Objectives: To assess the association of skin-to-stone distance (SSD) and stone-free rates following extracorporeal shockwave lithotripsy (SWL) using two statistical methods: logistic regression and a matched-pair analysis approach. Patients and Methods: Patients with a solitary radio-opaque upper ureteral calculus diagnosed on noncontrast computed tomography were included. Patients were treated with a Sonolith I-Sys Lithotripter (focal depth 17 cm). Stone treatment success was defined as stone free (fragments ≤3 mm) at 3 months. Failure was defined as persistent fragments beyond 3 months or requirement for intervention with ureteroscopy. The outcome was assessed by a plain kidney, ureter, and bladder radiograph (KUB) at 2 weeks. Logistic regression was used to determine association of patient and stone factors with treatment failure. The patient cohort was divided into tertiles by SSD, and matched-pair analysis was undertaken between individuals from the top and bottom tertiles (SSD ≤12 cm and SSD ≥14 cm). Matching criteria consisted of age, sex, maximum stone diameter (±2 mm), and stone density (±250 HU). Results: From a database of 2849 patients who underwent SWL, 397 patients were identified who had treatment of a single upper ureteral stone. Age (odds ratio [OR]: 1.03, 95% confidence interval [CI]: 1.01-1.04, p = 0.007), SSD (OR: 1.16, 95% CI: 1.03-1.32, p = 0.02), stone side (OR: 1.65, 95% CI 1.01-2.73, p = 0.05), stone diameter (OR: 1.09, 95% CI: 1.00-1.19, p = 0.05), and multiple sessions (OR: 4.65, 95% CI: 2.61-8.29, p < 0.001) were significantly associated with treatment failure by logistic regression univariable analysis. Multiple sessions was the only factor significantly associated with treatment failure on multivariable analysis (OR: 4.03, 95% CI: 2.18-7.42, p < 0.001). From a cohort of 141 patients with SSD ≥14 cm and 174 patients with a SSD ≤12 cm, 66 matches were identified (132 patients). Forty-nine patients (74.2%) with SSD ≥14 cm were deemed stone free at follow-up vs 51 patients (77.3%) with SSD ≤12 cm (p = 0.85). Conclusion: This study demonstrates by two statistical methods that SWL can provide efficacious treatment of upper ureteral stones in obese patients and that the upper threshold of SSD for SWL with Sonolith I-SYS could be revised to allow these patients the benefits of SWL.

You have accessJournal of UrologyStone Disease: Shock Wave Lithotripsy1 Apr 2017MP62-18 AMBULATORY SHOCK WAVE LITHOTRIPSY IS AN EFFICACIOUS AND COST-EFFECTIVE TREATMENT FOR LOWER POLE RENAL STONES BETWEEN 10-20MM IN SIZE: A PROSPECTIVE LARGE SINGLE CENTRE STUDY Daniel Good, Luke Chan, Karina Laing, Simon Phipps, Ben Thomas, Julian Keanie, David Tolley, and Mark Cutress Daniel GoodDaniel Good More articles by this author , Luke ChanLuke Chan More articles by this author , Karina LaingKarina Laing More articles by this author , Simon PhippsSimon Phipps More articles by this author , Ben ThomasBen Thomas More articles by this author , Julian KeanieJulian Keanie More articles by this author , David TolleyDavid Tolley More articles by this author , and Mark CutressMark Cutress More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1949AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES There is clinical equipoise as to the most cost effective approach for the treatment of lower pole stones between 10-20mm. We aimed to assess the clinical features, outcomes, complications, and cost-effectiveness of ambulatory SWL, FURS and PCNL in the treatment of lower pole (LP) stones (10-20mm) in a large tertiary referral stone centre. METHODS Consecutive patients treated for solitary LP stones (10-20mm) between 2008-13 were identified from a prospective database. Ambulatory SWL under sedo-analgesia (diclofenac +/- alfentanyl) was used as primary treatment in all cases (following a stone MDT assessment), with FURS and PCNL reserved for SWL contraindications, failure or patient choice. “Success” was defined as stone free and/or clinically insignificant stone fragments (=3mm) at 1 and 3 months follow-up. Effect of anatomy on SWL success was determined from using CT images and regression analysis. Average cost per treatment modality (including additional second-line treatments) was calculated using the NHS England 2014/15 National Tariff HRG codes. RESULTS 225 patients were included (mean age 54.9; median stone size 12mm). 198 (88%), 21 (9.3%) and 6 (2.7%) patients underwent SWL, FURS and PCNL as primary treatments respectively; for median stone sizes of 12mm, 12mm, and 20mm. Overall success rates were 82.8%, 76.1% and 66.7% respectively (p < 0.05). 63% of patients undergoing primary SWL were successfully treated after one session. Anatomical analysis determined infundibulopelvic angle and infundibular length to be significantly different in patients successfully treated with SWL (p = 0.04. SWL was performed with superior length of stay and complication rates compared to FURS or PCNL (p<05), and with a low auxiliary treatment rate (7%). SWL was significantly more cost-effective (mean £751/patient) than FURS (mean £1261) or PCNL (mean £2658) (p < 0.01). CONCLUSIONS SWL is a cost-effective, and efficacious primary treatment for patients with solitary LP stones (10-20mm). The majority of patients can be successfully treated with primary SWL in a dedicated stone centre, with the benefits of a short length of stay, low complication and auxiliary treatment rates, and without the need for general anaesthesia. The referral of such patients to high-volume lithotripsy centres with demonstrable outcomes should be given due consideration. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e834 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Daniel Good More articles by this author Luke Chan More articles by this author Karina Laing More articles by this author Simon Phipps More articles by this author Ben Thomas More articles by this author Julian Keanie More articles by this author David Tolley More articles by this author Mark Cutress More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Introduction: To assess the clinical features, outcomes, complications, and cost-effectiveness of shockwave lithotripsy (SWL), flexible ureterorenoscopy (FURS), and percutaneous nephrolithotomy (PCNL) in the treatment of lower pole (LP) stones (10-20mm) in a large tertiary referral center.Patients and Methods: Consecutive patients treated for solitary LP stones (10-20mm) between 2008 and 2013 were identified from a prospective database. SWL was used as primary treatment in all cases (following a stone multidisciplinary team assessment), with FURS and PCNL reserved for SWL contraindications, failure, or patientchoice. "Success'' was defined asstone free and/or clinically insignificant stone fragments (<= 3mm) at 1 and 3 months follow-up. Effect of anatomy on SWL success was determined from using CT images and regression analysis. Average cost per treatment modality (including additional second-line treatments) was calculated for each group using the National Health Service England 2014/15 National Tariff Healthcare Resource Group codes.Results: Two hundred twenty-five patients were included (mean age 54.9; median stone size 12 mm). One hundred ninety-eight (88%), 21 (9.3%), and 6 (2.7%) patients underwent SWL, FURS, and PCNL as primary treatments, respectively, for median stone sizes of 12, 12, and 20 mm. Overall success rates were 82.8%, 76.1%, and 66.7%, respectively (p < 0.05). Sixty-three percent of patients undergoing primary SWL were effectively treated after one session. Anatomical analysis determined infundibulopelvic angle and infundibular length to be significantly different in patients effectively treated with SWL (p = 0.04). The average cost per treatment modality was also significantly lower for SWL (750) pound than for FURS (1261) pound or PCNL (2658) pound (p < 0.01).Conclusion: SWL is both an efficacious and cost-effective primary treatment for patients with solitary LP stones (10-20 mm). The majority of patients can be effectively treated with primary SWL in a dedicated stone center, with the benefits of a short length of stay, low complication, and auxiliary treatment rates. The referral of such patients to high-volume lithotripsy centers with demonstrable outcomes should be given due consideration.

You have accessJournal of UrologyStone Disease: Shock Wave Lithotripsy1 Apr 2017MP62-16 SHOCK WAVE LITHOTRIPSY IS EFFICACIOUS FOR TREATING OBESE PATIENTS WITH UPPER URETERIC CALCULI : 5 YEAR PROSPECTIVE OUTCOMES FROM A DEDICATED CENTRE TREATING PATIENTS WITH A SKIN-TO-STONE DISTANCE OF MORE THAN 14CM William KM Gietzmann, Abishek Sharma, Edward Mains, ismail El-Mokadem, Ben G Thomas, Simon Phipps, David A Tolley, and Mark L Cutress William KM GietzmannWilliam KM Gietzmann More articles by this author , Abishek SharmaAbishek Sharma More articles by this author , Edward MainsEdward Mains More articles by this author , ismail El-Mokademismail El-Mokadem More articles by this author , Ben G ThomasBen G Thomas More articles by this author , Simon PhippsSimon Phipps More articles by this author , David A TolleyDavid A Tolley More articles by this author , and Mark L CutressMark L Cutress More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1947AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Obesity is increasingly common and often a predisposing factor in stone formation. Clinical reviews and guidelines indicate that SWL outcomes are poor for treating stones in patients with skin-to-stone distance (SSD) of >10-14cm, and regard a large SSD as an adverse predictor for SWL success (EAU Urolithiasis Guidelines 2016). There is a paucity of literature on treating such patients with SWL, and given the higher recognised perioperative morbidity of surgery in such a population, and the potential benefits of sedo-analgesia and short length of stay with ambulatory SWL, it is germane to re-evaluate the efficacy of SWL for treating such patients using a lithotriptor with a focal length of >14cm. METHODS Consecutive patients with a solitary radio-opaque upper ureteric calculus diagnosed on CT scan with a SSD ≥14cm were identified from a prospective database (2011-2016). Out-patient SWL was performed under sedo-analgesia (diclofenac ± alfentanil) using a Sonolith I-Sys, EDAP-TMS (focal depth 17cm). Outcome was assessed with an XRKUB at 2 weeks. Those with significant fragments (>3mm) received further treatment. Success was defined as patients being free of stones on XRKUB or as having asymptomatic clinically insignificant stone fragments (CISF) ≤3mm. Failure was defined as residual fragments >3mm (treated with ureteroscopy). RESULTS 182 patients met the inclusion criteria. 4 were lost to follow up. Median age was 54 years. Median stone size was 8mm (range 3-21). Overall stone-free rate (SFR) was 81% after mean 1.3 sessions. 63% were stone-free after a single session. 9% had CISF≤3mm. 11% required ureteroscopy. CONCLUSIONS SWL can provide efficacious treatment of upper ureteric stones in obese patients, traditionally thought to be poor candidates for such treatment due to their high SSD. The upper threshold of SSD for SWL selection should be revised, as such patients can receive the benefits of effective SWL treatment, without the need for general anaesthesia, when referred to a dedicated stone centre. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e833 Advertisement Copyright & Permissions© 2017MetricsAuthor Information William KM Gietzmann More articles by this author Abishek Sharma More articles by this author Edward Mains More articles by this author ismail El-Mokadem More articles by this author Ben G Thomas More articles by this author Simon Phipps More articles by this author David A Tolley More articles by this author Mark L Cutress More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Objective: Laparoscopic nephroureterectomy (LNU) offers a superior morbidity profile compared with open nephroureterectomy (ONU) in treating upper urinary tract urothelial cell carcinoma. Evidence of oncological equivalence between LNU and ONU is limited. We compare operative and oncological outcomes for LNU and ONU using matched-pair analysis. Methods: Of 159 patients who underwent a nephroureterectomy at a single institution between April 1992 and April 2010, 13 pairs of ONU and LNU patients were matched for gender, age, tumour location, tumour grade and stage. Operative details, post-operative characteristics and recurrences were collated and survival rates analysed using the Kaplan-Meier method. Results: There was no significant difference in mean operation time between LNU (191 min) and ONU (194 min, p = 0.92). There was no significant difference in the 5-year survival rate between LNU and ONU (overall survival 59.1% vs. 73.5%, p = 0.18; progression-free survival 24.0% vs. 56.0%, p = 0.14; cancer-specific survival 60.9% vs. 73.5%, p = 0.56; bladder cancer recurrence-free survival 8.7% vs. 0.0%, p = 0.09). Conclusion: Amidst limited RCT and comparative studies, this study presents further evidence of oncological equivalence between LNU and ONU. There was a trend towards poorer outcomes following LNU though, which merits further study.

The perioperative and oncological outcomes of laparoscopic radical nephrectomy (LRN) for T1–T2 renal cell carcinoma (RCC) are well established. We aim to determine whether LRN is a comparable alternative to open radical nephrectomy (ORN) in the treatment of T3 RCC using a matched pair analysis study design.

UNLABELLED:WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Shockwave lithotripsy (SWL) can be used to treat stones at any position within the ureter, as long as the stone is radio-opaque and there is a path for the shockwave to reach the stone. However the results of SWL to distal ureteric calculi, with the patient in a prone position, were inferior to those of treating stones within the upper ureter. The transguteal approach allows the lithotripsy shockwave to reach the lower ureter via the greater selatle foramen. This study shows that this approach for SWL to distal ureteric calculi is more effective than the prone approach.OBJECTIVE:To compare the outcomes of extracorporeal shockwave lithotripsy (ESWL) for distal ureteric stones treated using the prone and transgluteal (supine) approaches in a tertiary referral stone unit using a fourth generation lithotriptor.PATIENTS AND METHODS:We selected consecutive patients undergoing ESWL to distal ureteric stones over 1 year, during which we changed our treatment protocol from a prone to transgluteal (supine) approach. Patients were treated using the Sonolith Vision Lithotriptor (Technomed Medical Systems, Vaulx-en-Velin, France). Outcome was assessed using plain abdominal film of kidney, ureter and bladder (KUB) X-ray taken at 2 weeks then monthly as required. Treatment success was defined as complete clearance of stone fragments and treatment failure was defined as persistence of stone fragments beyond 3 months or the need for ureteroscopy.RESULTS:A total of 38 patients were treated in the prone position and 72 patients using a transgluteal approach. Patient and stone characteristics were identical in both groups. The mean (range) stone size was 7.8 (4-16) mm. The proportions of patients who were stone-free after one treatment session within the prone and transgluteal treatment groups were 40 and 78%, respectively (<0.001). The overall success rates for treatment within the prone and transgluteal groups were 63 and 92%, respectively (<0.001).CONCLUSIONS:Transgluteal ESWL to stones within the distal ureter leads to significantly higher stone-free rates than treatment using the prone approach. The majority of patients are rendered stone-free after one session of treatment and the overall success rates are similar to those of ureteroscopic management.

You have accessJournal of UrologyStone Disease: SWL, Ureteroscopy or Percutaneous Stone Removal (I)1 Apr 20131536 OUTCOME FROM SHOCKWAVE LITHOTRIPSY TO URETERIC CALCULI IN PATIENTS WITH HIGH SKIN-TO-STONE DISTANCE Sara Ramsey, Shirley Wallace, Carolann Stephenson, David Tolley, Ben Thomas, and Simon Phipps Sara RamseySara Ramsey Edinburgh, United Kingdom More articles by this author , Shirley WallaceShirley Wallace Edinburgh, United Kingdom More articles by this author , Carolann StephensonCarolann Stephenson Edinburgh, United Kingdom More articles by this author , David TolleyDavid Tolley Edinburgh, United Kingdom More articles by this author , Ben ThomasBen Thomas Edinburgh, United Kingdom More articles by this author , and Simon PhippsSimon Phipps Edinburgh, United Kingdom More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.3026AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Obesity is increasingly prevalent and can predispose to nephrolithiasis. The outcome from Shockwave Lithotripsy (SWL) is related to a number of factors including skin-to-stone distance (SSD). The focal depth of many second and third generation lithotriptors is limited to up to 13cm; a number of the latest machines have a greater focal depth. We report the outcomes of SWL to ureteric calculi at an SSD of over 13cm, using a contemporary lithotriptor with a focal depth of up to 17cm. METHODS Patients with a solitary radio-opaque ureteric calculus diagnosed on CT scanning, with an SSD of between 13 and 17cm, were selected from our prospective database. Those with a ureteric stent in situ were excluded. Patients were treated on an outpatient basis with a Sonolith I-Sys Lithotriptor (Vaulx-en-Velin, France) at a frequency of 2Hz using intravenous opiate analgesia if required. Outcome was assessed by a plain KUB XRay at 2 weeks then monthly as required. Further treatment was undertaken if significant fragments remained on post-treatment film. Success was defined as complete clearance of stone fragments. Failure was defined as persistence of stone fragments beyond 3 months or the need for ureteroscopy. Outcomes were assessed on an intention to treat basis. RESULTS 98 patients satisfied the inclusion criteria. Patient and treatment characteristics are shown in table 1. The majority of patients were male, mean age 51, with an upper ureteric stone of mean size 8mm, mean SSD 14cm. 2 patients with lower ureteric stones failed to tolerate treatment. 66 (67%) patients were stone free following a single session of lithotripsy. 24 patients underwent a further session of lithotripsy after which the overall stone free rate rose to 78 (80%). 3 patients were left with small residual fragments requiring no intervention. Overall numbers requiring no further procedure were 83%. 12 patients proceeded to ureteroscopy. Stone free rates were 69% for lower and mid ureteric stones, and 85% for upper ureteric stones. CONCLUSIONS The use of a contemporary lithotriptor in an experienced centre can produce excellent stone free rates following treatment of ureteric calculi in patients with SSDs of 13cm or greater. The use of machines with greater focal depths will allow more patients to undergo SWL for urinary calculi despite increasing obesity. Feature Number Gender Male / Female 87 / 11 Age (Years) Mean, Median, (range) 51, 50, (17-79) Left / right 40 / 58 SSD (cm) Mean, Median, (Range) 14, 14, (13-17) Stone Location PUJ / UU / MU / LU 14 / 68 / 5 / 11 Stone size (mm) Mean, Median, (Range) 9, 8, (4-19) Iv analgesia Yes / No 39 / 59 Localisation Fluoro / USS +Fluoro 70 / 21 Shocks Mean, Median, (Range) 3408, 3674, (464-5221) Sessions of lithotripsy 1 / 2/ 3 72 / 22 / 2 Ureteroscopy No / Yes 86 / 12 © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e629-e630 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Sara Ramsey Edinburgh, United Kingdom More articles by this author Shirley Wallace Edinburgh, United Kingdom More articles by this author Carolann Stephenson Edinburgh, United Kingdom More articles by this author David Tolley Edinburgh, United Kingdom More articles by this author Ben Thomas Edinburgh, United Kingdom More articles by this author Simon Phipps Edinburgh, United Kingdom More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Purpose: We analyzed the indications for and outcomes of percutaneous nephrolithotomy using upper pole access. Materials and Methods: Between 2007 and 2009 prospective data were collected by the Clinical Research Office of the Endourological Society (CROES) from consecutive patients at 96 centers globally. Data on 4,494 patients were included in this analysis. Patients were divided into upper and lower pole access groups based on the location of percutaneous renal access. Preoperative characteristics and outcomes were compared between the 2 groups by univariate and multivariate tests. Results: The upper pole access group had more staghorn stones (21.7% vs 15.5%, p<0.001) and a greater stone burden (mean +/- SD 476 +/- 390.5 vs 442 +/- 344.9 mm(2), p = 0.091). Mean operative time was 92.4 +/- 46.1 and 75.1 +/- 41.3 minutes in the upper and lower pole groups, respectively (p < 0.001). The stone-free rate was lower in the upper pole access group (77.1% vs 81.6%, p = 0.030). The overall complication rate was higher in the upper pole group with a higher incidence of hydrothorax (5.8% vs 1.5%) but a lower incidence of pelvic perforation (1.8% vs 3.2%). Mean hospital stay was longer in the upper pole group (p = 0.048). Success and complication rates were similar in upper pole access subgroups, defined as definitive (staghom and isolated upper calyceal stones) and elective (pelvic, middle calyceal and lower pole stones) indications. Conclusions: Isolated upper pole access is indicated in a select group of patients with complex stones. Upper calyceal and staghom stones are more commonly managed by upper pole access, which is associated with a higher complication rate and longer hospital stay as well as a lower stone-free rate due to procedure complexity.

Purpose To compare the characteristics and outcomes of exit strategies following percutaneous nephrolithotomy (PCNL) using the Clinical Research Office of the Endourological Society (CROES) PCNL Global Study database. Materials and methods Two matched data sets were prepared in order to compare stent only versus NT only and TTL versus NT only. Patients were matched on the exit strategy using the following variables: case volume of the center where they underwent PCNL, stone burden, the presence of staghorn stone, size of sheath used at percutaneous access, the presence of bleeding during surgery, and treatment success status. For categorical variables, percentages were calculated and differences between the four groups were tested by the chi-square test. Results The only significant difference reported between the matched pairs was between NT and stent only groups. NT only PCNL was associated with significantly longer operating times ( p = 0.029) and longer hospital stay ( p < 0.001) than stent only PCNL. Conclusions Patients who undergo PCNL with less invasive exit strategy involving a stent only have shorter hospital stay than those who have postoperative NT. The intraoperative course is the primary driver of complications in PCNL and not necessarily the exit strategy.

UNLABELLED:What's known on the subject? and What does the study add? Laparoscopic radical nephrectomy is a well established treatment for localized RCC, where nephron-sparing approaches are not appropriate. As surgeon and departmental experience grow more extensive tumours will be tackled laparoscopically. However, little is known about the operative safety and oncological outcomes of the laparoscopic approach for locally advanced RCC. The present study describes the largest reported cohort of patients receiving laparoscopic radical nephrectomy for locally advanced RCC. In the context of suitably experienced personnel in an established centre, we have established that this approach is safe from operative, postoperative and oncological standpoints, with comparable data to existing open series.OBJECTIVE:To determine the operative, postoperative and oncological outcomes of laparoscopic radical nephrectomy (LRN) for locally advanced renal cell cancer (RCC), which, as surgeon and departmental experience increases, is being performed more often.PATIENTS AND METHODS:In total, 94 consecutive patients receiving LRN for pathologically confirmed T3 or T4 RCC at a tertiary referral centre between March 2002 and May 2010 were analyzed. Preoperative, operative, tumour and postoperative characteristics were evaluated together with recurrence and outcome data. Survival was estimated using the Kaplan-Meier method. Cox's proportional hazards model was used for multivariate analysis.RESULTS:In total, 77 patients had LRN with curative intent and 17 patients had LRN with cytoreductive intent. There were six LRNs (6.4%) that were converted to open procedures. Overall, there were two (2.1%) Clavien grade IIIa complications, one (1.1%) grade IVa complication and one (1.1%) postoperative death. Overall median follow-up was 17.4 months. In total, 22 (28.6%) patients receiving curative LRN developed a recurrence after a median of 13.9 months; 12 (54.5%) patients developed distant metastases, five (22.7%) patients had local recurrences and three (13.6%) patients had transcoelomic spread. Median predicted progression free survival was 48.4 months in patients undergoing LRN with curative intent. Median predicted overall survival was 65.6 months after curative LRN and 15.7 months after cytoreductive LRN. Multivariate analysis did not reveal any variables influencing recurrence or survival.CONCLUSIONS:In the context of suitably experienced personnel in an established centre, LRN for locally advanced RCC is safe from an operative and oncological standpoint. Patients clinically staged as T3 RCC must still be selected carefully for LRN in a multidisciplinary setting.

Restricted accessAbstractFirst published online September 1, 2011Comparison of Endoscopic Management and Laparoscopic Nephroureterectomy for Superficial Upper Tract Urothelial Cancer (UTUC): 20-Year Single Centre ExperienceL. Cutress, G.D. Stewart, […], W.J. Ang, S. Wells-Cole, A.C.P. Riddick, S.A. McNeill, S. Phipps, B.G. Thomas, and D.A. Tolley, +6 -6Volume 4, Issue 5https://doi.org/10.1016/j.bjmsu.2011.06.013

BACKGROUND AND PURPOSELaparoscopic nephrectomy (LN) has largely replaced open nephrectomy. The aim of this study was to describe a validated modular system for training urologists in LN in the context of the shorter training times available in the current era.METHODSAfter attendance at dry and wet laboratory courses, three mentees (trainee, new consultant, and an experienced open surgeon) were mentored through a five-module LN training system in our center followed by the mentee's own hospital. A minimum of 25 independent procedures were then performed by mentees in their own hospital.RESULTSThere were 17 to 32 mentored cases needed to become competent in LN, followed by up to 5 observed cases in the mentee's own center. Subsequently, data from the first 105 cases (80 LN and 25 laparoscopic nephroureterectomies [LNU]) performed by the three surgeons after the end of their training without observation by their mentor were retrospectively collected and analyzed. There were three conversions (2.9%). For LN and LNU, respectively: median operative time was 140 minutes (65-390 min) and 180 minutes (90-300 min); median estimated blood loss was 30 mL (0-2000 mL) and 50 mL (0-2000 mL); median postoperative stay was 4 days (2-45 days) and 6 days (3-27 days). Four (3.8%) patients needed a postoperative transfusion. There was no 30-day mortality.CONCLUSIONMentees matched the median British Association for Urological Surgeons (BAUS) registry operative time (LN, 120-180 min, LNU, 180-240 min) and had lower conversion rates (2.9% vs 6.4% for BAUS). Mentees matched median BAUS database reported blood loss (LN and LNU <500 mL) and length of stay (LN-4 days, LNU-5 days). This modular training program allows urologists to become independent in LN after a short period of focused training in the training center followed by a short period of mentoring in the mentee's own center.

PURPOSE:To determine the stage-specific operative, postoperative and oncologic outcomes, for patients undergoing a laparoscopic radical nephrectomy (LRN) for renal cell carcinoma (RCC) in a single center and assess changes over a generation of practice.PATIENTS AND METHODS:From December 1992 to July 2011, data were collected prospectively for 854 consecutive simple laparoscopic necphrectomies (LNs) and LRNs, 397 of which were LRNs for RCC. The first LRN was performed in December 1997. Stage-specific surgical and oncologic outcomes were assessed across the study period. Patients were then grouped into three equal consecutive cohorts. Case mix and surgical outcomes were compared to assess changes with departmental experience.RESULTS:There were 206, 71, 118, and 2 patients across stages pT1, pT2, pT3, and pT4, respectively. Median operative time was significantly shorter for pT1 tumors (125, 150 and 150 min for pT1-3, P<0.021), while median estimated blood loss (EBL) was greater for pT3 tumors (50, 50, 100 mL, for pT1-3, P<0.001). Median follow-up time was 31, 30, and 18 months, respectively, across pT1-pT3. There was a significant difference in 5-year overall survival (82.4%, 68.4%, 58.9%), cancer-specific survival (99.5%, 83.6%, 66.5%) and progression free survival (86.5%, 66.3%, 47.5%) across these stage-specific subgroups. Over the three cohorts, there was an increase in LRN performed for locally advanced disease and cytoreduction. With greater surgical experience, there was improvement in median operative time and median EBL in localized disease over the three periods, but no significant changes for locally advanced disease.CONCLUSION:This is the largest reported series of LRN in the United Kingdom. Departmental experience has resulted in improved surgical outcomes for localized RCC, with expansion of practice in more complex advanced disease. Laparoscopic nephrectomy is both operatively and oncologically safe in T1 and T2 disease, and although technically more demanding, it is also safe in selected T3 disease.

Study Type – Therapy (case series)Level of Evidence 4What's known on the subject? and What does the study add?Endoscopic management of small, low‐grade, non‐invasive upper tract urothelial cell carcinoma (UTUC) is a management option for selected groups of patients. However, the long‐term survival outcomes of endoscopically‐managed UTUC are uncertain because only four institutions have reported outcomes of more than 40 patients beyond 50 months of follow‐up. Moreover, there is significant variance in the degree of underlying UTUC pathology verification in some of these reports, which precludes an analysis of disease‐specific survival outcomes.The present study represents one of the largest endoscopically managed series of patients with UTUC, with a long‐term follow‐up. The degree of verification of underlying UTUC pathology is one of the highest, which allows a grade‐stratified analysis of different outcomes, including upper‐tract recurrence‐free survival, intravesical recurrence‐free survival, renal unit survival and disease‐specific survival. These outcomes provide further evidence suggesting that endoscopic management of highly selected, low‐grade UTUC can provide effective oncological control, as well as renal preservation, in experienced centres.OBJECTIVE To report the long‐term outcomes of patients with upper tract urothelial cell carcinoma (UTUC) who were treated endoscopically (either via ureteroscopic ablation or percutaneous resection) at a single institution over a 20‐year period. PATIENTS AND METHODS Departmental operation records were reviewed to identify patients who underwent endoscopic management of UTUC as their primary treatment. Outcomes were obtained via retrospective analysis of notes, electronic records and registry data. Survival outcomes, including overall survival (OS), UTUC‐specific survival (disease‐specific survival; DSS), upper‐tract recurrence‐free survival, intravesical recurrence‐free survival, renal unit survival and progression‐free survival, were estimated using Kaplan–Meier methods and grade‐stratified differences were analyzed using the log‐rank test. RESULTS Between January 1991 and April 2011, 73 patients underwent endoscopic management of UTUC with a median age at diagnosis of 67.7 years. All patients underwent ureteroscopy and biopsy‐confirmation of pathology was obtained in 81% (n= 59) of the patients. In total, 14% (n= 10) of the patients underwent percutaneous resection. Median (range; mean) follow‐up was 54 (1–223; 62.8) months. Upper tract recurrence occurred in 68% (n= 50). Eventually, 19% (n= 14) of the patients proceeded to nephroureterectomy. The estimated OS and DSS were 69.7% and 88.9%, respectively, at 5 years, and 40.3% and 77.4%, respectively, at 10 years. The estimated mean and median OS times were 119 months and 107 months, respectively. The estimated mean DSS time was 190 months. CONCLUSIONS The present study represents one of the largest reported series of endoscopically‐managed UTUC, with high pathological verification and long‐term follow‐up. Upper‐tract recurrence is common, which mandates regular ureteroscopic surveillance. However, in selected patients, this approach has a favourable DSS, with a relatively low nephroureterectomy rate, and therefore provides oncological control and renal preservation in patients more likely to die eventually from other causes.