Meta-analysis of Optimal Management of Lower Pole Stone of 10 - 20 mm: Flexible Ureteroscopy (FURS) versus Extracorporeal Shock Wave Lithotripsy (ESWL) versus Percutaneus Nephrolithotomy (PCNL)

Background: the optimal management of lower calyceal stones is still controversial, because no single method is suitable for the removal of all lower calyceal stones. Minimally invasive procedures such as extracorporeal shock wave lithotripsy (ESWL), percutaneous nephrolithotomy (PCNL) and flexible ureteroscopy (fURS) are the therapeutic methods for lower calyceal stones. The aim of this study was to identify the optimal management of 10-20 mm lower pole stones. Methods: a meta-analysis of cohort studies published before July 2016 was performed from Medline and Cochrane databases. Management of 10-20 mm lower pole stone treated by fURS, ESWL and PCNL with follow-up of residual stones in 1-3 months after procedure were include and urinary stone in other location and size were excluded. A fixed-effects model with Mantzel-Haenzel method was used to calculate the pooled Risk Ratio (RRs) and 95% Confidence Interval (CIs). We assessed the heterogeneity by calculating the I2 statistic. All analyses were performed with Review manager 5.3. Results: we analized 8 cohort studies. The stone free rate from 958 patients (271 PCNL, 174 fURS and 513 ESWL), 3 months after operation, was 90.8% (246/271) after PCNL; 75.3% (131/174) after fURS; and 64.7% (332/513) after ESWL. Base on stone free rate in 10-20 mm lower pole stone following management, PCNL is better than fURS (overall RR was 1.32 (95% CI 1.13 – 1.55); p<0.001 and I2=57%) and ESWL (overall risk ratio 1.42 (95% CI 1.30 – 1.55); p=<0.001 and I2 = 85%). But, if we compare between fURS and ESWL, fURS is better than ESWL base on stone free rate in 10-20 mm lower pole stone management with overall RR 1.16 (95% CI 1.04 – 1.30; p=0.01 and I2=40%). Conclusion: percutaneus nephrolithotomy provided a higher stone free rate than fURS and ESWL. This meta-analysis may help urologist in making decision of intervention in 10-20 mm lower pole stone management

Endoscopic incision of protruding right ureterocele in a single collecting system: a case report

Protruding ureterocele is a very rare case found in the literature. We are reporting a 21 year-old female with an intermittent protruding mass from urethra, accompanied by dysuria, hematuria, and recurrent urinary tract infection. Inspection of the external genitalia revealed a protruding mass from the urethra which could be reduced manually. Excretory urography showed bilateral single collecting systems, grade II hydronephrosis of the right kidney, and a cobra head appearance of the lower right pelvis. The patient was diagnosed with a protruding right ureterocele in a single collecting system, and thus, endoscopic incision of a ureterocele was performed. Ultrasonography which was carried out three weeks after the procedure confirmed no residual hydronephrosis or ureterocele in the bladder. Voiding cystourethrography (VCUG) underwent at a three-month-follow up revealed a grade 5 vesico-ureteral reflux (VUR) on the right side. Surgical reimplantation was then considered. In conclusion, endoscopic incision was safe and yielded good result for protruding ureteroceles, but the need for secondary surgery in several conditions should be considered

Pilihan Terapi pada Overactive Bladder Refrakter

AbstrakOveractive bladder (OAB) merupakan suatu kondisi yang berkaitan dengan gangguan proses berkemih. International Continence Society menetapkan OAB sebagai suatu gangguan berkemih yang terdiri dari gejala desakan, dengan atau tanpa inkontinensia, umumnya disertai dengan sering berkemih dan nokturia, tanpa suatu bukti infeksi atau proses patologis lainnya. Saat ini, terapi lini pertama OAB meliputi perubahan gaya hidup, terapi fisik dan/atau perilaku, pengaturan jadwal berkemih, hingga pemberian obat golongan antimuskarinik. Ada beberapa kasus OAB yang memiliki respon kurang baik terhadap terapi lini pertama. Pasien dengan OAB yang tidak menunjukkan respon positif setelah menjalani terapi lini pertama selama tiga bulan harus menjalani pemeriksaan urodinamik dan sistoskopi untuk mengevaluasi penyebab lain dari gejala berkemih yang dialami. Untuk kasus refrakter, harus dipertimbangkan penggunaan terapi lini kedua yang bersifat lebih invasif. Injeksi botulinum toxin intravesika, neuromodulasi sakral, dan sistoplasti merupakan pilihan terapi lini kedua bagi OAB yang refrakter terhadap terapi konservatif lini pertama. Ketiga terapi lini kedua tersebut cukup invasif, sehingga terapi alternatif seperti stimulasi N. Tibialis posterior, Mirabegron, serta kombinasi dual antimuskarinik dapat menjadi pilihan.Kata kunci: OAB refrakter, overactive bladder, botox, neuromodulasi, sistoplasti, mirabegron&nbsp;AbstractOveractive bladder (OAB) is a condition related to voiding dysfunction. The International Continence Society defined OAB as a urinary urgency, with or without incontinence, usually with frequent voiding and nocturia, without evidence of infection or other pathological process. At the moment, the first line therapy for OAB includes lifestyle modification, physical and/or behavioral therapy, timed voiding, and antimuscarinic drugs. There are some cases of OAB that do not respond to first line therapy. Patients who do not respond positively to first line therapy within three months should undergo urodynamic andcystoscopic examination to evaluate other causes of the voiding dysfunction. For such refractory cases, a more invasive second line therapy should be considered. Intravesical botulinum toxin injection, sacral neuromodulation, and cystoplasty are considered second line therapy for OAB refractory to conservative first line therapy. However, these therapies are considered invasive; therefore, before deciding to use them, posterior tibial nerve stimulation, Mirabegron, and dual antimuscarinic drugs can be considered as less invasive alternatives.Keywords: refractory OAB, overactive bladder, botox, neuromodulation, cystoplasty, mirabegro