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The purpose of our study was to evaluate the ability of ureteral stents with different diameters to drain pus that accumulates in an obstructed kidney using an in vitro model.We developed an in vitro model of an obstructed kidney filled with pus. The model included a silicon kidney unit based on computed tomography (CT) data, a 3D printed ureteral stone based on a real extracted ureteral stone, a latex ureter model, a bladder vessel, and a fluid with qualities resembling pus. Identical printed stones were inserted into four ureter models containing stents with varying diameters (4.8F, 6F, 7F, 8F), each of which was connected to the kidney unit and the bladder vessel. The kidney unit was filled with artificial pus to pressures of 30 cmHThe rate of pressure drop and the final pressure measured in the kidney were unaffected by the diameter of the stent. For all stent diameters, the pressure reached non-obstructed levels within 30 s, final pressure was reached within 90-120 s, and minimal amounts of pus remained in the kidney after 120 min.In vitro experiments demonstrate that all stent diameters drain pus-filled, obstructed kidneys with the same efficacy. The common perception that larger diameter tubes are more effective under such circumstances should be re-examined.

Background and Purpose: Drainage of obstructed kidney due to extrinsic ureteral obstruction (EUO), required to prevent renal damage, is often achieved using double-J ureteral stents. But these stents fail frequently, and there is considerable debate regarding what stent size, type and configuration offer the best option for sustained drainage. Here, we examine the impact of stent diameter and choice of single/tandem configuration, subject to EUO and various degrees of stent occlusion, on stent failure. Methods: Computational fluid dynamics (CFD) simulations and an in vitro ureter-stent experiment enabled quantification of flow behavior in stented ureters subject to EUO and stent occlusions. Various single and tandem stents under EUO were considered. In each simulation and experiment, changes in renal pressure were monitored for different degrees of stent lumen occlusion, and onset of stent failure as well as simulated distributions of fluid flow between stent and ureter lumina were determined. Results: For an encircling EUO that completely obstructs the ureter lumen, with or without partial stent occlusion, the choice of stent size/configuration has little effect on renal pressure. The pressure increases significantly for ~90% stent lumen occlusion, with failure at >95% occlusion, independent of stent diameter or a tandem configuration, and with little influence of occlusion length along the stent. Conclusions: Stent failure rate is independent of stent diameter or single/tandem configuration, for the same percentage of stent lumen occlusion, in this model. Stent failure incidence may decrease for larger diameter stents and tandem configurations, because of the larger luminal area.

Urolithiasis is a frequent disease with cited rates of recurrence after initial diagnosis that vary widely and range between 35% and 50%. We assessed the radiographic recurrence rate in patients with urinary stones and its risk factors. We retrospectively identified patients who were diagnosed with urinary stones on non-contrast computed tomography from 2010 to 2011, and underwent another imaging examination at least six months afterwards. We collected patient demographic, clinical, laboratory and radiologic data and compared patients with and without urinary stone recurrence. Ultimately, 237 patients were included in the study; the mean follow-up was 6.7 years; 88 patients (37.1%) had recurrence based on our recurrence criteria. On univariate analysis, the significant parameters for recurrence were baseline serum calcium and uric acid, stone location in the kidney, surgical intervention and stone burden volume. On multivariate analysis, surgical intervention (OR 3.07, p = 0.001), baseline calcium (OR 2.56, p = 0.011), baseline uric acid (OR 1.30, p = 0.021) and stone location in the kidney (OR 2.16, p = 0.012) were associated with higher risk of recurrence. These findings may guide personalized follow-up protocols for patients with urolithiasis based on their risk factors.

Most patients with ureterolithiasis are managed successfully with conservative treatment. In this context, delineation of clinical risk factors that identify patients with low risk for surgical intervention may reduce use of Non-Contrast Computed Tomography (NCCT). Here, emergency department patient files from a 14-month period were reviewed retrospectively, to identify patients who underwent NCCT and showed a ureteral stone. Demographic, clinical and laboratory information was collected. Patients were grouped to either requiring surgical intervention (Group 1) or having successful conservative management (Group 2). The cohort included 368 patients; 36.1% ultimately required surgical intervention (Group 1) and 63.9% were successfully treated conservatively (Group 2). On univariate analysis, patients who required surgical intervention were older, had longer duration of symptoms, had history of urolithiasis and surgical intervention for urolithiasis and had higher serum creatinine levels. Multivariate analysis identified the following risk factors associated with surgical intervention: creatinine >1.5 mg/dL, duration of symptoms ≥ 1.5 days and age > 45 years. Patients with 0, 1, 2 or 3 of the identified risk factors had 19%, 32%, 53% and 73% likelihood, respectively, of surgical intervention. Incorporating these data may reduce the use of NCCT scans in patients who are likely to pass a stone via conservative management.

BACKGROUND: Urologic guidelines recommend perioperative instillation of chemotherapy after transurethral resection of bladder tumor (TURBT) to decrease tumor recurrence, yet implementation of this recommendation is partial due to associated morbidity. Hypertonic saline destroys cells by osmotic dehydration and might present a safer alternative. OBJECTIVE: To evaluate the safety of 3% hypertonic saline (Hypersal) intravesical instillation following TURBT in rats and in humans. METHODS: In 8 rats whose bladders were electrically injured, intravesical blue-dyed Hypersal was administered. We measured serum sodium levels before and after instillation and pathologically evaluated their pelvic cavity for signs of inflammation or blue discoloration. Twenty-four patients were recruited to the human trial (NIH-NCT04147182), 15 comprised the interventional and 10 the control group (one patient crossed over). Hypersal was given postoperatively. Serum sodium was measured before, 1 hour and 12–24 hours after instillation. Adverse effects were documented and compared between the groups. RESULTS: In rats, average sodium levels were 140.0 mEq/L and 140.3 mEq/L before and following instillation, respectively. Necropsy revealed no signs of inflammation or blue discoloration. In humans the average plasma sodium levels were 138.6 mEq∖L, 138.8 mEq∖L and 137.7 mEq∖L before, 1 hour and 12–24 hours after instillation, respectively. During the postoperative follow-up there was one case of fever. A month after the surgery, dysuria was reported by 5 patients while urgency and hematuria were reported by one patient each. The most severe adverse events were grade 2 on the Clavien-Dindo scale. Adverse events were similar in the control group. CONCLUSIONS: Hypersal instillation is safe and tolerable immediately after TURBT.

To quantify the occurrence of stent failure and the dynamic behavior of urine flow in ureter-stent systems, including the relative flow in the ureter and stent lumina, subject to various degrees of ureter and stent blockage. Numerical simulations based on computational fluid dynamics (CFD) were used to quantify urine flow behavior in stented ureters, in the presence of extrinsic ureteral obstruction (EUO) and stent occlusions. Two stented ureter configurations were considered, one with circumferential occlusion of the ureter and the second with pressure on one side of the ureter wall. The pressure within the renal unit for different degrees of ureter closure and stent lumen occlusion was determined systematically. Onset of stent failure and the distribution of urine flow between stent and ureter lumina were determined. In the case of EUO completely encircling the ureter, causing 100% obstruction of the ureter lumen, pressure in the renal unit is essentially unaffected until the stent lumen reaches ~ 90% occlusion, and fails only with > 95% occlusion. Occlusions of 50% in stent side holes in the vicinity of the EUO only alter local flow patterns but have no significant influence on renal unit pressure. For EUO deforming and compressing the ureter from one side, with ~ 50% reduction in ureter lumen, urine drainage proceeds with negligible increase in renal pressure even with 100% occlusion in the stent lumen. CFD simulations show that stent failure under EUO tends to occur suddenly, only when both ureter and stent lumina become almost fully blocked.

Tal Amitay-Rosen,1 Ishai Dror,2 Yaniv Shilo,3 Brian Berkowitz2 1Department of Physical Chemistry, Institute for Biological Research, Ness-Ziona, 7410001, Israel; 2Department of Earth and Planetary Sciences, Weizmann Institute of Science, Rehovot, 7610001, Israel; 3Department of Urology, Kaplan Medical Center, Affiliated with the Hebrew University of Jerusalem, Rehovot, 7661041, IsraelCorrespondence: Brian Berkowitz, Department of Earth and Planetary Sciences, Weizmann Institute of Science, Rehovot, 7610001, Israel, Tel +972-8-9342098, Fax +972-8-9344124, Email brian.berkowitz@weizmann.ac.ilIntroduction: Ureteral stents are effective in alleviating flow disruptions in the urinary tract, whether due to ureteral stones, strictures or extrinsic ureteral obstruction. However, significant stent encrustation on the external and/or internal stent lumen walls can occur, which may interfere with stent functioning and/or removal. Currently, there is only limited, generally qualitative, information on the distribution, mineral structure, and chemical content of these deposits, particularly in terms of stent lumen encrustation.Objective: To quantify, in an initial investigation, external and internal encrustation in representative, intact ureteral stents. The study investigates possible correlations between patterns of external and internal encrustation, determines mineral structure and chemical composition, and examines the potential for stent lumen obstruction even in the absence of external stent wall encrustation.Study Design: High-resolution, laboratory micro-computed tomography (micro-CT) was used to non-destructively image external and internal stent encrustation in four representative stents. X-ray diffractometry (XRD) and scanning electron microscopy–energy dispersive x-ray spectroscopy (SEM-EDS) enabled parallel analysis of mineral structure and chemical content of samples collected from external and internal encrusted material along the distal, proximal and mid-ureteral stent regions.Results: Extensive stent lumen encrustation can occur within any region of a stent, with only incidental or minor external encrustation, along the entire length of the stent. External and internal encrusted materials in a given stent are generally similar, consisting of a combination of amorphous (mostly organic) and crystalline mineral deposits.Conclusion: Micro-CT demonstrates that significant stent lumen encrustation can occur, which can lead to partial or full stent lumen occlusion, even when the exterior stent wall is essentially free of encrusted material.Keywords: micro-computed tomography, stent deposition, mineral composition, obstruction, stent lumen

Background and Purpose: Drainage of an obstructed kidney due to extrinsic ureteral obstruction (EUO) is imperative. Ureteral stents, commonly employed to facilitate drainage, often fail under EUO; ...

Background and Purpose: Extrinsic ureteral obstruction is caused frequently by pelvic malignancies or metastatic lymphadenopathy, necessitating renal drainage with ureteral stents to prevent renal ...

To quantify the relative volumetric flows in stent and ureter lumina, as a function of stent size and configuration, in both unobstructed and externally obstructed stented ureters.Magnetic resonance imaging was used to measure flow in stented ureters using a phantom kidney model. Volumetric flow in the stent and ureter lumina were determined along the stented ureters, for each of four single stent sizes (4.8F, 6F, 7F, and 8F), and for tandem (6F and 7F) configurations. Measurements were made in the presence of a fully encircling extrinsic ureteral obstruction as well as in benchmark cases with no extrinsic ureteral obstruction.Under no obstruction, the relative contribution of urine flow in single stents is 1-10%, while the relative contributions to flow are ~6 and ~28% for tandem 6F and 7F, respectively. In the presence of an extrinsic ureteral obstruction and single stents, all urine passes within the stent lumen near the extrinsic ureteral obstruction. For tandem 6F and 7F stents under extrinsic ureteral obstruction, relative volumetric flows in the two stent lumina are ~73% and ~81%, respectively, with the remainder passing through the ureter lumen.Magnetic resonance imaging demonstrates that with no extrinsic ureteral obstruction, minimal urine flow occurs within a stent. Stent lumen flow is significant in the presence of extrinsic ureteral obstruction, in the vicinity of the extrinsic ureteral obstruction. For tandem stents subjected to extrinsic ureteral obstruction, urine flow also occurs in the ureter lumen between the stents, which can reduce the likelihood of kidney failure even in the case of both stent lumina being occluded.

Patients with high-risk prostate cancer are at higher risk of treatment failure, development of metastatic disease, and mortality. There is no consensus on the treatment of choice for these patients, and either radical prostatectomy (RP) or external beam radiation therapy (EBRT) is recommended. Surgery is less common as the initial treatment for high-risk patients, possibly reflecting the concerns regarding morbidity as well as oncological and functional outcomes. Another high-risk group includes patients with failure of previous EBRT or focal treatment. For these patients, salvage radical prostatectomy (SRP) can be offered.To describe our experience with surgery of high-risk patients and SRP.This cohort included all high-risk patients undergoing RP or SRP at our institution between January 2012 and December 2019. We reviewed the electronic medical charts and collected pathological, functional, and oncological outcomes.Our cohort included 39 patients; average age was 67.8 years, and average follow-up duration was 40.9 months. The most common postoperative morbidity was transfusion of packed cells. There were no life-threatening events or postoperative mortality. Continence was preserved (zero to one pad) in 76% of the patients. Twenty-three patients (59%) had undetectable prostate specific antigen levels following the surgery, 11 (30%) were treated with either adjuvant or salvage EBRT, and 12 patients (31%) were found with no evidence of disease and no additional treatment was needed.Radical prostatectomy and SRP are safe options for patients presenting with high-risk prostate cancer, with good functional and oncological outcomes.

Radical cystectomy is a complicated surgery with significant risks. Complications of Clavien-Dindo grade 3-4 range from 25% to 40% while risk of mortality is 2%. Pelvic surgery or radiotherapy prior to radical cystectomy increases the challenges of this surgery.To assess whether radical cystectomy performed in patients with prior history of pelvic surgery or radiation was associated with increased frequency of Clavien-Dindo grade 3 or higher complications compared to patients without prior pelvic intervention.We retrospectively evaluated all patients who underwent radical cystectomy at our center over a 7-year period. All patients with pelvic radiation or surgery prior to radical cystectomy comprised group 1, while group 2 included the remaining patients.In our study, 65 patients required radical cystectomy at our institution during the study period. Group 1 was comprised of 17 patients and group 2 included 48 patients. Four patients from group 2 received orthotopic neobladder, while an ileal conduit procedure was performed in the remaining patients. Estimated blood loss and the amount of blood transfusions given was the only variable found to be statistically different between the two groups. One patient from group 1 had four pelvic interventions prior to surgery, and her cystectomy was aborted.Radical cystectomy may be safely performed in patients with a history of pelvic radiotherapy or surgery, with complication rates similar to those of non-irradiated or operated pelvises.

Background To compare the efficacy of different ureteral stents subject to extrinsic ureteral obstruction (EUO), in a controlled in vitro stented ureter experiment. Methods We employ an in vitro ureter-stent experimental set-up, with latex tubing simulating flexible ureters attached to vessels simulating renal units and bladders. The flow behavior of five ureteral stents—polymeric 8F, tandem 6F, tandem 7F, endopyelotomy and metal—was tested under a ureteral deformation configuration of 40°, with 2000 g external force over a 3.5 cm length of the ureter. A constant fluid flow was applied through the ureter-stent configurations, and pressure fluctuations in the renal unit were monitored. We considered a renal unit pressure of 10 cmH2O or flow discontinuation in the bladder as stent failure. Urine containing debris was mimicked by use of a colloidal solution. Results Of all assessed ureteral stents, under EUO conditions, only the single 8F stents remained patent throughout the length of the experiment. All other stents—tandem 6F and 7F, single 7F, metal and endopyelotomy—displayed limitations. Conclusions Tandem and metal stents show no superiority over large luminal polymeric stents for EUO treatment in this in vitro model. Larger luminal stents offer excellent resistance to external pressure and allow adequate colloidal flow. The need for frequent exchange and bladder irritation should also be considered in the choice of stent configuration for treatment of kidney drainage under EUO.

Introduction and Objective: Eighty percent of patients with distal ureteral stones

Background and Purpose: Ureteral injuries such as avulsion are directly related to mechanical damage of the ureter. Understanding the tensile strength of this tissue may assist in prevention of iatrogenic injuries. Few published studies have looked at the mechanical properties of the animal ureter and, of those, none has determined the tensile strength of the human ureter. Therefore, the purpose of this work was to determine the tensile strength of the human ureter. Methods: We harvested 11 human proximal ureters from patients who were undergoing nephrectomy for either kidney tumors or nonfunctioning kidney. The specimens were then cut into multiple circumferentially and longitudinally oriented tissue strips for tensile testing. Strips were uniaxially stretched to failure in a tensile testing machine. The corresponding force and displacement were recorded. Finally, stress at failure was noted as the tensile strength of the sample. Circumferential tensile strength was also compared in the proximal...

To assess the efficacy of dietary management for the treatment of idiopathic hyperoxaluria in a large tertiary care center and examine the influence of patient factors, compliance, and follow-up on oxalate reduction, which has not been previously investigated.Retrospectively, 149 patients with kidney stones with idiopathic hyperoxaluria who received dietary management at our stone clinic were evaluated. Changes in urinary parameters on 24-hour urine collections were calculated for all patients and those with abnormal values in the overall short-term (30-240 days) and long-term (240 days) time periods. Changes in urinary oxalate were evaluated with respect to patient characteristics and compliance measures.Urine oxalate and supersaturation of calcium oxalate were significantly (P.001) reduced by 8.9 ± 19.2 mg/d and 1.7 ± 4.3, respectively. A total of 48.3% of the patients reduced their urinary oxalate to normal. Urine oxalate reductions were similar in the short-term and long-term periods. Women lowered urine oxalate nearly twice as much as men (12.7 ± 2.0 mg/d vs 6.7 ± 2.2 mg/d, P = .022) and body mass index (BMI) negatively correlated with oxalate reduction (Pearson's r = -0.213). Reported noncompliance and keeping follow-up appointments did not affect oxalate, however, there was a significant correlation between increasing urine volume and reducing oxalate (Pearson's r = -0.21).This study confirms that meaningful reductions of urine oxalate and supersaturation of calcium oxalate can be achieved with dietary management of hyperoxaluria on a larger clinical scale. Furthermore, we identified that women and patients with low BMIs had greater urine oxalate reductions and urine volume may also be used by clinicians as a measure of dietary compliance.

We compared symptoms in women with detrusor overactivity with impaired contractility and women with detrusor overactivity who had preserved contractility.The study included 359 consecutive women with detrusor overactivity who underwent multichannel urodynamics at our department between 2009 and 2011. The women were divided into 2 groups, including 151 (42%) with detrusor overactivity and impaired contractility, and 208 (58%) with detrusor overactivity and preserved contractility. We compared the 2 groups.Women with detrusor overactivity and impaired contractility were older (mean ± SD age 73.2 ± 17.3 vs 54.1 ± 20.7 years) with a higher frequency of diabetes mellitus (49% vs 31%, each p0.001). The prevalence of previous urinary retention and recurrent cystitis was significantly higher in women with impaired contractility (7% vs 1%, p0.01 and 22% vs 7%, p0.001, respectively). Mean post-void residual urine was greater in the group with impaired contractility (89 ± 42 vs 21 ± 18 ml) and the mean maximal flow rate was lower (11 ± 6 vs 23 ± 5 ml per second, each p0.001). The frequency of storage symptoms was similar in the 2 groups. However, voiding symptoms were more common in women with impaired contractility, including a slow stream in 69% vs 42%, an intermittent stream in 72% vs 26%, hesitancy in 35% vs 22%, straining in 84% vs 26%, terminal dribbling in 73% vs 42% and incomplete emptying in 71% vs 49% (p0.001).Women with detrusor overactivity and impaired contractility are older than women with detrusor overactivity and preserved detrusor contractility. Urinary retention and recurrent cystitis are more frequent in women with detrusor overactivity and impaired contractility, and voiding symptoms are significantly more common.

Objectives To determine the proportion of benign testicular lesions among candidates for testicular sparing surgery (TSS) and to assess the safety and efficacy of this procedure. Methods and Materials Sixteen patients underwent surgical exploration for testicular tumors with TSS intent in our center. Surgery was performed via an inguinal approach with temporary cord occlusion and frozen section (FS) analysis of the lesions. Benign findings allowed for TSS, whereas cancer prompted total orchiectomy. Results The lesions measured 8–25 mm in the largest diameter. Eleven of the 16 lesions were benign (69%) and TSS was accomplished in these cases. Complete concordance was observed between the results of FS and permanent sections. Of the 5 patients with cancer, 3 had pure seminoma, and embryonal carcinoma and teratoma were found in 1 patient, each. Surveillance was applied in 4 of these patients, and chemotherapy was used in the patient with embryonal carcinoma. With an average follow-up duration of 48 months, all are alive and free of disease. All 11 patients in whom TSS was accomplished had an uneventful postoperative course, and with an average follow-up duration of 28 months, 9 have normal scrotal physical examination and ultrasound, whereas 2 patients were lost to follow-up. Conclusions Sixty-nine percent of testicular lesions under 25 mm are benign. TSS is safe and effective in patients with small benign lesions. Cancer is reliably detected by FS, and testicular exploration is not associated with local or distant recurrence in any of our patients.

Objectives To define the rate of positive surgical margins (PSMs) and analyze the outcome of patients with PSMs. The outcome and proper management of patients with positive PSMs during nephron sparing surgery (NSS) are questionable. In this study we define the clinical outcomes of PSMs at NSS and suggest management. Methods Clinical records of 114 renal units who underwent open NSS for a renal mass between May 1995 and September 2005 were reviewed. Results PSMs were suspected on frozen section in 17 of 114 renal units (15%). Tumors with suspected PSMs at frozen section were smaller (2.9 ± 1.6) in comparison to those with negative surgical margins (3.4 ± 1.8 cm) (P = .001). Nine of 17 (53%) cases underwent total nephrectomy (5 immediately, 4 delayed). In 4 (24%), immediate re-excision of the renal crater was performed. A total of 4 (24%) that were followed up clinically were with no evidence of disease. Therefore, in 13 of 17 (77%) cases, the presence of tumor cells at the remaining side of the kidney could be evaluated histologically. In 2 cases from the immediate response group, tumor cells were found in the side opposite to the resection. There was no residual tumor in any case subjected to delayed nephrectomy. At median follow-up of 71 months, 15 of 17 patients are alive and with no evidence of disease. Two patients died because of unrelated causes. The overall 5-year survival rate is 98.2% and there is no cancer-specific mortality. Conclusions The true PSM rate is in the range of 1.75%-5.26%. No disease progression or deaths attributable to renal cell carcinoma were associated with PSMs. Total nephrectomy should be avoided as a response to PSMs.

Objectives To determine the effect of prostate volume on the diagnostic yield of prostate biopsies. Materials and methods 155 consecutive patients underwent 12-core transrectal ultrasound guided needle biopsies. Data were collected prospectively on age, serum PSA, digital rectal examination (DRE), previous prostate biopsies, prostate volume and pathologic result. Univariate and multivariate logistic regressions were undertaken to determine the effect of prostate volume on the risk for a positive biopsy. Results 45 patients (29%) were diagnosed with cancer. The median patient age was 63 (range 48–82) years, the median PSA level was 6.7 ng/ml (0.5–156 ng/ml), and the median prostate volume was 57 ml (16–273 ml). 42 patients (27%) had an abnormal DRE and 51 (33%) had undergone previous prostate biopsies. Positive biopsy rates were 39%, 33%, and 14% for prostate volume below 46 ml, between 45 and 73 ml, and above 72 ml, respectively. Univariate analysis showed that age, serum PSA, DRE and prostate volume were all associated with a positive biopsy. Multivariate analysis adjusted for age, PSA and DRE showed a significant risk increase for a positive biopsy in smaller prostates. (OR = 5.6 95% CI 1.75–17.89; and 8.86 95% CI 2.72–28.82, for prostate volume between 45 and 72 ml and below 45 ml, respectively). Conclusion The diagnostic yield of prostate biopsies is significantly lower in large prostates. As the result the standard 12-core biopsy may be insufficient for the diagnosis of cancer in large prostates.

Ureteral injuries such as avulsion are directly related to mechanical damage of the ureter. Understanding the tensile strength of this tissue may assist in prevention of iatrogenic injuries. Few published studies have looked at the mechanical properties of the animal ureter and, of those, none has determined the tensile strength of the human ureter. Therefore, the purpose of this work was to determine the tensile strength of the human ureter.We harvested 11 human proximal ureters from patients who were undergoing nephrectomy for either kidney tumors or nonfunctioning kidney. The specimens were then cut into multiple circumferentially and longitudinally oriented tissue strips for tensile testing. Strips were uniaxially stretched to failure in a tensile testing machine. The corresponding force and displacement were recorded. Finally, stress at failure was noted as the tensile strength of the sample. Circumferential tensile strength was also compared in the proximal and distal regions of the specimens.The tensile strength of the ureter in circumferential and longitudinal orientations was found to be 457.52±33.74 Ncm(-2) and 902.43±122.08 Ncm(-2), respectively (P0.001). The circumferential strength in the proximal portion of the ureter was 409.89±35.13 Ncm(-2) in comparison with 502.89±55.85 Ncm(-2) in the distal portion (P=0.08).The circumferential tensile strength of the ureter was found to be significantly lower than the longitudinal strength. Circumferential tensile strength was also lower with more proximal parts of the ureter. This information may be important for the design of "intelligent" devices and simulators to prevent complications.

INTRODUCTION AND OBJECTIVES: Previous studies investigating urinary stone risk after colon surgery have demonstrated significant reductions in urinary pH, volume, citrate, and magnesium that correspond to an increased incidence of kidney stones. These studies, however, have consistently included patients with inflammatory bowel disease (IBD) which may bias their findings due to known urinary abnormalities present prior to surgery and differences in length of bowel removed compared to other types of colon surgery. This study aims to evaluate urinary stone risk after colon surgery in patients with and without IBD. METHODS: Retrospectively, baseline 24-hour urine samples of 21 kidney stone patients with a history of colon resections were evaluated from a data set of over 800 patients. Urinary chemistries of those who required colon surgery for IBD (9 patients) and non-IBD reasons (12 patients) were compared to each other and a control of 52 first-time stone formers without bowel disease. RESULTS: The IBD colectomy group had a significantly lower urinary pH (5.55 vs 6.08, P1⁄40.003), magnesium (41.8mg/d vs 103.7mg/d, P1⁄40.0002), citrate (109.8mg/d vs 230.4mg/d, P1⁄40.0001), sodium (95.2mmol/d vs 177.9mmol/d, P1⁄40.013), and calcium (109.8mg/d vs 230mg/d, P1⁄40.01) than the control. The non-IBD colectomy group had lower pH (5.69 vs 6.09, P1⁄40.015) and higher supersaturation of uric acid (1.62 vs 0.87, P1⁄40.015) compared to the control. The IBD colectomy group revealed a lower magnesium (P1⁄40.04), citrate (P1⁄40.007), and sodium (P1⁄40.045) than the non-IBD colectomy group. 66% of the colectomies in the IBD group were total while 100% of the colectomies in the non-IBD group were partial. CONCLUSIONS: The urinary stone risk of colectomy patients with IBD is significantly different from colectomy patients without IBD and is more reflective of abnormalities present in IBD patients prior to surgery such as low citrate, magnesium, and urinary pH. It is likely the IBD patients biased the findings of previous studies investigating the urinary stone risk after colon surgery. Patients who underwent colon surgery for non-IBD reasons, however, have few urinary abnormalities and a urinary risk more similar to first-time stone formers. The difference in urinary risk of colectomy patients with and without IBD may be explained by the intrinsic stone risk present in IBD and the differences in length of bowel removed.

Recommendations for active surveillance versus immediate treatment for low risk prostate cancer are based on biopsy and clinical data, assuming that a low volume of well-differentiated carcinoma will be associated with a low progression risk. However, the accuracy of clinical prediction of minimal prostate cancer (MPC) is unclear.To define preoperative predictors for MPC in prostatectomy specimens and to examine the accuracy of such prediction.Data collected on 1526 consecutive radical prostatectomy patients operated in a single center between 2003 and 2008 included: age, body mass index, preoperative prostate-specific antigen level, biopsy Gleason score, clinical stage, percentage of positive biopsy cores, and maximal core length (MCL) involvement. MPC was defined as5% of prostate volume involvement with organ-confined Gleason scoreor = 6. Univariate and multivariate logistic regression analyses were used to define independent predictors of minimal disease. Classification and Regression Tree (CART) analysis was used to define cutoff values for the predictors and measure the accuracy of prediction.MPC was found in 241 patients (15.8%). Clinical stage, biopsy Gleason's score, percent of positive biopsy cores, and maximal involved core length were associated with minimal disease (OR 0.42, 0.1, 0.92, and 0.9, respectively). Independent predictors of MPC included: biopsy Gleason score, percent of positive cores and MCL (OR 0.21, 095 and 0.95, respectively). CART showed that when the MCL exceeded 11.5%, the likelihood of MPC was 3.8%. Conversely, when applying the most favorable preoperative conditions (Gleasonor = 6,20% positive cores, MCLor = 11.5%) the chance of minimal disease was 41%.Biopsy Gleason score, the percent of positive cores and MCL are independently associated with MPC. While preoperative prediction of significant prostate cancer was accurate, clinical prediction of MPC was incorrect 59% of the time. Caution is necessary when implementing clinical data as selection criteria for active surveillance.

INTRODUCTION AND OBJECTIVES: Kidney stone clinics evaluate and manage metabolic risk factors such as hyperoxaluria with the purpose of preventing kidney stone recurrence. While dietary modification has been shown to reduce urine oxalate in controlled studies, a question remains of whether results can be reproduced in actual clinical practice, taking into account patient noncompliance and quality of care. This study also ascertains whether certain patient characteristics independently affect a patient’s ability to decrease urine oxalate. METHODS: Retrospectively, 267 kidney stone patients from 2005 to 2011 with urine oxalate values greater than 40 mg/d on 24-hour urine sampling were evaluated. Chart reviews for each patient included recording patient characteristics, dietary modification counseling, noncompliance, failure to keep appointments, and the change in urine oxalate values. Enteric and primary hyperoxalurics were excluded. RESULTS: Overall, hyperoxaluric patients had a significant decrease in urine oxalate of 8.94 mg/d (5.8 to 12.0). 48.1% of patients were able to decrease their urine oxalate to below 40mg/d, the upper threshold of normal. From the patient characteristics we found females were able to significantly reduce urine oxalate compared to males (12.6 mg/d vs 6.55 mg/d, p 0.012), BMI negatively correlated with delta oxalate (Pearson’s r -0.213, p 0.01), and having a previous kidney stone appeared to limit a patient’s delta oxalate (7.61 mg/d vs 15.1 mg/d, p 0.052). Of the 267 patients only 59% completed a second 24 hour urine sample, 27.4% of patients did not keep a follow-up appointment at some point during their treatment, and 10% were noted as being noncompliant. There was no clear effect of these compliance measures on delta oxalate. Change in urine volume, however, did negatively correlate significantly with delta oxalate (Pearson’s r -0.210, p 0.01). CONCLUSIONS: Overall, patients who were seen in the outpatient kidney stone clinic who were treated with dietary management had a significant reduction in urine oxalate and almost half were able to reduce their oxalate to below the upper threshold of normal. Females and patients with a lower BMI are able to reduce urine oxalate better. There appears to be a trend towards reduced urine oxalate reduction if a patient has a previous stone history. Patient compliance and follow-up remains a significant challenge, however the only compliance measure that correlated with a greater oxalate reduction was increasing urine volume.

Hemorrhagic radiation cystitis (HRC) is a significant clinical problem that occurs after pelvic radiation therapy and is often refractory.To evaluate the efficacy and safety of hyperbaric oxygen therapy (HBO) for HRC.Daily 90 minute sessions of HBO at 2 ATM 100% oxygen were given to 32 HRC patients with ASTRO grades 3-4 hematuria.The median age was 72.5 (48-88 years). The median time interval between radiation therapy and HBO was 4 years (1-26 years). The patients received a median of 30 HBO sessions (3-53). Hematuria resolved in 27 patients (84%) and persisted in 5. Cystectomy was required in two, and ileal-conduit and bilateral percutaneous nephrostomies were performed in one and two patients, respectively. With a median follow-up of 12 months (5-74 months), the hematuria cleared completely in 16 patients (59%) and mild hematuria requiring no further treatment recurred in 10 others. Another patient with ASTRO grade 4 hematuria needed bladder irrigation and blood transfusions. Complications included eardrum perforation in four patients and transient vertigo and mild hemoptysis in one case each. None of them required HBO discontinuation.HBO controlled bleeding in 84% of the patients. A durable freedom from significant hematuria was achieved in 96% of the patients. HBO seems to be an effective and safe modality in patients with HRC.

Urethral diverticula are a common cause of chronic genitourinary symptoms in women. They occur in 5% of women overall, with higher frequencies in selected populations of symptomatic women. The classical presentation is with recurrent urinary tract infections and post-micturition dribbling but almost any urinary symptom may be a presenting feature. Newer imaging modalities such as magnetic resonance imaging and perineal ultrasound are now widely available and urethral diverticula, that were previously unrecognized, can now be more easily detected. However, despite the availability of effective diagnostic techniques, diagnosis is often delayed. This is due to a lack of awareness among clinicians. These patients are often inappropriately treated for other conditions, significantly delaying the proper management of their condition. A high index of suspicion, a careful examination and referral for appropriate investigation will improve the number correctly diagnosed and lead to considerable benefit since most symptomatic cases can be cured by appropriate surgery. This review aims to summarize the presentation, investigation and management of female urethral diverticulum. Hopefully, greater awareness will lead to more timely diagnosis and appropriate treatment.

To evaluate the concordance between testicular tumor size and benign histology in order to identify a cut-off size, below which the rate of benign lesions would be highest.During the years 1995-2008, we performed 131 consecutive testicular operations for testicular tumors. Ten of these were testicular preserving surgery, whereas the other 121 patients had radical orchiectomy. We searched for the rate of benign lesions in the following 3 groups of tumor diameter: 10 mm or less, 11-20 mm, and greater than 20 mm. ROC analysis was used to find the optimal size cut-off below which the rate of benign lesions would be highest.Benign lesions were found in 11 patients (8%), including epidermoid cyst (n = 4), Leydig cell tumor (n = 3), fibrosis (n = 1), adenomatoid tumor (n = 2), and 1 patient with a simple cyst. Small tumor size strongly correlated with benign histology. The mean diameter of benign vs. malignant lesions was 15 mm and 41 mm, respectively (P0.05). The rate of benign lesions in tumors with a diameter of 10 mm or less, 11-20 mm and greater than 20 mm was 50%, 17%, and 2%, respectively. Receiver Operating characteristic (ROC) analysis with 87% sensitivity and 83% specificity revealed a cut-off value of 18.5 mm tumor diameter below which the proportion of benign lesions was 38.5% compared with 2% above it (P0.05).While benign lesions comprise only 8% of all testicular tumors, their proportion among small lesions is much higher. With a size cut-off of 18.5 mm, 38.5% of smaller lesions are benign. These findings support consideration of testicular exploration for small testicular lesions aiming at preservation rather than predetermined radical orchiectomy.

In 2003 a total of 43 soldiers in the Israel Defense Forces committed suicide; only 20% of them were known to the IDF mental health services. Somatic symptoms are often the only presentation of emotional distress during the primary care visit and may be the key to early identification and treatment.To examine whether the information in the medical records of soldiers can be used to identify those suffering from anxiety, affective or somatoform disorder.We conducted a case-control study using the information in the electronic medical records of soldiers who during their 3 year service developed affective disorder, anxiety, or somatoform disorder. A control group was matched for recruitment date, type of unit and occupation in the service, and the Performance Prediction Score. The number and reasons for physician visits were collated.The files of 285 soldiers were examined: 155 cases and 130 controls. The numbers of visits (mean +/- SD) during the 3 and 6 month periods in the case and control groups were 4.7 +/- 3.3 and 7.1 +/- 5.0, and 4.1 +/- 2.9 and 5.9 +/- 4.6 respectively. The difference was statistically significant only for the 6 month period (P0.05). The variables that remained significant, after stepwise multivariate regression were the Performance Prediction Score and the presenting complaints of back pain and diarrhea.These findings may spur the development of a computer-generated warning for the primary care physician who will then be able to interview his or her patient appropriately and identify mental distress earlier.

Radical retropubic prostatectomy (RRP) has been associated with blood loss requiring blood transfusion.To define risk factors for blood transfusion.The charts of 303 patients who underwent RRP between the years 1992 and 2002 were prospectively reviewed. Blood loss, blood requirements and correlative clinical data were recorded and a multivariate analysis model was applied.Data was available in 293 cases (97%). A total of 122 patients were transfused (42%) with a median of 2 units of packed cells. Median estimated blood loss was 766 ml (range 150-2800). Blood loss declined progressively during the study period (1220 ml in 1992 to 826 ml in 2002). Multivariate analysis reveals that estimated blood loss and transfusion rate are related to performance of pelvic lymph node dissection, prostate size and percentage of cancer in the prostatectomy specimen.Our series indicates that blood preparation may be spared in patients who are not candidates for pelvic lymph node dissection with prostate smaller than 57 gr. and with less than 77% in the biopsy specimen (equivalent to66% of cancer in the prostatectomy specimen).

Over the last decades percutaneous nephrolithotripsy (PCNL) has been developed as an alternative for open renal operations in the treatment of complex renal stones. Currently, different approaches are used for the collecting system.To estimate the overall morbidity of different approaches to the collecting system during PCNL; to compare the complication rates for PCNL through the upper pole of the kidney with lower pole access and multiple access approaches.We retrospectively reviewed 174 patients (178 renal units) who underwent PCNL. They formed three groups according to surgical access: upper pole (n = 107), lower pole (n = 51) and multiple (n = 20). Inter-group data on procedure related complications were compared.Postoperative fever was more frequent in the upper pole group (34%) compared to the other two groups (25% each, p0.49). There was a higher rate of pulmonary complications in the upper pole and multiple access groups (21% and 20%, respectively) compared with the lower pole group (2%, p=0.007). The rate of bleeding and need for blood transfusion was significantly higher in the multiple access group than in the other groups (20% vs 5% and 6%, respectively, p0.05).The upper and multiple access approaches were associated with a higher overall incidence of pleural effusion compared with the lower pole access. The incidence of bleeding and transfusion rates were similar using the upper and lower pole accesses but higher in the multiple access group. Provision of an enhanced surgical field and greater maneuverability together with 'the treatable nature of the associated complications favor an upper pole access, especially for removing a large stone burden.

To evaluate the long-term outcomes following radical retropubic prostatectomy for localized prostate cancer.The charts of 401 patients who underwent radical retropubic prostatectomy between 1992 and 2004 were reviewed.The average age was 63 years with a median PSA of 8.5 and median Gleason score of 5. Ninety one percent of the cases were diagnosed by a single prostate biopsy set (average 7 cores, range 3-16). Pelvic lymph node dissection was performed in 84 patients (21.7%). Nodal involvement was noted in 5 (6%). Capsular invasion was found in 91 patients (24%), positive surgical margin in 78 (20.1%) and seminal vesicle involvement in 37 (9.5%). The average admission stay was 5.2 days (3-22). Fever (11.4%), urine leakage (8%), wound infection (4%) and pulmonary embolism (1.5%) were the most common early complications. One year after the operation 72% of the patients were fully continent. Of the 172 patients who underwent nerve-sparing procedure, 80 patients (46.5%) regained their sexual potency one year after the operation and did not require pharmacological assistance. Median follow-up time was 84 months. The five and eight years overall survival rates were 85% and 73%, respectively. Ten years survival of 136 patients (35%) with clinical stage T1C was 95%. Biochemical failure was observed in 68 patients (18%). The average time to biochemical failure was 12.5 months (range 0-76. median 12). Forty five patients (12%) died, twenty one (5.4%) due to metastatic disease. Mortality correlated to pre-operative PSA, clinical stage and Gleason score.At one year follow up, most of the patients are continent and 46.5% have spontaneous erection following nerve-sparing procedure. The overall survival and the long-term outcomes of radical retropubic prostatectomy are equal to those reported in the current literature.

Ureteropelvic junction obstruction (UPJO) is defined as an impairment of urine outflow from the pelvis to the ureter. Several treatment approaches are in use.To present the different endo-urological approaches--retrograde and antegrade techniques --for UPJO using the holmium: YAG laser.We followed 67 patients who underwent endopyelotomy between 1994 - 1997 and compared the different approaches for the treatment of UPJO.A total of 67 patients were operated, 52 patients using retrograde approach and 15 using antegrade approach. In the retrograde approach success was achieved in 48 patients (93%) and in 14 patients (94%) in the antegrade approach. Complications rate was 10% and 40%, respectively. Hospital stay was 2.2 days in the retrograde approach and 4.6 in the antegrade approach.The success rate in the different endourologic approaches was high and no difference between the two approaches was identified. From our experience, lower complication rate and shorter hospital stay make the retrograde approach more advantageous.