Stone clearance in lower pole nephrolithiasis after extra corporeal shock wave lithotripsy – the controversy continues

BACKGROUND: To determine factors influencing the clearance of fragments after extra-corporeal shock wave lithotripsy (ESWL) for lower pole calyceal (LPC) stones. METHODS: In the period between July 1998 and Oct 2001, 100 patients with isolated lower polar calyceal calculi ≤ 20 mm, in patients aged ≥ 14 years, were included in the study. Intravenous urograms (IVU) were reviewed to define the LPC anatomy (width of the infundibulum and pelvicalyceal angle). Study end points i.e. stone free status; number of shock waves used and number of sessions were correlated with variables like LPC anatomy, body mass index and stone size. RESULTS: At three months follow up the clearance for stone size ≤ 10 mm, 11–15 mm and 16–20 mm were 95, 96 and 90% respectively. Patients with acute LPC (<90°) and obtuse angle (>90°) had stone clearance of 94 and 100% respectively. For the infundibular width of < 4 mm, the stone clearance was 93% were as for > 4 mm, it was 100%. For body mass index (BMI) less than and > 30 kg/m(2), the stone clearance was 92 and 95% respectively. CONCLUSIONS: There is a trend towards more ESWL sessions and shock wave requirement in patients with acute pelvi-calyceal angle and narrow infundibulum but it is not statistically significant. Size (≤ 20 mm) and BMI has no relation with stone clearance. With modern lithotripter, stones up to 20 mm could primarily be treated by ESWL, irrespective of an un-favorable lower polar calyceal anatomy and body habitus

Update of the ICUD-SIU consultation on upper tract urothelial carcinoma 2016: treatment of low-risk upper tract urothelial carcinoma

Introduction The conservative management of upper tract urothelial carcinoma (UTUC) has historically been offered to patients with imperative indications. The recent International Consultation on Urologic Diseases (ICUD) publication on UTUC stratified treatment allocations based on high- and low-risk groups. This report updates the conservative management of the low-risk group. Methods The ICUD for low-risk UTUC working group performed a thorough review of the literature with an assessment of the level of evidence and grade of recommendation for a variety of published studies in this disease space. We update these publications and provide a summary of that original report. Results There are no prospective randomized controlled studies to support surgical management guidelines. A risk-stratified approach based on clinical, endoscopic, and biopsy assessment allows selection of patients who could benefit from kidney-preserving procedures with oncological outcomes potentially similar to radical nephroureterectomy with bladder cuff excision, with the added benefit of renal function preservation. These treatments are aided by the development of high-definition flexible digital URS, multi-biopsies with the aid of access sheaths and other tools, and promising developments in the use of adjuvant topical therapy. Conclusions Recent developments in imaging, minimally invasive techniques, multimodality approaches, and adjuvant topical regimens and bladder cancer prevention raise the hope for improved risk stratification and may greatly improve the endoscopic treatment for low-risk UTUC

Re: indwelling ureteral stents and sexual health: a prospective multivariate analysis . MC Sighinolfi et al. J.Urol 2007, 178 229-31

We read with interest the article by Sighinolfi et al. who prospectively assessed the impact of indwelling ureteral stents on sexual function using the IIEF-5 and Female SFI. At 45 and 60 days after stent insertion 83% of men reported some grade of sexual dysfunction, and 30% of women reported no sexual activity due to stent related anxiety. In recent years there has been an increasing awareness of the need for validated tools to measure objectively the considerable morbidity associated with ureteral stenting, and to address its influence on daily activities. These tools have remained elusive. In this respect the present study significantly adds to the existing literature. Nevertheless we would like to address some issues that we believe deserve scrutiny. Although the authors recognize the robustness of the USSQ developed by Joshi et al. they failed to use it in their study. The USSQ is a validated self-administered instrument with good evaluative and discriminant properties, which explores stent related morbility in 6 areas. The questionnaire has been adopted in several clinical trials and has recently been validated by our group in Italian in a prospective cohort of 66 patients of box sexes with indwelling stents. In the USSQ sexual function for both sexes is investigated with 3 questions evaluating transient but complete sexual dysfunction , pain during intercourse and overall satisfaction for those subjects with a pre-stent active sex life. The 2 specific questionnaires on sexual dysfunction were chosen by Sighinolfi et al. for a more thorough assessment. However one has to recognize that they have not been formally validated in Italian and thus a bias may have been introduced. Moreover with the IEEF-5 the evaluation of pain during intercourse, commonly reported complaint (64% and 45% of men at 1 and 4 weeks after stent insertion, respectively in our series) remains unexplored. Finally a single multidimensional questionnaire with a separate index score for each domain such as the USSQ, would have allowed an easier and more reliable correlation between sexual dysfunction and all other symptoms. Within the same cohort used for our validation study we perform a multivariate analysis to identify predictors of stent related morbidity, including patient age, gender and BMI and stent length, size and location of distal extremity with respect to the midline has determined on abdominal X-ray. Stent distal loop crossing the midline, which was previously shown to impact symptoms negatively , proved to be an independent predictor of morbidity for all USSQ domains including sexual matters. In particular 82% and 100% of original active male and female patients with this condition, respectively reported impaired sexual function at 1 week, compared to 43%and 80% respectively with the stent not crossing the midline (p<0,01). This easily determinable parameter was not investigated by the authors

Predictors of morbidity in patients with indwelling ureteric stents: results of a prospective study using the validated Ureteric Stent Symptoms Questionnaire

OBJECTIVE: To assess the predictors of morbidity in patients with indwelling ureteric stents using a validated questionnaire. PATIENTS AND METHODS: Eighty-six consecutive patients with indwelling double-J ureteric stent of different length and size enrolled at an Italian tertiary academic centre were prospectively evaluated with the Italian-validated Ureteric Stent Symptoms Questionnaire (USSQ), which explores the stent-related symptoms in six domains. Ureteric stents were placed for benign ureteric obstruction or after uncomplicated ureterorenoscopy, and were all removed after 28 days. The questionnaire was administered on days 7 and 28 after stent placement and on day 28 after removal. A plain abdominal X-ray was performed on days 7 and 28 after placement to determine stent location. Univariable and multivariable analyses tested the association of patient age, sex and body mass index (BMI), and stent side, length, calibre and distal loop location, with the index score of the various domains on days 7 and 28. RESULTS: All patients completed the study. At multivariable analysis, on day 7, sex, BMI and stent calibre were significantly associated with one domain (general health, body pain and work performance, respectively), while location of stent distal loop was significantly associated with five domains (urinary symptoms, body pain, general health, work performanc, and sexual matters). On day 28, body mass index was significantly associated with two domains (body pain and general health), while location of stent distal loop remained significantly associated with the same five domains (urinary symptoms, body pain, general health, work performance and sexual matters). CONCLUSION: Location of stent distal loop with respect to midline had the strongest association with most domains of the USSQ on both days 7 and 28 after stent placement. The visualization of stent distal loop crossing the midline may therefore identify patients at higher risk of post-procedural morbidity requiring early management