A comprehensive update on urinary tract lithiasis management.

In the past decade, the field of urology has been one of the most rapidly progressing in applied technological advancements at the level of both medical diagnostics and treatment. The introduction of modern robotic laparoscopy has changed the face of minimally invasive surgery. For endourology specialists, stone surgery continues to be in the forefront of daily practice and innovations and new technologies are constantly being developed, aiming towards ever higher stone free rates and earlier recovery for the patient. But, is there a price? Indeed, in addition to advances in conservative treatment and prevention, modern endourology and stone disease management in particular enjoys a large variety of sophisticated new equipment and disposables, used either alone or in combination, developed from various companies at considerable cost. It is more than often that even expert professionals are not totally familiar with the whole range of treatment options and devices that are available in the market, as they commonly bear different names despite being used for the same purpose. Furthermore, a question of integrity might arise when using newly developed equipment directly in the operating theatre, with respect to the efficacy of the device as well as the learning curve required by the operator. In this review, we shall outline the latest advances in interventional lithotripsy technology and also demonstrate the most effective ways to use each particular modality efficiently and safely, with respect to the latest published guidelines and evidence-based recommendations.

Factors predicting success of emergency extracorporeal shockwave lithotripsy (eESWL) in ureteric calculi--a single centre experience from the United Kingdom (UK).

Few studies show that "emergency extracorporeal shockwave lithotripsy (eESWL)" reduces the incidence of ureteroscopy in patients with ureteric calculi. We assess success of eESWL and look to study and identify factors which predict successful outcome. We retrospectively studied patients presenting with their first episode of ureteric colic undergoing eESWL (within 72 h of presentation) over a 5-year period. Patient's age, gender, stone size and location, time between presentation and ESWL, number of shock waves and ESWL sessions, and Hounsfield units (HU) were recorded. 97 patients (mean age 40 years; 76 males, 21 females) were included. 71 patients were stone free after eESWL (73.2 %) (group 1) and 26 patients failed treatment and proceeded to ureteroscopy (group 2). The two groups were well matched for age and gender. Mean stone size in group 1 and 2 was 6.4 mm and 7.7 mm, respectively, (p = 0.00141). Stone location was 34, 21, and 16 in upper, middle and lower ureter in group 1 compared to 11, 5, and 10 in group 2, respectively. Mean HU in group 1 was 480 and 612 in group 2 (p value 0.0036). In group 2, significantly, more patients received treatment after 24 h compared with group 1 (38 vs 22.5 %). The number of shock waves, maximal intensity, and ESWL sessions were not significantly different in the two groups. No complications were noted. eESWL is safe and effective in patients with ureteric colic. Stone size and Hounsfield units are important factors in predicting success. Early treatment (≤24 h) minimizes stone impaction and increases the success rate of ESWL.

Update on intracorporeal laser lithotripsy.

Nowadays, rigid and flexible ureteroscopy is a precise, minimal invasive surgery that can assess the entire collecting system in order to treat a stone with intracorporeal lithotripsy. The implication of laser technology has revolutionized the intracorporeal lithotripsy. Currently, laser lithotripsy is advancing in two different directions: improvements of the existing Ho:YAG laser platform and the development of novel laser systems. Herein, we review the current literature upon intracorporeal lithotripsy.

The Barts 'flank-free' modified supine position for percutaneous nephrolithotomy.

BACKGROUND: The last decade has seen the emergence of a variety of supine positions for carrying out percutaneous nephrolithotomy (PCNL). These positions all differ with regard to ease of puncture under image guidance, operative field availability, ability to make and dilate multiple tracts and ease of combining retrograde intrarenal surgery (RIRS). As all of these positions have their limitations regarding the important parameters mentioned above, there is a need for a supine position which addresses some of the difficulties. METHODS: We describe and illustrate our flank-free modified supine position, which we believe addresses a number of the issues. RESULTS: Our position allows easy percutaneous access under fluoroscopy (torso only tilted to around 15°), space for placing (flank free of support) and dilating multiple tracts (kidney lies in a fairly neutral position and hence less mobile), a fairly horizontal tract allowing low intrarenal pressures and easy washout of fragments as well as allowing RIRS in a position of relative familiarity. The lesser torso rotation compared with the Valdivia, Galdakao modified and the Barts modified Valdivia positions also means it is more comfortable for patients. CONCLUSIONS: Our results are encouraging and easily comparable with published series on prone position, Valdivia, complete supine and the Barts modified Valdivia positions. We would like to highlight the Barts 'flank-free' modified supine position as one of the standard positions for carrying out supine PCNL.

The new digital flexible ureteroscopes: 'size does matter'--increased ureteric access sheath use!

OBJECTIVES: To evaluate whether the use of sheaths to access the ureter has increased after the introduction of new digital ureterorenoscopes in patients undergoing flexible ureteroscopy. METHODS: 140 patients with kidney stones were randomised to be scoped with either an old-generation fibre-optic flexible ureteroscope (DUR-8, Elite, ACMI; distal tip diameter = 6.75 Fr) or a new-generation digital LCD flexible ureteroscope (Invisio D-URD flexible ureteroscope; distal tip diameter = 8.7 Fr). We recorded the necessity to use a sheath to access the ureter, sheath-related and postoperative complications, and whether or not a JJ stent was left behind. RESULTS: 157 (80 fibre-optic and 77 digital) ureterorenoscopies were performed. Ureteral access sheaths were used significantly more frequently with digital scopes (p = 0.00174). Two patients in the digital scope group had a small distal ureteric perforation from the introducer sheath compared with none in the fibre-optic scope group. CONCLUSIONS: A statistically significant increase in sheath use was observed in the new-generation digital flexible ureteroscopy group. Despite the improvement in image quality, better durability and improved stone clearance, there are some potential drawbacks of these scopes. The increased distal tip diameter can result in increased use of ureteric access sheaths and this may increase morbidity and expense.

Use of a virtual reality simulator to improve percutaneous renal access skills: a prospective study in urology trainees.

OBJECTIVES: This study aims to assess the impact of a virtual reality trainer in improving percutaneous renal access skills of urological trainees. METHODS: A total of 36 urology trainees participated in this prospective study. Initially, they were taken through the exercise of gaining access to the lower pole calyceal system and introducing a guidewire down the ureter. Trainees' performance was then assessed by virtual reality-derived parameters of the simulator at baseline and after 2 h of training. RESULTS: Participants who underwent training with the simulator demonstrated significant improvement in several parameters compared to their baseline performance. There was a statistically significant correlation between total time to perform the procedure and time of radiation exposure, radiation dose and correct calyx puncture (p < 0.01). Trainees needed a mean of 15.8 min from skin puncture to correct guidewire placement into the pelvicalyceal system before and 6.49 min following training. CONCLUSIONS: We found percutaneous renal access skills of trainees improve significantly on a number of parameters as a result of training on the PERC Mentor TM VR simulator. Such simulated training has the potential to decrease the risks and complications associated with the early stages of the learning curve when training for percutaneous renal access in patients.

Entonox® inhalation to reduce pain in common diagnostic and therapeutic outpatient urological procedures: a review of the evidence.

INTRODUCTION: Entonox(®) (50% nitrous oxide and 50% oxygen; BOC Healthcare, Manchester, UK) is an analgesic and anxiolytic agent that is used to successfully reduce pain and anxiety during dental, paediatric and emergency department procedures. In this article we review the application and efficacy of Entonox(®) in painful local anaesthesia urological procedures by performing a systematic review of the literature. METHODS: A MEDLINE(®) search was performed using the terms 'nitrous oxide', 'Entonox', 'prostate biopsy', 'flexible cystoscopy' and 'extracorporeal shock wave lithotripsy'. English language publications of randomised studies were identified and reviewed. RESULTS: The search yielded five randomised studies that investigated the clinical efficacy of Entonox(®) as an analgesic for day case urological procedures. Three randomised controlled trials (RCTs) investigated Entonox(®) in transrectal ultrasonography guided prostate biopsy. All three reported significant reductions in pain score in the Entonox(®) versus control groups. One RCT reported significant reduction in pain during male flexible cystoscopy in the Entonox(®) group compared with the control group. One RCT, which examined the use of Entonox(®) during extracorporeal shock wave lithotripsy, found its use significantly decreased the pain score compared with the control group and this was comparable to intravenous pethidine. CONCLUSIONS: Evidence from varied adult and paediatric procedures has shown Entonox(®) to be an effective, safe and patient acceptable form of analgesia. All published studies of its use in urological day case procedures have found it to significantly reduce procedural pain. There is huge potential to use this cheap, safe, effective analgesic in our current practice.

Use of a segmental thermoexpandable metal alloy stent in the management of malignant ureteric obstruction: a single centre experience in the UK.

INTRODUCTION: The Memokath 051™ is a semipermanent inert metal alloy ureteric stent which can bridge strictures and, compared to double J stents, causes less bladder irritation and pain, is more resistant to external compression forces and may be more effective in patients with malignant ureteric obstruction. We present our experience with this novel stent in such cases. METHODS: All suitable patients referred to us with malignancy-associated ureteric strictures over a 4-year period had ureteric Memokath 051™ stents inserted. Data on aetiology and position of the strictures as well as length of the Memokath stents used and their efficacy and complications were recorded prospectively. RESULTS: 42 ureteric Memokath 051™ stents were inserted in 37 patients (mean age 64 years). 40.5% of strictures were related to gynaecological cancer, 21% to bowel cancer, 14% were post radiation, 14% occurred in prostate cancer patients and 9.5% were found in other cancers. The mean follow-up was 22 months (range 5-60 months). The main complications were stent migrations in 5, urinary tract infections in 3 and blockage of stent due to progressive transitional cell carcinoma of the ureter in 2 cases. CONCLUSION: Memokath 051™ ureteric stents are safe, effective and durable in the long-term treatment of malignant strictures.

Percutaneous nephrolithotomy for removal of a calcified intra-renal artillery shell fragment.

Residual metallic fragments after intra-abdominal penetrating injuries due to fragments of artillery shells are generally inert, although they may rarely re-activate. The authors present a case where such a fragment presented as a renal stone 17 years after injury. The literature was reviewed and the initial difficulties with the radiological diagnosis, as well as treatment approaches and post-operative findings are discussed in the light of existing reports. An additional challenge arose as the authors working in a tertiary endourology centre attempted to remain as minimally invasive as possible, but were limited by the very nature of the foreign body.

Treating bladder-outflow obstruction with thermo-expandable prostate metal stents.

Bladder-outflow obstruction is a common age-related clinical entity due to a variety of benign and malignant diseases of the prostate. Surgical treatment is not suitable for high-risk elderly patients who seek minimally invasive management. We present a prostatic thermo-expandable metal stent for treating bladder-outflow obstruction. In this review, we include the design characteristics of this novel device, the performance assessment in comparison with alternative devices, the limitations, our personal clinical experience, as well as a long-term perspective. According to our experience among 127 patients (who underwent insertion of 192 stents) after 1, 2 and 3 years, 82, 61 and 47% of the original stents were functional without apparent complications, respectively. The mean single stent indwelling time was 1 year, with a maximum of 4 years. In 41% of patients, the stent needed to be removed and/or exchanged owing to stent encrustation (15%), migration (10%), penile pain (6%), bladder-outflow obstruction symptoms (5%), urinary incontinence (<3%), tissue granulation (<3%), recurrent urinary tract infections (<3%) or urethral stricture (<3%). The thermo-expandable prostatic stent seems to be an effective minimally invasive treatment of bladder-outflow obstruction, especially in high-risk patients.

Pain in extracorporeal shock wave lithotripsy.

Pain tolerance has long been identified as a factor influencing successful treatment of renal calculi by shock wave lithotripsy (SWL). We aimed to clarify which factors directly influence pain tolerance to predict which patients are likely to undergo successful treatment. We analysed retrospectively 179 patients who received their first SWL for a solitary kidney stone. All patients were on a non-opioid analgesia protocol and were treated on an outpatient basis. The target was to deliver 4,000 shock waves at an energy level of 4. In total, 53% of patients could tolerate the targeted shock wave number and energy and were retrospectively allocated into group A. Those who required a reduction in either energy levels or shock wave number were allocated in group B. Multivariate and univariate analysis showed that female patients, who are young with thin body habitus, have lower pain tolerance to SWL.

Nitrous oxide inhalation to improve patient acceptance and reduce procedure related pain of flexible cystoscopy for men younger than 55 years.

PURPOSE: Flexible cystoscopy in men younger than 55 years is painful despite the current best standard anesthesia (20 ml 2% lidocaine gel 15 minutes before endoscopy). The anesthetic value of lidocaine gel is debated and led us to seek an alternative. Nitrous oxide is a well established analgesic and anxiolytic agent, and it significantly reduces pain associated with transrectal ultrasound guided prostate biopsy. We studied its use in flexible cystoscopy in men younger than 55 years. MATERIALS AND METHODS: A total of 61 patients were prospectively randomized to receive air (31) or Entonox (30). Both groups had 3 minutes of gas via a breath activated facemask (either Entonox or air) before endoscopy. The gel control group was comprised of 8 patients who underwent cystoscopy after instillation of lidocaine gel. The air and Entonox groups had lidocaine gel as per best standard. Vital signs were recorded before, during and after cystoscopy. Patients completed a visual analog score for gel insertion and cystoscopy. RESULTS: There were no statistically significant differences between the groups in terms of baseline characteristics. Pain scores for cystoscopy (p<0.001) and intraoperative pulse rate (p=0.008) were significantly less with Entonox. Side effects were transient and seen more often with Entonox (p<0.05). More of the air group would require more analgesia (p=0.001) or a general anesthetic (p=0.011) if undergoing repeat cystoscopy. CONCLUSIONS: Nitrous oxide inhalation significantly reduces cystoscopy related pain without significant complications. We propose that Entonox should be the anesthetic agent of choice for men younger than 55 years.

Intravesical explosions during transurethral endoscopic procedures.

Every Urologist, during the course of fulguration treatment of bladder tumours, has at some time or another experienced small intravesical explosions usually manifesting as a "pop". Major intravesical explosions are rare but potentially devastating complications of transurethral endoscopic resections. The damage to the bladder can range from small mucosal tears to bladder rupture, which can either be intraperitoneal (requiring laparotomy and open bladder repair) or extraperitoneal. We review the literature on intravesical explosions to determine the aetiology of these explosions and suggest strategies to prevent these. A comprehensive literature search was performed using Medline and Ovid to obtain information using search terms: intravesical explosions, transurethral procedures, endoscopic procedures, diathermyIntravesical explosions occur due to the production of explosive gases during use of diathermy on human tissues. The most dangerous combination is hydrogen and oxygen. Hydrogen alone is not explosive and it only becomes explosive when admixed with oxygen. Oxygen is not produced in sufficient quantity during diathermy to cause explosions but can enter into the bladder from the atmosphere during endoscopic procedures. Careful operative technique (correct use of the Ellick evacuator bulb and reducing the frequency of manual irrigations of the bladder) with minimisation of the operative time and using the coagulation current at moderate power as well as judicious coagulation of tissues can reduce the risk of this dangerous complication arising.

Overview of intestinal parasitic prevalence in rural and urban population in Lucknow, north India.

Intestinal parasitic infestations are a common finding in the developing world, however, the patterns of parasitic distribution and rates are different everywhere. Intestinal parasitic prevalece in urban and rural areas in Lucknow, Uttar Pradesh were determined in this community-based study. Multistage random sampling was adopted to collect stool samples from urban and rural population in Lucknow district. Door to door survey was done. Stool samples were processed by standard methods for parasitological examination. One thousand and seventy one stool samples were collected from urban Alambagh, (n=648) and rural Mati, (n=343) areas. Overall one hundred and twenty three (11.5%) subjects had intestinal infection. Intestinal infestation rate was 5.4% and 20.8% in the urban and rural areas respectively. Giardia lamblia (22%) was the commonest pathogenic protozoan detected. The soil transmitted helminths detected were Ascaris (11.4%) and Hookworm (2.4%). Infection had no predilection for either sex or age group in both areas. The prevalence of parasitic infection appears to be relatively low in this region, probably due to improving access to health care. However due to the sheer numbers of affected individuals involved, intestinal parasitosis remains an important public health problem.

'Will you be doing my operation doctor?' Patient attitudes to informed consent.

BACKGROUND: As part of the consent process, it is part of a doctor's duty of care to reveal any material risk. Depending upon the level of supervision, whether the operating surgeon is a trainee may be such a risk, but in our experience this is not routinely discussed with patients pre-operatively. We set out to discover patients' attitudes to being operated on by trainee urological surgeons. PATIENTS AND METHODS: A total of 101 completed questionnaires were received from patients (90 male, 11 female, mean age 72 years) undergoing transurethral resection of the prostate (TURP), transurethral resection of a bladder tumour (TURBT) or cystodiathermy on various aspects of their attitudes to being operated on by junior doctors as part of training. RESULTS: The response rate was 77%. Of the respondents, 94 patients (91%) thought that junior doctors should perform surgery as part of their training. Only 11 of 73 (15%) said they would be happy for a junior doctor, competent to perform the procedure, to operate unsupervised. Of 98 patients, 80 (82%) thought they should be told if the operation was going to be performed by a junior doctor, and 85 (87%) that they should be told their name and designation. CONCLUSIONS: For consent to be 'informed', the experience and identity of the surgeon should be made known to patients. Most patients are happy to be operated on by a junior doctor under consultant supervision, but would want to be told and know their name and status.

Urethral catheter: a pain in the neck!

Long-term urinary catheterization is well recognized in the literature as being associated with significant morbidity and mortality. We present a rare and previously unreported complication of a cervical spine abscess resulting from methicillin-resistant Staphylococcus aureus septicaemia originating from the urinary tract in a patient with a urinary catheter.

Nitrous oxide (Entonox) inhalation and tolerance of transrectal ultrasound guided prostate biopsy: a double-blind randomized controlled study.

PURPOSE: We performed a randomized, placebo controlled double-blind trial to evaluate the effectiveness of Entonox (BOC Gases, Manchester, United Kingdom), that is 50% nitrous oxide and oxygen, as analgesia during transrectal ultrasound guided prostate biopsy. MATERIALS AND METHODS: Patients referred for transrectal ultrasound guided prostate biopsy for the first time as an outpatient procedure were recruited subject to exclusion criteria and randomized to breathe Entonox or air via similar breath activated devices. At the end of the procedure patients completed a visual pain analog scale. Patients who refused study participation also completed the visual analog pain scale to assess the placebo effect of receiving gas through a mask. RESULTS: A total of 110 patients were studied. Statistical analysis using 1-way analysis of variance showed a highly significant difference in pain perception among the 3 groups (F [2,107] = 73.348, p <0.001). This significant decrease in pain was noted in the Entonox versus air and Entonox versus placebo groups. There was no significant difference in the air and placebo groups. Seven of the 51 patients receiving Entonox complained of feeling drowsy during the procedure, which resolved at completion of the procedure. In this group 49 patients would undergo this procedure again if needed. In 2 of the 45 patients in the group receiving air the procedure was abandoned due to pain, while another 19 would prefer more analgesia and 2 would prefer general anesthesia if the procedure was to be repeated. CONCLUSIONS: Our study shows that Entonox is a safe, rapidly acting and effective form of analgesia for the pain of prostate biopsy. We believe that it should be the analgesia of choice for this procedure.

Renal cell carcinoma: incidental detection during routine ultrasonography in men presenting with lower urinary tract symptoms.

OBJECTIVE: To compare renal cell carcinomas (RCCs) presenting incidentally in patients referred for lower urinary tract symptoms (LtJTS) with those presenting symptomatically, by stage, intervention and outcome. PATIENTS AND METHODS: The case notes of all male patients (100) diagnosed with RCC between 1991 and 1998 were reviewed and modes of presentation recorded. The patients were divided into two groups: those who were referred with LUTS (frequency, urgency, hesitancy, poor stream, nocturia) and in whom RCC would not have been suspected and was thus detected incidentally on routine ultrasonography; and all patients in whom carcinoma might have been suspected from their symptoms but, for the purposes of this study, also included patients in whom RCC was diagnosed during ultrasonography for unrelated intra-abdominal pathology. Details of diagnostic imaging and clinical staging were similarly recorded for both groups and where surgical intervention was undertaken, histopathological data were also noted. The clinical course and long-term outcome of incidentally detected tumours was then compared with their symptomatically presenting counterparts. RESULTS: The mean (range) follow-up for all patients was 30 (1.5-96) months; for those in the incidental group it was 31 (1-86) months and in the symptomatic patients 29 (1-96) months. Organ-confined disease was found in two-thirds of patients with incidental tumours and in 38% of those in whom the tumour may have been suspected; the difference was statistically significant (chi-squared test P<0.05). The mean (SD) size of tumours discovered incidentally and in symptomatic patients was 5.9 (1.94) cm and 9.2 (3.39) cm, respectively; this difference was also statistically significant (t-test, P<0.001). Of the 24 patients with incidentally detected tumours, 14 (58%) were alive with no recurrence, and of the 76 presenting symptomatically, 27 (35%) were alive with no recurrence at the last follow-up; disease survival curves showed a statistically better survival rate for those with organ-confined tumours. CONCLUSION: Incidentally diagnosed RCC represents a significant proportion of those who are ultimately diagnosed with the malignancy. Opportunities which arise for appropriate screening of the upper tracts during routine urological investigations (e.g. ultrasonography of the upper tracts in patients referred for LUTS) should be endorsed, contrasting with the more traditional approach, which argues that it yields no ultimate survival advantage.