Giovanni Marchini

Robotic Assisted Laparoscopic Ureteral Reimplantation in Children: Case Matched Comparative Study With Open Surgical Approach

PURPOSE Surgical treatment may be required in some patients with vesicoureteral reflux. With the recent development of robotic assistance, laparoscopic treatment of vesicoureteral reflux has gained popularity. We sought to evaluate our initial experience with pediatric robotic assisted laparoscopic intravesical and extravesical ureteral reimplantation, and to compare outcomes with the open technique. MATERIALS AND METHODS A retrospective chart review was performed on all patients who underwent robotic assisted laparoscopic ureteral reimplantation between 2007 and 2010. Comparisons were made with a case matched cohort of patients who underwent the open technique. The groups were compared using t tests for numerical variables and chi-square comparisons or Fishers exact test for categorical variables. A Kaplan-Meier model was used to compare success rates. RESULTS A total of 19 patients underwent intravesical and 20 underwent extravesical robotic assisted laparoscopic ureteral reimplantation during the study period. They were compared to 22 patients undergoing intravesical and 17 undergoing extravesical open ureteral reimplantation. Although the robotic assisted approach was associated with a longer operative time (p <0.001), children undergoing intravesical robotic assisted reimplantation had a shorter duration of urinary catheter drainage, fewer bladder spasms and a shorter hospital stay compared to those undergoing the intravesical open technique (p <0.01). There were no significant differences in these parameters when comparing extravesical robotic assisted reimplantation to the extravesical open technique. Overall success rates were similar among patients who underwent robotic assisted laparoscopic ureteral reimplantation and open reimplantation (p >0.5). CONCLUSIONS Robotic assisted laparoscopic ureteral reimplantation offers similar success rates to the gold standard, open ureteral reimplantation. Future large scale studies will be required to define further the costs and benefits of robotic assisted laparoscopic ureteral reimplantation in the surgical treatment of vesicoureteral reflux.

Percutaneous Nephrolithotomy in Obese Patients: Comparison Between the Prone and Total Supine Position

BACKGROUND Percutaneous nephrolithotomy (PCNL) can be performed in the prone or in the supine position. Comparisons between the two techniques in obese patients are rare in the current literature. METHODS The records of obese patients (body mass index >30) who underwent PCNL in the prone or complete supine positions were reviewed. All patients had a noncontrast CT before and after the procedure. Stones were graded according to the Guy stone score and complications according to the Clavien grading. The stone-free rates, operative time, surgical complications, and hospital stay were analyzed. RESULTS A total of 56 PCNL were performed in 42 patients. Twenty-four PCNL were performed in the prone and 32 in the total supine position. Stone-free rate on the first postoperative day was 50% in the prone and 46.9% in the supine position (P=1.0). Final stone-free rates were 83.3% and 78.1%, respectively (P=0.74). Mean operative time was 164.6 minutes in the prone and 120.3 minutes in the supine position (P=0.0017), and hospital stay was 4.38 and 2.68 days (P=0.014), respectively. The transfusion rate was 20.8% in the prone and zero in the supine position patients (P=0.01). Excluding Guy IV stones, transfusion rate was 8.3% in the prone position (P=0.1). Significant surgical complications rate was 12.5% in the prone and 3.1% in the supine position (P=0.302). CONCLUSION PCNL performed in the prone or in the complete supine position in obese patients presents similar outcomes. The supine decubitus position has the advantages of a significantly shorter operative time and hospital stay.

Contemporary Trends of Inpatient Surgical Management of Stone Disease: National Analysis in an Economic Growth Scenario

PURPOSE To assess trends in urologic surgical management of upper tract urolithiasis in Brazil over the past 15 years. MATERIALS AND METHODS The Public Health System of Brazil (SUS) provides health coverage to 47% to 74% of the population. SUS has a longitudinal hospital inpatient database (SIH/SUS). Hospital discharges between January 1,1998 and December 31, 2012 were abstracted from the SIH/SUS. All inpatient hospitalizations for patients of any age with a primary/secondary diagnosis code of N20.x (calculus of kidney or ureter) were abstracted (ICD-9/10). All urolithiasis-related procedure codes were analyzed. The absolute number of procedures/year and the proportion among all techniques were analyzed for Brazil and also separately for the five distinguished regions of the country. Prevalence trends over the studied period were quantified by the estimated annual percent change (EAPC) using the least squares linear regression methodology. Significance was set at P<0.05. RESULTS The number of surgical interventions for stone disease increased significantly from 10080 to 24713 (+145%; EAPC=1008.1; P<0.001). The most common surgical modalities in 1998 were nephrectomy (n=2918; 29%), ureterolithotomy (n=2361; 23%), and pyelolithotomy (n=1771; 18%). In 2012, ureteroscopy (URS) was the most commonly performed procedure (n=8725; 35%), followed by ureterolithotomy (n=5822; 24%), and nephrectomy (n=3466; 14%). Between 1998 and 2012, percutaneous nephrolithotomy had the highest significant relative increase (+791.8%; EAPC=0.6%; P<0.001), followed by URS (+607%; EAPC=1.78%; P<0.001). Pyelolithotomy showed the most significant decrease (-47.5%; EAPC = -0.91%; P<0.001). All five regions presented a significant positive increase in the EAPC (P<0.001). CONCLUSION Trends of stone disease surgical management in the public health system of Brazil follow worldwide tendencies toward less invasive treatment modalities.

Impact of laparoscopic surgery training laboratory on surgeon's performance

Minimally invasive surgery has been replacing the open standard technique in several procedures. Similar or even better postoperative outcomes have been described in laparoscopic or robot-assisted procedures when compared to open surgery. Moreover, minimally invasive surgery has been providing less postoperative pain, shorter hospitalization, and thus a faster return to daily activities. However, the learning curve required to obtain laparoscopic expertise has been a barrier in laparoscopic spreading. Laparoscopic surgery training laboratory has been developed to aid surgeons to overcome the challenging learning curve. It may include tutorials, inanimate model skills training (box models and virtual reality simulators), animal laboratory, and operating room observation. Several different laparoscopic courses are available with specific characteristics and goals. Herein, we aim to describe the activities performed in a dry and animal-model training laboratory and to evaluate the impact of different kinds of laparoscopic surgery training courses on surgeon’s performance. Several tasks are performed in dry and animal laboratory to reproduce a real surgery. A short period of training can improve laparoscopic surgical skills, although most of times it is not enough to confer laparoscopic expertise for participants. Nevertheless, this short period of training is able to increase the laparoscopic practice of surgeons in their communities. Full laparoscopic training in medical residence or fellowship programs is the best way of stimulating laparoscopic dissemination.

Absolute Hounsfield Unit Measurement on Noncontrast Computed Tomography Cannot Accurately Predict Struvite Stone Composition

BACKGROUND The purpose of our study was to determine, in vivo, whether single-energy noncontrast computed tomography (NCCT) can accurately predict the presence/percentage of struvite stone composition. METHODS We retrospectively searched for all patients with struvite components on stone composition analysis between January 2008 and March 2012. Inclusion criteria were NCCT prior to stone analysis and stone size ≥4 mm. A single urologist, blinded to stone composition, reviewed all NCCT to acquire stone location, dimensions, and Hounsfield unit (HU). HU density (HUD) was calculated by dividing mean HU by the stones largest transverse diameter. Stone analysis was performed via Fourier transform infrared spectrometry. Independent sample Students t-test and analysis of variance (ANOVA) were used to compare HU/HUD among groups. Spearmans correlation test was used to determine the correlation between HU and stone size and also HU/HUD to % of each component within the stone. Significance was considered if p<0.05. RESULTS Fourty-four patients met the inclusion criteria. Struvite was the most prevalent component with mean percentage of 50.1%±17.7%. Mean HU and HUD were 820.2±357.9 and 67.5±54.9, respectively. Struvite component analysis revealed a nonsignificant positive correlation with HU (R=0.017; p=0.912) and negative with HUD (R=-0.20; p=0.898). Overall, 3 (6.8%) had <20% of struvite component; 11 (25%), 25 (56.8%), and 5 (11.4%) had 21% to 40%, 41% to 60%, and 61% to 80% of struvite, respectively. ANOVA revealed no difference among groups regarding HU (p=0.68) and HUD (p=0.37), with important overlaps. When comparing pure struvite stones (n=5) with other miscellaneous stones (n=39), no difference was found for HU (p=0.09) but HUD was significantly lower for pure stones (27.9±23.6 v 72.5±55.9, respectively; p=0.006). Again, significant overlaps were seen. CONCLUSIONS Pure struvite stones have significantly lower HUD than mixed struvite stones, but overlap exists. A low HUD may increase the suspicion for a pure struvite calculus.

Genome gender diversity in affected sib-pairs with familial vesico-ureteric reflux identified by single nucleotide polymorphism linkage analysis.

Study Type – Aetiology (case series)

Preoperative Planning with Noncontrast Computed Tomography in the Prone and Supine Position for Percutaneous Nephrolithotomy: A Practical Overview

OBJECTIVE To evaluate kidney/adjacent organs positional changes in patients undergoing percutaneous nephrolithotomy (PCNL) using noncontrast computed tomography (NCCT) in prone and supine positions. METHODS Patients scheduled PCNL were prospectively enrolled in the study and underwent NCCT in supine and in prone position (with boosters). Two imaginary lines for the posterior calyx of upper/mid/lower poles of both kidneys in prone and supine decubitus were considered and compared. Line I (LI): drawn horizontally in the coronal plane in contact with the posterior edge of the kidney. Line II (LII): drawn from the antero-lateral edge of the vertebra through the middle of the posterior calyx (ideal puncture line). Renal depth (d) was measured from LI to the anterior extremity of the vertebra. The maximum access angle (a) considered the window available in the axial plane to perform a secure approach to each calyx. RESULTS Thirty-seven patients were analyzed; 56.7% were female; mean BMI was 28.3±4.9 kg/m(2). For the right kidney, prone position was associated with more organs crossed by LI (54.1% vs 18.9%; p<0.01) and LII (56.8% vs 27%; p=0.03) in the upper calyx. For the left kidney, LII crossed more organs in prone in the upper calyx (54.1% vs 29.7%; p=0.03). Both kidneys showed a tendency to be deeper in the supine position, which provided a wider access angle. CONCLUSIONS Supine NCCT is not accurate to plan PCNL access in prone position. Prone decubitus is associated with more potential organ injuries in the upper pole. In supine, the kidney situates deeper in the abdomen but the access angle is wider than in prone.

MP10-18 SEPTIC SHOCK FOLLOWING SURGICAL DECOMPRESSION OF OBSTRUCTING URETERAL STONES: A PROSPECTIVE ANALYSIS

Purpose: To investigate risk factors for septic shock and death in patients with obstructive pyelonephritis due to ureteral stone, who underwent urinary tract decompression. Patients and methods: We prospectively enrolled patients who presented at the emergency department of our institution with clinical signs of pyelonephritis, systemic inflammatory reaction syndrome (SIRS) and obstructive ureteral stone confirmed by computed tomography scan. Forty patients that underwent urinary tract decompression were included. Demographical, medical and laboratorial characteristics were recorded; antibiotic regimen and time from presentation to decompression were compared between patients with septic complications. Results: Septic shock and death occurred in 6 (15%) and 2 (5%) patients, respectively. Gender, age and co-morbidities were not associated with septic complications. Urinary culture was negative in 40% of the cohort and the most prevalent pathogen was Escherichia coli. Administration of antibiotics other th...

MP71-18 LOW-VOLUME PROSTATE IN BENIGN PROSTATIC HYPERPLASIA (BPH): A RISK FACTOR FOR SYMPTOMATIC BLADDER DIVERTICULA REQUIRING SURGICAL TREATMENT

INTRODUCTION AND OBJECTIVES: to evaluate the association between prostate volume, age, and occurrence of bladder diverticula requiring surgical treatment on patients with symptomatic BPH. METHODS: we performed a retrospective search on our prospectively collected database searching for patients with BPH managed surgically between Jan/10 and Oct/14. Analyzed data comprised age at, prostatic volume measured on abdominal ultrasound, type of prostatic surgery, and presence of bladder diverticula requiring surgical treatment ( 3cm and/or symptomatic). Patients were divided in regards to diverticula requiring surgical treatment. Groups were compared using Student T test and Chi-square/Fisher exact test. Logistic regression was performed to seek for associations between the presence of the symptomatic diverticula and preoperative parameters. Significance was set at p<0.05. RESULTS: A total of 1532 patients were surgically treated for BPH in the analyzed period and 41 (2.6%) had symptomatic bladder diverticula. Mean diverticula size was 6.8 2.9cm and mean number of diverticula per patient was 1.5 0.8 (1-5). Treatment of the diverticula was performed laparoscopically in 13 (31.8%) patients, by endoscopic incision in 14 (34.1%), and by open resection in 14 cases (34.1%). Patients with treated diverticula did not differ from the other cohort in regards to age (66.9 8.3 vs. 68.5 8.8 years, respectively; p1⁄40.16) and surgical technique (p1⁄40.11). Mean prostate volume was significantly lower in the treated diverticula group (53.6 45.0 vs. 80.7 51.9g, respectively; p<0.01). Prostate volume and age distributions among patients with and without diverticula are depicted in figures 1A and B. Logistic regression revealed only prostate volume to significantly impact the presence of symptomatic diverticula requiring surgical treatment (OR1⁄4-0.03; 95% CI 0.955 e 0.988; p1⁄40.01). Roc curve analysis revealed a significant association with an AUC of 0.73 (p<0.001)(fig.1c). CONCLUSIONS: In patients with BPH, there is a significant association between prostate volume and risk of symptomatic bladder diverticulum. Bladder diverticula requiring surgical treatment are more common in patients with low prostate volume.

2095 GOUT, STONE COMPOSITION AND URINARY STONE RISK: A CASE MATCHED COMPARATIVE STUDY

Abstract PURPOSE: to establish the most common stone composition, serum and urinary biochemical features of patients with gout and urolithiasis. MATERIALS AND METHODS: we retrospectively searched for patients with gout diagnosis among those in our stone registry. A case-matched cohort of stone-formers was generated from our registry having the same age, gender and BMI. Primary end-points were baseline 24-hour urinary metabolic panels and stone composition. Medications were taken in consideration. Groups were compared using Students t test and Chi-square/Fishers exact test (significant if p<0.05). RESULTS: Stone panel evaluation: 181 patients met our inclusion criteria. There was no significant difference in 24-hour UA between non-gout and gout cohorts; hyperoxaluria was more common in gout patients (74 vs. 61%; p=0.009). Stone composition analysis: 393 patients were included. Gout cohort had lower amount of CaOMH (39.4 vs. 54.7%), CaODH (6.0 vs. 11.2%) and CaPh (9.6 vs. 14.1%; p<0.001) and higher of UA (42.7 vs. 18.2%; p<0.001). Pure UA stones were more common in gout patients (52.2 vs. 22.3%; p<0.001); CaOMH (45.2 vs. 68.6%; p<0.001), CaOHD (0.6 vs. 3.5%; p=0.017) and CaPh (1.6 vs. 4.9%; p=0.033) were more frequent in non-gout patients. Gout patients taking allopurinol had less pure UA (30.4 vs. 56.4%; p=0.001) and more CaOMH stones (69.6 vs. 40.7%; p<0.001) than those without medications. CONCLUSIONS: UA stones are the most common pure stone composition in patients with gout, but 48% will have non-UA stones. Allopurinol changes the distribution of stone composition in patients with gout, to a pattern similar to non-gout stone formers.