A population based study of the changing demographics of patients undergoing definitive treatment for kidney stone disease.

PURPOSE: We examined temporal changes in the demographics of patients undergoing definitive treatment for kidney stones during a 20-year period in Ontario, Canada. MATERIALS AND METHODS: Using the Ontario Health Insurance Plan physician claims database and the Canadian Institute for Health Information Discharge Abstract Database we performed a population based cross-sectional time series analysis by identifying all kidney stone treatments done between July 1, 1991 and December 31, 2010. The demographics assessed were patient gender, age and socioeconomic status. The rate and/or proportion of kidney stone treatments per strata of these demographics were calculated for each 1-year block of the study period. We used time series analysis with exponential smoothing and autoregressive integrated moving average models to assess for trends with time. RESULTS: We identified 116,115 patients who underwent treatment for kidney stones during the study period. The rate of stone procedures performed per year increased steadily from 85/100,000 to 126/100,000 population. With time the rate of females who were treated increased significantly from 40/100,000 to 53/100,000 (p <0.0001). In contrast, the rate of males who were treated remained stable, increasing from 82/100,000 to 83/100,000 (p = 0.11). In regard to age the rate of patients older than 64 years increased significantly with time from 67/100,000 to 89/100,000 (p <0.0001). In regard to socioeconomic status approximately 20% of the patients were in each of the 5 income quintiles during the entire study period. CONCLUSIONS: Our population based study shows an increased rate of females and of patients older than 64 years undergoing definitive treatment for kidney stones with time.

The role of prophylactic versus selective ureteric stenting in kidney transplant patients: a retrospective review.

OBJECTIVE: To evaluate the role of prophylactic versus selective ureteric stenting in the development of postoperative ureterovesical complications in kidney transplant recipients. METHODS: Records of 614 transplant patients seen from January 2006 to May 2011 were retrospectively reviewed. The primary outcome was the rate of ureterovesical complications, defined as the development of ureteric obstruction or a ureterovesical anastomotic leak. The secondary outcomes were the rate of urinary tract infections and forgotten stents. Using a χ2 test, we compared the primary and secondary outcomes across the selective and prophylactic cohorts. Logistic regression was used to compare the 2 cohorts while adjusting for potential confounders. RESULTS: The selective and prophylactic cohorts consisted of 258 and 330 patients, respectively. Unadjusted analysis showed that the prophylactic group had a significantly lower rate of ureterovesical complications than did the selective group (2.12% vs 6.20%; odds ratio, 0.33; P= .01). After adjustment for differences in sex and donor type, the prophylactic group still had a lower risk for ureterovesical complications (odds ratio, 0.30; P= .009). Rates of urinary tract infections and forgotten stents did not differ significantly between the 2 groups. CONCLUSIONS: Prophylactic stenting is associated with a significantly lower rate of ureterovesical complications than is selective stenting.

Robotic-assisted laparoscopic pyeloplasty for ureteropelvic junction obstruction A retrospective review of a high-volume Canadian center.

INTRODUCTION: At present, there is no literature on the outcomes of robotic-assisted laparoscopic pyeloplasty (RALPyelo) in a Canadian context. Our objective was to perform a retrospective review of RALPyelo cases at a high-volume Canadian center. METHODS: We performed a retrospective review of patients who underwent RALPyelo at St. Michael's Hospital, between January 2012 and May 2019. Demographics, operative details, and pre- and postoperative imaging results (ultrasounds, computed tomography [CT] scans, and diuretic renal scan [DRS ]) were recorded. Patients were excluded if at least one-year followup data was unavailable. Our primary outcome was clinical and radiologic improvement defined as 1) symptom improvement; 2) stable/improved split renal function on DRS ; and 3) either improvement in the degree of hydronephrosis on ultrasound or CT, or improved drainage time on DRS. Secondary outcomes included postoperative complications, need for diagnostic intervention, and reintervention for recurrent UPJO. RESULTS: A total of 156 patients underwent RALPyelo after exclusions. The median age was 42 and 66% were female. Mean followup was 2.5 years. For our primary outcome, 87% had clinical and radiologic improvement. Diagnostic investigation for possible recurrent/persistent obstruction, based on symptoms and/or imaging results, was required in 17% of cases, but only 3% required reintervention for recurrent UPJO. Accordingly, the overall treatment success was 97%. The most common postoperative complication was urinary tract infection (18%), and urine leak was seen in only 2% of patients. CONCLUSIONS: The results of our study compare favorably with currently reported outcomes in the literature and demonstrate the safety and high level of success of RALPyelo at a high-volume Canadian center.

A prospective study examining the incidence of bacteriuria and urinary tract infection after shock wave lithotripsy with targeted antibiotic prophylaxis.

PURPOSE: Controversy exists regarding antibiotic prophylaxis before shock wave lithotripsy. The AUA (American Urological Association) guideline recommends universal antibiotic prophylaxis, whereas the EAU (European Association of Urology) guideline recommends prophylaxis only for select patients. We evaluated the use of targeted antibiotic prophylaxis in preventing urinary tract infections in patients undergoing shock wave lithotripsy. MATERIALS AND METHODS: A prospective single cohort study was performed during 6 months with patients undergoing shock wave lithotripsy. All patients underwent urine dipstick and culture before shock wave lithotripsy. Targeted antibiotic prophylaxis was provided at the discretion of the treating urologist. All patients had a urine culture performed after shock wave lithotripsy and completed a survey documenting fevers or urinary symptoms. The primary outcome was the incidence of urinary tract infections, urosepsis and asymptomatic bacteriuria after shock wave lithotripsy. The secondary outcome was the sensitivity and specificity of urinary dipstick leukocytes and nitrites. RESULTS: A total of 526 patients were enrolled in the study. Of the 389 patients included in the determination of the primary outcome, urinary tract infection developed in only 1 (0.3%), urosepsis did not develop in any patients and asymptomatic bacteriuria developed in 11 (2.8%). Eight (2.1%) patients were administered antibiotic prophylaxis. The specificity of urine dipstick nitrites was high (95%) while the sensitivity was poor (9.7%). CONCLUSIONS: In our cohort study using targeted antibiotic prophylaxis the rates of urinary tract infection after shock wave lithotripsy and rates of asymptomatic bacteriuria were extremely low, with no development of urosepsis. This finding questions the need for universal antibiotic prophylaxis before shock wave lithotripsy.

Determination of optimal stent length: a survey of urologic surgeons.

Introduction: Ureteral double-J stent length is an important factor affecting stent-related symptoms. Multiple techniques exist to determine ideal stent length for a given patient, however, little is known about what techniques urologists rely on. Our objective was to identify how urologists determine optimal stent length. Material and methods: An online survey was e-mailed in 2019 to all members of the Endourology Society. The survey sought to assess what methods are commonly used to determine choice of stent length, along with frequency of stent placement post ureteroscopy, duration of stenting, availability of different stent lengths and the use of stent tether. Results: 301 urologists (15.1%) responded to our survey. Following ureteroscopy, 84.5% of respondents would stent at least 50% of the time. Following uncomplicated ureteroscopy, most respondents (52.0%) would leave a stent for 2-7 days. Patient height was most commonly ranked first as the method of choice in determining stent length (47.0%), followed by estimation based on experience only (20.6%) and intra-operative direct measurement of ureteric length (19.1%). Most respondents utilized multiple methods in determination of optimal stent length. Most respondents (66.5%) were interested in a simple intra-operative technique utilizing a special ureteral catheter that would help choose the most appropriate stent length. Conclusions: Post-ureteroscopy stent insertion is common and patient height is the most common method of choice used in determining optimal stent length. Most respondents were interested in using a simple, novel ureteral catheter device that would allow them to more accurately select optimal stent length.

A clinical nomogram to predict the successful shock wave lithotripsy of renal and ureteral calculi.

PURPOSE: Although shock wave lithotripsy is dependent on patient and stone related factors, there are few reliable algorithms predictive of its success. In this study we develop a comprehensive nomogram to predict renal and ureteral stone shock wave lithotripsy outcomes. MATERIALS AND METHODS: During a 5-year period data from patients treated at our lithotripsy unit were reviewed. Analysis was restricted to patients with a solitary renal or ureteral calculus 20 mm or less. Demographic, stone, patient, treatment and 3-month followup data were collected from a prospective database. All patients were treated using the Philips Lithotron® lithotripter. RESULTS: A total of 422 patients (69.7% male) were analyzed. Mean stone size was 52.3±39.3 mm2 for ureteral stones and 78.9±77.3 mm2 for renal stones, with 95 (43.6%) of the renal stones located in the lower pole. The single treatment success rates for ureteral and renal stones were 60.3% and 70.2%, respectively. On univariate analysis predictors of shock wave lithotripsy success, regardless of stone location, were age (p=0.01), body mass index (p=0.01), stone size (p<0.01), mean stone density (p<0.01) and skin to stone distance (p<0.01). By multivariate logistic regression for renal calculi, age, stone area and skin to stone distance were significant predictors with an AUC of 0.75. For ureteral calculi predictive factors included body mass index and stone size (AUC 0.70). CONCLUSIONS: Patient and stone parameters have been identified to create a nomogram that predicts shock wave lithotripsy outcomes using the Lithotron lithotripter, which can facilitate optimal treatment based decisions and provide patients with more accurate single treatment success rates for shock wave lithotripsy tailored to patient specific situations.

Predictors of health-related quality of life recovery following laparoscopic simple, radical and donor nephrectomy.

OBJECTIVES: To objectively quantify the recovery of health-related quality of life (HRQL) in patients undergoing laparoscopic nephrectomy. To determine which factors are predictive of a more expedited recovery. MATERIALS AND METHODS: Patient recovery was prospectively measured among patients undergoing laparoscopic simple (n= 12), radical (n= 42) and donor (n= 95) nephrectomy. All procedures were performed using a 3- or 4-trocar, transperitoneal fully-laparoscopic technique with intact specimen extraction using impermeable sacs for simple and radical nephrectomy, and hand extraction for donor nephrectomy. Postoperative recovery and quality of life were measured using the Postoperative Recovery Scale (PRS) administered preoperatively, immediately postoperatively and as an outpatient at 4, 8, 12, and 16 weeks postoperatively. ANOVA and Pearson's χ² tests were performed on demographic data. Multivariate logistic regression analysis was used to calculate odds ratios for factors predictive of recovery. RESULTS: Statistically significant differences were found at baseline for age (P = 0.02), gender (P < 0.01), body mass index (BMI; P = 0.03), surgical side (P < 0.01) and activity-based lifestyle (P = 0.04) across the three groups. Minimal adverse events were seen. Factors predictive of expedited recovery include age < 50 years (OR: 2.1, P < 0.01), body-mass index (BMI) < 30 kg/m² (OR: 1.7, P < 0.01), active lifestyles (OR: 1.3, P < 0.01) and those patients undergoing nephrectomy for benign or malignant indications rather than for organ donation (OR: 1.4, P < 0.01). There was a significant delay in the donor group vs the non-donor group with respect to the median number of days both groups took to recover 75% and 90% of their baseline PRS scores (11 days, P = 0.02; 20 days, P = 0.02, respectively). CONCLUSIONS: Predictive factors of recovery from laparoscopic nephrectomy include age, BMI, lifestyle and surgical indication. Differences between HRQL recovery following donor vs non-donor laparoscopic nephrectomy are significant, and suggest the possible interplay of underlying psychological factors.

Clips Can be Safely Used for Vascular Control of the Renal Vessels During Laparoscopic Donor Nephrectomy.

OBJECTIVE: To review our experience using clips to control the renal vessels during laparoscopic donor nephrectomy (LDN) and determine the safety of this practice. METHODS: We performed a retrospective review of patients who underwent LDN at our centre January 1, 2007-September 17, 2019. The primary outcome was the rate of complication associated with vascular control of the renal vessels, which included (1) conversion to open to manage bleeding, (2) additional procedures for bleeding, and (3) major bleeding requiring blood transfusion. Secondary outcomes included the rate of renal artery/vein clip dislodgement or crossing, change in hemoglobin, warm ischemia time and the incidence of intra-operative complications and postoperative in-hospital complications. RESULTS: We included 503 patients who underwent LDN, of which 497 were left sided. The main renal artery was controlled with 3 titanium clips in 489 (97%) cases. The main renal vein was controlled with 2 polymer-locking clips in 478 (95%) cases. For our primary outcome, there were no conversions to open to manage bleeding, no secondary procedures due to bleeding and no major bleeding requiring blood transfusion. Additionally, there were no donor deaths. Regarding our secondary outcomes, there were 5 intraoperative events related to the titanium clips being placed on the renal artery and 1 intraoperative event related to the polymer-locking clips on the renal vein, none of which resulted in any morbidity. CONCLUSION: Using 3 titanium clips on the renal artery and 2 polymer-locking clips on the renal vein during left LDN is safe and provides excellent vascular control.

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.

Urinary potassium is a clinically useful test to detect a poor quality diet.

Poor eating habits, a strong predictor of health outcomes, are not objectively assessed in routine clinical practice. In this study, we evaluated the use of urinary potassium (K(+)) as a means to identify people consuming a poor quality diet. Consecutive patients with kidney stones (n = 220), aged 18-50 y, from a population-based lithotripsy unit, collected a single 24-h urine sample to assess urinary K(+). They also completed a FFQ to derive the recommended foods score (RFS), an index of overall diet quality, and had their blood pressure, heart rate, weight, and height measured. Urinary K(+) was related positively with the intake of recommended food items, including vegetables, fruit, whole grains, low-fat dairy products, fish and poultry, and wine and negatively to those not recommended by current dietary guidelines, including red meat, fast food, and high-energy drinks. Urinary K(+) was also correlated with the RFS (r = 0.226; P < 0.001). Using a receiver operating characteristic curve, K(+) excretion values below the gender-specific median (men, 60 mmol/d; women, 41 mmol/d) were identified as the optimal cutoff values for a poor quality diet, indicated by the RFS. Higher urinary K(+) was inversely related to adjusted BMI (P-trend = 0.03), diastolic blood pressure (P-trend = 0.04) and heart rate (P-trend = 0.006), after controlling for potential confounders. Urinary K(+) provides a summary measure of diet quality, is significantly related to BMI, blood pressure, and heart rate, and may be useful clinically to detect poor dietary habits and monitor response to dietary interventions.

Routine Preoperative Electrocardiograms in Patients at Low Risk for Cardiac Complications During Shockwave Lithotripsy: Are They Useful?

INTRODUCTION: Routine preoperative electrocardiogram (ECG) before shockwave lithotripsy (SWL) is frequently performed despite recommendations against its use in asymptomatic patients undergoing low-risk surgical procedures. This study assesses whether routine preoperative ECG before SWL is useful in patients at low risk for cardiac complications. MATERIALS AND METHODS: A retrospective study of SWL at our center (2003-2013) reviewed all cardiac-related preoperative cancellations, intraoperative complications, postoperative admissions, and emergency department presentations in patients at low risk for cardiac complications. Patients received SWL with sedation and continuous five-lead ECG monitoring. RESULTS: Of 30,892 referrals, preoperative ECG triggered 13 (0.04%) cancelations in low-risk patients (1 with new atrial fibrillation and 12 with ischemia/previous infarction). Of these patients, 1 had a subsequent abnormal cardiac work-up and 11 underwent uncomplicated SWL without cardiac intervention (2 had unknown history). Of 27,722 treatments, 5 (0.02%) were stopped prematurely in low-risk patients because of arrhythmia (3 had normal preoperative ECG, 1 had abnormal ECG, and 1 did not complete ECG). Three patients developed an arrhythmia with sedation and 2 patients were admitted postoperatively because of cardiac complications (1 for atrial fibrillation and 1 for hypertension), of whom all had normal preoperative ECG. No patients presented to our emergency department with cardiac complications after SWL. CONCLUSIONS: In patients at low risk for cardiac complications, preoperative ECG triggered very few cancellations and did not predict early termination of treatment or cardiac complications after SWL. These findings suggest that in low-risk patients, routine preoperative ECG has little effect on treatment or complication rate and should be omitted.

Practical comparison of four nitinol stone baskets.

BACKGROUND AND PURPOSE: The use of stone baskets for repositioning of stones or removal of fragment in conjunction with ureterorenoscopy has become widespread. We tested the performance of the ACMI Sur-Catch NT, Bard Dimension, Boston Scientific Zero-tip, and Cook N-Circle in a pig kidney model of flexible ureterorenoscopy. MATERIALS AND METHODS: Opening characteristics of the basket were measured with mechanical calipers at 1-mm increments and compared with published reports to ensure the tested baskets were representative. Pig kidneys were placed in a basin and the ureters secured with a suture to a weight for stability. Flexible renoscopy was performed using a 16F flexible cystonephroscope. An 8-mm calculus was placed in the lower pole. Using each of four designs, the time necessary to grasp the stone, time to release the stone, and total time to move a stone from the lower-pole calix to the upper-pole were recorded. Total time experiments were repeated six times with each basket by three surgeons for a total of 18 attempts, and catch-and-release experiments were repeated six times by four surgeons for a total of 24 attempts per basket. RESULTS: The Sur-Catch was significantly slower for catch and release (P < 0.001) and total time; P < 0.05) compared with all other baskets. There were no differences between the other baskets in either catch, release, or total times. There was no difference between surgeons (P < 0.0634) or between attempts one through six (P = 0.538). CONCLUSIONS: Baskets with added complexity of the wire configurations (Sur-Catch) or a deflectable-wire mechanism (Dimension) offer no advantages and may slow capture and release of stones.

Changing Patient Position Can Eliminate Arrhythmias Developing During Extracorporeal Shockwave Lithotripsy.

INTRODUCTION: Extracorporeal shockwave lithotripsy (SWL) has a low complication rate. While serious complications are rare, cardiac arrhythmias, such as ventricular tachycardia, may occur. The etiology of these arrhythmias is poorly understood, but it appears to be due to stimulation of the heart by the shock waves. OBJECTIVE: This study examines the effect of rotating the patient 15° to 20° when an arrhythmia occurs. METHODS: Eight hundred nineteen patients were prospectively evaluated for arrhythmias during SWL. The initial patient position was dependent on the location of the stone and the body mass index (BMI) of the patient. If a sustained arrhythmia developed, treatment was withheld for 2 minutes and then recommenced. If the patient developed an arrhythmia again, the patient was rotated 15°-20° away from the original position and treatment recommenced. RESULTS: Twenty patients developed significant arrhythmias during SWL. Arrhythmias occurred more frequently in patients with a lower BMI (p < 0.01), of younger age (p = 0.01), and with right-sided stones (p = 0.035). After the first rotation, 11 patients had no further arrhythmias, and 4 patients had a reduction of their arrhythmia to unsustained minor arrhythmias that did not require cessation of the treatment. The remaining five patients required a second repositioning. Three of these patients required gated SWL to abolish the arrhythmia. CONCLUSION: Changing the position of the patient by rotating the patient by 15 to 20° can eliminate arrhythmias that develop during SWL.

Shockwave Lithotripsy Practice Pattern Variations Among and Between American and Canadian Urologists: In Support of Guidelines.

PURPOSE: Shockwave lithotripsy (SWL) is a widely utilized form of treatment for urolithiasis. There are new evidence-based recommendations regarding pre-SWL patient work-up and the performance of SWL. The purpose of this study is to determine practice patterns for SWL and to determine if regional variation exists between Canada and the United States. MATERIALS AND METHODS: A 19-question survey was prepared. Canadian urologists were surveyed through e-mail correspondence. In the United States, members of the Endourologic Society and members of two large stone management groups were surveyed. Canadian and American results were compared using the chi-square and Fisher's exact tests. RESULTS: Ninety-four Canadian urologists and 187 U.S. urologists completed the survey. Practice patterns differed between countries. Intravenous sedation was more commonly used in Canada (Canada 94.7% vs United States 17.9%, p < 0.001); routine antibiotics were more commonly given in United States (Canada 2.1% vs United States 78.1%, p < 0.001); a shock rate of 2 Hz was more common in Canada (Canada 76.6% vs United States 16.2%, p < 0.00001); rate of discontinuing ASA for renal and ureteral stone treatment was higher in the United States (renal Canada 88.3% vs United States 95.7%, p < 0.02; ureteral Canada 62.4% vs 90.3%, p < 0.0001); and ureteral stents were more commonly used if treating a large stone or patients with solitary kidneys in the United States (large stones Canada 58.2% vs United States 88.8%, p = 0.0001; solitary kidney Canada 50.6% vs 66.3%, p = 0.02). CONCLUSIONS: This study highlights the absence of standardization of SWL. Significant regional differences exist in practice patterns and performance of SWL between Canadian and American urologists.

Best Stent Length Predicted by Simple CT Measurement Rather than Patient Height.

INTRODUCTION AND OBJECTIVES: Ureteral stent length is important, as stents that are too long might worsen symptoms and too short are at higher risk of migration. The purpose of this study was to determine if patient or radiologic parameters correlate with directly measured ureteral length and if directly measured ureteral length predicts proper stent positioning. METHODS: During stent placement, ureteral length (ureteropelvic junction to ureterovesical junction distance) was directly measured by endoscopically viewing a ureteral catheter (with 1-cm marking) emanating from the ureteral orifice. A 22, 24, or 26 cm stent was chosen to be closest to the measured ureteral length. For ureters >26 cm, a 26 cm stent was chosen. Ends of an "ideally positioned" stent were fully curled in the renal pelvis and bladder, without crossing the bladder midline. Rates of ideal stent position were compared between patients with matching stent and ureteral lengths and those with stent lengths differing by ≥1 cm (mismatched). The measured ureteral length was correlated with patient height, L1-L5 height, and length measured on CT. RESULTS: Fifty-nine ureters from 57 patients were included. Height was reasonably correlated with L1-L5 height (Spearman correlation coefficient [rho] = 0.79), although both were poorly correlated with directly measured ureteral length (rho = 0.18 for height and 0.32 for lumbar height). Ureteral lengths measured on CT correlated well with direct measurement (rho = 0.63 for axial cuts and rho = 0.64 for coronal cuts). Matched stent length was associated with higher rates of ideal stent position than mismatched (100% vs 70.9%, p = 0.006). CONCLUSIONS: CT measurements, rather than height, correlate well with measured length and could be used to choose the appropriate stent length. Stents matching directly measured ureteral lengths are associated with high rates of ideal stent position.

Comparison of Peditrol irrigation device and common methods of irrigation.

BACKGROUND AND PURPOSE: The Peditrol is a novel hands-free irrigation device that delivers a bolus of irrigant through the ureteroscope when the foot pedal is deployed. The purpose of this study was to compare the flow and pressures created by the Peditrol with those of commonly used methods of irrigation. MATERIALS AND METHODS: Flows through a flexible 6.9F Olympus ureteroscope (F-URS) and a 7.5F semirigid ACMI ureteroscope (S-URS) were measured in duplicate with the working channel empty and with a 2.2F Nitinol basket or a laser fiber in the working port. Irrigant flow was pressurized by gravity drainage at 100 cm H(2)O (GI), pressurized irrigant bag at 300 cm H(2)O (PI), handheld 60-cc syringe (HS), and the Peditrol. A 20-gauge angiocatheter was placed through the parenchyma into the renal pelvis of an ex-vivo cadaveric porcine kidney and attached to a pressure transducer. Pressures were measured in triplicate using the same irrigation techniques. RESULTS: With a basket or 200-microm laser fiber in the working port of the F-URS, Peditrol mean flows were superior to those of PI (3.3 and 6.3 times, respectively; P < 0.001) but similar to those of HS (0.7 to 1.1 times). All irrigation types resulted in intrarenal pressures greater than gravity irrigation (P < 0.05). The Peditrol demonstrated intrapelvic pressures <40 cm H(2)O when used with a 12/14F ureteral access sheath (AS). Without an AS, the intrapelvic pressure reached 92 cm H(2)O, similar to the pressures reached with the S-URS under various irrigation conditions (84-287 cm H(2)O) and comparable to the HS method through the F-URS (97 cm H(2)O). CONCLUSIONS: The Peditrol irrigation device generates superior flow through an F-URS compared with GI or PI, particularly with an instrument in the working port. Intrarenal pressures when used with an F-URS and AS are low. When an AS is not used, the intrarenal pressure is similar to or lower than pressures obtained using an S-URS with different irrigation modalities.

Semirigid ureteroscopy of the proximal ureter can be aided by external lower-abdominal pressure.

BACKGROUND AND PURPOSE: Smaller semirigid ureteroscopes with large working channels and excellent optics are widely available. Ureteroscopic treatment of upper-ureteral stones has become increasingly popular, although flexible ureteroscopy is more frequently the method of choice. Access to the upper ureter with a semirigid ureteroscope (SR-URS) can be challenging and hazardous, especially when negotiating the iliac vessels. We sought to determine whether lower-abdominal pressure (LAP) facilitated SR-URS access to the upper ureter for safe laser lithotripsy. PATIENTS AND METHODS: Thirty-two consecutive patients who underwent ureteroscopic management of upper- ureteral stones were evaluated. Twenty-four (75%) were male; seventeen (53%) had a right-sided stone. The mean largest stone diameter was 10.2 +/- 4.6 mm. These 32 patients were compared with a matched cohort of patients who underwent SR-URS procedures without the use of LAP. RESULTS: Access to the upper ureter was possible in 30 patients (94%). The LAP was helpful in 18 patients (56%): it facilitated passage of the SR-URS in 16 patients (50%) and laser fiber placement in 11 cases (34%). Access to the upper ureter was possible in all women. The mean operative time was 54 minutes in the LAP group and 75 minutes in the matched cohort without LAP (P = 0.026). There were no significant deformities of the SR-URS and no complications. CONCLUSIONS: Contrary to popular practice, the upper ureter can be accessed safely and efficiently with a 7.5F SR-URS in nearly all patients. Lower-abdominal pressure can be helpful to negotiate passage of the endoscope over the iliac vessels or to place the laser fiber on stones.

Lumbar plexopathy as a complication of percutaneous nephrolithotomy in a horseshoe kidney.

Treatment of nephrolithiasis in horseshoe kidneys can be challenging due to anomalies in renal position, collecting system anatomy and vascular supply. We report on a patient who was referred after a failed percutaneous nephrolithotomy for a left moiety staghorn calculus in a horseshoe kidney. Two punctures had been performed involving upper and middle posterior calyces. Both were very medially placed and inadvertently traversed the psoas muscle, resulting in lumbar plexopathy with permanent deficit. This complication presented postoperatively with left leg weakness, paresthesia, and pain which impaired independent ambulation. The patient went on to be successfully treated for her stone disease with robotic-assisted laparoscopic pyelolithotomy.

Ureteroscopy: anesthetic considerations.

Ureterorenoscopy (URS) is a vital procedure in the armamentarium of the modern-day urologist for the management of ureteral and renal pathology. With advances in ureteroscopic design and the introduction of short-acting anesthetics, URS can now be performed efficiently with high patient satisfaction and minimal posteroperative recovery time. Recently, URS under local anesthesia, with or without sedation, has become a viable option for a high percentage of correctly selected patients. For those patients who then require deeper sedation or general anesthesia, anesthesia can be induced quickly with the new agents such as remifentanil, propofol, and desflurane, without a prolonged postoperative recovery period.