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Factors Affecting Outcomes of Percutaneous Nephrolithotomy in Horseshoe Kidneys
Moreover, what is pathophysiological way of pelvic pain, sexual dysfunction, and infertility development in young men? We need to improve our knowledge in the diagnosis and management of C trachomatis infection to decrease the rate of the complications due to this disease. Tommaso Cai, M.D. Department of Urology Santa Chiara Regional Hospital Trento, Italy Riccardo Bartoletti, M.D. Department of Urology University of Florence Florence, Italy References 1. Park H, Sim SM, Lee G. The presence of Chlamydia is associated with increased leukocyte counts and pain severity in men with chronic pelvic pain syndrome. Urology. 2015;85:574-579. 2. Cai T, Pisano F, Magri V, et al. Chlamydia trachomatis infection is related to premature ejaculation in chronic prostatitis patients: results from a cross-sectional study. J Sex Med. 2014;11:3085-3092. 3. Mazzoli S, Cai T, Addonisio P, et al. Chlamydia trachomatis infection is related to poor semen quality in young prostatitis patients. Eur Urol. 2010;57:708-714.
In the editorial comment,5 the editors suggest 3 topics to improve our knowledge in chlamydia research and in sharing patients’ agony. We fully agree with their opinions. In addition, we have added other urgent matters to the discussion: What is the ideal sample for CT detection in each genital chlamydia infection? Is there a way to avert the potential urethral contamination? If not possible, can a quantification strategy using real-time polymerase chain reaction provide an alternative method to minimize urethral contamination? Finally, nucleic acid amplification test (NAAT) recently became the gold standard for CT diagnosis. However, positive results with NAAT only indicate the presence of a target pathogen, not the presence of disease. In other words, many men found to be infected with chlamydia via the NAAT standard do not have chlamydia-specific symptoms or signs. We must understand the difference between sexually transmitted infection and sexually transmitted disease. We appreciate this ongoing discussion regarding chlamydia infection. Gilho Lee, M.D. Department of Urology Dankook University College of Medicine Dongnam-gu Cheonan, Korea
Reply by the Authors We appreciate the well-advised comments on sexual dysfunction and male fertility diseases caused by chlamydia infection in chronic prostatitis (CP) patients.1 The role of Chlamydia trachomatis (CT) in urethritis has been well characterized.2 Similar to other gramnegative uropathogens, CT in the urethra can ascend to the epididymis, prostate, and seminal vesicles, where it can establish a bridgehead.2 Krieger and Riley reported that prostatic biopsy from well-characterized CPechronic pelvic pain syndrome patients who do not have urethritis revealed the presence of CT in the prostate.3 The prostate produces large amounts of ejaculatory components to provide an adequate medium for sperm survival. In contrast, chlamydia infections can cause chronic inflammation, disturbing the normal prostate function. White blood cells in expressed prostatic secretion may also negatively affect sperm.2,4 The white blood cells recruited to infectious areas subsequently secrete cytokines and chemokines, which leads to prostate damage and may adversely affect sperm function.2,4 However, the roles of CT infection in CPechronic pelvic pain syndrome and male fertility are still under debate. To settle the controversy, not only positive data from in vitro studies and clinical association studies but also well-designed studies are needed to establish a direct cause and the effect on male genital organs based on Koch postulates.
UROLOGY 85 (6), 2015
References 1. Mazzoli S, Cai T, Addonisio P, et al. Chlamydia trachomatis infection is related to poor semen quality in young prostatitis patients. Eur Urol. 2010;57:708-714. 2. Mackern-Oberti JP, Motrich RD, Breser ML, et al. Chlamydia trachomatis infection of the male genital tract: an update. J Reprod Immunol. 2013;100:37-53. 3. Krieger JN, Riley DE. Chronic prostatitis: Charlottesville to Seattle. J Urol. 2004;172(6 Pt 2):2557-2560. 4. Aitken RJ, Baker MA. Oxidative stress, spermatozoa and leukocytic infiltration: relationships forged by the opposing forces of microbial invasion and the search for perfection. J Reprod Immunol. 2013;100:11-19. 5. Cai T, Bartoletti R. Re: Park et al.: The presence of chlamydia is associated with increased leukocyte counts and pain severity in men with chronic pelvic pain syndrome (Urology 2015;85:574-579). Urology. 2015;85:1521-1524.
Factors Affecting Outcomes of Percutaneous Nephrolithotomy in Horseshoe Kidneys TO THE EDITOR,
We congratulate the authors1 for giving insight of various factors modulating the outcomes of percutaneous nephrolithotomy (PNL) exclusively on horseshoe kidneys (HSKs) where literature is still scarce.
1523
However, certain clarifications are needed to better understand this article. A recent article2,3 has shown that the length of the PNL tract, stone density, and obesity significantly affect the outcomes of PNL apart from the degree of hydronephrosis and stone bulk and complexity (STONE score). Morbidly obese patients are significantly more likely to experience lower stone-free rates and increased postoperative complication.4 The authors did not mention about how many stones were located specifically in the inferior calyx and what was the access used for inferior calyx because inferior calyceal location is known to affect the outcomes of PNL and needs more auxiliary procedure especially in HSKs. The number of intercostal access was very high (42.6%) in the study considering the lower position of HSK than the normal kidney as shown in another study where supracostal access was performed in 22.2% of cases.5 The authors mention that 18.5% of punctures were made in the inferior calyx. In HSKs, as the inferior calyx is medially rotated it, could be difficult to puncture. Bimalesh Purkait, M.B.B.S., M.S., M.Ch. Apul Goel, M.B.B.S., M.S., M.Ch., D.N.B., M.N.A.M.S. Department of Urology King George’s Medical University Lucknow, India References 1. Tepeler A, Sehgal PD, Akman T, et al. Factors Affecting Outcomes of Percutaneous Nephrolithotomy in Horseshoe Kidneys. Urology. 2014;84:1290-1294. 2. Okhunov Z, Friedlander JI, George AK, et al. S.T.O.N.E. nephrolithometry: novel surgical classification system for kidney calculi. Urology. 2013;81:1154-1159. 3. Sharma K, Goel A, Gupta S. Re: Okhunov et al.: S.T.O.N.E. nephrolithometry: novel surgical classification system for kidney calculi (Urology 2013;81:1154-1160). Urology. 2013;82:979. 4. Fuller A, Razvi H, Denstedt JD, et al. The clinical research office of the endourological society percutaneous nephrolithotomy global study: outcomes in the morbidly obese patient—a case control analysis. Can Urol Assoc J. 2014;8:E393-E397. 5. Shokeir AA, El-Nahas AR, Shoma AM, et al. Percutaneous nephrolithotomy in treatment of large stones within horseshoe kidneys; Access to the horseshoe kidneys was supracostal in 10 (22. 2%) and subcostal in 35 kidneys (77.8%). Urology. 2004;64: 426-429.
1524
Reply by the Authors We would like to extend our gratitude to the authors for their constructive comments on our study with regard to highlighting the factors affecting the outcomes of percutaneous nephrolithotomy (PNL) in horseshoe kidneys. So far, investigators have proposed scoring systems that use the findings of computed tomography to predict the outcome of PNL for kidney stones.1,2 Stone size, number of calices involved, tract length, stone density, grade of hydronephrosis, and body mass index have been specified as important factors affecting the success of these procedures. The Guy’s stone score and STONE nephrolithometry have been validated as predictors for success. Although the presence of renal abnormality is used as a parameter in the Guy’s stone score, there is paucity of information about renal abnormalities for the STONE scoring system. In our study, we aimed to assess patient- and procedurerelated factors related to outcomes of PNL in horseshoe kidneys. We observed that PNL procedures were more complicated due to the factors malrotation and ectopic location. We may consider that the upper pole is the recommended access site even for stones located in the lower calyx; however, in our series, the lower calyx was the access site in 10 cases with lower calyx stones that could not be reached through middle or upper calyx access. Intercostal accesses were applied through the space between the 12th and 11th costae in 23 cases (42.6%); thoracic complications were not observed in any of these cases. In the remaining patients, renal access was achieved via the subcostal area. Abdulkadir Tepeler, M.D. Department of Urology Faculty of Medicine Bezmialem Vakif University Istanbul, Turkey References 1. Okhunov Z, Friedlander JI, George AK, et al. S.T.O.N.E. nephrolithometry: novel surgical classification system for kidney calculi. Urology. 2013;81:1154-1159. 2. Thomas K, Smith NC, Hegarty N, Glass JM. The Guy’s stone score—grading the complexity of percutaneous nephrolithotomy procedures. Urology. 2011;78:277-281.
UROLOGY 85 (6), 2015
In the editorial comment,5 the editors suggest 3 topics to improve our knowledge in chlamydia research and in sharing patients’ agony. We fully agree with their opinions. In addition, we have added other urgent matters to the discussion: What is the ideal sample for CT detection in each genital chlamydia infection? Is there a way to avert the potential urethral contamination? If not possible, can a quantification strategy using real-time polymerase chain reaction provide an alternative method to minimize urethral contamination? Finally, nucleic acid amplification test (NAAT) recently became the gold standard for CT diagnosis. However, positive results with NAAT only indicate the presence of a target pathogen, not the presence of disease. In other words, many men found to be infected with chlamydia via the NAAT standard do not have chlamydia-specific symptoms or signs. We must understand the difference between sexually transmitted infection and sexually transmitted disease. We appreciate this ongoing discussion regarding chlamydia infection. Gilho Lee, M.D. Department of Urology Dankook University College of Medicine Dongnam-gu Cheonan, Korea
Reply by the Authors We appreciate the well-advised comments on sexual dysfunction and male fertility diseases caused by chlamydia infection in chronic prostatitis (CP) patients.1 The role of Chlamydia trachomatis (CT) in urethritis has been well characterized.2 Similar to other gramnegative uropathogens, CT in the urethra can ascend to the epididymis, prostate, and seminal vesicles, where it can establish a bridgehead.2 Krieger and Riley reported that prostatic biopsy from well-characterized CPechronic pelvic pain syndrome patients who do not have urethritis revealed the presence of CT in the prostate.3 The prostate produces large amounts of ejaculatory components to provide an adequate medium for sperm survival. In contrast, chlamydia infections can cause chronic inflammation, disturbing the normal prostate function. White blood cells in expressed prostatic secretion may also negatively affect sperm.2,4 The white blood cells recruited to infectious areas subsequently secrete cytokines and chemokines, which leads to prostate damage and may adversely affect sperm function.2,4 However, the roles of CT infection in CPechronic pelvic pain syndrome and male fertility are still under debate. To settle the controversy, not only positive data from in vitro studies and clinical association studies but also well-designed studies are needed to establish a direct cause and the effect on male genital organs based on Koch postulates.
UROLOGY 85 (6), 2015
References 1. Mazzoli S, Cai T, Addonisio P, et al. Chlamydia trachomatis infection is related to poor semen quality in young prostatitis patients. Eur Urol. 2010;57:708-714. 2. Mackern-Oberti JP, Motrich RD, Breser ML, et al. Chlamydia trachomatis infection of the male genital tract: an update. J Reprod Immunol. 2013;100:37-53. 3. Krieger JN, Riley DE. Chronic prostatitis: Charlottesville to Seattle. J Urol. 2004;172(6 Pt 2):2557-2560. 4. Aitken RJ, Baker MA. Oxidative stress, spermatozoa and leukocytic infiltration: relationships forged by the opposing forces of microbial invasion and the search for perfection. J Reprod Immunol. 2013;100:11-19. 5. Cai T, Bartoletti R. Re: Park et al.: The presence of chlamydia is associated with increased leukocyte counts and pain severity in men with chronic pelvic pain syndrome (Urology 2015;85:574-579). Urology. 2015;85:1521-1524.
Factors Affecting Outcomes of Percutaneous Nephrolithotomy in Horseshoe Kidneys TO THE EDITOR,
We congratulate the authors1 for giving insight of various factors modulating the outcomes of percutaneous nephrolithotomy (PNL) exclusively on horseshoe kidneys (HSKs) where literature is still scarce.
1523
However, certain clarifications are needed to better understand this article. A recent article2,3 has shown that the length of the PNL tract, stone density, and obesity significantly affect the outcomes of PNL apart from the degree of hydronephrosis and stone bulk and complexity (STONE score). Morbidly obese patients are significantly more likely to experience lower stone-free rates and increased postoperative complication.4 The authors did not mention about how many stones were located specifically in the inferior calyx and what was the access used for inferior calyx because inferior calyceal location is known to affect the outcomes of PNL and needs more auxiliary procedure especially in HSKs. The number of intercostal access was very high (42.6%) in the study considering the lower position of HSK than the normal kidney as shown in another study where supracostal access was performed in 22.2% of cases.5 The authors mention that 18.5% of punctures were made in the inferior calyx. In HSKs, as the inferior calyx is medially rotated it, could be difficult to puncture. Bimalesh Purkait, M.B.B.S., M.S., M.Ch. Apul Goel, M.B.B.S., M.S., M.Ch., D.N.B., M.N.A.M.S. Department of Urology King George’s Medical University Lucknow, India References 1. Tepeler A, Sehgal PD, Akman T, et al. Factors Affecting Outcomes of Percutaneous Nephrolithotomy in Horseshoe Kidneys. Urology. 2014;84:1290-1294. 2. Okhunov Z, Friedlander JI, George AK, et al. S.T.O.N.E. nephrolithometry: novel surgical classification system for kidney calculi. Urology. 2013;81:1154-1159. 3. Sharma K, Goel A, Gupta S. Re: Okhunov et al.: S.T.O.N.E. nephrolithometry: novel surgical classification system for kidney calculi (Urology 2013;81:1154-1160). Urology. 2013;82:979. 4. Fuller A, Razvi H, Denstedt JD, et al. The clinical research office of the endourological society percutaneous nephrolithotomy global study: outcomes in the morbidly obese patient—a case control analysis. Can Urol Assoc J. 2014;8:E393-E397. 5. Shokeir AA, El-Nahas AR, Shoma AM, et al. Percutaneous nephrolithotomy in treatment of large stones within horseshoe kidneys; Access to the horseshoe kidneys was supracostal in 10 (22. 2%) and subcostal in 35 kidneys (77.8%). Urology. 2004;64: 426-429.
1524
Reply by the Authors We would like to extend our gratitude to the authors for their constructive comments on our study with regard to highlighting the factors affecting the outcomes of percutaneous nephrolithotomy (PNL) in horseshoe kidneys. So far, investigators have proposed scoring systems that use the findings of computed tomography to predict the outcome of PNL for kidney stones.1,2 Stone size, number of calices involved, tract length, stone density, grade of hydronephrosis, and body mass index have been specified as important factors affecting the success of these procedures. The Guy’s stone score and STONE nephrolithometry have been validated as predictors for success. Although the presence of renal abnormality is used as a parameter in the Guy’s stone score, there is paucity of information about renal abnormalities for the STONE scoring system. In our study, we aimed to assess patient- and procedurerelated factors related to outcomes of PNL in horseshoe kidneys. We observed that PNL procedures were more complicated due to the factors malrotation and ectopic location. We may consider that the upper pole is the recommended access site even for stones located in the lower calyx; however, in our series, the lower calyx was the access site in 10 cases with lower calyx stones that could not be reached through middle or upper calyx access. Intercostal accesses were applied through the space between the 12th and 11th costae in 23 cases (42.6%); thoracic complications were not observed in any of these cases. In the remaining patients, renal access was achieved via the subcostal area. Abdulkadir Tepeler, M.D. Department of Urology Faculty of Medicine Bezmialem Vakif University Istanbul, Turkey References 1. Okhunov Z, Friedlander JI, George AK, et al. S.T.O.N.E. nephrolithometry: novel surgical classification system for kidney calculi. Urology. 2013;81:1154-1159. 2. Thomas K, Smith NC, Hegarty N, Glass JM. The Guy’s stone score—grading the complexity of percutaneous nephrolithotomy procedures. Urology. 2011;78:277-281.
UROLOGY 85 (6), 2015