As current endourologic treatment for upper urinary tract stones has been dramatically improving, first standard treatment for over 2cm renal stone still remains percutaneous nephrolithotomy (PNL). The current instruments of PNL have changed and developed to miniaturization such as mini-PNL, ultramini-PNL, and micro- PNL. However, even if tract sheath size used in PNL is smaller, it is possible to occur various complications when you make a false step to perform the procedure. The first critical step in PNL is definitely “percutaneous puncture” with needle. It’s no exaggeration to say that the success of PNL procedure is influenced by the skill of percutaneous puncture.

  Advances of a flexible ureteroscope is that flexible ureteroscope can reach all parts of the urinary tract. In spite of its therapeutic benefits, flexible ureteroscopic treatment for renal and ureteral calculi may be associated with some minor or major complications.

  A retrospective review of the records of 1000 cases who underwent flexURS from April 2010 to August 2016 was performed. To compare the complications after introduction of flexURS, the patients were divided into five groups (First 200 to Fifth 200, respectively). Complication rates of flexible ureteroscopic treatment in Clavien grading scale Ⅲ〜Ⅴ were 8.5%, 4.5%, 3%, 3% and 2%. To reduce severe complications, it is necessary to have performed about 200 cases. Increased surgeon experience tended to decrease the risk of severe complications and inaccessible ureter, but the incidence of urosepsis and ureteral stenosis were not reduced. We will show troubleshooting for our complications.

  According to the new treatment evaluation criteria of urolithiasis in 2015, residual stone ratio was recommended to determine the therapeutic efficacy in association with the recording stone size in volume. We retrospectively assessed the association of treatment evaluation by the old and new criteria with the prognosis in 64 kidneys treated by TUL-assisted PNL (TAP). According to the old criteria, two-year recurrence-free rates of “no residual stone”, “residual stone ≤4.0mm” and “residual stone ≥4.1mm” were clearly stratified (p=0.01 ; 92.3%, 66.1% and 58.2%, respectively). In contrast, according to the new criteria, two-year recurrence-free rates of “no residual stone”, “residual stone <5%” and “residual stone ≥5%” were not significantly different (p=0.05 ; 92.2%, 60.3% and 64.3%, respectively), and the stratification of the latter two groups was especially poor. In conclusion, treatment evaluation by residual stone ratio might not reflect the prognosis in cases with relatively large stones treated with TAP.

  Objectives : We investigated whether a shortened stent placement duration before ureteroscopic lithotripsy with a holmium laser (URSL) contributed to a reduction in postoperative febrile urinary tract infection (post-UTI).

  Methods : We performed a study of 109 patients who underwent URSL. All patients underwent indwelling ureter stent placement before URSL (pre-stent) for various reasons. In half of the patients (Group B, n = 55), the pre-stent duration was shortened as much as possible, whereas in the other half (Group A, n = 54), URSL was performed without the pre-stent duration being shortened. We compared post-UTI incidence in the two groups.

  Results : The pre-stent duration was significantly shorter in Group B than in Group A (16.9 vs. 34.4 days), and the post-UTI incidence was significantly reduced in Group B compared to Group A (5.5% vs. 20.4%). In Group A, the incidence of post-UTI was high among patients who underwent pre-stenting for obstructive pyelonephritis (35.0%). Compared to the patients who the duration of pre-stent was less than 28 days, the incidence of post-UTI was significantly higher in the patients who the duration was more than 29 days (8.3% vs. 28.0%). Female patients and patients in Group A were independently more likely to develop post-UTI.

  Conclusions : Our findings suggest that patients who undergo pre-stenting are at a high risk of developing post-UTI after URSL, especially those with obstructive pyelonephritis. Because of higher incidence of post-UTI among patients who the pre-stent duration was more than 29 days, the duration should be shortened as much as possible to reduce the occurrence of post-UTI.

  Purpose : Urolithiasis in bedridden patients is recently increasing, but it remains uncertain how to manage such cases. In this study, we aimed at clarifying safety and efficacy of upper urinary stone treatment after obstructive pyelonephritis in bedridden patients.

  Materials and Methods : After April 2010, 80 bedridden patients with obstructive pyelonephritis were admitted to our institution. The overall survival and the pyelonephritis recurrence rate estimates were generated using Kaplan Meier methods.

  Results : 67 patients underwent surgery (TUL : 49 patients, PNL : 8, ESWL : 7, nephrectomy : 4). The median age was 81 years and the female ratio were 69 %. The overall complications occurred in 18 (27%) patients and mortality rates were 4.5%. The 3-year overall survival and pyelonephritis free rate was 78% and 69%, respectively.

  Conclusions : Stone removal for bedridden patients after obstructive pyelonephritis could be performed with slightly increasing morbidity rates. The recurrence rate about pyelonephritis was about 30% at 3 years.

  We retrospectively evaluated the indication of transurethral lithotripsy (TUL). Between April 2008 and October 2017, 918 patients underwent TUL. The median age was 62 years, and median size of stone was 1.1 cm. The median number of procedures was 1, median operative time was 60 minutes, and stone-free rate was 97.7%. The complications were pyelonephritis (7.6%), sepsis (1.2%), minor injury (3.7%), major injury (0.2%), and stenosis (0.2%). In the group with stones larger than 3.0 cm, the stone-free rate was 85.5% (p<0.0001). In the group with stones larger than 2.0 cm, the pyelonephritis rate was 13.8% (p=0.0010). The predictive risk factors for pyelonephritis at TUL were female (p<0.0001), previous pyelonephritis (p<0.0001), previous diabetes mellitus (p=0.0017), and stones larger than 2.0 cm (p=0.0054). Our study suggests that TUL is a good indication for stones less than 2.0 cm and a reasonable option for stones less than 3.0 cm.

  We examined predictive risk factors for systemic inflammatory response syndrome (SIRS) after ureteroscopic lithotripsy, and associations among preoperative bladder urine cultures, renal pelvic urine cultures, and stone cultures. We recruited 120 patients in this study. Preoperative bladder urine culture was positive in 49/120 patients (40.8%). Renal pelvic urine culture was positive in 15/118 patients (12.7%), and stone culture was positive in 17/114 patients (14.9%). Ten patients (8.2%) developed SIRS. Multivariate analysis revealed that a positive renal pelvic urine culture was the only significant risk factor for postoperative SIRS. Among SIRS patients, 7 patients showed a positive preoperative bladder urine culture, but pathogens revealed by renal pelvic urine culture or stone culture were consistent with those by preoperative bladder urine culture in only 3 of them. We recommend the culture of renal pelvic urine and stones for patients with a high risk of postoperative SIRS.

  Objective : We performed ESWL for renal stones exceeding 20 mm using Dornier Delta II Far Sight, and report the results of treatment.

  Method : From January 2011 to March 2017, 58 patients with renal stones (including staghorn calculus) exceeding 20 mm, which necessitated ESWL as the initial treatment, were targeted, comprising 41 males and 17 females, with a median age 58 of years (33 to 79). The long diameter was 23 mm (21 to 58), the short diameter was 16 mm (6 to 40) at the median value, and 7 cases were staghorn calculus. In 12 cases, ureteral stent was placed before ESWL administration.

Results : The average number of ESWL enrollment was 5.1 (1 to 16), the calculus disappearance rate was 37.9%, and the residual stone of 4 mm or less was 34.5%. According to the “new criteria for urinary calculi” proposed by Yamaguchi et al., 3 cases were less than 1 cm³, 9 cases were 1 cm³ or more and less than 2 cm³, 19 cases were 2 cm³ or more and less than 5 cm³, and 20 cases were 5 cm³ or more. As a result of ESWL treatment, 21 cases were without residual stone and 19 cases were less than 5% residual stone.

  Conclusion : When ESWL is performed for renal stones exceeding 20 mm using Dornier Delta II Far Sight, sufficient informed consent on high residual stone ratio is considered necessary.

  We retrospectively compared a group treated by only extracorporeal shock wave lithotripsy (SWL) with a group additionally treated by transurethral lithotripsy (TUL) for urinary tract stones. Between January 2012 and December 2017, ninety-four patients were initially treated by SWL and stone-free. “Stone-free” was defined as the situation that stones were completely removed or the residual fragments were ≦4mm. The age, sex, body mass index (BMI), stone location, Hounsfield units (HU), stone size, stone-surface area (SSA), existence of hydronephrosis before the operation, and skin-to-stone distance (SSD) were evaluated to determine the predictive factors for successful treatment by only SWL.

  Thirty-two patients (34.0%), who were initially treated by SWL, needed to additional treatment with TUL. Univariate analysis of ninety-four patients showed that U1 stones ［U2-3 vs. U1 ; OR, 3.33 ; 95%CI, 1.37-8.35 ; p = 0.0075］, SSD ≦ 100 mm ［SSD ≧ 100 mm vs. SSD<100mm ; OR, 7.96 ; 95%CI, 2.49-35.70 ; p=0.0002］ were predictive factors for successful treatment by only SWL. Multivariate analysis of the ninety-four patients showed that “U1 stone”［U2-3 vs. U1 ; OR, 3.69 ; 95%CI, 1.42-10.13 ; p=0.0070］ and “SSD ≦100mm”［SSD≧100mm vs. SSD<100mm ; OR, 8.40 ; 95%CI, 2.51-39.20 ; p=0.0002］ were predictive factors for successful treatment by SWL. “U1 stones” and “SSD≦100mm” are effective to predict treatment success using only SWL based on the results of this study.

  Analysis of both urinary flow and bladder outlet morphology is necessary in order to diagnose occlusion within the lower urinary tract and determine the applicability of surgical removal in patients with benign prostate hypertrophy (BPH).

  Four-dimensional virtual reality images (Urodynamic 4D-CT) of patient voiding were created using Area Detector CT and image analysis software. This method clearly illuminated urinary conditions such as bladder outlet obstructions (BOO), bladder contraction, and urethral dilation during the actual act of urination.

  Factors indicative of operational applicability were found to be a QOL score＞4.5 points, prostatic volume＞33mL, and residual urine＞94.5mL (multivariate analysis n=141).

  Combined with conventional diagnostic methods, Urodynamic 4D-CT scanning proved useful in determining surgical applicability for difficult patients. Urodynamic 4D-CT also proved helpful in visualizing dynamic mechanisms of BOO as well as the shape of the bladder and urethra in less problematic patients.

  Objective : Mixed reality (MR), Augmented Reality (AR), Virtual Reality (VR) technology is an indispensable technology in medical image analysis to improve spatial recognition. We applied these techniques to 3D image of preoperative patient images and examined the possibilities for navigation surgery and surgical education in urological surgery.

  Methods : VR and MR navigation surgery was performed in Robotic and open partial nephrectomy and robotic prostatectomy.

  Result : Compared to conventional surgery, these navigations contributed to shortening of tumor resection time and reduction of bleeding in partial renal surgery. The surgeon can intuitively experience the sense of distance of the organ dissection including the tumor and blood vessel surroundings, the spatial recognition of peripheral organs has been improved.

  Since HoloLens can record from the viewpoint of the surgeon, it also helped surgical education.

  Conclusion : VR and MR are useful tools not only for surgical navigation but also for simulation and education.

  To assess the effectiveness of laparoscopic adrenalectomy for patients with malignant adrenal tumors, we compared perioperative details of patients who received laparoscopic adrenalectomies for benign versus malignant tumors performed in Yokohama City University Hospital between August 2003 and June 2015.

  Patients were divided into two groups : 133 patients with benign adrenal tumors (65 primary aldosteronism, 33 Cushing’s syndrome, 21 pheochromocytoma, and 14 other adenomas) versus 16 those with malignant tumors (14 metastatic tumors and two adrenal cortical carcinomas).

  The average diameter of the tumor at diagnosis in the malignant group was significantly larger than that in the benign group : 40.5 and 26.9 cm, respectively. There were no significant differences between the two groups regarding the mean blood loss, total operative time, or postoperative period of hospitalization.

  There were ten patients with perioperative complications in the benign group, including bleeding and adjacent organ injuries, whereas there were no complications in the malignant group. There were neither open adrenalectomy conversions nor deaths in either group.

  Therefore, laparoscopic adrenalectomy can be safely carried out even for malignant adrenal tumors.

  We aimed to investigate hospitalization-related expenses between robot-assisted radical cystectomy (RARC) and open radical cystectomy (ORC). We analyzed 61 patients who underwent radical cystectomy between January 2014 and January 2017 (RARC : 6, ORC : 55). We compared hospitalization-related expenses, period of hospitalization, surgical time, estimated blood loss (EBL), time to accomplishment of 100-m walking independence, oral feeding resumption, and pelvic drain removal. Surgical time was longer in patients who underwent RARC than in those who underwent ORC. However, lower EBL and hospitalization-related expenses were observed in patients who underwent RARC. Using the Clavien-Dindo classification grade 3 and higher, there were 10 complications associated with ORC and none with RARC. RARC is better than ORC regarding hospital expenditures, due to lower EBL and complication rates. RARC may become an important surgical option in terms of medical expenses, when considering the recent rise in national medical expenses.

  We assessed the effect of nerve sparing (NS) procedure on patients-reported urinary outcomes after RALP using by the International Consultation on Incontinence on Incontinence Questionnaire Short Form (ICIQ-SF), IPSS and OABSS before and 1, 3, and 6 month after surgery. 325 patients were divided into groups with non-NS (NNS), unilateral NS (UNS) and bilateral NS (BNS). Patients who had any NS surgery (ie, UNS or BNS) had significantly lower ICIQ-SF compared with those who had NNS surgery up to 3 month after surgery. No significant difference was seen at 6 mo.

Almost the same results were shown in studies in both IPSS and OABSS. Multivariate analysis indicated that any NS surgery and lower scores in both IPSS and OABSS before surgery were significant predictors of lower ICIQ-SF up to 3 month. We found that any NS surgery improves urinary outcomes in the first 3 month after surgery.

  A 89-year-old female had lower leg edema. CT showed a left hydronephrosis and ureterosciatic hernia. A ureteral stent was inserted into left ureter and was removed after 2 months. After 17 months, she had pyelonephritis, and ureteral stent was inserted again. The stent was changed once, but she hoped to remove it. After 1 year, she had pyelonephritis, sepsis, and DIC. However she was cured, she must change it forever. According to the major part of papers, ureterosciatic hernia did not reappear by removal of a ureteral stent, but we should remove it carefully and consider operations when it reappears.