Changes in upper urinary tract stone composition in Australia over the past 30 years.

OBJECTIVES: To investigate upper urinary tract stone composition rates in Australia To investigate changes in stone composition in Australia over the past 30 years PATIENTS AND METHODS: The Institute for Clinical Pathology and Medical Research (ICPMR) database was used to obtain - stone composition statistics from 2009-2011 Historical comparisons of stone composition rates were obtained from previous Australian studies; Rofe; 1981, and Baker; 1993 for epidemiological data from the 1970s and 1980s respectively. Stone composition data was separated into gender and age-groups RESULTS: From the 791 stones analysed between 2009 and 2011, calcium oxalate remains the dominant type accounting for 64% of stones in our dataset, which compares to 68% from both the 1970s and 1980s. Uric acid stones contributed 16% of contemporary stone compositions, comparable to 16% in the 1970s and 17% in the 1980s. Struvite stones showed a decreasing trend from 14% in the 1970s, to 12% in the 1980s and 7% in the current data. For struvite stones, while the female 21-30 age-group was the most prolific for struvite stone formation in the 1980s, the peak group in contemporaneous records is 61-70 year-old men. CONCLUSION: Stone composition in Australia has remained relatively static over the past 30 years. Modifications in diet and body habitus have not resulted in significant changes in the proportion of uric acid and calcium oxalate stones detected. The decreasing trend in the proportion of struvite stones most likely reflects improved management of urinary tract infections within the Australian population.

Patterns of care and outcomes of men with germ cell tumors in a high-volume Australian center.

AIM: To evaluate disease presentation, treatment practices, and outcomes of patients with germ cell tumor (GCT) treated in a high-volume cancer center in Australia. METHODS: This is a retrospective analysis of 609 patients diagnosed with GCT in the Sydney West Cancer Network between 1990 and 2013. Cause and date of death, and second malignancy information was sourced from The Centre for Health Record Linkage. RESULTS: The median age was 33 years (range, 14-85). Primary site was testis in 590 (96.9%), mediastinum in nine (1.5%), and retroperitoneum in nine (1.5%). History of undescended testis was present in 48 (7.9%). Pure seminoma was seen in 334 (54.8%), with 274 (82.0%) being stage I. There was a decline in use of adjuvant radiotherapy from 83% in 1990-1997 to 29% in 2006-2013. Nonseminoma GCT (NSGCT) was diagnosed in 275 (45.2%), with 162 (58.9%) being stage 1. Active surveillance has increased as the initial treatment, from 58% between 1990 and 1997 to 89% between 2006 and 2013. Metastatic disease at presentation was seen in 162 (26.6%): 55 (34.0%) seminoma and 107 (66.0%) NSGCT. With median of 15-year follow-up, 18 (3.0%) have died from GCT and 70 (11.5%) from all causes. Ten-year overall survival was 93% and GCT-specific survival was 97%. Forty patients developed a secondary malignancy, with 38 receiving chemotherapy, radiotherapy, or both. CONCLUSIONS: This large Australian series illustrates a changing pattern of care and outcomes and compares them favorably with other series. This serves as a basis for future comparison of outcomes for this malignancy.

Evolution of stone management in Australia.

UNLABELLED: What's known on the subject? and What does the study add? There is very little contemporary data regarding stone management in Australia. This study assesses the impact of technological advances on stone management practises, and raises questions as to why there is an increasing rate of intervention for stone disease in Australia. Knowledge of management trends as demonstrated in this paper give individual surgeons a guideline for contemporary practise in this country. OBJECTIVE: • To examine trends in the operative management of upper urinary tract stone disease in Australia over the past 15 years. MATERIALS AND METHODS: • The Medicare Australia and Australian Institute of Health and Welfare databases were used to determine the annual number of renal colic presentations and procedural interventions undertaken for stone disease. RESULTS: • In Australia over the past 15 years, the annual number of procedural interventions for upper urinary tract stones has increased, primarily due to the rising number of endoscopic procedures performed. • During this period, shock wave lithotripsy numbers have remained steady whilst open and percutaneous procedures have been in decline. CONCLUSION: • The introduction of and subsequent preference for less invasive techniques has changed the management pathway of patients presenting with stone disease in Australia. • Further studies are necessary to determine whether this escalation in endoscopic procedures is due to an increase in the incidence of stone disease, earlier detection, a lower intervention threshold or a higher retreatment rate.

Renal cell carcinoma: stage, grade and histology migration over the last 15 years in a large Australian surgical series.

OBJECTIVE: • To verify whether migration towards earlier-stage renal cell carcinoma (RCC), which has been observed in the USA over the last decade, also applies to Australia. PATIENTS AND METHODS: • Between January 1993 and December 2007, 547 nephrectomies performed in public and private hospitals in western Sydney were analysed from a retrospectively collected database. • Data were divided into three consecutive time groups. • Tumour-node-metastasis (TNM) stage as well as patient demographics, size, grade and histology of tumours and proportion of benign tumours were also assessed. RESULTS: • In all, 499 nephrectomies were performed for RCC. The median age was 62 years, with a male:female ratio of 1.9 : 1. Similarly sized tumours were identified in each time group [group 1 (1993-1997), 54.8 mm; group 2 (1998-2002), 52.0 mm; group 3 (2003-2007), 52.2 mm, P= 0.6]. • Pathological stage II disease decreased from 18.1 to 11.1%, but stage III disease showed an increase from 13.9 to 21.5% over that time period (P= 0.02). • The proportion of stage I and stage IV disease has remained relatively the same. There has been a statistically significant upward histological migration for the papillary subtype from 1.3 to 10.2% (P= 0.01). • There has also been an increasing representation of Fuhrman grade III tumours over time, from 17.6 to 30.8%, and a decreasing proportion of Fuhrman grade I tumours from 16.2 to 7.1% (P= 0.03). • There was a decrease in the incidence of benign tumours originally thought to be malignant on preoperative investigations, from 10% in group 1 to 4% in group 3 (P= 0.03). CONCLUSION: • The recent US phenomenon of migration towards earlier-stage, smaller RCCs as well as increased representation of benign tumours was not observed in the present study. The results of the present study, however, show an upward histological migration for papillary RCCs and an increasing representation of more aggressive Fuhrman grade III tumours.

Urinary stone disease - assessment and management.

Background Urinary stones affect one in 10 Australians. The majority of stones pass spontaneously, but some conditions, particularly ongoing pain, renal impairment and infection, mandate intervention. Objective This article explores the role of the general practitioner in the assessment and management of urinary stones. Discussion The assessment of acute stone disease should determine the location, number and size of the stone(s), which influence its likelihood of spontaneous passage. Conservative management, with the addition of alpha blockers to facilitate passage of lower ureteric stones, should be attempted in cases of uncomplicated renal colic. Septic patients require urgent drainage and antibiotics. Other indications for referral and intervention include ongoing pain, renal impairment and stone size unlikely to pass spontaneously. There are many ways to eliminate stones, but laser lithotripsy is being used with increasing frequency. Up to 50% of people with a first presentation of stone disease will have a recurrence within 5 years. General advice for stone prevention consists of increasing fluid intake, especially water (sufficient to maintain dilute urine output), avoiding added salt and maintaining a well balanced low oxalate diet. Some patients may require a more detailed metabolic assessment and specific dietary advice.

National trends in surgical therapy for benign prostatic hyperplasia in Australia.

BACKGROUND: To determine national trends in the utilization of surgical procedures for the treatment of benign prostatic hyperplasia (BPH) in Australia over the last 20 years. METHODS: The Medicare Australia and Australian Institute of Health and Welfare databases were used to determine the annual number of surgical procedures and hospital admissions for BPH. RESULTS: From 1998 to 2017, surgical procedures for BPH have increased by 79% which is largely commensurate with population growth. From 1998 to 2008, transurethral resection of the prostate (TURP) was the predominant surgical therapy, accounting for 96% of all surgical treatments. From 2008 to 2017, TURP use reduced to 70% and in the last 5 years has been replaced with photoselective vaporization (16%), UroLift (8%) and holmium laser prostatectomy (6%). UroLift is used significantly more in younger men (P < 0.001). CONCLUSION: There has been a substantial increase in surgical treatments for BPH over the last 20 years. In the last 5 years, TURP use has declined due to an increase in laser prostatectomy and UroLift procedures.

Geographical variation in the management of urolithiasis in Australia.

BACKGROUND: To examine any geographical variation in the management of urolithiasis amongst the Australian states and territories. METHODS: Retrospective study with data obtained from the Medicare Australia database, the Royal Australasian College of Surgeons and the Urological Society of Australia and New Zealand. RESULTS: Minimally invasive stone treatment with shock wave lithotripsy (SWL) and ureteroscopy (URS) accounted for the majority of stone treatments in Australia (98%). Variation of stone treatment modalities exists amongst the Australian states and territories with an inverse relationship between the use of SWL and URS. We compared Western Australia (WA) and Queensland (QLD) which have a comparable geographical area. SWL accounts for 1% and 22% of stone treatments in WA and QLD, respectively. In WA, urologists are concentrated in two cities with no SWL available in the private sector. In QLD, urologists are distributed in 11 cities with SWL available in both the public and private sector. The three largest states or territories by geographical area - the Northern Territory, WA and QLD - have stone treatment rates of 1:1337, 1:1110 and 1:2432 per capita of privately insured patients, respectively. In comparison, smaller Australian states/territories such as Tasmania and Victoria have stone treatment rates of 1:619 and 1:765 per capita of privately insured patients, respectively. CONCLUSION: The distribution of urologists and treatment modalities available in each state or territory appear to play a contributory role in choice of treatment modality. In addition, inequality to stone treatment access exists in geographically large Australian states/territories.

Comparison of cost of care for tethered versus non-tethered ureteric stents in the management of uncomplicated upper urinary tract stones.

BACKGROUND: Many surgeons use a stent after ureteroscopic lithotripsy (URSL). For short-term stenting purposes, a surgeon has the choice of either a tethered or a non-tethered stent. Stents may be associated with complications that entail an additional cost to their use. There is a paucity of data on the direct healthcare cost of using stent type after either primary or secondary URSL. METHODS: We retrospectively reviewed medical records for patients who underwent URSL for uncomplicated urolithiasis between January 2013 and December 2013 at two tertiary referral hospitals. Costs data was sourced from the costing department with complete data available for 134 patients. The overall medical care cost was estimated by computing the cost of surgery, stent-related emergency department presentations, re-admissions and stent removal. RESULTS: A total of 113 patients had tethered stents and 21 had non-tethered stents, with similar age and gender composition between the two groups and complications rates. The mean cost of URSL and stent placement was A$3071.7 ± A$906.8 versus A$3423.8 ± A$808.4 (P = 0.049), mean cost of managing complications was A$309.4 ± A$1744.8 versus A$31.3 ± A$98.9 (P = 0.096), mean cost of out-patient clinic stent removal was A$222.5 ± A$60 versus A$1013.6 ± A$75.4 (P < 0.001) for endoscopic stent removal, overall mean cost of care was A$3603.6 ± A$1896.7 versus A$4468.1 ± A$820.8 (P = 0.042) for tethered and non-tethered stents, respectively. CONCLUSION: It is cheaper to use a tethered ureteric stent compared with non-tethered stents for short-term stenting after uncomplicated URSL, with a mean cost saving of A$864.5.

Semi-Automatic Electronic Stent Register: a novel approach to preventing ureteric stents lost to follow up.

BACKGROUND: Ureteric stents are indispensable tools in modern urology; however, the risk of them not being followed-up once inserted poses medical and medico-legal risks. Stent registers are a common solution to mitigate this risk; however, manual registers are logistically challenging, especially for busy units. METHODS: Western Sydney Local Health District developed a novel Semi-Automatic Electronic Stent Register (SAESR) utilizing billing information to track stent insertions. To determine the utility of this system, an audit was conducted comparing the 6 months before the introduction of the register to the first 6 months of the register. RESULTS: In the first 6 months of the register, 457 stents were inserted. At the time of writing, two of these are severely delayed for removal, representing a rate of 0.4%. In the 6 months immediately preceding the introduction of the register, 497 stents were inserted, and six were either missed completely or severely delayed in their removal, representing a rate of 1.2%. A non-inferiority analysis found this to be no worse than the results achieved before the introduction of the register. CONCLUSION: The SAESR allowed us to improve upon our better than expected rate of stents lost to follow up or severely delayed. We demonstrated non-inferiority in the rate of lost or severely delayed stents, and a number of other advantages including savings in personnel costs. The semi-automatic register represents an effective way of reducing the risk associated with a common urological procedure. We believe that this methodology could be implemented elsewhere.

The Influence of Body Mass Index on Outcomes in Ureteroscopy: Results from the Clinical Research Office of Endourological Society URS Global Study.

INTRODUCTION: Although ureteroscopy (URS) has been established as a viable treatment for stones in obese patients, its safety and success has not been fully elucidated. The current study describes the worldwide prevalence of obesity in patients with urolithiasis and examines trends in URS outcomes, safety, and efficacy. METHODS: This study utilized the Clinical Research Office of the Endourological Society (CROES) URS Global Study, which was a prospective, multicenter study including 11,885 patients treated with URS for urinary stones at 1 of 114 urology departments across 32 countries. The relationship between body mass index (BMI), diabetes, and creatinine, with retreatment, stone-free rates, complications, and long hospital stay, was examined with a multivariate logistic regression analyses. RESULTS: Of the 10,099 URS patients with BMI data, 17.4% were obese and 2.2% were super obese. Overall, 86.7% patients were stone free and 16.8% required retreatment. Higher BMI was associated with lower stone-free rates, and any deviation from normal weight was associated with higher retreatment rates. In multivariate analysis controlling for several variables including stone size, the association between BMI and lower stone-free rates with higher retreatment rates persisted. Intraoperative complications occurred in 518 (5.1%) patients, and 343 (3.4%) experienced a postoperative complication. Postoperative complications were more frequent in the underweight and super obese subjects, and there was no relationship between BMI and intraoperative complications. DISCUSSION: Although URS for stone disease was found to be an overall safe procedure for obese and super obese patients, efficacy of the procedure may be lower compared with normal-weight subjects and higher retreatment rates may be necessary.

Safety, efficacy and predictors of local recurrence after percutaneous radiofrequency ablation of biopsy-proven renal cell carcinoma.

PURPOSE: To evaluate the safety and efficacy of percutaneous radiofrequency ablation (RFA) for localised renal cell carcinoma (RCC) and examine potential associations between age, gender, tumour size, location, chronic kidney disease, comorbidities, learning curve and local recurrence. METHODS: We retrospectively analysed survival outcomes for patients with biopsy-proven RCC treated by RFA at Westmead Hospital. Complication data were gathered from all patients that underwent renal RFA. 3 and 5 year local recurrence-free (RFS), disease-free (DFS) and overall survival (OS) outcomes were reported. Univariate and multivariate analysis was used to examine each potential predictor. RESULTS: A total of 168 patients were eligible for the study. Forty-eight patients with biopsy-proven RCC had minimum 3-year follow-up. Our complication rate was 1.2 % (2/168) and local recurrence rate 10.4 % (5/48). Five-year RFS, DFS and OS were 86.8, 82.3 and 92.6 % on a median 4.1-year follow-up (IQR 3.4-4.9). None of the patient or tumour-specific characteristics were associated with RFS. CONCLUSION: Radiofrequency ablation performed at our centre was a safe and effective procedure with low complication rates and durable RFS. Tumour characteristics, comorbidities and learning curve were not associated with local recurrence.

Laparoscopic suturing: effect of instrument handling on suture strength.

BACKGROUND AND PURPOSE: In open surgery, handling of suture at any position other than the end is discouraged because of evidence that handling deforms and weakens the material. The limited operative field of laparoscopic surgery necessitates repeated instrument handling of suture, and the effect of such handling has not been investigated. We assessed the effect of trauma imposed on various suture materials by laparoscopic needle holders and forceps. Also, the ideal suturing technique (interrupted v continuous) according to the physical characteristics of the suture material and the optimal length for laparoscopic sutures were determined. MATERIALS AND METHODS: Sutures of 2-0 and 3-0 polyglactin 910 and 2-0 poliglecaprone 25 were tested. Controlled damage was inflicted by grasping the suture for 1 second between the jaws of either toothed laparoscopic grasping forceps or a laparoscopic needle holder at a pressure of 45 MPa. Blind physical testing was then performed using a computer-controlled tensile testing system. The length and proportion of suture extension prior to breaking and the tensile strength were measured. Samples of undamaged and controlled damaged specimens, before and after breakage, were examined by scanning electron microscopy (SEM). RESULTS: The mean percentage extension in the control group was 46.3 mm for 3-0 Monocryl, 26.3 mm for 3-0 Vicryl, and 28.1 mm for 2-0 Vicryl. The mean tensile strengths were 47.9 N, 42.4 N, and 70.4 N for 3-0 Monocryl and 3-0 and 2-0 Vicryl, respectively. The 3-0 Monocryl and 3-0 Vicryl had significantly reduced tensile strength after damage compared with control sutures, whereas 3-0 Vicryl and 2-0 Vicryl had significantly impaired extension. After infliction of controlled damage with laparoscopic needle holders, the percent extension of damaged sutures was significantly less than that of undamaged sutures. Tensile strength was significantly lower for 3-0 Vicryl and 3-0 Monocryl after damage than before. The handling of Monocryl by laparoscopic needle holders and graspers produced punched-out defects and scratch marks, respectively. A number of damaged 2-0 and 3-0 Vicryl samples from the laparoscopic needle holder group showed disruption or unravelling of the braided filaments. CONCLUSION: We expect that our results underestimate the potential effect on suture strength and extension inflicted by laparoscopic suturing. The exact length of suture material cannot be recommended from the findings. However, interrupted sutures should be preferred, particularly for long suture lines. In addition, the findings support the use of laparoscopic graspers in preference to needle holders. The combination of a grasper in one hand and needle holder in the other is ideal. Finally, urologists initially embarking on laparoscopic reconstruction must take meticulous care in their suturing technique and, in particular, the number of times and force with which the suture is grasped.

Bone formation in the urinary tract: case report.

A case of osseous metaplasia of the ureter presenting as a small upper-ureteral calculus is reported. This rare phenomenon may represent an unusual nucleus for stone formation in the urinary tract. The etiology of this condition is uncertain; we speculate that trauma to the ureter may stimulate osseous metaplasia.

Comparison of urinary stone and stent encrustation: biochemical analysis.

PURPOSE: To compare biochemical analysis of stent encrustation with that of urinary stones from the same patient. PATIENTS AND METHODS: Any patient presenting from February to December 2000 with a symptomatic ureteral or renal calculus that necessitated stenting and delayed calculus retrieval was enrolled in the study. The stent and stone were sent to the same laboratory for qualitative and semiquantitative chemical analysis. A total of 50 stents and matched calculi were available for comparison; four stents were excluded because they had insufficient encrustation for analysis. RESULTS: Two patients had open ureterolithotomy; the remainder were treated by endoscopic or percutaneous means. Every stone containing calcium oxalate had a stent that was positive for calcium oxalate. Four uric acid stones were available for comparison, and three of the four matched stents tested positive for uric acid. CONCLUSION: Biochemical analysis of urinary stent encrustation is a good predictor of urinary stone composition, especially for calcium oxalate-containing stones. Uric acid stent encrustation is likely to occur in patients with uric acid stones.

Simple technique for identifying the linea alba in lower abdominal incisions.

BACKGROUND: Identification of the true midline in infra-umbilical longitudinal incisions is often difficult. Traditional methods of identification can be unreliable. METHODS: An alternative technique for identifying the linea alba, based on the attachments of the median umbilical ligament, is presented. RESULTS: The technique is both reliable and reproducible in identifying the midline. CONCLUSION: This technique is recommended as a means of avoiding muscle incision and facilitating wound closure.

Intracorporeal ribbon gauze in laparoscopic surgery.

Good haemostasis optimizes laparoscopic visibility and performance. The use of suction reduces pneumoperitoneum and collapses the operative space, and the resulting fall in intra-abdominal pressure can increase the rate of bleeding. Therefore, other methods of improving laparoscopic visibility need to be investigated. In the present report we describe the effectiveness of a 20-40-cm length of 3-inch ribbon dressing gauze when introduced into the peritoneal cavity via a 10-12 mm laparoscopic port. Current results indicate that intracorporeal ribbon gauze can be used successfully during laparoscopic procedures as a suction filter, to assist haemostasis, to facilitate dissection and to provide atraumatic organ retraction.

Stopping anticoagulation before TURP does not appear to increase perioperative cardiovascular complications.

OBJECTIVE: To evaluate the impact of stopping anticoagulant medications prior to transurethral resection of the prostate on peri-operative cardiovascular complications. METHODS: Retrospective series (305 patients) undergoing TURP at a tertiary hospital between 2006 and 2010. All men were evaluated in preadmission clinics with defined protocols, with a low threshold for cardiovascular investigation. Incidence of postoperative bleeding and cardiovascular and cerebrovascular events was determined for 3 patient cohorts: group A--where anticoagulants were ceased preoperatively; group B--who were not receiving any anticoagulants; and group C--who underwent TURP while taking aspirin. RESULTS: Of 305 patients, 194 (64%) did not receive anticoagulation therapy, 108 (35%) stopped receiving anticoagulation therapy pre-TURP, and 3 (0.98%) underwent TURP while taking aspirin. Anticoagulants used were aspirin (22.6%), warfarin (4.9%), antiplatelets (4.9%), and combination treatments (3.9%). Incidence of postoperative hemorrhage (early and delayed) was not significant (P = .69) between group A (10/108) and group B (7/194). Transfusion rate was 0.6% (2/305). Overall incidence of cardiovascular events was 0.98% (group A, n = 1 vs group B, n = 2), and incidence of deep vein thrombosis (0.32%; group A, n = 0 vs group B, n = 1) was not statistically significant (P = .30 and P = .37, respectively). Overall incidence of cerebrovascular events (0.65%; group A, n = 1 vs group B, n = 1) was not significant (P = 1.00). There were no deaths. CONCLUSION: Men who have discontinue anticoagulation therapy before TURP do not appear to have a higher incidence of cardiovascular or cerebrovascular events, or bleeding-associated morbidity. It is possible that the morbidity attributed to discontinuing anticoagulation in this population may be overemphasized. Larger prospective studies are needed to better evaluate this clinical problem.