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Purpose Cystine stones are widely considered hard and difficult to treat. Hounsfield Units (HU) are used in other stone types to estimate ‘hardness’ and treatments based on that finding. Our objective was to report mean HU of cystine stones in vivo in a large case series of cystinuria patients and assess for differences in genotype. Methods A prospective case series of cystinuria patients referred to a specialist centre was analysed. CT imaging was assessed by two independent radiologists to determine in vivo attenuation of cystine calculi. Mean HU was compared for both cystinuria genes (SLC3A1 and SLC7A9) using an independent t-test. Results 164 adult cystinuric patients were identified (55% male), median age 43 years (range 18–80). Median follow up was 31 months (IQR 10–62). Genetic data available for 153/164 (93%) demonstrated 97 SLC3A1 (63%) and 55 (36%) SLC7A9 mutations (39 homozygous, 16 heterozygous) and one heterozygous for both SLC3A1/SLC7A9. 107 patients had CT images available demonstrating calculi. Median HU across the cohort was 633 (5th to 95th centile 328–780). There was no difference in mean HU between SLC3A1 and SLC7A9 genotypes (p = 0.68) or homo and heterozygous SLC7A9 (p = 0.70). Mean HU correlated with stone size (Pearson correlation coefficient = 0.51, p Conclusion In this large single centre cystinuria cohort, mean HU was low for stones that are difficult to treat. Calculi of 1000 are unlikely pure cystine, and in a known cystinuric would suggest conversion to another stone type.

Purpose To summarize current knowledge on intracorporeal laser lithotripsy in flexible ureterorenoscopy (fURS), regarding basics of laser lithotripsy, technical aspects, stone clearance, lithotripsy strategies, laser technologies, endoscopes, and safety. Methods A scoping review approach was applied to search literature in PubMed, EMBASE, and Web of Science. Consensus was reached through discussions at the Consultation on Kidney Stones held in September 2019 in Copenhagen, Denmark. Results and conclusions Lasers are widely used for lithotripsy during fURS. The Holmium laser is still the predominant technology, and specific settings for dusting and fragmenting have evolved, which has expanded the role of fURS in stone management. Pulse modulation can increase stone ablation efficacy, possibly by minimizing stone retropulsion. Thulium fibre laser was recently introduced, and this technology may improve laser lithotripsy efficiency. Small fibres give better irrigation, accessibility, and efficiency. To achieve optimal results, laser settings should be adjusted for the individual stone. There is no consensus whether the fragmentation and basketing strategy is preferable to the dusting strategy for increasing stone-free rate. On the contrary, different stone scenarios call for different lithotripsy approaches. Furthermore, for large stone burdens, all laser settings and lithotripsy strategies must be applied to achieve optimal results. Technology for removing dust from the kidney should be in focus in future research and development. Safety concerns about fURS laser lithotripsy include high intrarenal pressures and temperatures, and measures to reduce both those aspects must be taken to avoid complications. Technology to control these parameters should be targeted in further studies.

Background and ObjectivesCystinuria is a rare genetic cause of recurrent urolithiasis and requires multimodal treatment, and stringent follow up. We wanted to evaluate the fears and concerns of patients with cystinuria during the COVID-19 pandemic. Materials and MethodsAn online survey using Google Forms was emailed to 165 patients with cystinuria who are maintained on a prospective database and had previously consented for email correspondence. ResultsFifty-five responses were received following a single invitation, 23 were men and 32 women with a median age of 43 (range: 18-72) years. Thirty-nine (70.9%) out of 55 were isolating during the COVID-19 pandemic although only 7(12.7%) were given specific advice to shield officially. Six (10.9%) reported having COVID or COVID like symptoms, but none reported having a positive test. Only 9 (16.4%) had been able to work as usual. In comparison, 20 (36.4%) were able to work from home. Ten out of 19 patients (52.6%) on chelating medication described difficulty in access to their medicine, either due to a shortage at the pharmacy or prescription access. Reassuringly 34 (61.8%) patients described no issues with access to any of their cystinuria medications.Twenty-two patients (40%) reported experiencing pain or passing a stone during the COVID-19 pandemic, while 30 (54.5%) reported no problems. Of patients who felt it applicable, 16/31 (51.6%) were worried about attending the Emergency Department during this time. Of patients who had scheduled hospital appointments during this time, 26/44 (59.1%) had experienced cancellations. The majority of the respondents (37 (67.3%)) did not state any difference in the ability to stay hydrated during the lockdown.Twenty-eight (50.9%) were more anxious about their overall health during the pandemic, and 20 (36.4%) had expressed more concern about their kidney stones. ConclusionThis personal fully patient-reported snapshot of the impact of the COVID-19 pandemic on a population of cystine stone formers in the United Kingdom has highlighted additional challenges for patients with a rare disease. The lockdown measures enforced have had a varying effect on patients’ ability to work as normal, access medications, health anxieties, in addition to cancellations of the planned hospital appointments and Emergency Department attendance, which will impact on their future health and pose evolving challenges in delivery of their future care.

INTRODUCTION AND OBJECTIVE:Cystinuria is recognised to cause concern about children inheriting the disease, however the impact of pregnancy in cystinuria has not been well studied. Management in pr...

Objectives: The objective of this article is to investigate the current clinical practice and outcomes of extracorporeal shock wave lithotripsy (SWL) in the United Kingdom. Patients and methods: Patient demographics, stone characteristics and SWL protocols were collected prospectively for 30 consecutive new patient referrals at each of seven contributing UK institutions performing SWL. Final outcomes in terms of stone-free rates (SFRs), and complications were recorded. Results: Completed demographic data were available for 204 patients. Treatment protocols varied between centres. Mean patient age was 51 years. Over 70% of stones treated measured between 5 and 10 mm, and one-third were in the ureter, with two-thirds in the kidney, where the majority (31% overall) were in the lower pole. The overall cumulative SFR was 50.3% (range 33–70% between centres). SWL was notably more effective for ureteric stones (SFR 59.3% overall) than for renal calculi (SFR 45.6% overall). Complications were noted in six patients. Conclusion: This study provides a valuable snapshot of real-life clinical practice and demonstrates considerable variability in the application of SWL in the UK. The results support existing data which suggest that SWL is a safe and well tolerated treatment modality; however, overall SFRs were low.

To determine the feasibility of crystalluria as a biomarker for stone disease in patients with cystinuria.All patients attending a multidisciplinary cystinuria clinic provided early morning urine (EMU) and clinic urine (CU) samples for crystal measurement over a 2-year period (August 1, 2010, to July 31, 2012). Association between presence of crystals, presence of stone(s), and new stone growth (NSG) was determined using the chi-square test. Crystal numbers in EMU and CU were compared in patients with stones/NSG and no stones/stable disease using the Mann-Whitney U test.There was a statistically significant difference between the presence of crystalluria and presence of stones for CU (chi-square test = 5.86, df = 1, p = 0.02) but not EMU (chi-square test = 1.92, df = 1, p = 0.17) and between the presence of crystalluria and NSG for CU (chi-square test = 8.10, df = 1, p = 0.004) but not EMU (chi-square test = 1.32, df = 1, p = 0.25). Patients with stones and NSG have higher levels of crystalluria in CU than patients with no stones or stable disease (stones, median = 41, interquartile range [IQR] = 600 vs median = 0, IQR = 21, p = 0.01; NSG, median = 49, IQR = 525 vs median = 0, IQR = 40, p = 0.01).The presence of crystalluria in CU samples is associated with the presence of stones. Crystalluria is comparable to ultrasound and may serve as a useful adjunct to predict whether a patient with cystinuria has stones, which could guide the frequency of clinic review and imaging.

Purpose of review The present review identifies the latest scientific investigations within the fields of fragmenting and dusting to discuss optimizing treatment. In addition, new settings such as 'popcorning' are scrutinized carefully. Recent findings During the past years, endoscopic techniques have continuously developed and changed the management of the treatment of kidney stones using ureteroscopy (URS). The most currently used energy source for stone disintegration is holmium laser lithotripsy. This technique offers different options for the surgeons to treat their patients suffering from kidney stones. Summary URS with the holmium laser allows surgeons to use a variety of different strategies for treating urinary stones. There are two techniques which are most frequently used within this field: firstly fragmenting, using low frequencies and high pulse energy to break stones into small fragments before removal. On the other hand, dusting has been popularized in the field of endourology in recent years. This uses high frequencies and low pulse energy to form fine dust particles which then pass spontaneously down the ureter.

Higher blood pressures (mean systolic difference 16.8 mmHg) when compared to matched individuals are already reported in patients with calcium urolithiasis. We present the prevalence of hypertension and renal impairment in patients with cystinuria from our specialist single centre. We analysed our prospective database of adult patients with cystinuria who attend our cystinuria service. This included details of the medical and operative management of their disease. Descriptive statistics were used to analyse and present the data. 120 patients were included with a median age of 40 (19–76) years, 66 were male (55%) and 54 were female (45%). 54/120 patients (45%) were taking medications to prevent stone formation. 78% (94/120) patients reported having undergone one or more stone-related procedure. 59% (55/94) of these having required at least one PCNL or open procedure during their lifetime. Prevalence of hypertension was 50.8% (61/120), and double in males compared to females (62.1% vs. 37.0%, P = 0.0063). Mean baseline creatinine was 88.2 (49–153) µmol/l and eGFR was 77.6 (32–127) ml/min/1.73 m2. When categorized by CKD stage, only 24.6% (27% vs. 21%, M vs. F) patients had normal renal function (being an eGFR > 89 ml/min/1.73 m2). 57.6% patients were CKD stage 2 and 17.8% CKD stage 3. Females had a slightly greater incidence of renal impairment. All patients who have previously undergone a nephrectomy (n = 10) or have a poorly functioning kidney (n = 19) have renal impairment (CKD stage 2 or 3). Incidence of hypertension in patients with cystinuria is 51%, with a male preponderance. Only 25% of patients with cystinuria have normal renal function. This highlights the long-term cardiovascular and renal risks that the metabolic effects of cystinuria pose, in addition to the challenges of managing recurrent urolithiasis in a young population.

Objective To examine the genetic mutations in the first UK cohort of patients with cystinuria with preliminary genotype/phenotype correlation. Patients and Methods DNA sequencing and multiplex ligation-dependent probe amplification (MLPA) were used to identify the mutations in 74 patients in a specialist cystinuria clinic in the UK. Patients with type A cystinuria were classified into two groups: Group M patients had at least one missense mutation and Group N patients had two alleles of all other types of mutations including frameshift, splice site, nonsense, deletions and duplications. The levels of urinary dibasic amino acids, age at presentation of disease, number of stone episodes and interventions were compared between patients in the two groups using the Mann–Whitney U-test. Results In all, 41 patients had type A cystinuria, including one patient with a variant of unknown significance and 23 patients had type B cystinuria, including six patients with variants of unknown significance. One patient had three sequence variants in SLC7A9; however, two are of unknown significance. Three patients had type AB cystinuria. Three had a single mutation in SLC7A9. No identified mutations were found in three patients in either gene. There were a total of 88 mutations in SLC3A1 and 55 mutations in SLC7A9. There were 23 pathogenic mutations identified in our UK cohort of patients not previously published. In patients with type A cystinuria, the presence of a missense mutation correlated to lower levels of urinary lysine (mean [se] 611.9 [22.65] vs 752.3 [46.39] millimoles per mole of creatinine [mm/MC]; P=0.02), arginine (194.8 [24.83] vs 397.7 [15.32] mm/MC; P

Life expectancy continues to increase and as a result more frail, elderly and co-morbid patents are undergoing surgery (Brodak et al. Clin Interv Aging. 10:379–85, 2015). This is acutely seen in the management of men with prostatic disease. Urologists are increasingly encountering the older man with larger (>100 cc) prostates and concurrent and multiple co-morbidities. Urological diseases such as bladder and renal stones, bladder tumours and benign prostatic enlargement often necessitate concurrent or staged operative management. The grossly enlarged prostate can hinder or obstruct progress in the initial operation due to mass effect and bleeding. Identification and planning is key for successful outcomes in these men. Ensuring that the right equipment is available is a critical step before the cystoscopic inspection of the lower urinary tract has even started.

This study aimed to externally validate a previously described nomogram that predicts the need for renal exploration in the trauma setting.The predicted probability of nephrectomy was manually calculated using prospectively collected data from consecutive patients with renal trauma who presented to our institution between May 2001 and January 2010. To assess nomogram performance, receiver operating characteristic curves against the observed exploration rate were generated, and areas under the curve were calculated. Calibration curves were generated to assess performance across the range of predicted probabilities. Logistic regression modeling was used to determine clinical factors predicting exploration in a contemporary setting, and a nomogram was derived and internally validated using bootstrapping.The established nomogram was applied to the 320 patients who presented during the 9-year period. The global performance of the established nomogram was very high, with an area under the curve of 0.95. However, the model performance was poor for higher predicted probabilities, thus lacking predictive ability in the population where the model has the greatest potential utility. A clinical tool was generated to better predict trauma nephrectomy in our contemporary population, using platelet transfusion within the first 24 hours, blood urea nitrogen, hemoglobin, and heart rate on admission. The global accuracy for the new model was similar to the previous nomogram, but it was significantly better calibrated for patients with higher probabilities of nephrectomy, with good predictive accuracy even in patients with Grade 5 injuries.Older nomogram fails to accurately predict renal exploration in high-grade injuries in the contemporary setting. A new nomogram that more accurately predicts the need for exploration is presented.Therapeutic study, level IV; prognostic study, level III.

What's known on the subject? and What does the study add? Previously, donors with asymptomatic stones found incidentally on CT were not considered ideal donor candidates because of the presumed risk of morbidity to both the donor and recipient. Increasingly, studies show that these risks are low. This study aims to evaluate the long-term safety of using ex vivo ureteroscopy to remove the stones from the donor kidney on the bench before donation. Outcomes so far suggest that this technique can safely render a kidney stone-free before transplantation. This has led to 20 more transplants in our institution than would otherwise be possible. Objectives To evaluate the prevalence of asymptomatic renal stones in our potential donor population. To assess the safety and success of ex vivo ureteroscopy (ExURS) to remove stones from explanted donor kidneys before transplantation. Patients and Methods We conducted a retrospective analysis of 377 computed tomography (CT) angiograms of potential kidney donors between October 2004 and May 2007 to assess the prevalence of asymptomatic renal stones in our donor population. Between October 2005 and October 2011, kidneys from suitable donors underwent ExURS. Stones were removed using basket extraction or were fragmented with holmium laser on bench before transplantation. Immediate and long-term complications of the transplanted recipients were recorded. Donors were followed with yearly ultrasonography of the remaining kidney in addition to standard follow-up protocol. Results Review of 377 CT angiograms between October 2004 to May 2007 showed a 5% prevalence of asymptomatic renal stones. Out of 55 potential donors (19 identified between October 2004 to May 2007 and a further 36 identified since May 2007), 20 donors with stones proceeded to donation, with stone size ranging from 2 to 12 mm. Of the patients, 17 proceeded to ExURS. Stones were removed in 10 patients; five with basket retrieval, four with laser fragmentation and one with both laser fragmentation and basket retrieval. There were no early or late allograft stone-related complications and no evidence of stones on follow-up imaging at a mean (range) of 10 (1–24) months. There has been no reported stone recurrence in any of the donors to date and no stone on ultrasonography of eight donors with >1-year follow-up (mean 26 months, range 12–49 months). Conclusions Asymptomatic renal stones are present in 5% of our donors. ExURS can be safely used to remove stones in these kidneys before transplantation, without the risk of subjecting the donor to an additional stone-removing procedure. Continued long-term follow-up of donors and recipients is still required to ensure the safety of this approach.

Cystine capacity is an assay for assessing urinary cystine saturation and risk of a stone episode in patients with cystinuria. Lowering the threshold for this test improves its sensitivity, potentially enabling relaxation of follow-up regimens for patients at lowest risk of stone episodes and dose modification of medications for those at highest risk.

In this month’s issue of European Urology, Skuginna et al presented the results of a prospective randomised control trial investigating the use of stepwise voltage ramping during extracorporeal shock wave lithotripsy (ESWL) [1]. We commend the authors on conducting a large randomised trial to answer a question in stone treatment in an area with a paucity of good evidence. The current European Association of Urology guidelines on urolithiasis suggest that power ramping is associated with less renal damage, although the evidence is mixed with respect to stone outcomes [2]. Although the primary outcome measure of this trial was evidence of renal haematoma (on routine ultrasonography at 24 h), the authors also assessed important clinical outcome measures such as stone fragmentation, stone-free rates (SFRs), and need for secondary intervention. These all have relevance to patients undergoing ESWL, and evidence for these has previously been conflicting. Data were also collected on levels of b2microglobulin and microalbumin in the urine 24 h after treatment to try and assess tubular or glomerular damage, respectively. This is a large trial, and 418 patients were randomised to either stepwise voltage ramping or fixed maximal voltage. In the stepwise group, patients received 500 shock waves (SW) at power level 7, 1000 SW at power 8, and 1000 SW at power 9. By contrast, in the fixed group, the patients received all 2500 SW at power 9. These power levels may seem high to some readers, and it is important to realise that lithotripsy was performed under either general or regional anaesthesia, which may not be the practice in other units. The results of this study seem very clear; ramping of power induced statistically fewer ultrasound-detected renal haematomas (5.6%) compared with fixed maximal voltage (13%). This is a notable difference and one that would seem to justify power ramping regardless of other outcome measures. However, what is not clear from the paper is whether any of these were clinically relevant. The inference is that they were not, and certainly they were all haemodynamically stable throughout. Thus although the number of haematomas overall is high with 39 of 418 patients affected, none may have been clinically apparent. The authors did not find a statistical difference in the urinary markers of renal damage at 24 h after treatment, although there was a trend (p = 0.06) for b2microglobulin. Are these results of any clinical relevance? Previous animal models have demonstrated less renal damage with smaller areas of haemorrhagic lesions on pathologic examination with pretreatment [3]. There is only limited evidence for long-term structural and functional effects of lithotripsy, although it is recognised that haemorrhage initiates an inflammatory response leading to disruption of nephrons, interstitial oedema, fibrosis, and scar formation [4]. Given that ESWL is often repeated multiple times on young patients with benign pathology, limiting haemorrhage and haematoma formation with the potential for long-term renal damage is important. Because this study did demonstrate less haematoma formation, it does seem reasonable to conclude that this remains important despite lack of clinical symptoms.

Summary points Lower urinary tract symptoms (LUTS) are common in men and increase in frequency and severity with age. Over one third of men aged 50 or more are living with moderate to severe symptoms, equating to 3.4 million men in the United Kingdom alone and 24 million in countries of the European Union.1 Most men with LUTS can be managed effectively in primary care, with either conservative lifestyle measures or medical treatment.2 We discuss the causes of LUTS in men and summarise the current evidence on assessment and management of patients. #### Sources and selection criteria We performed a search of PubMed to identify peer reviewed original articles, meta-analyses, and reviews, using the search terms “lower urinary tract symptoms”, “benign prostatic hyperplasia”, and “overactive bladder”. In addition we reviewed national and international guidelines and the Cochrane Collaboration and clinical evidence databases. We considered only papers written in English, with emphasis on more recent articles where available and where we deemed the scientific validity to be sufficient. Terms such as prostatism, symptoms of benign prostatic hyperplasia (BPH), and clinical BPH have been ascribed to men presenting with LUTS.3 These …

Cystinuria is a genetic disease that leads to frequent formation of stones. In patients with recurrent stone formation, particularly patients

The lifetime risk of forming a kidney stone among Caucasian men is about 8–10 %. Among patients who have formed one kidney stone, the lifetime recurrence rate is 60–80 % while 10 % of men will form a further stone within a year. Although urinary stones are a recurrent problem in the majority of patients, metabolic evaluation is not cost-effective for all patients who have formed only one stone. Furthermore fluid intake, dietary habits and lifestyle have a direct effect on the pathogenesis of most stones. Therefore it is important to assess the risk factors for stone recurrence in patients so that they can then be assigned to either a low-risk or high-risk group of stone formers. This will allow for earlier recognition of the problem and may assist in the prevention of recurrent stone formation. This review summarises important risk factors for stone recurrence and provides a logical protocol for the management of recurrent stone disease.

Objective To review our experience from a high volume stone center with a focus on efficacy, safety, and renal function. Methods Stones requiring percutaneous nephrolithotomy (PCNL) in patients with solitary kidneys can pose significant anxiety to the urologist. Limited data are available in published reports in this setting. A comprehensive retrospective review of medical records was performed on patients who underwent PCNL and had a solitary kidney or a single functioning renal unit. Data were collected on patient demographics, stone burden, outcomes, complications, and renal function. Results Of 378 PCNLs performed between January 2003 and September 2011, 22 were performed in 17 patients with a single functioning kidney. Three procedures were performed in a transplanted kidney. In those with solitary calculus, the longest mean length and stone surface area were 37 mm and 825 mm 2 , respectively. Stone-free rate was 59%. Auxiliary procedures were required in 6 cases, resulting in a stone-free rate of 77%. Median inpatient stay was 4 days. Serum creatinine values improved from 144 to 126 umol/L before and after the procedure and mean estimated glomerular filtration rate improved similarly from 51 to 59 mls/minute, respectively. Blood transfusion was required in 1 patient, sepsis developed in 3, and 2 patients required a stent for obstruction. Conclusion PCNL in solitary kidneys is safe with an acceptable complication rate if performed in a high volume center. Outcomes are good, although auxiliary procedures may be necessary. Renal function remains stable or improves after procedure.

This chapter details the management of patients who are found to have bacteriuria on microscopy. Emphasis is placed on how to triage and manage these patients in primary care. Red flag findings are highlighted so that patients can be referred for imaging/admission. Asymptomatic bacteriuria, a common finding that only requires treatment in certain patient groups, is reviewed.

hyperparathyroidism were evaluated using logistic regression with a priori adjustment for age, gender and body mass index (BMI). RESULTS: Stone forming patients with primary hyperparathyroidism were more likely to be women (p 0.001) and had higher levels of urinary calcium (difference 107 mg/day, p 0.006) but lower levels of urinary uric acid (difference 88 mg/day, p 0.045). Hypercalciuria was present in 64% of those with hyperparathyroidism and 38% of those without hyperparathyroidism (p 0.018). Calcium oxalate supersaturation (SSCaOx), calcium phosphate supersaturation (SSCaPhos), calcium/kilogram and calcium/creatinine were also elevated in primary hyperparathyroid patients. After adjusting for age and BMI, women were 4.9 fold (CI 1.8–13.1) more likely to have hyperparathyroidism. Other predictors of hyperparathyroidism included hypercalciuria (aOR 3.5, CI 1.3–9.7), elevated SSCaOx (aOR 6.6, CI 2.7–15.9), elevated SSCaPhos (aOR 4.7, CI 1.8–12.4), elevated calcium/kg (aOR 9.1, CI 3.7–22.4), and elevated calcium/creatinine (aOR 4.7, CI 1.5–14.5) in separate models after adjustment for age, gender and BMI. Other 24-hour urine parameters and metabolic defects were not associated with primary hyperparathyroidism. CONCLUSIONS: Stone forming patients with primary hyperparathyroidism are more likely to be women and have elevated urinary calcium, SSCaOx and SSCaPhos after adjustment for age, gender and BMI. They also excrete more calcium/kg even after accounting for differences in patient size, but 36% of stone patients with primary hyperparathyroidism did not have hypercalciuria. There were no obvious cutoffs for any urine parameters which reliably differentiated those with hyperparathyroidism among stone formers.

Management for blunt high grade renal injury is controversial with most disagreement concerning indications for exploration. At our institution all patients are considered candidates for conservative treatment regardless of injury grade or computerized tomography appearance with clinical status the sole determinant for intervention. We define clinical factors predicting the need for emergency intervention as well the development of complications.We analyzed the records of 117 patients with high grade renal injury (III to V) secondary to blunt trauma who presented to our institution in an 8-year period. Patients were categorized by the need for emergency intervention and, in those treated conservatively, by complications. We generated logistic regression models to identify significant clinical predictors of each outcome.Grade III to V injury occurred in 48 (41.1%), 42 (35.9%) and 27 patients (23%), respectively. Of the 117 patients 20 (17.1%) required emergency intervention. On multivariate analysis only grade V injury (RR 4.4, 95% CI 1.9-10.5, p = 0.001) and the need for platelet transfusion (RR 8.9, 95% CI 2.1-32.1, p0.001) significantly predicted the need for intervention. A total of 90 patients (82.9%) who did not require emergency intervention underwent a trial of conservative treatment, of whom 9 (9.3%) experienced complications requiring procedural intervention. On multivariate analysis only patient age (RR 1.06, 95% CI 1.02-1.1, p = 0.004) and hypotension (RR 12, 95% CI 1.9-76.7, p = 0.009) were significant predictors.High grade injury can be successfully managed conservatively. However, grade V injury and the need for platelet transfusion predict the need for emergency intervention while older patient age and hypotension predict complications.

Renal trauma is often managed conservatively. Repeat imaging within 48 hours of injury is recommended but to our knowledge the value of further delayed imaging is unknown. We determined the usefulness of routine followup imaging beyond 48 hours in cases of conservatively managed renal trauma.Of 377 patients who presented to our institution with renal injury in the last 8 years we identified 138 who underwent a trial of conservative treatment and repeat imaging more than 48 hours after injury. Followup imaging was categorized as routine in 108 patients (group 1) and indicated in 30 (group 2), and assessed for complications and the need for subsequent intervention.Of the patients 121 (76%) were male. Mean age was 36 years. All except 4 injuries were the result of blunt trauma, predominantly due to road traffic accidents. Injury was grade 1 to 5 in 26, 24, 44, 33 and 11 cases, respectively. We identified 108 patients with routine followup imaging (group 1) while 30 were re-imaged due to a clinical indication. The rate of progression was 0.93% in group 1 with only 1 complication requiring a management change. In contrast, 20% of group 2 patients had progression requiring a treatment change (p = 0.0004).Routine re-imaging in patients with renal trauma outside the initial 48-hour window in the absence of a clear clinical indication had little benefit and changed treatment in less than 1%.

Objective: A critical appraisal of the management of patients with cystine stones treated in our unit in the past 6 years and to analyze the outcome of multimodality therapies. Study Design: An observational, single-centre retrospective study. Methods: We reviewed the records of all patients with stones referred to our centre over a 6-year period from 1998 to 2005. Data recorded included demographic details, medical therapies received/prescribed, compliance with medical therapies, mode of treatment, stone clearance and any recurrence during this period of study. Results: A total of 30 cystinuric patients were treated in our institution over the period of 6 years from 1998 to early 2005. Of these 16 were males and 14 females with an average age at last follow-up of 39 years (range 15–70). Two patients were successfully managed medically. The remaining patients (n = 28) underwent a total of 237 procedures (pre- and postreferral to our unit), with an average of 7.9 procedures per patient for 126 stone episodes (4.2 episodes/patient). The modes of treatment included extracorporeal shockwave lithotripsy (n = 143), ureterorenoscopy and intracorporeal lithotripsy (n = 50), percutaneous nephrolithotomy (n = 28) and open procedures (n = 16). Two patients needed open surgery at our unit. Prior to referral to our dedicated unit, patients had received treatment with extracorporeal shockwave lithotripsy (multiple sessions), ureteroscopy (n = 14), percutaneous nephrolithotomy (n = 4) and open stone removal (n = 14). Most of the stones at our unit were managed using minimally invasive therapies. Conclusion: Compliance of cystinuric patients with medical treatment is often poor and patients experience recurrent stone episodes requiring multiple interventions. Modern management of cystine calculi should be with staged minimally invasive procedures to avoid the complications of multiple open procedures wherever possible along with appropriate medical prophylaxis.

Loin pain haematuria syndrome (LPHS) is a syndrome of severe chronic pain of unknown aetiology. This study assessed pain, mood variables and psychiatric status in patients (n=26) with LPHS. Patients were assessed before and after treatment with capsaicin. Assessment inventories used were the McGill Pain Questionnaire, the Pain Discomfort Scale, the General Health Questionnaire and the Hospital Anxiety and Depression Scale. Pain relief was achieved in 65% of patients. In this group pain (P0.001) and psychiatric (P0.01) scores were significantly reduced. By comparison, in those patients who did not gain pain relief, scores remained steady (P0.05). In addition, most pain-free patients completely stopped their opiate analgesia without addictive symptoms. These results suggest an organic pathology to LPHS and militate against suggestions of primary psychological cause or drug addiction. The results also show that the psychiatric disturbances associated with this chronic pain disappear if the pain disappears.

Although electrohydraulic lithotripsy (EHL) is regularly used to fragment urinary calculi, it has the potential to cause significant renal tract damage. We report a complication of EHL use during flexible ureterorenoscopy, where recovery was complicated by delayed, prolonged haematuria secondary to the formation of a pseudoaneurysm in an interlobar renal artery. Embolisation was achieved by the insertion of a coil.