John Withington

Percutaneous nephrolithotomy in England: practice and outcomes described in the Hospital Episode Statistics database.

To investigate the postoperative outcomes of percutaneous nephrolithotomy (PCNL) in English National Health Service (NHS) hospitals.

Cystinuria-a urologist's perspective.

Cystinuria is a genetic disease that leads to frequent formation of stones. In patients with recurrent stone formation, particularly patients <30 years old or those who have siblings with stone disease, urologists should maintain a high index of suspicion of the diagnosis of cystinuria. Patients with cystinuria require frequent follow-up and a multidisciplinary approach to diagnosis, prevention and management. Patients have reported success in preventing stone episodes by maintaining dietary changes using a tailored review from a specialist dietician. For patients who do not respond to conservative lifestyle measures, medical therapy to alkalinize urine and thiol-binding drugs can help. A pre-emptive approach to the surgical management of cystine stones is recommended by treating smaller stones with minimally invasive techniques before they enlarge to a size that makes management difficult. However, a multimodal approach can be required for larger complex stones. Current cystinuria research is focused on methods of monitoring disease activity, novel drug therapies and genotype–phenotype studies. The future of research is collaboration at a national and international level, facilitated by groups such as the Rare Kidney Stone Consortium and the UK Registry of Rare Kidney Diseases.

The changing face of urinary continence surgery in England: a perspective from the Hospital Episode Statistics database

To quantify changes in surgical practice in the treatment of stress urinary incontinence (SUI), urge urinary incontinence (UUI) and post‐prostatectomy stress incontinence (PPI) in England, using the Hospital Episode Statistics (HES) database.

Assessment of Stone Complexity for PCNL: A Systematic Review of the Literature, How Best Can We Record Stone Complexity in PCNL?

INTRODUCTION This study aims to systematically review the literature reporting tools for scoring stone complexity and the stratification of outcomes by stone complexity. In doing so, we aim to determine whether the evidence favors uniform adoption of any one scoring system. METHODS PubMed and Embase databases were systematically searched for relevant studies from 2004 to 2014. Reports selected according to predetermined inclusion and exclusion criteria were appraised in terms of methodologic quality and their findings summarized in structured tables. RESULTS After review, 15 studies were considered suitable for inclusion. Four distinct scoring systems were identified and a further five studies that aimed to validate aspects of those scoring systems. Six studies reported the stratification of outcomes by stone complexity, without specifically defining a scoring system. All studies reported some correlation between stone complexity and stone clearance. Correlation with complications was less clearly established, where investigated. CONCLUSIONS This review does not allow us to firmly recommend one scoring system over the other. However, the quality of evidence supporting validation of the Guys Stone Score is marginally superior, according to the criteria applied in this study. Further evaluation of the interobserver reliability of this scoring system is required.

The forgotten ureteric stent: what next?

The forgotten ureteric stent is a ‘never event’, because it is entirely preventable and conveys the potential for serious harm. Forgotten stents tend to encrust and encrusted stents are difficult to remove, frequently entailing significant complications [1]. Singh et al. [2], from a retrospective series of 19 forgotten ureteric stents, even reported one death as a direct consequence. Clearly, strategies for the prevention of this harm are essential.

Hospital Volume Does Not Influence the Safety of Percutaneous Nephrolithotomy in England: A Population-Based Cohort Study.

PURPOSE This study aims to investigate the relationship between hospital case volume and safety-related outcomes after percutaneous nephrolithotomy (PCNL) within the English National Health Service (NHS). PATIENTS AND METHODS The study used the Hospital Episode Statistics (HES) database, a routine administrative database, recording information on operations, comorbidity, and outcomes for all NHS hospital admissions in England. Records for all patients undergoing an initial PCNL between April 1, 2006 and March 31, 2012 were extracted. NHS trusts were divided into low-, medium-, and high-volume groups, according to the average annual number of PCNLs performed. We used multiple regression analyses to examine the associations between hospital volume and outcomes incorporating risk adjustment for sex, age, comorbidity, and hospital teaching status. Postoperative outcomes included: Emergency readmission, infection, and hemorrhage. Mean length of stay was also measured. RESULTS There were 7661 index elective PCNL procedures performed in 163 hospital trusts, between April 2006 and March 2012. There were 2459 patients who underwent PCNL in the 116 units performing fewer than 10 PCNL procedures per year; 2643 patients in the 37 units performing 10 to 19 procedures per year; and 2459 patients in the 9 hospitals performing more than 20 procedures per year. For low-, medium-, and high-volume trusts, there was little variation in the rates of emergency readmission (L 9.7%, M 9.3%, H 8.4%), infection (3.0%, 4.2%, 3.8%), or hemorrhage (1.3%, 1.5%, 1.5%), and there was no statistical evidence that volume was associated with adjusted outcomes. Mean length of stay was slightly shorter in the medium- (5.0 days) and high-volume (5.0) groups compared with the low-volume group (5.3). The effect remained statistically significant after adjusted for confounding. CONCLUSION Hospital volume was not associated with emergency readmission, infection, or hemorrhage. Length of stay appears to be shorter in higher volume units.

Is PCNL changing in the UK – analysis of 9500 cases from the BAUS PCNL Registry

Introduction and methods: Percutaneous nephrolithotomy (PCNL) indications and techniques are evolving. BAUS developed an online data registry in January 2010 that now includes over 9500 procedures. We evaluate outcomes and practices in PCNL and compare with previous analyses of the registry at 1K and 5K procedures to highlight significant changes in PCNL practice in the UK. Results: A total of 9536 procedures were analysed and compared with previous analyses of 1028 cases (2011, 1K) and 5191 cases (2015, 5K). Submission of cases has stabilised at approximately 2200 cases per year. Most PCNL is still prone, but supine continues to increase significantly from 5K analysis (22.4% vs. 16.2%, P = 0.0001). Access by an interventional radiologist showed a small but significant decrease from 5K analysis (63.3% vs. 66.3%, P = 0.0004), but not significantly different from 1K analysis. No significant changes in tract dilatation methods are seen, with balloon dilatation most popular (64.3%). Consultants increasingly perform PCNL themselves rather than their trainees (96.5% vs. 84.4% (5K) vs. 79.0% (1K), P = 0.0001). Laser fragmentation usage has significantly increased (9.4% vs.7.0% (5K) vs. 5.8% (1K), P = 0.0001), with similar usage of ultrasound/lithoclast/lift out. Sub-analysis of 4490 cases showed 25.8% of cases used multiple stone fragmentation modalities. Nephrostomy tube usage postoperatively is significantly reduced (72.6% vs. 75.6% (5K), P = 0.0001). Intraoperatively 78.5% of patients were recorded as stone-free, which was confirmed in 69.1% on postoperative imaging, similar to previous analyses. Complication rates are shown in Table 1. Conclusions: PCNL practices continue to evolve in the UK. Continued contribution of data and subsequent careful analysis of the registry allows us a better understanding of PCNL in the UK.

MP68-15 SUPINE PERCUTANEOUS NEPHROLITHOTOMY FOR STAGHORN CALCULI – PROSPECTIVELY RECORDED EXPERIENCE IN A SINGLE TERTIARY REFERRAL ENDOUROLOGY UNIT

INTRODUCTION AND OBJECTIVES: Clearing staghorn calculi can take multiple procedures and multiple modalities with significant associated morbidity. In order to evaluate the safety and effectiveness of sPCNL for staghorn stones, we prospectively recorded patient characteristics, operative details and outcomes of these cases over a nine-year period. METHODS: We present our experience of supine percutaneous nephrolithotomy (sPNCL) for staghorn calculi performed at a single tertiary referral endourology unit, by two senior endourologists. Data were prospectively recorded in a pre-designed anonymised database. Basic demographic information, detailed radiological information regarding stone size, number and position and comorbid information were entered, followed by post-operative entry of operative detail, stone clearance, following CT imaging, within 3 months post-sPCNL and complications, were graded according to the Clavien-Dindo classification. RESULTS: 74 patients underwent sPCNL for staghorn calculi between February 2007 and August 2016. These included 32 (43%) female and 42 (57%) male patients, with a median age of 58 (range 1882), median BMI of 27 (20-46) and median Charlson Comorbidity Index of 2.5 (0-8).13 (18%) of patients had partial staghorn and 61 (82%) had complete staghorn calculi. Median stone density on CT was 970 Hounsfield Units (306-2032). Multiple access tracts were used in 9 (12%) patients. 43 (58%) had primary access in the lower pole, 17 (23%) in the interpolar region and 14 (19%) in the upper pole. Median operative time was 90 minutes (35-240). 50 (68%) patients had a ureteric stent placed intraoperatively. After a single procedure, stone clearance (residual fragments <2mm on CT, within 3 months postoperatively) was achieved in 39 (53%) of patients. 15 (20%) complications (Clavien-Dindo Grade II or above) were recorded, including 7 (10%) UTI or sepsis and 2 (3%) bleeding requiring transfusion. CONCLUSIONS: sPCNL for staghorn calculi is safe and effective in appropriately selected and counselled patients. In particular, patients should be advised that multiple procedures may be required in order to achieve clearance and that complication rates, including bleeding and infection are higher than for less complex stones.

PD16-10 IS PCNL A SAFE AND EFFECTIVE OPTION FOR OCTOGENARIAN PATIENT?. ANALYSIS OF OVER 4000 CASES FROM A NATIONAL DATABASE.

CONCLUSIONS: Patients experiencing more pain with their stent than the inciting stone are less willing to treat asymptomatic renal stones and are more willing to accept greater postoperative risk in order to forgo future ureteral stents. With increased emphasis on shared medical decision making, an enhanced understanding of factors affecting these decisions is important in order to appropriately counsel patients.

PD18-04 PCNL ACCESS BY UROLOGIST OR RADIOLOGIST: AN ANALYSIS OF THE BAUS PCNL REGISTRY

INTRODUCTION AND OBJECTIVES: Obtaining percutaneous access to the collecting system of the kidney is fundamental to safe and effective PCNL. Practice varies between countries, hospitals and individual surgeons as to whether access is obtained by a urologist or an interventional radiologist (IR). The objective of this study was to compare outcomes of urologist versus IR tracts using data from the BAUS PCNL data registry. METHODS: Data submitted to the BAUS PCNL data registry between 2009 and 2015 were analysed according to whether access was obtained by a urologist or an IR. We evaluated access success, number and type of tracts, perceived and actual access difficulty, as well as outcomes including stone free rate, length of stay and complications including transfusion rates. Stone complexity was assessed using the Guy’s Stone Score. Two-tailed Fisher’s exact test was used to assess differences between the groups. RESULTS: Overall, percutaneous renal access was undertaken by an IR in 3,453 of 5,211 procedures (66.3%); this rate appeared stable over the entire study period, for all categories of stone complexity and in cases where there was predicted or actual difficulty with access. Only 1% of procedures were abandoned because of failed access and this rate was identical in each group (see Table). IRs did more multiple tracts than urologists (6.8% vs 5.1%, p1⁄40.02) but did similar rates of supracostal punctures (8.2% vs 9.2%, p1⁄40.23). Ultrasound was used more commonly by IRs than urologists (56.6% vs 21.7%, p1⁄40.0001) to guide access. There were no significant differences in complication rates, lengths of stay or stone free rates on Day 1 post-operative imaging. CONCLUSIONS: In the UK most access for PCNL is obtained by an interventional radiologist. There do not appear to be any differences in outcomes of PCNL according to whether access is obtained by a urologist or an interventional radiologist. Our findings suggest that favourable PCNL outcomes may be expected where access is obtained by individuals who have been appropriately trained and who are skilled and proficient in the procedure. However, we believe that a multidisciplinary approach to the management of patients with complex stones may lead to better outcomes.