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Abstract

Introduction and objective

To minimize stent-related symptoms (SRS), a modified complete intra-ureteral stent with extraction suture was designed. The objective was to compare SRS of the conventional DJ stent and the complete intraureteral stent using the validated Ureteral Stent Symptom Questionnaire (USSQ).

Materials and Methods

We randomized 124 patients after uncomplicated ureteroscopic lithotripsy into complete intraureteral stent (CIUS) and conventional DJ stent (CUS) placement group. The USSQ scores were evaluated on postoperative day 1, day 7 (just before stent removal) and 4 weeks after stent removal (control values). Pain scores after stent removal were also recorded using visual analogue scale (VAS). Sub-domain analysis of all stent related symptoms and stent related complications were also compared.

Results

No significant intergroup differences were found in the domain scores of urinary symptoms (P = 0.74), pain (P = 0.32), general health (P = 0.27), work (P = 0.24), or additional problems (P = 0.29). However, statistically significant difference was noted on VAS scores (P = 0.015). Analysis of sub-domains of USSQ item scores revealed the CIUS group had significantly better scores for ‘‘urge incontinence’’ (1.21 vs. 1.00; p = <0.001), ‘‘discomfort on voiding’’ (2.07 vs. 1.50; p = <0.001), ‘‘difficulties with respect to light physical activity’’ (1.131 vs. 1.00; p = <0.001), ‘‘fatigue’’ (1.84 vs. 1.57; p = 0.002), “feeling comfortable” (3.68 vs. 3.16; p = 0.003), ‘‘need for extra help’’ (1.96 vs. 1.00; p = <0.001), and ‘‘change in duration of work’’(4.27 vs. 1.86; p = <0.001). However, the patients in the CIUS group were sexually inactive for the time till stent was indwelling (mean: 7.34 days). There was no difference in the complication rate between the 2 groups.

Conclusion

The use of complete intra ureteral stent placement with strings after URS decreases SRS.

Abstract

Introduction and objectives

Since the introduction of flexible ureterorenoscopes in the 1970’s, efforts have been made to reduce its size whilst optimizing the working channel for irrigation flow and introduction of accessory instruments. Meanwhile retaining optimal bidirectional deflecting properties and image quality. In an attempt to serve these seemingly conflicting interests, ureterorenoscopes have become more fragile. In this systematic scoping review we identified, mapped and reviewed scope-related and user-related parameters used to evaluate the quality of flexible ureterorenoscopes to identify key items and variability in grading systems.

Materials and methods

A literature search of four databases (MEDLINE (Ovid), Embase (Ovid), Web of Science, Google scholar and the Cochrane Library) was performed according to the PRISMA-guidelines enclosing articles published up to August 2020. A total of 2386 articles were screened.

Results

A total of 48 articles were included in this systematic scoping review. All studies had a prospective design. Five key items in the assessment of flexible URS were distinguished Maneuverability (87.5%), Optics (64.6%), Irrigation (56.3%), Handling (39.6%) and Durability (35.4%). After regrouping, every key item could be divided into specific subcategories. However, the quality-assessment showed a wide variation in denomination, method of measurement, circumstances of measurement, tools used during measurements, number of measurements performed, number of observers and units of outcomes.

Conclusion

The research field regarding quality assessment of ureterorenoscopes is heterogeneous. In this systematic scoping review we identified five key parameters: Maneuverability, Optics, Irrigation, Handling and Durability, used to grade flexible ureterorenoscopes. However, within these categories we found a wide variety in terms of method of measurements. A standardized, uniform grading tool is required to assess and compare the quality of flexible ureterorenoscopes in the future.

Objectives

To compare the functional outcomes of on- vs off-clamp robot-assisted partial nephrectomy (RAPN) within a randomized controlled trial (RCT).

Materials and Methods

The CLOCK study (CLamp vs Off Clamp the Kidney during robotic partial nephrectomy; NCT 02287987) is a multicentre RCT including patients with normal baseline function, two kidneys and masses with RENAL scores ≤ 10. Pre- and postoperative renal scintigraphy was prescribed. Renal defatting and hilum isolation were required in both study arms; in the on-clamp arm, ischaemia was imposed until the completion of medullary renorraphy, while in the off-clamp condition it was not allowed throughout the procedure. The primary endpoint was 6-month absolute variation in estimated glomerular filtration rate (AV-GFR); secondary endpoints were: 12, 18 and 24-month AV-GFR; 6-month estimated glomerular filtration rate variation >25% rate (RV-GFR >25); and absolute variation in ipsilateral split renal function (AV-SRF). The planned sample size was 102 + 102 cases, after taking account crossover of cases to the alternate study arm; a 1:1 randomization was performed. AV-GFR and AV-SRF were compared using analysis of covariation, and RV-GFR >25 was assessed using multivariable logistic regression. Intention-to-treat (ITT) and per-protocol analyses (PP) were performed.

Results

A total of 160 and 164 patients were randomly assigned to on- and off-clamp RAPN, respectively; crossover was observed in 14% and 43% of the on- and off-clamp arms, respectively. We were unable to find any statistically significant difference between on- vs off-clamp with regard to the primary endpoint (ITT: 6-month AV-GFR −6.2 vs −5.1 mL/min, mean difference 0.2 mL/min, 95% confidence interval [CI] −3.1 to 3.4 [P = 0.8]; PP: 6-month AV-GFR −6.8 vs −4.2 mL/min, mean difference 1.6 mL/min, 95% CI −2.3 to 5.5 [P = 0.7]) or with regard to the secondary endpoints. The median warm ischaemia time was 14 vs 15 min in the ITT analysis and 14 vs 0 min in the PP analysis.

Conclusion

In patients with regular baseline function and two kidneys, we found no evidence of differences in functional outcomes for on- vs off-clamp RAPN.

Abstract

Objectives

To evaluate the association between intraoperative anesthetic parameters, primarily intraoperative hypotension, and postoperative renal function in patients undergoing nephrectomy.

Patients and Methods

We reviewed data from 3,240 consecutive patients who underwent nephrectomy between 2010–2018. Anesthetic parameters evaluated included duration of hypotension, tachycardia, hypothermia, volatile anesthetic use and mean arterial pressure at the post-anesthesia care unit.

Outcomes included acute kidney injury (AKI) and estimated glomerular filtration rate (eGFR) within the first year after nephrectomy. Associations between anesthetic parameters and outcomes were evaluated with multivariable logistic regression and generalized estimating equation, respectively, adjusted for predictors of renal function after nephrectomy.

Results

Before nephrectomy, 677 (21%) patients had moderate-severe chronic kidney disease. A quarter of patients (n=809) had postoperative AKI and 35% (n=746) had stage ≥3 chronic kidney disease 12-months after surgery. Only 12% of patients (n=386) had >5 minutes of intraoperative hypotension. While not statistically significant, longer duration of intraoperative hypotension was associated with slightly higher rates of AKI (OR per 10-minutes 1.14; 95% CI 0.98, 1.32). Prolonged hypothermia was associated with increased rate of AKI (OR per 10-minutes 1.02; 95% CI 1.00, 1.04), and decreased eGFR (change in eGFR per 10-minutes -0.19; 95% CI -0.27, -0.12), however, these results have limited clinical significance.

Conclusions

Under current practice, intraoperative anesthetic parameters are tightly maintained, restricting the significance of their effect on postoperative renal function. Future studies should evaluate whether hemodynamic parameters during the early post-operative period, when they are monitored less frequently, are associated with renal functional outcome.

Abstract

Objectives

To evaluate the association between intraoperative anesthetic parameters, primarily intraoperative hypotension, and postoperative renal function in patients undergoing nephrectomy.

Patients and Methods

We reviewed data from 3,240 consecutive patients who underwent nephrectomy between 2010–2018. Anesthetic parameters evaluated included duration of hypotension, tachycardia, hypothermia, volatile anesthetic use and mean arterial pressure at the post-anesthesia care unit.

Outcomes included acute kidney injury (AKI) and estimated glomerular filtration rate (eGFR) within the first year after nephrectomy. Associations between anesthetic parameters and outcomes were evaluated with multivariable logistic regression and generalized estimating equation, respectively, adjusted for predictors of renal function after nephrectomy.

Results

Before nephrectomy, 677 (21%) patients had moderate-severe chronic kidney disease. A quarter of patients (n=809) had postoperative AKI and 35% (n=746) had stage ≥3 chronic kidney disease 12-months after surgery. Only 12% of patients (n=386) had >5 minutes of intraoperative hypotension. While not statistically significant, longer duration of intraoperative hypotension was associated with slightly higher rates of AKI (OR per 10-minutes 1.14; 95% CI 0.98, 1.32). Prolonged hypothermia was associated with increased rate of AKI (OR per 10-minutes 1.02; 95% CI 1.00, 1.04), and decreased eGFR (change in eGFR per 10-minutes -0.19; 95% CI -0.27, -0.12), however, these results have limited clinical significance.

Conclusions

Under current practice, intraoperative anesthetic parameters are tightly maintained, restricting the significance of their effect on postoperative renal function. Future studies should evaluate whether hemodynamic parameters during the early post-operative period, when they are monitored less frequently, are associated with renal functional outcome.