Introduction: Non-visible haematuria (NVH) is associated with a small risk of upper-tract urothelial carcinoma (UTUC), though there is little consensus on its investigation, particularly with regard to upper-tract imaging. This study aimed to determine whether the presentation of UTUC can guide investigation of NVH in patients under 60 years old. Methods: All patients investigated at our one-stop haematuria clinics under a cancer pathway were reviewed during a 5-year period, with all patients undergoing cystoscopy and upper-tract imaging. Retrospective analysis of all UTUC cases from our urological cancer multidisciplinary team meeting database over a 10-year period was also undertaken. Results: 2,129 patients with a median age of 67 years underwent urgent investigation for haematuria between March 2015 and February 2020. 449 cases presented with NVH, of whom 124 (27.6%) were under 60. Out of 21 cases of UTUC, only 2 presented with NVH; both were over the age of 60 years. Factors that independently predicted diagnosis with urinary-tract malignancy were age ≥60 (OR 3.70, p < 0.001), visible haematuria (OR 2.50, p = 0.006), and suspicious cystoscopic findings (OR 58.06, p < 0.001). Review of all 119 UTUC cases over 10 years found 6 cases (5.0%) presenting with NVH, with one (0.8%) also presenting under 60 years. Conclusion: Diagnosis with UTUC is rare in patients presenting with NVH under the age of 60 years. Routine use of CTU in this low-risk group is best avoided, with ultrasonography constituting a safer first-line upper-tract imaging modality. Guidelines that risk-stratify NVH patients may be effective in reducing unnecessary investigations.

You have accessJournal of UrologyCME1 May 2022MP40-02 CAN THE PRESENTATION OF UPPER TRACT UROTHELIAL CANCER GUIDE US ON HOW TO IMAGE NON-VISIBLE HAEMATURIA?: A REVIEW OF 10 YEARS Kirolos Michael, Navin Ravindranath, Thomas Riley, Annette German, Andreas Bourdoumis, and Raveendra Surange Kirolos MichaelKirolos Michael More articles by this author , Navin RavindranathNavin Ravindranath More articles by this author , Thomas RileyThomas Riley More articles by this author , Annette GermanAnnette German More articles by this author , Andreas BourdoumisAndreas Bourdoumis More articles by this author , and Raveendra SurangeRaveendra Surange More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002600.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Presentation with non-visible haematuria (NVH) is associated with a small risk of upper urinary-tract transitional cell carcinoma (UUT-TCC), though there is little consensus among the urological community on the investigation of NVH, especially with regards to upper-tract imaging. For patients referred under 60 years old where the risk is even smaller, clinicians are faced with a dilemma of whether to routinely undertake CT urography, exposing patients to its associated risks versus potentially missing pathology. We present our 10-year experience of UUT-TCC cases and their presentation. METHODS: We reviewed the urological cancer multidisciplinary team (MDT) database for all cases of UUT-TCC diagnosed during a 10-year period between 2008 and 2018 at one large urological centre in the United Kingdom. UUT-TCC was diagnosed on the basis of MDT consensus from the radiological and histological findings. Data collected included the age at presentation, presenting complaint, the upper tract imaging modality utilised and the histologically confirmed site of malignancy. RESULTS: 119 patients were diagnosed with UUT-TCC during the period of interest at our centre; 64 (53.8%) were male, while 55 (46.2%) were female. 70 patients (58.8%) presented with visible haematuria (VH), 6 (5.0%) presented with NVH, while UUT-TCC was diagnosed incidentally in 43 patients (36.1%). The median age at diagnosis was 75 years (range 42 – 93) and 8 patients (6.7%) were diagnosed below the age of 60, of whom only one patient (0.8%) had presented with NVH; thus not meeting the National Institute for Health and Care Excellence (NICE) age criteria for urgent referral for NVH. CT urography was undertaken for all 6 patients presenting with NVH in the first instance which demonstrated hydronephrosis in 4, a renal parenchymal lesion in one and a renal pelvic filling defect in another; most if not all of these could have been identifiable on ultrasonography. Only one patient presented as TCC of the pelviureteric junction (PUJ) on imaging, which was subsequently confirmed histologically. CONCLUSIONS: NVH is a rare presenting complaint of UUT-TCC, especially in those under the age of 60. Our 10-year experience suggests that ultrasonography is likely a safe and accurate first-line imaging modality for younger patients presenting with NVH, though larger studies are needed to further evaluate this. Source of Funding: This project did not receive any funding from any public, commercial or not-for-profit organisation © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e674 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kirolos Michael More articles by this author Navin Ravindranath More articles by this author Thomas Riley More articles by this author Annette German More articles by this author Andreas Bourdoumis More articles by this author Raveendra Surange More articles by this author Expand All Advertisement PDF downloadLoading ...

The association between the mineral content of drinking water and urolithiasis remains elusive. The aim of this study is to investigate whether the mineral composition of tap water correlates with urinary calculus composition. Patients with calculi that underwent biochemical analysis at two urological centres in the North-West of England between November 2015 and December 2020 were included. Calculus composition was reviewed with respect to patient demographics, serum biochemical variables, and water mineral composition data obtained from the local water supply company using patient postcodes. 1711 urinary tract calculi from 1518 patients, living in 87 water supply zones were included. Water sodium concentration was an independent predictor of mixed calcium oxalate/uric acid calculi (OR 1.157, p < 0.001) and a negative independent predictor of calcium oxalate monohydrate (OR 0.896, p = 0.001) and dihydrate (OR 0.742, p = 0.034) calculi. Moreover, the magnesium-to-calcium ratio of tap water was a negative independent predictor of calcium oxalate monohydrate calculi (OR < 0.001, p = < 0.001), while tap water magnesium concentration inversely correlated with the percentage of calcium oxalate within calculi (rs = − 0.054, p = 0.026). Total water hardness did not independently predict calculus type. Many factors are implicated in the formation of urinary calculi. This study is the first to assess calculus composition in relation to tap water mineral content using postcode data on a case-by-case basis. Though total water hardness did not independently predict calculus composition, the interesting findings relating to water sodium and magnesium concentrations are in need of closer scrutiny in larger scale studies.

OBJECTIVE:To propose an algorithm for the management of bladder amyloidosis based on a systematic review of the literature, given that the bladder is the second most commonly affected organ of the urinary tract in the course of systemic or localized amyloidosis.METHODS:We searched PubMed, Cochrane Library and Scopus databases utilizing PRISMA methodology from inception to November 30, 2020 (PROSPERO: CRD42020207855).RESULTS:We included 76 studies with 184 patients (9 case series and 67 case reports). Presenting symptoms of bladder amyloidosis comprised of hematuria, irritative or obstructive urinary symptoms, and cystitis-like symptoms. The diagnosis of amyloidosis was established by histologic examination of specimens retrieved during transurethral resection of bladder lesions. Complete endoscopic resection, the cornerstone of management of localized disease, was feasible in 89.1% cases. The included patients were followed up for a mean of 54 months, within which 65 patients (35.3%) recurred. The time to first amyloidosis recurrence was 20 months (range: 1-168). Additionally, 16 individuals presented with concomitant bladder amyloidosis and bladder cancer, while 4 developed bladder malignancy during follow-up. Due to the frequent and early recurrences of patients with bladder amyloidosis, a check-up cystoscopy at 3, 12, and 24 months' after initial resection is recommended. Recurrences should be managed with transurethral resection, while intravesical instillations of dimethyl sulfoxide (DMSO) and cystectomy should be reserved for refractory cases.CONCLUSION:We propose a management algorithm for bladder amyloidosis based on the available evidence for this rare benign entity that mimics bladder cancer.

OBJECTIVE:The aim of this study was to assess the quality of TURBT (transurethral resection of bladder tumor) using surrogate parameters and evaluate adherence to the guidelines regarding the management of bladder tumors. MATERIALS AND METHODS:A clinical audit of all new diagnosis of bladder cancer was undertaken from January 2016 to January 2017. A total of 101 new bladder cancer cases were included. Surrogates of TURBT quality including presence of detrusor in the specimen, rate of re-TUR, presence of carcinoma in situ, and 3-month recurrence rates were analyzed. Adherence to guidelines regarding management of non-muscle invasive bladder cancer including time to re-TUR and utilization of single instillation chemotherapy was evaluated. RESULTS:Absence of detrusor muscle in the specimen of the initial TURBT was noted in 22.8% of the cases. The chance of including muscle in the specimen was almost four-fold for tumors larger than 3 cm. A single instillation of intravesical chemotherapy following TURBT was administered in only 40% of eligible patients; 54.3% of patients had a re-TUR, the majority (61.3%) for high-grade non-muscle invasive bladder cancer on initial TURBT. Re-TUR was done on average 10 weeks after initial TURBT. The 3-month recurrence rate was 36.0% with larger tumors (>3 cm) being more prone to early recurrences. Early recurrences were not affected by intravesical instillations with bacillus Calmette-Guérin or mitomycin C although there was a positive association between the presence of carcinoma in situ on initial resection and early recurrences. DISCUSSION AND CONCLUSION:One in two patients will have a re-TUR, and approximately one in two patients will have tumor on re-TUR. Single immediate chemotherapy instillations after TURBT are underutilized. The presence of carcinoma in situ on initial TURBT and tumor size were predictors of early recurrences.

Aim/Objective: To identify trends in the evidence base regarding the effectiveness of using α-blockers in children versus adults and compare outcomes. Methods: A literature search up using the key words including urolithiasis/renal/ureteric stone in children/paediatric population, medical expulsive treatment (MET), α-blocker/alfuzosin/tamsulosin/doxazosin. Included were randomized or controlled clinical trials in paediatric stone formers (aged ≤18 years). Outcome measures for assessment included the overall stone expulsion rate, expulsion time, the number of pain episodes and adverse drug effects and/or reactions. Further comparison of efficacy levels using respective studies from the adult population was performed in order to identify trends, similarities and differences. Results: A total of 8,259 articles were identified. Full text evaluation was possible for 28 articles. Although the picture is clearer in the paediatric group, the lack of reproducible results in adults certainly poses serious questions about data collection, analysis and interpretation in each individual study. The apparent paradox is due to the methodological differences between studies. Conclusion: The effectiveness of α-blockers and other medication as MET needs to be studied in multi-institutional, double-blind, placebo-controlled studies that would aim to prove superiority to placebo in contemporary clinical situations, with realistic end points and standardized outcome measure determination.

Plastic ureteral stents are one of the most commonly used consumables in urology for establishing and maintaining ureteral patency after extrinsic or intrinsic obstruction or following endourological procedures. The use of stents is however associated with a number of complications including infection, migration, stent failure, and stent-related lower urinary tract symptom and encrustation, leading to stone formation and stent retention. Forgotten and severely encrusted ureteric JJ stents are among the rarest yet most dreaded complications of upper tract endourology.[12] Literature references are limited to small case series and expert reviews and as a result, management guidelines are lacking. It was often that treatment strategy relied on the individual ingenuity, resourcefulness, and the expertise of the operating surgeon and the team. Standardization of the degree of stent encrustation has been proposed by Acosta-Miranda et al. in 2009 (known as the forgotten, encrusted, calcified FECal system). The FECal system quantified encrustation as Grades I–V, with Grades IV and V correlating with stent retention times of more than 2 years and associated with severe encrustation and stone formation of both proximal and distal ends of the double J stent.[3] Nevertheless, the development of miniaturized instruments and finer endoscopic skills has made even the most complex case seem achievable through minimally invasive surgery. Percutaneous nephrolitholapaxy in the supine position, originally described by Valdivia Uría et al., revolutionized large stone burden management and paved the way for endoscopic combined intrarenal surgery (ECIRS).[45] The successful management of the forgotten, severely encrusted, foreign body/double J stent in the urinary tract should involve a multimodality approach. Several patient factors need to be taken into consideration in addition to stone burden, especially comorbidities such as diabetes mellitus, obesity and also body habitus, skeletal deformities, and neurologic/mobility issues. All the above are directly related with less favorable surgical outcomes and decreased functional recovery following extensive renal stone surgery.[67] More importantly, existing anatomic abnormality (i.e., duplex system) and preexisting or ensuing renal dysfunction have recently been demonstrated to affect Clavien–Dindo-reported complications and as such influence overall outcome.[8] Based on our experience, a carefully planned multimodality approach would provide the most realistic chances for complete removal of the encrusted stent with the least risk for postoperative complications. The presence or absence of current or previous urinary tract infection should be thoroughly sought, and any history of antibiotic sensitivities should guide appropriate intraoperative prophylaxis. Local antimicrobial use guidelines should be followed where available. Detailed and recent delineation of intrarenal and ureteric anatomy in the form of computed tomography urography (three-dimensional where available) and split renal function by using nuclear scintigraphy (preferably dimercaptosuccinic acid) should provide the backbone for both surgical planning and postoperative recovery. Although some evidences exist that neoadjuvant shockwave lithotripsy (SWL) would be useful to weaken and even at times reduce the stone burden, the risk of post-SWL fulminant urosepsis due to infected stone burden should always be considered. Large (30F)-bore percutaneous nephrolithotomy (PCNL) should be regarded as the appropriate intervention for severe proximal encrustation and large pelvicalyceal stone burden. PCNL accompanied by ECIRS, using antegrade and retrograde laser ureterorenoscopy, in one or more sittings, offers the best chance for complete clearance of stent-related encrustation and lithiasis and successful stent removal.[9] As the ideal way of managing a situation is by preventing it from happening, use of hospital-run stent registries and novel coated stents in order to avoid stents from becoming forgotten and encrusted is already in use.

Introduction: The success of upper urinary tract endoscopy on one hand and the high cost of purchase and maintenance of the scopes on the other hand have driven the development of disposable digital flexible ureterorenoscopy (fURS). Materials and Methods: We performed an ex vivo comparison of 2 disposable digital fURS from different companies with a state-of-the-art reusable endoscope from another well-established scope manufacturer. The scopes were tested comparing parameters such as instrument handling, irrigation flow, image quality, and deflection. For the disposable scopes, the latter 2 were evaluated both, before and after vigorous stress testing. Results: Expectedly, the most consistent finding among the 3 instruments was the marked decrease on irrigation flow following insertion of a working element, most notably a guidewire. Depth perception and ergonomic handling were comparable in all 3 instruments. Poststress testing revealed a significant loss of upward deflection in both disposable instruments, more so when an auxiliary instrument is inserted into the working channel. However, this did not appear to be the case in downward deflection. Conclusions: To our knowledge, this is the first study that used a vigorous stress testing protocol comparing disposable and reusable fURS. The newer generation disposable scope fared better than the older one. Results are encouraging and indicate that improvements are ongoing and progressing, bringing the quality of disposable scopes to the level that we are used to from our reusable high performance scopes while at the same time avoiding costly damage repairs. Continuous research and evidence-based interpretation of results in the absence of commercial bias are paramount to ensure this ongoing development.

Purpose: The study aimed to assess the impact of the Memokath 051 stent (MK) on glomerular filtration rate (GFR) and split renal function in the management of ureteroileal anastomotic strictures. Materials and Methods: We treated 6 patients in the ages of 66–77 years, 2 of whom had bilateral strictures, with a total of 8 ureteroileal strictures using the MK stent. Five patients had chronic kidney disease (CKD) prior to MK insertion. Mean time between conduit surgery and MK insertion was 28.4 months. Serum creatinine, GFR, and MAG-3 renography were determined before stent insertion and postoperatively at 3 months. Results: Postoperative complications at 3-month follow-up included migration in 2 patients, occlusion in 2 patients, and urinary tract infection in 4 patients. The mean stent indwelling time was 353.4 ± 169.3 days. Mean preoperative creatinine, GFR, right, and left split renal function were 158.3 ± 76.3 μmol/L, 43.6 ± 32.9 mL/min/1.73 m2, 52.8 ± 22.2%, and 47.1 ± 22.2%, respectively. Mean postoperative values were 168.1 ± 84 μmol/L (p = 0.84), 40.8 ± 28.4 mL/min/1.73 m2 (p = 0.56), 51.1 ± 18.3% (p = 1), and 48.8 ± 18.3% (p = 1), respectively. Conclusion: MK stent is a safe and efficient minimally invasive long-term treatment option to preserve GFR in patients who develop CKD through ureteroileal anastomotic stricture. In spite of MK stent insertion and alleviation of obstruction, it was presumably inserted too late to improve renal function.

Aim: To scrutinize the rapid development of robotic versus traditional laparoscopic technique in pelvic urologic surgery. Introduction: In the last few decades, advances in research and development have led to tremendous progress in medical diagnostics and treatment of disease. Minimally invasive surgery has moved from experimental to becoming the dominant form of surgical management across the surgical specialties. Laparoscopy is nowadays used widely in abdominal surgery, from simple diagnostic laparoscopy to complex colorectal and gynecologic cancer procedures. Methods: A literature search of electronic databases (PubMed, Medscape, Embase) using the key words: “pelvic laparoscopy, urologic oncology, robotic surgery, minimally invasive access” was performed for all relevant articles in the English language. Data were extrapolated from the abstracts alone to avoid subjective bias in drawing conclusions. Results: Telemedicine and telesurgery, the diagnostic and operative process is conducted from a distance. The surgeon uses computer-assisted surgery away from the bedside via a robotic system and performs the surgical task at hand. In pelvic urological cancer surgery the use of robotic technique expands to female and reconstructive procedures as well. The leap forward is so massive, that traditional laparoscopic surgery is starting to be considered less, with a growing number of organizations being now more interested in developing a robotic service. Minimally invasive surgical techniques aim to improve surgical outcome in conjunction with delivery of high-quality patient care. Quality studies demonstrating superiority and cost effectiveness are lacking, however. Conclusions: Although tremendous accomplishments took place over a few years, there is still a lot of ground to be covered in standardizing the learning process and evaluating the outcome from the application of new technologies in the field of robotic pelvic surgery.

Objectives: To investigate a possible causal relationship for stone formation in pelviureteric junction obstruction and to outline management options.Materials and Methods: A literature search and evidence synthesis was conducted via electronic databases in the English language using the key words pelviureteric junction obstruction; urolithiasis; hyperoxaluria; laparoscopic pyeloplasty; flexible nephros-copy; percutaneous nephrolithotomy, alone or in combination. Relevant articles were analysed to extract conclusions.Results: Concomitant pelviureteric junction obstruction (PUJO) and renal lithiasis has been reported only scarcely in the literature. Although PUJO has been extensively studied throughout the years, the presence of calculi in such a patient has not received equal attention and there is still doubt surrounding the pathophysiology and global management.Conclusions: Metabolic risk factors appear to play an important role, enough to justify metabolic evaluation in these patients. Urinary stasis and infection are well known factors predisposing to lithiasis and contribute to some extent. The choice for treatment is not always straightforward. Management should be tailored according to degree of obstruction, renal function, patient symptoms and stone size. Simultaneous treatment is feasible with the aid of minimally invasive operative techniques and lapa-roscopy in particular.

INTRODUCTION:The aim of this review was to identify trends and developments in basic research, epidemiology, diagnosis, conservative and surgical management of urinary stone disease, and to demonstrate the evolution of urolithiasis management in the new millennium. EVIDENCE ACQUISITION:We performed a literature search on Medline according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement up to December 2015 using the following key words: urolithiasis prevalence, recurrent urinary stone, metabolic syndrome and urolithiasis, urinary stone/urolithiasis metabolic evaluation, shockwave lithotripsy, ureterorenoscopy, percutaneous nephrolithotomy/nephrolitholapaxy. The key words were chosen following consensus as the single most appropriate and descriptive terms that would yield maximal relevant results in a single search for each section. We then segregated only relevant articles in the English language of the highest quality evidence (systematic review/meta-analysis, prospective cohorts and prospective randomized trials, levels of evidence: 1A and 1B, respectively) as well as experimental research. The initial relevance screening was based on title and abstract, whereas further filtering included full text screening. The evidence is subsequently presented and discussed on each relevant section, preceded by seminal references that are used as a basis for comparison to formulate our conclusions. EVIDENCE SYNTHESIS:By using the key word "urolithiasis prevalence" we identified initially 1581 relevant articles. Following exclusion of duplicates and relevance screening, 154 articles were included for data extraction (9.77%). Of note, 31 articles focused on the pediatric population. By using the key words "metabolic syndrome and urolithiasis" we identified initially 127 relevant articles. Following exclusion of duplicates and relevance screening, 23 articles were included for data extraction (18.11%). It must be noted that the majority of studies are reviews, experimental models and prospective cohorts. By using the key words "urolithiasis metabolic evaluation" we identified initially 262 relevant articles. Following exclusion of duplicates and relevance screening, 179 articles were included for data extraction (68.32%). It must be noted that the majority of studies are reviews, experimental models and prospective cohorts. By using the key word "shockwave lithotripsy" we identified initially 695 relevant articles. Following exclusion of duplicates and relevance screening, 90 articles were included for data extraction (12.94%). By using the key word "ureterorenoscopy" we identified initially 2609 relevant articles. Following exclusion of duplicates and relevance screening, 186 articles were included for data extraction (7.12%). By using the key word "percutaneous nephrolithotomy" we identified initially 695 relevant articles. Following exclusion of duplicates and relevance screening, 381 articles were included for data extraction (10.42%). CONCLUSIONS:The management of urolithiasis has evolved greatly and in multiple directions in the past fifteen years. There is a definite compartmentalization of basic research, innovation and development focusing on distinct stages of the disease, from epidemiologic features to pathophysiology, medical and surgical aspects. Patients enjoy better delivery of care, having ever more effective options to deal with their condition. The multidisciplinary approach provides more reliable solutions and will continue to drive the development of better preventative and treatment strategies in the future.

Lithiasis of the urinary tract is nowadays recognized as a significant health care issue, affecting millions of people worldwide and resulting in hospital admissions, medication prescription, elaborate surgical treatment and loss of working hours. It is a multifactorial disease influenced by lifestyle, environmental and genetic factors, amongst others. The recently discovered association between the metabolic syndrome and nephrolithiasis represents another breakthrough in understanding stone disease and risk factors. A comprehensive analysis of the pathophysiology and the latest developments in research will be presented, as well as preventative and treatment options that can be employed in this special group of patients.