Celebrating 75 years.

INTRODUCTION: Following the introduction of shock wave lithotripsy (SWL), ureteroscopy (URS), and percutaneous nephrolithotomy (PCNL), the subspecialty of endourology was born in the late 1970s. The purpose of this study was to report milestones in Canadian endourology, highlighting Canada's contributions to the field. METHODS: A review of the literature was performed from the late 1970s to the present. The literature review included bibliographic and digital resources. Additionally, records and recollections by various individuals were used, including some who were directly involved. RESULTS: Endourology was born in Canada when SWL, URS, and PCNL emerged as minimally invasive treatment options for stones in the early to mid-1980s. According to our research, the first PCNL was performed at the University of Toronto in 1981. Dr. Joachim Burhenne, a Harvard-trained radiologist from Germany, first used extracorporeal SWL in Canada at the University of British Columbia (UBC) for the treatment of biliary stones. Treatment for urinary tract stones followed at UBC and Dalhousie University. The first worldwide use of the holmium laser for lithotripsy of urinary tract calculi took place at the University of Western Ontario. Other endourology milestones in Canada include the formation of the Canadian Endourology Group and the emergence of the Endourological Society-accredited fellowship programs at the University of Toronto and Western University in the 1990s. Canada hosted the 21st and 35th World Congress of Endourology and Shock Wave Lithotripsy annual meeting in Montreal and Vancouver, respectively. CONCLUSIONS: Canadian urologists have led many advances in SWL, URS, and PCNL over the past four decades and, for a relatively small community, have made significant contributions to the field. Through the training of the next generation of endourologists at Canadian institutions, the future of endourology in Canada is bright.

Outpatient bilateral supracostal tubeless percutaneous nephrolithotomy for staghorn calculi.

Percutaneous nephrolithotomy (PCNL) is the surgical procedure of choice to treat staghorn calculi. Most centres perform PCNL as the traditional inpatient procedure. However, outpatient PCNL has been successfully attempted and represents a feasible method of reducing hospital costs. We report the case of a 35-year-old female who underwent outpatient simultaneous PCNL for bilateral renal staghorn calculi. The patient was discharged in stable condition less than 3 hours following the procedure with minimal discomfort. To the best of our knowledge, this case report is the first to describe a successfully completed outpatient bilateral supracostal tubeless PCNL for staghorn calculi.

Plasma organochlorine levels and prostate cancer risk.

A case-control study was conducted to determine the association between plasma organochlorine levels and prostate cancer risk. Male clinic patients scheduled for prostate core biopsy or seeing their urologist for other conditions from 1997 through 1999 in Kingston, Ontario were eligible, excluding those with an earlier cancer. Age frequency matched controls (n=329) were compared with 79 incident prostate cancer cases. Before knowledge of diagnosis, the patients completed a questionnaire and donated 15 ml of blood for the measurement of 14 PCBs, and 13 organochlorine pesticides by gas chromatography. At least 70% of patients had detectable levels of nine PCB congeners and seven pesticides, and these chemicals were included in the risk analysis adjusted for total lipids. Geometric means for these PCB congeners, total PCBs, and p,p'-DDE are slightly lower for cases than controls, whereas the levels of p,p'-DDT and other pesticides are virtually equal. Adjusting for age and other confounders in multivariable logistic regression, odds ratios (ORs) are consistently below 1.0 for PCB congeners and total PCBs. For pesticides, most ORs are very close to the null. This study suggests that long-term low-level exposure to organochlorine pesticides and PCBs in the general population does not contribute to increased prostate cancer risk.

Correlation of CT scan versus plain radiography for measuring urinary stone dimensions.

OBJECTIVES: To correlate the measured dimensions of urinary stones from spiral non-contrast computerized tomography (CT) with that of plain radiography (KUB). METHODS: The transverse diameter as reported on CT was compared to the measured transverse diameter on KUB for 61 stones. The transverse and craniocaudal dimensions on CT were then re-measured for 30 urinary stones and again compared to the re-measured values for KUB. The craniocaudal dimension on CT was determined by measuring the stone on reconstructed coronal CT images. Measurements between imaging modalities were blinded and performed consecutively by a dedicated investigator. RESULTS: The mean transverse size of the stones on the initial CT report was 6.0 mm +/- 2.8 mm versus 5.6 mm +/- 2.3 mm on KUB (paired t-test, p = 0.05, 95% CI difference between the means -1.3 to 0.5). The stones were categorized in transverse size ranges of 1.0 mm to 5.0 mm, > 5.0 mm to 10.0 mm, and > 10.0 mm. A total of 14 stones failed to be put into the same size categories by the two methods. The largest difference in measurements was 5 mm. In the second analysis, where the CT dimensions were re-measured, the mean transverse dimension on CT was 4.5 mm +/- 2.1 mm versus 4.7 mm +/- 2.0 mm on plain radiography (paired t-test, p = 0.06, 95% CI difference between the means -0.02 to 0.6). Mean craniocaudal dimension of the stones on CT was 7.4 mm +/- 3.2 mm versus 6.0 mm +/- 2.7 mm on plain radiography (paired t-test, p = 0.0001, 95% CI between the means -2.0 to -0.9). When the stones were categorized in transverse size ranges of 1.0 mm to 5.0 mm, >5.0mm to 10.0mm, and >10.0mm, CT and KUB agreed for 30/30 stones. CONCLUSIONS: In this study, the initially reported CT transverse values were found to be significantly different from measured KUB values; moreover, large differences of up to 5 mm were found between the measurements. With fastidious measurement of stone dimensions on both CT and KUB, we found that the transverse dimension of stones measured by the two imaging modalities were similar. The craniocaudal measurements of the stones were found to be significantly different on CT versus KUB, with CT measurement being 1.4 mm larger on average.

Health advocacy training in urology: a Canadian survey on attitudes and experience in residency.

INTRODUCTION: Health advocacy is a well-defined core competency recognized by medical education and regulatory bodies. Advocacy is stressed as a critical component of a physician's function within his or her community and also of performance evaluation during residency training. We sought to assess urology residents' perceptions and attitudes toward health advocacy in residency training and practice. METHODS: We administered an anonymous, cross-sectional, self-report questionnaire to all final-year urology residents in Canadian training programs. The survey was closed-ended and employed a 5-point Likert scale. It was designed to assess familiarity with the concept of health advocacy and with its application and importance to training and practice. We used descriptive and correlative statistics to analyze the responses, such as the availability of formal training and resident participation in activities involving health advocacy. RESULTS: There was a 93% response rate among the chief residents. Most residents were well aware of the role of the health advocate in urology, and a majority (68%) believed it is important in residency training and in the urologist's role in practice. This is in stark contrast to acknowledged participation and formal training in health advocacy. A minority (7%-25%) agreed that formal training or mentorship in health advocacy was available at their institution, and only 21%-39% felt that they had used its principles in the clinic or community. Only 4%-7% of residents surveyed were aware of or had participated in local urological health advocacy groups. CONCLUSION: Despite knowledge about and acceptance of the importance of the health advocate role, there is a perceived lack of formal training and a dearth of participation during urological residency training.

Dietary patterns and risk of prostate cancer in Ontario, Canada.

Dietary patterns reflect combinations of dietary exposures, and here we examine these in relation to prostate cancer risk. In a case-control study, 80 incident primary prostate cancer cases and 334 urology clinic controls were enrolled from 1997 through 1999 in Kingston, Ontario, Canada. Food-frequency questionnaires were completed prior to diagnosis and assessed intake in the 1-year period 2-3 years prior to enrollment. Among controls, dietary intake was used in principal components analyses to identify patterns that were then evaluated with all subjects in relation to prostate cancer risk using unconditional logistic regression, controlling for age. Four dietary patterns were identified: Healthy Living, Traditional Western, Processed and Beverages. Increased prostate cancer risk is apparent in relation to the Processed pattern, composed of processed meats, red meats, organ meats, refined grains, white bread, onions and tomatoes, vegetable oil and juice, soft drinks and bottled water. The OR for the highest tertile compared to baseline is 2.75 (95% CI 1.40-5.39), with a dose-response pattern (trend test p < 0.0035). Our results suggest that a dietary pattern including refined grain products, processed meats and red and organ meats contributes to increased prostate cancer risk. Since dietary information was collected before subjects knew their diagnosis, recall bias was avoided.

A survey of urological manpower, technology, and resources in Canada.

INTRODUCTION: Knowledge of the current status of manpower and resources is important in understanding the state of any medical specialty, and critical in planning for future recruitment, funding and infrastructure development. METHODS: In 2003, the Canadian Urological Association (CUA) conducted two nationwide surveys examining manpower, resources, and the technology available. One survey went only to academic and hospital leaders across the country (the resources survey), while the other was sent to the entire general membership of the CUA. RESULTS: The response rate for the resources survey was 67%, while that for the membership survey was 50.4%. The respondents' ages were evenly distributed, with the modal 5-year range being 51 to 55 years of age. Eighty-eight percent of respondents were Canadian-trained. Two-thirds of respondents spent over 80% of their practice time in direct patient care, and most practiced general urology. The majority of respondents practiced in smaller hospitals: 57.6% in centres with 300 or fewer inpatient beds, and 47.2% of centres reported < 500 procedures/year. Community hospitals (62% of responses to the resources survey) generally had fewer advanced technologies than academic centres. A quarter of the cystoscopy equipment used by respondents was over 15 years old. CONCLUSIONS: The results of these surveys present a snapshot of the current state of urology resources and manpower across Canada, potentially allowing better planning and negotiations with hospitals and governments.

Inferior vena cavectomy for renal cell carcinoma with intracaval tumor thrombus.

Excision of the inferior vena cava for renal cell carcinoma with intracaval tumor thrombus is infrequently performed. Herein the authors report a 60-year old woman with a right renal cell carcinoma and massive occluding tumor thrombus of the inferior vena cava. Following a negative metastatic workup, this patient underwent surgery to remove the tumor and thrombus. Thrombectomy occurred via excision of the affected portion of inferior vena cava and proximal left renal vein. Reconstruction of the vena cava was not undertaken. The patient did not suffer any morbidity during recovery in hospital. Her renal function was normal upon discharge. All resection margins were negative for tumor. This experience is compared to those reported in the literature. Postoperative morbidity may be minimized by careful patient selection. Suitable patients should have a right-sided tumor with an occlusive subhepatic vena caval tumor thrombus.