Obesity and kidney stone disease. A systematic review

INTRODUCTION: Currently, abdominal obesity has reached an epidemic stage and obesity represents an important challenge for worldwide health authorities. Epidemiologic studies have demonstrated that the stone risk incidence increases with Body Mass Index, through multiple pathways. Metabolic syndrome and diabetes are associated with an increased renal stones disease incidence. The aim of this systematic review was to investigate the prevalence, morbidity, risk factors involved in the association between obesity and urolithiasis. EVIDENCE ACQUISITION: The search involved finding relevant studies from MEDLINE, EMBASE, Ovid, the Cochrane Central Register of Controlled Trials, CINAHL, Google Scholar, and individual urological journals between January 2001 and May 2017. The inclusion criteria were for studies written in the English language, reporting on the association between obesity and urinary stones. EVIDENCE SYNTHESIS: The underlying pathophysiology of stone formation in obese patients is thought to be related to insulin resistance, dietary factors, and a lithogenic urinary profile. Uric acid stones and calcium oxalate stones are observed frequently in these patients. Insulin resistance is thought to alter the renal acid-base metabolism, resulting in a lower urine pH, and increasing the risk of uric acid stone disease. Obesity is also associated with excess nutritional intake of lithogenic substances and with an increase in urinary tract infection incidence. Recent studies highlighted that renal stone disease increases the risk of myocardial infarction, progression of chronic kidney disease, and diabetes. Contemporary, bariatric surgery has been shown to be associated with hyperoxaluria and oxalate nephropathy. Certainly, the many health risks of obesity, including nephrolithiasis, will add more burden on urologists and nephrologists. CONCLUSIONS: Obesity related nephrolithiasis seems to necessitate weight loss as primary treatment, but the recognition of the associated complications is necessary to prevent induction of new and equally severe medical problems. The optimal approach to obesity control that minimizes stone risk needs to be determined in order to manage obesity-induced renal stones disease

Combined laparoscopic pyelolithotomy and endoscopic pyelolithotripsy for staghorn calculi. Long-term follow-up results from a case series

Purpose: Staghorn renal stones are a challenging field in urology. Due to their high recurrence rates, particularly those associated with an infective process, a complete removal is the ultimate goal in their management. We report our experience with a combined approach of laparoscopic pyelolithotomy and endoscopic pyelolithotripsy, the stone clearance rate, and long-term, follow-up outcomes. Methods: From June 2012 to October 2014, nine adult patients with large staghorn renal calculi (mean size, 7.2 cm; range, 6.2–9.0 cm) underwent a combined laparoscopic and endoscopic approach. The technique comprised laparoscopic pyelolithotomy and holmium-YAG laser stone fragmentation with the use of a flexible cystoscope introduced through a 12 mm trocar. Results: The average operative time was 140 min (range, 90–190 min). The mean estimated hemoglobin loss was 0.6 mmol/l (range 0.5–0.7 mmol/l). None of the patients required an open- surgery conversion. The mean hospital stay was 4 days (range, 2–6 days). A computed tomography urogram control at 6 months of follow up did not show any stone recurrence. Conclusions: Laparoscopic pyelolithotomy combined with endoscopic pyelolithotripsy could be a therapeutic option in cases where mini-invasive procedures, that is, extracorporeal shock wave lithotripsy, ureteroscopic lithotripsy, and percutaneous nephrolithotomy (PCNL) have failed. This technique has a high stone-clearance rate (75–100%) comparable with open surgery and PCNL. However, it could be technically demanding and should be performed by skilled laparoscopy surgeons

Lower urinary tract symptoms and benign prostatic hyperplasia and their impact on quality of life

LUTS is an acronym that refers to symptoms affecting the lower urinary tract, which are very common in elderly subjects (between 60 and 70%), and often associated with, but not always caused by, benign prostatic hypertrophy (BPH). BPH is a chronic condition characterized by an increase in the number of cells, particularly in the transition area of the prostate. BPH involves a compression of the surrounding tissues, consequently obstructing vescical voiding. Nycturia and urgency represent the most prevalent symptoms and those with the greatest impact on quality of life measured as urinary-specific health-related quality. The prevalence of BPH is directly proportional to age; therefore, the absolute number of subjects affected is growing throughout the world. BPH is one of the most common medical conditions affecting those over 50. The overall cost for the diagnosis and treatment of BPH-related LUTS, in the US, has been estimated at approximately 1.1 billion US$/year, compared to total annual expenditure for urological conditions of some 9 billion and this cost continues to increase. The quick prostate test, which was developed by the Italian Urology Society (SIU), is an easy to use instrument that can be utilized in first-level screening for evaluation of the male population with LUTS. This test can be used both in patients not on pharmacological treatment and as a therapy-monitoring instrument. A positive response to one of the questions is sufficient for requesting a more in-depth investigation, which may provide indications on the therapeutic strategy to be taken

Can daily intake of aspirin and/or statins influence the behavior of non-muscle invasive bladder cancer? A retrospective study on a cohort of patients undergoing transurethral bladder resection

Background: This study aimed to evaluate the behavior of non-muscle-invasive bladder cancer (NMIBC) in patients submitted to transurethral bladder resection (TURB) comparing subjects in chronic therapy with aspirin, statins, or both drugs to untreated ones. Methods: This retrospective study was conducted on 574 patients diagnosed with NMIBC who underwent TURB between March 2008 and April 2013. The study population was divided into two main groups: treated (aspirin and/or statins) and untreated. The treated group was further divided into three therapeutic subgroups: Group A (100 mg of aspirin, daily for at least two years); Group B (20 mg or more of statins, daily for at least two years); and Group C (100 mg of aspirin and 20 mg of statins together). The mean follow-up of patients was 45.06 months. Results: No significant differences were observed among the different groups at baseline. On multivariate analysis, statin treatment, smokers and high stage disease (T1) achieved the level of independent risk factor for the occurrence of a recurrence. When patients were stratified according to the different treatment; patients treated with statins (Group B) presented an higher rate of failure (56/91 patients; 61.5%) when compared to Group A (42/98 patients; 42.9%), Group C (56/98; 57.1%) and (133/287 patients; 46.3%). This difference corresponds to a significant difference in recurrence failure free survival (p = 0.01). Conclusions: Our results suggest that long-term treatment with aspirin in patients with NMIBC might play a role on reducing the risk of tumor recurrence. In contrast, in our investigation data from statins and combination treatment groups showed increased recurrence rates. A long-term randomized prospective study could definitively assess the possible role of this widely used drugs in NMIBC

Prospective study to compare antibiosis versus the association of N-acetylcysteine, D-mannose and morinda citrifolia fruit extract in preventing urinary tract infections in patients submitted to urodynamic investigation

BACKGROUND: The abuse of antimicrobical drugs has increased the resistance of microorganisms to treatments, thus to make urinary tract infections (UTIs) more difficult to eradicate. Among natural substances used to prevent UTI, literature has provided preliminary data of the beneficial effects of D-mannose, N-acetylcysteine, and Morinda citrifolia fruit extract, due to their complementary mechanism of action which contributes respectively to limit bacteria adhesion to the urothelium, to destroy bacterial pathogenic biofilm, and to the anti-inflammatory and analgesic activity. The purpose of this study was to compare the administration of an association of D-mannose, N-acetylcysteine (NAC) and Morinda citrifolia extract versus antibiotic therapy in the prophylaxis of UTIs potentially associated with urological mini-invasive diagnostics procedures, in clinical model of the urodynamic investigation. METHODS: 80 patients eligible for urodynamic examination, 42 men and 38 women, have been prospectively enrolled in the study and randomised in two groups (A and B) of 40 individuals. Patients of group A followed antibiotic therapy with Prulifloxacine, by mouth 400 mg/day for 5 days, while patients of the group B followed the association of mannose and NAC therapy, two vials/day for 7 days. Ten days after the urodynamic study, the patients were submitted to urine examination and urine culture. RESULTS: The follow up assessment didn't show statistical significant difference between the two groups regarding the incidence of UTI. CONCLUSIONS: The association of mannose and NAC therapy resulted similar to the antibiotic therapy in preventing UTIs in patients submitted to urodynamic examination. This result leads to consider the possible use of these nutraceutical agents as a good alternative in the prophylaxis of the UTI afterwards urological procedures in urodynamics.BACKGROUND: The abuse of antimicrobical drugs has increased the resistance of microorganisms to treatments, thus to make urinary tract infections (UTIs) more difficult to eradicate. Among natural substances used to prevent UTI, literature has provided preliminary data of the beneficial effects of D-mannose, N-acetylcysteine, and Morinda citrifolia fruit extract, due to their complementary mechanism of action which contributes respectively to limit bacteria adhesion to the urothelium, to destroy bacterial pathogenic biofilm, and to the anti-inflammatory and analgesic activity. The purpose of this study was to compare the administration of an association of D-mannose, N-acetylcysteine (NAC) and Morinda citrifolia extract versus antibiotic therapy in the prophylaxis of UTIs potentially associated with urological mini-invasive diagnostics procedures, in clinical model of the urodynamic investigation. METHODS: 80 patients eligible for urodynamic examination, 42 men and 38 women, have been prospectively enrolled in the study and randomised in two groups (A and B) of 40 individuals. Patients of group A followed antibiotic therapy with Prulifloxacine, by mouth 400 mg/day for 5 days, while patients of the group B followed the association of mannose and NAC therapy, two vials/day for 7 days. Ten days after the urodynamic study, the patients were submitted to urine examination and urine culture. RESULTS: The follow up assessment didn't show statistical significant difference between the two groups regarding the incidence of UTI. CONCLUSIONS: The association of mannose and NAC therapy resulted similar to the antibiotic therapy in preventing UTIs in patients submitted to urodynamic examination. This result leads to consider the possible use of these nutraceutical agents as a good alternative in the prophylaxis of the UTI afterwards urological procedures in urodynamics

Robot-assisted retroperitoneal lymphadenectomy in patient with type I papillary renal cancer recurrence after 5 years of follow-up

Papillary renal cell carcinoma (PRCC) is a rare cancer and is the second most frequent histologic type among all renal cell carcinoma, accounting for up to 15%. A 72-year-old man underwent a right radical nephrectomy 7 years ago with final histopathology diagnosis of type 1 PRCC with negative surgical margins. Five years after surgery, computed tomography scan imaging showed the presence of multiple masses suspicious for node recurrences disease localized in the renal lodge, in the inter-aorto-caval space, at the iliac vessels bifurcation and right common iliac vessels. Patient underwent a robotic retroperitoneal lymphadenectomy. The histopathological examination confirmed the recurrence of type I papillary renal cancer in all the specimens. No further recurrences have been observed at 24-month follow-up after surgery. This report is the first describing a robot-assisted minimally invasive surgical excision for type I papillary renal cancer nodal and renal fossa recurrences

T1 Bladder Cancer: Comparison of the Prognostic Impact of Two Substaging Systems on Disease Recurrence and Progression and Suggestion of a Novel Nomogram

Background: The T1 substaging of bladder cancer (BCa) potentially impacts disease progression. The objective of the study was to compare the prognostic accuracy of two substaging systems on the recurrence and progression of primary pathologic T1 (pT1) BCa and to test a nomogram based on pT1 substaging for predicting recurrence-free survival (RFS) and progression-free survival (PFS).Methods: The medical records of 204 patients affected by pT1 BCa were retrospectively reviewed. Substaging was defined according to the depth of lamina propria invasion in T1(a-c) and the extension of the lamina propria invasion to T1-microinvasive (T1(m)) or T1-extensive (T1(e)). Uni- and multivariable Cox regression models evaluated the independent variables correlated with recurrence and progression. The predictive accuracies of the two substaging systems were compared by Harrell's C index. Multivariate Cox regression models for the RFS and PFS were also depicted by a nomogram.Results: The 5-year RFS was 47.5% with a significant difference between T1(c) and T1(a) (p = 0.02) and between T1(e) and T1(m) (p < 0.001). The 5-year PFS was 75.9% with a significant difference between T1(c) and T1(a) (p = 0.011) and between T1(e) and T1(m) (p < 0.001). Model T1(m-e) showed a higher predictive power than T1(a-c) for predicting RFS and PFS. In the univariate and multivariate model subcategory T1e, the diameter, location, and number of tumors were confirmed as factors influencing recurrence and progression after adjusting for the other variables. The nomogram incorporating the T1(m-e) model showed a satisfactory agreement between model predictions at 5 years and actual observations.Conclusions: Substaging is significantly associated with RFS and PFS for patients affected by T1 BCa and should be included in innovative prognostic nomograms

B-TURP versus HoLEP. Peri-operative outcomes and complications in frail elderly (>75 y.o.) patients. A prospective randomized study

Background: The aim of this study was to compare the peri-operative and functional results between trans-urethral resection of the prostate (TURP) and holmium laser enucleation of the prostate (HoLEP) in the treatment of benign prostatic hyperplasia (BPH) associated with lower urinary tract symptoms (LUTS) in middle-old patients. Materials and methods: This prospective single-center study included patients over 75 years old treated with B-TURP or HoLEP for BPH associated with LUTS with prostate volume (PV) <100 mL. Primary endpoints were the intra-operative blood loss, percentage of loss of hemoglobin, blood transfusion, complications, and the comparison of functional outcomes. All patients were evaluated at 1, 3, 6, and 12 months of follow-up. Results: Overall, 96 patients undergoing HoLEP and 104 B-TURP were eligible and enrolled for the study. Post-operative results showed statistically significant differences between the two groups, all in favor of HoLEP group, specifically in terms of removed prostate tissue, PV reduction rate, hemoglobin values at 24 h, hemoglobin loss, operative time, length of hospitalization, days of catheterization, and urinary flow rates. There was no significant difference in terms of postvoid residual urine volume, perioperative complication, blood transfusion, International Prostate Symptom Score (IPSS), and IPSS quality of life scores. Conclusions: In middle-old patients, the HoLEP technique represents a prostate size-independent treatment option with a more favorable safety profile defined by less bleeding, lower blood transfusions, and a significantly lower hemoglobin drop than B-TURP

Penile metastasis from primary cholangiocarcinoma: the first case report

BACKGROUND: Metastatic penile carcinoma derived from cholangiocarcinoma (CCA) has not been previously reported in the literature. Common metastatic sites for CCA include the regional lymph nodes and adjacent organs. CCAs are not highly vascularised tumours, making hematogenous metastases uncommon. Hematogenous CCA metastases commonly occur at distant organs such as the lungs, adrenal glands, and bones. Median survival for patients with metastatic disease is generally less than 1 year. CASE PRESENTATION: A 74-year-old Caucasian man consulted us after having undergone penile ultrasonography for pain and increased thickness at the base of the penis after self-examination. The patient presented with a history of hepatitis C-related cirrhosis and intrahepatic CCA, diagnosed 3 years previously. A biopsy of the corpora cavernosa on both sides revealed a carcinoma harbouring the same histological and immunophenotypical features as the primary hepatic lesion. CONCLUSIONS: To date, there is no case of penile or urogenital system metastasis from CCA described in the literature. Therefore, this article represents the first case report of penile metastasis from CCA