Need For Ancillary Procedures Research Articles

Analysis of the Results of Extracorporeal Lithotripsy (ECL) in the Treatment of Stones of the Inferior Calcific Group (ICG): Does Variability in Calicial Anatomy Influence Them?

Introduction: Lower calyceal stones always pose a problem of optimal management: the results of ESWL are insufficient, with the possibility of generating a large quantity of residual fragments and recourse to complementary treatments. The different anatomical varieties of the lower calcific group can vary the results of treatment at this site. The objective of the study is to analyze the influence of the anatomy of the lower calyceal group (LCG) on the results of ESWL. Materials: A prospective observational study involving 57 patients with LCG stones who were treated by ESWL in our department between January 2021 December 2022 according to the French recommendations of the AFU lithiasis committee. Unfavorable LCG anatomy was defined according to Sampaio's criteria: a length of the inferior stem caliceal lower >10 mm, a width<5 mm and an infundibulo-pelvic angle < 90º. Fragment-free rate was assessed 3 months after ESWL with tomography urography (CTU). Failure was considered as the existence of fragments ≥ 3mm, the need for ancillary procedures after ESWL (ureterscopy, RIRS, PCNL or new ESWL), complications and risk factors associated with the development of perirenal hematoma were analyzed. Results: The median age was 48,5 years (range: 22-68), with 66,66% of the participants being men (38 men and 19 women). Approximately 14,03 % (n=8) of the patients were taking antiplatelet/anticoagulant drugs, and 8,77 % (n= 5) had High blood pressure. The median size of the lithiasis was 10 mm (range: 5-20 mm), with favorable LCG anatomy observed in 45,61 % (n= 26/57) of patients, including 34,61 % (n= 9/26) who required ancillary procedures after ESWL, compared to 64,51% (n= 20/31) in patients with unfavorable anatomy (54,39 % = 31/57). The stone-free after ESWL for both groups combined was 54,38 % (n= 31/57). Auxiliary procedures included ureteroscopy or RIRS. Two perirenal hematomas were observed in patients on antiplatelet/anticoagulant therapy, with a favorable outcome. ...

Comparison of mini-percutaneous nephrolithotomy and retrograde intrarenal surgery for 1-2 cm renal stones: A single-center experience.

Background: The management of renal stones has undergone significant advancements in recent years, with percutaneous nephrolithotomy (PCNL) and Retrograde Intrarenal Surgery (RIRS) emerging as minimally invasive alternatives to traditional Pyelolithotomy. This study aims to assess the effectiveness of Mini-PCNL and RIRS for renal stones measuring 1-2 cm, focusing on operative time, stone clearance, hospital stay, and the need for ancillary procedures. Methodology: This retrospective study collected data from the medical records of patients admitted to The Department of Urology at The Kidney Centre, Karachi, between January 1, 2021, and August 31, 2022. The study included 100 patients who underwent RIRS and 129 patients who underwent Mini-PCNL. Results: It was found that the operative time was statistically similar in both groups. However, the length of hospital stay was significantly higher in the Mini-PCNL group (more than 2 days in 88.4%), whereas in the RIRS group, the majority of patients stayed ≤ 2 days (78%). Overall stone clearance was 82.1%, with a slightly higher clearance rate in patients who underwent Mini-PCNL (85.3%) compared to RIRS (78%), though the p-value was not statistically significant. Conclusion: For renal stones sized 1-2 cm, both RIRS and Mini-PCNL demonstrate efficient treatment options with comparable stone-free rates. RIRS appears more comfortable and less morbid than Mini-PCNL, with a shorter hospital stay. Although Mini-PCNL requires an extended hospital stay to treat 1- to 2-cm renal stones, it is associated with fewer complications and a reduced need for a JJ stent, making it a viable alternative to RIRS in certain cases.

Frequency of Metabolic Syndrome in Patients with Type 2 Diabetes Mellitus

Background: The management of renal stones has undergone significant advancements in recent years, with percutaneous nephrolithotomy (PCNL) and Retrograde Intrarenal Surgery (RIRS) emerging as minimally invasive alternatives to traditional Pyelolithotomy. This study aims to assess the effectiveness of Mini-PCNL and RIRS for renal stones measuring 1-2 cm, focusing on operative time, stone clearance, hospital stay, and the need for ancillary procedures. Methodology: This retrospective study collected data from the medical records of patients admitted to The Department of Urology at The Kidney Centre, Karachi, between January 1, 2021, and August 31, 2022. The study included 100 patients who underwent RIRS and 129 patients who underwent Mini-PCNL. Results: It was found that the operative time was statistically similar in both groups. However, the length of hospital stay was significantly higher in the Mini-PCNL group (more than 2 days in 88.4%), whereas in the RIRS group, the majority of patients stayed ≤ 2 days (78%). Overall stone clearance was 82.1%, with a slightly higher clearance rate in patients who underwent Mini-PCNL (85.3%) compared to RIRS (78%), though the p- value was not statistically significant. Conclusion: For renal stones sized 1-2 cm, both RIRS and Mini-PCNL demonstrate efficient treatment options with comparable stone-free rates. RIRS appears more comfortable and less morbid than Mini-PCNL, with a shorter hospital stay. Although Mini-PCNL requires an extended hospital stay to treat 1- to 2-cm renal stones, it is associated with fewer complications and a reduced need for a JJ stent, making it a viable alternative to RIRS in certain cases.

Indocyanine green-marked fluorescence-guided off-clamp versus intraoperative ultrasound-guided on-clamp robotic partial nephrectomy: Outcomes on surgical procedure.

To compare surgical and functional outcomes between off-clamp robot-assisted partial nephrectomy with indocyanine-green tumour marking through preliminary superselective embolization and on-clamp robot-assisted partial nephrectomy with intraoperative ultrasound identification of the renal mass. One hundred and forty patients with a single renal mass underwent indocyanine-green fluorescence-guided off-clamp robot-assisted partial nephrectomy with preoperative superselective embolization (Group A, 70 patients) versus intraoperative ultrasound-guided on-clamp robot-assisted partial nephrectomy without embolization (Group B, 70 patients). We assessed operative time, intraoperative blood loss, complications, length of stay, renal function, need for ancillary procedures and blood transfusions. Mean tumour size was 24 versus 25 mm in Group A versus Group B (p= 0.19). Mean operative time was 86.5 versus 121.8 min (p= 0.02), mean blood loss was 72.8 versus 214.2 mL (p= 0.02), and mean haemoglobin drop on postoperative day 1 was 1.1 versus 2.6 g/dL (p= 0.04) in Group A versus Group B. One-month creatinine, hospital stay and enucleated tumour volume were comparable. Ten postoperative complications occurred in Group A (13.3%) and 11 in Group B (15.3%). Following superselective embolization, no patients required blood transfusions versus two patients in Group B. Postoperative selective renal embolization was needed in one case per group. Preoperative superselective embolization of a renal mass with indocyanine-green before off-clamp robot-assisted partial nephrectomy significantly reduces operative time and intraoperative blood loss compared to on-clamp intraoperative ultrasound-guided robot-assisted partial nephrectomy. A longer follow-up is needed to establish the effect on renal function.

Flexible ureteroscopy without ureteral access sheath

IntroductionUreteral access sheath (UAS) is widely used in flexible ureteroscopy and laser lithotripsy (FURS) based on better stone-free rates, lower intrarenal pressure and fewer complications. However, it also rises surgical costs and may injure the ureteral wall. The main objective of our study is to compare safety and efficacy of FURS with and without UAS to evaluate whether its use is justified in all cases. Materials and methodsWe performed a retrospective observational analytic study based on a prospective database. A total of 241 consecutive patients who underwent FURS for upper ureter and renal stones between January 2018 and May 2020 were included for analysis and divided into two groups upon UAS use. We compared demographic data, stone characteristics, prestenting, operative time, need for ureteral stent, postoperative urinary tract infection, renal colic and need for ancillary procedures. ResultsA total of 198 patients (82.2%) were included in the group without UAS. Operative time was significantly shorter in the group of patients without UAS than those with UAS (64.6 minutes ± 29.5 vs. 89.9 minutes ± 2.8 respectively; p 0.010). Both groups had similar rates of colic pain and urinary tract infection. Ancillary procedures were more frequent in the UAS group (37.2 vs. 21.2%; p 0.026), but significance was lost in multivariate assessment. ConclusionFURS without UAS seems to be as safe as FURS with UAS but requires less ancillary procedures. An additional advantage is shorter operative time.

Ureteroscopia flexible sin vaina de acceso ureteral

IntroductionUreteral access sheath (UAS) is widely used in flexible ureteroscopy and laser lithotripsy (FURS) based on better stone-free rates, lower intrarenal pressure and fewer complications. However, it also rises surgical costs and may injure the ureteral wall. The main objective of our study is to compare safety and efficacy of FURS with and without UAS to evaluate whether its use is justified in all cases. Materials and methodsWe performed a retrospective observational analytic study based on a prospective database. A total of 241 consecutive patients who underwent FURS for upper ureter and renal stones between January 2018 and May 2020 were included for analysis and divided into two groups upon UAS use. We compared demographic data, stone characteristics, prestenting, operative time, need for ureteral stent, postoperative urinary tract infection, renal colic and need for ancillary procedures. ResultsA total of 198 patients (82.2%) were included in the group without UAS. Operative time was significantly shorter in the group of patients without UAS than those with UAS (64.6 minutes ± 29.5 vs. 89.9 minutes ± 2.8 respectively; p 0.010). Both groups had similar rates of colic pain and urinary tract infection. Ancillary procedures were more frequent in the UAS group (37.2 vs. 21.2%; p 0.026), but significance was lost in multivariate assessment. ConclusionFURS without UAS seems to be as safe as FURS with UAS but requires less ancillary procedures. An additional advantage is shorter operative time.

Patient, Defect, and Surgical Factors Influencing Use of Ancillary Procedures after Facial Mohs Repairs.

This article determines if patient, defect, and repair factors can be used to predict the use of additional treatments to achieve optimal aesthetic results after repair of facial Mohs defects. An electronic chart review of patients undergoing Mohs excision and reconstruction of facial neoplasms from November 2005 to April 2017 was performed, reviewing patient demographics and history, tumor size, defect size and location, method and service of reconstruction, time between resection and repair, complications, and subsequent treatments. A total of 1,500 cases with basal cell and squamous cell carcinoma were analyzed. The average defect size was 3.09 ± 8.06 cm2; 81.9% of defects were less than 4 cm2 in size. Advancement flaps were used to repair 44.3% of defects. Complications and undesired sequelae (CUS) were noted in 15.9% of cases; scar hypertrophy or keloid (10.8%) was most common. Postoperative ancillary procedures were performed in less than one-quarter (23.4%) of patients to enhance the postrepair appearance; the most common procedures were intralesional corticosteroid injections and pulse dye laser treatments. CUS were more likely in females (19.6%), defects on the lips (28.7%) and on the nose (27.3%) (p < 0.001 for each). Females (22.7% vs. 12.7%), lip repairs (40.2% vs. 18.3%), transposition flaps (39.2% vs. 14.8%), and repairs performed by a dermatologist (17.9% vs. 11.2%) (p < 0.001 for each) were more likely to be treated with postoperative corticosteroid injections. Females (14.5% vs. 7.4%), patients under the age of 60 years (13.9% vs. 8.8%), and patients whose repair was performed by a dermatologist (11.9% vs. 2.9%) (p < 0.001 for each) were more likely to receive postoperative pulsed dye laser treatments. CUS and ancillary procedures after repair of facial Mohs defects are uncommon. Awareness of individual risk factors and defect characteristics allows the surgeon to choose the most appropriate repair technique while anticipating the potential need for ancillary procedures.

Endourologic Management (PCNL, URS, SWL) of Stones in Solitary Kidney: A Systematic Review from European Association of Urologists Young Academic Urologists and Uro-Technology Groups.

Introduction: Urolithiasis in solitary kidney (SK) presents significant management dilemma as any insult to the kidney or its drainage can lead to significant morbidity. The treatment options include shock wave lithotripsy (SWL), percutaneous nephrolithotomy (PCNL), and ureteroscopy (URS). Our aim was to conduct a systematic review of literature on all available endourologic techniques reporting on the management of stones in an SK. Materials and Methods: We conducted a systematic review according to the Cochrane and PRISMA checklist for all English-language articles from inception to December 2018. All studies with a minimum of 10 patients that reported on endourologic management (SWL, PCNL, or URS) were included. Data were extracted for patient and stone demographics, outcomes including stone-free rate (SFR), adverse events, and renal function. Results: After an initial search of 553 articles, 27 were included for the final review (10 PCNL, 1 mini-PCNL, 9 URS, 1 SWL, and 6 comparative studies). The choice of treatment seemed to be based on stone size, with PCNL, URS, and SWL offered for mean stone sizes between 25-50, 10-28, and 12-15 mm, respectively. PCNL, URS, and SWL were reported in 1445, 792, and 186 patients, respectively, with a final SFR of 67%-97.7%, 43%-100%, and 73%-80% and a complication rate of 26.4%, 15%, and 16.7% across the three groups. The renal function deterioration was reported in 4/16 PCNL studies and in 1/15 URS studies, while it remained unaffected in the SWL study. Conclusions: Our review shows a rise of endourologic techniques in the management of stones in SK. Although PCNL was used for larger stones, it had a higher risk of major complications, including blood transfusion. While a good SFR was obtained for patients irrespective of the treatment modality, the selected intervention needs to be balanced with its safety profile and the need for ancillary procedures.

Comparison of the Modified Lateral Position and Prone Position Techniques in Percutaneous Nephrolithotomy

Objectives: To evaluate the feasibility, operative time, efficacy and safety of the modified lateral position in percutaneous nephrolithotomy (PCNL) for renal calculi, comparing it with the standard prone position PCNL. Material and Method: The patient is placed with the thorax in the lateral position and the pelvis in an oblique position. Then the lower limbs are split and bent in the lowest position. Initial placement of a retrograde ureteral catheter, tract formation, stone fragmentation and retrieval, and optional extra procedures were accomplished with the patient in the same position. Results: The study comprised 82 patients; 29 in split-leg modified lateral position (SL-MLP) group and 53in conventional prone position (PP) group. Three patients (all in PP group) underwent sequential bilateral percutaneous nephrolithotomy (PNL) during the study period and each procedure was considered as an independent case. So, the studied cases, according to the number of PNL procedures, were 85; 29 in SL-MLP group and 56 in PP group. Conclusions: split-leg modified lateral position in percutaneous nephrolithotomy (SL-MLP PNL) has significantly lower operative time compared with conventional PP PNL. The stone free rate, need for ancillary procedures and complication rate were equal in both groups.

MP28-05 URETEROSCOPIC REMOVAL OF CALCULUS IN POORLY FUNCTIONING (

You have accessJournal of UrologyStone Disease: Surgical Therapy II1 Apr 2015MP28-05 URETEROSCOPIC REMOVAL OF CALCULUS IN POORLY FUNCTIONING (<10%) KIDNEYS DUE TO URETERIC STONE: A PROSPECTIVE OUTCOME ANALYSIS Prem Nath Dogra, Rajan Gupta, Prabhjot Singh, Ashish Kumar Saini, Rajeev Kumar, and Amlesh Seth Prem Nath DograPrem Nath Dogra More articles by this author , Rajan GuptaRajan Gupta More articles by this author , Prabhjot SinghPrabhjot Singh More articles by this author , Ashish Kumar SainiAshish Kumar Saini More articles by this author , Rajeev KumarRajeev Kumar More articles by this author , and Amlesh SethAmlesh Seth More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1228AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Nephroureterectomy is the standard of care for management of poorly functiong kidney (PFK) due to ureteric stone. In literature, overall complications following laparoscopic nephrectomy ranges from 6-17% with the majority being minor complications. Ureteric calculi are responsible for 16% of PFK. Our study is the first of its kind in which we have evaluated the role of ureteric calculus removal in PFKs due to ureteric calculus only and avoiding nephroureterectomy which is more morbid then ureteroscopy. METHODS All consecutive patients admitted in urology department from January 2013 to July 2014 with diagnosis of PFK due on ureteric calculus were included in the study. Patients underwent ureteroscopic (semi rigid) removal of the calculus. Intraoperative and immediate postoperative complications and any need for ancillary procedures / treatment in the follow up were recorded. On follow up subjective and objective assessment was done. RESULTS Total 20 patients were included in the study. 12 patients had impacted lower ureteric calculus. In 18 patients complete clearance was achieved in first sitting and double J stent was placed. In one patient interval ureteroscopy was done due to narrowing distal to stone and in second patient elective nephrectomy was done after 5 weeks because of pyonephrosis. Our mean follow up was 12 months (2-18 months). 17 patients were pain free, 2 had recurrent urinary tract infection which was resolved with antibiotics. All the patients showed regression in hydronephrosis on follow up imaging. None of the patient had pyonephrosis, pyelonephritis, newly developed hypertension, malignancy or improvement in renal function on follow up. CONCLUSIONS Ureteroscopic removal of calculus in PFK seems to be an attractive and logical option rather than subjecting the patients formidable surgical procedure like nephroureterectomy. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e313 Peer Review Report Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Prem Nath Dogra More articles by this author Rajan Gupta More articles by this author Prabhjot Singh More articles by this author Ashish Kumar Saini More articles by this author Rajeev Kumar More articles by this author Amlesh Seth More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Laparoscopic pyelolithotomy: An emerging tool for complex staghorn nephrolithiasis in high-risk patients

ObjectivesTo evaluate the effectiveness of laparoscopic pyelolithotomy (LP) for staghorn stones (>3–4cm) in patients with chronic liver disease or coronary artery disease. Patients and methodsIn all, 49 patients underwent LP; they were divided into four groups, with stones in group 1 in the renal pelvis only, in group 2 in the renal pelvis and one calyx, in group 3 in the renal pelvis and two calyces, and in group 4, in the renal pelvis and more than two calyces. Patient demography, stone characteristics, surgical outcomes and complications were evaluated. ResultsThe mean stone-free rate in one session was 90% among all groups. The mean (SD) stone size was 4.27 (1.72)cm. The stone-free rate decreased with greater stone burden, but the operative time, estimated blood loss and need for ancillary procedures increased with stone burden. No blood transfusion was required and one patient each in groups 2 and 4 had a urine leak. ConclusionLP provides acceptable results in complex cases for managing renal stone disease with a larger stone burden in high-risk situations.

PD28-03 COST-SAVINGS PROTOCOL IN THE ENDOUROLOGY SUITE DECREASES HEALTH CARE EXPENDITURES WITHOUT COMPROMISING QUALITY OF CARE

You have accessJournal of UrologyStone Disease: Evaluation I1 Apr 2014PD28-03 COST-SAVINGS PROTOCOL IN THE ENDOUROLOGY SUITE DECREASES HEALTH CARE EXPENDITURES WITHOUT COMPROMISING QUALITY OF CARE Dilan Gupta, August Matteis, Fotima Askarova, Chad Ritch, and Mantu Gupta Dilan GuptaDilan Gupta More articles by this author , August MatteisAugust Matteis More articles by this author , Fotima AskarovaFotima Askarova More articles by this author , Chad RitchChad Ritch More articles by this author , and Mantu GuptaMantu Gupta More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.2114AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Cost-containment strategies are imperative to the financial well being of physician practices and hospital systems. Disposable equipment represents a significant portion of the cost of endourological procedures. We investigated if a cost-saving protocol could lead to decreased expense without compromising quality of care. METHODS We retrospectively analyzed actual disposable equipment costs of 4 categories of Endourology procedures performed by 3 surgeons: percutaneous nephrolithotomy (PCNL, N=30), ureteroscopy for renal stones (URSR, N=30), ureteroscopy for ureteral stones (URSU, N=30), and ureteroscopy with biopsy (URSB, N=20). We also reviewed operative times (ORT), estimated blood loss, (EBL) length of stay (LOS), need for stents, complications, need for ancillary procedures, and stone-free rates (SFR). We created cost sheets detailing actual costs of each piece of available disposable equipment available by category (guidewires, access devices, dilators, stents, etc.). Finally, we implemented a prospective cost-savings protocol wherein each surgeon would be apprised of the cost of each piece of equipment requested along with the costs of alternatives. Costs were analyzed as well as outcomes after implementation of the protocol. RESULTS The average cost per patient before and after the protocol were as follows: PCNL $1222 vs. $719 (p<.001), URSR $926 vs. $516 (p<.001), URSU $814 vs. $463 (p<.001), and URSB $880 vs. $417 (p<.001). There was no statistical difference in ORT, EBL, LOS, SFR, complications, or need for stents or ancillary procedures. Savings realized by category showed the biggest cost savings to be in type of laser fiber and dilation devices used, but savings were realized in every category. Extrapolated over one year, the total cost savings for our Endourology suite alone would be in excess of $300,000. CONCLUSIONS Implementation of a cost-savings protocol leads to substantial decrease in health care expenditures in the Endourology suite without compromising quality of care. Similar initiatives throughout the country have the potential to significantly impact health care costs. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e770 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Dilan Gupta More articles by this author August Matteis More articles by this author Fotima Askarova More articles by this author Chad Ritch More articles by this author Mantu Gupta More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Single-Stage Minimally Invasive Approach for Large Staghorn Renal Calculus: Points of Technique

Introduction: A large complex staghorn renal calculus has been conventionally dealt with anatrophic pyelolithotomy or multiple access percutaneous nephrolithotomy.1 Although anatrophic nephrolithotomy has been attempted through a minimally invasive approach,2 this inflicts ischemic injury to the renal unit with a consequent nephron loss. Multiple access percutaneous nephrolithotomy may be associated with morbidities like blood loss, arteriovenous fistulas, iatrogenic injuries to the colon and incomplete clearance of calculi with a need for ancillary procedures. We demonstrate a minimally invasive approach that ensures a single-stage complete clearance of staghorn renal calculi with minimal morbidity and no ischemic impact on nephrons. Methods: Patients were evaluated in detail, including clinical, blood profile, and imaging (ultrasound, plain radiography, and CT urogram). Patients with a complex staghorn calculus and preserved parenchymal function underwent a laparoscopic approach through the transperitoneal route. An entry was gained into the Gerotas' fascia followed by identification of the renal hilum and the renal pedicle. After delineating the renal pelvis, an inverted U shaped pyelotomy is created. First attempt is made to remove the stone in toto. If nonretrievable, the staghorn stone is fragmented at major branch points using the lithotrite probe (EMS Lithoclast, probe inserted intracorporeally through the working port) and the major fragments are placed in a retrieval bag. Thereafter, the major caliceal extensions are fragmented using rigid ureteroscopy and lithoclast. Flexible ureteroscope is then inserted intracorporeally through the working port, the minor calices inspected for any residual calculi. After confirming complete clearance of calculi, a ureteric stent is inserted antegrade and the pyelotomy is closed. The ureteral stent is removed 6 weeks postprocedure. Imaging is repeated after the stent removal to ensure complete clearance of calculi. Results and Discussion: Between July 2012 and November 2012, three cases underwent a similar approach for the staghorn renal calculus. The mean age was 38.67 years. The mean body mass index was 23.4 kg/m2. All patients were males. The mean longitudinal stone size was 5.8 cm (range 4.8–7 cm). The laparoscopic approach was possible in all cases. The mean operation duration was 252.67 minutes. The mean blood loss was 95.67 mL. All patients recovered uneventfully. Ureteric stents were removed at 6 weeks postprocedure. In one case, a 7-mL lower caliceal fragment was detected on postprocedure imaging that was retrieved using flexible ureteroscopy during ureteric stent removal. In the other two cases, postoperative imaging revealed the complete clearance of calculi. All patients revealed a normal renal profile till last follow-up. Laparoscopic pyelolithotomy with intracorporeal lithotripsy and usage of rigid and flexible ureteroscopy is an effective option for single-stage management of the complex staghorn calculus. Intracorporeal lithotripsy facilitates removal of calculi that are unable to be retrieved in toto due to branching into calices. The procedure is well-tolerated with a negligible impact on nephrons. No competing financial interests exist. Runtime of video: 6 mins 44 secs

1680 ENDOSCOPIC-GUIDED PERCUTANEOUS NEPHROLITHOTOMY: A TECHNIQUE TO REDUCE RADIATION DOSAGE

You have accessJournal of UrologyStone Disease: SWL, Ureteroscopy or Percutaneous Stone Removal (II)1 Apr 20131680 ENDOSCOPIC-GUIDED PERCUTANEOUS NEPHROLITHOTOMY: A TECHNIQUE TO REDUCE RADIATION DOSAGE Andrea G. Lantz, Padraic O'Malley, Michael Ordon, and Jason Y. Lee Andrea G. LantzAndrea G. Lantz Toronto, Canada More articles by this author , Padraic O'MalleyPadraic O'Malley Toronto, Canada More articles by this author , Michael OrdonMichael Ordon Toronto, Canada More articles by this author , and Jason Y. LeeJason Y. Lee Toronto, Canada More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.3042AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Recent literature has highlighted the potential oncologic consequences of excessive diagnostic radiation exposure. Diagnosis and treatment of kidney stones often exposes patients to high levels of radiation. Percutaneous nephrolithotomy (PCNL) in particular, can be associated with large amounts of radiation exposure. Endoscopic-guided PCNL (ePCNL) is a relatively rare approach to PCNL that may have advantages in this regard, compared to standard PCNL techniques. The purpose of this study is to determine the radiation exposure (fluoroscopy time [FT] and effective dose of radiation [EDR]) related to ePCNL and to compare it to the published literature for standard PCNL techniques. METHODS A retrospective review of all ePCNL procedures performed at our institution from Nov 2011 to Oct 2012 was conducted. All cases were performed by a single surgeon using under-table, C-arm fluoroscopy. Total FT and radiation dosage for each case was recorded and the EDR was calculated using standard conversion tables. Pearson correlation was used to assess for covariates significantly correlated with longer FT and higher EDR. RESULTS A total of 29 ePCNL cases were reviewed. Mean patient age was 64 ±13 yrs, 45% were male, and mean BMI was 30 ±6.5 kg/m2. Mean stone size was 3.3 × 2.0 cm with 52% and 11% of stones being partial and complete staghorn calculi, respectively. Almost half (49%) of cases utilized an upper pole puncture, with 61% supracostal punctures; only one patient required 2 tracts. Mean FT was 4.2 ±3.6 mins and mean EDR was 2.8 ±2.4 mSv. Stone-free rate was 82% and 11% required ancillary procedures. Overall complication rate was 31% with the majority (7/9) being Clavien-Dindo grade 1-2. Longer FT correlated with increased stone size (p=0.002) and the need for ancillary procedures (p=0.005) while higher EDR correlated with increased skin-to-stone distance (SSD; p=0.013). Higher BMI did not correlate with FT, EDR or operative time. CONCLUSIONS This preliminary, single-centre review demonstrates that the ePCNL technique may be associated with a reduction in radiation dosage when compared to standard PCNL techniques (Table 1), with comparable stone-free and complication rates. Comparative Radiation Doses and Fluoroscopy Times for PCNL Author (year) Radiation Dose Fluoroscopy Time (min) Comments Current study 2.8 mSv 4.2 EDR Ritter (2012) NR 7.3 Inexperienced NR 6.2 Experienced endourologist Lipkin (2011) 4.45 mSv 6.9 EDR, air pyelogram group 7.67 mSv 10.7 EDR, contrast pyelogram group Jamal (2011) 43.3 mGy NR IR access + intraoperative c-arm data Mancini (2010) 8.66 mSv NR EDR Tepeler (2009) NR 10.19 EDR = effective dose of radiation, IR = interventional radiology, NR = not reported © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e691 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Andrea G. Lantz Toronto, Canada More articles by this author Padraic O'Malley Toronto, Canada More articles by this author Michael Ordon Toronto, Canada More articles by this author Jason Y. Lee Toronto, Canada More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Experience With More Than 1,000 Holmium Laser Prostate Enucleations for Benign Prostatic Hyperplasia

Holmium laser prostate enucleation is a contemporary treatment for benign prostatic hyperplasia. We report our experience with more than 1,000 procedures. From June 1998 to March 2009 we performed 1,065 holmium laser prostate enucleations. After receiving institutional review board approval we retrospectively reviewed the database. Reported short-term, intermediate term and long-term results are 0 to 6, 6 to 12 and greater than 12 months, respectively. Bladder stones were present in 50 patients (4.7%) and 87 of the 717 (12.1%) with laboratory studies available had renal insufficiency. Preoperative urinary retention was present in 411 cases (38.7%). Significant preoperative stress and urge incontinence was noted in 8 and 16 patients, respectively. Mean transrectal ultrasound prostate volume was 99.3 gm (range 9 to 391). Mean preoperative American Urological Association symptom score was 20.3 (range 1 to 35) and maximum urinary flow was 8.4 cc per second (range 1.1 to 39.3). Intraoperative or postoperative complications occurred in 24 cases (2.3%). Mean followup was 287 days (range 6 to 3,571). At short-term, intermediate term and long-term followup the mean symptom score was 8.7, 5.9 and 5.3, and maximum urinary flow was 17.9, 19.5 and 22.7 cc per second, respectively. At the most recent followup 3 patients (0.3%) were in urinary retention. One patient with maximum urinary flow 20 cc per second required a second procedure for bleeding prostatic regrowth. Urethral stricture was noted in 9 (0.9%), 11 (1.3%), 4 (1.3%) and 0 patients, and bladder neck contracture was found in 0, 7 (0.8%), 4 (1.3%) and 5 (6.0%) at short-term, intermediate term, long-term and greater than 5-year followup, respectively. At the most recent followup significant stress and urge incontinence was noted in 9 and 6 patients, respectively. Holmium laser prostate enucleation is safe and effective for benign prostatic hyperplasia. The complication rate is low, and incontinence and the need for ancillary procedures are rare for holmium laser prostate enucleation with durable long-term results.

MP-01.09 Flexible Ureteroscopy Assisted Semi-Rigid Retrograde Intra-Renal Surgery: A Cost-Effective Option in the Management of Upper Tract Urinary Calculi of

We compared outcomes of Semi-rigid Uretero-renoscope (URS), flexible URS and their combination along with laser lithotripsy for upper urinary tract calculi of <2 cm size in terms of fragmentation, active deflection mode usage time and lasing time, need for ancillary procedures and stone clearance.

Experience With More Than 1,000 Holmium Laser Prostate Enucleations for Benign Prostatic Hyperplasia

Holmium laser prostate enucleation is a contemporary treatment for benign prostatic hyperplasia. We report our experience with more than 1,000 procedures. From June 1998 to March 2009 we performed 1,065 holmium laser prostate enucleations. After receiving institutional review board approval we retrospectively reviewed the database. Reported short-term, intermediate term and long-term results are 0 to 6, 6 to 12 and greater than 12 months, respectively. Bladder stones were present in 50 patients (4.7%) and 87 of the 717 (12.1%) with laboratory studies available had renal insufficiency. Preoperative urinary retention was present in 411 cases (38.7%). Significant preoperative stress and urge incontinence was noted in 8 and 16 patients, respectively. Mean transrectal ultrasound prostate volume was 99.3 gm (range 9 to 391). Mean preoperative American Urological Association symptom score was 20.3 (range 1 to 35) and maximum urinary flow was 8.4 cc per second (range 1.1 to 39.3). Intraoperative or postoperative complications occurred in 24 cases (2.3%). Mean followup was 287 days (range 6 to 3,571). At short-term, intermediate term and long-term followup the mean symptom score was 8.7, 5.9 and 5.3, and maximum urinary flow was 17.9, 19.5 and 22.7 cc per second, respectively. At the most recent followup 3 patients (0.3%) were in urinary retention. One patient with maximum urinary flow 20 cc per second required a second procedure for bleeding prostatic regrowth. Urethral stricture was noted in 9 (0.9%), 11 (1.3%), 4 (1.3%) and 0 patients, and bladder neck contracture was found in 0, 7 (0.8%), 4 (1.3%) and 5 (6.0%) at short-term, intermediate term, long-term and greater than 5-year followup, respectively. At the most recent followup significant stress and urge incontinence was noted in 9 and 6 patients, respectively. Holmium laser prostate enucleation is safe and effective for benign prostatic hyperplasia. The complication rate is low, and incontinence and the need for ancillary procedures are rare for holmium laser prostate enucleation with durable long-term results.

Randomized Trial of Stone Fragment Active Retrieval Versus Spontaneous Passage During Holmium Laser Lithotripsy for Ureteral Stones

We assessed whether allowing spontaneous passage of small fragments is different from complete intraoperative extraction during semirigid ureteroscopy for ureteral stones. A total of 60 patients undergoing ureteroscopy and holmium laser lithotripsy were randomized to intraoperative fragment retrieval (group 1) or exhaustive lithotripsy and spontaneous fragment expulsion (group 2). The primary outcome was differences in unplanned medical and emergency room visits. Other outcomes were the rehospitalization, pain analgesia, time to complete recovery and 30-day stone-free rates. Patients in group 1 were younger (47 vs 54 years, p = 0.05). Other characteristics, including stone burden and site, presentation mode, and ureteral dilation and stent placement rates, did not differ between the groups. Group 2 patients had a higher rate of unplanned visits (3% vs 30%, OR 12.4, 95% CI 1.8-80.3, p = 0.01), a trend toward higher rates of rehospitalization (0% vs 10%, p = 0.24) and the need for ancillary treatment (0% vs 7%, p = 0.49), and a lower stone-free rate (100% vs 87%, p = 0.1). Complications developed in 1 group 1 patient and in 2 in group 2, including 2 with postoperative fever and 1 with mucosal undermining of the guidewire. Not actively retrieving fragments during semirigid ureteroscopy and holmium laser lithotripsy is associated with a higher risk of unplanned medical visits than complete intraoperative extraction. It also shows a tendency toward higher rates of rehospitalization, residual stones and the need for ancillary procedures.

"Spectaclesplasty" Periorbital Rotation Advancement in Crouzon Syndrome

Facial deformity in Crouzon syndrome is characterized by exophthalmos, exorbitism, mild hypertelorism, and maxillary hypoplasia with a Class III occlusion. The Göteborg craniofacial unit corrects this deformity in selected patients by the 2-stage procedure of "spectaclesplasty" followed by a Le Fort I maxillary osteotomy at skeletal maturity. "Spectacles" is a reference to the bilateral circumferential periorbital bony skeleton, and a spectaclesplasty is a differential rotation and advancement of this complex. Spectaclesplasty has been integrated as part of our protocol in managing Crouzon syndrome from birth to maturity. All patients who have undergone spectaclesplasty were retrospectively reviewed. A composite scoring system analyzing periorbital anatomy and aesthetics was used to compare the preoperative and most recent postoperative photographs. Complications and the need for ancillary procedures were recorded. Twenty-one patients have undergone spectaclesplasty since this technique was introduced in 1984. Mean follow-up time is 5 years 10 months. Compared with their preoperative aesthetics, the improvement was rated as excellent for 8 patients (38%), very good for 7 patients (33%), good for 5 patients (24%), and minimal for 1 patient (5%). No patient was rated as having no improvement. Mean perioperative blood loss was 111% of estimated red cell mass. Mean operative time was 6.4 hours. The mean duration of stay in the intensive care unit was 28 hours, and the mean hospital stay was 11 days. There were few complications and no incidences of mortality. Spectaclesplasty yields high-quality aesthetic results in most cases. It is our impression that spectaclesplasty en bloc rotation advancement of the periorbital bony skeleton can be safely performed before skeletal maturity of the lower face. Correction of the bony periorbital anatomy in early adolescence is important in alleviating psychosocial distress in this age group. In our hands, spectaclesplasty produces a more normal anatomic position of the periorbital soft tissues facilitating both function and aesthetics.

Results of shockwave lithotripsy for pediatric urolithiasis.

Shockwave lithotripsy (SWL) is widely practiced in the management of pediatric urolithiasis. However, the efficacy, need for ancillary procedures, and treatment-related complications are not as clearly defined as in the adult population. We reviewed the outcomes of SWL in the pediatric population at our lithotripsy unit. A retrospective review of all patients </=16 years of age treated with SWL between January 1991 and June 2002 was undertaken. One hundred patients with 115 stones underwent 131 SWL procedures (115 first treatments, 16 retreatments). The mean age was 10.7 years (range 10 months-16 years). Stone locations were as follows: caliceal 42.6%, renal pelvic 27%, and ureteral (30.4%). The mean stone size was 7.8 mm (range 2-23 mm). Risk factors for stone formation, the need for secondary therapies, and treatment-related complications were noted. The stone-free rate for a single-session SWL procedure, defined as complete absence of stone fragments on plain film, intravenous urography, or renal ultrasonography, was calculated based on 3-month follow-up. The efficiency quotient (EQ) was also calculated. Risk factors were identified in 31 children (27.0%), including metabolic and anatomic abnormalities. Patients with a risk factor were less likely to be stone free after one SWL session than those without risk factors (31.7% v 64.7%; P < 0.001). General (74.8%), neurolept (24.4%), and epidural (0.8%) anesthesia were utilized. Ureteral stents were placed in 25% of treatments. There were no intraoperative complications. Minor complications were seen in 4.6% of patients. Ancillary procedures were required in 10 patients. Following initial SWL treatment, 60.2% of patients were stone free. The retreatment rate was 13.9%. Following a second treatment, the stone-free rate increased to 68%. The EQ was 54.3. Employing a strict definition of treatment success, single-session SWL in our series offers moderate efficacy in the pediatric population. Patients who have a large stone or risk factor such as an anatomic abnormality are less likely to become stone free and might better undergo an endourologic procedure.