C. Kara

Safety and efficacy of percutaneous nephrolithotomy in infants, preschool age, and older children with different sizes of instruments.

OBJECTIVES To compare the morbidity and success rates among different age groups of children undergoing percutaneous nephrolithotomy (PCNL) using adult- or pediatric-sized devices. PCNL for renal stones in children may present problems because of small size, mobility of the pediatric kidney, and the small size of the collecting system. METHODS Patients were categorized into 2 age groups: those < or =7 years old at the time of PCNL (group 1, n = 17 [38.6%]), and those 8-16 years old (group 2, n = 27 [61.4%]). Group 2 children were further divided into subgroups according to the use of pediatric- (group 2a, n = 12 [27.3%]) or adult-sized devices (group 2 b, n = 15 [34.1%]). RESULTS Mean patient age was 4.1, 11.7, and 13.2 years in groups 1, 2a, and 2b, respectively. Fluoroscopy time, time to access the collecting system, operative time, and average postoperative hospital stay did not differ between the groups. However, hemoglobin decrease, bleeding during surgery, and blood transfusion rate was higher in group 2b. Stones were completely cleared in 82.4%, 83.3%, and 81.3% patients, and these percentages increased to 94.1%, 91.7%, and 93.7% with adjunctive shock wave lithotripsy and ureterorenoscopy in groups 1, 2a, and 2b, respectively. CONCLUSIONS Endourologic intervention in children usually requires instruments specific for preschool age; however, in older children with dilated collecting system, the use of adult instruments and techniques may achieve equal results.

A randomized comparison of totally tubeless and standard percutaneous nephrolithotomy in elderly patients.

OBJECTIVES To evaluate the safety, effectiveness, and feasibility of totally (tubeless and stentless) tubeless percutaneous nephrolithotomy (PCNL) in elderly patients. Tubeless PCNL is performed widely in adult patients. METHODS A total of 60 patients with renal stones were enrolled in this study. Patients were randomized to either a totally tubeless approach (group 1, 30 patients) or placement of an 18F nephrostomy tube (group 2, 30 patients). Patients were considered uncomplicated and suitable for randomization at the end of the operation if there was no significant bleeding or residual stone, and the pelvicaliceal system was intact. The incidence of complications, hospital stay, analgesic requirements, and stone-free rates were compared in 2 groups. RESULTS The mean age of the patients at receipt of the surgical procedure was 67.7 years (range, 60-77) vs 66.5 years (range, 61-74), respectively. The mean stone size was 25.6 vs 22.3 mm and stone-free rate was 86% vs 83% for group 1 and 2, respectively (P > .05). The mean hospitalization time was 1.5 and 3.2 days (P < .001), the mean analgesia requirement (pethidine HCl) was 0.5 and 1.4 mg/kg, respectively (P < .01). Decrease in hematocrit was similar in 2 groups. No blood transfusions were needed. CONCLUSIONS Totally tubeless PCNL is safe and effective procedure even in elderly patients with renal stones. The hospitalization and analgesic requirements are less than standard PCNL. However, the tubeless decision should be taken intraoperatively in selected patients.

Transurethral Cystolithotripsy With Holmium Laser Under Local Anesthesia in Selected Patients

OBJECTIVES To evaluate the feasibility and effectiveness of transurethral holmium:yttrium-aluminum-garnet (YAG) laser cystolithotripsy under local anesthesia in selected patients. METHODS Thirteen consecutive male patients with large bladder calculi (3 cm or greater) caused by benign prostatic hyperplasia underwent transurethral cystolithotripsy using holmium:YAG laser under local anesthesia. The operation was performed with all the patients in the lithotomy position (except 3 with pelvic prosthesis). All patients underwent transurethral holmium laser cystolithotripsy (HLC) with a flexible cystoscope under local anesthesia by 1 surgeon. A urethral Foley catheter was placed postoperatively. RESULTS Thirteen patients with a mean age of 58.2 years were managed with HLC. All patients were rendered stone-free, regardless of stone size. No patient underwent transurethral resection of the prostate at the completion of the procedure. The mean stone size was 3.6 cm (range 3-5) and the mean operative time was 51 minutes (range 45-65). The whole procedure was well tolerated and no significant differences were found in the mean pain score between the HLC group and a group of male patients who underwent flexible cystoscopy under local anesthesia (2.15 vs 1.86, respectively; P = .467). No major intraoperative complication occurred. The mean hospitalization was 2.3 days. After a mean follow-up of 16.6 months, no recurrent stone, urinary retention, or urethral stricture developed. CONCLUSIONS Transurethral holmium:YAG laser lithotripsy under local anesthesia appears to be a safe and effective technique for the large bladder calculi. Thus, it may be used as an alternative treatment option in selected patients.

Effect of Previous Open Renal Surgery and Failed Extracorporeal Shockwave Lithotripsy on the Performance and Outcomes of Percutaneous Nephrolithotomy

PURPOSE We evaluated the effects of previous open renal surgery and unsuccessful extracorporeal shockwave lithotripsy (SWL) treatment on the performance and outcomes of percutaneous nephrolithotomy (PCNL). PATIENTS AND METHODS A total of 410 consecutive PCNL procedures for renal calculi were performed at our institution from November 2006 to March 2009. Of these 410 patients, 86 (20.9%) with a history of failed SWL on the same side were categorized as group I, and 132 (32.2%) who had previous open renal surgery (+/-SWL) on the same kidney were categorized as group II. The remaining 192 patients (46.9%) without a history of SWL or open renal surgery comprised group III. Patient demographics, stone characteristics, operative findings, including operative time, time to access the collecting system, flouroscopy time, success rate, need for auxiliary treatments, and complications were documented in detail and compared in each group. RESULTS There were no differences between the three groups in age, sex, weight, and stone laterality. In the post-SWL group, mean stone burden was significantly lower than in groups II and III. Mean operative time, time to access the collecting system, fluoroscopic screening time, complication rates, nephrostomy removal times, and hospitalization times were similar in the each groups (P > 0.05 for each parameter). The stone-free rates after PCNL were 89.5% in group I; 87.1% in group II; and 88.5% in group III. These rates increased to 98.8%, 96.2%, and 96.8%, in groups I, II and III, respectively, after a second intervention (PCNL, SWL, or ureterorenoscopy). CONCLUSIONS Our study clearly demonstrates that PCNL with standard technique can be performed safely in patients with a history of open nephrolithotomy or SWL without a higher risk of complications and with a success rate similar to that of PCNL in patients with no previous intervention.

Is intracytoplasmic sperm injection essential for the treatment of hypogonadotrophic hypogonadism? A comparison between idiopathic and secondary hypogonadotrophic hypogonadism.

Although infertility of hypogonadotrophic aetiology is uncommon (0.5–1%), it is important as a potentially treatable cause of male infertility. Broadly, hypogonadotrophic hypogonadism (HH) is divided into two categories, idiopathic and secondary postpubertal. In order to determine whether gonadotrophin replacement is sufficient to treat hypo gonadotrophic infertile men or there is a substantial need for intracytoplasmic sperm injection to increase chances of pregnancy, we performed a retrospective clinical analysis of seventeen hypogonadotrophic adult men (aged 25–38). Five patients had orchiopexy for cryptorchidism; three prepubertal and two postpubertal. All had non-obstructive azoospermia and received a combination of human chorionic gonadotrophin (hCG) and follicle stimulating hormone (FSH) for 4–24 months. Viable sperms started to appear in the ejaculate 3 months after treatment. Natural conception was achieved in six men with secondary HH (developed after head trauma, infection and surgery). By contrast, intracytoplasmic sperm injection (ICSI) was needed to produce successful fertilisation in the eleven men with idiopathic HH after failed gonadotrophin treatment. In conclusion, we recommend that ICSI should be considered, in addition to gonadotrophins to enhance the fertility of men with IHH, once oligospermic.

Surgical excision of strangulated urethral prolapse mimicking urethral carcinoma under local anesthesia in a postmenopausal woman.

Urethral prolapse is frequently reported in girls; however, the clinical condition is frequently encountered in postmenopausal women by urologists and gynecologists. The treatment of urethral prolapse is controversial. Information regarding the treatment and pathophysiology of this clinical entity in postmenopausal women is sparse in the published literature. We report a case of strangulated urethral prolapse that was successfully treated by surgical excision under local anaesthesia.

MP-07.11: The Role of Percutaneous Nephrolithotomy in the Management of Medium Sized (1-2 Cm) Lower-Pole Renal Calculi

OBJECTIVES The objective of this study was to determine the efficacy (defined by stone-free rates) and safety of percutaneous nephrolithotomy (PNL) in the treatment of medium sized (1-2 cm) symptomatic lower pole renal calculi, and establishment of the short-term morbidity. METHODS We performed a retrospective analysis of 60 evaluable patients who had undergone PNL for 1 to 2 cm diameter lower-pole (LP) stones between November 2006 to March 2009 and compared these results with other treatment modalities in published literature. RESULTS In all cases, stones were located in the lower calix. Thirty-six procedures were performed on the left side, and 24 were performed on the right side. The mean time to access the collecting system was 20.4 minutes (range 8-70 min) and mean operative time was 62.2 minutes (range 13-155 min). Abdominal radiography performed on postoperative day 1 demonstrated a stone free status in 56 (93.3%) patients. However, 4 patients (6.7%) required ancillary procedures (secondary PNL in 1, retrograde intrarenal surgery in 1, and SWL in 2). After this secondary procedures a complete stone-free status was achieved in 98.3% of patients. The morbidity of patients undergoing PNL at our hospital was minimal, with a mean hospital stay of 3.7 days. CONCLUSIONS We demonstrated that, PNL is a safe and effective method for medium sized (1 to 2 cm) lower pole renal calculi and percutaneous removal should be considered the primary approach for lower pole stones greater than 10 mm.