Athanasios Papatsoris

Supine Valdivia and modified lithotomy position for simultaneous anterograde and retrograde endourological access

Gaspar Ibarluzea, Cesare M. Scoffone*, Cecilia M. Cracco*, Massimiliano Poggio*, Francesco Porpiglia*, Carlo Terrone†, Ander Astobieta, Isabel Camargo, Mikel Gamarra, Augusto Tempia‡, Jose G. Valdivia Uria¶ and Roberto Mario Scarpa* Department of Urology, Galdakao Hospital, Bizkaia, Basque Country, Spain, Departments of *Urology and †Anaesthesiology, University of Torino, San Luigi Hospital, Orbassano, Torino, ‡Urology, University of Piemonte Orientale, Azienda Ospedaliera Maggiore della Carita, Novara, Italy, and ¶Hospital Clinico Universitario Losano Blesa, Zaragoza, Spain

Bladder lithiasis: from open surgery to lithotripsy

Bladder calculi account for 5% of urinary calculi and usually occur because of bladder outlet obstruction, neurogenic voiding dysfunction, infection, or foreign bodies. Children remain at high risk for developing bladder lithiasis in endemic areas. Males with prostate disease or relevant surgery and women who undergo anti-incontinence surgery are at a higher risk for developing vesical lithiasis. Open surgery remains the main treatment of bladder calculus in children. In adults, the classical treatment for bladder calculi is endoscopic transurethral disintegration with mechanical cystolithotripsy, ultrasound, electrohydraulic lithotripsy, Swiss Lithoclast, and holmium:YAG laser. Novel modifications of these treatment modalities have been used for large calculi. Open and endoscopic surgery requires anesthesia and hospitalization. Alternatively, extracorporeal shock wave lithotripsy has been demonstrated to be simple, effective, and well tolerated in high-risk patients. Recently, simultaneous percutaeous suprapubic and transurethral cystolithotripsy has been tested as well as percutaneous cystolithotomy by using a laparoscopic entrapment sac.

Matrix metalloproteinase inhibitors as anticancer agents.

The important role of matrix metalloproteinases (MMPs) in the process of carcinogenesis is well established. However, despite very promising activity in a plethora of preclinical models, MMP inhibitors (MMPIs) failed to demonstrate a statistically significant survival advantage in advanced stage clinical trials in most human malignancies. Herein, we review the implication of MMPs in carcinogenesis, outline the pharmacology and current status of various MMPIs as anticancer agents and discuss the etiologies for the discrepancy between their preclinical and clinical evaluation. Finally, strategies for effective incorporation of MMPIs in current anticancer therapies are proposed.

Endometriosis of the urinary tract in women of reproductive age

Aim:  We present our experience with diagnosing and treating 22 cases of urinary tract endometriosis in women of reproductive age.

A Novel Thermo-Expandable Ureteral Metal Stent for the Minimally Invasive Management of Ureteral Strictures

PURPOSE We assess the safety, efficacy, and cost of the novel long-term indwelling thermo-expandable Memokath ureteral stent for the management of malignant and benign ureteral strictures. MATERIALS AND METHODS Since October 2004, we treated 73 patients (34 men), ages 23 to 84 years (mean 57.7) with 86 ureteral strictures (13 bilateral) with the Memokath 051 stent. The causes of the strictures were benign in 55 cases and malignant in 31 cases. Follow-up included radiography, renal ultrasonography, and renography if needed after 2 weeks, 3 months, and then every 6 months. RESULTS The mean operative time was 23 minutes, while the mean hospital stay was 1.5 days. The average indwelling time of an individual Memokath was 11.2 months. After a mean follow-up period of 17.1 months, there were 68 stents in situ. In 12 cases, spontaneous resolution of the ureteral stricture was revealed after a mean indwelling time of 9 months. The remainding six cases were treatment failures. In 15 cases, because of late complications, a Memokath exchange took place after a mean period of 18 months. A total of 26 complications were revealed after the insertion of 102 Memokath stents. These included six cases of urinary tract infections; 15 stent manipulations were needed because of stent dislodgement, and 5 stents were removed because of encrustration and blockage. In the long term, the overall costs for the Memokath treatment and follow-up were considerably less than with the conventional Double-J stent. CONCLUSIONS The ureteral Memokath stent is a promising, safe, and efficient treatment option for the minimally invasive management of both benign and malignant ureteral strictures.

Endoscopic and Laparoscopic Treatment of Ureteropelvic Junction Obstruction

PURPOSE Although open pyeloplasty remains the gold standard for treating ureteropelvic junction obstruction, endourology and laparoscopy have revolutionized the management of upper tract stenosis. We present our diagnostic and minimally invasive therapeutic algorithm for the treatment of ureteropelvic junction obstruction. MATERIALS AND METHODS A total of 13 females and 9 males with a mean age of 34.2 years suffering from ureteropelvic junction obstruction were treated with percutaneous endopyelotomy or laparoscopic dismembered pyeloplasty and followed for 47 to 61 months (mean 53.8) and 47 to 62 months (mean 52.5), respectively. Diagnosis was based on findings of ultrasound, excretory urography, furosemide washout renogram and retrograde ureteropyelography. In cases of ureteral kinking color duplex sonography and spiral computerized tomography were performed. In 14 patients with intrinsic stenosis percutaneous endopyelotomy was performed, while the remaining 8 patients (5 with crossing vessels, 2 with an extremely distended pelvis and 1 with a 2.5 cm. stricture) were treated with a laparoscopic dismembered Anderson-Hynes pyeloplasty. RESULTS In the endopyelotomy group (success rate 92.8%), mean operation time was 1.2 hours, estimated blood loss was 152 ml., unit doses of analgesics were 5.4 tablets, days of hospitalization were 4.2 and time to return to normal activities was 15.7 days. In the laparoscopic group (success rate of 100%) the aforementioned variables were 3.5 hours (p <0.05), 150 ml., 6.3 tablets, 5 and 17.8 days, respectively. Long-term followup excretory urography and/or diuretic renal scan demonstrated improvement in all patients. CONCLUSIONS Percutaneous endopyelotomy should be the treatment of choice for intrinsic ureteropelvic junction obstruction. Laparoscopic dismembered pyeloplasty, although technically challenging, provides excellent results for extrinsic or complicated ureteropelvic junction stenosis.

Prevention and treatment of urinary tract infection with probiotics: Review and research perspective

The spiralling costs of antibiotic therapy, the appearance of multiresistant bacteria and more importantly for patients and clinicians, unsatisfactory therapeutic options in recurrent urinary tract infection (RUTI) calls for alternative and advanced medical solutions. So far no sufficient means to successfully prevent painful and disabling RUTI has been found. Even though long-term oral antibiotic treatment has been used with some success as a therapeutic option, this is no longer secure due to the development of bacterial resistance. One promising alternative is the use of live microorganisms (probiotics) to prevent and treat recurrent complicated and uncomplicated urinary tract infection (UTI). The human normal bacterial flora is increasingly recognised as an important defence to infection. Since the advent of antibiotic treatment five decades ago, a linear relation between antibiotic use and reduction in pathogenic bacteria has become established as medical conventional wisdom. But with the use of antibiotics the beneficial bacterial flora hosted by the human body is destroyed and pathogenic bacteria are selectively enabled to overgrow internal and external surfaces. The benign bacterial flora is crucial for body function and oervgrowth with pathogenic microorganisms leads to illness. Thus the concept of supporting the human bodys normal flora with live microorganisms conferring a beneficial health effect is an important medical strategy.

Comparison of Stent-Related Symptoms Between Conventional Double-J Stents and a New-Generation Thermoexpandable Segmental Metallic Stent: A Validated-Questionnaire-Based Study

INTRODUCTION Double-J stents revolutionized the minimally invasive management of ureteral strictures, but have significant morbidity. We compare stent-related symptoms and quality of life between a conventional Double-J stent and a novel thermoexpandable metal segmental ureteral stent (Memokath) in patients with ureteral strictures. MATERIALS AND METHODS Seventy patients with a conventional Double-J stent or a Memokath stent for ureteral strictures were mailed a validated ureteral stent symptom questionnaire, which is a multidimensional measure that evaluates stent-related morbidity in six sections: urinary symptoms, body pain, general health, work performance, sexual matters, and additional problems. Statistical analysis compared the differences in these parameters between the two groups. RESULTS Forty-one patients (58.5%) responded, 23 with a Double-J stent and 18 with a Memokath stent. A subgroup of 10 patients had both a Double-J and a Memokath stent. Nearly 70% of patients with Double-J stents experienced urine frequency <or=2 hours versus 47% with Memokath stents. About 31.8% of patients with Double-J stents were extremely bothered by urinary symptoms versus 5.6% with Memokaths. About 66.7% of patients with Double-J stents had a negative view toward living with their current urinary symptoms versus 35.3% with Memokath stents. DISCUSSION The ureteral stent symptom questionnaire revealed that pain, urinary symptoms index, and general health were statistically better in the Memokath group. The Memokath group significantly outperformed the Double-J stent group in terms of the light and heavy activity. In terms of future stent insertion, patients preferred the Memokath stent. In the subgroup who had experienced both stents, the Memokath questionnaire revealed improvements in the domain of pain and the lower urinary tract symptoms index, though this was not statistically significant. This may reflect the small size of the study population. There were improvements in general health and other quality-of-life parameters, and there was a tendency in favor of the Memokath.

Diagnosis and Management of Postpercutaneous Nephrolithotomy Residual Stone Fragments

Residual stone fragments can occur in up to 8% of patients who are treated with percutaneous nephrolithotomy (PCNL). When left untreated, approximately half of these patients will experience a stone-related event, for which more than half will need a secondary surgical intervention. Predictors of adverse events are a residual fragment larger than 2 mm that is located in the pelvis or ureter. Preventive measures for the creation of residual fragments include a carefully selected access giving exposure to the bulk of the stone, the creation of multiple tracts, the use of single pulse pneumatic lithotripsy, the prevention of stone migration with ureteral balloons or stone cones, and careful flushing of the stones from the collecting system. Plain radiography of the kidneys, ureters, and bladder, linear tomography, and ultrasonography have all been used to judge the result of PCNL and to detect the presence of residual fragments. Thin-slice, unenhanced helical CT, however, is more sensitive and should be performed at 1 month after surgery. While medical therapy and shockwave lithotripsy possess a minor role, second-look flexible nephroscopy and/or flexible ureterorenoscopy seem to be the treatments of choice for residual stone fragments after PCNL.

Current status of ureteroscopic treatment for urolithiasis.

Intracorporeal treatment of urolithiasis is characterized by continuous technological evolution. In this review we present updated data upon the use of ureteroscopy for the management of urolithiasis. Novel digital flexible ureteroscopes are used in clinical practice. Ureteroscopic working tools are revolutionized resulting in safer and more efficient procedures. Special categories of stone patients such as pregnant women, children and patients on anticoagulation medication can now undergo uneventful ureteroscopy. Routine insertion of stents and access sheaths as well as bilateral ureteroscopy is still a controversial issue. Future perspectives include smaller and better instruments to visualize and treat a stone, while robotic ureteroscopy is becoming a fascinating reality.