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Urinary stone disease affects 2-3% of the general population. Ureteric stones are associated with severe pain and can have a significant impact on a patient's quality of life. Most ureteric stones are expected to pass spontaneously with supportive care; however, between one-fifth and one-third of patients require an active intervention. The two standard interventions are shockwave lithotripsy and ureteroscopic stone treatment. Both treatments are effective, but they differ in terms of invasiveness, anaesthetic requirement, treatment setting, number of procedures, complications, patient-reported outcomes and cost. There is uncertainty around which is the more clinically effective and cost-effective treatment.To determine if shockwave lithotripsy is clinically effective and cost-effective compared with ureteroscopic stone treatment in adults with ureteric stones who are judged to require active intervention.A pragmatic, multicentre, non-inferiority, randomised controlled trial of shockwave lithotripsy as a first-line treatment option compared with primary ureteroscopic stone treatment for ureteric stones.Urology departments in 25 NHS hospitals in the UK.Adults aged ≥ 16 years presenting with a single ureteric stone in any segment of the ureter, confirmed by computerised tomography, who were able to undergo either shockwave lithotripsy or ureteroscopic stone treatment and to complete trial procedures.Eligible participants were randomised 1 : 1 to shockwave lithotripsy (up to two sessions) or ureteroscopic stone treatment.The primary clinical outcome measure was resolution of the stone episode (stone clearance), which was operationally defined as 'no further intervention required to facilitate stone clearance' up to 6 months from randomisation. This was determined from 8-week and 6-month case report forms and any additional hospital visit case report form that was completed by research staff. The primary economic outcome measure was the incremental cost per quality-adjusted life-year gained at 6 months from randomisation. We estimated costs from NHS resources and calculated quality-adjusted life-years from participant completion of the EuroQol-5 Dimensions, three-level version, at baseline, pre intervention, 1 week post intervention and 8 weeks and 6 months post randomisation.In the shockwave lithotripsy arm, 67 out of 302 (22.2%) participants needed further treatment. In the ureteroscopic stone treatment arm, 31 out of 302 (10.3%) participants needed further treatment. The absolute risk difference was 11.4% (95% confidence interval 5.0% to 17.8%); the upper bound of the 95% confidence interval ruled out the prespecified margin of non-inferiority (which was 20%). The mean quality-adjusted life-year difference (shockwave lithotripsy vs. ureteroscopic stone treatment) was -0.021 (95% confidence interval 0.033 to -0.010) and the mean cost difference was -£809 (95% confidence interval -£1061 to -£551). The probability that shockwave lithotripsy is cost-effective is 79% at a threshold of society's willingness to pay for a quality-adjusted life-year of £30,000. The CEAC is derived from the joint distribution of incremental costs and incremental effects. Most of the results fall in the south-west quadrant of the cost effectiveness plane as SWL always costs less but is less effective.A limitation of the trial was low return and completion rates of patient questionnaires. The study was initially powered for 500 patients in each arm; however, the total number of patients recruited was only 307 and 306 patients in the ureteroscopic stone treatment and shockwave lithotripsy arms, respectively.Patients receiving shockwave lithotripsy needed more further interventions than those receiving primary ureteroscopic retrieval, although the overall costs for those receiving the shockwave treatment were lower. The absolute risk difference between the two clinical pathways (11.4%) was lower than expected and at a level that is acceptable to clinicians and patients. The shockwave lithotripsy pathway is more cost-effective in an NHS setting, but results in lower quality of life.(1) The generic health-related quality-of-life tools used in this study do not fully capture the impact of the various treatment pathways on patients. A condition-specific health-related quality-of-life tool should be developed. (2) Reporting of ureteric stone trials would benefit from agreement on a core outcome set that would ensure that future trials are easier to compare.This trial is registered as ISRCTN92289221.This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full inApproximately 1 in 20 people suffers from kidney stones that pass down the urine drainage tube (ureter) into the urinary bladder and cause episodes of severe pain (ureteric colic). People with ureteric colic attend hospital for pain relief and diagnosis. Although most stones smaller than 10 mm eventually reach the bladder and are passed during urination, some get stuck and have to be removed using telescopic surgery (called ureteroscopic stone treatment) or shockwave therapy (called shockwave lithotripsy). Ureteroscopic stone treatment involves passing a telescope-containing instrument through the bladder and into the ureter to fragment and/or remove the stone. This is usually carried out under general anaesthetic as a day case. For shockwave lithotripsy, the patient lies flat on a couch and the apparatus underneath them generates shockwaves that pass through the skin to the ureter and break the stones into smaller fragments, which can be passed naturally in the urine. This involves using X-ray or ultrasound to locate the stone, but can be carried out on an outpatient basis and without general anaesthetic. Telescopic surgery is known to be more successful at removing stones after just one treatment, but it requires more time in hospital and has a higher risk of complications than shockwave lithotripsy (however, shockwave lithotripsy may require more than one session of treatment). Our study, the Therapeutic Interventions for Stones of the Ureter trial, was designed to establish if treatment for ureteric colic should start with telescopic surgery or shockwave therapy. Over 600 NHS patients took part and they were split into two groups. Each patient had an equal chance of their treatment starting with either telescopic surgery or shockwave lithotripsy, which was decided by a computer program (via random allocation). We counted how many patients in each group had further procedures to remove their stone. We found that telescopic surgery was 11% more effective overall, with an associated slightly better quality of life (10 more healthy days over the 6-month period), but was more expensive in an NHS setting. The finding of a lack of any significant additional clinical benefit leads to the conclusion that the more cost-effective treatment pathway is shockwave lithotripsy with telescopic surgery used only in those patients in whom shockwave lithotripsy is unsuccessful.

Background To investigate the efficacy and safety of a second-generation bipolar transurethral electro vaporization of the prostate (B-TUVP) with the new oval-shaped electrode for large benign prostatic enlargement (BPE) with prostate volume (PV) ≥100ml. Materials and methods 100 patients who underwent second-generation B-TUVP with the oval-shaped electrode for male lower urinary tract symptom (LUTS) or urinary retention between July 2018 and July 2020 were enrolled in this study. The patients’ characteristics and treatment outcome were retrospectively compared between patients with PV Results 17/41 (41.5%) cases of PV ≥100ml and 24/59 cases (40.7%) of PV max) significantly increased after surgery only in PV Conclusions This is the first study investigating short-term efficacy and safety of second-generation B-TUVP with the oval-shaped electrode on large BPE. B-TUVP appears to be effective and safe for treating moderate-to-severe lower urinary tract symptoms and urinary retention in patients with large BPE.

Objectives: To estimate and quantify the loss of kidney function in solitary kidneys with small renal masses (SRMs) after laparoscopy-assisted renal cryoablation (LARC), from the European Registry for Renal Cryoablation (EuRECA) database. Patients and Methods: Of the 808 patients from eight European centers in the database, 102 patients had SRMs in solitary kidneys. Patient demographics, body mass index (BMI), American Society of Anesthesiologists (ASA) grade, Charlson comorbidity index, and tumor characteristics including nephrometry (PADUA) score where available were collected. Renal function data in the form of estimated glomerular filtration rate (eGFR) and chronic kidney disease (CKD) stratification both preoperatively and at 3 months postoperatively were collected. Results: The median (interquartile range [IQR]) age was 67 (59-81) years, the median (IQR) BMI was 26 (23.9-28.9) kg/m2, and the median (IQR) ASA score was 2 (2-3). The median Charlson score was 4 (range: 0-10). The median (IQR) tumor size in cross-sectional imaging was 26 (19-38) mm. The follow-up data were available for 72 patients with a median follow-up for this group of 38 (range: 10-132) months. The mean preoperative eGFR was 55.0 mL/minute/1.73 m2 (standard deviation [SD] = 18.1), and the mean postoperative eGFR was 51.8 mL/minute/1.73 m2 (SD = 18.8). The change was -3.1 mL/minute/1.73 m2 (95% confidence interval -5.2 to -1.0) units, which was statistically significant (p = 0.004). The change in the CKD stages comparing before and after LARC was not significant (paired two-tailed t-test, p = 0.06). Critically, the decrease in the eGFR did not translate to any significant adverse outcome and zero patients required dialysis. Conclusion: To the best of our knowledge, this is the largest study of renal function after LARC in SRMs in solitary kidneys. Cryotherapy in this imperative situation is safe, carries clinically insignificant reduction in renal function, therefore providing an option to minimize the risk of developing renal failure necessitating dialysis.

Renal cryoablation is becoming an established treatment option for small renal masses. It allows preservation of renal function without compromising cancer control. The technique has evolved considerably since it was first reported using liquid nitrogen over 20 years ago. We describe the modern technique for both laparoscopic and image guided renal cryoablation. Renal cryoablation is performed either laparoscopically or percutaneously depending on tumour characteristics. Common features include biopsy of the mass, protection of adjacent organs, and the use of compressed argon gas for freezing and helium for thawing. Dynamic monitoring is used to ensure adequate treatment. The shape of the iceball can be modified by adding extra needles or changing their positions. A double freeze/thaw is necessary for confident ablation of all cancer cells. The laparoscopic approach includes exposure of the tumour and may involve extensive mobilisation of the kidney. Laparoscopic ultrasound is essential for correct localisation of the tumour, needle placement, and monitoring the treatment. A Temperature probe is placed at the edge of the tumour to record treatment temperature. The percutaneous approach is typically performed with CT guidance. Adjacent organs can be protected by injecting saline or carbon dioxide. Early imaging is helpful to detect or rule out incomplete treatment. Post-operative follow-up is structured at specific intervals (e.g. 3, 6, 12 months then annually) and perhaps tailored or modified based on the degree of suspicion of inadequate treatment.

BACKGROUND: Cryoablation has emerged as an alternative to the more invasive partial nephrectomy for small renal masses. The approach can be carried out by two techniques, either laparoscopic cryoablation (LCA) or percutaneous cryoablation, (PCA) with CT guidance. We aimed to compare between the two procedures.MATERIALS AND METHODS: A systematic review and meta-analysis was conducted, including studies comparing the two techniques. Outcomes included incomplete ablation, late local recurrence, cancer-specific survival, procedure time, transfusion rates, hospital stay, and complications.RESULTS: A total of 1475 patients were included, 788 patients in the laparoscopic group and 687 patients in the percutaneous group. There was statistical difference favoring the laparoscopic group with regard to having less incomplete ablation (p = 0.0008) and higher cancer-specific survival patients (p = 0.04). However, there was longer hospital stays in the LCA group (p CONCLUSION: LCA was found to have less incomplete tumor ablation rates and higher cancer-specific survival rates, however, higher hospitalization time, more major complications (Clavien III), and was costlier compared with PCA.

Background:\ud Urothelial carcinomas of the upper urinary tract (UTUCs) are rare, with poorer stage-for-stage prognosis than urothelial carcinomas of the urinary bladder. No international consensus exists on the benefit of adjuvant chemotherapy for patients with UTUCs after nephroureterectomy with curative intent. The POUT (Peri-Operative chemotherapy versus sUrveillance in upper Tract urothelial cancer) trial aimed to assess the efficacy of systemic platinum-based chemotherapy in patients with UTUCs.\ud \ud Methods:\ud We did a phase 3, open-label, randomised controlled trial at 71 hospitals in the UK. We recruited patients with UTUC after nephroureterectomy staged as either pT2–T4 pN0–N3 M0 or pTany N1–3 M0. We randomly allocated participants centrally (1:1) to either surveillance or four 21-day cycles of chemotherapy, using a minimisation algorithm with a random element. Chemotherapy was either cisplatin (70 mg/m2) or carboplatin (area under the curve [AUC]4·5/AUC5, for glomerular filtration rate

To properly use the Ureteric Symptom Score Questionnaire (USSQ) to evaluate, in a randomized control study, the effect of tamsulosin, solifenacin, and their combination in improving symptoms and quality of life in patients with indwelling ureteral stents.After institutional review board approval, 260 patients with a ureteral stent were randomly assigned to receive tamsulosin 0.4 mg, solifenacin 5 mg, or placebo and further randomized to receive their combination. The validated USSQ was completed 1 and 4 weeks after stent insertion and 4 weeks after stent removal. Kruskal-Wallis test, chi-squared test (or Fisher's exact test), one-way analysis of variance, and T-test (or Wilcoxon rank-sum test if not normal data) were used for statistical analysis. The results were considered significant at p 0.05.Patients receiving tamsulosin or solifenacin expressed significantly lower urinary (p 0.001), pain (p 0.001 with stent in situ), and general health index (p = 0.002 in first and p 0.001 in fourth week with stent in situ) scores. Sexual life and quality of work were also positively influenced. Patients on combination therapy expressed lower urinary (p 0.001) and pain (p 0.001) scores in the fourth week with stent in situ and work performance in the first week and with stent in situ (p = 0.001) and after stent removal (p = 0.005). No patients had to discontinue medication due to side effects.Stent-related morbidity is a reality in the majority of patients. Simple medication, such as tamsulosin and solifenacin alone or in combination, improves stent-related symptoms and has a positive impact on quality of life.

Introduction The aim of this study was to determine the patient and disease factors predictive of adverse perioperative outcomes after nephrectomy using the British Association of Urological Surgeons (BAUS) audit database. Methods All nephrectomies entered on the BAUS database for the year 2012 were included and ten patient or disease factors were selected for analysis. Logistic regression was used to calculate the area under the receiver operating characteristic curve (AUC) (0.5 = no better than chance, 1.0 = perfect prediction) for each variable and 500 bootstrap samples were used to determine variable selection. Results Data were captured for 6,031 nephrectomies in 2012. World Health Organization performance status (WHO-PS) (AUC: 0.733) and anaemia (AUC: 0.696) were the most significant predictors of 30-day mortality in univariate analysis. WHO-PS (AUC: 0.626) and anaemia (AUC: 0.590) also predicted complications classified as Clavien–Dindo grades III–V. Anaemia (AUC: 0.722) and clinical T stage (AUC: 0.713) predicted need for transfusion. Conclusions Adverse perioperative outcomes after nephrectomy are predicted by clinical presentation with haematuria, poor WHO-PS and higher TNM (tumour, lymph nodes, metastasis) stage. This study used surgeon collected data as opposed to an administrative database, which may have advantages in terms of accuracy and breadth of data fields. These data form a basis for preoperative patient counselling and informed consent for nephrectomy. They can also be used as a standard against which surgeons and hospitals can compare their own results.

OBJECTIVE: To investigate the safety profile of percutaneous cryoablation of renal tumours MATERIALS AND METHODS: A retrospective review of all immediate and delayed complications from a multicentre database was performed and was categorised according to the Clavien-Dindo classification. Statistical analysis was performed for both overall complications (all Clavien-Dindo) and major complications (Clavien-Dindo 3 to 5). The following criteria were identified as potential predictive factors for complications: centre number, modality of image guidance, tumour size (≤ 4 cm vs. > 4 cm), number of tumours treated in the same session (1 vs. > 1) and tumour histology.RESULTS: A total of 713 renal tumours underwent ablation in 647 individual sessions. In 596 of the cases, one tumour was treated; in the remaining 51 cases, several tumours were treated per session. Mean lesion size was 2.8 cm. Fifty-four complications (Clavien-Dindo 1 to 5) occurred as a result of the 647 procedures, corresponding to an overall complication rate of 8.3%. The most frequent complication was bleeding (3.2%), with 9 cases (1.4%) requiring subsequent treatment. The rate of major complication was 3.4%. The only statistically significant prognostic factor for a major complication was a tumour size > 4 cm.CONCLUSION: Percutaneous renal cryoablation is associated with a low rate of complications. Tumours measuring more than 4 cm are associated with a higher risk of major complications.KEY POINTS: • Percutaneous kidney cryoablation has a low rate of complications. • Bleeding is the most frequent complication. • A tumour size superior to 4 cm is a predictive factor of major complication.

To analyse and compare data from the British Association of Urological Surgeons Nephrectomy Audit for perioperative outcomes of partial (PN) and radical nephrectomy (RN) for T1 renal tumours.UK consultants were invited to submit data on all patients undergoing nephrectomy between 1 January and 31 December 2012 to a nationally established database using a standard pro forma. Analysis was made on patient demographics, operative technique, and perioperative data/outcome between PN and RN for T1 tumours.Overall, data from 6 042 nephrectomies were reported of which 1 768 were performed for T1 renal tumours. Of these, 1 082 (61.2%) were RNs and 686 (38.8%) were PNs. The mean age of patients undergoing PN was lower (PN 59 years vs RN 64 years; P0.001) and so was the WHO performance score (PN 0.4 vs RN 0.7; P0.001). PN for the treatment of T1a tumours (≤4 cm) accounted for 55.6% of procedures, of which 43.9% were performed using a minimally invasive technique. For T1b tumours (4-7 cm), 18.9% of patients underwent PN, in 33.3% of which a minimally invasive technique was adopted. The vast majority of RNs for T1 tumours were performed using a minimally invasive technique (90.3%). Of the laparoscopic PNs, 30.5% were robot-assisted. There was no significant difference in overall intraoperative complications between the RN and PN groups (4% vs 4.3%; P = 0.79). However, PN accounted for a higher overall postoperative complications rate (RN 11.3% vs PN 17.6%; P0.001). RN was associated with a markedly reduced risk of severe surgical complications (Clavien Dindo classification grade ≥3) compared with PN even after adjusting for technique (odds ratio 0.30; P = 0.002). Operation time between RN and PN was comparable (141 vs 145 min; P = 0.25). Blood loss was less in the RN group (mean for RN 165 vs PN 323 mL; P0.001); however, transfusion rates were similar (3.2% vs 2.6%; P = 0.47). RN was associated with a shorter length of stay (median 4 vs 5 days; P0.001). A direct comparison between robot-assisted and laparoscopic PN showed no significant differences in operation time, blood loss, warm ischaemia time, and intraoperative and postoperative complications.PN was the method of choice for treatment of T1a tumours whereas RN was preferred for T1b tumours. Minimally invasive techniques have been widely adopted for RN but not for PN. Despite the advances in surgical technique, a substantial risk of postoperative complications remains with PN.

To properly use the Ureteric Symptom Score Questionnaire (USSQ) to evaluate, in a randomized control study, the effect of 2 different α-blockers in improving symptoms and quality of life in patients with indwelling ureteral stents.After institutional review board approval, 150 consecutive patients with a double-J ureteral stent inserted after extracorporeal shockwave lithotripsy (ESWL) or ureteroscopic stone treatment were randomly assigned to receive tamsulosin 0.4 mg, alfuzosin 10 mg, or placebo. The validated USSQ was completed 1 and 4 weeks after stent insertion and 4 weeks after stent removal. The Kruskal-Wallis test for independent samples for non-normally distributed ordinal variables, chi-square to compare proportions or differences, and 1-way analysis of variance (ANOVA) for independent samples to compare for differences in case of continuous variables were used for statistical analysis of the results.Patients receiving α-blockers expressed an overall statistically significant lower urinary (P .001), pain (P .001 with stent in situ), and general health index (P .002) scores. Sexual life and quality of life were also positively influenced. Quality of work was not influenced. No patients had to discontinue medication because of side effects or underwent stent removal before the due date. There was no difference in various outcomes between the 2 α-blockers.Stent-related morbidity is a reality in the majority of patients. Simple medication, such as α-blockers, reduce stent-related symptoms and the negative impact on quality of life. It seems that stent-related symptom improvement is independent to the type of α-blocker.

This study aims to evaluate the outcome of ureteroscopy/ureterorenoscopy (URS) as a salvage procedure for stones resistant to extracorporeal shock wave lithotripsy (ESWL). Between January 2009 and January 2012, 313 patients with upper tract lithiasis were treated by URS. Among them, 87 (27.8 %) had undergone URS after prior ESWL failed to achieve stone clearance (Salvage group). These patients were matched with a group of patients who underwent URS as first-line modality (Primary group). Stone-free rates and adjuvant procedures represented the primary points for comparison. Secondary points for comparison included complications, procedure duration, total laser energy used and length of hospitalization. Matching was possible in all cases. Stone clearance rates were 73.6 and 82.8 % for the Salvage and Primary group, respectively. The difference in stone clearance rates between the two groups was not statistically significant (p = 0.186). A total of 11 patients (12.6 %) in the Primary group and 18 patients (20.7 %) in the Salvage group underwent an adjuvant procedure (p = 0.154). No statistically significant differences were noted in terms of complications, procedure duration and length of hospitalization. In the Primary group, the laser energy used for stone fragmentation was higher (p = 0.043). The rate of ureteric stenting at the end of the procedure was higher for the Salvage group (p = 0.030). Previous failed ESWL is not a predictor for unfavorable outcome of URS. Salvage URS is associated, however, with an increased need for ureteric stenting at the end of the procedure.

OBJECTIVE: To assess complication rates and intermediate oncological outcomes of laparoscopic-assisted cryoablation (LCA) in patients with small renal masses (SRMs).PATIENTS AND METHODS: A retrospective review of 808 patients treated with LCA for T1a SRMs from 2005 to 2015 at eight European institutions. Complications were analysed according to the Clavien-Dindo classification. Kaplan-Meier analyses were used to estimate 5- and 10-year disease-free survival (DFS) and overall survival (OS).RESULTS: The median [interquartile (IQR)] age was 67 (58-74) years. The median (IQR) tumour size was 25 (19-30) mm. The transperitoneal approach was used in 77.7% of the patients. The median postoperative hospital stay was 2 days. In all, 514 patients with a biopsy-confirmed renal cell carcinoma (RCC) were available for survival analyses. The median (IQR) follow-up for the RCC-cohort was 36 (14-56) months. A total of 32 patients (6.2%) were diagnosed with treatment failure. The 5-/10-year DFS was 90.4%/80.0% and 5-/10-year OS was 83.2%/64.4%, respectively. A total of 134 postoperative complications (16.6%) were reported, with severe complications (grade ≥III) in 26 patients (3.2%). An American Society of Anesthesiologists score of 3 was associated with an increased risk of overall complications (odds ratio 2.85, 95% confidence interval 1.32-6.20; P = 0.005).CONCLUSIONS: This large series of LCA demonstrates satisfactory long-term oncological outcomes for SRMs. However, although LCA is considered a minimally invasive procedure, risk of complications should be considered when counselling patients.

BACKGROUND: Low morbidity has been advocated for cryoablation of small renal masses. OBJECTIVES: To assess negative perioperative outcomes of laparoscopic renal cryoablation (LRC) with ultrathin cryoprobes and patient, tumour, and operative risk factors for their development. DESIGN, SETTING, AND PARTICIPANTS: Prospective collection of data on LRC in five centres. INTERVENTION: LRC. MEASUREMENTS: Preoperative morbidity was assessed clinically and the American Society of Anaesthesiologists (ASA) score was assigned prospectively. Charlson Comorbidity Index (CCI) and Charlson-Age Comorbidity Index (CACI) scores were retrospectively assigned. Negative outcomes were prospectively recorded and defined as any undesired event during the perioperative period, including complications, with the latter classed according to the Clavien system. Patient, tumour, and operative variables were tested in univariate analysis as risk factors for occurrence of negative outcomes. Significant variables (p or = 3. Multivariate analysis showed that tumour size in centimetres, the presence of cardiac conditions, and female gender were independent predictors of negative perioperative outcomes occurrence. Receiver operator characteristic curve confirmed the tumour size cut-off of 3.4 cm as an adequate predictor of negative outcomes. CONCLUSIONS: Perioperative negative outcomes and complications occur in 17% and 15.5%, respectively, of cases treated by LRC with multiple ultrathin needles. Most of the complications are Clavien grade 1 or 2. The presence of cardiac conditions, female gender, and tumour size are independent prognostic factors for the occurrence of a perioperative negative outcome

We validated the Italian version of the Ureteral Stent Symptoms Questionnaire in male and female patients with an indwelling ureteral stent.A double-back translation of the original Ureteral Stent Symptoms Questionnaire was performed by 3 urologists and 4 professional translators. A total of 78 patients (cases) with and 35 healthy subjects without (controls) an indwelling ureteral stent were asked to complete the Italian version of the Ureteral Stent Symptoms Questionnaire and a visual analog scale for pain as well as the International Prostate Symptom Score (men) and Urogenital Distress Inventory-6 plus Incontinence Impact Questionnaire-7 (women). Cases were evaluated at weeks 1 and 4 after stent placement, and at week 4 after removal, while controls were evaluated once. The psychometric properties of the questionnaire were analyzed.A total of 66 cases and 30 controls were suitable for analysis. The questionnaire showed good internal consistency in all domains except global quality of life compared with that of the International Prostate Symptom Score (Cronbach's alpha0.75). Test-retest reliability was good except for the sexual matters domain (Pearson's coefficient0.7). Relatively high correlation coefficients (greater than 0.65) were found for the visual analog scale for pain, the International Prostate Symptom Score, the Urogenital Distress Inventory-6 and the Incontinence Impact Questionnaire-7 with the corresponding Ureteral Stent Symptoms Questionnaire domains, suggesting good convergent validity. Sensitivity to change and discriminant validity were also good (p0.001).The Italian version of the Ureteral Stent Symptoms Questionnaire is a reliable and robust instrument that can be self-administered to male and female Italian patients with an indwelling ureteral stent in the clinical and research settings.

In this study we prospectively compared 2 rates of shock wave delivery, 60 and 120 shock waves per minute, to determine whether rate affects outcome with the Dornier Lithotripter S, a lithotriptor with an electromagnetic shock wave source, for renal calculi.A total of 104 patients with uncomplicated single renal calculus were randomized and treated. Following a single treatment patients were reviewed at 3 months to determine outcome. A plain abdominal x-ray was performed and the size of any residual fragments was noted. Four patients were lost to followup, 1 in the 60 shock waves per minute group and 3 in the 120 shock waves per minute group.Of the 100 patients with complete followup 49 were treated at 60 shock waves per minute and 51 at 120 shock waves per minute. There was no statistically significant difference between mean stone area treated (p = 0.32) or additional analgesic use in the form of patient controlled alfentanil (p = 0.82). A successful outcome was defined by fragments smaller than 4 mm or stone-free status. At 60 shock waves per minute 59% of patients had a successful outcome compared with 61% at 120 shock waves per minute (p = 0.87) following a single treatment. Post-treatment complications were similar in both groups at 8% for 120 shock waves per minute and 10% for 60 shock waves per minute (p = 0.68).There was no significant difference in patient controlled analgesia use, complications or outcome between rates 60 and 120. Contrary to previous studies these results suggest that a slower rate of shock wave delivery during extracorporeal shock wave lithotripsy for renal calculi does not improve treatment efficacy with the Dornier Lithotripter S.

Endoluminal ultrasound probes have been disposable, making their regular use costly. We describe the technique and preliminary results of a reusable endoluminal ultrasound probe for examining ureteral anatomy.The 2.4-mm (7.2F) or 3-mm (9F) probe (Olympus, Tokyo) is passed up the ureter after a retrograde ureteropyelogram has been obtained. No intraoperative preparation of the probe is needed. An axial image as little as 1 cm or as much as 10 cm around the ureter can be obtained. Over the last 20 months, 50 procedures using endoluminal ultrasonography were performed in our unit: 36 (72%) for uretero-pelvic junction (UPJ) obstruction, 10 (20%) for upper-tract filling defects, and the remaining 4 (8%) for ureteral strictures.Endoluminal ultrasonography detected crossing vessels at the UPJ in 19 (53%) and a septum in 9 (25%) of the 36 renal units with UPJ obstruction. In eight of the 36 renal units with UPJ obstruction (22%), endopyelotomy was not done because of the presence of crossing vessels. A further 4 renal units (11%) had the direction of the incision modified because of the ultrasound findings. In the cases with upper-tract transitional-cell carcinoma, images correlated well with the nephroureterectomy specimen. The probe had to be replaced twice.This endoluminal ultrasound system produces clear images of the ureteral and periureteral anatomy. The reusable aspect of the probe removes an important obstacle to its common use for evaluating a variety of upper urinary tract abnormalities.

To present the perioperative outcomes from the British Association of Urological Surgeons (BAUS) nephrectomy dataset for 2012, the first year of public reporting of individual surgeon outcomes in the UK.All nephrectomies performed in the year 2012 and recorded in the database were analysed. These were divided into simple nephrectomy (SN), partial nephrectomy (PN), radical nephrectomy (RN), and nephroureterectomy (NU). The estimated capture rate for nephrectomy was 80%. The outcomes measured were 30-day mortality (30-DM), Clavien-Dindo complications grade ≥III, blood transfusion, conversion to open, and length of stay.The overall 30-DM was 0.55% (SN 0.53%; PN 0.10%; RN 0.52%; NU 1.27%). Clavien-Dindo complications grade ≥III were recorded in 3.9% of nephrectomies (SN 4.3%; PN 5.4%; RN 3.1%; NU 4.5%). Blood transfusion was required during surgical admission for 8.4% of nephrectomies (SN 5.2%; PN 3.4%; RN 11.1%; NU 8.3%). Conversion to open was carried out in 5.5% of minimally invasive nephrectomies (SN 6.1%; PN 4.0%; RN 5.5%; NU 5.6%). Open nephrectomy patients remained in hospital for a median of 6 days (SN 7; PN 5; RN 7; NU 8 days), which was higher than the median 4-day stay (SN 3; PN 4; RN 4; NU 5 days) for minimally invasive surgery.Nephrectomy in 2012 was a safe procedure with morbidity and mortality rates comparable with or less than published series. The collection of surgeon-specific data should be iterative with further refinement of data categories, support for the collection process and independent validation of results.

OBJECTIVE To assess the conservative management of pelvi-ureteric junction obstruction (PUJO), according to severity, accepted in paediatric urology but rarely reported in adults. PATIENTS AND METHODS A series of 23 patients (median age 58 years, 17 men and six women) with asymptomatic or minimally symptomatic PUJO were managed conservatively. The patients' age, preference and comorbidities were considered. The diagnosis of PUJO was based on intravenous urography and isotopic renography. After stringently reviewing the renograms based on relative renal function (RRF) and output efficiency (OE), 15 patients had an OE consistent with definitive PUJO. One patient had no further imaging due to associated comorbidities. Ten patients had right PUJO, three left and one with bilateral PUJO, with unilateral conservative management. The follow-up included annual renography and clinical consultation. Laparoscopic pyeloplasty was considered for patients with a >10% loss of RRF and/or

Crossing vessels at the ureteropelvic junction are associated with bleeding complications and a higher risk of failure after endopyelotomy. We compared computerized tomography (CT) angiography and endoluminal ultrasound for detecting crossing vessels before planned endopyelotomy.Preoperatively patients underwent CT angiography. Intraoperative evaluation included retrograde ureteropyelography, endoluminal ultrasound and ureteroscopy. Intraoperative findings were used to direct treatment.Endoluminal ultrasound detected 19 crossing vessels in 14 of 20 patients (70%), while CT detected 9 crossing vessels in 7 (35%). Endoluminal ultrasound identified a septum between the ureter and renal pelvis in 7 patients (35%) but CT demonstrated none. On the basis of imaging findings we selected 5 patients for pyeloplasty, and endoluminal ultrasound accurately predicted the absence or presence of crossing vessels in all 5. CT angiography was accurate in 3 patients. However, in 2 patients a total of 4 vessels were missed by CT. A total of 15 patients underwent endopyelotomy with no bleeding complications. The presence or absence of a septum on endoluminal ultrasound was confirmed in all patients. Imaging findings altered the treatment chosen in 4 patients and changed the direction of the incision at the ureteropelvic junction in another 4. Clinical and radiographic success was achieved in all 13 patients (100%) with adequate followup.Endoluminal ultrasound was more sensitive than CT angiography for identifying crossing vessels and septa. Treatment based on endoluminal ultrasound findings may decrease complications and improve the results of minimally invasive treatment for ureteropelvic junction obstruction.

A significant impediment to the measurement of the pressures and forces created by lithotripter shockwaves has been their destructive properties, which have rendered most measuring devices impractical. We have developed and tested a robust electromagnetic probe to measure cavitational forces in vitro in the focal zones of extracorporeal lithotripters. The probe responds to the pressure gradient generated by the radial motion of cavitation bubbles.The effects of shockwaves from the Dornier MPL 9000 electrohydraulic lithotripter were measured over the lifetime of multiple electrodes.The pulse energy from the electrodes dropped off rapidly after approximately 50% of the lifetime quoted by the manufacturer. The electrodes were more efficient at higher power settings. As a result, we altered our protocol for the treatment of ureteral stones to use a higher kilovoltage and a second electrode whenever necessary. Stone-free rates after shockwave lithotripsy (SWL) in situ for stones11 mm have increased from 68.2% to 83.3%, and the retreatment rate has dropped from 23% to 15%. Despite significantly higher power settings (23.7 kV v 18.7 kV; P0.0001), the need for sedoanalgesia has remained relatively constant (26% v 31%).Measurement of cavitational forces from lithotripters using a robust electromagnetic probe is useful in planning treatment strategy. We have demonstrated a clinically measurable improvement since implementing our new treatment protocol. Because the probe responds directly to cavitational forces, it should also prove useful for the objective comparison of different SWL machines.

To assess the effect of anatomic factors, especially the angle of the lower-pole infundibulum, on stone clearance following shock wave lithotripsy (SWL) in order to determine selection criteria for percutaneous nephrolithotomy.We retrospectively analyzed 116 patients with single lower-pole stones measuring 11-20 mm treated with SWL. Intravenous urograms were reviewed to measure the infundibulopelvic angle, the angle of the infundibulum to the vertical, and the anatomy of lower-pole calyces.The overall stone-free rate was 52%. Factors most closely associated with a stone-free status were obtuse infundibulopelvic angle, lack of calyceal distortion, and a large infundibular diameter. The infundibulopelvic angle was the only factor to attain significance in predicting stone-free status (p = 0.012). The size of the stone did not predict eventual stone-free status (p = 0.911), but larger stones were more likely to require intervention after SWL.For solitary lower-pole stones 11-20 mm in size, the angle of the lower-pole infundibulum as it relates to the pelvis plays a role in eventual stone clearance and should be taken into account before choosing a mode of treatment.

Background and Purpose: Ureteral Stent Symptoms Questionnaire (USSQ) is an intervention-specific health-related quality-of-life (HrQoL) measure. We describe development and validation of the Spanish version. Materials and Methods: We followed established methods to develop the Spanish version of the original USSQ. After pilot testing, we conducted a formal validation study; 70 patients, undergoing placement of ureteral stents, successfully completed the Spanish USSQ as well as the EuroQoL-5D (male and female), the ICIQ male and female lower urinary tract symptoms questionnaires at weeks 1 and 4 after stent insertions, and at week 4 after their removal. In addition, 40 healthy people acted as a control group and completed the same questionnaires twice at 3-week intervals. Statistical analyses were performed to evaluate reliability, validity, and sensitivity to change of the Spanish USSQ. Results: After revision of the initial two drafts after translation, back translation, and pilot testing, a final draft was developed that underwent field testing. Psychometric analyses revealed satisfactory internal consistencies (Cronbach alpha coefficients: 0.73-0. 85) and test-retest reliability (Spearman correlation coefficient: >0.6) for the domains of urinary symptom, body pain, and general health. It demonstrated satisfactory discriminant validity (sensitivity to change, p

To review our experience in the management of secondary pelvi-ureteric junction obstruction (PUJO) comparing endopyelotomy with pyeloplasty.We retrospectively analysed our database of 58 patients having undergone operative management of PUJO after failed primary management, including 41 with failed pyeloplasty and 17 failed endopyelotomy. Outcomes included mercapto-acetyltriglycine (MAG3) drainage capacity, symptomatic control and need for further intervention. Success was defined as freedom from failure in all three.Patients undergoing secondary pyeloplasty had better outcomes than endopyelotomy for symptomatic success (87.5% vs 74%), resolution of obstruction on MAG3 renography (96% vs 74%), and no need for further intervention (96% vs 71%). Overall success was 87.5% for pyeloplasty compared with 44% after secondary endopyelotomy.Outcomes of pyelopasty for secondary PUJO were superior when compared with endopyelotomy.

Endopyelotomy has become an accepted mode of treatment for primary and secondary ureteropelvic junction (UPJ) obstruction, but a 15% to 30% failure rate persists. The presence of crossing vessels at the UPJ has been implicated as a common cause of complications, failures, and recurrences. In the past, renal angiography was necessary to identify crossing vessels. We have utilized endoluminal ultrasonography to identify crossing vessels at the UPJ and to guide endoscopic incisional techniques. Previously, whenever crossing vessels were identified that could not be safely avoided during endopyelotomy, we had recommended dismembered pyeloplasty, an open surgical procedure with a long recovery time. We report our experience with laparoscopic division of crossing vessels in two patients, one with a symptomatic horseshoe kidney. Each patient had a large crossing vessel identified by endoluminal ultrasonography; consequently, endopyelotomy was abandoned. The location and distribution of the vessels were then delineated by angiography. The aberrant vessels were dissected free and divided laparoscopically. The patients returned to work within 1 week. Follow-up diuretic renal scans showed complete resolution of obstruction (T1/210 minutes) in one patient; no change was noted in the patient with a horseshoe kidney. Both patients have remained free of symptoms and normotensive for more than 12 months. Laparoscopic division of crossing vessels may play a role in the treatment of patients with extrinsic ureteral obstruction from aberrant vessels.

WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: One of the suggested factors for stent-related symptoms is that excess distal intravesical stent mass may cause bladder irritation. There is a lack of studies investigating this in a randomised controlled fashion using a validated questionnaire. This study compared two of the most commonly used length of stents (a 30 cm multi-length vs a 24 cm long stent) and showed no significance difference in stent-related symptoms in patients with either of these stents.To investigate whether excessive redundant intravesical stent component contributes to the severity of stent-related symptoms in patients with a ureteric stent. We compared stent-related symptoms in patients who had either a standard 24 cm or multi-length ureteric stent.In all, 162 patients with upper urinary tract calculi requiring ureteric stent insertion were randomised to receive either a 6 F × 24 cm Contour(TM) or multi-length 6 F × 22-30 cm Contour VL(TM) stent. Patients were requested to complete the validated Bristol Ureteric Stent Symptom Questionnaire (USSQ) at 1 and 4 weeks after stent insertion and 4 weeks after removal. The mean scores for each domain of the USSQ for both groups were compared using the Student's t-test. Any adverse events, e.g. stent migration, early removal of stent due to stent-related symptoms and failure of stent insertion, were also recorded.In all, 153 patients who had successful stent insertion were requested to complete the USSQ and 74% of patients returned at least the week 1 questionnaire. At 1 and 4 weeks with the stent in situ, comparison of the mean scores showed no significant difference in urinary symptoms, pain, general health, work performance, sexual dysfunction and number of days patients stayed in bed or reduced their routine activities. Three (2%) patients had their stent removed early due to stent-related symptoms and five (3%) had failed stent insertion.This study did not find any difference in symptoms between the 24 cm or multi-length Contour stents. However, the study was not powered to detect small differences particularly for the pain symptom domain. Stents should only be used sparingly and the stent dwell-time should be minimised.

Objective To compare the specificity of the American Urological Association (AUA) Symptom Index for benign prostatic hyperplasia (BPH) versus other urodynamically verified micturitional dysfunction in men. Patients and methods Fifty-seven consecutive men who had been referred for video-urodynamic evaluation of voiding symptoms were evaluated. The patients were divided into three groups: (i) BPH group (n = 24): (ii) non-BPH obstructed group (n = 20; nine bladder neck obstruction, 11 bulbous urethral stricture); and (iii) detrusor hyper-reflexia group: detrusor hyperreflexia without outlet obstruction (n = 13). Results The mean AUA symptom score for the BPH group was 18.9 (range 7–28). The mean score for the 20 non-BPH obstructed group was 17.6 (range 4–28) and the mean score for the 13 men with detrusor hyper-reflexia was 20.5 (range 12–27). There was no statistical difference in the AUA symptom score among the three groups. Conclusion The AUA Symptom Index does not specifically identify BPH or bladder outlet obstruction. The index cannot differentiate the site of obstruction as noted by the similar scores among men with BPH from those with bladder neck obstruction and urethral strictures. Moreover, The AUA Symptom Index scores are similar between men with voiding symptoms secondary to bladder dysfunction and bladder outlet obstruction.

The Clinical Research Office of the Endourological Society (CROES) registry is a global initiative from the Endourological Society. The participating surgeons contributed >10 000 caseswithout any financial incentive or support for data entry, reflecting a tremendous degree of enthusiasm and cooperation among peers. The findings help us to understand what occurs in real-world practice for patients with ureteral stones, a very painful condition. As described by Perez Castro et al., the global nature of the registry is remarkable and reflects the best aspects of the Endourological Society [1]. The participants had neither any financial incentive nor any support for data entry. The CROES office simply provided a Web-based database, and members entered data by the thousands. This enthusiasm to participate reflects the support that the Endourological Society has generated through annual meetings and the training of several generations of stone surgeons throughout the world. This study is perhaps best described as a registry. The participants were simply asked to record what they did at the time of ureteroscopy and did not adhere to a treatment algorithm. The nature of the registry did not allow for any patient-reported outcome measures (PROMs) or economic data and so is limited by measuring only aspects of treatment that surgeons themselves believed were most important. The large number of participating centres and surgeons in numerous countries, combined with the lack of standardisation of treatment, make the data generated challenging to analyse. As such, it is very difficult to draw firm conclusions about the reported findings. I consider this registry useful to generate hypotheses rather than answering them.

INTRODUCTION The aim of this study was to audit our experience of cystodiathermy under local anaesthetic (LA) at the time of flexible cystoscopy for recurrent superficial bladder transitional cell carcinoma (TCC). PATIENTS AND METHODS A total of 264 flexible cystoscopies were performed on patients with a past history of TCC. The number and site of recurrences were recorded and selected patients were offered cystodiathermy. Patient tolerability was noted. At follow-up, any recurrence was recorded. RESULTS Eighty patients (30%) had 91 procedures showing one or more recurrences. Fifty-one of the 80 patients (64%) were treated with cystodiathermy under LA. All completed treatment. Forty-five (88%) tolerated the procedure well. Forty-seven (92%) treatments were completed within 5 min. At a median follow-up of 15 weeks, 30 (59%) treated patients had no recurrence and three (6%) had recurrence at the site of treatment. CONCLUSIONS LA cystodiathermy is an effective and well-tolerated alternative to general anaesthetic cystodiathermy that enables treatment at the time of detection and may, thereby, reduce patient anxiety.

Ureteral stents result in significant morbidity in many patients. Manufacturers have altered stent design and composition to minimize symptoms. The Polaris™ stent is made of a Percuflex® combination, providing a firm proximal aspect with a softer distal aspect to minimize symptoms. In this prospective, randomized study we compared symptoms and quality of life after stent insertion to determine whether this stent is better tolerated than the InLay® stent.Between September 2002 and September 2006 we randomized 159 patients requiring stent insertion for stone disease to receive the InLay or the Polaris ureteral stent. Patients were asked to complete the validated Ureteral Stent Symptom Questionnaire 2 weeks after stent insertion and 1 week after removal.A total of 98 patients completed and returned each questionnaire, including 45 with the InLay and 53 with the Polaris. There were no significant differences between the groups on any health domain assessed. In the InLay and Polaris groups 91% and 94% of patients experienced pain with the stent in situ, which decreased to 40% and 43%, respectively, after stent removal. The urinary symptom score with the stent in situ was equal in the 2 groups (32, maximum 55). Of the InLay and Polaris groups 60% and 66% of patients, respectively, would be against receiving a further stent due to symptoms (p = 0.79).The Polaris stent, designed with the specific aim of improving urinary symptoms and pain associated with ureteral stents, continues to have a significant detrimental effect on patient quality of life.

To present a single centre prospective randomized study on the use of the bladeless Optiview system (Ethicon Endosurgery, Cincinnati, OH) to create the pneumoperitoneum in laparoscopic renal procedures reporting the results with regards safety, efficacy and complications and comparing it with the Hasson open technique.Sixty patients were randomly recruited, 27 to the open and 33 to the bladeless group at the Bristol Urological Institute, UK. Time to insertion, time to closure and any intraoperative and postoperative complication related to trocar insertion was recorded.All procedures were performed for renal pathology. BMI values were similar in both groups. The mean time to insertion of the 12 mm Hasson and Bladeless trocars were 443 and 125 seconds, respectively (p0.0001). The incision in the bladeless group was only closed when the defect exceeded 12 mm (38%) or extended for specimen removal (23%), resulting in a mean time to closure of 203 seconds. In the Hasson group, entry into the abdominal cavity could not be confirmed in two patients (7.4%) due to multiple adhesions. In the Bladeless group, there was one failed placement (3%) requiring conversion to the Hasson technique and two injuries to intraabdominal structures (peritoneal minor bruising, liver injury requiring conversion to open procedure, 6%), There was one incidence of gas leakage (3%). There were no reports of port site herniation at a mean follow up of 9 months.Direct placement of a bladeless trocar under direct vision in a desufflated abdomen can reduce port placement time when compared to the Hasson technique. The benefits are maximised by using the bladeless trocar for procedures not requiring intact specimen removal. However, despite visualisation of tissue layers, this port cannot prevent serious intra abdominal injuries that can occur in a higher percentage of cases in comparison to the Hasson technique.

We determined whether laparoscopic nephrectomy confers improved health related quality of life in the early postoperative period compared with open nephrectomy.Patients undergoing open or laparoscopic nephrectomy were prospectively recruited. Patients completed the Comorbidity Symptom Scale preoperatively as well as the SF-36(R) quality of life health survey and pain visual analog scale preoperatively, and 2 days and 1 month postoperatively.A total of 100 patients were recruited, of whom 71 completed all questionnaires, including 38 in the laparoscopic group and 33 in the open group. In the 2 groups mean patient age was the same (56.8 years) and there was a similar sex distribution. The laparoscopic group had improved quality of life scores with significantly higher physical component scores 1 month postoperatively vs the open group (-5.7% vs -22.2%, p = 0.009). The laparoscopic group also had significantly higher mental component scores 2 days postoperatively vs the open group compared to baseline (6.0% vs -6.6%, p = 0.009). The laparoscopic group had significantly lower pain visual analog scale scores 1 month postoperatively compared to baseline. Patients with higher Comorbidity Symptom Scale scores were more likely to undergo a laparoscopic approach (p = 0.036). Despite this they had a significantly shorter hospital stay (4 vs 6 days, p0.001).Quality of life benefits of laparoscopic over open nephrectomy were found in the early postoperative period despite more comorbidities in the laparoscopic group. This provides further evidence of the benefits of the laparoscopic approach over open surgery.

To determine the accuracy of radiographic studies, ureteroscopy, biopsy, and cytology in predicting the histopathology of upper-tract transitional cell carcinoma (TCC).From 1998 to 2006, 46 upper-tract lesions were diagnosed ureteroscopically and underwent nephroureterectomy, and 30 of them were subjected to direct ureteroscopic inspection and biopsy. Fresh samples were delivered to the cytopathology laboratory and histology samples were prepared whenever visible tissue was present. Radiological, ureteroscopic, cytology, and biopsy data were compared to the actual grades and stages of these 30 surgical specimens.Retrograde ureteropyelography was suggestive of malignancy in 29 of 30 cases, but did not predict the grade or stage accurately. Cytology was positive for malignancy in 21 of 30 cases (70%). Grading of ureteroscopic specimens was possible in all cases. At nephroureterectomy two cases were found to have no tumor (T(0)). Of the remaining 28 cases, the biopsy grade proved to be identical in 21 (75%). Grade 1 or 2 ureteroscopic specimens had a low-stage (T(0), T(a), or T(1)) tumor in 17 of 25 (68%); in contrast, 3 of 5 (60%) high-grade specimens had invasive tumor (T(2) or T(3)). For patients with grade 2 ureteroscopic specimens, combining exfoliated cell cytology and biopsy grade improved the accuracy in predicting high-stage and high-grade disease.This study confirms previous findings that ureteroscopic inspection and biopsy provides accurate information regarding the grade and stage of upper-tract TCC. Combining exfoliated cell cytology improves the predictive power of biopsy grade 2 disease for high-risk specimen grade and stage. Our data suggest that ureteroscopic findings may predict muscle invasion.

OBJECTIVE To report the guidelines of the British Association of Urological Surgeons (BAUS), commissioned by the National Institute for Health and Clinical Excellence (NICE) in response to safety concerns about the rapid uptake of new, complex laparoscopic procedures. METHODS A combination of expert opinion and review of published studies was used to produce a consensus document. RESULTS Patient demand and excellent published reports have prompted many consultant urologists with little previous laparoscopic training to learn laparoscopic procedures. Laparoscopic urological surgery involves some of the most complex procedures in all of surgery and there has been a lack of formal training for consultants. The guidelines produced by BAUS are designed to help consultant urologists gain experience safely, by a combination of didactic learning and mentorship. We recommend that urologists work with a mentor and master ablative laparoscopic surgery before attempting more complex procedures such as prostatectomy, cystectomy, pyeloplasty and partial nephrectomy. These guidelines were approved by BAUS Council in October 2006. CONCLUSIONS These guidelines are intended to be complementary to the NICE guidelines on specific procedures (available at http://www.nice.org.uk).

Drugs are increasingly being used to promote stone passage in renal colic. Diclofenac, nifedipine and tamsulosin cause ureteric smooth muscle relaxation in vitro; however, in clinical trials nifedipine and tamsulosin promote stone passage whereas diclofenac has no apparent benefit. We adapted a ureteric pressure transducer catheter in an attempt to compare the human ureteric response to these drugs in vivo. The catheter was inserted into the contralateral ureter following ureteroscopy for stone disease. Contraction frequency, pressure and velocity measurements were recorded at 24 h. Each patient was randomly allocated to receive oral diclofenac, nifedipine or tamsulosin. Measurements were taken following drug administration. Eighteen patients (mean age 50 years) were recruited. Two patients were excluded intraoperatively and three required early removal of the catheter. Prior to drug administration, the mean number of contractions recorded was 0–4.1/min and the peak contraction pressure ranged from 11 to 35 mmHg. Conduction velocity ranged from 1.5 to 2.6 cm/s. Ureteric peristalsis persisted in all patients despite these drugs. Diclofenac and nifedipine produced inconsistent ureteric pressure responses but had little effect on contraction frequency. Tamsulosin significantly reduced ureteric pressure but had no effect on contraction frequency. There are many limitations associated with the use of ureteric catheters, however, they may provide some useful information when used to record the response to an intervention in the same patient. These preliminary results suggest a reduction in pressure generation may be the essential factor in the promotion of stone passage. More work is required but these drugs may work by preventing the increased, uncoordinated muscular activity seen in renal colic whilst maintaining peristalsis, thereby promoting stone passage.

OBJECTIVE To examine changes in the pathophysiology and frequency of the transurethral resection (TUR) syndrome with two irrigation fluids, as variable amounts of irrigation fluid are absorbed during TUR of the prostate (TURP), and although polar solutes are required to prevent an effect on diathermy, the solutes may have effects when absorbed. PATIENTS AND METHODS Between December 2001 and March 2003, 250 patients were included in a prospective randomized trial comparing glycine 1.5% with 5% glucose irrigation fluids. We measured blood loss, fluid absorption, temperature change, biochemistry including a glycine assay, and peri-operative symptoms. Blood samples were taken immediately before and immediately, 5 and 24 h after TURP. Irrigating fluid absorption during TURP was measured with 1% ethanol as a marker and breath ethanol measurements. Operative details were recorded, including the type of anaesthesia (with or with no sedation), resection time and weight of resected tissue. Peri-operative symptoms were documented prospectively. TUR syndrome was defined as a serum sodium level of ≤ 125 mmol/L with two or more associated symptoms or signs of TUR syndrome. RESULTS Five (2%) patients had TUR syndrome; all five were irrigated with glycine, although this difference was not statistically significant (P = 0.06). Of the five men, three had hypotension, four were tired, one was nauseous, two had parasthesia, two had ‘uneasiness’, one had blurred vision and two were confused; none had chest pain. There was a large variation between the groups in the level of glycine assayed immediately after TURP; a high glycine level was associated with the TUR syndrome (P = 0.01). There was no difference between the groups in levels of sodium, potassium, urea, creatinine, osmolality, calcium, haematocrit, albumin serum levels or peri-operative blood loss (defined as a change from before to after TURP in haemoglobin level, accounting for transfusions). CONCLUSIONS An increase in serum glycine was associated with TUR syndrome; there were large variations in the amounts of glycine absorbed, reaching levels many times the upper limit of normal. In other studies, glycine was reportedly toxic, and that the levels recorded were many times the upper limit of normal may have both immediate and long-term effects.

Objectives To compare complication and success rates of antegrade and retrograde endopyelotomy performed over 10 years and to define possible risk factors associated with treatment failure. Methods From 1994 to 2004, 61 patients underwent a total of 68 endoscopic treatments: 19 antegrade and 49 retrograde endopyelotomy procedures. Antegrade endopyelotomy was always performed using diathermy. In the first 18 procedures retrograde endopyelotomy was performed using diathermy. In the most recent 30 procedures the incision was made using holmium laser. Endoluminal ultrasound was used in 78% of retrograde endopyelotomy and in 5% of antegrade endopyelotomy. Results The retrograde endopyelotomy patients demonstrated significantly lower complication rates (12.5% vs. 42%) and shorter hospital stay (1.5 vs. 7 days) than the antegrade endopyelotomy patients. The mean follow up of the patients who remained free from disease recurrence during the study period was 46 and 24 months for the antegrade and retrograde endopyelotomy group, respectively. The overall success rate (mean time to failure) of antegrade and retrograde endopyelotomy was 56% (31 months) and 70% (17 months), respectively. There was no statistically significant increase in the overall success rate of retrograde endopyelotomy using endoluminal ultrasound per se. Stratifying retrograde endopyelotomy by the type of energy used for the incision, the overall success rate (mean time to failure) was 80% (10 months) and 53% (21 months) for Holmium laser and diathermy, respectively ( p =0.0626). Conclusions The overall success of antegrade and retrograde endopyelotomy in this series appears to be largely a factor of lead-time bias and is similar enough to recommend retrograde endopyelotomy with holmium laser on the basis of its relative safety and shorter hospital stay.

Encrustion of ureteral stents is a well-known phenomenon which can be treated easily if recognized promptly. Severe encrustation, however, which leads to renal impairment, presents a challenge in management.Four patients with encrusted stents were referred to our institution for management. All had impaired function of the affected kidney. Each was managed by either retrograde ureteroscopy or a combination of percutaneous and ureteroscopic procedures.All four of the patients were rendered stone free following an average of 2.5 (range 1-3) procedures. Renal function improved in all patients postoperatively.Encrustation is a potentially serious complication of the use of ureteral stents, as it can lead to renal impairment. Timely endourologic intervention can result in recovery of renal function.

A variety of topical agents have been used for transitional cell carcinoma of the upper tract. Mitomycin C has limited systemic absorption when given intravesically because of its high molecular weight. We reviewed our experience with mitomycin C following endoscopic treatment of upper tract transitional cell carcinoma.Since 1991, 19 patients (21 renal units) have undergone a total of 28 treatments with mitomycin C for high volume, recurrent or multifocal transitional cell carcinoma. Of the 19 patients 12 had an absolute indication for nephron sparing treatment. Following ureteroscopic biopsy and treatment of upper tract transitional cell carcinoma, 40 mg. mitomycin C in 3 divided doses was instilled via a ureteral catheter, which was clamped between doses to give an exposure time of 30 minutes. Eighteen patients have undergone ureteroscopic surveillance following a total of 26 treatments.No systemic side effects occurred during or after treatment with mitomycin C. One patient had a prominent local inflammatory reaction following neodymium:YAG ablation and mitomycin C treatment of a renal pelvic tumor. The average size of the treated tumors was 17 mm. (range 5 to 30). The grade of the tumors (when known) was 1 in 5 patients, 1 to 2 in 2, 2 in 8 and 3 in 4. Most tumors were treated with either neodymium:YAG (6 cases) or holmium:YAG laser (8) or a combination of both (8). Following 1 to 4 treatments with mitomycin C 11 of 19 evaluable renal units (58%) were rendered free of disease. Six of those 11 renal units (54%) had an ipsilateral recurrence after a mean of 30 months of followup, 4 of which were treated endoscopically, and 7 (64%) are now disease-free without extirpative surgery. Four patients have undergone nephroureterectomy for persistent or recurrent disease. No patient has suffered local or distant progression of disease.Instillation of mitomycin C for upper tract transitional cell carcinoma appears to be safe and can be considered for adjuvant treatment in select cases. More data are necessary to determine its efficacy.

Complications following renal allograft transplantation have been well documented and, despite improvements in technique, continue to cause significant morbidity and mortality. The placement of indwelling ureteric stents is becoming more common both during primary neo-ureterocystostomy and in the management of subsequent ureteric complications. We present two cases of stent encrustation and urolithiasis treated by a combined percutaneous and flexible ureterorenoscopic approach. These cases illustrate the problems of stents in renal transplant patients and offer endo-urological solutions. It is imperative that stents are correctly placed in these patients and that appropriate plans are made for their removal or exchange.