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Objective: To analyse our experience with and the outcomes and lessons learned from percutaneous nephrolithotomy (PCNL) in the super obese (body mass index [BMI] ≥50 kg/m(2) )., Patients and Methods: In this institutional review board approved study we retrospectively reviewed our PCNL database between July 2011 and September 2014 and identified all patients with a BMI ≥ 50 kg/m(2) . Patient demographics, peri-operative outcomes and complications were determined. Additionally, we identified a number of special PCNL considerations in the super obese that can maximize safe outcomes., Results: A total of 21 PCNL procedures performed on 17 super obese patients were identified. The mean patient age was 54.8 years, the mean BMI was 57.2 kg/m(2) and the mean stone area was 1 037 mm(2) . Full staghorn stones were observed in six patients and partial staghorns in four patients. The mean operating time was 106 min and the mean haemoglobin decrease was 1.2 g/dL. The overall stone-free rate was 87%. There were four total complications: two Clavien grade II, one Clavien IIIb and one Clavien IVb. We identified several special considerations for safely preforming PCNL in the suber obese, including using extra-long nephroscopes and graspers, using custom-cut extra long access sheaths with suture 'tails' secured to easily retrieve the sheath, choosing the shortest possible access tract, readily employing flexible nephroscopes, placing nephroureteral tubes rather than nephrostomy tubes postoperatively, and meticulous patient positioning and padding., Conclusion: With appropriate peri-operative considerations and planning, PCNL is feasible and safe in the super obese. Stone clearance was similar to that reported in previous PCNL series in the morbidly obese, and is achievable with few complications., (© 2015 The Authors BJU International © 2015 BJU International Published by John Wiley & Sons Ltd.)

Objectives: To examine the differences in 24-h urine composition between nephrolithiasis patients with and without diabetes mellitus (DM) in a large cohort of stone-formers and to examine differences in stone composition between patients with and without DM., Patients and Methods: A retrospective review of 1117 patients with nephrolithiasis and a 24-h urine analysis was completed. Univariable analysis of 24-h urine profiles and multivariable linear regression models were performed, comparing patients with and without DM. A subanalysis of patients with stone analysis data available was performed, comparing the stone composition of patients with and without DM., Results: Of the 1117 patients who comprised the study population, 181 (16%) had DM and 936 (84%) did not have DM at the time of urine analysis. Univariable analysis showed significantly higher total urine volume, citrate, uric acid (UA), sodium, potassium, sulphate, oxalate, chloride, and supersaturation (SS) of UA in individuals with DM (all P < 0.05). However, patients with DM had significantly lower SS of calcium phosphate and pH (all P < 0.05). Multivariable analysis showed that patients with DM had significantly lower urinary pH and SS of calcium phosphate, but significantly greater citrate, UA, sulphate, oxalate, chloride, SSUA, SS of calcium oxalate, and volume than patients without DM (all P < 0.05). Patients with DM had a significantly greater proportion of UA in their stones than patients without DM (50.2% vs 13.5%, P < 0.001)., Conclusions: DM was associated with multiple differences on 24-h urine analysis compared with those without DM, including significantly higher UA and oxalate, and lower pH. Control of urinary UA and pH, as well as limiting intake of dietary oxalate may reduce stone formation in patients with DM., (© 2014 The Authors. BJU International © 2014 BJU International.)

Objective: To evaluate perspectives of urologists viewing live case demonstrations (LCD) and taped case demonstrations (TCD)., Method: A 15-question anonymous survey was distributed to attendees of the live surgery session at the American Urological Association 2012 national meeting (Atlanta) and the second International Challenges in Endourology meeting (Paris)., Results: Of 1000 surveys distributed, 253 were returned completed (response rate 25%). Nearly half of respondents were in the academic practice setting and nearly 75% were beyond training. Just over 30% had performed a LCD previously. The perceived benefit of an LCD was greater than unedited and edited videos (chi-squared P = 0.014 and P < 0.001, respectively). Nearly no one selected 'not helpful' and a few selected 'minimally helpful' for any of the three forms of demonstration. Most respondents identified that opportunity to ask questions (61%) and having access to the full unedited version (72%), two features inherent to LCD, improved upon the educational benefit of edited videos. Most (78%) identified LCD as ethical. However, those that did not perceived lower educational benefit from LCD (P = 0.019). A slim majority (58%) would allow themselves or a family member to be a patient of a LCD and the vast majority (86%) plan to transfer knowledge gained at the LCD session into their practice., Conclusions: Urologists who attended these LCD sessions identified LCDs as beneficial and applicable to their practice. LCDs are preferred over videos. The large majority considers LCD ethical, although not as many would volunteer themselves for LCD. Further studies are necessary to determine if there is actual benefit from LCD over TCD to patient care., (© 2013 The Authors. BJU International © 2013 BJU International.)

Objective: To evaluate perioperative and 6-month renal functional outcomes of patients undergoing off-clamp vs complete hilar control laparoscopic partial nephrectomy (LPN)., Patients and Methods: A retrospective review of 489 patients undergoing LPN was completed. Preoperative imaging assessed tumour characteristics. Patient demographics, perioperative parameters, and postoperative outcomes were documented. Multivariable regression analysis was used to assess factors contributing to changes in postoperative renal function between off-clamp and clamped LPN., Results: In all, 289 LPNs were performed on-clamp and 150 were performed off-clamp. Tumours in the on-clamp group were larger than those in the off-clamp group (mean [range] 3.3 [0.5-13.5] vs 2.7 [0.4-9] cm, P = 0.003). Univariable analysis comparing off-clamp to on-clamp cohorts showed that estimated glomerular filtration rate (eGFR) was better preserved in the off-clamp cohort at 6 months (-5.8% vs -11.4%, P = 0.046). Multivariable analysis of the groups showed that estimate blood loss (P = 0.015) and warm ischaemia time (WIT, P < 0.001) were the only significant predictors of decreased eGFR in the postoperative period. Difference in eGFR at 6 months was not significant when WIT was limited to 30 min. The complication rate was greater in the clamped cohort (10% vs 20%, P = 0.012). There was no difference in transfusion rate or positive margin status., Conclusions: LPN without hilar clamping is feasible, safe and associated with less renal injury as assessed by postoperative GFR in select patients. With experience, it can be applied to complex renal lesions., (© 2012 THE AUTHORS. BJU INTERNATIONAL © 2012 BJU INTERNATIONAL.)

After urinary diversion patients are at increased risk of long-term complications, including stones of the upper urinary tract and reservoir or conduit. Advances in instrumentation and techniques have expanded treatment options, while minimizing morbidity. Minimally invasive treatment methods include shockwave lithotripsy, antegrade and retrograde ureteroscopic lithotripsy and percutaneous nephrolithotomy. Percutaneous and laparoscopic techniques are applicable to stones within urinary diversions. Medical management is crucial for avoiding recurrent stones in these patients., (© 2011 THE AUTHORS. BJU INTERNATIONAL © 2011 BJU INTERNATIONAL.)

Objectives: To determine the aetiology of non-diagnostic renal fine-needle aspiration cytologies (FNACs) in a contemporary series., Patients and Methods: We retrospectively reviewed our institutional database of renal FNACs performed between 1995 and 2005. There were 118 patients with renal lesions that underwent FNAC. Indications for FNAC were indeterminate complex renal cysts, significant medical comorbidities, previous history of malignancy, multiple bilateral renal lesions, and suspected metastatic disease. A cytotechnologist was present during the FNA procedure to perform Diff-Quik staining and ensure an adequate sample of cells were obtained. Except for seven (six open, one ultrasound-guided), all of the FNACs were performed with CT guidance., Results: The median (range) number of passes for each FNAC session was 2.7 (1-6). Of the 16 FNACs performed for indeterminate complex renal cysts, nine (56%) were adequate with the cytodiagnosis of benign cysts. Of the seven inadequate specimens, three had benign cysts and another three were non-diagnostic due to acellularity. Therefore, the technical failure rate was 19% (3/16) for indeterminate complex renal cysts. The last patient had a cytodiagnosis of benign cyst and the final histological diagnosis of renal cell carcinoma (RCC; papilllary, grade III). Therefore, this represents a sampling error (false negative rate) of 0.8% (1/118). For the 102 solid renal masses, 22 (22%) had inadequate specimen by Diff-Quik staining. The technical failure rate (inability to obtain sufficient epithelial cells) was 16% (16). In 18 patients, immunocytochemistry (ICC) was used to differentiate primary renal parenchymal tumours from others such as transitional cell carcinoma (TCC), lymphoproliferative, colon, and lung. There were two FNACs with misdiagnosis (2%), where ICC was not used. In both, the cytodiagnosis was TCC and the final histological diagnosis was RCC in one and atypical urothelium in another., Conclusions: Non-diagnostic renal FNACs can be attributed to misdiagnosis (2%), sampling error (0.8%) and technical failure (16%).