Complex Stone Disease Research Articles

Is Totally Tubeless Percutaneous Nephrolithotomy a Safe and Efficacious Option for Complex Stone Disease?

Background: Percutaneous nephrolithotomy is the gold standard treatment for large, complex intrarenal stones. Historically, this was performed using a nephrostomy tube (PCN) and/or internalized ureteral stent at the end of the procedure. However, totally tubeless nephrolithotomy (tt-PCNL) is a novel technique where no tubes (no stent nor nephrostomy tube) are left post-operatively. We review the literature on this subject regarding peri-operative outcomes, post-operative outcomes, and potential complications of the procedure, discuss our technique, and make recommendations on implementation for centers not currently utilizing the procedure. Materials and methods: We performed a comprehensive search of the literature on totally tubeless nephrolithotomy using MEDLINE database search. Our search included prior review articles, meta-analyses, systematic reviews, primary research articles, case reports, and case studies. Results: In comparison to prior approaches where a stent or nephrostomy tube is placed, tt-PCNL has a similar complication rate and better post-operative outcomes. Totally tubeless PCNL has similar operative times and similar changes in hemoglobin. However, it had shorter length of stays across all studies. The mean difference in length of stay in the studies reviewed was 1.96 days. Additionally, tt-PCNL had decreased post-operative analgesic requirements and pain scores. Conclusions: This review highlights totally tubeless percutaneous nephrolithotomy as a safe and feasible surgical technique with improved outcomes in properly selected patients.

Stone centers: a national survey on surgical techniques performed in Italy.

Recurrent and complex stone disease may be considered a challenging disease. In 2018, the Calculus group of the SIU (Italian Society of Urology) set itself the goal of establishing the minimum requirements for a center that could continuously manage urolithiasis pathology, named a Stone Center. In this study we present the results of a pilot survey carried out in 2019 with the aim of drawing a map of the situation of Italian urological centers dealing with urinary stones. A total of 260 national urology departments dealing with urolithiasis surgery were contacted for this study. A survey was issued to each of the centers to determine the number of patients treated for urinary stones and the amount of procedures performed per year: 1) extracorporeal shock wave lithotripsy ESWL; 2) ureterorenoscopy URS; 3) retrograde intrarenal surgery RIRS; 4) percutaneous nephrolithotomy PCNL. Out of 260 centers contacted, 188 fulfilled the survey. Outcomes were quite variable, with approximately 37% of the centers lacking a lithotripter, and 46% of those that did have it performing fewer than 100 treatments per year. In terms of endoscopic procedures, more than 80% of the centers contacted performed URS or RIRS; however, when it came to percutaneous lithotripsy, these numbers dropped significantly; 33% of the centers contacted did not perform PCNL, and of those who did, 18% had less than 5 years of experience as a center. Our survey shows a very heterogeneous national picture about urolithiasis treatments. Our goal is to create national paradigms to be able to define stone centers where the patient suffering from complex urinary stones can find a network of professionals with an adequate armamentarium suitable for the management of their pathology.

Endoscopic retrograde cholangiopancreatography as a single-modality 'gold-standard' treatment for common bile duct stones in the elderly.

There are more octogenarians presenting with gallstone disease each year. Many are not suitable for surgical intervention. An alternative treatment option for common bile duct stones in the elderly is endoscopic retrograde cholangiopancreatography (ERCP) with or without stent insertion. We conducted a retrospective study using a prospectively collected database, analysing the outcomes of consecutive patients >80 years old who underwent an ERCP in a single centre for the treatment of common bile duct stones. In total, 156 patients, with a median age of 91 years, underwent an ERCP for choledocholithiasis over a 3-year period. ERCP was successful in 90% of patients but a proportion required repeat intervention. Forty-six (29%) patients had a concurrently inserted stent due to incomplete stone extraction. Six (4%) patients required a post-ERCP cholecystectomy due to ongoing symptoms. The overall ERCP complication rate was 7% (4% Clavien-Dindo 1 and 3% Clavien-Dindo 2), with no cases of post-ERCP pancreatitis or death. Patients were followed up over 5 years following index ERCP. There was a 60% 3-year survival and 30% 5-year survival rate following index ERCP. Importantly, of those who did not survive, only four patients (2.6%) had a death attributable to a biliary cause and none were fit for definitive surgery. ERCP can be considered as a possible definitive management option for treating common bile duct stones in the elderly, particularly in the comorbid population. Concurrent stenting is an effective temporizing strategy and mitigator of biliary-related readmission, but routine stent changes should be considered. Key messages What is already known on this topic Current guidelines advocate for laparoscopic cholecystectomy and common bile duct exploration in patients with choledocholithiasis. What this study adds Endoscopic retrograde cholangiopancreatography with or without stent insertion is a safe, alternative single-treatment modality for choledocholithiasis in the elderly comorbid population. How this study might affect research, practice, or policy Studies and guidelines evaluating treatment options for choledocholithiasis may be altered to accommodate patient-specific factors, including age and comorbid status, and the concurrent use of stenting as a either a temporizing or longer-term measure for complex stone disease.

Robotic Surgery for Stone Disease.

To evaluate recent literature regarding the role of robotic technology in the treatment of nephrolithiasis with particular attention to complex technical procedures. Robotic platforms including single-port robotics have been widely adopted in urological practice for the treatment of both malignant and benign conditions and has led to an expansion of the utilization of robot-assisted surgery to tackle challenging clinical scenarios such as bladder neck reconstruction, upper urinary tract reconstruction, and more recently complex stone disease. Presently, the American Urological Association guidelines on the surgical management of stones advise against using robotic, open, or laparoscopic techniques as a first-line approach for most patients with stone disease with the exception for patients with anatomical abnormalities, large or complex stones, or patients requiring a concomitant reconstructive operation. Clinicians have demonstrated the safety and feasibility of surgical robotics in the treatment of stone disease for a variety of operations including robotic pyeloplasty, pyelolithotomy, ureterolithotomy, and surgical interventions in urinary diversions as well as novel technologies for robotic ureteroscopy and percutaneous access. Numerous clinicians have demonstrated the safety and feasibility of using robot-assisted surgery to treat nephrolithiasis, mainly in complex renal anatomy. Further research is necessary to identify the best candidates for utilization of robotics in complex stone disease, and further technological developments will continue to further advance the use of these platforms in the treatment of nephrolithiasis.

Cost Effectiveness and Impact in Quality of Care of a Pediatric Multidisciplinary Stone Clinic.

Between October 2012 and January 2016, children with complex stone disease, previously treated in urology and/or nephrology clinics, were seen at a triannual pediatric combined stone clinic. We compared the number and cost of ultrasounds, emergency room (ER) visits, and stone surgeries performed before and after each patient's initial evaluation. All patients received satisfaction surveys. Among the 79 patients, 27 were seen at least twice in the combined clinic and followed multiple times in either urology or nephrology clinics. The mean number of ER visits per patient per year significantly decreased from 0.29 ± 0.36 to 0.10 ± 0.15 (P = 0.002). The mean cost of ER visits went from CAD$ 23.44 ± 28.80 to CAD$ 4.14 ± 12.18 (P = 0.002). Likewise, the mean annual number and cost of stone-related surgeries significantly decreased [(0.38 ± 0.63 versus 0.20 ± 0.32 after the MSC started (P = 0.026) and mean annual cost of surgeries went from CAD$ 182.97 ± 301.49 to CAD$ 41.59 ± 110.97 (P = 0.022)]. Among the survey responses returned, 75% of families believed the clinic was time-saving. Despite a small sample size, the number of ER visits and stone-related operations significantly decreased after the initial combined clinic intervention. Longer-term data will hopefully confirm if the positive findings continue.

MP06-03 AMBULATORY PERCUTANEOUS NEPHROLITHOTOMY IS SAFE AND EFFECTIVE IN EXTENDED SELECTION CRITERIA PATIENTS

You have accessJournal of UrologyStone Disease: Surgical Therapy I (MP06)1 Sep 2021MP06-03 AMBULATORY PERCUTANEOUS NEPHROLITHOTOMY IS SAFE AND EFFECTIVE IN EXTENDED SELECTION CRITERIA PATIENTS Gregory Hosier, Kashif Visram, Michael Di Lena, Naji Touma, and Darren Beiko Gregory HosierGregory Hosier More articles by this author , Kashif VisramKashif Visram More articles by this author , Michael Di LenaMichael Di Lena More articles by this author , Naji ToumaNaji Touma More articles by this author , and Darren BeikoDarren Beiko More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001973.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Ambulatory tubeless percutaneous nephrolithotomy (aPCNL) has been shown to be safe and effective in highly selected patients. However, these selection criteria preclude the vast majority of patients that undergo PCNL. The objective of our study was to compare complication and stone free rates after aPCNL in standard selection criteria vs. extended criteria patients. METHODS: Retrospective review of prospective data on all patients who underwent aPCNL at one academic center from 2007-2018. Extended criteria patients were defined as any: Age >75 years, BMI >30 kg/m2, ASA >2, bilateral stones, solitary kidney, staghorn calculi, stone burden >40 mm, multiple tracts, or pre-existing nephrostomy tubes/stents. Primary outcomes were complication rates (Clavien-Dindo classification) and stone free rates (no fragments >/=3 mm). All patients were discharged with a ureteric stent and no nephrostomy tube after meeting discharge criteria which included hemodynamic stability, no fever, and no significant pain. RESULTS: We identified 118 patients of which 92 (78%) met extended criteria. Mean BMI was 31 kg/m2 and 45% were ASA 3 or higher. Mean sum maximum stone diameter was 24 mm. Multiple stones were present in 25%, bilateral stones in 7%, staghorn stones in 4%, and pre-existing tubes/stents in 4%. There was no difference in complication (12% vs. 18%, p=0.56), Emergency department visit (12% vs 18%, p=0.56), or readmission (4% vs. 5%, p=1) rates between standard and extended criteria patients respectively (Table 1). Of the complications, 85% were Clavien-Dindo grade 1. Stone free rates were not different between standard (84%) and extended (83%) criteria patients (p=1). No extended criteria variables were associated with complications in univariate analysis. Stone burden >40 mm (OR 5.8, 95% CI 1.4-25.2, p=0.018) and multiple tracts (13.1, 95% CI 1.1-154.7, p=0.041) were associated with residual stone fragments. CONCLUSIONS: Complication and stone free rates were not different between standard and extended selection criteria patients undergoing aPCNL. This data supports the safety and efficacy of aPCNL in patients using extended selection criteria. As the COVID-19 pandemic continues to strain hospital resources, aPCNL offers a solution to deal with a growing backlog of patients with complex stone disease. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e89-e90 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Gregory Hosier More articles by this author Kashif Visram More articles by this author Michael Di Lena More articles by this author Naji Touma More articles by this author Darren Beiko More articles by this author Expand All Advertisement Loading ...

Guy’s Stone Score as a Predictor for Stone-Free Rate and Complications in Percutaneous Nephrolithotomy: A Single-Center Report from a Stone Belt Country

Objectives: To evaluate Guy’s Stone Score (GSS) as a grading system for the complexity of renal calculi before percutaneous nephrolithotomy (PCNL) and as a predictor for stone-free rate (SFR) and potential complications in the setting of a developing country with many cases of advanced complex stone disease. Patients and Methods: We performed a prospective study on 115 patients with renal stones who had PCNL between August 2017 and October 2018. Stone complexity was classified according to GSS using preoperative imaging. The rates of perioperative complications were assessed using the Clavien grading system, and the SFR was assessed in the 3rd postoperative week by abdominal X-ray and renal ultrasound. The χ² and one-way ANOVA tests were used for statistical analysis. A p value ≤0.05 was considered significant. Results: The study included 115 patients (77 males) with a mean age of 50.2 (±13.3) years. Cases were classified according to GSS into 4 grades; there were 24 (20.9%) grade I, 48 (41.7%) grade II, 25 (21.7%) grade III, and 18 (15.7%) grade IV cases. There was a significant inverse correlation between GSS grade and SFR (p < 0.001). The rate of complications using the Clavien grading system were significantly higher in GSS grades III and IV (p = 0.002). So were the rates of blood transfusion, the need for >1 access tract, and the duration of hospitalization. Conclusion: GSS is a simple and easily reproducible system to classify the complexity of renal stones. In our setting, it also proved an excellent tool to predict SFR, perioperative complications, and associated ancillary procedures. Ultimately, it can help surgeons and, above all, patients to make a more informed decision about their surgery.

Comparative Study of Percutaneous Tic Technique Vs Standard Percutaneous Nephrolithotomy

ObjectiveTo compare the PERC-tic technique, described as placement of dual wires under fluoroscopic guidance adjacent to the stone within the obstructed calyx, to standard percutaneous nephrolithotomy (PCNL) with working wires secured down the ureter. Materials and MethodsThis is a retrospective cohort study of patients who underwent a PCNL procedure between October 2016 and November 2018. Patients undergoing the PERC-tic technique were compared to patients undergoing standard PCNL. Regression models evaluated if PERC-tic PCNL was associated with equivalent stone-free rates to standard PCNL at 90 days, need for secondary procedures, and 90-day hospital readmission. ResultsThis study involved 126 PCNL cases of which 63 were done using the PERC-tic technique and 63 with standard PCNL. In multivariate analysis, there was no statistical difference in 90-day stone-free rate between standard PCNL and PERC-tic cohorts (P = .08). We did note a 6 times higher likelihood of needing secondary procedures for residual stones in the PERC-tic vs standard PCNL groups (71% vs 30% P <.0001). There was no statistical significance in 90-day hospital readmission rates between groups (P = .47). ConclusionOur findings suggest similar stone-free rate at 90 days and higher rates of secondary procedures after PERC-tic PCNL compared to the standard approach; however, there was no difference in complications. These findings may reflect decreased visualization with the PERC-tic technique or simply be reflective of the case difficulty requiring the use of the PERC-tic technique. These findings can be used for patient counseling when considering this technique for complex stone disease.

Frontiers of stone management.

The surgical tool-box for urinary stone disease is growing. In this review, we discuss recent developments in the surgical management of urolithiasis, with emphasis on tailoring the management to the individual patient, and attention to the quality of care. Shockwave lithotripsy remains a popular noninvasive treatment option for patients, with new data emerging on how to improve treatment outcomes as well as its limitations. Next-generation holmium lasers are expanding the role of dusting techniques for ureteroscopy but further studies are needed to assess safety and clinical outcomes. Advances in miniaturization and patient positioning are propelling percutaneous renal stone surgery toward endoscopic combined intrarenal and simultaneous bilateral surgery for patients with complex stone disease. Stone management will be increasingly personalized to the unique qualities of the patient, stone, desired outcome, and available expertise and technology. Future studies assessing the quality of stone surgery should incorporate objective metrics to better delineate the success and cost of the different techniques available.

Supine Percutaneous Nephrolithotomy in the Galdako-Modified Valdivia Position: A High-Volume Single Center Experience.

To describe the technique and outcomes of supine percutaneous nephrolithotomy (PCNL) in the Galdako-modified Valdivia position. Prospective data were collected from 303 patients undergoing PCNL in the Galdako-modified Valdivia position at our institution between 2007 and 2015. We report our technique with outcomes of operative times, stone-free rate (SFR), and complications. A total of 202 solitary stones with a mean size of 17.19 ± 5.82 mm, 42 stones in multiple calices, and 57 staghorns were treated. Mean operative time was 79.79 ± 35.72 minutes. A total of 244/303 (80.5%) patients had clearance or <2 mm stone on postoperative CT. Minor complications (Clavien-Dindo Classification [CDC] 1-2) occurred in 59 (19.5%) cases and major complications (CDC ≥3) occurred in 22 (7.3%) cases. Five (1.7%) cases required postoperative blood transfusion for bleeding complications. We demonstrate that PCNL in a high-volume center to be safe and efficacious in the Galdalko-modified Valdivia position. We show equivalent SFR and complication rates to large studies of prone PCNL, with potential to decrease operative time. In particular, supine position is optimum for obese or high-risk patients with complex stone disease, because of ease of positioning and lower theoretical risk of anesthetic complications.

MP22-12 THE RELATIONSHIP BETWEEN OPERATIVE TIMES AND COMPLICATION RATES IN PERCUTANEOUS NEPHROSTOLITHOTOMY PROCEDURES

You have accessJournal of UrologyStone Disease: Surgical Therapy I1 Apr 2016MP22-12 THE RELATIONSHIP BETWEEN OPERATIVE TIMES AND COMPLICATION RATES IN PERCUTANEOUS NEPHROSTOLITHOTOMY PROCEDURES Julie Stein, Kaitlan Cobb, John Michael DiBianco, and Patrick Mufarrij Julie SteinJulie Stein More articles by this author , Kaitlan CobbKaitlan Cobb More articles by this author , John Michael DiBiancoJohn Michael DiBianco More articles by this author , and Patrick MufarrijPatrick Mufarrij More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.700AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Prolonged operative time has long been associated with postoperative complications. Percutaneous nephrostolithotomy (PCNL) is a common approach for the treatment of complex stone disease, often requiring lengthy operative times and/or multiple surgical stages. Complications of PCNL, including hemorrhage, injury to adjacent organs/structures, and infection, have been reported to occur at higher rates in procedures that have had prolonged operative times. Additionally, some of these complications may limit the duration of PCNL procedures, thereby decreasing stone-free rates or requiring more surgical stages. We aimed to investigate the relationship between operative times and postoperative complications as classified by the Clavien-Dindo System of Surgical Complications. METHODS A retrospective review was performed on 66 patients who underwent PCNL by a single endourologist at George Washington University Hospital and Sibley Memorial Hospital in Washington, D.C. from October 2012 to December 2014. Data on basic patient demographics and characteristics, operative times, and complications were collected. Operative time was defined by surgery start time and stop time as recorded by the anesthesiologist. Complications were classified by the Clavien-Dindo system on a scale of 0 to 5. RESULTS Mean age of patients was 57.3 +/- 12.2 years. Overall complication rate was 14.9% with 0% Clavien I, 9.0% Clavien II, 0% Clavien III, 6.0% Clavien IV, and 0% Clavien V. Mean operative time was 232.0 +/- 72.7 minutes. A simple linear regression model revealed that operative time accounted for 6.1% of the variance in Clavien score (R2 = .061, p < 0.05). One-way Analysis of Variance (ANOVA) demonstrated that the presence of infection stones differed significantly between Clavien classes (F(2, 60) = 3.32, p = 0.043). Post-hoc analyses showed that infection stones were associated with a Clavien II complication (p = 0.05), but not with a Clavien IV complication (p > 0.05). CONCLUSIONS In our investigation, increased operative time of PCNL procedures was not associated with an increase in complications. The increase in mid-level complications observed in patients identified to have infection-based stones corroborates previous data on this particular group of stone patients. While, in general, it is advisable to minimize operative duration, this data does not suggest an increased complication risk with lengthier PCNL procedures. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e257-e258 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Julie Stein More articles by this author Kaitlan Cobb More articles by this author John Michael DiBianco More articles by this author Patrick Mufarrij More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Minimally invasive versus conventional large-bore percutaneous nephrolithotomy in the treatment of large-sized renal calculi: Surgeon’s preference?

Objective: The aim of this study was to compare the efficacy and safety of minimally invasive percutaneous nephrolithotomy (MIP) and conventional percutaneous nephrolithotomy (PCNL) in the treatment of patients with large renal stone burden. MIP has proven its efficacy and safety in the management of small renal calculi. However, conventional PCNL is still considered the standard method for treatment of large renal stones in the upper urinary tract. Materials and methods: A search of two longitudinal databases in two tertiary referral centres for complex stone disease identified 133 consecutive patients who were treated by either MIP or PCNL for renal stones 20 mm or larger between January 2009 and August 2012. Clinical data and outcome measures of the two methods were compared by Student’s t test, chi-squared test or Fisher’s exact test. A p value less than 0.05 was considered statistically significant. Results: Operative time was significantly shorter and hospital stay was significantly longer in conventional PCNL compared to MIP (p = 0.002 and < 0.001, respectively). There were no significant differences in primary stone-free rate or complication rate between the two methods. Only higher graded complications (above Clavien grade II) were significantly more common in conventional PCNL (p = 0.02). Conclusion: MIP is equally effective as conventional PCNL in the treatment of large renal calculi. Both methods have a similar complication rate. The shorter operative time in PCNL may be based on the larger diameter and quicker retrieval of large fragments; the longer mean hospital stay may be caused by the handling of the nephrostomy tube. The current data suggest that the choice of the method mainly depends on the surgeon’s preference.

Optimizing the void.

Patients do not enjoy performing 24-hour urine collections. Some dream up elaborate excuses as to why they have been unable to provide the samples. A couple of the more interesting ones include: “The caps came off the bottles and both spilled in the trunk of my car on the way to the lab” and “My wife thought it was a bottle of a new generic windshield washer fluid and put it in the car.” Despite this resistance, most patients carry out 24-hour voids successfully, following oral and written instructions as emphasized in the accompanying paper.1 The information gained can be very useful in identifying abnormalities in specific urinary risk factors for targeted fluid, dietary and/or pharmacologic intervention. The accompanying article addresses one of the many long-term controversies regarding these collections (i.e., the benefits of two consecutive compared with a single 24-hour urine collection done on a free diet).1 The authors concluded that two collections yielded a greater likelihood of identifying an abnormality in one or more of the measured parameters such that clinical decision-making would change in almost 50% of patients.1 Others have suggested that the optimal number is 3 to 6 collections.2,3 I suspect more information could be gleaned from a larger number of collections, but from a practical and cost-effective point of view, I agree with the choice of two. Many urologists have different opinions as to which stone formers should perform 24-hour urine collections. Some believe these tests are indicated only in patients with complex stone disease;4 others offer them to all stone formers because almost all are keen to explore investigations to identify strategies to reduce the risk of recurrences.5 Single and recurrent stone formers have been shown to have similar abnormalities.6 The current study looked at all patients referred to a tertiary care stone clinic and did not differentiate between these groups.1 I propose that all recurrent stone formers start off as single stone formers and I support all of these patients doing the collections. It is important to wait at least three months following an episode of renal colic and/or surgical intervention for stones before collecting 24-hour voids to obtain the most useful results. Performing these collections earlier leads to an artificially low assessment of risk due to higher urine volumes and lower calcium excretion during this timeframe.7 Occupational environment can also affect the propensity to form renal stones. Furthermore, many working patients have different patterns of fluid intake, dietary habits and physical activity during the week compared with the weekend. These disparities can lead to profound effects on the results of 24-hour voids in some patients and I try to arrange for one to be done on a working day and one on a weekend day. My philosophy has been to start intervention with fluid and dietary modification and to reserve drug intervention for those patients who do not comply with or fail to respond to lifestyle adjustments. I have found it very useful to have self-reported written dietary histories done in conjunction with the 24-hour urine collections. In doing so, individual dietary habits can be identified and targeted by our stone clinic dietician to improve abnormal urinary risk factors relevant to the type of stone. One of the most important aspects of these 24-hour voids is that they produce baseline data that can be used as a reference and teaching tool for patients and their families. Follow-up measurements, 6 to 12 months later, in conjunction with appropriate imaging, when appropriate, can provide a vigorous assessment of the improvements, in conjunction with stone recurrence and/or growth, due to recommended fluid intake, dietary moderation and pharmacologic therapy. In summary, there are numerous variables which have to be considered to optimize the information obtained from 24-hour voids so that effective strategies for reduced urine supersaturation can be implemented.

PWE-009 Per oral cholangioscopy: systematic evaluation in clinical practice

<h3>Introduction</h3> A new technological approach to per oral cholangioscopy (POC) has led to a re-examination of this technique for diagnosis and therapy of hepatobiliary disease. We present a single centre experience from a tertiary regional hepatobiliary unit. <h3>Methods</h3> Prospective analysis of indications and technical success including direct visualisation, tissue acquirement and analysis and therapeutic success. Analysis of contribution of POC to clinical decision making. <h3>Result</h3> Since June 08 to date 36 ERCPs have been undertaken with POC. The indications were indeterminate strictures 28/36 (78%), filling defect 4/36 (11%), POC directed electro-hydraulic lithotripsy (EHL) 4/36 (11%). In one case the bile duct could not be intubated with the cholangioscope. Good views were obtained in 34 of 36 cases (94%). Biopsies were attempted in 16 patients, all of whom had focal mucosal change. Biopsy was not attempted if the mucosa appeared completely normal. In 15 of the 16 cases biopsy was successful in obtaining useful tissue for assessment. 12/15 biopsies were judged to be accurate on basis of either a positive diagnosis of malignancy or a non-malignant result in patients who subsequently had a benign clinical course. Three of the four cases of filling defect were shown to be stones and one a carcinoma. EHL lead to complete stone clearance in three of four cases. The addition of POC appeared to critically influence clinical decision making in 21 of 32 cases (65%). There no significant complications related to the POC procedure that could be identified. <h3>Conclusion</h3> POC is currently being re-evaluated in the management of complex hepatobiliary disease. It appears to be safe and add significantly to the information used to manage patients with indeterminate strictures and filling defects. It is undoubtedly useful for the management of complex stone disease. We initially restricted our use of POC to the most challenging patients whom had previously undergone multiple ERCP9s. We intend to evaluate POC further as a primary ERCP technique in patients with proximal biliary strictures.

Laparoscopic surgery for renal stones: is it indicated in the modern endourology era?

To report the outcomes of laparoscopic surgery combined with endourological assistance for the treatment of renal stones in patients with associated anomalies of the urinary tract. To discuss the role of laparoscopy in kidney stone disease. Thirteen patients with renal stones and concomitant urinary anomalies underwent laparoscopic stone surgery combined with ancillary endourological assistance as needed. Their data were analyzed retrospectively including stone burden, associated malformations, perioperative complications and outcomes. Encountered anomalies included ureteropelvic junction obstruction, horseshoe kidney, ectopic pelvic kidney, fussed-crossed ectopic kidney, and double collecting system. Treatment included laparoscopic pyeloplasty, pyelolithotomy, and nephrolithotomy combined with flexible nephroscopy and stone retrieval. Intraoperative complications were lost stones in the abdomen diagnosed in two patients during follow up. Mean number of stones removed was 12 (range 3 to 214). Stone free status was 77% (10/13) and 100% after one ancillary treatment in the remaining patients. One patient had a postoperative urinary leak managed conservatively. Laparoscopic pyeloplasty was successful in all patients according to clinical and dynamic renal scan parameters. In carefully selected patients, laparoscopic and endourological techniques can be successfully combined in a one procedure solution that deals with complex stone disease and repairs underlying urinary anomalies.

Role of Laparoscopic Stone Surgery

To define the role of laparoscopic stone surgery in current urologic practice. All cases of laparoscopic surgery for renal calculus disease performed at a single institution during a 2-year period were reviewed. A total of 449 stone-removing procedures were performed by one of us (D.G.A.) during this interval, of which 5 were laparoscopic (1.1%). Of the five laparoscopic procedures, three were pyelolithotomy/pyeloplasty, one was laparoscopic-assisted percutaneous nephrostolithotomy, and one was caliceal diverticular stone removal. All 5 patients were rendered stone free, and no patient had perioperative complications. A laparoscopic approach is rarely needed in patients requiring stone removal. However, it can be a safe and effective approach in the management of select patients with complex stone disease.

Use of Lower Pole Nephrostomy Drainage Following Endorenal Surgery Through an Upper Pole Access

PNL via an UP puncture is efficient for treating complex stone disease. Access via the UP can provide better visualization, allowing greater stone clearance with a rigid instrument due to its more favorable alignment with the axis of the intrarenal collecting system. However, the presence of a NT through the upper pole tract, especially with a supracostal puncture, can generate significant patient discomfort. We reviewed our experience with a technique using tubeless UP access for PNL with concomitant placement of a NT via a LP calix. We performed a retrospective review of our experience using tubeless UP access for PNL with concomitant placement of an LP NT for postoperative drainage. Patient demographics, the number and location of accesses, stone size, stone-free rates, concurrent/additional procedures and complications were recorded. A total of 63 tubeless UP accesses were performed in 62 patients undergoing PNL, including unilateral access in 61 and bilateral access in 1. Supracostal UP punctures were used in 58 patients, including 40 above the 12th, 17 above the 11th and 1 above the 10th rib. Each patient underwent at least 2 accesses and 3 had 3 or more accesses placed. LP access was nondilated in 37 patients and dilated in 26. Of the patients 56.6% were stone-free after a single procedure, increasing to 96.2% following secondary procedures. Three of the 62 patients (4.8%) required transfusion, 3 (4.8%) required intervention for pleural morbidity and 1 (1.6%) required a stent for a nonsealing upper pole access. Tubeless UP access provides maximal efficiency for stone clearance during PNL, while minimizing the morbidity of an intercostal tube.

Using and Choosing a Nephrostomy Tube after Percutaneous Nephrolithotomy for Large or Complex Stone Disease: A Treatment Strategy

Percutaneous nephrolithotomy (PCNL) is a well-accepted technique for removal of large or complex renal calculi. However, little attention has been paid to strategies for nephrostomy tube (NT) selection. We reviewed the reasons for selecting three types of NT after PCNL for large or complex stone disease. A series of 106 consecutive renal units undergoing PCNL for stone burdens >2 cm by a single surgeon (JEL) were reviewed. Noncontrast CT (NCCT) was carried out on postoperative day 1, and secondary procedures were performed if fragments remained. The NTs studied were 8.5F and 10F Cope loops (CP), 20F reentry Malecot catheters (REM), and 20F circle loops (CL). Patient demographics, access site and number, complications, and stone type were examined. "Stone free" was defined as a negative NCCT or negative second-look PCNL. A total of 134 accesses were created in 106 renal units: 35 upper, 7 mid, and 92 lower; however, only 111 NTs were placed: 85 CP (76.6%), 19 REM (17.1%), and 7 CL (6.3%). Sixteen accesses were performed tubeless; all but two were in the upper pole. All 16 of these renal units had a concomitant NT placed in the lower pole. Multiple sites were accessed in 21 patients; 7 of these patients had CL placed. Five of ten patients with spinal-cord injury had REM/CL placed. Nineteen REM were placed: 10 for drainage of infection, and 9 for difficult anatomy. All renal units were rendered stone free: 31.1% with a single procedure and 95.6% with one or two procedures. There were no difficulties with drainage or access for secondary PCNL regardless of the NT employed. Complications included two hydrothoraces, one arteriovenous fistula, and one ureteral perforation. Three of four renal units in patients requiring transfusions underwent bilateral PCNL, and at least one renal unit required multiple accesses. Of kidneys with infection stones, 57.1% required REM or CL; only 12.0% of nonstruvite stones necessitated REM or CL. All patients having PCNL done for complex stone disease should have an NT placed; however, small (8.5F-10F) CP suffice in most cases and can provide greater patient comfort. To minimize pleural morbidity, tubeless upper-pole access should be considered if the kidney is judged to be stone free at the conclusion of PCNL. Circle loops are useful when multiple accesses are necessary, whereas REM are appropriate if access is difficult, gross residual stone remains, or pain is not an issue (i.e., spinal-cord injury).

Percutaneous nephrolithotomy: an update.

Percutaneous nephrolithotomy has undergone an evolution in technique and in equipment since its introduction in the late 1970s. This evolution continues today and is evidenced by the numerous publications about the technique. This review summarizes some of the important articles over the past year. Although ureteroscopy and shock wave lithotripsy predominate in the treatment of urolithiasis, percutaneous nephrolithotomy continues to play an important role. Percutaneous nephrolithotomy is advantageous as it causes minimal renal injury and maximizes stone clearance, especially in patients with complex stone disease. Although nephrostomy drainage tubes have always been placed after percutaneous nephrolithotomy, there may be specific indications for tubeless percutaneous nephrolithotomy. Percutaneous nephrolithotomy continues to be an important part of the urologist's armamentarium. Recent studies have redefined the role of percutaneous nephrolithotomy and future studies will further delineate the importance of this procedure in the treatment of urolithiasis.

Phase I Trial of a Temporary Ureteral Drainage Stent

The temporary ureteral drainage stent (TUDS; Boston Scientific/Microvasive, Natick, MA) is a biodegradable device that is designed to maintain patency for 48 hours with gradual softening and spontaneous expulsion thereafter. We evaluated the durability, patency, and safety of TUDS in a Phase I clinical trial. Eighteen stone patients requiring sequential percutaneous nephrolithotomies (PNL) for complex stone disease underwent antegrade TUDS placement following initial percutaneous treatment. Nineteen devices were placed in 21 attempts, with one patient undergoing bilateral TUDS placement. Day 2 nephrostograms were performed to allow assessment of stent status and to demonstrate antegrade flow. Stents were removed at the time of the secondary PNL (day 2 or 3). No complications occurred during TUDS placement. On day 2, 1 stent had passed into the bladder. Eleven stents were completely intact, with seven others partially intact. Day 2 ureteral patency was demonstrated in all 19 stented ureters. Eighteen TUDS were removed completely during the secondary PNL with one incident of partial retention. All stent material had passed out of the body in all patients by 1 month. No adverse events were attributable to the TUDS. The TUDS appears to facilitate ureteral drainage for at least 48 hours after placement. Although occasional stent tail detachments were noted, these did not interfere with device function. The safety profile of TUDS was favorable, with no complications attributable to the device itself. A larger prospective clinical study in patients receiving TUDS placed retrograde after uncomplicated ureteroscopic manipulation appears appropriate on the basis of these initial findings.