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Objectives: To assess the association of skin-to-stone distance (SSD) and stone-free rates following extracorporeal shockwave lithotripsy (SWL) using two statistical methods: logistic regression and a matched-pair analysis approach. Patients and Methods: Patients with a solitary radio-opaque upper ureteral calculus diagnosed on noncontrast computed tomography were included. Patients were treated with a Sonolith I-Sys Lithotripter (focal depth 17 cm). Stone treatment success was defined as stone free (fragments ≤3 mm) at 3 months. Failure was defined as persistent fragments beyond 3 months or requirement for intervention with ureteroscopy. The outcome was assessed by a plain kidney, ureter, and bladder radiograph (KUB) at 2 weeks. Logistic regression was used to determine association of patient and stone factors with treatment failure. The patient cohort was divided into tertiles by SSD, and matched-pair analysis was undertaken between individuals from the top and bottom tertiles (SSD ≤12 cm and SSD ≥14 cm). Matching criteria consisted of age, sex, maximum stone diameter (±2 mm), and stone density (±250 HU). Results: From a database of 2849 patients who underwent SWL, 397 patients were identified who had treatment of a single upper ureteral stone. Age (odds ratio [OR]: 1.03, 95% confidence interval [CI]: 1.01-1.04, p = 0.007), SSD (OR: 1.16, 95% CI: 1.03-1.32, p = 0.02), stone side (OR: 1.65, 95% CI 1.01-2.73, p = 0.05), stone diameter (OR: 1.09, 95% CI: 1.00-1.19, p = 0.05), and multiple sessions (OR: 4.65, 95% CI: 2.61-8.29, p < 0.001) were significantly associated with treatment failure by logistic regression univariable analysis. Multiple sessions was the only factor significantly associated with treatment failure on multivariable analysis (OR: 4.03, 95% CI: 2.18-7.42, p < 0.001). From a cohort of 141 patients with SSD ≥14 cm and 174 patients with a SSD ≤12 cm, 66 matches were identified (132 patients). Forty-nine patients (74.2%) with SSD ≥14 cm were deemed stone free at follow-up vs 51 patients (77.3%) with SSD ≤12 cm (p = 0.85). Conclusion: This study demonstrates by two statistical methods that SWL can provide efficacious treatment of upper ureteral stones in obese patients and that the upper threshold of SSD for SWL with Sonolith I-SYS could be revised to allow these patients the benefits of SWL.

To assess the clinical features, outcomes, complications, and cost-effectiveness of shockwave lithotripsy (SWL), flexible ureterorenoscopy (FURS), and percutaneous nephrolithotomy (PCNL) in the treatment of lower pole (LP) stones (10-20 mm) in a large tertiary referral center.Consecutive patients treated for solitary LP stones (10-20 mm) between 2008 and 2013 were identified from a prospective database. SWL was used as primary treatment in all cases (following a stone multidisciplinary team assessment), with FURS and PCNL reserved for SWL contraindications, failure, or patient choice. "Success" was defined as stone free and/or clinically insignificant stone fragments (≤3 mm) at 1 and 3 months follow-up. Effect of anatomy on SWL success was determined from using CT images and regression analysis. Average cost per treatment modality (including additional second-line treatments) was calculated for each group using the National Health Service England 2014/15 National Tariff Healthcare Resource Group codes.Two hundred twenty-five patients were included (mean age 54.9; median stone size 12 mm). One hundred ninety-eight (88%), 21 (9.3%), and 6 (2.7%) patients underwent SWL, FURS, and PCNL as primary treatments, respectively, for median stone sizes of 12, 12, and 20 mm. Overall success rates were 82.8%, 76.1%, and 66.7%, respectively (p 0.05). Sixty-three percent of patients undergoing primary SWL were effectively treated after one session. Anatomical analysis determined infundibulopelvic angle and infundibular length to be significantly different in patients effectively treated with SWL (p = 0.04). The average cost per treatment modality was also significantly lower for SWL (£750) than for FURS (£1261) or PCNL (£2658) (p 0.01).SWL is both an efficacious and cost-effective primary treatment for patients with solitary LP stones (10-20 mm). The majority of patients can be effectively treated with primary SWL in a dedicated stone center, with the benefits of a short length of stay, low complication, and auxiliary treatment rates. The referral of such patients to high-volume lithotripsy centers with demonstrable outcomes should be given due consideration.

To determine the stage-specific operative, postoperative and oncologic outcomes, for patients undergoing a laparoscopic radical nephrectomy (LRN) for renal cell carcinoma (RCC) in a single center and assess changes over a generation of practice.From December 1992 to July 2011, data were collected prospectively for 854 consecutive simple laparoscopic necphrectomies (LNs) and LRNs, 397 of which were LRNs for RCC. The first LRN was performed in December 1997. Stage-specific surgical and oncologic outcomes were assessed across the study period. Patients were then grouped into three equal consecutive cohorts. Case mix and surgical outcomes were compared to assess changes with departmental experience.There were 206, 71, 118, and 2 patients across stages pT1, pT2, pT3, and pT4, respectively. Median operative time was significantly shorter for pT1 tumors (125, 150 and 150 min for pT1-3, P0.021), while median estimated blood loss (EBL) was greater for pT3 tumors (50, 50, 100 mL, for pT1-3, P0.001). Median follow-up time was 31, 30, and 18 months, respectively, across pT1-pT3. There was a significant difference in 5-year overall survival (82.4%, 68.4%, 58.9%), cancer-specific survival (99.5%, 83.6%, 66.5%) and progression free survival (86.5%, 66.3%, 47.5%) across these stage-specific subgroups. Over the three cohorts, there was an increase in LRN performed for locally advanced disease and cytoreduction. With greater surgical experience, there was improvement in median operative time and median EBL in localized disease over the three periods, but no significant changes for locally advanced disease.This is the largest reported series of LRN in the United Kingdom. Departmental experience has resulted in improved surgical outcomes for localized RCC, with expansion of practice in more complex advanced disease. Laparoscopic nephrectomy is both operatively and oncologically safe in T1 and T2 disease, and although technically more demanding, it is also safe in selected T3 disease.

What's known on the subject? and What does the study add? Shockwave lithotripsy (SWL) can be used to treat stones at any position within the ureter, as long as the stone is radio-opaque and there is a path for the shockwave to reach the stone. However the results of SWL to distal ureteric calculi, with the patient in a prone position, were inferior to those of treating stones within the upper ureter. The transguteal approach allows the lithotripsy shockwave to reach the lower ureter via the greater selatle foramen. This study shows that this approach for SWL to distal ureteric calculi is more effective than the prone approach. Objective To compare the outcomes of extracorporeal shockwave lithotripsy (ESWL) for distal ureteric stones treated using the prone and transgluteal (supine) approaches in a tertiary referral stone unit using a fourth generation lithotriptor. Patients and Methods We selected consecutive patients undergoing ESWL to distal ureteric stones over 1 year, during which we changed our treatment protocol from a prone to transgluteal (supine) approach. Patients were treated using the Sonolith Vision Lithotriptor (Technomed Medical Systems, Vaulx-en-Velin, France). Outcome was assessed using plain abdominal film of kidney, ureter and bladder (KUB) X-ray taken at 2 weeks then monthly as required. Treatment success was defined as complete clearance of stone fragments and treatment failure was defined as persistence of stone fragments beyond 3 months or the need for ureteroscopy. Results A total of 38 patients were treated in the prone position and 72 patients using a transgluteal approach. Patient and stone characteristics were identical in both groups. The mean (range) stone size was 7.8 (4–16) mm. The proportions of patients who were stone-free after one treatment session within the prone and transgluteal treatment groups were 40 and 78%, respectively (

What's known on the subject? and What does the study add? Endoscopic management of upper tract urothelial carcinoma (UTUC) using either ureteroscopy and laser ablation, or percutaneous resection, is a management option for treating selected low-grade tumours with favourable characteristics. However, the evidence base for such practice is relatively weak, as the reported experience is mainly limited to small case series (level of evidence 4), or non-randomised comparative studies that are unmatched for tumour stage (level of evidence 3b), with variability of follow-up duration and reported outcome measures. The present systematic review comprehensively reviews the outcomes of all studies of endoscopic management of UTUC, including the role of topical adjuvant therapy. It establishes for the first time a structured reference for endoscopic management of UTUC, and is a foundation for further clinical studies. Objective To systematically review the oncological outcomes of upper tract urothelial carcinoma (UTUC) treated with ureteroscopic and percutaneous management. The standard treatment of UTUC is radical nephroureterectomy (RNU). However, over the last two decades several institutions have treated UTUC endoscopically, either via ureteroscopic ablation or percutaneous nephroscopic resection of tumour (PNRT), for both imperative and elective indications. Methods For evidence acquisition the Pubmed database was searched for English language publications in December 2011 using the following terms: upper tract (UT) transitional cell carcinoma (TCC), upper tract TCC, UTTCC, upper tract urothelial cell carcinoma, upper tract urothelial carcinoma, UTUC, endoscopic management, ureteroscopic management, laser ablation, percutaneous management, PNRT, conservative management, ureteroscopic biopsy, biopsy, BCG, mitomycin C, topical therapy. Results There are no randomised trials comparing endoscopic management with RNU. Most published studies were retrospective case series (and database reviews), or unmatched comparative studies. There was strong selection bias for favourable tumour characteristics in many endoscopically treated groups. There was variation in medical comorbidity and indication for treatment across different study groups. The biopsy verification of underlying UTUC pathology was inconsistent. The follow-up in most studies was limited, typically to a mean 3 years. Conclusions There is a high rate of UT recurrence with endoscopically managed UTUC, and a grade-related risk of tumour progression and disease-specific mortality. Overall, renal preservation may be high with ≈20% of patients proceeding eventually to RNU. For highly selected Grade 1 (or low-grade) disease managed in experienced centres, 5-year disease-specific survival (DSS) may be equivalent to RNU, although the small study groups and short follow-ups preclude comments on less favourable Grade 1 (or low-grade) tumour characteristics, or DSS, in the longer-term. For Grade 3 (or high-grade) disease, DSS outcomes are poor and endoscopic management should only be considered for compelling imperative indications in the context of the patient's overall life expectancy and competing comorbidity.

UNLABELLED: What's known on the subject? and What does the study add? Laparoscopic radical nephrectomy is a well established treatment for localized RCC, where nephron-sparing approaches are not appropriate. As surgeon and departmental experience grow more extensive tumours will be tackled laparoscopically. However, little is known about the operative safety and oncological outcomes of the laparoscopic approach for locally advanced RCC. The present study describes the largest reported cohort of patients receiving laparoscopic radical nephrectomy for locally advanced RCC. In the context of suitably experienced personnel in an established centre, we have established that this approach is safe from operative, postoperative and oncological standpoints, with comparable data to existing open series. OBJECTIVE: To determine the operative, postoperative and oncological outcomes of laparoscopic radical nephrectomy (LRN) for locally advanced renal cell cancer (RCC), which, as surgeon and departmental experience increases, is being performed more often. PATIENTS AND METHODS: In total, 94 consecutive patients receiving LRN for pathologically confirmed T3 or T4 RCC at a tertiary referral centre between March 2002 and May 2010 were analyzed. Preoperative, operative, tumour and postoperative characteristics were evaluated together with recurrence and outcome data. Survival was estimated using the Kaplan-Meier method. Cox's proportional hazards model was used for multivariate analysis. RESULTS: In total, 77 patients had LRN with curative intent and 17 patients had LRN with cytoreductive intent. There were six LRNs (6.4%) that were converted to open procedures. Overall, there were two (2.1%) Clavien grade IIIa complications, one (1.1%) grade IVa complication and one (1.1%) postoperative death. Overall median follow-up was 17.4 months. In total, 22 (28.6%) patients receiving curative LRN developed a recurrence after a median of 13.9 months; 12 (54.5%) patients developed distant metastases, five (22.7%) patients had local recurrences and three (13.6%) patients had transcoelomic spread. Median predicted progression free survival was 48.4 months in patients undergoing LRN with curative intent. Median predicted overall survival was 65.6 months after curative LRN and 15.7 months after cytoreductive LRN. Multivariate analysis did not reveal any variables influencing recurrence or survival. CONCLUSIONS: In the context of suitably experienced personnel in an established centre, LRN for locally advanced RCC is safe from an operative and oncological standpoint. Patients clinically staged as T3 RCC must still be selected carefully for LRN in a multidisciplinary setting.

Context Incidence, prevention, and management of complications of percutaneous nephrolitholapaxy (PNL) still lack consensus. Objective To review the epidemiology of complications and their prevention and management. Evidence acquisition A literature review was performed using the PubMed database between 2001 and May 1, 2011, restricted to human species, adults, and the English language. The Medline search used a strategy including medical subject headings (MeSH) and free-text protocols with the keywords percutaneous, nephrolithotomy, PCNL, PNL, urolithiasis, complications, and Clavien, and the MeSH terms nephrostomy, percutaneous/adverse effects, and intraoperative complications or postoperative complications . Evidence synthesis Assessing the epidemiology of complications is difficult because definitions of complications and their management still lack consensus. For a reproducible quality assessment, data should be obtained in a standardized manner, allowing for comparison. An approach is the validated Dindo-modified Clavien system, which was originally reported by seven studies. No deviation from the normal postoperative course (Clavien 0) was observed in 76.7% of PNL procedures. Including deviations from the normal postoperative course without the need for pharmacologic treatment or interventions (Clavien 1) would add up to 88.1%. Clavien 2 complications including blood transfusion and parenteral nutrition occurred in 7%; Clavien 3 complications requiring intervention in 4.1.%; Clavien 4, life-threatening complications, in 0.6%; and Clavien 5, mortality, in 0.04%. High-quality data on complication management of rare but potentially debilitating complications are scarce and consist mainly of case reports. Conclusions Complications after PNL can be kept to a minimum in experienced hands with the development of new techniques and improved technology. A modified procedure-specific Clavien classification should be established that would need to be validated in prospective trials.

Background: Xanthogranulomatous pyelonephritis is a chronic renal inflammatory condition associated with significant renal and peri-renal inflammation. Consequently, operative treatment of this condition has traditionally been by open nephrectomy rather than the laparoscopic approach. We report our experience with the diagnosis and management of XGP in our department, which has subsequently been histologically confirmed. Patients and methods: We reviewed records of all patients with a histological diagnosis of XGP between 1984 and 2007. 20 patients with a diagnosis were included. Patient demographics, preoperative presentation, diagnostic imaging, operative details, post-operative recovery and complications were included in our data. Results: 13 patients underwent open nephrectomy and 7 patients underwent a laparoscopic procedure, of which 1 was subsequently converted to an open procedure. Blood loss, analgesic requirement, time to first meal and length of stay (LOS) in hospital were all lower in the laparoscopic group compared with the open group (362.5 ml vs. 723.6 ml, p = 0.049; 65.3 mg vs. 146.9 mg, p = 0.153; 2.8 days vs. 4.2 days, p= 0.184; 4.4 days vs. 9.8 days, p = 0.084). Operative times were similar in both groups (157.5 min vs. 154.2 min, p= 0.888). There were 5 complications in the laparoscopic group and 13 in the open group. Conclusion: The laparoscopic approach, although technically challenging, provides superior intra-operative and post-operative recovery results compared to the open approach with comparable operative times and incidences of complications. In specialised centres and in experienced hands, laparoscopic nephrectomy should be considered as the first choice procedure in those patients with a suspected diagnosis of XGP.

Introduction: Nonenhanced computed tomography (NCT) is recognised as the most sensitive tool in diagnosis of renal tract calculi. However, its role as the sole imaging investigation, for decisions regarding management is less clear. Objective: To determine the proportion of new stone patient referrals in which management is altered by interpretation of a plain abdominal kidneys, ureters and bladder (KUB) radiograph in addition to NCT. Methods: One hundred consecutive new referrals to a national lithotripsy centre were considered prospectively for treatment of renal tract calculi. Results: A significant change in management was undertaken in 17 patients on the basis of KUB findings. Eleven patients had radio-lucent ureteric stones, for which extracorporeal shockwave lithotripsy (ESWL) was consequently not possible and who required endoscopic management. There were six inaccuracies in measurement of size or positioning on NCT. In a further 43 patients it was not possible to confirm management until the KUB was reviewed, although in these cases ESWL or expectant management was still pursued. Thus additional imaging with a KUB was required in order to confirm optimum management in 60 patients. Conclusion: Additional plain radiography confers a significant advantage in the planning of treatment for urolithiasis once the diagnosis has been established by NCT because of information it provides regarding radio-opacity as well as stone size and visibility. This information cannot be delivered by NCT alone. We therefore recommend that KUB imaging is performed on all new stone patients referred for treatment.

To evaluate whether the overall safety and efficacy profile of percutaneous surgery for urinary stone disease in older (70 years) patients might influence the decision for the procedure in the elderly.A large database was created from our patients (n = 1058) who underwent percutaneous surgery for stone disease between 1991 and 2003 in the Scottish Lithotriptor Centre, including clinical and operation details for each case. Only percutaneous nephrolithotomy cases with full details were studied (n = 779) and were grouped into two age groups: (1) between 17 and 69 years and (2) over 70 years. Statistical analysis evaluated differences in terms of operation-related adverse events, stone-free success rates, and clinical success rates (including stone-free cases and cases with residual fragments4 mm). Further analysis was performed for the same endpoints after stratification of the patients by (1) previous stone procedures and (2) special clinical features.In the overall database, no statistically important differences were found between the two groups in terms of stone burden before surgery, adverse events rates, complete stone-free rates, and clinical success rates. However, a statistical trend toward higher clinical success rates in favor of the younger group was seen (P = 0.051). Stratification of our database according to previous stone disease procedures or special clinical or anatomic characteristics has only shown a statistically important difference for clinical success rates in favor of the older group without special features (P = 0.01).In experienced hands, age-related morbidity or age itself should not be a discouraging consideration when deciding on performing percutaneous nephrolithotomy, as the procedure is as equally feasible and safe in the elderly as in the younger patient population.

Mucocutaneous and transconjunctival exposure are important portals for the transmission of blood-borne infections to surgeons and health-care workers. Despite this knowledge, few surgeons or their assistants wear protective equipment for procedures perceived to be affiliated with less risk. This study investigates the potential risk of mucocutaneous and transconjunctival blood splash injury during common laparoscopic and endourologic procedures undertaken using standard video endoscopy equipment.Masks combined with eye shields were consecutively collected from the surgeon, surgical assistant, and theater nurse after a variety of endourologic procedures over a 4-month period. These were analyzed macroscopically for visible blood droplets. Modern forensic techniques were then instituted to assess for nonvisible blood exposure.Eye shields from 118 procedures performed by five surgeons were collected. Two hundred and thirty-six masks were examined for visible and visually enhanced evidence of blood contamination. In total, 48.5% of surgeons' masks, 29.5% of assisting surgeons' masks, and 31.8% of scrub nurse masks were positive for either visible or visually enhanced blood contamination. In terms of evidence of blood splash, 84.2% of laparoscopic nephrectomies, 66.7% of pyeloplasties, and 58.3% of flexible ureteroscopies tested positive.Splash injuries remain commonplace, even with the use of video endoscopy equipment. Therefore, all health-care workers should be encouraged to wear eye and face protection when undertaking both endoscopic and laparoscopic urologic procedures. These observations may have broader implications relevant to all minimally invasive surgical procedures, because they demonstrate a much greater potential risk of blood-borne disease transmission during surgery than has been previously appreciated.

This article seeks to offer an alternative to traditional understandings of how doctrine can inform the ways that medical professionals and others care for people who suffer. Placing traditional christological reflections in conversation with an aesthetically generated christology, I consider how the beauty of encounter can shape us. First, I consider how encounters in general can shape us, and then I reflect in particular upon how encounters with Christ, as construed by Hans Urs Von Balthasar, can shape us. I suggest that personal encounters shape us by forcing us to cross stories with others and by affecting us at the level of personal desire. Then, I articulate how an encounter with Christ – especially with Christ's questioning, liberating gaze as described by Von Balthasar – can motivate people to approach others with this same gaze. Lastly, I focus upon how caregivers can embody Christ's gaze at the bedside in acknowledgement, intimacy, communion and respectful silence with those who suffer.

OBJECTIVE To review the safety and efficacy of supracostal puncture during percutaneous nephrolithotomy (PCNL) for renal calculi. PATIENTS AND METHODS Over a 12-year period, 66 patients had either an upper-pole puncture alone or combined with middle- or lower-pole puncture during PCNL for renal calculi. All punctures were made by an experienced uroradiologist and were either supra- or subcostal. We retrospectively reviewed all case notes and radiographs to determine stone-clearance rates and complications associated with the site and number of punctures. RESULTS There was an overall stone-free rate of 78% with upper-pole puncture alone or combined with middle- or lower-pole puncture. There was a 3% thoracic complication rate with upper pole punctures, and an overall complication rate of 30% for both thoracic and non-thoracic complications. CONCLUSION Upper-pole puncture in PCNL is associated with minimum morbidity if done by an experienced urologist or radiologist. The stone-free rate appears to be more dependent on stone size and complexity than the site of puncture.

OBJECTIVE To evaluate the efficacy of a fourth-generation lithotripter, the Sonolith Vision (Technomed Medical Systems, Vaulx-en-Velin, France) for treating single previously untreated renal calculi, and to compare the results with the reference standard HM-3 (Dornier MedTech Europe GmbH, Wessling, Germany) in the same population originally studied by the USA Cooperative Study Group in 1986. PATIENTS AND METHODS The Sonolith Vision uses an innovative electroconductive shock-wave generator with an elliptical reflector specially designed to give the maximum concentration of energy on the stone. We reviewed the treatment sessions from our prospectively maintained database of the first 1000 consecutive patients with urinary stone disease who were treated with the Sonolith Vision between September 2004 and March 2006. Patients with previously untreated solitary renal calculi in anatomically normal kidneys were included. The outcome was assessed by plain films for radio-opaque stones, and renal ultrasonography for radiolucent stones, at 1 and 3 months after lithotripsy; the results were analysed according to stone size and location. RESULTS Data from 309 patients who had a complete follow-up and with 373 renal calculi that matched the above criteria were analysed. The initial fragmentation rate was 94%. The stone-free rate for stones of 20 mm was 50%. The overall stone-free rate 3 months after lithotripsy was 75%. Within a month of lithotripsy, 221 patients (59%) became stone-free. Additional procedures to render patients stone-free after lithotripsy were needed in only 22 cases (7%). The overall efficiency quotient was 62%. The stone-free rates for lower, upper, middle calyceal and renal pelvic calculi were 74%, 70%, 78.5% and 75%, respectively. There were no serious complications. CONCLUSIONS When similar populations of stone formers were assessed the Sonolith Vision achieved a high success rate, comparable with that using the HM-3 machine but with lower analgesia requirements and very low re-treatment rates. This method of comparison belies the commonly held view that newer lithotripters are less effective than the original spark-gap machines.

In this section this month, we have two papers. The first is from authors from Scotland. They present a review of patients with an extended follow-up who have undergone extracorporeal shock wave lithotripsy (ESWL) or percutaneous nephrolithotomy (PCNL) for calyceal diverticular stones over a 15-year period to assess long-term outcome, irrespective of treatment. They concluded that PCNL is an effective and durable means of treating calyceal diverticular stones, regardless of stone size or location of the diverticulum. Despite low stone-free rates with ESWL, most patients are rendered symptom-free with minimal complications. The second paper is from the USA; the authors discuss the new generation of flexible ureteroscopes, which provide exaggerated active deflection to facilitate intrarenal manipulation. They compared the relative ease of manipulation around a calyceal model. The authors concluded that the Wolf Viper proved superior for manipulation in the hands of experienced endoscopists. OBJECTIVE To review patients with an extended follow-up after extracorporeal shock wave lithotripsy (ESWL) or percutaneous nephrolithotomy (PCNL) for calyceal diverticular stones (CDS), over a 15-year period, assessing the long-term outcome. PATIENTS AND METHODS In all, 56 patients were treated for symptomatic CDS disease by ESWL (38) or PCNL (18). The stone-bearing diverticula were in the upper calyces in 26, middle calyces in 24 and lower calyces in six patients, and in the right kidney in 22 and in the left in 34. The most frequent symptom was ipsilateral flank pain (84%) and 32% of patients presented with associated chronic urinary tract infections. In a retrospective analysis, we assessed stone size, diverticulum location, stone-free rate, symptom-free rate, complications and extended follow-up. RESULTS In the short-term in the ESWL group, 21% of patients were stone-free and 61% were asymptomatic; 8% developed symptoms and 8% developed recurrence or stone-growth in the long term. There were six minor complications. In the PCNL group, 15 patients (83%) were stone-free in the short term; two had a recurrence (11%) and two had stone growth (11) in the long term. There were three complications after PCNL. CONCLUSIONS This series shows that PCNL is an effective and durable means of treating CDS, regardless of stone size or location of the diverticulum. Despite low stone-free rates with ESWL, most patients were rendered symptom-free with minimal complications. The long-term recurrence rates, 8% for ESWL and 11% for PCNL, were comparable.

Summary There is controversy over whether shock wave lithotripsy (SWL) or ureteroscopy (URS) is the best management of ureteric calculi, especially for stones located in the upper ureter. This study compares URS and SWL management of upper ureteric stones directly for the first time using a different analysis tool, the matched pair analysis study design. This method enables meaningful comparisons to be made on a small number of matched patients, using precise like-for-like matching. Adult patients undergoing primary treatment of solitary radiopaque proximal ureteric stones were identified. Patients with stents, nephrostomies or stones at the pelvi-ureteric junction were excluded. Patients had a minimum of 3 months follow-up. Patients treated by primary URS were matched using four parameters (sex, laterality, stone size and location) to patients treated on a Dornier Compact Delta Lithotriptor. A total of 1479 patients had URS or SWL from which 27 upper ureteric stone matched pairs were identified. Three-month stone free rates were 82% for URS and 89% for SWL (McNemar's test, p = 0.625). Re-treatment was required in 11% and 26% following URS and SWL respectively (p = 0.219). Forty-one per cent of URS patients required an ancillary treatment, such as stent removal, compared with only 22% of SWL patients (p = 0.227). Introduction of a holmium:YAG laser for use with URS improved the stone free rate for URS to 100%. Using a robust like-for-like comparison of similar patients with very similar upper ureteric stones the outcomes following SWL and URS were comparable. Choice of treatment should therefore be based on parameters such as availability of equipment, waiting times and patient preference.

To investigate the effect of additional intravenous analgesia (besides oral analgesic premedication) on the treatment outcome in patients receiving extracorporeal shock wave lithotripsy (SWL) with Dornier Compact- Delta lithotriptor.Five hundred and twenty adults receiving SWL for solitary urinary stone of size/=10 mm were retrospectively reviewed. They received the same analgesic protocol--oral diclofenac 50 mg as premedication and additional intravenous bolus alfentanil if they experienced discomfort during ESWL. After reviewing the analgesic usage, they were divided into two groups, Group-A--received oral analgesic alone and Group-B--received both oral and additional intravenous analgesia during ESWL. Treatment outcome of the two groups was then compared.There were 306 patients in Group-A and 214 patients in Group-B. The stone-free rates at 3-month for Group-A and -B were 38.2% and 44.9% respectively (P = 0.100). The re-treatment/auxiliary procedure rates for the Group-A and Group-B were 40.8%/12.7%, and 35.0%/18.2% respectively. The additional use of intravenous analgesia improved the effectiveness quotient by 17.7% [from 0.249 (Group-A) to 0.293(Group-B)].The additional use of intravenous analgesia during SWL with Dornier Compact Delta lithotriptor resulted in improvement of effectiveness quotient.

There is consensus that more research is needed to help improve care at the end of life. Despite the fact that hospices take care of more and more dying persons every year, hospice organizations have not been highly involved in research. The National Hospice Work Group is comprised of hospice organizations that have made promotion of research a high priority. Structured interviews were conducted with members of the National Hospice Work Group to investigate how they think about the role of academic partners in their organizational missions, what their histories of involvement with academic partners are, and what they see as their most important academic needs for continuing to advance the research agenda. Members of the National Hospice Work Group see strategic partnerships with academic entities as essential to the goal of advancing research in end-of-life care.

We provide urologists with an overview of the anaesthetic consequences of the physiological changes which occur during laparoscopic surgery. An understanding of these issues is important as increased awareness by surgeons of potential problems will improve communication and understanding within the surgical team and thus help to improve patient safety. The article considers the physiological effects of pneumoperitoneum, patient position, and gas absorption as well as anaesthetic management of the changes which occur. Laparoscopic surgery offers many advantages for the patient requiring surgical treatment of urinary tract disease and the potential metabolic changes which can occur as a result are far outweighed by the shortened hospital stay and recovery time which result from use of this surgical approach.

The Technomed Sonolith Vision is the most recently developed electroconductive lithotripter. Using a case-control study, we compared the treatment outcomes of this machine with those of the Dornier Compact Delta for ureteral calculi.Patients (N = 107) with calculi from the ureteropelvic to the ureterovesical junction undergoing primary lithotripsy using the Technomed Sonolith Vision were identified between September 2004 and February 2005. All patients had 2-week and 3-month follow-up. These patients were compared with 524 patients from our database treated between October 2000 and August 2004 with a Dornier Compact Delta. The two groups were similar at baseline. Outcome variables measured were stone-free rate at 3 months, retreatment rate, and requirement for intravenous analgesia during the procedure.There was a superior stone-free rate for the Technomed, reaching significance for calculi up to 7 mm. The Technomed had a significantly lower re-treatment rate for calculi13 mm. There was no statistical difference in the requirement for intravenous analgesia. The Efficiency Quotient was superior for the Technomed (0.67 v 0.56).This latest-generation electroconductive lithotripter in its first 6 months of use has shown stone-free and re-treatment rates superior to those of the Dornier Compact Delta and approaching that of the Dornier HM-3. Lithotripsy remains our first-line treatment for all radiopaque ureteral calculi.

Objectives: The European Society of Urological Technology (ESUT) conducted a survey in order to assess and record the current trends between urologists with regard to the application of endourological stone management to identify trends and differences in treatment strategies among urologists. Methods: A total of 695 certified urologists and urological residents answered the ESUT Endourological Stone Management Questionnaire. There were 136 (28.7%) chief urologists, 240 (50.6%) staff urologists and 98 (20.7%) residents. The respondents were classified according to both the geographical origin (in four groups: Northern Europe (NE), Southern Europe (SE), Eastern Europe (EE) and Outside Europe (OE)), and department size (number of urological beds per department: small ≤25, medium 26–50 beds, large >50 beds) in order to identify any differences in the replies. Results: On average, 40.1 newly diagnosed patients and 73.6 revisits with urolithiasis are seen a month per department. According to the replies, there are no significant differences in total numbers of treatments in ESWL and/or endourological stone managements amongst the geographically based groups. Monthly, on average 68.5 ESWL treatments and 23.0 URS are performed per department. A significant majority of surveyed urologists performs URS with a rigid or semi-rigid instrument (79%) instead of a flexible instrument (21%, p =0.003). URS is more frequently performed outside Europe ( p =0.02) with a more frequent use of dormia catheters ( p p p =0.017). Nephrostomy tubes are used by 77.7% of the responding urologists. Monthly, 13.1 nephrostomy tubes are placed, mostly during PNL or after endourological procedures (40.7%). Conclusion: The data obtained from the 695 urologists and residents provides information on the performed procedures and the use of material. In general, respondents from different geographical locations perform similar procedures and use identical material; however URS and PNL are performed more frequently outside of Europe, whereas laser lithotripsy is frequently used in Northern European counties.

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

Objective: The factors associated with a successful outcome for the treatment of urinary lithiasis are well described. We reviewed current methods of imaging utilised in stone treatment planning, with specific reference to their ability to identify predictors of outcome. Methods: A literature search for articles concerning the investigation and management of patients with urolithiasis was conducted through PubMed ( www.ncbi.nlm.nih.gov/PubMed/ ). In addition a hand search of the abstract books from the most recent major urological conferences was performed to identify data of interest that have so far been presented in abstract form only. Results: Non-contrast computed tomography is superior in terms of diagnostic efficacy, with sensitivity and specificity approaching 100%. The intravenous urogram and contrast CT with 3-dimensional reconstruction provide the best anatomical detail. Conclusion: Although non-contrast helical computed tomography is the most sensitive investigation for suspected ureteric colic, the anatomical and functional information afforded by intravenous urography remains important for treatment planning in some patients.

Purpose of review Urosepsis from manipulation of the urinary tract during stone surgery can be catastrophic despite antibiotic prophylaxis and sterile pre-operative urine. We have reviewed recent literature with regards to pathogenesis, predictors of infected stones and prevention of urosepsis. Recent findings Bladder urine culture has been found to correlate poorly with infection in the upper urinary tract, defined by either stone or pelvic urine culture. This specimen, which has been the cornerstone in pre-operative preparation of patients, does not predict urosepsis. Authors recommending routine stone culture found that the presence of infected stones is highly predictive of potential sepsis. Terminology for systemic infection has been standardized and used in recent literature to define urosepsis. Summary Recent studies have recommended changes in the approach to the peri-operative management of stone surgery. Predictors of potential sepsis have also been identified.

Purpose: The Piezolith 3000 (Richard Wolf, Knittlingen, Germany) is the newest piezoelectric lithotriptor. Using a matched pair analysis model we compared treatment outcomes of this machine with those of an older generation Piezolith 2300 lithotriptor (Richard Wolf). Materials and Methods: Patients with solitary, radio-opaque urinary calculi undergoing primary lithotripsy using the Piezolith 3000 were identified. All patients had a 3-month followup. These patients were matched with those from our database treated between 1992 and 1999 with a Piezolith 2300. Patients were initially matched for gender, side and site of the stone. For stones other than those in the lower calix and lower ureter, matching was performed for size in terms of maximum and minimum diameter of the index stone. Additional anatomical factors of caliceal pelvic height and vertical distance of the lower ureteral stone from pubic symphysis were also measured. Thereafter stones with size ± 1 mm of the index stone were selected and the stone with the best matched anatomical factors was chosen. The initial stone fragmentation rate and stone-free rates at 3 months in the matched pairs were then compared. Results: A total of 25 matched pairs were found between October 2002 and December 2002. There was no statistical difference between the initial fragmentation rate for the Piezolith 3000 (68%) and the Piezolith 2300 (84%, McNemar's test p = 0.388). The stone-free rate at 3 months for the Piezolith 3000 and the Piezolith 2300 were 36% and 48%, respectively, again with no statistical difference (McNemar's test p = 0.581). Conclusions: Despite significant design changes and technical modifications, the new piezoelectric lithotriptor does not appear to provide a better treatment outcome than the older generation machine.

Purpose: Proof of the oncological safety of laparoscopic nephroureterectomy (LNU) relies on truly long-term outcome being at least equivalent to that of open surgery. We compared the long-term oncological outcome of laparoscopic versus open nephroureterectomy (ONU) in patients with upper tract transitional cell carcinoma (TCC). Materials and Methods: Between April 1992 and January 1999, 26 LNUs and 42 ONUs were performed at our hospital for suspected upper tract TCC. Hospital medical records were retrospectively reviewed to assess preoperative staging, pathology and followup. Results: There were 4 patients excluded from study (1 who underwent LNU and 3 ONU) since the histological diagnosis was other than TCC. Median followup for the laparoscopic and open groups was 101 and 96 months, respectively. There was local recurrence in 2 patients (8%) after LNU and in 6 patients (15.4%, p=0.3) after ONU. TCC recurred in the contralateral kidney or ureter in 2 LNU cases (8%) and 1 ONU case (2.6%, p=0.3). There was bladder recurrence in 7 patients (28%) following LNU compared with 15 patients (42%, p=0.2) after open nephroureterectomy. The 1 and 5-year metastasis-free survival rates were 80% and 72% for LNU compared with 87.2% and 82.1% for ONU (p = 0.33 and 0.26). Upper tract tumor grade and stage influenced the incidence of metastatic and contralateral disease, but not the incidence of local or bladder recurrence. Conclusions: In the surgical management of upper tract TCC, the laparoscopic approach does not affect long-term oncological control. Tumor stage and grade are important prognostic factors in the development of metastases and cancer specific mortality.

The Section of Endourology of the BAUS present an audit of their experience with laparoscopic nephrectomy covering a 1-year period. In this detailed analysis of results from 25 centres in the UK they found that results were similar to those reported in other parts of the world. They also showed that there was no difference in results between larger and smaller centres performing fewer than five cases per year, but suggest that this is a result of careful case selection and the use of mentors. OBJECTIVE To report the first UK national audit of laparoscopic nephroureterectomy, radical and simple nephrectomy. METHODS All members of the British Association of Urological Surgeons (BAUS) undertaking laparoscopic nephrectomy were invited to submit prospectively collected data from their centres to a nationally established database, using a standard proforma. The period covered by the audit was 1 July 2001 to 30 June 2002. The indications for surgery, peri- and postoperative data, and some demographic details were collected. RESULTS Data were received from 25 centres; 13 had undertaken five or fewer cases per year; 263 procedures were reported, including 20 of hand-assisted nephrectomy. Most cases were for nonfunctioning kidneys, or renal cell carcinoma, with transitional cell cancer and stones forming a smaller proportion. The mean (range) operative duration was 173 (89–335) min. The median postoperative stay was 4 days, with a wide range reflecting clinical and other reasons for delayed discharge. Two deaths were reported, giving a mortality of 0.7%. The mean conversion rate was 5.7% and the mean complication rate 16.8%; these rates were no higher in centres undertaking fewer than five cases per year than in the centres with a greater volume. CONCLUSION Encouragingly, this first UK audit of laparoscopic nephrectomy shows similar results to those published worldwide. The lack of any difference in outcome between smaller and larger centres may be explained by case selection and the use of mentors, as recommended by the BAUS Section of Endourology.

The contemporary management of ureteric stones is reviewed and evidence based recommendations about treatment are made. Stones measuring less than 4mm in diameter have a high chance of spontaneous passage and the main debate for optimum treatment of larger stones centres around the choice of shock wave lithotripsy or endoscopic management combined with laser fragmentation. Treatment recommendations should be based on patient preference, published evidence, local audit (surgeon expertise and availability of equipment) and cost. Artificial Neural Networks could become a useful tool for prediction of treatment outcome for ureteric stones, and further research is needed to clarify this potential. ESWL is less effective than ureteroscopy but it may prevent the need for more invasive treatment in a substantial proportion of patients. It should only be considered as initial treatment in patients with stones less than 10mm in size. The routine use of stents should be avoided as both fragmentation and stone free rates are noticeably lower. For larger stones, initial laser ureteroscopy serves better both for proximal or distal calculi and is more cost-efficient. Provided that no contraindications for general anaesthesia exist, laser ureterolithotripsy should be regarded as an excellent first line treatment modality for ureteric stone especially in greater stone burden. In the best hands, the outcome for endoscopic management of ureteric stone in all sites is better than ESWL and is cheaper, although equipment, expertise and experience are all required to achieve this superior outcome.

PURPOSE OF REVIEW Open partial nephrectomy is now recognized as the standard of care for small renal parenchymal tumors. Significant technical problems remain with regard to performing this procedure laparoscopically, namely warm renal ischemia during occlusion of the renal vascular pedicle and renal parenchymal bleeding following tumor excision and release of pedicle control. This article reviews the recent literature in the field of renal parenchymal hemostasis and its role in improving outcomes and increasing applicability for laparoscopic nephron-sparing surgery. RECENT FINDINGS Two themes emerge in reviewing the recent literature on renal hemostasis: the use of increasingly advanced tissue sealants and the use of physical methods. Advances in both areas are covered in this article. SUMMARY Laparoscopic partial nephrectomy has been developed in an attempt to reduce the morbidity of the open technique. We believe that advances in secure renal parenchymal hemostasis will increase the applicability of the laparoscopic procedure and bring it within the grasp of ordinary urologists.

Objective: To report a multicenter analysis after laparoscopic radical nephroureterectomy for pathologically confirmed upper tract transitional cell carcinoma. Materials and Methods: A total of 116 patients (72 males; mean age 68 years) underwent laparoscopic radical nephroureterectomy at five international institutions: 51 transperitoneally, 65 retroperitoneally. Location of the primary tumor was pelvicalyceal in 70 patients (60%), ureteral in 27 (23%), and multifocal in 19 (17%). In 18 patients (15%), transurethral resection was performed for concomitant bladder tumor. The median follow-up time was 25 months (range 3–93). A minimum follow-up of 1 and 2 years was available in 77 and 41 patients, respectively. Results: Five patients (4%) were converted to open surgery. The specimen was extracted intact in all 116 patients: using an Endocatch bag in 78 patients, a Lapsac in 5, and manually in 33. Pathologic staging was pTis in 5 (4%), pTa in 41 patients (35%), pT1 in 31 (26%), pT2 in 18 (15%), pT3 in 16 (13%), and pT4 in 5 (4%). Pathological grade was grade I in 26 patients (23%), grade II in 41 (35%), grade III in 34 (29%) and grade IV in 15 (12%). Histopathology revealed a positive surgical margin in five patients (4.5%): renal hilum (one), periureteral soft tissue (two), distal edge of the ureter/ bladder cuff (two). Local recurrence was noted in two patients (1.7%). Bladder recurrence was noted in 28 patients (24%) with a mean time to recurrence of 13.9±11.5 months. Distant metastases occurred in 11 patients (9%): lung (5), liver (3), bones (2), adrenal (1); mean time to metastasis was 13 months. Overall, 23 patients (20%) died. One-year and 2-year cancer-specific survival was 92% and 87%, respectively. Two-year cancer-specific survival according to pathologic stage was 89% for patients with pT1 disease, 86% for pT2, 77% for pT3, and 0% for pT4 ( p =0.0001). Two-year survival according to pathologic grade was 88% for grade I, 90% for grade II, 80% for grade III, and 90% for grade IV ( p >0.05). Conclusion: Laparoscopic radical nephroureterectomy appears to be an effective minimally invasive treatment for select patients with upper tract transitional cell carcinoma. Although the 2-year survival data reported herein are encouraging, longer follow-up is needed before laparoscopy can be considered as a standard treatment.

Shockwave lithotripsy (SWL) is the least invasive treatment for ureteral calculi and is the best accepted by patients and clinicians. This prospective study was performed to evaluate the results of SWL for all ureteral calculi.Between April 1999 and May 2000, there were 150 SWL treatments for ureteral calculi at our center. All patients who completed treatment (24 females, 126 males with an average age of 54 +/- 14 years) were entered in the study and were assessed at 1 and 3 months with a plain film of the kidneys, ureters, and bladder and an ultrasound scan or intravenous urogram if clinically indicated. The outcome has been analyzed according to stone size, location (lower ureter [LU], midureter [MU], and upper ureter [UU], number of treatments per stone, number of shocks per stone, and stone-free rate (SFR). The analgesia requirements during each treatment and complications have also been analyzed.The SFR in the UU was 77% at 1 month and 85% at 3 months. The SFR in the MU was 74% at both 1 and 3 months. The SFR in the LU was 65% at 1 month and 74% at 3 months. Overall, the SFR for all calculi was 72% at 1 month and 79% at 3 months. Ureteroscopic extraction was necessary in 19% of the patients and conservative management for the remaining asymptomatic fragments, which were 2 mm or smaller. All of these asymptomatic fragments were seen to have passed spontaneously on follow-up imaging studies. Ureteral stents were not placed routinely prior to SWL, but there were 32 calculi (21%) for which stents had been placed prior to SWL: 29 (19%) in the UU, 3 (2%) in the MU, and 0 in LU. There was no difference in the SFR or ureteroscopy rate in UU calculi treated with or without stents and no difference in the number of treatments needed to achieve these SFRs. The efficiency quotient for the UU was 55%, 45% for the MU, and 45% for the LU. Oral analgesia was given routinely; however, additional intravenous analgesia was necessary in 24% of treatments. No serious complications were seen.The Dornier Compact Delta lithotripter provides an effective noninvasive treatment for ureteral calculi that is achieved with minimal anesthesia and a low complication rate. Placement of ureteral stents prior to SWL does not enhance the SFR or obviate intervention if SWL fails. We recommend a low threshold for ureteroscopic treatment if significant progress is not made in fragmenting the stone with SWL.

Extracorporeal Shockwave Lithotripsy (SWL) is now the best noninvasive treatment for renal calculi, rendering many patients stone free. This prospective study was performed to evaluate the short-term results of patients undergoing SWL with the Dornier Compact Delta lithotripter for all renal calculi.Between April 1999 and May 2000, there were 500 renal calculi treated in 166 female and 334 male patients with a mean age of 53 +/- 15 years. All patients who completed treatment were entered in the study and assessed at 1 and 3 months with a plain film of the kidneys, ureters, and bladder. Stone-free rate and final outcome have been evaluated. Final outcome is defined as stone free or residual fragments 4 mm or less. Analysis has been made according to stone size, location, number of treatments per stone, and number of shocks per stone. The analgesia requirements during each treatment and complications have also been analyzed.The overall stone-free rate for stones10 mm was 62% at 1 month and 76% at 3 months. For stones 10 to 20 mm, these rates were 53% and 66%, while the rates for stones20 mm were 41% and 47%, respectively. The final outcome for stones10 mm was 90% at 1 month and 93% at 3 months, for stones 10 to 20 mm 73% and 84%, and for stones20 mm 57% and 67%, respectively. The effectiveness quotient for calculi10 mm was 60%. For calculi 10 to 20 mm, it was 51%, and for those20 mm, it was 31%. Oral analgesia was given routinely; however, additional intravenous analgesia was necessary in 22% of treatments. No serious complications have been seen.These results show that with proper patient selection, good results at 1 and 3 months can be achieved with minimal anesthesia during treatment and low retreatment rates. We do not recommend SWL as primary therapy for stones20 mm.

Objective: Laparoscopic nephroureterectomy (LNU) offers a superior morbidity profile compared with open nephroureterectomy (ONU) in treating upper urinary tract urothelial cell carcinoma. Evidence of oncological equivalence between LNU and ONU is limited. We compare operative and oncological outcomes for LNU and ONU using matched-pair analysis. Methods: Of 159 patients who underwent a nephroureterectomy at a single institution between April 1992 and April 2010, 13 pairs of ONU and LNU patients were matched for gender, age, tumour location, tumour grade and stage. Operative details, post-operative characteristics and recurrences were collated and survival rates analysed using the Kaplan-Meier method. Results: There was no significant difference in mean operation time between LNU (191 min) and ONU (194 min, p = 0.92). There was no significant difference in the 5-year survival rate between LNU and ONU (overall survival 59.1% vs. 73.5%, p = 0.18; progression-free survival 24.0% vs. 56.0%, p = 0.14; cancer-specific survival 60.9% vs. 73.5%, p = 0.56; bladder cancer recurrence-free survival 8.7% vs. 0.0%, p = 0.09). Conclusion: Amidst limited RCT and comparative studies, this study presents further evidence of oncological equivalence between LNU and ONU. There was a trend towards poorer outcomes following LNU though, which merits further study.

Objectives To assess the long-term outcome of the endourological management of upper tract transitional cell carcinoma (TCC) by laparoscopic nephroureterectomy (LNU) or open nephroureterectomy (ONU). Patients and methods The records and pathology reports were reviewed retrospectively for 67 nephroureterectomy specimens (42 obtained by ONU and 25 by LNU). The grade, stage, lymph node status and site of the tumour were recorded for each patient. The primary end-point of the follow-up was disease-related death. Results Overall there was a high proportion of G2 (44%) and G3 (39%) disease, with a significant correlation between increasing grade and stage of TCC (r = 0.74, P

Objective To compare endopyelotomy and primary reconstructive procedures in patients with pelvi-ureteric junction (PUJ) obstruction and with risk factors for endopyelotomy failure. Patients and methods Nineteen patients (eight female and 11 male, mean age 34.5 years, range 15–82) underwent endoluminal ultrasonography (US) before treatment for PUJ obstruction; the US findings were used to direct the treatment. Patients with unavoidable crossing vessels, massive hydronephrosis and crossing vessels associated with previous failed endopyelotomy were selected for reconstructive surgery. The clinical results of these patients (group 1) were compared with 12 consecutive patients who had undergone endopyelotomy before the use of endoluminal ultrasonography (group 2). Results Imaging detected 17 crossing vessels in 13 of the 19 patients. Six patients underwent primary reconstructive surgery and 13 underwent endopyelotomy. The endoluminal US findings changed treatment in some way in nine patients. Endopyelotomy was successful in 12 of the 13 patients and reconstructive surgery successful in five of six patients. The success after endopyelotomy improved from eight in 12 patients in group 2 to 12 of 13 in group 1 (P = 0.16, NS). Conclusions Endoluminal US can be used to select patients in whom endopyelotomy is likely to fail. Using primary reconstructive procedures in these patients might improve the overall outcome, but these preliminary findings need to be confirmed in a larger study.

Objective To compare innate spatial awareness skills, using the MIST-VR system (Ethicon Ltd, Edinburgh, a computer-based virtual reality system that objectively tests spatial awareness) among three groups of people (consultant urologists, urological trainees and controls who were not surgeons), because urological surgeons require spatial awareness for endoscopic and laparoscopic surgery, but trainees are selected by academic prowess rather than surgical aptitude. Subjects and methods The MIST-VR system was used to test 122 volunteers in three groups, i.e. 39 consultant urologists, 46 urological trainees and 37 controls (not surgeons). The demographic data recorded for each group included age, sex, eyesight, handedness, and endoscopic and laparoscopic experience. Volunteers performed a repetitive series of three tasks using the system. Their performance was measured in terms of time, errors and economy of movement, as well as the duration and accuracy of diathermy in Task 3. Results The consultants were significantly older than the trainees and controls (both P 2sd above the mean and several people could not complete Task 3. Conclusions Urologists do not differ from the general population in terms of innate spatial ability in this setting. There are several people who may have a defect in spatial awareness but the incidence was the same in each group. Urological trainees outperformed consultants in these tasks; the reasons for this are unclear. The MIST-VR system is of no help in aptitude testing for urological trainees, although it may have a role in teaching laparoscopic surgery. Testing other psychometric components may be more important for acquiring surgical skills than innate spatial-awareness skills. Further studies are required to investigate this possibility.

OBJECTIVE To review the results of our experience with a mentorship programme in laparoscopic nephrectomy, set up in 1999 by the British Association of Urological Surgeons Section of Endourology. METHODS Mentors were contacted in 2007 to submit data on the number of visits and the outcome, which included whether a urologist was able to establish an independent laparoscopic practice and sustain it. RESULTS Four urologists acting as mentors reported a total of 164 procedures carried out in the training of 39 urologists during 148 visits. There were no conversions to open surgery and only one major complication. Overall, 29 of 39 mentored consultants were able to establish an independent laparoscopic practice and 23 continue to do so. The number of visits was associated with initial success, although this was not statistically significant. Working in a large department was associated with being able to sustain a laparoscopic practice. More experienced consultants were less likely to have initial success, but were more likely to sustain a successful practice. CONCLUSIONS Mentorship for laparoscopic nephrectomy has been carried out safely thus far. Sustaining a laparoscopic practice requires a critical volume of cases. Future efforts should be focused on trainees rather than consultants.

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.