BACKGROUND: Urologic guidelines recommend perioperative instillation of chemotherapy after transurethral resection of bladder tumor (TURBT) to decrease tumor recurrence, yet implementation of this recommendation is partial due to associated morbidity. Hypertonic saline destroys cells by osmotic dehydration and might present a safer alternative. OBJECTIVE: To evaluate the safety of 3% hypertonic saline (Hypersal) intravesical instillation following TURBT in rats and in humans. METHODS: In 8 rats whose bladders were electrically injured, intravesical blue-dyed Hypersal was administered. We measured serum sodium levels before and after instillation and pathologically evaluated their pelvic cavity for signs of inflammation or blue discoloration. Twenty-four patients were recruited to the human trial (NIH-NCT04147182), 15 comprised the interventional and 10 the control group (one patient crossed over). Hypersal was given postoperatively. Serum sodium was measured before, 1 hour and 12–24 hours after instillation. Adverse effects were documented and compared between the groups. RESULTS: In rats, average sodium levels were 140.0 mEq/L and 140.3 mEq/L before and following instillation, respectively. Necropsy revealed no signs of inflammation or blue discoloration. In humans the average plasma sodium levels were 138.6 mEq∖L, 138.8 mEq∖L and 137.7 mEq∖L before, 1 hour and 12–24 hours after instillation, respectively. During the postoperative follow-up there was one case of fever. A month after the surgery, dysuria was reported by 5 patients while urgency and hematuria were reported by one patient each. The most severe adverse events were grade 2 on the Clavien-Dindo scale. Adverse events were similar in the control group. CONCLUSIONS: Hypersal instillation is safe and tolerable immediately after TURBT.
Most patients with ureterolithiasis are managed successfully with conservative treatment. In this context, delineation of clinical risk factors that identify patients with low risk for surgical intervention may reduce use of Non-Contrast Computed Tomography (NCCT). Here, emergency department patient files from a 14-month period were reviewed retrospectively, to identify patients who underwent NCCT and showed a ureteral stone. Demographic, clinical and laboratory information was collected. Patients were grouped to either requiring surgical intervention (Group 1) or having successful conservative management (Group 2). The cohort included 368 patients; 36.1% ultimately required surgical intervention (Group 1) and 63.9% were successfully treated conservatively (Group 2). On univariate analysis, patients who required surgical intervention were older, had longer duration of symptoms, had history of urolithiasis and surgical intervention for urolithiasis and had higher serum creatinine levels. Multivariate analysis identified the following risk factors associated with surgical intervention: creatinine >1.5 mg/dL, duration of symptoms ≥ 1.5 days and age > 45 years. Patients with 0, 1, 2 or 3 of the identified risk factors had 19%, 32%, 53% and 73% likelihood, respectively, of surgical intervention. Incorporating these data may reduce the use of NCCT scans in patients who are likely to pass a stone via conservative management.
Background: Proximal ureteral stones (PUS) have relatively low rates of spontaneous expulsion. However, some patients do well on expectant management. Our aim was to compare risk factors for surgical intervention in patients with PUS who underwent primary intervention to those subjected to expectant management. Materials and methods: We retrospectively reviewed the medical charts of patients presented to the emergency room with symptoms of renal colic and underwent computerized tomography between August 2016 and August 2017. A total of 97 consecutive patients were identified with up to 10 mm PUS. We collected patient demographics, clinical, and imaging data, and performed binary regression analysis for risk of intervention. Results: The average age was 49 years (range 17-97) and average stone size was 7.1 mm (range 3-10). Forty-one patients underwent immediate intervention while the remaining 56 patients were treated conservatively. Of the 56 patients treated conservatively, 26 underwent delayed intervention while 30 reported spontaneous stone expulsion. On univariate analysis of all 97 patients, statistically significant risk factors for intervention were found based on stone size, age, serum lymphocyte, platelet counts, and stone density. Of these risk factors, stone size ≥ 7 mm (p = 0.012, odds ratio = 5.4) and platelet count 230 K/mL (p = 0.027, odds ratio = 4.9) remained statistically significant on multivariate analysis. Conclusion: Stone size and platelet count were found to be risk factors for surgical intervention in patients with up to 10 mm PUS. These findings may assist in identifying patients who are more suitable for conservative approach.
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