Robotic-assisted laparoscopic pyeloplasty for ureteropelvic junction obstruction A retrospective review of a high-volume Canadian center.

INTRODUCTION: At present, there is no literature on the outcomes of robotic-assisted laparoscopic pyeloplasty (RALPyelo) in a Canadian context. Our objective was to perform a retrospective review of RALPyelo cases at a high-volume Canadian center. METHODS: We performed a retrospective review of patients who underwent RALPyelo at St. Michael's Hospital, between January 2012 and May 2019. Demographics, operative details, and pre- and postoperative imaging results (ultrasounds, computed tomography [CT] scans, and diuretic renal scan [DRS ]) were recorded. Patients were excluded if at least one-year followup data was unavailable. Our primary outcome was clinical and radiologic improvement defined as 1) symptom improvement; 2) stable/improved split renal function on DRS ; and 3) either improvement in the degree of hydronephrosis on ultrasound or CT, or improved drainage time on DRS. Secondary outcomes included postoperative complications, need for diagnostic intervention, and reintervention for recurrent UPJO. RESULTS: A total of 156 patients underwent RALPyelo after exclusions. The median age was 42 and 66% were female. Mean followup was 2.5 years. For our primary outcome, 87% had clinical and radiologic improvement. Diagnostic investigation for possible recurrent/persistent obstruction, based on symptoms and/or imaging results, was required in 17% of cases, but only 3% required reintervention for recurrent UPJO. Accordingly, the overall treatment success was 97%. The most common postoperative complication was urinary tract infection (18%), and urine leak was seen in only 2% of patients. CONCLUSIONS: The results of our study compare favorably with currently reported outcomes in the literature and demonstrate the safety and high level of success of RALPyelo at a high-volume Canadian center.

Determination of optimal stent length: a survey of urologic surgeons.

Introduction: Ureteral double-J stent length is an important factor affecting stent-related symptoms. Multiple techniques exist to determine ideal stent length for a given patient, however, little is known about what techniques urologists rely on. Our objective was to identify how urologists determine optimal stent length. Material and methods: An online survey was e-mailed in 2019 to all members of the Endourology Society. The survey sought to assess what methods are commonly used to determine choice of stent length, along with frequency of stent placement post ureteroscopy, duration of stenting, availability of different stent lengths and the use of stent tether. Results: 301 urologists (15.1%) responded to our survey. Following ureteroscopy, 84.5% of respondents would stent at least 50% of the time. Following uncomplicated ureteroscopy, most respondents (52.0%) would leave a stent for 2-7 days. Patient height was most commonly ranked first as the method of choice in determining stent length (47.0%), followed by estimation based on experience only (20.6%) and intra-operative direct measurement of ureteric length (19.1%). Most respondents utilized multiple methods in determination of optimal stent length. Most respondents (66.5%) were interested in a simple intra-operative technique utilizing a special ureteral catheter that would help choose the most appropriate stent length. Conclusions: Post-ureteroscopy stent insertion is common and patient height is the most common method of choice used in determining optimal stent length. Most respondents were interested in using a simple, novel ureteral catheter device that would allow them to more accurately select optimal stent length.

Clips Can be Safely Used for Vascular Control of the Renal Vessels During Laparoscopic Donor Nephrectomy.

OBJECTIVE: To review our experience using clips to control the renal vessels during laparoscopic donor nephrectomy (LDN) and determine the safety of this practice. METHODS: We performed a retrospective review of patients who underwent LDN at our centre January 1, 2007-September 17, 2019. The primary outcome was the rate of complication associated with vascular control of the renal vessels, which included (1) conversion to open to manage bleeding, (2) additional procedures for bleeding, and (3) major bleeding requiring blood transfusion. Secondary outcomes included the rate of renal artery/vein clip dislodgement or crossing, change in hemoglobin, warm ischemia time and the incidence of intra-operative complications and postoperative in-hospital complications. RESULTS: We included 503 patients who underwent LDN, of which 497 were left sided. The main renal artery was controlled with 3 titanium clips in 489 (97%) cases. The main renal vein was controlled with 2 polymer-locking clips in 478 (95%) cases. For our primary outcome, there were no conversions to open to manage bleeding, no secondary procedures due to bleeding and no major bleeding requiring blood transfusion. Additionally, there were no donor deaths. Regarding our secondary outcomes, there were 5 intraoperative events related to the titanium clips being placed on the renal artery and 1 intraoperative event related to the polymer-locking clips on the renal vein, none of which resulted in any morbidity. CONCLUSION: Using 3 titanium clips on the renal artery and 2 polymer-locking clips on the renal vein during left LDN is safe and provides excellent vascular control.

Assessing the Necessity of Routine Crossmatching for Blood Transfusion in Renal Transplantation.

INTRODUCTION: Routine crossmatch of packed red blood cells (pRBCs) is completed preoperatively at many centers despite conflicting evidence on the incidence of blood transfusions with renal transplantation. In the current economic climate, resource adjudication should be judicious and medically appropriate. The objective of this study was to determine the incidence, timing, and predictors of early postoperative pRBC transfusion in patients undergoing renal transplantation. METHODS: A retrospective review of all patients undergoing renal transplantation at our institution from January 2013 to May 2016 was performed. Demographic, biochemical, and clinical parameters were recorded. The primary outcome was early postoperative transfusion, defined as an intraoperative transfusion or within 2 days of surgery. Multivariable logistic regression was performed to identify associations with early postoperative transfusion. RESULTS: We identified 428 patients during the study period (average age 55 years, 60% male, 30% obese, 67% deceased donor, and 43% preoperative antithrombotic use). Forty (9.3%) patients required early postoperative transfusion (mean: 2.8 pRBCs/transfusion) and most did not require blood urgently. Only 20 (4.7%) patients required a transfusion intraoperatively or on the same day of surgery. Lower preoperative hemoglobin (per g/L unit: odds ratio [OR]: 0.943), female gender (OR: 2.752), and preoperative antithrombotic use (OR 2.369) were associated with a need for early postoperative transfusion. CONCLUSION: Transfusion in the early postoperative period following renal transplantation was less than 10%, suggesting that routine crossmatch may not be necessary for all patients. Preoperative hemoglobin, female gender, and preoperative antithrombotic use were associated with increased risk and may be useful to risk-stratify patients who require crossmatch.

Are Routine Laboratory Investigations Necessary Following Percutaneous Nephrolithotomy?

OBJECTIVE: To determine how effective routine postoperative blood work is in identifying complications after percutaneous nephrolithotomy (PCNL), the gold standard treatment for large volume stone disease. Although major complication rates are low, hemorrhagic and sepsis-related complications are serious and can occur. Routine post-PCNL complete blood count is routinely performed by most endourologists but may be a low-value practice. METHODS: A retrospective review was performed of all PCNL procedures at our center over a 3-year period. Patient demographic, stone characteristics and postoperative data were collected and analyzed. RESULTS: Three hundred and eighty-five patients (196 female and 189 males) underwent PCNL for the treatment of urolithiasis. Mean age was 55.8 years and mean length of stay in hospital was 1.74 days. Most patients (82.9%) had neither ureteric stent nor percutaneous tube prior to PCNL. Postoperatively, 4 patients (1.0%) required a blood transfusion and 14 patients (3.6%) developed urosepsis. Patients who required either a transfusion or developed urosepsis demonstrated abnormal vital signs (tachycardia, hypotension, or fever) postoperatively. Sixteen patients (4.2%) had normal vital signs but had an extended hospital stay only to monitor abnormal blood work results. None these patients required a transfusion nor developed urosepsis but had a length of stay that was a mean of 1.5 days longer patients with normal postoperative vital signs and blood work. CONCLUSION: Abnormal vital signs alone identified all patients that required transfusion or treatment for urosepsis after PCNL. Routine complete blood count testing postoperatively may not improve detection of infectious or bleeding complications and may prolong hospital admission unnecessarily.

Celebrating 75 years.

INTRODUCTION: Following the introduction of shock wave lithotripsy (SWL), ureteroscopy (URS), and percutaneous nephrolithotomy (PCNL), the subspecialty of endourology was born in the late 1970s. The purpose of this study was to report milestones in Canadian endourology, highlighting Canada's contributions to the field. METHODS: A review of the literature was performed from the late 1970s to the present. The literature review included bibliographic and digital resources. Additionally, records and recollections by various individuals were used, including some who were directly involved. RESULTS: Endourology was born in Canada when SWL, URS, and PCNL emerged as minimally invasive treatment options for stones in the early to mid-1980s. According to our research, the first PCNL was performed at the University of Toronto in 1981. Dr. Joachim Burhenne, a Harvard-trained radiologist from Germany, first used extracorporeal SWL in Canada at the University of British Columbia (UBC) for the treatment of biliary stones. Treatment for urinary tract stones followed at UBC and Dalhousie University. The first worldwide use of the holmium laser for lithotripsy of urinary tract calculi took place at the University of Western Ontario. Other endourology milestones in Canada include the formation of the Canadian Endourology Group and the emergence of the Endourological Society-accredited fellowship programs at the University of Toronto and Western University in the 1990s. Canada hosted the 21st and 35th World Congress of Endourology and Shock Wave Lithotripsy annual meeting in Montreal and Vancouver, respectively. CONCLUSIONS: Canadian urologists have led many advances in SWL, URS, and PCNL over the past four decades and, for a relatively small community, have made significant contributions to the field. Through the training of the next generation of endourologists at Canadian institutions, the future of endourology in Canada is bright.

Routine Preoperative Electrocardiograms in Patients at Low Risk for Cardiac Complications During Shockwave Lithotripsy: Are They Useful?

INTRODUCTION: Routine preoperative electrocardiogram (ECG) before shockwave lithotripsy (SWL) is frequently performed despite recommendations against its use in asymptomatic patients undergoing low-risk surgical procedures. This study assesses whether routine preoperative ECG before SWL is useful in patients at low risk for cardiac complications. MATERIALS AND METHODS: A retrospective study of SWL at our center (2003-2013) reviewed all cardiac-related preoperative cancellations, intraoperative complications, postoperative admissions, and emergency department presentations in patients at low risk for cardiac complications. Patients received SWL with sedation and continuous five-lead ECG monitoring. RESULTS: Of 30,892 referrals, preoperative ECG triggered 13 (0.04%) cancelations in low-risk patients (1 with new atrial fibrillation and 12 with ischemia/previous infarction). Of these patients, 1 had a subsequent abnormal cardiac work-up and 11 underwent uncomplicated SWL without cardiac intervention (2 had unknown history). Of 27,722 treatments, 5 (0.02%) were stopped prematurely in low-risk patients because of arrhythmia (3 had normal preoperative ECG, 1 had abnormal ECG, and 1 did not complete ECG). Three patients developed an arrhythmia with sedation and 2 patients were admitted postoperatively because of cardiac complications (1 for atrial fibrillation and 1 for hypertension), of whom all had normal preoperative ECG. No patients presented to our emergency department with cardiac complications after SWL. CONCLUSIONS: In patients at low risk for cardiac complications, preoperative ECG triggered very few cancellations and did not predict early termination of treatment or cardiac complications after SWL. These findings suggest that in low-risk patients, routine preoperative ECG has little effect on treatment or complication rate and should be omitted.

A survey of Canadian renal transplant surgeons: Use of ureteric stents and technique of the ureteroneocystotomy.

INTRODUCTION: The role of ureteric stenting in renal transplant has been well-demonstrated. The goal of this survey was to determine the utilization of ureteric stents by Canadian transplant surgeons, and how the ureteroneocystotomy and followup is performed. METHODS: An online survey was sent to the 40 surgeon members of the Canadian Society of Transplantation. The primary outcome was the rate of ureteric stent use at the time of renal transplantation. The secondary outcomes were the ureteric stent dwell time, use and type of prophylactic antibiotics, and the use of routine post-transplant ultrasonography. RESULTS: All respondents (25) used ureteric stent routinely and 92% remove the stent between four and six weeks postoperatively. Prophylactic antibiotics were used 64% of the time for ureteric stent removal. The majority of surgeons do not routinely perform a post-stent removal ultrasound. Fifty-six percent of respondents perform a refluxing anastomosis. CONCLUSIONS: Ureteric stents are routinely used in renal transplant in Canada. Areas for improvement and topics of debate identified from this survey are the need for peri-stent removal antibiotics, the role of post-stent removal ultrasound, the duration of stent dwell time, and the need for a non-refluxing ureteroneocystotomy.

Shockwave Lithotripsy Practice Pattern Variations Among and Between American and Canadian Urologists: In Support of Guidelines.

PURPOSE: Shockwave lithotripsy (SWL) is a widely utilized form of treatment for urolithiasis. There are new evidence-based recommendations regarding pre-SWL patient work-up and the performance of SWL. The purpose of this study is to determine practice patterns for SWL and to determine if regional variation exists between Canada and the United States. MATERIALS AND METHODS: A 19-question survey was prepared. Canadian urologists were surveyed through e-mail correspondence. In the United States, members of the Endourologic Society and members of two large stone management groups were surveyed. Canadian and American results were compared using the chi-square and Fisher's exact tests. RESULTS: Ninety-four Canadian urologists and 187 U.S. urologists completed the survey. Practice patterns differed between countries. Intravenous sedation was more commonly used in Canada (Canada 94.7% vs United States 17.9%, p < 0.001); routine antibiotics were more commonly given in United States (Canada 2.1% vs United States 78.1%, p < 0.001); a shock rate of 2 Hz was more common in Canada (Canada 76.6% vs United States 16.2%, p < 0.00001); rate of discontinuing ASA for renal and ureteral stone treatment was higher in the United States (renal Canada 88.3% vs United States 95.7%, p < 0.02; ureteral Canada 62.4% vs 90.3%, p < 0.0001); and ureteral stents were more commonly used if treating a large stone or patients with solitary kidneys in the United States (large stones Canada 58.2% vs United States 88.8%, p = 0.0001; solitary kidney Canada 50.6% vs 66.3%, p = 0.02). CONCLUSIONS: This study highlights the absence of standardization of SWL. Significant regional differences exist in practice patterns and performance of SWL between Canadian and American urologists.

Best Stent Length Predicted by Simple CT Measurement Rather than Patient Height.

INTRODUCTION AND OBJECTIVES: Ureteral stent length is important, as stents that are too long might worsen symptoms and too short are at higher risk of migration. The purpose of this study was to determine if patient or radiologic parameters correlate with directly measured ureteral length and if directly measured ureteral length predicts proper stent positioning. METHODS: During stent placement, ureteral length (ureteropelvic junction to ureterovesical junction distance) was directly measured by endoscopically viewing a ureteral catheter (with 1-cm marking) emanating from the ureteral orifice. A 22, 24, or 26 cm stent was chosen to be closest to the measured ureteral length. For ureters >26 cm, a 26 cm stent was chosen. Ends of an "ideally positioned" stent were fully curled in the renal pelvis and bladder, without crossing the bladder midline. Rates of ideal stent position were compared between patients with matching stent and ureteral lengths and those with stent lengths differing by ≥1 cm (mismatched). The measured ureteral length was correlated with patient height, L1-L5 height, and length measured on CT. RESULTS: Fifty-nine ureters from 57 patients were included. Height was reasonably correlated with L1-L5 height (Spearman correlation coefficient [rho] = 0.79), although both were poorly correlated with directly measured ureteral length (rho = 0.18 for height and 0.32 for lumbar height). Ureteral lengths measured on CT correlated well with direct measurement (rho = 0.63 for axial cuts and rho = 0.64 for coronal cuts). Matched stent length was associated with higher rates of ideal stent position than mismatched (100% vs 70.9%, p = 0.006). CONCLUSIONS: CT measurements, rather than height, correlate well with measured length and could be used to choose the appropriate stent length. Stents matching directly measured ureteral lengths are associated with high rates of ideal stent position.

Changing Patient Position Can Eliminate Arrhythmias Developing During Extracorporeal Shockwave Lithotripsy.

INTRODUCTION: Extracorporeal shockwave lithotripsy (SWL) has a low complication rate. While serious complications are rare, cardiac arrhythmias, such as ventricular tachycardia, may occur. The etiology of these arrhythmias is poorly understood, but it appears to be due to stimulation of the heart by the shock waves. OBJECTIVE: This study examines the effect of rotating the patient 15° to 20° when an arrhythmia occurs. METHODS: Eight hundred nineteen patients were prospectively evaluated for arrhythmias during SWL. The initial patient position was dependent on the location of the stone and the body mass index (BMI) of the patient. If a sustained arrhythmia developed, treatment was withheld for 2 minutes and then recommenced. If the patient developed an arrhythmia again, the patient was rotated 15°-20° away from the original position and treatment recommenced. RESULTS: Twenty patients developed significant arrhythmias during SWL. Arrhythmias occurred more frequently in patients with a lower BMI (p < 0.01), of younger age (p = 0.01), and with right-sided stones (p = 0.035). After the first rotation, 11 patients had no further arrhythmias, and 4 patients had a reduction of their arrhythmia to unsustained minor arrhythmias that did not require cessation of the treatment. The remaining five patients required a second repositioning. Three of these patients required gated SWL to abolish the arrhythmia. CONCLUSION: Changing the position of the patient by rotating the patient by 15 to 20° can eliminate arrhythmias that develop during SWL.

Simulation-based flexible ureteroscopy training using a novel ureteroscopy part-task trainer.

INTRODUCTION: Simulation-based training (SBT) is being increasingly used for novice trainees as a means of overcoming the early learning curve associated with new surgical skills. We designed a SBT flexible ureteroscopy (fURS) course using a novel inanimate training model (Cook Medical, Bloomington, IN; URS model). We evaluated the course and validated this Cook URS model. METHODS: A 2-week SBT fURS course was designed for junior level urology trainees at 2 Canadian universities. The curriculum included didactic lectures, hands-on training, independent training sessions with expert feedback, and use of the Cook URS part-task model. Baseline and post-course assessments of trainee fURS skills were conducted using a standardized test task (fURS with basket manipulation of a calyceal stone). Performances were video-recorded and reviewed by 2 blinded experts using a validated assessment device. RESULTS: Fifteen residents (postgraduate years [PGY] 0-3) participated in the course. Of the participants, 80% rated the Cook URS model as realistic (mean = 4.2/5) and 5 endourology experts rated it as useful as a training device (mean = 4.9/5), providing both face and content validity. The mean overall performance scores, task completion times, and passing ratings correlated with trainee clinical fURS experience - demonstrating construct validity for the Cook URS model. The mean post-course task completion times (15.76 vs. 9.37 minutes, p = 0.001) and overall performance scores (19.20 vs. 25.25, p = 0.007) were significantly better than at baseline. Post-course performance was better in all domains assessed by the validated assessment device. CONCLUSIONS: This study demonstrates that a SBT curriculum for fURS can lead to improved short-term technical skills among junior level urology residents. The Cook URS model demonstrated good face, content and construct validity.

Lumbar plexopathy as a complication of percutaneous nephrolithotomy in a horseshoe kidney.

Treatment of nephrolithiasis in horseshoe kidneys can be challenging due to anomalies in renal position, collecting system anatomy and vascular supply. We report on a patient who was referred after a failed percutaneous nephrolithotomy for a left moiety staghorn calculus in a horseshoe kidney. Two punctures had been performed involving upper and middle posterior calyces. Both were very medially placed and inadvertently traversed the psoas muscle, resulting in lumbar plexopathy with permanent deficit. This complication presented postoperatively with left leg weakness, paresthesia, and pain which impaired independent ambulation. The patient went on to be successfully treated for her stone disease with robotic-assisted laparoscopic pyelolithotomy.

A population based study of the changing demographics of patients undergoing definitive treatment for kidney stone disease.

PURPOSE: We examined temporal changes in the demographics of patients undergoing definitive treatment for kidney stones during a 20-year period in Ontario, Canada. MATERIALS AND METHODS: Using the Ontario Health Insurance Plan physician claims database and the Canadian Institute for Health Information Discharge Abstract Database we performed a population based cross-sectional time series analysis by identifying all kidney stone treatments done between July 1, 1991 and December 31, 2010. The demographics assessed were patient gender, age and socioeconomic status. The rate and/or proportion of kidney stone treatments per strata of these demographics were calculated for each 1-year block of the study period. We used time series analysis with exponential smoothing and autoregressive integrated moving average models to assess for trends with time. RESULTS: We identified 116,115 patients who underwent treatment for kidney stones during the study period. The rate of stone procedures performed per year increased steadily from 85/100,000 to 126/100,000 population. With time the rate of females who were treated increased significantly from 40/100,000 to 53/100,000 (p <0.0001). In contrast, the rate of males who were treated remained stable, increasing from 82/100,000 to 83/100,000 (p = 0.11). In regard to age the rate of patients older than 64 years increased significantly with time from 67/100,000 to 89/100,000 (p <0.0001). In regard to socioeconomic status approximately 20% of the patients were in each of the 5 income quintiles during the entire study period. CONCLUSIONS: Our population based study shows an increased rate of females and of patients older than 64 years undergoing definitive treatment for kidney stones with time.

The role of prophylactic versus selective ureteric stenting in kidney transplant patients: a retrospective review.

OBJECTIVE: To evaluate the role of prophylactic versus selective ureteric stenting in the development of postoperative ureterovesical complications in kidney transplant recipients. METHODS: Records of 614 transplant patients seen from January 2006 to May 2011 were retrospectively reviewed. The primary outcome was the rate of ureterovesical complications, defined as the development of ureteric obstruction or a ureterovesical anastomotic leak. The secondary outcomes were the rate of urinary tract infections and forgotten stents. Using a χ2 test, we compared the primary and secondary outcomes across the selective and prophylactic cohorts. Logistic regression was used to compare the 2 cohorts while adjusting for potential confounders. RESULTS: The selective and prophylactic cohorts consisted of 258 and 330 patients, respectively. Unadjusted analysis showed that the prophylactic group had a significantly lower rate of ureterovesical complications than did the selective group (2.12% vs 6.20%; odds ratio, 0.33; P= .01). After adjustment for differences in sex and donor type, the prophylactic group still had a lower risk for ureterovesical complications (odds ratio, 0.30; P= .009). Rates of urinary tract infections and forgotten stents did not differ significantly between the 2 groups. CONCLUSIONS: Prophylactic stenting is associated with a significantly lower rate of ureterovesical complications than is selective stenting.

The surgical management of kidney stone disease: a population based time series analysis.

PURPOSE: We evaluate population based trends in the use of extracorporeal shock wave lithotripsy, ureteroscopy and percutaneous nephrolithotomy during the last 20 years, as well as assess the re-treatment rate and morbidity from treatment over time. MATERIALS AND METHODS: Using administrative databases in the province of Ontario, Canada, a population based cross-sectional time series analysis was performed between July 1, 1991 and December 31, 2010. All extracorporeal shock wave lithotripsy, ureteroscopy and percutaneous nephrolithotomy procedures were identified, along with all hospital readmissions and emergency department visits within 7 days of treatment. The primary outcome was treatment use, and secondary outcomes were the need for ancillary treatment and hospital readmission or emergency department visit after treatment. Exponential smoothing and autoregressive integrated moving average (ARIMA) models were used to assess trends over time. RESULTS: We identified 194,781 kidney stone treatments performed during the study period. Time series modeling revealed a significant increase in the use of ureteroscopy over time (25% to 59% of all procedures, p <0.0001) and a reciprocal decrease in the use of extracorporeal shock wave lithotripsy (69% to 34% of all procedures, p <0.0001). A corresponding significant decrease in the need for ancillary treatment over time (23% to 15%, p <0.0001) and increase in the need for hospital readmission (7% to 11%, p <0.0001) or emergency department visit (7% to 11%, p=0.0024) after treatment were also demonstrated. CONCLUSIONS: Our population based study demonstrates a shift in the treatment paradigm with increased use of ureteroscopy over time and a reciprocal decrease in the use of extracorporeal shock wave lithotripsy. We also observed a corresponding decrease in ancillary treatment and increase in posttreatment morbidity over time.

Quantitative proteomic analysis reveals potential diagnostic markers and pathways involved in pathogenesis of renal cell carcinoma.

There are no serum biomarkers for the accurate diagnosis of clear cell renal cell carcinoma (ccRCC). Diagnosis and decision of nephrectomy rely on imaging which is not always accurate. Non-invasive diagnostic biomarkers are urgently required. In this study, we preformed quantitative proteomics analysis on a total of 199 patients including 30 matched pairs of normal kidney and ccRCC using isobaric tags for relative and absolute quantitation (iTRAQ) labeling and LC-MS/MS analysis to identify differentially expressed proteins. We found 55 proteins significantly dysregulated in ccRCC compared to normal kidney tissue. 54 were previously reported to play a role in carcinogenesis, and 39 are secreted proteins. Dysregulation of alpha-enolase (ENO1), L-lactate dehydrogenase A chain (LDHA), heat shock protein beta-1 (HSPB1/Hsp27), and 10 kDa heat shock protein, mitochondrial (HSPE1) was confirmed in two independent sets of patients by western blot and immunohistochemistry. Pathway analysis, validated by PCR, showed glucose metabolism is altered in ccRCC compared to normal kidney tissue. In addition, we examined the utility of Hsp27 as biomarker in serum and urine. In ccRCC patients, Hsp27 was elevated in the urine and serum and high serum Hsp27 was associated with high grade (Grade 3-4) tumors. These data together identify potential diagnostic biomarkers for ccRCC and shed new light on the molecular mechanisms that are dysregulated and contribute to the pathogenesis of ccRCC. Hsp27 is a promising diagnostic marker for ccRCC although further large-scale studies are required. Also, molecular profiling may help pave the road to the discovery of new therapies.

Does baseline radiography of the kidneys, ureters, and bladder help facilitate stone management in patients presenting to the emergency department with renal colic?

BACKGROUND AND PURPOSE: A baseline kidneys, ureters, and bladder (KUB) radiograph, at the time of computed tomography (CT) for ureteral stones, might aid interpretation of future KUBs. The CT scout radiograph might render the baseline KUB redundant, however. We sought to assess the diagnostic utility of baseline KUB for patients with ureteral stones. PATIENTS AND METHODS: Patients with ureteral stones were retrospectively identified. All had a baseline KUB in addition to CT and were reassessed after 4 to 60 days with KUB. Each patient's imaging was randomized 1:1 into either "KUB&CT" or "CT" groups. Three urologists independently assessed the imaging: CT (with scout film) and baseline KUB in the KUB&CT group, but only the CT (not KUB) in the CT group. Definitive stone assessment on follow-up KUB was defined as all three reviewers answering either Yes or No (not Indeterminate) to the question of stone passage or migration. RESULTS: Of 154 stones, the mean diameter was 4.8 ± 2.1 mm, density was 914 ± 300 Hounsfield units (HU), with 54.4% in the distal ureter. Stone visibility was 60.4% on KUB vs 43.5% on scout film (P<0.001). Scout film visibility favored the CT group (52.7 vs 35.0%, P = 0.027). After adjusting for body mass index, skin-to-stone distance, size, density, and location, definitive assessment rates were higher in the KUB&CT group (P = 0.047). When reviewers reassessed the CT group using the baseline KUB, they were able to do so definitively in an additional 16 (21.6%, P<0.001). Definitive assessments were associated with higher rates of stone visibility on scout film (86.1 vs 21.1%, P<0.001), KUB (86.1 vs 50.0%, P<0.001), and larger (6.0 vs 3.7 mm, P<0.001), denser stones (1046 vs 802 HU, P<0.001). CONCLUSIONS: The addition of a baseline KUB to the CT scout film improves the ability of urologists to determine stone outcome when following patients with KUB imaging and might reduce the subsequent need for additional imaging.

Prone versus supine lasix renal scan to assess surgical success after laparoscopic and robot-assisted pyeloplasty.

PURPOSE: Success after laparoscopic pyeloplasty (LP) for ureteropelvic junction obstruction is determined based on renal scan (RS) results and patient symptoms ± ultrasonography. The upright or prone position during RS may facilitate drainage. This study reports on outcomes after LP and robot-assisted pyeloplasty (RALP) and determines if patient position (supine vs prone) alters the results of the postoperative RS and surgical "success." PATIENTS AND METHODS: A retrospective review of LP and RALP performed by one surgeon between 2005 and 2012 was performed. Follow-up consisted of RS ± ultrasonography. The paired t test was used to assess for a significant difference between mean T1/2 for supine vs prone scans in each patient. Linear regression was used to determine if preoperative split renal function on the affected side or degree of preoperative hydronephrosis predicted difference in supine vs prone T1/2. RESULTS: There were 11 LP and 81 RALP performed; 84 had follow-up data. There were four (4.3%) failures. Thirty-eight patients had sufficient supine and prone RS for analysis. The difference in T1/2 between supine and prone RS was significant (mean difference 10.18 ± 27.28 min, P = 0.03). Strict success increased to 65.8% from 44.7% and combined strict plus technical success increased to 78.9% from 63.1% on prone vs supine RS. Split function and degree of hydronephrosis were not predictors of difference in RS results. CONCLUSIONS: LP and RALP have good technical results. Prone position for RS may facilitate drainage and may be a more accurate representation of postoperative outcome after pyeloplasty, particularly in equivocal cases.