European Urology Volume 61, issue 6, pages e53-e66, June 2012

Percutaneous Nephrolithotomy in the United Kingdom: Results of a Prospective Data Registry

James N. Armitage, Stuart O. Irving, Neil A. Burgess, for the British Association of Urological Surgeons Section of Endourology.


Percutaneous nephrolithotomy (PCNL) is commonly used in the management of large upper renal tract stones. It is highly effective but carries a greater risk of significant morbidity than less invasive treatment options such as ureteroscopy or extracorporeal shock wave lithotripsy.

Evaluate the current practice and outcomes of PCNL using a national prospective data registry.

Design, setting, and participants
All surgeons undertaking PCNL in the United Kingdom were invited to submit data to an online registry.

Effectiveness was assessed by stone-free rates and safety according to complications including blood transfusion, fever, and sepsis rates.

Results and limitations
Since January 2010, data on 987 patients who had 1028 PCNL procedures were collected. A total of 299 of 1012 procedures (30%) were for staghorn calculi, 299 (30%) for stones >2 cm, 329 (33%) for stones 1–2 cm, and 89 (9%) for stones <1 cm. There were no significant differences in rates of failed access or complications according to whether a urologist or radiologist obtained renal access. There was a nonsignificant trend to a higher transfusion rate with balloon dilatation (7 of 222 [3.2%]) compared with serial dilatation (2 of 245 [0.8%]) of the renal tract (p = 0.093). Totally tubeless procedures were not associated with higher complication rates but did lead to a significant reduction in median length of stay (3 d vs 1.5 d; p <0.0001). Intraoperatively, 78% of patients were believed to be stone free, which was confirmed in 68% with postoperative imaging. Blood transfusion was required in 24 of 968 patients (2.5%). The incidence of postoperative fever was 16% and of sepsis was 2.4%.

The PCNL data registry is a unique resource providing vital information on current practice and critical outcome data. Using the registry, endourologists can audit their practice against national outcome data for this benchmark procedure. It will help surgeons counsel patients during consent for this complex endourologic procedure about the possible outcome in their hands.

CROES PCNL Study Group.. Journal of Endourology – doi:10.1089/end.2012.0046

Prospective Comparison of Outcomes of Percutaneous Nephrolithotomy in Elderly Patients Versus Younger Patients

Zeph Okeke, M.D.,1 Arthur D. Smith, M.D.,1 Gaston Labate, M.D.,2 Alessandro D’Addessi, M.D.,3 Ramakrishna Venkatesh, M.D.,4 Dean Assimos, M.D.,5 Willem E.M. Strijbos, M.D.,6 and Jean J.M.C.H. de la Rosette, on behalf of the CROES PCNL Study Group., M.D.7

1Arthur Smith Institute for Urology, North Shore-Long Island Jewish Health System, New York, New York.
2Department of Urology, Urosalud, Buenos Aires, Argentina.
3Department of Urology, Catholic University School of Medicine, Rome, Italy.
4Department of Urology, University of Kentucky, Lexington, Kentucky.
5Department of Urology, Wake Forest University, Winston-Salem, North Carolina.
6Department of Urology, Atrium Medisch Centrum, Heerlen, The Netherlands.
7Department of Urology, AMC University Hospital, Amsterdam, The Netherlands.


The purpose of the study was to prospectively compare operative and postoperative characteristics and outcomes in elderly patients undergoing percutaneous nephrolithotomy (PCNL) compared with younger patients.

Patients and Methods:
Prospectively collected data from the Clinical Research Office of the Endourological Society (CROES) Global PCNL Study database were used. Elderly patients were defined as those aged 70 years and above, while younger patients were those between 18 and 70 years of age. Matched and unmatched group comparisons were performed based on imaging modality used for assessing stone-free status. Patient characteristics, operative data, and postoperative outcomes were compared.

The median age of the elderly group vs the young group was 74 years (range 70–93 years) vs 49 years. In the unmatched analysis, staghorn stones were seen at higher rates in the elderly group (27.8% vs 21.8%, P=0.014); however, the mean stone size was not significantly different (465.0 vs 422.8, P=0.063). The length of hospitalization was significantly longer in the elderly group compared with the young group in the unmatched analysis (5 days vs 4.1 days, P<0.001). The same difference was not apparent in the matched analysis (5.0 days vs 4.4 days, P=0.288). Overall complication rates were not significantly different in the unmatched analysis. In the matched analysis, however, a statistically significant higher rate of overall complications was seen. Stone-free rates were similar among all groups.

PCNL in elderly patients over the age of 70 years produces results comparable to those seen in younger patients. With only a slightly higher—be it statistically significant—complication rate, the stone-free rate in older patients was the same as in the younger group.

Journal of Endourology. doi:10.1089/end.2011.0481.

Cost Analysis of Metallic Ureteral Stents with 12 Months of Follow-Up

Eric R. Taylor, M.D., Aaron D. Benson, M.D., and Bradley F. Schwartz, D.O. Division of Urology, Southern Illinois University, Springfield, Illinois.


Background and Purpose:
The metallic ureteral stent was first developed for patients with ureteral obstruction related to malignant disease, but it can be used in all patients needing chronic indwelling ureteral stents, including those with benign disease. The traditional method of polymer stent management often necessitates multiple exchanges per year depending on patient and logistical factors. This has significant direct financial cost and likely a negative effect on patients’ overall health. The objective was to analyze and compare the costs associated with chronic indwelling metal and silicone-based ureteral stents.

Patients and Methods:
A prospective database of patients undergoing metal stent placement from February 2008 to June 2010 was reviewed. Mean charges for a single traditional nonmetal and metal stent insertion were calculated. Charges were based on direct hospital charges related to stent cost and surgery. Cost data were based on the fiscal year 2010 cost for polymer or metal stent insertions.

Twenty-one patients underwent metal stent placement at our institution. Of these, three traditional stent placements were omitted from analysis because of bundled charges for ureteroscopy at the same setting. Mean charges per single traditional and metal stent placement were $6072.75 and $9469.50, respectively. The estimated annual charges for traditional stents (3–6 exchanges) would be $18,218.25 to $36,436.50. Compared with metal stents, this is a potential financial savings of 48% to 74%. The mean direct cost to patients was 21.6% and 25.4% of the charges for metal and polymer stents, respectively. No patient needed early discontinuation of his or her metal stent because of lower urinary tract symptoms or gross hematuria.

Metal stents are well tolerated by patients with ureteral obstruction of various etiologies and provide a significant financial benefit compared with polymer ureteral stents. For patients who are not fit for surgical intervention regarding their ureteral occlusive disease, the metal Resonance stent is a financially advantageous and well-tolerated option.

Journal of Endourology. May 2012, 26(5): 489-493. doi:10.1089/end.2011.0405.

Retrograde Intrarenal Surgery in Treatment of Nephrolithiasis: Is a 100% Stone-Free Rate Achievable?

Martin Schoenthaler, M.D.,1 Konrad Wilhelm, M.D.,1 Arndt Katzenwadel, M.D.,1 Peter Ardelt, M.D.,1 Ulrich Wetterauer, Ph.D.,1 Olivier Traxer, Ph.D.,2 and Arkadiusz Miernik, M.D.1

1Department of Urology, University Medical Center Freiburg, Freiburg, Germany.
2Department of Urology, Tenon Univerity Hospital, Paris, France.


To achieve an almost 100% stone-free rate by means of further developing and standardizing the procedure.

Patients and Methods:
100 consecutive patients with single or multiple renal calculi were prospectively enrolled in the study. Flexible ureterorenoscopy was performed as a completely standardized operation by the same two experienced surgeons. Primary outcome was an “endoscopic” (immediate) stone-free status as determined by endoscopic inspection at the end of surgery. In cases of residual fragments, a reevaluation by CT was performed after 3 months.

The endoscopic stone-free rate was 97%. In three patients with a cumulative stone size >20?mm, a completely stone-free status could not be achieved in the primary procedure. In these patients, a CT scan after 3 months showed complete clearance from all residual fragments in two; this translates into a primary (after one procedure) stone-free rate after 3 months of 99%. Medium cumulative stone size was 9.8?mm (4–40?mm); in 44 patients, multiple calculi were extracted. Forty-nine patients received a ureteral stent at the end of the operation; two patients had to have stent placement for new onset hydronephrosis and/or colicky pain or fever. Overall complication rate was 7%. Results are limited, because no routine CT scan was used to evaluate stone clearance.

By means of a standardized surgical approach and use of technical equipment of the newest generation, it is possible to achieve very high stone-free rates without compromising safety. This approach, however, necessitates use of considerable resources, both technical/surgical and financial.

Journal of Endourology. doi:10.1089/end.2011.0639.

Prevalence of Nephrolithiasis in Human Immunodeficiency Virus Infected Patients on the Highly Active Antiretroviral Therapy

Omer A. Raheem, M.D., Hossein S. Mirheydar, M.D., Kerrin Palazzi, M.P.H., Marianne Chenoweth, R.N., Charles Lakin, M.D., and Roger L. Sur, M.D.

Division of Urology, Department of Surgery, University of California San Diego Health Care System, San Diego, California.


Background and Purpose:
Protease inhibitors, specifically indinavir, have historically been implicated as a cause of nephrolithiasis in the human immunodeficiency virus (HIV) infected patients. There is a paucity of data, however, on stone disease with nonindinavir etiologies since the introduction of highly active antiretroviral therapy (HAART). We sought to describe the prevalence of nephrolithiasis in the HIV population since the use of HAART.

Patients and Methods:
We retrospectively reviewed HIV-positive patients currently receiving HAART treatment in whom image proven kidney and/or ureteral urolithiasis developed, between 1998 and 2010. A detailed analysis of patients’ current treatment, surgical intervention, and metabolic studies was performed.

A total of 436 HIV-positive patients were included and 46 (11%) patients had nephrolithiasis. Each patient included in this study was receiving nonindinavir-based antiretroviral therapy. There were 41 men of whom 36 were Caucasian. Eleven (24%) patients underwent 24-hour urine collections with 11 metabolic abnormalities identified. Stone analysis was available for seven patients (four calcium oxalate monohydrate, one cystine, one uric acid, and one atazanavir).

We report the largest series of nephrolithiasis in an HIV population since the introduction of HAART and highlight not only the similar prevalence of nephrolithiasis to the non-HIV population but also the lack of consistent comprehensive metabolic evaluations in HIV patients with recurrent nephrolithiasis.

Journal of Endourology. doi:10.1089/end.2011.0478.

Cone Beam Computed Tomography for Percutaneous Nephrolithotomy: Initial Evaluation of a New Technology

Ornob P. Roy, M.D.,1 John F. Angle, M.D.,2 Alan D. Jenkins, M.D.,1 and Noah S. Schenkman, M.D.1

1Department of Urology, University of Virginia Health System, Charlottesville, Virginia.
2Department of Interventional Radiology, University of Virginia Health System, Charlottesville, Virginia.


Background and Purpose:
Cone beam CT (CBCT) is a novel imaging modality that combines the versatility of conventional C-arm imaging with the functionality of cross-sectional imaging. This is a pilot study to evaluate the capabilities of this new technology to obtain percutaneous access and for the immediate postoperative evaluation of residual fragments in percutaneous nephrolithotomy (PCNL).

Materials and Methods:
A retrospective analysis of all PCNL cases performed between April 2007 and November 2007 was performed. One urologist (NSS) and one radiologist (JFA) reviewed the studies postoperatively. Preoperative films were evaluated to see if CBCT influenced or improved percutaneous access. Postoperative films were evaluated that compared CBCT with conventional noncontrast CT to determine efficacy in finding postoperative stone fragments. Parameters of stone size, location, and quantity of fragments were compared.

For preoperative access, CBCT was used in 52 cases of PCNL between April 2007 and November 2007. In eight of these cases, CBCT altered the percutaneous access. In postoperative evaluation, 26 cases had both CBCT and conventional CT for comparison. In 11 cases with residual stones, conventional CT identified a greater number of fragments, but these were less than 2?mm. The postoperative recommendation for a secondary procedure concurred in 22 of 26 studies.

CBCT may provide advantages of improved preoperative imaging, which may result in better percutaneous access, and improved postoperative imaging, which allows surgeons to have “real-time” access to CT quality images. The intraoperative availability of these high quality tomographic images may obviate the need for other postoperative imaging and subsequent adjunctive procedures for residual fragments.

Journal of Endourology. doi:10.1089/end.2011.0664.

Ureteroscopic Management with Laser Lithotripsy of Renal Pelvic Stones

Gokhan Atis, M.D., Cenk Gurbuz, M.D., Ozgur Arikan, M.D., Lutfi Canat, M.D., Mert Kilic, M.D., and Turhan Caskurlu, M.D. Department of Urology, Goztepe Training and Research Hospital, Istanbul, Turkey.


Background and Purpose:
The development of semirigid and flexible ureteroscopes has permitted easier access to calculi throughout the urinary tract. We compared the use of semirigid and flexible ureteroscopy for the management of shockwave lithotripsy-refractory, isolated renal pelvic calculi by evaluating stone-free rates, operating room times, and associated complications.

Patients and Methods:
Ureteroscopic stone treatment was attempted in
47 patients with isolated renal pelvic stones between November 2008 and December 2010. The procedures were performed under general anesthesia. Semirigid ureteroscopy was routinely performed in all patients. If the stones were accessible in the renal pelvis with the semirigid ureteroscope (S-URS), they were then treated with the holmium:yttrium-aluminum-garnet (Ho:YAG) laser through S-URS under direct vision. If the stones were not accessible, flexible ureteroscopy was then performed. Preoperative, operative, and postoperative data were retrospectively analyzed.

In 25 of 47 patients, renal pelvic stones were accessible with S-URS, and the stones were fragmented with the Ho:YAG laser using S-URS. In the remaining 22 patients, the stones were accessed with the flexible ureteroscope (F-URS), and the fragmentation of stones was performed with the Ho:YAG laser using the F-URS. There were no significant differences in age, body mass index, grade of hydronephrosis, mean stone size, and stone laterality among the two groups. The mean operative times were 71.90±17.90 minutes in the S-URS group and 93.41±18.56 minutes in the F-URS group (P=0.001). The stone-free rates at postoperative day 1 and at the 1 month follow-up were 72% and 76% in the S-URS group and 81.8% and 86.4% in the F-URS group, respectively (P=0.861 and P=0.368). We found no significant differences among groups with regard to stone-free rates, complication rates, and hospital lengths of stay.

Although it is well known that flexible ureteroscopy permits a detailed caliceal examination and therapeutic interventions, semirigid ureteroscopy is also often another sufficient means of reaching the renal pelvis in selected patients.

Journal of Endourology. doi:10.1089/end.2011.0624.

Postshockwave Lithotripsy Outcome Evaluation in Ureteral Stones: Comparison Between Noncontrast Computed Tomography and Plain Abdominal Radiography

Hasan Soydan, M.D., Ilker Akyol, M.D., Temucin Senkul, M.D., Ferhat Ates, M.D., Sami Uguz, M.D., Omer Yilmaz, M.D., and Kadir Baykal, M.D.

Urology Department, GATA Haydarpasa Teaching Hospital, Istanbul, Turkey.


Background and Purpose:
There are no definite data indicating which modality to use to assess the efficacy of shockwave lithotripsy (SWL). Usually, plain abdominal radiography (PAR) is recommended in percutaneous nephrolithotomy (PCNL) afterward and in the follow-up of asymptomatic stones, whereas noncontrast CT (NCCT) is recommended in cases of residual fragments. We compared the efficacies of PAR and NCCT in terms of assessing the outcome of SWL treatment for radiopaque ureteral stones.

Patients and Methods:
Those patients with renal colic and a radiopaque ureteral stone of 5 to 20?mm that was detected on PAR were included in the study; body mass index (BMI) values were calculated and recorded. Patients whose PAR revealed opacities suspicious for ureteral stones were evaluated with NCCT at 3-mm slices. Stone status was assessed with PAR and NCCT on post-SWL day 3. Detection of no stone, a residual fragment of =4?mm, and a residual fragment of >4?mm was defined as success, clinically insignificant residual fragments, and failure, respectively.

On post-SWL day 3, both PAR and NCCT revealed stones in 31 patients, and no stones were seen in either modality in 29 patients. NCCT revealed stones whereas PAR had negative results for stones in two patients. These patients had upper ureteral stones of 7.5?mm (6–9 mm) before SWL. Mean stone size on NCCT after SWL was 2.5?mm (1–4?mm). Mean BMI of these two patients was 27.72, and mean BMI of the patients with upper ureteral stones that were revealed by both PAR and NCCT was 27.68; these two values were statistically similar.

PAR is capable of detecting clinically significant residual fragments, and patients can be followed up with PAR alone after SWL treatment for radiopaque ureteral stones. This approach both decreases the cost and prevents excessive radiation exposure.

Journal of Endourology. June 2012, 26(6): 621-624. doi:10.1089/end.2011.0547.

Feasibility of Totally Tubeless Percutaneous Nephrolithotomy Under the Age of 14 Years: A Randomized Clinical Trial

Seyed Mohamad Kazem Aghamir, M.D.,1 Alborz Salavati, M.D.,1 Mehdi Aloosh, M.D.,2,3 Hasan Farahmand, M.D.,1 Alipasha Meysamie, M.D.,4 and Gholamreza Pourmand, M.D.3

1Department of Urology, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran.
2Research Development Center, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran.
3Urology Research Center, Tehran University of Medical Sciences, Tehran, Iran.
4Department of Community Medicine, Tehran University of Medical
Sciences, Tehran, Iran.


To assess the outcome and safety of the totally tubeless percutaneous nephrolithotomy (PCNL) in comparison with standard PCNL in the children under the age of 14 years.

Patients and methods:
Twenty-three patients under the age of 14 with renal stones were enrolled in a prospective randomized clinical trial during March 2010 to June 2011. The inclusion criteria were existence of renal stone larger than 2.5?cm in diameter or extracorporeal shockwave lithotripsy-resistant kidney stone; furthermore, exclusion criteria were kidney anomalies, renal failure on admission, and serious bleeding or perforation in the collecting system during the operation. The patients were divided into two groups according to block randomization. Group A comprised of 13 children with mean age 10.31 (4–14) years, were rendered totally tubeless at the end of surgery, while 10 patients in group B with mean age 11.1 (9–14) years underwent standard PCNL. The incidence of complications, transfusion rate, analgesic use, hemoglobin drop, operation time, and hospital stay were compared between the two groups during a one-month study period.

The mean stone burden was 29.23?mm (SD=4.85) in group A versus 31.4?mm (SD=5.19) in group B. Hospitalization averaged 39.54 (SD=11.39) hours versus 58.7 (SD=10.37) (p<0.001) and the average analgesics use was 0.07 (SD=0.03) mg/kg of morphine versus 0.15 (SD=0.04) (p<0.001), respectively. Operation time, transfusion rate, complications, retreatment, and hemoglobin drop were not different, significantly.

Totally tubeless PCNL for pediatric population yields decreased hospital stay and analgesic use with no more complications. So, it can be considered as a standard and cost-beneficial procedure in appropriately selected group of patients.

Journal of Endourology. -Not available-, ahead of print. doi:10.1089/end.2011.0518.

Does the Hounsfield Unit Value Determined by Computed Tomography Predict the Outcome of Percutaneous Nephrolithotomy?

Adnan Gücük, M.D.,1 Ugur Üyetürk, M.D.,1 Ufuk Öztürk, M.D.,2 Eray Kemahli, M.D.,1 Mevlüt Yildiz, M.D.,1 and Ahmet Metin, M.D.1

1Department of Urology, Abant Izzet Baysal University Faculty of Medicine, Bolu, Turkey.
2Department of Urology, S.B Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey.


We aimed to evaluate whether the Hounsfield unit (HU) value predicts outcome in percutaneous nephrolithotomy (PCNL).

Patients and Methods:
One hundred and seventy-nine patients who had undergone PCNL in our clinics in the last 4 years were included. Demographic and clinical data of the patients and complications, if any, were recorded. The mean age of the patients was 45.3±14.3 years (range 5–82?y), and 111 of them were males (62%). The mean stone size and HU values were found to be 693.1±628.0 (95–4200) mm2 and 706.3±245.0 (214–1325), respectively.

In logistic regression analysis, the size of the stone, the opacity of the stone, and the HU values were found to be independent predictors of the failure of the procedure (P<0.05). A cutoff value of 677.5 was used for the HU in the receiver operating characteristics analysis. Having a HU value under the cutoff value increased the likelihood of procedure failure by 2.65 times, whereas stones residing in the staghorn localization increased failure by 5.68. It was also observed that if the stone’s size was 485?mm2 or more, the chance of failure increased by 1.9, whereas when the stone was nonopaque, failure increased by 6.04 times (P<0.05). There was a positive correlation between hematocrit decrease and a decrease in HU values (P<0.05), but no correlation was observed between the HU values and duration of surgery or fluoroscopy (P>0.05).

In addition to the size and location of the stones, the HU value determined in the unenhanced CT scan may be one of the parameters affecting PCNL outcomes. PCNL is a more efficient method in stones with higher HU values. Therefore, the HU values may be a useful tool for the selection of the treatment modality in patients with renal stones.

Journal of Endourology. April 2012, 26(4): 347-350. doi:10.1089/end.2011.0504.

The Utility of Noncontrast Computed Tomography in the Prompt Diagnosis of Postoperative Complications After Percutaneous Nephrolithotomy

Ehud Gnessin, M.D., Jessica A. Mandeville, M.D., Shelly E. Handa, R.N., and James E. Lingeman, M.D.

Department of Urology, Indiana University Health, Methodist Hospital, Indianapolis, Indiana.


Noncontrast computed tomography (CT) is commonly utilized after percutaneous nephrolithotomy (PNL) to assess stone-free (SF) status. In addition to assessing SF status, CT is useful in the recognition of complications after PNL. We characterized complications demonstrated by postoperative CT scan and compared hospital re-admission rates based on whether or not CT was performed.

We retrospectively reviewed records of 1032 consecutive patients from April 1999 to June 2010. Patients were divided into two cohorts based on whether they had a CT within 24 hours of PNL. Demographic data, CT findings, and need for re-admission for complication management were assessed.

Nine hundred fifty-seven patients (92.7%) underwent post-PNL CT. CT-diagnosed complications were perinephric hematoma in 41 (4.3%; 2 requiring embolization and 9 necessitating transfusion), pleural effusion in 25 (2.6%; 10 requiring intervention), colon perforation in 2 (0.2%), and splenic injury in 2 (0.2%). Of patients with postoperative complications, 33% required intervention. Among patients with a CT, 6 (0.6%) were readmitted despite negative postoperative CT (four perinephric hematomas, one calyceal-pleural fistula, and one pseudoaneurysm). The sensitivity of CT for diagnosing complications was 92.7%. Seventy-five patients (7.3%) did not undergo CT post-PNL. Of these, four (5.33%) were readmitted: three for perinephric hematomas and one for ureteral clot obstruction. Patients undergoing post-PNL CT were less likely to be readmitted because of missed complications (p=0.02).

Serious post-PNL complications are uncommon, but their prompt diagnosis and treatment is imperative. In addition to identifying residual stones, CT is useful in diagnosing postoperative complications. Postoperative CT could potentially be considered for all patients undergoing PNL, particularly in complex cases such as patients with anatomical abnormalities (renal anatomic abnormality or retrorenal colon), patients requiring upper pole access (risk of thoracic, hepatic, and splenic complications), and patients requiring multisite access (higher risk of perinephric hematoma or need for transfusion).

Urology Volume 79, Issue 6 , Pages 1247-1251, June 2012

Doppler Ultrasound-guided Percutaneous Nephrolithotomy With Two-step Tract Dilation for Management of Complex Renal Stones

Youming Xu, Zhonghua Wuemail address, Jianhua Yu, Shulong Wang, Fang Li, Jiushun Chen, Jin Liu, Kan Chen

Department of Urology, Hubei Provincial Corps Hospital, Chinese People’s Armed Police Forces, Wuhan, China

To report our experience and assess the safety and efficacy of Doppler ultrasound–guided percutaneous nephrolithotomy (PCNL) with 2-step tract dilation for complex renal stones.

Materials and Methods
From March 2009 to February 2011, 262 patients underwent PCNL. Eighty-three patients had a complete and 105 had partial staghorn calculus, and 74 had a renal pelvic stone of >2 cm in diameter. Thirty-five patients had renal surgical history. Doppler ultrasound–guided PCNL with 2-step tract dilation were performed. Stones were fragmented and cleared using a combination of ultrasonic and pneumatic lithotripters.

All PCNL procedures were successful. Successful access to the collecting system was 100%. Although most of the cases (231/262) were managed satisfactorily by a single tract, a second tract was used in 31 cases. Mean operation time was 56 minutes (range 25–145). The primary stone-free rate of PCNL was 80.9%. There were 39 auxiliary procedures (13 second PCNL and 26 extracorporeal shock wave lithotripsy). One month after treatment, the overall stone-free rate was 92.7%. Five patients (1.9%) received blood transfusion. Eight patients (3.1%) with a postoperative fever of =38.5°C were cured by intravenous antibiotics. No other severe complications occurred. The mean postoperative stay was 3.8 days (range 2–12).

Doppler ultrasound–guided PCNL with 2-step tract dilation for complex renal stones is safe, effective, and worthy of wider use in clinical practice.

Urology Volume 79, Issue 6 , Pages 1242-1246, June 2012

Medical Expulsive Therapy in a Tertiary Care Emergency Department

Nancy Itano, Elisabeth Ferlic, Rafael Nunez-Nateras, Mitchell R. Humphreys

Department of Urology, Mayo Clinic Arizona, Phoenix, Arizona

To assess the extent of Medical expulsive therapy (MET) use and practice patterns in our tertiary care emergency department. MET is the first-line intervention for select symptomatic urolithiasis recommended by the American Urological Association and supported by clinical trials investigating its efficacy. Nonetheless, MET is not always prescribed in the emergency department setting for symptomatic patients with ureteral stones.

Using the “International Classification of Diseases” diagnostic codes, we retrospectively reviewed the medical records of all emergency department patients treated for urolithiasis at our institution from January to December 2008. Abstracted patient data included demographic and medically relevant information; MET use was determined by reviewing the electronic prescriptions at discharge.

Of 165 patients identified with a diagnosis of renal colic owing to urolithiasis, 23 were excluded for suspected stone passage or failure to document a stone on cross-sectional imaging. Most (138 [97%] of 142) of the remaining patients met the criteria for outpatient treatment of symptomatic stone episodes and were eligible for MET. Urology consultation was requested in 19 outpatients (13%), and MET was prescribed for most (14 [73.7%] of 19). Of the 119 patients seen by an emergency department physician without urologic input and discharged, 17 (14%) received MET. Overall, tamsulosin was prescribed to 31 (22%) of 138 stone episodes treated with an outpatient trial of passage.

The underusage of tamsulosin in the emergency department of our
institution highlights the need for educational interventions to
improve the quality and cost of emergent patient care.

Urology Volume 79, Issue 6 , Pages 1230-1235, June 2012

Pulsed Fluoroscopy in Ureteroscopy and Percutaneous Nephrolithotomy

Mohamed A. Elkoushy, Walid Shahrour, Sero Andonian

Division of Urology, Department of Surgery, McGill University Health Centre, McGill University, Montreal, Quebec, Canada

To assess the impact of pulsed fluoroscopy (PF) at a rate of 4 frames per seconds (fps) on the total fluoroscopy time during ureteroscopy (URS) and percutaneous nephrolithotomy (PCNL).

A retrospective review of prospectively collected data was performed for consecutive patients undergoing URS and PCNL by a single surgeon between July 2009 and July 2011. PF was routinely used in all URS procedures since January 2011 and in all PCNL procedures since November 2010. Before these dates, standard fluoroscopy (SF) at a rate of 30 fps was used. Patient and stone characteristics together with operative data were compared using univariate and multivariate analyses.

There were a total of 163 URS (117 SF and 46 PF) and 100 PCNL (50 SF and 50 PF). In the URS cohort, there were no significant differences between both SF and PF groups in terms of age, gender, body mass index, stone location, and multiplicity (P =.20). For both URS and PCNL cohorts, the duration of surgery and stone-free rates were comparable in both SF and PF groups (P =.06). Compared with SF groups, patients in the PF groups were exposed to significantly less fluoroscopy during URS (109.1 vs. 44.1 sec, P<0.001) and PCNL (341.1 vs. 121.5 sec, P<0.001). These differences in mean fluoroscopy times retained their significance in multivariate analyses (P<.001).

The use of PF during URS and PCNL was associated with significantly lower fluoroscopy time, thus reducing radiation exposure to both patients and personnel.

Journal of Endourology. June 2012, 26(6): 625-629. doi:10.1089/end.2011.0526.

Outcomes of Retrograde Intrarenal Surgery Compared with Percutaneous Nephrolithotomy in Elderly Patients with Moderate-Size Kidney Stones: A Matched-Pair Analysis

Tolga Akman, M.D., Murat Binbay, M.D., Mesut Ugurlu, M.D., Mehmet Kaba, M.D., Muzaffer Akcay, M.D., Ozgur Yazici, M.D., Faruk Ozgor, M.D., and Ahmet Yaser Muslumanoglu, M.D.

Haseki Teaching and Research Hospital, Department of Urology, Istanbul, Turkey.


The aim of our study was to evaluate the outcomes of retrograde intrarenal surgery (RIRS) in elderly patients with stones of moderate size.

Patients and Methods:
Between September 2008 and June 2011, a total of 28 patients over 65 years of age with single renal stones that measured 1.5 to 3?cm were treated with RIRS. The outcomes of these patients were compared with those of the patients who underwent percutaneous nephrolithotomy (PCNL) using matched-pair analysis (1:1 scenario). The matching parameters were the size and location of the stone as well as age, sex, body mass index, degree of hydronephrosis, presence of previous shockwave lithotripsy, and open surgery. SPSS version 16 was used for statistical analysis.

Stone-free rates after a single procedure were achieved in 82.1% of patients for the RIRS and 92.8% of patients for the PCNL group. The second flexible ureterorenoscopy procedure was performed for five patients in the RIRS group. Finally, stone-free rates during the third month of the follow-up period were 92.8% in the RIRS group and 96.4% in the PCNL group. The mean operative time per patient was 64.5±20.9 minutes in the RIRS group after a total of 33 procedures, while it was 40.7±10.7 minutes in the PCNL groups (P<0.0001). The overall complication rates for the RIRS and PCNL groups were 7.1% and 10.7%, respectively. Blood transfusions were needed in two patients in the PCNL group. Hospitalization time was significantly shorter in the RIRS group (26.5±10.6?h per patient vs 60.0±28.8?h; P<0.0001). In both groups, stones were most frequently composed of calcium oxalate (68.4% in the RIRS group and 77.7% in the PCNL group).

RIRS has a low complication rate and represents a safe and effective treatment alternative in selected geriatric patients with kidney stones of moderate size.

Urology Volume 79, Issue 6 , Pages 1226-1229, June 2012

The Impact of Dietary Calcium and Oxalate Ratios on Stone Risk

Jessica N. Lange, Kyle D. Wood, Patrick W. Mufarrij, Michael F. Callahan, Linda Easter, John Knight, Ross P. Holmes, Dean G. Assimose

Wake Forest University School of Medicine, Winston-Salem, NC

To determine whether the ratio of dietary calcium and oxalate consumption at mealtime affects gastrointestinal oxalate absorption and urinary oxalate excretion.

A study was conducted with 10 non–stone-forming adults placed on controlled diets with daily calcium and oxalate contents of 1000 and 750 mg, respectively. Subjects consumed a balanced calcium/oxalate ratio diet for 1 week, observed a minimum 1-week washout period, and subsequently consumed an imbalanced calcium/oxalate ratio diet for one week. Urine specimens were collected on the last 4 days of each diet. Outcome measures included urinary creatinine, calcium, and oxalate as well as the Tiselius index for assessing urinary calcium oxalate supersaturation.

Total daily calcium excretion, oxalate excretion, and Tiselius index were similar between balanced and imbalanced dietary phases. There were significant differences in calcium excretion (mg/g creatinine) between balanced and imbalanced diets in the 1-6 pm (83.1 vs 110.2, P <.04), 6-11 pm (71.3 vs 107.2, P <.02), and 11 pm-8 am collections (55.0 vs 41.8, P <.02). There was significantly higher oxalate excretion on the balanced diet in the 1-6 pm time period (28.1 vs 16.7, P <.01). There were no differences in the Tiselius index in these collections.

These results demonstrate that the sequence of ingesting relatively large amounts of oxalate does not significantly affect calcium oxalate stone risk if the recommended daily quantity of dietary calcium is consumed.

Journal of Endourology. May 2012, 26(5): 478-483. doi:10.1089/end.2011.0465.

A Randomized Control Trial Evaluating Efficacy of Nephrostomy Tract Infiltration with Bupivacaine After Tubeless Percutaneous Nephrolithotomy

Hemendra N. Shah, M.Ch, D.N.B., MRCS (Ed),1,2 Rashmi H. Shah, M.S., D.N.B.,3 Hiren S. Sodha, M.S., D.N.B.,3 Amit A. Khandkar, M.S., D.N.B.,2 and Aniruddha Gokhale, M.Ch.2

1Department of Urology, S. L. Raheja (Fortis) Hospital, Mahim (West), Mumbai, India.
2Department of Urology, R. G. Stone Urological Research Institute, Mumbai, India.
3Minimal Access Surgery, R. G. Stone Urological Research Institute, Mumbai, India.


We conducted a randomized controlled trial to assess the efficacy of nephrostomy tract infiltration with bupivacaine in tubeless percutaneous nephrolithotomy (PCNL).

Patients and Methods:
All adult patients undergoing unilateral tubeless PCNL from July 1, 2007 to October 31, 2007 were included in the study. Patients were randomized to receive infiltration of bupivacaine in the nephrostomy tract at the end of the procedure or not to receive bupivacaine. To show a 10% difference in postoperative pain, a sample size of 30 persons per group would be needed. Postoperatively, the pain score were obtained at 4 and 24 hours by a nurse who was blinded to the protocol. The perioperative outcome of these patients (study group) was compared with those undergoing tubeless PCNL without nephrostomy tract infiltration of bupivacaine (control group).

Patient demographics and intraoperative parameters in both groups were comparable. Supracostal access was needed in 65.7% and 72.7% patients in the study and control group, respectively. The nephrostomy tract were infiltrated with bupivacaine in 31 patients. The visual analogue pain score at 4 hours and 24 hours for the study group was 2.66±1.07 & 2.23±0.50 respectively, while in control group was 5.15±1.52 and 3.22±1.11, respectively (P=0.000). There was a trend toward lesser analgesia requirement in the study group (94.8 vs 124.2 mg of diclofenac sodium). There was no difference in the duration of postoperative catheterization, hospital stay, stone-free rates, and complication between both groups.

Nephrostomy tract infiltration of bupivacaine in tubeless PCNL is associated with less postoperative pain and analgesia requirement.

Clinics vol.67 no.5 São Paulo  2012

Metabolic assessment of elderly men with urolithiasis.

Freitas Junior CH, Mazzucchi E, Danilovic A, Brito AH, Srougi M.

Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil.


To assess the presence of metabolic disorders in elderly men with urolithiasis.

We performed a case-control study. The inclusion criteria were as follows: (1) men older than 60 years of age and either (2) antecedent renal colic or an incidental diagnosis of urinary lithiasis after age 60 (case arm) or (3) no antecedent renal colic or incidental diagnosis of urolithiasis (control arm). Each individual underwent an interview, and those who were selected underwent all clinical protocol examinations: serum levels of total and ionized calcium, uric acid, phosphorus, glucose, urea, creatinine and parathyroid hormone, urine culture, and analysis of 24-hour urine samples (levels of calcium, citrate, creatinine, uric acid and sodium, pH and urine volume). Each case arm patient underwent two complete metabolic urinary investigations, whereas each control arm individual underwent one examination. NCT01246531.

A total of 51 subjects completed the clinical investigation: 25 in the case arm and 26 in the control arm. In total, 56% of the case arm patients had hypocitraturia (vs. 15.4% in the control arm; p = 0.002). Hypernatriuria was detected in 64% of the case arm patients and in 30.8% of the controls (p = 0.017).

Hypocitraturia and hypernatriuria are the main metabolic
disorders in elderly men with urolithiasis.

Keywords: Urolithiasis; Calculi; Citrate; Metabolism; Aging; Elderly.

Clinics vol.67 no.5 São Paulo  2012

Current practices in the management of patients with ureteral calculi in the emergency room of a university hospital

Oliver Rojas Claros; Carlos Hirokatsu Watanabe Silva; Horacio Consolmagno; Americo Toshiaki Sakai; Rodrigo Freddy; Oscar Eduardo Hidetoshi Fugita

Hospital Universitário da Faculdade de Medicina da Universidade de São Paulo, São Paulo/SP, Brasil


Urinary lithiasis is a common disease. The aim of the present study is to assess the knowledge regarding the diagnosis, treatment and recommendations given to patients with ureteral colic by professionals of an academic hospital.

Sixty-five physicians were interviewed about previous experience with guidelines regarding ureteral colic and how they manage patients with ureteral colic in regards to diagnosis, treatment and the information provided to the patients.

Thirty-six percent of the interviewed physicians were surgeons, and 64% were clinicians. Forty-one percent of the physicians reported experience with ureterolithiasis guidelines. Seventy-two percent indicated that they use noncontrast CT scans for the diagnosis of lithiasis. All of the respondents prescribe hydration, primarily for the improvement of stone elimination (39.3%). The average number of drugs used was 3.5. The combination of nonsteroidal anti-inflammatory drugs and opioids was reported by 54% of the physicians (i.e., 59% of surgeons and 25.6% of clinicians used this combination of drugs) (p = 0.014). Only 21.3% prescribe alpha blockers.

Reported experience with guidelines had little impact on several habitual practices. For example, only 21.3% of the respondents indicated that they prescribed alpha blockers; however, alpha blockers may increase stone elimination by up to 54%. Furthermore, although a meta-analysis demonstrated that hydration had no effect on the transit time of the stone or on the pain, the majority of the physicians reported that they prescribed more than 500 ml of fluid. Dipyrone, hyoscine, nonsteroidal anti-inflammatory drugs, and opioids were identified as the most frequently prescribed drug combination. The information regarding the time for the passage of urinary stones was inconsistent. The development of continuing education programs regarding ureteral colic in the emergency room is necessary.

Keywords: Ureterolithiasis; Emergency Department; University Hospital.

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