Impact of imaging in urolithiasis treatment planning.

PURPOSE OF REVIEW: Over the past 10 years, we have seen major advances in urological imaging including developments in digital imaging, ultrasound and computerized tomography (CT) scanning. All of these have had an impact on the management of urinary tract stone disease. In parallel with these, we have witnessed a greater appreciation of the potential harm of irradiation exposure. In this article, we aim to provide an overview of the impact of imaging in urolithiasis treatment planning in 2013. RECENT FINDINGS: A variety of imaging modalities are reviewed with a focus on the latest research and developments. Advances do not always improve quality, and the deterioration in digital KUB sensitivity is discussed. The role of ultrasonography in the diagnosis and follow-up of stone disease is explored as a clinically valuable alternative to ionizing radiation. The explosion of interest in cross-sectional imaging for urolithiasis (extending from the evaluation of loin pain, characterization of stone composition through to complex three-dimensional reconstructions of the pelvicalyceal system for surgical planning) is reviewed. SUMMARY: A detailed understanding of the performance of all the imaging modalities available to the stone surgeon in 2013 is vital in order to offer well tolerated and effective imaging strategies for all stages of the patient journey. CT has developed a pre-eminent role in the diagnosis of urinary stone disease, it has also found favour as a valuable surgical planning tool and is being advocated in the surveillance protocols. However, we must keep in mind the risks of radiation exposure in a patient population characterized by youth and a susceptibility to repeated acute disease episodes.

Maimonides: an early but accurate view on the treatment of haemorrhoids.

Moses Maimonides was not only one of the most influential religious figures of the middle ages, but also a pioneer in a wide variety of medical practices. A brief history of his life, and what is known about his medical education, is given here. His paper on haemorrhoids is summarised, as well as a review of the current understanding of the pathogenesis, prevention and treatment of this common condition. The comparison of Maimonides' writings to modern understanding of not only the prevention and treatment of haemorrhoids, but also his approach to the patient as a whole in terms of pre- and postoperative care, demonstrate how ahead of his time this great philosopher was.

Traumatic transection of the pancreatic duct.

A young man presented after a mountain biking accident having received a sharp blow from his handlebars to just below his right costal margin. Although initially he was clinically well and his primary investigations were normal, he was admitted for observation. After becoming peritonitic, his amylase increased to 502 U/ml, and an axial CT scan showed transection of the pancreas. An endoscopic retrograde cholangio-pancreatography (ERCP) was arranged in the operating department, confirming ductal damage. A stent was placed to bridge the pancreatic duct preoperatively, and a laparotomy lavage was carried out and an external drain placed. The patient recovered well and 12 weeks later, after the stent was removed, there was no evidence of pancreatic stricture. Pancreatic injuries must be suspected in blunt abdominal trauma, and preoperative endoscopic stenting may provide the definitive procedure for ductal injuries.

Laparoscopy extirpative renal surgery in the octogenarian population.

PURPOSE: Laparoscopic extirpative surgery for cancer is usually safe and effective, even in the elderly. However, the risk to benefit ratio of laparoscopic nephrectomies in patients aged over 80 has not been quantified objectively. The purpose of this study is to analyze the outcomes of this technique in the octogenarian population. MATERIALS AND METHODS: Between July 2001 and March 2008, 37 laparoscopic nephrectomies were performed for malignancy in patients over the age of 80. Patient demographics and perioperative and postoperative data were analyzed retrospectively. RESULTS: Population characteristics include a median age of 82, 65% female with a median American Society of Anesthesiologists score of 2. In all, 57% of the laparoscopic nephrectomies were left sided. Twenty-four laparoscopic nephrectomies were for renal cell carcinoma, with 13 nephroureterectomies for transitional cell carcinoma. A total of 32% had postoperative complications, three of which resulted in death. Average total length of hospital stay was 10.5 days. Stage of malignancy varied from pT(a) to pT(4), and the mean size of the specimen was 169 x 77 mm with a mean tumor size of 54 x 44 mm. At 1 year follow-up (n = 27), 85% were alive, and at 3 years (n = 21) 52% were alive and free of disease. CONCLUSION: Our small study suggests that laparoscopic nephrectomy in this age group is feasible, although the results are far from ideal. Cancer-specific survival rates are poor in this population, and therefore the risk to benefit ratio should be weighed up carefully prior to committing a patient in this age group to extirpative surgery.