Plain radiography still is required in the planning of treatment for urolithiasis.

INTRODUCTION: Nonenhanced computed tomography (NCT) is recognised as the most sensitive tool in diagnosis of renal tract calculi. However, its role as the sole imaging investigation, for decisions regarding management is less clear. OBJECTIVE: To determine the proportion of new stone patient referrals in which management is altered by interpretation of a plain abdominal kidneys, ureters and bladder (KUB) radiograph in addition to NCT. METHODS: One hundred consecutive new referrals to a national lithotripsy centre were considered prospectively for treatment of renal tract calculi. RESULTS: A significant change in management was undertaken in 17 patients on the basis of KUB findings. Eleven patients had radio-lucent ureteric stones, for which Extracorporeal Shockwave Lithotripsy (ESWL) was consequently not possible and who required endoscopic management. There were six inaccuracies in measurement of size or positioning on NCT. In a further 43 patients it was not possible to confirm management until the KUB was reviewed, although in these cases ESWL or expectant management was still pursued. Thus additional imaging with a KUB was required in order to confirm optimum management in 60 patients. CONCLUSION: Additional plain radiography confers a significant advantage in the planning of treatment for urolithiasis once the diagnosis has been established by NCT because of information it provides regarding radio-opacity as well as stone size and visibility. This information cannot be delivered by NCT alone. We therefore recommend that KUB imaging is performed on all new stone patients referred for treatment.

Recurrence after totally extraperitoneal laparoscopic repair: implications for operative technique and surgical training.

BACKGROUND: The totally extraperitoneal (TEP) approach is increasingly favoured for inguinal hernia repair. The learning curve is slow with high, early recurrence rates but the exact cause of recurrence is unknown. OBJECTIVE: To determine the reasons for recurrence, identify the critical operative steps and examine the influence of surgical experience and training on results. PATIENTS AND METHODS: All patients undergoing TEP between 1993 and 2004 were included. Patients requiring re-operation for recurrence were identified and examined in detail. RESULTS: Eight surgical teams performed 1682 TEP repairs. Fifty five hernias recurred (3.27%) with a median follow-up of seven years (range 1-11 years). In six recurrences, the first repair was itself for recurrence and in 24, the initial repair was bilateral. The initial hernia was direct in 26 and indirect in 29 patients. These distributions were similar to a control sample. At re-operation, indirect recurrence was more common with 18 direct, and 37 indirect cases (P=0.020). At re-operation, when the original mesh could be identified (18 repairs), it appeared to have moved superiorly in 13 cases. Typically, recurrence occurred in 10% of a surgeon's first 20 cases, 4% of the next 60 cases and falling to below 2% thereafter. CONCLUSION: TEP repairs have a tendency for indirect recurrence even after direct repair. Meshes tend to migrate superiorly. Results suggest that recurrence occurs most often because of failure to fully expose the deep inguinal ring and/or to adequately spread the mesh inferiorly and laterally. We recommend particular attention be paid to these technical aspects. Acceptable results are obtainable after an experience of 20 cases but further improvement in results occurs as experience reaches 80 operations. With a large number of consultants having little or no experience in TEP surgery, there is an urgent need for 'hands-on' training courses so that all patients have access to TEP, particularly those with bilateral or recurrent inguinal herniae.