A Stent for Every Stone? Prestenting Habits and Outcomes from a German Multicenter Prospective Study on the Benchmarks of Ureteroroscopic Stone Treatment (BUSTER).

INTRODUCTION: Previous studies have shown that prestenting in ureterorenoscopic stone removal (URS) is carried out more frequently in Germany than in other countries. OBJECTIVE: This investigation evaluated the impact of high prestenting rates on outcomes as well as the influence of stone characteristics and treatment habits on prestenting. METHODS: The dataset from the BUSTER observational study was used. Patient and stone characteristics, as well as treatment outcomes, were analyzed for 307 cases from 14 urological clinics in Germany. RESULTS: The overall prestenting rate was 70.0%. Prestenting rates were significantly higher for renal stones than ureteric stones (84.6 vs. 60.6%, p < 0.0001). Compared to the unstented cases, prestenting for renal stones improved stone-free rates (73.2 vs. 11.1%, p < 0.0001) and increased the rate of completely lesion-free URS (45.4 vs. 16.7%, p = 0.034) while reducing the rate of poststenting (from 100 to 80.8%, p = 0.041). None of these effects could be demonstrated when prestenting for ureteric stones. Prestenting rates were less variable for renal stones (57-100%) than for ureteric stones (0-100%, p < 0.01). CONCLUSIONS: This study confirms the benefits of prestenting in URS for renal stones but not for ureteric stones. There were considerable differences in prestenting rates between the participating clinics.

Ureteroenteric strictures: a single center experience comparing Bricker versus Wallace ureteroileal anastomosis in patients after urinary diversion for bladder cancer.

BACKGROUND: To evaluate the outcome and complication rate in a single institution experience using the two most commonly used techniques of ureteroenteric anastomosis, the Bricker and Wallace anastomosis. METHODS: A total of 137 patients underwent ileal conduit for bladder cancer. Ureters were anastomosed by two experienced surgeons, one performing a Bricker and the other, a Wallace anastomosis. Stricture was identified during clinical follow-up. RESULTS: Seventy-five patients underwent a Bricker anastomotic, and 65 received a Wallace anastomosis. The average age was 70 in both groups, males were predominant (66% Bricker, 70% Wallace). Follow up period was 36.5 months in Bricker group and 17 months in Wallace group. In both groups, the body mass index (BMI) was similar (26.1 kg/m2 Bricker and 26.4 kg/m2 Wallace). We observed that the stricture rate after performing the Bricker anastomosis technique was 25.3% (19/75) as compared to 7.7% (5/65) after Wallace anastomosis technique, which was statistically significant (p = 0.001). In the Bricker group, patients with strictures had higher BMI (28.3 vs. 25.7 kg/m2, p = 0.05). On average it took 8.5 months in the Bricker group and three months in the Wallace group (p = 0.6) to develop stricture. CONCLUSIONS: The stricture rate was significantly higher when Bricker technique was applied. Although the BMI was not different in both groups, patients with a higher BMI were more likely to develop stricture. We believe that the approach of the separate and refluxing technique of Bricker anastomosis especially in obese patients poses a higher risk for anastomotic stricture formation.

Outcome of single pediatric deceased donor renal transplantation to adult kidney transplant recipients.

INTRODUCTION: In times of organ shortage more kidneys were transplanted in 'expanded criteria kidney' programs. This study examines the outcome of adult kidney recipients from pediatric donors. MATERIALS AND METHODS: This single-center retrospective analysis evaluated eight adult patients who received a kidney from a deceased pediatric donor (age 5-17) between 06/2000 and 09/2011. RESULTS: The median donor age was 14 years (range 5-17). The median recipient age was 49 years (range 25-57). The median cold ischemia time was 13.3 h (range 4.3-20.1), while the median warm ischemia time was 53 min (range 42-60). The median follow-up was 35.8 months (range 7-142). Acute rejection was observed in 50.0% of cases. The median HLA mismatch was 2.0. The median 1-year creatinine level was 0.95 mg/dl, the uncensored 1-year graft survival was 75.0% and the 3-year graft survival 62.5%, respectively. No recipient died within the follow-up period. As severe surgical complications, one stenosis of the renal artery and one lymphocele needing surgical revision were observed. CONCLUSIONS: Renal transplantation of a deceased single pediatric donor to an adult recipient can be performed safely and shows a good outcome. Wherever feasible, single pediatric kidney transplantation can double the number of recipients over an 'en-bloc' transplantation. The price for a single pediatric kidney transplant may be a higher vascular complication rate and a higher rejection risk. Despite the higher risks, transplantation of a single pediatric donor kidney should be performed when accomplishable.

Outcomes after laparoscopic living donor nephrectomy: comparison of two laparoscopic surgeons with different levels of expertise.

OBJECTIVE: To test the effect of surgeon experience on donor and recipient outcomes after laparoscopic living donor nephrectomy (LLDN). Results of a LLDN expert were compared with those of an LLDN novice. PATIENTS AND METHODS: Between October 2008 and October 2010 the last 20 cases of a series of 130 consecutive LLDNs, performed by an expert (EXP) were compared with the first 20 cases of an LLDN novice (NOV). Donor and recipient outcomes were evaluated. The novice was mentored by the expert during his initial four LLDN cases. RESULTS: Donor and recipient demographics were not different between the two surgeon groups. Total operating time and warm ischaemia time during LLDN was significantly longer in the NOV group compared with the EXP group (273 min vs 147 min and 213 s vs 162 s, respectively). The incidence of donor complications was low in both groups. Length of hospital stay among donors did not differ between groups. Although delayed graft function, rejection rates and postoperative serum creatinine levels indicated slightly poorer recipient outcomes in the NOV group, differences did not reach statistical significance. CONCLUSIONS: Mentoring by an experienced urological laparoscopist may help an LLDN novice to generate acceptable donor and recipient outcomes. Whether or not prolonged operating times and warm ischaemia times during the early phase of an LLDN experience are risk factors for impaired graft function needs further evaluation.

Laparoendoscopic single-site (LESS) varicocelectomy with reusable components: comparison with the conventional laparoscopic technique.

BACKGROUND: This study aimed to compare laparoendoscopic single-site varicocelectomy (LESSV) with multiport laparoscopic varicocelectomy (MLV) in terms of intraoperative parameters and postoperative outcomes. METHODS: A retrospective case-control study investigated 10 male adolescents and 89 adults who underwent either LESSV or MLV at the authors' center. The reusable X-Cone single port was inserted transumbilically. A 5-mm 30° telescope was used together with a straight and a prebent laparoscopic instrument. The MLV procedure was performed using two 5-mm ports and one 10-mm port. RESULTS: Between January 2009 and November 2012, 20 patients underwent LESSV and 79 patients underwent MLV. The demographic data were comparable between the two groups. The mean operating time was 59.1 ± 15.5 min for LESSV and 51.2 ± 14.4 min for MLV (P = 0.04). In the LESSV group, no conversion to MLV was necessary. The hospital stay was 1.6 ± 0.7 days in the LESSV group versus 1.8 ± 0.5 days in the MLV group (P = 0.17). The postoperative pain scores did differ between the two groups. By day 2, significantly more patients in the LESSV group than in the MLV group fully recovered their normal physical activity (P = 0.02). Comparison of pre- and postoperative values showed relief of testicular pain and improvement of semen parameters for the majority of the patients. The overall incidence of complications was distributed equally between the two groups as follows: paresthesia of the upper thigh (8 %), wound infection (5 %), epididymitis (3 %) and hydrocele (4 %). All the patients in the LESSV group were fully satisfied with their cosmetic results compared with only 76 % of the patients in the MLV group (P = 0.01). CONCLUSIONS: The LESSV procedure performed with the reusable X-Cone is as safe and efficient as MLV. After LESSV, the parameters measuring postoperative patient satisfaction are significantly improved. Given its reusable components, including prebent laparoscopic instruments, the X-Cone platform is a cost-effective alternative to disposable or homemade single ports.

[The recommendations of the S2k guideline for the diagnosis, therapy and metaphylaxis of urolithiasis provide a safe course of action for ureterorenoscopic stone treatment - results of the BUSTER study]. / Die Empfehlungen der S2k-Leitlinie zur Diagnostik, Therapie und Metaphylaxe der Urolithiasis bilden einen sicheren Handlungskorridor für die ureterorenoskopische Steintherapie ­ Ergebnisse der BUSTER-Studie.

BACKGROUND: Given the high incidence, prevalence and rate of recurrence, urolithiasis stone treatment at a high stone-free rate should have a low complication rate. The German S2k guideline (GS2k-GL) for the diagnostic testing, therapy and metaphylaxis of urolithiasis provides recommendations for the first and second choice for stone treatment, depending on stone location and size. Ureterorenoscopy (URS) is the treatment of first choice for most stones. URS is only the second option for renal stones > 20 mm and proximal ureteric stones ≤ 10 mm. The objective was to examine the impact of using URS as the stone treatment of first or second choice on the endpoints stone-free rate and severity of complications. PATIENTS/METHODS: The multicentric prospective observational study "Evaluation of ureteroroscopic stone treatment - results with regard to complications, quality of life and the stone-free rate" (BUSTER) standardised recorded perioperative data from 307 patients who had undergone ureterorenoscopic stone treatment from January to April 2015 at 14 German urological clinics. Treatment decisions were not affected by the study protocol. RESULTS: In the univariate analysis, the stone-free rate for ureteric stones was significantly higher when URS was the treatment of first choice (OR 2.21, 95 % CI 1.11 - 4.40, p = 0.027). After adjustment for age, BMI, ASA score, preoperative ureteral stenting, stone location and size, presence of multiple stones, experience of the surgeon, acute or elective URS and operating time, the application of URS as treatment of first choice had no significant effect on the stone-free rate (OR 2.048, 95 % CI 0.890 - 4.710, p = 0.092). After adjustment for stone location and size as well as ureteral stenting following URS, the application of URS as treatment of first choice had no significant influence on the severity of complications (OR 1.019, 95 % CI 0.347 to 2.993; p = 0.973). CONCLUSION: On the basis of our data, URS proved to be a safe and effective stone treatment procedure regardless of the degree of guideline conformity. Although the stone-free rate was higher with URS as treatment of first choice, the results of URS as treatment of second choice were not significantly worse. The recommendations of the GS2k-GL offer a safe guide for ureterorenoscopic stone treatment. The tendency for higher stone-free rates in URS as a treatment of first choice should be examined in further studies.