Efficacy and Safety of Percutaneous Nephrolithotomy: A Single-center Initial Experience

BACKGROUND: In the age of modern medicine, thanks to the development of small-caliber nephroscope as well as various types of intracorporeal lithotripters, treatment options for renal stones have changed dramatically, and the area of percutaneous nephrolithotomy (PCNL) has expanded. Nowadays, PCNL is not only the first choice in the treatment of stones >2 cm, as well as complicated renal stones (staghorn stones, multiple stones, and stones associated with abnormal renal anatomy), but is also the method of optimal treatment for medium-sized stones not treated with other less invasive methods. AIM: The purpose of this study is to assess the efficacy and safety of PCNL as monotherapy in the treatment of renal stones larger than 15 mm. MATERIALS AND METHODS: This study presents a retrospectively prospective study of 14 (4 retrospective and 10 prospective) consecutive patients with renal stones larger than 15 mm treated with PCNL in the period from January 2020 to March 2020 at the GH “8 September” – Skopje. Pre-operative preparation of patients included: A history along with physical examination, a complete blood count and radiological examinations to assess the size of the stones, the anatomical features of the kidney and its function, and to accurately plan the operative approach. PCNL was performed in the prone-position; lithotripsy was performed with a double, pneumatic and ultrasonic intracorporeal lithotripter Swiss LithoClast Master with the use of the Karl Storz 24–26 fr nephroscope. Postoperatively, patients were monitored on the 1st, 7th, and 30th post-operative day, determining the demographic and clinical characteristics, the efficacy of PCNL, perioperative blood loss, the duration of the operative procedure, the duration of hospital stay, and the resulting intraoperative and post-operative complications. RESULTS: The study included eight men (57.1%) and six women (42.8%). The mean age of the patients was 52.35 ± 11.00. In 5 (35.71%) patients, the stones were localized in the left kidney, and in 9 (64.28%) patients in the right kidney. The average body mass index was 25.11 ± 3.92 kg/m². The average area of the stones was 371.24 ± 131.86 mm². Eleven (78.57%) patients had simplex stones, while 3 (21.42%) had complex stones (staghorn stones and multiple stones). The stones were localized in the renal pelvis, upper, middle, and lower calyx at 5 (35.71%), 2 (14.28%), 4 (28.57%), and 3 (21.42%) patients, respectively. The mean value of pre- and post-operative serum hemoglobin was 13.94 ± 1.00 g/dl and 11.77 ± 1.51 g/dl, respectively. The effectiveness of the procedure on the 1st post-operative day assessed by ultrasound diagnostics and kidney-ureter-bladder X-ray was 78.57%. The success rate on the 30th post-operative day after additional procedures was 92.85%. The average operating time in the entire series was 119.28 ± 9.42 min. The average hospital stay was 5.57 ± 1.11 days. The average operative blood loss was 2.19 ± 0.88 g/dl. CONCLUSION: The results of this retrospectively prospective study confirm that PCNL is a minimally invasive, safe, and effective method for removing renal stones. This method, with the development of new technologies, has an increasingly important role in the modern surgical treatment of nephrolithiasis. PCNL can also be performed in the early stages of the learning curve without compromising patient safety and treatment benefits. The procedure is safe and effective, performed even by less experienced urologists if the protocols established for this procedure are followed. This can achieve a rate of success comparable to most established standards without causing major complications

Treatment of Moderate-sized Kidney Stone with Third-generation Electromagnetic Shock Wave Lithotripter

BACKGROUND: The extracorporeal shock wave lithotripsy (ESWL) is a non-invasive method in the treatment of urinary tract stones and its discovery has led to a complete change in the therapeutic strategy for urolithiasis. Due to the low morbidity and excellent fragmentation of the stones, ESWL has proven to be an effective and non-invasive method in the treatment of renal stones. AIM: The aim of this retrospective study is to evaluate the efficacy and safety of the ESWL as a monotherapy in the treatment of moderate size kidney stones with stone area (SA) of 100–300 mm². MATERIALS AND METHODS: We made a retrospective study of 98 patients with moderate size kidney stones with SA of 100–300 mm², divided into two subgroups, into a group with a SA of 100–200 mm² and with 200–300 mm², treated with ESWL in the period of November 2018–December 2019. The patients were treated with a third-generation electromagnetic lithotripter (Lithoskop®, Siemens Medical Systems, Erlangen, Germany), with a source of electromagnetic shocks (Pulso™) and dual ultrasonographic/fluoroscopic system for detection of the stones. The stone location, size, maximum energy used, localization technique, number of shock waves, sessions, re-treatment rate, and additional procedures were reviewed. All the patients before the intervention had a complete laboratory and radiological examinations. Postoperatively, patients were monitored on the 1st, 30th, and 90th post-operative days. RESULTS: Ninety-eight patients with solitary kidney stone with a SA of 100–300 mm² were treated with ESWL. The study included 58 men (59.18%) and 44 women (40.81%). The average length and width of the stone were 15.47 ± 2.68 mm and 12.99 ± 2.83 mm, respectively. The average surface area of the stones in our series was 203.78 ± 72.85 mm². The mean number of treatments for the entire series of patients was 1.82 ± 0.91. The mean number of shock waves for the total series of patients was 3899.11 ± 40. The mean energy used for the overall patient series was 110106.17 ± 21489.61 mJ. The total re-treatment rate was 47.95%. The entire rate of additional procedures was 19.38%. The overall success rate (SR) in our study was 77.55%. The efficiency quotient for the upper-middle and lower calyx was 55.57, 57.15, and 30.81, respectively. CONCLUSION: ESWL is a safe and effective method in the treatment of renal stones, and we recommend as the first method in the treatment of moderate size kidney stone with a surface area of 100–300 mm². The treatment of each patient should be individualized and take into account all favored and non-favored factors that influence the decision to choose extracorporeal lithotripsy as a method of treatment of medium-sized stones

Methodology on Clinical Evaluation of Urinary Stents

In the framework of COST CA16217 “European Network of multidisciplinary research to improve the Urinary Stents (ENIUS)”, WG3 group worked on the validation of protocols for new stent designs. In this chapter, we address a methodology on clinical evaluation of urinary stents as well as the importance of clinical data and patients’ feedback regarding urinary stents. This methodology is meant to provide guidance on clinical aspects of urinary stent development, thus assisting all stakeholders in innovation and improvement of new stents designs during clinical investigation in both, pre- and post-market evaluation. In addition, as part of the methodology for urinary stents development, we were also focused to effective determination of any undesirable side effects that can appear in stented patients. That is the reason we performed analysis of all tools developed in order to obtain and deliver such information from the patients who underwent urinary stent placement and suggest a newer approach in obtaining this feedback through The Urinary Stent Related Health (UriSteRH) questionnaire

Management of acute renal colic according guidelines in general hospitalsand university hospitals

ABSTRACT Background: Renal colic is a frequent disorder with incidence of less than 1%. Guidelines are recommended as the best clinical practice , they facilitate decision-making in clinical diagnostic and therapeutic process, improve clinical practice, minimize the potential harms and reduce variations in the delivery of health care in the state. Aim is to evaluate implementation of current guidelines for renal colic in general hospitals and university hospitals Material and Methods: thirty-five urologists from eight general hospitals (GH) and sixteen urologists from two university hospitals (UH) were invited to participate in the survey. Results: Application of renal colic guidelines in (GH) was 3/21 versus 5/9 in UH. Urinalysis was performed almost equally in both GH and UH.Regarding the imaging methods, majority performX-ray urography and ultrasound in both hospitals and CT is only used in UH. According to the therapy of acute renal colic in GH as first line treatment is trospium chloride unlike in UH, where NSAIDs are prescribed in 65%. Conclusion: Administration of medicament therapy presents differences between GH and UH. Physicians in both type of hospitals need better implementation of guidelines. Keywords: renal colic, guidelines, general hospital, university hospita

Stenting or not prior to shock wave lithotripsy for upper and middle pole renal stone of 10-20mm

Objective: To evaluate the impact of routine ureteral stenting before SWL treatment for upper and middle pole stone of 10-20mm in size, on the prevention of post-SWL complications and to confirm whether this procedure affects the improvement of the success rate. Methods: Our study was retrospective study, carried out in GH “8th of September” - Skopje in the period from March 2022 to November 2022 with an analysis of the medical data of 41 patients treated with extracorporeal shock wave lithotripsy (SWL) for stones in the upper and the middle pol of 10 to 20mm in size. The first group included 13 patients treated with SWL, with a ureteral JJ stent placed before treatment, and the second group included 28 patients without a ureteral JJ stent. Patients were treated with an extracorporeal lithotripter of the third generation of electromagnetic lithotripters (Lithoskop®, Siemens Medical Systems, Erlangen, Germany). Both groups were compared in stone size, stone clearance pain, steinstrasse, UTI, lower urinary tract symptoms (LUTS), hematuria and number of SWL sessions. Results: The mean size of the stone in the group of patients with ureteral JJ stent was statistically significantly greater compared to the non-stented group (p=0.000012). The average number of sessions and re-treatment rate was significantly higher in patients with a ureteral JJ stent (p=0.006). There was a statistically significant difference in the energy used for stone disintegration in both groups (p=0.0028). Stone clearance occurred in 76.92% patients in stented group and 85.71% in non-stented group. In stented group lower urinary tract symptoms were found in 33.7 versus 0% in a non-stented group. “Steinstrasse” developed in 7.69% of the patients with JJ stent and in 7.14% patients without JJ stent. Regarding pain, lower urinary tract infections and hematuria, there was no statistically significant correlation between the two groups (p=0.84 p=0.14 p=0.17). Conclusion: Routine stenting for upper and middle pole stone of 10-20mm in size before SWL should not be recommended because it does not prevent the formation of a “stainstrasse”, does not improve the success rate and causes irritative symptoms of the lower urinary tract. Key Words: pre-stenting, stainstrasse, SWL, ureteral JJ stent

Predictability of D-dimer level on admission for hospital outcomes in hospitalized patients with Covid-19 pneumonia

The aim of this study was to evaluate the role of D-dimer as a biomarker in the assessment of COVID-19 prognosis in hospitalized patients. Material and methods: A total of 117 patients with confirmed COVID-19 pneumonia between the age of 19 and 89 years (mean age 53) were admitted to the City General Hospital 8th September, Skopje, Macedonia. In all patients, a D-dimer test for coagulation profile and lactate dehydrogenase (LDH) for disease progression were performed on the day of admission. Patient demographic data, presence of comorbidities, severe symptoms, and radiological findings were determined for each patient. We calculated the National Early Warning Score (NEWS 2) for assessment of acute illness severity. The level of oxygen saturation (SpO2) was also determined. Length of hospital stay and length of stay at home were filled later after hospitalization using medical records. Results: Patients were classified according to D-dimer level into a low group (D-dimer ≤ 2 mcg/ml) and a high group (D-dimer ≥ 2 mcg/ml). Elevated D-dimer level was associated with severity, hypoxia, and lethal outcome. Patients with a high level of D-dimer had a higher NEWS 2 score, worsen radiological findings, and higher LDH. Patients with low levels of Ddimer stayed at home longer than those with higher D-dimer levels. Conclusion: The D-dimer level is a useful marker in assessing the coagulation profile of patients with COVID-19 pneumonia regardless of the type of disease. Implementation of screening tools like the NEWS 2 score is also needed for better risk stratification on hospital admission. Keywords: D dimer, Covid-19 pneumonia, News2 scor

Arterial blood gas alterations in retroperitoneal and transperitoneal laparoscopy

Background: Due to its numerous benefits laparoscopic surgery become very popular among physicians, hospitals and patients nowadays. In the urologic pathology laparoscopy can be performed with retroperitoneal or transperitoneal approach. Insufflation of CO2 for achieving visibility in both of the approaches can be absorbed in the vessels and can lead to alterations in arterial blood gasses. Material and Method: Study population was elective urologic patients scheduled for laparoscopic surgery. Investigated arterial blood gas variables were determined in three time points: T0 before induction – basal, T1 after one hour of CO2 insufflation, and T2 at the end of the surgery. Results: Alterations in arterial blood gasses were seen in T1 and T2 for PaO2 in retroperitoneal vs transperitoneal group 173.3 ± 19 vs 196.6 ± 29 (p < 0.003) and 95.5 ± 5.4 vs 101.1 ± 8.2 (p < 0.001). The PaCO2 was also statistically significant in second observed time point T1 in retroperitoneal vs transperitoneal group 45.9 ± 4.1 vs 38.2 ± 0.3 (p < 0.002). Conclusion: The findings that we have presented can suggest that both approaches are safe although hypercarbia is observed in retroperitoneal group. Key Words: arterial blood gasses, retroperitoneal laparoscopy, transperitoneal laparoscopy, urologic laparoscopy. Corresponding author: Aleksandra Gavrilovska-Brzanov, University Clinic for Anesthesia, Reanimation and Intensive Care, Skopje, Republic of North Macedoni

Efficacy and Safety of Percutaneous Nephrolithotomy: A Single-center Initial Experience

BACKGROUND: In the age of modern medicine, thanks to the development of small-caliber nephroscope as well as various types of intracorporeal lithotripters, treatment options for renal stones have changed dramatically, and the area of percutaneous nephrolithotomy (PCNL) has expanded. Nowadays, PCNL is not only the first choice in the treatment of stones >2 cm, as well as complicated renal stones (staghorn stones, multiple stones, and stones associated with abnormal renal anatomy), but is also the method of optimal treatment for medium-sized stones not treated with other less invasive methods. AIM: The purpose of this study is to assess the efficacy and safety of PCNL as monotherapy in the treatment of renal stones larger than 15 mm. MATERIALS AND METHODS: This study presents a retrospectively prospective study of 14 (4 retrospective and 10 prospective) consecutive patients with renal stones larger than 15 mm treated with PCNL in the period from January 2020 to March 2020 at the GH “8 September” – Skopje. Pre-operative preparation of patients included: A history along with physical examination, a complete blood count and radiological examinations to assess the size of the stones, the anatomical features of the kidney and its function, and to accurately plan the operative approach. PCNL was performed in the prone-position; lithotripsy was performed with a double, pneumatic and ultrasonic intracorporeal lithotripter Swiss LithoClast Master with the use of the Karl Storz 24–26 fr nephroscope. Postoperatively, patients were monitored on the 1st, 7th, and 30th post-operative day, determining the demographic and clinical characteristics, the efficacy of PCNL, perioperative blood loss, the duration of the operative procedure, the duration of hospital stay, and the resulting intraoperative and post-operative complications. RESULTS: The study included eight men (57.1%) and six women (42.8%). The mean age of the patients was 52.35 ± 11.00. In 5 (35.71%) patients, the stones were localized in the left kidney, and in 9 (64.28%) patients in the right kidney. The average body mass index was 25.11 ± 3.92 kg/m². The average area of the stones was 371.24 ± 131.86 mm². Eleven (78.57%) patients had simplex stones, while 3 (21.42%) had complex stones (staghorn stones and multiple stones). The stones were localized in the renal pelvis, upper, middle, and lower calyx at 5 (35.71%), 2 (14.28%), 4 (28.57%), and 3 (21.42%) patients, respectively. The mean value of pre- and post-operative serum hemoglobin was 13.94 ± 1.00 g/dl and 11.77 ± 1.51 g/dl, respectively. The effectiveness of the procedure on the 1st post-operative day assessed by ultrasound diagnostics and kidney-ureter-bladder X-ray was 78.57%. The success rate on the 30th postoperative day after additional procedures was 92.85%. The average operating time in the entire series was 119.28 ± 9.42 min. The average hospital stay was 5.57 ± 1.11 days. The average operative blood loss was 2.19 ± 0.88 g/dl. CONCLUSION: The results of this retrospectively prospective study confirm that PCNL is a minimally invasive, safe, and effective method for removing renal stones. This method, with the development of new technologies, has an increasingly important role in the modern surgical treatment of nephrolithiasis. PCNL can also be performed in the early stages of the learning curve without compromising patient safety and treatment benefits. The procedure is safe and effective, performed even by less experienced urologists if the protocols established for this procedure are followed. This can achieve a rate of success comparable to most established standards without causing major complications

Comparative Proteomics Analysis of Urine Reveals Down-Regulation of Acute Phase Response Signaling and LXR/RXR Activation Pathways in Prostate Cancer

Detecting prostate cancer (PCa) using non-invasive diagnostic markers still remains a challenge. The aim of this study was the identification of urine proteins that are sufficiently sensitive and specific to detect PCa in the early stages. Comparative proteomics profiling of urine from patients with PCa, benign prostate hyperplasia, bladder cancer, and renal cancer, coupled with bioinformatics analysis, were performed. Statistically significant difference in abundance showed 20 and 85 proteins in the 2-D DIGE/MS and label-free LC-MS/MS experiments, respectively. In silico analysis indicated activation, binding, and cell movement of subset of immune cells as the top affected cellular functions in PCa, together with the down-regulation of Acute Phase Response Signaling and Liver X Receptor/ Retinoid X Receptor (LXR/RXR) activation pathways. The most promising biomarkers were 35, altered in PCa when compared to more than one group. Half of these have confirmed localization in normal or PCa tissues. Twenty proteins (CD14, AHSG, ENO1, ANXA1, CLU, COL6A1, C3, FGA, FGG, HPX, PTGDS, S100A9, LMAN2, ITIH4, ACTA2, GRN, HBB, PEBP1, CTSB, SPP1) are oncogenes, tumor suppressors, and multifunctional proteins with highly confirmed involvement in PCa, while 9 (AZU1, IGHG1, RNASE2, PZP, REG1A, AMY1A, AMY2A, ACTG2, COL18A1) have been associated with different cancers, but not with PCa so far, and may represent novel findings. LC-MS/MS data are available via ProteomeXchange with identifier PXD008407