Can we predict the ancillary treatments after extracorporeal shockwave lithotripsy for renal and upper ureteral stones?

OBJECTIVE: To quantify the predictors for the ancillary treatments after extracorporeal shock wave lithotripsy (SWL) for renal and upper ureteral stones. MATERIALS AND METHODS: From January 2014 to January 2017, patients undergoing SWL using an electromagnetic lithotripter machine (Compact Delta; Dornier MedTech GmbH, Wessling, Germany) for renal and upper ureteral stones ≤ 20 mm were retrospectively reviewed. All patients underwent CT urography prior to SWL. The cohort was subdivided into three groups according to stone attenuation values in Hounsfield Units (HU). Group I; HU < 500 (n = 20), group II; HU 500-1000 (n = 51) and group III; HU ≥ 1000 (n = 180). The parameters included for multivariate analysis were stone size, location, multiplicity, stone attenuation value, number of shocks and stone clearance rate by 3 months. The ancillary treatments were ureteroscopy (URS), ureteral stenting and hospital readmission for pain or fever. RESULTS: A total of 251 patients were included in the study. The overall SWL success rate was 92.4%. Mean stone size was 10.9 ± 2.1, 11.6 ± 3 and 11.4 ± 3.6 mm and mean stone attenuation values were 364 ± 125, 811 ± 154 and 1285 ± 171 HU for groups I, II and III respectively. The stone clearance rates by 3 months were 96%, 92% and 88.4% for groups I, II and III respectively. On subgroup analysis, group III required ancillary treatments in 70% of patients whereas group I, II, did not require any ancillary treatments. On multivariate analysis, stone multiplicity, stone location (lower calyceal stones) and HU were independent significant predictors for the need for ancillary treatments after SWL (p values < 0.05). CONCLUSIONS: Patients with stone attenuation value (HU) > 1000, multiple stones and/or lower calyceal stones have higher risk to necessitate ancillary treatments after SWL. These patients would likely benefit from upfront endoscopic lithotripsy for treating symptomatic renal or upper ureteral stones.

Can intraperitoneal bupivacaine decreases pain in patients undergoing laparoscopic live donor nephrectomy? A randomized control trial.

PURPOSE: To evaluate effect of intraperitoneal bupivacaine on postoperative pain in patients undergoing laparoscopic live donor nephrectomy. METHODS: Hundred patients undergoing laparoscopic live donor nephrectomy were included in the study and were divided randomly into two groups based on computer-generated randomization chart of fifty each. Patients were made familiar with VAS chart preoperatively. Group A received 20 mL of 0.5 % bupivacaine, while group B patients received 20 mL of 0.9 % normal saline intraperitoneally Postoperatively, patients were assessed based on VAS and requirement of rescue analgesic, hemodynamic parameters and presence of any adverse effects. Student's t test was used for statistical analysis. RESULTS: At all-time interval, mean pain scores were higher in group B than group A. The difference between the mean pain scores was statistically significant (p < 0.05) at 0, 2 and 4 h. The mean dose of rescue analgesia (pentazocin, 30 mg in one vial) in group A was 33 ± 26 mg which was significantly less as compared to group B where it was 62 ± 28 mg. There was statistically insignificant difference between all cardiorespiratory factories at all-time intervals except for heart rate and mean blood pressure at 0 h in group A as compared to group B. CONCLUSIONS: Intraperitoneal bupivacaine is a simple, safe, inexpensive method for control of postoperative pain in patients undergoing laparoscopic live donor nephrectomy. Use of the correct dose and concentration of the drug are essential for effective pain control.

Robot-assisted ureterocalycostomy: A single centre contemporary experience in adults.

OBJECTIVE: To present our technique and experience of robot-assisted ureterocalycostomy (RAUC) in managing secondary pelvi-ureteric junction obstruction (PUJO) in adults. PATIENTS AND METHODS: We retrospectively reviewed all patients from our centre who underwent RAUC, between 2011 and 2015, for secondary PUJO resulting from previous surgical intervention. Six procedures in five patients, including a bilateral RAUC were performed. The median (range) patient age was 33.7 (18-41) years. The outcome variables included operative time, duration of hospital stay, and objective evidence of unimpeded drainage on urography. RESULTS: The mean (range) operating time was 172 (144-260) min and estimated blood loss was 100 (50-250) mL. There were no conversions to open or laparoscopic surgery, and no intraoperative complications. Two patients had Clavien-Dindo Grade I complications that were managed conservatively and one patient had a Grade IIIb complication, which required balloon dilatation and re-stenting. After a median (range) follow-up of 11 (7-48) months, five of the six renal units had successful outcomes. CONCLUSION: The robot-assisted approach appears to be ideally suited for redo cases demanding fine dissection with meticulous suturing. In our present series of adult patients, we could safely and successfully perform RAUC with minimal morbidity. However, a larger multi-institutional outcome analysis is required to substantiate the role of the robot-assisted approach in performing UC.

Urethral Balloon Dilatation: Factors Affecting Outcomes.

UNLABELLED: Background/Aims/Objectives: The study aims to review our experience with balloon dilatation of urethral strictures and retrospectively analyze predictors of improved success rates. METHODS: One hundred and forty-four cases were analyzed from January 2011 to December 2012. Patients underwent balloon dilatation using 6-Fr Balloon dilator set (Cook Urological, Spencer, Ind., USA). Patients analyzed with respect to demography, uroflowmetry (Qmax) and need for auxiliary procedures in the immediate postoperative period, at 6 months and at 1 year. Comparisons were made between those who performed self-calibration against those who did not. RESULTS: Overall success rate of balloon dilatation in our study was 84.4%. Procedural failure was observed with 3 patients (2.1%). Auxiliary procedure was required in 21 cases (15.6%) during follow-up. The mean Qmax (ml/s) in those who regularly performed self-calibration (n = 73) and in those who did not perform self-calibration (n = 39) in the immediate postoperative period, at 6 months and at 1 year were 24.2 ± 10.5, 16.5 ± 7.5, 14.4 ± 6.3 and 21.2 ± 10.6, 14.5 ± 7, 10.8 ± 5.6, respectively. Statistical significance was noted at 1 year (p = 0.003). Lesser re-treatments were required in those who performed self-calibration (12.3 vs. 20.5%). Improved success rates were noted with focal and bulbar strictures. Iatrogenic strictures and pan-anterior urethral strictures had poor outcomes despite self-calibration. CONCLUSIONS: Balloon dilation with self-calibration significantly improves flow rates at 1 year and lessens auxiliary procedures required. It is simple, easy to perform under local anesthesia and repeatable in case of re-strictures.

Robotic repair of vesicovaginal fistula - initial experience

ABSTRACT Objective The most common acquired fistula of the urinary tract is Vesicovaginal fistulae (VVF) (1) posing social stigmata for the patient as well as a surgical challenge for the urologist. Here we present our initial experience with Robotic assisted laparoscopic repair of VVF, its safety and efficacy. Materials and Methods Seven out of eight fistulas were post hysterectomy; five had undergone abdominal while two had laparoscopic hysterectomy while one was due to prolonged labour. Two had associated ureteric injury. All underwent robotic assisted laparoscopic trans abdominal extravesical approach. Three 8 mm ports for robotic arms, one 12 mm port for camera and another 12 mm for assistant were used in a fan shaped manner. All had preoperative ureteric catheter placed. Bladder was closed in two layers and vagina in one layer. Omental flap placed in all cases except two where it was not possible. Drain and per urethral catheter placed in all cases. Double J stents were placed in two cases requiring ureteric implantation additionally. Results The mean age of presentation was 39.25 years (26-47 range) with mean BMI being 26.25 kg/m2 (21-32 range). Mean duration between insult and repair was 9.37 months (3-24 months). Only in single case there was history of previous repair attempt. On cystoscopy four had supratrigonal VVF and four were trigonal with mean size of 13.37 mm (7-20 mm). Mean operative time was 117.5 minutes (90-150). There were no intraoperative/postoperative complications or need for open conversion. Mean haemoglobin drop was 1.4 gm/dL (0.3-2 gm). Drain was removed once 24-48 hours output is negligible. One patient had post-operative urinary leak at 2 weeks which ceased with continuation of catheterisation for another 2 weeks. Catheter was removed after voiding cystourethrogram showed no leak at 2-3 weeks postoperatively. Mean duration of drain was 3.75 days (3-5) and per urethral catheterisation (which was removed after voiding cystourethrography) was 15.75 days (9-28). Mean hospital stay was 6.62 days (4-14). Post-operative bladder capacity was 324.28 cc (280-350) on voiding diary. Follow up ranged from 3-9 months. At 3 months of follow-up, these patients continued to void normally and there was no evidence of recurrence of VVF. Conclusion Robotic repair of VVF is safe and feasible and has additional advantages in the form of precise suturing under 3D vision and certainly a more striking and effective option especially in complex VVF repair associated with ureteric injuries (2).

Factors predicting outcomes of micropercutaneous nephrolithotomy: results from a large single-centre experience.

OBJECTIVES: To present our single-centre experience of the micropercutaneous nephrolithotomy (microperc) technique and define its role in the management of renal calculi as well as to analyse the factors predicting outcome. PATIENTS AND METHODS: We retrospectively analysed data from 139 patients who underwent microperc for renal calculi between June 2010 and November 2014 at our institution. The factors analysed were demographic variables, which included age, sex, stone volume, stone density (Hounsfield units [HU]) and stone location, and intra- and peri-operative variables, such as operating time, drop in haemoglobin level, stone clearance and complications. RESULTS: The mean ± sd (range) patient age was 38.99 ± 17 years (9 months to 73 years), stone volume was 1 095 ± 1 035 (105-6 650) mm(3) and stone density was 1 298 ± 263 HU. The mean ± sd (range) operation duration was 50.15 ± 9.8 (35-85) min, hospital stay was 2.36 ± 0.85 (2-5) days and drop in haemoglobin level was 0.63 ± 0.84 (0-3.7) mg/dl. Eight patients had renal colic that was managed by antispasmodic medication, four patients had renal colic severe enough to warrant JJ stenting and three patients had urinary tract infections which were managed with appropriate antibiotics. We were able to complete microperc in 130 patients, with 119 (91.53%) patients being rendered completely stone-free, while in 11 patients (8.46%) there were some residual fragments seen on imaging. On multivariate analysis, stone number, volume and density were found to be significant predictors of clearance. Conversion to mini- or standard percutaneous nephrolithotomy was required in nine patients (6.47%), with intra-operative complications and stone number being the significant factors warranting conversion on a multivariate basis. CONCLUSION: The outcomes in the present study suggest that microperc is a promising treatment method for solitary renal stones with volumes <1 000 mm(3) and stones with low density (HU), regardless of stone location. In the present series we achieved a high success rate with low morbidity; however larger, prospective and comparative studies from multiple centres are required to further establish the role of microperc in the management of renal calculi.

Prospective study of preoperative factors predicting intraoperative difficulty during laparoscopic transperitoneal simple nephrectomy.

OBJECTIVE: To prospectively study and identify, the preoperative factors which predict intraoperative difficulty in laparoscopic transperitoneal simple nephrectomy. PATIENTS AND METHOD: Seventy seven patients (41 males and 36 females) with mean age of 43 ± 17 years, undergoing transperitoneal laparoscopic simple nephrectomy at our institute between February 2012 to May 2013 were included in this study. Preoperative patients' characteristics recorded were: Gender of patients, history of intervention, palpable lump, BMI, urine culture, side, size of kidney, fixity of kidney on USG, perinephric fat stranding on preoperative CT scan, periureteral fat stranding, perinephric collection, enlarged hilar lymph nodes, renal vascular anomalies, differential renal function on renogram. Preoperative factors of these patients were noted and intraoperative difficulty in the surgery was scored between 1 (easiest) to 10 (most difficult or open conversion) by a single surgeon (who was a part of all studies either as operating surgeon or assistant). Using SPSS 15.0 software, multivariate and univariate analysis was done. RESULTS: In multivariate analysis presence of pyonephrosis on preoperative evaluation and BMI < 25kg/m(2) were found to be statistically significant factors predicting intraoperative difficulty during laparoscopic simple nephrectomy. On univariate analysis following factors were associated with increased surgeon's score: Lower BMI, palpable kidney, pyonephrosis, history of renal intervention, perinephric fat stranding, right side, fixity of kidney on USG with surrounding structures. CONCLUSION: Our findings suggest that presence of pyonephrosis as identified on preoperative imaging and a BMI of less than 25 Kg/m(2) are the most significant factors predicting intraoperative difficulty during laparoscopic simple nephrectomy.

Can CT Virtual Cystoscopy Replace Conventional Cystoscopy in Early Detection of Bladder Cancer?

Aim. To correlate findings of conventional cystoscopy with CT virtual cystoscopy (CTVC) in detecting bladder tumors and to evaluate accuracy of virtual cystoscopy in early detection of bladder cancer. Material and Method. From June 2013 to June 2014, 50 patients (46 males, four females) with history and investigations suggestive of urothelial cancer, with mean age 62.76 ± 10.45 years, underwent CTVC by a radiologist as per protocol and subsequently underwent conventional cystoscopy (CPE) the same day or the next day. One urologist and one radiologist, blinded to the findings of conventional cystoscopy, independently interpreted the images, and any discrepant readings were resolved with consensus. Result. CTVC detected 23 out of 25 patients with bladder tumor(s) correctly. Two patients were falsely detected as negative while two were falsely labeled as positive in CTVC. Virtual and conventional cystoscopy were comparable in detection of tumor growth in urinary bladder. The sensitivity, specificity, positive predictive value, and negative predictive value of virtual cystoscopy were 92% each. Conclusion. CTVC correlates closely with the findings of conventional cystoscopy. Bladder should be adequately distended and devoid of urine at the time of procedure. However, more studies are required to define the role of virtual cystoscopy in routine clinical practice.

Robotic versus conventional laparoscopic pyeloplasty in children less than 20 kg by weight: single-center experience.

PURPOSE: To compare outcomes of robotic versus conventional laparoscopic pyeloplasty in children less than 20 kg by weight. METHODS: Nineteen patients undergoing RP and twenty-five LP under 20 kg by weight were compared retrospectively with respect to demographics and operative, postoperative, and follow-up data. For all cases, a lateral transperitoneal approach was used and all anastomoses were stented. Success was defined as the resolution of preoperative symptoms and hydronephrosis postoperatively. If either case is not fulfilled, a renogram was obtained postoperatively. Student's t test was used for statistical analysis. RESULTS: Forty-four patients underwent forty-seven pyeloplasties (19 RP and 25 LP), with three patients undergoing bilateral simultaneous laparoscopic procedure with mean age of 2.7 and 2.4 years in RP and LP, respectively. The robotic procedures were superior in terms of shorter mean hospital stay by one and half day on an average. Minimum time taken for RP was 60 min, while for LP it was 90 min. Both procedures were comparable in terms of complication rate, success rate as well as operating time. CONCLUSIONS: This comparative study confirms the feasibility, efficacy, and safety of robotic pyeloplasty in infants and toddlers. The obvious advantage is being shorter hospital stay. Further prospective studies will be needed to show its superiority over LP.

Robot-Assisted Laparoscopic Donor Nephrectomy vs Standard Laparoscopic Donor Nephrectomy: A Prospective Randomized Comparative Study.

OBJECTIVE: The goal of this randomized controlled trial was to compare the outcomes of robot-assisted laparoscopic donor nephrectomy (RDN) with standard laparoscopic donor nephrectomy (LDN). MATERIALS AND METHODS: Forty-five voluntary kidney donors (27 for right subgroup and 18 for left subgroup) who met inclusion and exclusion criteria were randomized into 2 groups, RDN and LDN in 1:2 ratio. Primary endpoints were visual analogue scale (VAS) pain scores, analgesic requirement, and hospital stay of donors. Secondary endpoints were donor's intraoperative and postoperative parameters, graft outcomes, and donor surgeon's difficulty scores. RESULTS: All procedures were completed without any intraoperative complications. VAS pain scores at 6, 24, and 48 hours (p = 0.00), analgesic requirement (p = 0.00), and hospital stay (p = 0.00) were less in RDN than in LDN. Longer graft arterial length could be preserved with robotic approach on right side (p = 0.03) but not on left side (p = 0.77). The RDN group required more number of ports (p = 0.00), longer retrieval time (p = 0.00), and warm ischemia time (WIT) (p = 0.01). Total operative time (p = 0.14), hemoglobin drop (p = 0.97), postoperative donor complications (p = 0.97), and the recipient estimated glomerular filtration rate at 9 months (p = 0.64) were similar in both groups. Difficulty scores of console surgeon were less in most steps on right side but not on left side. Patient-side surgeon in RDN had higher difficulty scores for retrieval. CONCLUSION: RDN is safe and is associated with better morbidity profile than LDN. Robotic approach provides technical ease and facilitates preservation of longer length of renal artery on right side. Left RDN is associated with longer WIT; however, this does not translate into poor graft outcome.

Management Protocol for Chylous Ascites After Laparoscopic Nephrectomy.

OBJECTIVE: To devise a management protocol for chylous ascites after laparoscopic nephrectomy. PATIENTS AND METHODS: We retrospectively reviewed the data of the patients that underwent laparoscopic nephrectomy between January 2010 and January 2014 in our institution for different indications and were diagnosed with chylous ascites. We also analyzed a different management protocol that was used. RESULTS: The overall incident rate of chylous ascites was 0.77%. It was more commonly seen on left side and with simple nephrectomy rather than radical. Three out of 9 patients were managed by surgical intervention, rest were successfully managed on conservative treatment in the form of dietary modification, total parenteral nutrition, or octreotide. CONCLUSION: Chylous ascites is a rare but morbid condition following laparoscopic nephrectomy. To manage this complication, we propose preventive and treatment strategies based on symptoms and amount of chylous ascites using our experience and review of the literature.

Oxalobacter formigenes: Opening the door to probiotic therapy for the treatment of hyperoxaluria.

OBJECTIVE: The aim of this study was to determine the early effect of the administration of Oxalobacter formigenes on the metabolic pattern of patients with calcium oxalate stones, comparing it with potassium magnesium citrate (KMgCit). MATERIALS AND METHODS: Eighty patients were randomized to receive either 30 mEq of KMgCit or 700 million O. formigenes, both twice a day. Serum creatinine, serum urate, serum calcium and phosphorus, serum intact parathyroid hormone (if serum calcium >10.5 mg/dl) and 24 h urine metabolic evaluation for various metabolites (e.g. oxalate, calcium, phosphorus, citrate, magnesium, urate and creatinine) were evaluated at baseline and 1 month after starting the treatment. RESULTS: In both groups hyperoxaluria was the most common abnormality, followed by hypercalciuria. The incidence of hyperoxaluria decreased at 1 month compared to baseline in both KMgCit (77.5% vs 37.5%, p = 0.0006) and O. formigenes preparation (82.5% vs 15%, p < 0.0001) groups, while other urinary metabolic abnormalities were similar at baseline and 1 month in both groups. Three patients in the KMgCit had mild self-limiting secondary symptoms. CONCLUSION: Compared with KMgCit, O. formigenes preparation is more effective in decreasing the incidence of hyperoxaluria, opening the door to probiotic therapy as a potential new weapon against hyperoxaluria.

Robotic-assisted laparoscopic partial nephrectomy: A single centre Indian experience.

BACKGROUND: We summarise our experience with RPN emphasising on learning curve, techniques and outcomes. PATIENTS AND METHODS: A retrospective chart review of 57 patients was done. The preoperative workup included a triple phase CT angiography. The parameters analyzed were demographics, tumor characteristics, operative details, postoperative outcome, histopathology and follow-up. The data were compared with historical cohort of the laparoscopic partial nephrectomy (LPN). RESULTS: 58 renal units in 57 patients (45 males and 12 females) underwent RPN. The mean age was 53.08 ± 13.6 (30-71) years. The mean tumor size was 4.96 ± 2.33 (2-15.5) cm. Average operative time was 129.4 ± 29.9 (70-200) min.; mean warm ischemia time was 20.9 ± 7.34 (9-39) min. 8 renal units in 7 patients were operated with the zero ischemia technique. The average follow-up was 5.15 months (1-18). There was no recurrence. 15 patients underwent LPN. The mean tumor size was 4.3 ± 1.6 (1.6-8) cm. operative time was 230.7 ± 114.8 (150-300) min.; mean warm ischemia time was 31.8 ± 9 min. The nephromerty score in the LPN group was 7.1 ± 0.89, in the RPN group was 8.75 ± 1.21. CONCLUSION: Our results suggest that prior experience of LPN shortens the learning curve for RPN as seen by shorter warm ischemia time and operative time in our series. The nephrometry score in RPN were higher suggesting that complex tumour can be managed with robotic approach.

Complete Transperitoneal Laparoscopic Nephroureterectomy in Circumcaval Ureter with Upper Tract TCC: Initial Case Report.

Transitional-cell carcinoma (TCC) of the upper tract in a case of circumcaval ureter (CCU) is a rare entity. Laparoscopic transperitoneal nephroureterectomy in such case represents a unique challenge in the era of minimally invasive surgery. We report a case of complete transperitoneal laparoscopic nephroureterectomy with bladder cuff excision done for TCC in a case of CCU. This case report describes the first point of technique of the procedure done for this rare entity. A 38-year-old male patient underwent the procedure for high-grade TCC of right lower calix. The essential tenets of the procedure included performance of the technique in a manner contrary to the conventional nephroureterectomy. The case report describes the procedure in the following steps: management of lower ureter and bladder cuff followed upper tract procedure after transposition of bladder cuff posterior to inferior vena cava. The procedure was accomplished utilizing four ports and a 6 cm Pfannenstiel incision with operative time of 220 minutes and blood loss of 50 mL.

Percutaneous nephrolithotomy in pelvic kidneys: is the ultrasound-guided puncture safe?

OBJECTIVE: To demonstrate our experience with the use of ultrasound (USG) for puncture guidance while performing percutaneous nephrolithotomy in ectopic pelvic kidneys. METHODS: From January 1990 to December 2013, we have performed percutaneous nephrolithotomy in 26 patients with USG-guided punctures. The stones were solitary in 15 patients (58%) and multiple in 11 patients (42%). The mean stone size was 22 mm (range, 10-50 mm), including 3 staghorn calculi. All procedures were performed in an oblique-supine position, and the intraoperative complications as the postoperative outcome were reviewed. RESULTS: The mean operative time was 93 minutes, achieving complete stone clearance in 22 (88%) of the patients. One of the patients had urine leakage after removing nephrostomy, needing postoperative double J stenting. One patient had significant intraoperative bleeding requiring staging of the procedure and blood transfusion. No bowel injuries were identified. Mean hospitalization time was 5.6 days. CONCLUSION: USG-guided puncture is a safe and effective approach to the collecting system even in renal anomalies like in pelvic ectopic kidneys when performed in experienced hands.

Outcomes in a large series of minipercs: analysis of consecutive 318 patients.

BACKGROUND AND PURPOSE: The purpose of this study is to evaluate the outcomes of miniperc at our center. PATIENTS AND METHODS: This is a retrospective review of consecutive 318 minipercs done in a single tertiary urological center. The Miniperc system used was either Wolf (Richard Wolf) 14F with 20F Amplaz sheath or Storz (Karl Storz) nephroscope 12F with 15/18F sheath or 16.5/19.5F sheath. Data about the demography of patients, comorbidities, stone size, number and size of the tract, size of nephroscope, energy source used, total operative time, exit strategy, hospital stay, clearance of stones, total analgesic requirement, visual analogue pain score at 6 and 24 hours, hemoglobin drop and complications were analyzed by the chi-square test and analysis of variance test. RESULTS: The average age of patients, stone size, operative time, hemoglobin drop and hospital stay were 41.9±17.0 years, 15.26±6.35 mm, 60±19 minutes,1.0±0.6 g/dL and 2.8±1 day, respectively. Complete clearance rate was 98.7%. Fourteen (4.4%) patients had Clavien-Dindo level 1 complications and 1 (0.31%) patient had Clavien-Dindo level 2 complications. The size of the stone treated by miniperc did not affect the hemoglobin drop (p-value=0.26) or hospital stay (p-value=0.924). There is no significant increase in hemoglobin drop (p-value=0.064) or hospital stay (p-value=0.627) with increasing number of miniperc tracts. An increase in operative time is associated with the increase in hemoglobin drop (p-value=0.041). Different energy sources did not significantly affect the operative time (p-value=0.184). Placement of only ureteral catheter is associated with less analgesic requirement (p-value=0.000). CONCLUSIONS: Miniperc is a safe alternative to standard percutaneous nephrolithotomy. In carefully selected patients, the best exit strategy would be a tubeless procedure with ureteral catheter drainage.

Which is the preferred modality of renal access for a trainee urologist: ultrasonography or fluoroscopy? Results of a prospective randomized trial.

BACKGROUND AND PURPOSE: In percutaneous nephrolithotomy (PCNL), placement of the access tract into the kidney is an important aspect of the procedure and is responsible for the steep learning curve associated with the operation. The aim of the current prospective randomized trial was to assess the duration of radiation exposure along with the safety and efficacy of PCNL done by a trainee, utilizing either ultrasonography (US) or fluoroscopic guidance to obtain access. PATIENTS AND METHODS: Sixty-four patients with ≤3 cm renal calculi undergoing single-tract PCNL by trainee urologists (experience of <25 PCNL's) were randomized into US- and fluoroscopic-guided access groups (32 in each). In Group 1 (US guided), puncture was done using a 3.5/5 MHz US probe with a puncture attachment, whereas the triangulation technique with biplanar C-arm fluoroscopy was utilized in group 2 (fluoroscopic guided). Patient demographics, stone parameters, intraoperative characteristics, fluoroscopy durations, and postoperative outcomes were analyzed. RESULTS: Both groups were comparable as far as patient and stone characteristics were concerned. The fluoroscopy exposure during the puncture phase (T2) and overall (T) was significantly lower in the US group at 9.0±20.8 vs 43.8±34.8, (p<0.0001) and 204.3±84 vs 239.9±77.5, (p=0.04). Six patients in group1 required fluoroscopic adjustment (p=0.03). All other intra- and postoperative parameters were similar in both the groups. CONCLUSION: Both ultrasound and fluoroscopic guidance for renal access are equally safe and feasible in the hands of a trainee urologist. Total fluoroscopy duration and exposure time during puncture were both significantly less in the ultrasound group. Expertise in fluoroscopic-guided access is essential for a novice to effectively achieve access in all possible situations.

Evolution of shockwave lithotripsy (SWL) technique: a 25-year single centre experience of >5000 patients.

OBJECTIVE: To assess the impact of various treatment optimisation strategies in shockwave lithotripsy (SWL) used at a single centre over the last 25 years. PATIENTS AND METHODS: In all, 5017 patients treated between 1989 and 2013 were reviewed and divided into groups A, B, C and D for the treatment periods of 1989-1994 (1561 patients), 1995-2000 (1741), 2001-2006 (1039) and 2007-2013 (676), respectively. The Sonolith 3000 (A and B) and Dornier compact delta lithotripters (C and D) were used. Refinements included frequent re-localisation, limiting maximum shocks and booster therapy in group B and Hounsfield unit estimation, power ramping and improved coupling in group D. Parameters reviewed were annual SWL utilisation, stone and treatment data, retreatment, auxiliary procedures, complications and stone-free rate (SFR). RESULTS: The SFR with Dornier compact delta was significantly higher than that of the Sonolith 3000 (P < 0.001). The SFR improved significantly from 77.58%, 81.28%, 82.58% to 88.02% in groups A, B, C, and D, respectively (P < 0.001). There was a concomitant decrease in repeat SWL (re-treatment rate: A, 48.7%; B, 33.4%; C, 15.8%; and D, 10.1%; P < 0.001) and complication rates (A, 8%; B, 6.4%; C, 4.9%; and D, 1.6%; P < 0.001). This led to a rise in the efficiency quotient (EQ) in groups A-D from 50.41, 58.94, 68.78 to 77.06 (P < 0.001).The auxiliary procedure rates were similar in all groups (P = 0.62). CONCLUSION: In conclusion, improvement in the EQ together with a concomitant decrease in complication rate can be achieved with optimum patient selection and use of various treatment optimising strategies.

Staghorn classification: Platform for morphometry assessment.

INTRODUCTION: The majority of staghorn classifications do not incorporate volumetric stone burden assessment. Accurate volumetric data can easily be acquired with the ever-increasingly available computerized tomography (CT) scan. This manuscript reviews the available staghorn stone classifications and rationalizes the morphometry-based classification. MATERIALS AND METHODS: A Pubmed search was performed for articles concerning staghorn classification and morphometry. Twenty abstracts were shortlisted from a total of 43 published abstracts. In view of the paucity of manuscripts on staghorn morphometry (4), older staghorn classifications were analyzed with the aim to determine the most optimum one having relevance to the percutaneous nephrolithotomy (PCNL) monotherapy outcome. RESULTS: All available staghorn classifications are limited with non-widespread applicability. The traditional partial and complete staghorn are limited due to non-descript stone volumetric data and considerable overlap of the intermediate ones in either group. A lack of standardized definition limits intergroup comparison as well. Staghorn morphometry is a recent addition to the clinical classification profiling of a staghorn calculus. It comprises extensive CT volumetric stone distribution assessment of a staghorn in a given pelvi-calyceal anatomy. It allowsmeaningful clinical classification of staghorn stones from a contemporary PCNL monotherapy perspective. CONCLUSIONS: Morphometry-based classification affords clinically relevant nomenclature in predicting the outcome of PCNL for staghorn stones. Further research is required to reduce the complexity associated with measuring the volumetric stone distribution in a given calyceal system.