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Background Renal stone disease is common and can cause emergency presentation with acute pain due to ureteric colic. International guidelines have stated the need for a multicentre randomised controlled trial (RCT) to determine whether a non-invasive outpatient (shockwave lithotripsy [SWL]) or surgical (ureteroscopy [URS]) intervention should be the first-line treatment for those needing active intervention. This has implications for shaping clinical pathways. Objective To report a pragmatic multicentre non-inferiority RCT comparing SWL with URS. Design, setting, and participants This trial tested for non-inferiority of up to two sessions of SWL compared with URS as initial treatment for ureteric stones requiring intervention. Outcome measurements and statistical analysis The primary outcome was whether further intervention was required to clear the stone, and secondary outcomes included quality of life assessment, severity of pain, and serious complications; these were based on questionnaires at baseline, 8 wk, and 6 mo. We included patients over 16 yr with a single ureteric stone clinically deemed to require intervention. Intention-to-treat and per-protocol analyses were planned. Results and limitations The study recruited between July 1, 2013 and June 30, 2017. We recruited 613 participants from a total of 1291 eligible patients, randomising 306 to SWL and 307 to URS. Sixty-seven patients (22.1%) in the SWL arm needed further treatment compared with 31 patients (10.3%) in the URS arm. The absolute risk difference was 11.7% (95% confidence interval 5.6%, 17.8%) in favour of URS, which was inside the 20% threshold we set for demonstrating noninferiority of SWL. Conclusions This RCT was designed to test whether SWL is non-inferior to URS and confirmed this; although SWL is an outpatient noninvasive treatment with potential advantages both for patients and for reducing the use of inpatient health care resources, the trial showed a benefit in overall clinical outcomes with URS compared with SWL, reflecting contemporary practice. The Therapeutic Interventions for Stones of the Ureter (TISU) study provides new evidence to help guide the choice of modality for this common health condition. Patient summary We present the largest trial comparing ureteroscopy versus extracorporeal shockwave lithotripsy for ureteric stones. While ureteroscopy had marginally improved outcome in terms of stone clearance, as expected, shockwave lithotripsy had better results in terms of health care costs. These results should enable patients and health care providers to optimise treatment pathways for this common urological condition.

Faris Abushamma,1,2 Mahfouz Ktaifan,1 Abdoh Abdallah,1 Mohammad Alkarajeh,1 Mosab Maree,1,3 Ahmed Awadghanem,1,3 Ahmad Jaradat,1,2 Amir Aghbar,1,2 Sa’ed H Zyoud,4,5 Francis X Keeley Jr6 1Department of Medicine, College of Medicine and Health Sciences, An-Najah National University, Nablus, 44839, Palestine; 2Department of Urology, An-Najah National University Hospital, Nablus, 44839, Palestine; 3Department of Radiology, An-Najah National University Hospital, Nablus, 44839, Palestine; 4Department of Clinical and Community Pharmacy, College of Medicine and Health Sciences, An-Najah National University, Nablus, 44839, Palestine; 5Clinical Research Center, An-Najah National University Hospital, Nablus, 44839, Palestine; 6Bristol Urological Institute, North Bristol NHS Trust, Bristol, UKCorrespondence: Faris AbushammaDepartment of Medicine, College of Medicine and Health Sciences, An-Najah National University, Nablus, 44839, PalestineEmail farisabushamma@hotmail.comPurpose: Acute ureteric colic (AUC) is generally one of the most common reasons for emergency department attendance. Expectant management is recommended in non-complicated ureteral calculi. However, data regarding the optimal duration of observation or indications of early intervention (EI) are not well understood. This article describes the clinical and radiological factors that promote EI in AUC.Patients and Methods: This was an observational and retrospective cohort study. Patients with AUC diagnosed based on non-contrast computerized tomography (NCCT) between 2019 and 2020 were enrolled in the study. These patients were classified into two main categories: spontaneous passage of stone (SSP) and EI. In addition, a comparative analysis was performed to identify clinical and radiological variables that promote EI.Results: One-hundred and sixty-one patients were included. High WBCs are associated with a significant increase in EI. Forty-three percent (n=37) of patients with serum WBCs higher than 10 had an EI, while 23% had SSP (n=17;p< 0.001). High CRP level is also significantly associated with EI (n=36; 86%; p< 0.001). Upper and middle ureteral calculi are statistically associated with EI (n=54; 62%) in comparison to the SSP cohort (n=22; 30%;p< 0.001). EI is also linked to the maximal length of ureteric calculi (MCL) of 9 mm (6– 13mm), and HU density of stone of 700 (430– 990) H.U (p< 0.001). Ureteric stone volume of 0.2 (0.06– 0.3) cm3 is significantly associated with EI (p< 0.001). Ureteral wall thickness of 3 (2– 3 mm), the presence of extrarenal pelvis (n=20; 23%), and AP diameter of renal pelvis 18 (13– 28 mm) are all significantly associated with a higher rate of EI (p< 0.001). Multiple binary logistic regression analysis showed that MCL is the strongest predictor of EI.Conclusion: MCL is an independent and robust predictor of EI in AUC. Biochemical variables and radiological characteristics can also act as an adjunct to promote EI.Keywords: ureteral calculi, medical expulsive therapy, spontaneous stone passage, maximal length of ureteral calculi, pyonephrosis

INTRODUCTION AND OBJECTIVE:Performing image-guided biopsy of incidental small renal masses (SRMs) pre-treatment to minimise overtreatment of benign renal masses is advocated. This study aims to ass...

The final clinical session of the British Association of Urological Surgeons (BAUS) annual meeting is the Updates and Highlights session, where the most important advances in the main urological sub-specialities are summarised and presented by sub-specialist experts representing each BAUS section. The aim of the session is to disseminate knowledge on the latest research, new guidelines and changes to general and specialist clinical practice. This paper covers contemporary urological advances as presented at the Liverpool BAUS meeting in June 2018.

Public reporting of consultant/staff urologist outcomes must rely on commonly performed procedures, accurate data input, and adequate funding. Precautions must be taken to ensure that this information is utilised in the best interests of informing the public and surgeons.

Introduction Nitrofurantoin (NF) is prescribed for urinary tract infections (UTIs). Associated adverse pulmonary and hepatic side-effects are known. Current monitoring guidelines1 2 lack specific recommendations for monitoring. This work formed part of a clinical effectiveness project to raise awareness of side effects of prophylactic NF and allow recommendations for monitoring. Methods We undertook 1) Audit (1st-31st July 2020) of GP surgeries in local clinical commissioning group (CCG) who prescribed prophylactic NF and assessed their monitoring habits. (2) Assessment of GPs’ and urologists’ prescribing habits and awareness of complications associated with prophylactic NF. (3) Audit of patients diagnosed with nitrofurantoin-induced interstitial lung disease (NFILD) by our ILD center (2014–2020). Results 503 patients in local CCG were prescribed prophylactic NF at time of audit. 265/503 were on prophylaxis for 0–2 years, 40% of these for >6 months to 2 years. Of those patients on NF >6 months to 2 years, 45% received no monitoring, 21% received both lung and liver monitoring, 20% received only liver monitoring and 14% received only lung. 238/503 patients were on prophylaxis for >2 years; in this cohort 20% received no monitoring, 44% received both lung and liver monitoring, 21% received only liver monitoring and 15% received only lung. Of 125 questionnaire respondents prescribing prophylactic NF, 82% were GPs and 12% urologists. 47% followed CCG guidelines whilst 38% followed national guidelines. 58% were aware of liver complications and 72% aware of respiratory. However, 41% and 53% were never monitored for liver and lung complications respectively. Our centre diagnosed 46 patients with NIILD. 80.4% were female, mean age 72 years. 70% were prescribed NF for recurrent UTIs and 58.7% were prescribed for >6 months. Of this cohort, 61% displayed resolution (complete/with minimal fibrosis) on HRCT following removal of NF, 16% developed fibrosis and 23% showed no interval change. There was no difference in subset analysis of those treated with steroids from those not. Conclusion NF complications can bear significant impact on patient’s health. Improving awareness and monitoring is crucial and must be addressed. Increased clarity of monitoring guidelines will circumvent side effects of NF. References https://bnf.nice.org.uk/drug/nitrofurantoin.html https://remedy.bnssgccg.nhs.uk/media/3207/recurrent-utis-in-women-may-17.pdf

BackgroundLong-term nitrofurantoin (NF) treatment can result in pulmonary and hepatic injury. Current guidelines do not outline the type or frequency of monitoring required for detection of these injuries.AimTo assess 1) awareness of NF complications among prescribers; 2) monitoring practice; and 3) to describe the pulmonary sequelae of NF-related complications.Design & settingEvaluation of prescribing habits by questionnaires and review of GP databases, and case-note review in secondary care.MethodThe following study procedures were undertaken: 1) an electronic questionnaire was distributed to prescribers, interrogating prescribing and monitoring practices, and awareness of complications; 2) an analysis was undertaken (June–July 2020) of NF monitoring among GPs in the local clinical commissioning group (CCG); and 3) a case review was carried out of patients diagnosed with NF-induced interstitial lung disease (NFILD) at the interstitial lung disease (ILD) centre (2014–2020).ResultsA total of 125 prescribers of long-term NF responded to the questionnaire (82.4% GPs; 12.0% urologists). Many were unaware of the potential for liver (42.4%) and lung (28.0%) complications; 40.8% and 52.8% never monitored for these, respectively. Only 53.3% of urologists believed themselves responsible for arranging monitoring, while nearly all GPs believed this to be the prescriber’s responsibility (94.2%). One-third of all responders considered current British National Formulary (BNF) guidelines 'not at all sufficient/clear', with mean clarity scoring of 2.2/5. Among patients with NFILD (n = 46), NF had been prescribed most often (69.6%) for treatment of recurrent UTI and 58.6% (n = 27) were prescribed for >6 months. On withdrawal of the medication 61.4% displayed resolution (completely or minimal fibrosis), while 15.9% of patients had progressive lung fibrosis.ConclusionNF can cause marked or irreversible lung complications and there is currently a shortfall in awareness and monitoring. Existing monitoring guidelines should be augmented.

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

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

Introduction Surgeon-specific outcome data, or consultant outcome publication, refers to public access to named surgeon procedural outcomes. Consultant outcome publication originates from cardiothoracic surgery, having been introduced to US and UK surgery in 1991 and 2005, respectively. It has been associated with an improvement in patient outcomes. However, there is concern that it may also have led to changes in surgeon behaviour. This review assesses the literature for evidence of risk-averse behaviour, upgrading of patient risk factors and cessation of low-volume or poorly performing surgeons. Materials and methods A systematic literature review of Embase and Medline databases was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Original studies including data on consultant outcome publication and its potential effect on surgeon behaviour were included. Results Twenty-five studies were identified from the literature search. Studies suggesting the presence of risk-averse behaviour and upgrading of risk factors tended to be survey based, with studies contrary to these findings using recognised regional and national databases. Discussion and conclusion Our review includes instances of consultant outcome publication leading to risk-averse behaviour, upgrading of risk factors and cessation of low-volume or poorly performing surgeons. As UK data on consultant outcome publication matures, further research is essential to ensure that high-risk patients are not inappropriately turned down for surgery.

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

Nephrolithiasis contributes significantly to the worldwide healthcare burden. Patient-reported outcome measures (PROMs) are widely recognized as important outcome measures for patient-centered care. We sought to summarize what is currently known about PROMs in urinary stone disease and to characterize use of PROMs in randomized controlled trials (RCTs) for nephrolithiasis.Health-related quality of life (HRQOL) in patients with nephrolithiasis is reviewed. A search of both MEDLINE and EMBASE databases for RCTs in nephrolithiasis was performed to assess utilization of PROMs in these trials. All searches were for articles published between 1990 and 2014. Two independent reviewers reviewed all abstracts to determine inclusion for full-text review, with disagreements reviewed by a separate arbitrator.Validated methods for collecting PROMs include symptom diaries, pain scales, and validated HRQOL instruments. HRQOL is impacted in patients with nephrolithiasis and may be related to gender, proximity of a recent colic episode, or treatment modality. One validated instrument has been created in the nephrolithiasis population, while a treatment-specific questionnaire on ureteral stents has also been developed. PROMs are variably reported in RCTs for nephrolithiasis. Few trials utilize validated HRQOL instruments and none utilizes a disease-specific instrument.HRQOL is diminished in patients with urolithiasis, especially in times near to an acute stone event. Only one validated HRQOL instrument exists specific to nephrolithiasis. No validated instrument exists to assess the outcomes from different management options for renal and ureteral stones. Development of condition-specific PROMs instruments should aim to account for the heterogeneous and episodic nature of the disease and its treatment. Effective reporting of PROMs is lacking in the RCTs for nephrolithiasis. Future RCTs for urolithiasis standardize reporting of PROMs.

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

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

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

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

We performed a systematic review of the literature regarding the diagnosis and treatment of caliceal diverticulum (CD).The search strategy was conducted according to the Cochrane review guidelines for systematic reviews and Preferred Reporting Items for Systematic reviews and Meta-Analyses checklist.In total 1189 titles and abstracts were reviewed, of which 101 were selected for article evaluation. Of these 101 articles, 40 were selected for inclusion after full article evaluations. In the extracted article, intravenous urography (IVU), rather than CT urography, was the main imaging tool for diagnosis, although many articles had failed to provide any imaging modality information. The extracted articles included 88, 153, and 487 patients who underwent shock wave lithotripsy (SWL), flexible ureteroscopy/retrograde intrarenal surgery (fURS/RIRS), and percutaneous nephrolithotomy (PCNL), respectively. Stone-free rates were 21.3% (SWL), 61.4% (fURS/RIRS), and 83.0% (PCNL). The complication rates were 8.0% (SWL), 3.3% (fURS/RIRS), and 11.9% (PCNL). There was incomplete and inconsistent reporting of even basic clinical parameters, such as the size and location of the CD, number of stones, outcomes, and complications. There was a striking lack of follow-up data, despite a known high recurrence rate. The literature on laparoscopic management was too sparse to analyze.This meta-analysis revealed that there are not enough high-quality studies to evaluate the ideal strategy for the diagnosis and treatment of CDs. This systematic review emphasizes (a) the importance of contrast imaging for CD diagnosis, (b) higher success rates but also higher complication rates in PCNL compared with SWL and FURS, and (c) the need for standardized reporting of outcomes to include complications, number of interventions, symptom resolution, stone clearance, and CD ablation.

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

Objective: To report the complications of laparoscopic renal surgery from the British Association of Urological Surgeons (BAUS) database over ten years. Patients and methods: All entries for laparoscopic renal surgery between 2002 and 2012 were included for analysis. Data was refined, collated and presented in graphical or tabular form. The primary outcome measures were intra-operative, post-operative and overall complications rates. Secondary outcome measures were length of stay, conversion to open surgery and operative time. Results: A total of 16,869 cases were included for analysis. The overall complication rate was 14.7%, with intra-operative complications reported for 3.5% of procedures and post-operative complications reported for 12.1% of procedures. The overall complication rate decreased throughout the audit period, from 16.6% in 2002 to 15.1% in 2012. The capture rate is estimated at 30% and the group of surgeons motivated to self-report may not be representative of the whole group. Comparison with other series is difficult due to a lack of a standardized reporting format. Conclusion: This is the largest surgeon-reported series of laparoscopic renal surgery to date. There is an inherent bias in self-reported data which limits the conclusions that can be drawn, although the safe introduction of this technique and the continuing improvement in complication rates are suggested.

Objective: To conduct a systematic review and meta-analysis investigating the efficacy and safety of medical expulsive therapy (MET) in low risk of bias (RoB) randomised controlled trials (RCTs). Methods: A Cochrane style systematic review was conducted on published literature from 1990 to 2016, to include low RoB and a power calculation. A pooled meta-analysis was conducted. Results: The MET group included 1387 vs 1381 patients in the control group. The analysis reveals α-blockers increased stone expulsion rates (78% vs 74%) (P 5 mm (P = 0.02), as well as distal ureteric stones (P 5 mm one in eight, and for distal stones one in 10. Conclusion: The primary findings show a small overall benefit for α-blockers as MET for ureteric stones but no benefit with CCBs. α-blockers show a greater benefit for large (>5 mm) ureteric stones and those located in the distal ureter, but no benefit for smaller or more proximal stones. α-blockers are associated with a greater risk of side-effects compared to placebo or CCBs.

Objective To validate the Arabic version of the Ureteral Stent Symptoms Questionnaire (USSQ). Patients and methods The English version of the USSQ was translated into Arabic using a multi-step process by three urologists and two independent translators. The Arabic version was validated by asking 37 patients with temporary unilateral ureteric stents to complete the questionnaire at 2 weeks after stent insertion. The second group included 53 healthy individuals who agreed to complete the Arabic version of the questionnaire. The reliability of the Arabic version was evaluated for internal consistency using Cronbach’s α test. Domain structures were examined by interdomain (section) associations using Spearman’s correlation coefficient (r). The discrimination validity was evaluated by comparing the scores of patients with those of healthy individuals, using the Mann–Whitney test. Results Internal consistency was high for the sexual index and intermediate for urinary, pain and general health indices. There were good correlations of urinary symptoms with body pain (r = 0.596) and general health (r = 0.690). There was also a good correlation between body pain and general health (r = 0.681). For discrimination validity, there were significant changes in all domain scores when comparing patients with ureteric stents and healthy individuals (P

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

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

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

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

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

INTRODUCTION AND OBJECTIVES: LithoVue TM is a new single use digital flexible ureteroscope. The aim of this study was to evaluate it compared to a standard fibre-optic flexible ureteroscope, with respect to image quality and maneuverability within a live porcine renal collecting system. METHODS: Flexible ureteroscopy was performed in three anaesthetised pigs by six experienced endourologists using fluoroscopic guidance and standard techniques with the Boston Scientific LithoVue TM disposable digital flexible ureteroscope and compared to an Olympus P5 TM fiber optic flexible ureteroscope. Each operator operated on one kidney, and attempted to access all areas of the collecting system either by accessing the kidney over a wire of via and access sheath or both. Passage of a 1.9Fr Escape TM or 1.9 or 3 Fr Fr Zero-tip TM basket and a 200 micron TracTip TM or Flexiva TM laser fibre was undertaken, and effect on deflection and visibility noted. Users were asked standard questions on completion, and also rated image quality of the LithoVue TM system compared to the P5. RESULTS: All operators were able to access all areas of the collecting system, and complete the schedule of tasks including passage of the basket and laser fibre through the ureteroscope. Ureteroscope set up and use, access and navigation, image quality, field of view, depth of field, and lithotripsy compatibility were all rated as clinically acceptable. All operators answered the statement 0 The user was able to access, visualize, diagnose, and aid on the treatment of stones and conditions in the kidney, ureter and bladder better thanks or equal to the standard of care amongst current flexible ureteroscopes0 positively. When asked to compare the image quality of the LithoVue TM to the P5 , on a scale of 1 to 7, where 1 is superior P5 TM performance, 4 is similar performance, and 7 is superior LithoVue TM performance, operators gave a median score of 7, with a mean score of 6.86. CONCLUSIONS: The LithoVue TM single-use digital flexible ureteroscope gives excellent views of the collecting system when compared to a P5 TM fibre-optic ureteroscope and is able to access all calyces in a porcine model, without significant loss of deflection or visibility with passage of a laser fibre or 1.9Fr basket. Further studies in humans are needed to determine the clinical utility of this new ureteroscope.

Carcinoma in situ of the urinary tract is a high grade form of nonmuscle invasive urothelial cancer. Our understanding of this entity in the upper tract is poor, and case management remains challenging due to knowledge gaps regarding the definition, diagnosis, treatment options and followup of the disease. We reviewed the available literature for similarities and differences between bladder and upper tract carcinoma in situ, and herein summarize the best available data.We reviewed PubMed® and MEDLINE™ databases from January 1976 through September 2014. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement was used to screen publications. All authors participated in the development of a consensus definition of disease.A total of 61 publications were found suitable for this review. All studies were retrospective. Compared to bladder carcinoma in situ, upper tract carcinoma in situ appears to have lower progression rates and improved survival. All available studies demonstrate topical therapy to be effective in treating upper tract carcinoma in situ, with decreased recurrence rates compared to bladder carcinoma in situ. Highlighted areas of current knowledge gaps include variable definitions of disease, methods of drug delivery and ideal treatment course. Improving methods for detection may allow easier diagnosis and more effective treatment.Based on the available data, organ preserving therapy with topical agents is an alternative to radical surgery in select patients with upper tract carcinoma in situ, although this method has not been evaluated in prospective trials. A paradigm shift regarding detection and treatment is needed to improve care and allow better renal preservation. A consensus definition of the disease is offered, and several areas of major knowledge gaps and opportunities for future research are identified.

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

Urinary stone disease is an increasingly prevalent condition for many patients under the care of GPs. Recognizing the importance of lifestyle factors on stone development will enable GPs to manage their ‘at-risk’ patients more effectively. The aim of this article is to describe the important lifestyle factors that when modified will reduce both patients' risk of stone development and recurrence. Furthermore, the significance of stone disease as a marker of more systemic diseases, such as metabolic syndrome, is highlighted.

Consultant Outcome Publication (COP) regarding outcomes of operations done by individual surgeons was introduced to UK Urology in 2012 with the first publication of the Nephrectomy Outcomes Database. COP was championed as a policy to increase transparency of surgical outcomes for patients and also the quality of surgery. To date, there has been limited research assessing surgeon opinion on introduction of the mandatory health policy. We evaluated opinions of UK consultant urologists regarding COP and identified potential areas of improvement.

We review the recent publications on developing engineering and pharmaceutical agents to alleviate stent related symptoms, and examine basic science studies that may support a particular approach.Data on randomized controlled trials for relief of stent related symptoms were analyzed. Studies involving engineering and pharmacological agents to resolve stent related morbidity were assessed separately.A variety of physical characteristics of stents, including materials, diameter, length and shape, have been modified to reduce stent related symptoms. Numerous studies have been conducted to engineer the ideal stent without clear and definite conclusions. There are mixed results with materials and negative results with shape. Appropriate stent length appears to be important but decreased diameter has not been shown to help. A recent study using a ketorolac eluting stent showed no significant benefit. Even with the best material and length it appears that patients still have significant stent related symptoms. To relieve stent related symptoms several classes of oral medications have been proposed for off-label use based on intuition or experience. Recently prospective, randomized, placebo controlled trials have been performed, along with basic science studies regarding the pharmacology of the ureter. They showed a clear and consistent beneficial effect of alpha1-blockers in patients with indwelling ureteral stents.Although there have been many advances in stent composition, construction geometry and design, the ideal stent has yet to be engineered. By contrast, the oral administration of alpha-blockers has shown the greatest reduction in stent morbidity.

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? Although it has long been known that ureteric stenting is associated with significant morbidity in a high proportion of patients, predictors of morbidity remain largely elusive. In a multivariable analysis of potential predictors of morbidity using the Ureteric Stent Symptoms Questionnaire, an easy-to-determine variable, i.e. the location of stent distal loop with respect to body midline, emerged as the strongest predictor of morbidity. Patients with stent distal loop crossing the midline experienced worse symptoms. The visualization of stent distal loop may, thus, help identify patients at higher risk of morbidity requiring early management. OBJECTIVE To assess the predictors of morbidity in patients with indwelling ureteric stents using a validated questionnaire. PATIENTS AND METHODS Eighty-six consecutive patients with indwelling double-J ureteric stent of different length and size enrolled at an Italian tertiary academic centre were prospectively evaluated with the Italian-validated Ureteric Stent Symptoms Questionnaire (USSQ), which explores the stent-related symptoms in six domains. Ureteric stents were placed for benign ureteric obstruction or after uncomplicated ureterorenoscopy, and were all removed after 28 days. The questionnaire was administered on days 7 and 28 after stent placement and on day 28 after removal. A plain abdominal X-ray was performed on days 7 and 28 after placement to determine stent location. Univariable and multivariable analyses tested the association of patient age, sex and body mass index (BMI), and stent side, length, calibre and distal loop location, with the index score of the various domains on days 7 and 28. RESULTS All patients completed the study. At multivariable analysis, on day 7, sex, BMI and stent calibre were significantly associated with one domain (general health, body pain and work performance, respectively), while location of stent distal loop was significantly associated with five domains (urinary symptoms, body pain, general health, work performanc, and sexual matters). On day 28, body mass index was significantly associated with two domains (body pain and general health), while location of stent distal loop remained significantly associated with the same five domains (urinary symptoms, body pain, general health, work performance and sexual matters). CONCLUSION Location of stent distal loop with respect to midline had the strongest association with most domains of the USSQ on both days 7 and 28 after stent placement. The visualization of stent distal loop crossing the midline may therefore identify patients at higher risk of post-procedural morbidity requiring early management.

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

We reviewed the literature on the surgical treatment of urolithiasis. All prospective, randomized trials on the surgical treatment of stone disease were reviewed. Percutaneous nephrolithotomy (PNL) is superior to shockwave lithotripsy (SWL) or open surgery in the treatment of staghorn calculi. For ureteral stones, ureteroscopy appears to result in a higher stone-free rate and lower need for retreatment compared with SWL but has a higher complication rate and increased hospital stay. For lower pole renal calculi, PNL results in a higher stone-free rate and lower need for retreatment compared with SWL but has a higher complication rate and increased hospital stay. Most areas of surgical stone treatment have been addressed by a randomized controlled trial; however, most trials were of poor quality. Trials tend to focus only on radiologic outcomes. No study to date has been able to show a measurable quality of life benefit to patients, possibly because no condition-specific quality of life instruments have been developed. In addition, economic impact, both direct and indirect, has been rarely characterized. The surgical treatment of kidney stones is poorly researched. Future trials should be performed with adequate funding and patient-focused outcomes.

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