Required 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. ...

PD19-05 DOES PERCENTAGE OF SEMINOMA AT ORCHIECTOMY IMPACT PATIENT MORBIDITY AND PATHOLOGIC OUTCOMES AT POST-CHEMOTHERAPY RETROPERITONEAL LYMPH NODE DISSECTION FOR MIXED GERM CELL TUMOR?

INTRODUCTION AND OBJECTIVE: Post-chemotherapy retroperitoneal lymph node dissections (PC-RPLND) for pure seminoma are widely considered to have an increased potential for surgical complexity and morbidity secondary to increased post-chemotherapy desmoplastic changes. This places patients at increased risk, often with pathologic findings only revealing necrosis. We sought to determine if the percentage of seminoma in the orchiectomy specimen predicts necrosis on PC-RPLND for non-seminomatous germ cell tumors (NSGCT) and the associated impact on patient morbidity. METHODS: Patients with seminoma in the orchiectomy specimen who underwent PC-RPLND for NSGCT at Indiana University from 2009-2019 were identified to assess pathologic findings, required ancillary procedures at the time of PC-RPLND, and post-operative outcomes. Patients were categorized into quartiles to assess if increasing percentage of seminoma predicted necrosis. RESULTS: Of the 109 patients identified, pathologic analysis revealed necrosis in 30/109 (27.5%), malignancy 17/109 (15.6%), and teratoma 62/109 (56.9%). As percent seminoma increased by quartile, necrosis was more prevalent (23.7%, 25%, 33.3%, 41.7%), as was the radiographic size decrease in post-chemotherapy retroperitoneal masses. For patients with greater than 90% seminoma, necrosis was found 50% of the time. The incidence of concurrent nephrectomy, need for intra-operative vascular repair, and estimated blood loss during PC-RPLND was greatest in the 4th quartile. There was no significant difference in pre-operative serum tumor markers, patient age, body mass index, pre-operative comorbidities, length of stay, or post-operative Clavien-Dindo classification outcomes. CONCLUSIONS: As percent seminoma in the orchiectomy specimen increased, the incidence of necrosis, surgical complexity, and the need for concurrent ancillary procedures increased. However, it did not seem to change the hospital course or post-operative morbidity. Unfortunately, these results show that PC-RPLND cannot be eliminated even in patients with very high orchiectomy seminoma percentages as over half of these patients had teratoma or viable malignant elements in the retroperitoneum. Source of Funding: None

Artificial Neural Network System to Predict the Postoperative Outcome of Percutaneous Nephrolithotomy.

To construct, train, and apply an artificial neural network (ANN) system for prediction of different outcome variables of percutaneous nephrolithotomy (PCNL). We calculated predictive accuracy, sensitivity, and precision for each outcome variable. During the study period, all adult patients who underwent PCNL at our institute were enrolled in the study. Preoperative and postoperative variables were recorded, and stone-free status was assessed perioperatively with computed tomography scans. MATLAB software was used to design and train the network in a feed forward back-propagation error adjustment scheme. Preoperative and postoperative data from 200 patients (training set) were used to analyze the effect and relative relevance of preoperative values on postoperative parameters. The validated adequately trained ANN was used to predict postoperative outcomes in the subsequent 254 adult patients (test set) whose preoperative values were serially fed into the system. To evaluate system accuracy in predicting each postoperative variable, predicted values were compared with actual outcomes. Two hundred fifty-four patients (155 [61%] males) were considered the test set. Mean stone burden was 6702.86 ± 381.6 mm3. Overall stone-free rate was 76.4%. Fifty-four out of 254 patients (21.3%) required ancillary procedures (shockwave lithotripsy 5.9%, transureteral lithotripsy 10.6%, and repeat PCNL 4.7%). The accuracy and sensitivity of the system in predicting different postoperative variables ranged from 81.0% to 98.2%. As a complex nonlinear mathematical model, our ANN system is an interconnected data mining tool, which prospectively analyzes and "learns" the relationships between variables. The accuracy and sensitivity of the system for predicting the stone-free rate, the need for blood transfusion, and post-PCNL ancillary procedures ranged from 81.0% to 98.2%.The stone burden and the stone morphometry were among the most significant preoperative characteristics that affected all postoperative outcome variables and they received the highest relative weight by the ANN system.

Use of a Novel Flexible Mini-nephroscope in Minimally Invasive Percutaneous Nephrolithotomy

To assess the feasibility and safety of a novel flexible mini-nephroscope in minimally invasive percutaneous nephrolithotomy (PCNL). Presumably, limiting the size and number of tracts during PCNL has the potential of decreasing the morbidity of the procedure. We present our experience with this new technique. A retrospective analysis of patients with multiple kidney stones treated with mini-PCNL combined with a novel flexible mini-nephroscope was performed. Minimally invasive PCNL was done with rigid 12 F MIP-M nephroscope, followed by flexible mini-nephroscopy for smaller stones in other inaccessible calyces. Record was made of the operating time, stone-free rates, postoperative pain, morbidity, hospital stay, time to recovery, complication rates, and ancillary procedures. Matched-pair analysis was done with cases operated by flexible ureteroscopy performed with Flex X-2 or Flex X-c scope. Twenty-five patients in the study group were matched with 25 cases from the flexible ureteroscopy group. Both groups were comparable in terms of age, laterality, and mean composite stone burden. The mean operating time was 40.1 ± 10.6 minutes in the mini-PCNL group and 51.2 ± 8.8 minutes in the flexible ureteroscopy group. Mean hospital stay was similar in both groups. The primary stone clearance rate of 92% (23 of 25) in the mini-PCNL group was better than the clearance rate of 80% (20 of 25) in the flexible ureteroscopy group. Eight percent in the mini-PCNL group required ancillary procedures as compared with 20% of cases in the flexible ureteroscopy group. Postoperative pain and analgesia requirement in these patients was minimal. There were no significant complications. Flexible mini-nephroscope is an effective adjuvant to minimally invasive PCNL in achieving high clearance rate with minimum morbidity.

Assessing radiation exposure during endoscopic-guided percutaneous nephrolithotomy.

Percutaneous nephrolithotomy (PCNL) may be associated with significant ionizing radiation exposure for patients and operating room staff. Endoscopic-guided PCNL (ePCNL) is a technique that may be associated with less radiation exposure. This study examines ePCNL-related radiation exposure (fluoroscopy time, effective dose) and investigates variables that may predict increased exposure. A retrospective review of all consecutive ePCNLs performed at our institution, by a single surgeon, was conducted between November 2011 and November 2013. Patient demographics, stone characteristics and perioperative details were recorded, including radiation exposure. Pearson and Spearman correlation were used to assess variables correlated with radiation exposure. In total, 55 ePCNL cases were included in the study. The mean age was 60 ± 15 years, mean body mass index (BMI) 30.0 ± 6.4 kg/m(2) and mean stone size 3.2 × 2.1 cm. Seven cases (13%) involved complete staghorn stones, and 69% involved supracostal punctures. The mean fluoroscopy time was 3.4 ± 2.3 minutes, mean ED 2.4 ± 1.9 mSv. The treatment success rate, assessed 1-week postoperatively, was 87.3% and 7.3% of cases required ancillary procedures. The overall complication rate was 29%, but only 3 cases (5.5%) were Clavien ≥3. Longer fluoroscopy time correlated with increased stone size (p < 0.01), longer operative time (p < 0.01) and lower treatment success rates (p < 0.01); higher effective dose correlated with longer fluoroscopy time (p < 0.01) and increased skin-to-stone distance (p < 0.01). BMI did not correlate with fluoroscopy time or effective dose. Outcomes of ePCNL are comparable to traditional PCNL techniques and may be associated with lower radiation exposure, particularly beneficial for patients with higher BMI.

Tubeless simultaneous bilateral percutaneous nephrolithotomy: Safety, feasibility and efficacy in an Indian setting

To study the safety, feasibility and efficacy of tubeless simultaneous bilateral percutaneous nephrolithotomy. We retrospectively studied 85 patients who underwent tubeless simultaneous bilateral percutaneous nephrolithotomy in the Department of Urology, Kasturba Medical College, Manipal, Karnataka, India, from July 2006 to June 2013. The demographic profile and outcomes were compared with the other existing series reported in the literature. A total of 65 male and 20 female patients with a mean age of 45.7 ± 11.6 years underwent tubeless simultaneous bilateral percutaneous nephrolithotomy. The mean stone burden was 299 mm(2), with 12 staghorn calculi. Mean operative time was 87.6 ± 35.5 min. A total of 95% of stones were cleared with single access tracts. The success rate of tubeless simultaneous bilateral percutaneous nephrolithotomy (stone clearance) was 95.2%. Mean hemoglobin drop was 1.1 ± 0.9 gm% per patient, with 10.5% of patients requiring blood transfusion. Mean hospital stay was 69.6 ± 28.4 h. Complications included urosepsis (Clavien grade 4), acute kidney injury requiring hemodialysis (grade 3), pneumonia (grade = 2) and hydrothorax requiring intercostal drainage tube insertion (grade 3). On follow up, 4.7% of the renal units required ancillary procedures. Our findings confirm that tubeless simultaneous bilateral percutaneous nephrolithotomy is a safe and effective modality of treatment. It allows obviating a second anesthetic exposure, thus reducing analgesic requirement, hospitalization time and costs. This translates into a significant socioeconomic impact on the outlook of Indian patients presenting with bilateral renal stone disease.

Surgical Technique for Total Ankle Arthroplasty in Ankles with Preoperative Coronal Plane Varus Deformity of 10° or Greater.

Total ankle replacement for end-stage ankle arthritis with talar varus malalignment of ≥10° can achieve satisfactory outcomes in the ankle joint, and ≥10° of talar varus malalignment should not be considered a contraindication for surgery. Conduct a thorough clinical and radiographic evaluation of the entire lower extremity. In the operating room, conduct a physical examination prior to and following ankle exposure to determine the ancillary procedures required. Proceed with tendon and soft-tissue release as needed to correct pes cavus deformity and improve range of motion. Correct varus talar deformity via a standard resection of the ankle joint osteophytes, starting laterally and finishing medially. Consider transfer of the posterior tibial tendon to the peroneus brevis to help maintain correction of the varus deformity. Once you determine that the talar varus is correctable and you have prepared the posterior tibial tendon for transfer, perform the total ankle replacement. Evaluate the rest of the foot and perform any required ancillary procedures; most often a dorsiflexion osteotomy of the first metatarsal is necessary to correct forefoot valgus, which is commonly seen in forefoot-driven cavovarus deformities. Patients with preoperative coronal plane varus tibiotalar deformities of ≥10° who underwent total ankle replacement have shown significant improvement in clinical outcome scores at the time of mid-term follow-up.IndicationsContraindicationsPitfalls & Challenges.

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 ...

Complications and Associated Factors of Pediatric Extracorporeal Shock Wave Lithotripsy

We determined the safety, efficacy and complications of extracorporeal shock wave lithotripsy in managing pediatric urolithiasis and analyzed possible factors affecting the complication rate. We retrospectively reviewed 128 patients younger than 16 years who had undergone extracorporeal shock wave lithotripsy with a Lithostar® lithotripter between January 2000 and December 2010. Stone clearance and complications were assessed at postoperative week 1, and months 1 and 3. Success was defined as no radiological evidence of stone, or fragments 4 mm or less. Treatment failure was analyzed to find any correlation with stone size. Complications were assessed with a specific focus on rehospitalizations during postoperative week 1. The overall success rate was 93.5% (115 of 123 patients). Repeat treatment rate was 56.1% (69 patients). Extracorporeal shock wave lithotripsy failed in 8 children, who subsequently required ancillary procedures. Mean stone size in the treatment failure group was 17.03 mm, compared to 13.04 mm in the successfully treated group. A total of 22 patients (17.8%) had complications in postoperative week 1 but only 19 (15.4%, 12 boys and 7 girls) were rehospitalized at that time. Presence of a metabolic risk factor was the only predictive factor for complications. By comparison, we found a lower success rate and higher ancillary procedure rate in the group with complications. Extracorporeal shock wave lithotripsy is effective for pediatric urolithiasis, with a small but substantial morbidity rate. Parents should be informed about possible rehospitalization following extracorporeal shock wave lithotripsy due to complications independent of stone size.

The Role of Percutaneous Nephrolithotomy in the Management of Medium-Sized (1–2 cm) Lower-Pole Renal Calculi

Objectives : The objective of this study was to determine the efficacy (defined by stone-free rates) and safety of percutaneous nephrolithotomy (PNL) in the treatment of medium sized (1–2 cm) symptomatic lower pole renal calculi, and establishment of the short-term morbidity.Methods : We performed a retrospective analysis of 60 evaluable patients who had undergone PNL for 1 to 2 cm diameter lower-pole (LP) stones between November 2006 to March 2009 and compared these results with other treatment modalities in published literature.Results : In all cases, stones were located in the lower calix. Thirty-six procedures were performed on the left side, and 24 were performed on the right side. The mean time to access the collecting system was 20.4 minutes (range 8–70 min) and mean operative time was 62.2 minutes (range 13–155 min). Abdominal radiography performed on postoperative day 1 demonstrated a stone free status in 56 (93.3%) patients. However, 4 patients (6.7%) required ancillary procedures (secondary PNL in 1, retrograde intrarenal surgery in 1, and SWL in 2). After this secondary procedures a complete stone-free status was achieved in 98.3% of patients. The morbidity of patients undergoing PNL at our hospital was minimal, with a mean hospital stay of 3.7 days.Conclusions : We demonstrated that, PNL is a safe and effective method for medium sized (1 to 2 cm) lower pole renal calculi and percutaneous removal should be considered the primary approach for lower pole stones greater than 10 mm.

Correction of Varus Talar Deformities in Ankle Joint Replacement

There is limited information on surgical techniques for correcting a varus talar deformity in patients undergoing ankle joint replacement. This article reviews 32 patients with a varus talar deformity of >10°, who underwent a total ankle replacement . Of the 32 ankles, 15 had a varus talar deformity of >15°. The importance of appropriate preoperative assessment and a stepwise intraoperative approach is described in detail. With an average follow-up of 17 months, a satisfactory radiographic correction was obtained in 94% (30/32) of the ankles. It is noted that 75% (24/32) of patients required ancillary procedures after ankle replacement to obtain a plantigrade foot. This review will demonstrate that correction of moderate to severe varus talar deformities is possible when considering a total ankle replacement for the management of end-stage ankle arthritis.

Management of vesicovaginal fistula: An experience of 52 cases with a rationalized algorithm for choosing the transvaginal or transabdominal approach

Purpose:We aim to present our experience for the repair of vesicovaginal fistula (VVF) with special reference to surgical approach.Materials and Methods:From January 1999 to June 2005, 52 VVF patients with mean age of 32 years underwent operative treatment. Fistulas were divided into two groups, simple and complex, depending on site, size, etiology and associated anomalies. Simple VVFs were approached through the vaginal route and complex VVFs via the transabdominal route. Patients were evaluated at two to three weeks initially, three-monthly twice and later depending on symptoms.Results:Thirty-two (61.5%) had simple fistulas and 20 (38.5%) complex fistulas. The most common etiology was obstetric trauma in 31 (59.6%) patients, while the second most common cause was post hysterectomy VVF. Thirty-two (61.5%) patients were managed by transvaginal route, of which 17 had supratrigonal and 15 trigonal fistulas. Twenty (38.5%) patients with complex fistulas were managed by abdominal route. The mean blood loss, postoperative pain and mean hospital stay were shorter in transvaginal repair. Eleven (21.2%) patients required ancillary procedures for various other associated anomalies at the time of fistula repair. Three patients failed repair giving a success rate of 94.2%. At a mean follow-up of three years 48 women were sexually active, of these 10 (19.2%) complained of mild to moderate dyspareunia.Conclusion:Most of the simple fistulas irrespective their locations are easily accessible transvaginally while in complex fistulas we recommend the transabdominal approach. Depending on the clinical context both the approaches achieved comparable success rates.

Safety Profile and Complications of Transperitoneal Laparoscopic Pyeloplasty: A Critical Analysis

To critically assess the safety profile and complications of the transperitoneal approach to laparoscopic pyeloplasty at our center. From January 2002 to January 2004, 92 patients with a mean age of 22.78 +/- 15.15 years (range 14 months-65 years) with primary (N = 90) or secondary (N = 2) ureteropelvic junction obstruction were treated by transperitoneal laparoscopic pyeloplasty and were evaluated for this study. Renal stones were present in eight patients. A double-J stent was placed antegrade in 50 patients and in the rest through cystoscopy. All patients were followed up clinically and by renal scan. Of the 92 cases (93 renal units), 6 were converted to open pyeloplasty. Dismembered pyeloplasty was performed in 59, Fengerplasty in 8, and Foley Y-V-plasty in 20 units. A crossing vessel was present in 15 units (16.12%). The mean estimated blood loss was 63.6 mL (range, 30-200 mL). The mean operative time was 179.4 minutes (range 80-350 minutes). Overall, 17 patients (18.4%) had complications. Six patients had paralytic ileus and another six had increased drain output, which delayed the hospital stay to 7 days. Pyelonephritis and port-site hernia occurred in one patient each. Four patients required ancillary procedures: ureteroscopy for a migrating stent (1), percutaneous antegrade stenting (1), and SWL for residual stone (2). The mean hospital stay was 4 days (range 2-7 days). Of the 87 units (86 patients), 81 (93.3%) have shown improvement in symptoms and drainage pattern on renal scan at a mean followup of 12 (3-27) months. The transperitoneal approach to pyeloplasty is safe and effective, although patients with large stone bulk and multiple stones should be considered for an alternative approach. The double-J stent should be checked carefully for proper placement. Hemostasis of the cut margin of the renal pelvis, watertight anastomosis, and adequate drainage should also be ensured.

Reconstruction of the Face After Resection of Arteriovenous Malformations Using Anterolateral Thigh Perforator Flap

Arteriovenous malformations are high flow lesions that remain a challenge in the field of plastic surgery, interventional radiology, and neurosurgery. This is especially true for large lesions requiring a comprehensive team approach. From March 2001 to August 2004, six patients with arteriovenous malformation having extensive involvement of the skin underwent selective embolization followed by resection and reconstruction with anterolateral thigh perforator flap. The age of patients ranged from 22 to 43 years (average, 29 years); four were male and two were female. The size of the defect ranged from 8 x 10 cm to 12 x 14 cm. During the follow-up period from 3 months to 41 months, two patients required ancillary procedures to improve their aesthetic appearances. All patients achieved acceptable contour, appearance, and sensation without any incidence of recurrences. The anterolateral thigh perforator flap provides a large, thin and sensible flap. The anatomy of the flap is relatively constant and reliable. Despite the extensive involvement of arteriovenous malformation of the face, with selective embolization, maximal resection, and coverage with a well-vascularized tissue, it can be safely removed and successfully reconstructed.

PEDIATRIC UROLITHIASIS: 15 YEARS OF LOCAL EXPERIENCE WITH MINIMALLY INVASIVE ENDOUROLOGICAL MANAGEMENT OF PEDIATRIC CALCULI

We sought to identify whether changes in technology and local practice have improved outcomes in the minimally invasive management of pediatric stone disease. We reviewed retrospectively case notes and imaging from 1988 to 2003, noting treatment modality, stone-free rates, ancillary therapy and complications. A total of 122 children (140 renal units) with a mean age of 7.7 years underwent 209 extracorporeal shock wave lithotripsy (SWL) sessions. Stone size ranged from 6 to 110 mm. Stone-free rates were 84% for cases involving stones smaller than 20 mm, and 54% for those involving stones 20 mm or greater. For complex calculi 40% of patients were stone-free and 45% required ancillary procedures, with an overall complication rate of 26%. A total of 37 children (43 renal units) with a mean age of 6.4 years underwent 46 percutaneous nephrolithotomies (PCNLs). Stone size ranged from 8 to 155 mm. The overall stone-free rate was 79%. Of these patients 34% required ancillary procedures, with a major complication rate of 6%. A total of 35 children (35 renal units) with a mean age of 5.9 years underwent 53 ureteroscopies. Holmium laser was the most effective treatment modality in this group, with a 100% stone-free rate and no complications. For most renal stones smaller than 20 mm SWL was the most effective primary treatment modality. There was no statistical difference between the 2 lithotriptors for stone-free or ancillary procedure rate. The stone-free rate was dependent on stone size rather than type of lithotriptor. For renal stones 20 mm or greater and staghorn calculi we switched from SWL to PCNL as primary treatment, as stone-free rates were higher and the ancillary procedure and re-treatment rates were lower with PCNL. Electrohydraulic lithotripsy and pulse dye laser were initially used to treat ureteral stones. However, with the introduction of holmium laser technology we achieved higher stone-free rates and lower complication rates. Holmium laser lithotripsy is now used as a primary treatment modality for ureteral stones.

Contemporary Results of Endopyelotomy for Ureteropelvic Junction Obstruction

Introduction: Endopyelotomy is an accepted treatment option for ureteropelvic junction obstruction (UPJO). In this study, we reviewed our 7-year experience with antegrade endopyelotomy for UPJO. Materials and Methods: We reviewed the records of 35 consecutive antegrade endopyelotomy for UPJO between 1996 and 2002. Patients were included if they had shown radiographic evidence of UPJO on diuresis urography or intravenous urogram with signs and symptoms or deterioration of renal function. Results: A total of 34 consecutive patients underwent 35 antegrade endopyelotomy procedures in 35 renal units. One patient had bilateral endopyelotomy for bilateral UPJO. Eighteen renal units (51%) had concomitant renal calculi that required percutaneous nephrolithotomy, including 8 renal units with pelvi-ureteric junction stones. Twenty-four renal units (69%) had moderate degree of hydronephrosis whilst 11 renal units (31%) had severe hydronephrosis. The mean operating time for antegrade endopyelotomy was 94 ± 28 minutes and the mean hospital stay was 4.7 ± 2.8 days. No patients had conversion to open pyeloplasty and no patient required perioperative blood transfusion. The mean follow-up was 33 ± 23 months and the overall success rate following endopyelotomy was 83% (n = 29 renal units). The success rate for primary UPJO was 81%, whilst the success rate for secondary UPJO was 84%. Four renal units (11%) required ancillary procedures for failed endopyelotomy. Two patients required repeat endopyelotomy, and 2 patients needed open pyeloplasty. Two patients were lost to follow-up. Conclusion: Endopyelotomy remains a viable approach for UPJO compared to open reconstruction. Careful patient selection can optimise the surgical outcome and minimise endopyelotomy failures.

The effect of intracalyceal distribution on the clearance of renal stones of > or = 20 mm in children after extracorporeal lithotripsy.

To determine the effect of the intracalyceal distribution of renal stones on clearance rates after treating paediatric nephrolithiasis with extracorporeal shock wave lithotripsy (ESWL). We assessed a retrospective case series of children (aged < or = 14 years) undergoing lithotripsy on an MPL 9000 (Dornier GmbH, Germany) echo-guided lithotripter. Patients were identified using an international coding and indexing system and ESWL registry. In all, 125 children were treated during 1990-2003, but 21 had stones of > or = 20 mm. Stone clearance was assessed at 1 and 3 months, the stone-free state being defined as no radiological evidence of stone or fragments of < or = 3 mm. Failed treatments were analysed to identify any correlation with stone site. The overall stone-free rate was 81%; in four children the treatment failed (all girls) and subsequently they required ancillary procedures. Nineteen patients (90%) received up to three sessions of ESWL; two required four or more sessions. Of the four children in whom treatment failed, two had JJ stents; the stones were in the lower pole calyx in two, and the renal pelvis and lower pole calyx in two. The mean stone size in those where treatment failed was 25 mm, vs 21 mm in the stone-free group. The complication rate was 19%, but only one child required admission to hospital. ESWL is very effective for renal stones in children, with minimal morbidity. Lower pole and partial staghorn stones with a major component in the lower pole calyx should preferably be treated by a percutaneous approach.

Retrograde Intrarenal Lithotripsy Outcome After Failure of Shock Wave Lithotripsy

We report our experience with retrograde intrarenal lithotripsy (RIRL) for renal stones not alleviated by shock wave lithotripsy (SWL). A total of 28 females and 53 males with a mean age of 53 years (range 18 to 86) were studied. They had been treated with a mean of 3.2 previous SWLs. Mean stone size was 9.2 mm (range 4 to 22) and the mean number of stones per patient was 1.27 (range 1 to 5) for a total of 103 stones overall. In 70 patients there was 1 stone. Rigid and flexible ureteroscopes were used in 8 and 67 cases, respectively, while a combined approach was used in 6. A holmium:YAG laser was used for fragmentation in 52 patients. Success was defined as stone-free status or residual fragments less than 3 mm. The overall success rate was 67%. RIRL yielded a 46% stone-free rate. Of the 44 patients 17 (39%) had residual stones less than 3 mm, while 13 required ancillary procedures. There were no residual ureteral stones. Original stone size correlated inversely with the success rate. Most failures involved lower pole stones, in that laser fiber deflection prevented reaching them in 9 cases. The procedure was interrupted due to extravasation or bleeding in 5 patients and 6 had postoperative urinary tract infections (16% overall complication rate). RIRL effectively and safely alleviated upper tract stones unresponsive to earlier SWL. It can be considered salvage therapy in such cases. RIRL is well suited for treating stones less than 2 cm with better stone-free rates than SWL in the same circumstances. Residual stones were more likely in lower pole cases.

Does size and site matter for renal stones up to 30-mm in size in children treated by extracorporeal lithotripsy?

Objectives To determine the safety and efficacy of extracorporeal shock wave lithotripsy (ESWL) in the treatment of pediatric nephrolithiasis and to analyze the impact of renal stone size and location on stone clearance. Methods This was a retrospective case series of pediatric patients (14 years or younger) undergoing lithotripsy using a Dornier MPL 9000 echo-guided lithotriptor. Patients were identified using an international coding and indexing system (9th edition) and ESWL registry. One hundred five patients were treated from January 1990 to December 2001. Stone clearance was assessed at 1 and 3 months. A stone-free state was defined as no radiologic evidence of stone or fragments 3 mm or less. Treatment failure was analyzed to find any correlation with stone size and site. Results The overall stone-free rate was 95%. The treatment failed in 5 patients, who subsequently required ancillary procedures. Three patients received one session of ESWL, after which they were lost to treatment and were not analyzed further. Four of the five patients with treatment failure had a double- J stent; the stones were located in the lower pole calix in 2, renal pelvis and lower pole calix in 1, and at the ureteropelvic junction in 2 patients. The mean stone size in the treatment failure group was 15.88 mm compared with 14 mm in the stone-free group. The complication rate was 8%, but only 3 patients required admission. Conclusions ESWL is highly effective for pediatric renal stones, with minimal morbidity. Stone clearance is not adversely affected by a stone size up to 30 mm; however, lower pole caliceal stones and stones impacted at the ureteropelvic junction have relatively poorer clearance. Eighty percent of patients who failed to clear their stones had a double-J stent.

Treatment of Malignant Pleural Effusions with Tunneled Long-term Drainage Catheters

To assess the effectiveness of tunneled pleural catheters (TPCs) in the treatment of malignant pleural effusions (MPEs). Twenty-eight patients with symptomatic MPEs had 31 hemithoraces treated with TPCs placed under image guidance. Chemical sclerotherapy had failed in two patients and two had symptomatic locules. Drainage was accomplished by intermittent connection to vacuum bottles. Pleurodesis was considered achieved when three consecutive outputs were scant and imaging showed no residual fluid. All catheters were successfully placed. Dyspnea improved in 94% (29 of 31 hemithoraces) at 48 hours and 91% (20 of 22 patients) at 30 days. Control of the MPE was achieved in 90% of hemithoraces (28/31), although five required ancillary procedures. Pleurodesis occurred in 42% (13 of 31) of hemithoraces, including both that underwent an earlier attempt at chemical sclerotherapy and one treated locule. Continued drainage without pleurodesis controlled the effusion in 48% (15 of 31). In only 7% was hospital time necessary for care related to the TPC. Early, transient catheter-related pain was common, but only three complications (in two patients) occurred. Neither of these altered patient care. Regardless of whether pleurodesis is achieved, TPCs provide effective long-term outpatient palliation of MPEs.