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.

Canadian urology resident scholarly performance.

INTRODUCTION: Scholarly research is a key component of Canadian urology residency. Through comparison of scholarly performance of urology residents before residency with that achieved during residency, we aimed to elicit predictive factors for completion of research activities. METHODS: Electronic surveys were sent to 152 urology residents of 11 accredited Canadian programs. Survey questions pertained to post-graduate training year (PGY), formal education, scholarly activity completed before and after the start of residency, protected/dedicated research time, structured research curriculum and pursuit of fellowship training. RESULTS: Surveys were completed by 42 residents from 10 programs. Only 26% of residents had a structured research curriculum, 38% a dedicated research rotation and 43% protected research time. We found that 45% of residents published at least 1 manuscript so far during residency (mean 1.14 ± 0.32), and 43% submitted at least 1 manuscript (mean 0.86 ± 0.25). During residency, 62% of residents completed ≥1 formal research presentation (median number 1.5; range: 0-≥10). Only the level of PGY significantly affected the number of manuscripts published (p < 0.001) and number of formal research presentations (p < 0.001) completed during residency. In total, 86% of residents planning to pursue fellowship training had a mean number of publications and presentations during residency of 1.25 ± 0.37 and 2.25 ± 0.54, respectively. INTERPRETATION: Level of PGY significantly affected quantitative scholarly activity, but the numbers and types of presentations performed prior to residency, completion of an honours or graduate degree and plans to pursue fellowship training did not.

Assessing the accuracy of endoscopic estimates of lesion size in urology using in vitro models of the urinary tract.

BACKGROUND AND PURPOSE: Despite the frequency at which urologists endoscopically estimate lesion size, their accuracy has not been established. Our objectives were to determine the accuracy of cystoscopic and ureteroscopic estimates of lesion size using in vitro models of the urinary tract and to assess potential impacting factors. METHODS: Eleven staff urologists and 9 urology learners performed cystoscopy on a series of pig bladders containing mock papillary and flat lesions. Each provided three sets of size estimates: two using only the cystoscope to assess intraobserver agreement and the third with the aid of a ureteral catheter as a visual reference. Similar estimates were made with a flexible ureteroscope on papillary lesions within an inorganic upper urinary tract model. Differences in mean estimates and the agreement between repeated estimates were assessed. RESULTS: The level of endoscopic training did not influence the mean error of estimation (MEE) for either cystoscopy or ureteroscopy regardless of lesion size and appearance. Staff and learners consistently underestimated lesion size with median errors of 34% and 43%, with excellent (median intraclass correlation coefficient [ICC] of 0.97) and fair (median ICC of 0.56) reproducibility for cystoscopy and ureteroscopy, respectively. Use of the visual reference during cystoscopy did not improve the MEE. CONCLUSIONS: Urologists, regardless of their level of training, substantially underestimate lesion size by 34% to 43%. These findings are independent of lesion size and appearance, and the use of a visual reference during cystoscopy. Recognizing this tendency and adjusting estimates accordingly or improving instrumentation should improve clinical and operative decision-making.

Adult granulosa cell tumor of the testicle.

We report a rare case of adult granulosa cell tumor of the testis in a 68-year-old man. A case and literature review of the associated clinical features, histopathological characteristics and immunochemistry are presented. The tumor is typically slow growing but has a higher risk of malignancy when > 5 cm. Our patient was disease-free 18 months following a right radical orchiectomy.

Impact of body mass index on clinical outcomes associated with percutaneous nephrolithotomy.

INTRODUCTION: Percutaneous nephrolithotomy (PCNL) is the preferred treatment for patients with large renal calculi or stones that have not responded to extracorporeal shock wave lithotripsy (ESWL). The objective of this study was to compare outcomes and complications of PCNL in patients of various body mass indices (BMI) to determine the safety of this procedure in patients with elevated BMI. METHODS: A retrospective chart review of 114 patients who underwent PCNL between 2006 and 2009 was performed. Patients were separated into 4 groups with respect to their BMI: (1) ideal body weight (BMI <25 kg/m(2)), (2) overweight (BMW 25-29 kg/m(2)), (3) obese (BMI 30-39 kg/m(2)) and (4) morbidly obese (BMI ≥40 kg/m(2)). One-way ANOVA and univariate logistic regression analysis were used to assess the association between BMI (classified into 4 levels) and variables including age, sex, stone size, length of stay, incidence of complications and stone-free rates. RESULTS: The distribution of the 114 patients in each BMI category was: ideal body weight 39 (34%), overweight 24 (21%), obese 41 (36%), morbidly obese 10 (9%). There was no difference in the composition of groups with respect to age, sex, pharmacologically treated comorbidities or stone size. Mean length of stay in days, intra- and postoperative complication rates were not statistically different. Stone-free rates showed no significant difference between groups: 90% ideal body weight; 87% overweight; 90% obese; 80% morbidly obese (p = 0.83). INTERPRETATION: Outcomes of PCNL were statistically independent of BMI. PCNL is a safe and efficacious treatment of stone disease in patients of all sizes.

Variables influencing the likelihood of cardiac dysrhythmias during extracorporeal shock wave lithotripsy.

INTRODUCTION: Extracorporeal shock wave lithotripsy (ESWL) is a safe and effective treatment of upper urinary tract calculi. While serious side effects are rare, transient cardiac dysrhythmias (CD) may be associated with ESWL. The exact etiology of these events, which are often unpredictable, is poorly understood. Awareness of CD during ESWL and identification of risk factors for developing them could help clinicians predict and manage them safely and effectively. The current study examines selected variables to determine whether they may predispose individuals to developing CD during ESWL. METHODS: We compared 16 patients who experienced CD during ESWL to 56 control patients. Cases and controls were compared with respect to several continuous and discrete variables, including age, pre-treatment heart rate, number of shocks received during treatment, energy setting of the lithotripter, gender, presence of a ureteric stent, previous ESWL and side being treated. RESULTS: Cardiac dysrhythmias occurred more frequently in younger patients and in those being treated for right-sided stones. The other variables did not influence the likelihood of CD. All CD resolved promptly following conversion to electrocardiogram (ECG)-gating. CONCLUSION: Younger age and right-sided treatment predisposed individuals to developing CD during ESWL. Careful ECG monitoring should be performed during treatment.

Is an overnight stay after percutaneous nephrolithotomy safe?

OBJECTIVES: To establish a clinical care pathway that plans for hospital discharge the day after percutaneous nephrolithotomy (PCNL), to evaluate the safety, effectiveness and feasibility of this pathway, and to identify factors associated with a postoperative length of hospital stay (LOS) of >1 day. PCNL is the treatment of choice for patients with large kidney stones and those in whom extracorporeal shockwave lithotripsy has failed, and the mean LOS is typically 2-5 days. PATIENTS AND METHODS: We retrospectively reviewed the charts of 109 patients (mean age 57.4 years; 58 men, 53%) who had PCNL between 2006 and 2009. All had nephrostomy tubes placed after surgery. The patients' demographics, LOS, incidence of complications, clinical outcomes, stone-free rates, number of early postoperative emergency-room visits, need for subsequent admission and/or other procedures, were noted and analysed. The modified Clavien classification was used to describe the postoperative complications. Bivariate analyses were used to test for associations between LOS and other variables. RESULTS: The mean (range) stone size was 2.2 (0.9-5.9) cm, and the mean (SEM) LOS was 1.7 (0.13) days. Of the 109 patients, 20% had a LOS of >1 day for surgical, 3% for medical and 5% for social reasons. The stone-free rate was 89%. There was no difference in the number of subsequent hospital visits or ancillary procedures for patients discharged after one or more postoperative nights. No variables were associated with a longer LOS. CONCLUSIONS: An overnight hospital stay after PCNL is safe and represents an effective strategy for improved bed use in selected patients. A longer LOS was not affected by patient age or body mass index, stone size or operative time. We continue to use our clinical care pathway, as supported by these data.

Acute reversible kidney injury secondary to bilateral ureteric obstruction.

BACKGROUND: Acute reversible kidney injury (ARKI) secondary to bilateral ureteric obstruction (BUO) is a common urological problem. Our goals were to describe the etiology, management and outcomes of such patients identified between 2006 and 2009 and to compare them with a similar historical study published in 1982. METHODS: Chart review was performed on 49 patients with AKRI secondary to BUO. ARKI was defined as ≥33% decrease in serum creatinine after intervention. Those with malignant and benign causes of obstruction were identified and management and outcome data were collected. RESULTS: Of these 49 patients, 83% had BUO secondary to malignancy, 28% of these presenting for the first time. Prevalence of bladder cancer was increased (p = 0.04) and cervix trended lower (p = 0.07) compared with the earlier study; prostate cancer was unchanged (p = 0.51). The average survival was 239 days; 90% of patients died within a year after presenting with BUO from a malignant etiology. Compared with the 1982 group, there were trends towards a decrease in the frequency of retroperitoneal fibrosis (p = 0.08) and an increase in bilateral ureteric calculi (p = 0.16) in the benign group. CONCLUSIONS: Patients with ARKI secondary to BUO most likely have an underlying malignancy, with almost a third of them being diagnosed for the first time. Prevalence of bladder cancer increased while cervical cancer trended lower. The cause for the former is unclear; the latter may be due to aggressive screening. Prostate cancer remained unchanged despite the widespread implementation of prostate-specific antigen testing. Patients with an underlying malignancy do poorly and those with a newly diagnosed malignancy do worst. Those with ARKI secondary to benign causes did well.

Urolithiasis in the elderly.

OBJECTIVES: Urolithiasis is an increasing problem in patients ≥ 80 years. Our objective was to compare patients ≥ 80 years with urolithiasis to a younger cohort in terms of presentation and management. METHODS: Patients referred to a tertiary care stone clinic for management of urolithiasis over a 5 year period were reviewed. Data collected on clinical parameters for patients ≥ 80 years were compared with a random sample of those < 80 years. RESULTS: There were 26 patients ≥ 80 years and 102 in the sample < 80 years; mean age was 83.5 ± 0.6 and 50.1 ± 1.3 years, respectively. The older group had more comorbidities. The presenting complaint was more often flank pain in younger patients. Patients ≥ 80 years had larger stones. Early ureteric stent insertion was more likely in the elderly compared with the younger group (27% versus 7%, p < 0.01). Definitive therapy for patients ≥ 80 years was most often percutaneous nephrolithotomy (PCNL) (23%) compared with only 9% in the younger group. In contrast, the most common definitive treatment modality used for patients < 80 years was extracorporeal shock wave lithotripsy (ESWL) (35% versus 8%, p < 0.01). There was no difference in intraoperative complications. Thirty nine percent of the older group was managed as outpatients. More of the older group had postoperative complications but all were minor. CONCLUSION: Urolithiasis in the elderly is challenging to treat because they have more comorbidities and are less likely to present with classic symptoms of renal colic. This may lead to later presentation with larger and more complex stone disease. Early ureteric stent is often required and definitive PCNL is more likely than in the younger cohort. Despite these issues most can be treated safely and often as an outpatient.

Psoas abscess from ureteric stone perforation.

This case illustrates a rare complication of an impacted ureteric stone which eroded through the wall of the ureter leading to formation of a psoas abscess. Ureteric stent placement and percutaneous drainage of the abscess were insufficient to resolve the problem. Renal scan revealed poor function and the left kidney was removed. It showed evidence of acute supporative pyelonephritis with nephrolithiasis.

Bilateral renal sinus myelolipomas.

Adrenal myelolipomas are benign neoplasms consisting of hematopoietic cellular elements and adipose tissue. They are uncommon, found in 0.4% to 1% of the population at autopsy. Extra-adrenal myelolipomas (EM) are extremely rare with fewer than 50 cases reported. We describe the first case of bilateral EM of the renal sinus. They are difficult to diagnose on imaging alone when arising in this location and biopsies may not yield a definitive answer. Management options include both conservative and surgical approaches depending upon the certainty of the diagnosis, progression of the patient's symptoms and evidence of growth.

Suture urolithiasis in the renal pelvis secondary to prior subtotal colectomy.

We report upon a patient who underwent a subtotal colectomy 2 years prior to presenting for a percutaneous nephrolithotomy of a large stone in the left renal pelvis. At the time of surgery, a non-absorbable suture was found embedded in the stone. Both stone and suture were removed percutaneously.

Levels of 5alpha-reductase type 1 and type 2 are increased in localized high grade compared to low grade prostate cancer.

PURPOSE: In the prostate testosterone is converted to dihydrotestosterone by 5alpha-reductase type 1 and/or 2. Although 5alpha-reductase type 2 is predominant in normal prostates, type 1 is increased in cancer vs benign tissue. It is unclear whether 5alpha-reductase type 1/2 levels correlate with cancer grade. We compared the relative expression of 5alpha-reductase type 1 and 2 in localized high and low grade prostate cancer. MATERIALS AND METHODS: Immunostaining for 5alpha-reductase type 1/2 was evaluated in 64 prostate tissues from untreated men with localized prostate cancer. The percent of tumor area with moderate-high intensity staining was estimated for each Gleason pattern in the tissues. Adjacent benign tissue was evaluated in 26 prostate cancer specimens. RESULTS: Moderate-high staining for 5alpha-reductase type 1 increased from 18.8% +/- 2.9% (mean +/- SEM) in 34 Gleason pattern 3 cancers to 31.0% +/- 4.1% in 30 Gleason pattern 4/5 cancers (p = 0.016). Staining for 5alpha-reductase type 2 increased from 22.9% +/- 3.0% in 34 Gleason pattern 3 cancers to 39.2% +/- 4.1% in 30 Gleason pattern 4/5 cancers (p = 0.002). Compared to benign prostatic hyperplasia tissues staining for 5alpha-reductase type 1 was greater than 3-fold higher and staining for 5alpha-reductase type 2 was significantly lower in benign tissue adjacent to cancer (p = 0.006 and 0.0236, respectively). CONCLUSIONS: Levels of 5alpha-reductase type 1 and 2 are increased in localized high vs low grade prostate cancer. Levels of 5alpha-reductase type 1 are higher in benign tissue adjacent to cancer than in benign prostatic hyperplasia. These results raise the possibility that increased 5alpha-reductase type 1 in localized high grade cancers may contribute to the decreased effectiveness of the 5alpha-reductase type 2 selective inhibitor finasteride against high grade prostate cancer in the Prostate Cancer Prevention Trial.

Dystrophic calcified nodule of the testicle: a case report.

Dystrophic calcified nodule of the testis was first reported by Minkowitz and colleagues in 1965, with few subsequent reports. The etiology of this lesion is controversial and unknown partly owing to its rarity. We report the case of a 29-year-old man who presented with generalized right testicular pain. His ultrasound demonstrated a discrete calcified lesion. A right radical orchiectomy was performed identifying a 1.8 x 0.8 x 0.9-cm intratesticular calcific lesion with no evidence of intratubular germ cell tumour and negative tumour markers.

Is 24-hour urinary calcium a surrogate marker for dietary calcium intake?

OBJECTIVES: To determine whether the 24-hour urinary excretion of calcium was a reliable surrogate marker for dietary calcium intake. Although dietary calcium intake has been negatively correlated with the risk of recurrent calcium-based stones, detailed dietary histories are not routinely evaluated in most patients with recurrent stone formation. METHODS: The dietary records and corresponding 24-hour urine collections of 68 randomly selected women with a history of calcium-based renal stones and two or more outpatient clinic visits were studied. Subjects were excluded if they had conditions or took medications affecting calcium absorption or excretion. Multivariate regression analysis was performed on the most recent set of data per patient with 24-hour urinary calcium as the dependent variable. Independent variables included age, weight, and dietary calcium, sodium, potassium, magnesium, fiber, and animal protein. Regression analysis was performed on the differences between the first and last visits for dietary and urinary data. Using tertiles, the positive predictive value of 24-hour urinary calcium for the respective dietary intake tertiles was calculated. RESULTS: The regression model on absolute values showed all dietary parameters to have squared partial correlation coefficients of less than 0.3 (P = 0.015, R2 = 0.264). In the second regression analysis, the model did not significantly explain the variance (P = 0.656). The positive predictive value of a mean 24-hour urinary calcium level less than 3.75 mmol/L for calcium intake less than 585 mg/day was 45%. CONCLUSIONS: The results of the present study revealed that the 24-hour urinary calcium cannot be used as a surrogate marker for dietary intake of calcium. A detailed dietary history is needed for all women with recurrent stone formation for proper assessment and potential modification of calcium intake to reduce recurrences.

Solid pseudopapillary tumor of the pancreas mimicking malignant adrenal pheochromocytoma.

We report a 75-year old woman with clinical, laboratory and imaging characteristics suggestive of a malignant left adrenal pheochromocytoma with invasion of the tail of the pancreas. The mass involving the tail of the pancreas and the left adrenal was excised Detailed histological diagnosis revealed that the lesion was a rare exocrine tumor of the pancreas.