Purpose The purpose of this guideline is to provide a clinical framework for the diagnosis, prevention and follow-up of adult patients with kidney stones based on the best available published ...literature. Materials and Methods The primary source of evidence for this guideline was the systematic review conducted by the Agency for Healthcare Research and Quality on recurrent nephrolithiasis in adults. To augment and broaden the body of evidence in the AHRQ report, the AUA conducted supplementary searches for articles published from 2007 through 2012 that were systematically reviewed using a methodology developed a priori . In total, these sources yielded 46 studies that were used to form evidence-based guideline statements. In the absence of sufficient evidence, additional statements were developed as Clinical Principles and Expert Opinions. Results Guideline statements were created to inform clinicians regarding the use of a screening evaluation for first-time and recurrent stone formers, the appropriate initiation of a metabolic evaluation in select patients and recommendations for the initiation and follow-up of medication and/or dietary measures in specific patients. Conclusions A variety of medications and dietary measures have been evaluated with greater or less rigor for their efficacy in reducing recurrence rates in stone formers. The guideline statements offered in this document provide a simple, evidence-based approach to identify high-risk or interested stone-forming patients for whom medical and dietary therapy based on metabolic testing and close follow-up is likely to be effective in reducing stone recurrence.
Purpose The purpose of this guideline is to provide a clinical framework for the diagnosis, evaluation and follow-up of asymptomatic microhematuria. Materials and Methods A systematic literature ...review using the MEDLINE® database was conducted to identify peer reviewed publications relevant to the definition, diagnosis, evaluation and follow-up for AMH. The review yielded 191 evidence-based articles, and these publications were used to create the majority of the guideline statements. There was insufficient evidence-based data for certain concepts; therefore, clinical principles and consensus expert opinions were used for portions of the guideline statements. Results Guideline statements are provided for diagnosis, evaluation and follow-up. The panel identified multiphasic computed tomography as the preferred imaging technique and developed guideline statements for persistent or recurrent AMH as well as follow-up. Conclusions AMH is only diagnosed by microscopy; a dipstick reading suggestive of hematuria should not lead to imaging or further investigation without confirmation of three or greater red blood cells per high power field. The evaluation and follow-up algorithm and guidelines provide a systematic approach to the patient with AMH. All patients 35 years or older should undergo cystoscopy, and upper urinary tract imaging is indicated in all adults with AMH in the absence of known benign causation. The imaging modalities and physical evaluation techniques are evolving, and these guidelines will need to be updated as the effectiveness of these become available. Please visit the AUA website at http://www.auanet.org/content/media/asymptomatic_microhematuria_guideline.pdf to view this guideline in its entirety.
Purpose
Percutaneous nephrolithotomy (PCNL) is performed commonly in patients with large kidney stones, but the management of their postoperative pain presents a major challenge. While it is not ...routinely performed in PCNL patients, paravertebral block (PVB) has been described as an effective strategy for pain control after various non-urologic surgeries. This trial aims to assess the effect of paravertebral blockade on intraoperative and postoperative opioid use as well as postoperative pain control in patients undergoing PCNL.
Methods
This was a prospective, randomized, double-blind, placebo-controlled study. Patients who consented to participate were randomly assigned to undergo either PVB or a placebo intervention preoperatively. The patient, surgeon, and anesthesia team were all blinded to the randomization. The outcome parameters were intraoperative opioid requirement, postoperative visual analog scale (VAS) pain scores, postoperative opioid use, and postoperative antiemetic use.
Results
23 patients were enrolled in each arm of the study, and the two groups had no significant differences in baseline demographic or clinical characteristics. Patients in the PVB group had significantly lower intraoperative opioid use, postoperative opioid use, frequency of opioid use, and antiemetic. Patients in the PVB group also had lower postoperative VAS pain scores. There were no patients who suffered from complications attributable to PVB.
Conclusion
The results of this randomized, double-blind, placebo-controlled trial suggest that PVB should be considered an effective strategy to reduce opioid requirement and improve pain control for patients undergoing PCNL.
Purpose The increased use of abdominal imaging has led to more frequent detection of incidental renal cysts. Since the inception of the Bosniak classification system, management of Bosniak I, III and ...IV cysts has been clearly defined, while evaluation and management of Bosniak II and IIF cysts have remained a clinical dilemma. Discussions of new imaging modalities are becoming increasingly prevalent in the radiological literature. In this context we performed a comprehensive review of the recent literature on complex renal cysts focusing on new imaging modalities, surveillance strategies and biopsy. Materials and Methods We performed a comprehensive literature review of articles published from January 1, 1998 through December 31, 2013 via MEDLINE® , EMBASE and the Cochrane Collection using a predetermined search strategy. All studies included were performed in humans older than 18 years, were written in English and had an abstract available for review. We grouped studies into 1 of 5 categories, ie computerized tomography, magnetic resonance imaging, ultrasound, biopsy and surveillance. Results While computerized tomography and magnetic resonance imaging with and without contrast enhancement remain the gold standard to evaluate cystic lesions of the kidney, diffusion-weighted magnetic resonance imaging and contrast enhanced ultrasound have surfaced as new tools for assessment of complex cysts. Comparative effectiveness studies on these new imaging modalities are limited. Image guided biopsy has increasingly been shown to be useful for evaluation of intermediate (Bosniak II and IIF) complex cysts. We found few studies providing guidance on the duration and/or intensity of surveillance required for intermediate complex renal cysts. Conclusions Although new and enhanced techniques are in development and may be useful in the future management of complex renal cysts, there is a paucity of data regarding the value of these new techniques. Future research should focus on surveillance of intermediate complex renal cysts, particularly on the ideal frequency and type of imaging required.
Objectives To evaluate the durability of 4 next-generation flexible ureteroscopes in a randomized, multi-institutional, prospective study. Methods Patients at 3 institutions were randomized to 1 of 4 ...flexible ureteroscopes: the Wolf Viper, Olympus URF-P5, Gyrus-ACMI DUR-8 Elite (DUR-8E), and Stryker FlexVision U-500. Each center used 1 scope from each manufacturer until it needed major repair (primary endpoint). Intraoperative data included total time of use, number of scope insertions through an access sheath, working time in the lower pole, number of insertions and total time for accessory instrumentation in the working channel, number of laser insertions through the working channel, and total laser energy used. Results A total of 175 patients were randomized. The DUR-8E experienced early catastrophic failure (≤ 10 cases) at all 3 sites; however, this also occurred at 1 site each for the Stryker and Wolf scopes. The DUR-8E required major repair after the fewest average number of cases (5.3), the lowest average total time of usage (108 minutes), the fewest insertions through an access sheath (20.3), the shortest duration of laser firing (31.3 minutes), and the shortest instrument in the working channel time (224.7 minutes). As such, due to variation in durability within manufacturers, no differences could be demonstrated. Visibility ratings for the Wolf iper were significantly better than the DUR-8E ( P = .034) and the Flexvision ( P = .038). Conclusions The Wolf Viper, Olympus URF-P5, and Stryker Flexvision U-500 flexible ureteroscopes seem comparable with regard to durability. However, larger prospective registry-based studies are needed to document significant differences between them.
Abstract
Even though Napoleon Bonaparte was a mediocre Latin student, he made more extensive public use of that language throughout the French Empire than any secular ruler since Roman times. While ...Napoleon’s use of the images of imperial Rome to promote himself and his vision for France has been amply discussed elsewhere, the Latin inscriptions that accompanied this imperial imagery on medals and monuments have been largely overlooked. This article explores how Napoleon made use of these inscriptions for self-promotion and considers why Latin rather than French often appeared in public spaces. It also assesses who was responsible for the language and imagery of the inscriptions, where they appeared and who could read them and how.
Ureteral injury represents an uncommon but potentially morbid surgical complication. We sought to characterize the complications of iatrogenic ureteral injury and assess the effect of recognized vs ...delayed recognition on patient outcomes.
Patients who underwent hysterectomy were identified in the Healthcare Cost and Utilization Project California State Inpatient Database for 2007 to 2011. Ureteral injuries were identified and categorized as recognized—diagnosed/repaired on the day of hysterectomy and unrecognized—diagnosed/repaired postoperatively. We assessed the outcomes of 90-day hospital readmission as well as 1-year outcomes of nephrostomy tube placement, urinary fistula, acute renal failure, sepsis and overall mortality. The independent effects of recognized and unrecognized ureteral injuries were determined on multivariate analysis.
Ureteral injury occurred in 1,753 of 223,872 patients (0.78%) treated with hysterectomy and it was unrecognized in 1,094 (62.4%). The 90-day readmission rate increased from a baseline of 5.7% to 13.4% and 67.3% after recognized and unrecognized injury, respectively. Nephrostomy tubes were required in 2.3% of recognized and 23.4% of unrecognized ureteral injury cases. Recognized and unrecognized ureteral injuries independently increased the risk of sepsis (aOR 2.0, 95% CI 1.2–3.5 and 11.9, 95% CI 9.9–14.3) and urinary fistula (aOR 5.9, 95% CI 2.2–16 and 124, 95% CI 95.7–160, respectively). During followup unrecognized ureteral injury increased the odds of acute renal insufficiency (aOR 23.8, 95% CI 20.1–28.2) and death (1.4, 95% CI 1.03–1.9, p = 0032).
Iatrogenic ureteral injury increases the risk of hospital readmission and significant, potentially life threatening complications. Unrecognized ureteral injury markedly increases these risks, warranting a high level of suspicion for ureteral injury and a low threshold for diagnostic investigation.
Localized amyloidosis of the bladder is rare and often mimics bladder malignancy. It is typically associated with the extracellular deposition of monoclonal light chains, either κ or λ. The cause is ...unknown, but it is thought to be due to chronic inflammation/cystitis.
To highlight the importance of localized urinary bladder amyloidosis as a rare mimicker of urothelial malignancy and elucidate its clinical, histopathologic, and cytopathologic manifestations.
Cases of urinary bladder amyloidosis diagnosed during 2000-2023 were retrieved retrospectively from pathology archives. Electronic medical records, including cystoscopy findings and pathology slides including Congo red stain, were reviewed.
Here we present 6 patients with localized urinary bladder amyloidosis. Four of the 6 patients were women, with ages ranging from 46 to 69 years, and a mean age of 58 years. Five of 6 patients presented with hematuria, while in 1 patient, bladder amyloidosis was discovered incidentally. Cystoscopy findings invariably were concerning for malignancy, with raised erythema in 5 patients and fungating mass protruding into the bladder lumen in 1 patient. Bladder biopsies and urine cytology were negative for malignancy in all cases. Congo red-positive amyloid deposits involved lamina propria with sparing of the detrusor muscle. In 5 cases, the deposits were typed as derived from the λ light chain, whereas no information was available for 1 patient. Subsequent clinical workup ruled out systemic amyloidosis.
These cases of urinary bladder amyloidosis highlight the importance of considering rare amyloidosis in the differential diagnosis of hematuria and cystoscopy with a lesion mimicking malignancy.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, OILJ, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK, VSZLJ
Purpose Laparoscopic living donor nephrectomy is now the preferred technique for living donor renal transplantation. To our knowledge we provide the first published multi-institutional consensus ...describing practice patterns, technical considerations and interesting controversies involved in laparoscopic living donor nephrectomy. Materials and Methods We designed a survey with 33 multiple choice questions looking at demographics, patient selection, technical considerations, postoperative care and followup involved in laparoscopic living donor nephrectomy. Surveys were sent to the 58 fellowship training programs in the United States accredited by the American Society of Transplant Surgeons. Results The 32 responding programs performed approximately 40% of laparoscopic living donor nephrectomies in the United States in 2005. We found that almost all centers used a donor committee to screen candidates, enforce a body mass index cutoff, and use right kidneys when necessary and left kidneys in women of childbearing age. Regarding laparoscopic access, pure laparoscopy was favored 2 to 1 over the hand assisted technique and most of those who use nonbladed trocars do not close the fascia. Most surgeons divide the adrenal vein in left cases, use a vascular stapler on the renal artery and vein, and keep the ureter with the gonadal vein in the specimen. At most centers heparin is given before controlling the vessels. Extraction in pure laparoscopic cases is usually performed using a preplaced entrapment bag through a modified Pfannenstiel incision. Conclusions Our survey describes how most renal transplant centers with accredited fellowship programs in the United States approach laparoscopic living donor nephrectomy. Specifically trends are revealed regarding patient selection, laparoscopic access and surgical technique.
The management of the forgotten, encrusted, calcified (FECal) Double-J ureteral stents can represent one of the most difficult and challenging surgical conditions for the practicing urologist. We ...present a novel and simple grading system for the FECal stent and, taking into account our own experience and literature review, propose an algorithm in the management of the encrusted stent based on this new system.
A retrospective analysis of our stone database was performed from March 2000 to April 2007 revealing a total of nine patients presented with a FECal Double-J stent managed at our institution and included in our series for further analysis. Based on this population, our experience, and current surgical techniques, we designed a simplified grading system to universally define the retained indwelling FECal ureteral stents.
A total of nine patients with encrusted and retained ureteral stents were identified, graded, classified, and treated at our institution. Our population consisted of five women and four men with an average age of 54.4 years and average stent indwelling time of 11.44 months. We present our novel management algorithm based on our simplified FECal stent grading system.
The management of the FECal ureteral stent represents a formidable challenge due to the need for a multimodal approach with advanced endourological techniques. Our proposed grading system and management algorithm provide a simplified and directed alternative for the surgical management dilemma of the encrusted retained ureteral stent.
