Native Kidney Renal Cell Carcinoma in Renal Allograft Transplant Patients - Our Experience

The immunosuppression administered to renal transplant recipients to safeguard renal function elevates their susceptibility to renal cancer, which is estimated to be 15 times higher than in the general population. The current study aimed to analyze various aspects of native kidney renal cell carcinoma (RCC) in renal transplant recipients. This study involved a retrospective analysis of 11 patients who underwent nephrectomy for RCC in native kidneys among renal transplant recipients at our institution since 1992. Our institutional incidence was 0.4%. Median age at presentation was 57 (49-60) years. The ratio of male: female was 10:1. Most patients were asymptomatic at presentation and native kidney disease before transplantation was undetermined. In our study, the median time interval between diagnosis of RCC and transplant was 9.1 (8.4-11.2) years. All patients underwent native kidney nephrectomy. Clear cell type was more common than papillary type, 3.5 (2.5-4.2). Ten patients were diagnosed with stage I disease and one patient had stage IV disease. Fuhrman nuclear grading revealed low grades in nine patients and three patients had Grade 3. Immunosuppressive therapy modification was done in nine patients. Meticulous follow-up of renal transplant patients is essential for earlier diagnosis and appropriate treatment of native kidney RCC in transplant recipients. Authors recommend every year follow-up in transplant recipients with special emphasis on ultrasound of native kidney.

Native Kidney Renal Cell Carcinoma in Renal Allograft Transplant Patients - Our Experience

The immunosuppression administered to renal transplant recipients to safeguard renal function elevates their susceptibility to renal cancer, which is estimated to be 15 times higher than in the general population. The current study aimed to analyze various aspects of native kidney renal cell carcinoma (RCC) in renal transplant recipients. This study involved a retrospective analysis of 11 patients who underwent nephrectomy for RCC in native kidneys among renal transplant recipients at our institution since 1992. Our institutional incidence was 0.4%. Median age at presentation was 57 (49-60) years. The ratio of male: female was 10:1. Most patients were asymptomatic at presentation and native kidney disease before transplantation was undetermined. In our study, the median time interval between diagnosis of RCC and transplant was 9.1 (8.4-11.2) years. All patients underwent native kidney nephrectomy. Clear cell type was more common than papillary type, 3.5 (2.5-4.2). Ten patients were diagnosed with stage I disease and one patient had stage IV disease. Fuhrman nuclear grading revealed low grades in nine patients and three patients had Grade 3. Immunosuppressive therapy modification was done in nine patients. Meticulous follow-up of renal transplant patients is essential for earlier diagnosis and appropriate treatment of native kidney RCC in transplant recipients. Authors recommend every year follow-up in transplant recipients with special emphasis on ultrasound of native kidney.

Outcomes and predictors of clinical T1 renal mass (cT1) upstaged to pathological T3a (pT3a) after partial nephrectomy: A single-center experience

OBJECTIVES

Clinical T1 (cT1) renal mass treated surgically has a good prognosis, but there is an upstaging risk that potentially threatens oncological outcomes after partial nephrectomy (PN). We aim to analyze and study the incidence, predictors, perioperative morbidity, and oncological outcomes of pT3a upstaging.

METHODOLOGY

A retrospective study of 313 patients who underwent PN for cT1 renal mass at a single center from a single tertiary referral center between 2000 and 2021 was done. Demographic, perioperative, pathological, and outcome variables were reviewed. We compared these parameters between upstaged and non-upstaged groups. Multivariate logistic regression analysis was used to study preoperative variables associated with upstaging.

RESULTS

Nineteen patients were upstaged to pT3a. Making an incidence of 6.1%. Upstaged tumors were bigger (5.02 cm vs. 4.08 cm, p = 0.004), had higher clinical stage T1b (84.2 vs. 40.5%, p < 0.001), had more tumors which were central location (21 vs. 3.4%, p < 0.001), had more endophytic and mesophytic tumors (15.8 vs. 5.8% and 52.6 vs. 9.5%, p < 0.001), and had higher R.E.N.A.L Nephrometry score (8.05 vs. 6, p < 0.001). Upstaged tumors had more operative times (227 vs. 203 min, p = 0.01), more postoperative complications (68.4 vs. 13.1%, p < 0.001), more major complications of Clavien Dindo Grade 3 and above (15.8 vs. 4.4%, p < 0.001). Age (OR 1.035, p = 0.034), Radiological tumor dimension (OR 1.578, p = 0.003), Radiological or Clinical stage (T1b) (9.19, p = 0.008), Higher Nephrometry score (Intermediate and High) (OR 6.184, p = 0.004) were preoperative predictors of upstaging. Oncological outcomes were comparable.

CONCLUSION

Tumor upstaging was uncommon with more perioperative morbidity. Higher age, larger tumor size, higher tumor stage, and higher nephrometry scores were preoperative predictors of upstaging.

Prospective Randomized Controlled Trial to Compare Dusting vs Fragmentation Using Thulium Fiber Laser in Retrograde Intrarenal Surgery

Objective: To compare the dusting vs fragmentation modes with thulium fiber laser (TFL) in retrograde intrarenal surgery (RIRS) for upper tract stones using the same fixed low-power settings in both the arms. The primary objective was to compare the stone-free rate (SFR) and secondary objectives were to compare mean operating times, hospital stay duration, complication rates, need for secondary procedures, and laser efficacy. Materials and Methods: A prospective randomized trial, with patients having proximal ureteral or renal stones of 10-20 mm and planned for RIRS was done at a single institute. A total of 60 consecutively admitted patients with signed consent were included for randomization with 30 patients in each arm of dusting and fragmentation modes. Results: Median age in dusting and fragmentation arms of 41.5 and 45.5 years, median stone size of 10.45 and 12.25 mm, median stone volume of 351.6 and 490.7 mm3, and median stone density of 1263.5 HU in both arms with comparable hospital stay of median of 2 days in both arms. Lasing time was significantly lesser in the fragmentation group (20.5 minutes; interquartile range [IQR] 15.12-31.62) than in the dusting group (34.25 minutes, IQR 26.62-38.62, p < 0.001). Higher ablation speed for fragmentation mode (0.405 mm3/sec, IQR 0.337-0.635) than for dusting mode (0.17 mm3/sec, IQR 0.135-0.325, p < 0.001). SFRs and complication rates were comparable in both the arms. Conclusion: TFL in fragmentation mode has shorter lasing times and better laser efficacy than dusting mode with comparable minimal complications, SFRs, and hospital stay duration. Clinical Trial Registration number: CTRI050827.

Adverse health outcomes among people who inject drugs who engaged in recent sex work: findings from a national survey

OBJECTIVES

This study explores trends in sex work among people who inject drugs (PWID) by gender and the relationship between sex work and adverse health outcomes including overdose, injection-site, and blood-borne virus (BBV) infections.

STUDY DESIGN

The Unlinked Anonymous Monitoring Survey of PWID is an annual cross-sectional survey that monitors BBV prevalence and behaviours, including transactional sex, among PWID recruited through specialist services in England, Wales, and Northern Ireland.

METHODS

Trends in sex work among PWID (2011-2021) were described. Data were analysed to assess differences between PWID who engaged in sex work in the past year (sex workers [SWs]) and those who did not (non-SWs) by gender (Pearson Chi2 tests) (2018-2021). Associations between sex work in the past year and adverse health outcomes were investigated using logistic regression.

RESULTS

Between 2011 and 2021, sex work among PWID remained stable, with 31% of women and 6.3% of men who inject, reporting having ever engaged in sex work, and 14% of women and 2.2% of men engaging in sex work in the past year. Between 2018 and 2021, SWs had greater odds of reporting symptoms of an injection-site infection (adjusted odds ratio (aOR): 1.68 [95% confidence interval {CI}: 1.31-2.16], P < 0.001) and reporting overdose (aOR: 2.21 [CI: 1.74-2.80], P < 0.001) than non-SWs had in the past year. Among men, SWs had 243% greater odds of having HIV than non-SWs (aOR: 3.43 [CI: 1.03-11.33], P = 0.043).

CONCLUSIONS

Our findings highlight disproportionate vulnerability and intersection of overlapping risk factors experienced by PWID SWs and a need for tailored interventions which are inclusive and low-threshold.

A rapid review of antenatal hepatitis C virus testing in the United Kingdom

BACKGROUND

The United Kingdom (UK) has committed to the World Health Organization's viral hepatitis elimination targets. New case finding strategies, such as antenatal testing, may be needed to achieve these targets. We conducted a rapid review to understand hepatitis C-specific antibody (anti-HCV) and HCV RNA test positivity in antenatal settings in the United Kingdom to inform guidance.

METHODS

Articles and conference abstracts published between January 2000 and June 2022 reporting anti-HCV testing in antenatal settings were identified through PubMed and Web of Science searches. Results were synthesised using a narrative approach.

RESULTS

The search identified 2,011 publications; 10 studies were included in the final synthesis. Seven studies used anonymous testing methods and three studies used universal opt-out testing. Anti-HCV test positivity ranged from 0.1 to 0.99%, with a median value of 0.38%. Five studies reported HCV RNA positivity, which ranged from 0.1 to 0.57% of the testing population, with a median value of 0.22%. One study reported cost effectiveness of HCV and found it to be cost effective at £9,139 per quality adjusted life years.

CONCLUSION

The relative contribution of universal opt-out antenatal testing for HCV should be reconsidered, as antenatal testing could play an important role in new case-finding and aid achieving elimination targets.

A randomized controlled trial comparing infectious complications using mini perc with and without suction for renal stones less than 3 cm in size

The purpose was to do a study to compare infectious complications in patients operated for MiniPerc or Minimally invasive Percutaneous Nephrolithotomy (MPCNL) using MIP and MPCNL with suction using Shah Superperc sheath for medium-sized renal stones less than 3 cm in size. The primary objective of this study is to compare the infectious complications and the secondary objectives are to compare stone-free rates, complication rates and operative times. A prospective randomized controlled trial with patients having proximal ureteral and renal stones of 10-30 mm size and planned for MPCNL done at a single institute. A total of 80 consecutively admitted patients with written informed consent were included for randomization with 40 patients in each arm of MPCNL and suction MPCNL. The median age in MPCNL and suction MPCNL arms were 48 and 49 years, the median stone size of 15.45 and 16.7 cm, the Median stone volume of 1576.2 vs 1752 mm3, and the median stone density of 1258 and 1250 Hu, the median hospital stay of 3 days in both arms were comparable. Infectious complications were comparable in both arms. Operative time was significantly less in the suction MPCNL group (26.5 min-IQR 17-34.8) than in the MPCNL group (34.8 min-IQR 20-45), p = 0.021 and stone-free rates (SFR), were more in Suction MPCNL arm 97.5% than in MPCNL 87.5%, p = 0.04. Overall, the complication rates were comparable in both arms. Suction MPCNL procedure resulted in shorter operating times and more SFR than conventional MPCNL with comparable complication rates.

A multicentric non-randomized prospective observational study on the clinical efficiency of thulium fibre laser in large volume stones (> 1000 mm3)

PURPOSE

Our objective was to analyse the clinical efficiency of TFL in large volume stones during retrograde intrarenal surgery.

MATERIALS AND METHODS

Patients with large volume renal stones (> 1000 mm3) operated at two different centres, from May 2020 to April 2021, were enrolled in this study. Retrograde intrarenal surgery was performed using 60W Superpulse thulium fibre laser™ (IPG Photonics, Russia). Demographic data, stone parameters, laser time, and total operating time were recorded, and laser efficacy (J/mm3) and ablation speed (mm3/s) were calculated. NCCT KUB was done at 3 months postoperatively to calculate stone-free rate.

RESULTS

A total of 76 patients were included and analysed in the study. Mean stone volume was 1753.12 ± 1245.81 (1169.27-2193.25) mm3, mean stone density was 1104.46 ± 313.09 (875.00-1317.00) HU, mean laser time was 537.79 ± 689.89 (21.00-1080.00) sec, mean operating time was 43.38 ± 12.96 (35.00-51.25) min, mean laser efficacy was 20.30 ± 15.5 (8.88-25.57) J/mm3, and mean ablation speed was 1.32 ± 0.7 (0.82-1.64) mm3/sec. A strong positive correlation was found between the stone volume and ablation speed (r = 0.659, p = 0.000), and a moderate negative correlation was found between the stone volume and laser efficacy (J/mm3) (r = - 0.392, p = 0.000). With increasing volume of the stone, J/mm3 decreased significantly and ablation speed increased significantly (p < 0.001). Complications occurred in 21.05% (16/76) patients, most of which were Clavien grades 1-2. Overall SFR is 96.05%.

CONCLUSION

Laser efficiency increases at higher stone volumes (> 1000 mm3), as less energy is required to ablate every mm3 of stone.

Cutaneous lymphangitis carcinomatosa: a unique presentation of a rare disease

A 75-year-old man with a three-year history of metastatic lung adenocarcinoma was diagnosed with cutaneous lymphangitic carcinomatosa of unique morphology. He was admitted to our hospital for right neck swelling, erythema, and failure to thrive. Skin examination demonstrated an indurated, thickened, firm, hyperpigmented plaque extending from the right neck and chest to the right ear, cheek, and eyelids. Skin biopsy demonstrated poorly differentiated adenocarcinoma, morphologically consistent with metastasis from the patient's known pulmonary adenocarcinoma and showed dermal invasion, perineural invasion, and involvement of dermal lymphatics. The diagnosis was an atypical presentation of cutaneous lymphangitis carcinomatosa from metastatic lung adenocarcinoma. This case presentation affirms that cutaneous lymphangitis carcinomatosa has a variety of atypical presentations, so physicians must maintain a high index of suspicion when evaluating cutaneous lesions in patients with known or suspected internal malignancy.

Outcomes of Hem-o-Lok clip migration at vesico-urethral anastomotic site post-robotic-assisted laparoscopic radical prostatectomy: a single centre experience

BACKGROUND

Robotic-assisted laparoscopic prostatectomy (RALP) is the most preferred intervention for the management of prostatic malignancy worldwide. Hem-o-Lok clips (HOLC) are widely used for haemostasis and lateral pedicle ligation. These clips are prone to migrate and lodge at the anastomotic junction as well as inside the bladder causing lower urinary tract symptoms (LUTS) secondary to bladder neck contracture (BNC) or bladder calculi. The objective of this study is to describe the incidence, clinical presentation, management, and outcome of HOLC migration.

METHODOLOGY

Retrospective analysis of the database of Post RALP patients who developed LUTS secondary to HOLC migration was done. Cystoscopy findings, number of procedures required, number of HOLC removed intra-operatively, and follow-up of the patients was reviewed.

RESULTS

The incidence of HOLC migration requiring intervention was 1.78% (9/505). The mean age of the patient, BMI, Pre-operative Serum PSA were 62.8 years, 27.8 kg/m², and 9.8 ng/mL, respectively. The mean duration of appearance of symptoms due to HOLC migration was 9 months. Two patients presented with Haematuria and 7 presented with LUTS. Seven patients required a single intervention while 2 required up to 6 procedures for recurrent symptoms secondary to recurrent HOLC migration.

CONCLUSION

HOLC use in RALP may present with migration and associated complications. HOLC migration is associated with severe BNC and may require multiple endoscopic interventions. Severe dysuria and LUTS not responding to medical management should be treated using an algorithmic approach and there should be a low threshold for performing cystoscopy and intervention in these cases to improve outcomes.

Monoclonal antibody and protein therapeutic formulations for subcutaneous delivery: high-concentration, low-volume vs. low-concentration, high-volume

Biologic drugs are used to treat a variety of cancers and chronic diseases. While most of these treatments are administered intravenously by trained healthcare professionals, a noticeable trend has emerged favoring subcutaneous (SC) administration. SC administration of biologics poses several challenges. Biologic drugs often require higher doses for optimal efficacy, surpassing the low volume capacity of traditional SC delivery methods like autoinjectors. Consequently, high concentrations of active ingredients are needed, creating time-consuming formulation obstacles. Alternatives to traditional SC delivery systems are therefore needed to support higher-volume biologic formulations and to reduce development time and other risks associated with high-concentration biologic formulations. Here, we outline key considerations for SC biologic drug formulations and delivery and explore a paradigm shift: the flexibility afforded by low-to-moderate-concentration drugs in high-volume formulations as an alternative to the traditionally difficult approach of high-concentration, low-volume SC formulation delivery.

Robot-assisted versus conventional open kidney transplantation: a propensity matched comparison with median follow-up of 5 years

BACKGROUND

RAKT is a relatively newer approach for kidney transplant and has to be proven against the established approach, OKT. RAKT may be beneficial in obese patients as described in literature. Hence, we compared pre-, intra- and postoperative parameters with one year follow-up of both approaches by propensity matching similar characteristics patients.

METHODS

Data of 28 OKT and 28 RAKT propensity matched patients was collected during 2014 to 2022 through the institutional transplant registry. OKT and RAKT patients were propensity matched for confounding factors like donor age, eGFR, side along with recipient age, BMI and comorbidities. All graft kidneys were harvested laparoscopically.

RESULTS

Both the groups were comparable in terms of recipient age and BMI, donor age, creatinine, BMI, eGFR and comorbidities. Total ischemia time (P<0.001) and postoperative day (POD) 1 creatinine (P<0.001) was significantly more in RAKT. However, postoperative 1 month (P=0.12), 3 months (P=0.60) and 1 year (P=0.10) creatinine was comparable in both approaches. Postoperative complications (P=0.90) including hemoglobin drop (P=0.72) were comparable in both the groups. The days to half the creatinine from preoperative values was significantly less in OKT group (P=0.009). Serum Tacrolimus levels at day 3 (P=0.08) and day 7 (P=0.112) were also comparable in both the groups. Graft survival was 78.5% in OKT group and 82.14% in RAKT group with median follow-up of 60 months in both the groups.

CONCLUSION

In this comprehensive propensity matched analysis of RAKT with OKT, we conclude that RAKT has similar outcomes as OKT at 1 year and 5 years follow-up. CIT, TIT, time to half creatinine and POD 1 creatinine values were higher in RAKT group, but eventually have comparable outcomes at further follow-up. Thus, RAKT, a novel approach is non-inferior to established OKT approach. However, further larger trials are required.

Can we predict the ancillary treatments after extracorporeal shockwave lithotripsy for renal and upper ureteral stones?

OBJECTIVE

To quantify the predictors for the ancillary treatments after extracorporeal shock wave lithotripsy (SWL) for renal and upper ureteral stones.

MATERIALS AND METHODS

From January 2014 to January 2017, patients undergoing SWL using an electromagnetic lithotripter machine (Compact Delta; Dornier MedTech GmbH, Wessling, Germany) for renal and upper ureteral stones ≤ 20 mm were retrospectively reviewed. All patients underwent CT urography prior to SWL. The cohort was subdivided into three groups according to stone attenuation values in Hounsfield Units (HU). Group I; HU < 500 (n = 20), group II; HU 500-1000 (n = 51) and group III; HU ≥ 1000 (n = 180). The parameters included for multivariate analysis were stone size, location, multiplicity, stone attenuation value, number of shocks and stone clearance rate by 3 months. The ancillary treatments were ureteroscopy (URS), ureteral stenting and hospital readmission for pain or fever.

RESULTS

A total of 251 patients were included in the study. The overall SWL success rate was 92.4%. Mean stone size was 10.9 ± 2.1, 11.6 ± 3 and 11.4 ± 3.6 mm and mean stone attenuation values were 364 ± 125, 811 ± 154 and 1285 ± 171 HU for groups I, II and III respectively. The stone clearance rates by 3 months were 96%, 92% and 88.4% for groups I, II and III respectively. On subgroup analysis, group III required ancillary treatments in 70% of patients whereas group I, II, did not require any ancillary treatments. On multivariate analysis, stone multiplicity, stone location (lower calyceal stones) and HU were independent significant predictors for the need for ancillary treatments after SWL (p values < 0.05).

CONCLUSIONS

Patients with stone attenuation value (HU) > 1000, multiple stones and/or lower calyceal stones have higher risk to necessitate ancillary treatments after SWL. These patients would likely benefit from upfront endoscopic lithotripsy for treating symptomatic renal or upper ureteral stones.

Inner southern magnetosphere observation of Mercury via SERENA ion sensors in BepiColombo mission

Mercury's southern inner magnetosphere is an unexplored region as it was not observed by earlier space missions. In October 2021, BepiColombo mission has passed through this region during its first Mercury flyby. Here, we describe the observations of SERENA ion sensors nearby and inside Mercury's magnetosphere. An intermittent high-energy signal, possibly due to an interplanetary magnetic flux rope, has been observed downstream Mercury, together with low energy solar wind. Low energy ions, possibly due to satellite outgassing, were detected outside the magnetosphere. The dayside magnetopause and bow-shock crossing were much closer to the planet than expected, signature of a highly eroded magnetosphere. Different ion populations have been observed inside the magnetosphere, like low latitude boundary layer at magnetopause inbound and partial ring current at dawn close to the planet. These observations are important for understanding the weak magnetosphere behavior so close to the Sun, revealing details never reached before.

Laparoscopic ureteric reimplantation versus robotic-assisted laparoscopic ureteric reimplantation for lower ureter pathology: Single-institutional comparative study

OBJECTIVE

To compare and analyze the results of laparoscopic ureteric reimplantation and robotic-assisted ureteric reimplantation at our tertiary institute.

MATERIALS AND METHODS

We retrospectively reviewed data of adult patients who underwent laparoscopic ureteric reimplantation and robotic-assisted ureteric reimplantation between January 2000 and December 2020. Data were analyzed for 19 patients in the laparoscopic group and 47 patients in the robotic group. The data were compared in both the groups.

RESULTS

The most common presentation was flank pain (67.89%) followed by recurrent UTI (21.05%) in both the groups. The baseline characteristics and demographic data including age, gender, laterality, Charlson comorbidity index, and BMI were comparable in both the groups. The time range from previous surgeries to presentation varied from 7 days to 5 years. There is statistically significant difference between the operative time in the laparoscopic (224.23 ± 76.61 min) and robotic groups (187.06 ± 52.81 min) (p = 0.027). There is statistically significant difference between the hospital stay also between the two groups (9.07 ± 2.75 vs. 6 ± 1.65 days p-0.001). There were no differences in the complication rate and postoperative outcomes in both the groups. Mean length of follow-up was 28 ± 25.5 (2-108) months and 20.57 ± 19.91 (2-96) months in both the groups, respectively. The success rates in terms of symptomatic improvement, decrease in hydronephrosis, and improved drainage in the laparoscopic and robotic groups were 94.73% and 95.45%, respectively, which were statistically not significant.

CONCLUSIONS

Robotic ureteric reimplantation and laparoscopic ureteric reimplantation are comparable in clinical outcomes. Robotic-assisted laparoscopic ureteric reimplantation is feasible, safe, and faster with excellent outcomes, decreased hospital stay, and minimal complications.

Parker Solar Probe Observations of Solar Wind Energetic Proton Beams Produced by Magnetic Reconnection in the Near-Sun Heliospheric Current Sheet

We report observations of reconnection exhausts in the Heliospheric Current Sheet (HCS) during Parker Solar Probe Encounters 08 and 07, at 16 R _s and 20 R _s , respectively. Heliospheric current sheet (HCS) reconnection accelerated protons to almost twice the solar wind speed and increased the proton core energy by a factor of ∼3, due to the Alfvén speed being comparable to the solar wind flow speed at these near-Sun distances. Furthermore, protons were energized to super-thermal energies. During E08, energized protons were found to have leaked out of the exhaust along separatrix field lines, appearing as field-aligned energetic proton beams in a broad region outside the HCS. Concurrent dropouts of strahl electrons, indicating disconnection from the Sun, provide further evidence for the HCS being the source of the beams. Around the HCS in E07, there were also proton beams but without electron strahl dropouts, indicating that their origin was not the local HCS reconnection exhaust.

Initial Safety and Feasibility of Steerable Ureteroscopic Renal Evacuation (SURE), A Novel Approach for the Treatment of Urolithiasis

Background:

There is a need to reliably render urolithiasis patients completely stone free with minimal morbidity. We report on the initial safety and feasibility with steerable ureteroscopic renal evacuation (SURE) in a prospective study using basket extraction as a comparison.

Materials and Methods:

A pilot randomized controlled study was conducted comparing SURE with basket extraction postlaser lithotripsy. SURE is performed using the CVAC™ Aspiration System, a steerable catheter (with introducer). The safety and feasibility of steering CVAC throughout the collecting system under fluoroscopy and aspirating stone fragments as it was designed to do were evaluated. Fluoroscopy time, change in hemoglobin, adverse events through 30 days, total and proportion of stone volume removed at 1 day, intraoperative stone removal rate, and stone-free rate (SFR) at 30 days through CT were compared.

Results:

Seventeen patients were treated (n = 9 SURE, n = 8 Basket). Baseline demographics and stone parameters were not significantly different between groups. One adverse event occurred in each group (self-limiting ileus for SURE and urinary tract infection for Basket). No mucosal injury and no contrast extravasation were observed in either group. The CVAC catheter was steered throughout the collecting system and aspirated fragments. There was no significant difference in fluoroscopy time, procedure time, change in hemoglobin, or stone removal rate between groups. SURE removed more and a greater proportion of stone volume at day 1 vs baskets (202 mm³vs 91 mm³, p < 0.01 and 84% vs 56%, p = 0.022). SURE achieved 100% SFR at 30 days vs 75% for baskets, although this difference was not statistically significant (p = 0.20).

Conclusions:

This initial study suggests SURE is safe, feasible, and may be more effective in stone removal postlaser lithotripsy compared to basketing. More development is needed, and larger clinical studies are underway.

Holmium with MOSES technology or Thulium Fiber Laser in Miniperc with suction - A new curiosity

PURPOSE

To present initial clinical comparison between high-power Holmium with MOSES technology(HPH-M) and Thulium Fiber laser(TFL) during mini-PCNL for renal calculi with specific emphasis on fragmentation efficiency, fragment size distribution and stone-free rates(SFR).

MATERIAL AND METHODS

Between Aug2018-Dec2019, we performed mini-PCNL for renal calculi <3cm using HPH-M(Lumenis, Israel) or TFL(Urolase SP, IPG Photonics). Data was collected prospectively in our institutional stone registry. Propensity score matching(1:1) was performed using stone size and density as predictors resulting in matched cohort of 51 patients in each group. MiniPCNL with active suction sheath was standard across all patients. Primary end-point was SFR at immediate post-procedure and 1month using CT/Xray KUB. Stone fragments were retrieved and segregated to assess proportion of dust(<1mm), small(1-3mm) and large(>3mm) fragments.

RESULT

Both groups were comparable in terms of stone size(p=0.74), volume(p=0.17) and density(p=0.69). SFR at 48 hours was 78.43% in HPH-M group and 68.63 % in TFL group. Patients with residual fragments were completely clear at 1month. Lasing time(678.6v/s551.95 seconds;p=0.17), stone fragmentation rate(4.6v/s5.2 mm3/s;p=0.23) and total laser energy(21.9v/s16.3KJ;p=0.09) were comparable in both arms. Both groups produced similar dusting (46.8v/s46.41%;p=0.93). TFL produced a greater proportion of fragments >3mm(36%v/s22.68%, p=0.002). On sub-set analysis based on stone density, all outcome parameters were comparable except a shorter total operative time with TFL (p=<0.05).

CONCLUSION

HPH-M and TFL showed similar SFR. Within constraints of the laser fiber size and energy settings, both modalities were equivalent in terms of fragmentation efficiency and proportion of dusting across stone densities.

A deep learning system for prostate cancer diagnosis and grading in whole slide images of core needle biopsies

Gleason grading, a risk stratification method for prostate cancer, is subjective and dependent on experience and expertise of the reporting pathologist. Deep Learning (DL) systems have shown promise in enhancing the objectivity and efficiency of Gleason grading. However, DL networks exhibit domain shift and reduced performance on Whole Slide Images (WSI) from a source other than training data. We propose a DL approach for segmenting and grading epithelial tissue using a novel training methodology that learns domain agnostic features. In this retrospective study, we analyzed WSI from three cohorts of prostate cancer patients. 3741 core needle biopsies (CNBs) received from two centers were used for training. The κquad (quadratic-weighted kappa) and AUC were measured for grade group comparison and core-level detection accuracy, respectively. Accuracy of 89.4% and κquad of 0.92 on the internal test set of 425 CNB WSI and accuracy of 85.3% and κquad of 0.96 on an external set of 1201 images, was observed. The system showed an accuracy of 83.1% and κquad of 0.93 on 1303 WSI from the third institution (blind evaluation). Our DL system, used as an assistive tool for CNB review, can potentially improve the consistency and accuracy of grading, resulting in better patient outcomes.

A prospective comparative study of mini-PCNL using Trilogy™ or thulium fibre laser with suction

INTRODUCTION

There has been recent introduction of novel lithotripters and high-power lasers for stone disintegration. With miniaturization of PCNL, there is need of effective disintegration and faster stone-clearance. This study aimed to evaluate efficiency of Trilogy™ and Thulium fibre laser (TFL) in mini-percutaneous nephrolithotomy (mini-PCNL).

METHODS

This is prospective study comparing efficiency and outcomes of Trilogy™ and TFL in mini-PCNL between January 2019 and February 2020. Primary objective was to compare stone fragmentation rates, with secondary objectives beings stone-free rates and complications.

RESULTS

There were 60 mini-PCNL with suction using either Trilogy™ or TFL energy source. Mean stone size and density were 27.60 ± 10.17 mm, 22.04 ± 9.69 mm (p = 0.05) and 1172.9 ± 313.5HU, 1308.9 ± 333.9HU (p = 0.10) for Trilogy™ and TFL, respectively. Using 3D doctor imaging software from CT images, mean stone volumes were 3718.9 ± 3038.7mm³ for Trilogy™ and 3425.9 ± 3096.1mm³ for TFL(p = 0.77). Using probe-activation time or lasing time, stone-fragmentation rate was 5.98 ± 4.25mm³/sec for Trilogy™ and 3.95 ± 1.00mm³/sec for TFL(p = 0.015). Treatment time (puncture to complete clearance) was 32.48 ± 15.39 min for Trilogy™ and 28.63 ± 18.56 min for TFL(p = 0.38). Haemoglobin drop was 1.19 ± 0.76gm/dl for Trilogy™ and 0.99 ± 0.74gm/dl for TFL (p = 0.30). Trilogy™ arm had 96.6% complete clearance and TFL had 76.6% in TFL at 48 h. One patient in Trilogy™ arm required auxiliary RIRS for residual stone. Both arms had complete stone clearance at 1 month follow-up. Trilogy™ arm had 3 Clavien-Dindo grade-II complications while TFL had 2 Clavien-Dindo grade-II complications (UTI requiring antibiotics). There was no blood transfusion in either of arm.

CONCLUSION

Trilogy™ had significantly better stone fragmentation rate than TFL in managing renal stones. However, stone-free rates and complications were comparable for Trilogy™ and TFL.

Super-mini percutaneous nephrolithotomy (SMP) vs retrograde intrarenal surgery (RIRS) in the management of renal calculi ≤ 2 cm: a propensity matched study

Objective

To compare the effectiveness and safety of Super-Mini PCNL (SMP) and Retrograde Intrarenal Surgery (RIRS) in the management of renal calculi ≤ 2 cm.

Patients and methods

A prospective, inter-institutional, observational study of patients presenting with renal calculi ≤ 2 cm. Patients underwent either SMP (Group 1) or RIRS (Group 2) and were performed by 2 experienced high-volume surgeons.

Results

Between September 2018 and April 2019, 593 patients underwent PCNL and 239 patients had RIRS in two tertiary centers. Among them, 149 patients were included for the final analysis after propensity-score matching out of which 75 patients underwent SMP in one center and 74 patients underwent RIRS in the other. The stone-free rate (SFR) was statistically significantly higher in Group 1 on POD-1 (98.66% vs. 89.19%; p = 0.015), and was still higher in Group 1 on POD-30 (98.66% vs. 93.24%, p = 0.092) SFR on both POD-1 and POD-30 for lower pole calculi was higher in Group 1 (100 vs. 82.61%, p = 0.047 and 100 vs 92.61% p = 0.171). The mean (SD) operative time was significantly shorter in Group 1 at 36.43 min (14.07) vs 51.15 (17.95) mins (p < 0.0001). The mean hemoglobin drop was significantly less in Group 1 (0.31 vs 0.53 gm%; p = 0.020). There were more Clavien–Dindo complications in Group 2 (p = 0.021). The mean VAS pain score was significantly less in Group 2 at 6 and 12 h postoperatively (2.52 vs 3.67, 1.85 vs 2.40, respectively: p < 0.0001), whereas the mean VAS pain score was significantly less in Group 1 at 24 h postoperatively (0.31 vs 1.01, p < 0.0001). The mean hospital stay was significantly shorter in Group 1 (28.37 vs 45.70 h; p < 0.0001).

Conclusion

SMP has significantly lower operative times, complication rates, shorter hospital stay, with higher stone-free rates compared to RIRS. SMP is associated with more early post-operative pain though.

Feasibility, preliminary efficacy, and accessibility of a twitter-based social support group vs Fitbit only to decrease sedentary behavior in women

BACKGROUND

Health behavior change interventions delivered by social media allow for real-time, dynamic interaction, peer social support, and experimenter-provided content.

AIMS

We tested the feasibility, acceptability, and preliminary efficacy of a novel Twitter-based walking break intervention with daily behavior change strategies and prompts for social support, combined with a Fitbit, vs. Fitbit alone.

METHODS

In a 2-group pilot, 45 sedentary women from a heart clinic were randomized to Twitter + Fitbit activity tracker (Tweet4Wellness, n = 23) or Fitbit-only (control, n = 22). All received a Fitbit and 13 weeks of tailored weekly step goals. Tweet4Wellness consisted of a private Twitter support group, with daily automated behavior change "tweets" informed by behavior change theory, and encouragement to communicate within the group. Feasibility outcomes included recruitment and enrollment numbers, implementation challenges, and number and type of help requests from participants throughout the study period. Preliminary efficacy outcomes provided by Fitbit data were sedentary minutes, number of hours with >250 steps, maximum sitting bout, weighted sedentary median bout length, total steps, intensity minutes (>3.0 METS), and ratio of time spent sitting-to-moving. Acceptability outcomes included level of Twitter participation within Tweet4Wellness, and Likert scale plus open-ended survey questions on enjoyment and perceived effectiveness of intervention components. Survey data on acceptability of the features of the intervention were collected at 13 weeks (end-of-treatment [EOT]) and 22 weeks (follow-up).

RESULTS

The study was feasible, with addressable implementation challenges. Tweet4Wellness participants changed significantly from baseline to EOT relative to control participants on number of active hours p = .018, total steps p = .028, and ratio of sitting-to-moving, p = .014. Only sitting-to-moving was significant at follow-up (p = .047). Among Tweet4Wellness participants, each tweet sent during treatment was associated with a 0.11 increase in active hours per day (p = .04) and a 292-step increase per day (p < .001). Tweet4Wellness participants averaged 54.8 (SD = 35.4) tweets, totaling 1304 tweets, and reported liking the accountability and peer support provided by the intervention.

CONCLUSION

A Twitter-delivered intervention for promoting physical activity among inactive women from a heart clinic was feasible, acceptable, and demonstrated preliminary efficacy in increasing daily active hours, daily total steps, and the ratio of sitting-to-moving from pre to post for the intervention compared with the control. Lessons learned from this pilot suggest that the next study should expand the recruitment pool, refine the intervention to increase group engagement, and select active hours, total steps, and ratio of sitting-to-movement as primary sedentary behavior measures.

Tips and Tricks to Improve Ergonomics, Efficacy, Versatility, and Overcome Limitations of Micro Percutaneous Nephrolithotomy

Percutaneous Nephrolithotomy (PCNL) has evolved over the decades from Standard to Mini to Ultramini PCNL to Micro-perc, with miniaturisation being the dominant theme and supine approach gaining momentum world over.

Aim: In literature, miniaturised PCNL with microperc needle access system has raised concerns of intrarenal pressure and has some limitations with its success for larger stones. Our tips and tricks explain how to overcome these pitfalls by utilising the full construct of the needle system to its maximum potential. These will in turn help make the procedure versatile, precise, ergonomical, and enhance a surgeon's experience with improved outcomes for patients especially in large renal stones.

Materials and Methods: We describe the limitations of microperc needle access as stated in literature and proposals by the co-authors using microperc for miniaturised access on how to overcome the same.

Results: A simplified table describing the limitations and tips and tricks on overcoming these is provided for quick reference.

Conclusion: As Technological advancements and techniques for miniaturised access in urolithiasis improve, we believe our suggestions will help surgeons overcome the quoted limitations of microperc needle access for miniaturised PCNL, making this a versatile, safe and efficacious technique even in large and complex stones. A multi centre trial will be the best way to validate the suggestions proposed in this article.

European Association of Urology Section of Urolithiasis and International Alliance of Urolithiasis Joint Consensus on Percutaneous Nephrolithotomy

CONTEXT

Although percutaneous nephrolithotomy (PCNL) has been performed for decades and has gone through many refinements, there are still concerns regarding its more widespread utilization because of the long learning curve and the potential risk of severe complications. Many technical details are not included in the guidelines because of their nature and research protocol.

OBJECTIVE

To achieve an expert consensus viewpoint on PCNL indications, preoperative patient preparation, surgical strategy, management and prevention of severe complications, postoperative management, and follow-up.

EVIDENCE ACQUISITION

An international panel of experts from the Urolithiasis Section of the European Association of Urology, International Alliance of Urolithiasis, and other urology associations was enrolled, and a prospectively conducted study, incorporating literature review, discussion on research gaps (RGs), and questionnaires and following data analysis, was performed to reach a consensus on PCNL.

EVIDENCE SYNTHESIS

The expert panel consisted of 36 specialists in PCNL from 20 countries all around the world. A consensus on PCNL was developed. The expert panel was not as large as expected, and the discussion on RGs did not bring in more supportive evidence in the present consensus.

CONCLUSIONS

Adequate preoperative preparation, especially elimination of urinary tract infection prior to PCNL, accurate puncture with guidance of fluoroscopy and/or ultrasonography or a combination, keeping a low intrarenal pressure, and shortening of operation time during PCNL are important technical requirements to ensure safety and efficiency in PCNL.

PATIENT SUMMARY

Percutaneous nephrolithotomy (PCNL) has been a well-established procedure for the management of upper urinary tract stones. However, according to an expert panel consensus, core technical aspects, as well as the urologist's experience, are critical to the safety and effectiveness of PCNL.

A Single-Center Prospective Comparative Study of Two Single-Use Flexible Ureteroscopes: LithoVue (Boston Scientific, USA) and Uscope PU3022a (Zhuhai Pusen, China)

Introduction and Objective: Single-use flexible ureteroscopes have the benefit of decreasing infection transmission, avoiding sterilization need, and no maintenance cost. Primary objective was to compare in vivo performance and surgical outcomes with two single-use ureteroscopes: LithoVue (Boston Scientific, USA) and Uscope PU3022a (Zhuhai Pusen, China) with secondary objective being to compare in vivo vision by independent endourologist blinded to ureteroscope manufacturer. Materials and Methods: Fifty patients undergoing retrograde intrarenal surgery with <2 cm renal stones were prospectively allocated: Group 1 (25 patients) for LithoVue and group 2 (25 patients) for Uscope. Pre-, intra-, and postoperative parameters were evaluated. Vision of both ureteroscopes with and without accessory was evaluated by an independent endourologist, blinded to the make of the ureteroscope. Stone clearance was assessed with kidney, ureter, and bladder radiograph (KUB) and ultrasonography KUB at 1 month. Student's t-test for quantitative and chi-square for categorical data was used. Results: Pre- and intraoperative parameters such as need for ureteral dilatation (p > 0.05), ureteral access-sheath size (p = 0.78), accessibility to pelvicaliceal system (p > 0.05), and maneuverability (p > 0.05) were comparable in both groups. Lower-pole access was possible in all cases of LithoVue and slightly difficult in three cases of Uscope (p > 0.5). Intraoperative vision was hazy in four cases of LithoVue and eight cases of Uscope (p = 0.32) during lasing along with three cases of Uscope with accessory (p = 0.24). Blinded endourologist reported more cases of hazy vision with or without accessory or lasing in Uscope arm (p > 0.05). One device had malfunction in LithoVue arm. Complete stone clearance was achieved in all cases at 1 month. Conclusions: We conclude that performance of these two single-use ureteroscopes, LithoVue and Uscope, is comparable in clinical settings with similar clinical outcomes and complications.

SERENA: Particle Instrument Suite for Determining the Sun-Mercury Interaction from BepiColombo

The ESA-JAXA BepiColombo mission to Mercury will provide simultaneous measurements from two spacecraft, offering an unprecedented opportunity to investigate magnetospheric and exospheric particle dynamics at Mercury as well as their interactions with solar wind, solar radiation, and interplanetary dust. The particle instrument suite SERENA (Search for Exospheric Refilling and Emitted Natural Abundances) is flying in space on-board the BepiColombo Mercury Planetary Orbiter (MPO) and is the only instrument for ion and neutral particle detection aboard the MPO. It comprises four independent sensors: ELENA for neutral particle flow detection, Strofio for neutral gas detection, PICAM for planetary ions observations, and MIPA, mostly for solar wind ion measurements. SERENA is managed by a System Control Unit located inside the ELENA box. In the present paper the scientific goals of this suite are described, and then the four units are detailed, as well as their major features and calibration results. Finally, the SERENA operational activities are shown during the orbital path around Mercury, with also some reference to the activities planned during the long cruise phase.

Validity of a Novel Chicken and Porcine Model for Laparoscopic Neobladder Reconstruction

Introduction: Simulation-based training in laparoscopic urology is essential, as these surgeries require a skill set different from routine urologic procedures. We aim to describe and validate the chicken and porcine intestine model for laparoscopic neobladder reconstruction. Materials and Methods: Prospective observational study was conducted at our institute. Twenty novice and 20 trained laparoscopic surgeons were included in the study. The relevant chicken anatomy and surgical steps were described to all the surgeons. The surgeons were asked to fill a nine-point questionnaire after completing the exercise comprising bowel organization, ability to do urethroneovesical anastomosis, suturing time, suturing similarity, quality of suturing, tissue feel, integrity of anastomosis, realism, and usefulness of model after finishing the procedure, and score it on a scale of 1-5. Time taken to perform the entire exercise was noted in addition. An independent expert observer retrospectively rated the urethroneovesical anastomosis on a scale of 1-5. Results: All the participants in the study gave a mean score of 3.5 or more to all the questions asked in the questionnaire. Both the groups rated the usefulness of the model highly with a mean score of 4.6 and 4.45, respectively. The mean score of the questionnaire was 35.9 and 36, respectively, for both the groups. The quality of urethroneovesical anastomosis as observed by an expert was better in the expert group (p = 0.001). Conclusion: The chicken and porcine model for laparoscopic neobladder reconstruction is a useful and effective training tool. This model has face, content, and construct validity to be used as a teaching and training tool in laparoscopic urology.

Migration of Hem-O-Lok in Pelvicaliceal System Mimicking Renal Calculus Following Robotic Nephron-Sparing Surgery: A Case Report with Review of Literature

Background: Migration of Hem-O-Lok clips in pelvicaliceal system after nephron-sparing surgery (NSS) is rare. We present a rare case of clip migration 8 years after robotic NSS. Case Presentation: A 61-year-old female presented with right flank pain and fever 8 years after robotic NSS for clear cell carcinoma. She was reported to have an 11 mm right renal calculus (570 HU) on CT scan. She underwent flexible ureteroscopy that revealed three Hem-O-Lok clips with encrustations. We removed the clips after laser lithotripsy of the encrusted clips. She is now asymptomatic on follow-up. Conclusion: The possibility of intrarenal migration of Hem-O-Lok clips should be kept as differential diagnosis for patients presenting as renal calculus postminimal access NSS. They could act as nidus for stone formation, leading to recurrent urinary infection. Excessive tension on renorrhaphy sutures should be avoided to prevent migration of clips. The underrunning of any clip in the renal bed during reconstruction should be the standard of care.

Consultation on kidney stones, Copenhagen 2019: lithotripsy in percutaneous nephrolithotomy

PURPOSE

To evaluate the balance between existing evidence and expert opinions on the safety and efficacy of new technological improvements in lithotripsy techniques for percutaneous nephrolithotomy (PCNL).

METHODS

A scoping review approach was applied to search literature in Pubmed, Embase, and Web of Science. Consensus by key opinion leaders was reached at a 2-day meeting entitled "Consultation on Kidney Stones: Aspects of Intracorporeal Lithotripsy" held in Copenhagen, Denmark, in September 2019.

RESULTS

New-generation dual-mode single-probe lithotripsy devices have shown favourable results compared with use of ballistic or ultrasonic lithotripters only. However, ballistic and ultrasonic lithotripters are also highly effective and safe and have been the backbone of PCNL for many years. Compared with standard PCNL, it seems that mini PCNL is associated with fewer bleeding complications and shorter hospital admissions, but also with longer operating room (OR) time and higher intrarenal pressure. Use of laser lithotripsy combined with suction in mini PCNL is a promising alternative that may improve such PCNL by shortening OR times. Furthermore, supine PCNL is a good alternative, especially in cases with complex renal stones and large proximal ureteric stones; in addition, it facilitates endoscopic combined intrarenal surgery (ECIRS).

CONCLUSION

Recent technological improvements in PCNL techniques are promising, but there is a lack of high-level evidence on safety and efficacy. Different techniques suit different types of stones and patients. The evolution of diverse methods has given urologists the possibility of a personalized stone approach, in other words, the right approach for the right patient.