PURPOSE:The ASPiration to Improve Renal Calculi Removal Effectiveness study showed steerable ureteroscopic renal evacuation (SURE) with CVAC that significantly reduced residual stone volume at 30 days vs standard ureteroscopy (URS). This report presents 2-year health care consumption and stone events (SE) and their link to residual stone volume and other variables (n = 101 at primary end point; n = 93 at 2 years). MATERIALS AND METHODS:Logistic regression identified predictors of health care consumption events (HCEs), that is, emergency department visits, hospitalization, surgical retreatment, and SE across the study population. Incidence was compared between the treatment groups with Kaplan-Meier survival analysis. RESULTS:At 2 years, residual stone volume was significantly associated with both HCEs and SE. For every 100 mm3 increase in residual stone volume, the HCE risk increased by 50% to 54%, and the SE risk increased by 70%. Stone-free rate, the number of residual fragments (RFs), and RF total stone burden (based on diameter) were not predictors. Significantly fewer HCEs occurred in the SURE group (3 vs 20 events, p = 0.0004). Survival analysis confirmed this (4.3% vs 20%, log-rank p = 0.02), with a 73% risk reduction (hazard ratio 0.27, 95% Cl 0.09-0.80, p = 0.02). Fewer SE occurred in the SURE group, although not statistically significant. These subjects also had longer event-free survival. CONCLUSION:High-quality volumetric analysis supports evaluation of stone removal therapies, as residual stone volume predicts HCEs and SE. SURE significantly reduces the downstream incidence and risk of HCEs compared with standard URS.

Purpose: We report the first multicenter, prospective, randomized noninferiority controlled trial of steerable ureteroscopic renal evacuation (SURE) for nephrolithiasis treatment. Materials and Methods: Candidates for laser lithotripsy >= 18 years with >= 1 renal stone >= 7 mm and 7-20 mm stone burden were randomized 1:1 SURE vs ureteroscopy (URS). SURE was performed using the CVAC Aspiration System, a novel steerable irrigation-aspiration catheter. The primary efficacy end point was noninferiority in stone-free rate (SFR) based on zero residual fragments (RFs) 30 days postprocedure on noncontrast computed tomography. Secondary end points were superiority tests, stone clearance (percent stone volume reduction), residual stone volume (RSV), SFR (no RF >2 mm), and SFR (no RF >4 mm) 30 days postprocedure. Results: Of the subjects, 123 were randomized and 101 qualified for efficacy analysis (SURE 46 vs URS 55). Despite randomization, baseline URS stone volume was higher (SURE 485.0 +/- 432.5 mm(3) vs URS 713.3 +/- 558.5 mm(3)). The primary noninferiority end point was achieved (SURE SFR 48% vs URS SFR 49%, p = 0.027, -1.3% [90% confidence interval; -18%, 15%]). Stone clearance was significantly higher for SURE vs URS subjects (SURE 96.9 +/- 5.6% vs URS 92.9 +/- 11.6%, p = 0.036); RSV was significantly lower (SURE 14.3 +/- 3 0.9 mm(3) vs URS 70.2 +/- 144.9 mm(3), p = 0.012). SURE stone clearance and RSV were independent of baseline stone volume, but for URS degraded with increasing baseline stone volume. Safety was comparable between groups. Conclusions: SFR for SURE subjects was noninferior compared with URS subjects; stone clearance and RSV were significantly better with SURE, independent of baseline stone volume.

OBJECTIVE To evaluate the characteristics and outcomes of ureteroscopy (URS) in children treated in several hospitals participating in the Clinical Research Office of the Endourological Society (CROES) Study, and to present the overall results of pediatric URS compared with adults.PATIENTS AND METHODS The CROES Study collected data on consecutive patients treated with URS for urolithiasis at each participating center over a 1-year period. The collected prospective global database includes data for 11,885 patients who received URS at 114 centers in 32 countries. Of these URStreated patients, 192 were <= 18 years old.RESULTS Of the 114 centers participating in the study, 42% had conducted pediatric URS. Among the pediatric cases, 7 were infants, 53 were small children, 59 were school-aged children, and 73 were adolescents. A considerable number (37%) of the pediatric cases had previously undergone URS treatment. No differences in the surgical outcomes of the adults and children were reported. The URS-treated children had a greater number of positive preoperative urine cultures when compared with adult cases treated. A semirigid scope was used in the vast majority of pediatric cases (85%). According to the present data, within the group of URS-treated children, the younger the child, the more readmissions occurred.CONCLUSION URS is as efficient and safe in children as it is in adults. The data suggest that readmissions among URS-treated children are associated with age, with the likelihood of readmissions greater among younger age groups. (C) 2016 Elsevier Inc.

Advances in cancer chemotherapy for genitourinary tumors lagged behind those for other cancers such as the hematologic malignancies. Chemotherapeutic agents with activity against lymphoma and leukemia were discovered as early as the 1940s. Yet, it was not until 15-20 years later that actinomycin-D was shown to have activity against Wilms tumor and testicular tumors. 1 Zubrod C.G. Historic milestones in curative chemotherapy. Semin Oncol. 1979; 6: 490-505 PubMed Google Scholar

Purpose: Pediatric urolithiasis has been treated with shock wave lithotripsy, ureteroscopy and percutaneous nephrolithotomy with high success rates during short-term followup. We studied our success rate and modifiable risk factors in patients with at least 5 years of followup postoperatively.Materials and Methods: Retrospective chart review was performed for patients younger than 18 years who underwent upper tract stone surgery between 1999 and 2007, were stone-free afterward and had at least 5 years of followup. Recurrence rate, and anatomical and metabolic abnormalities were assessed.Results: Of 60 eligible children 30 (33 kidneys) had at least 5 years of followup. Average patient age at surgery was 10 years, 17 patients were female and 20 kidneys had anatomical abnormalities. Overall recurrence rate at 5 years was 55% (95% CI 38%-70%). Ureteral stones had a lower recurrence rate than renal stones (5 of 19 and 13 of 14, respectively, p < 0.001). Patients with abnormal anatomy had a 65% (95% CI 43%-82%) chance of recurrence within 5 years vs 38% (95% CI 18%-65%) in those with normal anatomy (p = 0.17). Of the 18 recurrences 10 required a second operation, 7 demonstrated abnormal anatomy and 14 involved calcium based stones. A 24-hour urine test in 13 children revealed 10 with hypercalciuria and 11 with hypocitraturia, with 9 patients exhibiting both conditions.Conclusions: We found a high recurrence rate in children with stones requiring surgical intervention, particularly those with abnormal anatomy. This finding should be confirmed in a larger multicenter study of recurrence rates. In the meantime our results suggest a need for aggressive diagnosis and treatment of metabolic abnormalities.

PURPOSE:In the mid 1800s Dr. J. Marion Sims reported the successful repair of vesicovaginal fistulas with a technique he developed by performing multiple operations on female slaves. A venerated physician in his time, the legacy of Dr. Sims is controversial and represents a significant chapter in the mistreatment of African-Americans by the medical establishment. This review compares the modern debate surrounding his legacy with the presentation of his operation in widely consulted urological texts and journals.MATERIALS AND METHODS:A literature review was performed of medical, sociological and periodical sources (1851 to the present) regarding J. Marion Sims and vesicovaginal fistula repair.RESULTS:During the last several decades, while the controversy around Dr. Sims' surgical development has produced a steady stream of articles in the historical and popular literature, relatively little mention is found in standard urology textbooks or journals. With increased public attention, some have debated the removal or modification of public tributes to Dr. Sims. This move has been countered by arguments against the validity of judging a 19th century physician by modern standards.CONCLUSIONS:While historians, ethicists and the popular press have debated Dr. Sims' legacy, medical sources have continued to portray him unquestionably as a great figure in medical history. This division keeps the medical profession uninformed and detached from the public debate on his legacy and, thus, the larger issues of ethical treatment of surgical patients.

PURPOSE:It has been proposed that younger children are less likely to pass renal calculi spontaneously, and that children younger than 10 years are more likely to have an identifiable metabolic abnormality and subsequently a higher risk of recurrence. We report our clinical outcomes in children with urinary calculi, specifically examining these factors.MATERIALS AND METHODS:We performed a retrospective review of all pediatric patients diagnosed with renal or ureteral calculi at our institution between 2000 and 2007. Of 150 patients evaluated and treated during this period 80 (86 stones) had sufficient followup data to be included. Patients were divided into 2 groups according to age, namely 10 years or younger and older than 10 years. There were 39 patients in the younger group and 41 patients in the older group. Stone size and location, successful passage or intervention, recurrence and 24-hour urine metabolic study results were recorded.RESULTS:Of the younger cohort stones were ureteral in 43% and renal in 57%. The opposite trend was seen in older patients, with 69% having ureteral and 31% having renal stones (p = 0.02). Mean stone size (greatest dimension) did not differ significantly between the older and younger groups (6.9 mm vs 5.5 mm, p = 0.17). Overall stone passage rate was 34% for younger and 29% for older patients (p = 0.65). No significant mean size differences in passed stones existed between the groups (3.2 mm vs 2.5 mm, p = 0.31). Overall younger vs older ureteral stone passage rate was 37% vs 41% (p = 0.58), and for renal stones it was 32% vs 0%. Stones recurred in 7 younger and 6 older patients.CONCLUSIONS:Younger children were more likely to present with renal stones, while older children had more ureteral stones. Overall children 10 years old or younger are as likely to pass stones as older children. Renal stones are more likely to be successfully managed expectantly in younger children. Metabolic abnormalities and stone recurrences are observed at similar rates between younger and older children.

Introduction: Drugs and their metabolites are known factors in 1% to 2% of all kidney stones. Certain antiepileptic drugs are known to cause stone formation. Phenytoin is used as a first line antiepileptic therapy for many seizure disorders. We present what we believe to be the first report of a phenytoin metabolite urinary stone.Methods: A 79-year-old woman with a fever and seizure disorder was found to have a right pelvic kidney with hydronephrosis and multiple large calcifications. She had been taking the antiepileptic medication phenytoin for the past 10 years. Average total serum phenytoin level from the year prior was in the normal range. Free phenytoin levels were not routinely monitored, but the one value available was elevated at 5.1 ng/dL. The patient underwent a percutaneous nephrolitomy, ultimately expiring from medical complications after the procedure. Final stone analysis revealed a composition of 35% phenytoin metabolite (5-(para-hydroxyphenyl)-5-phenylhydantoin) and 65% proteinaceous material. An extensive review of literature including PubMed, MedLine, and various internet search engines was performed, searching for any prior reports of urinary calculi formed from phenytoin or its metabolite.Results: No previous reports of phenytoin or phenytoin metabolite urinary stones were found in the medical literature. Phenytoin has many known ill effects on the genitourinary system including acute interstitial nephritis, nephrotic syndrome, acute renal failure, and priapism. Now we can add urinary lithiasis to the list of its potential adverse effects. This article represents the first report of a phenytoin metabolite urinary stone.Conclusion: A metabolite of the commonly used antiepileptic medication phenytoin can cause clinically relevant urolithiasis leading to significant morbidity and even mortality. Clinicians should have an increased level of suspicion for metabolite stone formation in symptomatic patients taking antiepileptic medications. Further studies on phenytoin metabolism and its potential for inducing urinary lithiasis should be performed.