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The cornerstone of management of staghorn calculi includes complete clearance of the stone with minimal morbidity. The AUA Nephrolithiasis Guidelines mentions percutaneous nephrolithotomy (PCNL) as the treatment of choice for staghorn calculi. The management of staghorn calculi is one of the most challenging among endourologic procedures because the operating surgeon has to do the balancing act of complete stone clearance with minimal morbidity. We discuss the possible difficulties one may encounter during the procedure. The complications discussed include inability to gain access, wire kinks, wire slippage, stone migration, and bleeding. The troubleshooting in rigid approach to staghorn calculus involves proper preoperative assessment with contrast-enhanced CT scan. The basic principles of endourology which include proper vision, understanding the relevant surgical anatomy, and use of proper-sized and appropriate instruments, all help in reducing the risks involved in this approach. Timely recognition and treatment of surgical complications help in reducing the morbidity and related mortality.

Pediatric ureteroscopy was first performed in 1929 by Hugh Hampton Young. The procedure was performed on a 2-month-old boy with massively dilated ureters secondary to posterior urethral valves. Young utilized a 9.5-Fr pediatric cystoscope to visualize the ureter as well as the intrarenal collecting system. After many decades, ureteroscopic management of pediatric stone disease was described by Ritchey et al. and Shepherd et al. in 1988. Since then, with the miniaturization of endoscopic instruments, improvement in imaging modalities, improvement in intracorporeal lithotripters and ancillary instruments, ureteroscopy has become a safe and effective endourological treatment in this patient population. But there are some important differences as compared to adult ureteroscopy. In this chapter, we discuss the difficulties which can occur during pediatric ureteroscopy and the tips and tricks to overcome them.

Introduction: Transplantation of kidneys from living related donors is the treatment of choice for patients with end stage renal disease. With lessmorbidity and early recovery, laparoscopy has become the standard of care for donor nephrectomies. The precise knowledge of vascular anatomy is crucial to a successful outcome. Computed tomography (CT) findings are misleading and less informative in a small number of cases. The reported accuracy of CT angiography in assessing the vascular anatomy is around 85 to 100 %. We did a prospective study to assess the diagnostic accuracy of CT angiography in the evaluation of vascular anatomy in comparison with intra operative findings.Aim: To assess the accuracy of CT in predicting the anatomy in patients who underwent laparoscopic donor nephrectomy.Materials and methods: 392 patients who underwent laparoscopic donor nephrectomy in our institute between January 2010 and December 2012 were included in our study.Results: CT scan correlated well with the intra operative findings in most of our patients with good sensitivity and specificity. CT interpreted a case of double renal vein as single and a case of circumaortic vein reported on CT was not detected intra operatively. A case of right side early branching was not detected on CT. A case of a retroaortic branch of renal vein was missed on CT scan. The incidental findings detected on CT scan such as calculi, mass and hemangioma or fibroid can be of help in managing the patient after surgery.

Although it is well documented that the lack of nitrogen in the diet of wood-feeding termites is compensated by the nitrogen-fixing capacity of their gut microbiota, the bacteria responsible for this activity are largely unknown. Here, we analyzed the diversity and expression of nitrogenase genes (homologs of nifH) in four species of dry-wood termites (Kalotermitidae), which thrive on a particularly nitrogen-poor resource. Although each species harbored a highly diverse suite of termite-specific homologs in their microliter-sized hindgut, only a core set related to nifH genes of Treponema and Azoarcus spp., 'Azobacteroides pseudotrichonymphae', the first member of the Bacteroidales identified as a diazotroph, and termite-gut-specific anfH genes of hitherto unknown origin were preferentially expressed. Transcription patterns corroborated that the populations of active diazotrophs differ fundamentally between termite genera. Capillary-picked suspensions of the flagellates Devescovina arta and Snyderella tabogae revealed that their bacterial ectosymbionts each possess two paralogs of nifH, which apparently have been acquired consecutively during evolution of Bacteroidales, but only one of them (anfH) is actively expressed. Transcription patterns correlated neither with the molybdenum content of the diet nor with intestinal hydrogen concentrations, measured with microsensors. We propose that the nitrogen-fixing community in different dry-wood termites is shaped by the symbionts of their specific flagellate populations. Our findings suggest that the diazotrophic nature of 'Armantifilum devescovinae' has an important role in the nitrogen metabolism of dry-wood termites and is the driving force of co-evolution with its flagellate host.

• To evaluate the results of miniperc vis-à-vis standard PNL in the treatment of stones of 1-2 cm in size. Miniperc may represent a reasonable procedure in patients with nonbulky urolithiasis offering a similar outcome as standard percutaneous nephrolithotomy (PNL) with advantage of reduced morbidity.• 55 procedures including 27 miniperc and 28 standard PNL were performed for renal stones 1-2 cm in size. Pediatric patient, active urinary tract infection, renal malformation, uncorrected coagulopathy and morbid obesity patients were excluded from the study. • The parameters studied were demography, operative time, postoperative analgesic requirement, hemoglobin drop, complications and stone clearance.• Mean tract size was 18.2 ± 2 F (15-20) and 26.8 ± 2 F (24-30), P value0.0001 in the miniperc and standard PNL, respectively. Holmium LASER and pneumatic lithotripter were the main energy sources used in miniperc and standard PNL, respectively. • Miniperc operative time was longer than that of standard PNL (45.2 ± 12.6 vs 31 ± 16.6 min, P= 0.0008 respectively). • Conversely, there was an advantage of miniperc over standard PNL in terms of a significantly reduced hemoglobin drop (0.8 ± 0.9 vs 1.3 ± 0.4 gram%, P= 0.01), analgesic requirement (55.4 ± 50 vs 70.2 ± 52 mg tramadol, P= 0.29) and hospital stay (3.2 ± 0.8 vs 4.8 ± 0.6 days, P ≤ 0.001), respectively. • Intra- operative conversion of the procedure into a tubeless PNL was significantly more in the miniperc group (P ≤ 0.001). The miniperc and standard PNL group had clearance rates of 96% and 100%, respectively at 1 month follow up.• This study demonstrated significant advantages of the miniperc procedure in terms of reduced bleeding leading to a tubeless procedure and reduced hospital stay. • The stone free rates and the complications were similar in either group.

therefore elected to biopsy the distal ureter using a large, backloading forceps, the BIGopsy® forceps (Cook Medical) to improve the quality of the specimen. We developed a novel technique to utilize the forceps without the use of a ureteral access sheath to gain access to the distal ureteral lesion. RESULTS: This video represents a detailed, step-by-step technique for the use of large, backloading forceps for distal ureteral tumors. Four ureteral biopsies were obtained without complications, and the patient was discharged from day surgery in good condition. Final pathology was positive for carcinoma in situ associated with papillary tumor invading into the lamina propria. CONCLUSIONS: Endoscopic retrieval of adequate tissue for diagnostic purposes in the upper tract is occasionally challenging. Large backloading forceps is an improvement, but its use is currently recommended with an access sheath only. With our technique, using a large backloading ureteroscopic biopsy forceps is feasible without an access sheath for tissue diagnosis in the distal or intramural ureter.

OBJECTIVE • To evaluate the results of miniperc vis-a-vis standard PNL in the treatment of stones of 1-2 cm in size. Miniperc may represent a reasonable procedure in patients with nonbulky urolithiasis offering a similar outcome as standard percutaneous nephrolithotomy (PNL) with advantage of reduced morbidity. PATIENTS AND METHODS • 55 procedures including 27 miniperc and 28 standard PNL were performed for renal stones 1-2 cm in size. Pediatric patient, active urinary tract infection, renal malformation, uncorrected coagulopathy and morbid obesity patients were excluded from the study. • The parameters studied were demography, operative time, postoperative analgesic requirement, hemoglobin drop, complications and stone clearance. RESULTS • Mean tract size was 18.2 ± 2 F (15-20) and 26.8 ± 2 F (24-30), P value

Introduction: Widespread use of laparoscopy for major urological procedures has brought a whole new gamut of complications with it. Vascular complications are the second commonest complica...

• To compare the content validity (realism and usefulness) of percutaneous renal access (PRA) obtained on a live porcine model and a high-fidelity computer-based surgical simulator (PERC Mentor, Simbionix; Lod, Israel) in our skills laboratory for trainees interested in PRA training, so as to determine which of the two is a more appropriate and effective training model.• In all, 24 'experts' performed PRA in a live porcine model and using the PERC Mentor. • The porcine model access required a live anaesthetized pig with a pre-placed ureteric catheter. The access was done with flouroscopic guidance using a 22-G 'skinny' needle (Cook Medical, Bloomington, IN, USA). • Then the specific task of PRA using a similar case scenario was done using the PERC Mentor. • The experts rated the models using a questionnaire based on a 5-point Likert scale, consisting of 10- and three-items of realism and usefulness, respectively.• Of the 10 items of realism assessed, the porcine model was rated as better than the PERC Mentor for 'overall realism', 'movement of the kidney', 'tactile feedback of perinephric space', 'fluoroscopic realism' and 'complications encountered' (All P0.001). • It was inferior to the PERC Mentor for 'orientation to the flank', 'aspiration', 'repetitive performance' and 'organisational feasibility' (All P0.001). • 'Tactile feedback of successful access' was similar in both models (mean [sd] points, 4.24 [0.7] vs 4.6 [0.5]). • Of the three items of usefulness, 'overall usefulness' (4.6 [0.6] vs 4.65 [0.5]) and 'use as a training tool' (4.32 [0.5] vs 4.75 [0.4]) was similar; however, the porcine model was a much better assessment tool (P0.001).• Both models have relative advantages and disadvantages. The live porcine model is a more realistic assessment tool for PRA. The specific advantage of the PERC Mentor is of repetitive tasking and easier set up feasibility. • The overall usefulness was same for both the models.

Introduction: Percutaneous nephrolithotomy (PCNL) is the standard technique for management of large renal calculi. Our main goal is to achieve complete stone clearance, which can be attain...

The aim of this study was to evaluate the effect of stone attenuation value on the effectiveness of extracorporeal shockwave lithotripsy (SWL) for upper urinary tract stones.In this prospective study, 99 patients underwent SWL for solitary renal and upper ureteral stones from January 2007 to March 2009. All patients underwent CT scan before SWL. The mean attenuation value of stones in our study was 1213.3 +/- 314.5 Hounsfield units (HU). Group A consisted of 42 patients with stones of attenuation value1200 HU and group B had 57 patients with stones of attenuation value1200 HU. Stone size, location, requirement of number of shockwaves, shock intensities (power), retreatment rate, complication rate, auxiliary procedure rate, and effectiveness quotient (EQ) ratio were studied.The mean total number of shocks required to fragment the stones in groups A and B were 1317.1 +/- 345.3 and 1646.5 +/- 610.8, respectively (p = 0.001), with a mean shock intensity of 12.2 +/- 0.7 and 12.4 +/- 0.5 kV, respectively (p = 0.03). Retreatment was not required in patients of group A, but 14.03% patients in group B required retreatment (p0.0001). Clearance rate in group A was 88.1%, whereas in group B it was 82.5% (p = 0.35). Auxiliary procedure rates were 9.5% and 10.5% in groups A and B (p = 0.22), respectively. EQ was 80.4% and 66.2% in groups A and B (p = 0.03), respectively. Complication rates were similar with 2.4% and 3.5% in groups A and B, respectively (p = 0.37). Significant correlation was recorded for total number and intensity of shocks with stone attenuation value.The EQ of SWL for upper urinary tract stones was significantly better for stones with lower attenuation value. The number and intensity of shocks required to fragment these stones with lower attenuation value were also significantly lower.

Introduction: Retrocaval ureter is an uncommon venous anomaly, in which the right ureter courses posterior to the inferior vena cava and partially encircles it. This can cause varying degr...

To establish the efficacy of early removal of a nephrostomy tube after percutaneous nephrolithotomy (PCNL), to challenge the wisdom of tubeless PCNL, as we hypothesized that it would result in a shorter hospital stay, comparable benefit and safety, while maintaining the option of check nephroscopy ensuring far superior stone clearance.In all, 22 patients were prospectively randomized equally into two groups, group 1 (early nephrostomy removal) or group 2 (tubeless) during a 1-month study period. Inclusion criteria for the study were: a simple stone of3 cm, no significant bleeding, no perforation, single-tract access and 'on-table' complete stone clearance. In group 1, a 20 F nephrostomy, 6 F retrograde ureteric catheter and a Foley catheter were used, while in group 2 only a 6 F retrograde ureteric catheter and Foley catheter were placed at the end of the procedure. Computed tomography (CT) with no contrast medium was done on the first morning after surgery before removing all catheters/tubes, and patients discharged subsequently. The variables assessed were stone clearance, hospital stay, analgesic requirement, postoperative complications and auxiliary procedures.The mean (SD) stone bulk was similar between the groups, at 2737 (946.9) and 2934.2 (2090.7) µL, respectively. Despite an on-table complete clearance, clearance assessed by CT was nine of 11 vs eight of 11 in groups 1 and 2, respectively. CT showed a 6 mm stone in one patient in group 1, while the remaining patients had stones of4 mm. The mean (SD) analgesic requirement, haemoglobin decrease, urine leak and hospital stay in the two groups were 72.7 (51.8) vs 68.2 (46.2) mg of tramadol (P= 0.25), 1.6 (0.7) vs 1.6 (0.9) g/dL (P= 0.39), 13.9 (6.3) vs 7.1 (14.2) h (P= 0.018) and 72.8 (2.1) vs 70.2 (18.5) h (P= 0.09), respectively. Complications noted were early haematuria in none vs three (P= 0.21), urinoma none vs one, and fever in two vs one, respectively; one patient in group 1 required a check nephroscopy for a residual fragment. Overall clearance including re-treatment was 10/11 vs eight of 11 (P= 0.009), respectively.Early tube removal after PCNL results in an equivalent analgesic requirement, decrease in haemoglobin and hospital stay as tubeless PCNL. It has a significantly lower incidence of early haematuria, better clearance rates and preserves the option of check nephroscopy. It can be considered as an accepted standard of care, with the preserved advantages of tubeless PCNL.

The surface of many termite gut flagellates is colonized with a dense layer of bacteria, yet little is known about the evolutionary relationships of such ectosymbionts and their hosts. Here we investigated the molecular phylogenies of devescovinid flagellates (Devescovina spp.) and their symbionts from a wide range of dry-wood termites (Kalotermitidae). From species-pure flagellate suspensions isolated with micropipettes, we obtained SSU rRNA gene sequences of symbionts and host. Phylogenetic analysis showed that the Devescovina spp. present in many species of Kalotermitidae form a monophyletic group, which includes also the unique devescovinid flagellate Caduceia versatilis. All members of this group were consistently associated with a distinct lineage of Bacteroidales, whose location on the cell surface was confirmed by fluorescence in situ hybridization. The well-supported congruence of the phylogenies of devescovinids and their ectosymbionts documents a strict cospeciation. In contrast, the endosymbionts of the same flagellates ('Endomicrobia') were clearly polyphyletic and must have been acquired independently by horizontal transfer from other flagellate lineages. Also the Bacteroidales ectosymbionts of Oxymonas flagellates present in several Kalotermitidae belonged to several distantly related lines of descent, underscoring the general perception that the evolutionary history of flagellate-bacteria symbioses in the termite gut is complex.

The key requisite of any percutaneous nephrolithotomy technique is access to the collecting system. The kidney has a high degree of vascular network and is liable for vascular injury. Therefore, for an ideal puncture, a percutaneous tract would be developed that leads straight from the skin through a papilla and the target calix into the renal pelvis. Percutaneous renal access can be achieved under fluoroscopic control or using an ultrasonography (US)-guided puncture. The shortcomings and side effects of extensive radiation during therapeutic procedures are well known. The choice of method for the type of access depends on training and personal preference. The advantages of US-guided puncture are avoidance of radiation, avoiding adjacent and visceral injury and, most importantly, intrarenal vascular injury. US offers the shortest and straight access to the collecting system with minimal morbidity. US-guided access is of particular importance in the pediatric population and in special situations in which the procedure is performed with the patient in the supine position. I believe US-guided puncture has a significant reduction in complications. The available ultrasound probes come with a puncture attachment and, on US scanning, the puncture pathway is represented by an electronic dotted line on the scanner screen, which facilitates exact placement of the needle. US-guided access is optimal with a needle guide, because the electronic dotted line helps in assessing the depth and plane of the puncture needle. This helps in reaching the desired calix in the most accurate way. US access without a needle guide is useful in bedside procedures, in grossly hydronephrotic systems, and nonavailability of an electronic guide. We think the punctures with this technique are suboptimal. Both methods need a certain degree of training and orientation. The training in US should be structured.

To analyze the fate of residual stones after percutaneous nephrolithotomy (PCNL) and identify the factors that predict spontaneous passage.We retrospectively analyzed the records of 2469 patients who underwent PCNL at our center between January 2000 to January 2008.Residual fragments (RF) were identified in 187 (7.57%) patients. The most common site of RF was lower calix (57.7%), and the mean size of RF was 38.6 +/- 52 mm(2). Eighty-four stones passed spontaneously at a mean follow-up of 24 months (range 1-100 mos). Of the stones that passed spontaneously, 65.47% did so in 3 months. RF25 mm(2) and those situated in the renal pelvis had the best chance of clearance. Stepwise multiple regression analysis showed that a history of intervention (P0.006), metabolic abnormalities such as hypercalcuria (P0.001) and hyperuraecemia (P0.03), preoperative nephrostomy drainage (P0.05), presence of a Double-J stent, (P0.001), time of presentation of residue (P0.08), size of residue (P0.007), and surgeon experience (P0.001) were significant factors in predicting the fate of RF after PCNL.The most common site of post-PCNL RF was the lower calix. Renal pelvic RF25 mm(2) have the best chance of spontaneous passage. Approximately half the RF will pass spontaneously, and the majority will clear in 3 months. The size of the residual stone, history of intervention, renal failure, and metabolic hyperactivity are predictors of persistence of RF.

The purpose of this study was to evaluate the effectiveness of combined ureteroscopic holmium YAG lithotripsy for renal calculi associated with ipsilateral ureteral stones.Between August 2002 and March 2007, retrograde flexible ureteroscopic stone treatment was attempted in 351 cases. Indication for treatment was concurrent symptomatic ureteral stones in 63 patients (group I). Additional operative time and perioperative complication rates were compared to a group of 39 patients submitted to ureteroscopic treatment for ureteral calculi exclusively (group II).Mean ureteral stone size was 8.0 +/- 2.6 mm and 8.1 +/- 3.4 mm for groups I and II, respectively. Mean operative time for group I was 67.9 +/- 29.5 minutes and for group 2 was 49.3 +/- 13.2 minutes (p0.001). Flexible ureteroscopic therapy for renal calculi increased 18 minutes in the mean operative time. The overall complication rate was 3.1% and 2.5% for groups I and II, respectively (p = 0.87). Mean renal stone size was 10.7 +/- 6.4 mm, overall stone free rate in group I was 81%. However, considering only patients with renal stones smaller than 15 mm, the stone free rate was 88%. Successful treatment occurred in 81% of patients presenting lower pole stones, but only 76% of patients with multiple renal stones became stone free. As expected, stone free rate showed a significant negative correlation with renal stone size (p = 0.03; r = -0.36). Logistic regression model indicated an independent association of renal stones smaller than 15 mm and stone free rate (OR = 13.5; p = 0.01).Combined ureteroscopic treatment for ureteral and ipsilateral renal calculi is a safe and attractive option for patients presenting for symptomatic ureteral stone and ipsilateral renal calculi smaller than 15 mm.

More than 40 years ago, ten species of devescovinid flagellates were described to occur in the gut content of the termite Incisitermes marginipennis. Based on light microscopic examinations, the flagellates were then classified into the two genera Devescovina and Metadevescovina. Here, we combined molecular phylogenetic analysis of the small subunit rRNA genes of the gut flagellates with the first ultrastructural investigation of the genus Metadevescovina. Our results suggest that I. marginipennis contains only one species of devescovinid flagellates, Metadevescovina modica, which comprises three variants of the same phylotype (or =99.5% sequence similarity). Monophyly of all Metadevescovina sequences obtained from Pterotermes and Incisitermes species in this and previous studies and the absence of filamentous bacterial epibionts typical of Devescovina species (M. modica is densely colonized with spirochetes) corroborate the validity of the genus Metadevescovina and allow its differentiation from other genera of devescovinid flagellates.

OBJECTIVE To compare the outcome, safety and efficiency of extracorporeal shock wave lithotripsy (ESWL) using an electromagnetic lithotripter for upper urinary tract stones in children and adults. PATIENTS AND METHODS We retrospectively reviewed data over a 5-year period for patients with solitary, renal and upper ureteric stones measuring

Ejaculatory duct obstruction (EJDO) has traditionally been managed with transurethral resection of ejaculatory ducts (TURED). However, wide resection has potential complications and risk of postoperative morbidity. We demonstrate a technique using transrectal ultrasonography (TRUS) and fluoroscopy to assist with transurethral incision of the ejaculatory duct (TUIED) to treat hematospermia due to obstruction by either a stone or a prostatic cyst.Twenty-five patients with ejaculatory disorders including hematospermia underwent TUIED between 1997 and 2005. Diagnosis, the cause of hematospermia, and the level of EJDO was confirmed by semen analysis, semen culture, and TRUS. All patients were subjected to TRUS-guided seminal vesicle aspiration followed by seminal vesiculography using methylene blue mixed with contrast under biplanar TRUS guidance and fluoroscopic monitoring. After confirming the cause and level of obstruction, the ejaculatory duct was opened using endoscissors until the obstruction was relieved as confirmed by free flow of methylene blue. Stones were removed if any were present. A Foley catheter was kept in place for 24 hours.Improvement of symptoms was noted in 96% of patients with ejaculatory disorders. All patients with painful ejaculation and hematospermia had complete remission of symptoms at 3 months postoperatively; three patients had transient epididymo-orchitis, and none had retrograde ejaculation or incontinence.TUIED is a viable and minimally-invasive option for treating EJDO causing ejaculatory disorders including hematospermia with minimal morbidity and early recovery.

To describe an innovative bag for effective specimen retrieval with the aim of reducing the cost of surgery. Retrieval bags are useful in specimen retrieval after ablative surgery.The components of the retrieval bag are a polyethylene roll, nylon thread, and a 5 ureteral catheter. The lower end is double-sewn with an autoseal device. The neck of the bag consists of a folded edge of the polyethylene bag, which is single-sewn. The folded tunnel accommodates the 5F ureteral catheter and nylon thread. Introduction is performed through the 10-mm port with the help of an atraumatic grasper without any special introducer sheath. Two laparoscopic instruments are required to open, place the specimen within, and close the bag. The bag is extracted by extending the port incision, if required.The bag was used in 40 cases, including radical prostatectomy in 7, simple nephrectomy in 18, nephroureterectomy in 11, and adrenalectomy in 4. The running cost of the retrieval bag wasUS$2, the least expensive of the specimen retrieval systems currently available. The bag had good laparoscopic visibility in all cases. Organ entrapment required a certain learning curve. The overall entrapment time was 7.6 +/- 3.4 minutes. None of the specimens ruptured during entrapment. The entrapment time differed depending on the type of specimen retrieved. The retrieval time for kidney, prostate, and adrenal specimens was 8 +/- 3, 3 +/- 2, and 3 +/- 1.3, respectively.The retrieval bag is inexpensive and easy to make and maintain, and effectively useful with good maneuverability.

Purpose of review Complete removal of stones is crucial for preventing recurrence and morbidity. Currently percutaneous nephrolithotomy is the preferred treatment modality. The debate continues over the use of single tract versus multiple tract percutaneous nephrolithotomy. We review papers on the topic published over the past 12–24 months. Recent findings Articles related to single and multiple tracts were reviewed. We discuss the morbidities, advantages and disadvantages of both the approaches. To decrease the number of tracts few authors have shown the efficacy of flexible ureteroscopy and nephroscopy as an adjuvant procedure. The authors state that this option effectively decreases the disadvantages of multiple tracts, namely blood loss complications, without compromising on stone free rates. Summary Several techniques have been described for percutaneous access and stone removal, all of them associated with inherent problems. Although feasible, access to all the calices will be difficult through one percutaneous tract because of the peculiarities of the renal collecting system, in which case, multiple-access percutaneous nephrolithotomy is the mainstay of the treatment. The crucial point to understand is that all cases should be dealt with on an individual basis.

Ureteropelvic junction (UPJ) obstruction remains the most common cause of hydronephrosis in newborns and children. Open pyeloplasty has been the gold standard for management of UPJ obstruction in these patients. We report our technique and outcome with laparoscopic transperitoneal dismembered pyeloplasty in children.Nineteen patients, ages 2 to 14 years, underwent laparoscopic pyeloplasty at our center between June 2004 and December 2006. Thirteen pyeloplasties were on the left side and six on the right side. A transmesocolic approach was used in five left-sided UPJ obstructions. All operations were performed by the transperitoneal route using either three or four ports.Sixteen patients underwent dismembered (Anderson-Hynes) pyeloplasty, while three had a nondismembered Foley's Y-V pyeloplasty. Mean operative time was 198 minutes (range 105-300 min). Mean estimated blood loss was 45 mL (range 30-130 mL). Mean length of stay was 4 days (range 3-5 d). Mean followup was 13.8 months (range 2-30 mos). Postoperatively, one child had a urinary tract infection that necessitated hospital admission and administration of intravenous antibiotics. Eighteen of 19 patients demonstrated improved drainage with no evidence of obstruction on diuretic renography and/or excretory urography. One patient is awaiting follow-up. There was no conversion to open surgery.Laparoscopic pyeloplasty in children is a safe, minimally invasive treatment option that duplicates the principles and techniques of definitive open surgical repair. It is technically challenging; with increasing expertise, operative times are reduced significantly.

Bleeding is a major concern during percutaneous nephrolithotomy (PCNL), especially with the use of multiple tracts. This prospective study aimed to identify factors affecting blood loss during PCNL.Data were collected prospectively from 236 patients undergoing 301 PCNL procedures at our institute since June 2002. Blood loss was estimated by the postoperative drop in hemoglobin factored by the quantity of any blood transfusion. Various patient-related and intraoperative factors were assessed for association with total blood loss or blood transfusion requirement using stepwise multivariate regression analysis.The average hemoglobin drop was 1.68 +/- 1.23 g/dL. Stepwise multivariate regression analysis showed that the occurrence of operative complications (P0.0001), mature nephrostomy tract (P0.0001), operative time (P0.0001), method of access guidance (fluoroscopy v ultrasound) (P = 0.0001), method of tract dilatation (P = 0.0001), multiple (or =2) tracts (P = 0.003), size of the tract (P = 0.001), renal parenchymal thickness (P = 0.05), and diabetes (P = 0.05) were significant predictors of blood loss. The overall blood transfusion rate for all patients was 7.9%. Preoperative hemoglobin, multiple tracts, stone size, and total blood loss were significant in predicting perioperative blood transfusion requirement. Factors such as age, hypertension, renal insufficiency, urinary infection, the degree of hydronephrosis, stone bulk, and the function of the ipsilateral renal unit did not have any effect on the blood loss. Technical factors such as the operating surgeon and the calix of entry also did not affect the blood loss.Diabetes, multiple-tract procedures, prolonged operative time, and the occurrence of intraoperative complications are associated with significantly increased blood loss. Atrophic parenchyma and past ipsilateral intervention are associated with reduced blood loss. On the basis of this evidence, maneuvers that may reduce blood loss and transfusion rate include ultrasound-guided access, use of Amplatz or balloon dilatation systems, reducing the operative time, and staging the procedure in cases of a large stone burden or intraoperative complications. Reducing the tract size in pediatric cases, nonhydronephrotic systems and those with a narrow infundibulum, and secondary tracts in a multiple-tract procedure may also reduce blood loss during PCNL.

“Big” scars for stone removal are only needed in unusual circumstances. This is true given the fact that technology is fast evolving and instruments becoming smaller and smaller. The management of urolithiasis in children has undergone a paradigm shift in the past decade. Management of pediatric urolithiasis necessitates a balance between stone clearance and morbidity related to the procedure. A variety of treatment options are available, which include shock wave lithotripsy (SWL), percutaneous Nephrolithotomy (PCNL), and retrograde intra renal surgery (RIRS) and open surgery. Concerns regarding endourologic treatment include eVect on the renal development and function, the side eVects of radiation, and the implications of residual stones. Children with pediatric urolithiasis need to be worked up metabolically to prevent recurrence. The treatment options should be chosen with prudence, as each of the treatment options has its share of problems. SWL has been the treatment of choice for renal calculi less than 15 mm in size. The stone-free rates range from 68 to 84% [1]. In our study, ESWL was found to be safe and eVective in children as was in adults for solitary renal and upper ureteric stones less than 2 cm in size. We found that children required fewer and lower energy shock waves to achieve equivalent results. Considering that long-term data are awaited regarding functional consequences of shock waves on pediatric kidneys, it would be prudent to shock these kidneys as little as possible. In this context, we feel to minimize the “shock loss,” and optimizing the number and energy of shock waves, the patient should be given optimum anaesthesia with the use of ultrasound and Xuoroscopy for localizing and monitoring of stone fragmentation [2]. PCNL remains the most eVective option for treating large stones in this age group. The obvious downside of this approach is the potential for life-threatening complications such as bleeding; hence, surgeon experience is paramount in deciding the number and site of access. Stone-free rates of more than 90% have been shown in pediatric age group [3]. Percutaneous Nephrolithotomy has been described even in children as small as 11 months, having complex calyceal stones and/or staghorn calculi. The method to gain access, ultrasound or Xuoroscopy, is a matter of experience and personal preference. Ultrasound oVers the advantage of visualization of spleen and liver and avoids injury. It also minimizes radiation to these kids. The key to success in PCNL in these small patients is staging the procedure if required, miniaturization of instruments, and using ultrasound as the method of achieving access. PCNL oVers a good clearance rates with acceptable morbidity. Miniaturization of instruments particularly smaller nephroscopes and newer energy sources will decrease the morbidity of PCNL. The question is how small is small enough! In this regard, in our opinion, microperc is the “new kid on the block.” It has a role to play in percutaneous management of these small patients. Essentially, “microperc” involves performing the procedure through the eye of the needle. The microoptics of 0.9 mm diameter are used. The assembly has a integrated light head inserted through the working sheath of the needle, and PCNL can be done through the same needle sheath with a 3-way needle allowing irrigation, passage of Xexible telescope and a laser Wbre [4]. Although investigational, larger multicentre trials that are already underway will prove its utility. M. Desai (&) Nadiad, India e-mail: mrdesai@mpuh.org

There is a lack of consensus in the definition of stone-free rate (SFR) after ureteric or renal stone surgery. We propose a simple classification to define levels of SFR post-treatment.

To assess the safety and efficacy of percutaneous nephrolithotomy (PCNL) in the pediatric age group and the impact of certain technical modification on the ultimate outcome.We studied 45 renal units in 40 patients under 15 years of age who underwent PCNL at our institute. The average age was 9.2 years (range 11 months-15 years). There were 5 bilateral, 11 multiple, and 9 staghorn calculi. The average calculus size was 2.04 (0.9-4.5) cm. The PCNL was done with an ultrasound-guided peripheral puncture, a planned staged approach in some cases, and minimal tract dilatation with the use of a pediatric nephroscope and a specially designed slender probe for pneumatic intracorporeal lithotripsy.Complete stone clearance was achieved in 41 of the 45 renal units, giving an overall clearance rate of 91%. Minor pyrexia (100 degrees F/2 days) was seen in 10 patients, whereas serious pyrexia was seen in 5. One patient had a prolonged leak from the nephrostomy site, which responded to double-J stenting, and one patient had a pelvic perforation with hyponatremia, which responded to conservative treatment. The average fall in hemoglobin was 1.6 g/dL, but none of the patients required blood transfusion.We believe that our alterations in the standard technique of PCNL with the use of pediatric instruments can make it a safe and effective option in the modern management of pediatric urolithiasis.

′Microperc′ is a recently described technique in which percutaneous renal access and lithotripsy are performed in a single step using a 16 G micropuncture needle. ′Mini-microperc′ is a further technical modification in which an 8 Fr sheath is used to allow insertion of ultrasonic or pneumatic lithoclast probe with suction. The available evidence indicates that microperc is safe and efficient in the management of small renal calculi in adult and pediatric population. It can also be used for renal calculi in ectopic kidneys and bladder calculi. The high stone clearance rate and lower complication rate associated with microperc make it a viable alternative to retrograde intrarenal surgery.