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Introduction: Concurrent peritoneal dialysis (PD) catheter removal during renal transplantation is controversial, with limited evidence supporting this practice. Our objective was to determine the rate of delayed graft function (DGF) in patients on preoperative PD. Additionally, we sought to identify which patients can safely have their PD catheter removed during transplantation due to a low risk of DGF. Methods: We conducted a retrospective observational study between June 2011 and December 2015. The primary outcome was the diagnosis of DGF, defined as the need for dialysis within the first week of transplantation. Clinical and transplant factors, including graft type and donor criteria, were assessed for association with the primary outcome. Catheter-related complication rates were also compared between post-transplant PD and hemodialysis (HD). Results: Of our cohort of 567 patients, 145 patients (25.6%) developed DGF. Obesity (odds ratio [OR] 1.06; 95% confidence interval [CI] 1.00–1.11; p=0.04) and increased perioperative blood loss (OR 1.002; 95% CI 1.000–1.003; p=0.03) were predictors of DGF. Protective factors included living donor (LD) grafts (OR 0.15; 95% CI 0.05–0.49; p=0.002) and intraoperative graft urine production (OR 0.39; 95% CI 0.23–0.65; p

Introduction: After the introduction of shock wave lithotripsy (SWL), ureteroscopy (URS), and percutaneous nephrolithotomy (PCNL), the subspecialty of endourology was born in the late 1970s. The purpose of this study was to report milestones in Canadian endourology, highlighting Canada’s contributions to the field. Methods: A review of the literature was performed from the late 1970s to the present. The literature review included bibliographic and digital resources. Additionally, records and recollections by various individuals were used, including some directly involved. Results: Endourology was born in Canada when SWL, URS, and PCNL emerged as minimally invasive treatment options for stones in the early to mid-1980s. According to our research, the first PCNL was performed at the University of Toronto in 1981. Dr. Joachim Burhenne, a Harvard-trained radiologist from Germany, first used extracorporeal SWL in Canada at the University of British Columbia (UBC) for the treatment of biliary stones. Treatment for urinary tract stones followed at UBC and Dalhousie University. The first worldwide use of the holmium laser for lithotripsy of urinary tract calculi took place at the University of Western Ontario. Other endourology milestones in Canada include the formation of the Canadian Endourology Group and the emergence of the Endourological Society-accredited fellowship programs at the University of Toronto and Western University in the 1990s. Canada hosted the 21st and 35th World Congress of Endourology and Shock Wave Lithotripsy annual meeting in Montreal and Vancouver, respectively. Conclusions: Canadian urologists have led many advances in SWL, URS, and PCNL over the past four decades, and for a relatively small community have made significant contributions to the field. Through the training of the next generation of endourologists at Canadian institutions, the future of endourology in Canada is bright.

Introduction: Stone migration during ureteroscopy (URS) for proximal ureteric calculi is a constant challenge. Several retropulsion prevention devices have been developed to optimize URS outcomes. Our technique involves capturing the stone within a fourwire Nitinol stone basket and then performing laser lithotripsy to dust the stone while it is engaged in the basket. The dusted fragments wash out with the irrigation fluid and once small enough, the remaining stone is removed intact.Methods: A retrospective chart review was performed of all proximal semi-rigid URS procedures for a solitary calculus (2000– 2016). We compared our new technique introduced in 2010 to URS control procedures that did not use retropulsion prevention techniques or devices.Results: One hundred and forty patients underwent URS for proximal ureteric calculi. Mean stone diameter was 9.3±3.4 mm, with similar impaction rate between both groups (44.1% vs. 43.1% control; p=n/s). The mean surgical procedure time was 53.3±17.9 minutes for the new technique and 65.2±29.2 minutes for the control group (p=0.005). Compared to the new technique, the control group had a higher rate of retropulsion (33.3% vs. 14.7%; p=0.01) and required flexible URS more often to exclude or remove residual fragments (24.1% vs. 59.1%; p=0.001). Using the new technique, stone-free rates were higher (79.1% vs. 69.4%; p=n/s) and there was a lower likelihood of leaving residual fragments both

Introduction: The purpose of this study was to determine the variety and prevalence of renal and non-renal abnormalities detected on multidetector computed tomography (MDCT) that precluded patients from donating a kidney.Methods: Institutional review board approval was obtained and the requirement for informed consent was waived. A retrospective, single-centre review of 701 patients (444 female, 257 male; age range 18–86 years; mean age 43.2±11.9 years) that underwent renal donor protocol MDCT was conducted. A systematic review of the CT report, records from multidisciplinary renal transplantation rounds, and electronic medical records was performed to determine which patients were approved or declined as live renal donors. If declined as a donor, CT-identified reasons were categorized as abnormalities of renal vasculature, renal parenchyma, collecting system, or extra-renal.Results: A total of 81 patients were excluded as renal donors on the basis of CT findings. Abnormalities of the collecting system accounted for the most frequent cause of exclusion (n=41), with asymptomatic renal calculi being detected in 39 patients. Complex vascular anatomy and vascular abnormalities resulted in the exclusion of 29 patients. Supernumerary arteries and early arterial branching resulted in the exclusion of 20 patients, while renal vein anomalies leading to exclusion were uncommon (n=2). Abnormalities of renal parenchyma resulted in the exclusion of nine patients. Three patients were diagnosed with autosomal dominant polycystic kidney disease, two patients had renal cell carcinoma, and two patients had areas of cortical scarring. A complex cystic lesion requiring surveillance imaging was encountered in one patient and a large area of renal infarction related to prior adrenalectomy was demonstrated in one patient. Extra-renal abnormalities leading to exclusion were limited to two patients with pulmonary nodules.Conclusions: MDCT plays a critical role in the preoperative assessment of potential renal donors by identifying contraindications to donor nephrectomy and providing accurate vascular mapping. This study is anticipated to be informative for those involved in the workup of potential living renal donors by quantifying the incidence and reasons for donor exclusion identified on CT.

Background: We describe the practice variability of CUA (Canadian Urological Association) members and factors which predict these patterns for common stone scenarios. Methods: We asked 308 English- and 52 French-speaking CUA members to complete online surveys in their respective languages. We collected demographic information on fellowship training, shock wave lithotripsy (SWL) access, academic setting and whether they are at a hospital with regionalized surgical services. Respondents indicated their actual as well as ideal treatment for scenarios of renal, proximal and distal ureteric calculi. Results: In total, 131 urologists responded (36% response rate), all of whom treated urolithiasis. Of this number, 17% had endourology fellowship training, 76% had access to SWL, 42% were at an academic institution and 66% were at institutions with regionalized surgical services. Actual and ideal treatment modalities selected for symptomatic, distal and proximal ureteric stones (4, 8, 14 mm) were consistent with published guidelines. There were discrepancies between the use of ureteroscopy and SWL in actual versus ideal scenarios. Actual and ideal practices were congruent for proximal ureteric stones and asymptomatic renal calculi. In multivariate analysis, respondents were less likely to perform ureteroscopy on proximal 4- and 8-mm stones if they were at a hospital with regionalized surgical services (OR: 0.097; 95% CI: 0.01-0.76, p = 0.03 and OR: 0.330; 95% CI: 0.13-0.83, p = 0.02). Interpretation: There is clinical variability in the management of urolithiasis in Canada; however, management approaches fall within published guidelines. Type of hospital and access to operating room resources may affect treatment modality selection.

The focus of this guideline is the management of ureteral stones. Specifically, the topics covered include: conservative management, medical expulsive therapy, active intervention with either shockwave lithotripsy (SWL) or ureteroscopy (URS), factors affecting SWL treatment success, optimizing success, and special considerations (e.g., pregnancy, urinary diversion). By performing extensive literature reviews for each topic evaluated, we have generated an evidence-based consensus on the management of ureteral stones. The objective of this guideline is to help standardize the treatment of ureteral stones to optimize treatment outcomes.

Introduction: Simulation-based training (SBT) is being increasingly used for novice trainees as a means of overcoming the early learning curve associated with new surgical skills. We designed a SBT flexible ureteroscopy (fURS) course using a novel inanimate training model (Cook Medical, Bloomington, IN; URS model). We evaluated the course and validated this Cook URS model. Methods: A 2-week SBT fURS course was designed for junior level urology trainees at 2 Canadian universities. The curriculum included didactic lectures, hands-on training, independent training sessions with expert feedback, and use of the Cook URS parttask model. Baseline and post-course assessments of trainee fURS skills were conducted using a standardized test task (fURS with basket manipulation of a calyceal stone). Performances were videorecorded and reviewed by 2 blinded experts using a validated assessment device. Results: Fifteen residents (postgraduate years [PGY] 0–3) participated in the course. Of the participants, 80% rated the Cook URS model as realistic (mean = 4.2/5) and 5 endourology experts rated it as useful as a training device (mean = 4.9/5), providing both face and content validity. The mean overall performance scores, task completion times, and passing ratings correlated with trainee clinical fURS experience – demonstrating construct validity for the Cook URS model. The mean post-course task completion times (15.76 vs. 9.37 minutes, p = 0.001) and overall performance scores (19.20 vs. 25.25, p = 0.007) were significantly better than at baseline. Post-course performance was better in all domains assessed by the validated assessment device. Conclusions: This study demonstrates that a SBT curriculum for fURS can lead to improved short-term technical skills among junior level urology residents. The Cook URS model demonstrated good face, content and construct validity.

Introduction: The ubiquitous use of diagnostic imaging has resulted in an increased incidental detection of small renal masses (SRM). Patient- and tumour-related factors affect treatment decisions greatly; however, with multiple treatment options available, surgeon-specific characteristics and biases may also influence treatment recommendations. We determine the impact of surgeon-specific factors on treatment decisions in the management of SRM in Canada.Methods: An online survey study was conducted among Canadian urologists currently registered with the Canadian Urological Association. The questionnaire collected demographic information and recommended treatments for 6 SRM index cases involving theoretical patients of various ages (51-80 years) and comorbidities.Results: A total of 110 urologists responded (17% response rate) to the survey. Of these, 18% were over 65 years old and 45% were from academic centres. With increasing patient age and comorbidity, active surveillance and thermal ablative therapies were more the recommended treatment. Laparoscopic/robotic surgery was more commonly recommended by academic urologists and those under 65. Recommending surgery (radical nephrectomy or partial nephrectomy) for both elderly (about 80 years old) index patients correlated with surgeon age (surgeons over 65, p < 0.001), surgeons with no oncologic fellowship training (p = 0.021), surgeons with a non-academic practice (p = 0.003), surgeons with a personal history of cancer (p = 0.038) and surgeons with a family history of cancer death in the last 10 years (p = 0.022).Conclusions: There are various factors that influence the management options offered to patients with SRMs. Our results suggest that surgeon age, personal history of cancer, practice-type and other surgeon-specific variables may affect treatments offered among urologists across Canada.

Nephrolithiasis represents a significant burden of illness for Canadians. It has a lifetime risk of 10%–15% and a recurrence risk of up to 50% within 5–10 years and up to 75% at 20 years.1 While most stones pass spontaneously, the direct and indirect costs of managing stones in the United States was estimated to be in excess of US$5.3 billion in 2000.2 Although shock wave lithotripsy and endourologic procedures have revolutionized surgical stone therapy and allow the vast majority of stones to be treated in a minimally invasive fashion, most patients would prefer stone prevention to stone recurrence. The question then becomes that of determining the optimal method for diagnosing the etiology of stone formation in particular patients so that a coherent and evidence-based prevention strategy encompassing dietary recommendations and medical therapy can be implemented. The current gold standard for assessing stone formation risk includes multiple 24-hour urine assessments carried out along with serum electrolyte measurements. Rossi and colleagues3 present data comparing centralized laboratory assessments of calcium oxalate and calcium phosphate supersaturation with 24-hour urine assessments of concentrations. The authors demonstrate that in 150 stone formers 24-hour urine concentration values tend to overestimate the number of patients at risk for supersaturation (i.e., 24-hour urine concentrations have a high false-positive rate or lower specificity). They suggest that measurement of urinary supersaturation might prevent overtreatment of patients at risk for stone recurrence. It is premature, however, to recommend replacing 24-hour urine collection with centralized urinary supersaturation assessments. The patients in the current study were known stone formers and were undergoing treatment at the time of study, and so they may not be representative of de novo stone formers or of patients not on stone-prevention therapy. In addition, although it is theoretically appealing, there are no prospective data available to suggest that patients followed with serial urinary supersaturation (rather than 24-hour urine collections) have lower risk for stone recurrence or more favourable clinical outcomes, nor are there data to suggest that altering urinary supersaturation alters the natural history of stone formation. Further, a formal cost–benefit analysis of centralized urinary supersaturation versus 24-hour urine collection is needed to assess the trade-offs between a more costly test (the former) and a test with potentially more false-positive results (the latter). Finally, it is not surprising that the measured supersaturation of calcium oxalate and calcium phosphate will be lower than supersaturation levels calculated from 24-hour collection data because the latter data do not account for ionic stabilizers and stone inhibitors such as citrate. Perhaps modification to Equil 2 calculations to incorporate citrate concentration might lead to a more accurate estimation of supersaturation from 24-hour urine values. More work is clearly needed before it is recommended that physicians replace the venerable 24-hour urine collection (imperfect and limited though it is) in the medical evaluation of recurrent stone formers.

Karakiewicz and colleagues1 have demonstrated that age at diagnosis appears to be an independent prognostic factor for cancer-specific survival in patients with renal cell carcinoma (RCC), confirming findings reported by other investigators.2–4 Unlike other sites such as the colon and prostate, younger patients presenting with RCC appear to have a better prognosis than older patients. Although one must interpret the results of retrospective studies with caution (e.g., perhaps younger patients received more detailed staging and follow-up imaging, or perhaps they were more likely to receive adjuvant therapy if needed), the data seem compelling. This survival benefit suggests that an age-tailored approach to managing RCC is important. Given the favourable survival data for younger patients, the importance of nephron-sparing surgery increases, even in cases where it may not be imperative. This is particularly true when combined with data suggesting that long-term renal function is superior following nephron-sparing surgery5 and cancer-specific survival is equivalent to open surgery. Although partial nephrectomy remains the gold standard form of nephron-sparing surgery, the role for other renal ablative technologies such as radio-frequency ablation, cryotherapy, high-intensity focused ultrasound and the Gamma Knife remains to be defined — particularly in the treatment of the disease in younger patients. Minimizing patient morbidity while maximizing survival and long-term cure rates is important to all patients, but it is doubly important in younger patients.