How physician and patient perceptions differ regarding medical management of stone disease.

PURPOSE: We compared patient and urologist perceptions regarding the medical management of stone disease. MATERIALS AND METHODS: A total of 159 patients were prospectively interviewed. Patients were asked 3 questions concerning subjective tolerance of stone passage and surgical intervention weighed against the use of daily preventive medication. The same questions were sent to members of the Endourological Society. RESULTS: Mean +/- SD patient age was 51 +/- 14 years. Recurrent stone formers comprised 72% of patients and 76% had undergone a prior surgical procedure while 43% were taking prophylactic medication. Overall 81% and 88% of patients responded that they would rather take medication than tolerate a single stone event at home or in the emergency room, respectively. Likewise 92% of patients stated that they would prefer daily medication compared to any surgical procedure. Among 61 urologists 26%, 38% and 18% responded that patients would likely tolerate 1, 2 or an unlimited number of stone passages at home, respectively, before agreeing to take medication. Of the urologists 66% estimated that patients would tolerate up to 2 acute stone events requiring an emergency room visit before starting medication. In addition 20%, 31% and 33% of urologists presumed that patients would accept the need for surgery annually, every other year or every third year rather than take medication. CONCLUSIONS: Most patients with stones will consider preventive medical therapy to avoid recurrent pain or a surgical procedure. In contrast, most urologists perceive that patients prefer to avoid medication even if it means tolerating several acute stone events and/or surgical procedures.

Simplified robot-assisted partial nephrectomy: step-by-step technique and perioperative outcomes.

Controversies have been raised and still exist regarding several technical aspects of robot-assisted partial nephrectomy (RAPN). While the "perfect RAPN" has still to be determined, we aimed to report a simplified technique of RAPN in a step-by-step fashion and the perioperative outcomes of a single-center series. A simplified technique of RAPN was developed, refined and standardized over the past 7 years in an academic department of urology to make it as safe and as reproducible as possible, the main goal being to make it an "easy to learn" technique for fellows. This technique is presented in 12 key steps. The patients' characteristics and perioperative outcomes were prospectively collected and are reported herein. Since the first case performed in our department in 2010, 406 patients have undergone RAPN with a standardized and stable simplified technique after the first 30 cases, involving several key steps including systematic use of the transperitoneal approach, minimal visceral mobilization of the colon, systematic psoas exposure and ureter identification, minimal dissection of the perinephric fat, arterial clamping with early unclamping, no use of hemostatic agents or drain. The majority of RAPN were performed by surgeons with either low experience (i.e., < 20 procedures; 46.3%) or intermediate experience (i.e., 20-50 procedures; 17.2%). The mean warm ischemia time was 15.3 min. Conversions to an open approach and to radical nephrectomy were required in 14 (3.5%) and 21 (5.2%) cases, respectively. From 132 patients who experienced post-operative complications (32.5%), 47 experienced a major complication (11.6%). The positive surgical margin rate was 5.6%. The simplified technique of RAPN was feasible and reproducible with satisfactory perioperative outcomes. Most of the key steps have been assessed through single-center and multicenter clinical studies.

The Learning Curve for Robot-assisted Partial Nephrectomy: Impact of Surgical Experience on Perioperative Outcomes.

Robot-assisted partial nephrectomy (RAPN) outcomes might be importantly affected by increasing surgical experience (EXP). The aim of the study is to investigate the effect of EXP on warm ischemia time (WIT), presence of at least one Clavien-Dindo ≥2 postoperative complication (CD ≥ 2), and positive surgical margins (PSMs) to define the learning curve for RAPN. We evaluated 457 consecutive patients diagnosed with a cT1-T2 renal mass were evaluated. EXP was defined as the total number of RAPNs performed by each surgeon before each patient's operation. Median WIT was 14min and the rate of CD ≥ 2 and PSMs was 15% and 4%, respectively. At multivariable regression analyses adjusted for case mix, EXP resulted associated with shorter WIT (p<0.0001) and higher probability of CD ≥ 2-free postoperative course (p=0.001), but not with PSMs (p=0.7). The relationship between EXP and WIT emerged as nonlinear, with a steep slope reduction within the first 100 cases and a plateau observed after 150 cases. Conversely, the relationship between EXP and CD ≥ 2-free course resulted linear, without reaching a plateau, even after 300 cases. Patient summary: Perioperative outcomes after robot-assisted partial nephrectomy (RAPN) are importantly and individually affected by surgeon's experience. After 150 RAPNs, no further improvement is observed with respect to ischemia time, but the learning curve appears endless with respect to complications.

Management of urinary stone disease in general practice: A French Delphi study.

BACKGROUND: Recommendations for the management of urolithiasis in primary care are lacking in France. The Delphi method was used to seek consensus from an expert panel regarding outpatient management of urolithiasis. METHODS: We gathered 25 French experts from five clinical specialties: general practice, urology, nephrology, emergency medicine and radiology. The first survey was formulated after an exhaustive literature review. At each of the three rounds, the experts were given the results of the previous round and were asked again to complete the survey. The threshold of 70% of the vote was taken as defining consensus. A final round of validation involving five additional general practitioners was conducted. RESULTS: Twenty experts participated in the study (five urologists, four nephrologists, four general practitioners, four emergency physicians, and three radiologists, participation rate = 80%). According to the survey results, most patients could be treated as outpatients (70.5% of the votes) but a biological (urine dipstick and culture, serum creatinine ± serum ß-hcg) and imaging (renal ultrasound + Kidney-Ureters-Bladder X-ray or low-dose CT san) work-up is recommended within 24 hours. Non-steroidal anti-inflammatory drugs are the analgesics of choice. An aetiological work-up should be performed after the second episode of renal colic. A follow-up imaging should be carried out yearly in urolithiasis patients. CONCLUSION: With the use of the Delphi method, we propose a multidisciplinary recommendation for the management of urolithiasis patients in primary care.