Transforaminal Percutaneous Endoscopic Discectomy using Transforaminal Endoscopic Spine System technique: Pitfalls that a beginner should avoid

Transforaminal Percutaneous Endoscopic Discectomy(TPED) is a minimally invasive technique mainly used for the treatment of lumbar disc herniation from a lateral approach. Performed under local anesthesia, TPED has been proven to be a safe and effective technique which has been also associated with shorter rehabilitation period, reduced blood loss, trauma, and scar tissue compared to conventional procedures. However, the procedure should be performed by a spine surgeon experienced in the specific technique and capable of recognizing or avoiding various challenging conditions. In this review, pitfalls that a novice surgeon has to be mindful of, are reported and analyzed.

Technique of Percutaneous Transforaminal Endoscopic Discectomy for the Treatment of Lumbar Disc Herniation

Percutaneous Transforaminal Endoscopic Discectomy is a minimally invasive surgery with little pain, less blood loss, less hospital stay and the surgery can be done in local anesthesia, which was started during late 20th century. Kambin and Gellmann in 1973 in the United States and Hijikata in Japanin 1977 individually preformed posterolateral percutaneous nucleotomy for the resection of the nucleus pulposus and release of compressed exiting nerve root, which is now spreading through the world and many surgeons are developing their skill but it needs experience and patience for successful outcomes. Along with advanced instruments now the surgery can be performed only giving a small skin incision of 8 - 10 mm and is as effective as the conventional method of surgery and open microdiscectomy surgery for the treatment of symptomatic lumbar disc herniation. In this review, we are explaining the technique of minimally invasive Percutaneous Transforaminal Endoscopic Discectomy surgery along its advantages and complications which can be encountered while performing this technique.

Two-level percutaneous endoscopic lumbar discectomy for highly migrated upper lumbar disc herniation: A case report

BACKGROUND The technique of percutaneous endoscopic lumbar discectomy(PELD)as a transforaminal approach has been used to treat highly migrated lower lumbar disc herniations.However,due to the different anatomic characteristics of the upper lumbar spine,conventional transforaminal PELD may fail to remove the highly migrated upper lumbar disc nucleus pulposus.Therefore,the purpose of this study was to describe a novel surgical technique,two-level PELD,for the treatment of highly migrated upper lumbar disc herniations and to report its related clinical outcomes.CASE SUMMARY A 60-year-old male presented with a complaint of pain at his lower back and right lower limb.The patient received 3 mo of conservative treatments but the symptoms were not alleviated.Physical examination revealed a positive femoral nerve stretch test and a negative straight leg raise test for the right leg,and preoperative visual analog scale(VAS)score for the lower back was 6 points and for the right leg was 8 points.Magnetic resonance imaging(MRI)demonstrated L2-L3 disc herniation on the right side and the herniated nucleus pulposus migrated to the upper margin of L2 vertebral body.According to physical examination and imaging findings,surgery was the primary consideration.Therefore,the patient underwent surgical treatment with two-level PELD.The pain symptom was relieved and the VAS score for back and thigh pain was one point postoperatively.The patient was asymptomatic and follow-up MRI scan 1 year after operation revealed no residual nucleus pulposus.CONCLUSION Two-level PELD as a transforaminal approach can be a safe and effective procedure for highly migrated upper lumbar disc herniation.

The Clinical Effect of Percutaneous Transforaminal Endoscopic Discectomy in the Treatment of Low Lumbar Single Segment Disc Herniation

Objective: To observe the clinical effect percutaneous transforaminal endoscopic discectomy (PTED) in the treatment of single lumbar disc herniation. Methods: From August 2017 to June 2019, 42 patients with low lumbar single segment lumbar disc herniation were treated with percutaneous transforaminal endoscopic discectomy surgery in our hospital. The operation time, incision size, bleeding volume and hospitalization time were recorded respectively. The patients were evaluated before operation, 1 month and 6 months after operation. Visual analogue scale (VAS) and assessment were used to evaluate the lumbocrural pain. The JOA score and the Oswestry disability index (ODI) were used to evaluate the lumbar function, and the modified macnab score was used to evaluate the clinical effect in the last follow-up. Results: All the 42 patients successfully completed the operation without any other operation. There were no severe complications such as dural injury and nerve root injury. The operation time was (76.98 ± 8.58) min, the incision size was (8.45 ± 1.2) mm, the bleeding volume was (20.14 ± 2.93) ml, and the hospitalization time was (4.55 ± 1.13) d. One month and six months after the operation, the visual analogue scale (VAS), the evaluation of lumbar function (Oswestry) and the disability index (ODI) were significantly improved compared with those before the operation (P Conclusion: The treatment of low lumbar but segmental lumbar disc herniation with percutaneous intervertebral foramen, with small incision, less bleeding and quick recovery, can improve the pain and dysfunction of patients.

Segmental artery injury during transforaminal percutaneous endoscopic lumbar discectomy:Two case reports

BACKGROUND Since Kambin experimentally induced arthroscopy to treat herniated nucleus pulposus,percutaneous endoscopic lumbar discectomy(PELD)has been developed.The branch of the segmental artery around the neural foramen may be damaged during PELD using the transforaminal approach.We report 2 rare cases in which segmental artery injury that occurred during PELD was treated with emergency embolization.CASE SUMMARY In case 1,a 31-year-old man was transferred to our emergency department with left lower quadrant abdominal pain after PELD at a local hospital.Lumbar spine magnetic resonance imaging after the surgery showed a hematoma of the left retroperitoneal area and the psoas muscle area.Under suspicion of vascular injury,arteriography was performed.Pseudoaneurysm and blood leakage from the left 4th lumbar segmental artery into the abdominal cavity were identified.Emergency transarterial embolization was performed using fibered microcoils for bleeding of the segmental artery.In case 2,a 75-year-old woman was transferred to our emergency department with low blood pressure,right flank pain,and drowsy mental status after PELD at a local hospital.When the patient arrived at the emergency room,the blood pressure decreased from 107/55 mmHg to 72/47 mmHg.Low blood pressure persisted.Under suspicion of vessel injury,arteriography was performed,and the right 4th lumbar segmental artery rupture was confirmed.Emergency transarterial embolization was performed for bleeding of segmental artery.CONCLUSION We were able to find the bleeding focus by angiography and treat the injury of the segmental artery successfully through emergency transarterial embolization.

Comparison of pain media and inflammatory factors after percutaneous transforaminal endoscopic discectomy and traditional fenestration operation treatment of protrusion of lumbar intervertebral disc

Objective:To compare the differences in pain mediators and inflammatory factors after percutaneous transforaminal endoscopic discectomy and traditional fenestration operation treatment of protrusion of lumbar intervertebral disc. Methods:80 patients with protrusion of lumbar intervertebral disc treated in our hospital between March 2013 and December 2015 were collected and divided into observation group and control group (n=40) according to randomized parallel contrast. Control group received traditional fenestration operation and observation group received percutaneous transforaminal endoscopic discectomy. Before operation and 1 week after operation, fluorescence spectrophotometry was used to determine serum pain medium levels;ELISA was used to determine pro-inflammatory factor and anti-inflammatory factor levels. Results:Before operation, differences in serum pain medium and inflammatory factor levels were not statistically significant between two groups (P>0.05). 1 week after operation, serum pain media norepinephrine (NE), dopamine (DA), 5-hydroxytryptamine (5-HT), prostaglandin E2 (PGE2) and substance P (SP) levels as well as pro-inflammatory factors interleukin-1β(IL-1β), interleukin-6 (IL-6), interleukin-18 (IL-18) and tumor necrosis factor alpha (TNF-α) levels of observation group were lower than those of control group (P<0.05) while serum anti-inflammatory factors interleukin-4 (IL-4), interleukin 10 (IL-10), soluble tumor necrosis factor receptor I (sTNF-RI) levels were higher than those of control group (P<0.05). Conclusions:Percutaneous transforaminal endoscopic discectomy can effectively treat protrusion of lumbar intervertebral disc and is more advantageous in alleviating patients’ perception of pain and reducing inflammation.

Comparison of the pain and inflammatory stress after percutaneous transforaminal endoscope discectomy and open fenestration discectomy

Objective:To study the differences in pain and inflammatory stress after percutaneous transforaminal endoscope discectomy and open fenestration discectomy.Methods: Patients with lumbar intervertebral disc herniation who underwent surgical treatment in our hospital between January 2013 and January 2017 were selected and randomly divided into two groups: Percutaneous transforaminal endoscope discectomy (PTED) group and control group. Patients in PTED group received percutaneous transforaminal endoscope discectomy, while control group received open fenestration discectomy. Serum levels of pain substances SP, NPY, PGE2 and NGF, inflammatory mediators IFN-γ, TNF-α, IL-17 and MMP3 as well as stress response substances Cor, NE, OH-, O2- and MDA of two groups of patients were determined the same day after surgery and 3 days after surgery.Results: The same day after surgery and 3 d after surgery, serum SP, NPY, PGE2, NGF, IFN-γ, TNF-α, IL-17, MMP3, Cor, NE, OH-, O2- and MDA levels of PTED group were significantly lower than those of control group. Conclusion: Percutaneous transforaminal endoscope discectomy for lumbar intervertebral disc herniation causes less postoperative pain and inflammatory stress than open fenestration discectomy.

Ultrasound guidance for transforaminal percutaneous endoscopic lumbar discectomy may prevent radiation exposure: A case report

BACKGROUND Percutaneous endoscopic lumbar discectomy(PELD)has become a mature and mainstream minimally invasive surgical technique for treating lumbar disc herniation(LDH).Repeated fluoroscopy,with more than 30 shots on average,is inevitable to ensure its accuracy and safety.However,exposure to X-rays may pose a threat to human health.We herein report a case of ultrasound(US)-assisted PELD in two levels of LDH to explore a new possibility that can reduce the radiation dose during puncture and cannulation in PELD.CASE SUMMARY A 38-year-old man with low back pain and left leg pain for more than 7 years came to our clinic,his symptoms had aggravated for 1 month,and he was diagnosed with L3-4 and L4-5 disc herniations.He received US-guided PELD with good results:His straight leg elevation increased from 40 to 90 degrees after PELD,and his visual analog scale(VAS)and Oswestry Disability Index scores both significantly decreased immediately and 6 mo after PELD.With the guidance of US,he received only two shots of fluoroscopy(fluoroscopic time:4.4 s;radiation dose:3.98 mGy).To our knowledge,this is the first case of US-guided puncture and cannulation of PELD for LDH at two levels.CONCLUSION US could be used to guide PELD and has the potential to largely reduce radiation than traditional X-ray guidance.

Percutaneous Endoscopic Lumbar Discectomy versus Conventional Open Discectomy: A Prospective Randomized Comparative Trial

Introduction: The majority of series considered the conventional open discectomy as the gold standard for the treatment of lumbar disc prolapse. Despite of the popularity of the lumbar endoscopic discectomy nowadays, many neurosurgeons still prefer conventional open discectomy. Purpose: Our study has been designed to compare between percutaneous endoscopic lumbar discectomy and conventional open discectomy;regarding surgical results, complications, clinical and functional outcomes. Patients and Methods: This study is a clinical prospective randomized controlled trial conducted upon 30 patients suffering from prolapsed lumbar disc, from December 2016 to May 2018. Those patients were divided randomly into 2 groups, 15 patients each. One group treated by percutaneous endoscopic interlaminar lumbar discectomy (PELD) and the other group treated by conventional open discectomy (COD). Operative time, wound size, Intraoperative blood loss, Intraoperative complications, postoperative hospital stay, Postoperative complication and the results of visual analogue score (VAS) and modified MacNab’s criteria were assessed. Results: This study included 30 patients (18 males and 12 females). The mean age was about 35 years. Although, there was postoperative improvement of the VAS and MacNab’s criteria in the two groups, there was no statistically significant difference between the preoperative and postoperative VAS of low back pain and radicular pain for the two groups in the follow up period. Conclusion: Both techniques give good results for patients;each technique has some advantages over the other.

Percutaneous antegrade management of large proximal ureteral stones using non-papillary puncture

Objective:To evaluate the feasibility and the safety of medial non-papillary percutaneous nephrolithotomy(npPCNL)for the management of large proximal ureteral stones.Methods:We evaluated prospectively collected data of 37 patients with large proximal ureteral stones more than 1.5 cm in diameter treated by prone npPCNL.Depending on stone size,in-toto stone removal or lithotripsy using the Lithoclast®Trilogy(EMS Medical,Nyon,Switzerland)was performed.Perioperative parameters including operative time(from start of puncture to the skin suturing),stone extraction time(from the first insertion of the nephroscope to the extraction of all stone fragments),and the stone-free rate were evaluated.Results:Twenty-one males and 16 females underwent npPCNL for the management of large upper ureteral calculi.The median age and stone size of treated patients were 58(interquartile range[IQR]:51-69)years and 19.3(IQR:18.0-22.0)mm,respectively.The median operative time and stone extraction time were 25(IQR:21-29)min and 8(IQR:7-10)min,respectively.One case(2.7%)of postoperative bleeding and two cases(5.4%)of prolonged fever were managed conservatively.The stone-free rate at a 1-month follow-up was 94.6%.Conclusion:The npPCNL provides a straight route to the ureteropelvic junction and proximal ureter.Approaching from a dilated portion of the ureter under low irrigation pressure with larger diameter instruments results in effective and safe stone extraction within a few minutes.

Perioperative and long-term results of ultrasonography-guided single-and multiple-tract percutaneous nephrolithotomy for staghorn calculi

BACKGROUND It is possible that this condition will lead to urosepsis and progressive deterioration of renal function in the absence of surgical intervention.Several recent clinical studies have shown that multi-tract percutaneous nephrolithotomy(MPCNL)has a similar stone free rate(SFR)as standard percutaneous nephrolithotomy(S-PCNL).As a result,M-PCNL was also recommended as a treatment option for staghorn calculi.AIM To examine the perioperative and long-term results of ultrasonography-guided single-and M-PCNL.METHODS This was a retrospective cohort study.Between March 2021 and January 2022,the urology department of our hospital selected patients for the treatment of staghorn calculi using percutaneous nephrolithotomy.The primary outcomes were com plication rate and SFR,and the characteristics of patients,operative parameters,laboratory measurements were also collected.RESULTS In total,345 patients were enrolled in the study(186 in the S-PCNL group and 159 in the M-PCNL group).The SFR in the M-PCNL group was significantly higher than that in the S-PCNL group(P=0.033).Moreover,the incidence rates of hydrothorax(P=0.03)and postoperative infection(P=0.012)were higher in the M-PCNL group than in the S-PCNL group.Logistic regression analysis demonstrated that post-operative white blood cell count(OR=2.57,95%CI:1.90-3.47,P<0.001)and stone size(OR=1.59,95%CI:1.27-2.00,P<0.001)were associated with a higher overall complication rate in the S-PCNL group.Body mass index(OR=1.22,95%CI:1.06-1.40,P=0.004)and stone size(OR=1.70,95%CI:1.35-2.15,P<0.001)were associated with increased overall complications in the M-PCNL group.CONCLUSION Multiple access tracts can facilitate higher SFR while slightly increasing the incidence of acceptable complications.

Impact of frailty on outcomes of elderly patients undergoing percutaneous coronary intervention: A systematic review and metaanalysis

BACKGROUND Frailty is a common condition in elderly patients who receive percutaneous coronary intervention(PCI).However,how frailty affects clinical outcomes in this group is unclear.AIM To assess the link between frailty and the outcomes,such as in-hospital complic-ations,post-procedural complications,and mortality,in elderly patients post-PCI.METHODS The PubMed/MEDLINE,EMBASE,Cochrane Library,and Web of Science databases were screened for publications up to August 2023.The primary outcomes assessed were in-hospital and all-cause mortality,major adverse cardiovascular events(MACEs),and major bleeding.The Newcastle-Ottawa Scale was used for quality assessment.RESULTS Twenty-one studies with 739693 elderly patients undergoing PCI were included.Frailty was consistently associated with adverse outcomes.Frail patients had significantly higher risks of in-hospital mortality[risk ratio:3.45,95%confidence interval(95%CI):1.90-6.25],all-cause mortality[hazard ratio(HR):2.08,95%CI:1.78-2.43],MACEs(HR:2.92,95%CI:1.85-4.60),and major bleeding(HR:4.60,95%CI:2.89-7.32)compared to non-frail patients.CONCLUSION Frailty is a pivotal determinant in the prediction of risk of mortality,development of MACEs,and major bleeding in elderly individuals undergoing percutaneous coronary intervention.

Unloading and successful treatment with bioresorbable stents during percutaneous coronary intervention:A case report

BACKGROUND With the development of percutaneous coronary intervention(PCI),the number of interventional procedures without implantation,such as bioresorbable stents(BRS)and drug-coated balloons,has increased annually.Metal drug-eluting stent unloading is one of the most common clinical complications.Comparatively,BRS detachment is more concealed and harmful,but has yet to be reported in clinical research.In this study,we report a case of BRS unloading and successful rescue.This is a case of a 59-year-old male with the following medical history:“Type 2 diabetes mellitus”for 2 years,maintained with metformin extended-release tablets,1 g PO BID;“hypertension”for 20 years,with long-term use of metoprolol sustained-release tablets,47.5 mg PO QD;“hyperlipidemia”for 20 years,without regular medication.He was admitted to the emergency department of our hospital due to intermittent chest pain lasting 18 hours,on February 20,2022 at 15:35.Electrocardiogram results showed sinus rhythm,ST-segment elevation in leads I and avL,and poor R-wave progression in leads V1–3.High-sensitivity troponin I level was 4.59 ng/mL,indicating an acute high lateral wall myocardial infarction.The patient’s family requested treatment with BRS,without implanta-tion.During PCI,the BRS became unloaded but was successfully rescued.The patient was followed up for 2 years;he had no episodes of angina pectoris and was in generally good condition.CONCLUSION We describe a case of a 59-year-old male experienced BRS unloading and successful rescue.By analyzing images,the causes of BRS unloading and the treatment plan are discussed to provide insights for BRS release operations.We discuss preventive measures for BRS unloading.

Efficacy and safety of percutaneous transhepatic biliary radiofrequency ablation in patients with malignant obstructive jaundice

BACKGROUND Percutaneous transhepatic cholangiodrainage(PTCD)and endoscopic retrograde cholangiopancreatography/endoscopic nasobiliary drainage are the most common clinical procedures for jaundice control in patients with unresectable malignant obstructive jaundice,yet the safety and effect of endobiliary radiofrequency ablation(EB-RFA)combined PTCD is rarely reported,in this article,we report our experience of EB-RFA combined PTCD in such patients.AIM To retrospectively study the efficacy and safety of EB-RFA combined PTCD in patients with unresectable malignant obstructive jaundice.METHODS Patients with unresectable malignant obstructive jaundice treated with EB-RFA under PTCD were selected,the bile ducts of the right posterior lobe was selected as the target bile ducts in all cases.The general conditions of all patients,preoperative tumour markers,total bilirubin(TBIL),direct bilirubin(DBIL),albumin(ALB),alkaline phosphatase(ALP),and glutamyl transferase(GGT)before and on the 7th day after the procedure,as well as perioperative complications,stent patency time and patient survival were recorded.RESULTS All patients successfully completed the operation,TBIL and DBIL decreased significantly in all patients at the 7th postoperative day(P=0.009 and 0.006,respectively);the values of ALB,ALP and GGT also decreased compared with the preoperative period,but the difference was not statistically significant.Perioperative biliary bleeding occurred in 2 patients,which was improved after transfusion of blood and other conservative treatments,pancreatitis appeared in 1 patient after the operation,no serious complication and death happened after operation.Except for 3 patients with loss of visits,the stent patency rate of the remaining 14 patients was 100%71%and 29%at the 1^(st),3^(rd),and 6^(th)postoperative months respectively,with a median survival of 4 months.CONCLUSION EB-RFA under PTCD in patients with unresectable malignant obstructive jaundice has a satisfactory therapeutic effect and high safety,which is worthy of further clinical practice.

Effects of PEAR1 gene polymorphism on big endothelin-1 levels in Chinese patients with acute myocardial infarction after percutaneous coronary intervention

Acute myocardial infarction (AMI) has been associated with poor prognosis,even after revascularization with percutaneous coronary intervention (PCI),likely due to coronary endothelial cell dysfunction and injury.^([1,2])Endothelin-1 (ET-1),a peptide that serves as a vasoconstrictor of smooth muscle cell proliferation,can reflect endothelial cell functional states.Due to low circulation levels and short plasma half-life time,measuring plasma ET-1 levels is difficult.In contrast,big ET-1.

The global,prevalence,and risk factors of postoperative fever after percutaneous nephrolithotomy:A systematic review and meta-analysis

Objective:This study aimed to explore the global,prevalence,and risk factors of fever after percutaneous nephrolithotomy(PCNL)by conducting a systematic review and meta-analysis.Methods:The high-sensitivity searching was conducted without time limitation until December 30,2020 in Web of Sciences,Scopus,and PubMed based on inclusion and exclusion criteria.Results:The prevalence rates of fever and sepsis among patient undergoing PCNL were estimated 9.5%(95%confidence interval[CI]:9.3%-9.7%),and 4.5%(95%CI:4.2%-4.8%),respectively.Nephrostomy tube was used in 9.96%(95%CI:9.94%-9.97%)of patients.The mean preoperative white blood cells of patients were 6.401×109/L;18.3%and 4.55%of patients were considered as the positive urinary culture and pyuria,respectively.About 20.4%of patients suffered from residual stones.The odds ratios(ORs)of fever in patients who suffering from diabetes mellitus,hydronephrosis,staghorn stones,and blood transfusion were 4.62(95%CI:2.95-7.26),1.04(95%CI:0.81-1.34),2.57(95%CI:0.93-7.11),and 2.65(95%CI:1.62-4.35),respectively.Patients who underwent PCNL in prone position were more likely to develop fever(OR:1.23;95%CI:0.75-2.00)than patients in supine position.Conclusion:The current study showed that patients who suffer from diabetes mellitus,hydronephrosis,staghorn stones,nephrostomy tube or double-J stent,blood transfusion,and also patients who underwent PCNL in prone position surgery are more likely to develop a postoperative fever after PCNL.

Two-Stent Strategy for Bifurcation Lesions in Percutaneous Transluminal Coronary Angioplasty: Real-World Evidence

Background: Bifurcation lesions pose a high risk for adverse events after percutaneous coronary intervention (PCI). Evidence supporting the benefits of the two-stent strategy (2SS) for treating coronary bifurcation lesions in India is limited. This study aimed to evaluate the clinical outcomes of various 2SSs for percutaneous transluminal coronary angioplasty for bifurcation lesions in India. Materials and Methods: This retrospective, observational, multicentric, real-world study included 64 patients over 8 years. Data on demographics, medical history, PCI procedures, and outcomes were recorded. Descriptive statistics were computed using the SPSS software. Results: Patients (n = 64) had an average age of 65.3 ± 11.1 years, with 78.1% males. Acute coronary syndrome was reported in 18.8%, chronic stable angina in 40.6%, and unstable angina in 34.4% of participants. Two-vessel disease was observed in 98.4% of patients, and 99.4% had true bifurcation lesions. The commonly involved vessels were the left anterior descending artery (50%), left circumflex coronary artery (34.4%), and first diagonal artery (43.8%). Mean percent diameter stenosis was 87.2% ± 10.1%. The mean number of stents used was 2.00 ± 0.34. The 2SS techniques included the T and small protrusion (TAP) (39.1%), double kissing (DK) crush (18.8%), and the culotte techniques (14.1%). Procedural and angiographic success rate was 92.18%. Major adverse cardiovascular events at 1-year follow-up occurred in 7.8% of cases. Conclusion: The 2SS for bifurcation lesions showed favorable in-hospital and follow-up outcomes. Findings can serve as a resource for bifurcation angioplasty in India. Larger real-world studies with robust methodology are needed to validate these results.

Metabolic syndrome and the urinary microbiome of patients undergoing percutaneous nephrolithotomy

Objective:To identify possible stone-promoting microbes,we compared the profiles of microbes grown from stones of patients with and without metabolic syndrome(MetS).The association between MetS and urinary stone disease is well established,but the exact pathophysiologic relationship remains unknown.Recent evidence suggests urinary tract dysbiosis may lead to increased nephrolithiasis risk.Methods:At the time of percutaneous nephrolithotomy,bladder urine and stone fragments were collected from patients with and without MetS.Both sample types were subjected to expanded quantitative urine culture(EQUC)and 16 S ribosomal RNA gene sequencing.Results:Fifty-seven patients included 12 controls(21.1%)and 45 MetS patients(78.9%).Both cohorts were similar with respect to demographics and non-MetS comorbidities.No controls had uric acid stone composition.By EQUC,bacteria were detected more frequently in MetS stones(42.2%)compared to controls(8.3%)(p=0.041).Bacteria also were more abundant in stones of MetS patients compared to controls.To validate our EQUC results,we performed 16 S ribosomal RNA gene sequencing.In 12/16(75.0%)sequence-positive stones,EQUC reliably isolated at least one species of the sequenced genera.Bacteria were detected in both“infectious”and“non-infectious”stone compositions.Conclusion:Bacteria are more common and more abundant in MetS stones than control stones.Our findings support a role for bacteria in urinary stone disease for patients with MetS regardless of stone composition.

Ultrasound-guided paravertebral nerve block anesthesia for percutaneous endoscopic laser unroofing treatment of symptomatic simple renal cysts—An innovative ambulatory surgery mode

Objective:This study was designed to evaluate the feasibility,efficacy,and safety of percutaneous ureteroscopy laser unroofing as an ambulatory surgery for symptomatic simple renal cysts under multilevel paravertebral nerve block anesthesia.Methods:From December 2015 to September 2017,33 simple renal cyst patients who had surgical indications were enrolled.Under ultrasound guidance,the T10/T11,T11/T12,and T12/L1 paravertebral spaces were identified,and 7-10 mL 0.5%ropivacaine was injected at each segment.Then a puncture needle was placed inside the cyst cavity under ultrasonic monitoring.A guidewire was introduced followed by sequential dilation up to 28/30 Fr.The extra parenchymal portion of the cyst wall was dissociated and incised using a thulium laser,and a pathological examination was performed.Results:Sensory loss to pinprick from T8 to L1 and sensory loss to ice from T6 to L2 were observed in all patients.None of the patients complained of pain during surgery.No serious complications occurred perioperatively.After the surgery,all patients recovered their lower limb muscle strength quickly,got out of bed,resumed oral feeding,and left the hospital within 24 h of admission.The pathologic diagnosis of all cyst walls was a simple renal cyst.The mean follow-up was 35.8 months.At the end of follow-up,the cyst units were reduced in size by more than 50%compared to the preoperative size,and no patient experienced a recurrence.Conclusion:Multi-level paravertebral nerve block for percutaneous ureteroscopy laser unroofing as an ambulatory surgery mode is feasible,safe,and effective for the treatment of simple renal cysts in selected patients.

Predictive factors for percutaneous nephrolithotomy bleeding risks

Objective:This study aimed to identify predictive factors for percutaneous nephrolithotomy(PCNL)bleeding risks.With better risk stratification,bleeding in high-risk patient can be anticipated and facilitates early identification.Methods:A prospective observational study of PCNL performed at our institution was done.All adults with radio-opaque renal stones planned for PCNL were included except those with coagulopathy,planned for additional procedures.Factors including gender,co-morbidities,body mass index,stone burden,puncture site,tract dilatation size,operative position,surgeon's seniority,and operative duration were studied using stepwise multivariate regression analysis to identify the predictive factors associated with higher estimated hemoglobin(Hb)deficiency.Results:Overall,4.86%patients(n=7)received packed cells transfusion.The mean estimated Hb deficiency was 1.3(range 0-6.5)g/dL and the median was 1.0 g/dL.Stepwise multivariate regression analysis revealed that absence of hypertension(p=0.024),puncture site(p=0.027),and operative duration(p=0.023)were significantly associated with higher estimated Hb deficiency.However,the effect sizes are rather small with partial eta-squared of 0.037,0.066,and 0.038,respectively.Observed power obtained was 0.621,0.722,and 0.625,respectively.Other factors studied did not correlate with Hb difference.Conclusion:Hypertension,puncture site,and operative duration have significant impact on estimated Hb deficiency during PCNL.However,the effect size is rather small despite adequate study power obtained.Nonetheless,operative position(supine or prone),puncture number,or tract dilatation size did not correlate with Hb difference.The mainstay of reducing bleeding in PCNL is still meticulous operative technique.Our study findings also suggest that PCNL can be safely done by urology trainees under supervision in suitably selected patient,without increasing risk of bleeding.