Matthew Bultitude

Management of encrusted ureteral stents impacted in upper tract

OBJECTIVES To present our series of patients with ureteral stent encrustation and give indwelling times and management. Encrustation is one of the most serious complications of ureteral stents. METHODS A retrospective review was undertaken of all encrusted stents during a 4-year period. The inclusion criterion was a stent that required some form of intervention above the ureteral orifice to remove it. Combinations of extracorporeal shock wave lithotripsy, ureteroscopy, percutaneous nephrolithotomy, and open surgery were used to achieve stent removal. RESULTS Forty-nine impacted encrusted stents were treated in 41 patients. Of these, 75.5% had become encrusted within 6 months and 42.8% within 4 months. The mean indwelling time was 5.6 months. Forty-seven stents were removed by endourologic techniques, with 4 requiring extracorporeal shock wave lithotripsy alone, 28 ureteroscopy, and 10 a combination of both. Five patients underwent successful percutaneous nephrolithotomy. One patient underwent open surgery, and in one removal failed. The mean number of procedures per patient was 1.94. CONCLUSIONS Stent encrustation can pose a serious challenge to the endourologist, and indwelling times should be minimized to avoid problems. Patients often require multiple treatments and a combination of extracorporeal shock wave lithotripsy and ureteroscopy offers highly successful outcomes and often avoids the need for more invasive techniques.

Management of renal colic

#### Summary points Urinary stone disease is increasingly prevalent, with a lifetime risk of about 12% in men and 6% in women.1 Age of onset of a first stone episode for men rises from their 20s and peaks at age 40-60 years, with an incidence of three cases per 1000 population per year. Women appear to peak a little younger in their late 20s. The male to female ratio is narrowing, with one study showing a reduction from 1.7:1 to 1.3:1 over a five year period.2 Presentation varies according to geographical and seasonal factors, with higher incidences in warmer climates and during the summer months.3 This review includes the latest information from meta-analyses, systematic reviews, randomised trials, current guidelines, and other peer reviewed evidence to provide a background on presentation, investigation, and medical and surgical management of patients with renal colic. #### Sources and selection criteria We performed a PubMed search to identify peer reviewed original articles, meta-analyses, and reviews using the search terms “renal colic” and “ureteric stone”. We also reviewed national and international guidelines, and the Cochrane Collaboration and clinical evidence databases. We considered only papers written in English, with the emphasis on more recent articles if available or if we deemed the scientific validity to be …

Engaging responsibly with social media: the BJUI guidelines

*Peter MacCallum Cancer Centre, University of Melbourne, †Epworth Prostate Centre, Epworth Healthcare Richmond, Melbourne, Australia, ‡New York University, New York, NY, ¶Division of Urologic Surgery and Center for Surgery and Public Health, Brigham and Womens Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA, **Department of Urology, University of Michigan, Ann Arbor, MI, USA, §Guys Hospital, Kings College London, London, UK, and °Department of Urology, Queens University, Kingston, ON, Canada

Standard versus Tubeless Percutaneous Nephrolithotomy: A Systematic Review

Objective: This article systematically analyses comparative studies to evaluate the efficacy and safety of tubeless percutaneous nephrolithotomy (PCNL) versus standard PCNL. Methods: The Medline, EMBASE, PsycINFO, Cochrane and DARE databases were searched from 1997 to February 2011. Comparative studies evaluating outcomes from standard versus tubeless PCNL were included. Primary outcome measures were post-operative pain scoring, analgesic requirements, duration of hospitalisation/convalescence, operation time, major/minor complications and stone-free rates. Results: Twenty-four studies were included (11 randomised control trials and 13 retrospective or prospective studies). Levels of pain recorded, analgesic requirements, duration of inpatient stay and convalescence time were all significantly reduced in the tubeless PCNL group. Cost was reduced in two studies. Morbidity was not significantly different between the groups. There was no significant difference between groups regarding stone-free status. Discussion: This systematic review has demonstrated that tubeless PCNL is a viable alternative to tubed PCNL in uncomplicated cases. Benefits are as described above. There is no evidence suggesting that patient safety is compromised by the absence of post-operative nephrostomy. The tubeless method has been reported in challenging cases such as stag-horn stones, horseshoe or ectopic kidneys. Promising outcomes have been demonstrated in elderly patients and when clinical needs demand a supracostal approach. Multi-centre randomised controlled trials are needed to fully establish the effectiveness of the tubeless method.

Predictors of Outcome for Blunt High Grade Renal Injury Treated With Conservative Intent

PURPOSE Management for blunt high grade renal injury is controversial with most disagreement concerning indications for exploration. At our institution all patients are considered candidates for conservative treatment regardless of injury grade or computerized tomography appearance with clinical status the sole determinant for intervention. We define clinical factors predicting the need for emergency intervention as well the development of complications. MATERIALS AND METHODS We analyzed the records of 117 patients with high grade renal injury (III to V) secondary to blunt trauma who presented to our institution in an 8-year period. Patients were categorized by the need for emergency intervention and, in those treated conservatively, by complications. We generated logistic regression models to identify significant clinical predictors of each outcome. RESULTS Grade III to V injury occurred in 48 (41.1%), 42 (35.9%) and 27 patients (23%), respectively. Of the 117 patients 20 (17.1%) required emergency intervention. On multivariate analysis only grade V injury (RR 4.4, 95% CI 1.9-10.5, p = 0.001) and the need for platelet transfusion (RR 8.9, 95% CI 2.1-32.1, p < 0.001) significantly predicted the need for intervention. A total of 90 patients (82.9%) who did not require emergency intervention underwent a trial of conservative treatment, of whom 9 (9.3%) experienced complications requiring procedural intervention. On multivariate analysis only patient age (RR 1.06, 95% CI 1.02-1.1, p = 0.004) and hypotension (RR 12, 95% CI 1.9-76.7, p = 0.009) were significant predictors. CONCLUSIONS High grade injury can be successfully managed conservatively. However, grade V injury and the need for platelet transfusion predict the need for emergency intervention while older patient age and hypotension predict complications.

Flexible ureterorenoscopy: prospective analysis of the Guy's experience

OBJECTIVE To report our outcomes with small diameter, actively deflectable flexible ureterorenoscopy from a prospective database. PATIENTS AND METHODS 114 flexible ureterorenoscopies were performed in 105 patients (mean age, 49.5 years; range, 19-85 years; 71 males, 34 females) over a 9-month period. Of these, 101 were for refractory stones following failed ESWL and 13 for diagnostic reasons. An Olympus URF P3 flexible ureteroscope with pressure irrigation was used. Electrohydraulic lithotripsy was used to fragment stones and the fragments were retrieved with Graspit, triradiate graspers or tipless baskets. RESULTS Stents had previously been placed in 53% and dilatation of the ureteric orifice was necessary in 15%. In the stone group, the median operating time was 55 min (range, 15-210 min) and the median screening time 2.2 min (range, 0.3-9.1 min). Success was defined as complete stone clearance or good fragmentation to 2 mm or less. Overall success in this group was 72.3%. There was no statistically significant difference between lower and other calyces (P=0.83 Chi-square test). Successful outcome was achieved in 72% for stone size 10 mm or less, 80% for 11-20 mm and 50% for greater than 20 mm. Two or more procedures were needed in 8 patients. In the diagnostic group, the median operating time was 45 min (range, 20-60 min) and the median screening time 2 min (range, 0.3-8.3 min). The majority were for upper tract filling defects. Access and successful diagnosis was achieved in all cases. The major complication rate was 2.6%. The ureteroscope needed repair once during this series. CONCLUSIONS Flexible ureterorenoscopy is an effective diagnostic and therapeutic tool in a select group of patients. It should be considered for ESWL-resistant upper tract stones but the results are poor in stones larger than 20 mm and percutaneous nephrolithotomy may be a better option in these patients.

The management of lower urinary tract symptoms in men

#### Summary points Lower urinary tract symptoms (LUTS) are common in men and increase in frequency and severity with age. Over one third of men aged 50 or more are living with moderate to severe symptoms, equating to 3.4 million men in the United Kingdom alone and 24 million in countries of the European Union.1 Most men with LUTS can be managed effectively in primary care, with either conservative lifestyle measures or medical treatment.2 We discuss the causes of LUTS in men and summarise the current evidence on assessment and management of patients. #### Sources and selection criteria We performed a search of PubMed to identify peer reviewed original articles, meta-analyses, and reviews, using the search terms “lower urinary tract symptoms”, “benign prostatic hyperplasia”, and “overactive bladder”. In addition we reviewed national and international guidelines and the Cochrane Collaboration and clinical evidence databases. We considered only papers written in English, with emphasis on more recent articles where available and where we deemed the scientific validity to be sufficient. Terms such as prostatism, symptoms of benign prostatic hyperplasia (BPH), and clinical BPH have been ascribed to men presenting with LUTS.3 These …

Incidental renal stones in potential live kidney donors: prevalence, assessment and donation, including role of ex vivo ureteroscopy

Previously, donors with asymptomatic stones found incidentally on CT were not considered ideal donor candidates because of the presumed risk of morbidity to both the donor and recipient. Increasingly, studies show that these risks are low. This study aims to evaluate the long‐term safety of using ex vivo ureteroscopy to remove the stones from the donor kidney on the bench before donation. Outcomes so far suggest that this technique can safely render a kidney stone‐free before transplantation. This has led to 20 more transplants in our institution than would otherwise be possible.

Percutaneous Nephrolithotomy: Update, Trends, and Future Directions.

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.

Loin pain haematuria syndrome: distress resolved by pain relief

&NA; Loin pain haematuria syndrome (LPHS) is a syndrome of severe chronic pain of unknown aetiology. This study assessed pain, mood variables and psychiatric status in patients (n=26) with LPHS. Patients were assessed before and after treatment with capsaicin. Assessment inventories used were the McGill Pain Questionnaire, the Pain Discomfort Scale, the General Health Questionnaire and the Hospital Anxiety and Depression Scale. Pain relief was achieved in 65% of patients. In this group pain (P<0.001) and psychiatric (P<0.01) scores were significantly reduced. By comparison, in those patients who did not gain pain relief, scores remained steady (P>0.05). In addition, most pain‐free patients completely stopped their opiate analgesia without addictive symptoms. These results suggest an organic pathology to LPHS and militate against suggestions of primary psychological cause or drug addiction. The results also show that the psychiatric disturbances associated with this chronic pain disappear if the pain disappears.