associated with limited survival. ...Alternative options for decompression include tandem ureteral stents, metallic stents and metal‐mesh stents, though the preferred method remains controversial. We reviewed and updated our outcomes with tandem ureteral stents for malignant ureteral obstruction, and carried out a PubMed search using the terms “malignant ureteral obstruction,” “tandem ureteral stents,” “ipsilateral ureteral stents,” “metal ureteral stent,” “resonance stent,” “silhouette stent” and “metal mesh stent.” A comprehensive review of the literature and summary of outcomes is provided. The majority of studies encountered were retrospective with small sample sizes. The evidence is most robust for metal stents, whereas only limited data exists for tandem or metal‐mesh stents. Metal and metal‐mesh stents are considerably more expensive than tandem stenting, but the potential for less frequent stent exchanges makes them possibly cost‐effective over time. Urinary tract infections have been associated with all stent types. A wide range of failure rates has been published for all types of stents, limiting direct comparison. Metal and metal‐mesh stents show a high incidence of stent colic, migration and encrustation, whereas tandem stents appear to produce symptoms equivalent to single stents. Comparison is difficult given the limited evidence and heterogeneity of patients with malignant ureteral obstruction. It is clear that prospective, randomized studies are necessary to effectively scrutinize conventional, tandem, metallic ureteral and metal‐mesh stents for their use in malignant ureteral obstruction.
Objective To determine anatomical variations between the prone, supine, and supine oblique positions that are likely to affect percutaneous renal access. Material and Methods Twenty patients ...underwent computed tomography urograms in the supine and prone positions. Twenty patients underwent supine oblique and prone scans. Mean nephrostomy tract length, maximum access angle, and anterior–posterior renal position were calculated. Results Mean nephrostomy tract length was shorter in the prone position (82.6 mm right kidney, 85.4 mm left kidney) compared with the supine position (108.3 mm right kidney, P <.001; 103.7 mm left kidney, P <.001). Prone tract length was also shorter than supine oblique tract length (86.1 mm vs 96.5 mm; P = .048). Mean maximum access angle was significantly greater ( P = .018 right kidney; P = .007 left kidney) in the prone position (right kidney 99.7°, left kidney 104.0°) compared with the supine position (right kidney 87.7°, left kidney 89.4°). The same was true for the prone compared with the supine oblique position (75.8° vs 58.7°; P = .004). No difference was noted in anterior–posterior renal position between the supine and prone positions (20.3 mm vs 26.7 mm; P = .094) or supine oblique and prone positions (22.8 mm vs 15.6 mm; P = .45). Conclusions The prone position is associated with a significantly shorter nephrostomy tract length and more potential access sites, which may improve ease and safety of percutaneous renal access.
Introduction & Objective
Surgical complications are difficult to predict, despite existing tools. Frailty phenotype has shown promise estimating postoperative risk among the elderly. We evaluate the ...use of frailty as a predictive tool on patients undergoing percutaneous renal surgery.
Methods
Frailty was prospectively analyzed using the Hopkins Frailty Index, consisting of 5 components yielding an additive score: patients categorized not frail, intermediate, or severely frail. Primary outcomes were complications during admission and 30-day complication rate. Secondary outcomes included overall hospital length of stay (LOS) and discharge location.
Results
A total of 100 patients recruited, of whom five excluded as they did not need the procedure. A total of 95 patients analyzed; 69, 10, and 16 patients were not frail, intermediate, and severely frail, respectively. There were no differences in blood loss, number of dilations, presence of a staghorn calculus, laterality, or location of dilation. Severely frail patients were likely to be older and have a higher American Society of Anesthesiologists score and Charlson comorbidity index. Patients of intermediate or severe frailty were more likely to exhibit postoperative fevers, bacteremia, sepsis, and require ICU admissions (P < 0.05). Frail patients had a longer LOS (P < 0.001) and tended to require skilled assistance when discharge (p < 0.0001).
Conclusions
Frailty assessment appears useful stratifying those at risk of extended hospitalization, septic complications, and need for assistance following percutaneous renal surgery. Risks of sepsis, bacteremia, and post-operative hemorrhage may be higher in frail individuals. Preoperative assessment of frailty phenotype may give insight into treatment decisions and represent a modifiable marker allowing future trials exploring the concept of “prehabilitation”.
The gold standard treatment for upper tract urothelial carcinoma (UTUC) is radical nephroureterectomy (RNU). The role of endoscopic resection is limited to low-risk patients. In this study, we ...present our 30-year experience in the endoscopic management of UTUC.
In this retrospective study, we identified 141 patients who underwent percutaneous UTUC resection. Demographic and clinical data were collected, including tumor characteristics, bacillus Calmette-Guérin (BCG) and mitomycin use, tumor recurrence, progression to RNU, and overall survival (OS), and compared in univariate and multivariate analyses.
Median follow-up was 66 months. Recurrence occurred in 37% of low-grade patients and 63% of high-grade (HG) patients, with a median time to recurrence of 71.4 vs 36.4 months, respectively. Grade was the only predictor of recurrence (HR 2.12, p = 0.018). The latest time to recurrence occurred after 116 months of surveillance. RNU was avoided by 87% of patients. Age, imperative indications for endoscopy, a history of bladder cancer, and tumor stage and grade were predictors of OS; however, in multivariate analysis, grade and stage lost significance. BCG and mitomycin did not protect against recurrence, progression to RNU, or death over resection alone.
Percutaneous management of UTUC allows for renal preservation in the majority of patients with resectable disease. Patients with HG tumors are more likely to experience recurrence, but are not at an increased risk of death. Intraluminal BCG and mitomycin continue to have a limited adjuvant role to resection. Recurrence may occur many years following initial resection and therefore prolonged surveillance is advised.
What's known on the subject? and What does the study add?
Off‐clamp laparoscopic partial nephrectomy (LPN) is thought to preserve renal function by limiting warm ischaemia time (WIT) and consequently ...reperfusion injury. To date, studies using the off‐clamp technique represent a heterogeneous group, with limited follow‐up showing feasibility and safety in a restricted number of cases.
We report the largest experience of off‐clamp vs on‐clamp LPN with perioperative outcomes and intermediate follow‐up of renal functional outcomes with stratification by WIT.
OBJECTIVE
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To evaluate perioperative and 6‐month renal functional outcomes of patients undergoing off‐clamp vs complete hilar control laparoscopic partial nephrectomy (LPN).
PATIENTS AND METHODS
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A retrospective review of 489 patients undergoing LPN was completed.
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Preoperative imaging assessed tumour characteristics.
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Patient demographics, perioperative parameters, and postoperative outcomes were documented.
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Multivariable regression analysis was used to assess factors contributing to changes in postoperative renal function between off‐clamp and clamped LPN.
RESULTS
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In all, 289 LPNs were performed on‐clamp and 150 were performed off‐clamp.
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Tumours in the on‐clamp group were larger than those in the off‐clamp group (mean range 3.3 0.5–13.5 vs 2.7 0.4–9 cm, P= 0.003).
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Univariable analysis comparing off‐clamp to on‐clamp cohorts showed that estimated glomerular filtration rate (eGFR) was better preserved in the off‐clamp cohort at 6 months (−5.8% vs –11.4%, P= 0.046). Multivariable analysis of the groups showed that estimate blood loss (P= 0.015) and warm ischaemia time (WIT, P< 0.001) were the only significant predictors of decreased eGFR in the postoperative period.
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Difference in eGFR at 6 months was not significant when WIT was limited to 30 min. The complication rate was greater in the clamped cohort (10% vs 20%, P= 0.012).
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There was no difference in transfusion rate or positive margin status.
CONCLUSIONS
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LPN without hilar clamping is feasible, safe and associated with less renal injury as assessed by postoperative GFR in select patients.
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With experience, it can be applied to complex renal lesions.
Over 1%–15% of the population worldwide is affected by nephrolithiasis, which remains the most common and costly disease that urologists manage today. Identification of at-risk individuals remains a ...theoretical and technological challenge. The search for monogenic causes of stone disease has been largely unfruitful and a technological challenge; however, several candidate genes have been implicated in the development of nephrolithiasis. In this review, we will review current data on the genetic inheritance of stone disease, as well as investigate the evolving role of genetic analysis and counseling in the management of nephrolithiasis.
Percutaneous renal surgery provides a minimally invasive approach to the kidney for stone extraction in a number of different clinical scenarios. Certain clinical cases present inherent challenges to ...percutaneous access to the kidney. Herein, we present scenarios in which obtaining and/or maintaining percutaneous access is difficult along with techniques to overcome the challenges commonly encountered. Also, complications associated with these challenging percutaneous renal surgeries are discussed.
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