Stuart Irving

Multi‐length or 24 cm ureteric stent? A multicentre randomised comparison of stent‐related symptoms using a validated questionnaire

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 30u2009cm multi‐length vs a 24u2009cm long stent) and showed no significance difference in stent‐related symptoms in patients with either of these stents.

The dilemma of post-ureteroscopy stenting

Proponents of post-URS stenting often quote the anecdote of the memorable patient who, having not been stented, developed pain and/or sepsis requiring an emergency return to theatre for stenting. Others suggest that a stent is akin to a comfort blanket allowing them, if not the patient, to sleep easier after the procedure. European Association of Urology (EAU) Guidelines [1] recommend that ‘stents be inserted in patients who are at increased risk of complications (e.g. residual fragments, bleeding, perforation, UTIs or pregnancy) and in all doubtful cases, to avoid stressful emergencies’. Furthermore, most urologists would be inclined to place a stent after URS in a solitary kidney, in patients with renal impairment and to facilitate future access.

Retroperitoneal fibrosis in 2 brothers

Case 1. A 51-year-old man presented with a 3-month history of left loin pain. Excretory urography and ultrasound revealed moderate left hydronephrosis. Left retrograde ureterography revealed a tight stricture at the level of the 3rd and 4th lumbar vertebrae (fig. 1). Computerized tomography (CT) of the abdomen with contrast medium showed a dilated left renal pelvis. There was abnormal soft tissue surrounding the left ureter and extending along the proximal common iliac arteries. Isotope renography confirmed that the left kidney was nonfunctioning and left nephrectomy was performed. Histological examination revealed chronic interstitial nephritis with periureteral inflammation and fibrosis. Biopsies of the retroperitoneum were consistent with the clinical diagnosis of retroperitoneal fibrosis. Case 2. The 62-year-old brother of case 1 presented with a 1-month history of back pain. Ultrasound reveale da4c m. infrarenal fusiform aneurysm extending across the bifurcation to involve the right common iliac artery. Contrast enhanced CT confirmed these findings and showed excess soft tissue around the lower aorta consistent with an inflammatory response. Diagnosis was inflammatory aneurysm (fig. 2). At 10 months after presentation aortic lumbar graft repair was performed. Histological examination of the resected specimen showed collagenous tissue infiltrated by fat and inflammatory cells. The patient returned a month later with right loin pain. Ultrasound revealed right hydronephrosis and excretory urography showed a nonfunctioning right kidney. CT confirmed the presence of retroperitoneal fibrosis causing extrinsic ureteral obstruction. DISCUSSION

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.

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.

575 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.