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The Endourological Society, the premier urologic society encompassing endourology, robotics, and focal surgery, is composed of a diverse group of1300 urologists. However, limited information has been collected about society members. Recognizing this need, a survey was initiated to capture data regarding current member practices, as well as help the Society shape the future direction of the organization. Presented herein is the inaugural Endourological Society census report as the beginning of a continued effort for global improvement in the field of endourology. Using a REDCap

Objective: To examine the readability of urology webpages to assess their suitability for the general population and their inclusivity for varied levels of health literacy. Methods: We accessed all urology department websites from NHS trusts in England. A standard framework was used to assess these for ease of navigation, availability and quality of urology-specific information. Text was analysed using Flesch–Kincaid Grade Level and Ease Score to measure readability. Results: From the 132 NHS trust websites investigated, 117 (88.6%) had a urology-specific webpage, a considerable increase from 98 trusts (68%) in 2010. However, a smaller proportion of websites explained their services and procedures, and only 23.9% explained common urological conditions. Websites still appeared outdated, 23.9% had spelling errors, and 75.2% made none or poor use of images. The mean reading grade level was 13.40, equivalent to a UK reading age above 18 years, and the mean reading ease score was 30.35, in the range of ‘difficult’ text. Conclusion: Our data suggest that urology-specific webpages are not providing useful content for patients and are too complex for the general population to understand. Improvement would allow patients to be able to utilise such resources to aid decision making and to navigate complex NHS pathways. Level of evidence: Not applicable

Objectives To determine the safety of urological admissions and procedures during the height of the COVID‐19 pandemic using “hot” and “cold” sites. The secondary objective is to determine risk factors of contracting COVID‐19 within our cohort. Patients and methods A retrospective cohort study of all consecutive patients admitted from March 1 to May 31, 2020 at a high‐volume tertiary urology department in London, United Kingdom. Elective surgery was carried out at a “cold” site requiring a negative COVID‐19 swab 72‐hours prior to admission and patients were required to self‐isolate for 14‐days preoperatively, while all acute admissions were admitted to the “hot” site. Complications related to COVID‐19 were presented as percentages. Risk factors for developing COVID‐19 infection were determined using multivariate logistic regression analysis. Results A total of 611 patients, 451 (73.8%) male and 160 (26.2%) female, with a median age of 57 (interquartile range 44‐70) were admitted under the urology team; 101 (16.5%) on the “cold” site and 510 (83.5%) on the “hot” site. Procedures were performed in 495 patients of which eight (1.6%) contracted COVID‐19 postoperatively with one (0.2%) postoperative mortality due to COVID‐19. Overall, COVID‐19 was detected in 20 (3.3%) patients with two (0.3%) deaths. Length of stay was associated with contracting COVID‐19 in our cohort (OR 1.25, 95% CI 1.13‐1.39). Conclusions Continuation of urological procedures using “hot” and “cold” sites throughout the COVID‐19 pandemic was safe practice, although the risk of COVID‐19 remained and is underlined by a postoperative mortality.

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

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

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

Background: It is hypothesised that simulation enhances progression along the initial phase of the surgical learning curve. Objective: To evaluate whether residents undergoing additional simulation, compared to conventional training, are able to achieve proficiency sooner with better patient outcomes. Design, setting, and participants: This international, multicentre, randomised controlled trial recruited 94 urology residents with experience of zero to ten procedures and no prior exposure to simulation in ureterorenoscopy, selected as an index procedure. Intervention: Participants were randomised to simulation or conventional operating room training, as is the current standard globally, and followed for 25 procedures or over 18 mo. Outcome measurements and statistical analysis: The number of procedures required to achieve proficiency, defined as achieving a score of ≥28 on the Objective Structured Assessment of Technical Skill (OSATS) scale over three consecutive operations, was measured. Surgical complications were evaluated as a key secondary outcome. This trial is registered at www.isrctn.com as ISCRTN 12260261. Results and limitations: A total of 1140 cases were performed by 65 participants, with proficiency achieved by 21 simulation and 18 conventional participants over a median of eight and nine procedures, respectively (hazard ratio [HR] 1.41, 95% confidence interval [CI] 0.72–2.75). More participants reached proficiency in the simulation arm in flexible ureterorenoscopy, requiring a lower number of procedures (HR 0.89, 95% CI 0.39–2.02). Significant differences were observed in overall comparison of OSATS scores between the groups (mean difference 1.42, 95% CI 0.91–1.92; p < 0.001), with fewer total complications (15 vs 37; p = 0.003) and ureteric injuries (3 vs 9; p < 0.001) in the simulation group. Conclusions: Although the number of procedures required to reach proficiency was similar, simulation-based training led to higher overall proficiency scores than for conventional training. Fewer procedures were required to achieve proficiency in the complex form of the index procedure, with fewer serious complications overall. Patient summary: This study investigated the effect of simulation training in junior surgeons and found that it may improve performance in real operating settings and reduce surgical complications for complex procedures.

BackgroundContracting COVID-19 peri-operatively has been associated with a mortality rate as high as 23%, making prevention vital.ObjectivesThe primary objective is to determine safety of surgical admissions and procedures during the height of the COVID-19 pandemic using ‘hot’ and ‘cold’ sites. The secondary objective is to determine risk factors of contracting COVID-19.Design, Setting and ParticipantsA retrospective cohort study of all consecutive patients admitted from 1st March – 31st May 2020 at a high-volume tertiary urology department in London, United Kingdom. Elective surgery was carried out at a ‘cold’ site requiring a negative COVID-19 swab 72 hours prior to admission and to self-isolate for 14 days pre-operatively, whilst all acute admissions were admitted to the ‘hot’ site.Outcome Measurements and Statistical AnalysisComplications related to COVID-19 were presented as percentages. Risk factors for developing COVID-19 infection were determined using multivariate logistic regression analysis.Results and LimitationsA total of 611 patients, 451 (73.8%) male and 160 (26.2%) female, with a median age of 57 (interquartile range 44-70) were admitted under the urology team; 101 (16.5%) on the ‘cold’ site and 510 (83.5%) on the ‘hot’ site. Procedures were performed in 495 patients of which 8 (1.6%) contracted COVID-19 post-operatively with 1 (0.2%) post-operative mortality due to COVID-19. Overall, COVID-19 was detected in 20 (3.3%) patients with 2 (0.3%) deaths. Length of stay was associated with contracting COVID-19 in our cohort (OR 1.25, 95% CI 1.13-1.39). Limitations include possible under reporting due to post-operative patients presenting elsewhere.ConclusionsContinuation of surgical procedures using ‘hot’ and ‘cold’ sites throughout the COVID-19 pandemic was safe practice, although the risk of COVID-19 remained and is underlined by a post-operative mortality.Patient SummaryUsing ‘hot’ and ‘cold’ sites has allowed the safe continuation of urological practice throughout the height of the COVID-19 pandemic.

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

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

Context Medical expulsive therapy (MET) is widely used to promote spontaneous passage of urinary stones. However, there is conflicting evidence on the actual role of MET. Objective To evaluate the conformance of published randomized controlled trials (RCTs) on MET with the Consolidated Standards for Reporting Trials (CONSORT) criteria, and to clarify the current role of MET in management of urinary stones on the basis of our findings. Evidence acquisition We carried out an electronic search of the Cochrane Library, PubMed, and Embase databases for RCTs on MET. For each RCT included, we created a checklist table documenting the minimum essential items that should be included in reports of RCTs according to the CONSORT 2010 statement. Evidence synthesis Clinical heterogeneity between pooled studies in terms of the MET given, inclusion criteria, sample size, pre- and post-treatment imaging, and differential follow-up was profound. The overall methodological rigor of the pooled studies was low, as indicated by the moderate to poor conformance of the studies with the CONSORT criteria. The aforementioned reasons may explain the discrepancies found between the supporting results of several meta-analyses and those of well-designed placebo-controlled double-blind studies revealing no benefit from MET. Recent well-designed RCTs have shown no benefit from α-blockers versus placebo. However, on the basis of sensitivity analyses in a recently published meta-analysis, α-blockers may still promote spontaneous expulsion of large stones. Conclusions Conflicting data on MET may be explained by clinical heterogeneity and methodological flaws. Urologists must decide whether to follow single, large, well-conducted RCTs or pooled data from meta-analyses. The latter still support selective use of MET for larger urinary stones. Patient summary In this review we tested the accuracy of the studies published on various medications given to promote spontaneous passage of stones from the ureter. Although the majority of the studies were not designed properly, there is still some evidence to support medical expulsive therapy.

Objectives To develop and content validate a percutaneous nephrolithotomy assessment score, taking into consideration the procedure-specific risks. Methods This prospective international study utilized the Healthcare Failure Mode and Effect Analysis to systematically outline percutaneous nephrolithotomy and failure modes for each step. A total of 25 h was spent observing percutaneous nephrolithotomy carried out by six expert surgeons. Hazard analysis scoring was carried out by 11 experts. It was determined if the steps were single point weaknesses. Single point weaknesses and those assigned a hazard score ≥4 were included in the percutaneous nephrolithotomy assessment score. The tool was then content validated by 16 experts from 10 countries. Results Application of the Healthcare Failure Mode and Effect Analysis identified 64 failure modes; 37 failure modes had a hazard score ≥4. After adaptations based on expert feedback the final percutaneous nephrolithotomy assessment score was developed containing 10 phases, 21 processes and 47 subprocesses. All participants agreed that the tool contained pertinent procedural steps. Conclusions This study has developed and shown the international content validity of a novel percutaneous nephrolithotomy assessment score. The tool can be utilized in modular operating room training to quantify operator progress, and can be used in conjunction with other modules as part of a complete percutaneous nephrolithotomy curriculum for trainees.

Context Medical expulsive therapy (MET) for ureteral stones has become a controversial area due to the contradictory results of high-quality trials and meta-analyses. Objective We aimed to review the literature to evaluate the value of and future directions for MET for ureteral stone disease. Evidence acquisition A literature search of the MEDLINE database and the Cochrane Library was conducted to collect articles about MET for ureteral calculi published up to 28 October 2018. A total of 524 articles were screened. Sixty-nine publications that met the inclusion criteria for this review were chosen. Among the primary research articles on MET with stone clearance as the primary outcome, seven responded to high-quality requirements of Cochrane Collaboration's tool for assessing the risk of bias in randomised trials. Evidence synthesis The vast majority of randomised, double-blind, placebo-controlled trials without a high or an unclear risk of bias did not find a benefit of MET for increased ureteral stone passage rates. This is in contrast to results of meta-analyses that are skewed by low-quality trials. Conclusions The strength of evidence for the benefit of MET in ureteral stones is low, even for distal ureteral stones >5 mm. In the absence of further high-quality data, individual clinicians are required to decide for themselves whether to believe high-quality single trials or meta-analyses. Patient summary We evaluated the value of and future directions for medical expulsive therapy (MET) for ureteral stone disease. We found that outcomes varied between studies. Individual clinicians are required to decide for themselves which studies to believe. Alpha-blockers as MET may retain a role in a selective group of well-counselled patients with larger stones who understand the side effects and off-label use.

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

OBJECTIVES To analyse the trends in the number of deaths attributable to urolithiasis in England and Wales over the past 15 years (1999-2013). Urolithiasis has an estimated lifetime risk of 12% in males and 6% in females and is not perceived as a life-threatening pathology. Admissions with urinary calculi contribute to 0.5% of all inpatient hospital stays, and the number of deaths attributable to stone disease has yet to be identified and presented. MATERIALS AND METHODS Office of National Statistics data relating to causes of death from urolithiasis, coded as International Classification of Diseases (ICD)-10 N20-N23, was collated and analysed for the 15-year period from 1999 to 2013 in England and Wales. These data were sub-categorised into anatomical location of calculi, age, and gender. RESULTS In all, 1954 deaths were attributed to urolithiasis from 1999 to 2013 (mean 130.3 deaths/year). Of which, 141 were attributed to ureteric stones (mean 9.4 deaths/year). Calculi of the kidney and ureter accounted for 91% of all deaths secondary to urolithiasis; lower urinary tract (bladder or urethra) calculi contributed to only 7.9% of deaths. The data revealed an overall increasing trend in mortality from urolithiasis over this 15-year period, with an increase of 3.8 deaths/year based on a linear trend (R(2) = 0.65). Overall, the number of deaths in females was significantly higher than in males (ratio 1.5:1, P < 0.001); kidney and ureteric calculi causing death had a female preponderance (1.7:1, female:male); whereas calculi of the lower urinary tract was more common in males (1:2.2, female:male). CONCLUSIONS Stone disease still causes death in the 21st century in England and Wales. This trend of increasing deaths must be placed in the context of the concurrent rising incidence of urolithiasis in the UK and the number of stone-related hospital episodes. The primary cause of death relating to complications of stone disease for each individual case should be further investigated to facilitate prevention of complications of urolithiasis.

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

Procedures for urolithiasis are a core part of the development for the urologist in training. Understanding the learning curve of the procedures is important, allowing for planning in the training and assessment of trainees. The aim of this study was to systematically review the literature pertaining to learning curves in urolithiasis surgery.The review was registered on the PROSPERO database and conducted in keeping with the Preferred Reporting Items for Systematic reviews and Meta-Analysis statement. Embase, MEDLINE, and PsycINFO were systematically searched from inception to January 2018, with a reference review conducted. All empirical studies on learning curves in urolithiasis surgery were included irrespective of procedure. Articles describing pediatric surgery, nontechnical skills in surgery, or those not written in English were excluded.Of 390 articles identified from screening, a final 18 studies were included. Fourteen studies identified the learning curve in percutaneous nephrolithotomy. These studies identified a learning curve of between 30 and 60 cases for both operative time (OT) and complication rates. Four articles focused on flexible ureteroscopy (FURS); the learning curve for FURS has been outlined as 60 cases for OT and 56 cases for fragmentation efficacy.The complexities of determining learning curves are extensive; studies use different parameters to measure outcomes and observe skill acquisition rates of surgeons with differing prior experience. Evidence in this article can guide trainee urologists with regard to the expected rate of progress. Multi-operator multicenter research utilizing standard outcome measures should be conducted to establish definitive learning curves.

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

Context Percutaneous nephrolithotomy (PCNL) is the surgical standard for treating large or complex renal stones. Since its inception, the technique of PCNL has undergone many modifications. Objective To perform a collaborative review on the latest evidence related to outcomes and innovations in the practice of PCNL since 2000. Evidence acquisition A literature review was performed using the PubMed database between 2000 and July 2015, restricted to human species, adults, and the English language. The Medline search used a strategy including the following keywords: percutaneous nephrolithotomy, PNL, advances, trends, technique , and the Medical Subject Headings term percutaneous nephrostomy . Evidence synthesis Population-based studies have now provided a wealth of information regarding patient outcomes following PCNL. The complexity of the stone treated can be quantified using a variety of validated nephrolithometry classification systems. Increasing familiarity with the supine approach to PCNL has enabled simultaneous combined retrograde and antegrade surgery. Advances such as endoscopic guided percutaneous access may help urologists achieve access with less morbidity. Increasing miniaturization of equipment has led to the development of mini, micro, and ultramini techniques. The tubeless method of PCNL is now accepted practice with good evidence of safety in appropriately selected patients. Conclusions Modern-day PCNL allows personalized stone management tailored to individual patient and surgeon factors. Future studies should continue to refine methods to assess complexity and safety and to determine consensus on the use of miniaturized PCNL. Patient summary Modern-day percutaneous nephrolithotomy has transformed from an operation traditionally undertaken in one position, using one access method with one set of instrumentation and one surgeon, to one with a variety of options at each step.

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

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

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

Objective To detail the 9-year experience of renal trauma at a modern Level 1 trauma centre and report on patterns of injury, management and complications. Patients and methods We analysed 338 patients with renal injuries who presented to our institution over a 9-year period. Data on demographics, clinical presentation, management and complications were recorded. Results Males comprised 74.9% of patients with renal injuries and the highest incidence was amongst those aged 20–24 years. Blunt injuries comprised 96.2% (n = 325) of all the renal injuries, with road trauma being the predominant mechanism accounting for 72.5% of injuries. The distribution of injury grade was; 21.6% grade 1 (n = 73), 24.3% grade 2 (n = 82), 24.9% grade 3 (n = 84), 16.6% grade 4 (n = 56), and 12.7% grade 5 (n = 43). Conservative management was successful in all grade 1 and 2 renal injuries, and 94.9%, 90.7% and 35.1% of grade 3, 4 and 5 injuries respectively. All but one of the 13 patients with penetrating injuries were successfully managed conservatively. Conclusions Road trauma is the greatest cause of renal injury. Most haemodynamically stable patients are successfully managed conservatively.

Introduction Twitter is a popular microblogging platform for the rapid dissemination of information and reciprocal exchange in the urological field. We aimed to assess the activity, users and content of the online discussion, #KidneyStones, on Twitter. Methods We investigated the Symplur Signals analytics tool for Twitter data distributed via the #KidneyStones hashtag over a one year period. Activity analysis reflected overall activity and tweet enhancements. We assessed users’ geolocations and performed an influencer analysis. Content analysis included the most frequently used words, tweet sentiment and shares for top tweets. Results 3,426 users generated over 10,333 tweets, which were frequently accompanied by links (49%), mentions (30%) and photos (13%). Users came from 106 countries across the globe and were most frequently from North America (63%) and Europe (16%). Individual and organisational healthcare professionals made up 56% of the influencers of the Twitter discussion on #KidneyStones. Besides the words ‘kidney’ (used 4,045 times) and ‘stones’ (3,335), ‘pain’ (1,233), ‘urine’ (1,158), and ‘risk’ (1,023) were the most frequently used words. 56% of tweets had a positive sentiment. The median (range) number of shares was 85 (62–587) for the top 10 links, 45.5 (17–94) for the top 10 photos, and 44 (22–95) for the top 10 retweets. Conclusion The rapidly growing Twitter discussion on #KidneyStones engaged multiple stakeholders in the healthcare sector on a global scale and reached both professionals and laypeople. When used effectively and responsibly, the Twitter platform could improve prevention and medical care of kidney stone patients.