Shockwave Lithotripsy Is an Efficacious Treatment Modality for Obese Patients with Upper Ureteral Calculi: Logistic Regression and Matched-Pair Analyses from a Dedicated Center Comparing Treatment Outcomes by Skin-to-Stone Distance.

Objectives: To assess the association of skin-to-stone distance (SSD) and stone-free rates following extracorporeal shockwave lithotripsy (SWL) using two statistical methods: logistic regression and a matched-pair analysis approach. Patients and Methods: Patients with a solitary radio-opaque upper ureteral calculus diagnosed on noncontrast computed tomography were included. Patients were treated with a Sonolith I-Sys Lithotripter (focal depth 17 cm). Stone treatment success was defined as stone free (fragments ≤3 mm) at 3 months. Failure was defined as persistent fragments beyond 3 months or requirement for intervention with ureteroscopy. The outcome was assessed by a plain kidney, ureter, and bladder radiograph (KUB) at 2 weeks. Logistic regression was used to determine association of patient and stone factors with treatment failure. The patient cohort was divided into tertiles by SSD, and matched-pair analysis was undertaken between individuals from the top and bottom tertiles (SSD ≤12 cm and SSD ≥14 cm). Matching criteria consisted of age, sex, maximum stone diameter (±2 mm), and stone density (±250 HU). Results: From a database of 2849 patients who underwent SWL, 397 patients were identified who had treatment of a single upper ureteral stone. Age (odds ratio [OR]: 1.03, 95% confidence interval [CI]: 1.01-1.04, p = 0.007), SSD (OR: 1.16, 95% CI: 1.03-1.32, p = 0.02), stone side (OR: 1.65, 95% CI 1.01-2.73, p = 0.05), stone diameter (OR: 1.09, 95% CI: 1.00-1.19, p = 0.05), and multiple sessions (OR: 4.65, 95% CI: 2.61-8.29, p < 0.001) were significantly associated with treatment failure by logistic regression univariable analysis. Multiple sessions was the only factor significantly associated with treatment failure on multivariable analysis (OR: 4.03, 95% CI: 2.18-7.42, p < 0.001). From a cohort of 141 patients with SSD ≥14 cm and 174 patients with a SSD ≤12 cm, 66 matches were identified (132 patients). Forty-nine patients (74.2%) with SSD ≥14 cm were deemed stone free at follow-up vs 51 patients (77.3%) with SSD ≤12 cm (p = 0.85). Conclusion: This study demonstrates by two statistical methods that SWL can provide efficacious treatment of upper ureteral stones in obese patients and that the upper threshold of SSD for SWL with Sonolith I-SYS could be revised to allow these patients the benefits of SWL.

Primary SWL Is an Efficient and Cost-Effective Treatment for Lower Pole Renal Stones Between 10 and 20 mm in Size: A Large Single Center Study.

INTRODUCTION: To assess the clinical features, outcomes, complications, and cost-effectiveness of shockwave lithotripsy (SWL), flexible ureterorenoscopy (FURS), and percutaneous nephrolithotomy (PCNL) in the treatment of lower pole (LP) stones (10-20 mm) in a large tertiary referral center. PATIENTS AND METHODS: Consecutive patients treated for solitary LP stones (10-20 mm) between 2008 and 2013 were identified from a prospective database. SWL was used as primary treatment in all cases (following a stone multidisciplinary team assessment), with FURS and PCNL reserved for SWL contraindications, failure, or patient choice. "Success" was defined as stone free and/or clinically insignificant stone fragments (≤3 mm) at 1 and 3 months follow-up. Effect of anatomy on SWL success was determined from using CT images and regression analysis. Average cost per treatment modality (including additional second-line treatments) was calculated for each group using the National Health Service England 2014/15 National Tariff Healthcare Resource Group codes. RESULTS: Two hundred twenty-five patients were included (mean age 54.9; median stone size 12 mm). One hundred ninety-eight (88%), 21 (9.3%), and 6 (2.7%) patients underwent SWL, FURS, and PCNL as primary treatments, respectively, for median stone sizes of 12, 12, and 20 mm. Overall success rates were 82.8%, 76.1%, and 66.7%, respectively (p < 0.05). Sixty-three percent of patients undergoing primary SWL were effectively treated after one session. Anatomical analysis determined infundibulopelvic angle and infundibular length to be significantly different in patients effectively treated with SWL (p = 0.04). The average cost per treatment modality was also significantly lower for SWL (£750) than for FURS (£1261) or PCNL (£2658) (p < 0.01). CONCLUSION: SWL is both an efficacious and cost-effective primary treatment for patients with solitary LP stones (10-20 mm). The majority of patients can be effectively treated with primary SWL in a dedicated stone center, with the benefits of a short length of stay, low complication, and auxiliary treatment rates. The referral of such patients to high-volume lithotripsy centers with demonstrable outcomes should be given due consideration.

Matched-pair analysis of open versus laparoscopic nephroureterectomy for upper urinary tract urothelial cell carcinoma.

OBJECTIVE: Laparoscopic nephroureterectomy (LNU) offers a superior morbidity profile compared with open nephroureterectomy (ONU) in treating upper urinary tract urothelial cell carcinoma. Evidence of oncological equivalence between LNU and ONU is limited. We compare operative and oncological outcomes for LNU and ONU using matched-pair analysis. METHODS: Of 159 patients who underwent a nephroureterectomy at a single institution between April 1992 and April 2010, 13 pairs of ONU and LNU patients were matched for gender, age, tumour location, tumour grade and stage. Operative details, post-operative characteristics and recurrences were collated and survival rates analysed using the Kaplan-Meier method. RESULTS: There was no significant difference in mean operation time between LNU (191 min) and ONU (194 min, p=0.92). There was no significant difference in the 5-year survival rate between LNU and ONU (overall survival 59.1% vs. 73.5%, p=0.18; progression-free survival 24.0% vs. 56.0%, p=0.14; cancer-specific survival 60.9% vs. 73.5%, p=0.56; bladder cancer recurrence-free survival 8.7% vs. 0.0%, p=0.09). CONCLUSION: Amidst limited RCT and comparative studies, this study presents further evidence of oncological equivalence between LNU and ONU. There was a trend towards poorer outcomes following LNU though, which merits further study.

A generation of laparoscopic nephrectomy: stage-specific surgical and oncologic outcomes for laparoscopic nephrectomy in a single center.

PURPOSE: To determine the stage-specific operative, postoperative and oncologic outcomes, for patients undergoing a laparoscopic radical nephrectomy (LRN) for renal cell carcinoma (RCC) in a single center and assess changes over a generation of practice. PATIENTS AND METHODS: From December 1992 to July 2011, data were collected prospectively for 854 consecutive simple laparoscopic necphrectomies (LNs) and LRNs, 397 of which were LRNs for RCC. The first LRN was performed in December 1997. Stage-specific surgical and oncologic outcomes were assessed across the study period. Patients were then grouped into three equal consecutive cohorts. Case mix and surgical outcomes were compared to assess changes with departmental experience. RESULTS: There were 206, 71, 118, and 2 patients across stages pT1, pT2, pT3, and pT4, respectively. Median operative time was significantly shorter for pT1 tumors (125, 150 and 150 min for pT1-3, P<0.021), while median estimated blood loss (EBL) was greater for pT3 tumors (50, 50, 100 mL, for pT1-3, P<0.001). Median follow-up time was 31, 30, and 18 months, respectively, across pT1-pT3. There was a significant difference in 5-year overall survival (82.4%, 68.4%, 58.9%), cancer-specific survival (99.5%, 83.6%, 66.5%) and progression free survival (86.5%, 66.3%, 47.5%) across these stage-specific subgroups. Over the three cohorts, there was an increase in LRN performed for locally advanced disease and cytoreduction. With greater surgical experience, there was improvement in median operative time and median EBL in localized disease over the three periods, but no significant changes for locally advanced disease. CONCLUSION: This is the largest reported series of LRN in the United Kingdom. Departmental experience has resulted in improved surgical outcomes for localized RCC, with expansion of practice in more complex advanced disease. Laparoscopic nephrectomy is both operatively and oncologically safe in T1 and T2 disease, and although technically more demanding, it is also safe in selected T3 disease.

Endoscopic versus laparoscopic management of noninvasive upper tract urothelial carcinoma: 20-year single center experience.

PURPOSE: We compare the outcomes of endoscopic surgery to laparoscopic nephroureterectomy for the management of specifically noninvasive upper tract urothelial carcinoma. MATERIALS AND METHODS: A retrospective database review identified consecutive patients with clinically noninvasive upper tract urothelial carcinoma who underwent endoscopic surgery (59, via ureteroscopic ablation or percutaneous resection) or laparoscopic nephroureterectomy (70) at a single center during 20 years (1991 to 2011). Overall survival, upper tract urothelial carcinoma specific survival, upper tract recurrence-free survival, intravesical recurrence-free survival, progression-free survival and renal unit survival were estimated using Kaplan-Meier methods, with differences assessed using the log rank test. RESULTS: Median age and followup were 74.8 years and 50 months, respectively. Overall renal preservation in the endoscopic group was high (5-year renal unit survival 82.5%), although this came at a cost of high local recurrence (endoscopic surgery 5-year recurrence-free survival 49.3%, laparoscopic nephroureterectomy 100%, p <0.0001). For G1 upper tract urothelial carcinoma, endoscopic surgery 5-year disease specific survival (100%) was equivalent to that of laparoscopic nephroureterectomy (100%). However, laparoscopic nephroureterectomy demonstrated superior disease specific survival to endoscopic surgery for G2 disease (91.7% vs 62.5%, p = 0.037) and superior progression-free survival for G3 disease (88.9% vs 55.6%, p = 0.033). CONCLUSIONS: For G1 upper tract urothelial carcinoma, endoscopic management can provide effective oncologic control and renal preservation. However, endoscopic management should not be considered for higher grade disease except in compelling imperative cases or in patients with poor life expectancy as oncologic outcomes are inferior to those of laparoscopic nephroureterectomy.

Description and validation of a modular training system for laparoscopic nephrectomy.

BACKGROUND AND PURPOSE: Laparoscopic nephrectomy (LN) has largely replaced open nephrectomy. The aim of this study was to describe a validated modular system for training urologists in LN in the context of the shorter training times available in the current era. METHODS: After attendance at dry and wet laboratory courses, three mentees (trainee, new consultant, and an experienced open surgeon) were mentored through a five-module LN training system in our center followed by the mentee's own hospital. A minimum of 25 independent procedures were then performed by mentees in their own hospital. RESULTS: There were 17 to 32 mentored cases needed to become competent in LN, followed by up to 5 observed cases in the mentee's own center. Subsequently, data from the first 105 cases (80 LN and 25 laparoscopic nephroureterectomies [LNU]) performed by the three surgeons after the end of their training without observation by their mentor were retrospectively collected and analyzed. There were three conversions (2.9%). For LN and LNU, respectively: median operative time was 140 minutes (65-390 min) and 180 minutes (90-300 min); median estimated blood loss was 30 mL (0-2000 mL) and 50 mL (0-2000 mL); median postoperative stay was 4 days (2-45 days) and 6 days (3-27 days). Four (3.8%) patients needed a postoperative transfusion. There was no 30-day mortality. CONCLUSION: Mentees matched the median British Association for Urological Surgeons (BAUS) registry operative time (LN, 120-180 min, LNU, 180-240 min) and had lower conversion rates (2.9% vs 6.4% for BAUS). Mentees matched median BAUS database reported blood loss (LN and LNU <500 mL) and length of stay (LN-4 days, LNU-5 days). This modular training program allows urologists to become independent in LN after a short period of focused training in the training center followed by a short period of mentoring in the mentee's own center.

Long-term endoscopic management of upper tract urothelial carcinoma: 20-year single-centre experience.

UNLABELLED: Study Type--Therapy (case series) Level of Evidence 4. What's known on the subject? and What does the study add? Endoscopic management of small, low-grade, non-invasive upper tract urothelial cell carcinoma (UTUC) is a management option for selected groups of patients. However, the long-term survival outcomes of endoscopically-managed UTUC are uncertain because only four institutions have reported outcomes of more than 40 patients beyond 50 months of follow-up. Moreover, there is significant variance in the degree of underlying UTUC pathology verification in some of these reports, which precludes an analysis of disease-specific survival outcomes. The present study represents one of the largest endoscopically managed series of patients with UTUC, with a long-term follow-up. The degree of verification of underlying UTUC pathology is one of the highest, which allows a grade-stratified analysis of different outcomes, including upper-tract recurrence-free survival, intravesical recurrence-free survival, renal unit survival and disease-specific survival. These outcomes provide further evidence suggesting that endoscopic management of highly selected, low-grade UTUC can provide effective oncological control, as well as renal preservation, in experienced centres. OBJECTIVE: • To report the long-term outcomes of patients with upper tract urothelial cell carcinoma (UTUC) who were treated endoscopically (either via ureteroscopic ablation or percutaneous resection) at a single institution over a 20-year period. PATIENTS AND METHODS: • Departmental operation records were reviewed to identify patients who underwent endoscopic management of UTUC as their primary treatment. • Outcomes were obtained via retrospective analysis of notes, electronic records and registry data. • Survival outcomes, including overall survival (OS), UTUC-specific survival (disease-specific survival; DSS), upper-tract recurrence-free survival, intravesical recurrence-free survival, renal unit survival and progression-free survival, were estimated using Kaplan-Meier methods and grade-stratified differences were analyzed using the log-rank test. RESULTS: • Between January 1991 and April 2011, 73 patients underwent endoscopic management of UTUC with a median age at diagnosis of 67.7 years. • All patients underwent ureteroscopy and biopsy-confirmation of pathology was obtained in 81% (n = 59) of the patients. In total, 14% (n = 10) of the patients underwent percutaneous resection. • Median (range; mean) follow-up was 54 (1-223; 62.8) months. • Upper tract recurrence occurred in 68% (n = 50). Eventually, 19% (n = 14) of the patients proceeded to nephroureterectomy. • The estimated OS and DSS were 69.7% and 88.9%, respectively, at 5 years, and 40.3% and 77.4%, respectively, at 10 years. The estimated mean and median OS times were 119 months and 107 months, respectively. The estimated mean DSS time was 190 months. CONCLUSIONS: • The present study represents one of the largest reported series of endoscopically-managed UTUC, with high pathological verification and long-term follow-up. • Upper-tract recurrence is common, which mandates regular ureteroscopic surveillance. • However, in selected patients, this approach has a favourable DSS, with a relatively low nephroureterectomy rate, and therefore provides oncological control and renal preservation in patients more likely to die eventually from other causes.

Ureteroscopic and percutaneous management of upper tract urothelial carcinoma (UTUC): systematic review.

UNLABELLED: What's known on the subject? and What does the study add? Endoscopic management of upper tract urothelial carcinoma (UTUC) using either ureteroscopy and laser ablation, or percutaneous resection, is a management option for treating selected low-grade tumours with favourable characteristics. However, the evidence base for such practice is relatively weak, as the reported experience is mainly limited to small case series (level of evidence 4), or non-randomised comparative studies that are unmatched for tumour stage (level of evidence 3b), with variability of follow-up duration and reported outcome measures. The present systematic review comprehensively reviews the outcomes of all studies of endoscopic management of UTUC, including the role of topical adjuvant therapy. It establishes for the first time a structured reference for endoscopic management of UTUC, and is a foundation for further clinical studies. OBJECTIVE: To systematically review the oncological outcomes of upper tract urothelial carcinoma (UTUC) treated with ureteroscopic and percutaneous management. The standard treatment of UTUC is radical nephroureterectomy (RNU). However, over the last two decades several institutions have treated UTUC endoscopically, either via ureteroscopic ablation or percutaneous nephroscopic resection of tumour (PNRT), for both imperative and elective indications. METHODS: For evidence acquisition the Pubmed database was searched for English language publications in December 2011 using the following terms: upper tract (UT) transitional cell carcinoma (TCC), upper tract TCC, UTTCC, upper tract urothelial cell carcinoma, upper tract urothelial carcinoma, UTUC, endoscopic management, ureteroscopic management, laser ablation, percutaneous management, PNRT, conservative management, ureteroscopic biopsy, biopsy, BCG, mitomycin C, topical therapy. RESULTS: There are no randomised trials comparing endoscopic management with RNU. Most published studies were retrospective case series (and database reviews), or unmatched comparative studies. There was strong selection bias for favourable tumour characteristics in many endoscopically treated groups. There was variation in medical comorbidity and indication for treatment across different study groups. The biopsy verification of underlying UTUC pathology was inconsistent. The follow-up in most studies was limited, typically to a mean 3 years. CONCLUSIONS: There is a high rate of UT recurrence with endoscopically managed UTUC, and a grade-related risk of tumour progression and disease-specific mortality. Overall, renal preservation may be high with ≈20% of patients proceeding eventually to RNU. For highly selected Grade 1 (or low-grade) disease managed in experienced centres, 5-year disease-specific survival (DSS) may be equivalent to RNU, although the small study groups and short follow-ups preclude comments on less favourable Grade 1 (or low-grade) tumour characteristics, or DSS, in the longer-term. For Grade 3 (or high-grade) disease, DSS outcomes are poor and endoscopic management should only be considered for compelling imperative indications in the context of the patient's overall life expectancy and competing comorbidity.

The operative safety and oncological outcomes of laparoscopic nephrectomy for T3 renal cell cancer.

UNLABELLED: What's known on the subject? and What does the study add? Laparoscopic radical nephrectomy is a well established treatment for localized RCC, where nephron-sparing approaches are not appropriate. As surgeon and departmental experience grow more extensive tumours will be tackled laparoscopically. However, little is known about the operative safety and oncological outcomes of the laparoscopic approach for locally advanced RCC. The present study describes the largest reported cohort of patients receiving laparoscopic radical nephrectomy for locally advanced RCC. In the context of suitably experienced personnel in an established centre, we have established that this approach is safe from operative, postoperative and oncological standpoints, with comparable data to existing open series. OBJECTIVE: To determine the operative, postoperative and oncological outcomes of laparoscopic radical nephrectomy (LRN) for locally advanced renal cell cancer (RCC), which, as surgeon and departmental experience increases, is being performed more often. PATIENTS AND METHODS: In total, 94 consecutive patients receiving LRN for pathologically confirmed T3 or T4 RCC at a tertiary referral centre between March 2002 and May 2010 were analyzed. Preoperative, operative, tumour and postoperative characteristics were evaluated together with recurrence and outcome data. Survival was estimated using the Kaplan-Meier method. Cox's proportional hazards model was used for multivariate analysis. RESULTS: In total, 77 patients had LRN with curative intent and 17 patients had LRN with cytoreductive intent. There were six LRNs (6.4%) that were converted to open procedures. Overall, there were two (2.1%) Clavien grade IIIa complications, one (1.1%) grade IVa complication and one (1.1%) postoperative death. Overall median follow-up was 17.4 months. In total, 22 (28.6%) patients receiving curative LRN developed a recurrence after a median of 13.9 months; 12 (54.5%) patients developed distant metastases, five (22.7%) patients had local recurrences and three (13.6%) patients had transcoelomic spread. Median predicted progression free survival was 48.4 months in patients undergoing LRN with curative intent. Median predicted overall survival was 65.6 months after curative LRN and 15.7 months after cytoreductive LRN. Multivariate analysis did not reveal any variables influencing recurrence or survival. CONCLUSIONS: In the context of suitably experienced personnel in an established centre, LRN for locally advanced RCC is safe from an operative and oncological standpoint. Patients clinically staged as T3 RCC must still be selected carefully for LRN in a multidisciplinary setting.

Long-term comparative outcomes of open versus laparoscopic nephroureterectomy for upper urinary tract urothelial-cell carcinoma after a median follow-up of 13 years*.

BACKGROUND AND PURPOSE: Open nephroureterectomy (ONU) rather than laparoscopic nephroureterectomy (LNU) is still regarded as the standard of care for extirpative surgical management of upper urinary tract urothelial-cell carcinoma (UUT-UCC). The longest published follow-up of LNU is 7 years. We report outcomes for patients having surgery ≥10 years ago. PATIENTS AND METHODS: Consecutive patients with UUT-UCC who were treated with ONU (n=39) or LNU (n=23) between April 1992 to September 2000 were included. Preoperative, tumor, operative and postoperative characteristics, recurrence, and outcomes were collated. Survival was estimated using the Kaplan-Meier method. RESULTS: Median follow-up of censored patients was 163 months (13.6 y). Estimated mean overall survival (OS) was 111 months for ONU and 103 months for LNU. Mean progression free survival (PFS) was 175 months for ONU and 143 months for LNU. Probability of PFS at 10 years was 79% for ONU and 76% for LNU and was unchanged at 15 years. There was no significant difference between ONU and LNU in terms of OS (P=0.51, log-rank test), PFS (P=0.70) or cancer-specific survival (CSS; P=0.43). There were no prognostic differences between ONU and LNU after correcting for confounding variables. There was no increase in the probability of a bladder cancer recurrence from 10 to 15 years postoperation. CONCLUSION: Long-term follow-up of patients who were operated on more than 10 years ago suggests that LNU has oncologic equivalence to ONU because there were no significant differences in OS, PFS, or CSS between ONU and LNU patients followed for a median of 13 years.

Evaluation of outcome following lithotripsy.

PURPOSE OF REVIEW: Shockwave lithotripsy (SWL) is considered as an initial option for a significant proportion of urinary tract stones. Despite efforts for standardized terminology and methodology, published studies on lithotripsy outcome are very different. This review will focus on a brief description of evidence-based medicine and recent literature results on SWL outcome. RECENT FINDINGS: The introduction of hierarchy in scientific evidence is becoming more widespread. Various grading systems have attempted to rank recommendations according to type and amount of evidence. Different levels of evidence have been created for therapy, diagnosis and prognosis. Various authors have developed scoring systems and identified radiographic parameters to predict SWL outcome. The long-term safety of lithotripsy on renal function has been demonstrated. Randomized controlled trials and meta-analysis have shown that medical expulsive therapy and a slower shockwave rate will improve SWL outcome. SUMMARY: Evidence-based medicine is rapidly becoming an indispensable part of everyday medical practice. Common terminology is necessary for proper evaluation of SWL. Different types of studies are required to investigate efficacy, compare SWL to other options, complications and so on. Randomized clinical trials are of the highest value; matched-pair analyses and well designed controlled studies can offer significant help.

Mentorship in urological laparoscopic surgery: lessons learned.

OBJECTIVE: To review the results of our experience with a mentorship programme in laparoscopic nephrectomy, set up in 1999 by the British Association of Urological Surgeons Section of Endourology. METHODS: Mentors were contacted in 2007 to submit data on the number of visits and the outcome, which included whether a urologist was able to establish an independent laparoscopic practice and sustain it. RESULTS: Four urologists acting as mentors reported a total of 164 procedures carried out in the training of 39 urologists during 148 visits. There were no conversions to open surgery and only one major complication. Overall, 29 of 39 mentored consultants were able to establish an independent laparoscopic practice and 23 continue to do so. The number of visits was associated with initial success, although this was not statistically significant. Working in a large department was associated with being able to sustain a laparoscopic practice. More experienced consultants were less likely to have initial success, but were more likely to sustain a successful practice. CONCLUSIONS: Mentorship for laparoscopic nephrectomy has been carried out safely thus far. Sustaining a laparoscopic practice requires a critical volume of cases. Future efforts should be focused on trainees rather than consultants.

Ureteric stents compromise stone clearance after shockwave lithotripsy for ureteric stones: results of a matched-pair analysis.

OBJECTIVE: To identify the effect of the presence of a ureteric stent on the outcome of extracorporeal shockwave lithotripsy (ESWL), by comparing patients with ureteric stones with matched-pair analysis. PATIENTS AND METHODS: Patients undergoing ESWL with the Sonolith Vision lithotripter (Technomed Medical Systems, Vaulx-en-Velin, France) were identified from our prospectively maintained database. Only adult patients with a solitary, radio-opaque, previously untreated ureteric stone were considered for further analysis. A follow-up of >or=3 months with a plain abdominal film was used to identify residual fragments. Patients were exactly matched for gender, side, location in the ureter and size (in two dimensions, within +/-2 mm). If both diameters could not be matched exactly, the size was extended to +/-1 mm and then to +/-2 mm of both diameters. An effort was finally made to match patients by age. The treatment outcome in terms of stone-free rates was assessed and compared using McNemar's test. RESULTS: In all, 45 patients with a ureteric stent in place during ESWL were identified. The only patient who could not be adequately matched was a 40-year-old man with an 8 x 3 mm stone in the upper ureter. The best/closest match for age was selected. Most stones were in the upper ureter (77%); the mean stone size was 8.5 and 8.6 mm, respectively, with no statistical differences between the groups for age and size of stones (P = 0.41 and 0.86, Student's t-test). In 12 pairs, only patients with no stent were stone-free, compared to two pairs where the patient with a stent was stone-free. Using McNemar's test, the odds ratio was 6.0 (95% confidence interval 1.3-55.2) and the difference between the groups was statistically significant (P = 0.016). CONCLUSION: These results show that the presence of a stent is associated with a worse outcome after ESWL for ureteric stones. Ureteric stents should still be used in cases of obstruction, when there is a risk of sepsis, and in patients with intolerable pain or deteriorating renal function. However, their use in patients offered ESWL for ureteric stones should be considered with caution.

Safety and outcome of percutaneous nephrolithotomy in the elderly: retrospective comparison to a younger patient group.

AIM: To evaluate whether the overall safety and efficacy profile of percutaneous surgery for urinary stone disease in older (>70 years) patients might influence the decision for the procedure in the elderly. MATERIALS AND METHODS: A large database was created from our patients (n = 1058) who underwent percutaneous surgery for stone disease between 1991 and 2003 in the Scottish Lithotriptor Centre, including clinical and operation details for each case. Only percutaneous nephrolithotomy cases with full details were studied (n = 779) and were grouped into two age groups: (1) between 17 and 69 years and (2) over 70 years. Statistical analysis evaluated differences in terms of operation-related adverse events, stone-free success rates, and clinical success rates (including stone-free cases and cases with residual fragments <4 mm). Further analysis was performed for the same endpoints after stratification of the patients by (1) previous stone procedures and (2) special clinical features. RESULTS: In the overall database, no statistically important differences were found between the two groups in terms of stone burden before surgery, adverse events rates, complete stone-free rates, and clinical success rates. However, a statistical trend toward higher clinical success rates in favor of the younger group was seen (P = 0.051). Stratification of our database according to previous stone disease procedures or special clinical or anatomic characteristics has only shown a statistically important difference for clinical success rates in favor of the older group without special features (P = 0.01). CONCLUSION: In experienced hands, age-related morbidity or age itself should not be a discouraging consideration when deciding on performing percutaneous nephrolithotomy, as the procedure is as equally feasible and safe in the elderly as in the younger patient population.

Upper-pole puncture in percutaneous nephrolithotomy: a retrospective review of treatment safety and efficacy.

OBJECTIVE: To review the safety and efficacy of supracostal puncture during percutaneous nephrolithotomy (PCNL) for renal calculi. PATIENTS AND METHODS: Over a 12-year period, 66 patients had either an upper-pole puncture alone or combined with middle- or lower-pole puncture during PCNL for renal calculi. All punctures were made by an experienced uroradiologist and were either supra- or subcostal. We retrospectively reviewed all case notes and radiographs to determine stone-clearance rates and complications associated with the site and number of punctures. RESULTS: There was an overall stone-free rate of 78% with upper-pole puncture alone or combined with middle- or lower-pole puncture. There was a 3% thoracic complication rate with upper pole punctures, and an overall complication rate of 30% for both thoracic and non-thoracic complications. CONCLUSION: Upper-pole puncture in PCNL is associated with minimum morbidity if done by an experienced urologist or radiologist. The stone-free rate appears to be more dependent on stone size and complexity than the site of puncture.

Endourologic management of patients with upper-tract transitional-cell carcinoma: long-term follow-up in a single center.

PURPOSE: To evaluate the outcome of endoscopic management of upper-tract transitional-cell carcinoma (TCC). PATIENTS AND METHODS: From March 1991 to March 2006, 40 patients with upper-tract TCC were treated by an endoscopic approach as the primary management: 37 (90.2%) by ureteroscopy and by percutaneous techniques or both approaches in 2 cases each (5%). Follow-up was between 5 and 115 months (mean 41.6 months). Most of the patients, 26 (65%), had a normal contralateral kidney, and the indication for conservative management was low tumor grade or tumor size (<2 cm) and patient commitment to a rigorous follow-up protocol. Absolute and relative indications for conservative management such as solitary kidney were met in 14 patients (35%). RESULTS: Treatment consisted of electrocautery only in 15 cases (36.6%), neodymium:YAG or holmium:YAG laser only in 11 (26.8%), and combinations in 15 (36.6%). Most of the patients (74.3%) had an upper-tract recurrence. The renal-preservation rate was 70.7%, and the survival rate was 80%. CONCLUSIONS: Conservative treatment is preferred in patients with bilateral disease, a solitary kidney, or co-morbidities that contraindicate major surgery. Patients with low-grade, low-stage disease and normal contralateral kidneys also benefit from this approach provided adequate endoscopic follow-up can be achieved and the surgeon has a low threshold for carrying out ablative surgery.

Outcomes using a fourth-generation lithotripter: a new benchmark for comparison?

OBJECTIVE: To evaluate the efficacy of a fourth-generation lithotripter, the Sonolith Vision (Technomed Medical Systems, Vaulx-en-Velin, France) for treating single previously untreated renal calculi, and to compare the results with the reference standard HM-3 (Dornier MedTech Europe GmbH, Wessling, Germany) in the same population originally studied by the USA Cooperative Study Group in 1986. PATIENTS AND METHODS: The Sonolith Vision uses an innovative electroconductive shock-wave generator with an elliptical reflector specially designed to give the maximum concentration of energy on the stone. We reviewed the treatment sessions from our prospectively maintained database of the first 1000 consecutive patients with urinary stone disease who were treated with the Sonolith Vision between September 2004 and March 2006. Patients with previously untreated solitary renal calculi in anatomically normal kidneys were included. The outcome was assessed by plain films for radio-opaque stones, and renal ultrasonography for radiolucent stones, at 1 and 3 months after lithotripsy; the results were analysed according to stone size and location. RESULTS: Data from 309 patients who had a complete follow-up and with 373 renal calculi that matched the above criteria were analysed. The initial fragmentation rate was 94%. The stone-free rate for stones of <10 mm was 77%, for 11-20 mm was 69% and for >20 mm was 50%. The overall stone-free rate 3 months after lithotripsy was 75%. Within a month of lithotripsy, 221 patients (59%) became stone-free. Additional procedures to render patients stone-free after lithotripsy were needed in only 22 cases (7%). The overall efficiency quotient was 62%. The stone-free rates for lower, upper, middle calyceal and renal pelvic calculi were 74%, 70%, 78.5% and 75%, respectively. There were no serious complications. CONCLUSIONS: When similar populations of stone formers were assessed the Sonolith Vision achieved a high success rate, comparable with that using the HM-3 machine but with lower analgesia requirements and very low re-treatment rates. This method of comparison belies the commonly held view that newer lithotripters are less effective than the original spark-gap machines.

The British Association of Urological Surgeons: guidelines for training in laparoscopy.

OBJECTIVE: To report the guidelines of the British Association of Urological Surgeons (BAUS), commissioned by the National Institute for Health and Clinical Excellence (NICE) in response to safety concerns about the rapid uptake of new, complex laparoscopic procedures. METHODS: A combination of expert opinion and review of published studies was used to produce a consensus document. RESULTS: Patient demand and excellent published reports have prompted many consultant urologists with little previous laparoscopic training to learn laparoscopic procedures. Laparoscopic urological surgery involves some of the most complex procedures in all of surgery and there has been a lack of formal training for consultants. The guidelines produced by BAUS are designed to help consultant urologists gain experience safely, by a combination of didactic learning and mentorship. We recommend that urologists work with a mentor and master ablative laparoscopic surgery before attempting more complex procedures such as prostatectomy, cystectomy, pyeloplasty and partial nephrectomy. These guidelines were approved by BAUS Council in October 2006. CONCLUSIONS: These guidelines are intended to be complementary to the NICE guidelines on specific procedures (available at http://www.nice.org.uk).