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Objective: To compare the efficacy and morbidity of transurethral cystolithotripsy (TUCL) and percutaneous CL (PCCL) in the management of bladder stones in male children. Patients and Methods: A total of 100 boys, aged <14 years with a single bladder or urethral stone of <30 mm, were randomised into two equal groups. Initial diagnostic urethro‐cystoscopy and push back of urethral stones were done for patients in both groups. Patients in Group A had TUCL, while those in Group B had PCCL through a 20‐F sheath using a 12‐F nephroscope. The two groups were compared regarding preoperative criteria, intraoperative details, and postoperative outcomes. Results: The patients in this study had a median (range) age of 36 (4–144) months and stone size of 10 (5–26) mm. There was no statistically significant difference between the two groups for preoperative criteria. The assigned procedure was successful in 48 (96%) patients in Group A and 49 (98%) in Group B (P = 1). Complications were encountered in 11 (22%) patients in Group A and five (10%) in Group B (P = 0.171). The median (range) operative time was 21.5 (4–90) min in Group A and 13 (5–70) min in Group B (P < 0.001). In all, 47 (94%) stones needed disintegration in Group A vs 22 (44%) in Group B (P < 0.001). Conclusion: Both techniques have comparable success and complications rates. However, PCCL has a shorter operative time and less need for stone disintegration. [ABSTRACT FROM AUTHOR]

Objectives: To assess the role of the angiotensin receptor blocker losartan on the recoverability of renal function after de‐obstruction in patients with anuria and oliguria. Materials and Methods: This was a double‐blind randomized placebo‐controlled trial in anuric or oliguric patients with calcular obstruction of solitary kidney. Patients with an anomalous kidney or those with an American Society of Anesthesiology score of >3 were excluded. After relief of obstruction, patients were allocated to receive either losartan potassium 25 mg or placebo for 3 months. Serum creatinine (sCr) and renographic glomerular filtration rate (GFR) were measured at nadir and after 3 months. Changes in sCr and renographic GFR were calculated by subtracting the values at nadir from those at 3 months. Improvement, stabilization or deterioration of sCr and renographic GFR were defined as percentage increase or decrease from nadir ≥10%, while changes <10% were considered as stabilization. Results: A total of 76 patients completed 3 months of follow‐up. Demographics and peri‐operative data were comparable in the two groups. The median (range) sCr change was −1.05 (−1.8, 0.4) and −0.5 (−1.3, 0.1) mg/dL in the losartan and placebo, groups, respectively (P = 0.07). In the losartan group, renographic GFR had improved in 26 (59.1%) and deteriorated in six (13.6%) patients, while, in the placebo group, it had improved in eight (25%) and deteriorated in 10 patients (31.3%; P = 0.01). Losartan also enhanced renographic GFR improvement vs placebo by a median (range) of 6.9 (−9, 44) vs 1.4 (−10, 32) mL/min (P = 0.004). Conclusions: In patients with anuria and oliguria, losartan treatment contributes to renal function recoverability after relief of calcular obstruction of the solitary kidney. [ABSTRACT FROM AUTHOR]

Objectives: To define reference levels for intraoperative radiation during stent insertion, ureteroscopy (URS), and percutaneous nephrolithotomy (PCNL); to identify variation in radiation exposure between individual hospitals across the UK, between low‐ and high‐volume PCNL centres, and between grade of lead surgeon. Patients/Subjects and Methods: In all, 3651 patients were identified retrospectively across 12 UK hospitals over a 1‐year period. Radiation exposure was defined in terms of total fluoroscopy time (FT) and dose area product (DAP). The 75th percentiles of median values for each hospital were used to define reference levels for each procedure. Results: Reference levels: ureteric stent insertion/replacement (DAP, 2.3 Gy/cm2; FT, 49 s); URS (DAP, 2.8 Gy/cm2; FT, 57 s); PCNL (DAP, 24.1 Gy/cm2; FT, 431 s). Significant variations in the median DAP and FT were identified between individual centres for all procedures (P < 0.001). For PCNL, there was a statistically significant difference between DAP for low‐ (<50 cases/annum) and high‐volume centres (>50 cases/annum), at a median DAP of 15.0 Gy/cm2 vs 4.2 Gy/cm2 (P < 0.001). For stent procedures, the median DAP and FT differed significantly between grade of lead surgeon: Consultant (DAP, 2.17 Gy/cm2; FT, 41 s) vs Registrar (DAP, 1.38 Gy/cm2; FT, 26 s; P < 0.001). Conclusion: This multicentre study is the largest of its kind. It provides the first national reference level to guide fluoroscopy use in urological procedures, thereby adding a quantitative and objective value to complement the principles of keeping radiation exposure 'as low as reasonably achievable'. This snapshot of real‐time data shows significant variation around the country, as well as significant differences between low‐ and high‐volume centres for PCNL, and grade of lead surgeon for stent procedures. [ABSTRACT FROM AUTHOR]

Objective To describe the most common fluoroscopic-guided access techniques during percutaneous nephrolithotomy (PCNL) in a step-by-step manner and to assist in the standardisation of their technique and terminology. Methods A high-quality animation video was created for each of the respective fluoroscopic techniques, focusing into the parallel projection of external surgical manoeuvres and their effect in the three-dimensional space of the kidney. Results Four predominant fluoroscopic-guided percutaneous access techniques are available, each with different advantages and limitations. Monoplanar access is used when a stable single-axis fluoroscopic generator is available and is mostly based on surgeons' experience. Biplanar access uses a second fluoroscopy axis to assess puncture depth. The 'bull's eye' technique follows a coaxial to fluoroscopy puncture path and is associated with a shorter learning curve at the cost of increased hand radiation exposure. Hybrid and conventional triangulate techniques use target projection by two fluoroscopic planes to define the exact localisation of the target in space and access it through a third puncture site. Conclusions Fluoroscopic guidance during PCNL puncture is a very efficient method for access establishment. The percutaneous surgeon should be familiar with all available variations of fluoroscopic approach in order to be prepared to adapt puncture technique for any given scenario. [ABSTRACT FROM AUTHOR]

Objective • To compare the efficacy of prophylactic antibiotics in reducing post-surgical infections in patients undergoing ureterorenoscopic lithotripsy (URSL). Patients and Methods • The study was a double-blind, prospective, randomized controlled trial. • Between 2009 and 2012, 212 patients with preoperative sterile urine undergoing URSL were randomly allocated, in a ratio of 1:1:1:1, to receive prophylactic antibiotics with single-dose i.v. cefazolin (1 g), ceftriaxone (1 g) or oral levofloxacin (500 mg), or no treatment (control group), respectively. • Urine analysis and urine cultures were obtained between postoperative days 5 and 7. • Pyuria was defined as ≥10 white blood cells/high power field. Significant bacteriuria was defined as ≥100,000 colonyforming units uropathogens/mL. Febrile urinary tract infection (fUTI) was defined as a body temperature of 38.5 °C with pyuria or significant bacteriuria ≤7 days after surgery. Results • In total, 206 patients were eligible for analysis. • The rates of postoperative pyuria were significantly lower in patients with prophylaxis than in the control group (48.4 vs 64.7%, P = 0.04). • Patients receiving prophylaxis with levofloxacin and ceftriaxone had a significantly lower risk of pyuria compared with the control group (52.0 and 36.5 vs 64.7%, respectively; P < 0.05). • The rates of bacteriuria and fUTI tended to be lower in patients with prophylaxis, although the difference was not significant (4.5 vs 11.8%, P = 0.09, 1.3 vs 5.9%, P = 0.09). • There was no significant difference in rates of bacteriuria and fUTI between the four groups. Patients with proximal stones had a higher risk of developing postoperative fUTI (odds ratio 9.35; P = 0.03). Conclusion • Antibiotic prophylaxis significantly reduces the incidence of pyuria after URSL and tends to diminish the risk of bacteriuria and fUTI. [ABSTRACT FROM AUTHOR]

Study Type – Therapy (case series) Level of Evidence 4 OBJECTIVE To evaluate the use of Doppler ultrasonography (DUS) and rigid ureteroscopy (RU) for managing symptomatic ureteric stones during pregnancy. PATIENTS AND METHODS The study comprised 15 pregnant women with persistent renal pain; all were assessed with conventional US followed by DUS in both kidneys. RESULTS The mean period of gestation at presentation was 25.5 weeks. Stones were found in the right side in 11 patients (73%), in the left in three (20%) while no stone was found in the remaining patient (7%). There was a significantly higher mean resistive index in all 15 obstructed kidneys than in the contralateral normal kidneys. RU was used in all patients, with removal of the stones and fixation of JJ stent. All patients improved after the procedure and completed pregnancy safely up to full-term, except for premature labour in one patient. CONCLUSION DUS and RU are efficient for the diagnosis and treatment of symptomatic ureteric stones during pregnancy. [ABSTRACT FROM AUTHOR]

OBJECTIVE To evaluate patients with a history of urinary stones in intestinal reservoirs and compare them with similar patients who have never formed stones. PATIENTS AND METHODS One consequence of storing urine in an intestinal reservoir is urolithiasis, and there are several theories on its cause, all based on limited evidence. There are many factors predisposing to stone formation, and dietary and biochemical factors might be useful to distinguish those who form stones from those who do not. In a prospective study (with ethical committee approval) we identified 15 patients (six male and six female, mean age 29 years) who had formed stones after an enterocystoplasty (group 1), and another 10 (three male and seven female, mean age 44 years) with no history of urolithiasis after enterocystoplasty (group 2). The respective mean (range) follow-up was 14.6 (8–24) and 15.2 (6–23) years. They were investigated using our stone-screening protocol described previously and the results compared between the groups using an unpaired Student’s t-test, with statistically significance indicated at P < 0.05. RESULTS There was a statistically significant difference in almost all the variables assessed. The mean 24-h urine output was 41% higher ( P = 0.009) and the mean citrate excretion 173% higher ( P = 0.002) in group 2. The mean (range) urinary pH was 6.46 (6.0–7.0) and 6.93 (6.3–7.8) in groups 2 and 1, respectively ( P = 0.005). Of the stone-forming elements, only the excretion of calcium was significant (2.78 vs 5.2 mmol/day, P < 0.001). The biochemical risk of stone formation was significantly higher for both calcium oxalate and calcium phosphate stones in group 1 than group 2 ( P < 0.001 in both). From the dietary diaries there was a 24% higher fluid intake in group 2 ( P = 0.04). The difference between group 2 and group 1 for the intake of magnesium (18.2 vs 12.38 mmol/day) and phosphate (49 vs 37.8 mmol/day) was statistically significant ( P = 0.04 and 0.02, respectively). CONCLUSIONS Apparently the use of bowel in the urinary tract does not alone increase the risk of urolithiasis. Patients in group 1 were more prone due to the constituents of urine and possibly their dietary habits. This implies that with adequate fluid intake and eating a healthy balanced diet, the risk of urolithiasis can be reduced in patients with enterocystoplasty, as with idiopathic stone formers. [ABSTRACT FROM AUTHOR]

OBJECTIVE To assess the efficacy and safety of a transportable extracorporeal shock wave lithotripsy (ESWL) machine, the Modulith SLX-F2TM (Storz Medical Italia, Rome, Italy), in the management of solitary urinary calculi. PATIENTS AND METHODS The study included 233 patients (mean age 51 years; 172 male, 61 female) with symptomatic solitary renal (group A, 170, mean diameter 15.5 mm) or ureteric stones (group B, 63, mean diameter 9.5 mm) treated in a tertiary care institution. Exclusion criteria for the analysis were: pelvi-ureteric junction obstruction, multiple stones, stone diameter >2 cm, stones in a lower calyx with unfavourable anatomy, active infection, or impacted ureteric stones. Selected patients had ureteric stenting before treatment, and all patients were treated with no anaesthesia. Hospitalization, complications and subsequent auxiliary procedures were evaluated. Patients were assessed after a single ESWL session and after 3 months by a plain abdominal film and renal ultrasonography. Stone-free status was defined as no evidence of calculi, and clinical success as the presence of stone fragments of <4 mm. An efficiency quotient (EQ) was calculated for the ESWL treatment. Pain was assessed using a visual analogue scale. RESULTS The mean number of shocks used was 3779 and the mean (range) treatment time was 35 (5–55) min. The overall clinical success rate after one ESWL session was 83.7% and 82.5% for renal and ureteric stones, respectively, and the overall 3-month stone-free rate was 77% and 74.6%, respectively; the overall EQ was 0.64. When risk factors for persistent calculi were analysed simultaneously in a logistic regression model, only stones of >1 cm were statistically significant ( P < 0.05). Most patients reported that pain during ESWL was mild to moderate and easily tolerated. Only minor complications occurred, with an overall complication rate of 3.8%. CONCLUSIONS This transportable lithotripter is a safe and effective device for managing solitary stones throughout the urinary tract. Its main advantage is represented by the dual-focus system. Moreover, it shares with other contemporary machines several important features such as outpatient setting, no need for anaesthesia, easy patient positioning, and the capability of ancillary procedures. [ABSTRACT FROM AUTHOR]

Authors from the USA present a multi-centre experience using a transportable lithotripter for treating stones in all parts of the urinary tract. They found the lithotripter to be safe and effective, and felt that the Medstone STS-T represents an advance in the development of transportable lithotripters. A very large experience of partial nephrectomy for various reasons is presented by German authors. Of 717 patients, 65 had either a solitary kidney, synchronous bilateral tumours, or renal failure in the opposite kidney. They describe their technique using perfusion-cooling, and found that long-term dialysis could be avoided. To review a multicentre experience of using a transportable lithotripter (STS-T, Medstone, Inc, Aliso Viejo, CA. USA) for treating patients with urolithiasis in all parts of the urinary tract. In all, 326 patients with a total of 370 stones were treated as outpatients with the STS-T lithotripter. All patients received a single shock wave lithotripsy treatment and were followed after 4–6 weeks in the outpatient clinic, the primary endpoint being to determine the efficacy (as defined by the stone-free rate). Secondary objectives included establishing a database of patient demographic information, stone characteristics, stone location, procedural endpoints, and complication rates. In all there were 370 procedures, with a mean of 2394 shocks administered at an energy level of 24 kV. The mean treatment time was 51 min, excluding anaesthesia-induction time. The mean stone aggregate size was 8.2 mm; 62% of the stones were in the kidney while 38% were in various locations in the ureter. Of the treated stones, 90% had definite or probable evidence of fragmentation. The overall stone-free rate after one treatment with the STS-T was 52.8%. Of patients with residual fragments, most (61%) had fragments of <4 mm in aggregate diameter. The overall complication rate was 3.8%, the most common complication being postoperative pain. The Medstone STS-T lithotripter was an effective device for treating urolithiasis in all parts of the urinary tract. This system had a high margin of safety, as shown by the low complication rate. With no apparent sacrifice of efficacy compared to first-generation or fixed (not transportable) second-generation devices, the Medstone STS-T represents an important advance in the development of a truly transportable lithotripter. [ABSTRACT FROM AUTHOR]

A wide range of topics is covered in the Paediatric Urology section in this month's issue: retrograde ureteroscopy for distal ureteric stones, outcomes of continent catheterizable stomas for urinary and faecal incontinence, an exploration of a possible common cause between enuresis in childhood and urinary and faecal incontinence in adult life, and a description of a new surgical procedure, the colpo-wrap. To compare the efficacy and safety of ureteroscopy plus intracorporeal lithotripsy (ULT) with extracorporeal shock wave lithotripsy (ESWL) for treating distal ureteric calculi in childhood, as such stones are commonly treated by ESWL as the first option in adults but there is no agreement on the method of treating them in children. From July 2002 to July 2003, children presenting with ureteric stones were consecutively randomized for treatment using ULT or ESWL. The two groups were matched for age, sex and stone position in the distal ureter. A 7.5 F ureteroscope combined with a ballistic lithotripter or holmium-YAG laser was used for ULT. ESWL was administered using a second-generation lithotripter. The success rate, effectiveness quotient, complication rate and hospitalization were evaluated and compared using Student's t-test (chi-square) and Fisher's exact test as appropriate. In all, 31 patients (21 girls and 10 boys, mean age 7.2 years, range 2–17) were treated, by ULT in 17 (12 girls and five boys) and ESWL as a primary procedure in 14 (five boys and nine girls). After one ULT, all the girls and four boys, and after ESWL, four girls and two boys, were rendered stone-free at the first treatment. The total stone-free rate was 16 of 17 for ULT and six of 14 for ESWL ( P = 0.004). Eight patients had a second ESWL and three then became stone-free. The five patients in whom both ESWL treatments failed had a successful ULT. There was no significant difference between the groups in complication rate and hospitalization. General anaesthesia was required in all patients<12 years old treated by ULT or ESWL. The calculated efficiency quotient for treating distal ureteric calculi was significantly lower for ESWL than ULT ( P < 0.05). ULT should be recommended as the treatment of choice for distal ureteric calculi in children; using small ureteroscopes the target stone was treated safely and effectively. [ABSTRACT FROM AUTHOR]

To assess the nature, distribution and expression pattern of CD75, a neuraminidase-sensitive lymphocyte cell surface differentiation antigen, in calcium oxalate (CaOx) stone disease, as cell-surface sialic acid might be involved CaOx crystal binding, and lectin-binding assays suggest that sialic acid in the α2,6 position is upregulated in stone-forming kidneys. Human CaOx stone-forming and normal kidneys (13 each) and primary kidney epithelial cells (CAKI-1, three samples) were analysed. The protein pattern, distribution and expression of CD75 were analysed using Western blotting, immunohistology and semi-quantitative confocal laser scanning microscopy (cLSM). Production was investigated by α2,6-sialyltransferase specific reverse transcription-polymerase chain reaction. Western blotting showed one strong band at ≈ 43 kDa that reacted with anti-CD75 when renal epithelial and CAKI-1 tumour cell extracts were analysed. However, in renal tissue extracts of CaOx stone formers there were additional bands at 120 and 205 kDa. Image processing after cLSM showed that anti-CD75 reactivity was significantly greater on E-cadherin-positive distal and collecting tubular cells from CaOx stone-forming kidneys, at a mean ( sd) intensity of 87 (7), than on those from normal kidneys, at 41 (5) ( P = 0.005). CD75 expression in human kidney was primarily on the luminal surface of distal tubules and collecting ducts. Whether increased epithelial CD75 expression in CaOx stone disease is a cause or result of the disease remains to be clarified. [ABSTRACT FROM AUTHOR]

Objective To examine the role of clean intermittent catheterization (CIC) as a possible predisposing risk factor for bladder calculi, assessing risk factors in patients with and without bladder augmentation, and to evaluate management options for bladder calculi in these patients. Patients and methods The records of 403 patients who were using a regimen of CIC between January 1981 and March 1998 were reviewed to identify those forming bladder calculi; stones were diagnosed in 28 patients. The patients were categorized as: group 1, patients with no bladder augmentation who catheterized urethrally (227, group 1a) or via a Mitrofanoff conduit (18, group 1b); group 2, patients with augmented bladders who catheterized urethrally (100, group 2a) or via a Mitrofanoff conduit (58, group 2b). The incidence of bladder calculi in each group was determined and compared statistically where applicable. The success of the treatment options for stone management was reviewed. Results Bladder calculi developed in 5% of patients in group 1a, 8% in group 2a, 11% in group 1b, and 10% in group 2b; the incidence of calculi was not significantly different among the groups. Of these patients, 18 (64%) were asymptomatic at the time of diagnosis and significant bacteriuria was found in 23 (88%). Difficulty in catheterizing either the Mitrofanoff conduit or the native urethra was reported in 14 (50%) of these patients. Calculi were more often solitary (71%) and typically composed of struvite or apatite. Calculi were managed by open cystolithotomy in 15 patients (54%) and endoscopically in 13 (46%). Stones recurred in nine patients (32%) after treatment, comprising four of six patients treated endoscopically with electrohydraulic lithotripsy and in five of 15 after open cystolithotomy. The mean interval to recurrence was 22.8 months. Conclusion These results suggest that patients on a regimen of CIC are at risk of developing bladder calculi but the incidence of calculi is not influenced by bladder augmentation. The presence of a Mitrofanoff conduit was associated with a slightly increased incidence of calculus formation. Open cystolithotomy was associated with a lower stone recurrence rate but there were too few patients to draw definitive conclusions. [ABSTRACT FROM AUTHOR]

ObjectiveTo compare two in situ ballistic lithotripters, the lithoclast and the electrokinetic lithotripter (EKL), both of which can be used through the newer small‐bore ureteroscopes, for their ease of use, robustness, fragmentation time, adequacy of fragmentation and stone‐free rate. Patients and methodsForty‐six consecutive patients with ureteric stones refractory to treatment by extracorporeal shock wave lithotripsy were randomized to undergo fragmentation using the lithoclast (23 patients) or the EKL (23 patients). One patient was excluded from analysis in the EKL group. The adequacy of fragmentation was recorded, with the degree and significance of proximal migration for each device. After treatment patients were assessed by plain X‐ray and the stone‐free rate was determined. ResultsThe mean (median) initial stone burdens in the lithoclast and EKL groups were 69 (50) mm2 and 72 (52) mm2, respectively. The respective mean (median) procedure duration and fragmentation time were 54 (50) min and 90 (49) s in the lithoclast group, and 50 (42.5) min and 87 (52.5) s in the EKL group; the differences were not statistically significant. In four (14%) patients of each group there was significant proximal migration of the stones. The stones were completely fragmented in 17 of 23 (74%) patients in the lithoclast group and 19 of 22 (86%) in the EKL group. There was no fragmentation in one patient in each group. In the lithoclast and EKL groups, 20 of 23 (87%) and 17 of 22 (77%) were rendered stone‐free, respectively (P > 0.5). The equipment failed on two occasions in each group. ConclusionIn this randomized trial there was no significant difference in the stone‐free rate, procedure duration, fragmentation time, proximal stone migration rate and equipment failure between these in situ ballistic lithotripters. [ABSTRACT FROM AUTHOR]