Surgical Treatment of Upper Urinary Tract Lithiasis in Conakry

Introduction: The management of urinary lithiasis in our settings has long been conventional surgery. The recent introduction of endoscopy of the upper urinary tract represents a major advance in our department. The aim was to contribute to the study of the treatment of lithiasis of the upper urinary tract in Conakry and to report on our initial experience of ureteroscopy in Conakry. Methodology: This is a prospective descriptive study lasting one year, from January 1 to December 31, 2022, carried out at the Urology Department of the Ignace Deen National Hospital and at the PERCHIN Urological Clinic. The study included all patients treated surgically for lithiasis of the upper urinary tract who met the selection criteria. Results: The study included 57 patients. The mean age was 30 years, with extremes of 20 and 73 years;the most represented age group was 31 to 40 years, followed by 20 to 30 years with 29.9% and 26.3% respectively. Males predominated in 36 cases (63.15%), with a M/F sex ratio of 1.71. Left-sided renal colic was the most common, at 75.43% (n=43), and right-sided renal colic at 40.35%, associated with digestive signs at 43.85%. 77.19% had normal creatinine levels before surgery, versus 22.81% with elevated creatinine levels, i.e. 15.78% improvement in renal function after surgery. Urinary tract infection was found in 47.36%, and Escherichia coli in 31.57%, followed by staphylococcus aureus in 8.77%. Overall, 82.45% of patients had organic damage to the kidneys or ureters. Right ureterohydronephrosis was noted in 56.14%, followed by left hydronephrosis in 26.32%. Open surgery was predominant in 52.63% of cases, with endoscopic surgery (URS) accounting for a significant 47.36% during the study period. The endoscopic treatment used was laser ureteroscopy. In our study, 73.68% underwent drainage of the upper excretory tract, including 64.91% with a JJ catheter. The average length of stay was 07 days, with extremes of 02 and 28 days, and 81.4% of patients who underwent URS had a length of stay of less than 4 days. Conventional surgery had the highest complication rate (14.28%). The stone free rate for the two surgical treatment methods (open and endoscopic surgery) was 73% and 92.59%.

Risk factors of concurrent urinary sepsis in patients with diabetes mellitus comorbid with upper urinary tract calculi

BACKGROUND Urinary sepsis is frequently seen in patients with diabetes mellitus(DM)complicated with upper urinary tract calculi(UUTCs).Currently,the known risk factors of urinary sepsis are not uniform.AIM To analyze the risk factors of concurrent urinary sepsis in patients with DM complicated with UUTCs by logistic regression.METHODS We retrospectively analyzed 384 patients with DM complicated with UUTCs treated in People’s Hospital of Jincheng between February 2018 and May 2022.The patients were screened according to the inclusion and exclusion criteria,and 204 patients were enrolled.The patients were assigned to an occurrence group(n=78)and a nonoccurrence group(n=126).Logistic regression was adopted to analyze the risk factors for urinary sepsis,and a risk prediction model was established.RESULTS Gender,age,history of lumbago and abdominal pain,operation time,urine leukocytes(U-LEU)and urine glucose(U-GLU)were independent risk factors for patients with concurrent urinary sepsis(P<0.05).Risk score=0.794×gender+0.941×age+0.901×history of lumbago and abdominal pain-1.071×operation time+1.972×U-LEU+1.541×U-GLU.The occurrence group had notably higher risk scores than the nonoccurrence group(P<0.0001).The area under the curve of risk score for forecasting concurrent urinary sepsis in patients was 0.801,with specificity of 73.07%,sensitivity of 79.36%and Youden index of 52.44%.CONCLUSION Sex,age,history of lumbar and abdominal pain,operation time,ULEU and UGLU are independent risk factors for urogenic sepsis in diabetic patients with UUTC.

Oncological impact of different distal ureter managements during radical nephroureterectomy for primary upper urinary tract urothelial carcinoma

BACKGROUND The current standard surgical treatment for non-metastatic upper urinary tract urothelial carcinoma(UTUC)is radical nephroureterectomy(RNU)with bladder cuff excision(BCE).Typically,BCE techniques are classified in one of the following three categories:An open technique described as intrasvesical incision of the bladder cuff,a transurethral incision of the bladder cuff(TUBC),and an extravesical incision of the bladder cuff(EVBC)method.Even though each of these management techniques are widely used,there is no consensus about which surgical intervention is superior,with the best oncologic outcomes.AIM To investigate the oncological outcomes of three BCE methods during RNU for primary UTUC patients.METHODS We retrospectively analyzed the data of 248 primary UTUC patients,who underwent RNU with BCE between January 2004 to December 2018.Patients were analyzed according to each BCE method.Data extracted included patient demographics,perioperative parameters,and oncological outcomes.Statistical analyses were performed using chi-square and log-rank tests.The Cox proportional hazards regression model was utilized to identify independent predictors.P<0.05 was considered statistically significant.RESULTS Of the 248 participants,39.9%(n=99)underwent intrasvesical incision of the bladder cuff,38.7%(n=96)EVBC,and 21.4%(n=53)TUBC.At a median followup of 44.2 mo,bladder recurrence developed in 17.2%,12.5%,and 13.2%of the cases,respectively.Cancer-specific deaths occurred in 11.1%,5.2%,and 7.5%of patients,respectively.Kaplan-Meier survival curves with a log-rank test highlighted no significant differences in intravesical recurrence-free survival,cancer-specific survival,and overall survival among these approaches with P values of 0.987,0.825,and 0.497,respectively.Multivariate analysis showed that the lower ureter location appears to have inferior intravesical recurrence-free survival(P=0.042).However,cancer-specific survival and overall survival were independently influenced by tumor stage(hazard ratio[HR]=8.439;95%con
dence interval:2.424-29.377;P=0.001)and lymph node status(HR=14.343;95%CI:5.176-39.745;P<0.001).CONCLUSION All three techniques had comparable outcomes;although,EVBC and TUBC are minimally invasive.While based upon rather limited data,these findings will support urologists in blending experience with evidence to inform patient choices.However,larger,rigorously designed,multicenter studies with long term outcomes are still required.

Who needs further evaluations to diagnose upper urinary tract urothelial cancers among patients with abnormal findings by enhanced CT?

Objective:We evaluated who would need further evaluations such as retrograde pyelography(RP)and/or ureteroscopy to diagnose upper urinary tract urothelial cancers(UUTUCs)when abnormal findings for the upper urinary tract(UUT)were detected by enhanced computed tomography(CT).Methods:We retrospectively analyzed 125 patients who underwent enhanced CT for various reasons and had abnormal findings for the UUT.Patients whose tumors were suspected to be of extraureteral origin were excluded.All patients received RP and/or ureteroscopy to evaluate the UUTUCs.Results:The median age of the 125 patients was 70 years and gross hematuria(26.4%)was the most frequently observed symptoms.RP,ureteroscopy and both were performed for 121,59 and 55 patients,respectively.CT revealed tumor-like lesions in 58 patients and the other patients had non-tumor-like lesions.UUTUCs were found in 43(34.4%)of the 125 patients.All of them had tumor-like lesions on CT.In 58 patients who had tumor-like lesions on CT,univariate and multivariate analyses revealed that tumor diameter and tumor enhancement were significant predictive factors for UUTUCs.ROC curve analysis of enhanced CT to diagnose UUTUCs revealed that a tumor diameter of 18 mm was the best cutoff point.The sensitivity,specificity and accuracy were 90.0%,98.8% and 92.7% for RP and 95.5%,100% and 97.1%for ureteroscopy,respectively.Both of them had high sensitivity,specificity and accuracy.Conclusion:We should decide to evaluate the UUT according to the tumor diameter on enhanced CT.When we evaluate the UUT in patients with tumor diameters of less than 20 mm,ureteroscopy is recommended.

Dynamic Renal Scintigraphy in Diagnosis of Upper Urinary Tract Obstruction in Transplanted Kidney

Nuclide renal dynamic imaging was performed on 88 transplanted kidney. Two kinds of renal scintigraphic characteristics were identified in recipients with supravesical obstruction of the graft. First, the regular type was characterized by radioactivity defect area in kidney parenchyma during early uptake period followed by ureteropelvic retention. Second, the tubular type was typified by cortical retention and attenuation in collecting system during the whole test period with a special sign of “hollow kidney”. Non obstructive dilated calyces showed similar signs as the regular type. Acute rejection reaction and tubule necrosis demonstrated obstructive time activity curves. However, the radioactivity retention appeared in cortex. It was suggested that dilated calyces and obstructive renogram might not be reliable evidence for upper urinary tract obstruction. The signs of radioactivity attenuation in kidney parenchyma during early uptake period followed by ureteropelvic retention may be more valuable for the evaluation. As for tubular obstruction, specified “hollow kidney” was the characteristic sign which is helpful for the diagnosis.

Lymphoepithelioma-like carcinoma of the upper urinary tract: A systematic review of case reports

BACKGROUND Lymphoepithelioma-like carcinomas(LELCs)are rare,malignant epithelial tumors,generally considered a subtype of squamous cell carcinoma.LELCs are undifferentiated and can occur in multiple tissues,although LELCs in the urinary tract are extremely rare.As such,evidence does not provide clinicians with guidelines for the best practices.Even though this is a rare disease,it is associated with high morbidity and mortality.Therefore,we must learn to differentiate LELC types and identify risk factors for early identification.AIM To develop an evidence base to guide clinicians treating primary LELCs of the upper urinary tract(UUT-LELC).METHODS We performed a systematic review of all reports on UUT-LELC from the first published case in 1998 until October 2019,according to the PRISMA.A database was then developed by extracting data from previously published reports in order to analyze interactions between clinical characteristics,pathological features,interventions and outcomes.Survival was analyzed using Kaplan–Meier estimates,which were compared using log rank tests.RESULTS A total of 28 previously published cases were identified for inclusion.The median age was 72 years with a male to female ratio of 4:3.Pure type LELCs were most common with 48.3%(n=14),followed by 37.9%(n=11)predominant LELCs and 3.4%(n=1)focal LELCs.Epstein-Barr virus testing was negative in all cases.Fourteen patients received radical nephroureterectomy(RNU)-based intervention.Twenty-three patients survived with no evidence of further metastasis,although six died before the median 18 mo follow-up point.Survival analysis suggests pure histological subtypes,and patients who receive complete tumor resection have more favorable prognoses.As always in cancer care,early identification generally increases the probability of interventional success.CONCLUSION The most effective treatment for UUT-LELC is RNU-based therapy.Since cases are few in number,case reporting must be enhanced and publishing encouraged to both save and prolong lives.

Selection of staged or synchronous percutaneous nephrolithotomy for treatment of bilateral upper urinary tract calculi

Objective To evaluate the decision process to perform staged or synchronous bilateral percutaneous nephrolithotripsy ( PCNL) in the treatment of bilateral upper urinary tract calculi. Methods Patients with an indication for bilateral PCNL were enrolled in the study

Association between heat and upper urinary tract stones morbidity and medical costs: A study in the subtropical humid climate zone

Urolithiasis is a heat-specific disease.Exploring heat-related urolithiasis susceptibility subtypes,economic burden,and modifying factors could assist governments in targeting interventions to reduce the heat-related health risks of urolithiasis morbidity.We collected data on 23,492 patients with upper urinary tract stones(main subtypes of urolithiasis)from 2013 to 2017 in Nanjing,China.We adopted generalized additive quasi-Poisson models to examine the associations between daily mean temperatures and morbidity of upper urinary tract stones,while generalized additive Gaussian models were used to explore the relationships between temperatures and log-transformed medical costs.We examined the modification effects of disease subtypes(kidney and ureteral calculus),sex,and age through stratified analyses and the modif-cation effects of other meteorological factors by introducing interaction terms in the models.We found that short-term summer heat exposure has a statistically significant effect on ureteral calculus morbidity but not on kidney calculus morbidity.For ureter calculus,a 1℃ temperature increase was associated with a 4.36%(95%confidence interval[CI]:1.94%,6.83%)increase in daily hospitalization and a 5.44%(95%CI:2.71%,8.25%)increase in daily medical costs.The attributable fraction associated with heat(greater than the median value of daily mean temperature,26.8℃)was 7.85%(95%empirical confidence interval[eCI]:3.64%,11.44%)for hospitalization and 9.36%(95%eCI:4.91%,13.14%)for medical costs.The effects of heat on ureter calculus morbidity were significantly higher among the males and those with high sunshine duration than females and those with low sunshine duration.Short-term summer heat exposure was associated with increased morbidity and medical costs of ureteral calculus.Relevant government organizations should take effective intervention measures,including community health education,to reduce the health hazards and economic losses caused by heat.

Poor visualization of renal collecting system in intravenous urography as an indicator of invasive transitional cell carcinoma in the upper urinary tract

Background Transitional cell carcinoma of the upper urinary tract （UUT-TCC） accounts for 5% to 10% of all renal tumours and 5% to 6% of all urothelial tumours all over the world. In China, the proportion of UUT-TCC to all urothelial tumours may be 26%, which is higher than that in the western world. The early diagnosis of UUT-TCC is difficult and the present study elucidates the diagnostic value of poor or nonvisualization （PNV） in intravenous urography in patients with UUT-TCC and its correlations with pathological findings and clinical characteristics. Methods The data of 172 consecutive patients between January 1997 and January 2005 with UUT-TCC who underwent nephroureterectomy in our departments were selected and analyzed retrospectively. Results Of our sample, 144 cases presented with gross haematuria （83.7%） and 12 with microscopic haematuria （7.0%）. Forty-six cases （26.7%） were detectable by cytology. Filling defect identified 36 positive cases of 172 patients （20.9%）, PNV was present in the images of 105 of 172 patients （61.0%）. The detection rate by PNV （61.0%） was significantly different from that by cytology （26.7%） or by filling defect （20.9%） （P=-0.031, P=-0.001, respectively）. Univariate logistic regression analysis for PNV showed that tumour stage, grade and size were significant predictors （P=0.028; P=-0.031; P=-0.006, respectively）. Tumour stage and size were identified as independent risk factors in the multivariate logistic regression model （P=-0.042; P=-0.014）.Conclusions Except for suspected urolithiasis, urinary tuberculosis or congenital abnormalities, UUT-TCC should be considered if PNV exists in intravenous urography especially of old patients. The value of PNV is much more significant than filling defect in intravenous urography in the diagnosis of UUT-TCC. It is supposed that PNV carries more risk of higher stage and larger tumour size in UTT-TCC.

Clipping the extremity of ureter prior to nephroureterectomy is effective in preventing subsequent bladder recurrence after upper urinary tract urothelial carcinoma

Background Bladder recurrent disease is still a challenge in the treatment of upper tract urothelial carcinoma （UTUC）. This controlled study aims to investigate the efficacy of early clipping of the distal ureter prior to nephroureterectomy （NU） to prevent bladder recurrence after UTUC.

Laparoscopic nephroureterectomy for upper tract urothelial carcinoma-Update

Upper urinary tract urothelial carcinomas(UTUCs)are uncommon and account for only 5%e10%of urothelial carcinomas.Pyelocaliceal tumors are about twice as common as ureteral tumors.Sixty percent of UTUCs are invasive at diagnosis.Radical nephroureterectomy,including the excision of the distal ureter and bladder cuff is standard of care for treatment of localized UTUCs,because of the high potential for recurrence,multifocality,and progression.Since first laparoscopic nephroureterectomy(LNU)was introduced by Clayman et al.in 1991 and improvement of laparoscopic technique and equipment,LNU has been reported to be equivalent to conventional open method.We reviewed the current literature of patients with UTUCs treated by LNU focusing on technical aspects,peri-operative and oncological outcomes.Laparoscopic radical nephroureterectomy offers the advantages of minimally invasive surgery without deteriorating the oncological outcome for treatment of UTUCs.Indications tend to increase as operator skills increase.Indications for laparoscopic or open nephroureterectomy are in principle the same.The basic requirement for laparoscopic surgery in UTUCs is to achieve benefits of minimal invasive surgery and maintain oncologic principles.

Renal papillary necrosis with urinary tract obstruction:A case report

BACKGROUND Renal papillary necrosis(RPN)is a rare disease.It is difficult to distinguish RPN with urinary tract obstruction from upper urinary tract occupying lesions.We reported a case of RPN and made a definite diagnosis largely based upon its endoscopic characteristics.CASE SUMMARY A 75-year-old woman presented with right flank pain,visible hematuria and a body temperature greater than 39℃.Laboratory investigations revealed leukocytosis with 12.7×10/L white blood cells and 93.6%neutrophils.Blood creatinine was 333 umol/L.Ultrasonography showed hydronephrosis of the right kidney and a right distal ureteric lesion.After urgent placement of right ureteral double J stent and treatment with antibiotics,the patient’s symptoms and the blood abnormalities improved rapidly.Computed tomography urography showed the presence of multiple occupying lesions in the right pelvis.The endoscopic ureteroscopy revealed that renal papillary necrosis and the subsequent migration of sloughed papillae into the upper ureter and calyces.The sloughed papillae appeared like“cottons”,which were whitish,soft,and irregularly-shaped without blood supply.In addition,the necrotic and sloughed renal papillae were removed by flexible ureteroscopy to prevent further obstruction.Pathological examination found that infarcted renal papillae were associated with inflammatory exudation.Three months after discharge,follow-up computed tomography urography showed no obvious lesions in the renal pelvis.CONCLUSION This case revealed the endoscopic features of RPN.In addition,flexible ureteroscopy proves to be vital in diagnosis and treatment of RPN.

Metachronous urothelial carcinoma in the renal pelvis,bladder,and urethra:A case report

BACKGROUND Urothelial carcinoma(UC)is a common malignancy of the urinary system that can occur anywhere from the renal pelvis to the proximal urethra.Most UCs are in the bladder and have multifocal growth.Upper urinary tract UC(UTUC),which occurs in the renal pelvis or ureter,accounts for only 5%to 10%of UCs.CASE SUMMARY In March 2015,a 70-year-old male who initially presented to a local hospital with a complaint of painless hematuria was diagnosed with UTUC of the right renal pelvis.The doctors administered radical nephroureterectomy and bladder cuff excision.Although the doctors recommended intravesical chemotherapy and regular follow-up,he rejected this advice.In December 2016,the patient presented at our hospital with dysuria.We identified UC in the residual bladder and administered radical cystectomy and left cutaneous ureterostomy.In November 2021,he presented again with urethral bleeding.We detected urethral UC as the cause of urethral orifice bleeding and administered radical urethrectomy.Since then,he has visited regularly for 6-mo follow-ups,and was in stable condition as of December 2022.CONCLUSION UTUC is prone to seeding and recurrence.Adjuvant instillation therapy and intense surveillance are crucial for these patients.