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Introduction: Ambulatory percutaneous nephrolithotomy (PCNL) has been limited to highly selected patients. The objective of our study was to compare complication and stone-free rates after ambulatory PCNL in standard selection criteria vs. extended criteria patients. Methods: We conducted a retrospective review of prospective data on all patients who underwent ambulatory PCNL at one academic center from 2007–2018. Extended criteria patients were defined as one or more of: age >75 years, body mass index (BMI) >30 kg/m2, American Society of Anesthesiologists (ASA) >2, bilateral stones, solitary kidney, transplant kidney, complete staghorn calculi, stone burden >40 mm, multiple tracts, or prior nephrostomy tubes/stents. Primary outcomes were complication rates (Clavien-Dindo classification) and stone-free rates. Results: We identified 118 patients, of which 92 (78%) met extended criteria. Mean BMI was 31 kg/m2 and 45% were ASA 3 or higher. Mean sum maximum stone diameter was 24 mm. Multiple stones were present in 25%, bilateral stones in 7%, and complete staghorn stones in 4% of patients. There was no difference in complication (12% vs. 18%, p=0.56), emergency department visit (12% vs. 18%, p=0.56), or re-admission (4% vs. 5%, p=1) rates between standard and extended criteria patients respectively. Of the complications, 85% were Clavien-Dindo grade 1. Stone-free rates were not different between standard (84%) and extended (83%) criteria patients (p=1). No extended criteria variables were associated with complications in multivariable analysis. Conclusions: Complication and stone-free rates were not different between standard and extended selection criteria patients undergoing ambulatory PCNL. This data indicates that many of the preoperative patient and stone factors that have previously been used as exclusion criteria for ambulatory PCNL are not strictly necessary.

Introduction: In recent years, the method of vascular control during laparoscopic donor nephrectomy (LDN) has come under scrutiny due to catastrophic consequences of a device failure. This study sought to examine the surgical preferences of Canadian donor surgeons with regards to vascular control and their perception on the safety of these modalities. We also surveyed the experience with device malfunction and their subsequent management during LDN.Methods: An online survey was sent out to donor surgeons registered with the Canadian Society of Transplantation. Surveys were anonymous and voluntary. Descriptive statistics were used to analyze the collected responses. Recollection of the sequelae and outcomes from device malfunction were also queried.Results: Twenty-eight of 37 surgeons (76% response rate) responded to the survey. At least one surgeon from every institution in Canada performing LDN responded to the survey. Laparoscopic stapler is the most commonly used device for securing the renal artery (61%) and renal vein (67%). Overall, surgeons felt the stapler was the safest method of securing the renal artery. Stapler misfire and clip slippage were reported by eight (28.5%) and 1 2 (43%) surgeons, respectively. Most cases were salvageable: laparoscopically (30%), open conversion (30%), and by hand port (5%). Slippage of a plastic locking clip resulted in one emergent laparotomy on POD#1 and one stapler misfire was converted to open resulting in donor death.Conclusions: Although rare, hemorrhagic complications can occur from device malfunction resulting in poor outcomes for healthy volunteers undergoing LDN. Surgeons need to remain vigilant when selecting the appropriate modality for vascular control.

Background A primary obstacle to providing renal transplantation is limited access to donated kidneys. The living-donor pool for renal allografts was greatly expanded through implementation of a kidney paired donation program. Whereas some programs ship donor kidneys to the site of renal transplantation, others send the donor to the site of transplantation. Performing the nephrectomy and transplantation at the same location may optimize functional renal outcomes, but preferred surgical approaches may differ between surgical teams performing the donor workup and donor surgery. Our objective was to identify incongruence between the surgery planned by the team that performed the donor's workup, and the surgery that took place at the site of donation. Methods A retrospective chart review was performed between the site of preoperative surgical planning, and the site of surgery for kidney donors in the Canadian kidney paired donation program. Results Fifty-one donors were preoperatively prepared in any of six Canadian provinces, and then underwent surgery in a different province. The surgical procedure performed for 31% of the patients' nephrectomies differed from the procedure suggested by the surgical team who conducted the preoperative workup. Half of these differences were between left laparoscopic and left laparoscopic hand-assisted, but the remainder included more substantial changes of sides and/or laparoscopic versus open procedures. Conclusion Optimal patient care is challenged in a kidney paired donation program that uses the “traveling donor” approach due to differing surgical techniques selected by the surgeon at the site of donor workup and the surgeon at the site of donation.

Ureteric strictures are the most common urologic complication following renal transplantation. Different management options exist, ranging from temporizing drainage with ureteric stent or percutaneous nephrostomy tube to endoscopic interventions and open surgical repair. Although minimally invasive procedures are typically preferred, they often have a short duration of efficacy and multiple treatments are required. Open surgical repair allows for definitive management with minimal risk to the transplant. We review our experience with complicated ureteral strictures refractory to endoscopic management. We identified 10 renal transplant recipients who developed ureteric strictures that failed multiple endoscopic treatments. All 10 of these strictures were managed by means of pyelovesicostomy with the use of a Boari flap. The median time to ureteric stricture diagnosis was 2.5 months with a median of 4 endoscopic procedures before surgery. Median time from stricture diagnosis to surgical repair was 53 months. Overall success was 100%, with graft function being salvaged in all cases and no stricture recurrence after a mean follow-up of 18 months. We present a case series of complex ureteric strictures after renal transplantation managed by means of pyelovesicostomy with the use of Boari flap after failed endoscopic management. We demonstrate the safety and effectiveness of this approach of to treat complex ureteric strictures.

Objectives To evaluate whether hypothermic machine perfusion (HMP) of transplanted kidneys can improve long-term renal allograft function compared with static cold storage (CS). Methods We evaluated whether graft Doppler ultrasonography resistive indices improved with the use of HMP compared with CS preservation, and examined whether these improvements were predictive of long-term graft function. A total of 30 kidney transplants (15 pairs) were examined. One of the kidney pairs was placed on CS and transplanted first (CS group, n = 15). The other kidney of each pair was placed on HMP and transplanted after the CS group (HMP group, n = 15). Doppler ultrasonography was performed on days 1 and 7 after transplantation and resistive indices were evaluated. The estimated glomerular filtration rate (eGFR) was monitored for 24 months after transplantation. Results Despite longer cold ischaemia times, kidneys maintained with HMP had lower resistive indices (P = 0.005) with correspondingly higher eGFR throughout the follow-up. Subgroup analysis showed that the HMP-induced improvement in postoperative eGFR was greatest in kidneys obtained from donation after cardiac death (DCD), even at 2 years after transplantation (P = 0.008). Conclusions HMP of transplant kidneys appears to improve vascular resistance after transplantation and has a positive impact on long-term allograft function compared with CS in the population of recipients of DCD kidneys.

Introduction: Partial nephrectomy is the gold standard for treatment of small renal masses. Our study compares outcomes for obese (body mass index [BMI] ≥30) and healthy (BMI

SUMMARY Kidney paired donation (KPD) programs are an effort to bridge the disparity between kidney supply and demand. These programs combine several incompatible donor-recipient pairs in a national paired exchange database, thereby increasing the number of compatible matches. But KPD programs face unique challenges, particularly the large distances that often separate donors and recipients. Here we discuss key factors to consider when transitioning from a donor travelling model to a kidney shipment model in the Canadian context.

Introduction: Renal transplant is the gold standard treatment for end-stage renal disease (ESRD), and the prevalence of both ESRD and renal transplant has been steadily increasing over the past decade. However, involvement of urology in renal transplant has been declining. We examine the current state of urology involvement in renal transplant programs across Canada.Methods: A telephone survey of all surgical transplant centres in Canada was performed. Information regarding the number of transplant surgeons, their individual training background, and their involvement in specific procedures, including open and laparoscopic living donor nephrectomy, deceased donor nephrectomy, and recipient renal transplant were collected.Results: There are 59 Canadian transplant surgeons, including 27 (46%) who completed a urology residency and 32 (54%) with a general surgery background. With regards to procedures performed, 58 (98%) perform recipient renal transplant surgery, 36 (61%) perform laparoscopic donor nephrectomy, and 17 (29%) perform open donor nephrectomy. There was no significant difference in the number of surgeons that perform renal recipient surgery, laparoscopic or open donor nephrectomies, and deceased donor nephrectomies between surgeons of the two different training backgrounds.Conclusions: The role of urology in Canadian renal transplant has declined significantly over the past decade. Given the medical and surgical complexity of renal transplant, along with the growing need for renal transplants, a multidisciplinary team approach is imperative. Strong urology involvement with the transplant team is crucial for optimal care of these complex patients.

We present an unusual complication secondary to indwelling urethral catheter placement. Routine catheter placement by the obstetrics team in a postpartum female leads to retention of the catheter and inability of its removal by both the obstetrics and urology teams. Although a retained urinary catheter is relatively common, inability to remove a catheter secondary to placement inadvertently into a ureter is extremely rare. In this paper we will discuss the options in removing a retained catheter and present our case of a retained catheter secondary to placement within the right proximal ureter.

SUMMARY Laparoscopic donor nephrectomy (LDN) is the gold standard for kidney donation. Recent literature has led to considerable debate regarding the safest route to provide vascular control during this procedure. The most common devices used for vascular control during LDN are staplers and surgical clips. Opinions regarding the safety of these devices vary, as both are prone to dysfunction. Certain clips have already been contraindicated for use on the donor artery owing to reports of catastrophic complications of falling off. Donor safety is paramount to the continued success of renal transplantation in Canada. A review of existing practice at each institution may be called for to ensure the safest standards possible are in place. An appendix to this commentary is available at canjsurg.ca.

In the contemporary era of minimally invasive surgery, very few T1/T2 renal lesions are not amenable to nephron-sparing surgery. However, centrally located lesions continue to pose a clinical dilemma. We sought to describe our local experience with three cases of laparoscopic nephrectomy,ex vivopartial nephrectomy, and autotransplantation. Laparoscopic donor nephrectomy was performed followed by immediate renal cooling and perfusion with isotonic solution. Back-table partial nephrectomy, renorrhaphy, and autotransplantation were then performed. Mean warm ischemia (WIT) and cold ischemic times (CIT) were 2 and 39 minutes, respectively. Average blood loss was 267 mL. All patients preserved their renal function postoperatively. Final pathology confirmed pT1, clear cell renal cell carcinoma with negative margins in all. All are disease free at up to 39 months follow-up with stable renal function. In conclusion, the described approach remains a viable option for the treatment of complex renal masses preserving oncological control and renal function.

Left ventricular assist device (LVAD) therapy is an established treatment option for select patients with advanced heart failure. Advances in technology and patient management have resulted in improved post-implant outcomes. Consequently, more patients with LVADs are presenting for evaluation and care of non-cardiac surgical disease. However, there is a paucity of literature regarding the optimal perioperative and surgical management of such patients. We present the case of a 71-year-old male with a HeartMate II (Thoratec Corporation, Pleasanton, CA) LVAD, who underwent a laparoscopic left nephroureterectomy for an upper urinary tract transitional cell carcinoma. His perioperative course was uneventful due to the multidisciplinary efforts of cardiac surgery, cardiac anesthesia, nephrology and urology. To our knowledge, this is the first reported case of a laparoscopic nephroureterectomy in a patient with a HeartMate II LVAD.

Introduction: Renal transplantation remains the gold standard treatment for end-stage renal disease, with living donor kidneys providing the best outcomes in terms of allograft survival. As the number of patients on the waitlist continues to grow, solutions to expand the donor pool are ongoing. A paradigm shift in the eligibility of donors with renal anomalies has been looked at as a potential source to expand the living donor pool. We sought to determine how many patients presented with anatomic renal anomalies at our transplant centre and describe the ex-vivo surgical techniques used to render these kidneys suitable for transplantation.Methods: A retrospective review was performed of all patients referred for surgical suitability to undergo laparoscopic donor nephrectomy between January 2011 and January 2015. Patient charts were analyzed for demographic information, perioperative variables, urological histories, and postoperative outcomes.Results: 96 referrals were identified, of which 81 patients underwent laparoscopic donor nephrectomy. Of these patients, 11 (13.6%) were identified as having a renal anomaly that could potentially exclude them from the donation process. These anomalies included five patients with unilateral nephrolithiasis, four patients with large renal cysts (>4 cm diameter), one patient with an angiomyolipoma (AML) and one patient with a calyceal diverticulum filled with stones. A description of the ex-vivo surgical techniques used to correct these renal anomalies is provided.Conclusions: We have shown here that ex-vivo surgical techniques can safely and effectively help correct some of these renal anomalies to render these kidneys transplantable, helping to expand the living donor pool.

Introduction: Laparoscopic living donor nephrectomy is the standard of care at high-volume renal transplant centres, with benefits over the open approach well-documented in the literature. Herein, we present a retrospective analysis of our single-institution donor nephrectomy series comparing the mini-open donor nephrectomy (mini-ODN) to the laparoscopic donor nephrectomy (LDN) with regards to operative, donor, and recipient outcomes.Methods: From 2007‒2011, there were 89 cases of mini-ODN, at which point our centre transitioned to LDN; 94 cases were performed from 2011‒2014. In total, 366 patients were reviewed, including donor and recipient pairs. Donor and recipient demographics, intraoperative data, postoperative donor recovery, recipient graft outcomes, and financial cost were assessed comparing the surgical approaches.Results: We demonstrate a reduced estimated blood loss (347.83 vs. 90.3 cc), lower intraoperative complication rate (4 vs. 11) and shorter length of hospital stay (2.4 vs. 3.3 days) for patients in the LDN group. Operative time was significantly longer for the LDN group (108.4 vs. 165.9 minutes), although this did not translate to a longer warm ischemia time (mean 2.0 minutes for each group). The rate of delayed graft function and recipient 12-month creatinine were comparable for ODN and LND. Overall cost of LDN was $684 higher for an uncomplicated admission.Conclusions: Despite a longer surgical time and higher upfront cost, our study supports that LDN yields several advantages over the mini-ODN, with a lower estimated blood loss, fewer intraoperative complications, and shorter length of hospital stay, all while maintaining excellent renal allograft outcomes.

Static cold storage is generally used to preserve kidney allografts from deceased donors. Hypothermic machine perfusion may improve the outcome after transplantation but few studies with limited power have addressed this issue. We reviewed evidence of the effectiveness of storing kidneys from deceased donors after cardiac death before transplantation using cold static storage solution or pulsatile hypothermic machine perfusion.We searched electronic databases in September 2011 for systematic reviews and/or meta-analyses, randomized, controlled trials and studies of other designs that compared delayed graft function and graft survival. Sources included The Cochrane Library, PubMed® and EMBASE®. Studies excluded from review included those that did not discriminate between donation after cardiac death and donation from a neurologically deceased donor. Primary outcomes were delayed graft function and 1-year graft survival. Statistical analysis was done using RevMan (http://ims.cochrane.org/revman).Nine studies qualified for review. Pulsatile perfusion pumped kidneys from donation after cardiac death donors had decreased delayed graft function compared to kidneys placed in cold storage (OR 0.64, 95% CI 0.43-0.95, p = 0.03). There was a trend toward improved 1-year graft survival in the pulsatile perfusion group but statistical significance was not attained (OR 0.74, 95% CI 0.48-1.13, p = 0.17).Pulsatile machine perfusion of donation after cardiac death kidneys appears to decrease the delayed graft function rate. We noted no benefit in 1-year graft survival. Due to the great heterogeneity among the trials as well as several confounding factors, the overall impact on allograft function and survival requires more study.

We report the first case of totally tubeless outpatient percutaneous nephrolithotomy (PCNL). Our patient was discharged home safely less than 4 hours following uncomplicated PCNL with no nephrostomy tube, ureteral stent, or urethral catheter. Follow-up the next day in clinic confirmed that the procedure was successful, as the patient was clinically well and stone free. To our knowledge, this is the first case report of totally tubeless (no nephrostomy, no ureteral stent) PCNL performed on a truly outpatient basis.

412 Background: To examine the predictive capability of pre-operative anatomic imagining characterization of the R.E.N.A.L. Nephrometry Score (RNS) in assessing pathologic upstaging of clinical T1 (cT1) lesions to pathologic T3 (pT3) in partial and radical nephrectomy specimens. Methods: We conducted a retrospective review of all patients undergoing radical and partial nephrectomies between January 1, 2011 and May 31, 2014 for cT1 renal masses. All pre-operative imaging scans were reviewed and the R.E.N.AL. Nephrometry score (radius for tumor size as maximal diameter, exophytic/endophytic tumor properties, nearness of deepest portion of tumor to collecting system or sinus, anterior/posterior descriptor and location relative to polar line) was applied to each scan. Chi-square, Fisher exact test, and Student t test were utilized to examine associations. Results: Of the 229 patients who underwent partial or radical nephrectomy for cT1, 124 (54%) underwent partial nephrectomy. On pathologic evaluation 195 (85%) patients had malignancy. Of all tumors 26 (13%) were pathologically upstaged to pT3 with the majority attributable to renal sinus/fat (35%) or perinephric fat (31%) involvement. High RNS (>10) was significant in predicting pathologic T3 upstaging (p=0.039) but did not predict high grade (Furhman grade 3-4) disease (p=0.803). While a high nephrometry score trended toward predicting malignancy vs benign disease (p=0.086), a higher mean nephrometry score (7.81 vs. 6.84) significantly predicted malignancy (p=0.015). When controlled for cT1a lesions, tumor location relative to polar lines (L=3 vs. L1+2) was predictive of pT3 upstaging (24 vs. 6%, p=0.03). Age >65 was significantly associated with upstaging (26 vs. 7%, p=0.0001). Conclusions: Surveillance of small renal masses is common but high RNS and age >65 significantly predicted pathologic upstaging. Mean nephrometry score was also useful in predicting malignancy. Nephrometry score may aid in deciding on early surgical intervention.

471 Background: To identify predictors of post-operative renal insufficiency by analyzing pre-operative imaging volumetrics among patients undergoing radical nephrectomy (RN) for renal cell carcinoma (RCC). Methods: A retrospective review of all patients undergoing RN for RCC between January 2011 and August 2013 was performed. Estimated glomerular filtration rate (eGFR) was calculated employing the modified diet in renal disease (MDRD) formula using the pre-operative and one-year serum creatinine values. Pre-operative and 1-year post-operative CT/MRI scans were reviewed. AW Volume Share 5 workstations were utilized to calculate volumes. Statistical analysis using Chi-square and Fisher exact test were employed. Results: Of the 147 patients undergoing RN 65 patients met the inclusion criteria. Patients with smaller tumor volumes (3) were more likely to have a greater decline in their post-operative eGFRs (>35%) when compared to patients with larger tumors (58 vs. 21%; p=0.0165). Patients with a pre-operative eGFR >60 ml/min/1.73m2 had a greater (>25%) drop in their 1-year eGFR (81 vs. 47%; p=0.0084). A smaller volume (3) of parenchyma of the ipsilateral kidney was associated less compensatory (3) were more likely to have a greater degree (>10%) of compensatory hypertrophy (78 vs. 43% p=0.0234) and less blood loss (25%) hypertrophy (age >65, 100% vs. 31%, p25%) however, did not predict 1-year eGFR (35%) change (p=0.2203). New kidney disease (eGFR2) occurred in 71% patients. Conclusions: Volumetric imaging shows promising potential and may become a valuable tool in predicting post-operative renal insufficiency for patients undergoing nephrectomy and should be investigated further both in RN and partial nephrectomy cohorts.

512 Background: Feasibility of partial nephrectomy for small renal masses extends beyond standard clinical tumor size. We analyze patient characteristics and anatomic tumor factors to determine variables associated with surgical complications after partial nephrectomy. Methods: Retrospective review of all patients who underwent partial nephrectomy at our institution between January 1, 2012 and Aug 31, 2013. Follow-up extended to 8 week post-operative outpatient clinic visit. The R.E.N.AL. Nephrometry score is a tumor descriptive (the maximum radius, exophytic/endophytic, nearness to collecting system/sinus, anterior/posterior position, location relative to polar line) that was applied to each pre-operative scan. Standardized grading systems and statistical analysis were applied. Results: Of the 83 patients who underwent partial nephrectomy 72 had a laparoscopic approach. Seventeen (20%) patients had complications and seven were Clavien-Dindo grade 3 to 4. Two patients had laparoscopic partial nephrectomies converted intra-operatively to radical nephrectomies; two other laparoscopic partial nephrectomies were converted to open partial nephrectomies. Forty-three (52%) of operated patients were either obese, morbidly obese, or super obese. Fifteen (18%) of patients had pathologic oncocytomas or angiomyelipomas. In univariate analysis Charlson comorbidity score (>6 p=0.0027), diabetes (42% p=0.0195), age (>70 p=0.02034), and total R.E.N.A.L. Nephrometry score (10-12, 67%, p=0.0254) were associated with complications. Nephrometry score also correlated with warm ischemic time (WIT) in laparoscopic cases (low 26 min [SD +/- 11.71], intermediate 31 min [SD +/- 7], high 34 min [SD +/- 14]). Conclusions: Categorizing renal masses according to the R.E.N.A.L. Nephrometry score may help us council patients towards expected WITs, complication rates, and predicted renal function outcomes. This is increasingly important as the majority of our patients are either obese, elderly, or have significant comorbidities; all of which have been shown to be associated with increased complication rates.

We report a case of an unanticipated intra-operative transesophageal echocardiography (TEE) finding of pulmonary artery thromboembolism in a 72yr woman being prepared for radical nephrectomy and caval thrombectomy. Intra-operative TEE performed to evaluate the extent of caval thrombus found the presence of pulmonary artery tumor thromboembolism in an otherwise asymptomatic patient after induction and prior to commencing surgery. A chest Computed Tomography (CT) scan confirmed a large saddle tumor thromboembolus. A multidisciplinary approach was utilized to facilitate radical nephrectomy with caval thrombectomy and pulmonary artery thromboembolectomy. This case shows the importance of adequate perioperative imaging and utilization of intra-operative TEE to evaluate the extent of disease. To our knowledge, we are the first to present a case of RCC with cava tumour thrombus in which the pulmonary artery tumour thromboembolism was detected incidentally on intraoperative TEE.

This study helps to shed light on a long-standing dilemma in renal transplant surgery: whether to remove the peritoneal dialysis (PD) catheter at the time of transplant surgery or to leave it in place until established renal allograft function down the road.1 The potential benefits to removing the PD catheter at the time of surgery are that you eliminate the need for a second procedure, as well as avoid the potential complications fraught with having a PD catheter (e.g., infection, peritonitis) as highlighted in this study.1 On the other hand, in the face of delayed graft function (DGF) having PD catheter in place postoperatively leaves the potential to use that catheter for temporizing peritoneal dialysis while waiting for the allograft to recover function.2 However, as pointed out in several studies including this one, peritoneal dialysis in the post-transplant setting is also fraught with a high risk of potential complications, including fluid leakage from the incision if the peritoneum is violated during the transplant surgery.3–5 Therefore, the overall benefit to leaving a PD catheter in place seems to be minimal, especially in the live-donor population of transplants where the DGF rate is exceedingly low. In Winnipeg, we have had a very similar experience with our perioperative PD catheter situations; our new policy is to remove PD catheters on all transplant patients. As pointed out by the authors in this study,1 in the setting of DGF temporary dialysis can be facilitated by a central catheter which is very easy to place and remove and is associated with a low complication rate. In fact, most transplant recipients already have a central line in place at the time of surgery for central venous pressure monitoring and drug administration, so utilizing this line or switching it over to a dialysis line is very convenient. Despite the need for future prospective studies, the evidence points to an overall benefit of PD catheter removal at the time of kidney transplantation. This seems to outweigh the benefits of leaving in the PD catheter. Obviously, every patient and clinical scenario is different and there may be situations were this rule does not apply. Warren and colleagues make a strong case for PD catheter removal at the time of surgery.1