Percutaneous nephrolithotomy with retrograde nephrostomy access: a forgotten technique revisited.

PURPOSE: We retrospectively assessed outcomes in a single institution series of percutaneous nephrolithotomy using retrograde nephrostomy access. MATERIALS AND METHODS: We retrospectively evaluated the records of 333 consecutive patients treated between May 2003 and July 2008. Measured variables included patient demographics, retrograde nephrostomy site, postoperative drainage, operative time, stone clearance rate and degree, requirement for secondary procedures, stone composition and complications. RESULTS: A total of 333 patients were included in study, including 162 females and 171 males with a median age of 56 years (range 17 to 87). Median hospital stay was 2 days (range 1 to 13). Antegrade access was required in 14 patients (4%) due to difficult or suboptimal anatomy. A nephrostomy tube was placed in 33 of 329 patients (10%), mainly for postoperative irrigation. Mean operative time was 76 minutes (range 25 to 246). Of the patients 79% achieved complete clearance, 19% had residual fragments 4 mm or less and 2% had significant persistent stones greater than 4 mm. Postoperatively 11 patients (3%) required shock wave lithotripsy. Analysis revealed calcium oxalate in 57% of stones, uric acid in 24%, struvite in 5% (infection stones) and other in 21%. Complications included 4 patients (1%) with significant postoperative hemorrhage, including angioembolization in 2, transfusion of 4 U packed red blood cells in 1 and observation in 1. CONCLUSIONS: The retrograde technique to establish a percutaneous nephrostomy tract for percutaneous nephrolithotomy is safe and effective with stone clearance and complication rates comparable to those of antegrade access.

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.

The unsuspected nonpalpable testicular mass detected by ultrasound: a management problem.

Ultrasound is recognized as a valuable method of detecting testicular masses. Rarely, ultrasound will detect a testicular mass that was not clinically suspected. We present the case of a 43-year old man who presented with an unsuspected testicular mass detected by ultrasound. He underwent inguinal orchiectomy. The pathology showed a Leydig Cell tumor with cytological atypia. A review of the literature suggests that most incidentally discovered testicular masses are tumors, but there is disagreement as to whether they are usually benign or malignant. In view of the fact that many of these lesions are benign, if tumor markers are not elevated, inguinal exploration and excision of the lesion with frozen section examination is an acceptable management approach.

A comparison of extracorporeal shock wave lithotripsy and ureteroscopy under intravenous sedation for the management of distal ureteric calculi.

INTRODUCTION: We have performed a study to compare shock wave lithotripsy (SWL) and ureteroscopy under intravenous sedation for the management of distal ureteric calculi. MATERIALS AND METHODS: Patient tolerance, procedure times and treatment outcomes were prospectively evaluated in 110 patients undergoing 138 SWL treatments, and 172 patients undergoing ureteroscopy under intravenous sedation for the management of distal ureteric calculi. RESULTS: Men tolerated SWL better than ureteroscopy. Over 90% of women tolerated both procedures well. Procedure times were 52 minutes for SWL and 27 minutes for ureteroscopy. Treatment was successful in 72% of patients undergoing SWL, and 95% of patients undergoing ureteroscopy. CONCLUSIONS: In women with distal ureteric calculi requiring treatment, we recommend ureteroscopy under intravenous sedation as the treatment of first choice. In men the better tolerance of SWL must be weighed against the higher success rate of ureteroscopy. If both treatment modalities are available, patients with small distal ureteric calculi, in whom ureteroscopy is likely to be successful, should be informed of and offered their choice of either treatment modality.

Personal finances of residents at three Canadian universities.

OBJECTIVES: To address 3 research questions (What financial choices do residents make? Are the financial choices of residents similar to those of the general public? Are the financial choices of surgical residents reasonable?), we examined financial data from Canadian residents. METHODS: A written survey was administered to 338 residents (103 of them surgical residents) at 3 Canadian training institutions (University of Toronto, Queen's University and University of Manitoba). Resident household cash flows, assets and liabilities were characterized. Finances for residents were compared with those of the general public, by means of the Survey of Household Spending and Survey of Financial Security. RESULTS: Median resident income was 45,000 dollars annually (Can dollars throughout). With a working spouse, median household income was 87,500 dollars. Among residents, 62% had educational debt (median 37,500 dollars), 39% maintained unpaid credit-card balances (median 1750 dollars), 36% did not budget expenses, 25% maintained cash reserves <275 dollars, and 22% contributed neither to retirement nor nonretirement investments. Residents spent more on vehicles compared with members of the general public (median 17,500 dollars v. 10,720 dollars, p = 0.002) and on monthly housing (median 875 dollars v. 729 dollars, p < 0.001), respectively. Residents were more likely to carry student loans than people in the general population (61% v. 21%), more likely to carry vehicle loans (74% v. 29%) and less likely to carry credit-card debts (39% v. 50%, respectively). Surgical residents had income expectations after graduation higher than current billings justified. Fewer surgical (69%) than anesthesiology residents (88%, p < 0.05) contributed to Registered Retirement Savings Plans. CONCLUSIONS: From this limited sample, residents spend more than age- and income-matched members of the general public. Many residents save too little, fail to budget, and carry high educational and credit-card debts. Surgical residents' expectations of future income may be unrealistic. Further study is warranted.