Dusting versus Basketing during Ureteroscopy-Which Technique is More Efficacious? A Prospective Multicenter Trial from the EDGE Research Consortium.

PURPOSE: There is scant evidence in the literature to support dusting vs active basket extraction during ureteroscopy for kidney stones. We prospectively evaluated and followed patients to determine which modality produced a higher stone-free rate with the fewest complications. MATERIALS AND METHODS: Members of the Endourologic Disease Group for Excellence research consortium prospectively enrolled patients with a renal stone burden ranging from 5 to 20 mm in this study. A holmium laser was used and all patients were stented postoperatively. Ureteral access sheaths were used in 100% of basketing cases while sheaths were optional when dusting. The primary study outcome was the stone-free rate at 6 weeks as determined by x-ray and ultrasound. RESULTS: A total of 84 and 75 patients were enrolled in the basketing and dusting arms, respectively. Stones in the dusting group were significantly larger (mean ± SD stone area 96.1 ± 65.3 vs 63.3 ± 46.0 mm2, p <0.001). The stone-free rate was significantly higher in the basketing group on univariate analysis (74.3% vs 58.2%, p = 0.04) but not on multivariate analysis (1.9 OR, 95% CI 0.9-4.3, p = 0.11). In patients who underwent a basketing procedure operative time was 37.7 minutes longer than in those treated with a dusting procedure (95% CI 23.8-51.7, p <0.001). There was no statistically significant difference in complication rates, hospital readmissions or additional procedures between the groups. CONCLUSIONS: The stone-free rate was higher for active basket retrieval of fragments at short-term followup on univariate analysis but not on multivariate analysis. There was no difference in postoperative complications or procedures. The 2 techniques should be in the armamentarium of the urologist.

Robotic dismembered pyeloplasty: a 6-year, multi-institutional experience.

PURPOSE: The introduction of the da Vinci Surgical System to perform complex reconstructive procedures, such as repair of ureteropelvic junction obstruction, has helped to overcome some of the technical challenges associated with laparoscopy. We review our large multi-institutional experience with long-term followup of robotic dismembered pyeloplasty. MATERIALS AND METHODS: A total of 140 patients from 3 university medical centers underwent robotic dismembered pyeloplasty. An institutional review board approved retrospective chart review was performed to collect demographic, preoperative, operative and postoperative data. Patients were analyzed as an entire cohort and then divided into various subgroups. RESULTS: Of the cases 117 (84.6%) were primary repairs and 23 (16.4%) were secondary repairs. There were 13 (9.3%) patients who underwent concomitant stone extraction and 5 (3.6%) procedures were performed on patients with solitary kidneys. A crossing vessel was found in 77 (55%) patients. Mean operative time was 217 minutes (range 80 to 510), estimated blood loss was 59.4 ml (range 10 to 600), mean length of hospital stay 2.1 days (range 0.75 to 7) and mean followup was 29 months (range 3 to 63). Radiographic resolution of obstruction on first postoperative diuretic renal scan or excretory urogram was noted in 134 patients (95.7%). There was a 7.1% major complication rate and a 2.9% minor complication rate. No statistically significant differences were found in any parameters among patients from the various cohorts. CONCLUSIONS: To our knowledge this review represents the largest multi-institutional experience of robotic dismembered pyeloplasty with long-term followup. Robotic pyeloplasty appears to be safe, durable and efficacious for primary and secondary ureteropelvic junction obstruction with or without concomitant stone extraction, and for patients with a solitary kidney.

Robotic reconstruction of the upper urinary tract.

PURPOSE: Reconstructive surgery of the upper urinary tract can be complicated. During the last 2 decades minimally invasive techniques have emerged as viable options for these complex procedures. We reviewed our experience with robotic surgery for upper urinary tract reconstruction. MATERIALS AND METHODS: Between May 2002 and December 2006, a single surgeon performed certain robotic reconstructions on the upper urinary tract in 26 males and 37 females (65 renal units), including dismembered pyeloplasty, dismembered pyeloplasty with stone extraction, ureteroureterostomy, ureterolysis with omental wrap, ureterocalicostomy, ureteral reimplantation and upper pole nephroureterectomy. We compared demographic, preoperative, intraoperative and postoperative data on patients undergoing these various procedures. RESULTS: Across all cases mean blood loss was 125 cc, mean operative time was 244.8 minutes and mean length of stay was 2.8 days. The rate of radiographic and symptomatic improvement was 97.3% and 100%, respectively. We observed 2 major complications during a mean followup of 18.7 months. CONCLUSIONS: Our data illustrate that robotics can be successfully and safely used for virtually any type of upper urinary tract reconstruction. Robotic techniques are a viable option for upper urinary tract reconstruction.

Robotic-assisted laparoscopic ureterocalicostomy.

INTRODUCTION: Ureterocalicostomy is a well-established treatment option for patients with recurrent ureteropelvic junction obstruction or proximal ureteral stricture refractory to endoscopic management in the setting of diminutive or intrarenal pelvis or significant peripelvic fibrosis. We report a case of robotic-assisted laparoscopic ureterocalicostomy using the da Vinci robotic system in a patient with proximal ureteral stricture refractory to endoscopic management. TECHNICAL CONSIDERATIONS: All techniques described to date for ureterocalicostomy have been either open or purely laparoscopic. We report a case of robotic-assisted laparoscopic ureterocalicostomy in a patient with refractory proximal ureteral stricture secondary to multiple interventions for stones. We used laparoscopy for the initial dissection and exposure and robotic techniques for lower pole amputation and ureterocaliceal anastomosis. Intraoperative nephroscopy was also performed through the lower pole calix. The patient had resolution of the obstruction at 10 weeks postoperatively with the stent out and radiographic confirmation of excretion and drainage. CONCLUSIONS: Robotic-assisted laparoscopic ureterocalicostomy is a feasible alternative to open or laparoscopic techniques for treating refractory proximal ureteral stricture or ureteropelvic junction obstruction. To our knowledge, this is the first described case of robotic-assisted laparoscopic ureterocalicostomy with intraoperative nephroscopy.

Ureterocalicostomy: a contemporary experience.

OBJECTIVES: To report our contemporary experience with ureterocalicostomy to determine whether the indications or results have changed in modern practice. Ureterocalicostomy is a well-established treatment for patients with complicated ureteropelvic junction (UPJ) obstruction and other forms of proximal ureteral obstruction. Although both retrograde and antegrade endourologic interventions have become accepted forms of management, the success rates do not approach those of open or even laparoscopic interventions, potentially leading to a greater number of patients with treatment failure and the need for more complicated reconstruction. METHODS: Between July 1991 and February 2004, 11 patients (4 women and 7 men), aged 19 to 68 years (mean 38), underwent open surgical ureterocalicostomy. The indications for surgery were primary UPJ obstruction in 4, failed cutting balloon incision for UPJ obstruction in 3, proximal ureteral stricture after ureteroscopic stone removal in 2, and obliterated UPJ after percutaneous nephrolithotomy and failed antegrade endopyelotomy in 1 patient each. RESULTS: Hospitalization ranged from 4 to 7 days (mean 5.1). No patient experienced a significant perioperative complication. With follow-up ranging from 5 to 32 months (mean 10.1), relief of obstruction was evident in all patients as documented by intravenous urography or nuclear renography. Furthermore, differential function on the involved side improved from a mean of 54.6% preoperatively to 60.1% postoperatively (P <0.05). CONCLUSIONS: The spectrum of indications for ureterocalicostomy has changed, although excellent results can still be achieved. Although laparoscopic approaches are currently being evaluated, most patients currently undergoing this reconstructive procedure still require open operative intervention.

Percutaneous nephrostolithotomy: predictors of length of stay.

PURPOSE: Percutaneous nephrostolithotomy (PNL) is commonly used to treat patients with complex renal calculi. A goal at our medical center is to discharge patients home less than 24 hours after PNL. We performed a study to determine factors that caused patients to be hospitalized longer than this period. MATERIAL AND METHODS: The available hospital records and office charts of 133 consecutive patients undergoing initial PNL at our institution between January 1, 1999 and December 31, 2000 were reviewed. All PNL procedures were performed by one of us using a (DGA) 1-stage technique. Mean patient age was 52 years (range 25 to 84). Of the subjects 85 were male and 48 were female. RESULTS: A total of 91 patients (68%) were discharged home less than 24 hours after surgery. The overall stone-free rate was 91%. Mean length of stay in the entire group was 1.97 days. Mean length of stay in those hospitalized longer than 24 hours was 4.12 days. Mean operative time, including time to obtain access, was 188.6 minutes. Multivariate analysis demonstrated that neurogenic bladder, endocrine comorbidity and perioperative complications were factors associated with a length of stay of greater than 24 hours. Univariate analysis demonstrated that preoperative urinary tract infection and infection related calculi were also associated with a length of stay of greater than 24 hours. CONCLUSIONS: The majority of patients undergoing PNL can be discharged home less than 24 hours after surgery. Patients with neurogenic bladder, those with endocrine comorbidity, those who sustain significant perioperative complications and those harboring stones associated with urinary tract infection or preoperative urinary tract infection are more likely to require longer hospitalization.

Ileal ureter substitution: a contemporary series.

OBJECTIVES: To review our contemporary experience with ileal ureter reconstruction. Despite advancements in surgical technology and technical expertise, ureteral injuries continue to occur. These injuries can be extensive, and ileal ureter reconstruction may be necessary. METHODS: A total of 18 ileal ureter substitutions were performed in 16 adults (10 men and 6 women) by a single surgeon during a 6-year period. The mean patient age was 49.4 years (range 25 to 72). The mean follow-up was 18.6 months (range 7 to 59). All ileal ureter substitutions were performed in an isoperistaltic, refluxing fashion. Follow-up included clinical evaluation, nuclear renography, intravenous urography, and serum chemistry testing. RESULTS: Postoperative nuclear renography demonstrated no relative loss of function of the affected renal unit and no evidence of functional obstruction. An unobstructed state was also confirmed with intravenous urography. No statistically significant metabolic changes were found in any patient, as assessed by serum chemistry testing. None of the patients had evidence of new stone formation. Two patients developed an isolated, symptomatic urinary tract infection during follow-up, and one has had recurrent urinary tract infections, a problem that was present preoperatively. CONCLUSIONS: Ileal ureter substitution remains an effective treatment for patients with complex ureteral strictures or injuries. Stone activity does not appear to increase, and metabolic sequelae are uncommon in properly selected patients.

Computerized tomography guided access for percutaneous nephrostolithotomy.

PURPOSE: Access for percutaneous nephrostolithotomy (PNL) using conventional fluoroscopic guidance may carry an increased risk of damage to surrounding organs in patients with renal calculi and aberrant anatomy. In these situations cross-sectional anatomical imaging may facilitate safe percutaneous access. We describe our experience with computerized tomography (CT) guided percutaneous access for such patients undergoing PNL. MATERIALS AND METHODS: Between June 2000 and December 2001, 154 patients underwent PNL at our institution. Five of these patients (3%) required a total of 6 percutaneous access tracks under CT guidance. All patients in this group had anatomical abnormalities precluding standard access to the collecting system without risk to adjacent organs. These abnormalities included a retrorenal colon in 2 and a severely distorted body habitus due to spinal dysraphism in 3. RESULTS: Percutaneous access was achieved without complication in all cases. At subsequent PNL 5 of the 6 renal units (83%) were rendered completely stone-free. CONCLUSION: CT guided percutaneous access is infrequently required for PNL. However, there is a select group of patients with anatomical anomalies that may predictably require this procedure to facilitate safe and efficacious PNL.

Selecting Treatment for Distal Ureteral Calculi: Shock Wave Lithotripsy versus Ureteroscopy.

Shock wave lithotripsy (SWL) and ureteroscopy (URS) are both effective treatments for removal of distal ureteral calculi, associated with high success rates and limited morbidity. The American Urological Association Ureteral Stones Clinical Guidelines Panel has found both to be acceptable treatment options for patients, based on the stone-free results, morbidity, and retreatment rates for each respective therapy. However, costs and patient satisfaction or preference were not addressed, and the report was based on data derived from older endoscopic and lithotripsy technology. Each of these treatment options has valid advantages and disadvantages. Both modalities are reasonable treatment options for the majority of patients with distal ureteral calculi. Whereas SWL is less invasive, the high, immediate success rate with minimal morbidity and decreased cost makes URS a very valid competitor. The results of treating patients with larger stones favor URS.

Drug-induced urinary calculi.

Urinary calculi may be induced by a number of medications used to treat a variety of conditions. These medications may lead to metabolic abnormalities that facilitate the formation of stones. Drugs that induce metabolic calculi include loop diuretics; carbonic anhydrase inhibitors; and laxatives, when abused. Correcting the metabolic abnormality may eliminate or dramatically attenuate stone activity. Urinary calculi can also be induced by medications when the drugs crystallize and become the primary component of the stones. In this case, urinary supersaturation of the agent may promote formation of the calculi. Drugs that induce calculi via this process include magnesium trisilicate; ciprofloxacin; sulfa medications; triamterene; indinavir; and ephedrine, alone or in combination with guaifenesin. When this situation occurs, discontinuation of the medication is usually necessary.